Identifying abuse among women: use of clinical guidelines by nurses and midwives
E.K. Svavarsdottir: e-mail: firstname.lastname@example.org
Title. Identifying abuse among women: use of clinical guidelines by nurses and midwives.
Aim. This aim of this study to identify the incidence of violence against women seeking healthcare services and evaluate the use of clinical guidelines to identify interpersonal violence.
Methods. A cross-sectional survey was carried out. Data were collected over a period of 7 months in 2005 and 2006. The samples consisted of 14 nurses, 10 midwives and 208 women in Iceland (101 women visiting the Emergency Department and 107 receiving prenatal care at the High Risk Prenatal Care Clinic).
Results. Twenty women (19·6%) who visited the Emergency Department and 21 women (19·8%) who came to the High Risk Prenatal Care Clinic had been sexually abused at some point in their lives by close family members. Within the preceding 12 months, 18 women at the Emergency Department (19·1%) and eight at the High Risk Prenatal Care Clinic (7·5%) reported physical abuse, and 22 women (22·2%) at the Emergency Department and 12 (11·5%) at the High Risk Prenatal Care Clinic reported emotional abuse. A majority of the nurses and midwives indicated that the guidelines were efficient for assessing/screening for gender violence in emergency and high risk clinical settings.
Conclusion. Screening for abuse of women at emergency and high risk clinics is crucial, not only to offer the women the immediate interventions they might need, but also to ensure the future provision of appropriate healthcare services.
What is already known about this topic
- • Abuse of women adversely affects their physical and/or psychological health.
- • Gender violence against women leads to health risk behaviours.
- • Intimate partner violence against women increases the likelihood of suicide attempts and/or thoughts of suicide because of substance abuse or chronic depression.
What this paper adds
- • One-fifth of the women visiting the Emergency Department and the High Risk Prenatal Care Clinic had at some point experienced sexual abuse by a close family member and about the same number visiting the Emergency Department had been physically and/or emotionally abused within the preceding 12 months.
- • A majority of the nurses and the midwives indicated that the clinical guidelines were efficient when screening for gender violence in emergency and high risk clinical settings.
- • The Evaluation Interview Frame provided a secure base for the nurses to approach the topic of abuse of women.
Implications for practice and/or policy
- • Screening should be implemented for abused women on a regular basis at Emergency Departments and high risk prenatal clinics, together with a first response based on well-developed and culturally-acceptable clinical guidelines.
- • The guidelines used in this study could be used for detection of and first response to abuse among women visiting Emergency Departments and high risk healthcare settings.
Violence against women by a close family member is receiving increased attention worldwide among healthcare professionals (Krug et al. 2002), not only because of the high frequency of gender violence within families, but also because of new and often striking research evidence about the impact of violence against women on their physical and psychological health (Krishnan et al. 2004, Hydén 2005), well-being (Taylor 2005), employment and education (Jewkes et al. 2002, Riger et al. 2002), and on their psycho-social functioning in general (Krishnan et al. 2004, Ham-Rowbottom et al. 2005). Intimate partner violence against women has also been found to cause negative attitudes towards pregnancy (Coggins & Bullock 2003); change relationships (Goodkind et al. 2003); facilitate childhood behavioural problems (Jarvis et al. 2005); have an impact on the possibility of being employed or attending school (Jewkes et al. 2002, Riger et al. 2002); and increase the potential for suicide attempts (Krishnan et al. 2004).
Further, women experiencing abuse by a close family member are often in frequent contact with the healthcare system, which emphasizes the importance for nurses and midwives to screen for abuse (Glass et al. 2001, Webster et al. 2001, Bacchus et al. 2002, Duncan et al. 2006, Hindin 2006, Datner et al. 2007) and to offer the best initial response. However, little is known about what screening procedures within clinical settings might be most beneficial to identify abused women.
Violence against women is often unseen, unknown and hidden in families. At the same time, awareness of abuse of women is increasing in western societies. Healthcare professionals are therefore now paying more attention than before to abuse in families, and are starting to show more understanding of the issue. Abuse within families has a serious impact on the quality of life, well-being and general health of women and their children. It is therefore important to offer women who are survivors of family abuse healthcare services based on clinical guidelines. In a study on 384 women visiting a prenatal clinic in North Carolina in the United States of America, Covington et al. (1997) concluded that systematic screening techniques, using direct questions combined with multiple assessments, increased reporting of prenatal violence compared with a single routine assessment.
