Knowledge of child abuse and neglect in nursing students: Assessment and perspectives

Misdiagnosis of child abuse and neglect can delay early treatment. Some authors have pointed out that nurses can miss child abuse and neglect diagnoses due to a lack of knowledge. It is unclear whether the lack of knowledge is due to students' insufficient preparation in nursing school and/or a deficiency in continuing education. An 18‐item questionnaire was administered to final‐year nursing students to assess their degree of knowledge on child abuse and neglect and to evaluate if the lack of knowledge was due to insufficient teaching/training during nursing school. The students were also asked to evaluate themselves by assigning a score to their knowledge. A statistical comparison was performed to define whether sufficient/insufficient results were associated with the following variables: sex, pediatric or general nursing student, attending pediatric lectures, training in pediatric wards/ambulatories, and attending specific lectures on child abuse and neglect. The study population comprised 175 students (154 females, 20 males, 1 unknown). Exactly 66.3% of the participants had ≤9/18 correct answers. Of all students, 77.7% self‐evaluated their level of knowledge as ≤5/10. The comparisons yielded statistically significant differences between the groups with sufficient objective knowledge and those unrelated to training in pediatric wards/ambulatories or pediatric nursing students. Overall, there was little objective knowledge on the subject, which may be related to insufficient teaching/training in nursing schools. Useful corrective strategies include further teaching on child abuse and neglect, preferably using a practical approach. Further, common teaching/training programs should be conducted by both pediatric and general nursing schools.


| INTRODUC TI ON
According to the 29th Report of the Children's Bureau, child abuse and neglect are widespread.In the United States Child Protective Service Agencies, more than 4 million referrals for suspected child maltreatment occurred in 2018, involving approximately 7.8 million children [1].
Even though child abuse and neglect are associated with significant morbidity and mortality [2], it is often unreported.Identifying child abuse and neglect is particularly difficult for healthcare providers.Child abuse and neglect can vary widely in severity, type, outcome, and chronicity, resulting in challenging diagnoses [3].
Misdiagnosis caused by poor or inadequate knowledge of child abuse can delay early treatment leading to chronic psychiatric and medical disorders [4].In this case, incorrect information may be reported to judicial authorities, causing legal issues in civil, juvenile, family, divorce, and criminal courts [5][6][7].
Few studies have explored healthcare providers' ability to correctly identify signs, symptoms, and factors suspicious of child abuse and neglect.Some authors have pointed out that due to a lack of knowledge, nurses can miss the red flags of child abuse and neglect, attributing them to natural conditions and/or accidental traumas [8].
The lack of education and training in these healthcare workers can result in a failure to protect children.
The scientific literature does not clarify whether the abovementioned knowledge deficit is due to insufficient preparation of students in nursing schools and/or a deficiency in continuing education after graduation, and few studies have been conducted on this topic.Additionally, no extensive suggestions have been provided regarding possible corrective approaches to compensate for this deficiency.
Consequently, in this study, we administered a questionnaire to final-year nursing students to assess their knowledge about child abuse and neglect, evaluate whether the lack of knowledge is due to insufficient teaching/training during nursing school, and identify corrective strategies.

| MATERIAL S AND ME THODS
To evaluate knowledge on child abuse and neglect, an 18-item questionnaire was anonymously (the authors did not know which students completed the questionnaire) administered to final-year nursing students at the University of Turin (Italy) (Table 1).Ethical approval was waived for this research by the University Review Board because the study was not interventive and was completely anonymized at the origin.It is important to note that there are two types of nursing programs in Italy: general and pediatric.At the beginning of the first year of nursing school, students are required to choose either a general or pediatric program.Although the general program is not centered on pediatrics, it also contains some lectures/training TA B L E 1 Questionnaire results with the numbers and percentages of correct/incorrect answers.The pilot test results were checked for errors caused by systematic erroneous interpretations of questions/answers (particularly negatively phrased questions).The final version of the questionnaire was created after the validation process.All the above mentioned procedures were carried out in Italian because it was the native language of the authors, nurses, and nursing students.
The study population comprised 175 students.The first question tested the students' knowledge of child abuse and neglect epidemiology (Table 1).Questions 2-7 focused on child sexual abuse (CSA) (Table 1).Questions 8-13 evaluated the students' awareness of physical maltreatment in children (Table 1).Questions (#14-18) were focused on neglect (Table 1).All questions were characterized by five multiple-choice answers (only one was correct).Students' knowledge was considered sufficient if they correctly answered more than 50% of the 18 questions (final score > 9/18).This allowed us to divide the population into two groups: Group A students with sufficient (>9/18) objective knowledge and Group B students with insufficient objective knowledge (≤9/18).
Additionally, in the last part of the questionnaire (after the abovementioned 18 questions), the students were asked to answer this question: "What score (from 1 to 10 points) would you assign to your knowledge of child abuse and neglect?"By comparing the re- sults of this answer with those of the 18 aforementioned questions, the authors aimed to understand whether nursing students had high or low self-awareness of their level of knowledge (Figure 1).
The questionnaire also contained questions that allowed us to divide the population according to the following variables (see The mean and standard deviation of the final scores of the 18item questionnaire were calculated.Variable distributions were compared using the chi-squared test (when the expected value for each cell was five or higher) and Fisher's exact test (when the expected value for each cell was less than five).For all tests, the significance level was set at α = 0.001.
IBM SPSS Statistic software (version 25) was used for statistical analyses.

