Decision-Making and Relationship Competence When Reporting Suspected Physical Abuse and Child Neglect: An Objective Structured Clinical Evaluation.

Mandatory reporting of suspected child abuse and neglect highlights the challenges between the ethical and legal obligations of social workers and the need to maintain the therapeutic relationship with the client. The ability to bridge this tension is paramount to ensure continued psychosocial treatment and the well-being of children. This paper discusses a study to determine the decision-making factors of social work students and practitioners when facing a suspicion of child abuse and neglect, how they justify their decision to report or not report to child protection services, and the current and future relationship repair strategies used with simulated clients during an objective structured clinical evaluation (OSCE). Nineteen BSW, MSW, and experienced practitioners (N = 19) underwent an OSCE with one of two child maltreatment vignettes, physical abuse or neglect. Fisher's exact test was used to examine participants' historical and current reporting behaviors. Independent samples T-tests, Cohen's D, and qualitative content analysis was used to examine participants' decision making and relationship repair strategies when faced with suspected child abuse and neglect. Results showed that six participants discussed the duty to report during the OSCE while 13 participants did not. Participants' who discussed and did not discuss the duty to report during the OSCE articulated clear reasons for their decision and identified relationship repair strategies in working with the client. A sub-group of participants who identified the child maltreatment but did not discuss the duty to report, provided more tentative and complex reasons for their inaction and next steps in working with the client. All participants demonstrated a degree of competence and critical reflection in the OSCE, with integration for future learning. These findings are discussed and implications for future practice are offered.

The proliferation of child maltreatment both globally and in the Western world has led to the continued urgency to manage this ongoing public health concern (Cyr et al. 2013). In the United States there was an estimated 4.0 million reports of suspected child abuse or neglect in 2015 and the third highest percentage of reports originate from social service personnel (10.9%) (US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau 2017). Social workers are often at the forefront of this challenge given their legislated role as mandatory reporters (National Association of Social Workers 2008). Mandatory reporting involves accurate, informed, and reasoned decision-making to maintain the best interests of the child. As the decision to report child maltreatment often damages the therapeutic relationship (Tufford 2016), social workers are challenged with maintaining the relationship to provide psycho-education to prevent future maltreatment. Both roles of decision maker and treatment provider are complex and social work students, as well as those new to the profession, may lack the requisite knowledge to manage this complexity. The purpose of this research was to investigate the factors that impact Bachelor of Social Work (BSW), Master of Social Work (MSW), and experienced practitioners’ decision-making to report or not report to Child Protective Services (CPS) a case of suspected physical abuse or neglect during an Objective Structured Clinical Examination (OSCE). The research also examined the strategies participants used to repair the relationship with the client in the event of a report to CPS.

Literature Review

Objective Structured Clinical Examination

The origins of the OSCE derive from medical education and were designed to assess knowledge and clinical skills using a standardized process (Harden and Gleeson 1979), which allowed for rigorous and objective comparisons between students. Use of the OSCE has moved beyond medical education to the allied health professions of nursing (Manning et al. 2016), pharmacy (Martin et al. 2020), and occupational therapy (Roberts et al. 2019). In recent years, the OSCE has been adapted for use in social work with a focus on mental health (Washburn et al. 2016), direct practice skills (Rawlings 2012), child protection (Pecukonis et al. 2016), and work with seniors (Gellis and Kim 2017).

The OSCE methodology for use in social work (Bogo et al. 2014) also follows a standardized format whereby students verbally interact for 15 min with a trained actor, called a standardized or simulated client with a predesigned case vignette. The students’ performance is observed and rated by a trained rater, usually an academic or professional with experience in the topic under study. Following the interview, students complete written reflections on their performance, which are also rated. The OSCE adapted for social work has demonstrated reliability and validity for the methodology and rating scales (Bogo et al. 2011a). The OSCE, as a means of examining decision-making and relationship repair within the context of mandatory reporting, received less attention in the research literature and yet to be explored. This study aims to advance this area of research.

Factors that Affect Mandatory Reporting

There are certain considerations that affect a practitioner’s decision to report to CPS when faced with suspected child maltreatment. Practitioners often do not report based on legislative standards but as a response to subjective perceptions and emotions (Kuruppu et al. 2020; Nouman et al. 2020). Students, in particular may be swayed by their emotional responses to case material more than practitioners (Tufford et al. 2019; Fleming et al. 2015). In addition, prior negative experiences with CPS and bias against the effectiveness of CPS often act as a deterrent to involve the child welfare system and contribute to a prioritization of self-addressing the maltreatment concerns through a combination of education, support, and outside resources (Tufford and Morton 2018; Nouman et al. 2020).

Practitioners may fear potentially legal and violent repercussions for reporting (Nouman et al. 2020; Pietrantonio et al. 2013), not recognize abuse and neglect (Tufford et al. 2015), and have insufficient knowledge of reporting procedures (World Health Organization 2013). The professional judgment involved in the decision to report child maltreatment can be a subjective, moral stance (Regehr et al. 2010) and students will often consider mitigating factors beyond the abuse such as the perpetrator’s age, marital status, substance use, and history of violence (Smith 2006). The loss of the therapeutic relationship serves as an additional influential factor (Tufford et al. 2019) as well as the level of engagement between the family and other helping professionals such as previous practitioners or social service agencies (Nouman et al. 2020).

Practitioners can also have subjective judgments over what constitutes minimal, moderate, and severe maltreatment. Factors taken into consideration include the child’s age, the type of abuse, the injury and its circumstances, and the practitioner’s familiarity with the family (Herendeen et al. 2014). These factors often lead to a “decision threshold” (Baumann et al. 2011) whereby the assessed harm to the child was of sufficient severity for them to report. Although practitioners are more likely to report as the severity of the maltreatment increases, practitioners can also normalize the presented behaviors and delay reporting based on their subjective judgements of what constitutes severe discipline. In these situations, reporting to CPS is often considered a last result (Nouman et al. 2020).

