Barriers to screening for domestic violence in the emergency department

Identifying the barriers faced by obstetricians and registrars in screening or enquiry of intimate partner violence in pregnancy: A systematic review of the primary evidence

INTRODUCTION

Intimate partner violence (IPV) disproportionally affects women compared to men. The impact of IPV is amplified during pregnancy. Screening or enquiry in the antenatal outpatient setting regarding IPV has been fraught with barriers that prevent recognition and the ability to intervene.

AIMS

The aim of this systematic review was to determine the barriers that face obstetricians/gynaecologists regarding enquiry of IPV in antenatal outpatient settings. The secondary objective was to determine facilitators.

METHODS

Primary evidence was searched using Ovid MEDLINE, Ovid Maternity and Infant Care, PubMed and Proquest from 1993 to May 2023. The included studies comprised empirical studies published in English language targeting a population of doctors providing antenatal outpatient care. The review was PROSPERO-registered (CRD42020188994). Independent screening and review was performed by two authors. The findings were analysed thematically.

RESULTS

Nine studies addressing barriers and two studies addressing facilitators were included: three focus-group or semi-structured interviews, six surveys and two randomised controlled trials. Barriers for providers centred at the system level (time, training), provider level (personal beliefs, cultural bias, experience) and provider-perceived patient level (fear of offending, patient readiness to disclose). Increased experience and the use of validated tools were strong facilitators.

CONCLUSION

Barriers to screening reflect multi-level obstruction to the identification of women exposed to IPV. Although the antenatal outpatient clinic setting addresses a particular population vulnerable to IPV, the barriers for obstetricians are not unique. The use of validated cueing tools provides an evidence-based method to facilitate enquiry of IPV among antenatal women, assisting in identification by clinicians. Together with education and human resources, such aids build capacity in women and obstetric providers.

Conceptualizing Domestic Violence Within Clinical Documentation

Domestic and family violence (DFV) is a global issue with significant impacts on victim-survivors. The emergency department (ED) serves as the initial point of contact for victim-survivors. Given the significant role that clinical notes play in the management of patients and the communication between healthcare professionals, understanding how healthcare practitioners describe and document abuse reported in emergency settings is crucial. Yet, there remains a gap in understanding how health professional document DFV in the medical records of women presenting to the ED. Therefore, this qualitative descriptive study explored how DFV is documented in patient records of women presenting to the ED. Clinical notes from healthcare workers, including medical practitioners, nurses, social workers, mental health clinicians and ambulance officers, were qualitatively analyzed. Overall, the study included 43 presentations from 32 women (aged 18-56 years old) who visited a regional ED, during which instances of DFV were noted. An inductive content analysis resulted in the identification of four categories, including (a) DFV articulated in direct speech, (b) Unambiguous DFV, (c) Unconfirmed DFV, and (d) Problematic relationship. Although most references to DFV in the clinical notes included direct quotations from the patient's descriptions of abuse or were documented unambiguously by healthcare professionals, a notable number of clinical notes exhibited a degree of caution or reluctance to acknowledge DFV dynamics when describing these events. These findings support the need for sustained and consistent professional training among healthcare professionals concerning the identification, documentation, and response to disclosures, suspicions, and allegations of DFV to better support victim-survivors presenting to the ED and other hospital settings.

A scoping review of the healthcare provided by nurses to people experiencing domestic violence in primary health care settings

Background

Domestic and family violence is a significant and growing public health concern in many communities around the world. Nurses are often the first and sometimes only point of contact for people seeking healthcare following DFV incidents and are therefore well placed to identify and support these vulnerable people. The aim of this scoping review is to examine the English language studies of healthcare provided by nurses in primary healthcare settings to people experiencing domestic and family violence.

Methods

A scoping review of the following databases was undertaken between March-June 2021: CINAHL, Medline, and PubMed. Primary studies were included if written in English, published from 2000 onwards, and focused on the care provided by primary healthcare nurses to people experiencing DFV. A critical appraisal of included studies was conducted using the Mixed Methods Appraisal Tool (MMAT). Results were synthesised narratively.

Results

Six studies were included, from the United States (n = 2), United Kingdom (n = 1), Sweden (n = 2), and Brazil (n = 1). Five studies were quantitative and one qualitative. A fundamental aspect of the healthcare provided by nurses, reported by all studies, was the screening of DFV. Other healthcare provided includes physical and mental health assessment and referral to other services, including sexual assault clinics, social supports, and law enforcement agencies. Findings suggest the level of DFV screening conducted by nurses is limited. Nurses' knowledge of how to support people experiencing DFV was also reportedly limited. Two studies reported that nurses were unfamiliar with DFV practice guidelines and the existence and availability of support networks for people experiencing DFV.

Conclusion

Findings suggest inconsistency in primary healthcare nurses' level of education, skill and knowledge, and detection of people experiencing DFV. As the largest healthcare professional discipline, nurses have frequent contact with people experiencing DFV. There is an urgent need for nurses to be better educationally prepared and more organisationally supported in order to adequately respond and provide healthcare to people experiencing DFV. Given that the number of people experiencing DFV has increased due to the COVID-19 pandemic, it is ever more important for nurses to be well equipped to identify and respond appropriately.

