FACILITATORS AND BARRIERS TO MEDICAL EVALUATION OF CHILD MALTREATMENT IN NORTHERN BRITISH COLUMBIA by Stephanie Lynn Rex B.A. Memorial University of Newfoundland , 1993 B.S.W ., University of Northern British Columbia , 1998 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEG REE OF MASTER OF SOCIAL WO RK UNIVERS ITY OF NORTHERN BRITISH COLUMBIA August 2015 © Stephanie Rex , 2015 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Abstract The goal of this qualitative study was to gather insights into how the primary care system could maximize opportunities to identify and address child maltreatment when children present for both routine and acute medical care . Through personal semi-structured interviews with twelve northern physicians/nurse practitioners I learned about systemic barriers they faced which prevents health care providers from accessing critical health and social history, sharing diagnostic information with investigators in an understandable way, and developing competence in conducting these assessments. Participants provided practical suggestions for addressing these concerns and highlighted facilitators that assisted them in completing these assessments. As the national approach to primary care transitions to a new model of interprofessional primary care teams , it presents numerous opportunities to improve systemic procedures for information exchange and interprofessional collaboration . FACILITATORS AND BARRI ERS TO MED ICAL EVALUATIO N II Table of Contents A bstract Table of Contents II List of Tables IV List of Figures v Acknowledgements VI Dedication VII Chapter One: Literature Review Background Purpose of the study Research Questions Potential Benefits of this Study Conceptual Framework Personal Standpoint Definition of Terms Thesis Structure 1 2 3 3 Chapter Two: Literature Review Prevalence of Child Maltreatment Defining Child Maltreatment Enduring Impact of Child Maltreatment Legal Mandates and Roles in Child Maltreatment Investigation Physician/Nurse Practitioner's Role Child Maltreatment in Northern British Columbia Health Care in the Canadian Context Health Care in the British Columbia Context Health Care in the Northern British Columbia Context Recruitment and Retention Problems in Northern British Columbia Structural Barriers to Health and Health Care Access Chapter Three : Research Design Methods Research Sample Recruitment Process Data Collection Data Ana lysis Ethical Considerations Summary Chapter Four: Research Findings 4 4 6 8 10 11 11 13 14 16 18 31 32 33 34 35 36 39 39 42 43 44 44 46 47 48 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Demographics Manifest and Latent Themes Summary Ill 48 50 69 70 70 Chapter Five: Discussion Interpretation of Key Findings Barriers to Child Maltreatment Evaluation Facilitators to Child Maltreatment Evaluation Significance of Findings Congruency with Previous Research Study Limitations Recommendations Directions for Future Research Personal Reflection Conclusion 81 References 83 71 73 74 74 75 76 80 80 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION IV List of Tables Table 1: Participant Demographics 43 Table 2: Themes and Sub-themes 49 v FACILITATORS AND BARRIERS TO MEDICAL EVALUATION List of Figures Figure 1: Prevalen ce of Child Maltreatment in Canada 12 Figure 2: Categories of Child Maltreatment 14 Figure 3: Northern Health Authority Region 35 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Acknowl edge ments A thesis is a tremendous undertaking that requires support and commitment not only from the student, but also from the people surrounding them . My husband , John , and three children , Adrienne Marley, and Ethan have provided encouragement and support which allowed me to do my never-ending "homework" over the past five years . A special thank you to my parents who have always been my cheerleaders. I have been fortunate to have Dr. Glen Schmidt as a professor in both my undergraduate and graduate programs . I appreciate your guidance throughout this thesis and thank your for sharing your knowledge and expertise with me over the years . To my committee members , Dr. Joanna Pierce and Dr. Neil Hanlon , thank you for your guidance , feedback and support with this project. I have been especially grateful for the support of my team at the Suspected Child Abuse and Neglect Clinic who have generously shared their knowledge with me and inspired me when I felt disheartened in this work . Thank you to Nicola Godfrey, RN , Dr. Kirstin Miller, Dr. Sasha Riome-York , Dr. Sandra Lamb , Dr. Kathleen O'Malley, Dr. Elizabete Rocha , and Chantelle Wilson . VI FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Dedication This thesis is dedicated to the children and youth I have had the privilege of working with throughout my career as a social worker. Some have not survived their experiences of chronic child maltreatment others are surviving and struggling to cope with the devastating effects but some of them are somehow thriving in spite of these experiences. Each of them has left a mark on my heart; such is the nature of social work. VII FACILITATORS AND BARRIERS TO MEDICAL EVALUATION 1 Chapter One: Introduction In July 1992 5-year-old Matthew Vaudreuil died following a lifetime of abuse and neglect at the hands of his mother. Matthew's death resulted in a judicial inquiry, which led to massive legislative changes and restructuring of child protection services in this province . Unfortunately, in the 22 years since Matthew's death , at least six other children in northern British Columbia (BC) have died as a result of child maltreatment and many others continue to experience maltreatment (British Columbia Representative for Children and Youth , 2009). The inquests , reviews , and inquiries stemming from these deaths resulted in continued reorganization of child protective services (C PS ) and suggested changes in the approach to health care provision for vulnerable children. The Representative for Children and Youth (RCYBC ) details these recommendations in her 2009 report (p. 139-142). When a child is harmed due to abuse or neglect, the Crown has a legislative obligation to respond to ensure the child is protected. These duties fall under the mandate of police, child welfare social workers , and physicians/nurse practitioners. An effective response relies on interactions between these three provincially funded systems to identify children who have been maltreated, investigate the concern , gather evidence, and ensure the child 's health and safety needs are met. Despite recommendations from the 2009 RCYBC report , it appears that little progress has been made in addressing systemic problems in the health care system or in improving collaboration between these systems. Research has demonstrated that physicians feel ill prepared to evaluate maltreated children and that th ere are deficits in their educational preparation for this work (Heisler, Starling , Edwards, & Paulson , 2006 ; Herend een, Blevins, Anson , & Smith , 2014; Lane & Dubowitz, 2009 ). Other FACILITATORS AND BARRIERS TO MEDICAL EVALUATION studies have shown that despite mandatory reporting laws , many medical providers remain hesitant to involve child protection workers when child abuse or neglect is suspected (Flaherty, Jones , & Sege , 2004; Sege et al. 2011 ). There continue to be systemic barriers to sharing of critica l health information (Health Council of Canada , 2012) . While child protection services in BC have been extensively explored through various inquiries and investigations , in my observation , the same is not true of the medical aspects of child protection . In this study, I used a qualitative approach to interview twelve physicians/nurse practitioners about their experiences providing medical evaluation of children who had been maltreated. This chapter provides a background to the study, and describes the purpose , research questions , and potential benefits . The conceptual lens and personal standpoint of the researcher, and definition of terms , are subsequently described . Background This thesis explored systemic problems relating to primary health care for vulnerable children . In Matthew Vaudreuil's case , these included: failure to recognize and report suspicious injuries and concerning health conditions , lack of communication amongst health care providers and between health care providers and child protection workers , and lack of continuity of medical care (Gave , 1995). During the inquest into Matthew's death , Judge Gave (1995) made the foll owing observations relating to his encounters with the primary health care system : Matthew ... had been taken to the doctor 75 times and had been seen by 24 different physicians (Matthew in Vancouver, para 5) . Although he was nea rly six years old at the time of his death, Matthew weighed only 36 po unds. Bruises covered his face , arms , legs, and back. Th ere were wh at appea red to 2 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION be rope burns on his shoulders and wrists , as if he had been bound . His buttocks were covered in bruises and welts . He had a fractured arm , 11 fractured ribs and what looked like the imprint of a foot on his back. Matthew had been tortured and deprived of food before he was killed (How Matthew died, para 2) ...Medical examinations of Matthew were seen as isolated interventions ; physicians did not pay sufficient attention to Matthew' s medical and social history. Some physicians who had a basis for concern about Matthew's safety and well-being did not make a report to the ministry, as they should have (Conclusions from Matthew's story, para 11 ). Purpose of the study I recognized the wisdom behind Judge Gave 's observations of the health care system , but wondered what changes have since been implemented to remedy these problems. The goal of this study was to explore how physicians/nurse practitioners in northern British Columbia evaluate child maltreatment encountered in primary care settings. Physicians/nurse practitioners in primary care settings may be the first point of contact after a child is maltreated and are in a key position to initiate a positive change in the child 's situation . High profile reviews of child deaths and critical injuries in northern British Columbia revealed inadequacies in the medical response to suspected child maltreatment. In my experience as a social worker, I noticed many missed opportunities to identify and address child maltreatment when children present for both routine and acute medical care . These experiences led me to wonder how the system could be more responsive to the safety and health needs of maltreated children. Research Questions I explored factors that facilitated medical evaluation of child maltreatm ent as well as barriers by asking three research questions: 1.) How do north ern physicians/nurse practitioners view their role in child maltreatment evaluation? 2.) 3 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION How do northern physicians/nurse practitioners determine what interventions are required? 3.) What resources do northern physicians/nurse practitioners access when responding to this issue? Potential Benefits of this Study An understanding of the lived experiences of northern physicians/nurse practitioners doing this work can guide the development of protocols relevant to northern and rural practice . Social workers and medical professionals have complementary roles in child protection . Consequently, I thought it was important to explore facilitators and barriers from the medical perspective to highlight opportunities for improved collaboration between these disciplines for overall systems improvement. Conceptual Framework This research was guided by ecological theory and my commitment to social justice and advocacy. Facilitating change for the benefit of clients and society is a key practice principle of social work and is the foundation of this research (British Columbia College of Social Workers , 2009) . I have worked with maltreated children for the past fifteen years and have witnessed the systemic barriers children and the ir families face as they interact with the systems designed to help them . While I recognize there are many barriers, I see that there are also opportunities for th ese systems to adapt, incorporate new practices, and evolve . Ecological theory assumes that intervention introduced at any point in the system would create an impact on each part of the system leading to change as the individuals adapt to achieve system stability (Germain & Gitterman , 1996). 4 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION One of the dominant social work models is the eco logical or "person-inenvironment" model (Dela ney, 1995). The effect of the geographica l context on professional practice is not a new concept however there is an emerging understanding of the distinct practice challenges presented in northern , remote areas (Zapf, 2002) . The ecological model involves an assessment of a person in the context of their environment and considers interactions between the person and the systems that involve them (Clancy, 1995). These systems include : microsystems , mesosystems , exosystems , and macrosystems . Microsystems involve interactions between an individual and the systems that directly involve that person (Clancy, 1995). In this research , I considered the physician/nurse practitioner as the individuals under study rather than the maltreated child . At the microsystem level , I looked at interactions between children and physicians/nurse practitioners responsible for assessing suspicious injuries or providing ongoing health care services . The mesosystem is the interaction of the systems that are involved with the person (Clancy, 1995). At the mesosystem level , I explored the interactions between physicians/nurse practitioners and the resources they accessed to assist them in responding to child maltreatment concerns . The exosystem is described as the interaction between the systems that provide services to a person but do not directly involve that person (Clancy, 1995). At the exosystem level , I exp lored the training and education of physicians/nurse practitioners , and the exchange of information amongst health care providers and those responsible for ensuring a chi ld 's safety. The macrosystem involves the interaction between larger socia l, political, cu ltural, and economic forces (Clancy, 1995). Th e macrosystem consists of socio-political and economic conditions that increase a child 's 5 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION 6 vulnerability for maltreatment these include poverty racism , social inequality, unequal distribution of resources , and colonization . It also includes the area of social and organizational policy. Consideration of the macrosystem is demonstrated in the literature review through reference to social determinants of health , barriers to health care access , and distribution of health care resources in northern BC and in the recommendations for organizational and policy changes . Personal Standpoint My interest in this topic emerged over the course of my social work career as I observed interactions between vulnerable children and health care providers . In my first job , as a guardianship social worker, I had all the legal duties and responsibilities of a parent for children and youth in care who had been permanently removed from their parents' care due to abuse and neglect. I held that position for eight years . As part of that role , I often attended health care appointments with foster children. Also , I attended "intake medica Is," which are medical examinations required whenever a child comes into foster care or changes foster homes . It is preferred that these medicals are done by the child 's family physician , but for convenience , physician availability, and to meet Ministry of Children and Family Development (MCFD) timelines, these are frequently done at walk-in clinics or by th e foster parent's family doctor, who typically had never met the child . I noticed th at, during all routine medical appointments , a foster parent or caregiver's description of a child 's history and presenting symptoms, which is largely based on th at person's perception , influenced the diagnosis and treatment plan . Frequently, the foster parent provided the history even when they had just met the child . I found myse lf FACILI TATO RS AND BARRIERS TO MED ICAL EVALUATION questioning the process of how children in unstable circumstances are diagnosed with medical conditions and the accuracy of the information doctors use to determine treatment plans . These questions continued to plague me when I switched jobs and began working at the Northern Health Suspected Child Abuse and Neglect (SCAN) team . held that position for four years . My role was to condu ct comprehensive psychosocial assessments of children undergoing forensi c medical evaluation of maltreatment. I had the opportunity to review a child 's complete records including medical records , child welfare files , and RCMP transcripts of interviews . I also obtained collateral information from a variety of sources including family , foster parents, schools , and the child . Upon reviewing this information , I was often