The following individuals
certify that they have read, and recommend to the Faculty of Graduate and
Postdoctoral Studies for acceptance, a thesis/dissertation entitled:
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Emergency
Healthcare Providers Perspectives on
Providing Care to Racialized Immigrant Women Experiencing Intimate Partner
Violence
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submitted by
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in partial fulfilment
of the requirements for
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the degree of
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Master of Science in
Nursing
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in
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The Faculty of
Graduate and Postdoctoral Studies
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Examining
Committee:
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Associate Professor
Nursing
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Supervisor
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Professor
Nursing
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Supervisory Committee Member
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Title / Department Associate Professor
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Supervisory Committee Member
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Additional Examiner
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Additional Supervisory
Committee Members:
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Supervisory Committee Member
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Supervisory Committee Member
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Background: Intimate partner violence (IPV) impacts all Canadian women regardless
of socioeconomic status, race, age, and ethnicity. In Canada, prevalence rates
are estimated to be 6% to 8% during a 5-year period, but many experts argue
rates may be even higher. As well, racialized immigrant women experiencing IPV
are likely to face interpersonal and structural barriers to care when accessing
services and engaging with HCPs. To this date, research focusing on emergency
department (ED) healthcare professionals’ (HCP) perspectives and experiences
caring for racialized immigrant women experiencing IPV has been limited.
Purpose: The purpose of this study was to explore and better understand ED
HCPs’ perspectives on providing care for racialized immigrant women
experiencing IPV who are seeking care in the ED. The research was conducted at a
large urban hospital located in the lower mainland in British Columbia (BC). A
significant percentage of the population where the hospital is located are
foreign-born immigrants’ originating from India and are of Punjabi-Sikh
descent. Given this population demographic, it is highly likely HCPs have cared
for Punjabi-Sikh women in the ED setting.
Method: A qualitative descriptive research design was employed. Cultural
safety was the theoretical framework used in this study. A convenience sampling
approach was used to recruit 5 HCPs. The HCPs consisted of ER nurses, forensic
nurses, and social workers who were primarily employed in the ED. In-depth,
individual interviews were conducted and a thematic approach to analysis was
conducted.
Implications: WILL DO AFTER FEEDBACK OF CHAPTER 5
Lay Summary
Intimate partner
violence (IPV) impacts all Canadian women regardless of socioeconomic status,
race, age, and ethnicity. Racialized immigrant women experiencing IPV are
likely to face barriers to care when accessing services and engaging with HCPs.
The purpose of this study was to explore and better understand ED HCPs
perspectives on providing care for women experiencing IPV who are seeking care
in the ED. The research was conducted at a large urban hospital located in the
lower mainland in BC. Qualitative description was used, and 5 HCPs were
recruited. The HCPs consisted of a mix of ED nurses, forensic nurses, and
social workers, who were primarily employed in the ED.
Preface
The research
conducted in this study received harmonized approval from the University of
British Columbia’s Research Ethics Board [UBC REB # H16-00851] and the Fraser
Health Research Ethics Board.
Acknowledgements
I
would like to express my sincere appreciation to my principal supervisor Dr.
Helen Brown. Without your guidance, patience, support and wealth of knowledge I
would have never been able to complete this endeavour. I would also like to
express my gratitude to my supervisory committee members Dr. Colleen Varcoe and
Dr. Victoria Bungay for your expertise and insight during this process. I would
also like to thank the amazing women who participated in this study. I am in
awe to your dedication in providing quality and compassionate care, and
advocacy to women impacted by intimate partner violence. I would like to thank my family and friends
for your endless love and support and words of encouragement when at times I
felt discouraged. Lastly, I dedicate this study to Maple Batalia a young woman
who lost her life to a senseless violent crime due to intimate partner
violence. You inspired me to bring a voice to this matter and stress the
importance of providing awareness to this important topic, intimate partner violence.
Your life was an inspiration and it still inspires me today.
Violence against
women, particularly intimate partner violence (IPV), is not only a Provincial
and National health issue but also a global one. According to the World Health
Organization (WHO, 2012) IPV “refers to any behaviour within an intimate
relationship that causes physical, psychological or sexual harm to those in the
relationship” (p. 1). The WHO (2013) estimates globally 35% of women have
experienced IPV in their life. Women are more likely than men to experience IPV
and more likely than males to experience physical abuse (Statistics Canada,
2013). According to Cherniak, Grant, Mason, Moore and Pellizzari (2005) “all
women, regardless of socioeconomic status, race, sexual orientation, age,
ethnicity, health status, and presence or absence of current partner, are at
risk for IPV” (p. 365). In Canada, prevalence rates are estimated to be 6% to
8% during a 5-year period, but many experts argue rates may be even higher
(Cherniak et al. 2005; Statistics Canada, 2013). In British Columbia (BC) 32%
of female adolescents (aged between 15 to 23 years) have experienced IPV and
women aged between 24 to 34 years of age are more likely to experience IPV than
any other age group (Statistics Canada, 2013). I[CMV2] PV has significant impacts on morbidity and mortality in women. Women
experiencing IPV, for example are at increased risk for substance abuse, mental
disorders, chronic physical disorders, and sexual health issues (Cherniak et
al. 2005; Heenan & Astbury, 2002; Karakurt, Smith & Whiting, 2014;
McCauley et al. 2015). Women who experience IPV are also disproportionately
affected by: chronic somatic disorders, depression, anxiety disorders, suicidal
ideation, suicide, eating and gastrointestinal disorders, sleeping disorders,
chronic fatigue, chronic pain, complications of pregnancy and childbirth,
hypertension, and worsening of chronic medical conditions and unable to manage
chronic medical conditions such as diabetes, and asthma (Cherniak et al. 2005;
Heenan & Astbury, 2002; Wuest et al. 2009; Wuest et al. 2008). The
aforementioned medical conditions highlight the serious health impact that IPV
has on women experiencing violence and the high likelihood healthcare
professionals (HCP) will be caring for and interacting with women experiencing
or at risk for IPV (Hyman, Forte, Du Mont, Romans & Cohen, 2009).
IPV has significant
personal, physical, mental and financial impacts on women’s lives, the impact
being even greater for racialized immigrant[1] women living in
poverty, and for women facing barriers to health and social well-being
(Cherniak et al. 2005; Holtmann & Rickards, 2018).
In the Canadian population, 20.6% in 2011 were foreign-born who arrived as immigrants; most of the
foreign-born populations were from South Asia (Statistics Canada, 2016). [CMV3] Immigrant women comprise 20.2% of the Canadian female population and
55% of these immigrant women are visible minorities[2] (Statistics Canada, 2015). Hence, immigrant
women represent a significant proportion of the Canadian population. The terms
visible minority and immigrant are often used interchangeably by the Canadian
government when collecting census information about the Canadian population.
While debate exists about the use of terms such as ‘visible minority’ and
‘immigrant’, the importance of considering racialization should be highlighted
as it draws attention to the structural context and power relations that are
continuous with racism (CRIAW, 2005; Ng-See-Quan, 2005). Visible minority “is used to denote the difference in skin tone and
the word ‘minority’ to denote numerical smallness or weakness in power
relations” (Pendakur, 2005). In this
study, I used the term racialized
immigrant woman to underscore the critical importance of accounting for the
social, economic, historical and political context shaping immigrant women’s
lives and their experiences, risks for and health care needs associated with
IPV.
The Canadian
Research Institute for the Advancement of Women (CRIAW, 2005) stated the term racialized is used to refer to women
who:
“…experience racism because of their race, skin colour, ethnic
background, accent, culture or religion…[and includes women] of colour…from
different ethnic, linguistic, religious, or cultural minorities, [and women
with different birth countries including Canada] who are targets of
racism…Racialized women have different cultures, histories, religions, family
norms, life experiences, and are subject to different stereotypes. What they
have in common is they are racialized – they are subjected to racism and made
to feel different because of their racial/ethnic background (p. 2).
Using the term racialized acknowledges the fact the obstacles women encounter are
entrenched “in the historical and contemporary racial prejudice of society and
are not a product of our own identities or shortcomings” (City for All Women
Initiative (CAWI), 2016, p.2). All women, including racialized immigrant women,
face countless obstacles and challenges when disclosing IPV, which will be
discussed in the next few sections.
IPV impacts women
and their families, including children who are exposed to IPV. Children who are
exposed to IPV face greater risk for engaging in violent behaviour than[BH4] [CMV5] those who do not, as well as being more likely to suffer from
depression and anxiety (Kennedy, Bybee & Greeson, 2015; Visser et al.
2015). Being depressed in childhood also predisposes children to be depressed
in adolescence and adulthood (Kennedy et al. 2015). It has also been noted
children who are exposed to IPV are more likely to have trouble focusing in
school, which can affect future academic success and monetary earnings (Kennedy
et al. 2015; Visser et al. 2015). In a US study, female children being exposed
to IPV were more likely to experience IPV later in life, and male children
exposed to IPV were more likely to perpetrate IPV towards their partners also
later in life (Kennedy et al. 2015; Visser et al. 2015).
IPV has significant
personal, physical, mental and financial impacts on women’s lives, the impact
being even greater for racialized immigrant women living in poverty, and women
lacking access to social determinants of health (Cherniak et al. 2005; Holtmann
& Rickards, 2018). These impacts of IPV extend beyond the lives of
individual women, having social and economic costs that influence systemic
resources necessary to both prevent and tackle violence. For example, women who
seek care for IPV in emergency department (ED) settings may or may not have
access to care and resources to adequately address their needs (Zhang,
Hoddenbagh, McDonald & Scrim, 2012). Compared to the general population of
women, racialized immigrant women face even greater barriers and challenges
related to complex systemic obstacles that influence the disclosure of violence
(Hyman, Forte, Du Mont, Romans & Cohen, 2009). For racialized immigrant women, the risks for
and rates of IPV are exacerbated by social, cultural, and political barriers,
including social isolation, language barriers, discrimination, fear of
deportation, an unwillingness or inability to displace themselves and their
children from the nuclear family, and the cultural meaning of divorce (Ahmad,
Driver, McNally, & Stewart, 2009; Du Mont & Forte, 2012; George &
Rashidi, 2014).
Racialized immigrant
women may also face financial barriers limiting their access to healthcare
services. Racialized immigrant women were more likely to be in a low-income
bracket than non-racialized immigrant women, and 28% of racialized immigrant
women were considered low-income compared with 14% of non-racialized immigrant
women (Statistics Canada, 2011). Furthermore, racialized immigrant women who
were not experiencing violence tend to underutilize healthcare services (Ahmad
et al. 2009; George & Rashidi, 2014; Hyman et al. 2009). Thus, racialized
immigrant women who are experiencing IPV may also be unlikely to utilize
healthcare services and seek help due to multiple barriers within the
healthcare system, such as racism and discrimination and lack of specific
resources such as translation services (Lipsky, Caetano, Field & Larkin,
2006; Setia, Quesnal-Vallee, Abrahamowics, Tousignant & Lynch, 2011). HCPs
can play a critical role in reducing barriers to health care for all women
experiencing IPV; effective IPV prevention and care also require knowledge of
the specific dynamics and experiences of women in order to tailor policy and
practice within health care settings.
The economic, social
and family costs of IPV are, therefore, extensive. IPV not only impacts the
woman and family but every member of Canadian society; from the spouse to
children, employers to support workers who work with women experiencing IPV,
schools where children of these women attend, and policy makers to governments
who allocate public funds for IPV (Zhang et al. 2012). From an economic
perspective, it is estimated IPV cost Canadians $7.4 billion or $220 per
Canadian in 2009 (Zhang et al. 2012). Health-related economic costs of IPV are
estimated to be at $2.05 billion nationally. The economic costs of IPV in BC
alone are $502 million, and estimated costs of women leaving their abusive
partners are approximately $6.62 billion (Zhang et al. 2012). The Canadian ED
visits by women experiencing IPV cost the health care system $5.9 million and
acute hospitalizations cost the health care system $14.8 million in 2009 alone.
Women experiencing IPV are also more likely to be economically disadvantaged by
lost wages. In 2009, it was estimated women experiencing IPV lost $33.7 million
in wages (Zhang et al. 2012). IPV related costs are estimated to be at $6
billion consisting of medical attention, hospitalizations, lost wages, lost
education, and pain and suffering (Zhang et al. 2012). It appears women
experiencing IPV are likely to be economically challenged and to face economic
hardships due to IPV. As well, globally, a significant amount of health care
resources are being targeted towards caring for women living with IPV (Feder,
Hutson, Ramsay & Taket, 2006).
Based on estimates
from the National Violence Against Women Survey conducted in the United States (US),
approximately one-third of the 5 million IPV incidents perpetrated against
women resulted in medical attention with the majority of women receiving
treatment and care in the ED (Lipsky, Caetano, Field & Larkin, 2006). In
the US there are also estimates 11 percent to 55 percent of women experiencing
IPV will visit an ED in their lifetime (Sormanti & Shibusawa, 2008).
One US study estimated 4% to 20% of women
experiencing IPV visit the ED (Raj & Silverman, 2002). A Canadian study
estimated13.9% of female IPV victims visit the ED (Hollingsworth &
Ford-Gilboe, 2006). Physicians and nurses from the ED are most likely to be the
first to see women impacted by IPV who are [CMV6] seeking care (Leppakoski, Astedt-Kurki & Paavilainen, 2010). Thus,
the ED is an important context where women living with IPV may turn for care. Rates
of IPV recognition by HCPs are dismal; some studies suggest a figure of only 2%
to 8% of women being correctly recognized (Furniss, McCaffrey, Parnell &
Rovi, 2007). Many physicians and nurses still feel uncomfortable asking
patients’ questions about IPV (DeBoer, Kothari, Kothari, Koestner & Rohs,
2013; Furniss et al. 2007; Leppakoski et al. 2010). Explanations of the
uneasiness HCPs feel when questioning female patients about IPV consist of
being unsure what to do with a positive response, lack of time and privacy, and
personal biases and beliefs (Cherniak et al. 2005; DeBoer et al. 2013;
Leppakoski et al. 2010). Since a significant number of women experiencing IPV
are likely to visit the ED it is critical to understand HCPs experiences and perspectives
of caring for women who are experiencing IPV.
There is a lack of
research focused on how to provide effective, safe, ethical and responsive care
to racialized immigrant women experiencing IPV within the ED. The emphasis on
screening for IPV in
the ED setting places primary emphasis on the reliability of instruments and
tools used for detecting IPV (Svavarsdottir, 2009), while research is limited
on providing effective care for racialized immigrant women. [CMV7] In Chapter 2, I discuss this research evidence further to underscore
the importance of the completed research.
HCPs,
such as social workers, do encounter women experiencing IPV(McMahon &
Armstrong, 2012). Social workers are in a unique position to assess, identify,
intervene, advocate and provide resources and education to women experiencing
IPV and guide policy-makers (McMahon & Armstrong, 2012). However, research
shows only 10% of social workers routinely ask women if they are experiencing
IPV despite literature detailing best practices for social workers recognizing
women experiencing IPV (McMahon & Armstrong, 2012). There is also literature within the
nursing discipline that provides best practices on caring for pregnant women
experiencing IPV (Anderson, Marshak & Hebbeler, 2002; Decker, Frattaroli,
McCaw, Coker, Miller, Sharps et al., 2012; McMahon & Armstrong, 2012). [CMV8] Best practices include “assessing for health and safety [and]
identifying support systems” (McMahon & Armstrong, 2012, p. 14). While
studies exist on practices for some HCPs, there is less research focused on
nurses and social workers providing IPV care in the ED context. Another study
discussed best practices for HCPs when caring for women who have a history of
strangulation (Faugno, Waszak, Strack, Brooks & Gwinn, 2013). The authors
of this study all came from nursing backgrounds but there was no actual mention
what type of HCPs the study was aiming to target. However, in the case study
examples they did use forensic nurses in the scenarios (Faugno et al. 2013).
