How public health nurses identify and intervene in child maltreatment based on the National Clinical Guideline

Resea ch A icle How Public Heal h Nu ses Iden i y and In e ene in Child Mal ea men Based on he Na ional Clinical Guideline Paa ilainen Eija,1Helminen Mika,2Flinck Aune,3and Leh omäki Leila4 1School o Heal h Sciences (Nu sing Science), Uni e si y o Tampe e, E el¨ a-Pohjanmaa Hospi al Dis ic , Finland 2School o Heal h Sciences, Uni e si y o Tampe e and Science Cen e , Pi kanmaa Hospi al Dis ic , Finland 3School o Heal h Sciences, Uni e si y o Tampe e, Na ional Ins i u e o Heal h and Wel a e, Technologies and P ac ices Assessmen Uni , FinSoc, Finland 4The Finnish Union o Public Heal h Nu ses, Finland Co espondence should be add essed o Paa ilainen Eija; eija.paa ilainen@u a. i Recei ed 1 Augus 2014; Accep ed 27 Oc obe 2014; Published 19 No embe 2014 Academic Edi o : Ka hleen Finlayson Copy igh © 2014 Paa ilainen Eija e al. This is an open access a icle dis ibu ed unde he C ea i e Commons A ibu ion License, which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed. Objec i es. To desc ibe how Finnish public heal h nu ses iden i y and in e ene in child mal ea men and how hey implemen he Na ional Clinical Guideline in hei wo k. Design and Sample. C oss-sec ional su ey o 367 public heal h nu ses in Finland. Measu es. A web-based ques ionnai e de eloped based on he con en a eas o he guideline: iden i ying, in e ening, and implemen ing. Resul s. The esponden s epo ed hey iden i y child mal ea men mode a ely (mean 3.38), in e ene in i be e (4.15), and implemen he guideline mode a ely (3.43, scale be ween 1 and 6). Those wi h expe ience o wo king wi h mal ea ed child en epo ed hey iden i y hem be e (𝑃 < 0.001), in e ene be e (𝑃 < 0.001), and implemen he guideline be e (𝑃 < 0.001) han hose wi h no expe ience. This di e ence was also ound o hose who we e awa e o he guideline, had ead i , and pa icipa ed in aining on child mal ea men , as compa ed o hose who we e no awa e o he guideline, had no ead i , o had no pa icipa ed in such aining. Conclusions. The public heal h nu ses wo ked qui e well wi h child en who had expe ienced mal ea men and amilies. Howe e , he esul s poin ou se e al de elopmen al a ge s o inc easing aining on child mal ea men , o de ising ecommenda ions o child mal ea men , and o applying hese ecommenda ions sys ema ically in p ac ice. 1. Backg ound Child mal ea men is a public heal h p oblem and a iola ion o child en’s human igh s [1]. The la es esea ch in Finland [2,3] shows ha child en and you h expe ience a wide ange o mal ea men a home-meaning physical, emo ional, and sexual iolence, neglec , and wi nessing iolence be ween pa en s. The same o ms o child mal ea men a e obse ed in o he coun ies in Eu ope and globally [4–8]. In addi ion, esea ch a en ion has been paid o child en li ing in amilies whe e in ima e pa ne iolence is pa o hei e e yday li e [2,9]. Al hough much has been done o disco e ing he si ua ion o child en li ing in iolen homes, e o is s ill needed o knowing mo e abou iden i ica ion and p e en ion p ac ices, o de eloping hem. Resea che s in he child mal ea men ield show ha child mal ea men wi hin he amily has an eno mous e ec on child en and hei u u e physical, emo ional, and social wel a e, o en esul ing in inequali y and ma ginaliza ion [10, 11]. A me a-analysis on he heal h consequences [12]s essed ha all o ms o child mal ea men should be conside ed impo an isks o heal h. Li elong impai men s in lea ning, beha iou , and bo h physical