Barriers to effective screening for domestic violence by registered nurses in the emergency department

Automating risk stratification for geriatric syndromes in the emergency department

BACKGROUND

Geriatric emergency department (GED) guidelines endorse screening older patients for geriatric syndromes in the ED, but there have been significant barriers to widespread implementation. The majority of screening programs require engagement of a clinician, nurse, or social worker, adding to already significant workloads at a time of record-breaking ED patient volumes, staff shortages, and hospital boarding crises. Automated, electronic health record (EHR)-embedded risk stratification approaches may be an alternate solution for extending the reach of the GED mission by directing human actions to a smaller subset of higher risk patients.

METHODS

We define the concept of automated risk stratification and screening using existing EHR data. We discuss progress made in three potential use cases in the ED: falls, cognitive impairment, and end-of-life and palliative care, emphasizing the importance of linking automated screening with systems of healthcare delivery.

RESULTS

Research progress and operational deployment vary by use case, ranging from deployed solutions in falls screening to algorithmic validation in cognitive impairment and end-of-life care.

CONCLUSIONS

Automated risk stratification offers a potential solution to one of the most pressing problems in geriatric emergency care: identifying high-risk populations of older adults most appropriate for specific GED care. Future work is needed to realize the promise of improved care with less provider burden by creating tools suitable for widespread deployment as well as best practices for their implementation and governance.

The Domestic Abuse Act 2021 England and Wales: implications for nurses

As the COVID-19 pandemic enveloped the globe there was a parallel increase in the incidence of domestic abuse (DA). This has been ascribed to the restrictions in movement and growing tensions during lockdown periods. The Domestic Abuse Act covering England and Wales was about to be passed prior to the COVID-19 outbreak, but progress halted as attention focused on managing infection control and treatment nationally. The unfolding DA 'shadow pandemic' led to pressure groups lobbying for specific changes to the Act which, in its revised form, became law in April 2021. This article sets out the changes in definition, statutory response and prevention of DA and relates these to nursing practice. Health education and promotion theory is considered and linked to nursing practice with those who are both victims/survivors and perpetrators of DA.

Australian hospital staff perceptions of barriers and enablers of domestic and family violence screening and response

Background

Hospital presentations provide unique opportunities to detect DFV. However, up to 70% of women experiencing Domestic and Family Violence (DFV) go undetected by hospital staff. While routine DFV screening is internationally encouraged, there is still much debate surrounding its implementation. The aim of the study was to determine staff perceptions of barriers and enablers of DFV screening and response.

Methods

A cross-sectional survey was conducted at a tertiary level public hospital and health service. Health care staff in allied health, maternity and mental health divisions (n = 615) were invited to participate by email and through team meetings. 172 responses were analysed.

Results

Less than a third of respondents reported routinely asking patients about DFV, with 34.9% reporting they did not have sufficient training to assist with DFV. Increased levels of training were positively correlated with screening practices, preparedness and knowledge. Major barriers were presence of partner and language barriers, while written protocols and supportive work environment were the principal enablers of screening.

Conclusion

Staff generally believed that routine screening was important and should encompass all forms of abuse. Many felt ill-equipped to ask about or manage disclosure of DFV. More training improves staff capacity for DFV detection and response, and written guidelines should be made available to all staff.

Principles of care for women experiencing intimate partner violence: Views of expert Japanese health professionals and advocates

In Japan, interventions for Intimate Partner Violence (IPV) in the health care setting are rare, partly due to Japanese cultural norms that marginalize women's IPV experiences. A thematic analysis of narratives of eight Japanese health professionals who are experts in IPV care identified shared core values and practices that have guided their development of culturally relevant IPV interventions: supporting women's autonomy to define what is at stake for her, appreciating unique trajectories and timing for recovery, and practicing shared decision-making. These shared practices may be essential for training health professionals to respond to IPV in Japan and elsewhere.

Tensions and Ambivalent Feelings: Opinions of Emergency Department Employees About the Identification and Management of Intimate Partner Violence

The objective of this study was to examine factors facilitating and constraining the identification and management of intimate partner violence (IPV) at an emergency department (ED). Semi-structured interviews were conducted with 18 ED employees of a university hospital in the Netherlands. All interviews were audiotaped, transcribed verbatim, and analyzed by using qualitative content analysis in Atlas.ti. Constraining factors were lack of knowledge, awareness, and resources at the ED. ED employees felt many barriers to bringing up IPV. Facilitating factors were good cooperation among staff, the involvement of one team member in producing an IPV protocol, having received training on child abuse, and private consulting rooms. The ED setting and the ED employees' task perception and attitude contained both constraining and facilitating factors: ED employees saw it as their task and responsibility to help IPV victims, but their priorities were to secure a high turnover and treat acute physical problems. Although ED employees expressed openness and willingness to help, they also took the view that victims had a considerable responsibility of their own in disclosing and managing IPV, which led to ambivalent feelings. In conclusion, ED employees faced tensions in IPV identification and management caused by lack of awareness, knowledge and resources, conflicting priorities at the ED, and ambivalent feelings. Improvements can be made by supporting ED employees with guidelines in the form of a protocol and with training that also addresses the tensions ED employees face.

