Classificatory multiplicity: intimate partner violence diagnosis in emergency department consultations

Souza B.D., Wise J.

Beryl de Souza and Jan Wise explain the role and responsibilities of an expert witness

Walby S., Olive P., Towers J., Francis B., Strid S., Krizsán A., Lombardo E., May-Chahal C., Franzway S., Sugarman D., Agarwal B., Armstrong J.

McGarry J., Nairn S.

There is a clear body of evidence which indicates that a substantial number of people who have experienced domestic violence and abuse attend the emergency department (ED). However, many individuals do not receive effective identification or support. The present study sought to explore the perceptions of ED staff about the perceived value and utilisation of a new domestic abuse nurse specialist role that has been created in one ED in the UK. A qualitative design was used and involved sixteen in-depth interviews with a range of practitioners. The findings highlight that staff highly valued the role of the nurse specialist as one which offered support both professionally and personally. However, the study has also drawn attention to the conundrum that surrounds identification and management of abuse and of enquiry more generally. The ED is ideally suited to identify at risk individuals but is not institutionally organised in a way that prioritises the social concerns of their patients and this nursing role is one way that this issue can be addressed. In light of recent UK and global policy directives further research is needed to explore the development and implementation of identification, management and support in the future.

Woolgar S., Lezaun J.

There is in science and technology studies a perceptible new interest in matters of ‘ontology’. Until recently, the term ‘ontology’ had been sparingly used in the field. Now it appears to have acquired a new theoretical significance and lies at the centre of many programmes of empirical investigation. The special issue to which this essay is a contribution gathers a series of enquiries into the ontological and reflects, collectively, on the value of the analytical and methodological sensibilities that underpin this new approach to the make-up of the world. To what extent and in what sense can we speak of a ‘turn to ontology’ in science and technology studies? What should we make of, and with, this renewed interest in matters of ontology? This essay offers some preliminary responses to these questions. First, we examine claims of a shift from epistemology to ontology and explore in particular the implications of the notion of ‘enactment’. This leads to a consideration of the normative implications of approaches that bring ‘ontological politics’ to centre stage. We then illustrate and pursue these questions by using an example – the case of the ‘wrong bin bag’. We conclude with a tentative assessment of the prospects for ontologically sensitive science and technology studies.

Basu S., Ratcliffe G.

Aim To improve the detection and quality of care of patients who attend the emergency department (ED) with confirmed or suspected domestic abuse (DA).Design A quality improvement report on the design, implementation and evaluation of a specialised service and structured training programme to detect and manage DA presentations within an emergency medicine department.Setting The study was set in the ED at the Northern General Hospital, Sheffield, UK.Key measures for improvement Key measures for improvement included introducing a service within the ED to help staff manage DA and coordinate responses; improve staff confidence in detecting DA; develop a structured and consistent process by which to manage DA presentations.Strategies for change An Independent Domestic Violence Advocate service was introduced into the department in July 2011 through a multiagency agreement. A structured training and education programme was delivered to ED staff. A ‘communications form’ was developed for DA risk assessment and case management. The process was reviewed quarterly.Results One hundred and seventy-two referrals were made to the service (121 distinct clients) over a 12-month period. Staff reported greater confidence in detecting DA, and community partners highlighted the role the service had in improving DA detection and care quality within the city.Conclusions Strong leadership and prioritising the issue within the department has facilitated the development of the process and contributed substantially to its success. Support from community partners has been invaluable in tailoring the service and education programme to the needs of staff and patients within the department.

Catallo C., Jack S.M., Ciliska D., MacMillan H.L.

