Specialist domestic abuse training for emergency department clinical staff: A review of the literature

Abstract

Aim: Emergency departments are often the first point of contact for women suffering from domestic abuse and identifying how healthcare staff can support women is important to tackle missed opportunities for timely intervention. Method: A review of research studies was undertaken between 2012 and 2024 using electronic databases AMED, CINAHL Ultimate, MEDLINE, EB-SCO, and the RCNi. The search words "emergency department , ED, accident and emergency, A & E, domestic abuse, domestic violence, intimate partner violence, family violence, staff-training education, development, learning" were used and retrieved n=93, reduced n=18, and finally n=7. Findings: The findings identify a training and role-specific issue related to emergency department nursing, and the need to have a supportive environment for positive action to be taken on behalf of the victim and their families. Four themes were identified; "don't ask," "stereotyping," moral distress" and "systemic support." In 'don't ask' the thread of conscious incompetence ensures staff reluctance to talk to women in case it opens a 'can of worms.' Discussion: The difficulties experienced by emergency nurses were compounded by staff being unaware of their departments policy on dealing with domestic abuse. Contrary to WHO recommendations, the evidence identified domestic abuse screening in most emergency departments happens on an ad-hoc basis and is subject to the experience and confidence of the individual clinician. Conclusion: Training is required to myth bust the factors related to domestic abuse, yet training is not enough, there needs to be a shift in attitudes toward domestic abuse, and in an institutional context, staff should feel supported and empowered to respond to women appropriately.

Full text

16
Journal of Nursing Theory and Practice
1 Corresponding auther: East Lancashire Hospitals NHS Trust, Blackburn, UK.
Email Address: jessica.goldie@elht.nhs.uk. © 2025 The author(s). Published by University of Central Lanca-
shire Open Journals (Hosted and supported by Open Journal Systems).
This is an open access article under the CC-BY licence (https://creativecommons.org/licenses/by/4.0/).
https://doi.org/10.17030/uclan.jtnp.615
Accepted 15 October 2024; Published 14 April 2025
Abstract
Aim: Emergency departments are often the rst point of
contact for women su󰀨ering from domestic abuse and
identifying how healthcare sta󰀨 can support women is
important to tackle missed opportunities for timely in-
tervention. Method: A review of research studies was
undertaken between 2012 and 2024 using electronic
databases AMED, CINAHL Ultimate, MEDLINE, EB-
SCO, and the RCNi. The search words “emergency de-
partment, ED, accident and emergency, A & E, domes-
tic abuse, domestic violence, intimate partner violence,
family violence, sta󰀨- training education, development,
learning” were used and retrieved n=93, reduced n=18,
and nally n=7. Findings: The ndings identify a training
and role-specic issue related to emergency department
nursing, and the need to have a supportive environment
for positive action to be taken on behalf of the victim and
their families. Four themes were identied; “don’t ask,”
“stereotyping,” moral distress” and “systemic support.”
In ‘don’t ask’ the thread of conscious incompetence en-
sures sta󰀨 reluctance to talk to women in case it opens a
‘can of worms.’ Discussion: The di󰀩culties experienced
by emergency nurses were compounded by sta󰀨 being
unaware of their departments policy on dealing with do-
mestic abuse. Contrary to WHO recommendations, the
evidence identied domestic abuse screening in most
emergency departments happens on an ad-hoc basis
and is subject to the experience and condence of the
individual clinician. Conclusion: Training is required to
myth bust the factors related to domestic abuse, yet train-
ing is not enough, there needs to be a shift in attitudes
toward domestic abuse, and in an institutional context,
sta󰀨 should feel supported and empowered to respond
to women appropriately.
Introduction
The Royal College of Emergency Medicine (RCEM) iden-
tied up to 12% of emergency department attendances
in the United Kingdom (UK) were women su󰀨ering from
domestic abuse (Boyle et al., 2015). In Australia, wom-
en su󰀨ering domestic abuse (DA) present to emergency
departments (ED’s) three times more than other women
(Dawson et al., 2019) and ED’s are often the rst point
of contact with healthcare providers (Tarzia et al., 2020).
