Original Article
Disclosure of Intimate Partner Violence in Current Marital/Partner Relationships Among Female University Students and Among Women at an Emergency Department Erla Kolbrún Svavarsdóttir, PhD, RN1,2 and Brynja Orlygsdottir, PhD, RN1
ABSTRACT Detecting intimate partner violence (IPV) might empower women to start working on the impact that the abuse experience has had on their lives. Little, however, is known about disclosure of abuse in community and in clinical settings. The purpose of this study was to explore whether there was a difference in the disclosure of abuse experience among women who were attending the emergency department (ED) at Landspitali University Hospital or were located at a university site, that is, at the University Square at the University of Iceland. A crosssectional research design was used. Data were collected at the same time in 2009 over a period of 9 months from N = 306 women ranging in age from 18 to 67 years (n = 166 at the University Square and n = 140 at the ED). A significantly higher proportion of the women at the ED reported that they were victims of IPV in their current marital/partner relationship and scored higher on the Women Abuse Screening Tool total scale than the women at the university site. This gave a clear indication that the women at the ED experienced significantly more frequent and more severe IPV in their current marital/partner relationship compared with the women at the university site. Identifying IPV in primary and clinical settings might, therefore, function as a protective factor if these women are offered appropriate first response and interventions. KEY WORDS: abuse disclosure; women who are victims of IPV
ntimate partner violence (IPV) is a sensitive issue, both for the women who are victims of the abuse as well as for the society in which they live. Women who experience abuse in their intimate relationships have been found to seek healthcare services from emergency departments
I
Author Affiliations: 1Faculty of Nursing, University of Iceland; and 2 Landspitali University Hospital. The study received funds from the LUH Scientific Fund, from the Scientific Fund at the University of Iceland, and from Icelandic Nurses Association science fund. The authors declare no conflict of interest. Correspondence: Erla Kolbrun Svavarsdottir, PhD, RN, Faculty of Nursing, University of Iceland, Eirberg, Eiriksgata 34, IS-101 Reykjavik, Iceland. E-mail: [email protected]. Received August 1, 2014; accepted for publication January 2, 2015. Copyright © 2015 International Association of Forensic Nurses DOI: 10.1097/JFN.0000000000000061
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(EDs) as well as from community healthcare settings more frequently than do women who are not experiencing violence in their intimate relationships. IPV is a major public health issue that has devastating short- and long-term impact on the health and well-being of women who are victims of abuse in their intimate relationships (Anderson & Bang, 2012; Chouliara, Karatzias, & Gullone, 2013; Golding, 1999; Hegadoren, Lasiuk, & Coupland, 2006; Pico-Alfonso et al., 2006; Seedat, Stein, & Carey, 2005; Sullivan & Holt, 2008; Svavarsdottir, Orlygsdottir, & Gudmundsdottir, 2014). Despite socioeconomic status, religion, or race, the prevalence of IPV toward women in current marital/ partner relationships has been reported as high as 29% (Coker, Smith, & Fadden, 2005; Hathaway et al., 2000; Nelson, Baldwin, & Taylor, 2012; Nerøien & Schei, 2008; Svavarsdottir, 2010; Svavarsdottir & Orlygsdottir, 2009a). Furthermore, the relationship between IPV and Volume 11 • Number 2 • April-June 2015
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Original Article
health consequences has been well established in both clinical- and population-based studies (Flemke, 2009; Gharaibeh & Oweis, 2009; Krause, Kaltman, Goodman, & Dutton, 2007; Leiner, Compton, Houry, & Kaslow, 2008; Leppäkoski, Åstedt-Kurki, & Paavilainen, 2010; Svavarsdottir & Orlygsdottir, 2009a, 2009b; Wilson, Vidal, Wilson, & Salyer, 2012; Zlotnick, Capezza, & Parker, 2011). Clearly, the impact of such traumatic events as physical, psychological, and sexual abuse in childhood and later in adulthood is directly related to women’s health issues (Al-Modallal, Abuidhail, Sowan, & Al-Rawashdeh, 2010; Amar & Alexy, 2005; Chouliara et al., 2013; Hepworth & McGowan, 2012; Paranjape, Sprauve-Holmes, Gaughan, & Kaslow, 2009; Pigeon et al., 2011; Sigurdardottir & Halldorsdottir, 2013; Svavarsdottir & Orlygsdottir, 2008). Pico-Alfonso and colleagues (2006) found that when compared to women who were not victims of IPV, women who were exposed to physical and psychological abuse, or to psychological abuse only, had a noticeably increased level of severe depression and anxiety symptoms; this included the possible development of posttraumatic stress disorder (PTSD) as well as suicidal thoughts and attempts. IPV is linked to: physical injuries; poor mental health, including depression, anxiety, PTSD, and suicidal intention; and a wide range of adverse negative physical health consequences. However, little is known as to whether disclosure of abuse and admitting to being a victim of IPV in a current marital/partner relationship to a nurse in clinical settings varies according to the site where the data collection takes place (e.g., community setting vs. ED). Research comparing the disclosure of IPV in a current intimate relationship among young female university students in the community and, at the same time, among women who were attending an ED at a national hospital could not be found. Furthermore, healthcare professionals such as nurses at EDs and in community settings need sufficient training (Engnes, Lidén, & Lundgren, 2013; Svavarsdottir & Orlygsdottir, 2009a) to be able to respond effectively to gender based violence and to be able to offer an appropriate first response when women reveal to them in clinical settings that they are victims of IPV in their current marital/partner relationship. The Women’s Response to Battering Model (Campbell & Soeken, 1999) was the conceptual framework underpinning the study. In this model, health is considered to be the outcome variable that is influenced by physical, emotional, and/or sexual abuse; by self-care; and by motivation and energy. The model focuses on both the direct and indirect effects of abuse on women’s health. Increased physical and nonphysical abuse was reported to result in increased health problems for women. The purpose of this study was to explore whether there was a difference in disclosing an abuse experience in current intimate relationships among women who were attending an ED at a national hospital compared with a Journal of Forensic Nursing
group of young female university students who were attending a cafeteria or a reading area/facility at a university square (USq). Specifically, the following research questions guided this study: (a) What is the frequency of relationship tension, amount of difficulty when working out arguments, and frequency of abuse in current intimate relationships among female university students who were located at a USq and among women who attended an ED at a national hospital? (b) Is there a significant difference in disclosure of IPV in current marital/partner relationships among female university students and among women who seek healthcare services at an ED at a national hospital and/or a university hospital?
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Methods
A cross-sectional research design was used. Data collection took place between April and December 2009.
Sample Women were eligible for participation in the study if they met the following inclusion criteria: (a) aged 18–67 years, (b) were seeking healthcare services from the ED Landspitali University Hospital (LUH) or were female university students who were located in the community at a USq, and (c) were able to read and write Icelandic or English. Women were excluded from the study if they were under the influence of alcohol, had taken an overdose of medicine, or used illegal drugs as assessed by nurses through observation and standard clinical assessments used in the ED. Of the 328 women who were introduced to the study, four women rejected participation, leaving the sample with 324 women (98.78% participation rate). However, of the 324 questionnaire packages that were distributed to the women, forms from 18 women in total (from both the USq and the ED) had too many missing items and were therefore unusable, resulting in a convenience sample of 306 women ranging in age from 18 to 67 years who participated in the study.
