EMPIRICAL STUDIES
doi: 10.1111/scs.12521
Impact of an educational intervention for district nurses about preparedness to encounter women exposed to intimate partner violence € rnkvist RN, PhD (Associate Professor)1,2, Per Wa €ndell MD, PhD (ProEva Sundborg RN, PhD1,2 , Lena To 1,2 1,2 fessor) and Nouha Saleh-Stattin RN, MPH, PhD 1
Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm County, Huddinge, Sweden and 2Division of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
Scand J Caring Sci; 2017 Impact of an educational intervention for district nurses about preparedness to encounter women exposed intimate partner violence
Aim: To evaluate the impact of an educational intervention on the preparedness of district nurses at primary healthcare centres to encounter women exposed to intimate partner violence. Methodological design: An observational quasi-experimental study. Participants were divided into an intervention group (n = 117) and a control group (n = 204), both from the eastern part of Sweden. A group of nurses from across Sweden (the ‘national group,’ n = 217) was also recruited. The Violence Against Women Health Care Provider Survey was used pre- and 1 year postintervention to measure the intervention’s impact. This survey, which measured preparedness, included eight factors: practitioner preparedness, self-confidence, lack of control, comfort following
Introduction Intimate partner violence (IPV) is a public health problem that spans all countries and classes (1). In Sweden, 46% of women have experienced serious physical, psychological or sexual abuse at some point during their lives (2). The United Nations has defined IPV as physical or sexual abuse, emotionally abusive behaviour, financial control, isolation and threats of these kinds of actions (3). Women who have been exposed to IPV are encountered at every level of the healthcare system, from primary to geriatric care (4, 5). District nurses in Sweden Correspondence to: Eva Sundborg, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm County, Alfred Nobels all e 12, 141 83 Huddinge, Sweden. E-mail:
[email protected] © 2017 Nordic College of Caring Science
disclosure, professional support, practice pressures, abuse inquiry and consequences of asking. ANOVA, the paired Wilcoxon test, the Mann–Whitney U test and the Kruskal– Wallis test were used to analyse the data. Findings: Pre-intervention preparedness was equal in all three groups. In the intervention group, preparedness related to the factor practitioner lack of control increased (p = 0.003), but a comparison of change between the intervention and control groups showed no significant intervention effect (p = 0.069). Conclusions: The results indicate that the intervention had a low impact on district nurses’ preparedness. The educational intervention must be adjusted; a main focus of changes should be the addition of continuing postintervention supervision and support. Keywords: district nurse, intimate partner violence, preparedness, education, encounter, nursing care. Submitted 15 July 2017, Accepted 15 August 2017
encounter women of all ages in their clinical work, which is carried out at primary healthcare centres, primary child healthcare centres, schools and homes (home nursing care). This gives district nurses a unique opportunity to identify women exposed to IPV and make a difference in their lives by promoting good health and alleviating suffering – the main purposes of nursing (1, 6). One of the district nurse’s many professional responsibilities is identifying women exposed to IPV (7). IPV is also known as a risk factor for child maltreatment (8). The results of a study performed in Finland (9) indicated that training might have increased public health nurses’ knowledge to intervene in child maltreatment (9). When they encounter someone exposed to IPV who lives with underage children, district nurses and other healthcare personnel in Sweden are required to report the situation to the social services (7). District nurses’ preparedness to encounter women exposed to IPV is connected to their ability to identify 1
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these women (10). According to the theory of reasoned action, attitudes and subjective norms determine a person’s intended behaviour (11). For nurses to be prepared to encounter women exposed to IPV in a professional way, they therefore need to understand the nature of violent relationships, why women stay in abusive situations (12) and the social and psychological ramifications of these situations (13, 14). Preparedness also entails a general, subjective feeling of being ready to ask about IPV and respond to the answer (15), confidence in one’s ability to address the issue, comfort when discussing IPV with colleagues, and being prepared to routinely bring up the topic (16). It includes being able to have open dialogues about IPV and establish positive and trusting relationships that give women the sense that they are heard and understood (17, 18). Nurses also need to have enough support from their managers and colleagues to deal effectively with IPV (16). Preparedness can be hampered by a number of factors. For instance, without the support and encouragement of those responsible at the workplace, many important details, like what to do if a women discloses IPV, may be left out of the healthcare routine (19). Additionally, some nurses may believe that IPV is a private matter and that