Corporal Punishment: Evaluation of an Intervention by PNPs

ARTICLE

Corporal Punishment: Evaluation of an Intervention by PNPs Gail Hornor, DNP, CPNP, Deborah Bretl, MSN, RN, PPCNP-BC, Evelyn Chapman, MSN, RN, CPNP, Ellen Chiocca, MSN, CPNP, RNC-NIC, Carrie Donnell, MSN, CPNP, Katharine Doughty, MS, RN, CPNP-BC, Susan Houser, CPNP, Bridget Marshall, DNP, CPNP, Kristen Morris, DNP, RN, CPNP, & Saribel Garcia Quinones, DNP, PNP-BC ABSTRACT Gail Hornor, Pediatric Nurse Practitioner, Center for Family Safety and Healing, Nationwide Children’s Hospital, Columbus, OH. Deborah Bretl, Pediatric Nurse Practitioner, Children’s Hospital of Wisconsin, Milwaukee, WI. Evelyn Chapman, Pediatric Nurse Practitioner, Children’s Hospital at Montefiore, New York, NY. Ellen Chiocca, Associate Professor of Clinical Nursing, DePaul University, Chicago, IL. Carrie Donnell, Pediatric Nurse Practitioner, Center for Child Protection and Well-Being, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN. Katharine Doughty, Pediatric Nurse Practitioner, Center for Family Safety and Healing, Nationwide Children’s Hospital, Columbus, OH. Susan Houser, Pediatric Nurse Practitioner, CASARC Child Advocacy Center of San Francisco, San Francisco, CA. Bridget Marshall, Assistant Professor, Colorado Mesa University, Grand Junction, CO. Kristen Morris, Assistant Professor, University of Saint Francis, Fort Wayne, IN. Saribel Garcia Quinones, Clinical Assistant Professor, New York University, New York, NY. Conflicts of interest: None to report. Correspondence: Gail Hornor, DNP, CPNP, Nationwide Children’s Hospital, Center for Family Safety and Healing, 655 E Livingston Ave, Columbus, OH 43205; e-mail: gail.hornor@ nationwidechildrens.org. 0891-5245/$36.00 Copyright Q 2015 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedhc.2015.04.016

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Introduction: Corporal punishment (CP) is defined as the use of physical force with the intention of causing a child to experience pain but not injury for the purpose of correction or control of the child’s behavior. CP has been linked to a variety of negative consequences for children, including physical abuse, eternalizing behavioral problems, and slowed cognitive development. Many American children continue to experience CP at the hands of their parents and other caregivers. The purpose of this study was to evaluate learner attitude toward CP before and after implementation of a pediatric nurse practitioner–designed educational intervention and influences upon learner attitude and beliefs about CP. Method: This study used a pre- and postsurvey design to assess learner attitude about CP before and after participation in an educational intervention. Influences upon learner attitudes and beliefs regarding CP were also described. Learners (N = 882) were health care providers. Results: Nearly all learners (n = 747; 84.7%) stated that the way their parents disciplined them influenced their attitudes toward CP. Fewer than one fifth of learners who were also parents (n = 126; 14.4%) reported that their child’s health care provider had ever discussed child discipline with them. Prior to the educational intervention, more than one third of learners (n = 351; 39.88%) endorsed spanking as sometimes necessary, yet significantly fewer learners (n = 251; 28.9%; p < .001) made this statement after the educational intervention. Child discipline management was included in the health care provider education for fewer than half of learners (n = 365; 41.4%). Discussion: The potential for experiencing CP as a child to result in negative consequences for children has been well documented, yet many American parents continue to use CP as a form of child discipline, and some pediatric health care professionals continue to endorse its use. Pediatric health care providers, including nurses and pediatric nurse practitioners, need to be educated about child discipline and CP. All pediatric health care providers need to advocate

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for the use of positive parenting principles and discourage the use of CP. J Pediatr Health Care. (2015) -, ---.

