Chapter 5
Discussion and Recommendations
In
this chapter, I discuss how the findings described in in chapter 4 contribute
to existing literature. Specifically, I outline how the themes add, extend
and/or indicate new directions for knowledge development within the context of
health care provider practice for women seeking IPV care in the ED. Following
the discussion of the findings, I will detail recommendations for health care
practice, policy, education and research while also outlining the limitations
of the study.
The
study findings underscore the critical importance of IPV care for women from
the perspective of ED health care providers. From the literature, it has been
documented that many racialized immigrant women face
structural and systematic barriers to access healthcare services;health care providers in this study shared
their perspectives about ED care barriers such as the lack of translation
services, lack of support and inconsistent services for women, while also
discussing their views that shape IPV
care for women in the ED(Cherniak et al. 2005; Lee & Hadeed, 2009; Thandi, 2011). [BH1]
IPV
related resources for ED health care providers.
Health care providers in this study
emphasized how thelack of resources for women
experiencing IPV was a significant factor shaping their care for women in the
ED. In addition, the participants highlighted that even when resources were
present, there was a lack ofawareness among HCPs and particularly for those
that may have relevance for racialized immigrant women. Within the study site,for
example, there is a large population of Punjabi-Sikh immigrants and many may
not be able to communicate fluently in English (Statistics Canada, 2014). The
findings from this study support other studies wherein language barriers and
the lack of education and awareness about services and resources provided act
as to impedecare for racialized immigrant women(Ahmad et al. 2009[BH2] ).
In this study HCPs described the lack
of awareness of resources, services, training and referral opportunities resources
and services for women. Similarly, Al-Natour et al. (2014) found that HCPs
experienced challenges when trying to refer women due to the lack of awareness
about accessing appropriate resources or navigating the healthcare system[BH3] .
Enhancing the availability of resources to women impacted by IPV was a key
theme in this study, along with the importance of tailoring care to the needs
of racialized immigrant women. As one ER participant mentioned, resources are
sometimes not available in other languages; thus, specific populations of women
experiencing IPV may have difficulties understanding and knowing where to go
for IPV care and how to obtain more
information about IPV. HCPs in
this study, as in other studies (cite some?) indicated that they were unaware
of resources and where to refer these women.
In
addressing IPV among racialized immigrant women, resources are always a
necessary consideration both at the ED level and for women seeking care
themselves.e. Resources include sufficient HCPs[BH4] , sufficient personnel at the ED, and
sufficiently trained HCPs on caring for women impacted byIPV[BH5] . According to participant three and five,
the major discussion within the ED with women impacted by IPV is whether they
have available resources to seek help and potentially leave their partners. These
findings align with the findings from a study by Kaplan and Komurcu (2017) who
found out that HCPs felt ill-equipped when dealing with IPV experiencing women
due tolack of resources and knowledge.
Racialized[BH6] immigrant women face many barriers that
exacerbate other health care barriers when living with IPV, such as poverty and
education[BH7] . The findings from participant one and
participant three indicated inadequate information and education on the part of
HCPs in offering care to women experiencing IPV. The absence of the required
resources meant thatHCPsin this study feltthey were unable to provide the
required assistance to women in the ED[BH8] .
Language
as a barrier.
In this study, it was evident that
language acts as amajor
hindrance accessing health services, especially amongst racialized immigrant
women. The available pamphlets at SMH are only in English. This reduces the
effectiveness of using pamphlets and other literally materials among racialized
immigrant women. These findings also point to the difficulty of HCPs
communicating with thesewomen as they need an interpreter to assist in the
conversation. This creates a barrier for history taking and a comprehensive
assessment that is necessary for effective IPV care and can also influence the
necessary privacy and confidentialitywomen need in the ED. The findings revealed
that language acts as a barrier to care forracialized immigrant populations and
the populations described by HCPs in this study wereSyrian immigrants and the
Indo-Canadian population. Similarly, studies by Ahmad et al. (2009) and Du Mont
and Forte (2012)confirmed language as a primary
barrier for racialized women impacted by IPV when seeking help.
The
findings further indicated that some HCPs[BH9] experienced
difficulties speaking to their
clients as some of these women were not fluent in English, especially the
Syrian immigrants who spoke certain Arabic dialects where finding appropriate
translators was challengingEven when translation services are available, translators
can fail to understand and translate accurately hence adversely affecting the
quality of services provided to women experiencing IPV and impacting the
quality of care HCPs can provide to women impacted by IPV (Lipsky et al. 2006;
Setia et al. 2011).
