Please note: This course does not meet the Pennsylvania Board of Nursing's requirements for Child Abuse reporting. For our Pennsylvania-approved course, please click here.
If you are licensed in New York you must contact NursingCE.com's Customer Support to receive an official NYS completion certificate after you complete your purchase for the contact hours. Please contact [email protected] or call 800-683-6758 after completing the post-course assessment.
The purpose of this module is to provide comprehensive information pertaining to child maltreatment and intimate partner violence.
At the completion of this module, you will be able to:
- Describe national statistics associated with child maltreatment.
- Explain your responsibilities as a mandatory reporter.
- Identify the state agency that investigates allegations of child maltreatment.
- Describe barriers that contribute to under recognition and underreporting of suspected cases of child maltreatment.
- Describe the role of the sexual assault nurse examiner.
- List the four major types of child maltreatment.
- Define the terms, medical neglect, educational neglect, emotional neglect, economic abuse, and abandonment.
- Explain how parent substance use disorder affects the child.
- Identify risk factors for child maltreatment.
- Identify protective factors that reduce the risk of child maltreatment.
- Describe actions the nurse should take when assessing a child when maltreatment is suspected.
- Explain how to document the care of a child who has a physical injury and physical abuse is suspected.
- Discuss the responsibility of the nurse when working with clients experiencing intimate partner violence.
- Identify the components of primary, secondary, and tertiary prevention levels of intervention.
- Discuss actions for the nurse to take when experiencing moral distress.
- Locate the number for the national hotline which can be used to determine where to report suspected abuse.
Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (e.g., clergy, coach, or teacher). There are four common types of maltreatment: Physical Abuse, Sexual Abuse, Emotional Abuse, and Neglect.
Statistics and Data
Data from U.S. Department of Health and Human Service’s report, Child Maltreatment 2014, is provided below:
- In 2014, approximately 702,000 children were victims of maltreatment
- Approximately 1,546 children died from abuse or neglect
- Neglect accounted for 75% of the cases of maltreatment
- Physical abuse accounted for 17% of the cases of maltreatment
- Younger children are most vulnerable
- And 8.3% were sexually assaulted
According to the Child Welfare Information Gateway (CWIG) fact sheet, federal legislation provides the basis for state laws on child maltreatment by providing a list of acts or behaviors that define child abuse or neglect. The Federal Child Abuse Prevention and Treatment Act defines child abuse and neglect as, at minimum:
“Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or any act or failure to act which presents an imminent risk of serious harm.”
All 50 states and the District of Colombia have mandatory reporting statutes stipulating individuals required to report suspected cases. However, the specific circumstances and the individuals who are mandatory reporters vary from state to state. Most state child protection laws include harm caused by parents or caregivers but not harm caused by other people. However, some state laws include intimate partner violence witnessed by the child as abuse of neglect.
The state child protective service agencies determine the response to the allegations of child maltreatment. In most states, the majority of the reports are investigated. If the results of the investigation show that the charges of child maltreatment are founded according to the statutes and policies of the state, then the disposition is substantiated. If the results of the investigation show that the charges of child maltreatment are unfounded according to the statutes and policies of the state, then the disposition is unsubstantiated.
Despite mandatory reporting statutes, child maltreatment is considerably unrecognized and unreported. In fact, there is evidence that shows only one in three children who experience maltreatment is identified and reported to child protective services.
It is especially important for nurses to serve as advocates for children who are maltreated. Nurses are frequently the first health care professional to come in contact with a child and his or her family and in that case, should be the one to identify a potential incidence of child maltreatment. Plus, nurses who work in inpatient settings have lengthy interactions with children and their families which provides them the opportunity to identify indications of abuse or neglect.
Although nurses who work with children should always be aware of indications of neglect or abuse, Kraus, a pediatric emergency room nurse shares her story and offers the following advice:
- If the story doesn’t fit the injury, be suspicious
- Always perform a head-to-toe assessment
- Child maltreatment occurs in all social, economic, racial and ethnic groups
Even though nurse- opportunity to take action when there is a reason to suspect child maltreatment, a number of barriers contribute to under recognition and underreporting of suspected cases of child maltreatment.