This demonstrates literature pertaining to HCP experiences about IPV in the ED
is not specific enough to drive recommendations for specific HCPs such as
social workers and nurses.
The ED is a common
point of contact for women experiencing IPV (Van der Wath, Van Wyk & Janse
van Rensburg, 2013). However, women experiencing IPV are more often not
identified by ED nurses; as mentioned [CMV9] earlier, prevalence rates in detecting IPV by HCPs are low (Du Mont
& Forte, 2012). The ones who are detected usually do not receive the
necessary care and treatment and experience multiple challenges (DeBoer et al.
2013; Furniss et al. 2007; Leppakoski et al. 2010). Reasons for lack of
detection include stereotypes held by ER nurses, discomfort with the subject
matter of IPV, lack of training and education and personal experiences of IPV
(DeBoer et al. 2013; Furniss et al. 2007; Leppakoski et al. 2010). One
phenomenological study aimed to understand the essence of ED nurses’
experiences caring for women experiencing IPV (Van der Wath et al. 2013).
Findings in this study included emotional distress and anger when caring for
women experiencing IPV, and recurrent and intrusive memories long after (Van
der Wath et al. 2013). Again, understanding ED nurses’ perspectives on IPV is
important in providing safe and ethical care.
Racialized immigrant
women who experience IPV face specific barriers in seeking help than compared
to Canadian born women (Cherniak et al. 2005; Ahmad & Ali, 2005; Hyman et
al. 2006).Depending on the age and time since migration, access to resources,
and even if racialized immigrant women are able to communicate in English,
these women may also face significant communication barriers when interacting
with HCPs. In situations where intimate partners/perpetrators are providing
translation and are present with their partners during interactions with HCPs,
women can lack the privacy necessary for them to feel safe and comfortable in
disclosing their abuse. Cherniak et al. (2005) state:
language barriers, social isolation, and lack of direct questioning by
clinicians act as significant barriers to the disclosure of abuse…many women
may fear deportation or the breakdown of sponsorship agreements, loss of
community status and respect, and loss of child custody…there may be familial
or religious pressure to maintain the sanctity of the marriage and family
integrity…This also complicates the recognition and experience of abuse and
adds to fears of disclosing and reporting to authorities (p. 371).
Racialized immigrant
women also face unique challenges reporting their abuse due to actual
experiences of discrimination and racism from police and HCPs (Bauer,
Rodriguez, Quiroga, & Flores-Ortiz, 2000). These interpersonal and systemic
barriers impact how HCPs communicate with and act to support racialized
immigrant women; experiences that may not be shared by Canadian-born women
living with IPV (Ahmad, et al. 2009; Du Mont & Forte, 2012; George &
Rashidi, 2014). Effective IPV care for racialized immigrant women within the ED
requires understanding ED HCPs perspectives through research and empirical
evidence.
To this date,
research focusing on ED healthcare professionals’ perspectives and experiences
caring for racialized immigrant women experiencing IPV has been limited despite
the fact they face disproportionately more barriers to effective care.
The purpose of this
study was to explore and better understand ED HCPs perspectives on providing
care for racialized immigrant women experiencing IPV who are seeking care in
the ED. [CMV10] The research was conducted at an urban hospital[BH11] located in the lower mainland in British Columbia. A significant
percentage (40.5%) of the population in this community are foreign-born
immigrants and 37.6% of these immigrants who live in this community state their
place of birth to be India, and 33% of these immigrants reported speaking
Punjabi at home. The most frequently reported religion in this community is
Sikhism at 22.6% (Statistics Canada, 2014). Given this population demographic,
it is highly likely HCPs recruited for this study would have been providing care
for Punjabi-Sikh women in the ED setting.[BH12] . Given the importance of tailoring IPV prevention and care within the
ED context, it is necessary to investigate HCPs perspectives on caring for
women experiencing IPV who access care in the ED.
Research Questions
1) Providing care for women living with
IPV?
(2) The ED environment for how it shapes care
for women experiencing IPV?
(3) Assessment and care for racialized
immigrant women experiencing IPV?
Exploration of these
questions revealed potential insight into how ED health care professionals can
better care for women experiencing IPV and help inform nursing practice. The
results of this study may help inform policy-makers and enhance ED care for
women impacted by violence. Policy-makers may inject more resources and funding
to enhance care for women experiencing IPV due to insights provided by ED
HCPs.
IPV has significant
social, emotional, physical and economic implications for women and society as
a whole and impacts the whole healthcare system. Racialized immigrant women
experiencing IPV face even more barriers and challenges, making it critical
research be conducted to inform care for women. The research was conducted in a
large urban area where one of the largest immigrant populations reside in the
lower mainland, thereby bringing into the study a focus on providing care for racialized
immigrant women.
ED HCPs play an
important role in caring for women experiencing IPV. Therefore, it is crucial
to understand HCPs perspectives on caring for racialized immigrant women
experiencing IPV in order to inform professional practice. This literature
review focused on what is known about ED HCPs’ practice in relation to IPV. As
stated in Chapter 1, the purpose of
this study was to explore and better understand ED healthcare professionals’
perspectives on providing care for racialized immigrant women experiencing IPV
who are seeking care in the ED.
A literature review
was conducted, and no limits to search date were selected in order to maximize
search results. The following combinations of search terms and phrases were
used: “intimate partner violence”, “domestic violence”, “family violence”, “domestic
abuse”, “health risks”, “health impact”, “impact”, “emergency department”,
“ER”, “emergency”, “nursing”, “nurse”, “healthcare professional”,
“multidisciplinary” and “interdisciplinary”. The search engines used were
Cumulative Index of Nursing Allied Literature (CINHAL), Science Direct, OvidSP,
ProQuest, Web of Science, Pub Med, Statistics Canada, Canadian Research Index,
and Canadian Public Policy Collection. Some relevant articles were found
pertaining to HCPs and care in the ED, most were related to screening and
detection, however more articles were found pertaining to ED healthcare
experiences and perspectives on caring for women experiencing IPV.
Globally it is
estimated 1 in 3 women have experienced IPV (WHO, 2013). IPV affects all women
regardless of race, ethnicity, religion, age, and socioeconomic status. As
mentioned in Chapter 1, IPV not only impacts women, but also the family
network. It has been well documented children of women experiencing IPV are at
an increase risk for physical and behavioural problems (Alhusen, Bullock,
Sharps, Schminkey, Comstock & Campbell, 2014;English, Marshall &
Stewart, 2003). Neonates of women experiencing IPV are more likely to be low
birth weight which has been associated with increased risk for diabetes and
coronary artery disease for these neonates in adulthood (Alhusen et al. 2014;
Barker, Eriksson, Forsen & Osmond, 2002). Women experiencing IPV are also
more likely to use alcohol and drugs then women who are not experiencing IPV can
also negatively impact their health outcomes (Weaver, Gilbert, El-Bassel,
Resnick & Noursi, 2015). IPV in women’s lives also impacts relationships
surrounding decisions to stay or leave a violent partner; research highlights
the complex issues for women such as shame, family pressure to remain in the
relationship, fear of deportation, and lack of financial, social and family
supports (Ahmad et al. 2009; George & Rashidi, 2014; Thandi, 2011).
IPV has negative
health related consequences for women. Women experiencing IPV are more likely
to suffer from sleep disturbances, depression, anxiety, post-traumatic stress
disorder (PTSD), and have higher rates of chronic pain and disability than
compared to women who do not experience IPV (Ahmad et al. 2009; Aldarondo and
Sugarman, 1996; Bauer, Rodriguez, Perez-Stable, 2000; Campbell, Jones &
Dienemann, 2002; Coker, Smith, Bethea, King & McKeown, 2000; Health Canada,
1999, Hegarty, Gunn, Chondros, Small, 2004; Plichta and Falik, 2001; Wuest et
al. 2009). IPV is associated with long-term and chronic health problems
consisting of physical and mental health issues which may continue long after
the abuse has stopped (Campbell et al. 2002; Coker et al. 2000; Guruge, 2012).
Not surprisingly, women experiencing IPV are more likely to access health
services frequently than women who do not experience IPV. Women who suffer from
physical injuries related to IPV usually have injuries to their face, head,
back, neck, breast, and abdomen (Campbell et al. 2002; Coker et al. 2000;
Guruge, 2012; Muellman, Lenaghan, & Pakieser, 1996). IPV also results in
neck and back pain, arthritis, headaches and migraines, hypertension, peptic
ulcers, and irritable bowel syndrome (Breiding, Black, & Ryan, 2008; Campbell
et al. 1997; Coker et al. 2000; Lesserman & Dorssman, 2007; Letourneau,
Holmes, & Chasedunn, Roark, 1999). Mental health problems accompanying IPV
include depression, anxiety, post-traumatic stress disorder, substance use and
dependence, and suicidal thoughts (Barrett, Teesson, Mills, Katherine, 2014;
Gibson, Callands, Magriples, Divney & Kershaw, 2015). IPV is also
associated with sexual and reproductive health problems such as pelvic pain,
menstrual irregularities, sexually transmitted infections (STI) and unwanted
pregnancies (Ahmad et al. 2009; Guruge, 2012; Lee & Hadeed, 2009; Raj, Liu,
McCleary-Sills & Silverman, 2005; Wuest et al. 2009; Zarif, 2011). Children
of women who experience IPV are known to have poorer physical, mental, and social
development, poorer temperaments and females are more likely to experience IPV
themselves later in life and males more likely to be IPV perpetrators also
later in life than compared to children of women who do not experience IPV
(Gibson et al. 2015; Islam et al. 2017). Children of women experiencing IPV are
more likely to have low birth-weights, and higher mortality rates overall
(Bogat, DeJonghe, Levendosky, Davidson, von Eye, 2006; Burke, Lee &
O'Campo, 2008).
IPV-related medical
issues create substantial societal and health care system costs. The economic costs
of IPV in the US are close to $5.8 billion including medical and mental health
care services, lost productivity, reduction in lifetime earnings, and physical
and psychological injuries (National Center for Injury Prevention and Control,
2003). Canadian employers are also impacted by IPV with losses estimated at
$77.9 million (Zhang et al. 2012). Social and family costs to all Canadians are
equally as extensive; for example, children exposed to IPV are more likely to
suffer from hyperactivity, physical aggression and mental health issues, with
associated medical costs of $1.1 million, and more likely to earn less with
estimated losses of future income consisting of $227.9 million attributed to
social and emotional disorders than compared to children not exposed to IPV
(Dauvergne and Johnson 2001; Zhang, et al. 2012).
Women experiencing
IPV are more likely than women not experiencing IPV to access healthcare
services and interact with HCPs such as nurses (DeBoer et al. 2013;
Hollingsworth & Ford-Gilboe, 2006). Nurses must have the necessary skills
and knowledge to be able to care for and recognize potential women experiencing
IPV in order to provide support and resources for women. Nurses also need to
learn about the context of women’s lives to create safe spaces which may
increase the potential for disclosure that can connect women to appropriate
resources, safety planning and community services. Thus, research focusing on
HCP perspectives on caring for women in the ED can contribute to improved care
for women.
Individual
and social risk factors have been reported that are associated with increased
risk for IPV; such as age, poverty, lack of education, pregnancy, migration,
and lack of social and family supports (Alhusen & Wilson, 2015; Association
of Women’s Health, Obstetric and Neonatal Nurses, 2015;Bhandari, Levitch,
Ellis, Ball, Everett, Geden & Bullock, 2008; Li, Kirby, Sigler, Hwang, LaGory
& Goldenberg, 2010). In addition, women experiencing IPV are more likely to
have had partners exposed to IPV and/or experienced physical abuse in childhood
than compared to partners who were not exposed and/or experienced physical
abuse (Bhandari et al. 2008; Gibson, 2015; Guruge
et al. 2012;Islam et al. 2017; Lee & Hadeed, 2009; Li
et al. 2010). Other risk factors includeIPV perpetratorsbeing more likely to
have anti-social traits and to abuse alcohol and/or drugs then compared to
non-IPV perpetrators (Bhandari et al. 2008; Eckhardt, Murphy & Sprunger,
2014;Islam et al. 2017; Li et al. 2010). [MOU14] These risk factors combined with being exposed to IPV as a child
increases the chances exponentially of perpetrating and experiencing IPV later
in life creating a cycle of IPV that may be passed on to future generations.
Women who are
pregnant or post-partum are also at increased risk for IPV (Agrawal, Ickovics,
Lewis, Magriples & Kershaw, 2014). Post-partum women are more likely to be
at increased risk for depression, and unintended pregnancies (Agrawal et al.
2014; Eckhardt et al. 2014). Mothers who
are experiencing IPV are more likely to have infants experience sleeping
problems then mothers who do not experience IPV (Agrawal et al. 2014). Age also
plays a factor in women experiencing IPV as women between the ages of 16 to 24
are more likely to experience IPV than older women and IPV risk doubles in
pregnant women under the age of 20 years (Agrawal et al. 2014; Stöckl, March,
Pallitto & Garcia-Moreno, 2014). Women who are adolescent mothers are also
at risk for experiencing IPV due to poverty and having limited support networks
(Bhandari et al. 2008; Eckhardt, Murphy & Sprunger, 2014; Kennedy et al.
2015; Li et al. 2010).
Living in poverty, with
limited socioeconomic resources and exposure to higher rates of violence and
crime has also been linked to IPV. For example, living in poverty contributes
to IPV as financial concerns act as a significant stressor for perpetrators who
enact IPV towards their partners (Agrawal et al. 2014; Bhandari et al. 2008;
Eckhardt, Murphy & Sprunger, 2014; Kennedy et al. 2015; Li et al. 2010).
Women who experienced IPV are also more likely to have been exposed to
childhood physical and sexual abuse and more likely to have been exposed to IPV
as children, than compared to women who did not experience childhood physical
and sexual abuse (Barrios et al. 2015). Women who are homeless are also more
likely to experience IPV than women who are not homeless (Bazargan-Hejazi, Kim,
Lin, Ahmadi, Alireza, Khamesi & Teruya, 2014; Kennedy et al. 2015). Women
suffering from depression and/or depressive symptoms are more likely to have
experienced IPV than women who have not experienced depression (Bazargan-Hejazi
et al.2014; Kennedy et al. 2015). Women with lower education levels were also
more likely to experience IPV, as well as substance abuse amongst IPV
perpetrators were also evident with rates as high as 50 to 70% (Bhandari et al.
2008; Capezza, Schumacher & Brady, 2015; Coulter & Mercado-Crespo,
2015; Li et al. 2010).
Newly migrated women are also at risk for IPV due to negative
experiences continuous with immigrating to a new country such as language
barriers, adapting to a new country’s norms, particularly if they are living in
Canada for less than 2 years and seeking asylum for threats to personal and
family safety (Stewart, Gagnon, Merry & Dennis, 2012).