| RE SULTS
The main results are reported in Tables 1, 2 What score (from 1 to 10 points) would you assign to your knowledge of child abuse and neglect?" (Figure 1).ambulatories and pediatric or general nursing students (Table 3).In contrast, the statistical analysis did not yield statistically significant results (p-value ≥ 0.001) for sex, attended pediatric lectures, and attended specific lectures on child abuse and neglect (Table 3).
Particularly, most incorrect answers were in the questionnaire section that explored nursing students' knowledge of CSA (questions #2-#7).The students' awareness of a child's hymenal anatomy was particularly deficient.Only 14.3% recognized that high convexity is not an anatomical variation in the morphology of the hymen (question #2).Furthermore, only 13.7% correctly indicated which infection was most likely to be associated with sexual intercourse (Question 7).The analysis indicated a slightly higher number of correct answers for question 6 (30.9%); nevertheless, 69.1% did not know that a scar on the posterior fourchette could be a sign of CSA [3].Furthermore, even if the correct answers to question #3 were above 50%, 46.3% of all nursing students were unaware of the importance of performing vulvar swabs when examining the anogenital area in cases of suspected CSA.
Regarding the section dedicated to physical abuse (questions #8-#13), the nursing students had better results compared to the CSA section.In no questions, correct answers were ≤15%.However, the students showed poor (percentages >15% and ≤35%) knowledge of which typical finding is associated with abusive head trauma (question #10) and the significance of posterior rib fractures in nonambulatory children (question #12) [10].
The section where the study population showed better knowledge was neglect (questions 14-18).The students only demonstrated an insufficient awareness of the risk factors associated with child neglect in question #17.However, the nursing students failed to correctly answer the first epidemiological question (Question 1).
Only 6.9% correctly answered that neglect was the most common [11].
In light of the above, it is possible to state that there was overall low objective knowledge of child abuse and neglect in this population.

| Comparison with other studies about students' knowledge in other countries
We reviewed the scientific literature (PubMed and Scopus databases) to identify other studies that evaluated nursing students' knowledge using questionnaires/surveys.This review yielded a few

General nursing students 43 109
Pediatric nursing students 16 7 Note: One student did not provide information about the following variables: sex and training in pediatric wards/ambulatories.Two students did not provide information about the variables: attended pediatric lectures, attended specific lectures on child abuse and neglect.
studies.In one of them, Pisimisi et al. assessed the knowledge and attitude of a Greek population [8].However, a direct comparison of the results of the two studies is not possible because Pisimisi et al.'s questions, especially those referring to specific knowledge on this topic, differed from those of this study.Particularly, they asked nursing students to self-rate their awareness of child abuse and neglect using a 5-point Likert scale.Therefore, their analysis was based on self-reported (subjective) knowledge [8].However, in this study, we aimed to evaluate objective knowledge using multiple-choice questions.In this study, students were asked to self-score their subjective awareness of their competence only in the final part of the analysis.Thus, the methodologies used in the two studies were significantly different.Furthermore, unlike the study by Pisimisi et al., this study evaluated only final-year students.This strategy was chosen because the aim was to objectively determine the specific knowledge of students who were almost leaving nursing school to work as healthcare providers.Similar considerations were suggested by Poreddi et al. [15].The questionnaire was distributed to second-, third-, and fourth-year nursing students at a college in Bangalore (South India).The researchers evaluated students' objective knowledge of child abuse and neglect.However, the results of their questions cannot be directly compared with our results because they focused on different topics, and each question was not associated with multiple-choice answers but with only three possible responses (yes, no, not sure).
In light of the above, articles analyzing nursing students' knowledge of child abuse and neglect are hardly comparable due to different study designs.Despite these differences, all the aforementioned articles pointed out the following common result: nursing students from different countries demonstrated similar unsatisfactory levels of knowledge about child abuse and neglect [8,15].
The aforementioned results seem to be a recurring finding in other (few) available studies in which the knowledge/attitudes of other healthcare professional students were analyzed.In 2022, a study from the same university as the present study was published, reporting that medical students lack objective knowledge [9].In