Despite numerous studies of the impact of intimate partner/family violence on women’s health, i.e. alcohol and drug misuse (Hirsch 2001, Ogle & Baer 2003) and physical injury (Swan & Snow 2003), few studies have focused on appropriate first response among nurses when women reveal abuse or on nursing interventions for women experiencing abuse by a close family member. Nevertheless, nurses are the largest group of employees among healthcare professionals and are most often the first healthcare professional who provides care to women at Emergency Departments (ED) and high risk clinics. It is important in future research to provide information to help clinicians decide whether and how to adopt and implement interventions into clinical practice (Leeman et al. 2006).
A literature search revealed only one recently-published clinical guidelines for nurses which focused on best practice first response after screening for abuse of women: Nursing Best Practice Guideline: Abuse of women, Screening, Identification and Initial Response (RNAO 2005). These clinical guidelines were designed to be used for the development of policies, procedures, protocols and educational programmes, and as an assessment and documentation tool, but the authors suggest that it can be used as a resource tool and adapted to each practice setting or environment.
Further, only one new study was found in which the impact of a nursing intervention when women had experienced abuse was tested. McFarlane et al. (2006) assessed safety behaviour, the use of community resources and extent of violence following two interventions: (a) a wallet-sized referral card and (b) a 20-minute nurse case management protocol. Their sample consisted of 360 abused women who had experienced physical or sexual abuse within the preceding 12 months. During the 2 years following treatment, both treatment groups reported statistically significantly fewer threats of abuse, assaults, danger risks for homicide and events of workplace harassment, but there was no statistically significant difference between the groups. Nevertheless, little is known about how and in what ways nurses working in ED and midwives working in high risk prenatal clinics can intervene with women who have experienced abuse, and no study was found that focused on the use of clinical guidelines for these healthcare professionals regarding best practice initial response when women disclose to them that they are victims of gender violence.
The Women’s Response to Battering model (Campbell & Soeken 1999) was used as the conceptual framework for the study reported here. In this model, which is based on Orem’s (1991) self-care deficit theory of nursing, health is the central concept and is influenced by physical and non-physical abuse (emotional, psychological and control tactics including sexual demands) and self-care agency [self-esteem (a foundational characteristic), motivation and energy (power components)]. The Women’s Response to Battering model focuses on the direct effect of abuse on health and the indirect effect of abuse on women’s health, mediated through self-care agency as a protective factor (Campbell & Soeken 1999). Increased physical and non-physical abuse are reported to result in increased health problems for women. In addition, increased self-care is reported to result in decreased health problems (Campbell & Soeken 1999). Therefore, increasing self care agency (self-esteem, motivation and energy) may be an effective intervention to improve health among women who are victims of abuse.
The Women’s Response to Battering model (Campbell & Soeken 1999) was used to guide the choice of variables under study (e.g. physical, emotional and sexual abuse; physical and psychological health), to explain women’s health responses to battering, and to suggest an appropriate first response among clinicians (intervention direction) to facilitate battered women’s recovery and to protect their health.
The aim of this study was to identify the incidence of violence against women seeking healthcare services and evaluate the use of clinical guidelines to identify interpersonal violence.
A cross-sectional survey design was adopted and the study was performed in Iceland.
Nurses and midwives
Nurses working at an ED in October/November, 2005 and midwives working at a High Risk Prenatal Care Clinic (HRPCC) in the beginning of January 2006 were invited to participate in the study. Of 65 nurses working at the ED, 14 agreed to participate (21·5%), and 10 of the 11 midwives working at the HRPCC opted to participate (91·67%). All the nurses and midwives who participated in the data collection gave written consent. They attended a lecture on violence against women, watched a 90-minute film for healthcare professionals on intimate partner violence, and participated in two to five seminars on how to use the long and short versions of the newly-developed and modified clinical guidelines on identification of women’s abuse, and on offering a best practice initial response. The guidelines were originally developed in Ontario, Canada (RNAO 2005), but had been modified based on new information from the literature and adapted to fit the Icelandic culture.