- Health care providers, including nurses, have an inadequate understanding of what child maltreatment is, how to identify at risk children, and how to intervene.
- Often, health care workers are unfamiliar with the statues in their state or jurisdiction that set out the mandatory reporter obligations.
- The health care provider may lack the confidence to function in the role of mandatory reporter.
- Fear of litigation or being sued for reporting suspected maltreatment.
- Damage to the nurse-client relationship is a fear of some nurses along with the fear that a report to child protective service puts the child at greater risk because the family will discontinue the nurse-client relationship and avoid seeking treatment for the child.
It is critical that all health care providers who work with children have the requisite knowledge and skills to recognize and report to act when there are indications of child maltreatment.
Types of Maltreatment
Most states identify four major types of maltreatment: physical abuse, neglect, sexual abuse and emotional abuse. Some states include abandonment and parenteral substance use disorder as a form of neglect. See the link below to review the child maltreatment statues in your state.
PHYSICAL Abuse is physical injury that did not occur due to an accident. Physical abuse can range from minor bruises to broken bones or even death. Such injuries are considered abuse even when the caregiver did not intent to harm the child. Obvious indications of physical abuse include bruises that are in various stages of healing and look like they are from a hand or belt, burns from cigarettes or scalding water, fractures, internal bleeding, strangulation marks on the neck, injuries to the face or head and perforated ear drum. Less obvious indications of violence include headaches, dizziness, falls, insomnia, and depression. Consider the possibility of abuse if you notice that the child shrinks when touched or seems frightened by the caretaker. The nurse should be alert when there are frequent visits to the health care setting and/or the caregiver labels the child as “accident prone.”
SEXUAL Abuse as defined by Child Abuse Prevention and Treatment Act (CAPTA) is provided below:
Employment, use, persuasion, inducement, enticement, or coercion of any child to engage in any sexually explicit conduct or stimulation of such conduct for the purpose of producing any visual depiction of such conduct; or rape, and in the case of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other forms of sexual exploitation of children or incest with children.
Child Welfare Information Gateway (CWIG) provides information about possible indications of sexual abuse displayed by the child:
- Has difficulty walking or sitting
- Experiences nightmare
- Wets the bed
- Refuses to change clothes for gym
- Demonstrates bizarre, sophisticated or unusual sexual knowledge or behavior
- Becomes pregnant or acquires asexually transmitted infection
- Attaches quickly to strangers
CWIG provides information about possible indications of sexual abuse displayed by the caregiver:
- Is unduly protective of the child or severely limits the child’s contact with other children, especially of the opposite sex.
- Is secretive and isolated.
- Is jealous or controlling with family members.
Rape is forced sexual intercourse a nonconsensual activity that involves penetration of the vagina or anus or oral cavity by a body part or inanimate object. Both men and women can be victims of rape. However, statistics show that the highest risk is for females under the age of 34, in a low income bracket and live in a rural community.
A sexual assault nurse examiner (SANE) is a register nurse who has special training to conduct sexual assault evidentiary examination for rape victims. The SANE is also qualified to serve as an expert witness in court. Be prepared to assist the SANE with the physical examination and support the client during the examination. Sexual assault evidence kits are used for collecting blood, oral swabs, hair samples, nail swabs, or scrapings and genital, anal, or penile swabs.
Emotional Abuse includes behavior that minimizes the child’s feelings of self‑worth or humiliates, threatens, or intimidates. Blaming the child for situations over which he or she has no control, isolating the child from friends, and punitive, inconsistent discipline are examples of emotional abuse.
CWIG provides information about possible indications of emotional abuse displayed by the child:
- Displays extremes in behavior, such as overly compliant or demanding behavior.
- Is either inappropriately adult or inappropriately infantile (head banging).
- Is delayed in physical or emotional development.
- Has attempted suicide.
- Reports a lack of attachment to a parent.
CWIG provides information about possible indications of emotional abuse displayed by the child:
- Constantly blames, belittles or berates the child.
- Is unconcerned about the child or refuses to consider offers of help for the child’s problems.
- Overtly rejects the child.
NEGLECT includes the failure on the part of the caregiver to provide physical, medical, educational, financial or emotional needs.