The impact of DA contributes to a variety of presenting
illnesses in ED’s such as mental illness, self-harm, drug
and alcohol abuse, depression, and overdoses (Boyle,
2015). Due to 30% of DA occurring during pregnancy,
there is also a strong correlation with termination of preg-
nancies, sexually transmitted disease, and other medi-
cally unexplained symptoms (Boyle, 2015). With up to
70% of all female murder victims in the UK having suf-
fered DA (NIA, 2022), the role of ED’s is vitally important
in helping women disclose it (Tarzia et al., 2020). Due to
the importance of ED’s in tackling the health outcomes of
DA, the RCEM recommend training sta󰀨 to ensure they
are willing to ask direct questions about DA, to believe
women when condentially disclosing DA, interact in a
non-judgemental and holistic way, undertake assess-
ment of their immediate safety and contact Police in the
relative safety of the ED (Boyle, 2015). Firstly, the De-
partment of Health (2017) resource entitled Responding
to domestic abuse denes DA as….
“Any incident or pattern of incidents of controlling, co-
ercive or threatening behaviour, violence, or abuse be-
tween those aged sixteen or over who are or have been,
intimate partners or family members regardless of gen-
der or sexuality. The abuse can encompass, but is not
limited to psychological, physical, sexual, nancial, emo-
tional…” (DH, 2017, p. 8).
NICE (2016) guidelines suggest DA includes psycho-
logical, physical, sexual, emotional, and nancial abuse,
as well as honour-based violence and female genital
mutilation (FGM). However, FGM is not addressed in
this paper due to specic NICE (2016) guidelines on this
journal homepage: https://pops.uclan.ac.uk/index.php/jtnp
JNTP Vol.1 No.1 (April 2025) 001001a615
Literature Review
Specialist domestic abuse training for emergency depart-
ment clinical sta󰀨: A review of the literature
Jess Goldie 1a , Paul Regan b
a East Lancashire Hospitals NHS Trust, Blackburn, UK; b Senior Lecturer in Adult Nursing, School of Nursing and Midwifery, University of Central
Lancashire.
Key Words: Domestic abuse; intimate partner violence; domestic violence; accident and emergency; ED
JNTP

17
issue. Whilst recognising some women prefer the term
“survivor,” which is a matter of ongoing discussion, those
who have experienced DA are referred to as victims, to
recognise the signicant ongoing impact and trauma of
DA when presenting to ED’s in crisis (DH, 2017).
Domestic abuse prevalence and societal
change
Domestic abuse costs the UK’s National Health Service
(NHS) approximately £1.75 billion per year (Home O󰀩ce,
2019) and is considered by the World Health Organisa-
tion (2021) to be a violation of women’s human rights. In
the report by Oliver et al. (2019), on behalf of the Home
O󰀩ce, estimate that in 2018, the scal impact of DA for
England and Wales was £66 billion, and in 2021 £74
billion (DAC, 2021). Domestic abuse is a major public
health concern, causing both acute and chronic health
issues and a󰀨ecting 1 in 3 women in the UK (Women’s
Aid, 2022). Domestic abuse is experienced in a majority
of cases by women perpetrated by men, and the O󰀩ce
of National Statistics (ONS) identied 1.7 million women
(6.9% of women) and 799,000 (3%) of men aged 16 to
74 years to be victims (ONS, 2022a). There has been
an increase of 7.7% from 2021 with 5%, or 2.4 million
adults, experiencing DA in the year ending March 2022
(ONS, 2022a). This is not to say that violence against
males is unimportant, but to recognise the dynamics of
female-on-male or male-on-female violence are di󰀨erent
(Hine et al., 2022). However, once the numbers are re-
viewed, a clear pattern emerges whereby not only are
women overwhelmingly the victims (77%) and males the
perpetrators (96%), but women also su󰀨er more severe
and more frequent incidences of DA, over longer periods,
with worse outcomes than male victims (Women’s Aid,
2022). Typically, women experience thirty-ve instances
of DA before seeking help (DH, 2017). Professional train-
ing should therefore be women-focused to specically
address the needs of the primary victim group (Hine et
al., 2022).