If the social
context of women’s lives is highly influential on their risk and exposure to
IPV, then women experiencing racialization face additional barriers; yet,
research detailed the nature of these barriers is lacking within the context of
IPV. Several studies reported racialized immigrant women do not disclose IPV
related to communication and language barriers, fear of deportation, a lack
understanding of sponsorship agreements, a fear of loss of status and community isolation, and
pressure to remain married in order to maintain family integrity and status
(Cherniak et al. 2005; Thandi, 2011). Lee and Hadeed (2009) also claim
racialized immigrant women are less likely to report IPV to authorities and
face challenges accessing care and treatment for IPV-related injuries influenced
by language, and social and institutional barriers. Specific to emphasis on
disclosure in the literature, Ahmad et al.
(2009) study findings make the following claims about why racialized
immigrant women may not disclose abuse:
social stigma; women’s gender roles (silence, marriage obligations,
subordination); children’s well-being; lack of social support; and knowledge
gaps and myths. Most of the reasons at the root of delayed help-seeking were
linked to the socio-culturally prescribed values and norms and/or the
immigration context. The latter was more dominant when participants discussed
their children’s well-being, social support and knowledge of available services
(p. 617).
Women experiencing
IPV from one study spoke about social stigma and shame related to disclosure of
IPV and these disclosures were perceived to bring suffering and loss of respect
to their family (Ahmad et al. 2009). The women in this study reported feeling
obligated to stay within their marriage for their children’s sake and well-being
and expressed worry about how to support their children on a single-income and
provide adequate food and shelter. The findings emphasized how the women
expressed difficulties in child-minding as they did not have family members to
take care of their children when working. Other factors reported included how
women’s circumstances contributed to remaining in violent relationships further
exacerbated social isolation, thereby reducing their chances of building
relationships with others in their new country (Ahmad et al. 2009).
Several studies have
also demonstrated racialized immigrant women are more likely to experience
barriers to healthcare and report racial discrimination when attempting to
access services (Hyman et al. 2009). According to one Canadian study, 1 in 5
minorities have experienced racism within the Canadian health care system (Ali,
Massaquoi, & Brown, 2003). Racialized immigrant populations are also known
to have reduced usage of social services whencompared with caucasian Canadian women,
35.3% vs. 51.4 % (Ali et al. 2003). [MOU15] In several Canadian studies, the strongest predictor of help-seeking
behaviour amongst racialized immigrant women was the severity of IPV, and
number of incidents (Amanor-Boadu, Messing, Stith, Anderson, O’Sullivan,
Campbell et al. 2012; Cherniak et al. 2005; Hyman et al. 2009). Women who
experienced more than one incident of physical/sexual violence and feared for
their lives, were more in danger and more likely to seek help. Factors women
consider when deciding to leave or stay was dependent on the housing situation,
access to income and benefits, immigration status, racism and sexism, and
responses from service providers (Amanor-Boadu et al. 2012; Cherniak et al.
2005; Hyman et al. 2009). Whether women stay or leave their violent partners is
complex and the tendency to see the issue as simply one of “just leaving” can
undermine the support and care women need. Similarly, emphasizing the priority
of women’s disclosure of IPV can obscure the critical focus on barriers created
by HCPs and within larger health care systems. Focusing on women leaving
abusive partners and emphasizing disclosure of IPV, while a focus in research,
can detract from the importance of reducing barriers to care that arise from
HCP and health care systems; therefore, this thesis aimed to contribute
knowledge for optimal care within the ED.
Women experiencing
IPV may not be aware of where and how to seek IPV related care (Spencer,
Shahrouri, Halasa, Khalaf & Clark, 2014). Some women may reach out for help
from family members and/or friends and may be encouraged to not to contact
authorities and to resolve IPV related issues in the household and not to
disclose IPV to authorities and HCPs (Spencer, et al. 2014).
Yet, despite a
reported lack of awareness of IPV care resources and services, women in the US experiencing
IPV are three times more likely to visit the ED and access health care services
then women not experiencing IPV (Campbell, 2002; Feder, et al. 2006). In
several studies, women living with IPV did not discuss their situation unless
asked by nurses, social workers or physicians; reported detection rates for IPV
by ER nurses in several studies was estimated at only 10% (Efe & Taskin,
2012; Elliott, Nerney, Jones & Friedmann, 2002; Valente, 2000). These
findings highlight the importance of ER nurses having the knowledge and skill
to build relationships where women may feel safe to disclose IPV. The emphasis
on screening women for IPV in research focused on language and cultural
barriers, women experiencing IPV partners being present, lack of knowledge and
training, time constraints, lack of resources, and uncertainty of what to do
with a positive response (Furniss, McCaffrey; Zarif, 2011). Some women, but not
all women experiencing IPV, welcome HCPs asking about IPV; however, in one
study it was reported HCPs do not take advantage of this opportunity (DeBoer et
al. 2013).
Research pertaining
to IPV and the ED department has focused on screening and detecting IPV amongst
female patients with an emphasis on why ED nurses and other HCPs’ hesitate in
screening and asking patients about IPV (Boursnell & Prosser, 2010; Efe
& Taskin, 2012; Reisenhofer & Seibold, 2007; Ritchie, Nelson &
Willis, 2009; Robinson, 2010; Tower, Rowe & Wallis, 2012; Yonaka, Yoder,
Darrow & Sherck, 2007). Despite
these studies, few best practices exist to guide HCPs caring for women
experiencing IPV in the ED environment, and literature on understanding
challenges HCPs experience when caring for women impacted by IPV. Thus,
research is needed to better understand HCPs’ experiences, particularly within
a context where women living with IPV are seeking care.
Women experiencing
IPV have reported negative interactions and experiences with HCPs such as
social workers, nurses and physicians when seeking care (Feder et al. 2006; Tower
et al. 2012). Women described receiving poor quality assessments and labelling
of their health concerns which led them to feeling stigmatised and judged
(Tower et al. 2012). They felt their health concerns were not taken seriously
and they received incompetent care (Tower et al. 2012). As a result, they
resisted care and did not feel comfortable confiding with HCPs about
experiencing IPV, further isolating themselves from potentially helpful
resources (Tower et al. 2012). Yet,
there are important factors reported in the literature that impact HCPs
responses to IPV (Feder et al. 2006; Furniss et al. 2007; Yonaka, Yoder, Darrow
& Sherck, 2007). For example, HCPs felt care for women experiencing IPV was
outside of their professional boundaries, perceived IPV as a personal or
private issue, lacked knowledge and education, conflict with personal attitudes
and values on IPV, and reported lack of time (Feder et al. 2006; Furniss et al.
2007; Reisenhofer & Seibold, 2007; Yonaka, Yoder, Darrow & Sherck,
2007). As well, in other studies, structural constraints, and how acute service
management are arranged and orientated were mentioned as other barriers
limiting HCPs responding to women experiencing IPV (Hollingsworth &
Ford-Gilboe, 2006; Hyman et al. 2009; Reisenhofer & Seibold, 2007; Tower et
al., 2012). The biomedical focus of care dominates in the ER has been argued to
undermine the care women living with IPV need. Tower et al. (2012) found in
their study physicians felt the ED was not an appropriate place to assess and
treat women for IPV due to its physical layout and lack of privacy and
maintaining confidentiality (Tower et al., 2012).
According to a
Jordanian study, screening for IPV can increase detection rates of women
experiencing IPV (Al-Natour, Gillespie, Felblinger & Wang, 2014). However,
screening rates by nurses are estimated to be anywhere to be 10% to 39%
(Al-Natour et al. 2014; Malecha, 2003; Thurston, Tutty, Eisener, Lalonde,
Belenky & Osborne, 2007). One study conducted in Ontario found IPV
detection rates to range from 4.1% to 17.7% (Beynon, Gutmanis & Tutty, Wathan&
MacMillan, 2012; MacMilan et al. 2006). These variances in screening in the
literature is problematic as it highlights the fact there are inconsistencies
in the evidence that support screening. Despite the lack of robust evidence in
the US, IPV screening is recommended for all women seeking care in the ED as
well as staff training as per professional organizations such as American
College of Nurse-Midwives and American Nurses Association (Btoush, Campbell
& Gebbie, 2009). However, this contradicts the WHO, Canadian Task Force,
and the UK’s Health Technology Assessment Programme, stating insufficient
evidence to support if screening for IPV is effective (Jewkes, 2013). However,
one study stated early detection leads to early referrals to resources for
women experiencing IPV may need (Al-Natour et al. 2014). However, there are
other studies stating the fact screening does not lead to positive health
outcomes and reducing IPV (Falb et al. 2014). It is unclear, although, if
screening is considered unfavourable due to it being ineffective or the lack of
HCPs adherence to screening protocols. It is also unclear if perhaps reducing
IPV is correlated to the strength and amount of resources offered and provided
by healthcare organizations to HCPs (Faib et al. 2014). One Jordanian study
stated nurses were more likely to screen women for IPV who were seeking care
for physical injuries than any other chief complaints (Al-Natour et al. 2014).
Another study stated HCPs were more likely to screen women for IPV who are
exhibiting depression and anxiety (Smith, Danis, Helmick, 1998). This is
problematic as this indicates some HCPs only screen woman with physical
injuries, depression and anxiety instead of screening all women HCPs encounter.
In addition, the U.S. Preventive Services Task Force (2004) states evidence to
support screening women for IPV in primary and acute care settings is lacking,
of poor quality, and benefits and harms of screening cannot be determined. Another
Canadian study also stated there was inadequate evidence to recommend for or
against screening for IPV (Canadian Task Force for Preventive Health Prevention
and Treatment of Violence Against Women, 2001).
As mentioned
earlier, at the current moment, screening has not generated significant
evidence to ensure its favourable uptake with HCPs and due to several barriers
reported in the literature. Common barriers to screening by HCPs include: not
having time to screen and disinterest in screening, lack of confidence in
referring women to appropriate resources, lack of support from management,
family/partner presence, and lack of IPV education and training (Al-Natour et
al. 2014; Beynon et al. 2012). Other barriers include not believing women
experiencing IPV will have access to social worker support and mental health
resources, blaming women experiencing IPV for their situations, uncomfortable
asking women if they are experiencing IPV, and believing screening is not part
of a nurse’s or physician’s occupation (Al-Natour et al. 2014; Beynon et al.
2012). Another important reason for lack of screening is concerns about safety
as “nurses have concerns and fears about their own and victims’ safety when
screening for IPV” (Al-Natour et al. 2014, p. 1483). Nurses are concerned about
their own safety due to perceived lack of security in ED settings, and women
experiencing IPV fearing retaliation from IPV perpetrators, and severity of IPV
after disclosure (Al-Natour et al. 2014; Häggblom & Möller, 2006). This
information highlights the fact IPV screening may put nurses and women who
disclose IPV at risk for even more violence which most likely deters HCPs from
screening and women for disclosing in the first place. Even if screening is
positive for IPV, HCPs encountered challenges when attempting to refer women to
appropriate resources and unaware how to access and navigate the healthcare
system to help these women. However, when screening for IPV, nurses were more
likely to refer women experiencing IPV to social workers than any other HCPs
(Al-Natour et al. 2014).
While studies have
focused on HCPs’ providing care for women living with IPV, there is limited
research focused on HCPs’ in the ED and racialized immigrant women experiencing
IPV. However, research does exist on HCPs’ perspectives on IPV such as
highlighting problematic responses of HCPs who label and stigmatize women
experiencing IPV. In one study, the authors detail HCPs’ responding with anger
and frustration towards those seeking care especially if they have visited the
ED before due to IPV (Häggblom & Möller, 2006). HCPs’ who are older and experienced and have
experienced IPV themselves are reported to be more likely to screen for IPV
(Beynon et al. 2012). In the same study by Häggblom & Möller,, the findings indicated
a “strong sense of nurses ‘engagement and concern to respond to women survivors
of violence” (p. 1079). In the same study, HCPs reported consoling women who
were experiencing IPV to the best of their ability even though they felt
ill-equipped to do so; they reported using intuition when suspecting IPV to
screen patients (Häggblom &Möller[BH16] )).
Nurses also express
stress, anxiety and shock when seeing women with extreme IPV related physical
injuries and anger towards physicians who showed little to no concern toward
these women experiencing IPV (Kaplan & Komurcu, 2017). HCPs’ also state
feeling ill-equipped when dealing with women experiencing IPV and reported
frustrations over the lack of support and resources from other HCPs and
decision-makers and leaders. HCPs who havespeciality training in assessing
women experiencing IPV felt more comfortable caring for these women and noted
changes within themselves about negative attitudes towards IPV and
victim-blaming (Kaplan & Komurcu, 2017).
Women experiencing
IPV are more likely to suffer from physical, mental, and reproductive illnesses
and more likely to access healthcare services and visit the ED than women who
are not experiencing IPV (Cherniak et al., 2005). Racialized immigrant women
experiencing IPV are more likely to face interpersonal and structural barriers
to care when accessing services and engaging with nurses, physicians, social
workers and law enforcement, and are more likely to experience vulnerability
associated with financial insecurity and lack community and family supports.
(Ahmad, 2009; Dasgupta, 2000; George & Rashidi, 2014; Hyman et al., 2009).
Compounding these contexts of risk, women living with IPV are also likely to
experience negative interactions with HCPs that further discourage seeking care
and treatment. When women do seek care, they come to EDs; yet, there is limited
literature to guide HCPs such as nurses, physicians and social workers to care
for women who are living with IPV. Racialized immigrant women who are
experiencing IPV face unique challenges in disclosing IPV due to language
barriers, isolation and pressure not to disclose IPV. In the next chapter I
will discuss the study design and research methodology that was undertaken for
the research.
Chapter 3: Methodology
In
this chapter, the research design, theoretical framework and methods will be
discussed. Sample selection and recruitment, data collection, data analysis and
ethical considerations will also be discussed. As stated in Chapter 1, the
purpose of this study was to explore and better understand ED healthcare
professionals’ perspectives on providing care for racialized immigrant women
experiencing IPV who are seeking care in the ED.
Research Method
This
qualitative study utilized qualitative description as its research method.
Qualitative description uncovers the experiences and describe the events or
phenomena from data collection in everyday language; description is the focus
with less emphasis on interpretation (Sandelowski, 2000). According to
Sandelowski, “researchers conducting qualitative descriptive studies stay
closer to their data and to the surface of words and events” (p. 336). The
findings constructed using a qualitative description approach are subject less
to multiple layers of interpretation which means there is less focus on
detailing the multiple potential meanings within the data (Sandelowski[BH17] )).
Qualitative
description research draws from a naturalistic inquiry approach and employsconvenience
sampling techniques (Sandelowski, 2000). Data collection techniques include
open-ended individual and/or focus group interviews that could be minimally to
moderately structured. Qualitative description research was selected for this
study as it is considered to be appropriate for a master thesis and novice
researchers. As this was the first research study I have undertaken,
qualitative description was an appropriate choice as I learned to immerse
myself in the data, while also learning about how to identify patterns and
construct themes that were reflected in the participants data; I focused on the
meanings within the participants data.