Physical Neglect is the failure to provide food, shelter, hygiene or appropriate supervision.
Medical Neglect is the failure to provide needed medical care including untreated medical or mental health conditions, dental care, or glasses.
Educational Neglect is the failure to provide education for the child, including special education when needed.
Emotional Neglect is the failure to provide a child the love and support needed to thrive and to develop into a healthy adult.
Economic Abuse is the failure to provide for the needs of the child when adequate funds are available.
Abandonment occurs when the parent leaves the child behind and his or her whereabouts are unknown. Some states identify abandonment as a form of neglect.
Substance Use Disorder is also included in the definition of child maltreatment in some states.
Intimate Partner Violence is another type of abuse that is included in the definition of child maltreatment in some states. Certainly, living in a chaotic environment where children frequently witness has a negative effect on the growth and development of a child. Information about this topic is provided later in the module.
When states include substance use disorder as a definition of abuse, according to CWIG the following parental actions constitute abuse:
- Child harm due to the mother’s use of an illegal drug or substance during pregnancy
- Manufacture of methamphetamine in the presence of a child
- Selling, distributing, or giving illegal drugs to a child
- Use of controlled substances by a caregiver that impairs the ability to provide care for the child
Check the website below for more information about substance use disorder by a parent.
Individual Risk Factors For Child Maltreatment:
- Children younger than 4 years of age
- Special needs that may increase caregiver burden (e.g., disabilities, mental retardation, mental health issues, and chronic physical illnesses)
Risk Factors for Perpetrators of Abuse
Individual Risk Factors:
- Parents’ lack of understanding of children’s needs, child development and parenting skills
- Parents’ history of child maltreatment in family of origin
- Substance use disorder and/or mental health issues including depression in the family
- Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income
- Nonbiological, transient caregivers in the home (e.g., mother’s male partner)
- Parental thoughts and emotions that tend to support or justify maltreatment behaviors
Family Risk Factors
- Social isolation
- Family disorganization, dissolution, and violence, including intimate partner violence
- Parenting stress, poor parent-child relationships, and negative interactions
Community Risk Factors
- Community violence
- Concentrated neighborhood disadvantage (e.g., high poverty and residential instability, high unemployment rates, and high density of alcohol outlets) and poor social connections.
Protective Factors for Child Maltreatment
Protective factors buffer children from being abused or neglected. These factors exist at various levels. Protective factors have not been studied as extensively or rigorously as risk factors. However, identifying and understanding protective factors are equally as important as researching risk factors.
There is scientific evidence to support the following protective factors:
Family Protective Factors
- Supportive family environment and social networks
- Several other potential protective factors have been identified. Research is ongoing to determine whether the following factors do indeed buffer children from maltreatment.
- Nurturing parenting skills
- Stable family relationships
- Household rules and child monitoring
- Parental employment
- Adequate housing
- Access to health care and social services
- Caring adults outside the family who can serve as role models or mentors
Community Protective Factors
- Communities that support parents and take responsibility for preventing maltreatment
Individual Risk Factors for Violence
- History of being abused or exposure to violence
- Low self‑esteem
- Fear and distrust of others
- Poor self‑control
- Inadequate social skills
- Minimal social support/isolation
- Immature motivation for marriage or childbearing
- Weak coping skills
Recognizing Potential Child Maltreatment/Neglect
- Unexplained injury or injuries
- Unusual fear of the nurse and others
- Injuries/wounds not mentioned in history
- Fractures, including older healed fractures
- Presence of injuries/wounds/fractures in various stages of healing
- Bite marks
- Handprint bruising
- Cigarette or immersion burns
- Robe or belt marks
- Subdural hematomas
- Trauma to genitalia
- Malnourishment or dehydration
- General poor hygiene or inappropriate dress for weather conditions
- Parent considers child to be a “bad child”
Accidental injuries usually occur along the most bony areas (knees, shins, elbows), whereas suspicious bruising can be seen in places like the inner thighs, stomach, feet, hands, back, buttocks, neck and back of arms and legs.
