Adverse childhood experiences (ACE) are defined as “abuse and household dysfunction during childhood” (Felitti et al., 1998, p. 246). A published seminal study defined three categories of ACE: abuse, neglect, and household dysfunction (Felitti et al., 1998). Abuse was considered physical, emotional, or sexual. Neglect included physical and emotional variations. Household dysfunction included exposure to someone who was currently or previously in the same living quarters who was violent, mentally ill, used substances, incarcerated, or was separated and/or divorced (Felitti et al., 1998).
Evidence shows that ACE have an impact on the long-term health of individuals (Kalmakis & Chandler, 2015). A pathway of how ACE translate into long-term adverse health outcomes has been described in the literature (Brown et al., 2009). Exposure to the chronic stress of childhood trauma can disrupt neurodevelopment (Perry & Pollard, 1998). This disruption may cause social, emotional, and cognitive impairment (Felitti et al., 1998; Schafer & Ferraro, 2012). For some individuals, the adoption of risky health behaviors is used as a coping mechanism to stressful events in their lives (Dube et al., 2001; Ford et al., 2011). Disease, disability, and social problems can develop as a result, ultimately increasing the likelihood of early death. Nurse practitioners (NPs) must be prepared to identify and refer a client who has experienced ACE.
More than one half of adults surveyed in the original ACE study had experienced at least one ACE, and one quarter of participants had experienced at least two or more (Felitti et al., 1998). Merrick et al. (2017) reported 80% of participants with mental health issues reported at least one ACE. The number of ACE experienced is associated with an increased risk of adverse health outcomes. At 30% exposure rate, the five states with the highest percentage of children aged 0 to 17 who have experienced two or more ACE in the United States are Oklahoma, Arizona, Kentucky, Montana, and Mississippi (United Health Foundation, 2016). The economic lifetime cost for a child victim of nonfatal child abuse and neglect was estimated in 2010 at $210,012 (Fang, Brown, Florence, & Mercy, 2012) and escalated to $830,928 in 2015 (Peterson, Florence, & Klevens, 2018). Fatal event per victim cost rose from $1.3 million to $16.6 million during the same period (Peterson et al., 2018). This estimate includes medical expenses, productivity loss, criminal justice costs, and special education costs.
Only one study was identified in the literature evaluating NP screening among adult patients (Kalmakis, Chandler, Roberts, & Leung, 2017). Approximately 30% of NPs regularly screened for ACE and perceived that their responsibility was screening adult populations. Lack of time and confidence were identified as top barriers to screening practices by NPs (Kalmakis et al., 2017). The purpose of the current study was to determine the relationship between NP knowledge of ACE and screening practice for childhood trauma in a mid-southern state adult population.
Design and Procedures
A descriptive study design surveying NPs at various stages of professional practice at a single point in time was used to evaluate screening practices and knowledge of ACE in NPs. An NP listserv was used to access the NP population. The listserv has the potential to capture data from all NP specialties. Variables examined in the current study included NP knowledge of childhood trauma, NP identified barriers to childhood trauma screening, level of educational preparation, area of specialization, county of practice, and frequency of NP screening for childhood trauma.
Before data collection, Human Subjects Review Board approval was obtained from the university where the study was conducted. The sample was a convenience sample and participants were recruited from the membership of a NP organization in a mid-southern state. Approval to send the questionnaire to members was obtained from the board of directors of the state NP organization. Data were collected via an anonymous online questionnaire with participation being solicited with an e-mail sent to all members of the organization in summer 2018. The e-mail explained the purpose of the study and contained a link to complete the questionnaire, which was administered in Qualtrics™ survey software. An informed consent document was presented, and consent was obtained in the first question of the survey. Informed consent contained purpose, potential risks, and benefits. Participants were made aware that the questionnaire would take approximately 10 to 15 minutes to complete. Contact information was provided to each participant. Inclusion criteria for the study were nurses who: (a) finished their advanced practice nursing degree and (b) practice in an area treating adult patients.