struck by the sheer number of missed opportunities to recognize child abuse , particularly in medical settings . My next job was the Chief Social Worker at University Hospital of Northern British Columbia (UHNBC) where I was responsible for the social work department, including paediatric and emergency unit social workers. As a supervisor, I was involved in serious cases of suspected child maltreatment and observed intera ctions between various professionals as they responded to these cases in the hospital setting . This included medical staff such as nurses , paediatricians, child life specialist, emergency room physicians , and social workers as well as Royal Canadian Mounted Police (RCMP), and MCFD social workers as th ey interacted with hospital staff during the early stages of investigation . In th e hospital setting , I also noticed gaps in the system that allow vulnerable children to be overlooked. These experiences have shown me that there continue to be missed opportunities to 7 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION 8 identify and address child maltreatment when children present for both routine and acute medical care . As a social worker in Prince George , I have been responsible for coordinating patients' access to various services across the North ern Health (NH) region of BC . noticed differences in the clinical resources available to children in the NH region versus the more populated areas such as Van co uver, Kamloops , and Vancouver Island which also have SCAN Clinics . I wondered how child maltreatment evaluation , which is often time-sensitive and resource intensive co uld be done effectively in the NH region with less access to primary care physicians and specialists such as paediatricians and psychologists . Definition of Terms The term child maltreatment is an umbrella term used to refer to all forms of child abuse and neglect. In this thesis , child maltreatment refers to " ... any acts or series of acts of commission or omission by a parent or other caregiver that result in harm , potential for harm , or threat of harm to a child ... harm may or may not be the intended consequence" (Leeb , Paulozzzi , Melanson , Simon , & Arias , 2008 , p. 11 ). This includes forms of maltreatment that are widely recognized : physical abuse , sexual abuse , neglect, emotional abuse , and witnessing intimate-partner violence . Child Protection Services (CPS) . In Canada , the responsibility for child protection falls under the jurisdiction of the provinces and territories . In British Columbia , this is the mandate of the Ministry of Children and Family Developm ent (MCFD). The legislated duties and responsibilities are delegated to social workers employed by MCFD . FACILITATORS AND BARRIERS TO MED ICAL EVALUATION Persona/Information Protection Act (PIPA) is the privacy legislation governing the collection , use , and disclosure of personal information in private physicians' offices. Under PIP A an individual must consent to disclosure of their personal information unless specific criteria are met (College of Physicians and Surgeons of British Columbia website , 2015) . Primary care refers to the " ... critical entry point of co ntact to the health care system and serves as the vehicle for continuity of care across the system " (Health Council of Canada , 2005) . It includes prevention and treatment of illness, health promotion healthy child development, and referrals to and coordination with other levels of care (Health Canada , 2011 ). Primary Care Home is the term used for a new model of care adopted by the Northern Health Authority, where patients will access integrated health care services through a primary care provider who may be a physician or nurse practitioner and a multi-disciplinary (now termed "interprofessional) team which can include nurses , social workers , dieticians , physiotherapists , occupational therapists , and mental health clinicians (Northern Health website , 2015). The terms , general practitioner (GP) and primary care physician are used interchangeably in the literature , however I use the term physician to refer to all primary care physicians including paediatricians . A nurse practitioner (NP) is a registered nurse with advanced training in nursing, often a master's degree in nursing , and the advanced nursing practice competencies required for registration as a nurse practitioner with the College of Registered Nurses of British Columbia (CRNBC) . The nurse practitioner's scope of practice in primary care is broader than that of a registered nurse but is not equal to 9 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION that of a physician . Within the parameters set out by the CRNBC nurse practitioners are able to diagnose , consu lt, order, and interpret a range of tests , prescribe medications and treat certain health conditions (CRNBC , 2015). The Representative for Children and Youth (RYC) is a "non-partisan , independent officer of the Legislature , reporting directly to the Legislative Assembly and not a government ministry" (RYCBC website , 2015) . The role of the representative is to act as an independent advocate for vulnerable children and youth and provide oversight for government-funded prescribed programs and services for vulnerable children , youth , and families . Thesis Structure This thesis is comprised of five chapters . Chapter one introduced the background, research questions , and conceptual framework and provides a definition of terms . Chapter two provides a review of relevant literature relating to the prevalence and impact of child maltreatment, a historical background to the physician's role in medical child maltreatment assessment, current issues relating to diagnostic evaluation , and issues facing physicians and nurse practitioners in the northern BC practice setting. Chapter three outlines the study design , methodology, data collection , and data analysis. Chapter four outlines the findings and describes the major themes and subthemes and analysis and interpretation . Chapter five includes a discussion of the key findings , recommendations for system improvements, study limitations, suggestions for future research , personal reflection, and conclusion . 10 FACILITATORS AND BARRIERS TO MEDI CAL EVALUATION Chapter Two: Literature Review Child maltreatment is considered a cultural phenomenon , largely defined by the socio-economic and cultural realities of a society. From a health perspective , child ma ltreatment is "a major international health problem with unacceptable levels of morbidity and mortality" (Sittig , Uiterwaal , Moons Nieuwenhuis , & van de Putte , 2011 , p. 2) . In Canada a reported 230 children died between 1998-2003 as a resu lt of child maltreatment (AuCoin , 2005) . Evidence is mounting of the cumulative and life-long impact of child maltreatment on physical and mental health . This chapter provides an overview of the prevalence of child maltreatment, health and social consequences , outlines roles and mandates in child abuse investigation , and provides a structural context for medical evaluation of child maltreatment in British Columbia. These topics are explored using pertinent literature to establish connections between these concepts and highlight possibilities for improvement in medical evaluation of child maltreatment in northern British Columbia . Prevalence of Child Maltreatment It is difficult to accurately measure the prevalence of child maltreatment in Canada. This is due to underreporting and cases , which were investigated by child protective services (CPS) but not substantiated due to lack of evidence (Allan , & Lefebvre, 20 12). Most studies of chi ld maltreatment, such as the Canadian Incidence Study (C IS), rel y on data from cases reported to and assessed by CPS but unverified by other sources (Allan, & Lefebvre, 2012). While these are useful data, they do not provide information about unreported or repeated episodes of child maltreatment, which occur fo llowing intervention by child protection services. 11 12 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Another recent Canadian study found 32 .1 °/o of adu lts reported childhood experiences of abuse , 26 .1 o/o reported physica l abuse , 10 .1 °/o reported sexual abuse , and 7 .9o/o reported exposure to intimate partner violen ce (Afifi et al., 2014 ). According to that study, British Columbia (BC ) has th e seco nd high est rate of child maltreatment (35 .8°/o) in Canada (Afifi et al. , 2014). Th ese data were obtained from a nationally representative sample of 23 , 395 adu lts age eig htee n and older who participated in the 2012 Community Hea lth Study and were as ked abo ut childhood experiences of abuse (Afifi et al. , 2014 ). The results are detailed in th e table below which was adapted for an article in the National Post (Boesveld , 2014 ): Figure 1. Prevalence of Ch il d Maltreatment in Canada report b.lJ th anadian · edical .·.·u.:iation Journal 1 u/8 1/i e 1 erccntagc oftlw.· tr..'ho hat'£' .·l!fJl red child abu .·c a.. ,. high a.· ,'J..J % PREVALENCE OF CHILD ABUSE* [\ C:\ . ,\U.\ . m n PI'., t \ l' l·. H ' 1. I. 'lOI~ I I·. \ t.\ 1 I \ l\1. 1. Physical abuse Slapped on face, head or ears. hit or spanked Pushed, grabbed, shoved, scOmething thrown at Kicked. bit, punched1 choked, burned attacked Any physical abuse Sexual abuse Ex.posure to intimate partner violence Any chHd a.bus,e Number of child abuse typesH 66.1 % 69.8% No abuse llype only 2 types 3 types "23.39S reJpond«!>nts O(t>ed l 8 ~o's and ~ld4!-r. W«He qvestionE'd ""Th e tihte-e child abu~ ·ty pes i!ltr>ft; phys-Ecal abuse, Sie'ltual tabu• :O.fll flt I I \ . "II\~ \11 Ill( \ I \;,, I l l 'llfl . .101 lt \1 and e-xposur.fl' "to inltmate pa rtrnl'r violrtk25 1-5 >25 200 + 20 + 5-10 1-5 1-5 1-5 1-5 200 + 11-15 1-5 20 + 1000+ Paediatrician Family Medicine Emergency Room Family Medicine Family Medicine Family Medicine Family Nurse Practitioner Family Medicine Paediatrician Family Medicine Family Nurse Practitioner Paediatrician 3 4 5 6 7 8 9 10 11 12 Recruitment Process Participants were initially recruited via convenience sampling of physicians/nurse practitioners encountered through my employment at Northern Health , and through snowball sampling of physicians/nurse practitioners who worked at hospitals and health clinics in the Northern Health Authority region . This broadened the sample population by using natural gatekeepers who shared the research criteria but had not referred patients to the Northern Health Suspected Child Abuse and Neglect (NH SCAN) clinic . A Northern Health representative sent an email regarding this study to all the physicians/nurse practitioners with a northern health email address. I faxed a recruitment poster and information letter to all the Northern Health Integrated health/primary health clinics in Northern BC and it was forwarded to all paediatricians in northern British Columbia via the BC Pediatrics Association (N =10) and to a group of nurse practitioners in northern British Columbia via a study participant (N=23). UHNBC social workers placed recruitment posters in key areas of that hospital. Initially, I received an enthusiastic response from a cohort 43 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION who had graduated from the same medical school. These participants were recruited by another participant via snowball sampling . As the study progressed , and themes emerged , it became apparent that an additiona l purposive approach was needed to broaden the sample to avoid potential contamination . I recognized that I needed to recruit participants from a variety of practice settings and with a diversity of education and experience to broaden the sampling population . Using a key informant approach , I identified potential participants who could add diversity due to their level of experience or practice setting and contacted them directly to request their participation . I interviewed everyone who agreed to participate , met screening criteria , and responded within a six-month period . Data Collection The primary data collection method was semi-structured interviews using an interview guide . I conducted each interview personally either face to face or by telephone and audio-recorded them. Immediately following each interview, I wrote general notes based on observations of comments or ideas that struck me as important while conducting the interview or during the conversations with the participant following the structured portion of the interview (Creswell , 2007). My notes helped me keep track of my insights and observations during the interviews . As previously mentioned, I used a reflective journal to record these notes including my insights and any changes in the research design . Data Analysis I analysed the data as I collected and processed it. In the early stages, I used the information from the reflective journal to identify codes and possible lines of 44 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION inquiry. I personally transcribed each interview and repeatedly reviewed the audio files during analysis. Verbatim text with grammatical errors could have presented a barrier to the member-checking process so I used suggestions from Carlson (201 0) and eliminated filler words false starts , and pauses to improve readability of the transcripts. Saldana (2013) stated , "Coding is not a precise science ; it's primarily an interpretive act. " (p. 4 ). I read each transcript a minimum of four times . Upon first reading , I circled the key points made by the participant. This is known as precoding , which Saldana (2013) described as "coloring rich or significant participant quotes or passages that strike you as "worthy of attention " (p.16). Boyatzis (1998) calls these "codable moments. " During the second reading , I highlighted phrases that seemed to capture a unique theme or summarize a key concept in a different colour for easy retrieval for further analysis. This is part of a larger process known as open coding (Saldana , 2013). I used an Excel spreadsheet for each question to record the initial data and entered the key statements noted during open coding . These statements in the participants' own words became in vivo codes (Saldana , 2013). I listened to each audio file and carefully read each transcript during this data entry. When all data were logged , I used this spreadsheet to identify themes reported with the most frequency . I used a dictionary to clarify the meaning of in vivo terms and then grouped these into categories of themes that shared a common meaning . These became the manifest themes, which represent the "visible or apparent content" of the participant's comments as they were explicitly stated (Boyatzis, 1998, p. 16). 45 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Upon the third reading , I exa mined patterns in th e data and paid attention to frequency of the manifest themes . The summation feature of the Excel spreadsheet allowed for easy identification of both frequent themes and novel themes . Paying close attention to both frequently and seldom occurring themes yielded valuable information about what participants agreed upon and differences in their experiences and training in child maltreatment assessment. A fourth reading of the transcripts allowed me to dig deeper into the data and search for latent themes that emerged through the analysis of the data. Latent themes are generated through deep analysis of the data using the researcher's theoretical lens and personal experience to interpret the data and examine "underlying aspects of a phenomenon" (Boyatzis, 1998, p. 16). Ethical Considerations The study was reviewed by both UNBC and Northern Health ethics review boards. Participants provided informed consent and were advised that their involvement was voluntary and they could withdraw at any time without penalty. Additional precautions were in place to ensure potential ethical and legal risks related to the legal obligation to report child maltreatment were addressed. At the beginning of each interview, I verbally informed participants of their duty to report child maltreatment, that any failure to report a child in need of protection overrides any promise of confidentiality, and I must report the information about suspected abuse to MCFD . This information was also included in the written consent. To ensure confidentiality and anonymity, participants were given an opportunity to 46 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION review and approve quotations used in this dissertation and identifying information was omitted. Summary I used a qualitative approach to explore the experiences of twelve physicians/practitioners who provided medical evaluations of maltreated children in northern BC . I gathered data through semi-structured interviews and analyzed the transcribed data using thematic analysis . The manifest and latent themes are described in detail in the follow chapter. 