bringing up the issue could make things worse for the women who have been exposed (13, 14). Practice pressures can also hamper preparedness. These pressures, which can originate both at the individual and workplace levels (17), include a lack of routines, time and resources for asking women about IPV and intervening (16). Finally, nurses may worry that asking about IPV could affect their relationship with the woman or her family. They may also worry about legal issues and even their own safety (16). Far from all nurses are prepared to encounter women exposed to IPV (10). Measures are therefore needed to prepare nurses for these encounters, not least nurses working in primary health care (10). In an earlier study by ‘Blinded for Anonymity’ (19), district nurses described a process of hesitation with regard to asking women about IPV. The process was characterised by nurses’ feelings of ambivalence about whether or not to ask. District nurses continued to hesitate until they had gone through the process of hesitation and felt prepared to ask women if they had been exposed to IPV. The study identified several barriers and facilitators that impacted progress through the hesitation process, and one facilitator was education about IPV (19). Research has shown that education is an effective way to develop nurses’ skills and knowledge about IPV screening and intervention (6, 20–25). Such education helps nurses understand the dynamics of IPV, the importance of intervening and how to intervene and support women exposed to IPV by providing good nursing care (26, 27). Throughout the world, numerous educational
interventions have been designed to improve nurses’ knowledge of IPV (28–31). However, it is difficult to compare these interventions and evaluate their impact. They have covered different aspects of IPV, measured a variety of outcomes, taken place in a variety of settings (from primary to accident and emergency care), been of different lengths, and included different professions (16, 18, 32–37). Only a few studies have evaluated interventions that included nurses working in primary health care. One such study investigated the results of a 35-minute educational video on child, elder, sexual and domestic violence (38). The video improved the short-term knowledge and attitudes of physicians and ‘others,’ a group that included both nurses and other health professionals. Another study (6) evaluated a theoreticallybased, three-and-a-half hour in-service programme about IPV for public health nurses. The programme was created on the basis of interviews investigating nurses’ perceived needs. It provided information about preventive community resources and training in nursing communication skills. The researchers found no significant difference in the level of knowledge but a significant improvement in skill level. Both of these previous studies measured change via a pre- and poststudy questionnaire. In Sweden, there is a National Centre for Knowledge on Men’s Violence Against Women at Uppsala University. This centre attempted to map out educational interventions in Sweden’s healthcare system but could not because documentation was often missing. However, they did find that the extent and educational content of courses about IPV in universities varies widely (15). Because so little information was available on previous interventions, and because of the crucial importance of preparedness, we designed such an intervention for district nurses in Sweden.
Aim The aim of this study was to evaluate the impact of the educational intervention on the preparedness of district nurses at primary healthcare centres to encounter women exposed to IPV.
Method Design and setting This observational quasi-experimental study included an intervention group, a control group and a ‘national group’ of district nurses. The intervention group consisted of district nurses working at primary healthcare centres in Stockholm County. The control group was made up of district nurses working at primary heathcare centres in © 2017 Nordic College of Caring Science
An educational intervention about IPV nearby S€ odermanland County, and the national group included district nurses from across Sweden. The national group was recruited to obtain information about preparedness among district nurses across the nation that could then be compared with information on preparedness in the other two groups (Fig. 1). All three groups completed Swedish version of The Violence Against Women Health Care Provider Survey before the intervention (39). The intervention group completed the same survey 1 year after the educational intervention, and the control group, 1 year after the pre-intervention survey. The national group did not repeat the survey after the intervention.
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County Council’s purchaser–provider area were invited to participate in the control group. The S€ odermanland County Council area was chosen because the county council had no plans to offer nurses education about IPV before the postintervention survey, whereas the Stockholm County Council planned to offer such education. National group. The Swedish District Nurses’ association has members from across Sweden, including both urban and rural areas. We asked the association to randomly select 200 nurses and send us the list of names and contact information. This national group consisted of 217 of the 4000 members of the Association.