Feelings of uncertainty that may contribute to non-reporting to CPS may stem from inexperience, inadequate training, and unfamiliarity with relevant legislation and reporting obligations (Pietrantonio et al. 2013). The ability to self-regulate emotions acts as a facilitating factor allowing practitioners to better navigate challenging discussions of mandatory reporting with families without allowing emotional dysregulation to negatively affect their decision-making (Bogo et al. 2017). It also provides practitioners with a greater sense of confidence and control in an otherwise emotional and vulnerable situation. Practitioners and social work students with high confidence in their self-efficacy and performance are more likely to describe themselves as being emotionally calm and can draw from previous practice experiences than those with low confidence. Practitioners and students with low confidence report feeling more dysregulated, frustrated, distressed, and uncertain (Bogo et al. 2017). In addition, low confidence practitioners and students often find it more challenging to draw upon knowledge frameworks to guide their practice and are more likely to experience difficulties engaging the client (Bogo et al. 2017). The level of confidence for many practitioners and students may also be dependent on the case situation including the client’s culture, specifically disciplinary belief systems, the number of years lived in the country of origin, and existing support networks (Tufford et al. 2019).

The Therapeutic Relationship and Mandatory Reporting

The therapeutic relationship is an integral component across treatment approaches (Castonguay et al. 2010; Miehls 2017). Social workers act as the relationship-building agent through the provision of emotional sensitivity and verbal responsiveness to client concerns including caregiving challenges (Rollins 2019). However, maintaining the therapeutic relationship while concurrently upholding the duty to report suspected child maltreatment can undermine the efforts of social workers (Rawlings and Blackmer 2019). The potential loss of the relationship or intense conflict with the caregiver often serve as deterrents to reporting in favor of addressing the maltreatment within the therapeutic milieu (Tufford 2014; Bogo et al. 2017; Kuruppu et al. 2020). When faced with the prospect of a report to CPS caregivers often experience intense feelings of fear, betrayal, stigma, and anxiety, which may be vocalized through anger, denial, disagreement, and blame directed towards the social worker (Tufford 2016).

The few historical studies conducted on the outcome of the therapeutic relationship following mandatory reporting reveal that roughly one quarter of cases following a report to CPS resulted in a negative outcome, such as termination of the therapeutic relationship, decreased disclosure, missed appointments, increased tardiness, feelings of anger, and violence towards the practitioner; while three quarters resulted in no effect or a positive effect on the therapeutic relationship (client relief and increased self-disclosure) (Steinberg et al. 1997; Watson and Levine 1989; Weinstein et al. 2000). Indeed, beyond outright withdrawing from treatment, social workers may find other families who continue in treatment become tense and limit disclosures (Tufford 2012). The impact of the rupture is dependent on the presence and strength of the client-worker relationship and varies from family to family (Tufford and Lee 2020).

In an effort to manage the complexity of reporting and continued treatment with the family often under trying circumstances, the medical, psychology, and social work literatures have explored various means by which to repair the relationship. The use of collaborative and non-judgmental approaches to determine caregivers’ perceptions has been advocated in the medical literature (Pietrantonio et al. 2013). A collaborative approach can facilitate discussion and calm caregivers’ automatic fears that their child will be taken from their home (Asnes and Leventhal 2010). Other strategies such as calling CPS in conjunction with the mandatory reporter, validating caregivers’ emotions, and maintaining composure while concurrently holding caregivers’ intense emotions have been suggested in the literature (Asnes and Leventhal 2010; Tufford 2012; Pietrantonio et al. 2013; Steinberg et al. 1997).

COVID-19 and Mandatory Reporting

For the past year in 2020, decision-making and relationship repair strategies when reporting suspected child maltreatment have occurred against the backdrop of the COVID-19 pandemic. The onset of the pandemic ushered a decrease in reporting to CPS as families isolated and reduced contact with mandatory reporters due to the respiratory nature of the virus (Campbell 2020). However, children are at increased risk for abuse due to the accumulation of stress and unanticipated caregiver job loss related to the economic downturn (WHO 2020). Social workers, whose practice is built on the foundation of a solid therapeutic relationship with clients, have a critical role to play in mitigating child maltreatment during the on-going health crisis. Strategies such as positive reframing, which emphasizes client strengths and reappraises stressors as being less critical (Hillson and Kuiper 1994), identifying families at-risk, providing virtual services, recognizing parental resilience, and increasing community awareness, can support families to manage the economic and caregiver challenges brought on by the pandemic (Lawson et al. 2020; Usher et al. 2020). The present study, which examines decision-making and relationship repair strategies, is of significant importance and timely, given the new contextual reality under which child abuse and neglect is taking place.

Study Objective

While the research literature identifies numerous factors that affect the decision to report child maltreatment along with various relationship repair strategies, reporting is partly based on the severity of maltreatment (Nouman et al. 2020). Social workers’ perceptions regarding severity of maltreatment are not uniform. The purpose of this study is to examine how social work students and practitioners report to CPS based on the severity of the maltreatment and then maintain the relationship, both presently and following the report. The research questions which guide this study are the following:

How do social work students and practitioners’ characteristics inform mandatory reporting behaviors?

How do social work students and practitioners justify their decision to report or not report in simulated child abuse or neglect scenarios?

What current and future relationship repair strategies do social work students and practitioners use in simulated child abuse or neglect scenarios?

