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Introduction   

Travel nurses may encounter suspected abuse and neglect during the care that they provide. Nurses and other healthcare providers are responsible for understanding the mandatory reporting requirements for known or suspected abuse or neglect of elders or children, and any state laws that must be followed in relation to these vulnerable populations. 

Elder abuse is defined as any intentional or negligent act against an adult who is 65 years or older that has the potential to cause an adverse effect on the health or safety of the individual. In the United States, 10% of elders have experienced reported abuse from family, caregivers, assisted living facility staff, and other perpetrators (1). An abuser may be a female or a male and is often a close family member. The Council on Aging (2021) states that approximately 66% of abusers are identified as the adult child or spouse of the abused (2). 

The other vulnerable population that makes up a significant proportion of reported abuse cases is children. In 2020, data analyzed across the United States revealed that over 1,700 children (up to 18 years of age) died due to harm and injury caused by child abuse and neglect. Approximately 1 in 7 children have suffered from abuse, harm, or exploitation. It is estimated that child abuse and neglect are grossly underreported, so these numbers are likely significantly higher (3).  

Mandated Reporting 

The Federal Government of the United States requires that each state implement its provisions and guidance for reporting child abuse. This mandate was enacted in 1974 under The Federal Child Abuse Prevention and Treatment Act (CAPTA) (4). In 2010, the federal government enacted the Elder Justice Act within the Patient Protection and Affordable Care Act. 

Nurses traveling to locations other than their home state must remain cognizant that laws may differ. Each state has its own policy and law governing the definitions of what is reportable and the reporting requirements.  

Depending upon the state, the suspected abuse may require being reported to one or more different agencies. These agencies may include but are not limited to, a police station, a county child welfare services agency, Child Protective Services (CPS) or Adult Protective Services (APS), or a Department of Health and Human Services.  

The National Adult Protective Services Association (NAPSA) provides APS contact information for all U.S. States and territories. This service may be accessed via https://www.napsa-now.org/help-in-your-area. Once a state or territory is selected, the proper authoritative organization is displayed with contact information.  

The Child Welfare Information Gateway, found at https://www.childwelfare.gov/state-child-abuse-and-neglect-reporting-numbers/, is a service of the Children’s Bureau within the Administration for Children and Families of the U.S. Department of Health and Human Services. This service provides access to: 

• Law and Policies 
• Publications 
• Research 
• Databases with information regarding abuse and neglect prevention, adoption, and equity. 

Responsibilities as a Mandated Reporter 

The Child Abuse Prevention and Treatment Act mandates the reporting of cases of child abuse for certain professionals, including nurses. Failure to report suspected cases of child abuse may result in a misdemeanor offense. The requirements for reporting suspected abuse vary from state to state. While healthcare providers must report suspected cases to local authorities, the specifications of who is a mandatory reporter and what must be reported vary (5). 

When signs of abuse or neglect are seen, the travel nurse should follow the facility’s reporting policy. The nurse should notify their supervisor of any suspicion of abuse for further guidance to facility policy and state reporting requirements. 

Recognizing Risk Factors 

Risk Factors for Abuse and Neglect 

The following are risk factors for abuse and neglect: 

• Poverty 
• Lack of education 
• Rural locality 
• Migratory workers 
• Belonging to an indigenous tribe 
• LGBTQ member 
• Lack of social support system, especially girls aged 12 – 16 
• Disability 
• History of abuse 

Conducting Screening Interviews 

When interviewing children and elderly populations about any possible abusive behavior or concerns, it is best to utilize open-ended questions. Allowing the individual to express their thoughts and feelings about events in their own words promotes trust. When assessing patients, it is the responsibility of the nurse to establish reasonable cause of harm. It is best to find a private place to speak and always remember to remain calm. Being honest and upfront with the patient about what concerns there are and what will happen if it is determined that abuse or neglect is likely to be an assuage. It is essential to be supportive regardless of the answers that are given. They listen to the patient and assure them they are not at fault.  

It is essential to avoid making judgments, overreacting, promising or making commitments that cannot be met, or conducting a formal investigation or interrogation. Screening for abuse and neglect is a complex subject and must be completed with the patient while avoiding influence from the potential abuser. Separating the patient from the caregiver or other individuals that may be present can potentially cause strife. Abusers typically do not allow the abused to be alone with other individuals or may have previously threatened the patient that harm would result if they shared abusive events. Other staff may be needed to intervene or redirect attention away from the patient to allow for a comprehensive and complete head-to-toe assessment and discussion to make a better determination if the patient has any overt or covert signs of abuse or neglect. 

Identifying Abuse and Neglect in Children 

The World Health Organization has defined harm in children as “. . . all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that result in actual or potential harm to the child’s health, development, or dignity.” Signs and symptoms of abuse and neglect may differ based on the age of the child. The term child has a broad range from newborn to 18, so the nurse must know various common characteristics. Abuse of children may be medical, neglect, emotional, sexual, or physical. 

Specific characteristics may be more common depending on the type of abuse the child is being subjected to. The nurse should remember that abuse does not always fit an expected pattern and be diligent in recognizing and voicing concerns about red flags or intuitive feelings. Certain behaviors are typically concerning and must be investigated further, such as displays of fear towards adults, withdrawal from activities and peers, new onset reactions of anger, aggression, defiance, or hyperactivity, poor school performance, and sleep disturbance. Signs and symptoms of abuse are specific to the type of abuse and may be seen at any age (6).  

