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Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department
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Australasian Emergency Nursing Journal journal homepage: www.elsevier.com/locate/aenj
Research paper
Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department Elham Saberi a,∗ , Nicole Eather a , Sharene Pascoe a,b , Mary-Louise McFadzean a , Frances Doran c , Marie Hutchinson d a
Northern New South Wales Local Health District, PO Box 498, Lismore, NSW, 2480, Australia University Centre for Rural Health North Coast, PO Box 480, Lismore, NSW, 2480, Australia c Southern Cross University, Rifle Range Rd, Lismore, NSW 2480, Australia d Southern Cross University, Hogbin Drive, Coffs Harbour, NSW, 2450, Australia b
a r t i c l e
i n f o
Article history: Received 16 November 2016 Received in revised form 26 January 2017 Accepted 3 February 2017 Available online xxx Keywords: Domestic violence Routine screening Emergency department Survey
a b s t r a c t Background: Domestic violence (DV) has significant health impacts for victims and their families. Despite evidence that routine screening increases the identification of DV and opportunities for support; routine screening is uncommon in Australian emergency departments (EDs). This study explored ED clinicians’ level of support for DV screening; current screening practices; and perceived barriers and readiness to screen prior to a pilot intervention. Methods: Census survey of 76 ED clinicians. A number of questionnaire items were generated through a review of the literature, with readiness to screen for DV assessed through the short version of the Domestic Violence Healthcare Provider Scale [1]. The confidential and anonymous online survey was hosted on the Qualtrics platform. Descriptive and comparative statistical analysis was performed using IBM SPSS version 22. Results: Most clinicians supported screening for DV in the ED. In the absence of protocols, 72.3% (n = 55) of clinicians reported currently engaging in case-based screening, which preferenced women with physical injury. The majority did not always feel comfortable screening for DV (79.7% n = 59) and reported they had received insufficient training for this role (88.7% n = 55). Lower perceived self-efficacy and fear of offending were statistically associated with discomfort or negative beliefs about DV enquiry (p = < 0.05). Conclusion: Emergency department clinicians reported feeling ill-equipped and under-prepared to inquire about and respond to DV. These findings provide valuable insight about the training and support needs of ED clinicians prior to the commencement of routine screening in EDs. © 2017 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.
Introduction Domestic violence (DV) is well recognised as a complex public health issue that has profound and harmful effects upon victims and their families [2,3]. Global prevalence data indicates that close to one third of women have experienced DV and this is associated with immediate and significant health effects including injury, poorer birth outcomes, psychological distress and sexually transmitted disease [3] as well as huge costs to the health system and national economies [4,5]. Given the prevalence and impact of DV it is imperative that health professionals across all healthcare set-
∗ Corresponding author. E-mail address: [email protected] (E. Saberi).
tings are competent in identifying and responding to this form of violence. Routine inquiry about DV can assist in identifying those at risk. A recent meta-analysis reported that screening for DV increased identification by 133% compared with usual care [6]. Identification creates opportunities for women to access education, support, referral and safety planning. Additionally, screening as an intervention has subtle but important benefits for women experiencing violence regardless of whether the violence is disclosed [7]. Research repeatedly demonstrates that screening by healthcare professionals is acceptable to women and, importantly, women are unlikely to disclose their experience of violence unless directly asked [8–11]. There is growing awareness of violence against men committed by their domestic partners, with the scale of the problem also likely to be under reported [2].
http://dx.doi.org/10.1016/j.aenj.2017.02.001 1574-6267/© 2017 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.
Please cite this article in press as: Saberi E, et al. Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.02.001
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Survey secon Demographic characteriscs Is screening warranted in ED
Current screening pracces
Comfort in screening
Factors liming screening
Role most suited to screening Domesc Violence Healthcare Provider Scale (short)
Social worker support
Item type I item - current role classificaon 1 yes/no item 1 item – in what circumstances is screening warranted in ED (rounely all woman; rounely all men; in certain clinical circumstances; for high risk groups of paents) 1 item - which paent groups could be screened (for example: women who have an unexplained injury or an injury that may have resulted from violence; men who have an unexplained injury or an injury that may have resulted from violence; paents with a history of drug and alcohol misuse) 7 items – circumstances in which screening (for example: women who have an unexplained injury or an injury that may have resulted from violence; men who have an unexplained injury or an injury that may have resulted from violence; paents with a history of drug and alcohol misuse) 4 items- comfort in screening (yes, always, no never, in some circumstances; have you had sufficient training for DV; have you had specific training on cultural issues and DV; do you feel comfortable idenfying cultural issues in screening for DV) 3 items plus open ended response item (for example: lack of privacy for paents; I do not know how or who to refer to in situaons of DV; I would find it difficult to cope with the personal emoonal burden of screening) 5 items lisng categories of health professionals in the ED 3 items - Perceived self-efficacy (I feel confident that I can make the appropriate referrals for abused paents); 3 items Fear of offending paents (I am afraid of offending the paent if I ask about DV); 3 items- Professional role resistance (Invesgang the cause of DV is not part of medical or nursing pracce) I item – (I have ready access to social workers or community referrals to assist in the management of DV)
Fig. 1. Summary of survey sections and example items.
