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A realistic view of domestic violence screening in an Emergency Department
Accident and Emergency Nursing ( 2002) 10, 31–39 ° C 2002 Elsevier Science Ltd doi:10.1054/aaen.2001.0312, available online at http://www.idealibrary.com on
A realistic view of domestic violence screening in an Emergency Department C. Ramsden, M. Bonner
Clair Ramsden M.A. RN ENB199 & 998, Clinical Nurse Consultant, Emergency Department, The Sutherland Hospital, Locked bag 21, Taren Point, Sydney NSW 2229, Australia Tel.: 00 61 2 9540 7120; E-mail: ramsdenc@ sesahs.nsw.gov.au Michelle Bonner B.S.W M.A, Domestic Violence Project Officer, South Eastern Sydney Area Womens Health Service, Royal South Sydney Community Health Complex, Sydney Australia Correspondence to: C. Ramsden Manuscript accepted: 25 October 2001
Sutherland Hospital is a district hospital serving The Sutherland Shire, a metropolitan area of Sydney. It has a population of approximately 220,000 which is predominantly Anglo-Saxon in ethnic origin. The Emergency Department provides emergency services for 30,000 new patients per annum. New South Wales Department of Health obtained Commonwealth funding from Partnerships Against Domestic Violence to pilot routine screening for domestic violence within 2 Area Health Services. One of the participating sites was the Emergency Department in South East Sydney Area Health Service. The aim was for nursing and medical staff to screen, for three months, all women sixteen years old and over. Information cards on state-wide domestic violence resources and referral flow charts were developed for the pilot. Staff undertook training and issues were addressed prior to the screening. In this article we will discuss the findings, including the rate of screening by the staff, disclosure rate of domestic violence, and action taken on disclosure. We will then proceed to explain the difficulties in undertaking screening within an Emergency Department, and make recommendations for those Emergency Departments interested in commencing C 2002 Elsevier Science Ltd screening. °
Introduction Domestic Violence is a range of violent, abusive or intimidating behaviours carried out by an adult against a partner, or former partner, to control and dominate that person. It is most often violent behaviour by a man against a woman (SESAHS 1998). Domestic Violence has a profound effect on children and young people and under the new New South Wales (NSW) Children and Young Persons (Care and Protection) Act 1998, now constitutes a form of child abuse. The total incidence of domestic violence in NSW cannot be accurately assessed for a number of reasons. However, the Australian Bureau of Statistics Women’s Safety Survey (McLennan 1996) found that 23% of women in
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Australia who had ever been married or in a defacto relationship experienced violence by their partner at some time during the relationship. In a study undertaken by the Queensland Domestic Violence Taskforce (1998), women experiencing domestic violence were found to have higher levels of stress, anxiety, depression and other psychiatric disorders. The task force also found that women victims of domestic violence were more likely to have higher rates of alcoholism, almost 5 times more likely to attempt suicide, to be 9 times more likely to abuse drugs and to frequently present to medical care givers with psychosomatic complaints. The cost of this to individuals, the community and the health system is high. In 1991, the NSW Women’s Coordination Unit
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estimated the total cost of domestic violence to the NSW government to be as high as $9 million per annum taking into account GP visits, psychiatric, community health, dental and hospital services (NSW Domestic Violence Committee, 1991). Emergency Departments (EDs) are crucial points in the health system for identifying and intervening early in domestic violence. From the literature it is clear that EDs are seeing women who are victims of domestic violence although the exact numbers of women vary. Shea et al. (1997) estimate that injuries inflicted by domestic violence account for 22% to 35% of visits to the Emergency Department. Other investigators have estimated that 6 to 30% of visits by women to EDs are related to domestic violence (Hayden et al. 1991). Within the Australian context, a study undertaken in 1990 at the ED at St Vincents Hospital, Sydney showed that 12% of cases of alleged violence were the result of domestic violence (Cuthbert, Lovejoy and Fulde in SESAHS Domestic Violence Policy 1998). In Queensland in the same year at the Royal Brisbane Hospital, it was shown that 20% of women presenting to the ED were either current or past victims of domestic violence. Despite these numbers the identification rate of victims of domestic violence is low; in a 1994 study it was found that less than half of the women who reported going to the ED specifically because of their injuries were identified as victims of domestic violence (Ellis 1999). Women use the ED as one of their primary health services when they are in a violent relationship but are unlikely to disclose unless asked directly. Hayden et al. (1991) reported that 89% of women would feel comfortable disclosing domestic violence, however 36% would only disclose if asked directly. This is reiterated by Haywood and Haile-Mariam (1999) who state that ‘most patients are willing to disclose inter-personnel violence when asked directly, non-judgementally and sensitively’. It was also reported by women that one of the most undesirable behaviours of health professionals was to treat the physical injury without inquiring how it occurred. Screening enables women who are in a domestic violence situation to be identified
32 Accident and Emergency Nursing ( 2 0 0 2 ) 1 0 , 3 1 – 3 9
early and to receive the appropriate care. Ellis (1999) argues that screening in ED must be undertaken if the domestic violence continuum is to be stopped. Keller also believes that screening should be undertaken and debates that just as the health care system doesn’t wait for patients to disclose suicidal tendencies, neither should it wait for disclosures of domestic violence (1996).