and men al heal h a e s ongly linked o ad e se expe iences in childhood. Exposu e o child mal ea men can dis up no mal biological and social de elopmen , c ea ing a cascade o e en s ha lead o oxic s ess which esul s in changes in he de eloping ne ous, ca dio ascula , immune, and me abolic sys ems which las a li e ime [13]. Awa eness o he se ious long- e m con- sequences should encou age be e iden i ica ion o hose a isk and he de elopmen o e ec i e in e en ions o p o ec child en om iolence [1,14]. In he UK, he Na ional Ins i u e o Heal h and Clinical Excellence (NICE) guidance Hindawi Publishing Co po a ion Nu sing Resea ch and P ac ice Volume 2014, A icle ID 425460, 7 pages h p://dx.doi.o g/10.1155/2014/425460 2Nu sing Resea ch and P ac ice was de eloped o aise heal hca e p o essionals’ awa eness o he ale ing ea u es o child mal ea men [15]. In Finland a guideline has also been w i en [10] conce ning iden i ying andin e eninginchildmal ea men ,basedonasys ema ic li e a u e e iew [16]. In he Finnish guideline, he isk ac o s o he child, he pa en s, and he amily, signs and symp oms, and he p inciples o iden i ying hem and in e ening in child mal ea men a e desc ibed. The cen al means o iden i ying and also in e ening in mal ea men include, o example, knowing and e alua ing he signs o mal ea men o a child, discussion wi h hei pa en s abou he amily si ua ion and ela ionships wi hin he amily, and discussion abou child ea ing p ac ices, home isi s, and mul ip o essional p ac ices [10]. The guideline is mean o be a ool o e idence-based p ac ice [17,18], used by public heal h nu ses (PHNs) and in mul ip o essional collabo a- ion wi h o he p o essionals mee ing and wo king wi h child en, adolescen s, and amilies in di e en se ings. In pape s e alua ing mul ip o essional p ac ices, he knowledge exchange conce ning he si ua ion o he child and he amily is equen ly ine ec i e o no amily o ien ed: p o essionals may no ac i ely include he amily in he collabo a ion o hey do no wo k in ensi ely enough oge he (e.g., see [19,20]). Iden i ying and in e ening in amilies’ high- isk si ua ions and child mal ea men is no as e idence-based as i could be. PHNs,asheal hca ewo ke swhomee almos allchil- d en and hei amilies a clinics, schools, and homes, a e key pe sons in iden i ying, p e en ing, and in e ening in child mal ea men . In Finland PHNs p o ide ca e o child en and amilies ac oss a wide age ange, om ma e ni y ca e and p eschool o school-aged child en, and in many di e en se ings including clinics, clien s’ homes, and schools. Be o e school age (age 7 in Finland), child en and hei amilies isi child heal h clinics a leas 16 imes and, once in school, child en and young people will see a PHN a leas once a yea . These se ices a e ee o all amilies and almos all amilies use hem [21]. The objec i e o he cu en esea ch was o desc ibe how Finnish PHNs iden i y and in e ene in child mal ea men and how hey implemen he clinical guideline conce ning hese issues in hei wo k. Findings can be used o he de elopmen o iden i ica ion and in e en ion p ac ices and educa ion. 2. Resea ch Ques ions This s udy was designed o add ess he ollowing esea ch ques ions. (1) How do PHNs iden i y child mal ea men ? (2) How do hey in e ene in child mal ea men ? (3) How do hey desc ibe hei implemen a ion possibil- i ies conce ning iden i ying and in e ening in child mal ea men ? (4) Wha a e he backg ound ac o s ha p omo e iden- i ica ion, in e en ion, and implemen a ion? 3. Me hods 3.1. Design and Sample. The esponden s o