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1. Assessing children at risk: organizational and professional
conditions within children’s hospitals
Veronica Svärd
University of Gothenburg Department of Social Work, Göteborg, Sweden
Correspondence:
Veronica Svärd,
Department of Social Work,
University of Gothenburg P.O. Box
720, SE 405 30 Göteborg, Sweden
E-mail: veronica.svard@socwork.gu.se
Keywords: child maltreatment,
children at risk, health care
professional, inter-professional work,
organization, risk management
Accepted for publication: March 2016
ABSTRACT
According to the Swedish Social Services Act, all health personnel are
required to report children whom they suspect are subject to
maltreatment. This paper describes the organizational and professional
conditions in four Swedish children’s hospitals regarding the reporting
process. Specifically, the study focused on knowledge of risk to children,
legal frameworks and the perceptions of organizational support and
explored the differences between the hospitals and professional groups.
The method used was a quantitative questionnaire, and 295 personnel
responded. Hospitals differed in the level of organizational support
offered to staff. Importantly, the professional groups showed different
levels of knowledge and awareness about structures supporting their
reporting obligations, with nurses and nurse assistants showing a lower
level of awareness than physicians and hospital social workers. The
paper argues that all professional groups need to have equal access to
education, with the opportunity to become more involved in the
assessment and reporting process and to strengthen multidisciplinary
structures. Further, this would reduce risk, dispel the perception that
work with children is ‘dirty work’ and counter strategies of avoidance
among some professionals.
INTRODUCTION
In 1982, all personnel within Swedish health care
institutions were mandated to make a report to social
services when they suspected that a child might be at risk
of harm. Although no national statistics are available,
studies indicate that these health care personnel do not
seem to report to the extent that they should (Lagerberg
2001; Borres & Hägg 2007; Tingberg et al. 2008).
Further, it has been noted that the number of incoming
reports to social services is considerably lower from
health care institutions than from other institutions
(Cocozza et al. 2007; Östberg 2010), which raises
questions about the specific conditions within health
care institutions. Supportive organizational conditions
within children’s hospitals that have a unique
opportunity to identify children at risk may be essential,
especially for ill and already vulnerable children who
regularly attend hospitals.
Internationally, it has been shown that hospital
personnel are often unwilling to report child abuse and
neglect to responsible authorities (Tirosh et al. 2003;
Theodore & Runyan 2006). One reason for this is that
physicians lack certainty when diagnosing child abuse
and neglect. For example, they have difficulties in
distinguishing accidents from non-accidents (Van
Haeringen et al. 1998). Other studies show that psycho-
social signals are noticed less often than other types of
signals (Al-Moosa et al. 2003) and the paediatricians in
Shor’s (1998) study were likely to assess psychological
and emotional abuse and neglect as less harmful than
physical forms of abuse. Paavilainen et al. (2002)
indicate that time pressure and workload make person-
nel unsure about when to diagnose, and Svärd (2014b)
shows that suspicions are more often directed at under-
privileged than at privileged groups of parents. It has
also been shown that personnel are unsure about the
level of evidence required and harbour fear of making
Child and Family Social Work 2016 © 2016 John Wiley & Sons Ltd
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doi:10.1111/cfs.12291
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2. a report (Lee et al. 2007) but that dialogue with social
services increases the feeling of certainty and the report
rates (Flaherty & Sege 2005).
The amount of training about child abuse and neglect
that the professionals receive during their education
varies between countries. In China, for example, all
responding physicians and nurses stated that they had
not received any training on the subject, and 85% would
not suspect abuse if they encountered an injured child
(Hesketh et al. 2000). Nearly all Canadian and North
American participants in Wright et al.’s (1999) study
answered that they had had some training about child
abuse, although the authors found significant training
gaps in postgraduate medical education in response to
it. In Sweden, Mårtensson & Janson (2010) show that
27% of those in paediatric training have had some kind
of formalized education about child abuse/neglect and
29% were offered training about how a report should
be made. Further, Swedish physicians’ uncertainty
about diagnosing, their lack of knowledge of the laws
and the level of evidence required for making a report
to social services have been shown to influence
assessment and reporting (Borres & Hägg 2007).