Study Context and Procedure Data were collected from two sites: from the reading area and the cafeteria area of the USq, University of Iceland, and from the waiting room area at the ED of the LUH (or, if they were with their partners in the waiting room, they were introduced to the study when their partners were waiting outside the examination room at the ED). Women were introduced to the study by healthcare professionals and the data collectors at each site. Ten of the 65 nurses (15.4%) working at the ED at the Landspitali University Hospital and two data collectors who worked on data collection at the USq were trained for the data collection. These nurses had participated in previous research programs by the same principal investigator. They had received training for the data collection regarding IPV by attending lectures about violence against women, watching a 90-minute film www.journalforensicnursing.com
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for healthcare professionals on IPV, and participating in 2–5 seminars on how to use newly developed and modified clinical guidelines in their practice to identify abuse and offer best practice first response. If the women were interested in participating, they received an introductory letter regarding the study. Women who agreed to participate and gave their written consent received a paper-and-pencil questionnaire package regarding their background information (e.g., age, educational level, marital status, employment, etc.) and their perceptions regarding their physical and mental health status and smoking habits. The women were then randomly assigned to answering questions regarding IPV in their current relationships (Women Abuse Screening Tool [WAST]; Brown, Lent, Schmidt, & Sas, 2000) via one of three different data collection procedures: (a) self-report (n = 53 at the USq, n = 44 at the ED), (b) computer format (n = 53 at the USq, n = 48 at the ED), and (c) face-to-face format (interview) procedure (n = 60 at the USq, n = 48 at the ED). That is, the first woman each day who was introduced to the study was offered the paper-and-pencil format, then the computer was offered to the second woman, and then the interview was offered to the third woman. These methods of data collection were chosen because it has been reported in the literature (Svavarsdottir, 2010) that disclosure of abuse varies based on the method of data collection used. It took the women about 15–30 minutes to answer the two questionnaires, and each interview lasted between 5–30 minutes.
Ethical Considerations Approval for the study was received from the National Bioethics Committee of Iceland and from the nursing director and the medical director at the ED-LUH, the chief nurse executive at the LUH, and the chief medical executive at the LUH. The study was reported to the Icelandic Data Protection Authority. Women who disclosed an abusive relationship were offered consultations with a psychiatric nurse and were offered consultations with the IPV crises team at LUH. Women who were with their partners in the USq or the waiting room of the ED were not approached to take part in the study.
Instruments Regardless of the data collection method used (i.e., paperand-pencil self-report, electronic data collection, or participation through an interview), the women received exactly the same set of questions.
Sociodemographic Information The sociodemographic instrument was developed by two of the investigators (Svavarsdottir & Orlygsdottir, 2006). Demographic information was gathered from the women who were located at the USq and from the women who 86
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were seeking healthcare services at the ED (13 items) regarding age, education, marital/intimate status, ethnicity, employment, and their perceptions about physical and mental health ranging from very good to bad (1–4). The WAST developed by Brown et al. (2000) is used to screen for abuse in current marital/partner relationships. The instrument consists of eight items. The two first questions assess, on a scale of 1 (no tension/difficulty) to 3 (a lot of tension/great difficulty), the degree of relationship tension and the amount of difficulty that the woman and her partner have in working out arguments. The remaining six questions are used to gain a more complete assessment of the abuse by asking the respondent to rate the frequency of various feelings and experiences of physical, emotional, and sexual abuse on a scale from 1 (often) to 3 (never). The WAST items are recoded and summed to calculate the overall score. The instrument has been found to be reliable and valid (Fogarty & Brown, 2002). The Cronbach’s alpha for the Icelandic version of the WAST has been reported to be between 0.77 and 0.97 (Svavarsdottir, 2010; Svavarsdottir & Orlygsdottir, 2009a, 2009b, 2008). The instruments had been translated from English into Icelandic by a group of healthcare professionals, the researchers, and a linguist and then translated back into English to establish validity and equivalence of meaning. At the same time, this ensured cultural sensitivity. The instruments had been pilot tested on a group of 20 women at the ED and had been used in prior research by the principal investigator (Svavarsdottir, 2010; Svavarsdottir & Orlygsdottir, 2009a, 2008).
Data Analysis Data analysis was conducted by using the SPSS statistical package version 20.0. The data met assumptions of normal distribution as indicated by histograms and P–P plots of standardized residuals. Descriptive statistics were computed on the demographic characteristics and major study variables (e.g., relationship tension, amount of difficulty when working out arguments, frequency of abuse, symptoms of PTSD, and physical and mental health). Chi-square tests and independent t tests were conducted to test for significant differences in the women’s experience of IPV based on the site (ED or USq). The alpha level was set at 0.05 to reduce the likelihood of committing a Type I error.
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Results Participants’ Characteristics and Health Status Of the 306 women who participated in the study, 166 women participated at the USq, and 140 women participated at the ED. No significant difference was found in the proportion of women at these two sites regarding whether they smoked nor how they perceived their psychological health status (see Table 1). Furthermore, there was no significant difference Volume 11 • Number 2 • April-June 2015
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TABLE 1. Demographic and Health Status Information Regarding the Women Who Participated in the Study Variables
University square
Emergency department
n
%
n
%
Interview
60
36.1
48
34.3
Paper and pencil
53
31.9
44
31.4
Computer
53
31.9
48
34.3
Interview
4
25.0
12
30.8
Paper and pencil
5
31.3
13
33.3
Computer
7
43.8
14
35.9
18–25
65
39.2
23
16.7
26–35
60
36.1
41
29.7
36–45
26
15.7
32
23.2
46–55
10
6.0
24
17.4
5
3.0
18
13.0
164
99.4
124
91.2
2
1.2
8
5.8
Married/ cohabiting
164
99.4
124
91.2
Separated
1
0.6
12
8.8
7
4.5
38
29.5
High school
69
44.2
34
26.4
University
80
51.3
57
44.4
Yes
86
54.1
102
77.9
No
73
45.9
29
22.1
Yes
32
19.5
34
24.8
No
132
80.5
103
75.2
Very good
69
41.6
38
27.5
Good
85
51.2
54
39.1
Moderate
11
6.6
33
23.9
1
0.6
13
9.4
Very good
66
39.8
50
36.2
Good
84
50.6
59
42.8
Moderate
14
8.4
22
15.9
2
1.2
7
5.1
Test statistics, p value Chi-square/Mann–Whitney
Type of responses
0.208
0.901
0.328
0.849
Disclosure of IPV
Age (years)
56 and older
7,163
0.000
Nationality Icelandic Another
4.940
0.026
12.182
0.000
Marital status
Education Secondary
8,156
0.000
Children in the home 17.805
0.000
1.227
0.268
Smoke
Physical health
Bad
8,161
0.000
10,277
0.092
Psychological health
Bad
Note. N = 306; n = 166 at the University Square and n = 140 at the Emergency Department. n varies because of missing data.