Screening for DV in health care settings is recommended in Australia and internationally [12,13]. In Australia, routine screening occurs predominantly in services specifically identified as women’s and children’s services [12]. Rates of routine inquiry about exposure to DV are reported as low in emergency settings, ranging from 2% to 13%.[14]. However, the ED is the first point of contact for many health service users and therefore provides an important opportunity for screening and identification. It is estimated that women experiencing violence attend EDs three times more frequently than those who have not experienced this form of abuse [15]. A recent Australian study reported that 12% of women presenting to EDs did so as a result of an acute episode of DV but less than one in seven of these women were asked about exposure to violence [14]. Whereas data from the United States confirmed that 20% of men attending the ED disclosed DV from a partner in the previous year [16]. A number of studies have examined clinicians’ attitudes, beliefs and knowledge about screening for DV [17–19]. Common barriers to screening identified by clinicians include unease about disclosure leading to further violence, concern about infringing on patient autonomy or causing offence, and lack of evidence on the effectiveness or outcomes from screening [19]. Other reported barriers include inadequate knowledge and lack of education; lack of systems level support and referral systems; environmental factors such as waiting room pressures, throughput targets and medical models of care delivery; insufficient time and lack of privacy; and professional role resistance [17,18]. This study explored ED clinicians’ level of support for DV screening in the department; current screening practices; perceived barriers and enablers to screening; and readiness to screen in
an Australian regional hospital ED. The purpose was to identify training, education and support needs for clinicians prior to the implementation of a DV screening pilot intervention.
Methods A cross-sectional sample of nursing and medical staff employed in one regional public hospital ED in New South Wales, Australia, were recruited for this exploratory survey study. The total possible study sample of staff in the ED was 95. Questionnaire items were generated through a review of the literature, with health care providers’ readiness to screen for DV assessed through items taken from a shortened version of the Domestic Violence Healthcare Provider Scale (short DVHPS) [20]. The DVHPS and short DVHPS have been previously validated in populations similar to those of this study, with demonstrated structural validity and reliability [19,20]. The short DVHPS examines six factors: 1) perceived self-efficacy; 2) fear of offending patients; 3) perceptions about victims/personality traits; 4) professional role resistance; 5) perceptions of victim disobedience; and 6) psychiatric support [19]. For this study, items related to perceptions about victims personality traits and disobedience were excluded as the study was focused upon perceptions about screening rather than healthcare professionals’ perceptions about victim characteristics. For items related to ‘psychiatric support’, wording was changed to ‘social worker support’ to reflect the Australian regional ED context for this study. The questionnaire structure is summarised in Fig. 1, and was as follows: current role classification (1 item); perceptions as to whether screening for DV is warranted in the ED
Please cite this article in press as: Saberi E, et al. Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.02.001
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Table 1 Variation in the four top ranking categories in which DV screening in the ED is warranted according to occupational category. Worker category (n=)
In certain clinical circumstances n (%)
For high risks groups of patients n (%)
Routinely for all women n (%)
Routinely for all men n (%)
nurse (58) medical officer (11)
41 (59.4) 5 (7.2)
23 (33.3) 7 (10.1)
11 (15.9) 2 (2.8)
6 (8.6) 0
n = 69; Missing n = 7.
Table 2 Variations in current self-reported screening practices according to occupational category. Worker category Respondents
Woman with injury n (%)
Pregnant woman with injury n (%)
Men with injury n (%)
Women with mental illness n (%)
Men with mental illness n (%)
Patients with a history of drug and alcohol n (%)
nurse medical officer X2 (value)df
33 (60) 10 (18.2) 0.015 (15.812)6
26 (47.2) 9 (16.3) 0.194 (8.650)6
10 (18.2) 5 (9) 0.036 (13.820)6
6 (10.9) 2 (3.6) 0.050 (12.602)6
5 (9) 1 (1.8) 0.038 (13.32)6
3 (5.4) 1 (1.8) 0.639 (4.27)6
n = 55; Missing n = 11.
(3 items); self-reported current DV screening practices (7 items); comfort in screening and previous DV education (4 items); factors limiting ability to screen (4 items); role most suited to screening for DV in the ED (5 items); and 10 five-point likert scale items on readiness to screen for DV. Readiness to screen was measured in terms of healthcare professionals’ perceived self-efficacy in screening (3 items), fear of offending patients (3 items), and professional role resistance (3 items). The readiness to screen items required respondents to select a response to each statement from 1 (strongly disagree) to 5 (strongly agree). The confidential and anonymous online survey was hosted on the Qualtrics platform. Ahead of the survey being made available, members of the research team conducted information sessions in the ED, informing staff about the study and inviting their participation. The final response rate was 80% (n = 76).
Ethics The study received ethical approval as a quality improvement project from the relevant Human Research Ethics Committee. Implied consent was assumed through completion of the online survey.
Data analysis Data analysis was undertaken using IBM SPSS version 22 [21]. Initially, descriptive statistics were performed to calculate the proportion of respondents in the work group categories and the distribution of responses to each question (valid percentages reported). As the study data did not meet the assumptions of parametric methods, non-parametric alternatives were employed. For categorical variables, the Chi Square test for independence was used to determine relationships between the variables. To facilitate comparisons between scale score on the DVHPS, sum scores for each of the sub-scales were created employing the previously established factor structure for the instrument [19]. The MannWhitney U test was employed to establish statistical differences between groups (occupational group, comfort in screening for DV, belief on whether screening for DV is warranted in the ED, and currently screening for DV) and sum scores on the DVHPS sub-scales. Differences were considered significant at the p < 0.05 level.
