Journal of Mental Health, 2013; 22(6): 536–543 © 2013 Informa UK, Ltd. ISSN: 0963-8237 print / ISSN 1360-0567 online DOI: 10.3109/09638237.2013.841871
J Ment Health Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/19/14 For personal use only.
A survey of mental health professionals’ knowledge, attitudes and preparedness to respond to domestic violence†
SARAH NYAME1, LOUISE M. HOWARD2, GENE FEDER3 & KYLEE TREVILLION4 1
Core Trainee in Psychiatry, South London and The Maudsley NHS Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, UK, 2Professor & Head of Section of Women’s Mental Health, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK, 3Professor of Primary Health Care, School of Social and Community Medicine, University of Bristol, Bristol, UK, and 4Researcher, Section of Women’s Mental Health, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK
Abstract Background: A high proportion of psychiatric service users experience domestic violence, yet most cases remain undetected by clinicians. Aims: This study aimed to assess mental health professionals’ knowledge, attitudes and preparedness to respond to domestic violence. Method: Information was collected on psychiatrists’ and psychiatric nurses’ knowledge, attitudes and preparedness towards the assessment of domestic violence, using an adapted Physician Readiness to Measure Intimate Partner Violence Survey. Results: One hundred and thirty-one professionals were surveyed. Only 20 (15%) professionals routinely asked all service users about domestic violence and just 36 (27%) provided information to service users following disclosure. Most professionals (60%) felt that they lacked adequate knowledge of support services, and 27% felt that their workplace did not have adequate referral resources for domestic violence. Nurses reported greater readiness to assess and manage domestic violence than psychiatrists ( p < 0.001), despite psychiatrists reporting greater overall knowledge ( p < 0.001). Conclusions: Mental health professionals need to have clear referral pathways for service users who experience domestic violence, and to receive training on enhancing their knowledge and competencies to address domestic violence.
Keywords: domestic violence, mental health services, knowledge, attitudes
Introduction Domestic violence is an international public health problem, associated with substantial physical and psychiatric morbidity (Coker et al., 2002; Trevillion et al., 2010). A recent † This work was conducted at Institute of Psychiatry, King’s College London, De Crespigny Park, London, UK. Correspondence: Louise M. Howard, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK. Tel: +20 7848 5061. Fax: +20 7277 1462. E-mail: [email protected]
J Ment Health Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/19/14 For personal use only.
Psychiatric staff domestic violence survey 537 systematic review found that, in comparison to people without mental disorders, women and men with mental disorders (across all diagnostic categories) report a high prevalence and increased likelihood of being a victim of domestic violence (Trevillion et al., 2012b). In addition, psychiatric service users are found to report a higher prevalence of domestic violence than other healthcare service users or the general population (Oram et al., 2013). Despite these findings, domestic violence remains largely undetected by mental health services worldwide, with between 10% and 30% of cases documented in case notes (Howard et al., 2010). Clinicians rarely ask service users about domestic violence (Howard et al., 2010; Rose et al., 2011) and, if service users do disclose domestic violence, clinicians frequently fail to address the abuse within treatment plans (Agar et al., 2002; Klap et al., 2007; Trevillion et al., 2012a). Internationally, health policies advocate for mental health professionals to address domestic violence (Department of Health, 2008; Family Violence Prevention Fund, 2010; Royal College of Psychiatrists, 2002; Warshaw et al., 2003), including the development of NICE/SCIE guidelines on the prevention of domestic violence in health and social care settings (National Institute for Health and Clinical Excellence, 2012). However, the successful implementation of these policies is dependent on clinicians’ knowledge, attitudes and preparedness to respond to domestic violence. Therefore, this study aimed to examine these factors among psychiatrists and psychiatric nurses, and to investigate whether there were differences among the two professional groups.
Methods Design A cross-sectional survey of psychiatrists and psychiatric nurses working within a south London Mental Health NHS Trust between May 2009 and July 2011.
Participants Study information and materials were delivered by hand to psychiatric nurses (n = 71) working within five community mental health teams, and e-mailed to psychiatrists (n = 280) employed by the Mental Health Trust, as psychiatrists were based at multiple sites. Reminder e-mails were sent 2 weeks after initial contact. After complete description of the study to the participants, written informed consent was obtained. Fifty (70%) of the 71 nurses and 81 (29%) of the 280 psychiatrists who were invited to participate in the study completed the survey, giving an overall response rate of 37%.