Intimate partner violence screening in emergency department: a rapid review of the literature

AIMS AND OBJECTIVES

The aim of the review was to identify intimate partner violence screening interventions used in emergency departments and to explore factors affecting intimate partner violence screening in emergency departments.

BACKGROUND

Intimate partner violence against women is now clearly recognised as a global health and societal issue. Nurses working in emergency and urgent care settings can play a crucial role in identification, prevention and management of intimate partner violence. Research exploring optimal methods of intimate partner violence screening and factors affecting intimate partner violence screening in emergency departments are relatively limited.

DESIGN

Literature review: Rapid Evidence Synthesis.

METHODS

Literature published between 2000-2015 was reviewed using the principles of rapid evidence assessment. Six electronic databases: CINAHL, MEDLINE, EMBASE, Psych Info, the Cochrane Library and Joanna Briggs Library.

RESULTS

Twenty-nine empirical studies meeting the eligibility criteria were independently assessed by two authors using appropriate Critical Appraisal Skills Programme Checklists. Intimate partner violence screening in emergency departments is usually performed using electronic, face to face or pen- and paper-based instruments. Routine or universal screening results in higher identification rates of intimate partner violence. Women who screen positive for intimate partner violence in emergency departments are more likely to experience abuse in subsequent months. Factors that facilitate partner violence screening can be classified as healthcare professionals related factors, organisational factors and patient-related factors.

CONCLUSIONS

Emergency departments provide a unique opportunity for healthcare professionals to screen patients for intimate partner violence. Competence in assessing the needs of the patients appears to be a very significant factor that may affect rates of intimate partner violence disclosure.

RELEVANCE TO CLINICAL PRACTICE

Knowledge of appropriate domestic violence screening methods and factors affecting intimate partner violence screening in emergency can help nurses, and other healthcare professionals provide patient-centred and effective care to victims of abuse attending emergency department.

Cardiac Response Rate Variability in Physically Abused Women of Childbearing Age

Physical abuse directly affects maternal and fetal/infant health, with documented reports of higher rates of pregnancy termination, neonatal death, and lower birth weights. Although the Centers for Disease Control and Prevention recommend repeated interviews of women of childbearing age to screen for abuse, the paper-and-pencil instruments available for such screening are adversely affected by the hesitancy of women to disclose physical abuse. Biophysical measures of physiological stress adaptations may hold potential for identifying physically abused childbearing women. This pilot investigation used a Latin square design to assess the effects of physically abusive trauma on the cardiac rate response of three clinical groups and one control group of childbearing-age women. Participants were screened using the Child-bearing Health Questionnaire. Cardiac response rates were measured during a standardized orthostatic challenge using a Tanito cardiac rate response monitor. Forty participants participated with an average age of 27. Multiple analyses of variance revealed that there were significant differences between cardiac rate responses at the 5-min interval. Post hoc testing using Dunnett’s t indicated that only the abused pregnant women had significantly higher cardiac responses to orthostatic challenges; differences were apparent at the 5-min testing period. The findings suggest that physical abuse may alter the vasovagal response beyond the attenuation associated with pregnancy. These findings support further testing with larger samples to identify vasovagal changes in abused pregnant women.

Intimate Partner Violence Screening Practices in California After Passage of the Affordable Care Act

Under the Affordable Care Act (ACA), insurance coverage should include screening for intimate partner violence (IPV). In this article, we present self-reported IPV screening practices and provider confidence from a post-ACA cross-sectional survey of 137 primary care clinicians in California. Only 14% of the providers reported always screening female patients for IPV and about one third seemed never to screen. Female providers were more likely to screen and use recommended direct questioning. Most providers lacked confidence in screening, referral, and record-keeping. Serving a low-income population predicted more frequent screening and better record-keeping. Overall, IPV screening in primary care was inadequate and needs attention.

Nursing student's perceptions and understanding of intimate partner violence

Intimate partner violence (IPV) is a significant health issue in the Australian population and nurses have a role in assessment, intervention and support of families. World Health Organization Statistics indicate that as many as 61% of women, under the age of 50 have been physically abused by their partners. As nurses are in a unique position to identify, assist and support women living with IPV a greater understanding of student nurse's knowledge and attitudes may assist undergraduate programs to ensure better preparation of nurses for this role. A nurse's readiness to manage IPV may be influenced by their knowledge, attitudes, beliefs and behaviors, largely related to their self-efficacy in identifying these women (i.e. via screening procedures) and providing effective interventions. Students from all levels of the undergraduate program of an Australian regional university were invited to participate in focus groups and a subsequent survey that explored their perceptions, attitudes and knowledge of IPV. The results showed students had limited and stereotypical beliefs regarding what constitutes IPV and who perpetrates it. They indicated that they were under prepared to deal with IPV situations in clinical practice but did identify communication as a core skill required. Nursing students may not understand the significance of the issues of IPV nor fully understand the social, economic and health impacts at an individual and societal level. This may result in further under detection of the problem. The results of this study indicate a number of important implications for undergraduate nursing education curricula.