Results The majority of respondents were nurses (80.2% n = 61), followed by medical officers (14.4% n = 11; comprising 6 residents and 4 registrars). To establish clinicians’ support for DV screening descriptive analyis was performed. The vast majority reported the belief that screening for DV is warranted in the ED (82.3% n = 65), with 10.6% (n = 8) undecided and 2.5% (n = 2) believing screening is not warranted. All respondents who stated that screening was not warranted in the ED were nurses. Of those who supported screening for DV, the majority supported case-finding for particular high-risk patient groups or screening in certain clinical circumstances (see Table 1). When compared to nurses, medical respondents were less likely to support routine screening for both men and women, while 17.1% (n = 13) of nursing respondents supported routine screening for all women. A Chi Square test of independence was performed to establish whether these differences were statistically significant. The difference between the two groups was not significant X2 (7.882, N = 69, df 5, p < 0.163). Current screening practices The majority of respondents reported that they currently screen in specific circumstances (see Table 2). For both nurses and medical officers the patient group reportedly screened most often were women with unexplained injury, or injury that may stem from violence. Fewer respondents reported currently screening pregnant women or men with unexplained injury. Patient groups least likely to be screened were those with a history of drug and alcohol misuse. A Chi Square test of independence demonstrated a statistically significant difference between the two occupational groups for current screening practices for men with injury X2 (13.82, N = 55, df 6, p < 0.036) and women with injury X2 (15.81, N = 55, df 6, p < 0.015). Barriers to screening The majority of respondents (78.5% n = 56) reported that they were only comfortable screening for DV in certain circumstances. Similarly, the majority reported receiving insufficient training about screening for DV (83.3% n = 55). No statistically significant relationship was identified between self-reported comfort in screening for DV and perception as to whether screening was warranted in the ED X2 (0.557, N = 66, df 2, p < 0.757); or self-reported comfort in screening for DV and current screening practices X2
Please cite this article in press as: Saberi E, et al. Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.02.001
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Table 3 Between group differences on DVHPS self-efficacy sub-scale. DVHPS sub-scale scores
Nurse Mean (SE)
Medical officer Mean (SE)
Never comfortable screening for DV Mean (SE)
Comfortable screening for DV Mean (SE)
Perceived self-efficacy
8.54* (0.26)
9.87 (0.47)
6.33* (0.88)
8.87 (0.25)
Mann-Whitney U. b only one subject in this field. * Denotes statistically significant at p < 0.05 Asymp. Sig. (2 tailed). Table 4 Between group differences on DVHPS fear of offending sub-scales DVHPS sub-scale scores
Screening is warranted in the ED Mean (SE)
Screening is not warranted in the ED Mean (SE)
Fear of offending patients
6.54* (0.32)
11.00 (0.73)
Mann-Whitney U. * Denotes statistically significant at p < 0 0.05 Asymp. Sig. (2 tailed).
(0.066, N = 66, df 1, p < 0.797). For the item, I have no time to ask about DV in my practice, 19 (34.5%) nurses agreed with this statement, while 1 (9%) medical officer agreed. This between group difference was statistically significant X2 (4.814, df 1, N = 55, 5 p < 0.26). Differences between groups in readiness to screen Between group analysis on scores (Tables 3 and 4) for the DVHPS sub-scales employing the Mann-Whitney U test identified that, mean self-efficacy scores for nurses were significantly lower than the scores for medical officers (p = < 0.05). The analysis also identified significant associations between self-reported self-efficacy and; comfort in screening for DV (p = < 0.05); having received sufficient training in DV (p = < 0.01). For the fear of offending sub-scale, significant associations were identified between lower scores for fear of offending patients and the belief that DV screening is warranted in the ED, suggesting fear of offending played a significant role in influencing whether enquiry about DV occurred. Discussion This study examined the perceptions and current DV screening practices of a group of ED clinicians prior to the implementation of a DV screening pilot intervention. The study found that ED clinicians currently employ a case-finding approach to DV screening in the absence of a mandated screening policy. While clinicians were generally supportive of DV screening in the ED, the majority did not feel adequately prepared to undertake DV screening. Thus, clinicians who feel under-prepared for screening may be more likely to inquire about DV when indicators of violence are present. This approach increases the likelihood of missing cases of DV, with only one in seven women presenting to the ED as a result of acute DV, actually being screened for DV [13]. Our results provide important guidance for the development of appropriate training, education and support for ED clinicians prior to commencing routine DV screening. While the vast majority of clinicians surveyed were supportive of DV screening in the ED, most recommended a case-finding approach, which involves inquiring about violence only when potential indicators of violence are present, and reported that they currently screen selectively using case-finding methods. The rates of screening reported were similar to those reported in other studies of screening for DV in emergency settings [13,22]. In the state in which this survey was conducted, DV screening has been mandated for more than a decade in antenatal, early childhood, mental health and drug and alcohol services as these groups