Exploring barriers to domestic violence screening among culturally and linguistically diverse and migrant women in a regional midwifery setting

BACKGROUND

Women are at an increased risk of experiencing domestic violence (DV) from an intimate partner during the antenatal and post-partum period, contributing to poorer health outcomes for mother and baby. The antenatal period presents a critical window of opportunity for screening and intervention. In Australia, screening guidelines vary across state and territory health departments. NSW Health has introduced compulsory antenatal DV screening, however, screening appears to be more commonly deferred for women of CALD and non-English speaking backgrounds suggesting barriers to screening.

AIM

To identify barriers to undertaking DV screening of culturally and linguistically diverse (CALD) and migrant women in a regional setting METHODS: Qualitative semi-structured interviews were conducted with midwives who undertook antenatal DV assessment at a regional hospital in rural New South Wales serving a high CALD and migrant population.

FINDINGS

Eleven midwives participated in the interviews. Four emergent themes were apparent as barriers to DV screening: communications challenges, including literacy and use of interpreters, issues with maternity services including lack of flexibility and continuity, a woman's family issues and cultural difficulties.

CONCLUSION

The antenatal period presents a critical window for screening and intervention for those living with intimate partner violence from CALD and migrant groups. While it is acknowledged that there are complex language, maternity service, family and cultural barriers that impact on the ability to undertake screening in a regional setting, recognising these is the first step in addressing them and being able to intervene to break the DV cycle.

Exploring the readiness of senior doctors and nurses to assess and address patients' social needs in the hospital setting

BACKGROUND

Adverse social circumstances are a key factor in health outcomes. Hospitals are an opportune setting for assessing and addressing the unmet social needs of patients, however, the readiness of healthcare workers in hospitals to undertake such tasks requires further exploration in the Australian context. This study aimed to generate a theory of doctors' and nurses' readiness to assess and address patients' social needs in a hospital setting.

METHODS

A constructivist grounded theory methodology was applied, with purposive and theoretical sampling used to gather diverse perspectives of readiness during semi-structured interviews with twenty senior doctors and nurses from a variety of clinical specialties working in hospitals serving communities experiencing inequitable social and health outcomes. Line-by-line coding, memo writing, and diagramming were used in analysis to construct an interpretive theory of readiness. Application of constant comparison analytic processes were used to test the robustness of the theory.

RESULTS

The readiness of doctors and nurses varies across individuals and departments, and is founded upon a state of being comfortable and confident to assess social need as determined by a range of personal attributes (e.g. knowledge of social need; skills to assess social need); a state of being willing and prepared to assess and address social need facilitated by supportive environments (e.g. departmental culture); and enabling characteristics of the clinical encounter (e.g. time, rapport).

CONCLUSIONS

We found that the readiness of doctors and nurses is dynamic and impacted by a complex interplay of personal attributes along with contextual and situational factors. These findings indicate that any efforts to strengthen the readiness of doctors and nurses to assess and address social needs must target personal capabilities in addition to characteristics of the working environment.

Organizational factors affecting nurses' tendency to report child abuse and neglect

OBJECTIVE

To examine the factors that affect the tendency of nurses working in mother and child health clinics (MCHC) to report child abuse to the authorities.

DESIGN

Cross-sectional survey.

SAMPLE

Three hundred and forty-one female nurses working in MCHC across Israel.

MEASUREMENTS

(1) Social and organizational variables; (2) the tendency to report child abuse and neglect; (3) attitudes toward reporting child abuse and neglect.

RESULTS

On average, the participants perceived that they have good collaboration with other staff members and with welfare services. They showed a favorable attitude toward reporting child abuse, but less than half (44.8%) would report child abuse suspicion to the authorities. None of the organizational variables (MCHC type, collaboration among staff, collaboration with welfare services) were correlated with the tendency to report child abuse and neglect, yet all three variables were significantly correlated with attitudes toward reporting child abuse. Nurses' attitudes toward reporting were mediated by the organizational variables.

CONCLUSIONS

The effect of the organizational factors on the actual tendency to report child abuse is mediated by nurses' attitude toward reporting. Organizational constraints probably encourage MCHC nurses to be cautious before reporting child abuse and neglect to the authorities, restricting adherence to the law, which requires direct reporting.

Health Care Providers' Readiness to Identify and Respond to Intimate Partner Violence

Screening rates for intimate partner violence (IPV) among most health care providers are low; yet, positive interactions with providers can benefit people who experience IPV, with respect to increased safety, support, and self-efficacy. Missing is a broad assessment and comparison of knowledge, attitudes, and behavior across the range of providers who are likely to be involved in a response to IPV disclosure. The purpose of our study was to assess health care providers' IPV preparation, knowledge, opinions, and practices and examine differences across three types of health care providers (medical providers, nursing staff, and social/behavioral health providers). We used an anonymous online survey to gather self-reported information on preparation, knowledge, opinions, and practices around IPV. A random sample of 402 providers was drawn from 13 clinics in a large multispecialty outpatient practice setting. The respondents (N = 204) consisted of medical providers (n = 70), nursing staff (n = 107), and social/behavioral health providers (n = 27). Data analyses consisted of univariate, bivariate, and multivariate analyses. Social/behavioral health providers reported more preparation, knowledge, victim understanding, and less job-related constraints, yet they reported lower screening rates than medical providers and nursing staff. Overall, no provider group seemed well-equipped to work with patients who disclose IPV. Our findings identify unmet needs within our health system to better train health care providers and restructure care models to support IPV identification and response. A focus on interprofessional training and care collaboration would bolster competency and reduce constraints felt by the health care workforce.