Postpartum nurses' perceptions of barriers to screening for intimate partner violence: a cross-sectional survey

Background

Intimate partner violence (IPV) is a human rights violation that is pervasive worldwide, and is particularly critical for women during the reproductive period. IPV includes physical, sexual and emotional abuse. Nurses on in-patient postpartum units are well-positioned to screen women for IPV, yet low screening rates suggest that barriers to screening exist. The purpose of this study was to (a) identify the frequency of screening for IPV, (b) the most important barriers to screening, (c) the relationship between the barriers to screening and the frequency of screening for types of abuse, and (d) to identify other factors that contribute to the frequency of screening for IPV.

Methods

In 2008, we conducted a cross-sectional survey of 96 nurses from postpartum inpatient units in three Canadian urban hospitals. The survey included the Barriers to Abuse Assessment Tool (BAAT), adapted for postpartum nurses (PPN). Ordinary least squares (OLS) regression models were used to predict barriers to screening for each type of IPV.

Results

The frequency of screening varied by the type of abuse with highest screening rates found for physical and emotional abuse. According to the BAAT-PPN, lack of knowledge was the most important barrier to screening. The BAAT-PPN total score was negatively correlated with screening for physical, sexual, and emotional abuse. Using OLS regression models and after controlling for demographic characteristics, the BAAT-PPN explained 14%, 12%, and 11% of the variance in screening for physical, sexual and emotional abuse, respectively. Fluency in the language of the patient was negatively correlated with screening for each type of abuse. When added as Step 3 to OLS regression models, language fluency was associated with an additional decrease in the likelihood of screening for physical (beta coefficient = -.38, P < .001), sexual (beta coefficient = -.24, P = .05), and emotional abuse (beta coefficient = -.48, P < .001) and increased the variance explained by the model to 25%, 17%, and 31%, respectively.

Conclusions

Our findings support an inverse relationship between rates of screening for IPV and nurses' perceptions of barriers. Barriers to screening for IPV, particularly related to knowledge and language fluency, need to be addressed to increase rates of screening on postpartum units.

Survivors of intimate partner violence: implications for nursing care

As IPV increases in our society, hospitals need to prepare to best meet the needs of these individuals. Hospitals should have policies that encourage critical care nurses to consider abuse with the patients they serve. These policies need to ensure private, confidential interviewing of all patients and standardize the follow-up for any identified cases. There needs to be routine prompts in an assessment and history that clarify whether the person is in a violent situation. Nurses should understand more specifically the context of IPV and know the community resources available to survivors of this violence. Last, nurses need to recognize the physical, psychological, and emotional support they can give to these individuals. The acronym RADAR, developed by the Massachusetts Medical Society, succinctly represents the thought processes that need to occur with all domestic violence cases: R: Perform routine screening. A: Ask direct questions. D: Document findings. A: Assess patient (and children) safety. R: Review patient options and provide referrals. The ultimate aim for hospitals is to empower nurses to provide compassionate care for survivors and establish emotional climates conducive to IPV disclosure and subsequent care.

Counselor- versus provider-based HIV screening in the emergency department: results from the universal screening for HIV infection in the emergency room (USHER) randomized controlled trial

OBJECTIVE

We compare rates of rapid HIV testing, test offer, and acceptance in an urban emergency department (ED) when conducted by dedicated HIV counselors versus current members of the ED staff.

METHODS

The Universal Screening for HIV Infection in the Emergency Room [USHER] trial is a prospective randomized controlled trial that implemented an HIV screening program in the ED of an urban tertiary medical center. ED patients were screened and consented for trial enrollment by an USHER research assistant. Eligible subjects were randomized to rapid HIV testing (oral OraQuick) offered by a dedicated counselor (counselor arm) or by an ED provider (provider arm). In the counselor arm, counselors-without other clinical responsibilities-assumed nearly all testing-related activities (consent, counseling, delivery of test results). In the provider arm, trained ED emergency service assistants (nursing assistants) consented and tested the participant in the context of other ED-related responsibilities. In this arm, ED house officers, physician assistants, or attending physicians provided HIV test results to trial participants. Outcome measures were rates of HIV testing and test offer among individuals consenting for study participation. Among individuals offered the test, test acceptance was also measured.

RESULTS

From February 2007 through July 2008, 8,187 eligible patients were approached in the ED, and 4,855 (59%) consented and were randomized to trial participation. The mean age was 37 years, 65% were women, and 42% were white. The overall testing rate favored the counselor arm (57% versus 27%; P<.001); 80% (1,959/2,446) of subjects in the counselor arm were offered an HIV test compared with 36% (861/2,409) in the provider arm (P<.001). HIV test acceptance was slightly higher in the provider arm (counselor arm 71% versus provider arm 75%; P = .025).