Background In 1999, the (NSW) Department of Health undertook a review of its Domestic Violence policy. One of the recommendations was that the revised policy should include a provision for routine, standardized assessment for domestic violence of women presenting to Emergency Departments with injuries. Following this, ‘Partnerships Against Domestic Violence’ provided Commonwealth funding to the NSW Health Department to pilot routine screening. South East Sydney Area Health Service agreed to undertake the pilot with five of its services including The Emergency Department at The Sutherland Hospital. The Sutherland Hospital is a district Hospital serving the Sutherland Shire, a metropolitan area of Sydney. It has a population of approximately 220,000 that is predominantly Anglo-Saxon and socioeconomic population ranging from affluent lifestyle to very low-income earners. The Emergency Department (ED) provides Emergency services for 30,000 new patients per annum. It employs 43 nursing and 15 medical staff. The department has one full-time in-hours social worker and one part-time social worker who covers 12 hours on weekends. The ED participated in the screening pilot project for 12 weeks between October and December 2000.
Aims of the DV pilot The overall aims of the screening pilot were: • To reduce the effects of and the incidence of domestic violence through early identification and appropriate provision of information, support and referral of victims
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• • • •
of domestic violence and accompanying children Identify experience of domestic violence early in the healthcare response To prevent victimization or re-victimization of children To promote help-seeking behaviour in victims of domestic violence and to prevent the escalation of violence To enhance intra-Health responses to victims of domestic violence presenting to NSW Health services and increase awareness amongst health practitioners about domestic violence.
Training The Education Centre Against Violence, which is the resource and training unit for domestic violence, sexual assault and child protection for the NSW Health Department, developed a training program including the screening protocols and flow-charts. The training program consisted of a four-hour workshop for all staff involved in the screening to attend. The training discussed the issues of domestic violence, the role of screening and included role-play and videos. The role-play assisted the staff to familiarize themselves with the questioning and responses. Information on support services and resources was also included.
Resources A state-wide resource card on DV services was developed and printed for the pilot. A resource folder of information, local services and Department of Health policies was strategically placed in the ED for staff to access. A laminated resource list of essential DV services was on a display notice board, ensuring staff had easy access to information.
Screening process The objectives of the pilot were for nursing and medical staff to screen all women sixteen years old and over regardless of reason for presentation. The period of the screening was three months. Taking part in the screening was voluntary and those women whom staff assessed to be physically and mentally unwell
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and unable to answer the questions were not screened. A screening form was developed for the staff to use during the pilot. It included the preamble, questions and any action taken; the reason for not screening was also documented on this. A carbon copy without the patients’ identifying information was collected by the project officer to analyse the data. The original was placed in the patients’ medical records. The questions were preceded by a preamble In this Health Service we have begun a new project to routinely ask all women the same questions about violence. This is because violence in the home is very common and can be serious and we want to improve our response to women experiencing domestic violence. You don’t have to answer the questions if you don’t want to. This information will remain confidential to the Health Service except where you give us information that indicates that you or children are at immediate risk of serious harm.
Staff then asked the screening questions, posing all 3 irrespective as to how the woman responded to the preceding questions. 1. Within the last 12 months have you been hit, slapped or hurt in other ways by your partner or ex-partner? 2. Are you frightened of your partner or ex-partner? 3. Are you safe to go home when you leave here? If domestic violence was identified in any of the above questions a fourth question was asked. 4. Would you like some assistance with this? If domestic violence was not identified, the information card was given to the woman and she was told, ‘here is some information that we are giving to all women about domestic violence’. No children over the age of 3-years-old, partners, family or friends were to be present during the screening. The staff were directed to handout the information resource card to the women regardless as to whether domestic violence was disclosed or not. Any further action taken was documented on the screening form.
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Fig. 1 Screening rate for domestic violence Oct–Dec 2000.
Fig. 2 Disclosure rate of domestic violence Oct–Dec 2000.
Evaluation The NSW Health Department and the University of Sydney received approval from the Southern Sydney Ethics Committee to evaluate the pilot. This Evaluation involved questionnaires on the screening process, telephone interviews with the women and focus groups with the staff. During the months of October through to December 2000, 2446 women over the age of 16 presented to the ED, of these 245 women or 10% were screened for domestic violence (Fig. 1). Staff attempted to screen another 89 women but were unable to complete the process. Where it was documented why screening did not occur, the main reasons given were that the woman was either physically or mentally unwell, or that a partner or family member was present. Other reasons documented were the women had dementia, were widowed or they had no partner.