Conceptual Framework

The conceptual framework (Fig. 1), based on earlier doctoral research of Tufford (2012), outlines a decision-making and relationship repair guide for social workers faced with mandatory reporting. The OSCE scales and questions in the present study derive from this framework. The framework begins with a proactive stance including explaining the limits of confidentiality, informed consent, and relationship building, prior to commencing treatment and the disclosure of reportable material. From these initial strategies, the framework proceeds to outline the factors to consider when faced with suspected child maltreatment. These include legislative factors at the state level, factors that involve the mandatory reporter such as their personal experiences with CPS, situational factors of the case including culturally based disciplinary strategies, professional factors of the social worker including training in child maltreatment recognition, and relationship factors which refer to the impact of reporting to CPS on the relationship.

Fig. 1

Conceptual framework

Based on these discrete but inter-related factors the social worker decides to report or not report to CPS. In the event of reporting, the social worker can draw from a number of strategies. Reporting strategies involve giving clients options around how the report is made, while information strategies centre on information regarding the role, function, and benefits of CPS and the provision of psycho-education. Affect regulation strategies are divided between those that involve the mandatory reporter (e.g., grounding techniques and supervision) and those that involve the family (e.g., validation and acknowledging the impact of reporting). Advocacy strategies include advocating for the child’s best interests and caregivers’ strengths while social workers can also use professional and resource strategies. Finally, cultural strategies acknowledge the client’s culture such as utilizing a translator. Emerging from these strategies is the impact on the relationship which can be maintained or strengthened leading to continued treatment, or strained and tense possibly resulting in the client withdrawing from treatment.

Methodology

Study Design

Ethics approval was obtained for all study procedures. The overall research consists of three phases to develop and validate the Performance Rating Scale, Post-OSCE Reflection Rating Scale, and Post-OSCE Reflection Questionnaire used in the Objective Structured Clinical Examination (OSCE) for mandatory reporting of suspected child abuse and neglect. Phase 1 consisted of completing face validity of the rating scales and reflection questions with academic faculty and social work practitioners. This was followed by pilot testing the rating scales and reflection questions in a single station OSCE with one case vignette on child physical abuse and a small sample of participants (N = 6). Phase 2 incorporated feedback and revisions gleaned from Phase 1; as well as, the addition of a second vignette on child neglect with a larger sample of participants (N = 19). Phase 3 involves testing the rating scales and the reflection questions with a larger sample of participants in a five station OSCE involving five child maltreatment vignettes. The current paper presents the results derived from Phase 2.

Recruitment and Sample

Participants included third year BSW students, fourth year BSW students, MSW students, and experienced social workers with at least three years of practice experience with children and families. Recruitment of the student participants consisted of study invitation letters uploaded to the BSW and MSW Facebook pages of three local universities. Recruitment of the experienced practitioners involved the assistance of social work directors at local hospitals and children’s mental health centres to forward the study information letters to social workers through their staff directory. Potential participants were invited to contact the research assistant for more information and/or to schedule a time to participate in the OSCE. The final sample (N = 19) included two BSW students, 14 MSW students, and three experienced social workers. Participants were offered a $50.00 gift card for their time and contribution to the research.

Procedures

During the OSCE, participants were to assume the role of a social worker during a second session with the client, who was portrayed by a standardized client. Participants were randomly assigned and blinded to whether they received the physical abuse or neglect scenario. In the physical abuse scenario hitting a child with an object would be reportable under provincial mandatory reporting legislation. Similarly, in the neglect scenario, leaving children unsupervised under the age of 10 would also be reportable under current legislation. Participants had approximately five minutes to review the written vignette immediately prior to the 15 min OSCE session. An OSCE rater, an experienced social work practitioner, was present in the OSCE room to observe and complete the Performance Rating Scale. Upon completion of the 15 min OSCE, the participant, the OSCE rater, and the standardized client engaged in a 15 min reflective dialogue. Participants then proceeded to a computer lab for 30 min to complete the Post-OSCE Reflection Questionnaire responses. The OSCE rater who observed the OSCE session, reviewed the participant’s responses and rated their responses using the Post-OSCE Reflection Rating Scale.

Measures

Three measurement instruments were used in the study: (1) The Performance Rating Scale is composed of nine Likert scale questions. The nine-point Likert scale questions measure participants’ competencies in discussing the duty to report, approaching the child maltreatment issue, repairing the relationship, maintaining cultural competence, and conducting a systemic assessment. The performance rating scale is completed by a trained rater during the simulated interview. (2) The Post-OSCE Reflection Questionnaire is comprised of 11 structured reflection questions. These questions centre on decision-making factors, use of self, relationship repair strategies, and application to future learning. Participants complete the Post-OSCE Reflection Questionnaire following the simulated interview. (3) The Post-OSCE Reflection Rating Scale is comprised of 11 Likert scale questions. The nine-point Likert scale questions assess the depth, quality, and application of reflection on the Post-OSCE Reflection Questionnaire by the participants. This scale addresses areas of critical reflection, conceptualizations of the child maltreatment issue and decision-making, the use of knowledge, the clinical relationship, self-regulation, and professional development. This reflection rating scale is completed by a trained rater. The scales and questions were developed by the first author during Phase 1 of the study and were refined using face validity and a small pilot (N = 5). They are adapted from the work of Bogo et al. (2011a).

Vignettes

Physical Abuse

The scenario focuses on Alima, a Black woman in her 30 s, who emigrated from Mozambique five years prior with her husband Ayan and four-year-old son Yuran. Alima hopes to sponsor her parents to immigrate to Canada but finds the process to be complex and challenging. Her husband is not home often due to work. In addition to these stressors, her son’s teachers recently contacted her regarding his aggressive behavior towards other children, namely screaming, hitting, and grabbing toys. During the OSCE session, Alima discloses an incident that occurred at home that results in her striking her son on the face with an open hand and on the buttocks several times with a wooden stick. She indicates the strategies that were suggested to her, in the prior session, were not effective. Throughout the OSCE session, Alima expressed resolve that her disciplinary strategy does not warrant a report to the CPS because physical discipline is a traditionally sanctioned practice that is passed down from generation to generation in her country of origin, was effective during her own formative years, and originates from a place of love and care.