Women seeking healthcare services
Women who visited the ED and attended prenatal care at the HRPCC at the time when the study took place were recruited. The inclusion criteria were that the women were (a) 18–67 years of age; (b) were seeking healthcare services from the ED or the HRPCC and (c) were able to read and write Icelandic or English. Women who were under the influence of alcohol or drugs were excluded from the study. The nurses and midwives introduced the study to the women while their partners waited outside the examination rooms (posters introducing the study had also been posted in the women’s toilets in the ED and at the HRPCC. Of the 110 women who attended the HRPCC and were introduced to the study, three rejected participation (giving no specific reason), leaving a sample of 107 (97·3% participation rate). Of the 103 women who were introduced to the study at the ED, two rejected participation (without giving any reason), resulting in a sample of 101 (98·0% participation rate). Those who agreed to participate were reminded that the study took place in two phases: first, a self-report questionnaire would be given to them and then they would be offered to an interview with the nurse or midwife. It took about 4–12 minutes to answer the two questionnaires and interviews lasted between 10 and 54 minutes.
Development of the guidelines
The ‘Guidelines for Nurses and Midwives on Screening, Evaluation and First Response against Abuse of women’ (Svavarsdottir & Orlygsdottir 2006a) are a modification and further development of the Canadian ‘Nursing Best Practice Guideline. Abuse of women: Screening, Identification and Initial Response’ (RNAO 2005). After having received permission to further develop and adapt the Canadian guidelines for the Icelandic culture, a team that consisted of the principal investigator, a nursing researcher, an registered nurse working at the study hospital, a midwife with a Master’s degree working at the HRPCC and a linguist in English and Icelandic met on a regular basis over a period of 1 year. Although the Icelandic version of the guidelines was based on the Canadian clinical guidelines, new research findings were integrated into the Icelandic version. The guidelines were organized differently and divided into two versions, a long version (21 pages), and a short version (two pages). Information for Icelandic women who have experienced or are experiencing physical, emotional or sexual abuse, such as lists of institutions or organizations, was also added to the guidelines.
The long version of the Icelandic guidelines includes a definition of violence, examples of how nurses can start a discussion about violence with women, hindrances to using screening tests, research results of the impact of violence on women’s health, nurses’ views on women who had been abused, nurses’ beliefs about their clients, client confidentiality, documentation (e.g. electronic documentation), what nurses should never do, respect toward clients, safety, a safety checklist, how to make a safety plan with the woman and resources offered in Iceland (including telephone numbers).
The short version is set up in a format which fits into nurses’ and midwives’ pockets. This version includes a flow chart that is intended to help to identify abuse among women. In addition, violence is defined and an example is given on how to open a discussion about violence with a client. The importance of a caring attitude towards victimized women is emphasized, as well as the importance of confidentiality. Electronic information sources are given and there is a list of important phone numbers and institutions to turn to.
Before they introduced the study to the women the nurses and midwives in the study were encouraged to read the longer version of the guidelines first and then the shorter version to review the main emphases in the longer version. In both versions, the most important information was extracted and presented in grey boxes for ease of use.
The content of both versions and their applicability to clinical practice were critically discussed at the seminars held for the nurses and midwives participating in the study. The Icelandic guidelines were then pilot-tested among five nurses, three midwives and 33 women receiving healthcare service at the ED. Following the pilot-test some changes were made in the ‘Evaluation Interview Framework for Nurses and Midwives’, which is a nine-item, semi-structured interview framework (Svavarsdottir & Orlygsdottir 2005) intended for screening interviews with abused women.
Data were collected with women seeking health care for a variety of reasons at the ED from January to May 2006. At the HRPCC, data were collected between March and October 2006 from pregnant women seeking prenatal care in their first trimester. After collecting these data, the nurses and midwives received an open-ended questionnaire about their experiences of participating in the study.
Background information on the women and the nurses’ and midwives’ demographics and their opinions about using the guidelines in the clinics, their experiences of participating in the study and evaluation of the screening interview were gathered using open-ended questionnaires. Screening for the women’s abuse was performed through a semi-structured interview. The open-ended instruments were developed by the investigators (based on literature review). The screening instrument was translated from English into Icelandic by a group of healthcare professionals, the researchers and a linguist and then back-translated into English to establish validity and equivalence of meaning and ensure cultural sensitivity. To establish validity, the open-ended instruments and the semi-structured interview schedule were pilot-tested with a group of 20 women at the ED.