For the current study, NP is defined as a RN with a minimum of a master's degree and certification in an advanced practice specialty (e.g., family nurse practitioner, certified nurse-midwife, acute care, psychiatric–mental health). Exclusion criteria eliminated providers who practice outside the state where data were collected and those retired from clinical practice. The informed consent document notified participants they could withdraw at any time. The questionnaire was posted for 4 weeks, and members of the NP organization received a reminder e-mail 2 weeks after the initial e-mail invitation was sent.
The questionnaire used in the current study was the Survey on Assessing Adult Patients for a History of Childhood Trauma developed by Kalmakis and Chandler (2015). Permission for use was obtained from Kalmakis. The survey contains 21 questions. Completion of the survey took approximately 10 to 15 minutes. The survey was developed initially as part of a study assessing the practice, skill, attitude, and barriers as perceived by family practice physicians screening adults for physical or sexual maltreatment during childhood (Weinreb et al., 2010). Alpha coefficients ranged from 0.84 to 0.99. Construct validity was shown through factor analysis for the 12-item barrier portion of the survey. A second study was conducted and adapted to evaluate NPs specifically in Massachusetts (Kalmakis et al., 2017). The second study found Cronbach's alpha scores ranging from 0.72 to 0.79 (Kalmakis et al., 2017). With permission from Kalmakis, the tool was adjusted to include the name of the current state in which it was being used. This tool has been used similarly in the past; the new use of the tool with a population of NPs from a different state allowed continued confidence in the source of information. Demographic information collected included: primary specialties of NPs, education level, formal education about ACE, and county of residence.
Variables measured as part of the Survey on Assessing Adult Patients for a History of Childhood Trauma were NP knowledge of childhood trauma, NP-identified barriers to childhood trauma screening, and frequency of NP screening for childhood trauma. NP knowledge of childhood trauma was collected via questions regarding number of years in practice, perceived percentage of adult men and women who have a history of childhood abuse, personal ACE score, and contact with someone who has an ACE score. Additional questions regarding knowledge using a 4-point Likert scale included confidence in screening, perceived role of screening, and perceived usefulness of screening. NP-identified barriers to childhood trauma screening were collected via a question using a 3-point Likert scale for the options: not enough time to ask; not enough time to evaluate/counsel; uncomfortable asking; men/women unlikely to be victims; perception that history of child abuse is not a medical problem; perception that asking about abuse can retraumatize; perceived limited influence on patients who have abuse history; asking about abuse history offends patients; no reimbursement for screening; difficult to verify reports of abuse; and completing multiple primary care recommendations. Frequency of NP screening for childhood trauma was measured based on a 4-point Likert scale response for men and women at initial and follow-up visits.
Responses to the survey were downloaded from Qualtrics into a Microsoft® Excel® spreadsheet then into SAS version 9.4. Data were evaluated for complete versus incomplete responses. Demographic data were calculated using descriptive statistics, including frequencies and percentages. Knowledge of screening practices was compared between screening status (i.e., never, rarely, or sometimes screen versus usually or always screen), specialty practice area, and level of education. Barriers to screening were evaluated using descriptive statistics and examined based on specialty practice area and size of practice location.
A total of 71 NPs accessed the survey and agreed to participate. Of these, 16 did not fit study criteria, and nine gave consent but did not provide responses to any study instruments. This provided 46 complete surveys for analysis. Reasons for exclusion were retired from clinical practice (n = 2), practiced outside of a designated mid-southern state (n = 6), did not see adults (n = 2), and had not finished NP education (n = 6). Participant age ranged from 28 to 67, with an average of 53 years. Most participants were educated at the Master of Science in Nursing (MSN) level (n = 30). Other participants were prepared at the Doctor of Nursing Practice (DNP) (n = 15) and PhD (n = 1) level. Distribution of APRN specialties included 38 family practice, six mental health, one women's health, and one acute care (Table 1). Participating NPs had practices covering 22 different counties throughout a designated mid-southern state.