Materials The Physician Readiness to Measure Intimate Partner Violence Survey (PREMIS) (Short et al., 2006) was used to measure health professionals’ knowledge of and attitudes towards domestic violence. The PREMIS scale was developed in the USA and evaluated with a sample of 166 general physicians and 67 primary care physicians (Short et al., 2006). For the purposes of this study, the anglicised version of the PREMIS scale was adapted with minor modifications made to increase its relevance for UK community mental health care (e.g. amending phrasing from “physical injuries” to “mental health symptoms” and omitting an item about photographing physical injuries). The PREMIS comprises five sections:
538
S. Nyame et al.
(1) Respondent Profile; (2) Background; (3) Domestic Violence Knowledge; (4) Opinions and (5) Practice Issues, and is separated into 10 sub-scales:
J Ment Health Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/19/14 For personal use only.
(1)
Background: Perceived Preparedness, comprising 10 items rated on a Likert scale from 1 = “not prepared” to 7 = “quite well prepared”. Questions include: (a) asking appropriate questions about domestic violence, (b) responding appropriately to disclosures and (c) helping service users to create a safety plan. (2) Background: Perceived Knowledge, comprising 14 items rated on a Likert scale from 1 = “nothing” to 7 = “very much”. Questions include: (a) signs/symptoms of domestic violence, (b) clinicians’ role in detecting domestic violence and (c) knowledge of referral sources for service users. (3) Domestic Violence Knowledge: Actual Knowledge, contains 37 true/false multiple choice items assessing clinicians’ knowledge about domestic violence. Questions include: (a) signs that may indicate a service user is experiencing domestic violence, (b) the most appropriate ways to ask about domestic violence and (c) stages of change in service users’ acknowledgement and response to abuse. (4) Opinions: Staff Preparation, comprising three items rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. Questions include clinicians’ skills in discussing domestic violence with women, men and people from different cultural or ethnic backgrounds. (5) Opinions: Legal Requirements, comprising one item rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. The single item asks about clinicians’ awareness of legal requirements in reporting cases of domestic violence. (6) Opinions: Workplace Issues, comprising six items rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. Questions include how much clinicians’ workplace allows them adequate time to respond to service users experiencing domestic violence. (7) Opinions: Self-Efficacy, comprising three items rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. Questions include clinicians’ comfort in discussing domestic violence with service users. (8) Opinions: Alcohol and Drugs, comprising three items rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. Questions include clinicians’ knowledge about the relationship between substance misuse and domestic violence. (9) Opinions: Victim Understanding, comprising six items rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. Questions include clinicians’ opinion that service users experiencing domestic violence could leave the violent relationship if they wanted. (10) Practice Issues: Practice Issues, comprising 11 items that are scored on a scale ranging from 1 to 115. Questions include: (a) clinicians’ identification of cases of domestic violence in the previous 6 months, (b) clinicians’ experience of routine enquiry, (c) clinicians’ experience of responding to disclosures and (d) clinicians’ familiarity with Trust policies on domestic violence. Analysis Descriptive statistics and Pearson chi-square tests were used to compare demographic characteristics of nurses and psychiatrists. Median and inter-quartile range (IQR) percentiles (25% and 75%) were calculated; non-parametric Mann–Whitney U-tests were used to compare psychiatrists’ and nurses’ responses on the PREMIS (Short et al., 2006). Analyses
Psychiatric staff domestic violence survey 539 did not correct for multiple testing, but as multiple tests were undertaken significance levels have been interpreted with caution (Perneger, 1998). IBM SPSS statistics version 19 was used for all analyses (IBM Corp., 2010). Ethical approval
J Ment Health Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/19/14 For personal use only.
The study received ethical approval from Joint South London and Maudsley and The Institute of Psychiatry NHS Research Ethics Committee (reference 09/H0807/7). Results Response rate Of the 131 mental health professionals who completed the survey, 23 (18%) failed to complete one or more of the 10 sub-scales of the PREMIS; therefore, the total number of professionals completing each of the 10 sub-scales varies. Characteristics of study sample The mean age of professionals was 37.5 years (SD 8.19); 69 (53%) were male and 61 (47%) were white. The average number of years qualified was 10.78 years (SD 7.38) and the average number of years worked in a psychiatric setting was 6.62 (SD 5.97). Of the 71 (54%) professionals who reported receiving any training about domestic violence, 52 (73%) had received between 1 and 5 h training and 19 (27%) had received six or more hours training. The types of training comprised video/web-based programmes (n = 22), lectures or presentations (n = 45) and skill-based training sessions (n = 26). PREMIS scores In relation to rates of identification of domestic violence, 15% (20/131) of professionals routinely asked all new service users about their experiences of domestic violence and
J Ment Health Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/19/14 For personal use only.