Aims To report a study of processes used by women to disclose intimate partner violence to healthcare professionals in urban emergency department settings. Background Women seek emergency care for impairment related to intimate partner violence yet face barriers non-judgmental and supportive care. Design A two-phase sequential explanatory mixed methods study. Methods The study was conducted in Ontario, Canada (May 2006–December 2007). In a sub-analysis of quantitative data with 1182 participants, 15% of women patients reported intimate partner violence, but only 2% disclosed to a healthcare professional. To understand these results, grounded theory with 19 participants was completed. Results/findings Participants identified that the basic social problem was the violence ‘being found out’ by healthcare professionals while receiving care. To address this problem, women undertook a process to minimize intrusion including: deciding to seek care, evaluating the level of trust with the presenting healthcare professional, and establishing personal readiness to disclose. The trajectory of this process was different for each participant with some negotiating all phases leading to violence disclosure. The length of time it took for participants to move through each phase varied across all participants. Common to all participants was the anticipation and the actual experience of intrusion and its influence on women's willingness to disclose intimate partner violence. Conclusion The results suggest nurses may be able to facilitate disclosure of intimate partner violence through limiting intrusion. This can include assessment in a private setting, and fewer professionals who interact with the client.

Beynon C.E., Gutmanis I.A., Tutty L.M., Wathen C.N., MacMillan H.L.

Intimate partner violence (IPV) against women is a serious public health issue and is associated with significant adverse health outcomes. The current study was undertaken to: 1) explore physicians’ and nurses’ experiences, both professional and personal, when asking about IPV; 2) determine the variations by discipline; and 3) identify implications for practice, workplace policy and curriculum development. Physicians and nurses working in Ontario, Canada were randomly selected from recognized discipline-specific professional directories to complete a 43-item mailed survey about IPV, which included two open-ended questions about barriers and facilitators to asking about IPV. Text from the open-ended questions was transcribed and analyzed using inductive content analysis. In addition, frequencies were calculated for commonly described categories and the Fisher’s Exact Test was performed to determine statistical significance when examining nurse/physician differences. Of the 931 respondents who completed the survey, 769 (527 nurses, 238 physicians, four whose discipline was not stated) provided written responses to the open-ended questions. Overall, the top barriers to asking about IPV were lack of time, behaviours attributed to women living with abuse, lack of training, language/cultural practices and partner presence. The most frequently reported facilitators were training, community resources and professional tools/protocols/policies. The need for additional training was a concern described by both groups, yet more so by nurses. There were statistically significant differences between nurses and physicians regarding both barriers and facilitators, most likely related to differences in role expectations and work environments. This research provides new insights into the complexities of IPV inquiry and the inter-relationships among barriers and facilitators faced by physicians and nurses. The experiences of these nurses and physicians suggest that more supports (e.g., supportive work environments, training, mentors, consultations, community resources, etc.) are needed by practitioners. These findings reflect the results of previous research yet offer perspectives on why barriers persist. Multifaceted and intersectoral approaches that address individual, interpersonal, workplace and systemic issues faced by nurses and physicians when inquiring about IPV are required. Comprehensive frameworks are needed to further explore the many issues associated with IPV inquiry and the interplay across these issues.

Choo E.K., Nicolaidis C., Newgard C.D., Hall M.K., Lowe R.A., McConnell M.K., McConnell K.J.

There is little information about which intimate partner violence (IPV) policies and services assist in the identification of IPV in the emergency department (ED). The objective of this study was to examine the association between a variety of resources and documented IPV diagnoses.Using billing data assembled from 21 Oregon EDs from 2001 to 2005, we identified patients who were assigned a discharge diagnosis of IPV. We then surveyed ED directors and nurse managers to gain information about IPV-related policies and services offered by participating hospitals. We combined billing data, survey results, and hospital-level variables. Multivariate analysis assessed the likelihood of receiving a diagnosis of IPV depending on the policies and services available.In 754 597 adult female ED visits, IPV was diagnosed 1929 times. Mandatory IPV screening and victim advocates were the most commonly available IPV resources. The diagnosis of IPV was independently associated with the use of a standardized intervention checklist (odds ratio: 1.71; 95% confidence interval: 1.04-2.82). Public displays regarding IPV were negatively associated with IPV diagnosis (odds ratio 0.56; 95% confidence interval: 0.35-0.88).IPV remains a rare documented diagnosis. Most common hospital-level resources did not demonstrate an association with IPV diagnoses; however, a standardized intervention checklist may play a role in clinician's likelihood of diagnosing IPV.