Swedish social worker education, in contrast, always
includes knowledge about dysfunctional families, child
welfare and protection and the Social Services Act
(2001: 453).
Sweden is characterized by having a preventive child
welfare system focusing on giving support to families,
rather than a child protection system (Khoo et al.
2002). This is reflected in the national guidelines about
reporting, which highlight that children at risk of harm
may be involved in a wide range of situations, such as
sexual exploitation, self-destructive behaviour or being
witness to violence or other harmful social situations.
The Social Services Act further stipulates that all
personnel working with children shall report such
suspected risk situations to social services without any
requirements for evidence, as social services are
responsible for further investigations.
With the purpose of promoting teamwork based on
mutual respect for the knowledge and expertise of the
various professions, inter-professional collaboration in
health care has been supported in recent decades
(World Health Organization (WHO) 1998). The
current trend within health care is increased
specialization and separation of proficiencies. Inter-
professional teamwork is intended to bridge the gaps
between the professions’ knowledge areas, and well-
functioning teams may be essential to strengthen the
integration of differing knowledge areas (Robinson &
Cottrell 2005). Hospital social workers (HSWs) seem
– to a greater extent than other hospital personnel – to
have a particular interest in promoting inter-
professional collaboration (Abramson & Mizrahi 1996;
Harr et al. 2008) and upholding the holistic approach
to making assessments of children at risk. Although
health care personnel do not seem to report to the extent
that they should, HSWs often take an active position in
assessments of children who might be at risk, although
some take a more reflective or even passive approach,
the latter as a consequence of following the physician’s
judgements and decisions (Svärd 2014a). This may be
related to the internal hierarchies within hospitals but
may also be about unclear professional roles. As Rees
(2010) argues, unclear roles and responsibilities can
result in a case concerning emotional abuse not being
interpreted as ‘abuse’ and thus no action being
undertaken.
When unclear professional roles are a hindrance to
making adequate assessments and reports, supportive
organizational conditions may be even more important.
The field of research on child protection teams is strong
(refer to, e.g. Harr et al. 2008; Agirtan et al. 2009), but
the research on other forms of organizational support
is weaker. However, in their systematic review, Louwers
et al. (2010) found that, in emergency departments,
training and checklists that showed indicators of child
abuse increased awareness among the staff because they
broke some barriers to reporting. Another systematic
review by Newton et al. (2010) evaluated the effective-
ness of professional (e.g. educational initiatives) and
organizational (e.g. implementation of specialized
teams) interventions, such as documentation or clinical
assessments that aimed to improve assessment
processes among physicians in emergency departments.
They found that the interventions and professional
practices for handling child abuse and neglect produced
modest and varied effects and emphasized the need for
theoretically driven and evaluated interventions –
interventions that should target other professionals,
such as nurses and social workers, and at which
professional behaviours and organizational strategies
should aim in order to optimize the role of multidisci-
plinary teams.
To summarize, earlier studies point out a range of
factors hindering professionals from making adequate
assessments and reporting to social services. These
studies stress the importance of a multidisciplinary
approach and professional and organizational interven-
tions, although they argue that these need to be further
evaluated. What we do not know is the degree to which
professional and organizational support is used, imple-
mented and recognized in Swedish children’s hospitals.
Children at risk: conditions within hospitals V Svärd
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3. The aim of the study
Based on a quantitative questionnaire, this study
examines the organizational and professional conditions
within four Swedish children’s hospitals concerning
work with children suspected of being at risk of harm.
More specifically, this research focuses on the
knowledge and working experiences of physicians,
nurses, nurse assistants and HSWs and on the available
organizational and professional support that they state
they have. The following questions are addressed:
• What self-reported knowledge do personnel have
about children at risk and how confident are they
about what the law implies for their work and duty
to report?
• To what forms of organizational support do the
respondents state that they have access? Do they, for
example, have access to specialists, guidelines or
supervision?
• Which professionals do they consult when suspecting
a child may be at risk? Do they consult other
professions, or do they primarily turn to their own
profession?
• Are there any major differences between the hospitals
and the professions regarding the questions
mentioned in the preceding texts?
