Pediatric Nurses' Differentiations Between Acceptable and Unacceptable Parent Discipline Behaviors

A Q-Study

Grace W. K. Ho, PhD, RN; Deborah A. Gross, DNSc, RN, FAAN


J Pediatr Health Care. 2015;29(3):255-264. 

In This Article

Abstract and Introduction


Background Nurses are mandated to report suspected cases of child maltreatment. However, it is unclear how nurses decide what constitutes child abuse or evidence for reporting. It is crucial to examine how nurses define various forms of child maltreatment, including child abuse and its differentiation from physical discipline, to enhance our services to families with young children.

Objective The present study examined pediatric nurses' views on acceptable versus unacceptable discipline behaviors to better understand parent behaviors that nurses are likely to deem reportable to child protective services.

Methods Using Q methodology, a convenience sample of 48 pediatric nurses from one urban medical center sorted 71 statements related to the behavior or outcome of punishing a child via the Internet application FlashQ. The statements were sorted on a predefined continuum ranging from "Most Unacceptable" to "Most Acceptable." By-person factor analysis was used to uncover groups of nurses with similar sorts and to generate a unique sort that represented the viewpoint of nurses in that group.

Results Two distinct viewpoints were uncovered. Although there was consensus on what constitutes most acceptable and most unacceptable parent behaviors, nurses varied on their endorsement of using physical force as a form of discipline, suggesting a potential for discrepant tendencies to identify and report child abuse.


Nurses in the United States are bound by law to report any "reasonable suspicion" of child maltreatment, including all forms of abuse and neglect. However, it is unclear how nurses define child abuse, a factor that likely influences their decision to report a suspected case of maltreatment. Some evidence suggests that nurses' endorsement of physical discipline use may influence their decision to report, but we found no published studies directly examining nurses' viewpoints on various discipline behaviors, including those that may be considered harsh or less socially acceptable. The purpose of this study is to explore what one group of mandated reporters, pediatric nurses, view as acceptable and unacceptable parent discipline behavior to set the stage for a better understanding of nurses' decisions to report child abuse.

Professionals who are mandated reporters (e.g., law enforcement, teachers, social workers, and health care providers) provide the majority of child maltreatment reports to child protection agencies (Flaherty, Sege, Mattson, & Binns, 2002). However, only 8.4% of these referrals come from health care providers, including nurses (Eisbach & Driessnack, 2010). To date, little is known about the factors that contribute to nurses' suspicion, identification, or reporting of child maltreatment. In an integrative review of literature published between 1996 and 2007, Piltz and Wachtel (2009)) found 17 studies that examined barriers that hinder nurses' reporting of suspected child maltreatment; only four of these studies were conducted in the United States. Findings from those studies (i.e., Adams, 2005, Flaherty et al., 2000, Limandri and Tilden, 1996, Smith, 2006) largely reflect the factors and challenges that health care professionals face with suspected child maltreatment, namely insufficient knowledge and training and difficulties identifying cases that lack overt signs of injury.

Although recent child maltreatment training has been shown to enhance confidence and acumen in identification and reporting among nurses (Fraser et al., 2010, Herendeen et al., 2014), Paavilainen and colleagues (2002)) suggest that knowledge of injury assessment and identification alone may not be sufficient to change reporting practices among nursing and medical staff. This suggestion is supported by Eisbach and Driessnack (2010)), who found that nurses' reporting decisions are frequently complicated by the nature of the data presented to them. For example, although severe and suspicious injuries were found to warrant immediate reporting, nurses in their study described encountering numerous other cases in which signs and symptoms were less overt or were presented with only subjective data (e.g., the child's disclosure of maltreatment). In these cases, intuition and biases may dictate reporting decisions (Ling & Luker, 2000).

Several other factors have shown to influence the suspicion, identification, and reporting of child abuse. Suspicion and intent to report have been positively associated with professional experience (Hansen et al., 1997) and with being White, born in the United States, and disapproving of physical discipline use (Ashton, 2004, Ibanez et al., 2006). Patient ethnicity, family and case history, and clinician's familiarity with the client have also been found to influence reporting (Dakil et al., 2011, Flaherty et al., 2008, Jones et al., 2008, Zellman, 1992). Taken together, these findings suggest that nurses' definitions of child abuse vary and that child maltreatment suspicion, identification, or reporting may be biased by nurses' characteristics, beliefs, or professional experience. Therefore, it is imperative to examine how nurses define which parental behaviors constitute child abuse, because these definitions are likely to drive reporting decisions.

The purpose of this study was to examine how pediatric nurses differentiate acceptable physical discipline from child abuse. This study is part of a larger examination of how mothers of Chinese descent living in the United States differentiate physical discipline from child abuse and how those perspectives differ from those of mandated reporters. The study focuses on discipline and abuse of young children, ages 3 to 6 years. This age group was chosen based on national data showing that physical discipline use peaks for children between ages 4 and 5 years (Straus & Stewart, 1999) and that nearly 80% of preschool-aged children are disciplined with spanking and slapping, a prevalence rate without marked change since 1975 (Zolotor, Theodore, Runyan, Chang, & Laskey, 2011).