47 FACILITATORS AND BARRI ERS TO MEDI CAL EVALUATION Chapter Four: Research Findings The interview transcripts were coded and analysed using thematic analysis. A thoroug h review and interpretation of the data yielded five manifest themes with twenty subthemes , and four latent themes . Manifest themes were generated from concepts directly obtained from the data , while latent themes were revealed from deep analysis using critical thought and interpretation . All themes are detailed in this chapter and illustrated in Table 2. Relevant quotes were used to provide context and a fuller account of these themes . Demographics Most participants saw cases of child maltreatment in acute care settings such as the emergency room , paediatric unit, or their office settings . Two participants saw the majority of suspected cases through their residency or as a medical student. Five participants have additional training and education in diagnostic evaluation of suspected maltreatment and four of the twelve saw these children at a Suspected Child Abuse and Neglect (SCAN) Clinic. Half of the participants had training or experience in both urban settings and small northern communities . 48 FACILITATORS AND BARRIERS TO MEDICA L EVALUATION Tab le 2 Themes and Sub-themes The followin g table ill ustrates the themes and subthemes identified : Manifest Themes Assessment Sub-Themes • • Competence • Absence of decision Challenges Consultation and Co llaboration Skewed picture Latent Themes • Information-sharing problems support tools • Time constraints • • • • Need for caution Collaboration • Preference for local consultation Consultation Benefits and challenges of provincial consultation ' Northern Practice Setting Training and Education • Community visibility • • Impact of travel • • • Backlash It's all on you Capacity building Interprofessional education and training Systems • System navigation • Communication difficulties • • • Expectations Absence of feedback Limited continuity of care • Interprofessional expectations • Personal commitm ent 49 FACILI TATORS AND BARRIERS TO MEDICAL EVALUAT ION Manifest and Latent Themes Assessment challenges . All participants viewed their role as threefold : assessment and treatment of medical needs gathering a thorough history from the parent or caregiver, and ensuring there is a plan for the child 's safety. This entailed seeking alternative explanations assessing risk factors for the child and the family , and reporting to MCFD and or police . Assessment challenges most referenced included a skewed picture created by limited information , con cerns about personal competence , absence of decision support tools , time constraints , and need for caution . Skewed Picture . Overall , participants agreed that the inadequate patient history available during their assessment made it difficult to provide a complete assessment or concrete answers . "We don 't fact check what our patients tell us" (Participant 6) . " ... we only see a snapshot" (Participant 8). " ... in some ways , we are at the mercy of what you are told " (Participant 11 ). Most noted that they could not tell if the parent or caregiver was telling them the full story of what happened , leading to a skewed or incomplete picture , and potential missed cases of child maltreatment. Well I think that the thing that always sort of sits in the back of my head is that we learn in residency and in medical school the statistics about how high th e number of people that present to emergency departments who have been abused or who have experienced say spousal abuse or potentially child abu se or elder abuse and I think a lot of it ends up undetected because the prob lem is that they have something else they present with , abdominal pain , th ey present with something else and so we deal with that problem and so I guess the one question I would have is how much are we missing? (Participa nt 3) One participant also identified privacy laws as barriers to sharing of criti cal medical and social history between health care providers and child welfare social workers . . . .a lack of knowing the ecology of the child . The past hi story, the socia l history, you know you 're given every one out of thousand dim ensio ns of a 50 FAC ILITATORS AND BARRIERS TO MED ICAL EVALUAT ION child , so it's an incomplete picture . You know that is what I feel is the biggest limitation. Other limitations are administrative bureaucracy all the different silos I find FOIPPA (Freedom of Information and Protection of Privacy Act) difficult, because it blocks easy access of information . (Participant 12) Competence. Inexperience and infrequency of cases were described as obstacles to achieving and maintaining competen ce in diag nostic assessments of these cases . "Barriers , for me I think that would be for me lack of knowledge on how to proceed and what to expect for differential diagnoses ... " (Participant 7). This was referenced across all participants despite their level of training or years of experience . I think that most physicians , if you ask them , feel woefully inadequately prepared to deal with suspected child abuse and neglect and don 't know beyond the most grossly obvious what to look for, how to look for it, and what to do , once they find it. (Participant 6) ... many physicians are very uncomfortable with it in a primary care setting . They feel insecure in their knowledge , they have a therapeutic relationship with the family , they often have an antagonistic relationship with the ministry, and the issues of identification and then what to do , and it all seems so complicated and so overwhelming that I think they'd rather ignore it. (Participant 12) ... we don 't see this every day. It keeps happening infrequently so I see kids with pneumonia or asthma day in and day out but this one you see once or twice a year so your expertise isn't great so whenever you see something you have to reinvent the whole wheel and go back to square one if you like . That's another challenge , unfamiliarity. It's not like you see a kid you do this and you walk out. It takes a bit of time to get going . And we are in the north and it is always a challenge to do things on your own without having the expertise of a team like you would have in where they are highly special ized and they see things frequently and there is a team of people who ca n deal with issues. We don 't have all that. (Participant 9) Absence of decision support tools (DSTs). The majority of respondents (eleven out of twelve) were not aware of any specific screening or decision support tools available to assist them in identifying and addressing all types of child 51 FACILITATORS AND BARRI ERS TO MED ICAL EVALUATION maltreatm ent. Many were unsure of how to conduct a thorough assessment and wh at steps to take in ensuring a child 's safety. So no there's none that I know of. There's no good clear support too ls to walk me through like there would be for a sexual assault for an adult or things like ; that there s very clear guidelines but I don 't see those in suspected abuse and neglect. They just tell you if you suspect it, report it. And it's vague enough that you feel should I? Shouldn 't I? I don 't know . What does it look like? How do I recognize it when I see it? And then retrospectively you often see all the times that you 've missed it and you feel awful that you did , so how do we help? No there 's no good decision support tools . (Participant 6) I think with all the medical legal stuff it's a little murky, so if Northern Health had a policy or there was something clear about how you went through this process then you know to make sure that you 've contacted the appropriate people , and that there is certain resources that need to be given to well I guess the ministry would do all that so I mean I don 't know I assume I'm doing the right thing I hope I am but I don 't know. So you know maybe there is some sort of procedure that needs to be followed . (Participant 3) Child abuse assessment is considered an area of specialty (Adams et al. , 2015). Physicians and nurse practitioners with advanced training in child abuse assessment were able to identify diagnostic or screening tools they utilized to assess children referred to the SCAN Clinic. No respondent could identify a screening tool they used to identify both physical and sexual abuse in children in their regular practice setting . All participants expressed a need for decision support tools relating to identification and assessment of child maltreatment in their practice setting . I think that's the hardest part, you know you maybe have some sort of sp idey se nses that something is going on but whether or not you act on that or ask th e right questions to get the right answers because you never want to assume , but I just kind of wonder if we are under-diagnosing . (Partici pant 7) If there was some sort of standard form that was filled out during th e assessment time and the reporting would be more structured rath er than free verse . (Partici pant 5) Information sharing problems. Deeper analysis revea led inform ation sharing problems as a latent theme. Some of the respondents with hospital 52 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION experience were aware of the Paediatric Sexual Abuse Protocol at UHNBC , which was developed by a local paediatrician for use at UHNBC . As I was completing this research , the SCAN Clinic team revised the protocol to broaden the scope and ensure it is relevant for any health care setting in Northern Health . I cannot comment on how many physicians and nurse practitioners are aware of this revised DST. Interestingly, I was not aware that the revised tool was operational until I began updating policies for the social work department in my new role as interim chief social worker at UHNBC . This was despite the fact that social workers in my department have key responsibilities under this protocol. This oversight in com munication highlighted the need to ensure key stakeholders are promptly informed of any changes in protocols or DSTs . Time constraints. Several participants referred to time pressures associated with completing a thorough assessment, coordinating diagnostic testing , and meticulously documenting the findings . "I think they need to see less patients per hour so they can spend more time with their patients." (Participant 8) . . . .you are in a busy clinical environment, meaning you are running around dealing with kids who are septic, having seizures or neonates, who are ventilated and stuff like that and then there are these non-urgent requests just like what happened recently. That is a time-consuming process that's a major challenge for a busy clinician, who is running the hospital clinical work to be burdened with this is difficult. I'm not saying that the work is not important, it is very important, but perhaps somebody else could do that in a non-urgent way. (Participant 9) Practically speaking , it's the time in our office . One child I saw had funny bruises and the amount of time it took me to get the history, and then [take] photos in my office and put everything [down], [it] was extremely time consuming . I was an hour behind in my office then . (Participant 2) Need for caution. Participants referred to a need for added precautions in these cases to safeguard against legal and social ramificati ons. "If something 53 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION 54 presents acutely then I must take all steps to make it as legally airtight as possible ; not to screw up the evidentiary process ." (Participant 12). They have to carefully review all the details and ensure they are able to back up their opinions. In sharing information with others , they must avoid making prelimin ary statements because these may need to be retracted . This means they need to take control over the information shared to ensure it is as accurate and as ce rtain as possible . Because one of the con cerns I have in these situations is that it's been made clear to me that if we suspect versus we know you don 't put more information than you know. But in medicine sometimes , we give our opinions more liberally so it would be helpful to have some sort of document that would help us refra in from committing to things that we aren 't sure of and reminding us how to proceed in these very important matters . (Participant 5) This theme is also closely connected to the theme of time constraints , as this preparation and attention to detail is time-consuming . When you go into court you have to absolutely know your stuff left right and centre . So being asked an opinion and being asked to put that down in paper, I need to be recompensed for that because that's going take me a long time because I have to be so meticulous and so careful. (Participant 12) Other participants worried about being wrong and damaging the doctor-patient relationship as the child 's extended family members are also patients in their practice . I would assume , that a lot of the kids that we see are probably bei ng und erdiagnosed . Just from fear of the provider of making those con clusions and trying to balance the acts of seeing their parents as patients but also the child and keeping that relationship intact. (Participant 7) And to be honest, I have not heard anything from that family since . And that's another thing that happens. You done something and you've alienated that whole family. Which in some ways can 't be helped and thank goodness there 's more than just one person here because th ey ca n just see someone else . Well in this scenario , I've just alienated a whol e set of people and something that just goes along with it. (Participant 11 ) FACILITATORS AND BARRIERS TO MED ICAL EVALUATION Collaboration and Consultation . In this sample of physicians and nurse practitioners none of them addressed cases of child maltreatment independently. They relied on a variety of professionals to ass ist them in responding but tended to rely on local colleagues and professionals they knew and trusted . Those with advanced training and experience in child maltreatment assessment identified benefits and challenges of consultation with provin cial experts . Coll aboration . Those in shared pra cti ce settings su ch as integrated health team or multidisciplinary teams listed multidisciplinary colleagues as a source of assistance . . . .that would be the GPs in my clinic the other nurse practitioner who has been working there for [omitted] years , so the clinic here would be a resource (gestured to the SCAN Clinic) , one of the registered nurses I work with , she's really skilled and has been working in our clinic for [omitted] years so having her as a resource , our social worker is a great resource , so just accessing pretty much everyone on the team and discussing it. (Participant 7) All participants identified that they consulted with local medical colleagues and health care social workers at the SCAN Clinic, hospital , or their integrated team . All but one stated they contacted MCFD social workers and collaborated with RCMP . Some sought advice and assistance from other professionals such as th e local Infant Development Program , psychiatric nurse , or radiologist. Consultation. Overall , participants described the experience of con sulting with colleagues in positive terms and noted that they received a quick, helpfu l response . As one person said , "Without the SCAN clinic here , it would have been Google and a wing and a prayer! " (Participant 6). I think it's been a positive experien ce consulting with co lleagues , everyone seems equally concerned and wants to address th e issue as well , speaking with [another physician] before I came here and she was saying how she doesn 't really feel too comfortable being responsible for th e assessment eith er 55 FACILITATO RS AND BA RRIE RS T O MEDI CAL EVA LUATI ON and neither do I but everyone is willing to help and we're all on the same page in that rega rd . (Participant 7) Half of th e participants indicated that they got what they needed through invo1 lving professionals in the Northern Health region . Preference for local consultation . Upon deeper analysis , this emerged as a latent theme . Respondents seemed to prefer co nsulting with those they knew and trusted . The importance of relationships to a unifi ed res ponse is highlighted in this respo nse : It's really tough to work with someon e that you don't even know their name . So its one of those things I think we really need to do a mu ch better job of working together as opposed to working in silos . I think that's one of the biggest things for me that would be helpful is to know who my team is." (Participant 11 ) Only those with advanced train ing in child maltreatment assessment identified provincial experts, located at BC Children 's Hospital , as a source of assistance . Most pa rticipants had never consulted with provincial experts for these types of cases . When questioned , I offered a prompt such as , "like BC Children 's". While I noticed a confidence in local resources , it seemed that some participants did not have enough experience to recognize the lim itations of local resources and wh en th e services of BC Children's were needed to make the determination regarding child maltreatment. ... We have the resources , if I need to do a skeletal survey, I cou ld do that. If I needed to do a CT head I could do that I mean I don 't know I've never had to ask an ophthalmo logist up here to do a retinal evaluation of a potential shaken baby and you have to sedate the baby to do that but still th at might be doable up here . We