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O L D E R PE O P L E

Care for emergency department patients who have experienced domestic violence: a review of the evidence base Philippa Olive

BSc (Hons), MSc, RN, RSCN

Senior lecturer – emergency nursing, Department of Nursing, University of Central Lancashire, Preston, UK

Submitted for publication: 15 November 2005 Accepted for publication: 19 May 2006

Correspondence: Philippa Olive Senior lecturer – emergency nursing Department of Nursing University of Central Lancashire Preston PR1 2HE UK Telephone: þ44 01772 893626 E-mail: [email protected]

Journal of Clinical Nursing 16, 1736–1748 Care for emergency department patients who have experienced domestic violence: a review of the evidence base Aims. A literature review was conducted to identify and evaluate the research base underpinning care for emergency department patients who have experienced domestic violence. Background. The extent of domestic violence in the general population has placed it high on health and social policy agendas. The Department of Health has recognized the role of health care professionals to identify and provide interventions for patients who have experienced domestic violence. Method. Systematic review. Results. At least 6% of emergency department patients have experienced domestic violence in the previous 12 months although actual prevalence rates are probably higher. Simple direct questioning in a supportive environment is effective in facilitating disclosure and hence detecting cases of abuse. Although routine screening is most effective, index of suspicion screening is the current mode of practice in the UK. Index of suspicion screening is likely to contribute to under-detection and result in inequitable health care. Patients with supportive networks have reduced adverse mental health outcomes. Women will have negative perceptions of emergency care if their abuse is minimalized or not identified. Women want their needs and the needs of their children to be explored and addressed. Access to community resources is increased if patients receive education and information. Conclusion. Domestic violence is an indisputable health issue for many emergency department patients. Practitioners face challenges from ambiguity in practice guidelines and the paucity of research to support interventions. Recommendations for practice based on the current evidence base are presented. Relevance to clinical practice. The nursing care for patients in emergency and acute health care settings who have experienced domestic violence should focus on three domains of: (1) Providing physical, psychological and emotional support; (2) Enhancing safety of the patient and their family; (3) Promoting self-efficacy. OLIVE P (2007)

Key words: acute care, domestic violence, emergency care, nurses, nursing

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2007 The Author. Journal compilation 2007 Blackwell Publishing Ltd doi: 10.1111/j.1365-2702.2006.01746.x

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Care for emergency department patients

Introduction The term ‘domestic violence’ has been used within this paper as it is the most commonly used and recognized term for intimate partner abuse, and is defined as: ‘…the actual or threatened physical, sexual, financial, or emotional abuse of a person by someone with whom they have or have had an intimate, familial or emotional relationship’ (Royal College of Nursing 2000, p. 2).

Domestic violence is associated with long-term negative health consequences resulting from physical and psychological sequelae (Campbell 2002). Adverse health outcomes associated with domestic violence are described by Campbell (2002) as injury, stress, chronic pain, depression, posttraumatic stress disorder, sexually transmitted diseases and gastrointestinal and gynaecological symptoms. The global nature and serious impact of domestic violence is recognized by the World Health Organization (WHO) who illustrate that that not only does domestic violence have a profound effect on health, but also on an individual’s self-esteem and ability to participate in the world (Krug et al. 2002). To discover the degree of domestic violence in the UK a computer assisted questionnaire was undertaken as part of the 2001 British Crime Survey (BCS) (Walby & Allen 2004). The survey found that domestic violence is manifest across all cultures and societal groups with one in four women and one in six men having experienced abuse by a current or former partner (Walby & Allen 2004). The extent of domestic

violence in the general population has placed tackling domestic violence high on social and health policy priorities (Home Office 1999a,b, Department of Health 2000, 2005). Although not a discrete priority for health improvement in the white paper Saving Lives: Our Healthier Nation (Department of Health 1999), the adverse health outcomes of domestic violence, for example stress, substance misuse and depression are features associated with priority areas such as coronary heart disease, accidents and mental health, respectively. The importance placed on care for patients who have experienced domestic violence is evident in the Department of Health (2005) document Responding to domestic abuse: a handbook for health professionals. This handbook identifies the role of health care professionals to identify and provide interventions for people who are experiencing domestic violence.

Aims and objectives The aim of this study is to present a critical review of all the available research relevant to the emergency care of patients who have experienced domestic violence. The objectives are to: 1 Identify and bring together all research to collate the body of knowledge for the emergency care of patients who have the experienced domestic violence; 2 Critically discuss the findings in light of research design, practice guidelines and the context of healthcare; 3 Develop recommendations for practice founded on the current research base.

Table 1 Literature search strategy Database

Search terms

The Cochrane Library

MeSH and/or keyword Domestic violence or spouse abuse or battered women or abuse emergency MeSH and/or keyword Interpersonal abuse or interpersonal violence or domestic abuse or domestic violence or spouse abuse or spouse violence or interpersonal relations or partner abuse or partner violence or battered women or family violence or battered females and emergency nursing or emergency medicine or emergency services or emergency care or emergency medical services or emergency service hospital Keyword Interpersonal abuse or interpersonal violence or domestic abuse or domestic violence or spouse abuse or spouse violence or interpersonal relations or partner abuse or partner violence or battered women or family violence or battered female and Emergency Department of Health: http://www.dh.gov.uk Home Office: http://www.homeoffice.gov.uk, http://www.crimereduction.gov.uk, http://www.homeoffice.gov.uk/crime/domesticviolence Royal College of Nursing: http://www.rcn.org.uk Women’s Aid Federation http://www.womensaid.org.uk

