Hindawi Publishing Corporation Nursing Research and Practice Volume 2014, Article ID 759682, 8 pages http://dx.doi.org/10.1155/2014/759682

Research Article Assessing and Enhancing Health Care Providers’ Response to Domestic Violence Tuija Leppäkoski,1,2 Aune Flinck,1,2,3 and Eija Paavilainen1,2 1

School of Health Sciences, (Nursing Science), University of Tampere, Finland The District Hospital of Southern Ostrobothnia, Finland 3 National Institute for Health and Welfare, Finland 2

Correspondence should be addressed to Tuija Lepp¨akoski; [email protected] Received 11 December 2013; Accepted 13 March 2014; Published 22 April 2014 Academic Editor: Maria Helena Palucci Marziale Copyright © 2014 Tuija Lepp¨akoski et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This study aimed to examine possible changes from 2008 to 2012 in the skills of health care staff in identifying and intervening in domestic violence (DV). A longitudinal descriptive study design with volunteer samples (baseline; 𝑛 = 68, follow-up; 𝑛 = 100) was used to acquire information regarding the present state and needs of the staff in practices related to DV. The results of the baseline survey were used as a basis for planning two interventions: staff training and drafting practical guidelines. Information was collected by questionnaires from nurses, physicians, and social workers and supplemented by responses from the interviews. The data were analysed using both quantitative and qualitative methods. A chi-square test was used to test the statistical significance of the data sets. In addition, participants’ quotes are used to describe specific phenomena or issues. The comparison showed that overall a small positive change had taken place between the study periods. However, the participants were aware of their own shortcomings in identifying and intervening in DV. Changes happen slowly, and administrative support is needed to sustain such changes. Therefore, this paper offers recommendations to improve health care providers’ response to DV. Moreover, there is a great need for evaluating the training programme used.

1. Introduction Domestic violence (DV) is globally recognised as a major but underreported public health and social problem among heterosexual and same-sex couples [1, 2]. It results in injuries and other negative short- and long-term effects on the health of all the family members [3, 4]. Children and young people in families where DV has taken place are at risk of abuse and associated detrimental health outcomes [5–7]. Nurses and physicians play a vital role in addressing these problems. Early identification of DV can reduce its consequences and may help to prevent further violence. Unfortunately, health care professionals do not engage with these issues and they do not routinely screen for health risks such as DV or child abuse (CA) and neglect. In a Swedish study by Sundborg et al., only half of the nurses working in primary health care always asked women about DV and did so mostly when the patient was physically injured [8]. Health

professionals do not ask about or identify DV, even in cases where it is obvious [9–12]. According to a Finnish study by Husso et al., it seems that there is a tendency for health care staff to focus on fixing the injuries and consequences of DV while dismissing the violence that is the cause of symptoms and injuries [13]. Consequently, asking about violence is undesirable. On the other hand, patients generally find being asked about violence acceptable [7, 8, 11, 12]. Various studies have shown that nurses and doctors ascribe their reluctance to or discomfort with inquiring about DV to factors such as lack of time, behaviours attributed to women living with abuse (e.g., denial), lack of training and effective interventions, the complexities of providing whole family care, and partner presence [10, 11, 14–16]. A lack of knowledge of the causes and effects of DV often leads to feelings of inadequacy and frustration [13]. For example, trauma caused by DV is not always recognized by health care professionals. The victim’s trauma may affect the victim’s

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Nursing Research and Practice

ability to discuss the problem. Furthermore, nurses who work in a fast-paced environment may be used to seeing immediate results when they intervene with patients, whereas DV is a complex issue and not the one that can be solved in one visit [17]. Overall, awareness of one’s own attitudes, myths, and stereotypes (e.g., men are always offenders; violence is only physical; violence only concerns marginal groups) plays an important role in one’s readiness to deal with intimate partner violence (IPV) [8, 11, 17, 18]. The most frequently reported facilitators to ask about DV, alongside training community resources and professional tools, are protocols and police [7, 15]. Multifaceted and intersectoral approaches that address the individual, interpersonal, workplace, and systemic issues faced by nurses and physicians when inquiring about DV are required [15]. It has also been mentioned that strong leadership and prioritization of the issue have facilitated the development of the care process to detect and manage DV presentations [19]. Training and organizational change within healthcare systems can increase the identification and knowledge of DV, as well as health professionals’ readiness to ask victims about it [16, 19– 21]. However, so far, the effect of systematic screening for DV has remained somewhat unclear. Randomized controlled trials have shown that there is insufficient evidence to recommend routine screening for DV [22, 23]. The Finnish national publication “Recommendations for the prevention of interpersonal and domestic violence” (2008) stresses local and regional work and the importance of strategic planning, in addition to training [24]. A “National clinical nursing guideline for identifying and intervening in child maltreatment within the family in Finland” has also been drawn up based on practical work [25]. During this research project, the staff participating in the study was trained to recognise and address DV. Finally, the follow-up survey was conducted. The study searched for answers to the following questions. (1) How did the staff ’s ability to detect violence change during the research period of 2008–2013? (2) How did the staff ’s readiness to intervene in violence change during this time period?