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found in the proportion of frequency of disclosure of abuse as reported by the women based on the method of data collection that was used (paper and pencil, electronic, interview), either among the women at the US or those at the ED. However, a significant difference was found in the women’s age based on the site; the age range of the women at the USq was significantly younger than those at the ED. Furthermore, a significantly higher proportion of the women at the ED had separated with their husband or partner within the last 6 months and were of a nationality other than Icelandic (see Table 1). In addition, more of the women at the USq had high school or university education, had children in their home, and rated their physical health to be very good or good when compared with the women at the ED (see Table 1).
Frequency of Abuse in Current Marital/Partner Relationships Disclosure of abuse was evaluated by the women’s response to the WAST instrument. There were no significant differences found, based on the sites, regarding the women’s experience of relationship tension or on the amount of difficulty when solving conflicts in their current relationship. Four of the women (2.4%) at the USq and eight women (5.8%) at the ED reported that communications between them and their partner indicated a lot of tension, and two women (1.2%) at the USq and six women (4.3%) at the ED reported that they and their partner often resolved conflicts with difficulty, indicating that between 1.2% and 5.8% of the women felt that their marital/partner relationship included more tension and difficulty. However, a significant difference was found regarding the women’s experience of feeling down or bad about themselves after arguments; getting physically hurt after disagreement; being frightened by what their partner said or did; and being physically, psychologically, or sexually abused. That is, for 160 women (96.4%) at the USq and for 125 women (89.3%) at the ED, disagreement often or sometimes resulted in the women feeling down or bad about themselves (USq never = 3.6%, ED never = 10.7%; w2 = 5.989, p = 0.014). Three women (1.8%) at the USq and 15 (10.8%) at the ED reported that disagreement often or sometimes resulted in them being physically hurt (USq never = 98.2%, ED never = 88.5%; w2 = 11.110, p = 0.001), and nine women (5.5%) at the USq and 32 (23.4%) at the ED reported that they were often or sometimes frightened by what their partner said or did (USq never = 95.2%, ED never = 78.8%; w2 = 19.897, p = 0.000). Three women (1.8%) at the USq and 18 (12.9%) at the ED reported that their husband/partner had often or sometimes physically abused them (USq never = 98.2%, ED never = 87.1%; w2 = 14.508, p = 0.000), 10 women (6%) at the USq and 35 (25.2%) at the ED reported that their husband/ 88
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partner had often or sometimes psychologically abused them (USq never = 94.0%, ED never = 74.8%; w2 = 22.072, p = 0.000), and none of the women at the USq but eight women (5.8%) at the ED reported that their husband/partner had sometimes or often sexually abused them (USq never = 100%, ED never = 94.2%; w2 = 9.972, p = 0.002); seven of these women reported that they had sometimes been sexually abused by their partner, and one of these women reported that she had often been sexually abused by her partner (see Table 2). Furthermore, a significantly higher proportion of the women at the ED reported that they were victims of IPV in their current marital/partner relationship than did the women at the USq (ED = 27.9%, USq = 9.6%; w2 = 17.098, p < 0.000; see Table 3). The women at the ED also scored significantly higher on the WAST total scale compared with the women at the USq, indicating that the women at the ED experienced significantly more frequent and more severe IPV in their current marital/partner relationship compared with the women at the USq (ED mean = 9.68, USq mean = 10.76; t = 2.385, p < 0.022; see Table 4).
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Discussion
IPV is considered to be a serious threat to health and wellbeing, both for the individuals who are victims of the abuse as well as for society as a whole. Failure to recognize IPV may result in insufficient health treatments and/or inappropriate interventions. Therefore, disclosure of abuse is a phenomenon that requires close attention among healthcare professionals. To facilitate disclosure of abuse, healthcare professionals need to establish trusting relationships with their clients. In the clinical guidelines regarding women’s abuse, screening, and initial responses (Svavarsdottir & Orlygsdottir, 2009b), it is emphasised that a trusting relationship needs to be established between the healthcare professional and the woman before women feel safe to disclose abuse. However, it is only within such a safe environment that disclosure of abuse can take place. The findings from this Icelandic study are new in that no research was found that tested, in the same study, disclosure of abuse simultaneously at two different settings, that is, at an ED and in the community, by using the same measures at both sites. Interestingly, however, no differences were found in the proportion of women who disclosed abuse in their current intimate partner relationship based on the method of data collection used, namely, the paper-and-pencil format, the electronic data gathering format, or the interviews. This finding may therefore be of particular interest to clinical practitioners such as nurses. Healthcare professionals in Iceland may wish to choose the method (e.g., paper and pencil, computer, or an interview) that best fits their clinical environment when screening for IPV to detect abuse in Volume 11 • Number 2 • April-June 2015
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n varies because of missing data.
My partner has sexually abused me.
My partner has psychologically abused me.
My partner has physically abused me.
Frightened by what my partner says or does.
Disagreement may result in me getting physically hurt.
Disagreement result in me feeling down or bad about myself.
My partner and I work out arguments with (difficulty).
Generally, communications between me and my partner indicate (tension).
0.0 (5.8)
0 (8)
6.0 (25.2)
10 (35)
1.8 (12.9)
3 (18)
5.5 (23.4)
9 (32)
1.8 (10.8)
3 (15)
96.4 (89.3)
160
%
(125)
n
Often/Sometimes
1.2 (4.3)
2 (6)
2.4 (5.8)
4
%
(8)
n
A lot/often
6
(129)
165
(104)
156
(122)
163
(108)
157
(123)
163
(15)
n
(132)
164
(131)
162
n
Never
(94.2)
100
(74.8)
94.0
(87.1)
98.2
(78.8)
95.2
(88.5)
98.2
(10.7)
3.6
%
(95.7)
98.8
(94.2)
97.6
%
Somewhat/sometimes, none/never
9.971
22.072
14.508
19.897
11.110
5.989
2.905
2.241
Chi sq.
