Nurse Home Visitors’ Perceptions of Mandatory Reporting of Intimate Partner Violence to Law Enforcement Agencies

Abstract

In the United States, there is an ongoing debate about requiring health care professionals to report intimate partner violence (IPV) to law enforcement agencies. A comprehensive examination of the perspectives of those required to report abuse is critical, as their roles as mandated reporters often pose legal, practical, moral, and ethical questions. Even so, the perspective of health care professionals who are required to report is often overlooked and research is scarce on mandated reporters who work outside of clinical settings, such as nurses who engage in home visitation with clients. The purpose of this study was to examine nurse home visitors’ perspectives regarding the mandatory reporting of IPV, specifically focusing on their attitudes toward reporting, perceived awareness of reporting requirements, and intended reporting behaviors. A web-based survey was administered to nurses in the Nurse-Family Partnership home visitation program across the United States. A total of 532 completed surveys were returned (response rate = 49%). In terms of support for reporting IPV, 40% of nurses indicated that they should “always” be required to report. Almost half of the sample indicated that they would report a case of IPV, yet less than one-third of participants were aware of a legal mandate. Attitudes and support toward reporting as well as the perception of a reporting requirement significantly predicted intention to report. Furthermore, 29% of participants did not know if they were required to report IPV perpetrated against their clients. Comprehensive information about mandatory reporting duties is needed for health care professionals in home visitation settings. The findings of the current study highlight the need to reduce variation among practitioners and establish consistent program practices that are grounded in the program’s principals, supported by existing research, and compliant with existing state policies.

Keywords

mandatory reporting intimate partner violence home visitation nurses survey

Each year in the United States, 4.8 million physical assaults and rapes are committed against 1.5 million women by an intimate partner (Tjaden & Thoennes, 2000). Intimate partner violence (IPV) is associated with deleterious short- and long-term consequences for female victims of abuse (Campbell, 2002; Coker, 2007). Consequently, many health care organizations and providers are committed to implementing universal screening programs, despite the lack of evidence to these initiatives within the clinical setting and the paucity of evidence-based interventions in which to refer abused women postscreening (MacMillan et al., 2009). Beyond the discussion of whether women should be screened for their exposure to violence, there is an ongoing debate in many jurisdictions about requiring health care professionals to report IPV to law enforcement agencies. Those in support of IPV reporting argue that mandatory reporting will hold the abuser legally accountable for the violence and facilitate prosecution (Coulter & Chez, 1997; Houry, Feldhaus, Thorson, & Abbott, 1999; Rodriguez, McLoughlin, Nah, & Campbell, 2001). Furthermore, identification and treatment for victims of IPV will improve if health care workers are mandated to report abuse (Bauer et al., 1999; Rodriguez, McLoughlin, Bauer, Paredes, & Grumbach, 1999). Those opposed to mandated reporting laws argue that reporting IPV undermines patient autonomy and privacy (Bauer et al., 1999; Houry et al., 1999; Iavicoli, 2005), may negatively affect the patient–provider relationship (Bauer et al., 1999; Houry et al., 1999; Iavicoli, 2005), may limit victim disclosure of IPV (Gielen et al., 2000), may deter victims of abuse from seeking medical care, and may put the victim at greater risk of harm or retaliation by the perpetrator (Bauer et al., 1999; Sachs, Koziol-McLain, Glass, Webster, & Campbell, 2002).

Most U.S. states legally mandate health care professionals to report injuries to patients that result from illegal acts, such as use of a gun, knife, or other weapon, sexual acts, and injuries resulting from criminal activities to law enforcement authorities (Bauer et al., 1999; Houry et al., 1999; Sachs et al., 2002). These requirements potentially apply to injuries sustained as a result of IPV (Houry et al., 1999); however, only six states (CA, CO, KY, NH, NM, RI) specifically mandate that IPV itself should be reported to law enforcement (Futures Without Violence, 2004; Hyman, Schillinger, & Lo, 1995; Iavicoli, 2005). These laws mainly apply to physicians or health care professionals providing medical treatment to victims in clinical settings (Hyman et al., 1995).