Nurse Practitioner (NP) Characteristics
As part of the survey, nine question responses were identified as measurements of knowledge (Table 2). Through the questions, multiple perspectives of ACE knowledge were evaluated. Perceived prevalence of physical and sexual abuse in men and women were two components. NP role, usefulness to the patient, and NP confidence to screen and use results were also considered representative of ACE knowledge. Personal experience with ACE was considered through self-reported individual and acquaintance history of childhood trauma. Formal training in patient screening for ACE was also assessed.
Knowledge of Nurse Practitioners (NPs) by Specialty and Education to Address Adverse Childhood Experiences (ACE) in Practice
Most participants were family nurse practitioners (FNP) (83%) and psychiatric–mental health NPs (PMHNPs) (13%). An additional 4% of participants were either a certified nurse midwife or an acute care NP. Responses from the certified nurse midwife and acute care NP were excluded due to only one response in each group. Practice categories with a single response were not compared to FNP and PMHNP categories due to high risk for statistical bias. A difference was found in means for the ACE knowledge questions (Table 2) regarding practice specialty. PMHNPs unanimously agreed a great extent of their role was to screen for physical and sexual abuse and screening was very useful in their practice. All other measured knowledge questions had higher means for PMHNPs compared to FNPs.
A MSN degree was the highest level of education reported by 65% of participants, with 33% reporting a DNP. One participant reported a PhD; this response was excluded on the recommendation of the statistician. Mean values for knowledge were higher for six of the nine questions in those who reported DNP versus MSN education (Table 2). The three items with a higher mean for MSN education were history of personal trauma, perceived percentage of men impacted by abuse, and formal training on screening.
Screening routinely was determined by averaging the 4-point Likert score questions pertaining to self-reported screening practices on physical and sexual abuse for men and women. A required method of screening was not defined in the survey. Any approach NPs considered appropriate, such as directly asking patients or administering a paper survey before the visit could be included. Values were given, corresponding with responses of 1 = rarely/never, 2 = sometimes, 3 = usually, and 4 = always. Participants averaging a mean score ≥2.6 were determined to be routine screeners. Of the 46 NPs, seven (15%) were screening routinely for childhood abuse compared with 39 (85%) who were not routinely screening. The imbalance of screeners to non-screeners did not support statistical testing. However, the nine knowledge question means indicate there was a difference in the ACE knowledge of NPs who screened for ACE routinely and those who did not. All knowledge questions measured in the survey found higher mean scores in NPs who routinely screened (Table 3). A difference was seen in the number of women compared to the number of men who were screened. Screening for abuse in a new patient visit was usually/always by 32.6% of participants in female patients and 21.7% in male patients.
Knowledge of Nurse Practitioners (NPs) by Screening Status for History of Childhood Abuse
The NPs' role in screening was reported as moderate or great by 67.4% of participants. However, as many as 26.7% of NPs reported they were not at all confident with their ability to screen. The top five conditions identified as commonly seen in adult patients with a history of child abuse are: depression, anxiety, substance use disorder, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). When an adult patient in an adult primary care practice discloses a history of abuse as a child, 80% (n = 37) of NPs reported they usually or always refer the patient to a mental health specialist for further care. Other response options for a plan of care with abuse history disclosure were discussing options of medications for treatment (58.7%), discussing the abuse and reactions in detail (56.5%), and bringing up the abuse history at follow-up visits (45.7%).
Participants rated a list of predetermined barriers as major (1), minor (2), or not a barrier (3). The mean of all NP responses for each predetermined barrier was calculated. Those reflecting a lower score indicate a higher level of the barrier. The top five most reported barriers were: not enough time to counsel patients, not enough time to screen for history of abuse, competing for primary care recommendations, difficult to verify reports, and fear of retraumatizing (Table 4). Patients seen are unlikely to be victims and the perception that childhood abuse is not a medical concern were barriers with the least impact on screening based on the mean responses of NPs.
Nurse Practitioners' (NP) Perceived Barriers to Screening
Barrier means reflect the most reported barrier by FNPs and PMHNPs, which was insufficient time to evaluate or counsel victims (Table 4). PMHNPs reported a mean equal to the insufficient time barrier was competing for multiple primary care recommendations. FNPs rated not enough time to ask about abuse with a mean score of 1.53 as their second-leading barrier in comparison to PMHNPs who rated it 2.67. The three reasons rated by PMHNPs as the smallest barriers all scored a mean of 2.83; these were uncomfortable inquiring about psychosocial issues, there is little I can do to help, and concern about offending patients by asking about abuse.