A survey of mental health professionals’ knowledge, attitudes and preparedness to respond to domestic violence†
SARAH NYAME1, LOUISE M. HOWARD2, GENE FEDER3 & KYLEE TREVILLION4 1
Core Trainee in Psychiatry, South London and The Maudsley NHS Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, UK, 2Professor & Head of Section of Women’s Mental Health, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK, 3Professor of Primary Health Care, School of Social and Community Medicine, University of Bristol, Bristol, UK, and 4Researcher, Section of Women’s Mental Health, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, London, UK
Abstract Background: A high proportion of psychiatric service users experience domestic violence, yet most cases remain undetected by clinicians. Aims: This study aimed to assess mental health professionals’ knowledge, attitudes and preparedness to respond to domestic violence. Method: Information was collected on psychiatrists’ and psychiatric nurses’ knowledge, attitudes and preparedness towards the assessment of domestic violence, using an adapted Physician Readiness to Measure Intimate Partner Violence Survey. Results: One hundred and thirty-one professionals were surveyed. Only 20 (15%) professionals routinely asked all service users about domestic violence and just 36 (27%) provided information to service users following disclosure. Most professionals (60%) felt that they lacked adequate knowledge of support services, and 27% felt that their workplace did not have adequate referral resources for domestic violence. Nurses reported greater readiness to assess and manage domestic violence than psychiatrists ( p < 0.001), despite psychiatrists reporting greater overall knowledge ( p < 0.001). Conclusions: Mental health professionals need to have clear referral pathways for service users who experience domestic violence, and to receive training on enhancing their knowledge and competencies to address domestic violence.
Keywords: domestic violence, mental health services, knowledge, attitudes
Introduction Domestic violence is an international public health problem, associated with substantial physical and psychiatric morbidity (Coker et al., 2002; Trevillion et al., 2010). A recent † This work was conducted at Institute of Psychiatry, King’s College London, De Crespigny Park, London, UK. Correspondence: Louise M. Howard, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK. Tel: +20 7848 5061. Fax: +20 7277 1462. E-mail: [email protected]
J Ment Health Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/19/14 For personal use only.
Psychiatric staff domestic violence survey 537 systematic review found that, in comparison to people without mental disorders, women and men with mental disorders (across all diagnostic categories) report a high prevalence and increased likelihood of being a victim of domestic violence (Trevillion et al., 2012b). In addition, psychiatric service users are found to report a higher prevalence of domestic violence than other healthcare service users or the general population (Oram et al., 2013). Despite these findings, domestic violence remains largely undetected by mental health services worldwide, with between 10% and 30% of cases documented in case notes (Howard et al., 2010). Clinicians rarely ask service users about domestic violence (Howard et al., 2010; Rose et al., 2011) and, if service users do disclose domestic violence, clinicians frequently fail to address the abuse within treatment plans (Agar et al., 2002; Klap et al., 2007; Trevillion et al., 2012a). Internationally, health policies advocate for mental health professionals to address domestic violence (Department of Health, 2008; Family Violence Prevention Fund, 2010; Royal College of Psychiatrists, 2002; Warshaw et al., 2003), including the development of NICE/SCIE guidelines on the prevention of domestic violence in health and social care settings (National Institute for Health and Clinical Excellence, 2012). However, the successful implementation of these policies is dependent on clinicians’ knowledge, attitudes and preparedness to respond to domestic violence. Therefore, this study aimed to examine these factors among psychiatrists and psychiatric nurses, and to investigate whether there were differences among the two professional groups.
Methods Design A cross-sectional survey of psychiatrists and psychiatric nurses working within a south London Mental Health NHS Trust between May 2009 and July 2011.
Participants Study information and materials were delivered by hand to psychiatric nurses (n = 71) working within five community mental health teams, and e-mailed to psychiatrists (n = 280) employed by the Mental Health Trust, as psychiatrists were based at multiple sites. Reminder e-mails were sent 2 weeks after initial contact. After complete description of the study to the participants, written informed consent was obtained. Fifty (70%) of the 71 nurses and 81 (29%) of the 280 psychiatrists who were invited to participate in the study completed the survey, giving an overall response rate of 37%.
