How healthcare providers can support women coping with violence

This article looks at the role of healthcare providers in the provision of culturally safe, sensitive and compassionate support to patients who are living with family violence (FV) and/or intimate partner violence (IPV). This area is of interest and priority because physicians’ offices are key but underutilized loci for the potential screening and detection of violence and provision of suitable advice and care.

Tools for screening for family violence in a clinical setting

There is no shortage of IPV/FV screening tools that could be used in a clinical environment. Three tools that can be used during obstetric visits are RADAR, HITS and AAS, as described in Deshpande & Lewis-O’Connor (2013).

“Pregnancy may present a unique opportunity to identify and screen for patients experiencing IPV. It is a longitudinal process involving repeated contact with health care providers, offering the unique opportunity to develop trust between the patient and members of the health care team…(p142) The steps of RADAR include the following: (1) Routinely screen adult patients, (2) Ask direct questions, (3) Document your findings, (4) Assess patient safety, and (5) Review options and referrals. … During the HITS assessment, a provider asks a patient the following: How often does your partner physically Hurt you, Insult or talk down to you, Threaten you with harm, and Scream or curse at you? Each category is graded on a scale of 1 (never) to 5 (frequently) and a sum of all the categories is generated. A total score of 10 is suggestive of IPV… Perhaps one of the most widely used IPV screening tools in the pregnant population is the Abuse Assessment Screen (AAS) tool (Figure 5). This is a short, five-question screen that involves the following open-ended questions: Have you ever been emotionally or physically abused by your partner or someone important to you? Since I saw you last have you been hit, slapped, kicked, or otherwise physically hurt by someone? If YES, by whom? Number of times? Nature of injury? Since you have been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone? If YES, by whom? Number of times? Nature of injury? Within the past year has anyone made you do something sexual that you did not want to do? If YES, then who? Are you afraid of your partner or anyone else?… For any of the three IPV screening tools (RADAR, HITS, and AAS) to be most effective in the clinical setting, they should be used longitudinally during obstetric visits (at the first prenatal visit, at least once per trimester, and at the postpartum checkups). By developing familiarity with key resources, state IPV reporting policies, screening methods, and both direct and indirect signs and symptoms of IPV, obstetrician-gynecologists can play a critical role in early prevention and reduction of IPV in their patients (p144-145) (ellipses and emphases inserted) (Deshpande & Lewis-O’Connor, 2013).

The availability of well-designed screening tools is not enough. Tools need to be used in the right way and at the right time, which necessitates training. This means acquiring competence and comfort not only in the technical aspects of tool use or the interpretation of results but also in the creation of rapport and conversational opportunities wherein the screening tool can enable candid responses and not false negatives. Rapport and cultural safety are essential to broach the difficult and painful topic of abuse and violence with a person who is already in significant pain and who must not be re-injured through on-the-nose questioning by an authority figure such as a doctor or nurse.

Gaps in knowledge, training, and practice

A critical area of training is cultural safety. During Edmonton interviews in 2019, Indigenous mothers and home visitors (HV) described their experience of a disturbing lack of respect, understanding and cultural safety in interactions with doctors and nurses. One immigrant mother MP1 indicated that she received no prior communication or support from a nurse who reported her situation to Children’s Services (CS). Thus, when CS followed up, MP1, who lacked stable immigration status at the time, was terrified of deportation and other consequences.

A participant SP5 (home visitor with a primarily Indigenous-family serving agency) described having to intercede for an Indigenous client who was humiliated by her doctor for the size of her family. The vignette below illustrates the powerlessness of patients to engage service providers and challenge their words. It also illustrates the level of bias and assumption that shapes high-handed insults garbed in medical authority.