Social and Community Violence Risk Factors
- Work stress
- Media exposure to violence
- Crowded living conditions
- Feelings of powerlessness
- Social isolation
- Lack of community resources (playgrounds, parks, theaters)
Nursing Assessment of a Child when Maltreatment is Suspected
- Hold the interview in a private setting.
- Be understanding and attentive.
- Avoid using terminology that might place the parent on the defensive for example, abuse or violence.
- When abuse is suspected, let the parent know a report will be made to child protective services.
- Initially interview the parent and the child together.
- Ask the parent about injuries to the child’s body.
- If abuse is suspected, the nurse should ask the parent to speak with the child in private. Refusal could mean there is a problem.
- Ask the parent if the child’s behavior has changed or if he/she has voiced new physical complaints.
- Observe the infant for excessive crying or fussiness.
- Observe the child for developmental delays.
- For preschool children, observe how they play or what they draw.
- Ask the child who takes care of them.
- Ask the child what he/she does for fun.
- Ask older children to tell you what worries them.
- Ask older children if they are experiencing pain.
- Ask what happens when someone in the household gets angry.
It’s always important for the nurse perform accurate and complete documentation. Accurate, complete documentation provides the nurse, the nurse’s coworkers and the agency legal protection. Good documentation is the best defense against malpractice. Know your agencies policies regarding documentation and follow the policies diligently in all situations and especially in high-risk situations such as when there is suspicion of abuse. Include a description of the client’s medical history, the family’s psychosocial history, and observations you made regarding interaction among family members. Document direct quotes regarding when the injury occurred and who caused it. Document physical injuries in narrative form as well as in pictorial form such as a body map.
According to the U.S. Department of Justice intimate partner violence (IPV), also known as domestic violence is the use of behavior that is used by an intimate partner to gain control or to maintain power and control of the other intimate partner. IVP can be physical, sexual, emotional, economic, or psychological actions or threats of actions that influence another person. This includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound someone.
Children who live in a home where there is violence may witness the violence first hand, come home to find the after effects of violence or see the perpetrator removed from the home by the police. IPV is associated with a number of long-term adverse effects including depression, low self-esteem, antisocial behavior, academic difficulty, seductive behavior, and difficulty with the law. Older children may attempt to run away from home.
There are three phases to the cycle of violence, the tension-building phase, the serious battering phase, and the honeymoon phase.
- In the tension building phase, the abuser is jittery and has minor flare ups where the victim may be abused verbally or hit or slapped. The victim feels like she is “walking on eggs,” and feels helpless.
- In the serious battering phase, serious injury can occur. The abuser’s mind set is “I just want to teach her a lesson.” The victim can be so tense; she provokes the abuser, “just to get it over with.” During this phase, the victim may come to the emergency department for medical care if there is severe physical injury. Emergency department nurses have a unique opportunity to identify intimate partner violence and to provide support and assistance to victims and their families. In this phase, the victim may conclude that she needs a safe place to hide from the abuser, especially if she fears for her own life and the lives of her children.
- In the honeymoon phase, the abuser displays loving behavior and may shower the victim with gifts. He apologizes, promises to change. The victim responds because she wants to believe that he is able to change and hopes that the cycle will not start again.
Nurses who provide care for victims of abuse have the opportunity to support the victim and offer resources for assistance. The nurse should
- Start by establishing rapport with the victim. Reassure her that she did nothing wrong.
- Allow the victim to tell the story without interruption.
- Ask the victim to tell what happened.
- Encourage the victim to work with a counselor who can direct her to resources and assist her to decide her plan of action.
- Direct the victim to support groups to minimize her feelings of isolation.
Below are the questions from an extensively used Abuse Assessment Screen that was developed by Soeken and colleagues.
- Within the year, have you been hit, slapped, kicked or otherwise physically hurt by someone?
- Since you have been pregnant, have you been hit, slapped, kicked or otherwise physically hurt by someone?
- Within the last year, has anyone forced you to have sexual activities?
- Have you ever been emotionally or physically abused by your partner or someone important to you?
- Are you afraid of your partner or anyone listed above?
As discussed above, the nurse should encourage the victim to talk about the incident, discuss the importance of personal safety, provide the victim with written information about referral information such as a mental health clinic and community advocacy groups. The nurse should offer support while remembering that it’s the victim who makes the decision about what to do.