MEDLINE/CINAHL AMED

PsychINFO/ ZETOC

Internet sites

2007 The Author. Journal compilation 2007 Blackwell Publishing Ltd

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Method: literature review A review, critically appraising all current and relevant available evidence is fundamental to evaluation (Glasziou et al. 2001) and the search strategy (Table 1) was developed to achieve this. Search terms were adjusted to complement and account for differences in database systems. No language or time restrictions were applied. The search strategy was very broad and encompassing; this approach was applied to capture all material and maximize the search product. Whilst this approach generates large volumes of material, posing difficulties in specificity, it provides confidence in the sensitivity of the search in precluding omissions. Abstracts were then reviewed and inclusion criteria included primary research papers relating to prevalence, screening or interventions for emergency department patients. The product of the literature search was collated into discrete categories designated as prevalence, screening

and intervention. Prevalence encompassed any studies of an epidemiological nature about domestic violence amongst emergency department patients. Screening was concerned with effectiveness of methods for screening emergency department patients for domestic violence. Intervention included any research aiming to evaluate interventions for emergency department patients who have experienced domestic violence.

Results Prevalence Prevalence of domestic violence has been researched within the general population (crime surveys) and health populations (health research). Domestic violence has a propensity to be under detected in crime surveys because of perceptions by some that it is not a crime and the personal risk of reporting. In an attempt to counter this, the BCS of 2001 (Walby &

Table 2 Studies of prevalence of domestic violence in emergency department patients Time measure of domestic violence

Study

Setting

Measure

RR (%)

Abuse related visit

Sethi et al. (2004)

ED UK ED UK ED France ED USA ED USA ED USA ED USA ED USA ED AUS ED AUS ED, WIC USA ED AUS ED AUS

Written survey

87

*

Verbal survey

85

Verbal survey

100

Interviews

70

ISA

50

GWUUVPNSP

80

PSSS AAS ISA

74

*

94

*

CTS

68

*

*

CTS

54

*

*

ISA DAS Interview

78

*

82

*

Boyle and Todd (2003) Lejoyeux et al. (2002) Krishnan et al. (2001) Ernst et al. (2000) Mechem et al. (1999) Dearwater et al. (1998) Ernst et al. (1997) Roberts et al. (1996) De Vries-Robbe et al. (1996) Abbott et al. (1995) Bates et al. (1995) Roberts et al. (1993)

Adapted CTS

75

Now

*

In year

Lifetime

*

*

*

* *

*

* *

* * *

* *

*

* *

*

*

CTS – Conflict tactics scale; DAS – Danger assessment screen; AAS – Abuse assessment screen; IAS – Injury assessment screen; ISA – Index of spouse abuse; GWUUVPSP – George Washington university universal violence prevention screening protocol; PSSS – Patient satisfaction and safety survey; RR – Response rate. 1738


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Allen 2004) used a computer-assisted self-completion questionnaire to explore domestic violence. This method offered greater anonymity and encouraged the reporting of incidents of domestic violence that victims did not perceive as a crime. During 2001 the BCS (Walby & Allen 2004) estimated that 6% of women and 5% of men experienced physical assault or frightening threats within the previous year. This increased to 13% (women) and 9% (men) with the inclusion of acts of sexual violence. Two-thirds of women had endured more than one attack within the previous year raising the incidence for women to three times greater than men. Lifetime prevalence of domestic violence (non-sexual violence), was estimated at almost 26% for women and 17% for men. However, the prevalence of domestic violence within emergency department patients may be different as this is a population with inherent characteristics (acute injury and illness) not shared with the general population. The literature search identified 18 studies examining prevalence of domestic violence in patients attending emergency departments. Generally, the papers report descriptive cross-sectional surveys that identified cases of present or past domestic violence. Five studies were excluded, three that did not report response rates and a further two had such low response rates that sample bias must be considered. Table 2 presents a collation of studies reporting prevalence of domestic violence amongst emergency department patients. There is variety in the measurement of prevalence, including when it occurred and the instruments used to gather data. Seven different types of questionnaire have been applied and in eight studies the actual tool used is not disclosed

although some state that local experts have validated or adapted questionnaires. Additionally, studies vary in respect of their inclusion of non-physical or sexual types of domestic violence. Lifetime prevalence is the most commonly reported period of measure (Fig. 1). Lifetime prevalence was greater amongst patients in one English emergency department (Sethi et al. 2004) but similar in another (Boyle & Todd 2003) when compared with BCS (Walby & Allen 2004). Higher prevalence could be attributable to continuing adverse health outcomes. The studies demonstrate a range of 0Æ8–11Æ7% of emergency department attendances directly attributable to domestic violence although the majority of studies show the figure

20% Male victims

Female victims

Combined

15%

10%

5%

0%

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Figure 2 The ED patients who report experience of abuse within the last 12 months.

60% Female victims

Male victims

Combined

50%

40%

30%

20%

10%

0%

Figure 1 Lifetime prevalence of domestic violence.

2 1 9 0 8 5 3 5 6 7 6 3 4 00 00 99 00 99 99 99 99 99 99 99 00 00 l. 1 al. 1 l. 1 al. 1 al. 1 l. 1 al. 1 l. 2 al. 2 al. 2 al. 1 S 2 al. 2 a a a a C t t t t t t t B et et et et et te re s e be e ott e tes e rts e ux rnst hem thi yle ate Erns bert a ob Abb Se be E c w Bo ejoye B r o o R e a R R M L ies De Vr De


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Combined

10%

5%

0%

thi

Se

e

l. ta

04

20

yle Bo

l. ta

03

20

e

l. ta

ne

na

K

h ris

01

20

r ts

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l. ta

96

19

tt e bo b A

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95

19

tes

l. ta

19

95

e

Ba

Figure 3 The ED attendance directly related to episode of domestic violence.

to be between 1% and 3Æ5% (Fig. 3). Patients who have experienced domestic violence are more likely to attend the emergency department within a year of abuse than attend with an acute injury as a result of abuse (Campbell 2002). This is evident from Fig. 2, which highlights that between 1Æ3% and 15Æ3% of emergency department patients experienced abuse in the previous 12 months.