| New frontiers and perspectives
It is important to note that the questions used in this study were chosen based on the baseline knowledge of child abuse and neglect.
Even if not specifically specialized in this field, every nurse should possess the minimum skills to identify signs/symptoms/factors associated with abuse.Nurses are often the first healthcare providers with whom children and/or family members interact.Sometimes nurses are the only available healthcare providers, especially in places where children spend significant amounts of time.Thus, especially in the case of physical maltreatment and/or neglect, whose effects can be more easily observed, nurses can play a pivotal role in identifying signs of abuse.Some authors have reported the importance of school nurses in the healthcare of children in schools, highlighting their role in cases of suspected child abuse and neglect."public health nurses working in targeted, long-term home visitation programs have a unique role and responsibility with respect to preventing, considering, and then safely recognizing and responding to suspected child maltreatment" [19].
Even though healthcare providers' role in preventing and recognizing child abuse and neglect is pivotal, several studies have reported that worldwide, there is a gap in their knowledge of this topic [20][21][22].Frequently, they are unfamiliar with the main (physical and behavioral) signs of abuse in children and caregivers.This can negatively influence outcomes.Many authors have highlighted the severe acute and chronic consequences of misdiagnosis [23,24].If the chain of abusive events is not curbed by the appropriate intervention of healthcare providers, it can result in new abusive episodes that could potentially be life-threatening.Additionally, the long-term negative consequences on children are well known: low educational achievement, low-skilled employment, mental health issues, attempted suicide, drug/alcohol dependence, obesity, chronic pain in adulthood, and intergenerational transmission of child maltreatment [23,24].
Thus, misdiagnosing child abuse and neglect can generate significant social and economic burdens for society in the long term.
In light of the above, it is clear that for each country/society, one strategy to prevent and limit the abovementioned negative outcomes is to have skilled healthcare providers.Subsequently, in recent years, many authors have highlighted the importance of continuing education and training in child abuse and neglect for healthcare providers.This approach can improve skills [20][21][22].
Nevertheless The present analysis also highlighted that students are highly aware of their deficiencies.Indeed, 77.7% of students self-evaluated their knowledge of child abuse and neglect from 1/10 to 5/10 points.
This negative datum can be considered a positive starting point because students, aware of the negative consequences of a knowledge deficit, could be more prone to deepen their knowledge if more extensive school programs are provided.
Regarding the types of activities that should be implemented in school programs, the statistical analysis in this study demonstrates the importance of developing practical skills.The statistical comparison revealed that students who had taken part in practical childcare training had better results.In contrast, no statistical differences were observed when considering lectures on pediatrics.A practical approach to pediatrics can result in better-skilled students.Thus, even if lectures are useful, these data suggest that a practical approach is preferred for improving school programs.
The statistical evaluation also suggested another meaningful result: pediatric nursing students showed better results than those who studied general nursing.This result is not surprising because this type of education targets students who intend to work only in pediatric settings.However, this lack of knowledge among general nurses is a significant weakness because they may be employed in healthcare settings where children are patients.Thus, different competencies in child abuse and neglect between pediatric and general nurses is not a rational methodology because it goes against what usually occurs in practical routines.Thus, we suggest that teaching/ training about child abuse and neglect should be implemented in both pediatric and general programs.This approach can align the care provided to children across all settings.
In light of the above, all nursing schools should focus on developing and supporting specific programs that deal with child abuse and neglect.To achieve this goal, each nursing school should first define its current ability to train its students using questionnaires similar to those proposed in this manuscript.Then, the same ques- The scientific literature lacks specific information on preferred methodologies that should be used to teach child abuse and neglect.
Recently, Giannakas et al. conducted an interesting study in which they proposed a participatory approach for medical students [25].
Particularly, they created a workshop on role-playing using manikin and peer-to-peer teaching.This methodology could also be used for nursing students, as the study demonstrated that this approach improved participants' knowledge and self-confidence in child abuse and neglect [25].