The largest respondent concentration was 27% in the largest county. This county has the highest population concentration in the state, with >500,000 residents. In that location, the barrier of time was ranked as the most significant, with not enough time to ask and not enough time to evaluate and counsel means of 1.42 and 1.83, respectively (Table 4). There was a unanimous score on the history of childhood abuse as a medical problem indicating no barrier to screening. All counties of practice were divided into groups by population (Table 1). Across all population groups, the top three obstacles reported were: not enough time to counsel victims, not enough time to ask about history, and competing for primary care recommendations.
Awareness of childhood ACE is a crucial factor in providing care across lifespans throughout the nation. However, upon review of the literature, only one provider study from a northeast state was found. At 30% exposure rate, the mid-southern state was estimated as the third worst state in the nation for the percentage of children who have experienced two or more ACE (United Health Foundation, 2016). With the high impact of ACE in mid-southern states, this evaluation of knowledge and screening done by NPs supports future efforts to increase awareness of the importance of detection and treatment. The current study identifies a knowledge gap and barriers to ACE screening among mid-southern state NPs. APRNs play a vital role in the identification and treatment of ACE to limit their impact on long-term health.
Participants of the current study were from a single mid-southern state; they were all members of a professional organization accessed via listserv with an online survey. Participants represented a variety of ages, specialties, educational levels, and practice locations. Most participants were FNPs reporting a MSN education level. There were no clinical nurse specialists in the current study despite the survey invitation being sent to all members of the state association with a listserv membership. Previous studies on ACE have not evaluated knowledge in the clinical nurse specialist population for comparison.
All responses to ACE knowledge questions as measured by comparing means were higher for NPs with a specialty in psychiatric–mental health when compared with those in family practice. This finding was expected. An increased concentration on behavioral health-based education and volume of patients seen with specific complaints directly linked to mental health may account for this finding. Although most knowledge means were higher for DNP degrees compared to MSN education, formal training in screening for ACE was higher for MSN education.
Respondents reported there is a need to provide continuing education to all providers, with face-to-face education as the preferred method of learning. Material related to ACE education is increasingly available, but not universal at this time. Multiple modes of delivery could meet individual educational needs of NPs.
Numerous studies and organizations provide evidence acknowledging the association of childhood abuse and poor long-term health outcomes (Felitti et al., 1998; Oral et al., 2016; Shonkoff et al., 2012). Despite these findings, only 15% of NPs in the current study routinely screened patients. This is a lower rate than in previous studies using the same survey tool. However, as in other studies, NPs who screen routinely are more knowledgeable about the nine measured aspects of ACE than those who do not screen. Kalmakis et al. (2017) evaluated NPs seeing adult patients in Massachusetts and found that one third of NPs believed it was their responsibility and were routinely screening adult patients for childhood trauma. Weinreb et al. (2010) found that 29% of primary care physicians screened adult patients for childhood trauma.
Screening women was more commonly reported than screening men. ACE impact both sexes, making it essential for providers to be aware of the need for screening in men. Although many participants reported being uncomfortable with their ability to screen, the majority of NPs recognized their role in screening and responded to disclosures of abuse appropriately by referring to mental health specialists.
Barriers to screening across specialties and locations all indicated a central theme of time constraints in their leading reasons. Similar findings are reported by Kalmakis et al. (2017) who found time to be the most common barrier to screening. Collectively, barriers with the smallest impact on NP practice are the perception that childhood abuse is not a medical concern and patients are unlikely to be victims. Acceptance of childhood trauma as a relevant concern by NPs in treating patients is represented in other works (Kalmakis et al., 2017). The increased exposure and specialty education likely contributed to PMHNPs reporting higher levels of comfort in discussing childhood abuse and follow up.