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Of the 245 women who were screened for domestic violence, 36 patients or 14.6% disclosed previous or current domestic violence (Fig. 2). A further one woman disclosed being hit, slapped or hurt in other ways by her son and one woman disclosed being hit, slapped or hurt in other ways by her father.
Assistance offered Of the 8 women who wanted assistance, 3 were given information only. One was referred to the social worker only. One was given information and referred to the social worker. One was given information, and the staff also discussed options and gave support. One was given information, staff discussed options and gave support, referred to the social worker and documented that the police were already aware of the situation. One was given information, referred to the social worker and the police were notified.
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Twenty three women, or 64%, did not want further assistance when offered by staff. However, staff gave 16 women information and 1 woman was given information, support and options were discussed and a referral to social work was made. Three women refused information and for 2 women any action taken was not documented. For 4 women, it was not documented whether the woman did or did not want further assistance. Of these women, 4 were given information and 2 were referred to the social worker. One woman was unclear if she wanted further assistance (written on the form by staff) and the action taken by staff included information, support given and options discussed, referral to the social worker and documented that the police were already aware. For the woman who disclosed violence by her son, she did not want further assistance and information was refused. For the woman who disclosed violence by her father, she did want further assistance and information was given. The ED Social Worker maintained data on domestic violence referrals made to the social work department from the ED. In the 3 months prior to the project commencing, 2,608 female patients aged 16 years and over presented to the ED and 8 women (0.31%) were referred to the social work department for domestic violence. During the project, 2446 female patients aged 16 years and over presented to the ED and 14 women (0.6%) were referred to social work department for domestic violence.
Feedback from the women screened Part of the evaluation questionnaire asked women to complete two questions 1. Question: Is there a better way to ask the questions? Responses: ‘No, they were professional questions’ ‘There is no nice way to ask’ ‘No, being straight forward and direct helps’ ‘These questions make the victim confront the problem’
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2. Question: Is there anything else we should ask about? Responses: ‘Family life, i.e. Mum and Dad’ ‘Emotional abuse not just physical’ ‘Threats against themselves and their children’ ‘If there has been/or if they have experienced a history of DV’
Issues raised during the pilot During the pilot a number of issues were raised that other EDs will need to be aware of and take into consideration. These are influenced by the philosophy, politics and relationships of the department and need to be addressed prior to screening. Training Training was initially a 4-hour program with the aim that most staff involved would attend. However, staff were unable to attend for 4 hours training due to the lack of replacement staff available. As a result the majority of training provided was for 20–45 minutes at staff change over time. This was problematic as staff also used this time to have a break, get refreshments, debrief and talk to each other. 20–45 minutes was not adequate time to educate staff about a new procedure. Due to the sensitive nature of domestic violence a longer training time was necessary for the staff to raise questions and discuss the issues that they may have. Following this, 2-hour training was undertaken by 8 key nursing staff to act as a resource person for other staff members. Organizing medical staff to attend 20–45 minute training sessions was difficult due to a lack of time for staff to attend and the perception by medical staff that domestic violence was not their area of concern. Senior medical staff agreed that it was difficult to get medical staff to attend training as the staff argued that they were tired, over-worked and already pushed to attend training for other routine medical procedures. Medical staff were more likely to attend if the training was mandatory or structured into their orientation week.
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Ownership One of the major issues was the lack of ownership of the pilot both by nursing and medical staff. Nursing staff felt that they were not informed or involved in the initial decision to participate in the pilot, and as a result they felt that it was enforced on them. This was exacerbated by the lack of training available, which would have allowed for in-depth discussion. Generally, medical staff perceived that domestic violence was a social issue, which they saw as the responsibility of nursing staff. ED surroundings Participation by staff in the screening project was a challenge and the staff identified the reasons: lack of time to ask the questions, a lack of privacy and confidentiality for patients, no after-hours social worker for referrals and belief that these were inappropriate questions to ask in the history-taking for the type of presentation. Male nursing staff Whilst supporting the screening project in principle, all of the male nursing staff felt it was inappropriate for men to be asking women about domestic violence. Additionally, there were concerns that a man asking a woman about domestic violence may result in the male partner becoming agitated and violent and lead to a staff safety risk. It should be noted that during the pilot no aggressive incidents occurred as a result of the screening. Male victims of domestic violence Some of the staff argued that men should be screened for domestic violence as well as women. It was believed that men as victims were being neglected and this led to inequity in the pilot. Here, it was reiterated that this was a pilot project funded by the Commonwealth to screen women only. Elder abuse Elder abuse was also identified during the pilot. Nursing staff believed this was a real
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concern for a number of their elderly patients, male and female, who entered the ED from private homes, nursing homes and hostels. There was unease that this type of abuse was not identified in the screening process. Nursing staff were also unclear as to the procedures when elder abuse was suspected. Incentives Staff suggested as an option to encourage participation and commitment to the screening process, incentives should be provided for both nursing and medical staff to undertake the screening including financial incentives for the ED.