Perspectives and Values of Dental Medicine Students Regarding Domestic Violence

Background and Objectives: The purpose of this study is to evaluate dental medical students' opinions concerning domestic violence from a social and medical standpoint and from the perspective of the moral values of the physician-patient relationship. Materials and Methods: We performed an observational study with 4- and 5-year dental medical students at the UMF "Carol Davila" in Bucharest from October 2020-May 2021, using a questionnaire containing 20 items on domestic violence (DV). The questionnaire was uploaded online on the e-learning platform where the students have access. To collect the data, we used Microsoft Excel 365, and the statistical analysis was performed using Jamovi. Results: Of the 600 students enrolled, 415 answered the questionnaire, the answering rate being 69.16%. A total of 215 (53.1%) personally knew victims of DV, 4 (1.0%) considered that violence within a couple is necessary for certain situations, 401 (99.0%) considered that domestic violence is a fundamental problem in today's society, and 170 (41.5%) felt that in domestic violence situations, the blame lies solely with the partner who resorts to physical violence. Regarding the role of the physician, 220 (56%) considered that the physician should breach confidentiality and report cases when patients state they are a victim of DV, 337 (88.2%) thought that free medical treatment should be provided for DV victims who have a dire financial situation, and 212 (56.7%) considered that victims of DV are non-compliant patients. Conclusions: Domestic violence is a phenomenon well-known to stomatology students, which creates the premise of an excellent physician-patient relationship with them, aiding in proper management of ethical issues such as a potential need to breach confidentiality or evaluate the potential conflicts between autonomy and beneficence.

Professionals' views on working in the field of domestic violence and abuse during the first wave of COVID-19: a qualitative study in the Netherlands

BACKGROUND

The COVID-19 pandemic and lockdown evoked great worries among professionals in the field of domestic violence and abuse (DVA) as they expected a rise of the phenomenon. While many countries reported increased DVA, the Netherlands did not. To understand this discrepancy and the overall impact of the lockdown on DVA support services, we interviewed DVA professionals about their experiences with DVA during the rise of COVID-19, the impact of the lockdown on clients and working conditions, and views on eHealth and online tools.

METHODS

Semi-structured interviews were conducted among 16 DVA professionals with various specializations. This data was analyzed using open thematic coding and content analysis.

RESULTS

Most professionals did not see an increase in DVA reports but they did notice more severe violence. They experienced less opportunities to detect DVA and worried about their clients' wellbeing and the quality of (online) care. Furthermore, their working conditions rapidly changed, with working from home and online, and they expressed frustration, insecurity and loneliness. Professionals feel eHealth and online tools are not always suitable but they do see them as an opportunity to increase reach and maintain services when physical contact is not possible.

CONCLUSION

This study suggests DVA was probably under-detected during the lockdown rather than not having increased. The Dutch system heavily relies on professionals to detect and report DVA, suggesting a need for critical evaluation of the accessibility of professional help. Professionals experienced significant challenges and should themselves be supported psychologically and in their changed work practices to maintain their ability to aid survivors.

Sexist Myths Emergency Healthcare Professionals and Factors Associated with the Detection of Intimate Partner Violence in Women

This study analysed the capacity of emergency physicians and nurses working in the city of Granada (Spain) to respond to intimate partner violence (IPV) against women, and the mediating role of certain factors and opinions towards certain sexist myths in the detection of cases. This is a cross-sectional study employing the physician readiness to manage intimate partner violence survey (PREMIS) between October 2020 and January 2021, with 164 surveys analysed. Descriptive and analytical statistics were applied, designing three multivariate regression models by considering opinions about different sexist myths. Odds ratios and 95% confidence intervals (CIs) were considered for the detection of cases. In the past six months, 34.8% of professionals reported that they had identified some cases of IPV, particularly physicians (OR = 2.47, 95% CI = 1.14–5.16; OR = 2.65, 95% CI = 1.26–5.56). Those who did not express opinions towards sexist myths related to the understanding of the victim or the consideration of alcohol/drug abuse as the main causes of violence and showed a greater probability of detecting a case (NS) (OR = 1.26 and OR = 1.65, respectively). In order to confirm the indicia found, further research is required, although there tends to be a common opinion towards the certain sexual myth of emergency department professionals not having an influence on IPV against women.

What barriers prevent health professionals screening women for domestic abuse? A literature review

BACKGROUND

Domestic abuse is known to affect one in four women (although it is difficult to quantify) and has significant short- and long-term health implications. As people who often have regular contact with women in a variety of circumstances, including routine appointments, health professionals, particularly nurses and midwives, are in an ideal position to screen women for domestic abuse. However, it is recognised that there is a reluctance by some health professionals to undertake this important role.