have been identified as being at particular risk of experiencing violence [23]. It is notable that these patient groups, when presenting to the ED with unexplained injury consistent with violence, were not foregrounded by clinicians for DV assessment. This suggests that screening based on health professionals’ perception of whether patients are likely to experience DV may bias case selection. This is consistent with previous studies which found that screening by nurses in an ED was influenced by stereotypes and beliefs about victims and nurses’ perceptions of the demeanour of the woman [24,25]. Selective screening based on health professionals’ personal judgement may fail to target those most at risk. Our findings therefore suggest that clinicians in the ED would benefit from education regarding the evidence base for universal screening prior to the introduction of a screening program. Similar to results reported in other studies [26], healthcare professionals in this study reported that they had not received sufficient training in screening for DV. There was also a difference between groups for perceptions about whether there was time to ask about DV. Previous research has demonstrated that ED clinicians are more likely to inquire about DV when they have received training and are supported by access to DV advocates, clear documentation, referral pathways and unit based policies and procedures [27,28]. Training has been shown to support healthcare workers to reduce barriers to screening, alleviate concerns about screening for DV, enhance perceived self-efficacy in identifying and responding to DV, overcome fear of offending, and increase knowledge about intervention and referral pathways [29]. In terms of staff readiness to screen, clinicians with lower perceived self-efficacy were less likely to enquire about DV in their current practice. Additionally, fear of offending significantly influenced comfort about inquiring about DV. Unease about disclosure leading to further violence, concern about infringing on patient autonomy or causing offence, and lack of evidence on the effectiveness or outcomes from screening have all been previously reported as clinician concerns and reasons for not enquiring about DV [18]. In part, these concerns have been answered through the growing body of evidence which repeatedly reports that enquiring about DV does not increase risk of harm [18] and that women are generally accepting of such screening [6,10], with women who have experienced violence being more likely to support policies that mandate screening [9]. An important enabler for health professionals to enquire about DV is the creation of an institutional context where staff feel supported and able to respond appropriately. Both fear of offending and professional role resistance may be related to the ability to offer victims access to additional support in response to their identified needs. These results suggest that training on responding to disclosures and understanding appropriate information and referral pathways is needed to increase health providers’ comfort in communicating with adults and children affected by DV. However, education alone may not result in sustained improvement in screening practices. Barriers such as professional norms and narrow role interpretations may only be addressed by cultural change in the prevailing values and practices of a department. Changes that may support improved screening for DV include workflow re-design and supporting health professionals to advo-
Please cite this article in press as: Saberi E, et al. Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.02.001
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cate for and support systems change. Ambuel and colleagues note that ED culture can be improved to support DV screening and intervention, with improvement requiring change at the individual clinician level, as well as the systems level to support the active involvment of clinicans in the change process [30]. Hammock et al. report that a senior clinician serving as a role model and an advocate for screening can help shift norms about screening in the ED [31]. Limitations The small sample in this study is drawn from one Australian hospital ED, this may limit generalisability of the findings. Furthermore, as the data is recall of self-reported practice, it is possible that socially desirable responding and difficulty with recall may have influenced responses. Despite these limitations, the findings correlate with previous research regarding barriers and enablers to screening in health services. Implications and conclusion Routine screening for DV by a skilled health worker increases the identification of violence and provides opportunities for education and support. Clinicians in the study site ED currently employ and advocate a case finding approach to enquiry about DV, which risks leaving many instances of violence undisclosed. The introduction of routine screening for DV requires appropriate training and support. This study provides a platform for the development of appropriate training programs and systems level support for clinicians participating in a pilot intervention of routine DV screening in a regional hospital ED. These findings have relevance for other EDs developing front line responses to domestic and family violence. Conflicts of interest The authors confirm that they have no conflicts of interest to declare. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contribution statement MH, ES, MM, SP and NE conceived and designed the study and developed the study protocol. MH supervised data collection and analysed the data. MH, ES, SP and FD reviewed the data analysis and prepared the manuscript. All authors approved the manuscript for submission. References [1] Lawoko S, Sanz S, Helstrom L, Castren M. Assessing the structural validity and concurrent validity of a shortened version of the Domestic Violence Healthcare Providers Survey questionnaire for use in Sweden. Psychology 2012;3:183–91. [2] Morgan A, Chadwick H. Key issues in domestic violence Research in Practive, vol. 7. Canberra: Australian Institute of Criminology; 2009. [3] World Health Organisation. London School of Hygiene and Tropical Medicine, Council SAMR. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. In: Department of reproductive health and research WHO. Geneva: World Health Organisation; 2013.