would have the people and the resource s to do that so I can 't think of a situation , a potential situation , off the top of my head where I would need some resource that we don't have up here . (Parti cipant 3) 56 FACILITATORS AND BARRI ERS TO MEDI CAL EVALUATION Benefits and challenges of provincial consultation. Those with extensive expe rience and advanced training described both benefits and cha llenges to longdistance consultation . The relationship with provincial experts at BC Chi ldren's was see n in positive terms because they have common training , get together to review cases , and know one another. The experiences would be very positive like consulting with BC Children 's Hospital child protection team down there . Very exp erien ced people . Very open and willing always available to answer questions , to be helpful , to provide second opinions if needed . I personally think ... that the service that BC Children 's Hospital provided not just in terms of second opinion advice and support, but also in terms of education . They provided a tremendous amount of ongoing education . (Participant 12) Case-specific consultation with provincial experts was viewed as helpful to provide reassurance when there is doubt about the diagnosis. " ... when in doubt you don 't want to make the wrong diagnosis, so at that time you may want to call a provincial expert just to give you some moral support and some guidance ." (Participant 9). It is often the physician who is required to inform the family and investigators that child maltreatment is the suspected cause of injury and the responsibility still remains with that physician to provide justification for this diagnosis. The consultant physician is not the one actually seeing the injury, hearing the story, or providin g th e diagnostic opinion . One participant described a difficulty consulting on the se cases when the consultant physician had not had any contact with the person provid ing the history or the patient. The thing is the majority of them aren 't seeing them or hea ring the story and they haven 't had any contact with the child or the storyteller or the caregiver. So all they can do is just give their opinion based on wh at th ey hear from you. So the buck stops with you ultimately because you will have to take a position as to where you go with that because the report hinges on what you have to say. And a lot of it depends on wh at you ultimately have to say on whether this is accidental or non-accid ental. You can make or brea k a thing so I find 57 FACILITATORS AND BARRIERS TO MEDI CAL EVALUATION th at chall enging because you 're it. None of the other professiona ls can actu ally make that statemen t for you . (Participant 9) Northern practice setting. More experienced participants and those who had practiced in small northern communities identified barri ers related to the northern practice setting such as community visibility ba cklash , concerns about providerpatient relationship and the impa ct of travelling to acce ss specialists and equipment. Community visibility. In smaller rural communities , physicians may also be a member of the community and therefore may be required to interact with patients in a va riety of social contexts . This reality means they are more visible than those in la rger social settings who might never interact with patients on a personal level. You don 't have as many people to do the different jobs. So if you are one of two physicians in town and you live in a town of three thousand people , chances are , you socialize with these people that are also your patients . You ca n't clearly and decisively separate your personal life and your work practice life as you can in Vancouver where you might or in any other major city where you might work in area A but you live in area B so you never really cross . (Partici pant 6) So me pa rticipants noted obstacles related to this community visibility and the risk to the provider-patient relationship when identifying child maltreatment as one of several possibilities for suspicious injuries. You generally have a patient and their entire family is a patient. I don 't personally live in [community X] , I live in [community Y,] so there is a degree of separation there. But for people that live in [community X] , you ca n go to the grocery store and people can ask, "Why did you do that?" whil e you are buying mi lk. (Participant 11 ) Impact of travel. In an urban centre or children 's hospital , diagnostic testing can be done onsite as part of the normal course of medical assessment or as one person commented , " ... it was abu se until proven oth erwi se" (Participant 11 ). Child maltreatment is con sidered part of th e differential diagnosis for many childhood 58 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION injuries and so , additional testing can be done without additional inconvenience or making complicated arrangements . In outlying northern communities , required tests such as infant bloodwork requ ire the patient to travel to Prince George or a larger medical facility. I mean if you want to do any tests like an ultrasound or if it's a small child and you are looking to do some diagnosti cs oth er th an rud imentary bloodwork, that has to go to Prince Georg e, or [larg er community] from here . In terms of training for sexual abuse , I don 't have that and none of the other physicians I work with have that either so for that sort of thing we gen erally have people go to Prince George . (Participant 11 ). This travel can be costly for families living at or near th e poverty line . One participant highlighted how this barrier can lead to a perception that the parent is neglectful. So there are limitations to what you can do and what you can accomplish ... and for people that are really at a financial disadvantage , that trip to Prince George costs $20 in gas that they don 't have, so sometimes things that should get investigated don 't get investigated , which leads some people to think that this is neglect but when in all reality, it's that they are under such financial constraints that they choosing to feed their child rather than bring it to a cardiologist. (Participant 11 ) Aside from the financial costs of travel , there are potential relationship costs . The need for travel means the physician or nurse practitioner must commun icate their suspicion of maltreatment early in the course of treatment and prior to receivi ng the results of confirmatory testing . One participant described how thi s could negatively affect the patient-provider relationship consequently; th e physician/nurse practitioner might carefully weigh the decision to refer to a larger comm unity for additional testing . It's sort of one of those things that I wouldn 't be hum an if I didn 't say th at it makes you stop and think before you do som ethin g th at might have implications ... But sometimes wh en you think it' s go ing to be a big deal , ... you try and talk yourself out of som ething th at your gut te ll s you , you shouldn 't. 59 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION And in that case , you just have to go with your gut and be thankful that you don 't live in the same town .... But it does definitely there is more of an implication than I ever had when working at Children 's Hospital you come in with a kid who had a sei zure and you do a CT scan to see if they had retinal haemorrhages for shaken baby syndrome .... that's more of the fact that you are at a children 's hospital ICU and you can do those things , as opposed to here , where A you can 't, and B, what does that mean? Why are you doing that? And you have to answer to that fairly personally. (Participant 11) Backlash. Several participants described negative repercussions resulting from their involvement in these cases . These ranged from situational anger and accusations directed to the physician to legal complications resulting from their assessments. One participant described the experience of being reported to the College of Phys icians and Surgeons and threats of legal action . . . .parents or the caregivers accuse you of mal-intent. You report something as non-accidental and then they come at you and say, "Don 't you have children? My children are being taken away from me now, so how would you feel if your child is taken away? " So emotional blackmail when you are actually doing your duty; accusations and bitterness because you are trying to do the right thing . The perpetrator or the parents, it's not what they like to see and there is a conflict. So those are some of the challenges you get a little a bit of abuse as well because of that. (Participant 9) Physicians are sometimes reluctant to enter into possible accusatory situations because of the potential problems that can occur afterwards and I'm not saying that physicians are just afraid or bad people or anything like that it's just kind of a normal reluctance at first to accept that people can be of such a nature that they'll harm somebody and secondly that if somebody is accused there is a lot of implications that can go along with that, anger at the physician , legal problems, stuff like that ... (Participant 10) It's all on you. Several participants noted an increased level of responsibility for paediatricians who are expected to coordinate these complex assessments with limited resources and amongst competing priorities. Even in Prince George, certain diagnostic tests are not avai lable or should be interpreted by a specialist, such as a paediatric radiologist, who has the training and sees the volume of paediatric 60 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION 61 patients necessary to acquire expe rtise in interpreting the results. Most participants described having easy access to a paediatrician ; however, it was interesting to note that the paediatricians themselves acknowledged that they are general paediatricians who are expected to see everything . They are at a disadvantage compared to paediatricians in larger urban centres who specialize in child abuse, and have ready access to teams of other specialists as well as diagnostic equipment. So sometimes the imaging tests , like getting the X-rays done , and then getting it done with very high quality and then interpretations can be limiting although it's not hard to get images interpreted at a remote site , but sometimes the quality of the images isn 't always there , or there might be missing images , so that's one . Sometimes the blood tests that are required are not possible here , meaning the amount of blood we have to take to run the test in our lab is excessive for a baby or a small child . Whereas the BC Children 's they could draw it out on a much smaller amount because their machines are different. That's one . And the other is sometimes the samples have to be taken here but sent to Vancouver because we don 't run the tests here and there 's problems there . We get problems with samples breaking down on the trip , or waiting a few days , or being inaccurate , so that's a problem . And then for acute injuries , kids that are in hospitals with serious injuries I think there 's major practice limitations because we don 't have anyone more specialized than a general paediatrician. So you can 't even really get the opinion of a paediatric orthopaedic surgeon if you were wondering how much force is required for Fracture X. Also if you have a baby with especially, but, in a kid with a head injury it wouldn 't-we wouldn 't even- it wouldn 't be appropriate to keep them here because we don 't have any paediatric neurosurgeons , neurology, things like that. We can 't do CT scans of the head and MRis of the head under sedation if we wanted to , so there are limitations with those things . (Participant 1) .. .we are in the north and it is always a challenge to do things on your own without having the expertise of a team like you would have in where th ey are highly specialized and they see things frequently and there is a team of people who can deal with issues . We don 't have all that. (Participant 9) Training and Education. Eleven of the twelve participants noted the importance of increased training and education in identification and assessment of child maltreatment. Despite limited training in assessing child maltreatm ent, physicia ns and nurse practitioners are expected to provide this servi ce as part of general FACILITATORS AND BARRIERS TO MEDICAL EVALUATION 62 medicine . Implicit in this role , is an assumption that all physicians and nurse practitioners have this competency. I would say I wouldn 't feel all that comfortable with it and a lot of that is lack of experience and lack of training . .. . I remember we had a session , maybe an hour or two session , when I was a resident , but I don 't feel I was all that well trained in everything that I should be asking and looking for and how I would give my professional opinion . (Participant 4) Capacity building . Physicians and nurse pra ctition ers provided numerous suggestions for building capacity in child maltreatment assessment through ongoing education and training , ready access to information and availability of expert consultation . It'll be nice to have in-service training every now and then . I mean we had one two or three years ago . It would be nice to have regular education on those topics and maybe some decision-making tools , maybe a physician or a paediatrician who is an expert in doing this to be available at th e call of anyone , and we generally rely on a provincial radiologist to give us an opin ion so easier access to them , and prompt reporting of any findings , of abnormal or normal. Those would be some of the resources that we just need to have . (Participant 9) From a medical perspective , maybe some form of learning or medical education , like case-based medical education outlining what the steps are and what the resources are and education like that would probably be helpful ; and knowing particular to the north , what our resources are, or what provinci al experts we can access" (Participant 5) I think it would be nice to have a little education session on that. Cause for me in nurse practitioner's school I didn 't actually learn anyth ing really about assessing child sexual assault or any kind of child abuse. I mean you hear about it, you read about it in your text books , but we have never had any formal education and even similar in RN school , you know what that is but you don't actually have th e training so it would be helpful to go to an education on it whether it be a half day or a teleco nference or webin ar or full conferen ce in Prince George , set up in th e reg ion . (Participant 7) I know one year th e SCAN Clinic ca me and did a talk at Northern Doctor's Day and did go over cases and I found th at very useful. I think an update every once in a whil e to th e fami ly physicians wou ld be the best thing possible . FACILITATORS AND BARRIERS TO MEDICAL EVALUATION 63 These are things that are concerning: chi ldren who don 't follow up with appointments, who don 't come in , fractures that don 't match the history, like a few big glaring ones , bruises in children that don 't move, that kind of stuff; big reminders for doctors just to be vigi lant or aware of it. (Participant 2) Certainly in family practice residency there was no discussion . I did two months of paeds clinics and at no point, was tools around suspected neglect or abuse mentioned there was no support around that it wasn 't even really talked about as something that might come up. Med school we did time in the SCAN clinic but even that it was probably our biggest exposure was one visit to the SCAN Clinic. (Participant 6) lnterprofession al edu cati on and training . Several people highlighted a need for increased training for their multidisciplinary colleagues , such as nurses, emergency room doctors , police , and social workers . "I think if we did more training together and started to use the same language and learn from each other's experiences we would be on the same page more and that's the way." (Participant 8) . A shared understanding of common of signs of child maltreatment was thought to improve the odds of earlier recognition : I think Northern doctors or rural doctors in general really could use the emergency room , front line , walk in clinic , family doctors could use a screening tool , like you said , or, even a team that that is trained in like red flags to look for. I don 't even mean a medical doctor. I mean it could be someone like their triage nurse in the em erg , having additional training in looking for features concerning for possible child abuse . Because I think often times at least with the physical injuries in the sexual abuse the first point of contact is the emergency room , it's not with a paediatrician . And I think that if the first person to see them , like the triage nurse , or all th e nurses, have more training in terms of red flags ; that would be really good! Because if th ey bring to the doctors attention say this kids only 5 months old and he's got a bruise on his back I'm worried about inflicted injury then that will at least would steer the doctor in the right direction . (Participant 1) The same participant explained that when investigators