0.002
0.000
0.000
0.000
0.001
0.014
0.088
0.134
p value
Women Please check whether Table 2 data were appropriately structured. at the USq, n = 166 (Women at the ED, n = 140)
TABLE 2. Frequency of Relationship Tension, Amount of Difficulty When Working Out Arguments, and Frequency of Abuse in Current Marital/Partner Relationships (WAST) Among Women Located at the University Square (USq) and Among Women Who Attended an Emergency Department (ED) at a University Hospital
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TABLE 3. Proportion of Women Who Experienced Abuse in Current Marital/Partner Relationships (WAST) and Were Located at the University Square (USq) or Were Attending an Emergency Department (ED) at a University Hospital WAST total
n
%
150
90.4
16
9.6
Chi-square
df
p value
17.098
1
0.000
USq Not IPV IPV ED Not IPV IPV
101
72.1
39
27.9
clinical settings no matter whether that setting is in the community or at a busy ED. Likewise, nurses could use a forum of mixed screening procedures if that would be more appropriate (e.g., computer data gathering or an interview) at the same clinical setting. Nevertheless, although there was no difference found based on the method of data collection used at these two settings, a significant difference was found on disclosure of abuse based on the clinical sites used. A significantly higher proportion of the women at the ED reported being victims of IPV in their current marital/partner relationships compared with the female students at the university. Furthermore, the intensity and the magnitude of the IPV were significantly higher among the women who visited the ED compared with the female students who were located at the USq. This was the case for all three types of abuse, that is, the disclosure of physical, psychological, and sexual abuse as well as for the total amount of abuse experienced by the women. These findings are in harmony with earlier findings reported by the authors, but in our earlier work on IPV, we found that a significantly higher proportion of women at an ED reported being victims of IPV compared with women at a high-risk prenatal care clinic (Svavarsdottir & Orlygsdottir, 2009a, 2008). These findings on the high proportion of women at an ED who report being victims of IPV in current marital/partner relationships emphasize the need to specifically offer appropriate first response and proper interventions and support when women presenting to an ED disclose being victims of IPV. In addition, a significantly higher proportion of the women at the ED reported moderate-to-bad physical health compared with the female students at the university. The findings on the magnitude and intensity of IPV in current marital relationships among women who visited an ED and the impact of IPV on women’s health are in harmony with findings reported by Svavarsdottir and Orlygsdottir (2008) and with the Women’s Responses to 90
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Battering model study (Campbell & Soeken, 1999). Here, a major direct relationship was shown between abuse and women’s health problems, indicating that women who had been abused by intimate partners had more health problems and were therefore more likely to be more frequent users of the healthcare system by, for example, using an ED. Yet, the findings from this study highlight the need to use appropriate screening tools, both at busy EDs and within community settings, when detecting IPV in current marital/partner relationships. Although, in this Icelandic study, the amount and frequency of IPV were found to be significantly higher among the women at the ED, the WAST instrument was found to work appropriately regarding detecting IPV at both sites, that is, both at the USq and at the ED. Only less than 1% of the women at the ED and the USq did not answer the questions on the WAST instrument regarding their experiences of physical, psychological, or sexual abuse in their current intimate relationships. In addition, one has to keep in mind that, although the WAST screening tool was found to detect IPV at both sites and although a higher frequency of IPV was reported by the women at the ED, about 10% of the young female university students reported being victims of IPV in current marital/partner relationships. This emphasizes the need for healthcare professionals, such as nurses in primary healthcare settings, to be alert to and to be trained for detecting IPV to be able to offer appropriate first response and interventions when women disclose to them that they are experiencing IPV.
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Conclusion
By identifying IPV in clinical and primary healthcare settings, nurses might assist women who are victims of abuse in current marital/partner relationships to enter the road of wellness and healing. In this study, a significant number of women at the ED and at the USq reported IPV in their current marital/partner relationships, which underscores the importance of screening for IPV both within primary care settings as well as ED settings. Experiencing IPV is a
TABLE 4. Differences in Means (Independent t Test) Regarding Women’s Experience of Abuse in Current Marital/Partner Relationships (WAST) Among Women Who Were Located at the University Square (USq) or Were Attending an Emergency Department (ED) at a University Hospital WAST total
n
Mean (SD)
USq
16
12.67 (2.12)
ED
39
14.46 (3.26)
t test
p value
2.385
0.022
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major health issue that can have a long-term impact on women’s health and well-being and on their quality of life. Therefore, detecting IPV in clinical settings is crucial. Women who are victims of IPV need special psychotherapeutic interventions to reduce the impact of the abuse and to prevent it from worsening and/or continuing. Therefore, nurses need to find the fit between the appropriateness of asking questions about abuse or receiving written answers regarding IPV experience and their need for having received specific training in following through on disclosure of abuse by offering appropriate first response, support, and/or appropriate interventions (Svavarsdottir et al., 2014). Women who are victims of IPV need to feel accepted and be understood and need therapeutic care and guidance on how to keep safe. Psychological training and insight is therefore critical for healthcare practitioners such as nurses when assisting women who are victims of IPV. Detecting IPV in clinical and community settings can function as a protective factor for women if healthcare professionals who identify the abuse offer appropriate first response, support, and/or interventions.
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Acknowledgments
The authors thank all the women who participated in this study. They also give special thanks to Gudbjorg Palsdottir at LUH for her participation in facilitating the data collection process at the emergency department at LUH. All the nurses at the emergency department who participated in the data collection get special thanks as well as Lilja Þo´runn Þorgeirsdo´ttir, a BSc nurse, for participating in the data collection process at the University Square.
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Coker, A. L., Smith, P. H., & Fadden, M. K. (2005). Intimate partner violence and disabilities among women attending family practice clinics. Journal of Women’s Health, 14, 829–838. Engnes, K., Lidén, E., & Lundgren, I. (2013). Women’s experiences of important others in a pregnancy dominated by intimate partner violence. Scandinavian Journal of Caring Sciences, 27, 643–650. Flemke, K. (2009). Triggering rage: Unresolved trauma in women’s lives. Contemporary Family Therapy, 31(2), 123–139. Fogarty, C. T., & Brown, J. B. (2002). Journal of the American Board of Family Medicine, 15(2), 101–111. Gharaibeh, M., & Oweis, A. (2009). Why do Jordanian women stay in an abusive relationship: Implication for health and social well-being. Journal of Nursing Scholarship, 41(4), 376–384. Golding, J. M. (1999). Intimate partner violence as a risk factor for mental disorders: A meta-analysis. Journal of Family Violence, 14(2), 99–132. Hathaway, J. E., Mucci, L. A., Silverman, J. G., Brooks, D. R., Mathews, R., & Pavlos, C. A. (2000). Health status and health care use of Massachusetts women reporting partner abuse. American Journal of Preventive Medicine, 19, 302–307. Hegadoren, K. M., Lasiuk, G. C., & Coupland, N. J. (2006). Post-traumatic stress disorder part III: Health effects of interpersonal violence among women. Perspectives in Psychiatric Care, 42(3), 163–173. Hepworth, I., & McGowan, L. (2012). Do mental health professionals enquire about childhood sexual abuse during routine mental health assessment in acute mental health settings? A substantive literature review. Journal of Psychiatric and Mental Health Nursing, 20, 473–483. Krause, E. D., Kaltman, S., Goodman, L. A., & Dutton, M. A. (2007). Longitudinal factor structure of post-traumatic stress symptoms related to intimate partner violence. Psychological Assessment, 19(2), 165–175. Leiner, A. S., Compton, M. T., Houry, D., & Kaslow, N. J. (2008). Intimate partner violence, psychological distress and suicidality: A path model using data from African American women seeking care in an urban emergency department. Journal of Family Violence, 23(6), 473–481. Leppäkoski, T., Åstedt-Kurki, P., & Paavilainen, E. (2010). Identification of women exposed to acute physical intimate partner violence in an emergency department setting in Finland. Scandinavian Journal of Caring Science, 24(4), 638–647. Nelson, S., Baldwin, N., & Taylor, J. (2012). Mental health problems and mentally unexplained physical symptoms in adult survivors of childhood sexual abuse: An interactive literature review. Journal of Psychiatric and mental Health Nursing, 19, 211–220. Nerøien, A. I., & Schei, B. (2008). Partner violence and health: Results from the first national study on violence against women in Norway. Scandinavian Journal of Public Health, 36(2), 161–168. Paranjape, A., Sprauve-Holmes, N. E., Gaughan, J., Kaslow, N. J. (2009). Lifetime exposure to family violence: Implications for the health status of older African American women. Journal of Women’s Health, 18(2), 171–175. Pico-Alfonso, M. A., Garcia-Linares, M. I., Celda-Navarro, N., Blasco-Ros, C., Echeburúa, E., & Martinez, M. (2006). The impact of physical, psychological and sexual intimate male partner violence of women’s mental health: Depressive symptoms, post-traumatic stress disorder, state anxiety and suicide. Journal of Women’s Health, 15(5), 599–611. Pigeon, W. R., Cerulli, C., Richards, H., He, H., Perlis, M., & Caine, E. (2011). Sleep disturbances and their association www.journalforensicnursing.com