KEY WORDS Corporal punishment, discipline, child maltreatment

Corporal punishment (CP) is defined as the use of physical force with the intention of causing a child to experience pain but not injury for the purpose of correction or control of the child’s behavior (Straus, 1994). CP most commonly involves spanking, smacking, or hitting with a hand, but it can also include pinching, kicking, pulling hair, or hitting with an object such as a belt, cord, or stick (Zolotor & Puzia, 2010). CP use has been linked to a variety of negative consequences for children, including physical abuse, externalizing behavioral problems, and slowed cognitive development (Gershoff, 2002). Many American children continue to experience CP at the hands of their parents and other caregivers. The National Association of Pediatric Nurse Practitioners (NAPNAP, 2011) and the American Academy of Pediatrics (AAP, 2008) both oppose the use of CP and support the use of nonphysical means of discipline with children. Despite the condemnation by pediatric health care professional organizations, CP use continues to be widespread in the United States and other countries. More than 90% of American parents report using CP at least once, and 40% to 70% report having used CP in the past 6 months (Strauss, 2001). Similarly, 50% to 66% of Canadian parents report CP use (Bell & Romano, 2012). Given the number of children who continue to experience CP, pediatric health care providers, including pediatric nurse practitioners (PNPs), must develop strategies to address the use of CP and to instigate an attitudinal change toward its use. The purpose of this study was to evaluate the attitude of learners toward corporal punishment before and after implementation of a PNP-designed educational intervention and to describe influences upon learner attitude toward corporal punishment. BACKGROUND CP is not an effective method of discipline. CP has been shown to improve immediate compliance but not to achieve a long-lasting change in behavior (Gershoff, 2002; Oas, 2010). CP is associated with a lower rate of internalization of morals and values; CP does not teach children the lessons that their parents want them to learn. CP has been linked with a number of negative consequences for children, including increased risk of experiencing physical abuse (Sanapo & Nakamura, 2011; Zolotor, Theodore, Chang, Berkoff, & Runyan, 2008); externalizing behavioral problems (Mackenzie, Nicklas, Waldfogel, & Brooks-Gunn, 2012); criminal and antisocial behavior (Gershoff, 2002); slower cognitive development (MacKenzie et al, 2012; Straus & Paschall, 2009); and poorer adolescent and adult 2

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mental health outcomes (Afifi, Mota, Dasiewicz, MacMillan, & Sareen, 2012; Mulvaney & Mebert, 2010). Parental use of CP is affected by a variety of factors. Parents who experienced CP as a child are more likely to use physical methods to discipline their children (Bell & Romano, 2012; Simons & Wurtele, 2010). Conservative religious and political beliefs are linked with the support of CP (Ellison & Bradshaw, 2009). Parental stress influences the use of CP (MacKenzie et al, 2012). In a telephone survey of 500 parents in an urban southern city, Taylor, Hamvas, Rice, Newman, and DeJong (2011) found that the strongest predictor of parents’ positive attitude towards CP was their perception that the professional they were most likely to turn to for advice about child discipline approved of CP. Professionals parents were most likely to turn to for advice were pediatricians (48%), religious leaders (21%), and mental health professionals (18%) (Taylor et al., 2011). Parents who did not endorse the use of CP perceived their sources of advice to not support the use of CP. Changing parental and societal attitude regarding CP is the essential first step in changing parental and societal use of CP. Parents report that they listen to professionals, including pediatric health care providers, regarding child discipline (Taylor et al., 2011). However, in a telephone survey of the parents of 2068 children aged 4 to 35 months examining the use and predictors of discipline practices, Regalado, Sareen, Inkelas, Wissow, and Halfon (2004) found that more than half of the parents surveyed denied discussing discipline with their physician in a health care visit in the past year. Pediatricians report time constraints as a barrier to providing anticipatory guidance related to CP (Sege, Hatmaker-Flanigan, DeVos, Levin-Goodman, & Spviak, 2006). Health care provider attitude toward the use of CP may also be a concern. McCormick (1992), in a study of primary care physicians in Ohio, found that 59% of pediatricians and 70% of family practice physicians supported the use of CP. Fargason, Chernoffi, and Socolar (1996) found that 39% of academic pediatricians specializing in child abuse thought that CP was sometimes appropriate and only 29% taught residents how to address parents regarding the use of CP. Although the two studies are admittedly dated, there are legitimate concerns that physician attitude remains essentially unchanged. Tirosh, Shecter, Cohen, and Jaffe (2003) report Pediatric health that 58% of 107 physicare professionals, cians surveyed report support of the use including PNPs, of CP. need to be vocal Use of CP can result supporters of in negative consequences for children. nonphysical Changing parental and methods of societal attitudes todiscipline. ward the use of CP is Journal of Pediatric Health Care

the essential first step in changing use of CP. Pediatric health care professionals, including PNPs, need to be vocal supporters of nonphysical methods of discipline. Studies have shown that a considerable number of physicians continue to support the use of CP. Interestingly, no studies have been conducted to describe the attitudes of other health care professionals, including nurses, regarding the use of CP. All pediatric health care professionals, parents, and community members need to be educated regarding potential consequences of CP and alternative methods of discipline. METHODS Definitions For the purposes of this study, the following definitions were utilized:  Learner was defined as any health care professional (nurses, advanced practice nurses, physicians, nursing students, medical students, medical assistants, social workers, or other health care team members) attending the educational intervention.  Educational intervention was defined as a PowerPoint presentation developed by Lauren McAliley, PNP, and collaboratively reviewed and revised by participating members of the NAPNAP Child Maltreatment Special Interest Group (SIG). SIG members were nurse practitioner experts in the field of child maltreatment. The educational intervention was a 60-minute PowerPoint presentation that defined discipline and punishment, discussed research related to the effects of CP use on children and global efforts to eliminate its use, and offered alternative methods of discipline. The PowerPoint presentation was based on Lauren McAliley’s previous work in the development of the No Hitting Zone program at Rainbow Babies and Children’s Hospital in Cleveland, OH. The No Hitting Zone program was developed in response to staff and parent concern regarding the use of CP in the hospital setting. The No Hitting Zone program consists of a PowerPoint presentation, posters, brochures, and handouts addressing CP use. The PowerPoint presentation was the only aspect of the No Hitting Zone program utilized in this study.  Pediatric nurse practitioners were defined as PNPs who were members of the NAPNAP Child Maltreatment SIG and were advanced practice nurses working in the field of child maltreatment. Design A preintervention and postintervention quasiexperimental design was used, with data collected before and after the educational intervention. Prior to initiation of the study, Institutional Review Board approval was awarded by the following institutions: www.jpedhc.org