Community-based practitioners, such as public health nurses or social workers, interact with victims of IPV in nonclinical settings, for example, by providing education and services to disadvantaged families through home visitation programs. Home visitation providers frequently encounter women experiencing IPV (Eckenrode et al., 2000) and child victims of abuse and neglect (Chaffin & Bard, 2006), often within the same households (Appel & Holden, 1998; Edleson, 1999). They are trained to identify and report all instances of child abuse or neglect to child protective services (CPS; Zink et al., 2005); yet, their roles as mandated reporters of IPV between adults separate from their legal mandate to report child maltreatment are less clear.

Reporting laws for child abuse and neglect clearly delineate which activities constitute abuse, where reports are to be sent, and who is responsible for reporting (Futures Without Violence, 2004). Mental health professionals, nurses, and social workers are explicitly included in the groups of professionals mandated to report child abuse and neglect (Futures Without Violence, 2004). Laws pertaining to reporting IPV are less clear in their designations of who is considered a mandated reporter, as the term health care provider is commonly used (except in the case of Colorado, where only physicians are mandated to report IPV). Therefore, it is often open to interpretation whether nurses working in home visitation settings are mandated to report injuries resulting from IPV. Furthermore, health care providers may or may not be required to report IPV to law enforcement as a result of agency reporting requirements or case law (Futures Without Violence, 2004).

Ambiguity surrounding IPV reporting requirements for professionals involved in home visitation programs is problematic, as these laws have significant implications and consequences for the individuals who are mandated to report: Health care providers who fail to report IPV when they are mandated to do so can face substantial fines and even time in jail (Freed & Drake, 1999). However, inappropriately breaking confidentiality by reporting nonmandated offenses may leave the reporter vulnerable to managing legal and ethical consequences. Thus, being aware of mandated reporting laws is crucial for those providing services within home visitation programs, yet no comprehensive set of legal guidelines currently exists for this group of health care professionals. Freed and Drake (1999) suggest that public health nurses need to be informed of the IPV reporting laws in their states, as these laws can significantly affect the nurse–client relationship as well as the nursing strategies they use in home visitation practice. In addition to reporters’ awareness of these laws, their attitudes toward reporting policies have the potential to affect health service delivery. Practitioners who agree with mandated reporting of IPV may anticipate that reporting alone solves the problem and might consequently relinquish responsibility for the continued care of the abused woman (Hyman et al., 1995). Conversely, providers that hold negative attitudes toward IPV reporting may not adequately screen clients for abuse, depriving abused women of the opportunity to receive help (Hyman et al., 1995).

A comprehensive examination of the perspectives of those required to report abuse is critical, as their roles as mandated reporters often pose legal, practical, moral, and ethical questions. Even so, the perspective of health care professionals who are required to report is often overlooked and research is scarce on mandated reporters who work outside of clinical settings. Due to the increase in federal funding allotted for the creation and support of evidence-based home visitation programs in the United States (U.S. Department of Health and Human Services, 2010), coupled with the Institute of Medicine’s recent recommendation for screening all women for IPV as part of basic preventive health services (Institute of Medicine, Committee on Preventive Services for Women, 2011), issues surrounding home visitation providers’ roles as mandated reporters of IPV will undoubtedly receive increased attention. In addition, qualitative research with home visitors from the Nurse–Family Partnership, the largest home visitation program in the United States (see Olds, 2006 for an overview of the NFP), revealed that reporting IPV is a challenging issue for home visitors and warrants further investigation (Davidov, Jack, Frost, & Coben, in press). Examining and quantifying home visitors’ perspectives can provide valuable insight supporting families experiencing violence. Therefore, in the current study, we sought to assess nurse home visitors’ support for and attitudes toward mandatory reporting of IPV between adults using a quantitative framework. Furthermore, we examined their perceptions of reporting requirements for IPV as well as their intended reporting behavior when presented with a scenario describing the abuse of a client. Last, we attempted to predict the factors influencing (a) support for IPV reporting and (b) intended IPV reporting behavior.