It is not possible to understand the dynamics of DA
without considering wider social context and the role of
women within society. Marital rape was not made illegal
in the UK until 1992 (Williamson, 2016) and as British
society changes, so do attitudes towards DA. This is
reected at a systemic level; for example, in the recog-
nition of ‘coercive control’ as a crime in 2017 (Brennan
& Myhill, 2022). Social movements such as the 2017’s
‘#MeToo’ sparked awareness around issues of sexual
politics, even inuencing educational policy for primary
schools (Maricourt & Burrell, 2022). At the same time,
the rise of the misogynist ‘incel’ movement, which refers
to the self-proclaimed involuntary celibacy movement
(Thorburn et al., 2023) and the proliferation of graphic
online pornography, combine to inuence negative views
about women as property (Sharpe & Meade, 2021). A
survey by Ipsos UK and King’s College London found
that over half of the younger generation’s surveyed be-
lieve that women’s equality had ‘gone too far,’ and that
29% avoided speaking about women’s rights for fear of
reprisal (Campbell et al., 2024). This highlights the com-
plexity and contradictions within wider British society, as
the pendulum of online opinion gains inuence (Tietjen &
Tirkkonen, 2023).
Domestic abuse response in Law and
healthcare
The World Health Organisation (2005; 2014) reinforced
DA as a priority indicator to optimise women’s health
and emphasised healthcare professional’s signicant
role in tackling DA. In response, the HM Government’s
(2009) aimed to develop new ways of tackling DA by im-
proving criminal justice response to DA, targets of 72%
successful prosecutions and supporting victims through
the Independent domestic violence advisors (IDVA),
multi-agency risk assessment conferences (MARAC),
and increased early detection of DA. The Department of
Health (2017) in Responding to domestic abuse suggest
health services take a leading role in recognising and re-
sponding to DA and referred to a raft of measures such
as having a designated safeguarding professional, se-
rious case reviews, Frazer and Gillick competences for
under sixteens and domestic violence protection orders.
The Domestic violence disclosure scheme (“Clare’s law”)
also gave people the right to ask Police about a partner’s
previous violent o󰀨ending so they could make informed
choices about the relationship.
More recently the Domestic Abuse Act (2021) in section
1 “domestic abuse” refers to behaviour that is abusive if it
consists of any of the following: physical or sexual abuse,
violent or threatening behaviour, controlling or coercive
behaviour, economic abuse, psychological, revenge
porn, emotional or other abuse. The Act (2021) states it
does not matter whether DA behaviour consisted of a sin-
gle incident or many. The Act (2021) includes economic
abuse and adverse e󰀨ect on an ability to; acquire, use,
or maintain money or other property, or obtain goods
or services and lastly, to protect against the impact of
emotional, controlling, or coercive and economic abuse.
The Act (2021) when it came into e󰀨ect was expected
to cost £247 to £300m per year once fully implement-
ed and have a DA commissioner with a set function and
power to improve local authorities provision (DAC, 2021).
The DA commissioner’s responsibility aimed to improve
the availability of safe and secure accommodation, cre-
ate a presumption of specic measures, and clarify cir-
cumstances for civil and family Courts in England and
Wales to ensure children do not remain silent victims of
DA (DAC, 2021). We now present the search strategy
and critically appraise the retrieved research studies to
identify key themes in supporting women DA victims (and
their families) attending ED.
JNTP Vol.1 No.1 (April 2025) 001001a615J. Goldie, P. Regan

18
Search strategy
The literature search used the ‘problem/ population,
intervention, comparison, outcome’ (PICO) method
(Schardt et al., 2007) to develop a research question.
From PICO, key terms were identied, and electronic
databases searched including AMED, CINAHL Ultimate,
MEDLINE, EBSCO and RCNi. The following key search
words were used with Boolean operators ‘and’ ‘or’ but
not limited to the “emergency department (ED) or ED or
accident and emergency or accident & emergency or A
& E and/ or domestic abuse or domestic violence or inti-
mate partner violence or family violence and sta󰀨 training
or sta󰀨 education or sta󰀨 development or sta󰀨 learning.”
Due to ongoing developments in understanding DA and
changing cultural attitudes, the search was limited to
documents from 2012 to 2024. This yielded n=93 studies
and included if they specically referenced DA in the ED,
nurses, and female victims, but excluded if the focus was
directed toward common comorbidities such as mental
health issues or substance abuse (see table 1 entitled:
Inclusion/ exclusion criteria and gure 1: entitled: PRIS-
MA ow diagram).
Table 1: Inclusion and exclusuion criteria
Inclusion/
Exclusion
Criteria Rationale
Papers from 2012
onwards
To reect changing attitudes and policies: DH
guidelines written in 2015 along with NHS
pocket guide to safeguarding.
Peer reviewed, full
text, and in English
To nd the highest quality evidence. The
extract is insu󰀩cient to conclude from. I can
only speak English!