Unawareness
of forensic services.
Another important aspect that was revealed
in this study was the lack of awareness of the forensic team at SMH, especially
from ER nurses, RCMP, and other community members. While the forensic team is
located in the ER,many staffare unaware of the type of services provided by the
forensics team and the services they are able to provide to women affected by
IPV. Research has indicated that many women impacted by IPV do present
themselves in the ER,thus this lack of awareness acts as a significant barrier
to effective and timely care(Lipsky et al. 2006; Sormanti & Shibusawa,
2008). The findings revealed
that thislack of awareness about available forensic services at SMH is also a considerable barrier to
care for women. The findings not only indicated the lack of awareness about services
but also lack of knowledge about caring for racialized immigrant populations as
shared by HCP participants one, three and four respectively. While providing
services to women experiencing IPV, awarenessabout racialized immigrant
populations is of great importance. Awareness about racialized immigrant
populations would enable health professionals to offer tailored services to
women experiencing IPV. The findings suggested that knowledge about racialized
immigrant populationswould empower nurses to be more confident when interacting
with racialized immigrant women impacted by IPV whichmay facilitate better care
for women experiencing IPV by creating the relational space for effective care
and safety planning.
Cultural
context.
The findings also indicated that
women’s cultural context is relevant for how women seek care and the degree to
which women may engage in discussions that disclose violence; however, HCPs
need to be critical of tendency to locate violence within “culture” or align
with ethnicity to explain women’s help seeking behaviours decisions to seek
care. Creating safe spaces, contexts and relationship is far more important for
providing care for women than HCPs efforts to better know “culture” as it
relates to women’s needs.The findings of this study concur with those of Boursnell
& Prosser(2010) amdEfe & Taskin, (2012)who emphasize that ER nurses must have knowledge
about barriers for care affecting women impacted by IPV; barriers to care that
are relational and structural need to be tackled for the creation of safe
relationships as the basis for IPV care in the ED.
Wait
times, privacy and confidentiality and HCPs bias.
The study further revealed a number
of other barriers such as long waiting times in the ER, lack of privacy and
confidentiality, and biases by HCPs. It was evident thatERs may have long
waiting times which, in turn, can make things worse and difficult for women
experiencing IPV, especially for women living with trauma and violence and who
lack supportive spaces and relationships while seeking care[BH10] . The study revealed that IPV cases may make individuals [BH11] impatient
when waiting in the queue to see
a doctor unlike other forms of illnesses. The findings indicate that most of
the women experiencing IPV that seek help at the ED are at times just in need
of someone to talk to. This expectation is at times hard to meet since
emergency cases are always given priority in theED. The findings indicated that
waiting times can be reduced by assigning specific HCPs the role of attending
to women impacted by IPV in a given healthcare centre. Nevertheless, Al-Natour et al. (2014)
argued that HCPs lack time to attend to women experiencing IPV. This acts as a
barrier towards responding to women experiencing IPV. [BH12]
The lack of privacy and
confidentiality was also descrived by HCPs[BH13] are impacting how and
when women who have experienced IPV seek care.
Right now, forensic nurses are on-call at SMH. However, if there is twenty-four
hourscoverage, waiting times for these women could decrease., Cherniak et al. (2005)affirmed
that women who lack necessary privacy may feel uncomfortable and unsafe to
disclose IPV.
The study further revealed that women
experiencing IPV are at times met with bias from HCPs. It was evident that
women are likely to experience discrimination when seeking help from HCPs. As
such, women are not likely to receive care related with IPV and may as well fail
to receive suitable referrals. Similarly, personal biases among HCPs towards
women experiencing IPV were also reported by Cherniak et al. (2005), DeBoer et
al. (2013), and Leppakoski et al. (2010).
The findings of the study revealed
that offering support to children and young adults accompanying women seeking
assistance following IPV constitute a challengeto quality services. The delivery of quality services in
the presence of children to the patient demands for extra resources for keeping
them busy as they wait for their mothers. As a result, EDs often seek help from S.M.A.R.T workers to keep the
children busy during consultations. The findings revealed that the main
challenge is when the child is unwilling to let go of the mother and the ER
nurse has no option than to offer services in the child’s presence. Moreover,
the findings indicated that theER is not that well equipped to accommodate
children. Such an environment brings forth privacy concerns, especially if the
child is old enough to discern what is going on. HCPs[BH15]
views on the challenges faced by racialized women.