lack a basic understanding of child abuse it can be difficult to communicate the meaning of diagnostic results ; "police officers that can 't believe you ca n have a norm al genital exam after sexual FACILITATORS AND BARRIERS TO MEDICAL EVALUATION abuse, you know that's not helpful because it's almost like you have to convince them to pursue investigations and that shouldn 't be part of my job ." (Participant 1) Systems. Participants identified cha lleng es associated with navigating unfamiliar systems , interprofessional expectations , communication difficulties, absence of feedback , and lack of continuity of care . These challenges emerged as barriers to effective interprofessional collaboration in these cases . System Navigation. Most participants described positive interactions with medical providers , and police and child protection investigators , however participants expressed that they did not understand how to navigate those systems. "I don 't feel prepared to work in a system I don 't understand and it's different every time I encounter it. " (Participant 11) I mean a major one is just inexperience with the system , sometimes sort of daunting when you are faced in that situation like where do I go and what number do I call and if it's the weekend , do they need to see the SCAN Clinic, do they need , there is a lot of sort of unknowns because I don 't see it often and I haven 't had much experience with it, then I get kind of caught up in the bureaucracy of it. (Participant 5) Knowing what a social worker does . Knowing what our local ministry workers do . I think that would be like the first thing because I don 't actually know. I've tried to contact the ministry because our nearest MCFD office is in [a neighbouring community] and they've got one person that comes out here once per week and I don't know who that person is and I've been here for almost a year. I don 't honestly know what they do . (Participant 11) Other limitations are administrative bureaucratic, all the different silos , I find PIP A very difficult, because it blocks easy access of inform ation . Sometimes social workers will send me a section 93 , or whatever, you must release all your records . But that only pertains to public employees , and we 're not public employees and we 're not governed by that and they don 't seem to know that. (Participant 12) Communication difficulties . lnterprofessional communication was see n as cha llenging for several physicians in th ei r attempts to discuss medical and child 64 FAC ILITATORS AND BARRIERS TO MED ICAL EVALUATION 65 protection matters with police, social workers, and members of the criminal justice system . I think that another barrier would be language. I think that being in medicine and thinking and talking medicine we use a slightly different language or significantly different than someone in a different field for instance the police or the ministry and when I say something it might mean something to me but sometimes my words might be taken differently to other people. (Participant 8) .. .sometimes I think a limitation is that the social worker at the ministry that we talk to and myself might not be speaking the same language so like I might feel like there is a real child protection issue and the social worker might not agree . So even though I might feel like that's part of my role , it's like I feel like it's part of my role to make sure the kid is safe and that any of the other kids around are safe , but actually I can 't implement that part that's not really my job . (Participant 1) Expectation s. Physicians and practitioners identified that police and child protection workers can have unrealistic expectations about the certainty of medical opinion . This perspective can act as a barrier to effective collaboration . "It's the same thing as any medicine really , you can 't always give 100 °/o answer." (Participant 8). "I can 't make things up but [and] he can 't charge people unless he has a degree of certainty but that's just the legal system ." (Participant 2) There is a misconception about how much information we can gain from a parent who brings in a child for examination . We can assess a child and look for injuries but we are not more able to do a real good assessment of a situation in terms of an environment than a trained social worker would be. I think there is more of an expectation of physicians in a short med ica l visit th an might be the case ." (Participant 10) Honestly I think it would make my job a lot easier if the police and th e legal system would understand that nothing is 100°/o and I think th at's the most frustrating thing is that I think they often want to know how ce rta in are you that this is inflicted and it's pretty much almost never that you are certain. (Participant 1) FACILITATORS AND BARRIERS TO MEDICAL EVALUATION 66 "The trouble is not just doing the exam , it's you have to do the exam , interpret the findings and give them to the ministry possibly all in the same visit without a lot of time to pro cess. " (Participant 6) lnterprofessional expectations. Deeper analysis of this issue , and reflection from my own practice experiences , revealed this as a latent theme as participants also described their own lack of understanding of the role of CPS and police in gathering collateral information and meeting legislative requirements . I began to understand that physicians'/nurse practitioners' expectations of the role of police and CPS in these investigations might contribute to the problem . " ... I might feel like there is a real child protection issue and the social worker might not agree ... " (Participant 1). "I don 't honestly know what they do" (Participant 11 ). This may be connected to limited communication following child protection reports and lack of information regarding outcome of criminal investigations. Absence of feedback. There was a sense of uncerta inty from participants about the value of their assessments due to a lack of feedback and closure. " I don't' think we do very good assessments because we don 't know what happens with our assessments" (Participant 11 ). " ... I mean I don 't know, I assume I'm doing the right thing and I hope I am , but I don 't know" (Participant 3) We don't get any feedback later or any follow-ups. So with the two children I reported to the ministry, I didn 't get any follow-up and I have no idea about afterwards about what happens to them besides when they next come in for their next appointment. (Participant 2) Other participants worried that involving MCFD or police might put the child in more danger whil e waiting for a response. Is the ministry resourceful enough to deal with things in a timely manner? Am I going to put the child in more danger by disclosing and having the FACILITATORS AND BARRI ERS TO MEDI CAL EVALUATION 67 ministry come to the house in an hour or two hours or three hours? Is that okay? (Participant 6) Limited continuity of care . More than half of the participants (seven of twelve) could not identify established policy or procedures they use to facilitate continuity of care for children assessed for child maltreatment. This gap was identified as existing in both-general paediatrics and family medicine with no formal procedural remedy. "We don 't have continuity of care , we don 't even know what happens to our patients most of the time ; they disappear into the woodwork ."(Participant 8) .. the onus is always on the parent to bring the kid back so even if we say to them come back in three months we need to see how they are growing , if they don 't come back there is no system in place for that to be flagged . That is a problem beyond just educating people about it because all family doctors would probably realize that for these high risk kids that's not working , that beyond that we need to probably come up with a plan like maybe get the electronic records providers to figure out a way to have it sound an alarm in three months that so and so hasn 't phoned yet or whatever because that's a problem. I don't think it's appropriate to put the onus on the parents when we are already concerned about the parent's ability to parent to follow through. (Participant 1) Feedback following a child protection report was seen as essential to continuity of care by many participants. And also that there is some feedback for follow up of the child who is reported , goes back home and comes back to the clinic at some tim e in the future . I would want to know about what happened , what was the outco me of the reporting and whether there was any follow up other than just me in the medical sense . (Participant 10) Another participant stressed the importance of receiving the hea lth and socia l history of chi ldren in foster care . 1 think that if I'm following a child up over a long term with co ntinuity of ca re, the lack of feedback from th e ministry is significant. I see many child ren now, drug addicted babies, children coming from lots of chaos, neo nates and lots FACILITATORS AND BARRIERS TO MEDICAL EVALUATION of ea rly life . A huge percentage of my practice is children in foster care. And so not getting the prenatal history, the history on the parents , whi ch is all so important to help me do my job in trying to protect that child . (Participant 12) In the absence of formalized policies and procedures, some participants recognized that vulnerable children may need additional oversight and promising practices were described . Participants from an integrated health clinic ensure that any of their patients seen at the SCAN Clinic are called for follow-up by their multidisciplinary team to ensure that the medical recommendations are carried out. This same clinic sees all children in the first week of life and then the children are flagged for follow up if they do not come in for milestone check-ups . This follow-up allows an opportunity to check in with the family to ensure the child is doing well and there are no unmet medical or psychosocial needs . Personal commitment. Deeper analysis revealed that some participants made a personal commitment to follow up with at risk children . These participants described experiences that lead them to implement strategies in their personal practice setting to ensure the health care of vulnerable children was monitored . I don 't have any set policy or procedure but I am pretty particular about making sure that the kids who are at risk or who I think are at risk are not lost to follow-up . So for example , if they don 't come to appointments more than once or twice I call the ministry but I'll put it in writing and call the ministry or put it in writing and send it to the ministry um so it's not like a formal policy and it's possible I would still miss some but I don 't think I miss very many. (Participant 1) ...one of the greatest lessons that I have learned is not to abandon th ese children. Even if I see them once a year, just to check in , just to check that everything is staying ok, or sooner if they need it. Just as a presence in thei r lives. (Participant 12) 1 think if patients don't follow up, especially the children , if th ey don 't follow up as recommended , then they need to track the famili es down and find out what' s going on . If you send referrals on to a specialist and they don't show 68 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION up, I think you need to track that down , I think you 're responsible for that. That's been one of the recurring themes at our clinic is all these kids that have accessed services and haven 't had appropriate follow up. (Participant 8) Summary Medical evaluation of child maltreatment is fraught with challenges in primary care settings . Through listening to the perspectives shared by these northern physicians and nurse practitioners who have endeavored to provide this service in northern BC I have come to understand that their experiences mirror those of other medical providers internationally. The northern practice setting presents additional difficulties due to community visibility, dual relationships , limited resources , geographic considerations , and distance from specialty services and resources . These challenges were addressed through reliance on relationships , consultation , multidisciplinary collaboration , and personal commitments . Participants offe red many tangible suggestions for systemic improvements ; such as interprofessional training , use of electronic medical records to flag children for follow up , and regular reminders of child maltreatment warning signs . Recommendations will be described in the following chapter. 69 FACILITATORS AND BARRI ERS TO MEDICAL EVALUATION Chapter Five: Discussion The previous chapter described manifest and latent themes, wh ich emerged th roug h thematic analysis. This final chapter provides an interpretation of key findings , describes the significance of these findings , congruency with previous research , study limitations , recommendations , directions for future research, personal refection , and a conclusion . Interpretation of Key Findings I explored factors that facilitated medical evaluation of child maltreatment as well as barriers with three research questions: 1.) How do northern physicians/nurse practitioners view their role in child maltreatment evaluation? 2.) How do northern physicians/nurse practitioners determine what interventions are required? 3.) What resources do northern physicians/nurse practitioners access when responding to this issue? I discovered that northern physicians/nurse practitioners viewed their role as primarily to assess and treat injuries and ensure a child 's safety. They saw this as a serious responsibility with important repercussions for the child , the family , and themselves. Participants described a lack of practice guidelines and lack of decision support tools , so they determined what interventions were required by relying on resources such as their own education and training, consultation with people they knew and trusted , as well as collaboration with a wide variety of interprofess ional colleagues and specialists . To fulfil the full scope of their role , participants cautiou sly documented their findings and contacted MCFD . Some participants took steps to 70 FACILITATORS AND BARRI ERS TO MEDI CAL EVALUATION monitor the child 's health in their individua l practice settings fo llowing a chi ld maltreatment assessment as a personal commitment to their ongoi ng care. Barriers to Child Maltreatment Evaluation All participants in my study expressed an interest in obtaining further education and training in child maltreatment evaluation . Several participants noted tha t they did not see child maltreatment cases with sufficient frequency to develop or maintain competency in diagnostic assessment, which is congruent with the literature . Adams and her international colleagues acknowledged this reality in their efforts to develop a national certification program for child abuse evaluation (Adams et al , 2015). As outlined in chapter two , studies have consistency shown deficits in education and training for both physicians and nurse practitioners in recognizing and responding to child maltreatment. Despite robust evidence and wide acknowledgement of this competency issue , there are no official restrictions on scope of practice for physicians providing diagnostic medical opinion for suspected child maltreatment. Nurse practitioners have some restrictions regarding diagnostic tests they can order however, the medical evaluation of non-accidental injury and sexual assault are still within their general scope of practice (CRNBC, 2015). More at issue , there is no recognition of differential competencies from a provincial child protection standpoint. MCFD has no minimum standards for medical evaluation of child abuse (M CFD, 2004, p. 60). W hile SCAN Clinics are available for complex cases of child maltreatm ent, there is no requirement for CPS workers to access this service for complete assessment or cons ultation (MCFD , 2004, p.60). In my own experience , various MCF D socia l 71 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION workers and team leaders have told me that MCFD accepts a medical opinion from any physician to substantiate an allegation of abuse or neglect. Despite recurrent problems with missed cases of child maltreatment, various provincial inquests and RCYBC reports dealing with critical injuries and deaths of vulnerable children remain silent on the issue of competency (Flemming , 2007 ; Gave , 1995; RCYBC, 2009). Even when a child maltreatment specialist assesses a child , the medical evaluation has little utility if the decision makers lack the basic knowledge to interpret the findings . Participants in this study expressed frustration with what they perceived to be unrealistic expectations of the certainty of a medical examination . Those with more training and experience noted that CPS and police investigators appear unable to differentiate between the diagnostic opinion of a child abuse specialist and a general practitioner and seem to lack understanding of the rigor needed to conduct these assessments and provide a diagnostic opinion . Consultation and collaboration are based on mutual sharing of important information . Poor