I’ve been in a hospital situation or a clinic situation when that has happened with a doctor coming in and being so rude to a woman, an aboriginal woman, who at that point in time it was through Health For Two, and she didn’t want to go to the doctor and she was pregnant, and I’m going to say again, because off the top of my head, I think she had six kids but she might’ve had eight, and was pregnant again. Also, her choice. Also, the doctor did not make any inquiries on why she was pregnant again or why anything, he just, people like you need to get that clipped. You need to fix this situation because you can’t keep just producing these babies and blah, blah, blah.I sat there. I have to be honest with you, I was a little bit younger and a little bit floored that this was happening. It would never happen now to a client that I brought to the doctor, but I was I don’t know, maybe 35 somewhere there, and I couldn’t believe this was happening to this woman. When we left the room, she goes, “And that’s why.” I’m like, I’m so sorry. I put you through that trauma. I’m so sorry. But you need to go to a doctor for your baby’s sake. Then she turns and looks at me, she says, my grandmother chewed on a root in the bush and had her baby by herself. Nobody was there. I’m like, yes. Our grandmas did that, I said. But a lot of our grandmas never returned. A lot of stuff could’ve happened. I mean like a goddamn bear could’ve come and ate her back then and we would’ve never knew. We don’t know why she didn’t return. She just died in the bush. I said but now, there’s a difference, I said. I am so sorry that I didn’t say anything to that doctor, I said, but you know, I will. I will. I have to collect my brain and I will on your behalf. I promise you. I will say something, but we will find you another doctor. We would get you another doctor so you don’t have to go into emergency, I’m going to have this baby and I’ve never seen a doctor. I said, that’s wrong. I said you’re getting up there and I said if you’ve had more babies, I said, things can be starting to go wrong. I said, there’s so many different things. I went after and I noticed as I walked by, the doctor was in his office and I said, I was wondering if I could have a minute with you. He was like yup, sure. I’m just about done, blah, blah, blah. I said, I felt very ashamed of us today in this building treating that mother the way we did. I said because it took everything I had to get her to see a doctor, I said, and then you belittled her to no end. He looks at me and he goes, I told her what had to be said. I’m like no. You didn’t tell her what had to be said. You didn’t ask her why she had so many children. You don’t know if she’s an abused woman and her man just takes what he wants. I said you don’t know if this is a religious thing that she can’t take birth control. You don’t know anything about her. He just looked at me and he goes well, maybe I should’ve just thought it instead of just saying it. I’m like, honestly my friend, you could not have come off any more aggressive if you would’ve just thought it. I said you know, everybody’s human here. I said, and if you’re going to be a maternity doctor, these women are going to cross your path that have many children, and are you going to talk to them all like that? Well, does she raise all her kids? I said, a matter of fact, she does. I said, a matter of fact, she has all her children. He’s like, none of them were in the system. I said no. That was another assumption of his because she was aboriginal. I’m like no, she has all her kids, and he said you’re not just saying that? I said no, I’m not. I said my son goes to school with her kids. I said, that’s why I convinced her to come here because I said this was a safe place. Yeah. I was so mad at him. I don’t know. It must’ve been — oh, it was a while, and she come back because I was there, and he actually stopped her and said, I think I owe you an apology. I was a little bit aggressive the day I’ve seen you. I hope you see another doctor. I was set straight. I was set straight is what he said and she said, thank you and just walked away [Interview, Edmonton, SP5]

The above vignette speaks to a huge missed opportunity to extend supports to women in distressed life situations and/or violent homes and relationships. It also speaks to the verbal, emotional and physical traumas endured by Indigenous women in a healthcare system ridden with racism and judgement (recently reported in the wrenching story of Ms Joyce Echaquan, in Quebec in 2020).

The published literature indicates significant knowledge gaps and need for training amongst medical students and service providers (Canada and elsewhere) on (1) causes, signs, patterns, and consequences of gender/family violence (2) complex challenges and needs of marginalized and disempowered populations (3) concepts and practices of cultural safety (which has emerged from the field of transcultural nursing) (Ahmad, Hogg-Johnson, Stewart, & Levinson, 2007; Burnett et al., 2019; Carlson, Kamimura, Al-Obaydi, Trinh, & Franchek-Roa, 2017; Cormack et al., 2018; Curtis et al., 2019; Gutmanis, Beynon, Tutty, Wathen, & MacMillan, 2007; Jones et al., 2019; Knibb-lamouche, 2012; Mørk, Andersen, & Taket, 2014; Ramsden, 2002; Sprague et al., 2013; Zink, Regan, Goldenhar, Pabst, & Rinto, 2009).