Method

Procedures

This study was approved by the NFP Research and Publication Communication Committee, the West Virginia University’s Institutional Review Board (IRB), and the Oklahoma State Department of Health IRB. A quantitative, cross-sectional research design was employed to assess nurse home visitors’ perspectives regarding mandatory reporting of IPV. Recruitment e-mails containing an explanation of the study, information about incentives, and a link to an electronic survey were sent to 1,119 home visitors in the NFP program whose e-mail address was on file with the NFP National Service Office. Nurses who wished to participate in the survey were instructed to click the link embedded in the e-mail and were automatically directed to a webpage within the online survey system displaying the consent form for the study, and, after providing consent, were then directed to a separate webpage containing the survey questions.

Participants

The target population for this study included all NFP nurses from 355 NFP sites across the United States whose e-mails were on file with the NFP National Service Office. The recruitment e-mail containing the link to the electronic survey was sent to 1,119 nurse home visitors. Of these, 26 surveys were returned for disabled e-mail address, out-of-office messages, or because the respondent had previously opted out of receiving survey invitations; therefore, a total of 1,093 surveys were sent to valid e-mail addresses. The number of surveys returned was 534, resulting in a response rate of 49%. Due to large amounts of missing data, two surveys were discarded and therefore 532 surveys were used for analysis in the current study.

Measures

As there were no existing measures that capture home visitation providers’ perspectives with regard to mandatory reporting of IPV, a new survey instrument was developed based on previous literature. A reviewer with expertise in the areas of IPV and family violence was consulted throughout all stages of survey development and the final instrument was found to be acceptable by the reviewer. The survey was pilot tested with a group of nurses and social workers from a home visitation program in West Virginia that is similar to the NFP program. A paper-and-pencil version of the survey was administered to the pilot group, as not all home visitors had frequent access to e-mail. The pilot group of home visitors answered questions about the readability and clarity of each survey question and the instrument as a whole. Slight modifications were made to the measure based on feedback from the pilot group, mostly the inclusion of more answer choices for places to which IPV reports may be sent, such as domestic violence shelters. Due to the small number of surveys pilot tested (n = 9), these data were not used to establish reliability.

Support for IPV reporting

The term domestic violence was used in place of “intimate partner violence” or “IPV” throughout the survey, as previous focus groups with NFP nurses revealed that they are most comfortable with and often use this term when discussing violence between intimate partners. Support for IPV reporting was measured by presenting participants with the following statement: “I should be required to report instances of domestic violence.” The response set for this item was a scale ranging from 1 (never) to 5 (always).

Attitudes toward IPV reporting

To measure nurse home visitors’ attitudes toward mandatory reporting of IPV, a 16-item attitudinal scale containing two subscales was created. The first subscale contained 12 items assessing the perceived impact that mandatory reporting of IPV can have on abused women and their children. These items demonstrated high internal consistency reliability (Cronbach’s α = .84). The statements used in this subscale have been used in other studies of mandated reporting of IPV (Gielen et al., 2000; Malecha et al., 2000; Sachs et al., 2002) and child abuse (Steen, 2008) and were modified to increase relevance to home visitation practice. Participants were asked to respond to each statement on a 5-point Likert-type scale ranging from 1 (strongly agree) to 5 (strongly disagree). Positively worded items were reversed scored, with higher scores indicating that nurses believe mandatory reporting of IPV can have a negative impact on abused women and their children.

The second subscale consisted of four items measuring the perceived impact that mandatory reporting of IPV can have on nurse home visitors themselves (Cronbach’s α = .65). The response set for these items ranged from 1 (never) to 5 (always) and positively worded items were reverse scored, with higher scores signifying the perception that reporting of IPV can negatively affect nurse home visitors. These statements were modified from the CANNQ—a survey measuring nurses’ attitudes toward and knowledge of reporting child abuse and neglect (Mathews et al., 2008).