Discussion From the screening project it was clear that routine screening in Sutherland Hospital Emergency Department was not successful in that only 10% of female presentations were screened for domestic violence. The reasons for the low screening rate are outlined in the issues raised and are similar to those in the current literature which states that the main barriers to nurses screening in EDs are lack of privacy, time constraints and not knowing how to ask (Ellis 1999). If EDs are to adopt the screening project a number of issues should be addressed prior to the commencement to improve its chances of success. These are: Staff involvement A top-down, bottom-up approach should be adopted. Nursing, medical and allied health staff need to be involved with the planning and development of the screening from the beginning and consulted throughout the process. This may involve representatives from senior and junior staff on the implementation working party. The aim is to encourage ownership, to increase communication and to problem-solve. Training Prior to undertaking screening, staff should be trained around the issue of domestic violence and the rationale for screening. Role-play could be conducted during these sessions to enhance
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the skills of the staff to feel comfortable and confident with the interview and possible disclosure. Providing training across the health system is problematic due to lack of resources and time available. Each service will need to develop a training strategy and program that suits their individual needs, for instance training could be included in the orientation of new staff. Protocols Domestic violence protocols need to be written in advance or updated as the service evolves. These will formalize the process and give validation for the staff involved. Resources Staff need to be aware of resources available in the community and hospital setting for follow-up and referral for women in domestic violence situations. These could include a resource folder, checklist of main services with telephone numbers and information cards to be given out to the women. Personal experience of domestic violence There has to be an accompanying model that considers the issues for staff who may have a previous or current history of domestic violence. Screening for domestic violence may raise issues for staff, and managers need to be clear as to how they can prepare for this and support their staff. This may include staff awareness of an employees’ assistance program and how to access the counsellors. The pilot was successful in raising the awareness of nursing and medical staff of domestic violence as a health issue for the female patients attending Sutherland Hospital. Although screening for domestic violence did not work for the ED it was identified that another model more applicable to ED practices could be implemented. An early identification and intervention model was developed using clinical indicators in consultation with a peer tertiary hospital. This model complements the assessment strategies already in place for any patient attending the ED (Appendix 1). Domestic violence, sexual assault and elder
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abuse protocols were updated and staff were educated on the changes.
Recommendations Emergency departments are key players in the health system for identifying and intervening early for domestic violence. To undertake either a screening program or early identification model, senior and middle management need to be actively involved at both management and clinical level, supportive of the staff and clear that domestic violence is a concern that health service providers have to address. In 2001, health services can no longer ignore that domestic violence is a major health concern for women in NSW. Nursing and medical staff have to incorporate this into their daily practices and cannot treat a patient while continuing to ignore the main cause of the patient’s presentation to ED. Therefore, they have a responsibility to their patients to consider and recognize domestic violence. References Ellis JM 1999 Barriers to effective screening for domestic violence by registered nurses in their Emergency Department. Critical Care Nursing Quarterly 22 (1) Hayden SR, Barton, ED, Hayden M 1991 Domestic violence in the Emergency Department: how do women prefer to disclose and discuss the issues? Journal of Emergency Medicine 15 (4): 447–451 Haywood YC, Haile-Mariam T 1999 Violence Against Women Emergency Medicine Clinics of North America 17 (3) Keller EL 1996 Invisible victims: battered women in psychiatric and medical emergency rooms. Bulletin of the Menninger Clinic 60 (1): 1–21 McLennan W, Keller 1996 Australian Bureau of Statistics: Women’s safety – Australia 1996. Commonwealth of Australia NSW Children and Young Persons (Care and Protection) Act 1998 NSW Domestic Violence Committee 1991 NSW Domestic Violence Strategic Plan, 1 (4), NSW Womens Co-ordination Unit, Sydney Queensland Domestic Violence Taskforce 1998 Beyond these walls: report to the minister for family service and welfare housing department of family services Roberts GL, Lawrence JM, Rapahel B, O’Toole B, Stolz T 1993 Domestic Violence Victims in a Hospital Emergency Department. Medical Journal of Australia, 159: 307–310 Shea CA, Mahoney M, Lacey JM 1997 Breaking through the barriers to Domestic Violence Intervention. American Journal of Nursing 97 (6) South East Sydney Area Health Service 1998 Domestic Violence Policy and Protocol
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Appendix 1. Sutherland Hospital Emergency Department flowchart for suspected domestic violence presentations
Continues
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A realistic view of domestic violence screening in an Emergency Department C. Ramsden, M. Bonner