CONCLUSION

Routine rapid HIV testing in the ED was accomplished more frequently by dedicated HIV counselors than by ED staff in the course of routine clinical work. Without dedicated staff, HIV testing in this setting may not be truly routine.

Identification of women exposed to acute physical intimate partner violence in an emergency department setting in Finland

Intimate partner violence (IPV) is seen as a serious health risk factor for women with significant acute and long-term health consequences and it affects women from all ethnic and socioeconomic groups. Knowledge of these consequences of IPV may help emergency department (ED) professionals to identify these women and provide them with appropriate care, including information on a variety of community services, and refer those women to such services if necessary. The study aimed to describe the frequency of ED visits by women exposed to physical intimate partner violence as estimated by ED professionals (nurses, practical nurses, emergency medical technicians) and identification of acute IPV. In this study 'partner' is defined as a woman's husband, former husband, current or former cohabitant or partner. This design was used as part of a larger, descriptive, cross-sectional multi-centre and multi-method study. Data were collected from 28 EDs in 13 Finnish hospital districts. Altogether 488 questionnaires were returned, which yielded a response rate of 51%. The data were analysed using descriptive statistics and quantitative content analysis. Findings showed that 48% (n = 231) of the ED professionals reported that they encountered women in IPV relationships at least once a month. Over one-fifth of the ED professionals reported having repeatedly encountered the same women visiting the ED for IPV related injuries. Over half of the participants reported having problems 'often' or 'now and then' when identifying women exposed to IPV. Those with training on IPV estimated that they had identified women exposed to IPV more often. To conclude, the research suggests that improvement of identification of acute IPV requires that training be arranged and jointly agreed written procedures for handling IPV be introduced.

Myths and stereotypes: how registered nurses screen for intimate partner violence

INTRODUCTION

Intimate partner violence, sometimes referred to as domestic violence, is a prevalent problem in the United States and across the world. Emergency nurses are often the first health care providers to ask individuals about this health issue and are often the first to offer intervention and prevention measures.

METHODS

This study used a phenomenological qualitative approach to examine the role of the registered nurse in the emergency setting as it relates to intimate partner violence. Thirteen emergency nurses from the South Central United States were interviewed for this study.

RESULTS

Four major themes emerged during analysis of the interviews. The 4 themes were (1) myths, stereotypes, and fears; (2) demeanor; (3) frustrations; and (4) safety benefits.

DISCUSSION

This study suggests that emergency nurses are not screening for intimate partner violence based on a protocol as suggested by many professional organizations but rather are screening certain patients for violence based on the nurses' perception of whether particular patients are likely to be victims of violence.

Emergency provider attitudes and barriers to universal HIV testing in the emergency department

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED).

STUDY OBJECTIVE

The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines.

METHODS

Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions.

RESULTS

There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]).

CONCLUSIONS

After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.

Reporting behaviours of nursing students who have experienced verbal abuse

AIM

This paper is a report of a study exploring the reporting behaviours of nursing students who had experienced verbal abuse while gaining clinical experience.

BACKGROUND

Under-reporting of incidents of verbal abuse has been identified internationally as a limitation leading to incomplete data collection when researching aggression in healthcare facilities. This can call into question conclusions, recommendations and policy initiatives based on the research.

METHOD

Questionnaires were distributed in 2005 to a convenience sample of 156 third year nursing students from one preregistration nursing programme in England. A total of 114 questionnaires were returned, giving a response rate of 73.0%. Fifty-one students (44.7%) reported verbal abuse and all of these gave details of the behaviours concerned.

RESULTS

Thirty-two students (62.7%) of those reporting verbal abuse) stated that they had reported the incident and 19 (37.3%) of respondents stated that they had not. Only four incidents resulted in formal documentation. The most frequent feelings reported by respondents were embarrassment and feeling sorry for the abuser.

CONCLUSION

Failure to document experiences of verbal abuse formally was prevalent and reporting practices were variable. Both higher education institutions and healthcare providers should consider establishing process for formal reporting and documenting of incidents of verbal abuse during nurse education, and students should have access to formal support services.

Care provided in visits coded for intimate partner violence in a national survey of emergency departments

PURPOSE

This article describes the health status of and care provided to patients in visits coded to intimate partner violence (IPV) victims in a national survey of emergency departments (EDs). Visits coded for IPV were defined by International Classification of Diseases, 8th edition-Clinical Modification (ICD-9-CM) codes.

METHODS

Data from the National Hospital Ambulatory Medical Care Survey for 1997-2001 were analyzed. The sample consisted of 111 ED visits with ICD codes for IPV (or 12 IPV visits per 10,000 ED visits, and 21 female IPV visits per 10,000 female ED visits).