he cu en su ey we e ec ui ed om he egis e o he Finnish Union o Public Heal h Nu ses, in 2012. All he membe s who had an email add ess and appea ed o ha e wo ked in child- ela ed clinics (𝑛 = 800) we e sen he elec onic ques ionnai e in Feb ua y 2012 and we e eminded a e wo weeks. The boa d o he union ga e he e hical app o al and esea ch pe mission. Comple ing he su ey indica ed in o med consen and no iden i ie s we e collec ed [22]. In he le e a ached o he ques ionnai e, i was s a ed ha he pe mission o he esea ch was clea , he esul s will be published anonymously and illing in he ques ionnai e was in e p e ed as pa icipa ion in he s udy. Al oge he 367 PHNs answe ed he su ey, esul ing in he esponse a e o 46%. 3.2. Measu es. The su ey ins umen was de eloped o his s udy, and i s con en was based on he Na ional Clinical Guideline conce ning iden i ying and in e ening in child mal ea men and implemen ing he guidelines on his opic [10,16]. I included i e backg ound ques ions (gende , age, wo k expe ience, p esen job and loca ion, and wo k expe ience in ci ies/coun yside/bo h) and h ee ques ions conce ning whe he hey knew ha guidelines exis ed and, i so, whe he hey had ead hem and whe he hey had been ained on he opic. They we e also asked how many child mal ea men cases hey had encoun e ed o suspec ed, du ing he p e ious six mon hs. The su ey ins umen con- sis ed in Like Scale s a emen s (6 = o ally ag ee, 1 = o ally disag ee) di ided unde h ee sum a iables: iden i ying (8 s a emen s), in e ening (31 s a emen s), and implemen ing (8 s a emen s). The ins umen was de eloped by he g oup o esea che s (𝑛=12) who we e expe s in child mal ea men issues and/o s a is ical me hods. The ins umen was pilo es ed by sending he elec onic e sion o en PHNs who comple ed he ques ionnai e. Modi ica ions we e made based on hei esponses. 3.3. Da a Analysis. The means and s anda d de ia ions (SDs) o pe cen age dis ibu ions we e calcula ed o all demo- g aphic a iables. Responses o nu ses’ pe cep ions o how hey iden i y and in e ene in child mal ea men and how hey implemen he guidelines we e di ided in o g oups: disag ee ( esponses o 1–3) and ag ee ( esponses 4–6). These h ee a iables we e also combined as sum a iables, iden- i ying (C onbach’s Alpha 0.866), in e ening (0.957), and implemen ing (0.854), showing solid eliabili y [23]. Di e - ences be ween g oups acco ding o demog aphics we e es ed using Pea son co ela ions, 𝑡- es s, and ANOVA. Linea eg ession analysis was also done o see which ac o s explain iden i ying, in e ening, and implemen ing.Ha ingwo keda ma e ni y and amily planning, child heal h clinic, school heal h, and all o he places we e used as sepa a e independen bina y a iables in he model, oge he wi h suspicion o mal ea men (o ac ual mee ing o mal ea ed child en) and wo king yea s. Nu sing Resea ch and P ac ice 3 Table 1: Backg ound in o ma ion conce ning he pa icipan s (𝑁 = 367). Va iables Mean (SD) Age in yea s 42,5 (10,8) Wo king yea s as a nu se 12,3 (9,9) Pe cen ages Wo king in u ban a eas/coun yside/bo h 65,9/26,7/7,4 Knowledge o he exis ence o a guideline (yes/no)? 77,1/22,9 Had hey ead he guideline (yes/no)? 46,3/53,7 Had hey had educa ion on he opic (wi hin a yea /ea lie /ne e )? 