AIM

To identify the potential barriers preventing health professionals from screening women for domestic abuse and to consider how these barriers could be overcome.

METHOD

A literature review of electronic databases using predetermined search terms and inclusion/exclusion criteria was undertaken. Seven studies were identified for review, consisting of five qualitative and two quantitative pieces of research.

CONCLUSION

Several barriers to screening by health professionals were identified, including lack of training, education, time, privacy, guidelines, policies and support from the employer, with the most prevalent of these being a lack of training and education. Further research is required, specifically within the UK, to provide more details about how these barriers might be addressed.

Screening and receiving information for intimate partner violence in healthcare settings: a cross-sectional study of Arab and Jewish women of childbearing age in Israel

OBJECTIVES

We studied the proportion of women who have ever been screened (ES) for intimate partner violence (IPV) in a healthcare setting, received information (RI) about relevant services, or both, and explored disparities in screening and information provision by ethnicity and other characteristics.

DESIGN

In 2014-2015, we undertook a cross-sectional study, conducting interviews using a structured questionnaire among a stratified sample of 1401 Arab and Jewish women in Israel.

SETTING

A sample of 63 maternal and child health clinics (MCH) clinics in four geographical districts.

PARTICIPANTS

Women aged 16-48 years, pregnant or up to 6 months after childbirth.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used multivariable generalised estimating equation analysis to determine characteristics of women who were ES (Has anyone at the healthcare services (HCS) ever asked you whether you have experienced IPV?); RI (Have you ever received information about what to do if you experience IPV?); and both (ES&RI).

RESULTS

Less than half of participants (48.8%) reported ES; 50.5% RI; and 30% were both ES&RI. Having experienced any IPV was not associated with ES or ES&RI, but was associated with RI in an unexpected direction. Women at higher risk for IPV (Arab minority women, lower education, unmarried) were less likely to report being ES, RI or both. The OR and 95% CI for not ER&RI were: 1.58 (1.00 to 2.49) among Arab compared with Jewish women; 1.95 (1.42 to 2.66) among low education versus academic education women; 1.34 (1.03 to 1.73) among not working versus working. ES, RI and both differ across districts.

CONCLUSIONS

While Israel mandates screening and providing information regarding IPV for women visiting the HCS, we found inequalities, suggesting inconsistencies in policy implementation and missed opportunities to detect IPV. To increase IPV screening and information provision, the ministry of health should circulate clarification and provide support to healthcare providers to conduct these activities.

Opportunistic domestic violence screening for pregnant and post-partum women by community based health care providers

Background

Domestic violence against women is a global endemic that can commence or escalate during pregnancy and continue postpartum. Pregnant and postpartum women generally access health care providers more at this time than at any other time in their lives. Despite this, little is known about primary health care providers’ screening practices for domestic violence. The purpose of this paper is to present survey findings that identified domestic violence screening practices of community based health care providers in pregnant and postpartum women.

Methods

This paper reports on the survey results of a larger sequential mixed methods study that involved a survey and semi-structured interviews, and used a pragmatic approach to the data collection and analysis. The survey sought information via both fixed choice and open responses. Quantitative data from the surveys were entered into the Statistical Package for Social Science (SPSS™ Version 22) and analysed using descriptive statistics. Open responses were collated and then integrated and presented with the quantitative data.

Results

Results revealed that some health care providers did not screen for domestic violence. Factors contributing to this lack of screening included: a lack of recognition that this was part of their role; and a lack of domestic violence screening policies and/or reminder systems. Further barriers to domestic violence screening were identified as a lack of time, resources and confidence in undertaking the screening and referral of women when domestic violence was detected.

Conclusions

The findings reported in this paper confirm that further insights into the domestic violence screening practices of community based health care providers is required. Findings also have the potential to inform interventions that can be implemented to increase domestic violence screening and promote appropriate referral practices.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0620-2) contains supplementary material, which is available to authorized users.

Treatment for cases of violence by Brazilian emergency services focusing on family relationships and life cycles

This article analyzes data regarding cases of domestic violence treated by the emergency services through the following: the sociodemographic characteristics of the people who were treated; the events themselves; the evolution of care (from childhood to old age by gender); and the factors that differentiate cases of domestic violence compared to those committed by non-family members. Data from 24 Brazilian state capitals and the Federal District were analyzed, comprising 86 emergency services: a total of 4,893 individuals were surveyed. Of those people who were treated by emergency services, 26.6% suffered domestic violence: 40.0% were children/adolescents, 57.2% were adults and 2.8% were elderly. The adjusted model, which compared victims of violence committed by other family members with those who were not family members, showed that males were less likely to suffer from domestic violence; those that had fewer years of education were at increased risk; and that women were more likely to commit domestic violence compared to the category of "both genders". This study reinforces the fact that health sector professionals need to be able to deal with domestic violence by providing support, performing good practices, abiding by care protocols, taking care of injuries, and facilitating access to other services.