TABLE 1. Learner geographic area Geographic area Northeast Southeast Midwest Southwest Northwest West

Frequency

%

137 116 560 19 23 37

15.5 13.2 63.4 2.2 2.6 4.2

Nationwide Children’s Hospital; University of Saint Francis Fort Wayne; Heartland Alliance Health; University of California–San Francisco; Children’s Hospital of Wisconsin; Vanderbilt University; Montefiore Medical Center; New York University; and Colorado Mesa University. Sample Ten PNPs, all members of the NAPNAP Child Maltreatment SIG, provided the educational interventions to 882 learners. The Child Maltreatment SIG PNPs were a geographically diverse group practicing in California, Colorado, Indiana, Illinois, New York, Ohio, Tennessee, and Wisconsin (see Table 1 for a description of learner geographical distribution). Learners were primarily members of the nursing profession, ranging from undergraduate nursing students to advanced practice nurses (see Table 2 for a description of learner professions). ‘‘Other’’ refers to mental health therapists, teachers, juvenile probation officers, and teacher aides. More than half (n = 390, 51.2%) of participating learners were also parents. Instruments The Corporal Punishment Attitude and Knowledge Surveys (CPAKS) administered before and after the intervention (see Figures 1 and 2) were initially developed by Lauren McAliley, PNP, of Rainbow Babies and Children Hospital, Cleveland, OH, for use in their No Hitting Zone project. The surveys were collaboratively reviewed and revised by the participating Child Maltreatment SIG PNPs to ensure

TABLE 2. Learner profession Profession

Frequency

%

Nurse practitioner student Nursing student Nurse practitioner Registered nurse Social worker Medical assistant/state tested nurses aide Physician Child life Other

240 217 104 94 68 16 5 5 126

27.4 24.8 11.9 10.7 7.8 1.8 0.6 0.6 51.2

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FIGURE 1. Preintervention corporal punishment survey. 1. Please tell us who you are (check all that apply) __ NP/PA ___ NP/PA Student ___ RN ___ Nursing student __ Physician ___ Medical student ___ Social worker __ Medical assistant/STNA __ Child Life ___ OT/PT ___ Parent/guardian __ Other health care professional ________________________________ 2. Were you spanked or otherwise physically punished by your parents (hit with object, shoved, punched, kicked, etc)? __ Never ___ Rarely ___ Frequently ___ It was the main form of punishment 3. Were you spanked, paddled or otherwise physically punished by school teachers/authoriƟes? ___ No ___ Yes 4. What has influenced your beliefs about child discipline and punishment (check all that apply)? __ The way my parents disciplined me __ Teachings of my religion __ Paren ng books and magazines __ Radio and TV shows on the subject __ Talks with health care providers __ Opinions of friends / other parents __ What I have read on the internet __ Professional educa on 5. Child discipline management was a part of my educaƟon as a health care provider? __ No __ Yes 6. As a parent my child’s physician or other health care provider has discussed child discipline with me? (circle here if not a parent) __ No __ Yes Who (physician, nurse, social worker, etc) ________________ 7. Please read enƟre list carefully and then go back and check all that you believe to be true about spanking __ Spanking is some mes necessary __ Spanking is never necessary but may some mes by okay __ It is never okay to spank anywhere but on the bu ocks __ It is okay to slap an arm or the face instead of spanking __ It is okay to use a belt, a switch or a paddle to administer a spanking if you are careful __ Spanking is never okay __ Spanking is effec ve in pu ng an immediate stop to a bad behavior __ Spanking teaches las ng lessons about right and wrong __ Spanking is more effec ve than “ me outs” and “family rules” and “natural consequences” __ Spanking can be abusive __ Non-physical forms of discipline ( me out, removing privileges, grounding, etc) should be subs tuted for spanking most or all of the me __ Spanking teaches children how to behave be er next me __ Children who are never spanked are usually spoiled and their behavior is o en out of control __ Non-physical forms of discipline ( me out, grounding, etc) are more effec ve than spanking or other forms of discipline 8. Geographical region in which you pracƟce __ Northeast __ Southeast __ Midwest __ Southwest __Northwest __West

face validity; all were content experts in child maltreatment. Procedure Educational interventions were presented in a variety of settings, including undergraduate nursing classes, graduate nursing and social work classes, workplaces (as educational offerings), local and national conferences, and online (as an educational offering via NAPNAP). Learners were verbally informed that participation was voluntary and that failure to participate in the study would not prevent them from receiving the educational intervention. Learners completed the Pre-CPAKS imme4