Neglect

The scenario focuses on John, a White man in his 30 s whose wife suddenly passed away in a car accident, leaving him to be the sole caregiver of Sally, age six and Flora, age nine. His wife was a stay-at-home mother and was the full-time caregiver for their daughters. John is a warehouse worker who works day shifts, with occasional overtime in the evenings. The staff at his daughters’ elementary school have expressed recent concerns because the children look unkempt, emit a strong body odour, and have been observed playing outside late after school with inadequate clothing for the cold weather. During the OSCE session, John discloses taking a sleeping aid that sometimes causes him to sleep through the morning or during the day. He maintains that the older daughter takes good care of the younger daughter and the children are old enough to independently care for themselves. Throughout the OSCE, the father presents as aloof to the observations of the school staff.

Data Analysis

A mixed methods approach was used to analyze the data. Quantitative data were analyzed using IBM SPSS version 26. Fisher exact test was conducted to test the significance of the differences between those who had past experiences with mandatory reporting versus those who did not. Independent sample T-tests and Cohen’s d were conducted to examine differences among participants who initiated mandatory reporting of the allegations of child maltreatment during the OSCE and those who did not. The sample’s assumption of normality was confirmed by examining the distribution of variation, and the assumption of homogeneity of variance was confirmed using Levene’s test. The significance level was set at p < 0.05.

Qualitative content analysis was used to analyze the qualitative data manually by hand, as well as, with NVivo 12. Hsieh and Shannon (2005) define qualitative content analysis as “a research method for the subjective interpretation of the content of text data through the systematic classification process of coding” (p. 1278). Qualitative content analysis aligns well with studies that are research question focused, as opposed to studies which are exploratory in nature (Mayring 2019). In addition, qualitative content analysis aims “to provide knowledge and understanding of the phenomenon under study” (Downe-Wamboldt 1992, p. 314). The present study sought to answer specific research questions as well as to understand participants’ decision-making within the context of mandatory reporting of child abuse and neglect. This led researchers to conclude that qualitative content analysis was a suitable data analysis method for this study.

Four cycles of qualitative coding were completed. The first cycle of coding involved holistic coding by thoroughly reviewing participants’ responses to the Post-OSCE Reflection Questionnaire, as well as, exploring issues related to mandatory reporting and relationship repair strategies. The second cycle of coding involved magnitude coding to identify and quantify participants who initiated mandatory reporting of the allegations of child maltreatment versus those who did not during the OSCE. The third cycle of coding involved descriptive coding regarding the reasons why participants initiated mandatory reporting during the OSCE, identified the child maltreatment concerns but did not proceed with initiating mandatory reporting, and reasons for why child protection was deemed not needed. The fourth cycle of coding involved descriptive coding regarding the relationship repair strategies participants used during the OSCE. The conceptual framework was used to guide the content analysis to analyze the codes. The research team met and discussed the analysis process after each coding cycle to reach a consensus regarding codes, categories, and the appropriate categorization / quantification of participants.

Results

Mandatory Reporting Behaviors

Nineteen participants (N = 19) were engaged in the OSCE on mandatory reporting of child abuse and neglect. Table 1 presents the reporting behaviors of participants during the OSCE, as well as their past experiences reporting to CPS. The majority of participants identified as female and non-White. Participants were primarily younger (under the age of 30), completing their MSW degrees, with less than five years of practice experience, and have not had any prior experience reporting to CPS. Half of participants had prior training in mandatory reporting or child maltreatment; and, slightly more than half have not had any prior experience reporting to CPS.

Table 1

Participant demographics by reporting behavior during OSCE and past experience reporting to child protection (N = 19)

	Reporting behavior during OSCE				Past experience reporting to CPS
	Report		No report		Yes		No
	n	%	N	%	n	%	N	%
Gendera
Male	1	33.3	2	66.7	2	66.7	1	33.3
Female	5	33.3	10	66.7	5	33.3	10	66.7
Ethno-racial
White	2	28.6	5	71.4	4	57.1	3	42.9
Non-white	4	33.3	8	66.7	3	25.0	9	75.0
Age
< 30	2	18.2	9	81.8	5	45.5	6	54.5
≥ 30	4	50.0	4	50.0	2	25.0	6	75.0
Current degreeb
BSW	0	0.0	2	100.0	0	0.0	2	100.0
MSW	5	35.7	9	64.3	7	50.0	7	50.0
Years of social service experience
0–2	1	12.5	7	87.5	1	12.5	7	87.5
3–5	5	45.5	6	54.5	6	54.5	5	45.5
Prior training in mandatory reporting or child welfare
Yes	4	40.0	6	60.0	3	30.0	7	70.0
No	2	22.2	7	77.8	4	44.4	5	55.6
Experience reporting to CPS					–	–	–	–
Yes	2	28.6	5	71.4	–	–	–	–
No	4	33.3	8	66.7	–	–	–	–

aOne participant did not provide gender identity, therefore the sample size for gender is 18

bThree participants were experienced social work practitioners and not in a current degree program. Therefore, the sample size for current degree is 16

Overall, a third of the participants (n = 6) initiated mandatory reporting of the child maltreatment concerns during the OSCE, while, two-thirds (n = 13) did not. More so, none of the BSW students (n = 2) and only one out of the eight participants with less than 2 years of paid social service experience, reported the concerns of child maltreatment. Overall, a third of participants (n = 7) had past experiences reporting to CPS, while, the majority of participants did not (n = 12). Prior training in mandatory reporting or child maltreatment was not associated with current reporting behaviors during the OSCE or with past experience reporting to CPS. Overall, no statistical differences were noted between those who initiated mandatory reporting of the child maltreatment concerns during the OSCE versus those who did not, as well as those who had prior experience reporting to CPS in either practicum or workplace environments versus those who did not.