Looking from the outside in the question is, “why doesn’t she leave him?” The victim may choose to stay in the relationship for one or more reasons:
- Fear of retaliation-the abuser may threaten to kill her or the children if she leaves.
- Financial reasons-she may not have the money to leave and she may not have job skills to support herself and her children.
- Lack of a support network-family members want her to stay in the relationship.
- Fear of losing the children-she might lose custody of the children if she leaves.
The victim needs information about community safe houses and shelters. These facilities provide the victim with a place where she can feel safe and protected. Additionally, facility staff provides victims with emotional support, group counseling, legal representation and social services.
The nurse should provide the victim with information about a nearby shelter even if the victim’s decision is to stay in the relationship at the present time. The nurse should also recommend that the victim pack a bag with needed items and place it somewhere that the abuser will not find it. A partial list is found below.
- Money for living expenses
- Emergency phone numbers
- Clothing for self and children
- Keys to the house and the car
- Legal documents-birth certificates, driver’s license, social security cards
- Items of sentimental value
- Teach alternative methods of conflict resolution, anger management, and coping strategies in community settings.
- Organize parenting classes to provide anticipatory guidance of expected age‑appropriate behaviors, appropriate parental responses, and forms of discipline.
- Educate clients about community services that are available to provide protection from violence.
- Assist in removing or reducing factors that contribute to stress by referring caretakers to respite services, assisting an unemployed parent in finding employment, or increasing social support networks for socially isolated families.
- Teach individuals that no one has a right to touch or hurt another person, and make sure they know how to report cases of abuse.
- Identify and screen those at risk for abuse and individuals who are potential abusers.
- Assess and evaluate any unexplained bruises or injuries of any individual.
- Screen all pregnant women for potential abuse. This might be the one time in some women’s lives that they can access the health care system on a regular basis.
- Refer sexual assault or rape survivors to a local emergency department for assessment by a SANE/sexual assault abuse team. Caution the client not to bathe following the assault because it will destroy physical evidence.
- Assess and counsel anyone contemplating suicide or homicide, and refer the individual to the appropriate services.
- Support and educate the offender, even though a report must be made.
- Assess and help offenders address and deal with the stressors that can be causing or contributing to the abuse, such as mental illness or substance use disorder.
- Alert all involved about available resources within the community.
- Advocate for legislation designed to assist caregivers and to increase funding for programs that supply services to low‑income, at‑risk individuals.
- Establish parameters for long‑term follow‑up and supervision.
- Make resources in the community available to survivors of violence (telephone numbers of crisis lines and shelters).
- If court systems are involved, work with parents while the child is out of the home (in foster care).
- Refer to mental health professionals for long‑term assistance.
- Provide grief counseling to families following the death of a family member to suicide or homicide.
- Develop support groups for caregivers and survivors.
Caring for Clients Who Experience Violence
- Build trust and confidence with a client.
- Focus on the client rather than the situation.
- Assess for immediate danger.
- Provide emergency care as needed.
- It is NOT the job of the nurse to interrogate or investigate, reasonable cause is all that is needed to report to the agencies who will investigate.
- If you suspect with reasonable cause that abuse may have occurred, complete mandatory reporting, following state and agency guidelines.
The Nurse’s Awareness of Personal Emotions and Thoughts
As a nurse who provides care for children who are victims of maltreatment, you must be aware of your own emotions. First examine your personal views about child maltreatment. It’s important, even though it may be difficult, to set aside negative bias because you need to provide nonjudgmental care to the child and to the family. Some common emotions you might feel are as follows:
- Anguish can occur when the nurse has been a victim of abuse.
- Fear might be present if the perpetrator turns anger toward others (the nurse).
- Confusion is experienced when the nurse realizes child maltreatment could be a problem with one’s own family.
- Helplessness because the nurse cannot intervene to “fix the problem.”
- Discouragement because the problem is still present and a long-term solution has not been achieved.
- Embarrassment because the situation reminds the nurse of something in one’s own home.
- Blame the victim for actions the nurse sees as provoking the perpetrator or when the nurse just feels overwhelmed.