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Svavarsdottir, E. K., & Orlygsdottir, B. (2009a). Intimate partner abuse factors associated with women’s health: A general population study. Journal of Advanced Nursing, 65(7), 1452–1462. Svavarsdottir, E. K., & Orlygsdottir, B. (2009b). Identifying abuse among women: Use of clinical guidelines by nurses and midwives. Journal of Advanced Nursing, 65(4), 779–788. Svavarsdottir, E. K., Orlygsdottir, B., & Gudmundsdottir, B. (2014). Reaching out to women who are victims of intimate partner violence. Perspectives in Psychiatric Care, 1–12. doi:10.1111/ ppc.12080 Wilson, D. R., Vidal, B., Wilson, W.A., & Salyer, S. L. (2012). Overcoming sequelae of childhood sexual abuse with stress management. Journal of Psychiatric and Mental Health Nursing, 19, 587–593. Zlotnick, C., Capezza, N. M., & Parker, D. (2011). An interpersonally based intervention for low-income pregnant women with intimate partner violence: A pilot study. Archives of Women’s Mental Health, 14, 55–65.
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Disclosure of Intimate Partner Violence in Current Marital/Partner Relationships Among Female University Students and Among Women at an Emergency Department Erla Kolbrún Svavarsdóttir, PhD, RN1,2 and Brynja Orlygsdottir, PhD, RN1
ABSTRACT Detecting intimate partner violence (IPV) might empower women to start working on the impact that the abuse experience has had on their lives. Little, however, is known about disclosure of abuse in community and in clinical settings. The purpose of this study was to explore whether there was a difference in the disclosure of abuse experience among women who were attending the emergency department (ED) at Landspitali University Hospital or were located at a university site, that is, at the University Square at the University of Iceland. A crosssectional research design was used. Data were collected at the same time in 2009 over a period of 9 months from N = 306 women ranging in age from 18 to 67 years (n = 166 at the University Square and n = 140 at the ED). A significantly higher proportion of the women at the ED reported that they were victims of IPV in their current marital/partner relationship and scored higher on the Women Abuse Screening Tool total scale than the women at the university site. This gave a clear indication that the women at the ED experienced significantly more frequent and more severe IPV in their current marital/partner relationship compared with the women at the university site. Identifying IPV in primary and clinical settings might, therefore, function as a protective factor if these women are offered appropriate first response and interventions. KEY WORDS: abuse disclosure; women who are victims of IPV
ntimate partner violence (IPV) is a sensitive issue, both for the women who are victims of the abuse as well as for the society in which they live. Women who experience abuse in their intimate relationships have been found to seek healthcare services from emergency departments
I
Author Affiliations: 1Faculty of Nursing, University of Iceland; and 2 Landspitali University Hospital. The study received funds from the LUH Scientific Fund, from the Scientific Fund at the University of Iceland, and from Icelandic Nurses Association science fund. The authors declare no conflict of interest. Correspondence: Erla Kolbrun Svavarsdottir, PhD, RN, Faculty of Nursing, University of Iceland, Eirberg, Eiriksgata 34, IS-101 Reykjavik, Iceland. E-mail: [email protected]. Received August 1, 2014; accepted for publication January 2, 2015. Copyright © 2015 International Association of Forensic Nurses DOI: 10.1097/JFN.0000000000000061
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(EDs) as well as from community healthcare settings more frequently than do women who are not experiencing violence in their intimate relationships. IPV is a major public health issue that has devastating short- and long-term impact on the health and well-being of women who are victims of abuse in their intimate relationships (Anderson & Bang, 2012; Chouliara, Karatzias, & Gullone, 2013; Golding, 1999; Hegadoren, Lasiuk, & Coupland, 2006; Pico-Alfonso et al., 2006; Seedat, Stein, & Carey, 2005; Sullivan & Holt, 2008; Svavarsdottir, Orlygsdottir, & Gudmundsdottir, 2014). Despite socioeconomic status, religion, or race, the prevalence of IPV toward women in current marital/ partner relationships has been reported as high as 29% (Coker, Smith, & Fadden, 2005; Hathaway et al., 2000; Nelson, Baldwin, & Taylor, 2012; Nerøien & Schei, 2008; Svavarsdottir, 2010; Svavarsdottir & Orlygsdottir, 2009a). Furthermore, the relationship between IPV and Volume 11 • Number 2 • April-June 2015
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Original Article
health consequences has been well established in both clinical- and population-based studies (Flemke, 2009; Gharaibeh & Oweis, 2009; Krause, Kaltman, Goodman, & Dutton, 2007; Leiner, Compton, Houry, & Kaslow, 2008; Leppäkoski, Åstedt-Kurki, & Paavilainen, 2010; Svavarsdottir & Orlygsdottir, 2009a, 2009b; Wilson, Vidal, Wilson, & Salyer, 2012; Zlotnick, Capezza, & Parker, 2011). Clearly, the impact of such traumatic events as physical, psychological, and sexual abuse in childhood and later in adulthood is directly related to women’s health issues (Al-Modallal, Abuidhail, Sowan, & Al-Rawashdeh, 2010; Amar & Alexy, 2005; Chouliara et al., 2013; Hepworth & McGowan, 2012; Paranjape, Sprauve-Holmes, Gaughan, & Kaslow, 2009; Pigeon et al., 2011; Sigurdardottir & Halldorsdottir, 2013; Svavarsdottir & Orlygsdottir, 2008). Pico-Alfonso and colleagues (2006) found that when compared to women who were not victims of IPV, women who were exposed to physical and psychological abuse, or to psychological abuse only, had a noticeably increased level of severe depression and anxiety symptoms; this included the possible development of posttraumatic stress disorder (PTSD) as well as suicidal thoughts and attempts. IPV is linked to: physical injuries; poor mental health, including depression, anxiety, PTSD, and suicidal intention; and a wide range of adverse negative physical health consequences. However, little is known as to whether disclosure of abuse and admitting to being a victim of IPV in a current marital/partner relationship to a nurse in clinical settings varies according to the site where the data collection takes place (e.g., community setting vs. ED). Research comparing the disclosure of IPV in a current intimate relationship among young female university students in the community and, at the same time, among women who were attending an ED at a national hospital could not be found. Furthermore, healthcare professionals such as nurses at EDs and in community settings need sufficient training (Engnes, Lidén, & Lundgren, 2013; Svavarsdottir & Orlygsdottir, 2009a) to be able to respond effectively to gender based violence and to be able to offer an appropriate first response when women reveal to them in clinical settings that they are victims of IPV in their current marital/partner relationship. The Women’s Response to Battering Model (Campbell & Soeken, 1999) was the conceptual framework underpinning the study. In this model, health is considered to be the outcome variable that is influenced by physical, emotional, and/or sexual abuse; by self-care; and by motivation and energy. The model focuses on both the direct and indirect effects of abuse on women’s health. Increased physical and nonphysical abuse was reported to result in increased health problems for women. The purpose of this study was to explore whether there was a difference in disclosing an abuse experience in current intimate relationships among women who were attending an ED at a national hospital compared with a Journal of Forensic Nursing
group of young female university students who were attending a cafeteria or a reading area/facility at a university square (USq). Specifically, the following research questions guided this study: (a) What is the frequency of relationship tension, amount of difficulty when working out arguments, and frequency of abuse in current intimate relationships among female university students who were located at a USq and among women who attended an ED at a national hospital? (b) Is there a significant difference in disclosure of IPV in current marital/partner relationships among female university students and among women who seek healthcare services at an ED at a national hospital and/or a university hospital?