Decision-Making

Table 2 presents the Performance Rating Scale and Post-OSCE Reflection Rating Scale results regarding decision making for participants who initiated versus those who did not initiate mandatory reporting of the child maltreatment concerns during the OSCE. Overall, those who did not initiate mandatory reporting during the OSCE (n = 13) were rated higher in their competencies regarding child maltreatment and systemic assessment, compared to those who initiated mandatory reporting (n = 6). In contrast, participants who initiated mandatory reporting during the OSCE were rated higher in their critical reflections in the conceptualization of child maltreatment and decision making. Statistical differences with large effect sizes (Fritz et al. 2012) were found for participants who initiated mandatory reporting in their critical reflections in the identification of child maltreatment (M = 8.50 vs. M = 7.46, t(17) = −1.36, p = 0.01; Cohen’s d = −0.078), as well as, their reflections on the approach with the client regarding mandatory reporting (M = 7.33 vs. M = 1.69, t(17) = −6.94, p = 0.04, Cohen’s d = −2.79), compared to those who did not initiate mandatory reporting during the OSCE.

Table 2

Independent sample T-test in participants’ decision-making for those who report versus did not report (N = 19)

	Report(n = 6)		No report(n = 13)		t	p	Cohen’s d
	M	SD	M	SD
Child maltreatmenta
Approach to child maltreatment	4.33	2.16	6.92	2.14	2.45	0.67	1.20
Discuss the child maltreatment issue with the client	5.17	1.84	7.23	2.13	2.04	0.69	1.04
Discuss duty to report	2.50	2.35	3.54	3.31	0.69	0.05	0.36
Conceptualization of child maltreatmentb
Identification of child maltreatment	8.50	0.55	7.46	1.81	−1.36	0.01	−0.78
Information gathering of child maltreatment	6.67	1.03	5.46	2.54	−1.11	0.08	−0.62
Systemic assessmenta
Eco-systemic assessment of child maltreatment	4.17	1.72	5.92	1.61	2.17	0.49	1.05
Conceptualization of decision-makingb
Engaged in decision-making	7.83	0.75	6.08	2.06	−2.00	0.07	−1.13
Approach with client regarding mandatory reporting	7.33	2.73	1.69	0.86	−6.94	0.04	−2.79

aFrom the performance rating scale

bFrom the post-OSCE reflection rating scale

The Post-OSCE Reflection Questionnaire responses surfaced several reasons why participants initiated mandatory reporting, which ranged from certainty that the caregivers’ actions were considered maltreatment to the belief that the client could benefit from CPS support. In describing the decision to report the physical abuse concerns, one participant (#6) explained:

Contributing to my decision about reporting to [CPS] was that the parent plainly indicated that she had used physical discipline. It was my understanding that this was causing direct bodily harm to the child, and also contributing to stress resulting in fear, the client indicated that her son ran away when she threatened to hit him.

For the neglect scenario, another participant (#15) described “… the concerns brought by the teachers … and the fact that the children are left alone at night when he goes to a work shift”. Participants also discussed the disclosure of child maltreatment by the caregiver as a reason for their decision to report the concerns to CPS. One participant (#8) noted “the client, Alima, mentioned that using corporal punishment with her child, such as slapping him and hitting him with a stick”, while another participant (#17) explained “he also mentioned unsupervised play and the children preparing their own meals”.

In addition to a direct disclosure, corroboration of disclosure by an outside party also influenced participants’ decisions. One participant (#17) acknowledged “the reports that I got from the school teacher about concerns about infrequent bathing seemed to align with what I was hearing from the father”. The duty to report maltreatment to CPS with the client was also cited. One participant (#1) noted “I was able to emphasize that it was my legal obligation to report to CPS”, while another participant (#15) indicated “I explained to John clearly the reason why I would have to contact Youth Protection”. Participants also noted their belief that the client could benefit from CPS support. One participant (#3) explained “she may have limited understanding around alternative approaches to supporting her son to behave in a safe and friendly way”.

The Post-OSCE Reflection Questionnaire responses revealed participants’ beliefs that the child maltreatment was unintentional; and other interventions were more appropriate than CPS. In describing the decision not to report the child maltreatment concerns due to unintentional maltreatment, one participant (#12) explained “it is not really ‘neglect’ or harming the children … the family unit experienced a very sudden tragic loss … the children’s/father’s action may be a result of grief”. Another participant (#13) acknowledged the emotional state of the father when stating “the father is definitely grieving and appeared to not be fully present”. Other interventions were considered by participants as more appropriate than CPS such as counseling, “I would not report to CPS, however I would strongly recommend therapy for the children and their father” (participant #12), assistance from support networks including “the family doctor … the girls aunt … [and] neighbors” (participant #13), and the provision of material supports including “financial management and parenting” (participant #16) and “income / disability assistance, childcare” (participant #19).

On the other hand, a sub-group of participants (n = 11) identified the concerns as child maltreatment, but did not proceed with initiating mandatory reporting due to the fear of relationship rupture, that further action was needed prior to reporting, the belief that the caregiver intentions were benevolent towards their children, and feeling uncomfortable and uncertain in discussing the duty to report with the client. Of these 11 participants, nine possessed either a BSW or MSW degree, five had no prior child welfare training, and all participants had 5 years or fewer of paid experience in the social services sector.

Among the participants who identified the concerns as child maltreatment but did not proceed with initiating mandatory reporting, fear of losing the therapeutic relationship they had started to build with the client was a key concern. One participant (#5) noted “I did not communicate to Alima that I would have contacted CPS as I didn’t want to derail our relationship”. Still within the physical abuse vignette, another participant (#9) noted feeling “worried about losing rapport with her” and “not wanting to infuriate the client” (participant #10). Other participants asserted the need for further action prior to reporting, in particular, eliciting information regarding the maltreatment. One participant (#4) explained “I should have explored further about the details of when, how, and why she uses physical punishment” and another participant (#14) explained “I have not finished my assessment”. Another participant (#9) wanted to “have a conversation with my supervisor to discuss the information and discuss a way to explain it to my client”, while another participant (#2) acknowledged “I would want to know about her understanding of the role of CPS”.