Clair Ramsden M.A. RN ENB199 & 998, Clinical Nurse Consultant, Emergency Department, The Sutherland Hospital, Locked bag 21, Taren Point, Sydney NSW 2229, Australia Tel.: 00 61 2 9540 7120; E-mail: ramsdenc@ sesahs.nsw.gov.au Michelle Bonner B.S.W M.A, Domestic Violence Project Officer, South Eastern Sydney Area Womens Health Service, Royal South Sydney Community Health Complex, Sydney Australia Correspondence to: C. Ramsden Manuscript accepted: 25 October 2001
Sutherland Hospital is a district hospital serving The Sutherland Shire, a metropolitan area of Sydney. It has a population of approximately 220,000 which is predominantly Anglo-Saxon in ethnic origin. The Emergency Department provides emergency services for 30,000 new patients per annum. New South Wales Department of Health obtained Commonwealth funding from Partnerships Against Domestic Violence to pilot routine screening for domestic violence within 2 Area Health Services. One of the participating sites was the Emergency Department in South East Sydney Area Health Service. The aim was for nursing and medical staff to screen, for three months, all women sixteen years old and over. Information cards on state-wide domestic violence resources and referral flow charts were developed for the pilot. Staff undertook training and issues were addressed prior to the screening. In this article we will discuss the findings, including the rate of screening by the staff, disclosure rate of domestic violence, and action taken on disclosure. We will then proceed to explain the difficulties in undertaking screening within an Emergency Department, and make recommendations for those Emergency Departments interested in commencing C 2002 Elsevier Science Ltd screening. °
Introduction Domestic Violence is a range of violent, abusive or intimidating behaviours carried out by an adult against a partner, or former partner, to control and dominate that person. It is most often violent behaviour by a man against a woman (SESAHS 1998). Domestic Violence has a profound effect on children and young people and under the new New South Wales (NSW) Children and Young Persons (Care and Protection) Act 1998, now constitutes a form of child abuse. The total incidence of domestic violence in NSW cannot be accurately assessed for a number of reasons. However, the Australian Bureau of Statistics Women’s Safety Survey (McLennan 1996) found that 23% of women in
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Australia who had ever been married or in a defacto relationship experienced violence by their partner at some time during the relationship. In a study undertaken by the Queensland Domestic Violence Taskforce (1998), women experiencing domestic violence were found to have higher levels of stress, anxiety, depression and other psychiatric disorders. The task force also found that women victims of domestic violence were more likely to have higher rates of alcoholism, almost 5 times more likely to attempt suicide, to be 9 times more likely to abuse drugs and to frequently present to medical care givers with psychosomatic complaints. The cost of this to individuals, the community and the health system is high. In 1991, the NSW Women’s Coordination Unit
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estimated the total cost of domestic violence to the NSW government to be as high as $9 million per annum taking into account GP visits, psychiatric, community health, dental and hospital services (NSW Domestic Violence Committee, 1991). Emergency Departments (EDs) are crucial points in the health system for identifying and intervening early in domestic violence. From the literature it is clear that EDs are seeing women who are victims of domestic violence although the exact numbers of women vary. Shea et al. (1997) estimate that injuries inflicted by domestic violence account for 22% to 35% of visits to the Emergency Department. Other investigators have estimated that 6 to 30% of visits by women to EDs are related to domestic violence (Hayden et al. 1991). Within the Australian context, a study undertaken in 1990 at the ED at St Vincents Hospital, Sydney showed that 12% of cases of alleged violence were the result of domestic violence (Cuthbert, Lovejoy and Fulde in SESAHS Domestic Violence Policy 1998). In Queensland in the same year at the Royal Brisbane Hospital, it was shown that 20% of women presenting to the ED were either current or past victims of domestic violence. Despite these numbers the identification rate of victims of domestic violence is low; in a 1994 study it was found that less than half of the women who reported going to the ED specifically because of their injuries were identified as victims of domestic violence (Ellis 1999). Women use the ED as one of their primary health services when they are in a violent relationship but are unlikely to disclose unless asked directly. Hayden et al. (1991) reported that 89% of women would feel comfortable disclosing domestic violence, however 36% would only disclose if asked directly. This is reiterated by Haywood and Haile-Mariam (1999) who state that ‘most patients are willing to disclose inter-personnel violence when asked directly, non-judgementally and sensitively’. It was also reported by women that one of the most undesirable behaviours of health professionals was to treat the physical injury without inquiring how it occurred. Screening enables women who are in a domestic violence situation to be identified
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early and to receive the appropriate care. Ellis (1999) argues that screening in ED must be undertaken if the domestic violence continuum is to be stopped. Keller also believes that screening should be undertaken and debates that just as the health care system doesn’t wait for patients to disclose suicidal tendencies, neither should it wait for disclosures of domestic violence (1996).