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[4] The National Council to Reduce Violence against Women and their Children. The cost of violence against women and their children. Canberra, Australia. 2009. [5] Yount K, DiGirolamo A, Ramakrishnan U. Impacts of domestic violence on child growth and nutrition: a conceptual review of the pathways of influence. Soc Sci Med 2011;72:1534–54. [6] O’Doherty LJ, Taft A, Hegarty K, Ramsay J, Davidson LL, Feder G. Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis. BMJ 2014;348:g2913. [7] Spangaro J, Zwi A, Poulos R. “Persist: persist.” A qualitative study of women’s decisions to disclose and their perceptions of the impact of routine screening for intimate partner violence. Psychol Violence 2011;1:150–62. [8] Usta J, Antoun J, Ambuel B, Khawaja M. Involving the health care system in domestic violence: what women want. Ann Fam Med 2012;10:213–20. [9] Boyle A, Jones P. 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Factors influencing identification of and response to intimate partner violence: a survey of physicians and nurses. BMC Publich Health 2007;7. [20] Maiuro R, Vitaliano P, Sugg N, Thompson D, Rivara F, Thompson R. Development of a health care provider survey for domestic violence: psychometric properties. Am J Prevent Med 2000;19:245–52. [21] IBM Corp. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp; 2013. [22] Olive P. Care for emergency department patients who have experienced domestic violence: a review of the evidence. J Clin Nurs 2007;16:1736–48. [23] NSW Department of Health. Policy and procedures for identifying and responding to domestic violence. Policy Directive PD2006 084. October 2006. [24] Reisenhofer S, Seibold C. Emergency healthcare experiences of women living with intimate partner violence. J Clin Nurs 2013;22:2253–63. [25] Robinson R. Myths and stereotypes: how registered nurses screen for intimate partner violence. J Emerg Nurs 2010;36:572–6. [26] Larkin G, Hyman K, Mathias S, D’Amico F, MacLeod B. Universal screening for intimate partner violence in the emergency department: importance of patient and provider factors. Ann Emerg Med 1999;33:669–75. [27] Choo EK, Nicolaidis C, Newgard CD, Hall MK, McConnell MK, McConnell KL. Association between emergency department resources and diagnosis of intimate partner violence. Euro J Emerg Med 2012;19:83–8. [28] Hamberger LK, Rhodes K, Brown J. Screening and intervention for intimate partner violence in healthcare settings: creating sustainable system-level programs. J Women’s Health 2015;24:86–91. [29] O’Campo P, Kirst M, Tsamis C, Chambers C, Ahmad F. Implementing successful intimate partner violence screening programs in health care settings: evidence generated from a realist-informed systematic review. Soc Sci Med 2011;72:855–66. [30] Ambuel B, Hamberger LK, Guse CE, Melzer-Lange M, Phelan MB, Kistner A. 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Please cite this article in press as: Saberi E, et al. Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.02.001
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Contents lists available at ScienceDirect
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Research paper
Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department Elham Saberi a,∗ , Nicole Eather a , Sharene Pascoe a,b , Mary-Louise McFadzean a , Frances Doran c , Marie Hutchinson d a
Northern New South Wales Local Health District, PO Box 498, Lismore, NSW, 2480, Australia University Centre for Rural Health North Coast, PO Box 480, Lismore, NSW, 2480, Australia c Southern Cross University, Rifle Range Rd, Lismore, NSW 2480, Australia d Southern Cross University, Hogbin Drive, Coffs Harbour, NSW, 2450, Australia b
a r t i c l e
i n f o
Article history: Received 16 November 2016 Received in revised form 26 January 2017 Accepted 3 February 2017 Available online xxx Keywords: Domestic violence Routine screening Emergency department Survey
a b s t r a c t Background: Domestic violence (DV) has significant health impacts for victims and their families. Despite evidence that routine screening increases the identification of DV and opportunities for support; routine screening is uncommon in Australian emergency departments (EDs). This study explored ED clinicians’ level of support for DV screening; current screening practices; and perceived barriers and readiness to screen prior to a pilot intervention. Methods: Census survey of 76 ED clinicians. A number of questionnaire items were generated through a review of the literature, with readiness to screen for DV assessed through the short version of the Domestic Violence Healthcare Provider Scale [1]. The confidential and anonymous online survey was hosted on the Qualtrics platform. Descriptive and comparative statistical analysis was performed using IBM SPSS version 22. Results: Most clinicians supported screening for DV in the ED. In the absence of protocols, 72.3% (n = 55) of clinicians reported currently engaging in case-based screening, which preferenced women with physical injury. The majority did not always feel comfortable screening for DV (79.7% n = 59) and reported they had received insufficient training for this role (88.7% n = 55). Lower perceived self-efficacy and fear of offending were statistically associated with discomfort or negative beliefs about DV enquiry (p = < 0.05). Conclusion: Emergency department clinicians reported feeling ill-equipped and under-prepared to inquire about and respond to DV. These findings provide valuable insight about the training and support needs of ED clinicians prior to the commencement of routine screening in EDs. © 2017 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.
Introduction Domestic violence (DV) is well recognised as a complex public health issue that has profound and harmful effects upon victims and their families [2,3]. Global prevalence data indicates that close to one third of women have experienced DV and this is associated with immediate and significant health effects including injury, poorer birth outcomes, psychological distress and sexually transmitted disease [3] as well as huge costs to the health system and national economies [4,5]. Given the prevalence and impact of DV it is imperative that health professionals across all healthcare set-
∗ Corresponding author. E-mail address: [email protected] (E. Saberi).
tings are competent in identifying and responding to this form of violence. Routine inquiry about DV can assist in identifying those at risk. A recent meta-analysis reported that screening for DV increased identification by 133% compared with usual care [6]. Identification creates opportunities for women to access education, support, referral and safety planning. Additionally, screening as an intervention has subtle but important benefits for women experiencing violence regardless of whether the violence is disclosed [7]. Research repeatedly demonstrates that screening by healthcare professionals is acceptable to women and, importantly, women are unlikely to disclose their experience of violence unless directly asked [8–11]. There is growing awareness of violence against men committed by their domestic partners, with the scale of the problem also likely to be under reported [2].
http://dx.doi.org/10.1016/j.aenj.2017.02.001 1574-6267/© 2017 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.