Supporting female survivors of intimate partner violence with disabilities: Recommendations for social workers in the emergency department

Intimate partner violence (IPV) is a pervasive problem with grave consequences. Women with disabilities are among the most vulnerable groups disproportionately affected, with higher IPV rates than either women without disabilities or men with disabilities. The emergency department (ED) in particular affords a gateway into health services for female survivors of IPV, placing ED social workers in a prime position to observe potential signs of IPV and connect survivors to further assistance. This article explores the critical role ED social workers can fill in addressing the needs of female survivors of IPV with disabilities. We begin by providing background on the characteristics of IPV among women with disabilities, followed by a discussion of the opportunities and challenges inherent to assessing and intervening with survivors. We conclude by outlining recommendations for working with female survivors of IPV with disabilities in EDs, using our previous research on the topic as a guide.

Enhanced Versus Basic Referral for Intimate Partner Violence in an Urban Emergency Department Setting

BACKGROUND

Victims of intimate partner violence (IPV) frequently do not disclose abuse to medical providers. Therefore, research has examined the most effective screening and referral methods to help identify victims of abuse and connect them to needed resources.

OBJECTIVES

To determine the efficacy of referrals intended to connect IPV victims with behavioral health resources, while taking into consideration demographic and mental health variables.

METHODS

We examined a convenience sample of medically stable individuals in an emergency department setting. Participants were given the Mini-International Neuropsychiatric Interview and Partner Violence Screen measures to assess mental health and IPV victimization. Individuals that screened positive were randomized to a basic or enhanced referral and given a follow-up interview to determine referral success. Referrals were considered successful if an individual scheduled an appointment with provided behavioral health resources within the follow-up interval.

RESULTS

Two-hundred and one individuals were enrolled. Forty-one (20.4%) participants screened positive for IPV victimization. Male and female participants in the enhanced referral group were more likely to have a successful referral than those in the basic referral group, with a large effect size such that 72.7% of participants in the enhanced referral and 15.7% of participants in the basic referral group contacted referral resources. Both referral type and marital status significantly predicted referral success.

CONCLUSION

Comorbidity with mental health concerns measured as high within those that screened positive for IPV victimization. The enhanced referral showed to be an effective way to encourage participants to contact behavioral health resources.

Understanding management and support for domestic violence and abuse within emergency departments: A systematic literature review from 2000-2015

AIMS AND OBJECTIVES

To identify, review and critically evaluate published empirical studies concerned with the prevalence, management and support for survivors of domestic violence and abuse who present at emergency department.

BACKGROUND

Domestic violence and abuse is a global phenomenon with a wealth of studies that explore the different aspects of the issue including the economic, social and health effects on survivors and on society as a whole. Emergency department is widely recognised as one healthcare facility where domestic violence and abuse survivors will often disclose domestic violence and abuse. In the UK, National Institute of Clinical Excellence produced guidelines in 2014 requiring all sectors of health care and those they work alongside to recognise support and manage survivors of domestic violence and abuse. Whilst there is an increasing body of research on domestic violence and abuse, limited synthesised work has been conducted in the context of domestic violence and abuse within emergency department.

DESIGN

This review encompasses empirical studies conducted in emergency department for screening interventions, management and support for domestic violence and abuse patients including prevalence. This review included studies that included emergency department staff, emergency department service users and domestic violence and abuse survivors.

METHODS

A systematic approach across five electronic bibliographic databases found 35 studies meeting the inclusion criteria published between 2000-2015.

RESULTS

From the 35 studies, four descriptive overarching themes were identified (i) prevalence of domestic violence and abuse in emergency department, (ii) use of domestic violence and abuse screening tools and emergency department interventions, (iii) current obstacles for staff working in emergency department and (iv) emergency department users and survivor perspectives.

CONCLUSIONS

Having knowledgeable and supportive emergency department staff can have a positive benefit for the longer-term health of the domestic violence and abuse survivor who seeks help. The physical characteristics of domestic violence and abuse are often easier to identify and manage, but emotional and psychological aspects of domestic violence and abuse are often more complex and difficult for staff to identify. This therefore raises questions as to what approaches can be used, within these busy settings, when often survivors do not want to disclose.

RELEVANCE TO CLINICAL PRACTICE

Domestic violence and abuse has been shown to have a direct impact on the health and well-being of survivors who will often access emergency department services with direct injuries and associated medical conditions. This article is relevant to those working in the emergency department in raising awareness in a number of areas of practice for example the prevalence of male intimate partner violence survivors. Furthermore, patients do not always disclose domestic violence and abuse even in cases where there is clear sustained injury thus requiring staff to be vigilant to repeat attendees and patient history. This requires a well-maintained and effective reporting system for instances of suspected and disclosed domestic violence and abuse in order that staff can provide the appropriate care and support. Emergency department staff often deal with complex cases, this includes different aspects of domestic violence and abuse including physical, emotional and psychological abuse. Continual support and guidance, including educational interventions, would assist emergency department clinical staff to manage and discuss instances of domestic violence and abuse in their workplace and their interactions with domestic violence and abuse patients. Whilst training for emergency department staff is welcomed, there also needs to be a greater awareness of the potential complexity of domestic violence and abuse presentations beyond physical injury in order for staff to remain observant throughout consultations. It is also suggested that clear domestic violence and abuse assessment and referral mechanisms should be embedded into clinical practice, including emergency department, as described in the UK National Institute of Clinical Excellence guidelines (2014). Overall improvements in reporting mechanisms in emergency department for the identification, management and support for domestic violence and abuse survivors would add to the collective and growing body of evidence surrounding domestic violence and abuse and their presentations within healthcare settings. Such measures would enable those working in emergency department to support disclosure of domestic violence and abuse more effectively.