Professional relations, avoidance strategies and lack of
jurisdiction
As noted in the preceding texts, personnel often face
hindrance factors that obstruct assessments and
reporting. These factors may, for instance, be related
to varied knowledge areas within professional training,
professional relations and the ways in which organiza-
tions prioritize these issues and organize support for
personnel. In recent years, hospitals and other organiza-
tions have been transformed by discourses about risks
and how these can be managed (Power 2008). The
concept of risk – such as assessing children who may
be at risk – therefore implies a field of decision-making
about the future that organizations are expected to
manage. The increasing expectations of risk manage-
ment not only mean the mandated reporting to social
services but also expectations that hospitals will organize
and govern the risk management processes within the
organization (Power 2008).
As mentioned earlier, a multidisciplinary approach
seems to be essential for holistic assessments. Assessing
children who may be at risk is not necessarily a medical
concern: The risk situation can be about social, psycho-
logical or emotional issues, although these are often
intertwined. Therefore, the assessment does not belong
to just one profession and its knowledge base. The fact
that health care personnel are often unsure when
assessing may have to do with the fact that the concern
is of a non-medical nature in a medical context.
Gustafsson (1987, p. 6–11) argues that the ‘emergency
treatment model’ has become a standard model for
hospital care, with the consequence that personnel
describe situations full of contradictions because many
working tasks focus on patients’ inadequate social
situations. He argues that incongruities often derive
from this organizational condition. The emergency
treatment model is described as the coalescence of two
hierarchies: the medical hierarchy with the physician as
leader and the administrative hierarchy that promotes
efficiency, rationality and productivity (Gustafsson
1987). Shaw (2004) points out that when a client’s
problems are perceived not to be central to the medical
practice or the profession’s tasks, addressing these
problems may be seen as ‘dirty work’ that is avoided or
passed on to someone else. Understood from this
perspective, social, psychological and emotional issues
related to assessments of whether a child is at risk can
therefore be rationalized as non-prioritized tasks and
avoided.
Even though hospital care has promoted efficiency
and rationality, health care professionals have retained
a great deal of autonomy and still perform their
assessments without detailed external control
(Blomgren & Waks 2011). This is also the case with
children suspected of being at risk; although the
professionals are strictly required to make a report, there
is nevertheless wide professional discretion in
assessment. How assessments and decisions are made
is, most probably, also related to how professional work
is organized.
The hospital setting can be thought of not only as the
organizational frame for this study but also as an area
where the organizing of professional work is ongoing.
This organizing can be understood as a network of
actions between professionals and different parts of the
organization. Czarniawska (2005) argues that these
‘networks of actions’ should be explored to enable
understanding of the professionals’ roles in their
contexts. Clear roles are also said to be fundamental
for effective inter-professional teams (Reeves et al.
2010). When team members do not acknowledge,
understand or respect each other’s roles, this may
indicate that the professions’ different statuses on the
team have implications for their knowledge contribu-
tions (Kvarnström 2007).
Further, it is argued that professional groups are
competing for expert roles, tasks and work areas – and
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4. try to defend, expand and achieve monopoly over the
area. Abbott (1988) names this phenomenon as a
profession claiming jurisdiction over the area in
competition with rival professions. Maintaining
educational distinctions is one of several ways of
emphasizing jurisdictional boundaries and professional
differences in workplaces. Abbott (1988, p. 117–118)
uses the term ‘internal differences’ to describe members
of professions coming into closer interaction with
members of professions related to but other than their
own, which, he argues, may affect intra-professional
status and the organization of work. The jurisdictional
claims about children at risk within hospitals as outlined
are weak (Svärd 2014a), mainly because the Social
Services Act stipulates that all personnel are obliged to
report when they have a suspicion. How the lack of
jurisdiction influences the organization of risk
management within children’s hospitals is therefore of
analytical interest in this study.
METHODOLOGY AND DATA ANALYSIS
The purpose of the study is to gain a picture of the work
that personnel of the children’s hospitals do with
children who might be at risk and particularly what
organizational and professional support they state they
have in this work. The four largest university hospitals
were chosen, as it can be argued that they actively
promote evidence-based practice to a greater extent
than regional hospitals and may have more developed
organizational support for work with children at risk.