References to
DA, ED, nurses,
females
To keep the number of papers managea-
ble and relevant. Many papers are from a
social work perspective- I want the nursing
perspective. ED o󰀨ers challenges do not
present in other clinical areas. Females are
the primary victim group
Comorbidities
Discussion of how ED sta󰀨 address DA vic-
tims with mental health issues is a separate
lit review.
UK & Ireland,
Western Europe,
Canada, Australasia
Demographically, culturally & systemically
comparable.
Secondary sources
& opinion pieces
Only primary sources are included as they
are highest in the hierarchy of evidence.
Opinion pieces are excluded on the same
basis.
IDVA related re-
search
This is an excellent but initially expensive
initiative. This proposal concerns training for
existing sta󰀨 during a period of unprecedent-
ed demand and underfunding.
Geographically, di󰀨ering demographics and cultural
understanding of DA was considered, in addition to the
structural accessibility of health care. The United States
(US) was therefore excluded, although it is like the UK
demographically, historically, and culturally, the health-
care system is not free at the point of use and there is
evidence to suggest this results in the exclusion of wom-
en most at risk of DA (Klap et al., 2007). Countries with
large conservative religious populations, or theocracies,
were also excluded. The search was limited to the UK,
Western Europe, Canada & Australasia, which reduced
the number to n=18, after being manually reviewed. Re-
search studies that focused exclusively on independent
domestic violence advisers (IVDA’s) were ruled out be-
cause this literature search is concerned with the training
of existing clinical sta󰀨 rather than the creation of recent-
ly developed specialist roles not routinely found in ED,
despite recommendations they should be (Mason et al.,
2020). Research studies were appraised using the criti-
cal appraisal skills programme (CASP, 2022), and given
a CASP score, although the score alone did not deter-
mine inclusion due to the relative paucity of evidence.
The remaining studies were assessed according to Ev-
ans (2002) hierarchy of evidence, and n=7 articles met
the criteria for inclusion in this review [Basu & Ratcli󰀨e,
2012; Dawson et al., 2019; Lundh et al., 2022; Ritchie
et al., 2013; Saberi et al., 2016; Spangaro et al., 2021;
Vonkeman et al., 2019]. (See table 2 entitled: Table of
ndings).
A mixed methods quality improvement report by Basu
and Ratcli󰀨e (2012) studied referrals to a new DA ser-
vice over a 12-month period, alongside informal inter-
views with healthcare professionals to establish sta󰀨
satisfaction. Whilst the quantitative results of this study
initially appear impressive (172 referrals in 12 months,
up from one the previous year before the intervention),
there was no analysis of whether these referrals were
appropriate, or whether they resulted in improved out-
comes for DA victims. Furthermore, whilst the study also
found high sta󰀨 approval for the new DA initiative, one
of the researchers was an ED doctor working alongside
those he interviewed, so it was possible that healthcare
professionals did not feel able to give an open response.
Dawson et al. (2019) and Lundh et al. (2022) both used
semi-structured conversations and focus groups, whilst
Lundh et al. (2022) used a semi-structured interview
technique. A semi-structured approach o󰀨ers a degree of
exibility, allowing the researcher to delve more deeply
into a response, or seek clarity (Williamson & Whittak-
er, 2020). Focus groups of healthcare professionals are
a convenient method of gathering multiple opinions in a
straightforward way, although feeling pressure to give the
‘correct’ answer rather than a most truthful one is an is-
sue (Williamson & Whittaker, 2020).
In Spangaro et al. (2021), the mixed methods feasi-
bility study was conducted over six months and across 3
ED’s using a quantitative survey of multiple-choice ques-
tions and focus groups. Again, the closed-question sur-
vey does not allow for depth but does grant anonymity,
whilst the focus group ndings may be subject to partic-
ipants feeling uncomfortable or pressured to give a cer-
tain answer. Each method in this instance, compliments
and o󰀨sets the limitations of the other, giving an overall
richer and more robust picture. A longitudinal quantitative
study by Ritchie et al. (2013) was completed over 9 years
and accessed a random selection of clinical records to
JNTP Vol.1 No.1 (April 2025) 001001a615J. Goldie, P. Regan

19
assess the extent to which new DA training and accom-
panying documentation had been implemented. The
study took steps to ensure that condentiality was main-
tained and gives a good picture of the way that change
is implemented over time. However, it is limited in that it
only considers one intervention in one ED. The quantita-
tive research study by Vonkeman et al. (2019) was quite
specic as it sought to assess not only what had hap-
pened in the past (through an anonymised health record
review), but also what current practice and healthcare
professionals were willing to do in the future (through a
multiple- choice survey of ED sta󰀨).