Some participants, who identified the concerns as child maltreatment but did not proceed with initiating mandatory reporting, perceived the caregiver actions as benevolent towards their children. In describing Alima, one participant (#4) explained “she states she wants the best for her son”. In describing John, one participant (#14) acknowledged “it is clear he loves his daughters”, while another participant (#16) explained “I do not feel as though he is … wanting to harm his children”. Finally, discomfort and uncertainty in discussing the report resulted in participants not proceeding with mandatory reporting. One participant (#5) explained “I did not know how to address that her behaviour was not acceptable in this culture”, while another participant (#9) asserted “something that I struggled with in the interview was approaching the situation without coming across as judgmental and disregarding her cultural norms”.

Relationship Repair Strategies

Table 3 presents the Performance Rating Scale and Post-OSCE Reflection Rating Scale results regarding the use of relationship repair strategies for participants who initiated versus those who did not initiate mandatory reporting of the child maltreatment concerns during the OSCE. Overall, those who did not initiate mandatory reporting during the OSCE, were rated higher in their competencies in relationship repair strategies, compared to those who initiated mandatory reporting. However, participants who initiated mandatory reporting during the OSCE were rated higher in their critical reflections regarding self-regulation and clinical relationship. No statistical differences were noted between the two groups; however, two reflective responses regarding clinical relationship approached statistical significance with large effect sizes. Participants who initiated mandatory reporting during the OSCE were rated higher in their ability to recognize the relationship rupture (M = 7.65 vs M. 5.20, t(17) = −2.09, p = 0.06, Cohen’s d =  −1.18), as well as, their use of relationship repair strategies during their post-OSCE critical reflections (M = 7.83 vs M = 4.00, t(17) =  −3.83, p = 0.07, Cohen’s d =  −2.17), compared to those who did not initiate mandatory reporting.

Table 3

Independent sample T-test in participants’ relationship repair strategies for those who report versus did not report (N = 19)

	Report(n = 6)		No report(n = 13)		t	p	Cohen’s d
	M	SD	M	SD
Relationship repaira
Maintain balance of content and process during interview	4.50	2.35	4.85	2.54	0.28	0.44	0.14
Use strategies to maintain the worker-client relationship	7.20	1.64	6.08	3.35	−0.71	0.14	−0.42
Manage client affect	6.17	1.84	6.58	1.08	0.61	0.12	0.27
Self-regulationb
Emotional regulation regarding child maltreatment	7.17	2.14	5.50	3.10	−1.16	0.13	−0.63
Clinical relationshipb
Recognize relationship rupture	7.67	1.21	5.20	2.70	−2.09	0.06	−1.18
Conceptualization of relationship repair strategies	5.67	2.94	4.40	2.76	−0.87	0.94	−0.45
Use of relationship repair strategies	7.83	0.98	4.00	2.29	−3.83	0.07	−2.17

aFrom the performance rating scale

bFrom the post-OSCE reflection rating scale

We conducted qualitative content analysis of the Post-OSCE Reflection Questionnaire responses to identify which strategies from the conceptual framework (see Figure 1) were employed by the participants to repair the therapeutic relationship. Responses showed that affect regulation strategies and information strategies were the predominant strategies. Within the affect regulation strategies, one participant (#6) explained “I used empathy to let her know that I understood her good intentions”, while another participant (#17) noted “validating that he was in a hard situation”. In terms of information strategies, participants noted transparency of the reporting process. One participant (#1) explained “I answered as much questions as I could for the client”. Participants also expressed their intention to support the client. One participant (#1) described they would “continue to support the client as much as I can” and “I would work with CPS … to help her navigate accessing helpful supports” (participant #3).

While relationship repair strategies were not expected among participants who did not initiate mandatory reporting of the child maltreatment concerns, participants nevertheless identified ways they tried to maintain the therapeutic relationship during the OSCE and outlined next steps to engage with the client. Participants who decided not to report the child maltreatment concerns during the OSCE identified affect regulation strategies with empathy being a key feature in maintaining the therapeutic relationship. One participant (#12) cited “I was able to maintain the relationship because I used a lot of empathy” while another participant (#13) explained they tried “maintaining the relationship through empathy”. The participants who did not initiate mandatory reporting during the OSCE outlined resource strategies as their next steps in relationship repair with the client. One participant (#13) noted “encourage [them to] attend grief counselling … consent to speak to the health care professional” and “I would bring resources to the next meeting” (participant #19).

For the subgroup that identified the concerns as maltreatment but did not proceed with initiating mandatory reporting, affect regulation was the primary method they used to maintain the therapeutic relationship. Participants commented on being “supportive and non-judgmental” (participant #10) and “made sure he felt that he was supported … understood … not dictating what he should do with his life” (participant #18). Participants also outlined the information, advocacy, and affect regulation strategies they would use had they proceeded with reporting the child maltreatment concerns during the OSCE. With regard to information strategies, one participant (#2) explained “I would recap the confidentiality agreement … prepare her about my reporting and what she will expect” while another participant (#7) noted “offer to continue working on alternative strategies”. Advocacy strategies included the desire to “build on her strengths and perseverance” (participant #7) and “I would say that I am concerned about their safety” (participant #18). Affect regulation strategies involved the provision of support. One participant (#9) indicated, “I would let her know that I am still a resource that is here to support her”.