Screening The emergency department has been acknowledged as a place where people with injuries as a result of domestic violence may seek help, being the third choice after friends/family and police (Pakieser et al. 1998). A positive screen for domestic violence is the catalyst for developing an appropriate and negotiated plan of care. Screening involves asking the patient directly about their personal experience of domestic violence and screening can be routine or based on an index of suspicion. Routine screening means asking all patients within broad criteria, for example, all patients aged 16 or over about domestic violence. Index of suspicion screening means asking patients only if the health care professional feels there are factors present suggestive of domestic violence. Index of suspicion screening is the current mode of practice in most emergency departments in the UK. The effectiveness of any screening programme is determined by the accuracy of tests (Muir-Gray 2001), i.e., the sensitivity and specificity of the screening instrument (Bowling 2002). There is a strong body of evidence acknowledging that simple direct questioning is effective in facilitating disclosure of domestic violence and hence detecting cases (McFarlane et al. 1995, Feldhaus et al. 1997, Morrison et al. 2000). Research has shown that when emergency department patients are routinely asked about domestic violence, detec1740

tion rates significantly increase (Olsen et al. 1996, Larkin et al. 1999, 2000, Morrison et al. 2000). Despite the body of research, attempts to introduce routine screening in practice have not always been successful. Barriers to the introduction of routine screening have been classified as informational, institutional or affective (Davis & Harsh 2001). Informational factors correspond to inadequate knowledge and skills (Ellis 1999, Ramsden & Bonner 2002), although education alone has not demonstrated increased detection rates (Roberts et al. 1997). Institutional factors relate to lack of privacy (Ellis 1999, Davis & Harsh 2001, Ramsden & Bonner 2002), lack of after-hours social services (Ramsden & Bonner 2002) and lack of time (Ellis 1999). The lack of after-hours services could also possibly explain why patients in Larkin et al.’s (1999) study were more likely to be screened during daytime hours. Effective barriers to screening have been linked to lack of staff ownership of a project, a belief that the questions were inappropriate for the type of presentation and a feeling that men and older patients were being neglected (Ramsden & Bonner 2002). Methods that have demonstrated effectiveness in increasing the number of patients screened include medical record reminders (Olsen et al. 1996) and disciplinary action (Larkin et al. 2000). The introduction of a domestic violence policy increased case detection (Fanslow et al. 1998) although this increase was not sustained at one-year follow-up (Fanslow et al. 1999). Patients generally find being asked about domestic violence acceptable (Ramsey et al. 2002, Sethi et al. 2004, Hurley et al. 2005). However the effectiveness of screening is adversely affected if the health care professional displays any attributes that may suggest lack of empathy, understanding or respect as patients are less likely to disclose (Yam 2000, Dowd et al. 2002). Issues of child protection as a result of disclosure also concerned participants in Dowd et al.’s (2002) study. Glass et al. (2001) found that 80–87% of abused and non-abused women supported routine screening and patients in Ramsden and Bonner’s (2002) study felt that they would also have liked to have been asked about family life, emotional abuse as well as physical abuse and threats against their children.

Interventions The emergency department is characterized by managing single, out of the ordinary health deficit events and is not resourced to provide definitive interventions for long-term goals. The scope of care provided to patients who have experienced domestic violence should address short-term


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Table 3 Summary of studies showing research aims and design Study

Aim

Design

Muelleman and Feighny (1999)

To determine whether an ED based advocacy programme resulted in increased community resource utilization by battered women To investigate whether self-efficacy scores can be improved by an educational programme designed for battered women To determine associations between intimate partner violence and mental health outcomes and to assess the protective role of abuse disclosure and support on mental health among abused women To describe the resources used by women who have been battered To determine the perceptions of shelter advocates and battered women regarding the treatment of battered women in emergency departments To describe battered women’s perceptions of their ED experience To describe the perceptions of female domestic violence victim’s experiences in the ED and to determine potential barriers to related to outcomes

Positivist observational Type 3 before-after study

Varvaro and Palmer (1993)

Coker et al. (2002)

Pakieser et al. (1998) Campbell et al. (1994)

Yam (2000) Wendt-Mayer (2000)

goals and appropriate referral for ongoing health and social care. The literature search identified seven studies evaluating emergency department care for patients who have experienced domestic violence, a list of these is presented in Table 3. Only three of these aim to evaluate the effectiveness of specific intervention. The effectiveness of health care within the emergency department may be difficult to evaluate because of loss of follow-up of patients to other services. Some studies have overcome researching across practice boundaries; for example, referrals to and uptake of community resources were measured and had increased as a result of implementing an emergency department advocacy programme (Muelleman & Feighny 1999) and a domestic violence policy (Fanslow et al. 1998). Although these studies demonstrate increased use of resources there is no determination of impact upon the patients’ health and well-being. The paucity of research reporting effectiveness of interventions for domestic violence in terms of cause and effect influencing health and well-being outcomes has been widely reported in systematic reviews (Davidson et al. 2000, Ramsey et al. 2002, Wathen & MacMillan 2003, Coulthard et al. 2004). However, one study (Coker et al. 2002) sought to evaluate the protective role of abuse disclosure and support on the mental health of abused women. Although Coker et al.’s (2002) sample was from family practice, the act of disclosure may have occurred in any setting. Using validated instruments they found that disclosure of abuse was not associated

Positivist observational Type 3 before-after study Positivist observational cross-sectional retrospective survey

Positivist observational cross-sectional survey Positivist observational cross-sectional survey