Perceptions of reporting requirements and intended reporting behavior

Participants were also presented with the following scenario that they might encounter during a home visitation session:

You walk into your client’s apartment for a home visit and notice that she has a black eye and bruises on her arms. She is 28 weeks pregnant. You talk with your client about how she got the injuries. Your client tells you that she is used to her boyfriend pushing and shoving her, but he has become much more physically violent since the pregnancy. Your client assures you that the situation is “not that bad” and that her boyfriend promised never to hurt her again. She has not revealed to you that her boyfriend was physically abusive prior to this home visit.

To assess nurses’ perceptions of IPV reporting requirements, home visitors were asked, “To the best of your knowledge, is there a requirement mandating you to report this case (e.g., to law enforcement, to child protective services)?” and participants could respond with “yes,” “no,” or “I don’t know.” Measuring nurses’ actual awareness of mandatory reporting laws for IPV is constrained by the lack of comprehensive information about home visitors’ reporting duties as they relate to IPV between adults. Even if nurses conduct visits in a state that requires IPV reporting in clinical settings, these laws might not necessarily apply to practitioners working in home settings. Thus, as there is not currently an accurate way to gauge nurses’ knowledge of reporting laws, we chose to assess their perception of IPV reporting requirements.

Intended reporting behavior was measured by asking, “Would you report this case (e.g., to law enforcement, child protective services)?” and the response choices were “yes,” “no,” or “I don’t know.” Participants who answered affirmatively to this question were then directed to a question asking about the agencies to which they would report and could select from the following: law enforcement, child protective services, adult protective services, supervisor, and other. Participants could select all that applied and write in responses if they selected “other.” Demographic information including age, state, years in nursing practice, years in the NFP program, and number of children were also included in the survey.

Data Analysis

Analyses was conducted using STATA 10.0 software. Descriptive statistics were used to describe demographic and study variables. For logistic regression analyses, responses to the statement measuring support for IPV reporting were dichotomized into “always” and “often” versus “some of the time,” “rarely,” and “never.” Responses to the scenario that captured home visitors’ perceived awareness of reporting requirements and intended reporting behavior were dichotomized into “yes” versus “no” and “I don’t know.” Separate multiple logistic regression analyses were used to predict two outcome measures: support for mandatory reporting of IPV and intended reporting behavior after reading the scenario. Odds ratios and 95% confidence intervals are presented to show the magnitude and strength of associations between variables. Predictor variables included perceived awareness of an IPV-reporting requirement, support for IPV reporting, and both attitudinal subscales. Demographic characteristics (age, years in nursing practice, years in the NFP program, and number of children) were also entered into each regression model separately to assess for confounding; however, any demographic variable that was neither a significant predictor nor a confounder was dropped from the regression model. Differences in nurses’ support for mandatory reporting and intended reporting behavior were examined between nurses who were in states with mandatory reporting laws for IPV (in clinical settings) and those in states without such laws using chi-square tests. However, no significant differences were observed (data not shown), and whether nurses worked in a state that had an IPV-reporting law was not entered into the regression models. An alpha value of <.05 was used to indicate statistical significance.

Results

Nurses from 30 out of the 32 U.S. states with NFP implementing agencies completed the survey. All participants were female and had a mean age of 44 years (SD = 10.30). Home visitors reported being in nursing practice for a mean of 17.85 years (SD = 10.86) and had been involved in home visitation services with the NFP program for a mean of 4 years (SD = 3.13). The average number of children that nurse home visitors reporting having was two (SD = 1.17).

In terms of support for mandatory reporting of IPV in the context of home visitation services, 40% (212) of nurse home visitors thought that they should “always” be required to report instances of domestic violence, whereas 15% (79) thought they should be required to report “often.” Approximately one third of participants (180) agreed with reporting “some of the time,” 6% (33) responded that they should “rarely” report, and 5% (28) thought that they should “never” be required to report domestic violence.