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diately before the educational intervention. The 1-hour educational intervention was then presented, and learner questions were answered. The Post-CPAKS was completed at the conclusion of the educational intervention. Statistical Analysis Demographic, personal, and educational characteristics of learners were reported as frequency and percentage data. Responses to each spanking question before and after the educational intervention were compared by Wilcoxon signed rank tests, and comparisons between independent groups were calculated by v2 Journal of Pediatric Health Care

FIGURE 2. Postintervention corporal punishment survey.

1. Has today’s presentaƟon influenced your beliefs about child discipline and punishment? ____ Not at all _____ Somewhat ____ Strongly ____ Very strongly 2. Please read enƟre list carefully and then go back and check all that you believe to be true about spanking __ Spanking is some mes necessary __ Spanking is never necessary but may some mes by okay __ It is never okay to spank anywhere but on the bu ocks __ It is okay to slap an arm or the face instead of spanking __ It is okay to use a belt, a switch or a paddle to administer a spanking if you are careful __ Spanking is never okay __ Spanking is effec ve in pu ng an immediate stop to a bad behavior __ Spanking teaches las ng lessons about right and wrong __ Spanking is more effec ve than “ me outs” and “family rules” and “natural consequences” __ Spanking can be abusive __ Non-physical forms of discipline ( me out, removing privileges, grounding, etc) should be subs tuted for spanking most or all of the me __ Spanking teaches children how to behave be er next me __ Children who are never spanked are usually spoiled and their behavior is o en out of control __ Non-physical forms of discipline ( me out, grounding, etc) are more effec ve than spanking or other forms of discipline 3. AŌer today’s presentaƟon I am more likely to discuss child discipline with my paƟents/parents? ____ Yes ____ No

analysis. Relationships between variables were calculated with Spearman correlations. Alpha level of significance was set at # 0.05. RESULTS Beliefs and attitudes regarding child discipline and CP are influenced by a number of factors. Learners were questioned regarding their perceived influences upon their attitudes toward CP (see Table 3). Nearly all learners (n = 747; 84.7%) stated that the way their parTABLE 3. Influences upon learner beliefs about child discipline and punishment Influence

Frequency

%

The way their parents disciplined Professional education Friends/other parents Parenting books/magazines Talks with health care provider Religion Radio/TV Internet

747 506 327 252 204 179 79 78

84.7 57.4 37.1 28.6 23.1 20.3 9.0 8.8

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ents disciplined them influenced their attitudes toward CP. Learners were then asked if they were spanked or otherwise physically punished by their parents. More than half (n = 545; 63.2%) stated that they were rarely spanked by their parents. Approximately one fifth stated they were never spanked (n = 142; 16.5%) or frequently spanked (n = 175; 20.3%). Spanking or other forms of physical punishment was the main form of discipline experienced by more than one tenth of learners (n = 113; 12.8%). Other reported influences upon CP attitudes included professional education (n = 506; 57.4%), friends/other parents (n = 327; 37.1%), and parenting books/magazines (n = 226; 28.6%). Fewer than one fifth of learners who were also parents (n = 126; 14.4%) stated that their child’s health care provider had ever discussed child discipline with them (see Table 4, which describes the types of health care providers who discussed discipline with the parent learners). Child discipline management was included in the health care provider education for fewer than half of learners (n = 365; 41.4%). Yet learners’ responses to only one spanking question, ‘‘spanking is never OK,’’ -/- 2015

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TABLE 4. Discipline discussed by health care provider Type of health care provider who discussed discipline Physician Nurse practitioner Social worker Other