FINDINGS

The majority of visits coded to IPV were for patients who presented with mild to moderate pain (86%), physical or sexual violence (50%), and injuries to the body (38%). The majority of patients in visits coded to IPV received radiologic testing, wound care, and pain medications (odds ratios [ORs], 1.6, 3.3, and 2.3 respectively). Disposition was mostly referral to another physician or clinic (42%) or return to the ED when needed (20%), but much less to nonphysician services such as social services, support services, and shelters (14%). Uninsured IPV patients were more likely to receive radiologic testing and pain medications (ORs 5.1 and 3, respectively). Patients seen by nurses were 9 times more likely to receive wound care.

CONCLUSION

Caution should be exercised when interpreting the study results because they reflect only coded IPV visits in the ED and these might be the most obvious IPV cases. The results signal the need for further studies to evaluate access to and the quality of care for IPV patients and to improve screening, documentation, coding, and management practices.

Evaluation of an intimate partner violence curriculum in a pediatric hospital

OBJECTIVE

Intimate partner violence harms victims as well as families and communities. Many barriers account for limited intimate partner violence screening by nurses. The purpose of this study was to measure how participation in a curriculum about screening parents for intimate partner violence, at a pediatric hospital, affects a nurse's knowledge, attitudes, behaviors, and self-efficacy for intimate partner violence screening.

METHODS

In this interventional, longitudinal study, data were collected before participation in an intimate partner violence screening curriculum, after participation, and 3 months later. The measurement tool was adapted from Maiuro's (2000) Self-efficacy for Screening for Intimate Partner Violence Questionnaire.

RESULTS

Sixty-eight pediatric nurses completed all aspects of the study. At baseline, 18 (27%) nurses self-reported seeing a parent with an injury, and of those only 7 (39%) followed up with intimate partner violence screening. Factor analysis was performed on the baseline Self-efficacy for Screening for Intimate Partner Violence Questionnaire by using varimax rotation. Five factors were identified: conflict, fear of offending parent, self-confidence, appropriateness, and attitude. Only fear of offending parent was significantly different from times 1 to 3, indicating that nurses were less fearful after the training. Cronbach's alpha value for the total questionnaire at baseline was .85. Nurses reported significant improvement (baseline to 3-month follow-up) in several self-efficacy items.

CONCLUSIONS

Participation in a 30-minute curriculum on intimate partner violence screening was associated with improvements in self-efficacy and significantly lower fear of offending parents 3 months after training. Nurses also showed improvement in the perception of resources available for nurses to manage intimate partner violence. Thirty-minute hospital-based curriculums that include victim testimonial video and practice role-playing to simulate parent interactions are recommended.

Breaking the barriers: the promise of computer-assisted screening for intimate partner violence

Although intimate partner violence (IPV) affects hundreds of thousands of women, the majority of women seen in health care settings are not screened for IPV. Many women are hesitant to disclose their abusive situations to their health care providers and, sadly, there is evidence that when women do disclose violence, their health care providers do not give them needed support and information. This article discusses the importance of IPV screening and barriers that may contribute to the current lack of screening by providers and the low disclosure rate by IPV survivors, describes how computer-assisted screening for IPV can address those barriers, and reports the findings of an integrative review of studies about computer-assisted self-interview (CASI) IPV screening. Computer screening strategies consistently identified a higher prevalence of IPV and were the approach preferred by the study participants. The findings of these initial studies provide support for the development and testing of computer screening and intervention strategies for IPV.

Nurses' experience in clinical encounters with children experiencing abuse and their parents

AIM AND OBJECTIVES

The aim of this study was to identify nurse's experiences in the clinical care of children experiencing abuse. The objective was to assess how nurses remain professional especially when the suspected perpetrator is a parent.

BACKGROUND

The diagnosis of child abuse is a difficult one, yet essential because of the high morbidity and significant mortality rates. Young children may be unable to give a clear history; parents may be unwilling to be truthful, and the signs and symptoms of abuse are often not conclusive. A contributing factor to the challenges of providing nursing care to children in a context of abuse is the lack of education in this field. Nurses working in the care of paediatric patients may not be familiar with situations in which they cannot rely on histories provided by parents.

DESIGN

A qualitative study.

METHODS

Investigators used a qualitative design with a critical incident technique. Eleven nurses who cared for abused children and their parents at a tertiary care children's hospital were interviewed.

RESULTS

We highlighted three areas in the analysis of the interviews: Feelings of ambivalence, nurses' professionalism and the nurses' care strategies. Participants expressed difficulties in maintaining a professional role in clinical encounters with the parents. The nurses were unhappy in their conflicting roles of both policing (a judging function) and nursing (a caring function).

CONCLUSIONS

The nurses expressed that they had devised strategies to remain professional in the clinical encounter with abused children and their parents. To remain professional, education, counselling and experience was essential.

RELEVANCE TO CLINICAL PRACTICE

By identifying nurses' experiences in clinical encounters with children experiencing abuse and their parents, nurses can assess what kind of specific interventions should be used to improve the caring situation.