Participants A total of 110 district nurses were needed in each group to achieve a power of 95%. Intervention group. We estimated that the number of district nurses at 15 of the 202 primary healthcare centres in the Stockholm County Council’s purchaser–provider area was sufficient to achieve 95% power. The 15 primary healthcare centres were selected by drawing lots. All district nurses (n = 117) working at the 15 centres were invited to participate in the intervention group. Control group. All district nurses (n = 204) working at the 22 primary healthcare centres in the S€ odermanland
The educational intervention The educational intervention was developed by the first author (ES) in dialogue with the research team and on the basis of the large knowledge gap identified in an earlier study of knowledge about IPV in district nurses in Stockholm (10, 19). Recommendations from previous research regarding the length and basic content of educational interventions about IPV were also followed. A professional pedagogue working at Karolinska Universitetet reviewed the intervention and did not suggest any changes. See Table 1 for a description of the content of the final educational intervention, which consisted of PowerPoint lectures and group discussions. The
Pre-intervenon selecon of parcipants from health care centres in Stockholm1, Södermanland2 and across Sweden3
Parcipang district nurses1, n = 117 of whom 15 were educators
Parcipang district nurses2 n = 204
Pre-intervenon survey
Educaonal intervenon Figure 1 Flow chart of the observational quasiexperimental study. Health care centres where the district nurses worked. 1From Stockholm county (n = 15). 2From Sodermanland County (n = 22). 3From across Sweden (n = 4000; recruited from the Swedish District Nurses’ Association). © 2017 Nordic College of Caring Science
Post-intervenon survey (aer one year)
Parcipang district nurses3 n = 217
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intervention used cascade teaching methodology (40), a method in which an educator teaches a number of people who in turn teach many others. In the first step, 15 district nurses – one from each participating primary healthcare centre in the intervention group – were educated by the study leader. The nurses who participated in this first educational step were chosen by mutual agreement among the nurses at each centre; that is, the nurses discussed and decided which of them should be educated by the study leader. The study leader and 15 initial students met once a week for 2 weeks in groups of five. Each session lasted 3 hours. The sessions were designed to promote interactive learning and included discussions and reflections about the content of that session. Between the two sessions, the district nurses were required to practice what they had learned by asking one woman if she had experienced IPV. The study leader gave the 15 participants written study material and brochures containing information about IPV, its health consequences and available help. Additionally, she provided them with a manual that clarified the outcome of every part of the intervention that they would teach. She also shared ideas about how to clarify the topic of each part of the intervention to students and how to help the students reflect about what they were learning. In a second step, the 15 district nurses returned to their workplaces, where they gave the same educational intervention they had participated in to their co-workers (i.e. those district nurses at the centre who had volunteered to participate in the study). The 15 teachers used the same study material that the study leader had used. During the intervention, the district nurses who participated in the first step were supported by the study leader. They also received e-mails from the study leader with news about IPV and supportive information four times during the intervention. All participating nurses were invited to participate in network meetings for district nurses working in primary health care in Stockholm County who were interested in the topic of IPV. The overall aim of the educational intervention was to adequately prepare the participants to encounter women exposed to IPV so they could identify women exposed to IPV and provide them with nursing care. After completing the intervention, the participants were expected to have achieved the following learning outcomes: • Understand the nature of IPV. • Understand how the violence affects the life world of women exposed to IPV. • Relate to their own and other people’s feelings about IPV. • Develop a professional attitude with regard to encountering women exposed to IPV in a way that benefits the women. • Identify symptoms and signs of IPV. • Identify exposed women (know how to ask them about IPV).