The hospitals included were Astrid Lindgren Children’s
Hospital in Stockholm (the two major hospitals located
in Solna and Huddinge), Academic Children’s Hospital
in Uppsala, Queen Silvia’s Hospital in Gothenburg and
the children’s departments within Scania’s University
Hospital (located in Lund and Malmö).
The professional groups selected for this study were
physicians, HSWs, nurses and nurse assistants; the
latter group was chosen because they spend compara-
tively more time than the others with the children and
their families at the departments. Only personnel work-
ing in inpatient wards were selected, although some also
worked with outpatients. Personnel worked in a range of
different departments, specializing in emergency, oncol-
ogy, haematology, surgery, nephrology, neurology,
cardiology, infection, gastroenterology and endocrinol-
ogy. The HSWs had their own departments or teams
and worked within one or more children’s departments.
It was not possible to reach all personnel via their
professional organizations or trade unions and therefore
not possible to conduct a total population study. Neither
was it possible to obtain contact information from all
departments to enable the questionnaire to be sent to
the selected personnel. Therefore, the respondents do
not represent the total population of professionals
within the departments; they should instead be
considered as a sub-set of those actively working at the
time at which the study took place.
The study is based on a quantitative questionnaire,
which is designed, with inspiration from previous
research, by the author. The questionnaire had two
sections and included 22 questions in total. These were
either rating scales with five grades or had from 3 to 14
alternative responses, some of which were open-ended.
The first section asked for the respondent’s gender,
age and work experience. The second section
concerned self-reported education the respondent had
obtained in the area of children at risk and confidence
about what the Social Services Act implies for the
respondent’s work and duty to report. The question-
naire also asked for experiences of contact with children
at risk, which professional the respondents chose to
consult and whom they believed was responsible for
making a report. Some questions focused on whether
respondents had routines and guidelines, a child
protection team, a children’s advocacy centre or
expertise to consult when suspecting a child might be
at risk. The questionnaire was pretested by two
representatives of each selected profession, but not at
the same hospitals. Before the questionnaire was finally
used for the data collection, one question was added
and smaller language clarifications were made to enable
all professions to understand and answer them.
At the first stage, contact was made with the directors
of the children’s hospitals. After their approval to carry
out the study within the hospital was obtained, contact
was made with the directors of the different departments
or a contact person for a team of physicians or HSWs.
About 100 such persons were contacted. In sum, 23
visits were made to different departmental or team
meetings between April and June 2013. Physicians and
HSWs mostly had their workplace/team meetings with
their respective professions, whereas nurses and nurse
assistants had joint meetings. At the meetings, the
project was presented and the questionnaire was
distributed, filled in and collected. However, because
of time constraints at some meetings, these groups were
provided with addressed envelopes to send in the
questionnaire later. One reminder was sent to
departments who had received addressed envelopes. In
total, 365 questionnaires were distributed, and 295
(80.8%) were correctly completed and returned.
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5. Seventy-two physicians, 119 nurses, 70 nurse assistants
and 34 HSWs responded to the questionnaire.
There was a balance in the number of physicians
between the hospitals, but there was a higher proportion
of nurses at Scania and Astrid Lindgren Hospitals and
of HSWs at Astrid Lindgren Hospital. The HSWs
represent the total population in the hospitals quite well,
while there is a smaller representation of the other
professions because only those actively working at the
time at which the study took place were asked to
participate.
The respondents’ answers revealed their own under-
standing of the specific question. For example, when
they answered that their hospital has a child protection
team, this was not always the real situation.
An ethical application for this study was approved by
Mid Sweden University Ethical Review Board (2013).
The questionnaire was filled in anonymously and there-
after coded and added to a code list. Information about
the study was provided in writing to the staff when the
questionnaire was distributed and voluntary consent
was obtained from all participants.
Data were analysed using SPSS 22.0, and bivariate
analysis was conducted. The variables were analysed
according to either the four hospitals or the four profes-
sions. Open-ended reply alternatives are described in
the text but analysed as one variable.