Paley J., Eva G.

The reception of complexity theory in health care is characterised by a tendency to reify the idea of a complex system, which is basically an abstraction. This paper argues for three principal theses: first, to invoke complexity, to refer to complex systems, is to proffer a form of explanation; second, in the context of the social sciences, the form of explanation that complexity represents belongs to a family of explanations which the recent theoretical literature associates with social mechanisms; and, third, complexity explanations refer to a specific type of social mechanism, whose features differentiate it from the other members of the family. The most significant of these features is the jettisoning of the default link between order and design, which is precisely the principle omitted by an influential series of papers in the BMJ. Having defended these claims, the paper presents a brief case study illustrating the analysis.

Boursnell M., Prosser S.

This project was initiated to improve the quality of identification and response practices of Emergency Department (ED) nursing staff dealing with possible victims of domestic violence (DV). Nursing staff were trained to identify three key actions in the pathway for domestic violence presentations in the ED. A survey of ED staff was taken pre-training to determine a base-line measure of self-reported knowledge regarding domestic violence policies and practices. The survey was re-administered 1 month and 6 months post-training. A file audit was also undertaken prior to and following the training. Results show the training improved the nurses' confidence, practice and skills in the identification of, and response to, domestic violence, particularly in relation to children. ED nurses are well placed to identify and respond to domestic violence as the ED provides a gateway into health services for women and their children. This paper reports on a participatory action research project which aimed to improve quality and practice around DV for ED staff. The dissemination of the results in this paper are considered to be essential to health services due to dearth of information and research about best practice initiatives for responding to and recognizing domestic violence in the ED.

Howard L.M., Trevillion K., Khalifeh H., Woodall A., Agnew-Davies R., Feder G.

BackgroundThe lifetime prevalence of domestic violence in women is 20–25%. There is increasing recognition of the increased vulnerability of psychiatric populations to domestic violence. We therefore aimed to review studies on the prevalence of, and the evidence for the effectiveness of interventions in, psychiatric patients experiencing domestic violence.MethodLiterature search using Medline, PsycINFO and EMBASE applying the following inclusion criteria: English-language papers, data provided on the prevalence of or interventions for domestic violence, adults in contact with mental health services.ResultsReported lifetime prevalence of severe domestic violence among psychiatric in-patients ranged from 30% to 60%. Lower rates are reported for men when prevalence is reported by gender. No controlled studies were identified. Low rates of detection of domestic violence occur in routine clinical practice and there is some evidence that, when routine enquiry is introduced into services, detection rates improve, but identification of domestic violence is rarely used in treatment planning. There is a lack of evidence on the effectiveness of routine enquiry in terms of morbidity and mortality, and there have been no studies investigating specific domestic violence interventions for psychiatric patients.ConclusionsThere is a high prevalence of domestic violence in psychiatric populations but the extent of the increased risk in psychiatric patients compared with other populations is not clear because of the limitations of the methodology used in the studies identified. There is also very limited evidence on how to address domestic violence with respect to the identification and provision of evidence-based interventions in mental health services.

Ramage M., Shipp K.

Feder G., Ramsay J., Dunne D., Rose M., Arsene C., Norman R., Kuntze S., Spencer A., Bacchus L., Hague G., Warburton A., Taket A.

Olive P.

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.

Coben Jeffrey H

Choo S.Y., Wilson J., Beard N., McGrath M., Lubman D.I., Smith K., Scott D., Ogeil R.P.

Blake S., Nobles J.