The
findings emphasized HCPs view that racialized immigrant women are the least
likely to visit ER for IPV; the participants identified several factors such as
language barriers and the lack of awarenessof the ER is a point of care. HCPs
also described their views that racialized immigrant women often face resistance
from their family members in seeking medical care, citing “culture” as a
potential barrier to care. For example,HCPs
pointed to how racialized immigrant women are often are often accompanied by family
members probably to ensure non-disclosure of IPV. Spencer et al. (2014) found
that women experiencing IPV may seek assistance from family members only to be
discouraged not to disclose IPV[BH16] . While the HCPs
perspectives reflect their experiences, the analysis undertaken in this study
was based on a more critical notion of culture to shifts attention to the
culture of ED care that manifests in structural and interpersonal barriers –
such as bias – to IPV care for all women.
While on the recurrence of IPV
among racialized immigrant women indicated that women are less likely to seek
help due to the lack of awareness of their rights and their inability to open up
to HCPs, the findings here turn attention to health care culture – and the ED
environment for barriers to care for women that impact help-seeking and disclosure[BH17] . WhileSpencer et al.
(2014) confirmed that racialized women experiencing IPV are likely not to be
aware of where to seek assistance on IPV related care, the findings of this
study counter this individualizing orientation to ‘help seeking’. More often
than not, lack of awareness is not an individual’s problem or shortcoming, but
a complex interplay of structural and interpersonal factors that impact HCP
practice. In this study, not accessing or seeking out available services was
primarily understood by HCPs as related to language barriers and the lack of
trust and rapport with HCPs based on their societal norms and past history.
Cherniak et al. (2005) confirmed that language acts as a significant barrier
towards disclosing IPV related experiences.In addition, and importantly, racialized immigrant women also face challenges
of trusting ER nurses. The needs of IPV patientsvary from one patient to the next.
For instance, the study also revealed that racialized immigrant women
may also prefer female HCPs who are not of their ethnic background and the possible language barriers only
end up limiting the amount of disclosure as mentioned by participants four and
five (Hyman et al. 2009; Lipsky et al. 2006; Setia et al. 2011).
Recommendations
Practice.
Having strong and competent
translators and supporting them in their roles is important when communicating
with women experiencing IPV, especially for racialized immigrant women who
disproportionately face barriers to care.Additionally, having translators
available that speak a wide array of languages is critical to meet the needs
ofnew immigrant arrive in BC. There should also be a creation of a private area
for women impacted by IPV who come to ER for treatment. This has the potential of
benefiting these women and help increase privacy and discretion. The provision
of forensic nursing services in the ER is not only essential but vital for
comprehensive care. It is thus important to meet the medical and legal needs of
women impacted by IPV as well as ensure they receive compassionate and quality
care.
Anti-discrimination
training and more critical orientations to the culture of health care as it
impacts racialized immigrant womenare necessary to address biases, along with the
capacity to analyze the structural barriers to accessing IPV care for all women
in the ED. Hiring nurses who speak multiple languages or hiring of translators
may adequately solve issues involving language barriers. In addition, there
should be efforts to inform health care professionals who are likely to come
into contact with women experiencing IPV concerning the services offered in the
ER department. This would ensure that health care professionals are able to
offer the much-needed support and resources to women impacted by IPV in a
timely manner. Furthermore, the presence of adequately trained forensic nurses
to handle these cases will greatly help women impacted by IPV. Moreover, any ED
ought to have space or resources to accommodate children while their mothers seek
care in the ED.
Policy and education.
HCPs need to be properly trained
and educated about resources and services available for women impacted by IPV.
Furthermore, it is pertinent to have resources that are specifically tailored
to serve racialized immigrant women. The
resources should take account of how structural and institutional racism acts
ate barriers to seeking help and care within the context of IPV. In addition, te importance of non-judgemental
and compassionate care to all women impacted by IPV is critical, with
knowledge of how discrimination and bias affects access to and quality of IPV
care.
The results indicated that ER
nurses and HCPs were unaware of the type of services forensics nurses provide
and RCMP and women themselves were unaware that they can come to ER for
support. As such, there needs to be more education, awareness, and support such
as doing online courses, in-services, and reaching out to the RCMP and ER HCPs. Education
and raising awareness may help sensitize that ER is a critical point of care
for women experiencingIPV.There is need to educate the nurses about available
resources that can be used to offer services to racialized immigrant women
experiencing IPV.