11,2/34,6/54,2 How many (0/1–4/5 o mo e//missing) child mal ea men cases hey had me du ing six mon hs? 36,8/19,9/4,6//38,7 How many (0/1–4/5 o mo e//missing) suspec ed child mal ea men cases hey had me du ing six mon hs? 28,3/35,7/6,5//29,4 4. Resul s 4.1. Demog aphic Cha ac e is ics. Almos all o he espon- den s (𝑁 = 367) we e women ( he e we e only wo men), wi h a mean age o 42 ( anging om 23 o 64) and a mean wo king ca ee o 12 yea s ( anging om 0 o 37 yea s). Thi yeigh pe cen o hemwo kedin amilyplanningand ma e ni y, 45% in a child wel a e clinic, 30% in school heal h, and48%ino he clinics, o ins anceins uden heal hca e clinics o clinics o adul s. The esponden s may wo k in se e al clinics; o ins ance 107 esponden s wo ked in bo h ma e ni y and child wel a e clinics. Se en y-se en pe cen knew ha he e was a guideline, 46% epo ed hey had ead i , and 46% had pa icipa ed in aining on he opic. Du ing he p e ious six mon hs, 37% o he esponden s epo ed hey had no me mal ea ed child en, 20% had me 1–4 mal ea ed child en, and 5% had me i e o mo e mal ea ed child en, o he bes o hei knowledge. Co espondingly, 28% epo ed hey had no suspec ed any mal ea men cases, 36% had suspec ed ha 1–4 child en hey encoun e ed had been mal ea ed, and 7% had suspec ed ha i e o mo e child en had been mal ea ed (Table 1). 4.2. Iden i ying Child Mal ea men . The PHNs ag eed hey we e able o iden i y mal ea ed child en mode a ely well (mean 3.38, SD 0.84). Only 43% ag eed he child’s beha iou was a ac o in iden i ying child mal ea men , and 37% ag eed ha he pa en s’ beha iou was a ac o . Fi y- ou pe cen ag eed ha physical signs we e a ac o and 44% ag eed ha psychological signs we e a ac o . Only 15% o he PHNs mee mal ea ed child en o en, acco ding o hei own e alua ion (Table 2). 4.3. In e ening in Child Mal ea men . In e ening in child mal ea men was easie o he esponden s (mean 4.15, SD 0.91) han iden i ying i (mean 3.38). Mos (80%) esponden s el hey discussed e e yday p oblems and p oblems in he child’s de elopmen adequa ely (80%) and ha hey ad ised he pa en s o seek help when hey need i (88%). On he o he hand, he esponden s epo ed ha couple’s ela ionship p oblems a e discussed less o en (52%). The esponden s hough hey helped he mal ea ed child (52%) and he amily (50%) su icien ly well. Fi y-nine pe cen hough ha mul ip o essional collabo a ion was wo king well in hei Table 2: I ems included in iden i ying sum a iable and he pe cen ages ha ag ee/disag ee (𝑁 = 367). Iden i ying (ag ee 4–6/disag ee 1–3) PHNs mee mal ea ed child en o en 15/85% PHNs ecognize child mal ea men based on Child- ela ed isk ac o s 53/47% Risk ac o s ela ed o pa en s 66/34% Family- ela ed isk ac o s 67/33% The child’s beha io 43/57% The pa en s’ beha io 37/63% PHNs ecognize physical signs su icien ly well 54/46% PHN’s ecognize men al signs su icien ly well 44/56% municipali y,and50%o hem ecei eenoughsuppo o mul ip o essional collabo a ion om hei supe io s. Fi y- ou pe cen o he esponden s ha e join guidelines o child mal ea men cases, and 65% ha e clea ins uc ions on how o make a epo o child p o ec ion au ho i ies (Table 3). 4.4. Implemen ing he Clinical Guideline. PHNs epo ed hey implemen ed he ecommenda ions w i en in he guideline mode a ely (mean 3.43, SD 1.01). Among he esponden s, 87% conside ed he guidelines impo an . The guideline o child mal ea men guides he wo k o 57% o he espon- den s, and 87% epo ed hey will gladly adjus hei wo k p ac ices acco ding o he guideline. O he esponden s, 21% had ecei ed enough aining ega ding he guideline and 44% had s udied he con en o he guideline independen ly. Twen y- h ee pe cen o he esponden s had discussed he guideline a hei wo kplace, 44% suppo ed each o he in ac ions ollowing he guideline, and 38% hough ha hei wo kplace had su icien esou ces o ac ing acco ding o he guideline. 