Please cite this article in press as: Saberi E, et al. Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.02.001
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Survey secon Demographic characteriscs Is screening warranted in ED
Current screening pracces
Comfort in screening
Factors liming screening
Role most suited to screening Domesc Violence Healthcare Provider Scale (short)
Social worker support
Item type I item - current role classificaon 1 yes/no item 1 item – in what circumstances is screening warranted in ED (rounely all woman; rounely all men; in certain clinical circumstances; for high risk groups of paents) 1 item - which paent groups could be screened (for example: women who have an unexplained injury or an injury that may have resulted from violence; men who have an unexplained injury or an injury that may have resulted from violence; paents with a history of drug and alcohol misuse) 7 items – circumstances in which screening (for example: women who have an unexplained injury or an injury that may have resulted from violence; men who have an unexplained injury or an injury that may have resulted from violence; paents with a history of drug and alcohol misuse) 4 items- comfort in screening (yes, always, no never, in some circumstances; have you had sufficient training for DV; have you had specific training on cultural issues and DV; do you feel comfortable idenfying cultural issues in screening for DV) 3 items plus open ended response item (for example: lack of privacy for paents; I do not know how or who to refer to in situaons of DV; I would find it difficult to cope with the personal emoonal burden of screening) 5 items lisng categories of health professionals in the ED 3 items - Perceived self-efficacy (I feel confident that I can make the appropriate referrals for abused paents); 3 items Fear of offending paents (I am afraid of offending the paent if I ask about DV); 3 items- Professional role resistance (Invesgang the cause of DV is not part of medical or nursing pracce) I item – (I have ready access to social workers or community referrals to assist in the management of DV)
Fig. 1. Summary of survey sections and example items.
Screening for DV in health care settings is recommended in Australia and internationally [12,13]. In Australia, routine screening occurs predominantly in services specifically identified as women’s and children’s services [12]. Rates of routine inquiry about exposure to DV are reported as low in emergency settings, ranging from 2% to 13%.[14]. However, the ED is the first point of contact for many health service users and therefore provides an important opportunity for screening and identification. It is estimated that women experiencing violence attend EDs three times more frequently than those who have not experienced this form of abuse [15]. A recent Australian study reported that 12% of women presenting to EDs did so as a result of an acute episode of DV but less than one in seven of these women were asked about exposure to violence [14]. Whereas data from the United States confirmed that 20% of men attending the ED disclosed DV from a partner in the previous year [16]. A number of studies have examined clinicians’ attitudes, beliefs and knowledge about screening for DV [17–19]. Common barriers to screening identified by clinicians include unease about disclosure leading to further violence, concern about infringing on patient autonomy or causing offence, and lack of evidence on the effectiveness or outcomes from screening [19]. Other reported barriers include inadequate knowledge and lack of education; lack of systems level support and referral systems; environmental factors such as waiting room pressures, throughput targets and medical models of care delivery; insufficient time and lack of privacy; and professional role resistance [17,18]. This study explored ED clinicians’ level of support for DV screening in the department; current screening practices; perceived barriers and enablers to screening; and readiness to screen in
an Australian regional hospital ED. The purpose was to identify training, education and support needs for clinicians prior to the implementation of a DV screening pilot intervention.
Methods A cross-sectional sample of nursing and medical staff employed in one regional public hospital ED in New South Wales, Australia, were recruited for this exploratory survey study. The total possible study sample of staff in the ED was 95. Questionnaire items were generated through a review of the literature, with health care providers’ readiness to screen for DV assessed through items taken from a shortened version of the Domestic Violence Healthcare Provider Scale (short DVHPS) [20]. The DVHPS and short DVHPS have been previously validated in populations similar to those of this study, with demonstrated structural validity and reliability [19,20]. The short DVHPS examines six factors: 1) perceived self-efficacy; 2) fear of offending patients; 3) perceptions about victims/personality traits; 4) professional role resistance; 5) perceptions of victim disobedience; and 6) psychiatric support [19]. For this study, items related to perceptions about victims personality traits and disobedience were excluded as the study was focused upon perceptions about screening rather than healthcare professionals’ perceptions about victim characteristics. For items related to ‘psychiatric support’, wording was changed to ‘social worker support’ to reflect the Australian regional ED context for this study. The questionnaire structure is summarised in Fig. 1, and was as follows: current role classification (1 item); perceptions as to whether screening for DV is warranted in the ED
Please cite this article in press as: Saberi E, et al. Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.02.001
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Table 1 Variation in the four top ranking categories in which DV screening in the ED is warranted according to occupational category. Worker category (n=)
In certain clinical circumstances n (%)
For high risks groups of patients n (%)
Routinely for all women n (%)
Routinely for all men n (%)
nurse (58) medical officer (11)
41 (59.4) 5 (7.2)
23 (33.3) 7 (10.1)
11 (15.9) 2 (2.8)
6 (8.6) 0
n = 69; Missing n = 7.
Table 2 Variations in current self-reported screening practices according to occupational category. Worker category Respondents
Woman with injury n (%)
Pregnant woman with injury n (%)
Men with injury n (%)
Women with mental illness n (%)
Men with mental illness n (%)
Patients with a history of drug and alcohol n (%)
nurse medical officer X2 (value)df
33 (60) 10 (18.2) 0.015 (15.812)6
26 (47.2) 9 (16.3) 0.194 (8.650)6
10 (18.2) 5 (9) 0.036 (13.820)6
6 (10.9) 2 (3.6) 0.050 (12.602)6
5 (9) 1 (1.8) 0.038 (13.32)6
3 (5.4) 1 (1.8) 0.639 (4.27)6
n = 55; Missing n = 11.
(3 items); self-reported current DV screening practices (7 items); comfort in screening and previous DV education (4 items); factors limiting ability to screen (4 items); role most suited to screening for DV in the ED (5 items); and 10 five-point likert scale items on readiness to screen for DV. Readiness to screen was measured in terms of healthcare professionals’ perceived self-efficacy in screening (3 items), fear of offending patients (3 items), and professional role resistance (3 items). The readiness to screen items required respondents to select a response to each statement from 1 (strongly disagree) to 5 (strongly agree). The confidential and anonymous online survey was hosted on the Qualtrics platform. Ahead of the survey being made available, members of the research team conducted information sessions in the ED, informing staff about the study and inviting their participation. The final response rate was 80% (n = 76).