IPV related care requires specialized skills
on how to meet the needs of racialized
women and as such, training nurses will offer more effective and informed care to their patients.Some of the specialized skills that the
nurses can acquire includethe capability to identify inconsistencies with
stories that may not match injuries such as those related to IPV[BH18] [BH19] . [BH20]
Further research.
The
HCPs emphasized the significance of offering women experiencing IPV with
relevant resources. Nevertheless, HCPs indicated that there is lack of
resources and inability to access information within the ER setting. Therefore,
it would be important for future researchers to consider how accessibility of
information among HCPs can be improved. Specifically, they need to focus on how
resources for racialized women within the ER setting can be enhanced, and one
way of achieving, among others, that could be by educating HCPsEvidence
informed practices through research could improve the quality of services
offered to racialized immigrant women experiencing IPV.
Limitations.
The sample size of the
study was small and consisted of mostly forensic nurses, one ER nurse, and one
social worker and no ER physicians. The smaller sample size was a limitationwhen attempting to make
inferences and generalization of the findings[BH21] . Additionally, the small sample size was a limitationwith
regard the breadth, depth, and variability of the data; As a novice researcher, the researcher
may have held strong assumptions [BH22] about the topic under study (violence is cultural)
based on the ethnicity. Additionally, the research questions did not allow for deeper
probing, so the analysis lacked more critical breadth and depth. [BH23]
In addition, the researcher is of South Asian and Canadian descent and
may have unknowingly influenced results. The researcher might made efforts to consider their own thoughts
(reflexivity) when undertaking the study but the degree of influence likely was
still operating, as evidence by the continual need to have assumptions
challenged by the supervisory committee. . As such, the researcher may have
unknowingly influenced the results of the interviews. This could have
influenced the credibility of research outcomes. [BH24]
Summary
Chapter
five presented a discussion of findings in relation to the perspectives as well
as experiences of health care providers when caring for women experiencing IPV.
The chapter also presented recommendations and limitations of the study. The
discussion of the findings revealed that HCPs experience barriers including the
lack of translation services, the lack of support, and inconsistent services
for women. The perspectives and views of HCPs were shown to shape IPV care for
women in the ED. The discussion revealed that HCPs lack adequate resources to
attend to these women. Additionally, HCPs emerged to be unaware about available
resources in the ER department especially pertaining to forensic services.
Language was also identified as a key challenged faced by HCPs when offering
health care services to these women. Offering support to children and young
adults accompanying women seeking assistance following IPV was also revealed to
be a key challenge to quality services.
[BH1]There ought not to be a reference here, this is about your study so
remove these and use later when you discuss the findings in relation to what
these studies show.
[BH2]Any others you can add here?
[BH3]Good!
[BH4]? sufficient how?
[BH5]Is this your study or others?
[BH6]New topic, new para
[BH7]Reference this claim!
[BH8]Can you show what this adds, looking back at the studies you cite in
the lit review?
[BH9]You don’t need this detail here
[BH10]Can you cite similar studies to emphasize this importance?
[BH11]?? make who impatient, HCPs?
[BH12]This para is not clear, please edit for clarity
[BH13]You didn’t interview women so you can write this as if they said
these things, it is all through the lens of the HCPs so do check for that
throughout.
[BH14]I see you are only discussing some of your findings here. At the
start of the chapter, state how you are drawing from your findings to structure
this discussion so your reader can follow your logic about what you are
discussing; for example, there is no mention of motivation to provide care yet
that was a subtheme; provide your discussion rationale so its clear, otherwise
the reader wonders about the findings not discussed.
[BH15]And how does any of this related to literature? Is there any? If not
say this is under investigated area that needs more research!
[BH16]How is this study relevant for your findings about racialized women?
[BH17]Good!
[BH18]This is not in your data – say how it is about safe spaces so woman
feel safe to seek care!
[BH19]It was not said that nurses should police consistency in stories and
injuries, but create safety for disclosure, but so much more.
[BH20]You have already said this several times – it cannot be the sole
answer
[BH21]This is not a limitation, qualitative findings are never intended
to be generalizable.
It is reasonable to say the small
sample limited depth of the data only.
[BH22]This is not about being novice, it is about being an ER nurse; and
living in the world as a immigrant women potentially? Lived experience creates
assumptions, and so becoming critically conscious was challenging; unpacking
violence is cultural was your biggest challenge
[BH23]This is not accurate, your RQs did but your lack of experience with
research may have limited the depth reached.
[BH24]This is not accurate – its about knowingly becoming aware and you
are a novice at that, so say that!