Constructivist phenomenological inquiry Pluralist design, positivist Type 1 (descriptive) observational survey, and constructivist qualitative enquiry, focus groups

with a significant risk reduction for adverse mental health outcomes. However, if the listener’s reaction to the disclosure was consistently supportive a reduced risk of suicide ideation and actions were seen. Abused women with higher social support were also significantly less likely to report poor mental and physical health. Coker et al.’s (2002) findings suggest that abused women who receive more support may experience better mental health although it is also possible that those able to find social support are those who would not develop adverse mental health outcomes anyway. Varvaro and Palmer (1993) evaluated an educational support group using perceived self-efficacy scores of battered women pre and post the intervention. Increases in perceived self-efficacy scores were seen post-intervention. Whilst the sample for this study is too small to permit generalizability, it highlights a possible measure (self-efficacy) for evaluating outcomes for some interventions, such as safety planning. Whilst not showing improvement to measurable health outcomes, some studies demonstrate an increase in the use of shelters and counselling (Muelleman & Feighny 1999). Arguably, these findings suggest positive changes in selfefficacy. However, there may be potential harm from increased perception of self-efficacy. Interventions may improve safety behaviour and reduce risk but conversely the perception of increased safety may introduce increased risk behaviour and place the individual in more danger.


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Health care interventions have also been evaluated through exploration of the patients’ experience. Yam (2000) used a phenomenological approach to study a sample of women in shelters who had attended an emergency department within the past year. Women perceived emergency department staff to be unconcerned, controlling, rushed, only concerned with treating physical injury and lacking in humaneness and compassion. The women felt embarrassed, lonely, afraid, angry and frustrated and were concerned for their children. They would have liked emergency care to explore options, address safety issues and provide referrals. Wendt-Mayer (2000) also sampled women from shelters and applied a pluralist design of focus groups and survey questionnaires. Although the women attended the emergency department with complaints that were primarily physical in nature, 20% had purely emotional or psychological complaints. If the health care practitioner demonstrated a non-blaming approach, then the participants would be anxious to divulge the extent of their problem. Most common influences for non-disclosure related to fear of not being taken seriously if they were not willing to press charges, fear of their abuse being minimized and loss of confidentiality. Minimalization of abuse is a theme also identified in Campbell et al.’s (1994) survey of women in refuges. Fifty per cent of those surveyed reported a negative experience of care in the emergency department. The factors that were contributory to their negative experience were feelings of humiliation, being blamed and having their abuse minimized or not identified. The research demonstrates that women who have experienced domestic violence do seek care from the emergency department (Pakieser et al. 1998) with physical and psychological complaints (Wendt-Mayer 2000). Disclosure of domestic violence should take place in a supportive environment (Yam 2000, Coker et al. 2002) and the patient should be encouraged to develop supportive networks (Coker et al. 2002). Women receiving care in the emergency department want all their needs to be identified and to have the opportunity to address their children’s needs, and explore safety, options and be given referrals (Yam 2000, Ramsden & Bonner 2002). Women will have negative perceptions of emergency department care if their abuse is minimalized, not identified or if their decisions are not understood and respected (Campbell et al. 1994, WendtMayer 2000). Care that includes education and information will increase access to community resources (Muelleman & Feighny 1999). Emergency nurses have a vital role in providing care interventions for patients who have experienced domestic violence. In addition to any physical care required, this role includes giving support, enhancing safety and promoting 1742

self-efficacy. Support includes emotional and psychological care through listening and showing empathy, understanding and respect for patients’ decisions, which will vary according to individual circumstance. More tangible support is provided through informing patients that they are not alone and that many others have similar experiences and share their feelings. Working with patients, nurses can enhance safety by helping patients to assess risk and encouraging patients to have safety plans in place. Safety planning should address places to avoid when abuse starts, and access to money, important documents, supplies and a place of safety in case of emergency (Department of Health 2005). Nurses can promote self-efficacy by providing information about domestic violence, and support and options available. Information should include the national and local domestic violence helpline telephone numbers. National helpline telephone numbers for the countries of the United Kingdom can be found on the Women’s Aid Federation website (http:// www.womensaid.org.uk, accessed 30/03/06). This website also provides details of additional helplines providing specific support to children, men, people who are gay, lesbian, transgender or bisexual and for people who have experienced sexual violence. Information on the website is available in 11 languages. The Women’s Aid Federation services provide emotional and practical support to those experiencing domestic violence and to friends, family or external agencies calling on behalf of a woman (Women’s Aid Federation 2006) and hence are a valuable resource for nurses. Nurses should provide patients with information about other relevant local domestic violence services, for example refuge, counselling, legal, police, housing and social services. Additionally, information about community support groups that reflect the patient’s particular gender, race and sexuality may also be helpful. Safety of the patient and their children is paramount. Consequently, it is important that whilst supporting the patient and providing information that can enhance self-efficacy the nurse should ensure that the patient remains mindful of their risk from abuse. In collaboration with the patient nurses should endeavour to refer patients to other professionals who may be helpful such as a social worker, health visitor or school nurse. However, if the patient considers that they and their children are at risk they may have immediate safety requirements and referral to and placement with a women’s refuge can be arranged. An accurate record of the episode is essential, which may also be needed for legal action in the future. Forensic record keeping, for example, photography and exact descriptors can also be offered in cases of physical abuse, which provide good quality records for use at a later time if so desired by the patient. It is also possible that this process


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may also help the patient by explicitly validating their experience.