information sharing between medical providers and CPS remains a significant barrier to identifying and addressing child maltreatment. The 2009 RCYBC report recommended that physicians obtain medical and social history from MCFD social workers , and other health care providers in addition to the foster parent. Participants in this study identified challenges associated with poor information sharing between themselves and CPS . They were una ble to do a complete assessment due to limited or unrel iable hea lth and social history available during their assessments, whi ch created a skewed pictured of the child 's circumstances. A lack of feedback regarding th e outco me of a child protection repo rt made it difficult for participants to know wheth er their patients received the help they 72 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION needed and to clarify their own role in the child 's follow up care. Feedback also serves a useful educational purpose for physicians/nurse practitioners who would not otherwise know whether their concerns were justified . It also allows other professionals such as police and medical professionals to develop their knowledge about child protection matters. Faci litators to Child Maltreatment Evalu ation I had the opportun ity to interview participants who worked in a variety of practice settings includ ing sole practitioners , interprofessional teams, shared practice settings , and hospitals . I learned that they had a good understanding of their roles and responsibilities and did not approach these cases independently. All participants demonstrated an understanding of their mandated duty to report concerns to the MCFD and expressed a willingness to do this despite their concerns with that system. The participants also relied on consultation and collaboration with their colleagues to address these complex situations. Those who worked in shared practice settings described their team members in positive terms and saw them as accessible and supportive. In addition to their physician/nurse practitioner colleagues , participants described a reliance on their relationship with other professionals such as social workers at th e hospital or on their interprofessional team , social worker at SCAN Clin ic, and MCFD social workers, nurses, child development workers , and police to assist them in responding to chi ld protection concerns . The NH SCAN Clinic was identified as an important source of education , training and support to half of the participants. Pa rticipants described positive 73 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION experiences of contacting the NH SCAN Clinic for consultation , referring children , and receiving follow up reports . Others noted that they had attended presentations by the NH SCAN Clinic at the Northern Doctor's Day or during medical school , or had spent time there during their residency. The BC Children 's Hospital SCAN Clinic was seen as an important source of support and education for local paediatricians and physicians from the local SCAN Clini c. Significance of Findings Children will not be safer if they are not identified and accurately diagnosed. The participants , over half of wh ich were medical and nurse pra ctitioner graduates with five years or less of practice , report the same challenges with limited education and training in child maltreatment reported in the literature (Flaherty, Jones , & Sege , 2004; Heisler, Starling , Edwards, & Paulson , 2006). Missed opportunities for early intervention equate to greater likelihood of the child experiencing chronic physical and mental health problems throughout the life course . Considering th e prevalence of recurrent child maltreatment in northern BC , and the enduring impa ct of child maltreatment on a child 's life-long physi cal and mental health , it is esse ntia l fo r NH to take the lead and create opportunities for co ntinued professio nal development for medical professionals , interprofessional training , and to move forward on efforts to create a shared electronic medical record that would allow rap id exchange of information needed for continuity of ca re, decision-making , and risk assessment. Congruency with Previous Research This study mirrored th e findin gs of Zieg ler, Sa mm ut, and Piper (2005) who found that emergency department physicians req uired more training and resources 74 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION to complete child maltreatment assessments . Similarly, participants in my study described a need for more training for themselves as physicians, but also for nurses who do the initial screening , and family doctors/nurse practitioners who see the child in follow up (Webster & Temple-Smith , 201 0). Concerns expressed by participants regarding achieving and maintaining competency in child maltreatment assessment are compatible with the literature (Adams et al. , 2015 ; Anderst, Kellogg, & Jung, 2009; Flaherty, Jones , & Sege , 2004 ; Heisler, Starling , Edwards, & Paulson , 2006 ; Ziegler, Sammut, & Piper, 2005) . Barriers associated with the northern practice setting were similar to those reported by others such as Schmidt and Klein (2004) who studied the experiences of child protection workers practicing in northern and rural settings . Study Li mitati ons This study provided an opportunity to explore the perspectives of twelve northern physicians/nurse practitioners who volunteered to participate and to engage in a personal dialogue with me as a researcher. It is possible that the study design might have excluded those who would have liked to share their views but who preferred to remain anonymous , such as in an anonymous survey design . Th e study provides an opportunity to learn from the experiences of the participants but th ei r views are not representative of all those who do this work and th e res ults cannot be generalized to the larger group of physicians/nurse practitioners in northern BC . The northern practice setting is diverse and there are numerous ways that maltreated children access the health care system for treatment. I did not have the opportunity to talk to outpost nurses who see children on reserve and in small isolated 75 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION communities often prior to them accessing care from physicians or nurse practitioners . While I contacted physicians all over northern BC , 1 recognize that some sole practice physicians simply did not have the time to participate due to the high demand for their services and limited supports . Recommendations The following recommendations were extracted through analysis and interpretation of the qualitative data , from the literature review, and from the participants themselves . They represent recommendations for systemic change at the microsystem level , amongst physicians and nurse practitioners; mesosystem level between physicians/nurse practitioners and other service providers ; exosystem level between organizational systems (health, education , professional bodies, government agencies) ; and macrosystem level involving large-scale organizational policy changes . 1. Build Capacity of Northern Physicians/Nurse Practitioners through Education and Training. Education about child maltreatm ent should be incorporated into the curriculum of all physicians and nurse practitioners practicing in northern BC . Through partnership, Northern Health , the NH SCAN Clinic, and the Division of Family Practice should provide opportunities for case-based learning opportunities for physicians and nurse practitioners to ensure they have ongoing exposure to advancements in chi ld maltreatment evaluatio n. The stakeholders noted above should collaborate to provide regular reminders to physicians/nurse practitioners of things they should be aware of wh en evaluating at-risk children , similar to reminders 76 FACILITATORS AND BARR IE RS TO MEDI CAL EVALUATION provid ed for prostrate cancer screening, to ensu re child maltreatm ent remai ns in th ei r awareness as a differential diagnosis . 2. Utilize the Expertise of SCAN Clinics . Physicians and nurse practitioners should refer to the NH SCAN team for co nsultation , acute assessment, or follow-up care in severe or complex cases . Children residing in foster care who present with suspicious injuries or neglect should be acknowledged as complex cases. Under these circumstances, foster children should automatically be referred to a SCAN Clinic for a comprehensive assessment due to the recognized difficulty in obtaining an accurate, complete, medical and social history. This will provide an additional safeguard for children who are already at increased risk for subsequent abuse . 3. Util ize Electronic Medical Records to Improve Identification of and Continuity of Care for At-risk Children. NH and private physicians using electronic medical reco rds should build processes within the electronic medical records system to flag at-risk children . These electronic records should have the ability to gather data on children who have experienced a previous episode of maltreatment to ensure they are flagged for follow-up and that appropriate information is shared. The prim ary care physician/nurse practitioner should ensure families or caregivers are contacted for fo llow-up and, if needed , that MCFD is notified when the child 's essential health care needs are neglected . Th ese changes co uld offset the continuity of care challenges associated with the use of locum s, walk-in clinics, and transiency of at-risk children . 77 FACILITATORS AND BARRI ERS TO MEDI CAL EVALUATION 4. Create Procedures for Inter-agency Information-sharing. An updated memorandum of unde rstanding betwee n the Ministry of Children and Family Develop ment, th e Ministry of Hea lth , Northern Hea lth , and the Co llege of Physicians and Surgeons of BC sho uld be comp leted outlin ing procedures for ongoing sha ring of medical and socia l history between health ca re provid ers and MCFD . Th ese procedures shou ld allow for shari ng of electro nic medica l reco rd s betwee n public agencies (health authorities , MCF D) and private physician's offi ces . It makes se nse to me that th is should be a provincial initiative spearheaded by the five SCAN Clinics in the province as they have the ideal complement of trai ni ng and interprofessio nal expertise , and the resources to negotiate such an ag ree ment. 5. Provide Ready Access to Evidence-based Information on Child Maltreatment Assessment and Contact Information for Local and Provincial Resources . Partici pants described challenges they faced in accessing reliable evidencebased informatio n about child maltreatment assessment and conta ct information for local and provincial resources . I noticed that the College of Physicians and Surg eo ns of BC and the College of Registered Nurses of BC have rece ntly included updated information regarding this on their websites . The NH we bsite should also have easi ly accessib le information about child maltreatment assessment, including links to best practices , and resources available both provincia lly and locally for co nsu ltation and fo llow-up . Curre ntly, th ere is no inform ation on chi ld maltreatment on th e NH website and no links to th e NH SCAN Clinic. Each Division of Fam ily Practice should have inform ation on their website regarding child maltreatment assessment and lin ks to reso urces avai lable in the north . The 78 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION local SCAN team attends annual training on child maltreatment and keeps an updated resource of relevant child maltreatment literature on evidence-based practice . As the NH SCAN Clinic has a mandate to build capacity of northern health care providers , it makes sense to me that th ey develop a procedure to share this information regularly with all Northern divisions of Family Practice so they can maintain an updated resource for that is accessible northern physicians and nurse practitioners who are not employed by NH . 6. Expand lnterprofessional Training Opportunities. Several participants identified a need for their interprofessional colleagues to obtain training in child maltreatment evaluation so they know what to look for, who to contact for information and assistance , and how to interpret the findings . I can personally relate to the experiences of participant 1, who lamented about "police officers that can 't believe you can have a normal genital exam after sexual abuse , you know that's not helpful because it's almost like you have to convince them to pursue investigations and that shouldn 't be part of my job ." As a soci al worker at the SCAN Clinic, I had similar experiences co mmunicating with CPS workers wh o did not recognize the significance of infant brui si ng or who fa iled to understa nd the importance of obtaining co mplete medical history to providing a diag nostic opinion . lnterprofessional training opportunities wou ld allow for th e development of relationships between th ese groups and assist th em in developing informal connections , which we recogn ize as an importa nt element in northern and rural practice . NH SCAN Clinic multidisciplinary team should provide educational sessions to other relevant disciplines such as nursing students, new RCMP recruits, and social 79 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION work students during their undergraduate education. Several participants acknowledged the benefit of having the NH SCAN Clinic team members provide training to them during medical school and residency. I think it would be valuable for the NH SCAN team to provide these educational opportunities to other members of the interprofessional team such as social work students , nursing students, and new RCMP recruits . This provides an opportunity for the students to hear the information directly from the multidisciplinary team pose questions , and build personal connections with the interprofessional team . Directions for Future Research This was a qualitative study with a small number of participants. I would be curious to learn how we could develop a process for ensuring that at-risk children are not lost to follow-up with the new interprofessional primary care teams that are developing across northern BC. It would be helpful to use the information in this study to develop a large-scale quantitative study of all primary care physicians/nurse practitioners in northern BC to gather data on how they are tracking the follow-up care of children who have been assessed for suspected child maltreatment. Personal Reflection When 1started this research , I heeded so me wise advice and chose a topic I was passionate about. My first encounter with a seriously maltreated child , involved one of the children in the 2008 RCYBC report who later died as a result of her injuries . 1was her social worker and the first time I met her was in the Paediatrics Intensive Care Unit at the Prince George Regional Hospital ; as a novice social worker, 1was deep ly affected by her death . I shed many tears as I read the RCYBC 80 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION 81 report and saw how comp letely the various systems had failed to protect her. Using an ecological perspective in this study allowed me an opportunity to discover opportunities for change within at least one of those systems, the health care system, with the intention of impacting the other systems. I was able to explore ways to improve information exchange amongst health care providers, facilitate follow-up for vulnerable children , and suggest ways to improve collaboration between health care providers and other systems. As an experienced social worker now, with additio nal knowledge obtained during this research , I feel empowered to create systemic change so that children impacted by abuse can be identified early enough to prevent further harm . Conclusion The goal of this study was to explore how physicians/nurse practitioners in northern British Columbia evaluate child maltreatment encountered in primary care settings. This research identified that many of the problems Judge Gave (1995) identified with the medical system 's response to at-risk children remain unaddressed . Participants identified barriers they face when assessing suspicious injuries and concerning health conditions , including difficulties with communication between health care providers and child protection workers , issues related to geography and the northern practice setting , training and education issues , and system ic issues blocking continuity of medical care . Judge Gave (1995) noted th at physicians did not pay sufficient attention to Matthew's Vaudreuil's medical and socia l history, this study identified systemic barriers preventing health care providers from accessing this information . The physicians and nurse practitioners I interviewed had many FACILITATORS AND BARRIERS TO MEDICAL EVALUATION practical suggestions for addressing these concerns and highlighted facilitators that assisted them in completing these assessments . As the national approach to primary care transitions to a new model of interprofessional primary care teams , it presents numerous opportunities for systemic change including improved procedures for information exchange and interprofessional collaboration . 