The socio-demographic instrument was investigator-generated (Svavarsdottir & Orlygsdottir 2006b). Demographic information were requested on the women seeking health care at the ED and the HRPCC (13-items) and on the nurses working at the ED and the midwives working at the HRPCC (6-items). Questions posed to the women included age, ethnicity, education and employment status. The nurses and midwives were asked about length of work experience as a healthcare professional and length of employment at the current healthcare institution.
Nurses’ and midwives’ experiences of participating in the study
Information about the nurses’ and the midwives’ experience of participating in the study and their experiences of using the ‘Guidelines for Nurses and Midwives Regarding Screening, Evaluation and First Response against Abuse of women’ was gathered through an investigator – generated 22-item open-ended questionnaire (Svavarsdottir & Orlygsdottir 2006c). They were asked, for example, about their experiences of using the guidelines in the evaluation/screening interview, their perceptions about the content of the guidelines and their experiences of participating in the study.
The third instrument, Women’s Abuse: Screening and First Response. Evaluation Interview Frame for Nurses and Midwives (Svavarsdottir & Orlygsdottir 2005) is partly based on the Evaluation Criteria from Parker et al. (1990). The interview framework consists of nine broad questions, with each question having many subcategories. The healthcare professionals asked the women each question and filled in the questionnaire, e.g. ‘Yes’‘No’‘Do not know’, ‘Do not want to answer’. If the women responded ‘Yes’ to any of the questions, further were asked, e.g. ‘By whom?’, ‘How often?’. The questions asked had a different time-frame, e.g. ‘Have you ever been physically abused?’, ‘sexually abused?’, ‘emotionally abused?’; ‘Within the last 12 months have you been physically abused?’, ‘sexually abused?’, ‘emotionally abused?’; ‘Do you have someone who you can talk to about the violence?’; ‘Are you safe?’; ‘Would you like to talk about the violence?’; ‘What do you need now?’.
This study was approved by the appropriate ethics committee and service managers. The nurses, midwives and women participating in the study received oral and written introductions to its purpose and procedures before being recruited. When a woman visited the ED or a pregnant woman came to the HRPCC, a nurse or a midwife introduced the study to her. If women were interested in participating, they received an introduction letter about the study. Those who agreed to participate and gave written consent received a package of questionnaires. After having filled in the questionnaires, they were offered the interview with the nurse or midwife.
Descriptive statistics were computed for demographic characteristics and the major study variables, including physical, sexual and emotional abuse among the women, and the healthcare professionals’ experiences of using the guidelines and participating in the study.
The mean age of the women seeking care at the ED was 38·4 years and the average age of those at the HRPCC was 30·4 years. Most of the women, both at the ED and the HRPCC, were married or cohabiting. The nurses’ average age was 34·6 years and the mean age of the midwives was 52 years. On average, the nurses had 9·4 years of nursing experience and the midwives had on average 22 years of professional experience. The demographics of the sample are further listed in Table 1.
Table 1. Demographics of the nurses and the midwives as well as the women seeking healthcare services from the Emergeny Department (ED) and the High Risk Prenatal Care Center (HRPCC)
|Nurses||14|| || || |
| Age|| ||34·6 (27–52)|| || |
| Employed as a nurse|| ||9·4 (3–27)|| || |
| Employed in the ED|| ||7·6 (1–19)|| || |
|Midwives|| || ||10|| |
| Age|| || || ||52 (46–62)|
| Employed as midwife|| || || ||22 (16–40)|
| Employed at the HRPCC|| || || ||7 (5–13)|
|Women seeking healthcare services||101|| ||107|| |
| Age|| ||38·0 (18–68)|| ||30·4 (18–45)|
| Marital status|
| Married||41 (41·8)|| ||44 (41·5)|| |
| Cohabiting||28 (28·6)|| ||41 (38·6)|| |
| Single-parent||15 (15·3)|| ||9 (8·5)|| |
| Single||3 (3·0)|| ||0 (0·0)|| |
| Divorced||11 (11·2)|| ||2 (1·9)|| |
| Have contact with the father of my child||0 (0·0)|| ||10 (9·3)|| |
| Employment status|
| Full-time||59 (61·5)|| ||70 (68·0)|| |
| Part-time||20 (20·8)|| ||18 (17·5)|| |
| Don’t work outside the home||14 (14·6)|| ||14 (13·6)|| |
Sexual, physical and emotional abuse among women seeking healthcare services
Of the 101 participating women who sought care at the ED, 20 (19·6%) had been sexually abused at some point in their lives by a close family member; of the 107 women who sought prenatal care at the HRPCC, 21 (19·8%) had been sexually abused at some point in their lives by a close family member (Table 2). A majority of the women at the ED who reported abuse (n = 12; 66·7%) had been sexually abused more than 10 times and one had been sexually abused six to 10 times (5·6%). Nine women at the HRPCC (50%) had been sexually abused two to five times and seven (38·9%) had been sexually abused once. Two women at the ED (2·1%) but none at the HRPCC reported had been sexually abused within the last 12 months by a close family member; and four women at the ED (4·1%), but none at the HRPCC reported had been sexually abused within the last 12 months (Table 2).