When nurses are unable to do what they feel is best for the client due to constrains such as family decisions, lack of resources, or agency polices, they can feel alone and frustrated. This phenomenon is known as moral distress. According to the American Association of Critical Care Nurses, the definition of moral distress is when a person knows the right thing to do, but is constrained from taking it.
Initial moral distress occurs in the acute phase of the dilemma. For example, a provider decides to pursue aggressive medical treatment for an infant who has a massive head injury with no hope of recovery. The nurse feels angry and resentful and has feelings of distress for the infant who must endure the medical treatment.
Residual moral distress is when, after a period of time, there is still no acceptable resolution to the problem.
The American Association of Critical Care Nurses recommends the 4 A’s to rise above moral distress.
- Ask: Is this moral distress. During this step the nurse becomes aware of personal moral distress.
- Affirm: Recognize moral distress and accept the professional and personal responsibly to resolve the issue.
- Assess: View the situation and feelings of all persons involved including the client, the family, other health care providers and the agency. This allows you to begin to problem solve.
- Act: Take deliberate action to reconcile differences and resolve the problem.
Experts in the field of ethics also suggest that nurses:
- Follow the nurse’s code of ethics.
- Create an environment where nurses feel free to speak up.
- Bring disciplines together.
- Hold frequent conferences with families.
- Use resources provided by professional associations.
- Offer counseling services for nurses who are distressed about work place ethical dilemmas.
Each state has an agency designated to receive reports, it is usually child protective services (CPS). To determine who to report to, you can call the national hotline 1-800-4-A-CHILD
New York State Relevant Documents
- Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s fundamentals of nursing: Concepts, process, and practice (10th ed.). Upper Saddle River, NJ: Prentice-Hall.
- The Centers for Disease Control and Prevention (CDC, 2017) (Centers for Disease Control and Prevention [CDC], 2017)
- Dudek, S. G. (2014). Nutrition essentials for nursing practice (7th ed.). Philadelphia: Lippincott Williams & Wilkins.
- Eliopoulos, C. (2014). Gerontological nursing (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
- Halter, M. J. (2014). Varcarolis’ foundations of psychiatric mental health nursing: A clinical approach (7th ed.). St. Louis, MO: Saunders.
- Hockenberry, M. J., & W Wilson, D. (2015) Wong’s nursing care of infants and children (10th ed.). St. Louis, MO: Mosby.
- Ignatavicius, D. D., & Workman, M. L. (2016). Medical‑surgical nursing (8th ed.). St. Louis, MO: Elsevier.
- Karakachain, A., Colbert, A., Moral Distress: A Case Study, Nursing 2017 47(10): 13-15, 2017.
- Kraus, D., Why is Child Abuse Awareness Important to Trauma Nurses? Journal of Trauma Nursing 23(3): 116, 2016.
- Jordan, K., Steelman, S., Child Maltreatment: Interventions to Improve Reporting, Journal of Forensic Nursing 11 (2) 107-113, 2015.
- Lavigne, J., et.all, Pediatric Inpatient Nurses’ Perceptions of Child Maltreatment, Journal of Pediatric Nursing 34:17-22 (2017).
- Lowdermilk, D. L., Perry, S. E., Cashion, M. C., & Aldean, K. R. (2016). Maternity & women’s health care (11th ed.). St. Louis, MO: Elsevier.
- Marquis, B. L., & Huston, C. J. (2015). Leadership roles and management functions in nursing: Theory and application. (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
- Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2013). Fundamentals of nursing (8th ed.). St. Louis, MO: Mosby.
- Townsend, M., Morgan, K., (2017). Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidenced-Based Practice (7th ed.) Philadelphia, F.A. Davis Company.
- U.S. Department of Health and Human Services. Administration on Children, Youth and Families, Children’s Bureau. 2016. Child maltreatment 2014.
- U.S. Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau.
- Van der Zalm, Y. et.al, Psychiatric Nursing Care of Adult Survivors of Child Maltreatment: A Systematic Review of the Literature. Perspectives in Psychiatric Care 51: 71-78, 2014.
- Wood, D. Ten Best Practices for Addressing Ethical Issues and Moral Distress AMN Health Care News. March 2014. Retrieved November 4, 2017