4.5. Fac o s P omo ing Iden i ying, In e ening, and Imple- men ing. PHNs who had me mal ea ed child en epo ed hey we e able o iden i y child mal ea men be e han hose wi hou ha expe ience, acco ding o hei own e alua- ion (mean 3.79 e sus 3.07, 𝑃 < 0.001). They also in e ened in child mal ea men cases be e (mean 4.48 e sus 3.88, 4Nu sing Resea ch and P ac ice Table 3: I ems included in in e ening sum a iable and he pe cen ages ha ag ee/disag ee (𝑁 = 367). In e ening (ag ee 4–6/disag ee 1–3) PHNs discuss su icien ly well wi h amilies abou Risk ac o s in amilies 61/39% Child ea ing p ac ices 69/31% P oblems in he couple’s ela ionship 52/48% P oblems in e e yday li e 80/20% Child de elopmen 80/20% P oblems in child de elopmen 79/21% PHNs ad ice pa en s su icien ly well o Seek help when needed 88/12% Ac well in si ua ions when he child has a an um 76/24% Ac well when he child beha es badly 71/29% Ac well when he child does no ul ill expec a ions 60/40% Ac wellwhen hechildhasspecialneedso isill 69/31% Ac well when he child c ies 76/24% Discuss hei join child ea ing p ac ices 67/33% When suspec ing child mal ea men , PHN Asksabou i s aigh o wa dly 69/31% Always makes a child wel a e no i ica ion 86/14% Helps he mal ea ed child su icien ly well 52/48% Helps he amily su icien ly well 50/50% Documen s mal ea men su icien ly well 82/18% Guides o ollow-up ea men su icien ly well 81/19% Lis ens o he amily unde suspicion su icien ly well 83/17% Collabo a es su icien ly well wi h o he p o essionals 86/14% Thinks mul ip o essional collabo a ion wo ks well in he municipali y 59/41% Thinks mul ip o essional collabo a ion wo ks well in hei o ganiza ion 69/31% Knows who o con ac when suspec ing child mal ea men 87/13% When suspec ing child mal ea men PHN ge s enough suppo om Supe io s 50/50% Pee s 82/18% The clinic physician 69/31% Child p o ec ion 69/31% In ou clinic: We ha e join ins uc ions o handle child mal ea men cases 54/46% We ha e clea ins uc ions on how o make a child wel a e no i ica ion 65/35% I is possible o wo k acco ding o he child mal ea men guideline 59/41% 𝑃 < 0.001) and implemen ed he ecommenda ions o he guideline be e (mean 3.79 e sus 3.16, 𝑃 < 0.001). The same applied onu seswhowe eawa eo heguideline,had eadi , and pa icipa ed in aining on ecognizing and in e ening in child mal ea men (Table 4). Acco ding o he eg ession analysis, wi h wo king yea s and suspicion o mal ea men as addi ional independen a iables, hose wo king as school heal h nu ses we e able o iden i y cases be e han o he s. In addi ion, hose wo king as school heal h nu ses o a child wel a e clinics also in e ened be e han o he s. Those wo king a amily planning o ma e ni y clinics implemen ed he guideline be e han o he s. Those who had suspec ed child mal ea - men ob iously had be e iden i ica ion, in e en ion, and implemen a ion han hose who had no suspec ed child mal ea men (Table 5). Acco ding o he eg ession analysis, wi h wo king yea s and ac ual con ac wi h mal ea ed child en as addi ional independen a iables, only in e en ion was a a highe le el ( o hose who wo ked as school heal h nu ses) compa ed o o he s. Those who had me mal ea ed child en ob iously had be e iden i ica ion, in e en ion, and implemen a ion han hose who had no me mal ea ed child en. 5. Discussion The PHNs iden i ied child mal ea men o a mode a e deg ee. They hough ha hey iden i ied isk ac o s ela ed Nu sing Resea ch and P ac ice 5 Table 4: The e ec s o sepa a e backg ound ac o s on iden i ying, in e ening,andimplemen ing. Va iables