▪
Methods
A cross-sectional research design was used. Data collection took place between April and December 2009.
Sample Women were eligible for participation in the study if they met the following inclusion criteria: (a) aged 18–67 years, (b) were seeking healthcare services from the ED Landspitali University Hospital (LUH) or were female university students who were located in the community at a USq, and (c) were able to read and write Icelandic or English. Women were excluded from the study if they were under the influence of alcohol, had taken an overdose of medicine, or used illegal drugs as assessed by nurses through observation and standard clinical assessments used in the ED. Of the 328 women who were introduced to the study, four women rejected participation, leaving the sample with 324 women (98.78% participation rate). However, of the 324 questionnaire packages that were distributed to the women, forms from 18 women in total (from both the USq and the ED) had too many missing items and were therefore unusable, resulting in a convenience sample of 306 women ranging in age from 18 to 67 years who participated in the study.
Study Context and Procedure Data were collected from two sites: from the reading area and the cafeteria area of the USq, University of Iceland, and from the waiting room area at the ED of the LUH (or, if they were with their partners in the waiting room, they were introduced to the study when their partners were waiting outside the examination room at the ED). Women were introduced to the study by healthcare professionals and the data collectors at each site. Ten of the 65 nurses (15.4%) working at the ED at the Landspitali University Hospital and two data collectors who worked on data collection at the USq were trained for the data collection. These nurses had participated in previous research programs by the same principal investigator. They had received training for the data collection regarding IPV by attending lectures about violence against women, watching a 90-minute film www.journalforensicnursing.com
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for healthcare professionals on IPV, and participating in 2–5 seminars on how to use newly developed and modified clinical guidelines in their practice to identify abuse and offer best practice first response. If the women were interested in participating, they received an introductory letter regarding the study. Women who agreed to participate and gave their written consent received a paper-and-pencil questionnaire package regarding their background information (e.g., age, educational level, marital status, employment, etc.) and their perceptions regarding their physical and mental health status and smoking habits. The women were then randomly assigned to answering questions regarding IPV in their current relationships (Women Abuse Screening Tool [WAST]; Brown, Lent, Schmidt, & Sas, 2000) via one of three different data collection procedures: (a) self-report (n = 53 at the USq, n = 44 at the ED), (b) computer format (n = 53 at the USq, n = 48 at the ED), and (c) face-to-face format (interview) procedure (n = 60 at the USq, n = 48 at the ED). That is, the first woman each day who was introduced to the study was offered the paper-and-pencil format, then the computer was offered to the second woman, and then the interview was offered to the third woman. These methods of data collection were chosen because it has been reported in the literature (Svavarsdottir, 2010) that disclosure of abuse varies based on the method of data collection used. It took the women about 15–30 minutes to answer the two questionnaires, and each interview lasted between 5–30 minutes.
Ethical Considerations Approval for the study was received from the National Bioethics Committee of Iceland and from the nursing director and the medical director at the ED-LUH, the chief nurse executive at the LUH, and the chief medical executive at the LUH. The study was reported to the Icelandic Data Protection Authority. Women who disclosed an abusive relationship were offered consultations with a psychiatric nurse and were offered consultations with the IPV crises team at LUH. Women who were with their partners in the USq or the waiting room of the ED were not approached to take part in the study.
Instruments Regardless of the data collection method used (i.e., paperand-pencil self-report, electronic data collection, or participation through an interview), the women received exactly the same set of questions.
Sociodemographic Information The sociodemographic instrument was developed by two of the investigators (Svavarsdottir & Orlygsdottir, 2006). Demographic information was gathered from the women who were located at the USq and from the women who 86
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were seeking healthcare services at the ED (13 items) regarding age, education, marital/intimate status, ethnicity, employment, and their perceptions about physical and mental health ranging from very good to bad (1–4). The WAST developed by Brown et al. (2000) is used to screen for abuse in current marital/partner relationships. The instrument consists of eight items. The two first questions assess, on a scale of 1 (no tension/difficulty) to 3 (a lot of tension/great difficulty), the degree of relationship tension and the amount of difficulty that the woman and her partner have in working out arguments. The remaining six questions are used to gain a more complete assessment of the abuse by asking the respondent to rate the frequency of various feelings and experiences of physical, emotional, and sexual abuse on a scale from 1 (often) to 3 (never). The WAST items are recoded and summed to calculate the overall score. The instrument has been found to be reliable and valid (Fogarty & Brown, 2002). The Cronbach’s alpha for the Icelandic version of the WAST has been reported to be between 0.77 and 0.97 (Svavarsdottir, 2010; Svavarsdottir & Orlygsdottir, 2009a, 2009b, 2008). The instruments had been translated from English into Icelandic by a group of healthcare professionals, the researchers, and a linguist and then translated back into English to establish validity and equivalence of meaning. At the same time, this ensured cultural sensitivity. The instruments had been pilot tested on a group of 20 women at the ED and had been used in prior research by the principal investigator (Svavarsdottir, 2010; Svavarsdottir & Orlygsdottir, 2009a, 2008).