Limitations of the current study included a small sample. Participation with the online survey was less than expected, making the sample inadequate to analyze the data with Student's t test as planned initially. The self-reporting nature of the survey may have also been a limitation in reflecting real world screening rates in the state. Sample NPs and midwives from one state organization may not have been reflective of the knowledge and screening rates of all NPs. The survey tool was reliable and valid but assessed abuse screening components of ACE and did not consider other areas such as neglect and household dysfunction.
The level of knowledge and screening performed by NPs in one mid-southern state is lower than previously found in the literature. NPs who routinely screen are more knowledgeable about the nine knowledge questions regarding ACE. PMHNPs are more knowledgeable than FNPs, as is expected based on their educational focus on trauma and ineffective coping. Awareness of ACE and confidence in screening can be addressed through provider education. Didactic content in screening and trauma evaluation in graduate programs need to emphasize the NP role in practice. Continuing education related to ACE in face-to-face or online programs by state and national certification organizations is recommended to ensure NP skills are current and clinically relevant.
Confidence in screening is a potential result in continuing education and thus increases screening for ACE. There is a universal barrier identified in all practice population areas and across FNP and PMHNP specialties, which is not enough time to fully evaluate patients for ACE. A focus on efficient screening, appropriate interventions, and referral could help remove the perceived time barrier while allowing for a broader impact to NP patient populations through increased identification of factors contributing to adverse long-term health outcomes. NPs have the potential to positively impact the quality of life and health of the communities they serve.
- Brown, D. W., Anda, R. F., Tiemeier, H., Felitti, V. J., Edwards, V. J., Croft, J. B. & Giles, W. H. (2009). Adverse childhood experiences and the risk of premature mortality. American Journal of Preventive Medicine, 37(5), 389–396. https://doi.org/10.1016/j.amepre.2009.06.021 PMID: doi:10.1016/j.amepre.2009.06.021 [CrossRef]19840693
- Dube, S. R., Anda, R. F., Felitti, V. J., Croft, J. B., Edwards, V. J. & Giles, W. H. (2001). Growing up with parental alcohol abuse: Exposure to childhood abuse, neglect, and household dysfunction. Child Abuse & Neglect, 25(12), 1627–1640. https://doi.org/10.1016/S0145-2134(01)00293-9 PMID: doi:10.1016/S0145-2134(01)00293-9 [CrossRef]
- Fang, X., Brown, D. S., Florence, C. S. & Mercy, J. A. (2012). The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect, 36(2), 156–165. https://doi.org/10.1016/j.chiabu.2011.10.006 PMID: doi:10.1016/j.chiabu.2011.10.006 [CrossRef]22300910
- Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V. & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/S0749-3797(98)00017-8 PMID: doi:10.1016/S0749-3797(98)00017-8 [CrossRef]9635069