Iden i ying In e ening Implemen ing Age (co ela ion, signi icance) 0,01 NS 0,01 NS 0,14∗∗ Wo king yea s as a nu se (co ela ion, signi icance) −0,02 NS −0,03 NS 0,07 NS Wo king in u ban a eas/coun yside/bo h (ANOVA sig.) NS NS NS Knowledge o he exis ence o a guideline (𝑡- es sig.) ∗∗∗ ∗∗∗ ∗∗∗ PHN had ead he guideline (𝑡- es sig.) ∗∗∗ ∗∗∗ ∗∗∗ PHN had had educa ion on he opic (ANOVA sig.) ∗∗∗∗∗∗∗ How many (0, 1−4, 5, o mo e) child mal ea men cases hey had me du ing six mon hs (ANOVA sig.) ∗∗∗ ∗∗∗ ∗∗∗ How many (0, 1–4, 5 o mo e) suspec ed child mal ea men cases hey had me du ing six mon hs (ANOVA sig.) ∗∗∗ ∗∗∗ ∗∗∗ Es ima e signi icance (𝑃 alue): NS = no signi ican ; ∗<0,05; ∗∗ <0,01; ∗∗∗ <0,001. Table 5: Es ima ed uns anda dized eg ession coe icien s o all a iables om linea eg ession models, sepa a ely o iden i ying, in e ening,andimplemen ing (𝑁 = 367). Model a iables Iden i ying In e ening Implemen ing Ha e wo ked in: ma e ni y and amily planning 0,075 0,127 0,296 Ha e wo ked a : a Child Heal h Clinic −0,103 0,325 0,309 Ha e wo ked a : a School Heal h Clinic 0,216 0,301∗0,133 Ha e wo ked a : o he places 0,086 −0,381∗0,044 Wo king yea s 0,000 −0,003 0,012 Had me mal ea men cases (yes/no) 0,658∗∗∗ 0,390∗∗ 0,583∗∗∗ Ha e wo ked in: ma e ni y and amily planning −0,058 0,227 0,344∗ Ha e wo ked a : a Child Heal h Clinic −0,008 0,309∗0,096 Ha e wo ked a : a School Heal h Clinic 0,293∗0,316∗∗ 0,068 Ha e wo ked a : o he places −0,038 −0,317∗∗ −0,106 Wo king yea s −0,005 0,000 0,015∗ Had suspec ed mal ea men cases (yes/no) 0,507∗∗∗ 0,322∗∗ 0,310∗ Es ima e signi icance (𝑃 alue): ∗<0,05; ∗∗ <0,01; ∗∗∗ <0,001. o hechild,pa en s,o he amily hebes andissues ela ed o he child’s o he pa en s’ beha io he wo s . They iden- i ied signs o physical and emo ional abuse be e . Simila esul sha ealsobeen epo edinasu ey o hospi als a [24]. Di e en o ms o child mal ea men a e iden i ied a di e en le els: signs o physical mal ea men a e o en clea e han, o example, signs o emo ional mal ea men o neglec . The esponden s hough ha hey can in e ene in mal- ea men be e han hey can iden i y i . They discussed bo h e e yday issues and p oblems ela ed o child de elopmen wi h he pa en s a a child heal h cen e , bu hey ailed o discuss ela ionship issues su icien ly. These esul s also ag ee wi h ea lie esul s [9,25–27]. When suspec ing ha a child has been mal ea ed, he esponden s asked abou i di ec ly, made a child p o ec ion epo , and documen ed he e en in he child’s documen- a ion. In hei opinion, howe e , hey el ha hey we e no able o p o ide enough help o he child and he amily in he si ua ion. Acco ding o ou eg ession models, hose nu ses wo king a schools assessed hei child mal ea men iden i ica ion p ac ices mo e posi i ely han hose wo king a o he places. This may be because child en’s beha io o p oblems in school a endance may mo e likely lead o discussions abou he child’s si ua ion han a a child wel a e clinic. A clinic child en a e younge and do no exp ess being ill so clea ly. A amily planning o ma e ni y clinics nu ses implemen ed he guideline e y well a a knowledge le el and we e willing o use his knowledge. Howe e , a he iden i ying and in e ening le els, hey we e no able o apply hei willingness in eal si ua ions. Acco ding o ea lie s udies [9,25,27], PHNs eel ha hey a e in a good posi ion o ake he ac ions needed bu hey need mo e aining on applying hei knowledge in eal si ua ions when wo king wi h child en and amilies. Acco ding o he PHNs, mul ip o essional collabo a ion is no wo king e y well in he municipali