Table 2. Women seeking healthcare services from the Emergency Department (ED) at the LUH and from the High Risk Prenatal Care Center (HRPCC) at the PHCC: frequency of sexual, physical and emotional violence, perceived support and safety
|Have been sexually abused by a close family member||20 (19·6)||21 (19·8)|
|By whom: Brother, stepfather, uncle, prior partner, brother in law, father, grandfather, stepgrandfather, the father of my unborn child, my sister’s boyfriend, a close friend of the family|| || |
|How often |
|Once||2 (11·1)||7 (38·9)|
|2–5 times||3 (16·7)||9 (50·0)|
|6–10 times||1 (5·6)||1 (5·6)|
|More often||12 (66·7)||1 (5·6)|
|Sexually abused within the last 12 months by a close family member||2 (2·1)||0 (0·0)|
|Sexually abused within the last 12 months||4 (4·1)||0 (0·0)|
|Have been physically abused||51 (50·0)||42 (39·6)|
|Physically abused within the last 12 months||18 (19·1)||8 (7·5)|
|By whom: Prior partner, partner, boyfriend, father of my child|| || |
|Are now/have been in an intimate relationship where have been physically abused||33 (33·0)||23 (21·9)|
|Have been physically abused since pregnant|| ||5 (4·7)|
|By whom: the father of my child, father, friend of a friend|| || |
|Have been emotionally abused within the last 12 months||22 (22·2)||12 (11·5)|
|Have support from individual(s)/institution(s) where can now discuss the violence|
| Yes||44 (73·3)||43 (70·5)|
| No||16 (26·7)||18 (29·5)|
|From Whom: Best friend, my husband today, sister, psychologist, family members, parents, friends, sister-in-law, co-workers, Alcoholics Anonymous, psychiatrist, psychiatric nurse, lawer, Al-Anon.|| || |
|Feel safe now|
| Yes||9 (50·0)||7 (100)|
| No||9 (50·0)||0 (0·0)|
|Would like to talk about the violence|
| Yes||9 (56·3)||5 (62·5)|
| No||7 (43·8)||3 (37·5)|
|Have talked to someone else about the violence|
| Yes||13 (76·5)||7 (87·5)|
| No||4 (23·5)||1 (12·5)|
|How are you handling the situation:‘Not very well’, ‘Difficult’, ‘it is okay’, ‘I am trying’, ‘very well’, ‘Does not disturb me’, ‘Can handle it, but it is diffucult’, ‘Kind of okay’.|
|Need now:‘Better health’, ‘Support’, ‘Understanding from (other) people’, ‘Support from a women’s shelter’, ‘Support from the counselling center for abused women’, ‘To move’, ‘That he leaves me alone, ‘Rest’, ‘Security’, ‘To sleep’, ‘Consultation with a specialist’.|
Fifty-one women (50%) at the ED and 42 (39·6%) at the HRPCC reported having at some point been physically abused; 18 women at the ED (19·1%) and eight women at the HRPCC (7·5%) reported had been physically abused within the last 12 months (Table 2), and 33 (33%) at the ED and 23 (21·9%) at the HRPCC reported that they were either now, or had been, in an intimate relationship where they had been physically abused. Five (4·7%) women at the HRPCC reported had been physically abused since they became pregnant, and 22 women (22·2%) at the ER and 12 (11·5%) at the HRPCC reported emotional abuse within the last 12 months (Table 2).