- Ford, E. S., Anda, R. F., Edwards, V. J., Perry, G. S., Zhao, G., Li, C. & Croft, J. B. (2011). Adverse childhood experiences and smoking status in five states. Preventive Medicine, 53(3), 188–193. https://doi.org/10.1016/j.ypmed.2011.06.015 PMID: doi:10.1016/j.ypmed.2011.06.015 [CrossRef]21726575
- Kalmakis, K. A. & Chandler, G. E. (2015). Health consequences of adverse childhood experiences: A systematic review. Journal of the American Association of Nurse Practitioners, 27(8), 457–465. https://doi.org/10.1002/2327-6924.12215 PMID: doi:10.1002/2327-6924.12215 [CrossRef]25755161
- Kalmakis, K. A., Chandler, G. E., Roberts, S. J. & Leung, K. (2017). Nurse practitioner screening for childhood adversity among adult primary care patients: A mixed-method study. Journal of the American Association of Nurse Practitioners, 29(1), 35–45. https://doi.org/10.1002/2327-6924.12378 PMID: doi:10.1002/2327-6924.12378 [CrossRef]
- Merrick, M. T., Ports, K. A., Ford, D. C., Afifi, T. O., Gershoff, E. T. & Grogan-Kaylor, A. (2017). Unpacking the impact of adverse childhood experiences on adult mental health. Child Abuse & Neglect, 69, 10–19. https://doi.org/10.1016/j.chiabu.2017.03.016 PMID: doi:10.1016/j.chiabu.2017.03.016 [CrossRef]28419887
- Oral, R., Ramirez, M., Coohey, C., Nakada, S., Walz, A., Kuntz, A. & Peek-Asa, C. (2016). Adverse childhood experiences and trauma informed care: The future of health care. Pediatric Research, 79(1–2), 227–233. https://doi.org/10.1038/pr.2015.197 PMID: doi:10.1038/pr.2015.197 [CrossRef]
- Perry, B. D. & Pollard, R. (1998). Homeostasis, stress, trauma, and adaptation. A neurodevelopmental view of childhood trauma. Child & Adolescent Psychiatric Clinics, 7(1), 33–51, viii. https://doi.org/10.1016/S1056-4993(18)30258-X PMID: doi:10.1016/S1056-4993(18)30258-X [CrossRef]
- Peterson, C., Florence, C. & Klevens, J. (2018). The economic burden of child maltreatment in the United States, 2015. Child Abuse & Neglect, 86, 178–183. https://doi.org/10.1016/j.chiabu.2018.09.018 PMID: doi:10.1016/j.chiabu.2018.09.018 [CrossRef]30308348
- Schafer, M. H. & Ferraro, K. F. (2012). Childhood misfortune as a threat to successful aging: Avoiding disease. The Gerontologist, 52(1), 111–120. https://doi.org/10.1093/geront/gnr071 PMID: doi:10.1093/geront/gnr071 [CrossRef]
- Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., Garner, A. S. & Wood, D. L. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. https://doi.org/10.1542/peds.2011-2663 PMID: doi:10.1542/peds.2011-2663 [CrossRef]
- United Health Foundation. (2016). America's health rankings health of women and children report. Retrieved from http://assets.americashealthrankings.org/app/uploads/hwc-complete-report.pdf
- Weinreb, L., Savageau, J. A., Candib, L. M., Reed, G. W., Fletcher, K. E. & Hargraves, J. L. (2010). Screening for childhood trauma in adult primary care patients: A cross-sectional survey. Primary Care Companion to the Journal of Clinical Psychiatry, 12(6), PCC.10m00950. https://doi.org/10.4088/PCC.10m00950blu PMID:21494339
Nurse Practitioner (NP) Characteristics
|Mean age (SD) (range) (years)||53 (10) (28 to 67)|
| Family NP||38 (82.6)|
| Psychiatric–mental health NP||6 (13)|
| Certified nurse midwife||1 (2.2)|
| Acute care NP||1 (2.2)|
|Highest level of education|
| Master of Science in Nursing||30 (65.2)|
| Doctor of Nursing Practice||15 (32.6)|