In regards to next steps, this subgroup of participants indicated they would use information strategies and affect regulation strategies. Information strategies included the provision of psycho-education. One participant (#7) noted “I would work with her to equip her with tools and strategies to replace the ones she could not use here in Canada, so that she would still feel prepared to parent her child”. Another participant (#10) wanted to explore “the cultural and traditional values … the emotions towards the situation … the client on understanding the perspective of the child”. Affect regulation strategies involved the provision of empathy, support, validation, and compassion towards the client.

Discussion

This study sought to examine the decision-making processes and relationship repair strategies of undergraduate and graduate social work students and social work practitioners using simulated case vignettes of moderate to severe physical abuse or neglect. Overall, the majority of participants did not initiate reporting of the child maltreatment concerns during the OSCE. This reporting behaviour pattern was found despite educational level, years of experience, prior training in mandatory reporting or child welfare, and previous experience reporting to CPS. This finding suggests there are no underlying social work student or practitioner characteristics that inform mandatory reporting behaviors. This may be due to the unique considerations needed for each situation. This points to the importance of ongoing training and support for all practitioners, regardless of educational or practice background, who are in the critical position to detect child maltreatment, report the concerns to appropriate authorities, and maintain the therapeutic relationship to ensure the continued safety and well-being of vulnerable children. This study offers the initial examination of the complex decision-making factors and relationship repair strategies used with clients in a simulated scenario.

In examining participants’ decision-making, the three participants who did not initiate mandatory reporting of the child maltreatment concerns during the OSCE fell solely in the neglect vignette. Qualitative content analysis revealed that some participants viewed the father’s actions as unintentional and stemming from the sudden loss of his wife. Participants believed he was forced into an unexpected situation and was simply trying to do the best he could. This finding is consonant with Smith (2006) who found that participants will report to CPS when they were more certain abuse was occurring. While feeling sympathetic to the client’s loss these participants may have allowed their emotions to steer them away from needing to report and instead, draw them towards grief counseling or social supports from family and neighbors as preferred interventions. This finding supports a previous study (Tufford et al. 2015) which examined social work students’ responses to suspected child neglect. Participants in this latter study also asserted that the client was experiencing a mental health issue and that addressing this concern through counseling and social supports could potentially avoid reporting to CPS.

The intersecting identities of gender and socioeconomic status (SES) within the neglect vignette may also have factored into participants’ decision-making. This vignette presented a couple with defined gender role stereotypes with John being the breadwinner and his wife the homemaker and primary caregiver of the children. Her death thrust John into both breadwinner and caregiver roles for two young daughters, the latter role he was unaccustomed to holding. Should the situation be reversed and John had died, it is unclear how the participants who did not initiate mandatory reporting would have viewed a mother who left her children unsupervised and sent them to school inappropriately attired for the weather, given her role as primary caregiver. By contrast, John is also a warehouse worker and the family of lower SES. Studies have long concluded that child maltreatment is reported more often in perpetrators of lower SES families than middle or upper SES (Hill 2006; Lane et al. 2002); however, this study contradicts these earlier findings. Socio-economic status did not appear to factor into participants’ decision-making. This may stem from the bereavement focus of the vignette and led participants to concentrate on mental health concerns and the absence of emotional supports.

Of note is that more than half the sample (n = 11) identified the abuse and neglect concerns as maltreatment but did not proceed with initiating mandatory reporting with the caregiver. This could be attributed to the high number of students in the sample (n = 12) who have not experienced reporting suspected maltreatment in their practicum placements or early career employment. A number of these participants became emotionally dysregulated around surfacing their duty to report in session. Qualitative results showed that participants’ fear of relationship rupture and not knowing how to start this conversation without appearing disrespectful or infuriating the client were cited by some participants. Their emotional dysregulation and uncertainty may have led these participants to avoid this potentially challenging conversation. This finding supports Bogo et al.’s (2017) assertion that practitioners and students with low confidence report feeling more dysregulated. The finding also supports social work students and practitioners’ need for clinical supervision in their role as mandatory reporter as only one participant suggested they would consult with their supervisor around the case vignette and how to approach the client with their duty to report.

In Table 2, mean scores of the child maltreatment category were higher overall for the participants who did not initiate mandatory reporting to CPS versus the participants who did. While this is a surprising finding given the aim of the study, this may be the result of differing views of what constitutes best practices within mandatory reporting. Specifically, some of the OSCE raters in the study may view reporting as a process which should take place following the session as opposed to within the session. However, in Table 3 the mean scores of the approach with client regarding mandatory reporting were higher for participants who initiated mandatory reporting versus participants who did not, and the finding was statistically significant (M = 7.33 vs. M = 1.69, p = 0.04). For participants who initiated mandatory reporting, despite receiving lower scores during their OSCE performance, their reflection scores on how they approached the client were higher, compared to participants who did not initiate mandatory reporting. This may be attributed to the stress and anxiety during the performance part of the study; however, when this stress is removed and participants can engage in a retrospective examination of their performance, they were able to elucidate their approach more thoughtfully and deeply than their counterparts who did not initiate mandatory reporting. This finding is reflective of a study which compared students’ OSCE performance and reflection scores to their scores on their practicum placement. Students who performed well on the OSCE also performed well in the practicum and students who performed poorly on the OSCE tended to perform poorly in practicum (Bogo et al. 2012). However, not all students whose performance lacked on the OSCE had trouble in the practicum, which may be attributed to the pressure of performing in an OSCE in the presence of a rater. This may be a similar finding given the higher mean score in the reflection component as opposed to the performance component for these categories.