We found that both training and professional experience are associated with increased feelings of preparedness and self-confidence, promotion of professional networks, help with comfort initiating discussions of IPV, decreased anxiety about negative consequences of asking, increased comfort with discussions following abuse disclosure, practitioners feeling more in control, and decreased effects of practice pressures… (p 8 of 11; ellipses inserted) The key factors affecting readiness to identify and respond to IPV identified in the literature include: gaps in provider knowledge and lack of education regarding IPV; the perception of a lack of patient compliance (patient does not disclose); lack of effective interventions; and perceived system support, especially time. Other factors include provider self-efficacy, including feelings of powerlessness, and loss of control; safety concerns and fear of offending; affective barriers (e.g., lack of comfort, interest, and sympathy); poor interviewing or communication skills; providers’ personal experience with abuse; and their age and years in practice… (p 9 of 11; ellipses inserted) (Gutmanis et al., 2007).

Bridging gaps: the benefits of collaboration between public health providers and home visitors

One can safely assert that future research, planning and service design should look at ways to create bridges between anti-violence and health sectors. The gains therefrom would be the erosion of current inter-sectoral barriers, development of forums for knowledge sharing and collaborative learning, and most crucially, creation and use of routes of inter-service support and referral. For example, anti-violence experts can help to review medical training course material on the causes, signs, cycles, and effects of family violence. Conversely, doctors and nurses can train home visitors and anti-violence frontline on the physical fallouts of violence, e.g. effects of strangulation[1] which may leave no marks but may be audible in a hoarse voice, among other signs recognizable to the trained observer.[2]Spontaneous abortion, fetal injury, and fetal death are associated with trauma to the mother. IPV may cause maternal stress and provoke substance abuse, which can cause indirect adverse fetal health effects including low birth weight, intrauterine growth restriction, and fetal alcohol syndrome” (quoted from Deshpande & Lewis-O’Connor, 2013: 143; see also Burnett et al., 2019). Gentle knowledge sharing about such impacts on mother and fetus, baby and child can motivate mothers to open up in stages and to be receptive to offers of help. Healthcare providers, home visitors and anti-violence specialists could and should work together to establish norms and procedures of knowledge sharing about these difficult and fraught topics in diverse contexts, e.g. in doctors’ offices, in the homes of the women, or in service agency locations.

During our Alberta-wide conversations in 2019, we found evidence of the benefits of collaboration between home visitors and nurses in rural settings. The connections of home visitation agencies with public health workers were crucial to referral, program enrolment, and provision of some support to those in need. A predictor of maternal willingness to access supports, such as those via home visitation, was trust in the public health system and the referrals from the nurses with whom they interacted during prenatal and postnatal screening of babies. The public health nurses would often provide some prior information about the home visitation service that would lower the hurdles for engagement and enrolment.

It’s really easy for us to go because we have a public health nurse talk first….They also inform them this information we will provide to the family. When we do the intake visit, they already know, “Oh, you’re coming. Give us the information and support.” [FG, Calgary]

Interviewer:   What about with public health nurses? Do you work in collaboration with them?

Respondent 1:          Oh, we get referrals from them. We sometimes will take family to speak with a public health nurse if we want to talk about sexual health or prenatal classes or immunizations or dental. Yeah.

Respondent 2:          The public health generally is there for the immunizations and then that referral out. But there are also times that we consult with them on an ongoing when we’re worried about the baby’s weight or something that’s going on. We might be like, “Hey, well, we’re going to bring them in. We’re going to weigh them.” There is — depending on the situation on how close we work with them, but we do have a back and forth partnership. [Interview, Camrose]

Respondent 1:          And I think for us being unique in how we get referrals majority of our referrals come through a universal screen or prenatal or postnatal through AHS. So they’ve already talked to so many people. Families don’t really even know who we are when we come in and just the fact that they still let us come in and have that conversation and tell them a little bit more about us. So yeah, and they do, even after my intake in that conversation, a lot of times they still don’t have any idea of what’s going to happen, but they’re excited and interested in learning. [Interview, Raymond]

Respondent 2:          I think that’s kudos to quite a few of our referrals come from our public health nurses. So I think they must do an excellent job of kind of presenting what opportunity is being involved in this program.  [Interview, Raymond]

In the vignette below, the nurse and HV in rural Alberta joined efforts to engage a woman in a situation that concerned the nurse as being one of violence. The husband would decline the HV service if he was present during the offer of referral; the wife would become emotional and share details of her situation when he was absent but would similarly decline the program. The husband’s refusal of HV service may have been motivated by a desire to conceal the ongoing violence and to keep his wife isolated, a tactic integral to the maintenance of abusive control. The nurse and an HV joined efforts to try and create an opportunity for the HV to meet and engage the woman in the healthcare site during her baby’s immunization.