Background In 1999, the (NSW) Department of Health undertook a review of its Domestic Violence policy. One of the recommendations was that the revised policy should include a provision for routine, standardized assessment for domestic violence of women presenting to Emergency Departments with injuries. Following this, ‘Partnerships Against Domestic Violence’ provided Commonwealth funding to the NSW Health Department to pilot routine screening. South East Sydney Area Health Service agreed to undertake the pilot with five of its services including The Emergency Department at The Sutherland Hospital. The Sutherland Hospital is a district Hospital serving the Sutherland Shire, a metropolitan area of Sydney. It has a population of approximately 220,000 that is predominantly Anglo-Saxon and socioeconomic population ranging from affluent lifestyle to very low-income earners. The Emergency Department (ED) provides Emergency services for 30,000 new patients per annum. It employs 43 nursing and 15 medical staff. The department has one full-time in-hours social worker and one part-time social worker who covers 12 hours on weekends. The ED participated in the screening pilot project for 12 weeks between October and December 2000.
Aims of the DV pilot The overall aims of the screening pilot were: • To reduce the effects of and the incidence of domestic violence through early identification and appropriate provision of information, support and referral of victims
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• • • •
of domestic violence and accompanying children Identify experience of domestic violence early in the healthcare response To prevent victimization or re-victimization of children To promote help-seeking behaviour in victims of domestic violence and to prevent the escalation of violence To enhance intra-Health responses to victims of domestic violence presenting to NSW Health services and increase awareness amongst health practitioners about domestic violence.
Training The Education Centre Against Violence, which is the resource and training unit for domestic violence, sexual assault and child protection for the NSW Health Department, developed a training program including the screening protocols and flow-charts. The training program consisted of a four-hour workshop for all staff involved in the screening to attend. The training discussed the issues of domestic violence, the role of screening and included role-play and videos. The role-play assisted the staff to familiarize themselves with the questioning and responses. Information on support services and resources was also included.
Resources A state-wide resource card on DV services was developed and printed for the pilot. A resource folder of information, local services and Department of Health policies was strategically placed in the ED for staff to access. A laminated resource list of essential DV services was on a display notice board, ensuring staff had easy access to information.
Screening process The objectives of the pilot were for nursing and medical staff to screen all women sixteen years old and over regardless of reason for presentation. The period of the screening was three months. Taking part in the screening was voluntary and those women whom staff assessed to be physically and mentally unwell
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and unable to answer the questions were not screened. A screening form was developed for the staff to use during the pilot. It included the preamble, questions and any action taken; the reason for not screening was also documented on this. A carbon copy without the patients’ identifying information was collected by the project officer to analyse the data. The original was placed in the patients’ medical records. The questions were preceded by a preamble In this Health Service we have begun a new project to routinely ask all women the same questions about violence. This is because violence in the home is very common and can be serious and we want to improve our response to women experiencing domestic violence. You don’t have to answer the questions if you don’t want to. This information will remain confidential to the Health Service except where you give us information that indicates that you or children are at immediate risk of serious harm.
Staff then asked the screening questions, posing all 3 irrespective as to how the woman responded to the preceding questions. 1. Within the last 12 months have you been hit, slapped or hurt in other ways by your partner or ex-partner? 2. Are you frightened of your partner or ex-partner? 3. Are you safe to go home when you leave here? If domestic violence was identified in any of the above questions a fourth question was asked. 4. Would you like some assistance with this? If domestic violence was not identified, the information card was given to the woman and she was told, ‘here is some information that we are giving to all women about domestic violence’. No children over the age of 3-years-old, partners, family or friends were to be present during the screening. The staff were directed to handout the information resource card to the women regardless as to whether domestic violence was disclosed or not. Any further action taken was documented on the screening form.
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Fig. 1 Screening rate for domestic violence Oct–Dec 2000.
Fig. 2 Disclosure rate of domestic violence Oct–Dec 2000.
Evaluation The NSW Health Department and the University of Sydney received approval from the Southern Sydney Ethics Committee to evaluate the pilot. This Evaluation involved questionnaires on the screening process, telephone interviews with the women and focus groups with the staff. During the months of October through to December 2000, 2446 women over the age of 16 presented to the ED, of these 245 women or 10% were screened for domestic violence (Fig. 1). Staff attempted to screen another 89 women but were unable to complete the process. Where it was documented why screening did not occur, the main reasons given were that the woman was either physically or mentally unwell, or that a partner or family member was present. Other reasons documented were the women had dementia, were widowed or they had no partner.