Frequency

%

95 12 5 4

81.9 10.3 4.3 3.4

differed significantly between those whose professional education included discipline (n = 83; 22.8%) compared with those whose professional education did not include discipline (n = 78; 15.6%; p = .008). Differences in learner response to questions regarding spanking as a form of child discipline before and after the educational offering were examined (see Table 5). Prior to the educational intervention, more than one third of learners (n = 351; 39.88%) stated that spanking is sometimes necessary, yet significantly fewer learners (n = 251; 28.9%; p < .001) made this statement after the educational intervention. Approximately half of learners (n = 465; 52.8%) indicated that they believed nonphysical methods of discipline were more effective than spanking before the educational intervention compared with more than two thirds after the educational intervention (n = 586; 67.4%; p < .001). Before the educational intervention, fewer than one fifth of learners (n = 162; 18.4%) indicated that spanking is never OK, yet after the educational intervention, nearly one fourth (n = 197; 22.6%; p < .001) endorsed the statement that spanking is never OK. Significant changes in response to survey questions about spanking as a form of punishment before and after the educational intervention were noted for 10 survey

questions. Learner responses to spanking questions after the educational intervention were less supportive of spanking or other physical discipline except for one question. More learners before the educational intervention (n = 712; 80.8%) stated that nonphysical forms of discipline should be substituted for spanking most or all of the time compared with the response after the educational intervention (n = 672; 77.2%; p = .001). Only a small percentage of learners (n = 113; 12.8%) denied that educational intervention influenced their beliefs about child discipline and punishment (see Table 6), and more than three fourths (n = 679; 77%) stated that after the educational offering they were more likely to discuss child discipline with their patients/parents. Spearman correlation revealed that the learners who stated that the educational intervention influenced their beliefs about child discipline were more likely to discuss child discipline with their patients/parents (r = 0.221, p < .001). Learner responses to spanking questions according to whether they were spanked as a child were also explored (see Table 7). Both pre- and posteducational intervention learners who were never spanked (n = 9; 6.3% and n = 4; 2.8%, respectively) or rarely spanked (n = 59; 10.8% and n = 26, 4.9%, respectively) were significantly less likely to state that children who are never spanked are spoiled than were those spanked frequently (n = 36; 20.6%; p < .001 and n = 25; 14.4%; p < .001). Learners who were never, rarely, or frequently spanked as children were significantly different from each other both before and after the educational intervention in response to the question, ‘‘Spanking is sometimes necessary.’’ Learners who were never spanked (before intervention, n = 25; 17.6% and after intervention, n = 24; 17%) were the least likely to endorse the need for spanking. Learners who were rarely spanked (before,

TABLE 5. Comparison of responses to survey questions about spanking as a form of child discipline before and after the educational intervention Question

Before the intervention n (%)

After the intervention n (%)

Spanking sometimes necessary Spanking never necessary; sometimes OK Spank only buttocks OK to slap arm/face OK to use belt Spanking is never OK Spanking is effective immediately Spanking teaches lasting lessons Spanking more effective than time out Spanking can be abusive Substitute nonphysical discipline Spanking teaches better behavior Children never spanked are spoiled Nonphysical discipline is more effective

351 (39.8) 240 (27.2) 335 (38.0) 27 (3.1) 32 (3.6) 162 (18.4) 192 (21.8) 127 (14.4) 91 (10.3) 680 (77.2) 712 (80.8) 112 (12.7) 105 (11.9) 465 (52.8)

251 (28.9) 233 (26.8) 313 (36.0) 21 (2.4) 20 (2.3) 197 (22.6) 253 (29.1) 57 (6.6) 40 (4.6) 580 (66.7) 672 (77.2) 49 (5.6) 56 (6.4) 586 (67.4)

Wilcoxon signed rank test z 8.475 0.394 1.342 1.414 2.840 3.922 4.668 6.670 5.661 6.495 2.557 6.080 5.159 8.392

p value < .001* .694 .180 .157 .005* < .001* < .001* < .001* < .001* < .001* .001* < .001* < .001* < .001*

*Statistically significant.

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TABLE 6. Educational intervention influenced learner beliefs about child discipline and punishment Variable

n (%)

Presentation influenced my beliefs Not at all Somewhat Strongly Very strongly More likely to discuss spanking in practice

113 (12.8) 485 (55) 189 (21.4) 64 (7.3) 679 (77)

n = 226; 41.5% and after, n = 148; 27.6%) were more likely to endorse the need for spanking, and learners who were frequently spanked (before, n = 92; 52.6%; p < .001 and after, n = 74; 42.5%; p < .001) were most likely to endorse the need for spanking. Learner endorsement of nonphysical forms of discipline over spanking was also different before and after the educational intervention, depending upon spanking history as a child. Learners who were never spanked (before, n = 101; 71.1% and after, n = 116; 82.3%) were the most likely to state that

nonphysical methods of discipline are more effective than spanking, with learners who were rarely spanked (before, n = 280; 51.5% and after, n = 360; 68.8%) being less likely to endorse the use of nonphysical methods of discipline and those who were frequently spanked being the least likely to endorse the use of nonphysical methods of discipline (before, n = 74; 42.3% and after, n = 89; 51.1%, p < .001). Geographic differences in learner responses to spanking questions were also examined (see Table 8). Before the educational intervention, learners from the Northwestern region of the United States were significantly less likely to endorse spanking as sometimes necessary (n = 1; 4.3%) when compared with the Northeast (n = 69; 50.4%) and Midwest (n = 206; 58.7%, p < .001). Before the educational intervention, learners in the Northeast (n = 58; 42.3%) were significantly less likely to endorse nonphysical forms of discipline as being more effective than spanking when compared with the Northwest (n = 20; 87%; p = .002). Learners in the Southeast (n = 96; 82.8%) were significantly more likely to endorse the statement that spanking can be abusive