Facilitators and barriers for implementing home visit interventions to address intimate partner violence: town and gown partnerships

Pregnant women involved in violent relationships represent a population that is vulnerable for poor pregnancy and infant outcomes on several levels. This article describes the development of a "town and gown" partnership to assist pregnant women in violent relationships. Barriers and facilitating factors for research and home visitor (HV) nurse partnerships working with this vulnerable population were identified by HV participants in a qualitative focus group session. Methods used to develop and maintain the reciprocal relationship between the community (town) and academic researchers (gown) are described.

Visits coded as intimate partner violence in emergency departments: characteristics of the individuals and the system as reported in a national survey of emergency departments

INTRODUCTION

This study was conducted to explore the characteristics of intimate partner violence (IPV) victims whose visit was coded as IPV and the health care delivery system in emergency departments (ED).

METHODS

This study utilized a secondary data analysis of a national probability sample that comprised the National Hospital Ambulatory Medical Care Survey for 1997 to 2001.

RESULTS

There were 111 coded ED visits of IPV victims 16 years or older (equivalent of 482,979 out of 4 million national visits for the 5-year study period). Women (94%), African Americans (35%), those 25 to 44 years of age (64%), and uninsured patients (38%) were significantly more likely to be categorized as an IPV visit (odds ratios 14, 1.9, 2.7, and 2.4, respectively) compared with non-IPV visits. Characteristics of the health care delivery system (region, metropolitan vs. non-metropolitan, type of hospital, and type of health care provider) were not associated with IPV.

DISCUSSION

Caution should be implemented when interpreting the study results because they represent only coded IPV visits in the emergency department. The study findings suggest the critical need to improve identification, documentation, and coding of IPV visits.

Domestic violence: a worldwide exploration

The concept of domestic violence is important to nursing because further knowledge of this phenomenon can help drive more effective intervention and prevention approaches. Domestic violence, also known as gender violence, interpersonal violence, and domestic abuse, is a daily and often a deadly fact of life for millions of women and girls around the world. Attacks are perpetrated in settings that include public streets, at places of employment, in the home, while serving in the military, and in prisons and jails. The costs of this violence, both monetary and in human lives, are tremendous. Although nurses are in a unique position to screen for domestic violence and provide assistance and advocacy for victims, barriers exist related to victim disclosure and staff training and comfort levels. Advanced practice nurses can address the issue directly through appropriate treatment facilitation, including both physical and psychosocial intervention.

Assessment of trauma nurse knowledge related to forensic practice

Assessment of forensic practice specific to the trauma setting was the purpose of this pilot study. Thirty-eight trauma nurses from a level II trauma center completed a questionnaire related to their knowledge of forensic practice. Although 58% of nurses had some education related to forensics, emergency department nurses were significantly more knowledgeable about existence of protocols than were intensive care unit nurses. Most respondents indicated a willingness to incorporate forensic principles into practice. Forensic education and standardization of protocols would enhance clinical practice in the trauma setting.

Care for emergency department patients who have experienced domestic violence: a review of the evidence base

AIMS

A literature review was conducted to identify and evaluate the research base underpinning care for emergency department patients who have experienced domestic violence.

BACKGROUND

The extent of domestic violence in the general population has placed it high on health and social policy agendas. The Department of Health has recognized the role of health care professionals to identify and provide interventions for patients who have experienced domestic violence.

METHOD

Systematic review.

RESULTS

At least 6% of emergency department patients have experienced domestic violence in the previous 12 months although actual prevalence rates are probably higher. Simple direct questioning in a supportive environment is effective in facilitating disclosure and hence detecting cases of abuse. Although routine screening is most effective, index of suspicion screening is the current mode of practice in the UK. Index of suspicion screening is likely to contribute to under-detection and result in inequitable health care. Patients with supportive networks have reduced adverse mental health outcomes. Women will have negative perceptions of emergency care if their abuse is minimalized or not identified. Women want their needs and the needs of their children to be explored and addressed. Access to community resources is increased if patients receive education and information.

CONCLUSION

Domestic violence is an indisputable health issue for many emergency department patients. Practitioners face challenges from ambiguity in practice guidelines and the paucity of research to support interventions. Recommendations for practice based on the current evidence base are presented.

RELEVANCE TO CLINICAL PRACTICE

The nursing care for patients in emergency and acute health care settings who have experienced domestic violence should focus on three domains of: (1) Providing physical, psychological and emotional support; (2) Enhancing safety of the patient and their family; (3) Promoting self-efficacy.

Interactions between victims of intimate partner violence against women and the health care system: policy and practice implications

Intimate partner violence (IPV) affects the use of health care by increasing the risk of poor health outcomes. IPV victims seek health services as often as others but are less likely to receive needed services, more likely to overuse services, and more likely to have a poor relationship with their health care provider. This stems from patient and provider barriers to care that are exacerbated by the lack of a clear and consistent health care system response to IPV. Most health care systems are not equipped to assist either victims or providers seeking to help victims. There are a few models of system-wide interventions, but these are not the current standard. A strong health policy framework is needed, but the decision of the U.S. Preventative Task Force not to recommend universal screening is a setback. Overall, there is limited progress in moving the health care system toward assisting IPV victims.