Most of those who reported physical or sexual abuse (44 (73·3%) from the ED and 43 (70·5%) from the HRPCC), reported that they had support from individual(s) or institution(s) where they could discuss the violence (Table 2). Nine women (50%) at the ED and seven (100%) at the HRPCC who reported they had been physically abused within the last 12 months reported that they felt safe now; nine (56·3%) at the ED and five (62·5%) at the HRPCC said that they would like to talk about the violence, and most [13 at the ED (76·5%) and 7 (87·5%) at the HRPCC] reported that they had talked to someone else about the violence (Table 2).
Nurses’ and the midwives’ experiences of using the guidelines and participating in the study
Of the 14 nurses and 10 midwives who participated in the study, 10 nurses (71%) and seven midwives (70%) answered the questionnaire (Table 3). Their experiences of offering the women participation in the study was generally good:
Table 3. Nurses’ (n = 10) and midwives’ (n = 7) experience of participating in the study and using the Guidelines for Nurses and Midwives on Screening, Evaluation and Appropriate First Response Against Abuse of women
|Questions in the evaluation/screening interview unclear or difficult||3 (17·6)||12 (70·6)||2 (11·8)|
|Evaluation/screening interview structured in a satisfactory way||12 (70·6)||3 (17·6)||2 (11·8)|
|Recommend that the guidelines be used by nurses and midwives||13 (76·5)||0 (0)||4 (23·5)|
|Were pleased with participation in study||14 (82·4)||0 (0)||3 (17·6)|
I was a bit worried in the beginning but then I was OK, I found this a little difficult at first, It was a positive experience, I was embarrassed to start with, but I got used to it, It depended on whether the women had experienced abuse or not.
The nurses’ and midwives’ experiences of asking women about physical, emotional and sexual abuse were more varied. Typical answers to the open-ended questions were:
It was not difficult, except for asking about sexual abuse in the beginning, The experience was good, It was not a problem, It varied, It took a lot out of me to ask about sexual abuse, It was a difficult experience, I was a bit hesitant at first, It was a positive experience, I was insecure in the beginning, It is a sensitive topic, I felt uncomfortable asking about this, At first it was uncomfortable then it was normal, It was not a problem after having asked the first woman.
They also reported their experiences of using the long and short versions of the guidelines:
I read the guidelines carefully in the beginning, I read the long version twice, then the short version, The guidelines were very helpful, They were good, I used them to prepare myself and in the beginning, They were a solid base to build on, They were OK, they guided me, They were useful but they were too long.
In addition, the nurses and midwives indicated that the guidelines were:
Useful in order to approach their client in an appropriate manner, useful to document health information, useful in order to be aware of the importance of basic knowledge regarding family violence and the clinical skills needed when taking the evaluation/screening interview, helpful to get an overview over family violence and how to approach clients and to get information about appropriate first response, easy to understand, that they [i.e. the nurses and midwives] were more confident as a healthcare professionals discussing abuse with their clients after having read the guidelines, That it was good to have the shorter version in their pocket for review, That it was good to have open ended questions listed in the evaluation/screening interview to ask all the women, Reading the guidelines should be mandatory for all newly-hired healthcare professionals.
A general limitation of the study was the small number of ED nurses who participated. Also, in comparison with the general population, a high proportion of the women participating in the study, both at the ED and the HRPCC, had prior history and/or current experience with sexual, physical and/or emotional abuse. Further, the use of the instrument Abuse of women: Screening and First Response. Evaluation Interview Frame for Nurses and Midwives (Svavarsdottir & Orlygsdottir 2005) was only partly based on the evaluation criteria from Parker et al. (1990) and did therefore not meet the usual standards for rigour when measuring these phenomena. The findings, therefore, need to be interpreted with caution and cannot be generalized outside of study ED or high risk prenatal clinic.