| PhD||1 (2.2)|
|Formal ACE training|
| None||21 (30.4)|
| NP program training||21 (30.4)|
| Continuing education||18 (26.9)|
| Nursing school||9 (13)|
|County of practice population/Counties represented|
| >500,000 / 1||12 (26.7)|
| 100,000 to 500,000 / 4||14 (31.1)|
| 50,000 to 100,000 / 6||8 (17.7)|
| ≤50,000 / 11||11 (24.4)|
Knowledge of Nurse Practitioners (NPs) by Specialty and Education to Address Adverse Childhood Experiences (ACE) in Practice
|Knowledge||FNP (n= 38)||PMHNP (n = 6)||MSN (n = 30)||DNP (n = 15)|
|n (%)||Mean (SD)||n (%)||Mean (SD)||n (%)||Mean (SD)||n (%)||Mean (SD)|
|The perceived extent of NP role to screen for a history of childhood abusea||2.98 (0.85)||4 (0)||2.89 (0.82)||3.50 (0.85)|
| Not at all/small extent||13 (34.2)||0 (0)||12 (40)||2 (13.3)|
| Moderate/great extent||25 (65.8)||6 (100)||18 (60)||13 (86.7)|
|Usefulness to the patient for NP to screen for a history of childhood abusea||3.07 (0.79)||4 (0)||3.03 (0.85)||3.47 (0.61)|
| Not at all/somewhat||11 (28.9)||0 (0)||10 (33.3)||2 (13.3)|
| Moderately/very useful||27 (71.1)||6 (100)||20 (66.7)||13 (86.7)|
|Confidence in NP ability to screen for a history of child abusea||2.31 (1.07)||3.83 (0.41)||2.26 (1.16)||3.05 (0.87)|
| Not at all/somewhat||21 (56.8)||0 (0)||19 (63.3)||3 (21.4)|
| Moderately/very confident||16 (43.2)||6 (100)||11 (36.7)||11 (78.6)|
|Confidence in NP ability to use information about the history of childhood abusea||2.24 (0.97)||3.83 (0.41)||2.37 (1.16)||2.55 (0.92)|
| Not at all/somewhat||25 (65.8)||0 (0)||17 (56.7)||9 (60)|
| Moderately/very confident||13 (34.2)||6 (100)||13 (43.3)||6 (40)|
|Formal screening training|
| Training received||18 (47.4)||5 (83.3)||18 (60)||7 (46.7)|
| No training||10 (26.3)||1 (16.7)||12 (40)||8 (53.3)|
|Percentage of adult female patients believed to have a history of childhood abuseb||0.69 (0.47)||0.83 (0.41)||0.68 (0.48)||0.80 (0.41)|
| ≤10%||11 (30.6)||1 (16.7)||9 (32.1)||3 (20)|
| >10%||25 (69.4)||5 (83.3)||19 (67.9)||12 (80)|
|Percentage of adult male patients believed to have a history of childhood abuseb||0.26 (0.44)||0.83 (0.41)||0.36 (0.49)||0.29 (0.47)|
| ≤10%||26 (74.3)||1 (16.7)||18 (64.3)||10 (71.4)|
| >10%||9 (25.7)||5 (83.3)||10 (35.7)||4 (28.6)|
|NP has a personal ACE historyc||1.42 (1.45)||1.83 (1.17)||1.43 (1.25)||1.40 (1.68)|
| One or more ACE items||25 (65.8)||5 (83.3)||22 (73.3)||8 (53.3)|
| No ACE items||13 (34.2)||1 (16.7)||8 (26.7)||7 (46.7)|
|NP knows someone with a history of childhood abuse outside of professional roleb||0.74 (0.45)||1 (0)||0.73 (0.45)||0.87 (0.35)|
| Yes||28 (73.7)||6 (100)||22 (73.3)||13 (86.7)|
| No||10 (26.3)||0 (0)||8 (26.7)||2 (13.3)|
Knowledge of Nurse Practitioners (NPs) by Screening Status for History of Childhood Abuse
|Knowledge||Rarely or Never/Sometimes (n = 39)||Usually/Always (n = 7)|
|n (%)||Mean (SD)||n (%)||Mean (SD)|
|The perceived extent of NP role to screen for a history of childhood abusea||2.97 (0.84)||3.71 (0.76)|
| Not at all/small extent||14 (35.9)||1 (14.3)|
| Moderate/great extent||25 (64.1)||6 (85.7)|
|Usefulness to the patient for NP to screen for a history of childhood abusea||3.05 (0.78)||3.71 (0.76)|
| Not at all/somewhat||12 (30.8)||1 (14.3)|
| Moderately/very useful||27 (69.2)||6 (85.7)|