y o o ganiza ion whe e hey wo k. Common guidelines on how o ac on child mal ea men suspicions o how o make a child p o ec ion epo we e no used o en enough. Some o he esul s may seem o be con using, o example, conce ning ag eeing on he impo ance o he guidelines e en when no knowing hem e ywell.Thismaybedue o he ac ha he esponden s ag ee ha iden i ica ion and in e ening a e impo an bu hey do no know well enough wha o do and how o implemen hei knowledge in o mul ip o essional 6Nu sing Resea ch and P ac ice wo k. Acco ding o Leh om¨ aki [17], he a i udes owa ds ca e guidelines in gene al a e posi i e bu applying hem equi es suppo and adminis a i e e o om hei supe io s and de elopmen o join p ac ices. In his s udy, he esponden s a ed hemsel esasno ecei ingenoughsuppo om hei supe io s o child p o ec ion au ho i ies. Acco ding also o Yagasaki and Koma su [28], guidelines a e ega ded as impo an ; howe e hey a e no ully applied in o p ac ice. To be success ul in applying any esea ch-based guidelines, o ganiza ional, adminis a ional, mul idisciplina y, and indi- idual ba ie s ha e o be challenged by a s a egy ha gi es ools o e ec i e implemen a ion. PHNswhohadme mal ea edchild eno whohad pa icipa ed in aining on child mal ea men we e able o iden i y mal ea men and hey in e ened in i be e han hose who had no me such child en o pa icipa ed in such aining. Ea lie s udies ha e also gained simila esul s. Acco ding o Paa ilainen e al. [24], nu ses who ha e pa icipa ed in aining o who ha e me mal ea ed child en ind iden i ica ion and in e en ion e en mo e di icul han nu ses who ha e no encoun e ed hese issues a all. Based on his,i ispossible ha nu seswhoha eexplo ed heissue and ac ed on i ha e a mo e p o ound unde s anding o how di icul andcomplex heissueis.Also,whenaskingabou hese di icul issues wi h a c oss-sec ional design as we did in ou s udy, using a sel - epo ed ques ionnai e migh also be a limi a ion. Howe e , i seems ha PHNs did no o e es ima e hei capabili y in iden i ying o in e ening and many de elopmen al challenges can be p esen ed based on he esul s. 5.1. Implica ions o Nu sing P ac ice. PHNs a e gene ally awa e ha iden i ica ion o and in e en ion in child mal- ea men a e an impo an pa o hei job (see also [25]). Howe e , he lack o e o in c ea ing common guidelines and p ac ices and ensu ing he unc ionali y o mul ip o es- sional collabo a ion we e weaknesses in p ac ical wo k and ac ions [19]. This is a ques ion o wo k o ganiza ion and managemen andalsoo ocusingonac i i ies ha a e eally help ul and e ec i e o child en and amilies. PHNs a e in a posi ion o ake a leade ship ole in he p e en ion o child mal ea men as well as add essing he sys em ba ie s such as knowledge exchange challenges o coo dina ion wi hin mul ip o essional ac i i ies. This will lead o suppo ing amilies be o e isks o mal ea men a e ealized in o ac ual mal ea men in amilies. Sol ing o ea ing child mal ea - men casesis he esponsibili yo manyadminis a i ely sepa a e uni s: child heal h cen e s, hospi als, a day ca e, and in child p o ec ion. The manage s o hese uni s should ensu e ha collabo a ion, in bo h p e en ion and ea men le els, can wo k ac oss adminis a i e bounda ies. This kind o de elopmen can be done globally, based on in e na ional esea ch e idence and on he se ice sys em o child en and amilies in each coun y. 5.2. Implica ions o Nu sing Educa ion. Mo e a en ion should be paid o aining on child mal ea men in he basic and complemen a y educa ion o PHNs. This aining should include he opics o