Discussion Prevalence Most studies of prevalence imposed similar exclusion criteria, for example, patients who presented with critical illness or injury, intoxication or mental health problems. Whilst arguably ethically appropriate, these exclusions represent a considerable pool of patients and may affect generalizability and truth of findings. In light of the health consequences of domestic violence highlighted by Campbell (2002) such as stress, depression and substance misuse it is likely that prevalence rates of domestic violence would be greater if these patients had been included in the research. In addition, research design with a focus on physical abuse is also likely to underestimate true prevalence. Generalizabilty is also adversely affected by the diversity of research instruments and research design. Roberts et al. (1993) found that the majority of patients who had experienced domestic violence attended the Emergency Department between 5PM and 8AM , consequently the studies of Lejoyeux et al. (2002), Krishnan et al. (2001) and Bates et al. (1995) may be under-reporting prevalence rates as they surveyed participants during the day and very early evening. Six of the studies were conducted in the USA, four in Australia, two in the UK and one in France. This presents challenges when considering the findings in the context of UK emergency departments. Walby and Myhill (2001) recognize differences in health care contexts between the UK and the USA that also may preclude generalizabilty of findings, these include a lower incidence of violent crime in the UK; and differences in the criminal justice system, welfare systems, pattern of gender relations and social relations. Findings from Australian, French and English studies were at the lower end of the prevalence rate range. There may be more commonalities in health care systems and social violence between these countries than with the USA. The two studies that present a UK perspective (Boyle & Todd 2003, Sethi et al. 2004) demonstrate some congruence in their findings; approximately 1% of patients are attending the emergency department as a direct consequence of domestic violence and 6% have experienced domestic violence in the previous year. These figures are not particularly high. However, when translated into more meaningful data the number of patients affected is considerable. For example, in an average sized general hospital with an emergency department attendance of 70 000 patients per annum, this


equates (within a one-year period) to 700 female patients attending as a direct consequence of domestic violence and 4200 female patients who have experienced domestic violence during the previous 12 months. This number of patients is clearly significant for practice. It is also likely that characteristics of patient presentation will reflect the longterm health impacts of abuse, and domestic violence may not be immediately evident. Whilst some patients will present with actual physical injury it is likely that far more will have complaints such as stress, chronic pain, depression, gastrointestinal problems, gynaecological problems, suicidal intention and substance abuse (Campbell 2002).

Screening The literature on prevalence has identified that many patients do not attend with acute trauma, it is more likely that they will present with generalized complaints. The practice of index of suspicion screening poses many challenges. The instrument of index of suspicion screening (the health care worker) is likely to be shaped by subjectivity as well as personal knowledge base. Consequently challenges to the effectiveness of index of screening for domestic violence include inter-rater and test–retest reliability. An example of this is provided by Ellis (1999), who conducted a retrospective record review to audit whether screening was taking place. Charts were included in the review if they matched criteria for abuse. Ellis (1999) found that only 8Æ8% of those that matched the criteria had been screened. Therefore, it is likely that index of suspicion screening may result in underdetection of cases because of the diversity of clinical presentation and individual subjectivity. The health care professional’s subjectivity may also only recognize a limited view of patient experience and the effects of living with domestic violence. Maxwell (1992) proposes that access, equity, effectiveness, relevance, acceptability and efficiency are the elements of quality health care. Equity and quality are fundamental principles of health care service reform in the UK, first realized within the white paper The New NHS, Modern, Dependable (Department of Health 1997). Therefore, ineffective under-screening leading to under-detection and harbouring inequitable health care by preventing access to subsequent care is incongruent with current health policy. The complex health outcomes from domestic violence make it highly probable that index of suspicion screening contributes to inequity and reduced quality of health care for patients. The Department of Health (2000) practice guide suggested that routine, universal screening for domestic violence in the


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emergency care setting may be appropriate. However, whilst suggesting that routine screening may be appropriate the guideline stated that: Failure to pick up on warning signs during brief contact in the A&E department could be the loss of the only opportunity to offer help (Department of Health 2000, p. 19).

This statement implicitly suggests the practice of index of suspicion screening through the ‘picking up of warning signs.’ This ambiguity has probably arisen from the lack of evidence demonstrating effectiveness of interventions. Index of suspicion or selective screening continues to be recommended practice in the most recent practice guide (Department of Health 2005); however, it goes on to suggest that trusts should be working towards routine enquiry. The effectiveness of therapy has a direct impact on screening (Muir-Gray 2001) and, arguably, if interventions have not been shown to be effective then there is little point in screening at all. This is the stance of Ramsey et al. (2002) who conducted a systematic review to assess the acceptability and effectiveness of screening women for domestic violence in health care settings. Their review found that screening programmes generally increased detection; however, evidence of effectiveness of subsequent interventions on quality of life or mental health outcomes was not found. The lack of evidence is corroborated within other systematic reviews by Coulthard et al. (2004) and Nelson et al. (2004) where screening and interventions are judged by observable outcomes of benefit or harm. Ramsey et al.’s (2002) conclusion that screening programmes for domestic violence in health care settings cannot be justified is based on the principle of clinical effectiveness: that the practitioner must be reasonably certain that an intervention has demonstrated its capacity to produce a health benefit in practice through empirical evidence (NHS Executive 1996). This perspective is the likely rationale for the current system of index of suspicion screening in place in UK emergency departments. Although robust from a positivist perspective, Ramsey et al.’s (2002) review does not include interpretative research. The research findings from a search, which included these types of studies are presented here within the intervention section of the literature review.