Key papers
Overall, a range of study designs were used within the
included literature. All the studies (except for Ritchie et
al., 2013) were subject to potential self-selection bias,
wherein the participants had taken part because they al-
ready had an interest, or something to say, about DA.
Furthermore, although not stated in any of the papers,
it is possible that in each case except for Ritchie et al.
(2013), there was an element of ‘convenience sampling,’
for example: researchers approached their nearest ED,
where they had existing relationships, to ask for co-op-
eration. This could have far-reaching consequences be-
cause when all participants are nurses and medical sta󰀨
within a professional network, there may be a desire to
give professionally acceptable answers rather than truth-
ful ones (Williams & Whittaker, 2020). Additionally, none
of the studies selected spoke to victims of DA, relying
instead on secondary sources to communicate the pa-
tient perspective, and none spoke to non-professional
clinical ED sta󰀨, such as health care assistants who pro-
vide much of the interpersonal care in ED’s, with valu-
able insights to o󰀨er (Clark & Thomson, 2015). Whilst
each paper has limitations as discussed, all of those us-
ing qualitative methods did so with a reexive approach,
acknowledging and taking clearly explained steps to be
transparent. We will now discuss four key themes identi-
ed from the n=7 research studies: don’t ask, stereotyp-
ing, moral distress, and systemic support.
Key themes
‘Don’t ask’
A thread of conscious- incompetence runs throughout
the literature. Clinical sta󰀨 reported their reluctance to
enquire about DA for fear that it would ‘open a can of
worms’ which they felt ill-prepared to deal with. Basu &
Ratcli󰀨e (2012) discussed the ‘apprehension’ that ED
sta󰀨 experience when they encounter DA situations. Ten
years later, Lundh et al. (2022) described the insu󰀩cien-
cy that emergency nurses felt in the face of DA situations.
Dawson et al. (2019) also found that most healthcare
professionals interviewed were not aware of any of their
Trust or department specic policies relating to DA, which
resulted in less supportive action for women presenting
in the ED. Saberi et al. (2017) found that nurses reported
inadequate knowledge as a major barrier to addressing
DA in the ED. In the survey by Spangaro et al. (2022),
nurses reported feeling only ‘somewhat’ or ‘slightly’ con-
dent when encountering situations of DA, and 67% of
JNTP Vol.1 No.1 (April 2025) 001001a615J. Goldie, P. Regan
Figure 1: PRISMA ow diagram

20
respondents requested further training. In contrast, med-
ical sta󰀨 reported feeling ‘somewhat’ or ‘fairly’ condent.
Vonkeman et al. (2019) found that, even though clinical
ED sta󰀨 considered addressing DA to be their responsi-
bility, there was a lack of training which resulted in sta󰀨
feeling uncomfortable and unprepared. Dawson et al.
(2019) found that there was a general awareness of the
prevalence of DA due to increased cultural recognition,
but this did not translate into practice, and when sta󰀨
were unaware of their Trust’s policy they had a diverse
range of views on the best way to screen for and address
victims of DA.
Stereotyping
Cultural barriers and lack of common language are dif-
cult to legislate for, but there are also common myths
surrounding what a victim of DA looks like, and these ste-
reotypes inuence who a nurse considers to be at risk.
Saberi et al. (2017) found that the decision to ask DA
screening questions in ED’s inuenced nurses’ percep-
tions of the patient’s demeanour. Vonkeman et al. (2019)
found that health professionals failed to consider DA in
women from higher socio-economic classes. Whilst there
are undeniable links between DA and poverty there are
other factors centred around power and control, which
is why DA is prevalent across all social strata (Women’s
JNTP Vol.1 No.1 (April 2025) 001001a615J. Goldie, P. Regan
Authors Methodology Sample Data collection
tool Main ndings Strengths
Basu and
Ratcli󰀨e
(2012)
Mixed methods.
Qualitative- i.e., numbers
of referrals to specialist
agencies
Quantitative- i.e, interviews
with sta󰀨. Case study.
Single site
ED Dept in NW
England, over 1
year. HCP’s
Ongoing discussion
with n=12 nursing
sta󰀨 & 10 medics,
over 12 months
Referrals to specialist DA services
increased from 1 to 127.