Almost two thirds of the sample agreed that mandatory reporting can damage the relationship between nurse and client and would make it less likely that a client would tell them about the abuse (Table 1). Furthermore, half of the sample agreed that reporting can put women at greater risk of being abused or hurt. Conversely, two thirds of the sample thought mandatory reporting of IPV would make it easier for abused women to get help and protect children. The majority of participants disagreed that reporting IPV can traumatize children or damage a woman’s chances of custody of her children. Furthermore, Table 1 shows that the majority of nurse home visitors believes mandatory reporting of IPV “some of the time,” “rarely,” or “never” causes problems for nurse home visitors.

Table 1.

Nurse Home Visitors’ Attitudes Toward Mandatory Reporting of IPV

Impact on abused women and their children	Strongly agree or agree (%)	Strongly disagree or disagree (%)	Undecided (%)
“I feel that the mandatory reporting of domestic violence between adults . . .”
can damage the relationship between nurse and client	64.66	18.61	16.73
can disempower the battered woman	21.99	53.76	24.25
can prevent battered women from seeking further help	32.33	46.62	21.05
can further traumatize the child(ren)	20.68	60.53	18.79
can protect the child(ren)	88.35	3.94	7.71
can cause more disruption to the family	50.19	28.76	21.05
can damage the battered woman’s chances of custody	7.89	78.95	13.16
would make it easier for battered women to get help	64.29	12.97	22.74
would put women at greater risk for being abused or hurt	51.32	19.32	29.36
would make it less likely that a client would tell me about the abuse	62.22	18.61	19.17
would make my clients resent me for having to report	41.17	23.49	35.34
would help my clients because they would like for someone else to report the abuse	41.73	14.10	44.17
Impact on nurse home visitors	Always or often (%)	Some of the time (%)	Rarely or never (%)
I lack faith in law enforcement to respond appropriately when reports of domestic violence are made	23.31	50.56	26.13
I fear reprisals from reporting domestic violence	12.03	33.46	54.51
I fear litigation and/or legal liability from reporting domestic violence	9.40	21.99	68.61
Workload pressures are likely to deter me from reporting domestic violence	2.82	7.33	89.85

Approximately one-fourth (139) of participants indicated that there was a requirement mandating them to report the case described in the scenario, whereas more than half (271) responded that there was no such requirement and 23% (122) did not know. With regard to home visitors’ intended reporting behavior, 44% (236) indicated that they would report the case described in the scenario, whereas 27% (143) would not report the case and 29% (153) did not know if they would report. As can be seen in Table 2, of the 236 participants that would report, 49% (115) indicated that they would report to law enforcement, 60% (131) would report to CPS, and the majority (89%) indicated that they would report to their supervisor. An additional 8% (18) typed in answers ranging from reporting to domestic violence shelters, agencies, and hotlines to contacting the abused woman’s obstetrician. Several respondents explained that whether or not they would report the case depends on the age of the client. If the client was a minor, some participants explained that they would report to CPS and if the client was an adult, they would call law enforcement authorities.

Table 2.

Authorities to Which Nurse Home Visitors Would Send Reports of IPV

Authority	% (n)^a
Law enforcement	49 (115)
Child protective services	56 (131)
Adult protective services	20 (48)
Supervisor	89 (211)
Other	8 (18)

Note: Totals equal more than 100% because participants were asked to select all that apply.

Out of 236 participants who answered “yes” to the question, “Would you report this case (e.g., to law enforcement, child protective services)?” after reading the scenario.

Logistic Regression Analyses

The demographic variables (age, years in NFP, years in nursing practice, number of children) were not independently predictive of the outcome variables and did not display evidence of confounding; hence, they were not included in either regression model. Perceived awareness of an IPV reporting requirement, as well as both attitudinal subscales, were statistically predictive of support for mandatory reporting of IPV (Table 3). Specifically, nurse home visitors who thought there was a requirement to report IPV were almost four times more likely to support IPV reporting than nurses who thought there was no reporting requirement (OR = 3.95, p < .001). Nurse home visitors that thought reporting abuse can negatively affect abused women and their children were significantly less likely to support IPV reporting (OR = 0.86, p < .001). Furthermore, participants that thought reporting abuse can have negative consequences for home visitors were also significantly less likely to support mandatory reporting of IPV (OR = 0.85, p < .01).