82 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION References Adams , J . A. , Kellogg, N. D., Farst, K. J., Harper, N. S., Palusci, V . J., Frasier, ... Starling , S. P. (2015) . Updated guidelines for the medical assessment and care of children who may have been sexually abused. Journal of Pediatric and Adolescent Gynecology, in press accepted manuscript. http://dx.doi.org/10.1 016/j.jpag.2015.01.007 Afifi , T. 0 ., MacMillan , H. L. Boyle , M., Taillieu , T ., Cheung , K. , & Sareen , J. (2014). Child abuse and mental disorders in Canada. CMAJ : Canadian Medical Association Journal, 186(9), E324- E332 . doi:10.1503/cmaj.131792 AI-Busaidi , Z., (2008) . Qualitative research and its uses in health care. Sultan Qaboos Univ Med J. 8(1 ), 11 - 19. PMCID : PMC3087733. Retrieved from http ://www.ncbi .nlm .nih .gov/pmc/articles/PMC3087733/ Allan , K., & Lefebvre , R. (2012). Physical harm requiring medical treatment in substantiated maltreatment investigations. Based on , Trocme, N., Fallon, B., MacLaurin, B., Sinha, V., Black, T. , Fast, E. eta/. (201 0) . Chapter 4: Characteristics of Substantiated Maltreatment. In Public Health Agency of Canada (Ed.) , Canadian Incidence Study of Reported Child Abuse and Neg/ect-2008: Major Findings. Ottawa : PHAC . Canadian Child Welfare Research Portal: Toronto , ON . Retrieved from http ://cwrp.ca/infosheets/physical-harm-requiring-medical-treatmentsubstantiated-maltreatment-investigations Anderst, J ., Kellogg , N., & Jung , I. (2009) . Is the diagnosis of physical abuse changed when child protective services consults a child abuse pediatrics subspecialty group as a second opinion? Child Abuse & Neglect, 33(8) , 481489. Retrieved from http ://www.ncbi.nlm .nih .gov/pubmed/19766309 AuCoin , K. (2005) . Children and youth as victims of violent crime . Juristat, 25, 1-24, Retrieved from http://www.statcan .gc.ca/pub/85-002-x/85-002-x2005001 eng .pdf Bennett, S ., Ward , M., Moreau , K., Fortin , G., King , J., Ma cKay, M., & Plint, A . (2011 ). Head injury secondary to suspected child maltreatm ent: Results of a prospective Canadian national surveillance program. Child abuse & neglect, 35(11 ), 930-936 . http ://dx.doi. org/10.1016/j .chiabu .2011 .05 .018 83 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Boesveld, S. (2014, April 22). One-third of Canadians have suffered child abuse, highest rates in the western provinces , study says. National Post. Retrieved from http ://news.nationalpost.com/ news/canada/one-third-of-canadians-havesuffered-child-abuse-highest-rates-in-the-western-provinces-studysa ys#_ fed e rated= 1 Boyatzis , R. E. (1 998) . Transforming qualitative information : Thematic analysis and code development. Thousand Oaks : Sage. British Columbia College of Social Workers . (2009) . Code of ethics and standards of practice. Retrieved from http ://www.bccollegeofsocialworkers .ca/wpcontentluploads/2013/02/BCCSW-CodeOfEthicsStandardsApprvd .pdf British Columbia Ministry of Health . (2013) . British Columbia health authorities: Roles and responsibilities of health authorities overview. Retrieved from http ://www.health .gov.bc .ca/socsec/roles .html British Columbia Representative for Children and Youth. (2009) . Amanda, Savannah, Rowen and Serena : From loss to learning. Retrieved from http ://www.rcybc .ca/ lmages/PDFs/ Reports/FromLosstoLearningDec09 .pdf Canadian Paediatrics Society. (2008 ). Special considerations for th e health supervision of children and youth in foster care . Paediatric Child Health . 13( 2 ). 129-32. Retrieved from http://www.cps .ca/en/documents/position/foster-carehealth-supervision Canadian Paediatrics Society. (2009 ). A model of paed iatrics: Rethin king health care for children and youth . Paediatric Child Health, 14(5), 3 19-25 . Retrieved from http ://www.cps.ca/e nglish/statements/HRICPS09-+01 .htm Carlson , J. A . (201 0) . Avoiding trap s in member checking . The Qualitative Report 15(5), 1102-1113. Retri eved from http ://www.nova.edu/ssss/QRIQR155/carlson .pdf Cedar, P. P., Pearce, M. E., Christi an, W . M., Patterso n, K., Norris, K., Moniruzzam an, A ., ... & Spittal, P. M . (2008). Th e Cedar Project: Historical trauma , sexu al abu se and HIV risk among you ng Aboriginal people who use injection and non-injecti on drugs in two Ca nadian cities. Social Science & Medicine, 66(11 ), 2 185. Retrieved from : 84 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION http ://dx.doi .org/1 0.1016/j.socscimed .2008.03 .034 Clancy, J. (1995) . Ecological school social work: The reality and the vision . Social Work in Education , 17(1 ), 40-47 . doi : 10.1093/cs/17.1.40 College of Physicians and Surgeons of British Columbi a. (2007) . Professional standards and guidelines: Privacy legislation for the private sector. Retrieved from https ://www.cpsbc.ca/files/pdf/PSG-Privacy-Legislation-for-the-PrivateSector.pdf College of Registered Nurses of British Columbia . (2015 ). Scope of practice for nurse practitioners: Standards, limits and conditions. Retrieved from https ://www.crnb c.ca/Standards/Lists/StandardResources/688ScopeforNPs .p df Committee on Pediatric Emergency Medicine . (2012 ). The role of the pediatrician in rural emergency medical services for children . Pediatrics, 130(5 ), 978-982 . doi : 10.1542/peds .2012-2547 Committee on Early Childhood , Adoption , and Dependent Care (2002 ). Health care of young children in foster care . Pediatrics, 109 (3), 536-541 . doi:1 0.1542/peds .109 .3.536 Delaney, R., & Brownlee , K. (1995). Eth ical considerations for northern social workers . In Delaney, R. and Brownl ee, K. (Eds .), Northern social work practice (pp . 162- 81 ). Thund er Bay, La kehead University Press. Duffy, J., Squires, J., From kin, J. B., & Berger, R. P. (2011 ). Use of skeletal surveys to evaluate for physical abu se: An alysis of 703 consecutive skeletal surveys. Pediatrics, 127(1 ), 46-53. doi 10.1542/peds.201 0-0298 Edelson , J.D. (2004) . Shou ld childhood exposure to ad ult domestic violence be defined as child maltreatm ent under the law? In Jaffe , P.G., Baker, L.L. & Cunningham , A . (Eds.). Protecting children from domestic violence : Strategies for community intervention (pp. 8-29). New York , NY: Guilford Press. Erickson , M. F., & Ege land, B. (2011 ). Child negle~t. In J. E. B. Myers (Ed.) The APSAC handbook on child maltreatment (3r ed.), (pp.103-124). Thousand 85 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Oaks : Sage Publications Inc. Felitti , V . J ., Anda , R. F, Nordenberg , D. , Williamson , D. F., Spitz, A . M., Edwards , V . . .. Marks , J. S. (1998). The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine 14, 245-258 . Retrieved from http ://www.cdc.gov/violenceprevention/acestudy/year.html Firsten , T . (1991 ). Violence in the lives of women on psych wards . Canadian Woman Studies, 11 ( 4 ). Retrieved from http ://cws .journals .yorku .ca/index .php/cws/article/viewFile/1 0655/97 44 Flaherty, E.G ., Jones , R., & Sege , R. (200 4) . Telling their stories : Primary care practitioners stories of evaluating and reporting injuries caused by child abuse . Child Abuse & Neglect, 28, 939-945 . Flaherty, E. G ., Sege , R., Price , L. 1. , Kaufer Christoffel , K., Norton , D. P., & O'Connor, K. G . (2006). Pediatrician characteristics associated with child abuse identification and reporting : Results from a national survey of pediatricians Child Maltreatment, 11( 4 ), 361-369 . doi : 10 .1177/10 77559506292287 Flemming , S . (2007). Verdict at coroner's inquest: Savannah Hall. Coroner's court of British Columbia . Retrieved from http ://www.grantnativelaw.com/pdf/HaiiVerdict.pdf Frasier, L ., (2012) . Twenty-five years of APSAC-the medical perspective . APSAC Advisor, American Professional Society on the Abuse of Children, 24(1-2), 213. Frasier, L . D., Thraen , 1. , Kaplan , R., & Goede, P. (2012). Development of standardized clinical training cases for diagnosis of sexual abuse using a secure telehealth application. Child abuse & neglect, 36(2), 149-155. http ://dx .doi .org/1 0.1 016°/o2Fj .chiabu .201 1.06 .006 Germain , C . B ., & Gitterman, A . (199?) . Thn~ life model of social war~ pra~tice :. Advances in theory and pract1ce (2 ed). New York: Columbia Un1vers1ty Press. 86 FAC ILI TATORS AND BARRI ERS TO MEDI CAL EVALUATION Gree ley, C. S. , (20 12). The evol ution of the child maltreatm ent literature. Pediatrics, 130(2) 34 7-348 . Retrieved from : http ://www.ncbi .nlm.nih .gov/pmc/articles/PM C3408693/ Guest, G . MacQueen , K. M., & Namey, E. E. (2012) . Applied thematic analysis. Los Angeles : Sage . Retrieved from : http:// books .google .com/books Gave , T. (1995) Executive summary: Report of the Gave inquiry into child protection in British Columbia . Retrieved from http://www.qp .gov.bc .ca/gove/ Hart , S. N., Brassard , M. R., Davidson , H. A ., Rivelis , E., Diaz, V ., & Binggeli , N. J. (2011 ). Psychological maltreatment. In J. E. Meyers (Ed .) The APSAC handbook on child maltreatment (3rd ed.), (pp. 125-144 ). Thousand Oaks: Sage Publications Inc. Hea lth Canada. (2011 ). Canada 's health care system . Retrieved from http ://www.hc-sc.gc.ca/hcs-sss/pubs/system -regime/2011 -hcs-sss/indexeng.php#a9 Health Council of Canada. (2012 ). How do Canadian primary care phys icians rate the health system? Results from the 2012 Commonwealth Fund Internati onal Health Policy Survey of Primary Care Physicians. Retrieved from http ://www.healthcouncilcanad a.ca/rpt_det.php?id =444 Health Council of Canada . (2005 ). Hea lth care ren ewal in Canada: Accele rating change . Retrieved from www.hc-sc.gc.ca/hcs-sss/pub s/system-regime/2011 hcs-sss/index-e ng .php#a9 Heisler, K. W ., Starling , S. P., Edward s, H., & Paulson , J. F. (2006) . Chi ld abuse training , comfort, and kn owl edge among emergency medicine , family medici ne, and pediatric resid ents. Med Educ Online , 11(25) , 1-10 . Retrieved from http://www.med-ed-online.org Herend ee n, P. A ., Blevins , R., An son , E., & Smith , J. (2014). Barri ers to and co nsequences of mandated reporting of child abuse by nurse practitioners. Journal of pediatric health care, 28(1 ), e1-e7. 87 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Intern atio nal A ssociation of Forensic Nurses. (2015). Freq uently asked questions. Retrieved from http://www.forensicnurses.org/? page=Ce rtFAQ s Jarchow , C. E. (2004 ). Suspected child abuse and neglect (SCAN ) teams in British Co lumbia . BC Medical Journal, 46 (2) , 67-71. Retrieved from http ://www.bcmj .org/article/suspected -child-abuse-and-neg lect-scan-tea msbritish-columbia Kempe , C. H., Silverman , F. N. , Steele, B. F. , Droeugemeuller, W ., & Si lver, H. K. (1962). The battered child syndrome. Child Abuse & Neglect, 9, 143-154, 1985. Reprinted from Journal of the American Medical Association, 1962, 181 , 7-24 Retrieved from http://www.ki ndesm issha nd lung .de/med iapool/32/328527 /data/KempeBatteredChild 1962-reprint-CAN-1985.pdf Koetting , C. , Fitzpatrick , J. J., Lewin , L., & Kilanowski , J. (2012). Nurse practitioner knowledge of child sexual abuse in children with cognitive disabilities. Journal of forensic nursing , 8(2) , 72-80 . Retrieved from https ://fpb.cwru .edu/News/Docs/Fitzpatrick_ Koetting_forensicnursing2012 .pdf Lane , W. G., & Dubowitz, H. (2009). Primary care pediatricians' experience , comfort and competence in the evaluation and management of child maltreatment: Do we need child abuse experts? Child Abuse & Neglect, 33(2) , 76-83 . Leeb , R. T , Paulozzzi , L., Melanson , C., Simon , T ., & Arias , I. (2008). Child maltreatment surveillance: Uniform definitions for public health and recommended data elements. Atlanta: Centers for Disease Control and Prevention . Retrieved from www.cdc.gov/violenceprevention/pd f/C M_Surveillance-a .pdf Leslie , L.K., Hurlburt, M.S. , Landsverk, J., Rolls , J.A ., Wood P.A. , & Kelleher, K.J. (2003). Comprehensive assessments for children entering foster care: A national perspective , Pediatrics, 112, 134-143. Retrieved from http://pediatrics.aappublications.org/content/112/1 / 134.full.html Lester, S . (1999) . An introduction to phenomenological research. Taunton : Stan Lester Developments. Retri eved from http://www.sld .demon.co .uklresmethy.pdf 88 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Lewis , C ., Beckwith , J., Fortin , K., & Goldberg , A . (2011 ). Fostering health : Health care for children and youth in foster care . Rhode Island, 94(7) , 200-202 . Retrieved from https ://www.rimed .org/medhealthri/2011-07/201107 .pdf#pag e= 14 Lynam , M . J., Laack, C., Scott, L., Wong , S. M., Munroe , V., & Palmer, B. (201 0). Social paediatrics: Creating organi zational processes and practices to foster health care acce ss for children 'at risk'. Journal of Research in Nursing, 15( 4 ), 33 1-347 . doi :10.1177/1744987109360651 Makoroff, K. L., Brauley, J. L., Brandner, A . M., Myers , P. A., & Shapiro , R. A . (2002). Genita l exa minatio ns for a ll eged se xu al abu se of prepubertal girls : Find ings by pedia tric emerge ncy medicin e physician s compared with child abu se train ed phys icia ns. Child abuse & neglect, 26(12), 1235-1242. http ://dx.do i. org/10.1016/S0145-2134(02 )00419-2 Marlow, C. R. (2005 ). Research methods for generalist social work (4th ed .). Belmont, CA: Brooks/Cole . Merriam-Webster Dictionary (201 3). Retrieved from http ://www.merria mwebster.com /dictionary/substantiate Mikkonen , J., & Raphael , D. (201 0). Social Determinants of Health: The Canadian Facts . Toronto : York University School of Health Pol icy and Manage ment. Retrieved from http ://www.th eca nad ianfacts .org/ Ministry of Children and Family Development. (2004 ). Child and family development service standards. Retrieved from http ://www.mcf.gov.bc.ca/child_ protection/pdf/cfd _ ss_ may08 .pdf Neilson , M. (201 3, Fe bruary 9). Coo k not gui lty in step-son 's death . The Prin ce George Citizen . Retrieved fro m http ://www.princegeorgecitizen .com /news/local-news/cook-not-guilty-in-stepso n-s-death-1.1031436 North ern Hea lth (2011). Northern Health Authority 2011 /12-2013/14 Service plan. Retri eved from http ://www.northernhea lth .ca/Porta ls/O/About/Fin ancia i_Acco untabi lity/docum ents/201 1to20 14ServicePianNorth ernH ea lthFINALNOVEM BER252011 89 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Ortlipp , M. (2008) . Keeping and using reflective journals in the qualitative research process . The Qualitative Report (13) 4, 695-705 . Retrieved from: http ://www.nova .ed u/ssss/QRIQR 13-4/ortlipp.pdf Patton , M.Q . (2002) . Qualitative research and evaluation methods (3rd ed.). Thousand Oaks , CA: Sage . Publ ic Health Agency of Canada . (201 0). Canadian Incidence Study of Reported Child Abuse and Neglect-2008: Major Findings. Ottawa. Retrieved from http ://www.phac-aspc.gc.ca/ncfv-cnivf/pdfs/nfnts-cis-2008-rprt-eng. pdf Raman , S., Reynolds , S., & Khan , R. (2011 ). Addressing the well-being of aboriginal children in out-of-home care : Are we there yet? Journal of Paediatrics and Child Health, 47(11 ), 806-811 . doi :10.1111 /j .1440-1754.2011 .02030 .x Rea d , J., Perry, B. D., Moskowitz, A ., & Connolly, J. (2001 ). The contribution of early traumatic events to schizophrenia in some patients: A traumagenic neurodevelopmental model. Psychiatry, 64( 4 ), 319-345 . Retrieved from http ://www.rocaipi.cat/jornadesbaetulae/wpcontentluploads/2013/06/Traumagenic_ neurodevelopmental_model_psycho sis_John_ Read .pdf Reece , R. M. (2011 ). Medical evaluation of physical abuse . In J. B. Meyers (Ed .), The APSAC handbook on child maltreatment (3rd ed .) (pp . 