Theoretical Framework–Cultural Safety
The
theoretical framework that guided this qualitative study draws from the
principles of cultural safety. Cultural safety emerged in the 1980s based on
the work of a group of Maori nursing students and faculty members who were
concerned about perceived healthcare practices that were disempowering and
disrespecting the well-being and health of the Maori people and their culture,
and the inability to recruit and retain Maori nurses (Nursing Council of New
Zealand, 2011). The Maori people are Indigenous to New Zealand. Cultural safety
is a framework to deliver more appropriate health services while respecting the
unique cultural identity of patients. Originally, cultural safety mostly
applied to healthcare delivery to Maori and other Indigenous groups, but now
may be applied to any racialized and/or marginalized population. For example,
people living with disabilities, facing homelessness or in poverty also face
marginalization; the principles of culturally safe care extend beyond ethnicity
and considerstructural barriers and power relations within health care
therefore considering the ‘culture’ of health care itself (Cultural Connections
for Learning, 2013; Nursing Council of New Zealand, 2011). According to the
Nursing Council of New Zealand (2011) cultural safety is defined as:
the
effective nursing practice of a person or family from another culture and is
determined by that person or family. Culture includes, but is not restricted
to, age or generation; gender; sexual orientation; occupation and socioeconomic
status; ethnic origin or migrant experience; religious or spiritual belief; and
disability. The nurse delivering the nursing service will have undertaken a
process of reflection on his or her own cultural identity and will recognize
the impact that his or her personal culture has on his or her professional
practice. Unsafe cultural practice comprises any action which diminishes,
demeans or disempowers the cultural identity and well-being of an individual
(p. 7).
Cultural safety
includes actions that require recognizing and respecting cultural identities as
well as reflecting on one’s own culture and beliefs (Cultural Connections for
Learning, 2013). As the theoretical orientation for this study, cultural safety
draws attention to the importance of seeing culture as embedded in health care
institutions as well as relevant within the lives of people accessing care.
Cultural safety is not only applicable to nursing practice but may be applied
to any healthcare profession such as medicine and social work. To integrate
cultural safety into a healthcare professional’s practice involves 3 key
elements:
·
Cultural
Awareness: Involves acknowledging there may be
differences between the health care provider and patient (Cultural Connections
for Learning, 2013; Nursing Council of New Zealand, 2011). These differences
being between beliefs and practices of the healthcare provider and patient
respectively (Cultural Connections for Learning,2013; Nursing Council of New
Zealand, 2011). For instance, a HCP caring for a woman experiencing IPV may
recognize the power dynamic and the vulnerability of the patient which could
also be applied to any marginalized populations interacting with healthcare
providers (Cultural Connections for Learning, 2013; Nursing Council of New
Zealand, 2011).
·
Cultural
Sensitivity: Signals HCPs of the differences
that may exist between the provider and client. This initiates a process of
self-reflection and exploration of their own culture, beliefs, and experiences
that may impact their practice and how it may hinder developing therapeutic
relationships between HCPs and women experiencing IPV (Cultural Connections for
Learning, 2013; Nursing Council of New Zealand, 2011).
·
Cultural
Safety: Encouraging the development of a
culturally safe environment then the patient feels safe when accessing care
which involves mutual respect between the HCP and patient (Cultural Connections
for Learning, 2013; Nursing Council of New Zealand, 2011).
The rationale
for using cultural safety as a theoretical orientation to the study reflected
the importance of understanding how HCPs and racialized immigrant women
interact within the ED context, by specifically focusing on how HCPs’
contribute to creating safe environments. In addition, because power dynamics
are inherent within health care interactions and cultural safety draws
attention to power and context, this perspective drew my attention to how HCP
participants described their perspectives on caring for racialized women living
with IPV within a context imbued with power. Thus, cultural safety informed my
analysis by highlighting within the data barriers to creating safe spaces along
many axes of women’s experiences accessing ED care. Specificattention to power
dynamics and the culture of the ED were also foreground in my analysis that was
informed by the principles and concepts of cultural safety.
Sample Size, Selection and Recruitment
Using
a convenience approach, I set out to recruit up to 10 health care providers
from an ED located in a large urban hospital in the FHA region. The HCPs
consisted of a mix of ED nurses, forensic nurses, social workers, and ED
physicians who were primarily employed in the ED. The justification for this
diversity of HCPs reflects the reasoning a range of HCPs interact with women
experiencing IPV in the ED setting. (Boursnell & Prosser, 2010; Haeseler,
2013; Reijnders, Giannakopoulos & de Bruin, 2008; Ritchie, Nelson &
Wills, 2009). The inclusion criteria included participants having at least 3
years of ED experience and ideally being employed in permanent part-time or
full-time positions. The rationale for these criteria reflected the view a
minimum of 3 years will increase the likelihood the HCPs had the depth of ED
experience to share valuable experience and information about caring for women
experiencing IPV. Having HCPs who had stable employment in the ED will ensure
these HCPs had sufficient experience in the ED setting and can best speak to
the phenomena under study. However, I was only able to recruit 5 participants,
which included 3 forensics nurses, 1 ED nurse, and 1 social worker. I was
unable to recruit any ED physicians. I had discussed with my primary supervisor
if I should continue trying to recruit more participants; however, we
determined, given my novice level and the requirements for a master thesis, 5
participants would allow me to immerse myself in a reasonable amount of data to
learn the process of thematic analysis.
A
convenience sampling approach was used to recruit participants. Convenience
sampling involves “selection of the most readily available persons as
participants in a study” (Polit & Beck, 2012,p. 724). This type of sampling
approach was appropriate for this study; I contacted ED educators and managers
to distribute information about my study and within a short period of time I had
five participants. Recruitment of participants was undertaken through posters
(see Appendix A), displayed in highly visible areas and invitations were also
sent out via email to ED clinical educators, supervisors and managers to send
to all ED staff (Appendix B). Eight participants contacted me; yet only 5
participants were eligible to be part of the study. The 3 participants who were
excluded was due to one being employed as a RN for only 2 years, one who’s
primary employment was a diabetic RN, and the other who worked as a ED RN
outside the FHA. I asked potential participants to share the above information
to capitalize on the snowball technique as the convenience approach only
yielded 5 participants. Snowball sampling entails the “selection of
participants through referrals from earlier participants” (Polit & Beck,
2012, p. 743). However, I was unable to recruit any further participants from
snowball sampling. In the end, the sample was comprised of 3 forensics nurses,
1 ED nurse, and 1 social worker. The demographic information of the
participants can be found in Appendix D.
The Research Site
The
research was conducted by recruiting HCPs from a large urban hospital in the
lower mainland in BC. The city where the study was conducted is projected to
have the most population growth compared to other cities within the Fraser
Health region (FHA, 2012). 40% of BC immigrants live within the Fraser Health
region and immigrants form 32% of the total population; 52% of these immigrants
identify as female. Women within the Fraser Health region are more likely to speak
languages other than English then compared to males (FHA, 2012). According to
Statistics Canada (2014) 40.5% of the population of the city where the study
was conducted are foreign-born immigrants, as compared to 27.6% of BC’s
populationbeing foreign-born immigrants. 37.6% of immigrants who live in the
city where the research was conducted state their place of birth to be India,
and 33% of these immigrants speak Punjabi at home. 52.6% of the population in the
city where the study was conducted belong to a visible minority group, and
26.2% of the population belong to the South Asian ethnic group. The most
frequently reported religion in the city where this study was conducted is
Sikhism at 22.6% (Statistics Canada, 2014). Therefore, a significant percentage
of the population are of Punjabi-Sikh descent. When asking participants to
reflect on and share experiences of caring for racialized immigrant women
experiencing IPV, there is a significant likelihood, although this cannot be
certain, that they are able to speak about caring for racialized immigrant
women such as Punjabi-Sikh women who seek care in the ED. In addition, Fraser
Health also has the highest rate of IPV, making it approximately 2.5 times more
than the provincial average, and the city where the study was conducted had the
second highest rate of IPV within the Fraser Health region (FHA, 2012;
Statistics Canada, 2013). Good!
Data Collection
HCP
participants were invited to contact me for more information about the study.
Information about the nature of the study, research questions, time commitment
and any questions potential participants had was answered. During the consent
process, participants were advised they may withdraw from the study at any time
without consequences and their privacy and confidentiality would be protected.
One-to-one in-depth interviews were conducted with participants in a private
room located at the study site, where only I and the participant were present.
The interview was guided by open-ended questions (See Interview Guide attached
as Appendix E) focusing on participants’ experiences on providing care for
women seeking care who may or may not disclose IPV. Participants were advised
the interview expected to last 60 to 90 minutes. However, most interviews only
lasted for 30 to 60 minutes, with an average time of 45 minutes. Interviews
were audio-recorded by two different devices, one was a backup recorder should
one device failed to function, which did not happen. During the transcription
of the audio files, pseudonyms were used to protect participants’ identities.
Data
Analysis
Thematic analysis.
Thematic
analysis was used.This involves analyzing and identifying recurrent themes or
patterns within research findings (Braun & Clarke, 2006). All interview
data was transcribed verbatim and were re-checked to ensure data was accurately
transcribed. All of the interviews were transcribed using transcription
services. All transcripts were reviewed, cleaned and reviewed several times to
allow for immersion within the narrative data. All data were coded, and
recurring themes and patterns were identified until no new insights were
arising; data saturation was considered complete when no new themes were
identified, and only redundant information had been yielded (Polit & Beck,
2012). My supervisor oversaw analysis of the first interview transcripts and
read over subsequent interview transcripts to ensure a coherent approach and my
analytical processes were transparent. The research questions and the
theoretical framework – cultural safety guided my analysis by going back and
forth between reading the transcripts and highlighting any data that was linked
to my research questions. All data was coded and numbered and organized by
patterns and similarities.
Enhancing
trustworthiness.
To
ensure the findings remained true to the participants’ data, I aimed to
generate trustworthiness during data collection and analysis by being reflexive
and aiming to create dependability, confirmability, and credibility.
Dependability refers to data and findings being stable and consistent (Polit
& Beck, 2012); I created dependability by maintaining an audit trail, by
taking field notes, recordings and transcriptions of my activities during the
research process. The second criterion, confirmability, refers to how well the
results are actually derived from participants themselves and not from the
researcher (Polit & Beck). To maintain confirmability during data
collection and analysis I was reflexive about how my past experiences and
professional context may have shaped my analysis during the interview process
and during data analysis. Reflexivity “is the process of reflecting critically
on the self and of analyzing andmaking note of personal values that could
affect data collection and interpretation” (Polit & Beck,, p. 179). It was
important I was reflexive to ensure my own personal biases did not influence
the data and its analysis and enhanced the study’s credibility. As a Canadian
born Punjabi-Sikh female I have my own beliefs and opinions that may influence
results, as I am very passionate about IPV prevention and care. It is my
responsibility to be aware of potential biases and be critically conscious of
how my own experiences may be influencing data collection and analysis. Taking
reflexive notes helped me to create an ongoing critical consciousness required
from my practice and personal experiences that are closely connected to the
topic understudy. Some biases I had were connecting culture and race with IPV.
However, when I would have these biases, I made sure I was aware of these
biases, and they were not intentionally communicated to participants.
Intuiting
during the qualitative description process also enhanced trustworthiness of the
analysis (Polit & Beck, 2012). It “occurs when researchers remain open to
the meanings attributed to the phenomenon by those who have experienced it”
(Polit & Beck,, p. 496). As mentioned earlier, I worked to being reflexive
of my values, experiences and preconceptions, therefore working to be open to
the meanings during the interview process and demonstrating intuiting. In
addition, by intuiting I was also demonstrating reflexivity. Reflexivity “is
the process of reflecting critically on the self and of analyzing and making
note of personal values that could affect data collection and interpretation”
(Polit & Beck, p. 179). I also attempted to enhance trustworthiness by
demonstrating credibility. Credibility is a principle used in qualitative
studies referring to the confidence of research findings and how accurate the
findings represented the truth (Polit & Beck,). Credibility was also
pursued by focusing on trustworthiness, dependability and confirmability; these
processes mutually reinforce each other. I also enhanced credibility of my
research findings by using interpretive triangulation. Triangulation refers to
using multiple ways to collect and interpret findings (Polit & Beck). I
triangulated the interpretation of the research findings through discussion
with my supervisor toensure important ideas and themes had not been overlooked,
which may have been the case if findings were only analyzed by one researcher
instead of two.
Ethical Considerations
Approval
was obtained from the University of British Columbia (UBC) Research Ethics
Board (REB), and Fraser Health Research Ethics Board (FHREB) before commencing
this study to ensure this study was conducted in the upmost ethical and
confidential manner. Participants were advised about their rights as research
participants and they may withdraw from the study anytime without any negative
consequences which did not happen. Their privacy and confidentiality were
protected, and participants were identified by pseudonyms such as, P1, P2, P3
etc. All participants were asked to sign consent forms and participants were
given my phone number and email address if they had more questions and needed
more information (Appendix D). Participants were interviewed and were given a
$25 Starbucks gift card for their participation in this study. All electronic
transcribed records, field notes, and audiotapes were kept on a password
protected computer on a secure network drive at UBC and encrypted by using
full-disk encryption provided by UBC’s IT department; any paper documents were
kept in a locked filing cabinet in my home. Before commencing any interviews
with participants, participants were again advised about the study and were
told they may withdraw from the study anytime. I also asked participants if
they were interested in receiving information about final research findings,
which all of the participants were.
Conclusion
This
qualitative study utilized a descriptive approach to better understand EDHCPs
experiences caring for women experiencing IPV. Participants included one ED nurse,
one social worker, and three forensic nurses all employed at a large urban
hospital and convenience sampling techniques were used to recruit participants.
Posters and emails were sent to all ED staff to engage interest in the study.
Data was collected by conducting one-to-one interviews with all research
participants at the study site. Trustworthiness during data collection and
analysis was done by demonstrating principles of dependability, confirmability
and credibility. Additional strategies used were reflexivity and intuiting
during data collection and analysis. Thematic analysis was used to identify
common themes and patterns from the data until saturation had occurred, and
research findings were also triangulated. All participants’ rights to
confidentiality and privacy were respected and consent was obtained.
Participants were advised they may withdraw from the study anytime, and
approval from the UBC REB as well as FHREB was obtained before the study.
Chapter
4: Results
The
purpose of this qualitative study was to explore emergency department (ED)
health care providers’ (HCPs) perspectives on providing care for racialized
immigrant women experiencing intimate partner violence
(IPV) when they seek care in the ED. The study sample was comprised of five
purposively selected participants: three forensic nurses, one ED nurse, and one
social worker. The findings were organized into themes; sub-themes were constructed from to highlight
key aspects from the one-on-one
interviews with participants. Five themes were identified and will be discussed
here: HCPs perspectives on ED care for women experiencing IPV, ED context on
IPV resources, support and collaboration, challenges and barriers to care,
assessment and care and racialized immigrant women, and promoting women’s
safety. discussed[BV18] .
HCPs
Perspectives on ED Care for Women Experiencing IPV
Motivation
to provide care.
The
first theme constructed[MOU19] from the interviews reflects the specific interests, reasons, and
motivating factors for participants to prioritize care for women experiencing
IPV. This correlates with the purpose of the study on ED HCPs perspectives on
providing care to women experiencing IPV when they seek care in the ED, as well
as with the first research question of ED HCPs experiences of caring with women
experiencing IPV. Participants described their personal experience as
motivating them to provide safe care to women in the ED:
This
participant was also specifically motivated to ensure women’s safety by
recognizing the importance of understanding the nature of their relationship
with their intimate partner, along the role that support resources could play.
These factors were significant in this participant’s reflections on the
importance of safe care in the ED.