Table 3.

Logistic Regression Analyses Predicting Support for Mandatory Reporting of IPV and Intended Reporting Behavior

Variable	OR	95% CI
Support for mandatory reporting
Perceived awareness of reporting requirement	3.95***	[2.37, 6.58]
Impact on abused women	0.86***	[0.83, 0.90]
Impact on nurse home visitor	0.85**	[0.77, 0.94]
Intended reporting behavior
Perceived awareness of reporting requirement	13.30***	[7.62, 23.23]
Support for mandatory reporting of IPV	1.89**	[1.19, 3.00]
Impact on abused women	0.96*	[0.92, 1.00]
Impact on nurse home visitor	0.92	[0.83, 1.01]

Note: OR = odds ratio; CI = confidence interval.

p < .05. **p < .01. ***p < .001.

Perceived awareness of an IPV reporting requirement and support for mandated reporting of IPV were also statistically predictive of whether home visitors would report the case described in the scenario, as were beliefs about the consequences of reporting on abused women and children (Table 3). Those nurse home visitors who thought there was a requirement to report the abuse described in the scenario were significantly more likely to respond that they would report the scenario (OR = 13.30, p < .001). In addition, nurse home visitors who indicated greater support for mandated reporting of IPV were almost twice as likely to say that they would report the abuse described in the scenario (OR = 1.89, p < .01). Participants who thought reporting IPV can have negative consequences for their clients were significantly less likely to indicate that they would report the abuse in the scenario (OR = 0.96, p < .05).

Discussion

The majority of home visiting nurses we surveyed support reporting IPV and their attitudes predicted intentions to report. Furthermore, our sample has mixed beliefs about the impact that reporting can have on abused women and their children. General support for the reporting IPV has been previously demonstrated among samples of the general population, physicians, and abused women (Coulter & Chez, 1997; Gielen et al., 2000; Glass, Dearwater, & Campbell, 2001; Malecha et al., 2000; Rodriguez et al., 2001; Sachs et al., 2002). However, contradictory opinions about the risks and benefits of mandated reporting have also been shown in research with health care providers (see Rodriguez et al., 1999). Rodriguez and colleagues (1999) cite the complexity of handling IPV in clinical settings as the basis for physicians’ mixed attitudes regarding IPV reporting. Addressing IPV in the context of home visitation settings can be equally as difficult, as home visiting nurses deliver care within the family system, as this framework can present challenges to maintaining the fine balance between legal responsibility and confidentiality (Freed & Drake, 1999).

Examining participants’ specific beliefs about IPV reporting suggests that home visitation providers have mixed perceptions about the impact that IPV reporting can have on abused women and their children. The majority of nurse home visitors agreed that reporting can damage the relationships with their clients, put battered women at greater risk for being abused or hurt, and can limit the disclosure of abuse to the nurse. These concerns have been documented in other studies (Rodriguez et al., 1999; Sachs et al., 2002) as well as in focus groups with nurse home visitors (Davidov, Jack, et al., in press). These focus groups also revealed that home visitors perceive that IPV reporting laws may prevent women from seeking help; however, almost two-thirds of the current sample thought reporting IPV would make it easier for abused women to get help. Furthermore, the majority of home visitors thought that reporting would be beneficial and offer protection for abused women and their children.

Almost half of the sample indicated that they would report a case of IPV, yet only 27% of participants thought there was a requirement mandating them to report. This suggests that home visitors might report instances of IPV even when they believe there is no mandate to do so. This is of some concern given the potential negative consequences of mandated reporting of IPV, especially since home visitors agreed that reporting can put battered women at greater risk of being hurt or abused. Hyman et al. (1995) posit that providers who report IPV without first being educated about how to properly handle such cases can further endanger abused women. However, among our sample, it is possible that the nurses may consider reporting instances of IPV to their supervisors in the home visitation program, even when they believe there is no legal mandate that requires a report to an outside agency, such as to the police. This explanation is supported by the fact that most participants in the study who stated they would report the IPV described in the scenario also revealed that they would report the case to their supervisor. Reporting IPV within the confines of the home visitation program may be beneficial, as nurse home visitors can work with their supervisors to decide the best course of action to take when supporting a client who is experiencing IPV.