Table 1 The structure and content of the educational intervention Content of the educational intervention Understanding the nature of intimate partner violence (IPV) What is IPV really about? Definitions Historical background and legislation How can IPV be explained? Escalation of violence Normalisation process Why does she leave? Vulnerable persons Single women Older Women Women with disabilities (physical and psychiatric) Women who are addicted to drugs Women with a migrant background Honour-related violence People in homosexual relationships Teenage girls Consequences of IPV Economic consequences for society The impact of IPV on exposed women’s lives Consequences for women’s health Consequences for children’s health Before the encounter Encountering women exposed to IPV – how does it affect me Professional attitude Obligations of healthcare professionals Responsibilities of A professional encounter district nurses To identify women exposed to IPV How to ask? What if the woman does not disclose? What if the woman discloses? How to intervene Documentation Referral and collaboration Prevention Confidentiality Mandatory reporting Plan for intervention Structure of the educational intervention Two half-day training sessions (3 hours each) Written educational material Manual for educators Support to educators Network meetings offered
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An educational intervention about IPV
• •
Know how to intervene and provide nursing care, cooperate with other authorities and ask for professional support regarding women exposed to IPV and their children. Be able to independently contact the socials services and to initiate and lead the process of developing a local action plan at their workplace.
The survey The psychometrically tested Swedish version (41) of the The Violence Against Women Health Care Provider Survey was used to evaluate the educational intervention. The original English version of the survey was developed by F. Dickson and L.M. Tutty (16). The survey contains instructions to the participants followed by a description of a scenario regarding a patient. The participants were to respond to the 43 items in the survey on the basis of their own experience or of how they would act in the scenario. The items covered eight factors. The first is preparedness (eight items), which entails a general subjective feeling of being prepared to encounter women exposed to IPV – a feeling of being ready to ask about IPV and to respond to the woman’s answer. The second, self-confidence (seven items), entails feeling confident and comfortable with one’s ability to address the issue of IPV, including discussing IPV with colleagues, asking women about IPV and responding to their answers. The third is practitioner lack of control (seven items), which refers to the belief that IPV is a private matter with which nurses should not interfere and that bringing up the issue may make things worse for the women who have been exposed to IPV. Comfort following disclosure (two items) is the fourth factor. It refers to the ability to listen to a woman’s story and to know how to intervene after disclosure. The fifth factor, professional support (four items), refers to having enough support from one’s colleagues to deal effectively with IPV. Such support includes help from colleagues and professional supervision when needed. The sixth factor, practice pressures (five items), has to do with a lack of routines, time and resources for asking women about IPV and intervening. Abuse inquiry (seven items), is the seventh factor. It means that nurses routinely bring up the topic of IPV, know how to ask about it, are aware that it is important for them to identify women who have been exposed to IPV and are aware that it is important for them to intervene in the situation. The eighth and final factor, practitioner consequences of asking (three items), refers to whether nurses worry that their own safety may be affected if they bring up the issue of IPV. Possible responses were ‘strongly agree,’ ‘agree,’ ‘disagree’ or ‘strongly disagree.’ The survey also included 15 questions about demographic factors, education and training. The items are presented in Table 2. The responses alternatives to each question were coded from 1 to 4 such that 1 indicated the least positive and 4 the most positive response. The lower the response, the © 2017 Nordic College of Caring Science
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less prepared the district nurse felt, and the higher the score, the more prepared the district nurse felt.
Data analysis The statistical analyses were performed with STATA version 11.0. The analyses compared the pre- and postintervention outcome assessments within and between the intervention group and the control group. To avoid problems of mass significance, p values of ≤0.01 were considered statistically significantly different educational outcomes, and both parametric and nonparametric tests were performed. Results were only considered significant if the result of both tests was significant, even if the differences were marginal. Differences between all three groups at baseline were tested by ANOVA and Kruskal–Wallis test. Differences in the mean rank between pre- and postintervention assessments within the groups were tested by Student’s paired t-test and paired Wilcoxon’s test, and between the groups by Student’s t-test and Mann–Whitney’s U test. The results are presented as means or mean ranks with standard deviation or 95% confidence intervals instead of medians, as differences between parametrical and nonparametrical test were marginal.