|Confidence in NP ability to screen for a history of child abusea||2.35 (1.08)||3.33 (1.21)|
| Not at all/somewhat||22 (56.4)||1 (16.7)|
| Moderately/very confident||17 (43.6)||5 (83.3)|
|Confidence in NP ability to use information about the history of childhood abusea||2.24 (0.97)||3.39 (1.12)|
| Not at all/somewhat||26 (66.7)||1 (14.3)|
| Moderately/very confident||13 (33.3)||6 (85.7)|
|Formal screening training|
| Training received||20 (51.3)||5 (71.4)|
| No training||19 (48.7)||2 (28.6)|
|Percentage of adult female patients believed to have a history of childhood abuseb||0.71 (0.46)||0.83 (0.41)|
| ≤10%||11 (29)||1 (16.7)|
| >10%||27 (71.1)||5 (83.3)|
|Percentage of adult male patients believed to have a history of childhood abuseb||0.27 (0.45)||0.67 (0.52)|
| ≤10%||27 (73)||2 (33.3)|
| >10%||10 (27)||4 (66.7)|
|NP has a personal ACE historyc||1.39 (1.39)||2 (1.41)|
| One or more ACE items||25 (64.1)||6 (85.7)|
| No ACE items||14 (35.9)||1 (14.3)|
|NP knows someone with a history of childhood abuse outside of professional roleb||0.77 (0.43)||0.86 (0.38)|
| Yes||30 (76.9)||6 (85.7)|
| No||9 (23.1)||1 (14.3)|
Nurse Practitioners' (NP) Perceived Barriers to Screening
|All NP (N= 46)||FNP (n= 38)||PMHNP (n= 6)||Pop >500,000 (n=12)||Pop 100,000 to 500,000 (n= 14)||Pop 50,000 to 100,000 (n = 8)||Pop <50,000 (n= 11)|
|Not enough time to fully evaluate or counsel victims of childhood abuse||1.35 (0.64)||1.24 (0.54)||2.17 (0.75)||1.42 (0.79)||1.29 (0.61)||1.13 (0.35)||1.55 (0.69)|
|Not enough time to ask about a history of childhood abuse||1.67 (0.76)||1.53 (0.69)||2.67 (0.52)||1.83 (0.83)||1.71 (0.73)||1.13 (0.35)||1.91 (0.83)|
|Competing multiple primary care recommendations||2.02 (0.86)||2.03 (0.85)||2.17 (0.98)||2.33 (0.65)||1.86 (0.95)||2.13 (0.99)||1.82 (0.87)|
|Difficult to verify reports of histories of childhood abuse||2.24 (0.90)||2.24 (0.88)||2.33 (1.03)||2.42 (0.79)||2.29 (0.91)||2.13 (0.99)||2.18 (0.98)|
|Concern that asking about an abuse history may retraumatize my patient||2.26 (0.74)||2.21 (0.78)||2.50 (0.55)||2.58 (0.67)||1.93 (0.73)||2.13 (0.99)||2.45 (0.52)|
|There is little I can do to help those patients who have revealed a history of childhood abuse||2.37 (0.77)||2.32 (0.77)||2.83 (0.41)||2.33 (0.78)||2.36 (0.84)||2.38 (0.74)||2.55 (0.69)|
|Uncomfortable inquiring about psychosocial issues||2.41 (0.69)||2.30 (0.68)||2.83 (0.41)||2.42 (0.67)||2.29 (0.73)||2.38 (0.92)||2.64 (0.50)|
|Concern about offending my patients who have revealed a history of childhood abuse||2.46 (0.66)||2.39 (0.68)||2.83 (0.41)||2.75 (0.45)||2.29 (0.83)||2.25 (0.71)||2.45 (0.52)|
|No reimbursement to me for screening for childhood abuse||2.63 (0.64)||2.66 (0.58)||2.67 (0.82)||2.67 (0.65)||2.50 (0.76)||2.50 (0.76)||2.91 (0.30)|
|A history of childhood abuse is not a medical problem||2.63 (0.74)||2.66 (0.71)||2.33 (1.03)||3.00 (0.00)||2.79 (0.58)||2.00 (0.93)||2.45 (0.93)|
|The men I see as patients are unlikely to have been victims of childhood abuse||2.72 (0.62)||2.71 (0.61)||2.67 (0.82)||2.83 (0.58)||2.71 (0.61)||2.63 (0.52)||2.64 (0.81)|
|The women I see as patients are unlikely to have been victims of childhood abuse||2.76 (0.57)||2.76 (0.54)||2.67 (0.82)||2.83 (0.58)||2.79 (0.43)||2.75 (0.46)||2.64 (0.81)|