Participants
were also motivated to work with women experiencing IPV based on past
experiences of caring for a patient for whom a history of violence was
suspected; this experience acted as a catalyst for participants to focus on the
importance of IPV awareness and care, specifically when not reliant on women’s
disclosure:
I did have a patient once and she sort of was a catalyst for me to
become more involved. It was a warm summer day and she was wearing long
sleeves, it ended up that we needed to provide her some sedation. The reason
for her visit didn't ring any alarm bells as far as violence even the long
sleeve shirt. Everybody else in the [ED] that day was wearing short sleeves and
staff [were] dressed more appropriately for the weather. It ended up that she
required some sedation and while she was under sedation, she had a very
dysphoric reaction, she was crying, and she ultimately stated that she was
being terribly abused at home. She was very particular about her IV being
started in her hand; she didn't want anyone to lift her sleeves. That was sort
of a catalyst for me, this was not on our radar, we ask every single question
we are supposed to, and I always ask. I had asked her is everything safe for
you at home and in your relationships and those things. She had indicated
everything was fine but anyway, she was definitely the catalyst. I need to get
more involved and do more because it was hard to watch her leave (Participant
One, Forensics Nurse).
From
these participants’ responses, the motivation to care for women experiencing
IPV reflected both IPV experiences and memorable interactions with specific
women. Several other participants described their motivation to be employed as
an ED nurse as reflecting a commitment to providing ED care for women
experiencing IPV. Past experiences and professional
interactions with women experiencing IPV also was reflected in HCPs’ motivation
to ensure women experiencing IPV receive quality ED care.
Participants
were also asked to describe their experiences of caring for women accessing ED
care. Participants highlighted her experience of being involved in court
proceedings as relevant to her work in the ED:
I can go through someone recently…I actually went to court for this
case as well. Someone that she has befriended came into her home and was just
sleeping on the couch and she helped him in a time of need. One time she said
when she was at home reading her book, about 10 o'clock, he was high on alcohol
or drugs and he stormed in, obviously had the key, so there was no break and
enter, and he started to beat her and sexually assault her as well. And, that
wasn’t bad enough but on top of that, for some reason, the neighbors were
watching, so they didn't even help her. When she came in, she couldn't believe
what she had gone through because she's never experienced something like that.
She was so taken back that it was done by somebody that was close to her,
someone that she's been kind to and she thought they were friends. It wasn't even
what he did that bothered her; it bothered her that it was a friend. And that's
what she kept repeating, how could he do this to me, how could he do this to
me. And by the time she left, she was a little bit better and I think a lot of
women that come through, when we've checked them all over, we've healed their
wounds a little bit, given some pain killers, emotionally kind of calm them
down, she felt a little bit better when she left, but it takes months to get
over that. But when I did see her, in court recently, she looked very good
(Participant Two, Forensics Nurse).
The
above reflections shaped how this nurse prioritized both medical
care and emotional support. The nurse
also highlighted the expanded scope of forensic care, such as when they attended
court proceedings as a witness to offer support to
the client. The forensic nurses described [MOU21] the importance of offering guidance and counselling to women impacted
by IPV to help them overcome IPV-related stress. The above statements also help
answer the third research question of how HCPs approach assessment and care for
women experiencing IPV.
When
sharing their experiences, HCPs also highlighted the importance of empathy,
compassion, understanding and sensitivity when caring for women (PO2, PO5). Several of the HCPs with their own personal
experiences of IPV described the influence on the development of their
knowledge and skills for women in the ED:
I think first of all, when some women come in,
you need sensitivity, you need understanding. I think although nurses that do
this kind of job don't necessarily [need to have experienced] some kind of
violence in their lives, but I think without a little bit of experience in your
personal life, it doesn't have to be extreme but just something maybe in the
family or a relative or something, it really helps you to understand what
they're going through. I mean I have issues in the family with family members and
I think it would be really hard for me to care for somebody unless I actually
had experience with dealing with someone that's dealing with [IPV]. A
sensitivity, understanding, and knowing that each person that comes in is
unique and their experiences are unique and really letting' them lead the way
in which care they want (Participant Two, Forensics Nurse).
This participant
highlighted how empathy and lived experiences of IPV may provide a strategy for
providing tailored and responsive care[MOU22] .
ED Context: IPV Resources and Support and
Collaboration
Resources.
The
second theme that was constructed was ED HCPs perspectives on providing care in
the ED to women experiencing IPV and how resources, support and professional
collaboration impacts care to these women. The participants described their
role in the ED as one that included the provision of resources to women
experiencing IPV; providing resources was considered a complex task when
participants were also focused on protecting women’s safety. This theme is linked to the second research
question on how the ED environment shapes their care for women experiencing
IPV. Participants reflected on the importantrole that
HCPs play in relation to sharing resources to reduce personal safety risks:
She wanted resources, she wanted information. However, our social
worker had these business cards that folded up so small; it was a brochure that
folded up so small that it ended up looking like a business card. It had some
sort of phony information on the front, but it had lots of information once you
opened it. So, it wouldn't necessarily be on his radar in case he saw it in her
wallet or in her purse (Participant One, Forensics Nurse).
This participant
emphasized the tension related to providing IPV resources; while providing
information is important, it cannot be done in such a way that increases risks
to women’s personal safety. In contrast, other participants spoke about how the
lack of tailorable and culturally relevant resources to share with women and the
challenges associated with collecting assessment data in the ED meant some
women’s need related to IPV may go unmet:
I just wish I knew of more resources that appeal to women of South
Asian origin. Because that is so much of our [ED] population because then I
could also refer them and say you know there are places where you can go where
language isn't an issue, and there are staff there that understand such an
environment. I know there are a lot of safe places for women to go who are in
intimate partner violence situations, I just don't know of any that are
focused, on South Asian women, which I feel like it'd be nice if there were ED
nurses to offer care. I’d started thinking about a support group, I don’t
really know how to get something like that started, but a support group of
women who are strong and have been in that situation, or in that situational
crisis, you fear that there is no way out and there's no reprieve and there's
nothing beyond this situation and I think speaking with somebody who has been
through IPV from such a community would be helpful. It's just hard to set that
up in emergency, especially ours because it's so busy (Participant Three, ED
Nurse).
Participants
highlighted the importance of tailoring resources and support for racialized immigrant
women; resources that may reflect the needs of specific communities, based on
language, geography, and other factors deemed relevant by women. While the
participant did not detail how services could be tailored for immigrant women
and, I, as the researcher, did not probe more
deeply, this participant pointed to the importance of considering what support
may be meaningful and relevant for women beyond the ED visit, such as
connecting with other women who have lived
experiences of IPV. This theme correlates with the purpose of this study on ED
HCPs perspectives on providing care for racialized immigrant women.
When
asked about IPV-related resources and education available for HCPs to develop
their knowledge and skills for women in the ED, participants
indicated that some education would enhance their confidence to provide care,
along with resources to share with women:
I[MOU23] can't
really think of anything that is available to me, aside from social workers,
they're usually the first ones I go to, and I wish I did know of more resources
that were available to me to provide to other women, aside from listening for
that few minutes that you can usually spare in emergency. If there were
pamphlets available, maybe in multiple different languages saying this is a
number you can call, [or] safe places to go, or support groups you can talk to,
I think that would be helpful. I don’t remember any in nursing school that
talked about intimate partner violence. I don’t remember any particular
education or situations or having somebody come in and speak from a support
group or provide resources for women who are in intimate partner violent
situations [there] are things you can provide. I think that's why I have a hard
time referring to anybody other than Social Work, I wish I could talk to Social
Work about the resources [they] provide so I can also provide them because I
feel I don’t know what else to tell them except I'm getting the social worker
to come and talk to you, and we're get this all figured out. So currently no, I
don’t think there's anything that I've heard or seen or received education
about in order to help better provide better care as an ED nurse to women
experiencing abuse. But I think in the ED we're good at identifying when
there's a situation where there could be intimate partner violence, the
identification piece I think is a lot stronger than what to do once you
identify it (Participant Three, ED Nurse).
Participants
also emphasized the lack of funding for a helpful
resource, the Surrey Mobile Assault Response Team (S.M.A.R.T.).
Participants also mirrored the lack of educational and support resources in the
ED. The S.M.A.R.T is a 24-hour crisis response team that provides services in
affiliation with Surrey Memorial Hospital for women who have experienced
physical or sexual violence (Surrey Women’s Centre, 2017):
I know that one of the things we're struggling with is the
inconsistent response from our community partners because their funding model
has changed. We had very strong support; we had an S.M.A.R.T. worker on every
case around the Olympics when the health personnel partnership came in, so we
had 24-hour coverage. But then the sum of money they were using to fund that
finished and now they're having to find alternate ways to finance it [S.M.A.R.T]
so now they're using grad students or students (Participant Two, Forensics
Nurse).
The participant,
referring to S.M.A.R.T, emphasized the critical need for stable IPV funding and
resources for women. The lack of properly established channels in the community
and ED to report and seek support undermines the care that women can access.
Inconsistent or non-existent resources within the ED
and the community were described by all participants as impacting their
experiences of providing IPV care to women. The S.M.A.R.T team is an important
resource for ER HCPs when providing care to women impacted by IPV.
Participants
also described their lack of awareness of the
services provided by the forensic team at SMH and the role of the specifically
trained ED nurses:
It is important that we are sharing the knowledge of what's out there,
because I think a lot of the time, people don't understand that the Forensic
Nursing Service exists for interpersonal violence. I think because we come from
a history of SANE, the sexual assault nurse. They don’t understand that our
lens has expanded to well beyond only sexual assault, and the Vancouver team
still focuses entirely on sexual assault. They do not have an increased lens or
scope to interpersonal violence. I think not knowing that there are specific
resources for that in your ED and then where to go for follow-up and how you
can get follow-up and support in the present and then planning the long term
may be a hindrance in mitigating IPV (Participant One, Forensics Nurse[MOU25] ).
Another participant emphasized the importance of HCPs having an
understanding of the roles played by forensic nurses in the ED and any specific
barriers faced by women requiring to follow-up and the long-term support. The same participant questioned how women
might view coming to the ED for IPV assessment and care:
I guess do they think about coming to the emergency department, is
this the right thing? So how do we provide information to the public at large
because I think people see the emergency department as somewhere you go when
you have severe pain, when you need tests when you have chest-pain. I think
people don't realize that the emergency department is a resource for that [IPV]
(Participant One, Forensics Nurse).
Another participant stated that the ED is not seen as an
important point of care for women seeking support and care for IPV: “first of
all, [women experiencing IPV] don’t know that we're here, and I personally
think from what I've heard from people that they think emergency is just for
physical care only” (Participant Two, Forensics Nurse). All the participants emphasized how women themselves may not see the ED
as an entry point for care for IPV care. Yet, the participants did not speak
about or share any insights as to where they believed women would seek care if
not in the ED. This demonstrates important perspectives on providing care to
women experiencing IPV in the ED environment and how the ED shapes care for
these women.
Interprofessional collaboration.
The
importance of interprofessional[MOU26] collaboration when providing IPV care for women was emphasized by all
participants:
We work closely with the S.M.A.R.T Team…we work really closely with
them and they do a lot of follow-up safe care planning and things like that.
So, the immediate assessment and interview is fairly independent. We do try as
much as possible to work with an S.M.A.R.T. team worker as well. So, they'll be
present for the initial interview they're often here first for whatever
reason…so they do some sort of preliminary intro and support. Our interview
part is often done with the S.M.A.R.T team. Any physical exam that we have to
do, just for dignity, [we do in private]. We work with S.M.A.R.T workers which are
often social workers. They're the ones that we see the most. We get our
referrals from other nurses and from physicians. If we have any concerns about
certain things that are beyond our scope of practice, we collaborate with the
physicians or the nurse practitioners (Participant One, Forensics Nurse).
Another participant
highlighted the importance of collaborating with the social work team: “the
social worker is invaluable at making the safety outside the hospital
paramount. We touch base with the social worker regardless of whether the
S.M.A.R.T. worker is involved or not” (Participant Four, Forensics Nurse). The
nature of this “touch base” was not made clear, however this collaboration was
understood to improve care for women within and beyond the hospital ED. Collaborating with social work seemed to be
an important tool for ED HCPs:
I usually ask the social worker myself, like hey, could you check in
with them or do you have any suggestions for me. Sometimes when there are kids
involved then automatically Ministry of Children and Family Development (MCFD)
has to get in involved and then it ends up getting bigger and bigger. Often, I
will consult social workers first because I feel they're so good with dealing
with that kind of stuff and in emergency, it's always so hectic that you're not
the one person that they see the whole time they are there. So, I do refer them
to social workers because sometimes they have resources and stuff in the
community that I don’t even know about (Participant Three, ER Nurse).
The ED nurse participant described
collaboration with forensic nurses despite the lack of awareness about the care
forensic nurses provide for women experiencing IPV. [BV27] The ED nurse participant described how, in her experience, some
populations of women are less receptive to services provided by forensic
nurses:
We work with forensics quite a lot but always referring for sexual
assault and then it wasn't I think until the last maybe year or so that I
realized personally that they also did domestic violence cases as well, and it
didn't necessarily need to involve sexual assault. I will refer, but I find
personally that South Asian women are less willing to go that route than women
from other cultural backgrounds. I actually don’t know why; one woman just said
to me no, no, no, I don’t want to get the police involved and I said you don’t
have to necessarily get the police involved. This is just somebody you can
speak with who will explain things to you a little better and collect evidence
should you wish to proceed in the future about anything. But I think it's that
fear of getting police involved or getting anybody in trouble that kind of
prevents that further (Participant Three, ED Nurse).
The
collaboration between ED nurses and forensic nurses was understood to be
important, yet the services provided were described as variously taken up by
women. The participant above associated the lack of use of forensic service as
being potentially shaped by women’s hesitance to involving police. It seems
professional collaboration with ED HCPs forensic nurses are necessary and
important for ED HCPs when caring for women experiencing IPV.
Another
forensic nurse described collaboration and how they approach assessment and care with ED nurses
and social workers:
I get a report from the primary ED nurses whenever I have a case, so
I'm always making contact with them. I try very hard to make sure a social
worker if not already called and involved is then called or called by me. I
would say most of my cases; a social worker has seen them first. They've been
in at least to say hi, I'm here and my role when I get here, one of the things
I do is touch base with them [Participant Four, Forensics Nurse].
Another participant
highlighted the importance of collaborating with RCMP members when advocating
for their patients:
I recently heard that a police officer took a woman's phone from her,
however, she has children, she has friends, she has work, she has contacts on
her phone, she may or may not have said something to him on the phone which she
felt that put her at risk for somebody not believing her it's a bit of a
struggle because police could ask for anything, they want. But we want to be
able to take that down from a stressful position a little bit lower, like can
she have time to take contacts that are relevant and necessary for her before
she hands it over. Can instead of you saying I want to take your phone from you
say we really need some of the information on there, what do you need from your
phone before I take it? There's a difference of interaction styles and
sometimes we'll intervene a little bit to make sure that everybody's needs get
met without being harmful…we want to make sure that everybody is willing to
move forward and work together. And that starts sometimes from the acute
setting when she feels either heard and respected and supported, and so
generally when you, put it back on her as what do you want, that's a really
good way of building rapport. There is some RCMP that wants to sit in the same
room [during] the physical exam when the discussions are all happening and so
that will often times prevent full disclosure or comfort. And so, they are not
taking a statement at that time, therefore they don’t need to be there. And so,
to be able to stand firm for the rights of patients is you know it's something
that we have to think about (Participant Five, Social Worker).
Multidisciplinary collaboration was understood in this study as
involving individuals from different professions working together towards providing
effective and timely care to women experiencing IPV. A good example of multi-disciplinary collaboration is how the S.M.A.R.T team collaborates
with ED social workers, forensic nurses and ED nurses. While interprofessional
collaboration was seen to be a facilitator of care for women, participants also
spoke of the challenges and barriers within the ED that impacted assessment and
care for women
Challenges and Barriers to Care
HCPs bias.