RESULTS
Among the 295 respondents, a clear majority obtained a
major part of their professional education in Sweden;
only 6% were educated in another country. Women
employees predominate in Swedish health care institu-
tions and, in total, constituted 86.1% of the respondents
in this study. There were some gender differences
between the professions. The nurses, nurse assistants
and HSWs consisted of 96–97% women, whereas
national workforce data show that 90% of nurses, 86%
of assistant nurses and 84% of social workers (including
HSWs) are women (Statistics Sweden 2014). The low
number of men makes it impossible to make compari-
sons between genders within these professions in this
study. However, physicians are a more gender-equal
group, with close to 46% being men, although this
group also shows slightly fewer men than the national
statistic of 50% (Statistics Sweden 2014). The higher
number of women than men among this study’s respon-
dents probably reflects the fact that women often are
specialized in child health care (refer to, e.g. Ku 2011).
Conditions and support within the organizations
The respondents were asked about the extent to which
their hospitals organized support for work with children
who might be at risk. The organizational support is
divided into three types in this study: (i) child protection
teams, specialists and children’s advocacy centres
(CACs; cooperation between health care professionals,
social services, police and a prosecutor in cases of child
abuse and sexual assault); (ii) routines and guidelines;
and (iii) access to group supervision or a mentor to
discuss difficult cases. The results are presented in the
succeeding texts.
Nearly half of the respondents knew about a child
protection team, and one in four knew about a specialist
to consult. As Table 1 shows, the answers varied
between the hospitals. Almost 40% of the respondents
at Queen Silvia’s Hospital did not know whether they
had access to any of the suggested organizational
support, although some believed that there was a child
protection team when in fact there was not at the time
when the study was conducted. Interestingly,
remarkably few respondents at Astrid Lindgren,
Academic and Queen Silvia’s Hospitals were aware of
the CACs. Some of the variance may be explained by
how knowledge of the resources differs between the
professional groups. The physicians were more aware
of there being a specialized team working with children
Table 1 Resources in terms of child protection team, CAC or specialists known of within the hospitals, percentages
Astrid Lindgren Academic Queen Silvia Scania
Team 75.8 91.7 16.1 21.1
CAC 4.21
18.8 9.7 25.62
Other specialist 18.9 20.8 35.5 27.8
Do not know 14.7 4.2 37.7 31.1
Bolded number if the resource existed.
1
Only in Huddinge, not Solna.
2
Only in Lund, not Malmö.
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6. at risk, whereas the HSWs were more aware of a CAC.
Almost a third of the nurses and a quarter of nurse
assistants stated that they did not know of any specialist
resource at all.
Although the respondents at Queen Silvia’s Hospital
answered that they did not know whether they had
access to any of the suggested organizational support
mentioned in Table 1, they were most satisfied with
their guidelines and routines: 57.4% thought that these
were sufficient. The respondents at the Academic
Hospital were, in contrast, most critical: More than
20% stated that the guidelines and routines were not
sufficient. Slightly more than 40% of the respondents
at Astrid Lindgren did not know whether there were
any at all, whereas one third of all respondents did not
know whether there were any guidelines or routines at
their hospital.
The third kind of support concerns whether the
respondents have access to and use group supervision
or an individual mentor to receive supervision about,
for example, cases that appear harder to assess and
handle. These answers do not, however, say anything
about what kinds of cases the respondents have
discussed with their supervisor or mentor, so the cases
may not have concerned children suspected of being at
risk; the answers indicate that the respondents had the
opportunity to have supervision in these cases.
Slightly more than half of the respondents had access
to group supervision, but fewer than half of them used it
on a regular basis. However, Table 2 illustrates some
differences between the hospitals, showing that
respondents at Astrid Lindgren more often declare that
they have access to and use supervision, while at most
16.1% regularly used supervision within the other
hospitals. The respondents from Scania’s Hospital had
the least support, and, in total, very few respondents
stated that they used a mentor.
Professional conditions
In addition to the organizational aspects indicated in the
preceding texts, professional conditions may also have
importance for work with children suspected of being
at risk. One such condition may be the extent of the
knowledge that different professions have obtained from
earlier work experiences. When it comes to the
differences between the respondents’ years in their
profession, the nurse assistants stand out: 56% had been
in their profession for more than 20years, compared
with 23% of the nurses. Forty per cent of the nurses
had been in the profession for less than 6 years, 44% of
the HSWs more than 20years and 69% of the physicians
more than 11years.