Primary Care Providers with More Experience and Stronger Self-Efficacy Beliefs Regarding Women Veterans Screen More Frequently for Interpersonal Violence

BACKGROUND

Military sexual trauma (MST) and/or intimate partner violence (IPV) are common experiences in the growing group of women veterans using the Veterans Health Administration health care system. And even though MST screening is closely monitored at the facility level, little is known about individual primary care provider (PCP) behavior with regard to screening women for MST and IPV.

OBJECTIVES

To understand how PCP experiences and beliefs regarding women's health care influence PCP-reported screening for MST and IPV.

RESEARCH DESIGN AND PARTICIPANTS

We administered a cross-sectional online survey from September 2014 through April 2015 (supplemented by a mailed survey between April and May 2015) to 281 PCPs in 12 Veterans Health Administration medical centers.

MEASURES AND ANALYSIS

Surveys measured PCP-reported screening frequency for MST and IPV, experience with women veterans, self-efficacy, gender-sensitive beliefs, and perceived barriers to providing comprehensive care for women. We used multivariable ordered logistic regression analysis to identify correlates of screening, weighted for nonresponse and adjusted for clustering.

RESULTS

Ninety-four PCPs (34%) completed the survey. Being a designated women's health provider (p < .05) and stronger self-efficacy beliefs about screening women for MST (p < .001) were associated with reporting more frequent screening for MST. Being a designated women's health provider (p < .01), seeing women patients at least once per week (p < .001), and self-efficacy beliefs about screening women for IPV (p < .001) were associated with reporting more frequent screening for IPV.

CONCLUSIONS

Veterans Health Administration initiatives to enhance PCP opportunities to screen women veterans for trauma and to strengthen self-efficacy beliefs about comprehensive women's health care may increase screening of women veterans for MST and IPV.

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.

CE: Original Research: Intimate Partner Violence: The Knowledge, Attitudes, Beliefs, and Behaviors of Rural Health Care Providers

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BACKGROUND

Intimate partner violence (IPV) continues to be a pervasive health and social problem in the United States with serious short- and long-term consequences. Women in rural areas face particular challenges. Health care providers can play an important role in the lives of women who experience IPV; yet among providers, lack of knowledge, negative attitudes and beliefs, and low rates of screening are common.

OBJECTIVE

Though a large body of research exists regarding health care providers' IPV-related knowledge, attitudes, beliefs, and behaviors, little is known specifically with regard to rural providers. Given the challenges faced by rural women and the potential influence of their providers, it's important to understand rural providers' IPV-related knowledge, attitudes, beliefs, and behaviors. We conducted a study to learn more.

METHODS

Health care providers working in a large rural health network were asked to complete electronic surveys that examined their IPV-related knowledge, attitudes, beliefs, and behaviors. Descriptive and correlational statistical analyses of the data were conducted.

RESULTS

A total of 93 health care providers returned completed surveys. In general the respondents demonstrated good overall knowledge, judicious attitudes, and beliefs congruent with the available evidence related to IPV. Of concern were their knowledge and practice gaps regarding the prevalence of IPV, the higher risk of injury faced by women who leave their abusers, the ability of women to make appropriate choices about their situations, and what actions to take when someone discloses abuse.

CONCLUSION

The results of this study were encouraging with regard to the IPV-related knowledge, attitudes, beliefs, and behaviors of rural health care providers. But the findings also indicated important knowledge and practice gaps. Preparing providers to deliver compassionate, effective care to women who experience IPV is essential for the health and well-being of women and their families.

Readiness of nursing students to screen women for domestic violence

BACKGROUND

Although domestic violence against women is common in Israel and elsewhere, and though medical staff in Israel have a universal obligation to screen women for domestic violence, actual screening rates remain low.

OBJECTIVES

To examine which variables affect nursing students' intention to screen women for domestic violence when providing treatment, and whether the Theory of Planned Behavior (TPB) developed by Ajzen (1991) predicts this intention.

DESIGN

This study is a quantitative cross sectional study.

SETTINGS

A large academic nursing school in central Israel.

PARTICIPANTS

A convenience sample of 200 nursing students who had completed at least one year of studies took part in the study.

METHODS

Students completed a questionnaire based on the TPB.

RESULTS

Nursing students showed high intention to screen women for domestic violence when providing treatment. Normative beliefs, subjective norms, behavioral beliefs, perceived control, and knowledge were found to affect students' intention to screen women for domestic violence. The opinion of the clinical instructor was most significant for students.

CONCLUSIONS

The theoretical model predicted 32% of students' intention to screen women for domestic violence, with normative beliefs being the most significant variable.

Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm-Related Injury

Firearm injury is a leading cause of injury-related morbidity and mortality in the United States. We sought to systematically identify and summarize existing literature on clinical firearm injury prevention screening and interventions. We conducted a systematic search of PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycInfo, and ClinicalTrials.gov for English-language original research (published 1992-2014) on clinical screening methods, patient-level firearm interventions, or patient/provider attitudes on the same. Unrelated studies were excluded through title, abstract, and full-text review, and the remaining articles underwent data abstraction and quality scoring. Of a total of 3,260 unique titles identified, 72 were included in the final review. Fifty-three articles examined clinician attitudes/practice patterns; prior training, experience, and expectations correlated with clinicians' regularity of firearm screening. Twelve articles assessed patient interventions, of which 6 were randomized controlled trials. Seven articles described patient attitudes; all were of low methodological quality. According to these articles, providers rarely screen or counsel their patients-even high-risk patients-about firearm safety. Health-care-based interventions may increase rates of safe storage of firearms for pediatric patients, suicidal patients, and other high-risk groups. Some studies show that training clinicians can increase rates of effective firearm safety screening and counseling. Patients and families are, for the most part, accepting of such screening and counseling. However, the current literature is, by and large, not high quality. Rigorous, large-scale, adequately funded studies are needed.

Integrating intimate partner violence assessment and intervention into healthcare in the United States: a systems approach

The Institute of Medicine, United States Preventive Services Task Force (USPSTF), and national healthcare organizations recommend screening and counseling for intimate partner violence (IPV) within the US healthcare setting. The Affordable Care Act includes screening and brief counseling for IPV as part of required free preventive services for women. Thus, IPV screening and counseling must be implemented safely and effectively throughout the healthcare delivery system. Health professional education is one strategy for increasing screening and counseling in healthcare settings, but studies on improving screening and counseling for other health conditions highlight the critical role of making changes within the healthcare delivery system to drive desired improvements in clinician screening practices and health outcomes. This article outlines a systems approach to the implementation of IPV screening and counseling, with a focus on integrated health and advocacy service delivery to support identification and interventions, use of electronic health record (EHR) tools, and cross-sector partnerships. Practice and policy recommendations include (1) ensuring staff and clinician training in effective, client-centered IPV assessment that connects patients to support and services regardless of disclosure; (2) supporting enhancement of EHRs to prompt appropriate clinical care for IPV and facilitate capturing more detailed and standardized IPV data; and (3) integrating IPV care into quality and meaningful use measures. Research directions include studies across various health settings and populations, development of quality measures and patient-centered outcomes, and tests of multilevel approaches to improve the uptake and consistent implementation of evidence-informed IPV screening and counseling guidelines.

Awareness and Attitudes Towards Violence and Abuse among Emergency Nurses

PURPOSE

This study identifies degree of awareness and legal knowledge about overall abuse and violence, and investigates attitudes towards domestic violence in emergency nurses.

METHODS

The data collection period was between August and December 2012 for 131 nurses who worked in the emergency center of five hospitals in South Korea. This study surveyed emergency nurses about the recognition of abuse and violence, the legal knowledge of abuse and violence, and the attitudes towards domestic violence.

RESULTS

This study showed that approximately 60.0% of participants experienced incidents of suspected abuse or violence, but the reporting rates were low. Of all the participants, 70.2% knew that they must report the discovery of abuse or violent incidents, but 45.0% did not know that if someone who had duty to report but did not report that he/she had a legal responsibility. Most emergency nurses agreed that "even if the domestic violence is severe it should not be suggested to victims that they run away, leaving children at home", and "perpetrators are patients who need treatment."

CONCLUSIONS

Appropriate awareness about abuse and violence, and systematic education are required for emergency nurses so that they can provide appropriate interventions.

Conditions and Patterns of Intimate Partner Violence among Taiwanese Women

PURPOSE

Intimate partner violence (IPV) is a serious public health issue among women. IPV victims usually seek help from hospitals, and emergency nurses are the frontline staff with whom the victims come into contact first. This study examined the conditions and patterns of IPV in southern Taiwan.

METHODS

From designated hospitals in Kaohsiung under the Department of Health Injury Assessment Clinic, data were collected on 497 women regarding their injury assessment for IPV reported to the Kaohsiung City Government.

RESULTS

Taiwanese survivors were older compared to immigrant survivors. Taiwanese survivors also had higher education levels compared to immigrant survivors. Taiwanese survivors had higher employment rate than immigrant survivors did. The time between IPV and medical help seeking was longer for divorced than married women.

CONCLUSIONS

These results can facilitate understanding of the conditions and patterns of IPV in Taiwan, increase the awareness of nurses, especially the emergency nurses for the prevention of IPV, and increase professional competency for the provision of appropriate healthcare services to survivors of IPV.

Barriers to referral for elevated blood pressure in the emergency department and differences between provider type

A multidisciplinary sample of emergency department providers across the United States (n=450) were surveyed to identify barriers to referral for elevated blood pressure (BP) in the emergency department and differences between provider type. Registered nurses reported less knowledge of stage I hypertension (P=.043) and prehypertension (P<.01); were less aware of definitions for hypertension (P<.001); reported more difficulty in caring for patients who are asymptomatic (P=.007); required financial compensation to refer (P=.048); and perceived that BP referrals are influenced by the medical director (P<.001). Medical doctors reported more skills to refer (P=.008) and time as a barrier (P=.038). Physician assistants were more likely to report patients are not aware of health benefits (P=.035), doubted their concern for their BP (P=.023), and felt emotionally uncomfortable when referring (P=.025). Despite these differences, there was no significant difference between provider type and referral rates.