Ethics The study received ethical approval as a quality improvement project from the relevant Human Research Ethics Committee. Implied consent was assumed through completion of the online survey.
Data analysis Data analysis was undertaken using IBM SPSS version 22 [21]. Initially, descriptive statistics were performed to calculate the proportion of respondents in the work group categories and the distribution of responses to each question (valid percentages reported). As the study data did not meet the assumptions of parametric methods, non-parametric alternatives were employed. For categorical variables, the Chi Square test for independence was used to determine relationships between the variables. To facilitate comparisons between scale score on the DVHPS, sum scores for each of the sub-scales were created employing the previously established factor structure for the instrument [19]. The MannWhitney U test was employed to establish statistical differences between groups (occupational group, comfort in screening for DV, belief on whether screening for DV is warranted in the ED, and currently screening for DV) and sum scores on the DVHPS sub-scales. Differences were considered significant at the p < 0.05 level.
Results The majority of respondents were nurses (80.2% n = 61), followed by medical officers (14.4% n = 11; comprising 6 residents and 4 registrars). To establish clinicians’ support for DV screening descriptive analyis was performed. The vast majority reported the belief that screening for DV is warranted in the ED (82.3% n = 65), with 10.6% (n = 8) undecided and 2.5% (n = 2) believing screening is not warranted. All respondents who stated that screening was not warranted in the ED were nurses. Of those who supported screening for DV, the majority supported case-finding for particular high-risk patient groups or screening in certain clinical circumstances (see Table 1). When compared to nurses, medical respondents were less likely to support routine screening for both men and women, while 17.1% (n = 13) of nursing respondents supported routine screening for all women. A Chi Square test of independence was performed to establish whether these differences were statistically significant. The difference between the two groups was not significant X2 (7.882, N = 69, df 5, p < 0.163). Current screening practices The majority of respondents reported that they currently screen in specific circumstances (see Table 2). For both nurses and medical officers the patient group reportedly screened most often were women with unexplained injury, or injury that may stem from violence. Fewer respondents reported currently screening pregnant women or men with unexplained injury. Patient groups least likely to be screened were those with a history of drug and alcohol misuse. A Chi Square test of independence demonstrated a statistically significant difference between the two occupational groups for current screening practices for men with injury X2 (13.82, N = 55, df 6, p < 0.036) and women with injury X2 (15.81, N = 55, df 6, p < 0.015). Barriers to screening The majority of respondents (78.5% n = 56) reported that they were only comfortable screening for DV in certain circumstances. Similarly, the majority reported receiving insufficient training about screening for DV (83.3% n = 55). No statistically significant relationship was identified between self-reported comfort in screening for DV and perception as to whether screening was warranted in the ED X2 (0.557, N = 66, df 2, p < 0.757); or self-reported comfort in screening for DV and current screening practices X2
Please cite this article in press as: Saberi E, et al. Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.02.001
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Table 3 Between group differences on DVHPS self-efficacy sub-scale. DVHPS sub-scale scores
Nurse Mean (SE)
Medical officer Mean (SE)
Never comfortable screening for DV Mean (SE)
Comfortable screening for DV Mean (SE)
Perceived self-efficacy
8.54* (0.26)
9.87 (0.47)
6.33* (0.88)
8.87 (0.25)
Mann-Whitney U. b only one subject in this field. * Denotes statistically significant at p < 0.05 Asymp. Sig. (2 tailed). Table 4 Between group differences on DVHPS fear of offending sub-scales DVHPS sub-scale scores
Screening is warranted in the ED Mean (SE)
Screening is not warranted in the ED Mean (SE)
Fear of offending patients
6.54* (0.32)
11.00 (0.73)
Mann-Whitney U. * Denotes statistically significant at p < 0 0.05 Asymp. Sig. (2 tailed).