The
third theme that was constructed was challenges and barriers to care HCPs
experience when providing care to women impacted by IPV. This theme aligns with
the first two research questions of how ED HCPs provide care to women
experiencing IPV and how the ED environment shapes care for these women. The
following participant referenced personal judgement of women and the nature of
care provision in the ED as impacting care for women who have experienced IPV:
Sometimes the women that we see live vulnerable lifestyles. I can see
where judgment has, at times, gotten in the way. Understanding the triage
system, I understand that if somebody has reported interpersonal violence or a
sexual assault, that they have a triage level, they just do, it's kind of the
nature of the emergency department. So, the waiting I think can be really hard
for people. It takes so much courage to walk in there and tell people the
beginning of your story and then have [them] go sit there and we'll come back
to you and it's a long wait. So, I think that they've sort of combatted that by
doing a lot of nurse to nurse referrals (Participant Four, Forensics Nurse).
The same participant
went on to say that negative social judgments from other HCPs were challenging and common in the ED environment:
I did have an experience where the patient was very street-entrenched,
sex trade worker, severe, persistent mental illness, and ultimately, she wasn't
able to consent to services provided by [the] ER department. However, when she
was in a bed and she had a nurse assigned to her, so when I went to speak to
her, she wasn't necessarily forthcoming with information and I said well, I'm
on call all day, I'd be very happy to come and meet with you later. I just went
to provide some collaboration with the nurse who was attending to her and she
said, she'll probably be gone later, she does this all the time, I'm sure she
wasn't assaulted…well, she said she was and that's kind of not [laughs] our
place to figure out, right? [Pause] particularly with sex trade workers, if
they have reported a sexual assault, the comments just start that this is theft
under a hundred dollars, it's not a sexual assault. And then [pause] my blood
pressure goes up (Participant One, Forensics Nurse).
Other participants
also referred to how nurses’ attitudes and discrimination towards women experiencing
IPV impacts effective IPV care. The above situation
described by the forensic nurse reveals how women who visit the ED may not receive
care related to IPV or may not even receive appropriate referrals to the
S.M.A.R.T team and forensics nursing services based
on negative social judgements and deservedness for care. This impacts care to
women who are experiencing IPV.
Time and wait times.
Challenges
and barriers also exist within the ED department pertaining to long wait times
associated with systematic barriers:
If I could wave a magic wand and say what would I change, be different
for [women] to access care, I think it would be nice to have a special women's
place for them to come to, not just a place where there's other people there
and they're all there for different needs. And sometimes women might feel that
their need is not bad they haven't got a broken leg and they're not physically
injured and they may think that they're not there for any reason. They may make
it into nothing. I think something specifically lined for women would be a good
idea, sensitive to their needs. Reducing the waiting period would be great.
Although we are pretty good at getting them in through the doors very quickly
and our response time is pretty quick, but sometimes they have waited a little
bit longer and then they've just left because they just don't want to wait that
long once they get into ER maybe in a lineup or something and then when they're
triaged it might be a bit slow cause they're busy. Then by the time the
doctor's made them medically fit for us to be called, it all takes time and it
all adds up. And sometimes when a patient comes in, they may be high on alcohol
or drugs. By the time they've slept it off, they've changed their mind whatever
the delay and sometimes we come in and they tell us they don't want to have an
exam or they just, walk away (Participant Two, Forensics Nurse).
These systematic barriers and discriminatory attitudes towards
some women accessing ED care manifested in wait times; HCPs in this study
associated these dynamics with why some women decide to walk away rather than
receive care in the ED. HCPs also described other barriers, such as the lack of time to support
women that shaped their ability to provide good care:
Sometimes all a patient needs is time to share their story. And
sometimes it's hard to find that time to sit and listen to that story. There
isn't as much time to talk about this in comfort as you would like, and even,
we have two social workers on, and even [pause] they don’t have time, it's such
a busy department that there isn't anybody who can walk you through and support
you. There is, for our sexual assault cases, there's a support person who can
come and stay with you; I wish there was something like for women who come in
with intimate partner violence who can have somebody who's not necessarily a
partner, like from a healthcare point of view who can come and support you
through the healthcare process. I wish there was somebody like that. I mean
there is, for some cases, like with sexual assaults, but not necessarily for
women who are going through intimate partner violence. It's hard to provide the
care that I would like to provide because I feel like there's no time, no time
in emergency. If there were pamphlets available, maybe in multiple different
languages saying this is a number you can call, safe places to go, or support
groups you can talk to, something like that I think would be helpful
(Participant Three, ED Nurse).
While time was noted
to be lacking, this participant indicated that written material could offset
the lack of meaningful discussion to provide women with after their ED visit
strategies for ensuring safety. In addition to time, the fast-paced ED environment
itself was also seen as hindering care:
Well, in emergency it's so incredibly rushed, it's so busy. The person
having the STEMI, the heart attack is priority than the person who's got the
broken wrist you have to triage, and you have to give care to the people who
are the sickest and we focus so much on the medical sickness that sometimes the
sickest people are the ones where you don't see the injuries, the physical
injuries. I think in emergency, especially in an emergency as busy as Surrey's
there really isn't the time to sit and listen. We refer [these women] to
somebody but then they're sitting and waiting, and social work is busy with
that trauma case and it takes a while to get there and sometimes I have had
women just say I'm okay, I think I'm just going to go and leave. I think [that]
is unfortunate (Participant three, ED Nurse).
Thus, negative
social judgment, nature of ED care (e.g. triage and wait times) and the lack of
time, space and privacy were described by HCP participants as significant barriers to care for women seeking care.
The above mentioned pertains to the third research question of how the ED
environment impacts care to these women experiencing IPV and challenges HCPs
experience when providing care.
Lack of awareness of IPV services.
A
forensic nurse described HCPs’ lack of awareness of their role and services in
the ED as a barrier for women seeking IPV care and support:
It's a fairly new profession, it's a new service, it's fairly new even
though it's been around since about '95, a lot of people still don't know about
it. Nurses I work with that ask me what I do, and I say I'm a forensic nurse,
they haven't got a clue and if nurses don't know, people out there do not know.
I have recently been doing some outreach work with the RCMP and different
detachments; a lot of the police do not know so when the police are the first
people that meet these people outside on the street somewhere or wherever, they
get called to the scene, they don't know what to do with them. So, they may,
just say go home or go to a friend's house, they haven't got a clue just like
we say in forensic nursing the days like today I'm on call, I didn't get
called, it doesn't mean it didn't happen, there's a lot of violence happening to
women out there but they're just not accessing care. So, it happens every day
(Participant Four, Forensics Nurse).
The
lack of awareness of forensic nursing services may contribute to barriers to
care for women in the ED and greater visibility and knowledge on behalf of HCPs
could contribute to the needed support and resources to women impacted by IPV. The
above participant extends the same insight to suggest that RCMP officers
within the community are not aware of how women could obtain support and services
from forensic nurses in the ED.
Privacy.
Protecting patients’ privacy is
always challenging in the ED;participants in this
study indicated that many women they have cared for worry about privacy and
confidentiality. Participants indicated that patients experiencing IPV need to
be assigned a number instead of being only identified by name when an IPV
report is filed to protect their identity:
The only thing I can suggest is sometimes just a bit more privacy
because we're trying to get the doctors to keep the privacy of the patients and
especially in the triage admission area. I wished they'd ask every time if the
patient wants their doctors to be notified, the GP, because that's another
privacy issue. They may not want their GP to know. I'll just tell you a little
case I had recently. It was a staff member but she was so concerned she wanted
to see me but she was so concerned about privacy and I guaranteed that
everything would be private but there was something in the system that was,
some blood work was done or whatever, and, I think there has to be a system [in
place] where they have to have just a number and no name even written on there
because once it was in the system, her name just got out and she was very upset
about that. And I tried my hardest, but the system is not made to continue the
privacy in all areas, if you know what I mean. Although the triage might make
it private, the GP name might not be on it, but the computer system is not
quite private. So, there's barriers with staff… and the thing is she didn't
really want to come and see me, and I said to her well you know it might be a
good idea and you could tell she was distraught…she didn't know whether it was
a good idea or not…so yeah, it's a shame. Also, because we're one of the main
centers, centers of giving this care, this care is not everywhere, it's not
like I could have sent her to the clinic next door (Participant Two, Forensics
Nurse).
Unfortunately, as
described above, maintaining confidentiality and privacy for women experiencing
IPV was understood in this study as difficult to uphold since HCPs at times
speak about their patients to other HCPs, and technology such as computer
programs cannot guarantee keeping a patient’s information confidential. Again,
this pertains to research questions two on how the ED environment impacts care
to women experiencing IPV. Another example of how confidentiality and privacy
was difficult to uphold was stated by Participant Five:
[When] a police officer walks a woman in, everyone looks. They have to
talk about it at the front desk. It is not a quiet place, a place where they
could share any information without other people hearing. They now have to sit
in the waiting room until there's space [available] (Participant Five, Social
Worker).
Participants in this
study offered some suggestions on how to
uphold a patient’s confidentiality and privacy: “I think one of the most
important things is to provide a closed office or consultation room where IPV
victims can talk freely and openly. That's more difficult to do but I think
that's something that's important to me” (Participant Three, ED Nurse).
Participants
indicated that the ED admission process can contribute to harm due to a lack of
privacy and confidentiality; the physical space can feel unsafe, particularly
due to the attention drawn to women who are escorted to the ED by police.
Again, the ED environment impacts care to women experiencing IPV as well
creates challenges on how HCPs assess and care for women experiencing IPV.
Support
for children.
Another
important barrier identified in the data was the difficulty of supporting the
children of women experiencing IPV when their children are present in the ED
department:
My domestic violence patient is often accompanied…with children and
may or may not have another adult with them to help. So that really impacts
delivery of care because now I might call the ED's family support worker [if
available]. We got some resources that may be available certain hours. That
might be when the S.M.A.R.T. worker is involved, and we have a whole bunch of
stuff in our closet for kids to play with, because we see children and to make
a fun space for them to wait while mommy gets her care done. But sometimes I'm
trying to do an examination with a toddler on the lap and we're looking at the
left side, switching the toddler over, looking at the right side because [the
toddler] doesn’t want to separate. Sometimes they've viewed the violence and
they've just all been picked up together and brought [together], by a family
member or by the police. I pray I have a S.M.A.R.T. worker or I have the family
life specialist, there are delays that we have to accommodate, or you know the
older children that you know may be part of the consent giving process if the mother
doesn’t have anything urgent you know to interact with the children provide
some entertainment and safety while mom has her examination. But sometimes the
door just does not open. Or the door is not shut, we have the outside doors
shut but the inside door is open, so the kid knows they can pop in and see
mommy and see everything's okay. Yeah, it gets messy. But then when these
children are in the emergency environment, your kind of [wonder] what will
happen to them? I mean do they stay with the social workers or they go with
their mom all the way through, so they're not separated (Participant Four,
Forensics Nurse).
Providing a
supportive and empathetic environment for both the women who are experiencing
IPV and their children was described as challenging.
The participants spoke of the need for having a support worker and family life
specialist available so that they could focus on providing care to the
women, while knowing the children were also receiving support. Yet, they spoke
of how support workers and family life specialists have limited daytime hours,
with 24/7 coverage not available.
Assessment and Care
The
third research question focused on HCP experiences of providing assessment and
care to racialized immigrant women experiencing IPV. Participants described
assessment and care by outlining priorities for women:
My first priority I would say is first of all make sure there's no
injuries, that's our main priority that usually has been taken care of when [racialized immigrant women] come into emergency. So, once
[racialized immigrant women] come to us, they shouldn't have any obvious
injuries. So, after that, my main priority is to get them to calm down.
Sometimes they're able to talk; sometimes they're not able to talk. Their first
reaction is usually to blame themselves, even when they walk through the door,
they say it's my fault, I shouldn’t have done this, I should have known better.
And so, my main concern is to let them know that they're not alone, that women
do go through this and it's not just them, it's not their fault, and then calm
them down enough for them to open up to me to start healing (Participant Two,
Forensics Nurse).
Providing
emotional support is an important component in a forensics nurse’s assessment
for all women, but specifically for populations of women who are newcomers and
face racialization within both health care and immigration contexts:
I get a little bit of a story of what happened, so I know what kind of
care to give them, so I can organize my care. If I feel there is a need for a
pelvic exam, if it's a sexual assault, they've been penetrated, I do a head to
toe [assessment and] do a pelvic exam as well. Then my other concern is what
kind of medication they need, medication for sexually transmitted diseases, HIV
medication if they've had any kind of body fluid contact. Basically, we go
through the process. Then we kind of tweak it to the individual person [especially to racialized immigrant women]
(Participant Two, Forensics Nurse).
This
“tweaking” to the individual person was not elaborated on in relation to the
participants’ views on the experiences of racialized immigrant women accessing
IPV care in the ED some additional probing here may have revealed some specific
and important insights that could add depth to the data for this research
question.
Participants
also spoke to what cannot be learned or assessed during triage that may be
significant for IPV care all women and specifically for those experiencing racialization
as newcomers:
IPV is
not usually not identified in triage cause triage just
happens so quickly, that's the quickest
part, it's supposed to be 30 seconds to a minute so then you're focused on what
brings you in and, and then we do a
quick focus assessment and then it's not until they get into the next area that we're identifying. Those are the
cases where women come in not saying,
not mentioning that this is a result of intimate partner violence. It's not
until we bring them into the
care and treatment zones where we're actually doing a full assessment and listening to the story as to
what brought them in. When the story doesn't match the type of injuries, [such as] I fell down the stairs and
then they've got a black eye or multiple
abrasions or scratches, things like that that aren't consistent with the story
that they're telling you, that kind of
sets off red alarms for me. I find when I see constant eye contact between spouses back and forth or
waiting for the husband to answer or almost a timid
presentation, just really quiet, [and] just how family members react. Sometimes
there's a bit of hostility that
doesn't need to be there and that kind of sets a couple of red flags up for me that maybe there's
something else going on (Participant Three, ED Nurse[MOU28] ).
The same participant
also described an incident when she suspected IPV when performing a head-to-toe
assessment for racialized immigrant woman:
There was a mother-in-law to a [racialized immigrant
woman] who was, I think, the patient came in under, a
hand injury but I started doing a full head-to-toe assessment, just asking [if
there is] any other injuries, any headaches, chest pain, anything else going
on, any injuries anywhere else, and when you fell did you bump your head, all
this. And the mother-in-law [asked] why are you asking about all these other
things, focus on the hand, the hand's a problem, that’s what we need to fix, we
just need to see a specialist. And then I was kind of like well there's no need
for that kind of anger and behavior…I started looking at the daughter-in-law
and she was just staring at the ground…was being really quiet and wasn't really
answering any questions. And then I was [thought] oh, maybe I should try and
get her alone…And then the mother-in-law asked for the bathroom and then when
she went to the bathroom then I [asked] is there anything else going on. Are you being hurt at home? Do you feel safe
where you are and then I got a little bit more and [such as] oh, sometimes
they're, not very nice to me but it's okay, I have to live there. I think it's
the feeling of I have no other choice but this. That kind of hurts me at first
then you [think] there are other options, there are other places for you to go
(Participant Three, ED Nurse).