An exploration of the perceptions of emergency department nursing staff towards the role of a domestic abuse nurse specialist: a qualitative study

There is a clear body of evidence which indicates that a substantial number of people who have experienced domestic violence and abuse attend the emergency department (ED). However, many individuals do not receive effective identification or support. The present study sought to explore the perceptions of ED staff about the perceived value and utilisation of a new domestic abuse nurse specialist role that has been created in one ED in the UK. A qualitative design was used and involved sixteen in-depth interviews with a range of practitioners. The findings highlight that staff highly valued the role of the nurse specialist as one which offered support both professionally and personally. However, the study has also drawn attention to the conundrum that surrounds identification and management of abuse and of enquiry more generally. The ED is ideally suited to identify at risk individuals but is not institutionally organised in a way that prioritises the social concerns of their patients and this nursing role is one way that this issue can be addressed. In light of recent UK and global policy directives further research is needed to explore the development and implementation of identification, management and support in the future.

Israeli Arab Muslim women's willingness to be screened for intimate partner violence: A survey

In the present study, we explored whether the research model based on the Theory of Reasoned Action predicts Israeli Arab Muslim women's willingness to be screened for intimate partner violence at healthcare facilities. Three hundred women completed a questionnaire. Most women (68.4%) expressed willingness to be screened, however, only 16% of them had been screened over the past year. Women's beliefs about screening for intimate partner violence and the support of significant others were found to predict this willingness. The study may constitute an initial foundation for determining national policy with the aim of detecting and eradicating the phenomenon among this unique population.

Emergency healthcare experiences of women living with intimate partner violence

AIM AND OBJECTIVES

To explore healthcare experiences of Australian women living with intimate partner violence (IPV) and consider how these influence their understanding of IPV and sense of self.

BACKGROUND

Despite international campaigns condemning violence against women, IPV remains a worldwide problem and recent Australian community attitudes demonstrate ongoing beliefs condemning women in abusive relationships. Women experiencing IPV are over-represented in healthcare-seeking populations; however, they are rarely identified as experiencing abuse and are often not provided care directed towards achieving ongoing safety. While women seek empathetic healthcare, disclosure of abuse often results in being judged negatively or blamed.

DESIGN

A grounded theory study drawing on Clarke's (Sage Publications, London, 2005) analytic approach of situational analysis.

METHODS

Semi-structured interviews conducted with seven women. Data was analysed using NVIVO 8 software within a Situational Analysis framework.

RESULTS

Four major categories were identified: Accessing healthcare: challenges and barriers; Care women need vs. care women receive; Discourses of IPV and constructions of self; and Acknowledging IPV: moving on and re-constructing self. Women faced significant challenges in accessing emergency healthcare and healthcare then often lacked empathy. Women created an understanding of self from a world dominated by an abusive partner and needed assistance re-labelling their experiences as IPV. Healthcare professionals who provided empathetic care were instrumental in assisting this process, enhancing women's abilities to explore options for limiting abuse and assisting them to enhance their self-efficacy and reconstruct a positive sense of self.

CONCLUSIONS

Healthcare is one of the few avenues women living with IPV have to receive emotional and physical support. Healthcare that ignores psychosocial issues further damages women's sense of self.

RELEVANCE TO CLINICAL PRACTICE

Women require timely information and empathetic support from healthcare professionals to assist them in understanding and labelling their experiences as IPV. This enhances women's ability to feel deserving of, and ideally achieve, a life without violence.

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.

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.

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.

Current evidence on perinatal home visiting and intimate partner violence

OBJECTIVE

To describe current evidence on home visiting interventions for pregnant or postpartum women with specific intimate partner violence assessment and content.

DATA SOURCES

Online bibliographic databases including PubMed, CINAHL Plus, and Web of Science and a hand search of bibliographies of relevant articles.

STUDY SELECTION

Original research and intervention studies were included that contained (a) a well-described prenatal and/or postpartum home visitation; (b) an assessment of perinatal intimate partner violence; and (c) quantitative data describing health outcomes for the women and their infants.

DATA EXTRACTION

The search yielded 128 articles, and 8 relevant articles met all of the inclusion criteria. Nonresearch, nonintervention, and international articles were excluded.

DATA SYNTHESIS

No perinatal home visiting interventions were designed to address intimate partner violence. Programs that screened for intimate partner violence found high rates, and the presence of intimate partner violence limited the ability of the intervention to improve maternal and child outcomes.

CONCLUSIONS

Perinatal home visitation programs likely improve pregnancy and infant outcomes. Home visiting interventions addressing intimate partner violence in nonperinatal population groups have been effective in minimizing intimate partner violence and improving outcomes. This suggests that perinatal home visiting programs adding specific intimate partner violence interventions may reduce intimate partner violence and improve maternal and infant health. Continued rigorous research is needed.

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.