(0.066, N = 66, df 1, p < 0.797). For the item, I have no time to ask about DV in my practice, 19 (34.5%) nurses agreed with this statement, while 1 (9%) medical officer agreed. This between group difference was statistically significant X2 (4.814, df 1, N = 55, 5 p < 0.26). Differences between groups in readiness to screen Between group analysis on scores (Tables 3 and 4) for the DVHPS sub-scales employing the Mann-Whitney U test identified that, mean self-efficacy scores for nurses were significantly lower than the scores for medical officers (p = < 0.05). The analysis also identified significant associations between self-reported self-efficacy and; comfort in screening for DV (p = < 0.05); having received sufficient training in DV (p = < 0.01). For the fear of offending sub-scale, significant associations were identified between lower scores for fear of offending patients and the belief that DV screening is warranted in the ED, suggesting fear of offending played a significant role in influencing whether enquiry about DV occurred. Discussion This study examined the perceptions and current DV screening practices of a group of ED clinicians prior to the implementation of a DV screening pilot intervention. The study found that ED clinicians currently employ a case-finding approach to DV screening in the absence of a mandated screening policy. While clinicians were generally supportive of DV screening in the ED, the majority did not feel adequately prepared to undertake DV screening. Thus, clinicians who feel under-prepared for screening may be more likely to inquire about DV when indicators of violence are present. This approach increases the likelihood of missing cases of DV, with only one in seven women presenting to the ED as a result of acute DV, actually being screened for DV [13]. Our results provide important guidance for the development of appropriate training, education and support for ED clinicians prior to commencing routine DV screening. While the vast majority of clinicians surveyed were supportive of DV screening in the ED, most recommended a case-finding approach, which involves inquiring about violence only when potential indicators of violence are present, and reported that they currently screen selectively using case-finding methods. The rates of screening reported were similar to those reported in other studies of screening for DV in emergency settings [13,22]. In the state in which this survey was conducted, DV screening has been mandated for more than a decade in antenatal, early childhood, mental health and drug and alcohol services as these groups
have been identified as being at particular risk of experiencing violence [23]. It is notable that these patient groups, when presenting to the ED with unexplained injury consistent with violence, were not foregrounded by clinicians for DV assessment. This suggests that screening based on health professionals’ perception of whether patients are likely to experience DV may bias case selection. This is consistent with previous studies which found that screening by nurses in an ED was influenced by stereotypes and beliefs about victims and nurses’ perceptions of the demeanour of the woman [24,25]. Selective screening based on health professionals’ personal judgement may fail to target those most at risk. Our findings therefore suggest that clinicians in the ED would benefit from education regarding the evidence base for universal screening prior to the introduction of a screening program. Similar to results reported in other studies [26], healthcare professionals in this study reported that they had not received sufficient training in screening for DV. There was also a difference between groups for perceptions about whether there was time to ask about DV. Previous research has demonstrated that ED clinicians are more likely to inquire about DV when they have received training and are supported by access to DV advocates, clear documentation, referral pathways and unit based policies and procedures [27,28]. Training has been shown to support healthcare workers to reduce barriers to screening, alleviate concerns about screening for DV, enhance perceived self-efficacy in identifying and responding to DV, overcome fear of offending, and increase knowledge about intervention and referral pathways [29]. In terms of staff readiness to screen, clinicians with lower perceived self-efficacy were less likely to enquire about DV in their current practice. Additionally, fear of offending significantly influenced comfort about inquiring about DV. Unease about disclosure leading to further violence, concern about infringing on patient autonomy or causing offence, and lack of evidence on the effectiveness or outcomes from screening have all been previously reported as clinician concerns and reasons for not enquiring about DV [18]. In part, these concerns have been answered through the growing body of evidence which repeatedly reports that enquiring about DV does not increase risk of harm [18] and that women are generally accepting of such screening [6,10], with women who have experienced violence being more likely to support policies that mandate screening [9]. An important enabler for health professionals to enquire about DV is the creation of an institutional context where staff feel supported and able to respond appropriately. Both fear of offending and professional role resistance may be related to the ability to offer victims access to additional support in response to their identified needs. These results suggest that training on responding to disclosures and understanding appropriate information and referral pathways is needed to increase health providers’ comfort in communicating with adults and children affected by DV. However, education alone may not result in sustained improvement in screening practices. Barriers such as professional norms and narrow role interpretations may only be addressed by cultural change in the prevailing values and practices of a department. Changes that may support improved screening for DV include workflow re-design and supporting health professionals to advo-
Please cite this article in press as: Saberi E, et al. Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.02.001
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cate for and support systems change. Ambuel and colleagues note that ED culture can be improved to support DV screening and intervention, with improvement requiring change at the individual clinician level, as well as the systems level to support the active involvment of clinicans in the change process [30]. Hammock et al. report that a senior clinician serving as a role model and an advocate for screening can help shift norms about screening in the ED [31]. Limitations The small sample in this study is drawn from one Australian hospital ED, this may limit generalisability of the findings. Furthermore, as the data is recall of self-reported practice, it is possible that socially desirable responding and difficulty with recall may have influenced responses. Despite these limitations, the findings correlate with previous research regarding barriers and enablers to screening in health services. Implications and conclusion Routine screening for DV by a skilled health worker increases the identification of violence and provides opportunities for education and support. Clinicians in the study site ED currently employ and advocate a case finding approach to enquiry about DV, which risks leaving many instances of violence undisclosed. The introduction of routine screening for DV requires appropriate training and support. This study provides a platform for the development of appropriate training programs and systems level support for clinicians participating in a pilot intervention of routine DV screening in a regional hospital ED. These findings have relevance for other EDs developing front line responses to domestic and family violence. Conflicts of interest The authors confirm that they have no conflicts of interest to declare. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contribution statement MH, ES, MM, SP and NE conceived and designed the study and developed the study protocol. MH supervised data collection and analysed the data. MH, ES, SP and FD reviewed the data analysis and prepared the manuscript. All authors approved the manuscript for submission. References [1] Lawoko S, Sanz S, Helstrom L, Castren M. Assessing the structural validity and concurrent validity of a shortened version of the Domestic Violence Healthcare Providers Survey questionnaire for use in Sweden. Psychology 2012;3:183–91. [2] Morgan A, Chadwick H. Key issues in domestic violence Research in Practive, vol. 7. Canberra: Australian Institute of Criminology; 2009. [3] World Health Organisation. London School of Hygiene and Tropical Medicine, Council SAMR. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. In: Department of reproductive health and research WHO. Geneva: World Health Organisation; 2013.
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Please cite this article in press as: Saberi E, et al. Ready, willing and able? A survey of clinicians’ perceptions about domestic violence screening in a regional hospital emergency department. Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.02.001