In addition to perceived reporting requirements, nurse home visitors’ attitudes toward IPV reporting play a significant role in predicting their support for mandatory reporting of IPV. Specifically, beliefs about the impact of reporting on abused women and their children and on nurse home visitors themselves were significantly predictive of whether participants felt they should be mandated to report instances of IPV. Furthermore, those nurses that thought there was a requirement to report the case presented in the scenario were much more likely to indicate intention to report the abuse described in the scenario. This suggests that home visitors’ perceptions of IPV reporting requirements have a major impact on their intentions to report IPV. This is not surprising, as child abuse reporting research has shown reporters’ perceptions of legal requirements to be strongly related to the likelihood of reporting (Zellman, 1990).

It is important to note that 23% and 29% of home visitors in the current study did not know if there was a requirement mandating them to report the abuse described in the scenario and if they would report the case, respectively. Home visitors may be unsure of their duties to report because it is currently unclear whether IPV reporting laws extend to health care professionals working in home settings. Furthermore, the scenario presented to participants described the abuse of a pregnant woman, which creates the potential for overlap in reporting obligations. Nurses working in home visitation settings must monitor the safety of both their clients and their clients’ children. Our sample may have been unsure of their reporting requirements pertaining to the abuse of pregnant women, although more than half of the participants who would report the scenario indicated that they would report to child protective services, suggesting that some nurses did consider the abuse of a pregnant woman to be child maltreatment. A separate but similar study conducted with NFP home visitors also revealed uncertainty and variability surrounding reporting duties when children are exposed to IPV (Davidov, Nadorff, Jack, & Coben, in press). Even though several states do include IPV perpetrated in the presence of a child or against unborn children in their legal definitions of child maltreatment, the definitions vary widely from state to state and contain vague language (Futures Without Violence, 2004; Kratochvil, 2009; Mathews & Kenny, 2008), which may contribute to confusion among mandated reporters. As nurse home visitors work in settings where they often encounter women exposed to IPV and children who witness this violence, their knowledge of state laws surrounding these issues is paramount.

Limitations

Our results represent the perspectives of less than half of the target population of nurse home visitors in the NFP program, even though we achieved a response rate of 49%, which is typical of Internet survey response rates (Archer, 2008). Respondents answering “no” and “I don’t know” were grouped together for logistic regression analyses, and as the sample contained a substantial proportion of participants indicating that they were unsure of their answers to various survey questions, grouping in this manner may have influenced the results of the current study. Another limitation of the current study is that we did not include the age of the client in the scenario. Since several participants indicated that reporting IPV would depend on the age of the client, it would have been of interest to examine nurses’ perspectives when presented with a situation involving a client who was a minor as well as above the age of majority. Furthermore, we could only measure home visitors’ perceived awareness of reporting requirements as opposed to actual knowledge of IPV reporting laws. We were unable to measure nurses’ actual knowledge of reporting laws due to the lack of existing comprehensive information about IPV reporting laws and policies for health care providers in home visitation settings. Current IPV reporting laws focus mainly on requirements for physicians or health care professionals in clinical settings (Hyman et al., 1995) and may not apply to health care providers in home visitation settings. Future research should focus on compiling state-specific requirements for providers in home visitation settings to compare providers’ intended reporting behavior with state laws.