183-194). University of the Pacific: Sage . Ricci , L., Botash , A . S., & McKenney, D. M., (2011 ). Child abuse in emergency medicine . Medscape Reference, 1-6. Retrieved from http:l/emedicine .medscape .com/article/800657-overview#showall Rowse , V . (2009) . Support needs of children's nurses involved in child protection cases . Journal of nursing management, 17(6), 659-666. Saldana , J. (2013) . Th e coding manual for qualitative researchers (2nd ed .). Los Angeles : Sage. 90 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION 91 Schm idt, G ., & Kl ei n , R. (2 004). Geography and social worker retention} Rural Social Work 9} 23 5-243 . doi : 10.1080/ 15548730802237353 Sege , R., Flaherty E., Jones , R., Price , L. L., Harri s, D., Slora, E., Abn ey, D., & W asserman , R. (20 11 ). To report or not to re port : Exa min ation of th e initia l primary ca re manage ment of suspicious childhood injuries . Academic pedia trics , 11(6) 460-466 . Sittig , J . S. Uite rwaal , C . S ., Moons , K. G ., Nieuwen huis , E. S. , & van de Putte, E. M. (20 11 ). Child abuse inventory at eme rgency rooms : CHAI N-ER ration ale and design , BMC Pediatrics, 11(9 1 ), 2-6. Retrieved from htt p: //www.biomedcentral.com/14 71 -2 43 1/11/9 Teicher, M .H ., Parigger, A . (2015 ). The maltreatment and abuse chronology of exposure (MACE) scale for the retrospective assessment of abuse and neglect during development. PLoS ONE 10(2 ), e011742 3. doi : 10.1371 /journal.pone .0117 423 Tro cme, N ., Maclau rin , B ., Fallon , B., Kno ke , D., Pitm an , L., & McCormack, M. (2005) . Mesnmimk Wasatek: Catching a drop of light: Understanding the overrepresentation of First Nations childre n in Canada }s child welfare sy stem: An analysis of the Canadian incidence study of reported child abuse and neglect (CIS-2003) . Centre of Excellence for Chi ld Welfare . Retrieved f rom : https ://secureweb .mcgill .ca/crcf/sites/mcgill.ca .crcf/files/mesnmik_ wasatek_ r evised_ april_ 12.pdf Trocme, N ., MacMillan , H ., Fallon , B. , Marco , R. D. (2003). Nature and seve rity of ph ysical harm caused by child abu se and neglect: results from the Ca nad ian Incidence Study. Canadian Medical AssociationJ 169), 911- 15. Retrieved from : http ://www.mcgill .ca/files/crcf/2003-Nature_ Severity_ Physica l_ Harm. pdf Trocme N., & Wolfe , D. (2001 ). Child maltreatment in Canada : Selected results from the Canadian incidence study of reported child abuse and neglect. Ottawa , Ontario : Mini ster of Publi c W ork s and Go vernm ent Services Canada . Retrieved from http://www.can adiancrc.co m/pdfs/Ca nadia n_ lncidence_ Study_ Child_Abuse_ Selected_20 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Webster, S . M ., & Temple-Smith , M. (201 0). Children and young people in out-ofhome care: Are GPs ready and willing to provide comprehensive health assessments for this vulnerable group? Australian journal of primary health, 16( 4 ), 296-303. http://dx.doi.org/1 0.1071 /PY1 0019 Woodman J., Lecky, F., Hodes, D., Pitt, M ., Taylor, B., & Gilbert, R. (201 0). Screening injured children for physical abuse or neglect in emergency departments : a systematic review . Child Care Health Development, 36(2) , 153-64. doi : 10.1111 /j .1365-2214.2009 .01 025 .x Woodman , J., Pitt, M., Wentz, R ., Taylor, B ., Hodes, D. , & Gilbert, R. E., (2008) . Performance of screening tests for child physical abuse in accident and emergency departments , executive summary. Health Technology Assessment 12(33). Retrieved from http://www.hta .ac .uklpdfexecs/summ1233 .pdf Zapf, K. (2002) . Geography and Canadian social work practice. In F. Turner (Ed .). Social work practice: A Canadian perspective (2nd ed .), (pp. 69-83) . Toronto: Pearson Education Canada Inc. Ziegler, D. S ., Sammut, J. , & Piper, A . C. (2005) . Assessment and follow up of suspected child abuse in preschool children with fractures seen in a general hospital emergency department. Journal of Pediatrics and Child Health , 41 , (5-6), 251-255 . Retrieved from http:www.ncbi.nlm .nig.gov/pubmed/15953323 92 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Appendix A: Interview Guide Before we get started, in the interest of full transparency, I would like to remind you of an important limitation to confidentiality. I am legally obligated to report a child in need of protection due to suspected neglect, physical, sexual, or emotional abuse. If you disclose an unreported child protection concern during our interview, I am obliged to report the concern to MCFO for follow up and they will likely contact you for additional information . If you would like more information regarding mandated reporting, I have provided a copy of your professional standards and guidelines from the College of Physicians and Surgeons/ College of Registered Nurses of British Columbia . I would like to remind you that you may refuse to answer any questions during this interview. Screening Questions: 1. Do you see children from 0-12 in your practice setting? Y/N 2. Over the past five years , have you provided medical care to children in the Northern Health region? Y/N 3. Within the past five years , have you encountered cases of suspected child maltreatment in your practice setting? Y/N 4. What is your area of practice? a) Pediatrics b) Family medicine c) Emergency medicine 5. Practice setting . Please indicate all that apply: a) Shared practice b) Group practice c) Sole practice d) Hospital e) Health Centre) Integrated Health Team g) Primary Care Home Semi-structured Interview Questions: 1. About how often have you encountered cases of suspected child maltreatment in your career? 2. When a child presents with signs/ symptoms sugg estive of non-accidental injury/or neglect, what do you see as the physician/ nurse practitioner's role? 3. What are the limitations of your role? 4. Are th ere specific protocols or decision support tools to assist you in identifying and treating these children? 5. What other professionals have you relied on to assist you in responding? 6. Describe your experience consulting with colleagues or other professionals in the se situations. (Probes: Who is available locally? When do you consult with provincial experts?) 93 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION 7. Does the northern practice setting influence your ability to provide diagnostic evaluation of child maltreatment? (Probes: If so , in what way? If not, why not?). 8. What barriers do you encounter when asked to provide a diagnostic opinion for suspected child maltreatment? 9. What resources do you think physicians/nurse practitioners in your practice setting need to assist them in identifying and addressing cases of child maltreatment? 10. What would make your job easier when providing your medical opinion to police or child protection social workers about the possibility of non-accidental injury/ neglect? 11 . 1n your practice setting are there policies or procedures in place to facilitate continuity of care for children who are assessed for suspected child maltreatment? 12 . 1s there anything that I have not asked you that you th ink I should know? 94 FAC!I LITATORS AND BARRI ERS TO MEDICAL EVALUATION Appendix 8: Information Letter Stephanie Rex 250-640-5082 rexs@unbc.ca Dr. Glen Sch midt 250-960-6519 schmidt@unbc.ca. Dear Participant, You are invited to participate in a research project conducted by Stephanie Rex, a graduate student in the social work program at University of Northern British Columbia . The purpose of the study is to exp lore how child maltreatment is identified and evaluated in northern primary health care settings . Another goal of this research is to highlight opportunities for improvements in health care for this vulnerable patient population . Your participation is requested because you are a physician/nurse practitioner with experience in working with children who may have been maltreated . Should you agree to participate , you will be asked to describe your experiences in providing primary health care/diagnostic assessment for maltreated children during a single semi-structured interview. The interview will be approximately 45 minutes and can occur in person or by telephone according to your preference. RIS KS There are potential legal , social , and psychological risks associated with intentional non-reporting of suspected child maltreatment. The researcher is obligated to report any incidents of a child in need of protection due to suspected neglect/or physical , sexual , or emotional abuse to the Ministry for Children and Family Development (MCFD). Any disclosure of failure to report a child in need of protection overrides any promise of confidentiality, and the research must report the information about suspected abuse /neglect to MCFD. The researcher will provide a copy of the College of Physicians and Surgeons Child Abuse and Neglect Guidelines/College of Nu rses practice standards as part of the research information package. A list of local counselling resources will be provided to participants who require this assistance to address emotional or psychological distress. There is no financial remuneration for your participation , however the researcher will provide coffee and snacks if you participate during a meal break. BENEFITS Your input, from the perspective of a local primary care physician/nurse practitioner, could influence planning for health services so that they are reflective of and responsive to the needs of children in the northern region . VOLUNTARY Participation is voluntary and you may refuse to answer questions. If you need to withdraw at any time , you may do so without prejudice . Any information you provided wi ll be destroyed at that time . 95 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION CONFIDENTIALITY The information you provide will be reflected in the final thesis as well as presentations and publications. Anonymity cannot be guaranteed but a series of measures will be used to protect anonymity. Specifically, your anonymity will be maintained by removing identifying details connecting you with your responses. Your name will not be stored on file . Instead a code number will be used to protect your identity and the key linking your initials to the data will be stored separately on a password protected file and will be destroyed after the project is complete . During the project, interview recordings and transcripts will be stored on the researcher's personal computer with a secure login , password protection, and antivirus software . Hard copies will be stored in a locked cabinet in a locked office at the researcher's home with access only to the researcher. The home has a security system monitored by a private security company. Once the research is complete, recordings and electronic files stored on the researcher's computer will be deleted and transcripts will be incinerated . All identifying information will be deleted . The electronic file of analysed data will be password protected and stored on a UNBC committee member's computer account at UNBC. This account is located on a secure server with password and anti-virus protection . The stored electronic file will be deleted five years after the study is completed. An exception to confidentiality is disclosure of a child in need of protection that has not been reported to the Ministry of Children and Family Development (MCFD). Under this circumstance, the researcher must report this information to MCFD according to legal and ethical obligations . CONTACT INFORMATION If you have any questions about this study, please contact the researcher, Stephanie Rex, at 250-640-5082 or rexs@unbc .ca . You may also reach Dr. Glen Schmidt, thesis advisor, at 250-960-6519 or schmidt@unbc.ca . A copy of the thesis will be available after completion of the research in July 2015 and will be provided by contacting Stephanie at the phone number or email above . If you have any complaints about this research , please direct them to the UNBC Office of Research at 250-960-6735 or reb@unbc.ca . Your signature below indicates that you have read and understood the above information . You will receive a copy of this form . Signature Date 96 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Appendix C: Email Script Hello , my name is Stephanie Rex . I am a graduate student at UNBC in the Social Work Department. I am conducting research on facilitators and barriers to diagnostic evaluation of child maltreatment in the north . An understanding of the experiences of northern physicians/ nurse practitioners doing this work can guide the development of diagnostic evaluation protocols relevant to northern and rural practice . Participation in this research involves a 45-minute interview regarding your experiences providing diagnostic evaluation of child abuse/neglect in northern BC practice settings. The interviews can be conducted in person or by telephone at your convenience . Your total time commitment will be between 45-60 minutes . If you are willing to participate , you can contact me at rexs@unbc .ca or by text at 250-6405082 . Thank you . Stephanie Rex 97 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Appendix D: Recruitment Poster Free Snacks! f~ r f 1 0.. 98 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Appendix E: Informed Consent Letter INFORMED CONSENT I understand that Stephanie Rex, Masters student in the Social Work Program at the Un iversity of Northern British Columbia , is conducting a research project on the diagnostic evaluation of child maltreatment in Northern British Columbia . I understand that the purpose of this research project is to gain insight and information regarding the experiences of physicians/nurse practitioners in providing primary health care/diagnostic assessment to maltreated children in Northern BC . The goal of the study is to influence development of diagnostic evaluation protocols for maltreated children , which are reflective of northern practice realities and responsive to the needs of this vulnerable population . I understand that I was chosen because I provide primary health care to children age 0-12 who may have experienced abuse or neglect. The researcher, Stephanie Rex, will use an interview guide to explore my experiences providing medical evaluation of children as described above . 1. This consent is given on the understanding that Stephanie Rex will use her best efforts to protect my identity and maintain my confidentiality. 2. I understand that Physicians/Nurse Practitioners are required by law to report situations of a child in need of protection due to suspected neglecUor physical , sexual , or emotional abuse to the Ministry for Children and Family Development (MCFD) . Any disclosure of failure to report a child in need of protection overrides any promise of confidentiality, and the information about suspected abuse must be reported by the researcher to MCFD . 3. I give my consent freely and understand that I may end the interview, refuse to answer questions , and/or withdraw from the research process at any time . 4. I understand and agree that the information I have given to Stephanie Rex in our interview will be treated in the following manner: a) I will be assigned a random code to protect my identity, this code will be stored separately on the UNBC secure shared drive and deleted at the end of the research project. b) The interview will be audio recorded and transcribed ; hand-written notes will be taken during the interview. c) During the study, this non-identifying data will be stored by Stephanie Rex , in a locked filing cabinet, in a locked office , in her personal residen ce, which is alarmed and mon itored by a private security company. Electronic files will be stored on her personal computer using a secure log-in , password protection , and anti-virus software. d) The data w1ll be used only by Stephanie Rex for her thesis research, presentations, and publications regarding this research. e) Relevant statements made by me during the interviews may be used in presentations of the research however al l identifying information will be removed to protect my anonymity. F) Following co mpletion of th e research project, all paper copies will be burned , 99 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION audio recordings will be deleted , and electronic files will be deleted from Stephanie 's personal computer. The code linking the data to participants will be deleted at that time . A password protected electronic copy of the data will be stored by a member of Stephanie's committee on his UNBC computer, which is a secure system with password protection. Five years after the study is completed , the stored electronic copy will also be deleted. I understand that if I have any comments or concerns , I can contact the UNBC Office of Research at 250-960-6735 or reb@unbc .ca Signature Date Signed Researcher (please print) Signature Date Signed Participant (please print) 100 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Appendix F: UNBC Research Ethics Board Approval UNIVERSITY OF NORTHERN BRITISH COLUMBIA RESEARCH ETHICS BOARD MEMORANDUM To : CC: Stephanie Rex Glen Schmidt From : Michael Murphy, Chair Research Ethics Board Date: April23,2014 Re: E2014.0220 .01 0.00 Fac ilitators and Barriers t o Diagnostic Evaluation of Child Maltreatment in Northern British Columbia Thank you for submitting revisions to the Research Ethics Board (REB) regarding the above-noted proposal. Your revisions have been approved . We are pleased to issue approval for the above named study fo r a period of 12 months from the date of this letter. Continuation beyond that date will require further review and renewal of REB approval. Any changes or amendments to the protocol or consent form must be approved by the REB . If you have any questions on the above or require further clarification please feel free to contact Rheanna Robinson in the Office of Research (reb@unbc .ca or 250-960-6735) . Good luck with your research . Sincerely, Or. Michael Murphy Chair, Research Ethics Board 101 FACILITATORS AND BARRIERS TO MEDICAL EVALUATION Appendix G: NH Research Ethics Board Approval Nortnem Health Co1p0rate Office 600-299 Viclorta Street. Prince George, BC V2L 588 Teleohone 1250) 565--2 9. Fax: (250) 565-2640 www.nort m eallh.ca May 2, 2014,2014 File ltRRC · 2014-0006 Stephanie Re School of Soc1al Work Universtty of Northern British Columbi a Pnnce George , BC RE : Medica l Evaluation of child maltreatment in Northern British Columbia from the physician's perspective On behal f of the Northern Health Research Review Committee, I would like to t hank you for your submission titled " M dical Evaluation of Chil d M altreat ment in northern Bri tish Columbia from th physician's perspe ive.n The Committee has reviewed your application and your study has met the requirements of the Northern Health Research Review Committee and you may proceed. Enjoy your work ! Sincerely, Les Smit h, Chair . NH Research Rev1 ew Commi ttee LS / js 102