Interventions It is likely that many acute care settings share the characteristics of the emergency department: that is, caring for out of the ordinary health events. Consequently the findings may be transferable to all acute care settings. The body of research generally correlates with current practice guidelines (Depart1744

ment of Health 2005) recommending that health care interventions in the emergency department should be targeted towards both physical and psychological well-being. Recommended interventions include management of the presenting clinical condition, identification that abuse may be taking place, screening for abuse, the provision of support, respect and privacy, validation of abuse, safety planning, risk assessment, referral to community resources and accurate documentation of the event and history. Although the guidelines make recommendations regarding a supportive environment there is no recommendation that health care professionals should assist patients to identify and develop a supportive network other than by referral to community agencies. Children in homes where domestic violence has taken place may have also encountered abuse (Williams 2003) and associated adverse health outcomes. The importance in safeguarding children is highlighted by Krishnan et al. (2001) who show a relationship between childhood abuse and/or the witnessing of parental partner abuse and of being in an abusive intimate relationship as an adult. Williams (2003), p. 441) suggests that a ‘life course perspective of family violence is needed’ to connect the different types of abuse along the life continuum. Children in families where domestic violence takes place must be considered as being at risk of abuse themselves (Williams 2003). This is recognized in the research of Yam (2000) and Ramsden and Bonner (2002) where women wanted not only their needs but also their children’s needs to be addressed. Consequently domestic violence cannot be viewed independently, the context of abuse must also be considered. Care should, therefore, take into account the needs not only of the patient but also their families and children. Focus should be placed on family care and on safeguarding the patient and their children, a perspective that has only recently been wholly acknowledged within Department of Health guidance (Department of Health 2004, 2005). Studies of patient experience are founded on research of women in shelters, which may not be representative of the whole population of people who experience domestic violence. Furthermore, all the studies are set in the USA where domestic violence and social policies are different to the UK in areas of criminal justice, welfare and health systems (Walby & Myhill 2001). It is apparent that the research base for this area of practice is limited, an issue which has been highlighted previously in a number of systematic reviews leading to the conclusion that no evidence to support interventions exists. However, these reviews are based on an approach which places greater value on research conducted in a positivist tradition with randomized controlled trials


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as a gold standard. Whist it could be argued that interpretative research from patients lacks traditional scientific rigour it cannot be ignored, particularly in the light of the paucity of cause and effect studies in this field. The research base also fails to acknowledge male patients and those in same-sex relationships who experience domestic violence. In terms of evaluative research the studies presented here offer little by way of evaluation of the effectiveness of interventions provided. However, they do provide material, which can be used to inform practitioners, policy and further research design.

Conclusion At least 6% of emergency department patients have experienced domestic violence within the previous 12 months. The prevalence of domestic violence is likely to be higher amongst emergency department patients than in the general population. In consideration of the long-term adverse health outcomes associated with domestic violence it is also probable that there is a greater prevalence of domestic violence in all acute health care settings. People who have experienced domestic violence present to the emergency setting with a diverse range of complaints including: trauma, inappropriate history, vague complaints, stress, chronic pain, depression, gastro-intestinal complaints, gynaecological complaints, suicidal intention and substance abuse (Campbell 2002). The Department of Health (2005) has issued a handbook for health care professionals which identifies their role in identifying and providing interventions for people who are experiencing domestic violence. Children in families where domestic violence has taken place are at risk and may have encountered abuse and associated adverse health outcomes. Therefore care should be focused not only on the adult but also their family. An holistic approach is warranted and nursing care should be planned collaboratively with the patient, targeted towards physical and psychological well-being. Nursing care should incorporate activities within the domains of: 1 Providing physical, psychological and emotional support; 2 Enhancing safety of the patient and their family; 3 Promoting self-efficacy. The nursing activities or interventions within the three domains have been identified here as: 1 Provide physical, psychological and emotional support by: • Demonstrating empathy; • Understanding the complexities of domestic violence; • Assessing physical, emotional and psychological needs; • Acknowledging the wider health effects from domestic violence;


• Facilitating disclosure of domestic violence and acknowledging the patient’s experiences of abuse; • Maintaining privacy and personal safety. 2 Enhance safety of the patient and their family by: • Focusing on the needs of the family as a whole; • Including a full needs assessment for the patient and their children; • Addressing issues of safety for the patient and safeguarding of their children. 3 Promote self-efficacy by: • Patient-led care planning; • Providing education about domestic violence; • Providing information about local and national help and support, and the options available; • Encouraging patients to identify and develop a support network; • Referrals to other agencies/professionals; • Encouraging safety planning; • Facilitating informed decision making; • Recognizing the patient’s expertise regarding their situation; • Respecting and supporting their decisions. Although the majority of women find being asked about domestic violence acceptable (Sethi et al. 2004), patients in English emergency departments are screened only if the health care professional has an index of suspicion that abuse has taken place. It is highly likely that index of suspicion screening will result in under detection. Reluctance to commit to more effective screening methods is probably the result of an evidence base that does not demonstrate improved health and well-being outcomes from interventions for domestic violence in the emergency department. Unless routine screening for abuse is introduced the potential for under-detection will remain. Screening rates and detection are increased by having a domestic violence policy, medical record reminders and domestic violence education for staff. Unfortunately, not only is the evidence base for practice interventions limited, but it also originates from the USA where differences in health and social policies are likely to preclude generalizabilty. Insufficient evidence is a factor described by McDonnell (1998) that is likely to inhibit the use of research findings in practice. Clearly, there is a need for research and development in this field, particularly to evaluate the effectiveness of interventions in the emergency or acute care setting. Research should be inclusive and acknowledge men and individuals in same-sex relationships who experience domestic violence. One of the difficulties facing evaluation of this field of health care is that outcomes of care are not easily measurable