| Limitations
The main limitation of this study is the difficulty in generalizing the results to other geographical regions or countries, as our findings may reflect the organization of the specific educational system where it was conducted.
However, a comparison of different healthcare school professional systems suggests similar issues in student knowledge of child abuse and neglect worldwide [26][27][28].For example, the World Health Organization and the International Association of Medical Regulatory Authorities have suggested the need for common criteria for medical school accreditation [26][27][28].In the United States, "the responsibility for curriculum development rests with the medical school and is not specifically dictated by accrediting bodies" [29].In Italy (as in many European countries), for both medical and nursing schools, accreditation relies on offices that depend on the Ministry

TA B L E 1
(Continued)   questions effectively captured the topic under investigation.They also checked the survey for double-barreled and confusing questions.The authors conducted a pilot test on a subset of the intended population (15 nursing students who were not included in the study).

, and 3 .
"The population size included 175 students (the response rate was 100%; the participants were solicited during nursing school lectures): 154 females (88%), 20 males (11.4%), and 0 in the other category (one student F I G U R E 1 Graphical representation of students' self-awareness of their level of knowledge (x-axis, from 1 to 10 points) versus number of correct answers (y-axis).Four students did not answer the question "What score (from 1 to 10 points) would you assign to your knowledge of child abuse and neglect?"Thus, they are not depicted in this figure.didnot answer).Of all students, 66.3% scored ≤9/18, demonstrating insufficient knowledge (Group B).The mean and standard deviation of the scores of the 18-item questionnaire was 8.34 ± 2.49.Students demonstrated high self-awareness of their low level of knowledge, as 77.7% of all students assigned a score of ≤5/10 the question," addition to different methodologies, similar considerations were proposed in 2018 by Kong et al., who evaluated the clinical performance of medical students[16].In 2021, Al-Ani et al. pointed out that dental students in Hamburg (Germany) had inadequate knowledge about child abuse and neglect[17].
tionnaire should be used to assess which specific subjects should be implemented, including additional lectures and practical training where healthcare providers experienced in those subjects should be involved.Additionally, all schools should reassess the same students after implementing the aforementioned training program to verify whether the program was fruitful.

1 .
Which is the most widespread form of child abuse and neglect?a. physical abuse-2 (1.1%) b.

usually performed in combination with vulva swabs-94 (53.7%)
d. does not include the examination of the hymen-9 (5.1%) e. is usually performed in association with the steric evaluation of the impact of the suspected tool-25 (14.3%) 4. Referring to physical examination in a case of suspected sexual abuse (choose the wrong answer):a.the oropharynx must be analyzed in association with the evaluation of the genital area-11 (6.3%) b.

development in health, education, emotional development, nutrition, shelter and secure living conditions, considering family or caregivers resources-113 (64
c. the involvement of the minor in acts of violence against significant reference figures for the child-2 (1.1%) d. the involvement of a minor in sexual acts, with or without physical contact-5 (2.9%) e. the intentional use of physical violence against a minor that causes or has a high probability of causing damage to health, survival, development, or dignity, such as assault, corporal punishment, or serious attacks on the physical integrity or the life of the child/adolescent-12 (6.9%)TA B L E 1 (Continued)15.Which of the following conditions is not an example of neglect?a. accidental intake of psychotropic substances by a not-ambulatory child-13 (7.4%) b. dental neglect-15 (8.6%) c. non-adherence to medical prescriptions-5 (2.9%) d.

excoriations on knees and anterior tibial surfaces-136 (77.7%)
16 poor hygiene-6 (3.4%)16.Which investigation should be performed in case of suspicious chronic exposure to toxic substances in a child?

Table 2 )
: sex, pediatric or general nursing students, attended pediatric lectures, training in pediatric wards/ambulatories, and attended specific lectures on child abuse and neglect.Statistical analyses were then carried out to compare Groups A and B with all the above mentioned variables (sex, pediatric or general nursing student, attended pediatric lectures, training in pediatric wards/ambulatories, and attended specific lectures about child abuse and neglect).

18) objective knowledge Number of students with insufficient (≤9/18) objective knowledge
Distribution of nursing students based on selected variables.
TA B L E 2 , are we sure this is the only option available to