The results of the survey were used as a basis for planning follow-up interventions: staff training and drafting practical guidelines. The questionnaire asked for the following information: the participants’ demographic data (gender, age, occupation, length of time in current occupation, and employment status), the prevalence and/or treatment of DV (e.g., “Can you estimate how often you meet or treat women or men who are victims of DV?” “Can you estimate how often you meet or treat women or men at work who are perpetrators of DV?” “At work, have you met or treated men who have experienced DV?”), the identification of and intervention in DV (e.g., “Do you believe you would identify a patient who is experiencing or has experienced DV?” “Do you believe you would identify a patient who is or who has been violent in their relationship?” “Is there an operations model in your work unit for intervening in DV?” “Do you collaborate with different support authorities when meeting the victim and the perpetrator?” Furthermore, the participants were asked to identify issues that may be a barrier to the recognition of DV and the actions of the health care personnel with a patient who has experienced violence or who has used violence.), the quality of the DV training received (e.g., “Has DV been discussed in your professional basic training?” “Have you participated in training organized by your employer?”), and one open-ended question comprising the DV work in the participant’s unit within the last two years (see Tables 1 and 2). In addition, qualitative data were gathered by interviewing health care professionals, during two group interviews, police, a social worker, and crisis workers about their experiences regarding cooperation in practice, including barriers and possibilities, shared responsibilities, and motivation to react to DV. The outcome evaluation data were collected in May 2012 with the same instrument as at the beginning of the project, in 2008. In addition, qualitative data were gathered by interviewing health care professionals (𝑛 = 6).

2. Participants and Methods

2.3. Interventions. The educational intervention was planned on the basis of the results of the initial survey [26] and research evidence from earlier studies (e.g., [9, 27, 28]) and was completed over a four-month period, from January 2008 to May 2008. The training was carried out over three training sessions. The sessions were repeated twice with the same content so that as many shift workers as possible could participate. The themes of the sessions were orientation (2 × 4 h), DV from an ethical and legal point of view and raising the problem in discussion (2 × 7 h), and local, regional, and national service networks in DV and solving problems. At the same time of the training sessions, a development process was started to create practical guidelines to be used as a tool for determining how to identify, respond, and intervene in the following situations: where there are more reasons to suspect DV, when DV is brought up by the patient, and when the symptoms and signs of the happened DV are noticeable. The idea was that the staff can immediately

2.1. Participants. The study began in 2008 with an initial survey of health care professionals in a large central hospital and in one local primary health care organization. The participating units were an emergency clinic and a doctors’ office in primary health care, an emergency clinic, an orthopaedic ward, and an acute psychiatry emergency unit in specialized health care. The staff profile of the study included physicians, nurses, and social workers. The idea was to enhance not only the knowledge, skills, or attitudes of individuals with respect to domestic violence but also interdisciplinary understanding and collaboration. 2.2. Study Design. This is a longitudinal study with a pre/posttest design. An initial survey was used to gain information of the present state and needs of the health care workers in primary and specialized health care with respect to DV.