We have a great collaboration between the home, the public health care system and myself and that if there’s a client that they have a concern about or they’ve talked to the client, they’ll come and say, “Hey, [NAME], there’s this person.” For instance, just lately we’ve had one where the nurse …has concerns about maybe family violence in terms of control and that sort of stuff in the home. Mom is a new Canadian citizen or new to this country, so she comes from a different culture. And dad is always there and “No, that’s okay. We don’t want the program.” When dad has not been in the room, mom has been emotional and overwhelmed and shared things but has declined the program time and time again. So [COLLEAGUE] has connected with her to try to do the intake and stuff like that, “Oh, it will be okay.” And then she’ll come in the next week. So the nurse and I have chatted, and it was kind of agreed that you know what, maybe the next visit, if you know when she’s scheduled for the next baby’s immunizations, I’ll make sure. I’ll penciled into my day timer to be available here in the office so that you can come and we can do a work handoff. I can chat with her and maybe that will ease a transition or acceptance. So yeah, really we have great collaboration. [Interview, Raymond]

A participant working in a rural location indicated that her agency and public health were able to offset the impact of funding cuts by working together.  She described using public health prenatal classes as a platform to provide information about HV service, which was helpful to enrolment.

Our whole visitation took a real dive, I guess, about two years ago. Then my casework manager and myself really worked on promoting it. That’s when I got involved with public health. That’s been huge for us in attending the prenatal classes. I think now that we’re accessing people prior to the baby being born, it’s really improved our people getting involved in home visitation. Then also public health was cut so they can only do one home visit after a baby’s born, which before, they would do five and six. I think it’s really hard for them to only have one visit. Then sometimes in immunization when they’re at three months or six months or whatever, they’ll get an indication that someone’s too isolated or then the questions they’re asking, they could use some parenting support to development supports around the baby. They’ll also come in and contact…Now, they’re contacting me to say that when they have a red flag and they want someone more in the home, around for whatever reason, I have that flow in too. People are very open to that. When it comes to public health, people are very open to us coming in the home. They’re told about it usually at public health. The nurses refer in. I get quite a few referrals that way. I also go to the prenatal classes and do a little session where I introduce myself and tell them all about Parent Link, tell them about our Baby and Me program, home visitation, the parenting groups. A lot of people come in that way… Even though it’s been like a year and a half, it’s still, I think, a new — yeah. But it’s really working. In my humble opinion, I feel like we’re accessing more families this way that are vulnerable that I wouldn’t necessarily come in contact with. [Interview, Jasper]

Conclusion

Healthcare providers have a crucial role in screening for and supporting women who endure family violence. Challenges include gaps in understanding of gender and family violence, willingness to handle and support such cases, specific training (screening for violence and supporting survivors in timely and considerate ways) and inadequate or absent cultural safety.

Nevertheless, there is some evidence of the benefits of intersectoral collaboration, such as between nurses and home visitors who join forces to support women and to offset challenges and gaps in their respective sectors. More research is needed to understand how such collaborations can be bolstered, e.g. through platforms for cross-sector communities of practice, which necessitates policy and funding incentives to establish, use, evaluate and incrementally improve those platforms.

Notes

[1] “Choking and strangulation are often thought to be the same, but they are different. Choking is when something like a candy gets stuck in your breathing tube (wind pipe). This may stop the air going into your lungs. Strangulation (strangling) is when something presses or squeezes on your neck. The squeezing may stop the blood supply going to your brain, or it may stop the air going to your lungs. It may make you lose consciousness (black out) and stop breathing. Being strangled may cause you serious health problems. It may damage your brain causing difficulty with thinking and memory and may cause you to have a stroke. If you are pregnant you are at risk of losing your baby” (Government of Prince Edward Island Family Violence Prevention Services, n.d.). Further: “Strangulation is an important form of physical violence against women who are in abusive relationships. Overall, 27% of this sample experienced non-fatal strangulation, 10% of the abused controls and 45% of the attempted, and 43% of the completed homicide cases. Non- fatal strangulation, as opposed to other severe forms of physical violence such as striking with fists or another object, frequently leaves little in the way of observable injury, yet can result in serious physical and mental health consequences (ellipses inserted)”(Glass et al., 2008: 5).