Conclusion

The current study suggests that there is wide variability and uncertainty with regard to home visiting nurses’ perceived awareness of reporting obligations, intended reporting behaviors, and attitudes toward mandated reporting of IPV. This uncertainty might translate into home visiting nurses being unsure of the proper course of action to take when supporting a woman who is experiencing IPV. To address this issue, we recommend additional education about the positive and negative impacts that IPV reporting can have on abused women and their children as well as on home visitation practice. Comprehensive information about the risks and benefits of IPV reporting should be made available to health care providers in home visitation settings as well as methods for managing complexities inherent to being a mandated reporter, such as balancing patient confidentiality with legal responsibility. For example, providing home visitors with education and training about how to maintain clients’ trust after IPV is disclosed would be useful, as clients sometimes cancel visits with their home visitors after disclosing IPV out of fear of being reported (Davidov, Nadorff, et al., in press). Furthermore, as the results of this study demonstrate that home visitors’ perceptions of legal requirements to report are highly predictive of intentions to report IPV, it is essential that supervisors and home visitors are fully informed of IPV reporting requirements mandated by the state as well as those policies and procedures delineated by the home visitation program itself. To this end, accurate and up-to-date information about legal reporting requirements for IPV between adults, IPV during pregnancy, and children’s exposure to IPV should be made available. This information can be compiled and maintained at the program or agency level, and home visitation supervisors as well as local legal service agencies may aid in the interpretation of these requirements as part of the training curriculum for nurse home visitors. Education about mandatory reporting issues should be provided in conjunction with screening and assessment procedures for IPV and child maltreatment. Collaborations with local domestic violence service organizations and child protective services can offer additional benefits to home visitation programs as well. Future research is needed to more closely examine state-specific policies that influence IPV reporting. The findings of the current study highlight the need to reduce variation among practitioners and establish consistent program practices that are grounded in the program’s principals, supported by existing research, and compliant with existing state policies.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This work was supported, in part, by a grant from the National Center for Injury Prevention and Control, CDC [grant #5R49CE001170] to the West Virginia University Injury Control Research Center; and the National Institute of General Medical Sciences, NIH [grant T32 GM081741].

Bios

Danielle M. Davidov, PhD, is currently Research and Grants Coordinator and Adjunct Assistant Professor in the Department of Emergency Medicine at West Virginia University. Danielle earned her doctorate in public health sciences from the Department of Community Medicine at West Virginia University in 2010. She earned her BA in psychology from Marshall University in 2006. Her research interests are women’s sexual and reproductive health and intimate partner violence.

Michael R. Nadorff, MS, is a doctoral candidate in the clinical psychology program at West Virginia University. He received his bachelor of arts in psychology and computer applications from the University of Notre Dame in 2007. He received his master’s in science from West Virginia University with his thesis showing that nightmares were related with suicidal ideation independent of symptoms of depression, anxiety, PTSD, and insomnia (Nadorff, Nazem, & Fiske, 2011). He is expecting his PhD in clinical psychology in 2012. His doctoral dissertation work is investigating imagery rehearsal therapy for nightmares with the hope of determining whether this treatment is appropriate for individuals at risk for suicide. His primary research interest is investigating the relationship between sleep disturbance and suicidal behaviors.

Susan M. Jack, RN, PhD, is an assistant professor in the School of Nursing at McMaster University in Hamilton, Ontario, Canada. Susan has a bachelor of science (nursing) from the University of Alberta (1993), a doctor of philosophy from McMaster University (2003) and completed her postdoctoral fellowship training (2004-2006) in the Department of Psychiatry and Behavioural Neurosciences (McMaster University) and the Centre for Knowledge Translation (University of Alberta). Her research interests are in the prevention of family violence (intimate partner violence and child maltreatment), nurse home visitation programs, and knowledge translation.

Jeffrey H. Coben, MD, is a professor in the Departments of Emergency Medicine and Community Medicine at West Virginia University. He has served as scientific director of the West Virginia University Injury Control Research Center since 2004 and as director since 2009. He uses clinical, public health, and health services research methods to examine a variety of injury problems. He has published extensively on both intentional and unintentional injuries. His recent and currently active research is focused on the topics of intimate partner violence, rural/urban differences in injury causation, prescription drug abuse, and adverse medical events.

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