Nursing Research and Practice

3 Table 1: Demographic data on participants.

Variable

Category

Initial survey 2008 (𝑛 = 68)

Follow-up survey 2012 (𝑛 = 100)

Gender

Male Female

15% 85%

14% 86%

Age (years)

Mean Median Range Standard deviation

42 45 (24–59) 10

41 43 (21–60) 12

Age group

≤29 30–39 40–49 50–59 ≥60

16% 23% 37% 24%

29% 14% 23% 32% 2%

Nurse Practical nurse Social worker Doctor Others

65% 25% 4% 6%

62% 28%

Mean Median Range Standard deviation

16 15 (0.5–37) 11

16 15 (0.3–40) 12

Permanent Temporary

71% 29%

76% 24%

Occupational status

Occupation time

Employment

apply the knowledge gained from the course into practice. A multidisciplinary team that comprised staff nurses, social workers, and physicians worked together with the researchers. Over the years 2011–2013, the devised guidelines [29] have been integrated and implemented in practice to help and encourage the health care staff to identify and intervene in DV. So far, a total of 14 information events have been held with 237 participants. In addition, a project worker has visited different units to talk about the issue. 2.4. Data Analysis. Frequency tables were used to examine all variables. Pearson’s chi-square test was used to test the changes in opinions between 2008 and 2012. Statistical significance was set at the level of 5% (𝑃 < 0.05). Because of the low number of answers to some questions, the data were combined into two groups. Direct quotes were used to describe the participants’ experiences and attitudes regarding the DV interventions that they had made. 2.5. Ethical Issues. Ethical approval (R12857H) for the project was granted by the Ethical Committee of Pirkanmaa Hospital District. No personal data of the staff were recorded. Quotes have been used in such a way that the informants are not recognizable.

2% 8%

3. Results 3.1. The Participants’ Demographic Data. The 2008 sample consists of 68 respondents and the response rate was 35%. The 2012 sample consists of 100 respondents and the response rate was 50%. There have been no significant differences in the respondent demographics (gender distribution, occupational status, length of time in current occupation, and full- or parttime employment) during the study years of 2008 and 2012. In both years, less than one-sixth of the respondents were men. Ninety percent of the respondents are nurses with varying levels of education and 10% are other personnel, such as social workers and doctors (Table 1). In contrast, the age of the personnel differs to some extent between the study years. In the 2008 data, the median age of the respondents is 45 years. In the 2012 data, the median age of the respondents is 43 years. However, the difference is not significant. In the 2008 data, respondents between 40 and 49 years formed 37% of all respondents, whereas, in the data from 2012, they form less than a quarter of all the respondents (Table 1). 3.2. Identification of a Victim of DV and a Patient Who Has Used Violence. The results of the initial survey (26) revealed that the staff had different kinds of barriers to identification of and intervention in DV, for example, a lack of mentoring and role modelling and a perceived lack of privacy and

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Nursing Research and Practice Table 2: Changes of opinions of the respondent groups to manage DV. Initial survey 2008 Follow-up survey 2012 Significance test 𝜒2 df 𝑃 value

Questions Can you estimate how often at work you meet or treat women or men who are victims of DV?

At least once a month Once a month or less

(22) 33% (45) 67%

(28) 29% (70) 71%

0.558

Can you estimate how often at work you meet or treat women or men who are perpetrators of DV?

At least once a month Once a month or less

(15) 23% (51) 77%

(25) 26% (73) 74%

0.684

No Yes

(40) 60% (27) 40%

(39) 39% (61) 61%

Do you believe you would identify a patient who is experiencing or has experienced DV?

Always or often Once or never

(29) 43% (38) 57%

(54) 55% (45) 45%

Do you believe you would identify a patient who is or who has been violent in their relationship?

Always or often Once or never

(13) 19% (54) 81%

(34) 34% (66) 66%

Do you think that identification of DV is difficult or easy?

Difficult Easy

(60) 88% (8) 12%

(82) 86% (13) 14%

0.747

Do you think that intervention in DV is difficult or easy?

Difficult Easy

(63) 97% (2) 3%

(86) 90% (10) 10%

0.475

Is there an operations model in your work unit for intervening in DV?

No Yes Cannot say

(34) 51% (4) 6% (29) 43%

(12) 13% (34) 35% (50) 52%

Do you collaborate with different supporting authorities when meeting the victim and the perpetrator?

No Yes

(32) 51% (31) 49%

(47) 49% (49) 51%

Has DV been discussed in your professional basic training?

No Yes

(49) 77% (15) 23%

(53) 55% (43) 45%

7.577

Has your current employer organized supplementary training related to DV?

No Yes Cannot say

(37) 56% (10) 15% (19) 29%

(29) 30% (50) 52% (18) 18%

22.585 2

Assessing and enhancing health care providers' response to domestic violence.

This study aimed to examine possible changes from 2008 to 2012 in the skills of health care staff in identifying and intervening in domestic violence ...
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