Barriers to screening for domestic violence in the emergency department

The identification of victims of domestic violence is important to prevent further abuse and injury. The purposes of this pilot project were to identify potential barriers emergency department registered nurses encounter in screening patients for domestic violence and to assess nurses' educational backgrounds for continuing education and training needs. The most significant potential barriers to screening identified were a lack of education and instruction on how to ask questions about abuse, language barriers between nurses and patients, a personal or family history of abuse, and time issues. These findings may benefit other researchers who are trying to determine the continuing education needs of emergency department staffs.

Impact of domestic violence posters on female caregivers' opinions about domestic violence screening and disclosure in a pediatric emergency department

OBJECTIVES

The objectives of this study were to examine female caregivers' attitudes about the display of domestic violence (DV) resources in a pediatric emergency department (ED) and to explore whether these resources engendered positive feelings about DV screening and encouraged disclosure.

METHODS

We conducted a cross-sectional survey in a pediatric ED during 2 distinct periods, comparing responses of female caregivers before (pre) and after (post) displaying DV posters and cards. Women were surveyed about (1) personal experience with DV, (2) the appropriateness of DV posters and screening in a pediatric ED, and (3) willingness to divulge DV, if abused.

RESULTS

The 2 groups (pre, n = 133; post, n = 136) did not significantly differ with respect to age, race, education, or personal DV history. The majority endorsed that "it is appropriate to have DV posters," with the post group responding in this manner more often than the pre group (pre, 85%; post, 95%; odds ratio [OR], 3.3; 95% confidence interval [CI], 1.3-8.5). The post group was less likely to prefer pediatric ED DV screening (pre, 76%; post, 63%; OR, 0.5; 95% CI, 0.3-0.9) and tended to be less likely to say that they would divulge (pre, 85%; post, 75%; OR, 0.6; 95% CI, 0.3-1.1). In both groups, women with a DV history were less likely than women without this history to say that they would disclose DV to their pediatric ED provider (P < 0.001).

CONCLUSIONS

These results suggest the need for further exploration of how to most effectively help and provide resources for abused women in this setting.

Nurses' understanding of domestic violence

Domestic violence is considered to be an important health care issue world wide. In order to provide appropriate support and treatment to women who have been abused, it is essential that nurses understand and recognise domestic violence. This study aimed to explore nurses' understanding of domestic violence issues utilising a grounded theory approach. A total of 41 emergency nurses was interviewed in selected Australian and Japanese emergency departments. Analysis of data identified six groups of nurse perceivers of domestic violence: nave perceivers, inexperienced perceivers, compassionate perceivers, proactive perceivers, acting perceivers and reluctant perceivers. Findings indicate that the provision of ongoing education and instigation of policy and protocol enable nurses to respond in a structured manner when they encounter women who have been abused. As a result, nurses can contribute to the amelioration of violence in society and enhance the wellbeing of these women.

Support for emergency department screening for intimate partner violence depends on perceived risk

Emergency department (ED) screening for intimate partner violence (IPV) faces logistic difficulties and has uncertain efficacy. We surveyed 146 ED visitors and 108 ED care providers to compare their support for ED IPV screening in three hypothetical scenarios of varying IPV risk. Visitor support for screening was 5 times higher for the high-risk (86%) than for the low-risk (17%) scenario. Providers showed significantly more support for the need for ED IPV screening than visitors. Controlling for confounding by gender, race, experience with IPV, hospital, and marital status did not affect comparisons between groups. These responses indicate greater support for IPV screening in the ED for high-risk than for low-risk cases, particularly among visitors.

Intimate Partner Violence: Continuing Education for Registered Nurses

Intimate partner violence, also known as domestic violence, is a leading health problem affecting approximately 50% of women during the course of their lifetime. A large percentage of the abusers also abuse their children and older adults. Nurses are in a key position to identify and intervene with victims of abuse. However, a major barrier to screening and referral is lack of education. Nurses indicate a lack of education in their formal undergraduate and graduate programs. Therefore, nurses should be introduced to this topic through a 2-hour continuing education program.

Health care providers' opinions on intimate partner violence resources and screening in a pediatric emergency department

OBJECTIVES

The American Academy of Pediatrics has called upon pediatricians to routinely screen for intimate partner violence (IPV) as an active means by which to prevent child abuse. The pediatric emergency department (ED) is one potentially important site to screen and to provide women with IPV resources. This cross-sectional questionnaire investigated pediatric health care providers' (HCPs') opinions about displaying IPV posters and performing IPV screening in a pediatric ED.

METHODS

This cross-sectional survey was conducted in the ED of an urban, academic, tertiary care children's hospital that serves approximately 70,000 children each year. A convenience sample of 151 HCPs, defined as any person who provided medical care, including physicians, nurses, paramedics, and respiratory therapists, in the pediatric ED was surveyed using a 4-item questionnaire, designed by investigators, about their views regarding newly displayed IPV posters and resource cards, their opinions about universal IPV screening, and their personal use of the IPV materials. Between June and August 2004, surveys were distributed, along with return envelopes to be placed in a sealed box, to HCPs during their shifts in the ED.