TABLE 7. Comparison of responses to spanking questions according to whether participants were spanked as a child Were you spanked? Question Preintervention Spanking sometimes necessary Spanking never necessary; sometimes OK Spank only buttocks OK to slap arm/face OK to use belt Spanking is never OK Spanking is effective immediately Spanking teaches lasting lessons Spanking more effective than time out Spanking can be abusive Substitute nonphysical discipline Spanking teaches better behavior Children never spanked are spoiled Nonphysical discipline is more effective Postintervention Spanking sometimes necessary Spanking never necessary; sometimes OK Spank only buttocks OK to slap arm/face OK to use belt Spanking is never OK Spanking is effective immediately Spanking teaches lasting lessons Spanking more effective than time out Spanking can be abusive Substitute nonphysical discipline Spanking teaches better behavior Children never spanked are spoiled Nonphysical discipline is more effective

Comparison

Never n (%)

Rarely n (%)

Frequently n (%)

v

25 (17.6) 42 (29.6) 35 (24.6) 2 (1.4) 1 (0.7) 42 (29.6) 14 (9.9) 13 (14.4) 7 (4.9) 111 (78.2) 126 (88.7) 15 (10.6) 9 (6.3) 101 (71.1)

226 (41.5) 166 (30.5) 216 (39.7) 20 (3.7) 19 (3.5) 89 (16.4) 121 (22.2) 81 (14.9) 54 (9.9) 411 (75.6) 438 (80.5) 62 (11.4) 59 (10.8) 280 (51.5)

92 (52.6) 30 (3.5) 74 (42.3) 5 (2.9) 11 (6.3) 28 (16.0) 54 (30.9) 31 (17.7) 28 (16.0) 142 (81.1) 137 (78.3) 33 (18.9) 36 (20.6) 74 (42.3)

41.784 12.155 12.791 1.963 7.086 13.953 20.248 4.792 10.634 2.452 6.449 7.359 17.071 27.288

< .001* .002* .002* .375 .029* .001* < .001* .091 .005* .293 .040* .025* < .001* < .001*

24 (17.0) 35 (24.8) 36 (25.5) 1 (0.7) 2 (1.4) 47 (33.3) 30 (21.3) 2 (1.4) 3 (2.1) 96 (68.1) 115 (81.6) 7 (5.0) 4 (2.8) 116 (82.3)

148 (27.6) 164 (30.6) 194 (36.2) 13 (2.4) 9 (1.7) 111 (20.7) 168 (31.3) 34 (6.3) 22 (4.1) 362 (67.5) 425 (79.3) 27 (5.0) 26 (4.9) 368 (68.8)

74 (42.5) 33 (19.0) 77 (44.3) 6 (3.4) 8 (4.6) 35 (20.1) 51 (29.3) 19 (10.9) 13 (7.5) 109 (62.6) 120 (69.0) 13 (7.5) 25 (14.4) 89 (51.1)

25.840 9.469 11.846 2.580 5.639 10.966 5.466 11.665 5.655 1.576 9.603 1.592 23.357 35.575

< .001* .009* .003* .275 .060 .004* .065 .003* .059 .455 .008* .451 < .001* < .001*

2

p value

*Statistically significant.

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TABLE 8. Significant geographic difference in participants’ responses to spanking Question Preintervention Spanking sometimes necessary Spanking can be abusive Nonphysical discipline is more effective Postintervention Spanking sometimes necessary Spanking never necessary; sometimes OK Spank only buttocks OK to use belt Spanking is never OK Spanking is effective immediately Spanking more effective than time out Spanking can be abusive Nonphysical discipline should be substituted Children never spanked are spoiled Nonphysical discipline is more effective *Statistically significant.

Comparison

Northeast N = 137 n (%)

Southeast N = 116 n (%)

Midwest N = 550 n (%)

Southwest N = 19 n (%)

Northwest N = 23 n (%)

West N = 37 n (%)

v2

p value

69 (50.4) 85 (62.0) 58 (42.3)

55 (47.4) 96 (82.8) 64 (55.2)

206 (58.7) 441 (80.2) 289 (52.5)

6 (31.6) 15 (78.9) 11 (57.9)

1 (4.3) 15 (65.2) 20 (87.0)

14 (38.9) 28 (77.8) 23 (63.9)

23.057 24.598 19.036

< .001* < .001* .002*

52 (38.2) 38 (27.9) 50 (36.8) 3 (2.2) 24 (17.6) 45 (33.1) 7 (5.1) 75 (55.1) 96 (70.6) 16 (11.8) 74 (54.4)