Common signs of abuse based on type are as follows (7): 

Sexual Abuse 

• Sexual knowledge or behavior that is not acceptable for the child’s age 
• Pregnancy or fear of being pregnant  
• Bleeding or injury of genitals or anus 
• Admission of sexual abuse 

Emotional Abuse 

• Low self-esteem, lack of self-confidence 
• Withdrawal of social interaction 
• Emotional development is younger than expected 
• Attention seeking 
• Depression 

Neglect 

• Stunted growth patterns 
• Weight issues 
• Hygienic concerns 
• Stealing and hoarding food 
• School attendance or performance is poor 
• Inappropriate medical, dental, or psychological attention or follow-up care 

Medical 

• Unexplained illnesses 
• Overbearing or protective caregiver or parent 

Additional attention must be paid to identifying abusive head trauma in infants and young children. It may not be blatantly apparent as these cases often present with a lack of obvious illness or any external injuries. When injuries due to abusive head trauma are present, it is often manifested as fractures of long bones or the skull, bruising of the neck or head, or any visible bruising on an infant that is four months of age or less. Any unexplained or complex reasoning for the cause of fractures is a red flag for abusive head trauma (4). Diagnosing this alarming pattern of abuse is completed via ophthalmology examination to assess for retinal hemorrhage. This is because the inertia due to the back-and-forth force of shaking results in retinal shearing that is viewable with a fundal eye exam. An MRI or CT may also reveal brain bleeds, including subdural hematomas. Around 70% of abusive head trauma cases result in severe injuries (4). 

Identifying Abuse and Neglect in Elders 

There are six types of Elder Abuse identified and acknowledged by the court systems of the United States. This includes (1): 

• Physical 
• Emotional/Psychological 
• Sexual 
• Neglect or Abandonment 
• Financial Exploitation, including Healthcare Fraud and abuse 

Signs of Elder Abuse 

• Bruises, black eyes, welts, lacerations, or rope marks 
• Bone fractures, especially of the ribs or skull 
• Injuries, wounds, and bruises at various stages of healing 
• Open wounds, cuts, or punctures 
• Sprains, dislocations, or internal injuries/bleeding 
• Broken eyeglasses/frames, unkept appearance, or hygiene concerns  
• Signs of being restrained, such as ligature marks on wrists or ankles 
• Medication overdose or under-utilization of prescribed drugs 
• Elder’s report of being hit, slapped, kicked, or mistreated 
• Behavioral changes: flat affect, crying often, disengaged, fearful 
• Overprotectiveness by caregiver, refusal to allow visitors to see an elder alone 

Concerning Parent or Caregiver Behaviors  

Sometimes, a parent or caregiver’s demeanor or behavior sends red flags about child or elder abuse. Warning signs include individuals who (7): 

• Expressing little concern for the patient 
• The physical and emotional distress of the patient is not recognized 
• Blaming patient for things outside their control 
• Uses inappropriate and demeaning language 
• Uses harsh physical discipline 
• Demands an inappropriate level of physical capability or mental acuity 
• Severely limits the patient’s contact with others 
• Offers conflicting or unrealistic explanations for a patient’s injuries or no explanation at all 
• Repeatedly brings the patient for medical evaluations or tests, such as X-rays and lab tests, for concerns that do not match the diagnosis or presentation of the patient. 

Caring for a Patient with Suspected Abuse or Neglect 

Primary management of a patient with suspected abuse involves stabilizing and treating any obvious injury or acute illness, including assessing the patient’s airway, breathing, and circulation. Once the patient is hemodynamically stable, a complete history and physical examination should be performed. The appropriate authorities should be notified of any actual or suspected abuse as soon as it is recognized. Some healthcare facilities in larger areas may employ an abuse specialist for consultation. Early involvement in a role like this or with a social worker is advisable (8).  

The travel nurse must be mindful that the goal is to identify abuse, provide appropriate care, and alert the authoritative body to the potential or actual abuse. The nurse should not engage in trying to identify the abuser or gain a confession from anyone who is with the patient. In outpatient settings, the patient may need to be transferred to another facility for further workup diagnostic testing and imaging (8).  

Victims of sexual abuse should have their physical, mental, and psychosocial needs addressed. Depending on age, a baseline of sexually transmitted infections (STI) as well as pregnancy testing should be performed. The nurse should anticipate empiric treatment for HIV, gonorrhea, chlamydia, trichomonas, and bacterial vaginosis infection for the sexually assaulted victims. This only applies if the patient presents within 72 hours of the incident to receive appropriate care. Victims within child-bearing age may be offered emergency contraception (8).  

Prophylactic treatment is generally not initiated on patients who have not yet gone through puberty due to the low incidence of STIs in this age group. Any patient presenting that has anogenital injuries (requires prophylactic treatment), is suicidal, has forensic evidence collection orders, or urgent care needs for a symptom and injury must have an urgent evaluation by a healthcare provider (8).  

Preventing Abuse and Neglect in Vulnerable Populations 

Abuse and neglect are preventable. Studies have shown that early intervention and mitigation of further abuse can positively impact the outcomes of patients and caregivers. Increasing the availability of programs aimed to educate, provide resources, and lessen the burden on parents and caregivers reduces the chances that violence will escalate or continue. The following are ways to address and prevent violence in communities (3): 

• Support parents and caregivers with cultural change 
• Improve economic support and advocate for financial security 
• Promote parenting skills and provide early education 
• Encourage cultural change that supports caregivers 
• The report identified abuse and neglect to lessen the harm caused 

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