Complexity science is an interdisciplinary paradigm that helps people understand how outcomes, such as domestic violence and abuse (DVA), arise from within complex adaptive systems. This study aims to identify how complexity science has been applied in DVA literature. A systematic scoping review was conducted, searching across academic databases and Google for articles. Articles published from 1990 to 2020, written in English, had DVA partner abuse as a focus, and used complexity science as a focus or theoretical background to the paper, were considered for inclusion. Data was extracted and narratively synthesized in an iterative manner. Twenty-one studies were included, originating predominantly from the United States and New Zealand, and published mainly after 2009. Approximately 70% of authorships were comprised of interdisciplinary teams. Most papers strongly incorporated complexity science as a methodological approach and applied methods, such as systems modeling (agent-based modeling or systems dynamics modeling), aligning with computer science or engineering disciplines. Some used complexity theory combined with qualitative techniques (interviews or discourse analysis) strongly associated with social sciences research. Methods and findings were heterogeneous and often explored interactions between parts of the system and the subsequent phenomena that emerged from these interactions. Complexity science can: (a) support a holistic understanding of DVA; (b) combine different perspectives; (c) encourage interdisciplinary teams to work collaboratively around an issue such as DVA; (d) identify leverage points to assist in targeting scarce resources; (e) help predict emergent phenomena and unexpected consequences of policy change.

Camarda A., Bradford J.Y., Dixon C., Horigan A.E., DeGroot D., Kaiser J., MacPherson-Dias R., Perry A., Slifko A., Slivinski A., Bishop-Royse J., Delao A.M.

Sargeant S., Baird K., Sweeny A., Torpie T.

Screening for domestic violence in healthcare settings increases detection. The emergency department (ED) is one setting where victims frequently attend with injuries and illnesses sustained from violence. However, screening rates remain suboptimal. There is little research about how formal screening occurs, or how less structured interactions are negotiated within the ED context. This article explores this important, but non-mandatory procedure within the context of clinician–patient interactions in Australia. A descriptive qualitative study was undertaken with 21 clinicians across seven EDs in Australia. Thematic analysis was undertaken by two researchers. Results indicate a lack of confidence around DV screening, and tensions in clinicians initiating conversation while managing their own emotional stressors. No participants expressed knowledge of formal screening processes in their workplaces. Successful DV screening programs must provide clinicians with the tools to minimize perceived discomfort in initiating and sustaining conversations while accepting patient preferences regarding disclosure.

Carroll Á., Collins C., McKenzie J., Stokes D., Darley A.

BackgroundComplexity theory has been chosen by many authors as a suitable lens through which to examine health and social care. Despite its potential value, many empirical investigations apply the theory in a tokenistic manner without engaging with its underlying concepts and underpinnings.ObjectivesThe aim of this scoping review is to synthesise the literature on empirical studies that have centred on the application of complexity theory to understand health and social care provision.MethodsThis scoping review considered primary research using complexity theory-informed approaches, published in English between 2012 and 2021. Cochrane Database of Systematic Reviews, MEDLINE, CINAHL, EMBASE, Web of Science, PSYCHINFO, the NHS Economic Evaluation Database, and the Health Economic Evaluations Database were searched. In addition, a manual search of the reference lists of relevant articles was conducted. Data extraction was conducted using Covidence software and a data extraction form was created to produce a descriptive summary of the results, addressing the objectives and research question. The review used the revised Arksey and O’Malley framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR).Results2021 studies were initially identified with a total of 61 articles included for extraction. Complexity theory in health and social care research is poorly defined and described and was most commonly applied as a theoretical and analytical framework. The full breadth of the health and social care continuum was not represented in the identified articles, with the majority being healthcare focused.DiscussionComplexity theory is being increasingly embraced in health and care research. The heterogeneity of the literature regarding the application of complexity theory made synthesis challenging. However, this scoping review has synthesised the most recent evidence and contributes to translational systems research by providing guidance for future studies.ConclusionThe study of complex health and care systems necessitates methods of interpreting dynamic prcesses which requires qualitative and longitudinal studies with abductive reasoning. The authors provide guidance on conducting complexity-informed primary research that seeks to promote rigor and transparency in the area.RegistrationThe scoping review protocol was registered at Open Science Framework, and the review protocol was published at BMJ Open (https://bit.ly/3Ex1Inu).

Dheensa S., Feder G.