It
seems that having experience as an ED nurse and having strong assessment skills
in knowing when to probe more if there are inconsistencies in women’s stories
pertaining to injuries and observing interactions between these women with
their spouses and families plays a vital role in recognizing if racialized
immigrant women are experiencing IPV or not.
This
social worker participant went on to explain her role in IPV assessment for racialized immigrant women to determine what
their needs may entail and what resources relevant to their life context may be
needed:
With our role, the care priorities are to ensure that she is safe, she
understands that she's safe, that you build rapport so that there can be [an]
open honest discussion, that you're figuring as a social worker that we're
determining her narrative, what has, how has this become this way, and how does
she see herself in that way. We also want to take in theories, theories of
social work that we've used which are the person and the environment theory,
which is what is her life like, what is her role within her own environment,
how does it play with her, does she have a job, is she beholden to him because
of money, are there children that are not only at risk but that could be used
as a tool against her. What are all of those pieces and how do you know if it’s
an addiction or the readiness for change, does she want to leave, is she
wanting to press charges, is she wanting to make this secret now something
known…and to discuss that in terms of how it looks for her and her
individually. And then to make sure that there's somebody in the community, who
can pick up the pieces of her situation when she leaves here because hospital
social work is just in the hospital, so we can only support them for as long as
the patient is here, and that's unfortunate. So, we want to try and tag them up
with somebody outside of here. We try and discuss with them who they would be
comfortable seeing. You know do they have friends, if they have a job, do they
have any kinds of benefits, programs that we can have them in, do they want to
be involved with a women's center, do they want a telephone number for this or
that, are they older, work with the OMNI Centre because you know women in an older
stage of life are very different than women who are of childbearing in terms of
what resources are available to them. And so, we want to just make sure there’s
a thoughtful choice even though it's an acute crisis that perhaps we've at
least thought about what the best option for them would be, and always provide
them with resources, I guess the information about funding for various things
or whatever they might need, it all depends on the circumstance. So, very
individualized focus for every single situation (Participant Five, Social
Work).
HCPs
need to have strong assessment skills when caring for not only racialized immigrant women but all women
experiencing IPV; they need to be carefully attuned to be able to understand
women’s situations and their connection to physical injuries which may be
related to IPV. HCPs also need to be knowledgeable about resources and
providing all women, and particularly those facing systemic and structural
barriers to effective IPV care, the necessary support
to inform their ongoing safety planning.
Interestingly
and despite the population demographics served by the research site, one
participant claimed she did not see many racialized immigrant women in her
practice:
I think just because of our geographical location, we do have certain
groups of people that we see more than others, sex trade work, drug-use, mental
illness, those kinds of things, we do see cross-cultures and things like that.
I would think that there would be other groups that would be probably more
represented than they are in our service but again, who knows. So, I find that,
I don’t see a lot of Indo-Canadian women, but I do believe there to be. I do
believe that this is a problem in every community, but I don’t see a lot of
Indo-Canadian women in my practice. We don’t see a lot of recent immigrants
from anywhere in our [or] in in my practice. There are some, but I think if I
were to, and it's hard for me to say because I see hundreds of cases but
[pause] it's not an obviously well researched percentage but I'm [estimating
that] 70 to 80 percent [of my clients are] Caucasian Canadian women. I did see,
one Indo-Canadian woman, I just wish we saw more of these people, but that's
not what I mean. But I wish that whatever barriers, because I know this is
happening, it's happening in every community it's happening just as much in the
new immigrant community and the Indo-Canadian community and the Asian
community; I've never seen anyone from China and Japan or Korea. I know it's
happening…It happens across all cultures and all socio-economic [backgrounds]
(Participant One, Forensics Nurse).
This
participant resisted the notion that IPV is a phenomenon experienced
differentially within specific ethnic communities, which surfaces important
attention to the nature of my initial research orientation and questions; this
participant’s response contributes to understanding the importance of research
question three which was constructed to learn from HCPs about their experiences
of providing care to specific populations of women within the study geographic
area. The question itself aimed at learning from HCPs about their experiences
as they reflected on providing care for
specific communities of immigrant women, and those whose lives are affected by
racialization. Participant One indicated her thinking about IPV as pervasive
across communities and not reducible to any racialized groups.
Another
participant held a contradictory view that racialized immigrant women who seek
care in the ER for IPV present specific challenges related to being accompanied
by family. Being accompanied by family, while acknowledged for their supportive
role, was seen as potentially creating challenges for HCPs when deciphering the
nature of family support and dynamics relevant for IPV assessment and care,
along with translation needs:
When I see someone from the immigrant population come in, my first
question is she getting the support from family. The people that are with her
are they with her to make sure she doesn't do anything wrong or are they with
her to support her. I hate to say this and I hate to stereotype but with the
non- immigrant population I don’t think that way too much although that could
be the case with them as well. But with the immigrant population, with the
minorities, I feel there's of a lot of backlash in family for them to even
access care because I think of the unknown, they don't know what kind of care
we provide, even less than the rest of the population.
They think that we're [trying to] take away from their family, they think we’re
telling them to do something that is not right for them. They don’t realize
that care that we're giving them is the care that they will only request or
we're not going to do anything otherwise, we ask them what to do. And I don’t
think they're aware of that. Then the other thing is just to open up. I speak
Punjabi as well. I've had some women that come in and speak Punjabi. They don’t
want a translator. I'll just give an example of this person wanted the family
member to translate although I could speak Punjabi, but they wanted the family
member there, but then afterwards, looking back, we thought well maybe that
family member was the one that was the problem. So, it's very hard to know,
because they're so connected [with the] family, I think it's my personal issue
is knowing how to deal, I find it very hard just to deal with that one person.
Whereas a lot of people from other walks of life, they come in themselves and
they do what they want. They don’t have that family with them, which is good
and bad, there's a good and a bad side to that, but I think one of the cons of
some immigrant populations when they have their family with them, they're not
doing what they want, they're doing what the family wants (Participant Two,
Forensics Nurse).
While
the above participant stated that violence exists in every culture and all parts
of society, another participant felt there may be less awareness about issues
of IPV in newcomers, positing the broader social context as relevant:
I don’t know in some cultures how I should approach them, so I have to
just see how that person is and see how they open up to me. [I] encourage them
to open up and I basically just have to give them the reins and say what I can
do for you, more so than I do with other people. I think there's less awareness
with women, violence of women…we all know that violence exists in every culture
and all parts of society, but I think the awareness is less in immigrant
societies and they're not talked about and I think once we start talking about
it more, then we can have them open up more and can access them and help more.
I think awareness is the key (Participant Four, Forensics Nurse).
Another
forensics nurse suggested that a lack of awareness might also be connected to
the lack of knowledge about services in the Canadian context:
[Racialized] immigrant women may not know that
the services are here for them. Sometimes they're very isolated by culture
[and] language. The fact they might have to bring in someone to translate or
depend on us to get someone to translate for them can be pretty tricky. It's
very difficult for me to feel comfortable doing an exam for someone whose
English is shaky because I'm not sure I can communicate the legal ramifications
of their choices which is very important to me. I have not had a situation
where I needed a translator and not gotten one. Once I get here, I feel we can
give good language support but, do people even know that, do immigrant women
know that this is a place they can go for help. Essentially, I think of
immigrant women coming from places where there is trust with say the police and
hospital systems but then I know there are a country where that doesn’t exist,
and people avoid the hospital at all costs and police at all costs and they're
not even getting help at that level. So, I think that culturally or societally
we have some barriers for immigrant women getting here (Participant Four,
Forensics Nurse).
The participants also spoke about assisting Syrian immigrants, highlighting the
challenges created by language barriers, and striking a balance between
assisting woman and overcoming language and cultural
barriers is often difficult:
For example, an unemployed female Syrian refugee will need
very different resources than then a [Canadian Caucasian] woman who has a job. There has been challenges when working
with Syrian refugees…definitely the language barrier, [having] Arabic
interpreters, many of them have different dialects [and we are] not getting
[the] full information from [these] women. [We are] not able to get a full
disclosure. Then the resources are tough. There's only one doctor in all of
Surrey, not even Surrey, they're in Port Coquitlam that will take in women
since they don't speak their language. So, if we're looking for a physician to
provide ongoing care or whatnot, there are very few options for them. There's a
real struggle. I would say the language barrier, the cultural experiences from
ER nurses, not to mention the fact that there is a significant prejudice in our
community around Syrian refugees. So, they're really dealing with a lot of big
issues, just in terms of that. But then it is also the impact of violence.
Unfortunately, because of the limited resources for them, the way the MCFD
interact with Syrian refugees in particular is different. And so, we have to
tread very carefully in terms of that. So yeah, it is a tough one. You don’t
want to be the person that adds more stress and chaos, to this kind of
environment but you also have to follow the protocols put in place by the
hospital and our College in terms of reporting. So sometimes there's a bit of a
balancing act (Participant Five, Social Worker).
Having the
appropriate translators to effectively communicate with women experiencing IPV
represents systematic barriers for effective IPV care
within the ED environment. Notwithstanding the barriers related to language,
one participant makes an interesting point that some racialized immigrant women
do not prefer having HCPs of their own ethnicity or cultural background. One
participant believed that racialized immigrant women are not willing to
disclose IPV experiences to HCPs who shared their ethnicity or cultural
background:
I have heard from women that they would sometimes prefer not to have
somebody of their own cultural or ethnic background and sometimes they prefer
to have them. So, the fact that there are two of us here, sometimes we can give
those options. We have male staff, that [can] sometimes [be] a very big
challenge for rapport building if we have a male staff [member] go and do this
kind of intervention. The language barrier, not being able to speak in their
original language is a struggle. We're really lucky; we have a lot of Punjabi
[and] Hindi interpreters in the ER so we can at least call somebody quickly.
But when you have to add the element of somebody on the phone as an interpreter
or if the dialect is so difficult to find, sometimes a family member or a child
has to help. It limits the amount of disclosure you can get from a woman. And
this [is] generally the first time they're telling this complete story and you
want to make sure that every option [is available]. Those are [the] challenges
(Participant Five, Social Work).
Participant
three, an ED nurse, had a view that some immigrant women are more receptive to
her because she could speak Punjabi and Hindi:
From an emergency perspective and I think over the years, I've come
across quite a few women with intimate partner violence, from many different
backgrounds, but I think the ones that hit home for me was the ones with the same
ethnic background. I feel they're more open, [if] the women that I've come
across [come] from the same cultural background (Participant Three, ED Nurse).
One
participant claimed that a lack of
understanding and education about other cultures and backgrounds was a barrier to proving IPV care. This view
reflects a potentially problematic assumption that violence it cultural; such
views were expressed in the data and will be further discussed in Chapter 5:
I think it will be nice, I'm thinking, to have if someone could give
us more cultural orientation in with other cultures,
although you know life's experience, I do know some things but it's not enough.
I think it would be nice to have cultural orientation where some people
from different cultures come and talk to us on how their cultures deal with
these things and how [and] what we could do to help them. So, I think more,
outreach work from different cultures, and communication with them would be
good. We all know about how to deal with our own backgrounds, but I don’t know
how to deal with say someone from Japan or China, I don’t know, there's
similarities in a lot of cultures but [there is] a lot of differences as well.
And even from the Native population, I try to do readings and do the courses,
but I still don’t know that much as I know [about] my own [culture] so I think
a lot of more homework in that area would be good (Participant One, Forensics
Nurse).
Promoting Women’s Safety
Another important and recurring
theme that emerged during the interviews was safety and safety planning for
women. This theme correlates with all three research questions of how ED HCPs
provide care to women, how the ED environment shapes care for women impacted by
IPV, and how HCPs assess and care for these women. Safety of IPV can be
achieved by reducing barriers to access health services and transforming
systems and structure to create privacy at ED centers where disclosure does put
them at risk. According to participants safety is a major concern for women:
We do safety planning if there is some violencedisclosed. We want to make sure even if they say they haven't
been assaulted physically or sexually, we want to make sure that they're safe
when they go home. We want to make sure they have somewhere to go. So, safety
planning is a huge one I think for [women experiencing IPV]. And then of course
once they're out of our care, we want to make sure that they're followed up, we
want to make sure they get the full support. We know [these women] don't get
cured or they don’t deal with the situation or the problem in their life
overnight. It happens over many years and, this is just another avenue for them
to get support when they come in through the doors (Participant Two, Forensics
Nurse).
However, safety
planning also involves other HCPs:
My job is, to help identify the needs for safety, to talk to the
patient, to get them to open up because sometimes they don’t tell you
everything, so we don't have the full picture. My job is to make sure that all
the information is obtained from the patient as well as the social worker. We
work together as a team; I also call in the Surrey Women's Centre, there's an
afterhours support worker that usually attends if they can with every case that
comes through the door. We both as a team make sure that this person is safe,
not only safe physically but also safe mentally so we talk to her, we tell her
that you know maybe she needs to revaluate what she's doing or does she think
this is the last line, whatever it is she's doing out there that putting
herself at risk is that maybe she wants to try something a little different,
[but] done obviously with a lot of sensitivity (Participant Two, Forensics
Nurse).
Safety
and safety planning emerged to be critical towards offering care to women
experiencing IPV. Safety planning from the perspectives of HCPs in this study
emphasized the critical importance of reducing barriers for women experiencing
IPV who seek ED care. For instance,
privacy should be guaranteed to women experiencing IPV and that follow-up
support is a key necessity when providing care and promoting safety for women
accessing IPV care in the ED. Also, collaboration and working together as a
team was emphasized as a resource to ensure both emotional and physical safety
for women in the ED.
Conclusion
The interview process generated
interconnected and multilayered findings; five themes and related and layered
sub-themes were presented: interests, motivation and
reasons for working with women experiencing IPV, resources, education
and funding, lack of awareness, collaborating with other disciplines, barriers
to care, populations of women who visit the ED for IPV related care, assessment
and safety. The next chapter, chapter five, will discuss the findings, and
provide recommendations, while also noting the limitations of the study.
Appendix A: Poster
EMERGENCY HEALTH
CARE PROVIDERS PERSPECTIVES ON PROVIDING CARE TO RACIALIZED IMMIGRANT WOMEN
EXPERIENCING INTIMATE PARTNER VIOLENCE
Are you an emergency trained RN, forensic nurse, social worker, or
emergency physician?
Have you been employed in the emergency setting for at least three
years?
Do you have a full-time or part-time permanent position?
Consider joining a
study about emergency healthcare providers’ experiences caring for women
impacted by intimate partner violence.
Participation
involves a 60 to 90-minute interview with a UBC graduate student researcher
All participants will
receive a $25 Starbucks gift card, and snacks and refreshments will be
provided.
Please contact the primary contact person for more information
The University of British Columbia Investigator / Contact
Person: Supervisor/Principle
Investigator:
School of Nursing Beljinder
Mattu, RN Helen
Brown, RN, PhD,
T149-2211, Wesbrook
Mall Graduate
Student (MSN) Associate
Professor
Vancouver, B.C. V6T
2B5 778-228-0061 604 822 7445
(604) 822-7445 beljinder.mattu@fraserhealth.ca helen.brown@nursing.ubc.ca
School of Nursing
T149-2211, Wesbrook Mall
Vancouver, B.C. V6T 2B5
(604) 822-7445
Study Invitation
EMERGENCY HEALTH CARE PROVIDERS PERSPECTIVES ON PROVIDING CARE TO
RACIALIZED IMMIGRANT WOMEN EXPERIENCING INTIMATE PARTNER VIOLENECE
Dear Participant,
My name is Beljinder
Mattu and I am a Master of Science in Nursing student at the University of
British Columbia (UBC). I am doing research for my thesis on the topic of
emergency (ER) healthcare providers’ experiences with caring for women living
with intimate partner violence (IPV). I have always been interested in this
topic and I believe more research needs to be done about IPV at SMH. I am
particularly interested in what informs ER care providers care in relation to
IPV for women accessing care at SMH. My goal is to contribute knowledge for IPV
prevention and access to care in the ED along with the advancement of policy
and research to inform ED practice.