Data Analysis Data analysis was conducted by using the SPSS statistical package version 20.0. The data met assumptions of normal distribution as indicated by histograms and P–P plots of standardized residuals. Descriptive statistics were computed on the demographic characteristics and major study variables (e.g., relationship tension, amount of difficulty when working out arguments, frequency of abuse, symptoms of PTSD, and physical and mental health). Chi-square tests and independent t tests were conducted to test for significant differences in the women’s experience of IPV based on the site (ED or USq). The alpha level was set at 0.05 to reduce the likelihood of committing a Type I error.
▪
Results Participants’ Characteristics and Health Status Of the 306 women who participated in the study, 166 women participated at the USq, and 140 women participated at the ED. No significant difference was found in the proportion of women at these two sites regarding whether they smoked nor how they perceived their psychological health status (see Table 1). Furthermore, there was no significant difference Volume 11 • Number 2 • April-June 2015
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Original Article
TABLE 1. Demographic and Health Status Information Regarding the Women Who Participated in the Study Variables
University square
Emergency department
n
%
n
%
Interview
60
36.1
48
34.3
Paper and pencil
53
31.9
44
31.4
Computer
53
31.9
48
34.3
Interview
4
25.0
12
30.8
Paper and pencil
5
31.3
13
33.3
Computer
7
43.8
14
35.9
18–25
65
39.2
23
16.7
26–35
60
36.1
41
29.7
36–45
26
15.7
32
23.2
46–55
10
6.0
24
17.4
5
3.0
18
13.0
164
99.4
124
91.2
2
1.2
8
5.8
Married/ cohabiting
164
99.4
124
91.2
Separated
1
0.6
12
8.8
7
4.5
38
29.5
High school
69
44.2
34
26.4
University
80
51.3
57
44.4
Yes
86
54.1
102
77.9
No
73
45.9
29
22.1
Yes
32
19.5
34
24.8
No
132
80.5
103
75.2
Very good
69
41.6
38
27.5
Good
85
51.2
54
39.1
Moderate
11
6.6
33
23.9
1
0.6
13
9.4
Very good
66
39.8
50
36.2
Good
84
50.6
59
42.8
Moderate
14
8.4
22
15.9
2
1.2
7
5.1
Test statistics, p value Chi-square/Mann–Whitney
Type of responses
0.208
0.901
0.328
0.849
Disclosure of IPV
Age (years)
56 and older
7,163
0.000
Nationality Icelandic Another
4.940
0.026
12.182
0.000
Marital status
Education Secondary
8,156
0.000
Children in the home 17.805
0.000
1.227
0.268
Smoke
Physical health
Bad
8,161
0.000
10,277
0.092
Psychological health
Bad
Note. N = 306; n = 166 at the University Square and n = 140 at the Emergency Department. n varies because of missing data.
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found in the proportion of frequency of disclosure of abuse as reported by the women based on the method of data collection that was used (paper and pencil, electronic, interview), either among the women at the US or those at the ED. However, a significant difference was found in the women’s age based on the site; the age range of the women at the USq was significantly younger than those at the ED. Furthermore, a significantly higher proportion of the women at the ED had separated with their husband or partner within the last 6 months and were of a nationality other than Icelandic (see Table 1). In addition, more of the women at the USq had high school or university education, had children in their home, and rated their physical health to be very good or good when compared with the women at the ED (see Table 1).
Frequency of Abuse in Current Marital/Partner Relationships Disclosure of abuse was evaluated by the women’s response to the WAST instrument. There were no significant differences found, based on the sites, regarding the women’s experience of relationship tension or on the amount of difficulty when solving conflicts in their current relationship. Four of the women (2.4%) at the USq and eight women (5.8%) at the ED reported that communications between them and their partner indicated a lot of tension, and two women (1.2%) at the USq and six women (4.3%) at the ED reported that they and their partner often resolved conflicts with difficulty, indicating that between 1.2% and 5.8% of the women felt that their marital/partner relationship included more tension and difficulty. However, a significant difference was found regarding the women’s experience of feeling down or bad about themselves after arguments; getting physically hurt after disagreement; being frightened by what their partner said or did; and being physically, psychologically, or sexually abused. That is, for 160 women (96.4%) at the USq and for 125 women (89.3%) at the ED, disagreement often or sometimes resulted in the women feeling down or bad about themselves (USq never = 3.6%, ED never = 10.7%; w2 = 5.989, p = 0.014). Three women (1.8%) at the USq and 15 (10.8%) at the ED reported that disagreement often or sometimes resulted in them being physically hurt (USq never = 98.2%, ED never = 88.5%; w2 = 11.110, p = 0.001), and nine women (5.5%) at the USq and 32 (23.4%) at the ED reported that they were often or sometimes frightened by what their partner said or did (USq never = 95.2%, ED never = 78.8%; w2 = 19.897, p = 0.000). Three women (1.8%) at the USq and 18 (12.9%) at the ED reported that their husband/partner had often or sometimes physically abused them (USq never = 98.2%, ED never = 87.1%; w2 = 14.508, p = 0.000), 10 women (6%) at the USq and 35 (25.2%) at the ED reported that their husband/ 88
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partner had often or sometimes psychologically abused them (USq never = 94.0%, ED never = 74.8%; w2 = 22.072, p = 0.000), and none of the women at the USq but eight women (5.8%) at the ED reported that their husband/partner had sometimes or often sexually abused them (USq never = 100%, ED never = 94.2%; w2 = 9.972, p = 0.002); seven of these women reported that they had sometimes been sexually abused by their partner, and one of these women reported that she had often been sexually abused by her partner (see Table 2). Furthermore, a significantly higher proportion of the women at the ED reported that they were victims of IPV in their current marital/partner relationship than did the women at the USq (ED = 27.9%, USq = 9.6%; w2 = 17.098, p < 0.000; see Table 3). The women at the ED also scored significantly higher on the WAST total scale compared with the women at the USq, indicating that the women at the ED experienced significantly more frequent and more severe IPV in their current marital/partner relationship compared with the women at the USq (ED mean = 9.68, USq mean = 10.76; t = 2.385, p < 0.022; see Table 4).
▪
Discussion
IPV is considered to be a serious threat to health and wellbeing, both for the individuals who are victims of the abuse as well as for society as a whole. Failure to recognize IPV may result in insufficient health treatments and/or inappropriate interventions. Therefore, disclosure of abuse is a phenomenon that requires close attention among healthcare professionals. To facilitate disclosure of abuse, healthcare professionals need to establish trusting relationships with their clients. In the clinical guidelines regarding women’s abuse, screening, and initial responses (Svavarsdottir & Orlygsdottir, 2009b), it is emphasised that a trusting relationship needs to be established between the healthcare professional and the woman before women feel safe to disclose abuse. However, it is only within such a safe environment that disclosure of abuse can take place. The findings from this Icelandic study are new in that no research was found that tested, in the same study, disclosure of abuse simultaneously at two different settings, that is, at an ED and in the community, by using the same measures at both sites. Interestingly, however, no differences were found in the proportion of women who disclosed abuse in their current intimate partner relationship based on the method of data collection used, namely, the paper-and-pencil format, the electronic data gathering format, or the interviews. This finding may therefore be of particular interest to clinical practitioners such as nurses. Healthcare professionals in Iceland may wish to choose the method (e.g., paper and pencil, computer, or an interview) that best fits their clinical environment when screening for IPV to detect abuse in Volume 11 • Number 2 • April-June 2015
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n varies because of missing data.