BackgroundOver two million adults experience domestic violence and abuse (DVA) in England and Wales each year. Domestic homicide reviews often show that health services have frequent contact with victims and perpetrators, but healthcare professionals (HCPs) do not share information related to DVA across healthcare settings and with other agencies or services.AimWe aimed to analyse and highlight the commonalities, inconsistencies, gaps and ambiguities in English guidance for HCPs around medical confidentiality, information sharing or DVA specifically.SettingThe English National Health Service.Design and methodWe conducted a desk-based review, adopting the READ approach to document analysis. This approach is a method of qualitative health policy research and involves four steps for gathering, and extracting information from, documents. Its four steps are: (1) Ready your materials, (2) Extract data, (3) Analyse data and (4) Distill your findings. Documents were identified by searching websites of national bodies in England that guide and regulate clinical practice and by backwards citation-searching documents we identified initially.ResultsWe found 13 documents that guide practice. The documents provided guidance on (1) sharing information without consent, (2) sharing with or for multiagency risk assessment conferences (MARACs), (3) sharing for formal safeguarding and (4) sharing within the health service. Key findings were that guidance documents for HCPs emphasise that sharing information without consent can happen in only exceptional circumstances; documents are inconsistent, contradictory and ambiguous; and none of the documents, except one safeguarding guide, mention how coercive control can influence patients’ free decisions.ConclusionsGuidance for HCPs on sharing information about DVA is numerous, inconsistent, ambiguous and lacking in detail, highlighting a need for coherent recommendations for cross-speciality clinical practice. Recommendations should reflect an understanding of the manifestations, dynamics and effects of DVA, particularly coercive control.

Kirby S., Birdsall N.

This study examines whether increases in incidents of female domestic abuse occur during FIFA world cup tournaments, in countries, other than the UK. Columbian medical records providing national daily counts, relating to Violence Against Women (VAW) and females subject to Intimate Partner Violence (IPV), across two world cup tournaments (2014/2018) were analysed. The number of medical examinations rose by 43% (VAW) and 39% (IPV) during the 2014 Columbia match days, and 26% (VAW) and 27% (IPV) during the 2018 match days, when compared to non-match days (p < .001). The increases were higher on a weekend and when winning, rather than losing.

Gun C., Aldinc H., Yaylaci S.

Phares T.M., Sherin K., Harrison S.L., Mitchell C., Freeman R., Lichtenberg K.

The purpose of this paper is to produce a position statement on intimate partner violence (IPV), a major sociomedical problem with recently updated evidence, systematic reviews, and U.S. Preventive Services Task Force guidelines. This position statement is a nonsystematic, rapid literature review on IPV incidence and prevalence, health consequences, diagnosis and intervention, domestic violence laws, current screening recommendations, barriers to screening, and interventions, focusing on women of childbearing age (15-45 years). The American College of Preventive Medicine (ACPM) recommends an integrated system of care approach to IPV for screening, identification, intervention, and ongoing clinical support. ACPM only recommends screening that is linked to ongoing clinical support for those at risk. ACPM recommends greater training of clinicians in IPV screening and interventions and offers health systems and research recommendations.

Olive P.

Objectives To investigate the availability of intimate partner violence-related population health information in England and the possibility of identifying intimate partner violence-exposed population sample frames from administrative health data systems in England employing the International Classification of Disease. Methods Research design was an exploratory mixed method approach that involved trend analysis of numbers of applications of International Classification of Disease intimate partner violence classifications for admissions to NHS hospitals in England over a five-year period and semi-structured focus group interviews with clinical coders at an NHS Hospital. Results Use of International Classification of Disease intimate partner violence classifications was generally low across NHS Trusts in England. There was notable variation in the numbers of applications across NHS providers which demographic differences or rates of violence perpetration would not account for. The interview findings revealed conceptual ambiguity regarding intimate partner violence classifications which presented challenges for clinical coding and raised questions about the reliability and validity of International Classification of Disease’s intimate partner violence classifications. Conclusion It would not be possible to extract robust data about populations exposed to intimate partner violence for the purposes of audit, governance or research from health information systems using current International Classification of Disease-10 classifications. Development of these International Classification of Disease codes is essential for violence and abuse to be captured more accurately in health information systems and afforded greater prioritization and funding proportionate to the health burden and service demands that intimate partner violence is responsible for.