Even though a high percentage of the nurse assistants
and HSWs had been in their professions for many years,
this does not mean that they had stayed at the same
clinic. In fact, 18% of the HSWs and as many as 26%
of the nurses had been at their clinic for less than 1 year.
Among physicians, it was more common to have been at
their present clinic for between 6 and 20years, and,
among nurse assistants, it was more than 11years.
There is reason to believe that length of the working
experience influences the level of attention and certainty
in assessments.
As previous research indicates, lack of knowledge
among personnel is a hindrance in making assessments
about a child being at risk. Therefore, some questions
concerned whether the respondents agreed that they
had had sufficient education on this topic.
Social workers in general have more education than
physicians do about children at risk of harm. Neverthe-
less, it is a somewhat surprising result that a higher
percentage of the HSWs than the physicians agree that
they have sufficient education about physical abuse, as
this usually belongs to the area of medical knowledge
(refer to Table 3). Perhaps this result has to do with their
evaluation of the question from a different perspective:
Physicians may assess their medical ability to interpret
injuries as caused by abuse or as an accident, while
HSWs’ assessments are based on the societal norms
about acceptable physical actions against a child.
A less surprising result is that a higher percentage of
HSWs agreed that they have had sufficient education
about physical neglect and about psychological abuse
Table 2 Access and use of supervision and mentorship within hospitals, percentages
Astrid Lindgren Academic Queen Silvia Scania
Access to supervision 63.2 41.7 37.1 52.7
Using supervision 37.9 14.6 16.1 13.5
Access to a mentor 30.5 25.0 24.2 33.0
Using a mentor 9.6 8.3 8.1 3.4
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7. and neglect compared with physicians, nurses and nurse
assistants. These results are in accordance with the fact
that the standard social worker education programmes
in Sweden involve questions about dysfunctional
families and child welfare and protection. Social work
education also involves law studies and courses about
the Social Services Act, which is directly reflected by
the fact that all HSWs agreed that they are confident
with what this act implies for their work and their duty
to report.
As shown earlier, there were different understandings
among the staff from the different hospitals about the
support to which they had access. When the answers
are divided among the professions, another picture is
revealed, such as when it comes to awareness of
guidelines and routines regarding children who might
be at risk (refer to Table 4).
The guidelines and routines were most well-known
among the physicians and the HSWs: 85% of the HSWs
know about guidelines and routines, and more than
70% of them believe that they are sufficient, while more
than 40% of the nurses and the nurse assistants do not
know whether there are any at all. Although more than
a half of the physicians are satisfied with the guidelines
and routines, they are at the same time most critical:
23.6% think that they are insufficient.
Table 2 shows differences between the hospitals to the
extent that personnel had access to and used supervision
or a mentor. Although there are differences among
hospitals, the differences are even more significant
between professions.
As Table 5 shows, almost all HSWs use supervision,
while very few nurse assistants and especially physicians
and nurses used it. Mentors seem to be a type of support
that is infrequently offered, although physicians use
mentors slightly more than group supervision.
Inter-professional expectations and network of actions
How the professions organize their work and how their
network of actions appears has to do with knowledge,
hierarchies and who, among the professions in the
hospital setting, is considered to have the responsibility
to report to social services. There is, nevertheless, no
consensus within the hospitals about which profession
should have the responsibility to make reports. Thirty-
two per cent of the nurse assistants and 13% of the
nurses in this study responded that physicians should
have the responsibility to make reports, yet only 10%
of physicians agreed with this. Nine of every 10
physicians responded that the person who has a
suspicion should make a report, which is also what the
Social Services Act stipulates. However, 80% of the
nurses and 57% of the nurse assistants agreed that the
person who has a suspicion should report. This opinion
is most commonly held among the HSWs (91%). The
fact that some respondents believe that it is the physician
who should report may be related to the medical
hierarchy within the hospitals, but it may also be a
consequence of the fact that there is not a single
profession that is designated as having the responsibility
for this task.