[2] Initial signs of strangulation  include “Voice changes (e.g., hoarse, raspy voice, loss of voice);Pain when swallowing; Bleeding from mouth/coughing up blood; Abrasions, swelling, redness or bruises on the neck; Ligature marks from rope, cord, fabric; Swollen tongue; Difficulty with concentration, attention, coordination, memory; Difficulty using words, processing meaning of words; Headache; Light-headedness; Dizziness; Ear ringing; Facial/eyelid drooping; Breathing changes (e.g., hyperventilating); Sweating; Visual disturbances; Numbness/tingling; Confusion; Mental status changes (e.g., combativeness, agitation); Drowsiness; Cyanosis (blue tint to skin due to low oxygen); Petechiae (small red spots) under the eyelids, around eyes/face/beck/scalp; Bloody red eyes; Limb jerking; Seizures;  Loss of consciousness; Coma; Miscarriage if pregnant; Involuntary urination/defecation; Hormonal problems (e.g., neurogenic diabetes insipidus causing excessive thirst and urine production)”  (ABI Research Lab, 2020).

References

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Burnett, C., Crowder, J., Bacchus, L. J., Schminkey, D., Bullock, L., Sharps, P., & Campbell, J. (2019). “It Doesn’t Freak Us Out the Way It Used to”: An Evaluation of the Domestic Violence Enhanced Home Visitation Program to Inform Practice and Policy Screening for IPV. Journal of Interpersonal Violence, 088626051982716. https://doi.org/10.1177/0886260519827161

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Glass, N., Laughon, K., Campbell, J., Block, C. R., Hanson, G., Sharps, P. W., & Taliaferro, E. (2008). Non-fatal Strangulation is an Important Risk Factor for Homicide of Women. The Journal of Emergency Medicine, 35(3), 329–335. https://doi.org/10.1016/j.jemermed.2007.02.065

Government of Prince Edward Island Family Violence Prevention Services. (n.d.). Information for Victims of Strangulation. Retrieved July 18, 2020, from https://www.princeedwardisland.ca/sites/default/files/publications/css_straginfo14.pdf

Gutmanis, I., Beynon, C., Tutty, L., Wathen, C. N., & MacMillan, H. L. (2007). Factors influencing identification of and response to intimate partner violence: A survey of physicians and nurses. BMC Public Health, 7, 1–11. https://doi.org/10.1186/1471-2458-7-12

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Knibb-lamouche, J. (2012). Culture as a Social Determinant of Health: Examples from Native Communities. Institute on Medicine: Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities, 1–22.

Mørk, T., Andersen, P. T., & Taket, A. (2014). Barriers among Danish women and general practitioners to raising the issue of intimate partner violence in general practice: A qualitative study. BMC Women’s Health, 14(1), 1–10. https://doi.org/10.1186/1472-6874-14-74

Ramsden, I. M. (2002). Cultural Safety and Nursing Education in Aotearoa and Te Wai Pounamu (Victoria University of Wellington). Retrieved from http://www.nzno.org.nz/Portals/0/Files/Documents/Services/Library/2002 RAMSDEN I Cultural Safety_Full.pdf

Sprague, S., Kaloty, R., Madden, K., Dosanjh, S., Mathews, D. J., & Bhandari, M. (2013). Perceptions of Intimate Partner Violence: a cross sectional survey of surgical residents and medical students. Journal of Injury and Violence Research, 5(1), 2–10. https://doi.org/10.5249/jivr.v5i1.147

Zink, T., Regan, S., Goldenhar, L., Pabst, S., & Rinto, B. (2009). Intimate Partner Violence: What Are Physicians’ Perceptions? The Journal of the American Board of Family Medicine, 17(5), 332–340. https://doi.org/10.3122/jabfm.17.5.332

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