With regards to the relationship repair strategies, Table 3 notes that those participants who would report to CPS used relationship repair strategies more effectively (M = 7.20 vs. M = 6.08, p = 0.14) while those who did not report to CPS managed affect and balance better (M = 6.17 vs. M = 6.58, p = 0.12), which is not surprising since they did not discuss the need to report to CPS in the OSCE. Across all categories participants mainly drew from affect regulation strategies (involving the family) such as providing empathy, validation, support, and non-judgment and from information strategies specifically pertaining to providing information on CPS. Fewer participants drew from reporting strategies such as giving clients options around making the report, offering resources to the client, or advocating for the client. The focus on affect regulation and information strategies may be reflective of the early career nature of the participants and social work programs’ emphasis on verbally building the therapeutic relationship through empathy and validation (Bogo 2018). In addition, five participants who initiated mandatory reporting, one participant who did not initiate mandatory reporting, and five participants who identified the concerns as maltreatment but did not proceed with initiating mandatory reporting noted their intention to “support the client” in their reflective responses as a repair strategy but did not elucidate what this support would entail. For theses participants, the vague nature of this statement may be reflective of their overall indecisiveness around reporting.

Of note is that despite the clear cultural origins of Alima’s disciplinary strategy, no participants suggested resources that included a cultural component such as referring the client to culturally specific resources. This is concerning given the profession’s emphasis on attention to race, culture, and ethnicity (Canadian Association for Social Work [CASW] 2005; NASW 2008), that the study took place in a large, urban centre with multiple, ethno-specific resources, and the overall increasing need for child welfare practices that are culturally safe and sensitive (Lee et al. 2016, 2017). Awareness of the culture of both client and clinician is paramount (Bogo et al. 2011b). However, this finding is consistent with other studies which found fewer social work students and practitioners recognize the impact of culture when working with racialized clients (Tufford et al. 2015, 2017).

Limitations

There are several limitations with regards to this study. First, despite repeated recruitment at medical, mental health, and educational institutions, the final sample was small, particularly with regards to the BSW students and experienced social work practitioners. In addition, the sample was largely homogeneous with only three male participants and participants tended to be early career professionals with less experience. The sample was also voluntary, self-selected, and from a predominantly urban area. Further, there was no provision of training around decision-making regarding the mandatory reporting of child maltreatment or the relationship repair strategies; however, this limitation will be addressed in Phase Three of the research. The research design also posed limitations in that the study used one point-in-time measure without a clear baseline from which to evaluate participants. It is also possible some of the OSCE raters’ practice positions where not aligned with the study’s aim of discussing the duty to report in session with the client, and this bias may account for the higher scores for participants who did not initiate mandatory reporting. Finally, participants’ reflective responses were collected via questionnaire, so more detailed information or clarifications could not be obtained.

Implications for Social Work Practice

The following implications for social work practice stem from the current research findings and the mandatory reporting literature. These implications can assist social work practitioners when faced with concerns around child abuse and neglect, informing clients of the duty to report, and using relationship repair strategies in a purposeful and informed manner.

Provide Clinical Supervision for Mandatory Reporting

The high number of participants who identified the concerns as maltreatment but did not proceed with initiating mandatory reporting underscores the need for clinical supervision around mandatory reporting. The current study points to the need for supervision, which can assist students and practitioners in their decision-making processes and uncertainty in needing to report, particularly in situations where maltreatment exists alongside grief and devastating client situations or in situations where disciplinary practices are culturally based and inter-generational (Wilkins and Antonopoulou 2019). Effective clinical supervision in social work can also address the source and impact of emotional dysregulation which can silence the ability to discuss the duty to report with clients. This will promote affect regulation and assist students and practitioners in better regulating their emotions and feelings (Duckham et al. 2013).

Incorporate Training in Mandatory Reporting in the Social Work Curricula and Workplaces

Due to the complexity and inevitability of mandatory reporting, training in this area should be required in social work programs and workplaces with specific focus on children and families. Specialized education and training in child welfare produce a greater level of confidence and awareness, as well as greater competency in foundational, generalist practice skills among practitioners (Rawlings and Blackmer 2019). Training in mandatory reporting should also subsume the range of relationship repair strategies to avoid the over-reliance on selected strategies that may be insufficient for client needs. This study found that participants relied mainly on affect regulation and information strategies.

Strengthen Social Work and CPS Connections

While existing in tandem, community social work services and CPS often lack cooperative and collaborative relationships (Tufford and Morton 2018). Joint initiatives by community partners involving social workers and CPS could facilitate relationship building, stronger connections, and increased, reciprocal communication (Nouman et al. 2020). Where possible, child protection workers should inform the social worker of the outcome of the CPS investigation as increased communication will foster transparency between child protection workers and reporting social workers.

Attention to Diverse and Intersecting Identities

Given the increasingly diverse demographic background of clients and the implementation of cross-cultural competency requirements in social work educational curricula (Canadian Association for Social Work Education [CASWE] 2014; Council on Social Work Education [CSWE] 2015) and practice standards (CASW 2005; NASW 2008), attention to diversity and complex interplay of intersecting identities is paramount. However, study results demonstrated participants’ lack of attention to client race and culture and how these characteristics impacted disciplinary choice. Furthermore, intersecting identities of gender and socio-economic status were not considered in the neglect scenario. The competency to work across differences is important considering the historical injustices and continuing colonial effects of the helping professions and the child welfare system. Students, early career and experienced practitioners alike need to be sensitive and critically reflective of their positionality in working across differences.

Conclusion

This study examined the decision-making and relationship repair strategies of BSW and MSW students and experienced practitioners in a simulated client encounter around a moderate to severe vignette of child abuse or neglect. While some participants ventured into reporting the child maltreatment concerns, it is concerning that half of participants were sidelined around their mandatory reporting responsibilities and lacked the requisite knowledge and emotional regulation to safeguard the best interests of the child. Results from this study offer schools of social work and clinical supervisors the opportunity to play a significant role in preparing social work students and practitioners for this ongoing public health challenge, particularly amidst the isolating effects of the COVID-19 pandemic. As this study demonstrates, simulation can play a critical teaching tool for social workers to hone the performance skills and reflective capacities of those in the role of mandatory reporter.