Materials The Physician Readiness to Measure Intimate Partner Violence Survey (PREMIS) (Short et al., 2006) was used to measure health professionals’ knowledge of and attitudes towards domestic violence. The PREMIS scale was developed in the USA and evaluated with a sample of 166 general physicians and 67 primary care physicians (Short et al., 2006). For the purposes of this study, the anglicised version of the PREMIS scale was adapted with minor modifications made to increase its relevance for UK community mental health care (e.g. amending phrasing from “physical injuries” to “mental health symptoms” and omitting an item about photographing physical injuries). The PREMIS comprises five sections:
538
S. Nyame et al.
(1) Respondent Profile; (2) Background; (3) Domestic Violence Knowledge; (4) Opinions and (5) Practice Issues, and is separated into 10 sub-scales:
J Ment Health Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/19/14 For personal use only.
(1)
Background: Perceived Preparedness, comprising 10 items rated on a Likert scale from 1 = “not prepared” to 7 = “quite well prepared”. Questions include: (a) asking appropriate questions about domestic violence, (b) responding appropriately to disclosures and (c) helping service users to create a safety plan. (2) Background: Perceived Knowledge, comprising 14 items rated on a Likert scale from 1 = “nothing” to 7 = “very much”. Questions include: (a) signs/symptoms of domestic violence, (b) clinicians’ role in detecting domestic violence and (c) knowledge of referral sources for service users. (3) Domestic Violence Knowledge: Actual Knowledge, contains 37 true/false multiple choice items assessing clinicians’ knowledge about domestic violence. Questions include: (a) signs that may indicate a service user is experiencing domestic violence, (b) the most appropriate ways to ask about domestic violence and (c) stages of change in service users’ acknowledgement and response to abuse. (4) Opinions: Staff Preparation, comprising three items rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. Questions include clinicians’ skills in discussing domestic violence with women, men and people from different cultural or ethnic backgrounds. (5) Opinions: Legal Requirements, comprising one item rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. The single item asks about clinicians’ awareness of legal requirements in reporting cases of domestic violence. (6) Opinions: Workplace Issues, comprising six items rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. Questions include how much clinicians’ workplace allows them adequate time to respond to service users experiencing domestic violence. (7) Opinions: Self-Efficacy, comprising three items rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. Questions include clinicians’ comfort in discussing domestic violence with service users. (8) Opinions: Alcohol and Drugs, comprising three items rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. Questions include clinicians’ knowledge about the relationship between substance misuse and domestic violence. (9) Opinions: Victim Understanding, comprising six items rated on seven-point Likert scale from 1 = “strongly disagree” to 7 = “strongly agree”. Questions include clinicians’ opinion that service users experiencing domestic violence could leave the violent relationship if they wanted. (10) Practice Issues: Practice Issues, comprising 11 items that are scored on a scale ranging from 1 to 115. Questions include: (a) clinicians’ identification of cases of domestic violence in the previous 6 months, (b) clinicians’ experience of routine enquiry, (c) clinicians’ experience of responding to disclosures and (d) clinicians’ familiarity with Trust policies on domestic violence. Analysis Descriptive statistics and Pearson chi-square tests were used to compare demographic characteristics of nurses and psychiatrists. Median and inter-quartile range (IQR) percentiles (25% and 75%) were calculated; non-parametric Mann–Whitney U-tests were used to compare psychiatrists’ and nurses’ responses on the PREMIS (Short et al., 2006). Analyses
Psychiatric staff domestic violence survey 539 did not correct for multiple testing, but as multiple tests were undertaken significance levels have been interpreted with caution (Perneger, 1998). IBM SPSS statistics version 19 was used for all analyses (IBM Corp., 2010). Ethical approval
J Ment Health Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/19/14 For personal use only.
The study received ethical approval from Joint South London and Maudsley and The Institute of Psychiatry NHS Research Ethics Committee (reference 09/H0807/7). Results Response rate Of the 131 mental health professionals who completed the survey, 23 (18%) failed to complete one or more of the 10 sub-scales of the PREMIS; therefore, the total number of professionals completing each of the 10 sub-scales varies. Characteristics of study sample The mean age of professionals was 37.5 years (SD 8.19); 69 (53%) were male and 61 (47%) were white. The average number of years qualified was 10.78 years (SD 7.38) and the average number of years worked in a psychiatric setting was 6.62 (SD 5.97). Of the 71 (54%) professionals who reported receiving any training about domestic violence, 52 (73%) had received between 1 and 5 h training and 19 (27%) had received six or more hours training. The types of training comprised video/web-based programmes (n = 22), lectures or presentations (n = 45) and skill-based training sessions (n = 26). PREMIS scores In relation to rates of identification of domestic violence, 15% (20/131) of professionals routinely asked all new service users about their experiences of domestic violence and