My partner has sexually abused me.
My partner has psychologically abused me.
My partner has physically abused me.
Frightened by what my partner says or does.
Disagreement may result in me getting physically hurt.
Disagreement result in me feeling down or bad about myself.
My partner and I work out arguments with (difficulty).
Generally, communications between me and my partner indicate (tension).
0.0 (5.8)
0 (8)
6.0 (25.2)
10 (35)
1.8 (12.9)
3 (18)
5.5 (23.4)
9 (32)
1.8 (10.8)
3 (15)
96.4 (89.3)
160
%
(125)
n
Often/Sometimes
1.2 (4.3)
2 (6)
2.4 (5.8)
4
%
(8)
n
A lot/often
6
(129)
165
(104)
156
(122)
163
(108)
157
(123)
163
(15)
n
(132)
164
(131)
162
n
Never
(94.2)
100
(74.8)
94.0
(87.1)
98.2
(78.8)
95.2
(88.5)
98.2
(10.7)
3.6
%
(95.7)
98.8
(94.2)
97.6
%
Somewhat/sometimes, none/never
9.971
22.072
14.508
19.897
11.110
5.989
2.905
2.241
Chi sq.
0.002
0.000
0.000
0.000
0.001
0.014
0.088
0.134
p value
Women Please check whether Table 2 data were appropriately structured. at the USq, n = 166 (Women at the ED, n = 140)
TABLE 2. Frequency of Relationship Tension, Amount of Difficulty When Working Out Arguments, and Frequency of Abuse in Current Marital/Partner Relationships (WAST) Among Women Located at the University Square (USq) and Among Women Who Attended an Emergency Department (ED) at a University Hospital
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Original Article
TABLE 3. Proportion of Women Who Experienced Abuse in Current Marital/Partner Relationships (WAST) and Were Located at the University Square (USq) or Were Attending an Emergency Department (ED) at a University Hospital WAST total
n
%
150
90.4
16
9.6
Chi-square
df
p value
17.098
1
0.000
USq Not IPV IPV ED Not IPV IPV
101
72.1
39
27.9
clinical settings no matter whether that setting is in the community or at a busy ED. Likewise, nurses could use a forum of mixed screening procedures if that would be more appropriate (e.g., computer data gathering or an interview) at the same clinical setting. Nevertheless, although there was no difference found based on the method of data collection used at these two settings, a significant difference was found on disclosure of abuse based on the clinical sites used. A significantly higher proportion of the women at the ED reported being victims of IPV in their current marital/partner relationships compared with the female students at the university. Furthermore, the intensity and the magnitude of the IPV were significantly higher among the women who visited the ED compared with the female students who were located at the USq. This was the case for all three types of abuse, that is, the disclosure of physical, psychological, and sexual abuse as well as for the total amount of abuse experienced by the women. These findings are in harmony with earlier findings reported by the authors, but in our earlier work on IPV, we found that a significantly higher proportion of women at an ED reported being victims of IPV compared with women at a high-risk prenatal care clinic (Svavarsdottir & Orlygsdottir, 2009a, 2008). These findings on the high proportion of women at an ED who report being victims of IPV in current marital/partner relationships emphasize the need to specifically offer appropriate first response and proper interventions and support when women presenting to an ED disclose being victims of IPV. In addition, a significantly higher proportion of the women at the ED reported moderate-to-bad physical health compared with the female students at the university. The findings on the magnitude and intensity of IPV in current marital relationships among women who visited an ED and the impact of IPV on women’s health are in harmony with findings reported by Svavarsdottir and Orlygsdottir (2008) and with the Women’s Responses to 90
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Battering model study (Campbell & Soeken, 1999). Here, a major direct relationship was shown between abuse and women’s health problems, indicating that women who had been abused by intimate partners had more health problems and were therefore more likely to be more frequent users of the healthcare system by, for example, using an ED. Yet, the findings from this study highlight the need to use appropriate screening tools, both at busy EDs and within community settings, when detecting IPV in current marital/partner relationships. Although, in this Icelandic study, the amount and frequency of IPV were found to be significantly higher among the women at the ED, the WAST instrument was found to work appropriately regarding detecting IPV at both sites, that is, both at the USq and at the ED. Only less than 1% of the women at the ED and the USq did not answer the questions on the WAST instrument regarding their experiences of physical, psychological, or sexual abuse in their current intimate relationships. In addition, one has to keep in mind that, although the WAST screening tool was found to detect IPV at both sites and although a higher frequency of IPV was reported by the women at the ED, about 10% of the young female university students reported being victims of IPV in current marital/partner relationships. This emphasizes the need for healthcare professionals, such as nurses in primary healthcare settings, to be alert to and to be trained for detecting IPV to be able to offer appropriate first response and interventions when women disclose to them that they are experiencing IPV.
▪
Conclusion
By identifying IPV in clinical and primary healthcare settings, nurses might assist women who are victims of abuse in current marital/partner relationships to enter the road of wellness and healing. In this study, a significant number of women at the ED and at the USq reported IPV in their current marital/partner relationships, which underscores the importance of screening for IPV both within primary care settings as well as ED settings. Experiencing IPV is a
TABLE 4. Differences in Means (Independent t Test) Regarding Women’s Experience of Abuse in Current Marital/Partner Relationships (WAST) Among Women Who Were Located at the University Square (USq) or Were Attending an Emergency Department (ED) at a University Hospital WAST total
n
Mean (SD)
USq
16
12.67 (2.12)
ED
39
14.46 (3.26)
t test
p value
2.385
0.022
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Original Article
major health issue that can have a long-term impact on women’s health and well-being and on their quality of life. Therefore, detecting IPV in clinical settings is crucial. Women who are victims of IPV need special psychotherapeutic interventions to reduce the impact of the abuse and to prevent it from worsening and/or continuing. Therefore, nurses need to find the fit between the appropriateness of asking questions about abuse or receiving written answers regarding IPV experience and their need for having received specific training in following through on disclosure of abuse by offering appropriate first response, support, and/or appropriate interventions (Svavarsdottir et al., 2014). Women who are victims of IPV need to feel accepted and be understood and need therapeutic care and guidance on how to keep safe. Psychological training and insight is therefore critical for healthcare practitioners such as nurses when assisting women who are victims of IPV. Detecting IPV in clinical and community settings can function as a protective factor for women if healthcare professionals who identify the abuse offer appropriate first response, support, and/or interventions.
▪
Acknowledgments
The authors thank all the women who participated in this study. They also give special thanks to Gudbjorg Palsdottir at LUH for her participation in facilitating the data collection process at the emergency department at LUH. All the nurses at the emergency department who participated in the data collection get special thanks as well as Lilja Þo´runn Þorgeirsdo´ttir, a BSc nurse, for participating in the data collection process at the University Square.
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