The main findings from the evaluation/screening interview by a healthcare professional on abuse against women, indicate that one-fifth of the women who received health care at either the ED or the HRPCC in Reykjavik had at one point or another in their lives, experienced sexual abuse by a close family member. Further, two of the participating women who visited the ED had experienced sexual abuse by a close family member within the last 12 months, and four of the women coming to the ED had experienced sexual abuse within the last 12 months either by someone within or outside their family. However, the frequency of sexual abuse varied greatly between the two groups of women. For those who visited the ED, the frequency was much higher than for those coming to the HRPCC for prenatal care. Twelve of the 20 sexually abused women visiting the ED had been abused more than 10 times each, compared with only one woman at the HRPCC. Although the frequency of sexual abuse varied between the two groups, nearly half of the 21 women visiting the HRPCC who reported sexual abuse had experienced abuse by a close family member between two and five times, and seven of the sexually abused women at the HRPCC had experienced sexual abuse by a family member once. In addition, twice as many women at the ED had experienced physical and emotional abuse within the last 12 months as compared with the group who visited the HRPCC. These findings are in harmony with prior research (Krishnan et al. 2004, Ham-Rowbottom et al. 2005) and with the Women’s Responses to Battering model study (Campbell & Soeken 1999), where a major direct relationship was demonstrated between abuse and women’s health problems, indicating that women who had been abused by intimate partners have more health problems and are therefore more likely to be long-term users of the healthcare system.
Although the majority of the women, both at the ED and the HRPCC, indicated in the evaluation/screening interview that they now had support from individual(s) or institution(s) where they could discuss the violence, 16 at the ED and 18 at the HRPCC indicated that they did not have anyone to turn to for support. This finding is of particular concern for healthcare professionals working in these settings and supports the importance of routine screening for abuse against women by first response nurses and midwives. Further, even though seven of the women at the ED and three at the HRPCC did not want to talk to the healthcare professional about the violence, nine at the ED and women at the HRPCC did want to talk to the nurse or midwife about the violence. Offering women the opportunity to talk about the abuse is an important short-term intervention, whether or not they are willing or ready to talk about the violence at that time. Opening up the possibility for women to express themselves about their experience of abuse to a healthcare professional sends out a clear message that violence should never be tolerated and not kept hidden, and conveys the message that healthcare professionals care about women’s experiences and want to offer a best practice initial response.
A majority of the nurses and midwives reported that their experiences of participating in the study were good, as were their experiences of applying the guidelines in the evaluation/screening interview. However, despite their relatively long work experience as healthcare professionals, many of them admitted that it had been difficult in the beginning to discuss abuse with their clients. All stressed, however, that as they became more familiar with the topic, and after having gone through the first one or two evaluation interviews with the women, they became more secure and relaxed with the screening process. In the nurses’ and midwives’ views, the guidelines were crucial in order to handle themselves professionally while they were screening the women and to be able to offer a best practice first response. Further, a common theme that emerged in their answers to the open-ended questions was that the guidelines served as a secure base when opening a discussion on a very sensitive and complex issue with clients.
Both the nurses and midwives reported that the long and short versions of the guidelines were helpful, and that they used them to prepare themselves for the evaluation/screening interview as well as to overcome their own barriers and to gain information about security plans, support for women and an appropriate first response. Further, a majority recommended that the guidelines (both the long and short versions) be used and implemented into clinical practice without any changes. These findings are encouraging and emphasize the importance for nursing managers and clinicians to implement routine screening for abuse against women at ED and high risk pregnancy clinics.
Healthcare professionals increasingly need updating in research-based knowledge about violence within families and how to offer an initial response according to best practice guidelines. Screening for abuse of women on a regular basis at ED and high risk prenatal clinics and offering a first response based on well-developed and culturally-acceptable clinical guidelines can be a powerful short-term intervention. The guidelines that were developed and applied in this study are promising with regard to detection of and first response to abuse among women visiting ED and high risk healthcare settings. However, further research is needed to test the effectiveness of the guidelines as an intervention in other cultures and healthcare systems.
We would like to thank all the women, nurses, and midwives who participated in the study. Special thanks go to Kolbrun Kristiansen RN and Sigridur Sia Jonsdottir, Midwife, Ragnheidur Thorisdottir, RN and Eyrun Jonsdottir RN for assistance with data collection. We also acknowledge the editorial review of the manuscript by Dr Lynne Hall, RN, Dr PH.
This study was funded by grants from the Ministry of Health of Iceland, the University Research Fund at the University of Iceland, The Icelandic Nurses’ Association Science Fund and the Landspitali University Hospital Research Fund. The study was also supported by Kaupthing Bank, The Icelandic Center for Human Rights and by the Hekla Company.
EKS was responsible for the study conception and design. EKS & BO performed the data collection. EKS performed the data analysis. EKS was responsible for the drafting of the manuscript. EKS made critical revisions to the paper for important intellectual content. EKS provided statistical expertise. EKS & BO obtained funding. EKS provided administrative, technical or material support. EKS supervised the study.