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because of the nature of domestic violence and the context of the emergency department. Firstly, domestic violence frequently has progressive escalating qualities (Home Office 1999c) affecting the health and well being of the person and family by insidious degrees (Campbell 2002). This is characterized by many episodes and long-term exposure to abuse that commonly occurs prior to an individual acknowledging it or seeking help (Yearnshire 1997). Secondly, care for those who experience abuse is provided by a variety of agencies in health, social and voluntary sectors. Domestic violence is an indisputable health issue for many emergency department patients, their care however presents practitioners with difficulties in practice. Challenges stem from inconsistent practice recommendations and the lack of evidence to support practice interventions in a climate of clinical effectiveness. Whilst there is a lack of evidence for outcomes of screening and interventions this should not prohibit access to resources and care, which are considered by professional and patient opinion to have benefit. Therefore, in light of the research base to date presented here, the following recommendations are made: • Emergency and acute care service and practice should be supported and guided by a local interagency domestic violence policy; • Medical record reminders should be introduced to promote abuse screening; • Nurses should have access to and participate in ongoing, inter-professional education and training in domestic violence; • The nursing care for patients in emergency and acute health care settings who have experienced domestic violence should focus on the three domains of: 1 Providing physical, psychological and emotional support; 2 Enhancing safety of the patient and their family; 3 Promoting self-efficacy.

Contributions Study design: PO; data collection and analysis: PO and manuscript preparation: PO.

References Abbott J, Johnson R, Koziol-McLain J & Lowenstien SR (1995) Domestic violence against women: incidence and prevalence in an emergency department population. Journal of the American Medical Association 273, 1763–1767. Bates L, Redman S, Brown W & Hancock L (1995) Domestic violence experienced by women attending an accident and emergency department. Australian Journal of Public Health 19, 293–299.

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Bowling A (2002) Research Methods in Health, 2nd edn. Open University Press, Berkshire. Boyle A & Todd C (2003) Incidence and prevalence of domestic violence in a UK emergency department. Emergency Medicine Journal 20, 438–442. Campbell JC (2002) Health consequences of intimate partner violence. The Lancet 359, 1331–1136. Campbell JC, Pliska MJ, Taylor W & Sheridan D (1994) Battered women’s experiences in the emergency department. Journal of Emergency Nursing 20, 280–288. Coker AL, Smith PH, Thompson MP, McKeown RE, Bethea L & Davis KE (2002) Social support protects against the negative effects of partner violence on mental health. Journal of Women’s Health and Gender Based Medicine 11, 465–476. Coulthard P, Yong S, Adamson L, Warburton A, Worthington HV & Esposito M (2004) Domestic violence screening and intervention programmes for adults with dental or facial injury. The Cochrane Database of Systematic Reviews, 2004 Issue 2. Available at: http:// www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME (accessed 27 June 2005). Davis RE & Harsh KE (2001) Confronting barriers to universal screening for domestic violence. Journal of Professional Nursing 17, 313–320. Davidson L, King V, Garcia J & Marchant S (2000) Reducing Domestic Violence: What Works? Health Services Home Office Policing and Reducing Crime Unit, London. Dearwater S, Coben JH, Campbell JC, Nah G, Glass N, McLoughlin E & Bekemeier B (1998) Prevalence of intimate partner abuse in women treated at community hospital emergency departments. Journal of the American Medicine Association 280, 433–438. Department of Health (1997) The New NHS, Modern, Dependable. HMSO, London. Department of Health (1999) Saving Lives: Our Healthier Nation. HMSO, London. Department of Health (2000) Domestic Violence: A Resource Manual for Health Care Professionals. HMSO, London. Department of Health (2004) The Chief Nursing Officer’s Review of the Nursing, Midwifery and Health Visiting Contribution to Vulnerable Children and Young People. HMSO, London. Department of Health (2005) Responding to Domestic Abuse: A Handbook for Health Professionals. HMSO, London. De Vries-Robbe M, March L, Vinen J, Horner D & Roberts G (1996) Prevalence of domestic violence among patients attending a hospital emergency department. Australian and New Zealand Journal of Public Health 20, 364–368. Dowd MD, Kennedy C, Knapp JF & Stallbaumer-Rouyer J (2002) Mothers’ and health care providers’ perspectives on screenings for intimate partner violence in a pediatric emergency department. Archive of Pediatric and Adolescent Medicine 156, 794– 799. Ellis JM (1999) Barriers to effective screening for domestic violence by registered nurses in the emergency department. Critical Care Nursing Quarterly 22, 27–41. Ernst AA, Nick TG, Weiss SJ, Houry D & Mills T (1997) Domestic violence in an inner city ED. Annals of Emergency Medicine 30, 190–197.