The Study The purpose of this study is to explore and better understand ED HCPs
perspectives on providing care for women experiencing IPV who are seeking care
in the ED.I wish to answer the following research questions
during this study:
What are ED care providers’ experiences of:
(1) Providing care for women living with
IPV?
(2) The ED environment for how it shapes
their care for women?
(3) Assessment and care for racialized
immigrant women experiencing IPV?
What is Involved?
You
will be asked to participate in this study by completing an interview with
myself. The interview date and time will be arranged as according to your
availability and will be located on site. The interview is expected to last for
60 to 90 minutes approximately. Refreshments and snacks will be available and
you will be given a $25 Starbucks gift card after the interview for your
participation.
Privacy and Consent
You will be advised
that you may withdraw from the study during anytime without any penalty. Your
confidentiality and privacy will be protected during the interview and all
participants will have pseudo-names such as P1, P2, P3 etc. Your participation
will be entirely voluntarily and you may withdraw from the study anytime.
Consent will be obtained and you will be asked to sign a consent form if you
wish to participate. If you are interested in participating, you will be
explained about the study either by phone or via email and the consent form
will be emailed for yourself to overlook. When you are ready to be interviewed,
the study purpose will be reviewed and the consent form will be explained to
you. If you are interested in participating, you will be asked to sign the
consent form.
Thank you very much
for your interest in this study and I hope to hear from you very soon. Kindly
contact myself via telephone or email at (778) 228 0061 or
beljinder.mattu@fraserhealth.ca if you are interested or need more information.
Again, thank you for your time.
Sincerely,
School of Nursing
T149-2211, Wesbrook Mall
Vancouver, B.C. V6T 2B5
(604) 822-7445
1)
In what
hospital are you currently and primarily employed?
o Surrey
Memorial Hospital
o Vancouver
General Hospital
o Royal
Columbian Hospital
o Peace
Arch Hospital
2)
In what role do you practice?
o Emergency
Nurse
o Physician
o Forensic
Nurse
o Social
Work
3)
What is your gender?
o Female
o Male
o Other
4)
What is your age range?
o 20 to 30
years of age
o 31 to 40 years
of age
o 41 to 50
years of age
o 51 to 60
years of age
o
61 to 70 years of age
5)
What is your employment status?
o Full-time
o Part-time
6)
Overall years of experience as an healthcare
provider:
o 3 years
o 4 to 9
years
o 10 to 15
years
o 16 to 21
years
o Over 22
years
7)
Years of experience working in an emergency
department:
o 3 to 5
years
o 6 to 10
years
o 11 to 15
years
o 16 to 20
years
o Over 21
years
8)
What’s your highest level of
education?
o High
school Diploma
o Undergraduate
Diploma
o Undergraduate
degree
o
Graduate degree
Additional
Comments
Please
feel free to provide any additional comments:
Appendix D: Consent
CONSENT FORM
Title: EMERGENCY HEALTH CARE PROVIDERS PERSPECTIVES ON PROVIDING CARE TO
RACIALIZED IMMIGRANT WOMEN EXPERIENCING INTIMATE PARTNER VIOLENECE
Contact Person:
This research is part of graduate
thesis work in my Master of Science in nursing program at the University of
British Columbia
Principle Investigator:
Dr. Helen Brown, RN, PhD
School of Nursing - University of
British Columbia
Co-investigators:
Dr. Colleen Varcoe, RN, PhD
School of Nursing - University of
British Columbia
Dr. Victoria Bungay, RN, PhD
School of Nursing - University of
British Columbia
Beljinder Mattu, BSN
Graduate Student – University of
British Columbia
You are being invited to
take part in this research study because you are either an emergency (ER)
nurse, forensic nurse, social worker, or ER physician who is primarily employed
in an ER setting, have a minimum of 3 years of ER experience and in a permanent
part-time or full-time position.
Your participation is entirely voluntary. It
is important for you to understand what the research will entail before you
decide to participate. This consent form will explain about the purpose of this
study, why the research is being ensued, and how the research will be
conducted.
However, if you still would like to
participate, you will be asked to sign this form. If you decide to take part in this study you
are still free to withdraw from the study anytime without any penalty.
If you do not want to participate, you do not
need to provide any rationale and your decision will not impact your current or
future employment within Fraser Health.
Please read the following information
carefully before making your decision.
WHO IS CONDUCTING THE STUDY?
This study is being conducted in fulfillment of Beljinder Mattu’s
masters of science degree under the supervision of Dr. Helen Brown, RN, PhD,
who will be the primary supervisor involved in this study. Dr. Colleen Varcoe,
RN, PhD and Dr. Victoria Bungay, RN, PhD will also be part of the thesis
committee.
BACKGROUND
Violence against women especially intimate partner violence (IPV) is
not only a provincial or national health concern but also a global concern.
Women are 80% more likely to be victims of IPV and more likely than males to
experience physical abuse. IPV has quite wide physical, mental and financial
impacts within women’s lives, the impact being even greater for racialized
immigrant women living in poverty, and women lacking access to social determinants
of health. These impacts of IPV extend beyond women’s’ lives, and also impacts
society as a whole, more specifically within the health care system; IPV
creates a significant burden on the Canadian health care system and taxpayers
in general, as women who seek care for IPV require acute services often sought
out in emergency department (ED) settings. One US study estimated that 4% to
20% of IPV victims who are currently being abused visit the ED. A Canadian
study estimated that 13.9% of female IPV victims visit the ED. Physicians and
nurses from the ED are most likely to be the first to see IPV victims who are
seeking care. Thus, the ED is a major location where IPV victims may turn to
for care.
The purpose of this study is to explore and better understand your
perspectives on providing care for women experiencing IPV in the emergency
department, in order to contribute to effective, ethical, and responsive care.
The research questions for this study that I wish to answer are the
following:
What are ED care providers’ experiences of:
(1) Providing care for women living with IPV?
(2) The ED environment for how it shapes their care for women?
(3) Assessment and care for racialized immigrant women experiencing IPV?
ü Any ER trained RN, forensic nurse, social
worker, and ER physician
ü Has been employed in an ER setting for a minimum
of three years
ü Employed in a permanent part-time or full-time
position
All participants MUST meet the above
criteria to be eligible for participation in this study
The study will take place at your work site in a private pre-booked room
where only the researcher, observer, and yourself, will be present. You will be
interviewed for approximately 60 to 90 minutes and the interview will be
audio-recorded. You will be asked to participate outside of your work time. The
time and date of the interview will be arranged as according to your
availability and schedule. You will also be asked to answer a questionnaire
pertaining to demographic information. However, if there are any questions you
are not comfortable answering you may refuse at any time.
You will be asked about your experiences of caring for women
experiencing or living with IPV in the ER setting and will be encouraged to
speak candidly about your experiences without judgement.
There are no anticipated risks of harm involved in this
study.
WHAT ARE THE BENEFITS OF PARTICIPATING IN THIS STUDY?
There are no anticipated benefits to you from
taking part in this study.
WHAT HAPPENS IF I DECIDE TO WITHDRAW MY CONSENT TO
PARTICIPATE?
Your participation in this study is voluntary
and you may withdraw without any penalty and without providing any explanation
of any reasons for doing so. All data that has been collected up to this point
will only be used if consent is obtained from yourself, the participant.
WHAT WILL THE STUDY COST ME?
You will not incur any costs and
your parking will be compensated upon proof of receipt. You will also receive a
$25 Starbucks gift card for your participation in this study.
WILL MY INVOLVEMENT IN THIS STUDY BE KEPT
CONFIDENTIAL?
Your confidentiality will be respected. However, research records identifying you may
be inspected in the presence of the Investigator or his or her designate by
representatives from UBC [Dr. Helen Brown, Dr. Colleen Varcoe, Dr. Victoria
Bungay], and [University of British Columbia Research Ethics Board and Fraser
Health Research Ethics Board] for the purpose of monitoring the research. No
information or records that disclose your identity will be published without
your consent, nor will any information or records that disclose your identity
be removed or released without your consent unless required by law.
You will be assigned a unique study number as
a subject in this study. Only this
number will be used on any research-related information collected about you
during the course of this study, so that your identity [i.e. your name or any
other information that could identify you] as a subject in this study will be
kept confidential. Information that
contains your identity will remain only with the Principal Investigator and/or
designate. The list that matches your
name to the unique study number that is used on your research-related
information will not be removed or released without your consent unless
required by law.
WHO DO I CONTACT IF I HAVE QUESTIONS ABOUT THE STUDY?
If you have any questions or need more
information about this study before or during participation, you can contact
Beljinder Mattu at (778) 228-0061 or beljinder.mattu@fraserhealth.ca
WHO DO I CONTACT IF I HAVE ANY QUESTIONS OR CONCERNS
ABOUT MY RIGHTS AS A PARTICIPANT DURING THE STUDY?
Complaints or concerns arising from UBC research participation are
handled by the Research Participant Complaint Line
My signature on this consent form means:
- I have read and understood the
information in this consent form.
- I have had enough time to think about the
information provided.
- I have been able to ask for advice if
needed.
- I have been able to ask questions and
have had satisfactory responses to my questions.
- I understand that all of the information
collected will be kept confidential and that the results will only be used
for scientific purposes.
- I understand that my participation in
this study is voluntary.
- I understand that I am completely free at
any time to refuse to participate or to withdraw from this study at any
time.
- I understand that I am not waiving any of my
legal rights as a result of signing this consent form.
Name of Participant:
____________________________________
Signature_______________________________________________
Date: _________________
Name of Investigator:
____________________________________
Signature_______________________________________________
Date: _________________
|
Table 1.
Demographic Characteristics
|
|||
|
Characteristic
|
|
n
|
%
|
|
Gender
|
|
|
|
|
Male
|
|
|
|
|
Female
|
|
5
|
100
|
|
Other
|
|
|
|
|
Age
|
|
|
|
|
20-30
|
|
|
|
|
31-40
|
|
3
|
60
|
|
41-50
|
|
1
|
20
|
|
51-60
|
|
1
|
20
|
|
61-70
|
|
|
|
|
Main Source of
Employment
|
|
|
|
|
ER Nurse
|
|
1
|
20
|
|
Physician
|
|
|
|
|
Forensic Nurse
|
|
3
|
60
|
|
Social Work
|
|
1
|
20
|
|
Main Hospital of
Employment
|
|
|
|
|
Surrey Memorial
|
|
5
|
100
|
|
Vancouver General
|
|
|
|
|
Royal Columbian
|
|
|
|
|
Peace Arch
|
|
|
|
|
Employment Status
|
|
|
|
|
Full-time
|
|
2
|
40
|
|
Part-time
|
|
3
|
60
|
|
Overall years of
experience as a healthcare provider
|
|
|
|
|
3 years
|
|
|
|
|
4-9 years
|
|
2
|
40
|
|
10-15 years
|
|
|
|
|
16-21 years
|
|
2
|
40
|
|
Over 22 years
|
|
1
|
20
|
|
Years of
experience working in an emergency department
|
|
|
|
|
3-5 years
|
|
2
|
40
|
|
6-10 years
|
|
2
|
40
|
|
11-15 years
|
|
1
|
20
|
|
16-20 years
|
|
|
|
|
Over 21 years
|
|
|
|
|
Highest Level of
Education
|
|
|
|
|
Highschool
Diploma
|
|
|
|
|
Undergraduate
Diploma
|
|
1
|
20
|
|
Undergraduate
Degree
|
|
4
|
80
|
|
Graduate Degree
|
|
|
|
Appendix E: Semi-Structured Interview Guide
Preamble
My name is Bel Mattu
and I am a University of British Columbia (UBC) Master of Science in Nursing
student. Thank you for taking time out of your busy schedule to participate in
this study. I am conducting this study due to my interest in intimate partner
violence (IPV). This interest was kindled by the news of the senseless death of
Maple Batalia who was murdered by her former boyfriend in 2011. Maple was a
vibrant and ambitious young woman who was an aspiring model and a student at
Simon Fraser University (SFU). I was deeply impacted by Maple’s death as I felt
this young woman could have been any woman, including myself. Maple was also an
Indo-Canadian woman like myself and had her whole life ahead of her and her death
due to IPV was heart-breaking and shocking.
Questions
1) What are experiences of ED healthcare
providers when providing care for women living with IPV?
§ I am really interested in your thoughts and
experiences about providing care to women impacted by IPV.
§ Are there any specific experiences that stand
out to you?
§ What resources are available to you when
providing care to women experiencing IPV?
2) What are the ED healthcare providers’
experiences of the ED environment for how it shapes their care for women
experiencing IPV?
§ What are your thoughts about the ED
environment and how it impacts care to women impacted by IPV? How does this
impact your practice?
§ Are you able to provide specific examples?
(3) How do ED professionals approach
assessment and care for racialized immigrant women experiencing IPV?
§ What are some experiences when caring for
racialized immigrant women?
§ What are some specific experiences when caring
for racialized immigrant women experiencing IPV?
§ How do you assess women experiencing IPV in the
ED?
§ Are you able to provide specific examples of
what assessment skills/tools you use?
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[1]Immigrant refers to a
person who is or was a “landed immigrant...A landed immigrant/permanent
resident is a person who has been granted the right to live in Canada
permanently by immigration authorities…Most immigrants are born outside Canada,
but a small number are born in Canada” (Statistics Canada, 2015).
[2] Visible Minority:
“includes persons who are non-Caucasian in race or non-white in colour and who
do not report being Aboriginal” (Statistics Canada, 2015).
[BV18]I have worked my way through this chapter. The data you have
presented is very interesting. I am however, finding it a bit hard to follow
your analysis or understand the findings, or how they fit together to tell the
story of what you learned based on the guiding research questions. I think that
explaining how you used your questions to shape analysis in chapter three will
help, but more work is needed here to write up your findings in a more
analytical way. I know Colleen has
provided similar feedback but here are some suggestions I have for re-working
this chapter into a cohesive presentation of findings.
A. In the introduction to the
chapter specify how many overarching themes were identified and link them back
to your aim of the study. So for example, to help illustrate the findings
concerning the perspectives and experiences of ED staff in providing care to
racialized immigrant women affected by IPV I organized the findings into x
overarching themes. Specific sub themes were used to highlight key aspects of
the findings within each them (or something to this effect). Then a general
statement of what you learned.
B. I think that each theme needs to be explained in the sense of what
it means and how it relates to your overarching study purpose. I find it very
helpful if every theme section has an introductory statement that ‘defines’ the
them and tells the reader a bit about what you are talking about.
C. I think that some of the themes could be condensed. Usually I
recommend 3-4 overarching themes but I will defer to you and Helen on how you
want to present the findings.
D. The theme I really struggled
with was the HCPs Perspectives on IPV and Culture. I am not sure this is the
best language for your heading. How you are using the term culture here is not
congruent with your cultural safety framework. While you do note quite well
that there appeared a problematic assumption that violence is cultural you sort
of contradict yourself by using culture in the title of the theme.