These results correspond fairly well with the findings
in Table 3 that all HSWs believe that they are confident
about the Social Services Act, saying that everyone
working within health care has an obligation to make a
Table 3 Professionals’ that agree or strongly agree that they have obtained sufficient education, percentages
Physicians Nurses Nurse assistants HSWs
Physical abuse 54.2 31.4 23.2 58.8
Physical neglect 41.7 26.3 17.4 61.8
Psychological abuse and neglect 37.5 22.9 14.7 55.9
Social Services Act 79.2 59.8 37.9 100.0
Table 4 The professional’s awareness and evaluation of guidelines and routines, percentages
Physicians Nurses Nurse assistants HSWs Total
Yes, sufficient 54.2 47.5 36.2 70.6 49.1
Yes, insufficient 23.6 9.3 15.9 14.7 15.0
No guidelines 1.4 2.5 2.9 0.0 2.0
Do not know 20.8 40.7 44.9 14.7 33.8
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8. report if suspicious. Some 11% of the physicians, 14%
of the nurses and 32% of the nurse assistants believed
that they have poor or no knowledge at all about the
law – a result that also corresponds fairly well with their
varied answers about who should have the responsibility
to report.
The questionnaire asked the respondents to rank
which professions they choose to consult when they
have a suspicion that a child may be at risk. In an
open-ended question, 12 respondents wrote that they
consulted another profession or authority, such as a
nurse assistant, a CAC or social services. These are
shown in the variable ‘Other’ in Table 6.
It is most common in all professions except nurse
assistants to consult their own profession in the first
instance. The nurse assistants instead chose to consult
a nurse first and thereafter a physician, an HSW and,
lastly, another profession or authority. For the
physicians, their second most common choice is a
HSW and thereafter a nurse or a psychologist and,
lastly, another profession or authority. The nurse’s
second choice is a physician and thereafter an HSW,
another profession or authority and, lastly, a psycholo-
gist. The HSW’s second choice is a physician and there-
after a psychologist and then a nurse or another
profession or authority. A possible analysis of the
network of actions (Czarniawska 2005) between the
professional groups is that all groups besides the nurse
assistants value their own profession’s role in
assessment, whereas nurse assistants to a higher extent
avoid this task. This may be because they have received
very little education about it, even though 57% agree
that it is the person who has a suspicion who should
report.
DISCUSSION AND CONCLUSIONS
The aim of this paper was to explore how organizational
and professional conditions are constructed within
hospital organizations in Sweden concerning work with
children suspected of being at risk. The results show that
all selected hospitals offer different kinds of organiza-
tional support, which the professional groups know of
to different extents. There are also some differences
between the hospitals. For example, within the
Academic Hospital, as many as 92% of staff knew about
a child protection team, and within Astrid Lindgren
Hospital, 76% have knowledge about such a team; it is
more common that physicians are aware of such a team
than others. At Queen Silvia’s Hospital, there is low
awareness about any human kind of organizational
support, while there is most satisfaction with the
guidelines and routines. All hospitals offer at least one
of the organizational supports, but none of them seems
to have implemented all of them fully among the
personnel; there is a low awareness especially among
nurses and nurse assistants. Furthermore, very few
respondents use supervision or a mentor, although they
have access to it; only HSWs more regularly use such
support. The HSWs also differ from the others in that
as many as 85% of them know about guidelines and
Table 5 Access to and use of supervision, or a mentor, among professionals, percentages
Physicians Nurses Nurse assistants HSWs
Access to supervision 27.8 46.2 61.4 97.1
Using supervision 8.3 10.3 20.0 97.1
Access to a mentor 29.2 30.8 31.9 18.2
Using a mentor 12.5 3.4 4.3 14.7
Table 6 What profession the respondents choose to consult in first hand, percentages
Physician Nurse HSW Psychologist Other
Physicians 74.5 5.1 11.5 5.1 3.8
Nurses 31.0 55.3 8.1 1.6 4.0
Nurse assistants 30.3 62.1 4.5 0.0 3.0
HSWs 16.2 5.4 64.9 8.1 5.4
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Child and Family Social Work 2016 © 2016 John Wiley & Sons Ltd
8

9. routines. It is noteworthy that a quarter of physicians
asked for better guidelines and routines. This study
cannot answer in what way these guidelines and routines
are understood to be insufficient, but a conclusion may
be that hospitals should involve the various professions
in the improvement of them because different profes-
sions need somewhat different aspects to be developed.
