Gaining trust key to telling health-care provider about intimate partner violence

A recent study led by Ryerson University found that women who have experienced domestic violence stand a far greater chance of disclosing this information in an emergency department setting if they feel they can trust their health-care provider and have control over their decision to tell a nurse or physician.

"The emergency department is one place where abused woman often seek help," says Cristina Catallo, the study's lead author and a nursing professor at Ryerson's Daphne Cockwell School of Nursing. "However, health-care providers may not know how to best interact with women who have been abused." Catallo's research identified several common barriers that nurses and physicians may face including a lack of knowledge about domestic violence, a lack of time in their busy schedules to respond to violence issues, a fear of offending patients and a perception that identifying domestic violence is not a priority for emergency departments.

The researchers were interested in finding out what would encourage women to disclose to a health-care provider in the emergency department and to understand women's expectations from the health-care professionals who treat them. Catallo, along with her co-authors Susan Jack, Donna Ciliska and Harriet MacMillan from McMaster University in Hamilton, identified 19 women living in Ontario who reported domestic violence.

From May 2006 to December 2007, Catallo conducted up to four face-to-face interviews with each participant. The first interview was to establish a safe, trusting relationship for the interview, followed by subsequent meetings, lasting 60 to 90 minutes, where the researchers asked the women about their relationships and the types of abuse they experienced from their partners.

The researchers used a behaviour change theory to identify and map-out the steps that each woman takes from denial that she is in a violent relationship to disclosure of violence to an emergency health-care provider. The five steps identified and examined in this study were:

1. pre-contemplation (i.e. denial of the abusive relationship)
2. contemplation (i.e. recognizing the abuse)
3. preparation (i.e. planning ways to seek help)
4. action (i.e. going to the hospital emergency department and telling a nurse/physician)
5. maintenance (i.e. trying to maintain new changes such as leaving the abusive partner)

Although all of the women in the study did seek medical attention at least once during those 18 months, only a handful went through the five steps of the change theory to disclose the abuse to an emergency health-care provider. Other women were aware they were in an abusive relationship but were not ready to take action while others did not think that abuse was a problem in their relationships. Several women did go to the hospital to seek medical attention but did not tell the health-care provider they were being abused.

For those women who did disclose to a nurse or physician, they did so when the health-care provider was trustworthy and they felt safe, says Catallo. "The women from this study felt more comfortable disclosing to a health-care provider who was non-judgmental and who would protect their confidentiality. This was especially important for those women who sought emergency care multiple times before feeling ready to disclose. Having control over when to disclose violence was an important criterion for the women that we saw in this study," says Catallo.

In some cases, the decision to disclose was triggered by a significant event in these women's lives. "Sometimes the fear of death from the abuser, or potential injuries while pregnant became an important factor in women's decision to change their current situation," says Catallo. "These events were what we called 'turning points' that prompted abused women to take action."

Since the emergency department is one place where abused women often go for medical attention, there are a few factors that nurses and physicians can consider when helping women talk about their situation, says Catallo.

"If a health-care provider encounters a woman experiencing domestic violence, it is important that the health-care provider carries out an empathic and respectful assessment of the client. Health-care providers may misunderstand certain client behaviours, such as denial of abuse when asked, or some health-care providers can become frustrated when women seek acute care for abuse over multiple occasions. In these situations, it is crucial that the health-care provider offer a non-judgmental response. Women experiencing violence have to have power to make their own decisions—even if that means returning to an abusive partner."

The study, Identifying the Turning Point: Using the Transtheoretical Model of Change to Map Intimate Partner Violence Disclosure in Emergency Department Settings, has been published online in the journal ISRN Nursing.