41 (36.6) 33 (29.5) 52 (46.4) 2 (1.8) 14 (12.5) 42 (37.5) 8 (7.1) 77 (68.8) 94 (83.9) 5 (4.5) 66 (58.9)

139 (25.5) 151 (27.7) 191 (35.0) 11 (2.0) 145 (26.6) 148 (27.1) 18 (3.3) 370 (67.8) 422 (77.3) 28 (5.1) 386 (70.8)

6 (33.3) 7 (38.9) 7 (38.9) 0 2 (11.1) 8 (44.4) 2 (11.1) 10 (55.6) 16 (88.9) 0 13 (72.2)

0 0 0 (87.0) 0 0 0 0 21 (95.5) 22 (100) 0 22 (100)

13 (36.1) 4 (11.1) 13 (36.1) 4 (11.1) 12 (33.3) 10 (27.8) 5 (13.9) 27 (75.0) 22 (61.1) 7 (19.4) 25 (69.4)

22.201 14.618 18.012 13.721 23.446 17.052 13.741 18.966 19.474 21.552 27.925

< .001* .012* .003* .017* < .001* .004* .017* .002* .002* .001* < .001*

Journal of Pediatric Health Care

than were learners in the Northeast (n = 58; 42.3%; p < .001) prior to the educational intervention. After the educational intervention, Midwestern learners’ endorsement of spanking as sometimes necessary (n = 139; 25.5%) was significantly less than that of learners in the northeast (n = 52; 38.2%; p < .001). After the educational offering, learners in the Northwest (n = 21; 95.5%) were significantly more likely to state that spanking can be abusive than were Northeastern learners (n = 75; 55.1%; p = .002). DISCUSSION This study demonstrates that a significant number of health care providers, in a sample of primarily nurses, continue to endorse the use of spanking as an acceptable method of discipline and that some endorse the belief that children who are never spanked are spoiled. Learners’ attitudes toward spanking were significantly less supportive of spanking after the educational offering, yet more than one third of learners still believed that spanking was sometimes necessary, with fewer than one fourth stating that spanking was never OK. Learner approval of CP use was slightly decreased compared with previous studies (Fargason et al., 1996; McCormick, 1992) that examined physicians’ attitudes toward CP. However, clearly there is a need for nurses, including PNPs, to receive education regarding child discipline and CP. Child discipline education must be included in both undergraduate and graduate nursing curricula. Fewer than half of learners (n = 365; 46.4%) stated that child discipline management was included in their professional education. Pediatric health care professionals need to be educated regarding child discipline management so they feel comfortable discussing child discipline with parents. More than half of learners also identified themselves as parents, yet only 14% stated that Pediatric health their child’s health care professionals care provider had ever need to be discussed child discipline with them. The educated health care provider regarding child most likely to have disdiscipline cussed discipline with the learner parent was management so a physician. they feel Attitudes and beliefs comfortable regarding child discipline and CP are infludiscussing child enced by a variety of discipline with factors, one of them parents. being how the individual was disciplined as a child. Persons who experienced CP as a child typically are more supportive of CP use (Bell & Romano, 2012; www.jpedhc.org

Simons & Wurtele, 2010). Learners in this study who experienced physical discipline as a child were more supportive of spanking and other physical forms of discipline and less supportive of non-physical forms of discipline. American attitudes and beliefs related to CP are influenced by the geographic region in which the individual lives (Gershoff, 2002). CP continues to be permitted in several states, with the majority being in the Southeast and Southwest (Rollins, 2012). Gershoff (2002), in a meta-analysis of more than two decades of literature related to CP, states that the use of CP is favored most among parents living in the southern part of the United States and favored least by parents living in the Northeast, even when controlling for demographics such as education, income, race, and religion. The geographic differences in support of CP noted in previous studies were not found in this study. The majority of learners stated that their beliefs regarding child discipline and CP were influenced by participation in the educational intervention. More importantly, the majority of learners stated that after the educational intervention they believed that they were more likely to discuss child discipline with their patients and their families. Study Limitations Our study has some limitations. Geographic distribution of learners was not equally disbursed, with well over 50% of learners hailing from the Midwest and fewer than 5% from the Southwest, Northwest, and West. A more even geographical distribution may have offered stronger statistical relationships between geographic regions. Nursing was the profession of three fourths of learners, limiting the ability to make comparisons between professions. NURSING IMPLICATIONS The potential for experiencing CP as a child to result in negative consequences for that child has been well documented (Gershoff, 2002; MacKenzie et al, 2012; Straus & Paschall, 2009; Zolotor, 2014), yet many American parents continue to use CP as a form of child discipline and some pediatric health care professionals continue to endorse its use. Pediatric health care providers, including nurses and PNPs, need to be educated about child discipline and CP. All pediatric health care providers need to advocate for the use of positive parenting principles and discourage the use of CP. Despite its limitations, this study raises valid concerns. First, the attitudes and beliefs of PNPs and registered nurses regarding CP and child discipline continues to be a concern. Second, nurses are not consistently receiving education regarding child discipline management in their undergraduate or graduate programs. Third, pediatric health care providers are not adequately discussing child discipline with parents. -/- 2015