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Of the 245 women who were screened for domestic violence, 36 patients or 14.6% disclosed previous or current domestic violence (Fig. 2). A further one woman disclosed being hit, slapped or hurt in other ways by her son and one woman disclosed being hit, slapped or hurt in other ways by her father.
Assistance offered Of the 8 women who wanted assistance, 3 were given information only. One was referred to the social worker only. One was given information and referred to the social worker. One was given information, and the staff also discussed options and gave support. One was given information, staff discussed options and gave support, referred to the social worker and documented that the police were already aware of the situation. One was given information, referred to the social worker and the police were notified.
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Twenty three women, or 64%, did not want further assistance when offered by staff. However, staff gave 16 women information and 1 woman was given information, support and options were discussed and a referral to social work was made. Three women refused information and for 2 women any action taken was not documented. For 4 women, it was not documented whether the woman did or did not want further assistance. Of these women, 4 were given information and 2 were referred to the social worker. One woman was unclear if she wanted further assistance (written on the form by staff) and the action taken by staff included information, support given and options discussed, referral to the social worker and documented that the police were already aware. For the woman who disclosed violence by her son, she did not want further assistance and information was refused. For the woman who disclosed violence by her father, she did want further assistance and information was given. The ED Social Worker maintained data on domestic violence referrals made to the social work department from the ED. In the 3 months prior to the project commencing, 2,608 female patients aged 16 years and over presented to the ED and 8 women (0.31%) were referred to the social work department for domestic violence. During the project, 2446 female patients aged 16 years and over presented to the ED and 14 women (0.6%) were referred to social work department for domestic violence.
Feedback from the women screened Part of the evaluation questionnaire asked women to complete two questions 1. Question: Is there a better way to ask the questions? Responses: ‘No, they were professional questions’ ‘There is no nice way to ask’ ‘No, being straight forward and direct helps’ ‘These questions make the victim confront the problem’
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2. Question: Is there anything else we should ask about? Responses: ‘Family life, i.e. Mum and Dad’ ‘Emotional abuse not just physical’ ‘Threats against themselves and their children’ ‘If there has been/or if they have experienced a history of DV’
Issues raised during the pilot During the pilot a number of issues were raised that other EDs will need to be aware of and take into consideration. These are influenced by the philosophy, politics and relationships of the department and need to be addressed prior to screening. Training Training was initially a 4-hour program with the aim that most staff involved would attend. However, staff were unable to attend for 4 hours training due to the lack of replacement staff available. As a result the majority of training provided was for 20–45 minutes at staff change over time. This was problematic as staff also used this time to have a break, get refreshments, debrief and talk to each other. 20–45 minutes was not adequate time to educate staff about a new procedure. Due to the sensitive nature of domestic violence a longer training time was necessary for the staff to raise questions and discuss the issues that they may have. Following this, 2-hour training was undertaken by 8 key nursing staff to act as a resource person for other staff members. Organizing medical staff to attend 20–45 minute training sessions was difficult due to a lack of time for staff to attend and the perception by medical staff that domestic violence was not their area of concern. Senior medical staff agreed that it was difficult to get medical staff to attend training as the staff argued that they were tired, over-worked and already pushed to attend training for other routine medical procedures. Medical staff were more likely to attend if the training was mandatory or structured into their orientation week.
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Ownership One of the major issues was the lack of ownership of the pilot both by nursing and medical staff. Nursing staff felt that they were not informed or involved in the initial decision to participate in the pilot, and as a result they felt that it was enforced on them. This was exacerbated by the lack of training available, which would have allowed for in-depth discussion. Generally, medical staff perceived that domestic violence was a social issue, which they saw as the responsibility of nursing staff. ED surroundings Participation by staff in the screening project was a challenge and the staff identified the reasons: lack of time to ask the questions, a lack of privacy and confidentiality for patients, no after-hours social worker for referrals and belief that these were inappropriate questions to ask in the history-taking for the type of presentation. Male nursing staff Whilst supporting the screening project in principle, all of the male nursing staff felt it was inappropriate for men to be asking women about domestic violence. Additionally, there were concerns that a man asking a woman about domestic violence may result in the male partner becoming agitated and violent and lead to a staff safety risk. It should be noted that during the pilot no aggressive incidents occurred as a result of the screening. Male victims of domestic violence Some of the staff argued that men should be screened for domestic violence as well as women. It was believed that men as victims were being neglected and this led to inequity in the pilot. Here, it was reiterated that this was a pilot project funded by the Commonwealth to screen women only. Elder abuse Elder abuse was also identified during the pilot. Nursing staff believed this was a real
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concern for a number of their elderly patients, male and female, who entered the ED from private homes, nursing homes and hostels. There was unease that this type of abuse was not identified in the screening process. Nursing staff were also unclear as to the procedures when elder abuse was suspected. Incentives Staff suggested as an option to encourage participation and commitment to the screening process, incentives should be provided for both nursing and medical staff to undertake the screening including financial incentives for the ED.