Ethical considerations The study was conducted in full accordance with the Declaration of Helsinki (42). Ethical approval for this study was obtained from the Ethical Committee of Stockholm (2010/560-32). The managers at the primary healthcare centres in the intervention and control groups were informed about the study, as were the district nurses in the Swedish District Nurses’ Association. Participants received a written form explaining that participation was voluntary, that they would be anonymous and that confidentiality was guaranteed. The nurses were included only if they consented to participate. Written consent was not required, and returning a completed survey was taken to imply consent. Coded surveys were used in both the pre- and postintervention assessments. Participation in a study investigating an issue as serious as IPV may have a negative impact on participants. They may be reminded of personal memories and/or encounters with women exposed to IPV, and these memories may cause negative feelings. Participants were given the telephone number of a counsellor they could contact if this happened.
Findings Response rates and demographic characteristics Pre- and postintervention response rates and demographic characteristics are shown in Table 3. Most of the district nurses in all three groups were between the ages
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Table 2 Factors and items on the violence against women health care provider survey Preparedness 1. I would like to talk about the issue of abuse but don’t know what to say 2. I would be hesitant to ask about women abuse because I have little or no experience in dealing with this situation 3. I feel prepared asking about abuse of women who appear to me to be at risk of having been or being abused 4. I feel prepared asking about abuse of women who do not appear to me to be at risk of having been or being abused 5. I feel ready to respond to a woman who says ‘no’ to my question about abuse 6. I feel ready to respond to a woman who says ‘yes’ to my question about abuse 7. I feel prepared sharing information on women abuse to clients who respond ‘no’ 8. I am hesitant to ask about women abuse because I have not been appropriately trained Self-confidence 1. I am confident with my ability to address the issue of woman abuse 2. I feel that I am able to support this woman while she gets the right help 3. I would feel confident if I were required to ask women about abuse 4. I feel that I am a competent helper whether or not the woman and her situation change at this time 5. I feel comfortable supporting the woman during the interview even though she may not be ready to deal with this problem in the same way I would want her to 6. I feel comfortable discussing these practice situations with colleagues to help them deal effectively with woman abuse 7. I feel comfortable helping this woman access resources to help deal with the abuse Practitioner lack of control 1. Since this is a private family matter, I should not interfere 2. There isn’t anything I can do unless she asks for help 3. I would not ask her about women abuse because I don’t think she is ready to tell me 4. I feel that I am not able to help women who are abused 5. I am reluctant to intervene in case I make matters worse 6. I would not offer any assistance since there is no effective treatment for woman abuse 7. I would give her written information about women abuse and/or available resources, but would not talk about her situation Comfort following disclosure 1. I feel I am able to listen to women’s stories as they disclose the abuse they have experienced 2. I am able to continue the discussion after a disclosure to assess the needs of the client Professional supports 1. I feel comfortable discussing these practice situations with colleagues to help me deal effectively with woman abuse 2. I have enough supports from colleagues, mentors, supervisors, etc. to help me feel comfortable in asking about woman abuse and in dealing with the responses 3. I participate with my practice colleagues in planning and evaluating methods to develop or improve program delivery regarding woman abuse 4. I have opportunities for consultations regarding how to deal with situations such as Carol’s Practice pressures 1. I may forget to ask her about woman abuse 2. I just don’t have time today to address this possible abuse issue 3. I am reluctant to ask about woman abuse because there are not sufficient community resources to provide assistance 4. I am hesitant to ask about woman abuse because I might have to call the Children’s Aid Society or the police 5. I feel frustrated because I don’t have the time to talk about abuse Abuse inquiry 1. I routinely initiate the topic of woman abuse 2. I would ask her directly if her husband has ever hit her 3. I won’t put her on the spot by initiating the topic of abuse 4. I am hesitant to ask about woman abuse in case the woman stops seeing me 5. I am hesitant to ask some clients about woman abuse because to them it is culturally acceptable 6. I would introduce woman abuse by stating that abuse frequently occurs and that often women are hesitant to talk about it 7. It is an expectation to inquire about woman abuse Practitioner consequences of asking 1. I worry about my own safety when inquiring about woman abuse 2. I think about possible legal consequences when asking about woman abuse 3. I am hesitant to ask about woman abuse because I also treat/deal with other family members
of 50 and 59. Most in the intervention group had worked as district nurses