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PNPs need to be educated regarding child discipline principles and in turn educate parents regarding healthy child discipline practices. REFERENCES Afifi, T., Mota, N., Dasiewicz, P., MacMillan, H. L., & Sareen, J. (2012). Physical punishment and mental disorders: Results from a nationally representative US sample. Pediatrics, 130, 184-192. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health. (1998). Guidance for effective discipline. Pediatrics, 101, 723-728. Bell, T., & Romano, E. (2012). Opinions about child corporal punishment and influencing factors. Journal of Interpersonal Violence, 20, 1-22. Ellison, C., & Bradshaw, M. (2009). Religious beliefs, sociopolitical ideology, and attitudes toward corporal punishment. Journal of Family Issues, 30, 320-340. Fargason, C., Chernoff, R., & Socolar, R. (1996). Attitudes of academic pediatricians with a specific interest in child abuse toward the spanking of children. Archives of Pediatric & Adolescent Medicine, 150, 1049-1053. Gershoff, E. (2002). Corporal punishment by parents and associated child behaviors and experiences: A meta-analytic and theoretical review. Psychological Bulletin, 128, 539-579. MacKenzie, M., Nicklas, E., Waldfogel, J., & Brooks-Gunn, J. (2012). Corporal punishment and child behavioral and cognitive outcomes through 5 years of age: Evidence from a contemporary urban birth cohort study. Infant and Child Development, 21, 3-33. McCormick, K. (1992). Attitudes of primary care physicians toward corporal punishment. JAMA, 267, 3161-3165. Mulvaney, M., & Mebert, C. (2010). Stress appraisal and attitudes towards corporal punishment as intervening processes between corporal punishment and subsequent mental health. Journal of Family Violence, 25, 401-412. National Association of Pediatric Nurse Practitioners. (2011). NAPNAP position statement on corporal punishment. Journal of Pediatric Health Care, 25, 31-32. Oas, P. (2010). Current status on corporal punishment with children: What the literature says. The American Journal of Family Therapy, 38, 413-420. Regalado, M., Sareen, H., Inkelas, M., Wissow, L., & Halfon, N. (2004). Parents’ discipline of young children: Results from the

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national survey of early childhood health. Pediatrics, 113, 1952-1958. Rollins, J. (2012). 2012: Revisiting the issue of corporal punishment in our nation’s schools. Pediatric Nursing, 5, 248, 269. Sanapo, M., & Nakamura, Y. (2011). Gender and physical punishment: The Filipino children’s experience. Child Abuse Review, 20, 39-56. Sege, R., Hatmaker-Falnigan, E., DeVos, E., Levin-Goodman, R., & Spviak, H. (2006). Anticipatory guidance and violence prevention: Results from family and pediatrician focus groups. Pediatrics, 117, 455-463. Simons, D., & Wurtele, S. (2010). Relationships between parents’ use of corporal punishment and their children’s endorsement of spanking and hitting other children. Child Abuse & Neglect, 34, 639-646. Straus, M. (1994). Beating the devil out of them: Corporal punishment in American families. New York, NY: Lexington Books. Straus, M. (2001). Beating the devil out of them: Corporal punishment in American families and its effects on children. New Brunswick, NJ: Transaction Publishers. Straus, M., & Paschall, M. (2009). Corporal punishment by mothers and development of childrenÕs cognitive ability: A longitudinal study of two nationally representative age cohorts. Journal of Aggression, Maltreatment, & Trauma, 18, 459-483. Taylor, C., Hamvas, L., Rice, R., Newman, D., & DeJong, W. (2011). Perceived social norms, expectations, and attitudes toward corporal punishment among an urban community sample of parents. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 88, 254-269. Tirosh, E., Shechter, S., Cohen, A., & Jaffe, M. (2003). Attitudes towards corporal punishment and reporting of abuse. Child Abuse & Neglect, 27, 929-937. Zolotor, A. (2014). Corporal punishment. Pediatric Clinics of North America, 5, 971-978. Zolotor, A., & Puzia, M. (2010). Bans against corporal punishment: A systematic review of the laws, changes in attitudes and behaviors. Child Abuse Review, 19, 229-247. Zolotor, A., Theodore, A., Chang, J., Berkoff, M., & Runyan, D. (2008). Speak softly—and forget the stick: Corporal punishment and child physical abuse. American Journal of Preventive Medicine, 35, 364-369.

Journal of Pediatric Health Care