There are some aspects of the results that deserve to
be discussed further. It is clear that the professions do
not compete for an expert role in assessing children
who might be at risk. This is, however, a work task that
is not a question of jurisdiction, because all personnel
are required to report according to the Social Services
Act. In other words, it is everyone’s responsibility, but
no one owns responsibility. Although this can be said
to be dirty work (Shaw 2004) that is often considered a
difficult task for which individuals are not educated, it
may be that these cases are passed over to someone else
as an avoidance strategy. The lack of jurisdiction shapes
particular circumstances for collaboration; one positive
aspect might be that all personnel are supposed to be
involved in assessment that can strengthen holistic
assessments, while a negative aspect might be that it is
harder to define the roles of the collaborating personnel.
Status differences within hospital organizations may also
have the consequence that more or less tacit routines are
formed; when nurse assistants respond that they pass the
responsibility over to physicians, the kind of culture
within the hospitals may be described as ‘this is how it
works here’. There is a discrepancy between this
hospital culture and the individual obligation to report
– and it is probably a challenge for health care institu-
tions in general to change this culture. If promoting
individual accountability for child protection and
adequate reporting processes, the institutions may need
to put emphasis on more joint training and case
assessment and reporting.
In general, this study outlines a strong intra-
professional trust when personnel choose to consult
their own profession about a suspicion that a child might
be at risk – with the exception of the nurse assistants,
who mostly consult nurses. It may be that the nurse
assistants simply do not place the most trust in their
own profession, taking into account their stated lack of
knowledge and education. As the nurse assistants spend
a lot time with families within the inpatient wards, one
implication is that they may need to obtain more
education about assessment content and be more
actively involved in the assessment and reporting
processes.
Another interesting aspect of the result is that it seems
as though a new generation is taking over – especially
among the nurses, considering that a high percentage
of them have worked for fewer than 6 years in the
profession. There is reason to believe that longer
working experience involves increased attention and less
uncertainty in assessments, even though there is no
guarantee that it leads to increased reporting. However,
the high rate of turnover among nurses may be an
obstacle for continuity and knowledge transfer, because
they may not achieve additional education or the
opportunity to learn about and use available
organizational support. Further, considering the length
of the nurse assistants’ working experience, they have
remarkably low knowledge about the organizational
support available; this is echoed by almost one third of
them stating that physicians should take the responsibil-
ity for reporting children suspected of being at risk.
Many nurse assistants with long working experience will
soon retire, which makes it crucial that the new
generation of nurse assistants acquires better education
and knowledge. However, as long as such a high
percentage of all personnel currently lack education
about the subject, the organizational support available
may be of major importance for risk management at
hospitals. Spreading information about the structures
supporting work with children at risk most probably
should not involve much work for organizations.
Implementation of multidisciplinary assessments
such as those promoted, for example, by the World
Health Organization (WHO) (1998) could contribute
to minimizing barriers and status differences that may
be a hindrance to the utilization of knowledge contribu-
tions among professions (Kvarnström 2007). Child
protection teams and CACs are forms of multidisciplin-
ary structures that support holistic assessments, which
consider medical, psychological, emotional and social
aspects of risk. In practice, risk management may be
flawed if these structures are not known and supported
within hospitals. One implication, therefore, is to
improve organizational supports and structures that
promote multidisciplinary cooperation and assessment.
Such structures may be child protection teams, but they
may also be multidisciplinary team meetings at
departments that more clearly involve various
professions and encourage their knowledge
contributions.
To summarize, all hospitals offer some kind of
support to the staff who work with children at risk of
harm, but the findings suggests that all hospitals need
to develop and implement them better among all
professional groups. The hospitals included in this study
are the largest university hospitals in Sweden and are
expected to be at the forefront of evidence-based
Children at risk: conditions within hospitals V Svärd
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9

10. practice. Therefore, it is not inconceivable that
conditions within other areas of health care are worse
than those in this study. Furthermore, the findings
suggest that Swedish health care education and training
need to put more emphasis on child maltreatment
content and the mandated reporting required by the
Social Services Act; otherwise, the professionals’
promises to identify, support and protect children at risk
will continue to be flawed.
CONFLICT OF INTEREST
None.
ACKNOWLEDGEMENT
None.
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