Older people Ernst AA, Weiss SJ, Nick TG, Caselletto J & Garza A (2000) Domestic violence in a University emergency department. Southern Medical Journal 93, 176–181. Fanslow JL, Norton RN & Robinson E (1999) One-year follow-up of an emergency department protocol for abused women. Australian and New Zealand Journal of Public Health 23, 418–420. Fanslow JL, Norton RN, Robinson EM & Spinola CG (1998) Outcome evaluation of an emergency department protocol of care on partner abuse. Australian and New Zealand Journal of Public Health 22, 598–603. Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR & Abbott JT (1997) Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. Journal of the American Medical Association 277, 1357–1361. Glass N, Dearwater S & Campbell JC (2001) Intimate partner violence screening and intervention: data from eleven Pennsylvania and California community hospital emergency departments. Journal of Emergency Nursing 27, 141–149. Glasziou P, Irwig L, Bain C & Colditz G (2001) Systematic Reviews in Health Care: A Practical Guide. Cambridge University Press, Cambridge. Home Office (1999a) Breaking the Chain. The Home Office and the Women’s Office, London. Home Office (1999b) Living Without Fear – An Integrated Approach to Tackling Violence against Women. The Home Office and the Women’s Office, London. Home Office (1999c) British Crime Survey. HMSO, London. Hurley KF, Brown-Maher T, Campbell SG, Wallace T, Venugopal R & Baggs D (2005) Emergency department patients’ opinions of screening for intimate partner violence among women. Emergency Medicine Journal 22, 97–98. Krishnan SP, Hilbert JC & Pase M (2001) An examination of intimate partner abuse in rural communities: results from an hospital emergency department study from Southwest United States. Family and Community Health 24, 1–14. Krug EG, Dahlberg LL, Mercy JA, Zwi AB & Lozano R (eds) (2002) World Health Organisation: World Report on Violence and Health. World health Organisation, Geneva. Larkin GL, Hyman KB, Mathias SR, D’Amico F & MacLeod BA (1999) Universal screening for intimate partner violence in the emergency department: importance of patient and provider factors. Annals of Emergency Medicine 33, 669–675. Larkin GL, Rolniak S, Hyman KB, MacLeod BA & Savage R (2000) Effect of an administrative intervention on rates of screening for domestic violence in an urban emergency department. American Journal of Public Health 90, 1444–1448. Lejoyeux M, Zillhardt P, Chieze F, Fichelle A, McLoughlin M, Poujade A & Ades J (2002) Screening for domestic violence among patients admitted to a French emergency service. European Psychiatry: The Journal of the Association of European Psychiatrists 17, 479–483. Maxwell RJ (1992) Dimensions of quality revisited: from thought to action. Quality in Healthcare 1, 171–177. McDonnell A (1998) Factors which may inhibit the utilization of research findings in practice – and some solutions. In Research into Practice (Crookes PA & Davies S eds). RCN Publishing, Bailliere Tindall.

Care for emergency department patients McFarlane J, Greenberg L, Weltge A & Watson M (1995) Identification of abuse in emergency departments: effectiveness of a twoquestion screening tool. Emergency Nursing 21, 391–394. Mechem CC, Shofer FS, Reinhard SS, Hormig S & Datner E (1999) History of domestic violence among male patients presenting to an urban emergency department. Academic Emergency Medicine 6, 786–791. Morrison LJ, Allan R & Grunfeld A (2000) Improving the emergency department detection of domestic violence using direct questioning. The Journal of Emergency Medicine 19, 117–124. Muelleman RL & Feighny KM (1999) Effects of an emergency department-based advocacy program for battered women on community resource utilisation. Annals of Emergency Medicine 33, 62–66. Muir-Gray JA (2001) Evidence-Based Health Care. Churchill Livingstone, New York. Nelson H, Nygren P & McInerney Y (2004) Screening for family and intimate partner violence Agency for Healthcare Research and Quality (AHRQ). Health Technology Assessment Database 2005 Issue 2. Available at: http://www.mrw.interscience.wiley.com/ cochrane/cochrane_clhta_articles_fs.html (accessed 27 June 2005). NHS Executive (1996) Promoting Clinical Effectiveness. NHS Executive, London. Olsen L, Anctil C, Fullerton L, Brillman J, Arbuckle J & Sklar D (1996) Increasing emergency physician recognition of domestic violence. Annals of Emergency Medicine 27, 741–746. Pakieser RA, Lenaghan PA & Muelleman RA (1998) Battered women: where they go for help. Journal of Emergency Nursing 24, 16–19. Ramsden C & Bonner M (2002) A realistic view of domestic violence screening in an emergency department. Accident & Emergency Nursing 10, 31–39. Ramsey J, Richardson J, Carter YH, Davidson LL & Feder G (2002) Should health professionals screen women for domestic violence? Systematic Review. British Medical Journal 325, 314–327. Roberts GL, Lawrence JM, O’Toole JM & Raphael B (1997) Domestic violence in the emergency department: 2 detection by doctors and nurses general hospital. Psychiatry 19, 12–15. Roberts GL, O’Toole BI, Lawrence JM & Raphael B (1993) Domestic violence victims in a hospital emergency department. The Medical Journal of Australia 159, 307–310. Roberts GL, O’Toole Raphael B, Lawrence JM & Ashby R (1996) Prevalence study of domestic violence victims in an emergency department. Annals of Emergency Medicine 27, 747–753. Royal College of Nursing (2000) Domestic Violence: Guidance for Nurses. Royal College of Nursing, London. Sethi D, Watts S, Zwi SA, Watson J & McCarthy C (2004) Experience of domestic violence by women attending an inner city accident and emergency department. Emergency Medicine Journal 21, 180–184. Varvaro FF & Palmer M (1993) Promotion of adaptation in battered women: a self-efficacy approach. Journal of the American Academy of Nurse Practitioners 5, 264–270. Walby S & Allen J (2004) Domestic Violence, Sexual Assault and Stalking: Findings from the British Crime Survey. Home Office Research, Development and Statistics Directorate, London. Walby S & Myhill J (2001) Chapter 9. In What Works in Reducing Domestic Violence? A Comprehensive Guide for Professionals (Taylor-Browne J ed.). Whiting & Birch, London.


1747

P Olive Wathen CN & MacMillan Hl (2003) Interventions for violence against women: scientific review. Journal of the American Medical Association 289, 589–600. Wendt-Mayer B (2000) Female domestic violence victims: perspectives on emergency care. Nursing Science Quarterly 13, 340–346. Williams LM (2003) Understanding child abuse and violence against women – a life course perspective. Journal of Interpersonal Violence 18, 441–451.

1748

Women’s Aid Federation (2006) If You or a Friend Need Help: Domestic Violence Helplines. Available at: http://www.womensaid. org.uk (accessed 30 March 2006). Yam M (2000) Seen but not heard: Battered women’s perceptions of the ED experience. Journal of Emergency Nursing 26, 464–470. Yearnshire S (1997) Analysis of cohort. In Violence against Women (Bewley S, Friend J & Mezey G eds). Royal College of Obstetricians and Gynaecologists, London.