high isk amily en i onmen s (iden i ying and discussing hem), discussing he e e yday issues and p oblems o amilies, he isks and mani es a ions o mal ea men , he iden i ying symp oms and signs, and he conc e e means and me hods o iden i y and in e ene in mal ea men . The e should also be aining on issues ega ding mul ip o essional collabo a ion and legisla ion. The se ice sys em and legisla ion conce ning child en and amilies di e in each coun y; his has o cou se o be conside ed. Howe e , he heal h, well-being, and needs o child en a e global issues and can be used as he basis o educa ion. 5.3. Implica ions o Nu sing Resea ch. These esul s show well he si ua ion conce ning he iden i ica ion o and in e - en ion in child mal ea men by PHNs and how hey imple- men he guideline conce ning hese issues in hei wo k wi h child en and amilies. Fu he knowledge is needed, o example, on how o p o ide educa ion on hese issues and change PHNs’ p ac ices. This could be done by a ollow- up s udy wi h an educa ional in e en ion. Also, compa- able da a om o he coun ies would be in e es ing and impo an , p o iding knowledge o he si ua ion in di e en coun ies. This s udy is al eady in p ocess, and he e is al eady da a om Japan collec ed wi h he same ins umen . 6. Conclusion The p ima y p e en ion o child mal ea men is he mos impo an issue om he pe spec i es o child en, amilies, and hewholesocie y,inFinlandandglobally,al hough also seconda y and e ia y p e en ion a e e y c ucial o de elopmen . In aiming o p e en child mal ea men and inc ease he well-being o child en, guidelines and isk assessmen p ac ices o PHNs and suppo i e in e en ions o amilies wi h child mal ea men isk should be de eloped ande alua ed.Thiscanbedonebyusingguidelines o c ea ing e ec i e in e en ions and e alua ing he p ocess andou comesby ollowup esea ch. Con lic o In e es s The e is no con lic o in e es s. Re e ences [1] R. Reading, S. Bissell, J. Goldhagen e al., “P omo ion o chi- ld en’s igh s and p e en ion o child mal ea men ,” The Lance , ol. 373, no. 9660, pp. 332–343, 2009. [2] S. Lepis ¨ o, T. Luukkaala, and E. Paa ilainen, “Wi nessing and expe iencing domes ic iolence: a desc ip i e s udy o adoles- cen s,” Scandina ian Jou nal o Ca ing Sciences, ol.25,no.1, pp.70–80,2011. [3]N.Ellonen,J.K ¨ a¨ a i¨ ainen, V. Salmi, and H. Sa iola, “Las en ja nuo en ¨ aki al akokemukse (child ic im su ey: io- lence agains child en in Finland),” Poliisiamma iko keak- oulun Rapo eja 71/2008, Poliisiamma iko keakoulun, Tam- pe e, Finland, 2008. [4] R. Gilbe , A. Kemp, J. Thobu n e al., “Recognising and espo- nding o child mal ea men ,” The Lance , ol.373,no.9658,pp. 167–180, 2009. Nu sing Resea ch and P ac ice 7 [5]K.Helweg-La sen,N.Schu ,andH.La sen,Unge i sel ˚ A 2008, 2009, h p://www.si- olkesundhed.dk/upload/samle appo unges i sel.pd . [6]R.Ueda,Y.Yasuda,andK.Maeda,“Child- ea ingbeha iou o p e-school child en a M ci y in Japan in ela ion o he p e en ion o child mal ea men : simila i ies and di e ences be ween 1984–2006,” Japanese Jou nal o Heal h & Human Ecology, ol.74,pp.99–113,2008. 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Coben, “Nu se home isi o s’ pe spec i es o manda o y epo ing o child en’s exposu e o in ima e pa ne iolence o child p o ec ion agencies,” Public Heal h Nu sing, ol.29,no.5,pp. 412–423, 2012. [28] K. Yagasaki and H. Koma su, “P econdi ions o success ul guideline implemen a ion: pe cep ions o oncology nu ses,” BMC Nu sing, ol. 10, a icle 23, 2011. 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