Discussion From the screening project it was clear that routine screening in Sutherland Hospital Emergency Department was not successful in that only 10% of female presentations were screened for domestic violence. The reasons for the low screening rate are outlined in the issues raised and are similar to those in the current literature which states that the main barriers to nurses screening in EDs are lack of privacy, time constraints and not knowing how to ask (Ellis 1999). If EDs are to adopt the screening project a number of issues should be addressed prior to the commencement to improve its chances of success. These are: Staff involvement A top-down, bottom-up approach should be adopted. Nursing, medical and allied health staff need to be involved with the planning and development of the screening from the beginning and consulted throughout the process. This may involve representatives from senior and junior staff on the implementation working party. The aim is to encourage ownership, to increase communication and to problem-solve. Training Prior to undertaking screening, staff should be trained around the issue of domestic violence and the rationale for screening. Role-play could be conducted during these sessions to enhance
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the skills of the staff to feel comfortable and confident with the interview and possible disclosure. Providing training across the health system is problematic due to lack of resources and time available. Each service will need to develop a training strategy and program that suits their individual needs, for instance training could be included in the orientation of new staff. Protocols Domestic violence protocols need to be written in advance or updated as the service evolves. These will formalize the process and give validation for the staff involved. Resources Staff need to be aware of resources available in the community and hospital setting for follow-up and referral for women in domestic violence situations. These could include a resource folder, checklist of main services with telephone numbers and information cards to be given out to the women. Personal experience of domestic violence There has to be an accompanying model that considers the issues for staff who may have a previous or current history of domestic violence. Screening for domestic violence may raise issues for staff, and managers need to be clear as to how they can prepare for this and support their staff. This may include staff awareness of an employees’ assistance program and how to access the counsellors. The pilot was successful in raising the awareness of nursing and medical staff of domestic violence as a health issue for the female patients attending Sutherland Hospital. Although screening for domestic violence did not work for the ED it was identified that another model more applicable to ED practices could be implemented. An early identification and intervention model was developed using clinical indicators in consultation with a peer tertiary hospital. This model complements the assessment strategies already in place for any patient attending the ED (Appendix 1). Domestic violence, sexual assault and elder
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abuse protocols were updated and staff were educated on the changes.
Recommendations Emergency departments are key players in the health system for identifying and intervening early for domestic violence. To undertake either a screening program or early identification model, senior and middle management need to be actively involved at both management and clinical level, supportive of the staff and clear that domestic violence is a concern that health service providers have to address. In 2001, health services can no longer ignore that domestic violence is a major health concern for women in NSW. Nursing and medical staff have to incorporate this into their daily practices and cannot treat a patient while continuing to ignore the main cause of the patient’s presentation to ED. Therefore, they have a responsibility to their patients to consider and recognize domestic violence. References Ellis JM 1999 Barriers to effective screening for domestic violence by registered nurses in their Emergency Department. Critical Care Nursing Quarterly 22 (1) Hayden SR, Barton, ED, Hayden M 1991 Domestic violence in the Emergency Department: how do women prefer to disclose and discuss the issues? Journal of Emergency Medicine 15 (4): 447–451 Haywood YC, Haile-Mariam T 1999 Violence Against Women Emergency Medicine Clinics of North America 17 (3) Keller EL 1996 Invisible victims: battered women in psychiatric and medical emergency rooms. Bulletin of the Menninger Clinic 60 (1): 1–21 McLennan W, Keller 1996 Australian Bureau of Statistics: Women’s safety – Australia 1996. Commonwealth of Australia NSW Children and Young Persons (Care and Protection) Act 1998 NSW Domestic Violence Committee 1991 NSW Domestic Violence Strategic Plan, 1 (4), NSW Womens Co-ordination Unit, Sydney Queensland Domestic Violence Taskforce 1998 Beyond these walls: report to the minister for family service and welfare housing department of family services Roberts GL, Lawrence JM, Rapahel B, O’Toole B, Stolz T 1993 Domestic Violence Victims in a Hospital Emergency Department. Medical Journal of Australia, 159: 307–310 Shea CA, Mahoney M, Lacey JM 1997 Breaking through the barriers to Domestic Violence Intervention. American Journal of Nursing 97 (6) South East Sydney Area Health Service 1998 Domestic Violence Policy and Protocol
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Appendix 1. Sutherland Hospital Emergency Department flowchart for suspected domestic violence presentations
Continues
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