RESULTS

Of the 158 distributed surveys, 151 (96%) were returned. Of the sample, 30% were physicians, 53% were RNs, 10% were paramedics/emergency medical technicians, and 7% were other HCPs. Pediatric ED providers supported both IPV resource information and routine screening. Female providers were more likely than men to support the IPV posters. Five percent of the sample took IPV resource information for themselves or for later use with patients.

CONCLUSIONS

Our pediatric ED's providers' endorsement of IPV screening and of the presence of IPV posters demonstrates support for and recognition of the problem of IPV in their patients' families.

Intimate Partner Violence Against Women: Findings From One State's ED Surveillance System

INTRODUCTION

Victims of intimate partner violence against women (IPVAW) often come into contact with various health care professionals, including emergency nurses. Michigan has implemented an ED surveillance system to monitor IPVAW in the state.

METHODS

Twenty-three emergency departments participate in the Michigan Intimate Partner Violence Surveillance System. Female assault and maltreatment victims are identified using International Classification of Diseases Clinical Modification (ICD-9-CM) diagnostic and E codes (External Cause of Injury/Adverse Effects codes). For a 2-year period (1999-2000), patients' charts were reviewed, usually by an emergency nurse, to identify IPVAW victims.

RESULTS

A total of 3111 female assault and maltreatment victims were identified. Of the 2926 incidents for which physical and/or sexual violence was confirmed by chart review, 1136 (38.8% [95% confidence interval: 37.1% to 40.6%]) involved IPVAW.

DISCUSSION

A hospital ED surveillance system revealed that more than a third of female assault and maltreatment incidents were attributable to intimate partner violence, with a considerable proportion being young women abused by an ex-boyfriend. Surveillance also identified a need for improved documentation of female assault and maltreatment in ED records. We realized the benefits of using a public health surveillance process to monitor IPVAW incidence, identify high-risk groups, and reduce research costs.

Intimate partner violence screening and treatment: the importance of nursing caring behaviors

Intimate partner violence (IPV) is a major health concern worldwide. It is the primary cause of traumatic injury to women and one of the leading causes of death for pregnant women. Emergency department (ED) nurses are in a unique position to identify, IPV victims, however, many hospital EDs do not perform routine screenings. This article reviews the literature associated with barriers to screening for IPV and victim's experiences when seeking care in an ED following IPV.

Mutable influences on intimate partner abuse screening in health care settings: a synthesis of the literature

For more than a decade, professional medical and nursing associations have recommended universal screening for intimate partner abuse (IPA). This review of 44 studies examines IPA screening during this period. The purposes of the review are to (a) identify mutable influences on IPA screening, (b) summarize what is known about altering these influences, and (c) outline an agenda for improving IPA screening. Evidence to date indicates that screening is not universal. Promising approaches to improvement start with provider training and relatively simple environmental adjustments. Unanswered empirical questions include "What are the essential components of effective training? Which health care providers are best positioned to screen under which circumstances? Which of the untested mutable influences will further improve IPA screening practice?" The review leads to the following practice recommendations: (a) Interventions should focus on clinicians in training (e.g., medical residents), and (b) screening approaches must be tailored to various practice settings.

Prevalence of victims of violence admitted to an emergency department

OBJECTIVE

To collect data on the consultation frequency and demographic profile of victims of violence attending an emergency department (ED) in Switzerland.

METHODS

We undertook screening of all admitted adult patients (>16 years) in the ED of the CHUV, Lausanne, Switzerland, over a 1 month period, using a modified version of the Partner Violence Screen questionnaire. Exclusionary criteria were: life threatening injury (National Advisory Committee on Aeronautics score > or =4), or inability to understand or speak French, to give oral informed consent, or to be questioned without a family member or accompanying person being present. Data were collected on history of physical and/or psychological violence during the previous 12 months, the type of violence experienced by the patient, and if violence was the reason for the current consultation. Sociodemographic data were obtained from the registration documents.

RESULTS

The final sample consisted of 1602 patients (participation rate of 77.2%), with a refusal rate of 1.1%. Violence during the past 12 months was reported by 11.4% of patients. Of the total sample, 25% stated that violence was the reason for the current consultation; of these, 95% of patients were confirmed as victims of violence by the ED physicians. Patients reporting violence were more likely to be young and separated from their partner. Men were more likely to be victims of public violence and women more commonly victims of domestic violence.

CONCLUSIONS

Based on this monthly prevalence rate, we estimate that over 3000 adults affected by violence consult our ED per annum. This underlines the importance of the problem and the need to address it. Health services organisations should establish measures to improve quality of care for victims. Guidelines and educational programmes for nurses and physicians should be developed in order to enhance providers' skills and basic knowledge of all types of violence, how to recognise and interact appropriately with victims, and where to refer these patients for follow up care in their local networks.