Nursing sta󰀨 felt more comfortable
around DA victim’s and more con-
dent in the process
Authors knowledgea-
ble of ED.
12-month timeframe.
Study authors spe-
cialise in emergency
medicine. No conict
of interest
Dawson et
al. (2019)
Qualitative, multi-site Interviews con-
ducted with HCP’s
across 2 large
metropolitan ED’s,
diverse demo-
graphic.
Semi-structured
interview & focus
groups. Lead by
impartial research
nurses from out of
area
HCPs expressed lack of condence/
knowledge. Training needed.
Role clarication, policies & pro-
cesses needed to back up sta󰀨.
“Pandora’s box/ can of worms.”
Clear aims well met.
Study well designed
with clear outcomes
Lundh et
al. (2022)
Qualitative, single site. Semi structured
interview of RNs
in one ED.
Interviews con-
ducted by trained
interviewer in a
private setting. 1
interviewer known to
participants
Common themes of frustration at
lack of knowledge, insu󰀩cient time,
focus on patient ow & ‘easier op-
tion’. Need to structural change
Not wanting to start something they
can’t deal with
Clear aims, address-
ing a clear gap in
research. Limitations
acknowledged
Ritchie et
al. (2013)
Quantitative, single site Longitudinal- 9
years
Random selection
of clinical records
assessed
Training alone has no impact on
quality of care for victims of DA,
accompanied by robust systems for
documentation & referral
Authors specialists in
eld.
Good to see the
impact of intervention
over time. Conden-
tiality maintained. No
conict of interests or
biases
Sabheri et
al. (2017)
Quantitative census survey,
single site
Cross sectional
survey of ED sta󰀨
from 1 hospital.
n=69 in total-
n=58 nurses,
n=11 medics
Multiple choice
anonymous survey
Majority of sta󰀨 support routine
screening in ED.
Training shown to overcome many
of the barrier’s sta󰀨 discussed.
Structural support at institution level
is needed to empower sta󰀨
Selective screening will miss people
at risk
Well considered, good
response. Authors are
specialists in eld of
DA and ED
Spanga-
ro et al.
(2021)
Mixed methods feasibility
study, qualitative & quan-
titative
Mixed HCP’s
across 3 EDs in
Australia
Surveys & focus
groups over a
6-month period
Sta󰀨 supportive of routine screen-
ing. Challenges are time, busyness,
lack of privacy, and high number of
women requiring screening
Clear statement of
aims strong study
design & e󰀨ort to
incorporate all sta󰀨
Vonke-
man et al.
(2019)
Quantitative Review of health
records & anon-
ymous clinician
multiple-choice
survey.
Single site
4-month window
for record review.
Surveys shared 3 x
over 6 months
Lack of condence, lack of training,
fear of o󰀨ense, no use of existing
documentation, eagerness for
training
Clear statement of
aims condentiality
Researchers are ap-
propriately qualied
Table 2: Table of ndings

21
Aid, 2022). A common misconception throughout the
research studies is that broaching the issue of DA with
women may cause o󰀨ence (Lundh et al., 2022; Saberi et
al., 2017; Vonkeman et al., 2019). On the contrary, the ev-
idence suggests women are supportive of DA screening
(Dawson et al., 2019) and that victims of DA believe that
healthcare professionals should have compulsory train-
ing (Basu & Ratcli󰀨e, 2012). Women identied health-
care providers as the most trustworthy professionals to
disclose DA to in the ED and were more likely to disclose
DA when directly asked (Vonkeman et al., 2019).
Moral distress
Pauly et al. (2012) dene moral distress in health care
“…with the ethical dimensions of practice and concerns
related to di󰀩culties navigating practice while upholding
professional values, responsibilities and duties…” (p.2).
In other words, it is the ethical anxiety that the nurse fac-
es when unable to deliver the care the patient needs,
within the connes of ED, and in this situation, caring be-
comes a burden. The consequence of moral distress is
signicant and can lead to a lack of empathy, and wom-
en reporting coldness and lack of compassion contrib-
ute negatively to seeking help in the future (Duchesne
et al., 2022). Although the studies reviewed here do not
specically identify ‘moral distress,’ Dawson et al. (2019),
Saberi et al. (2016) and Vonkeman et al. (2019) suggest-
ed healthcare professionals may recognise an interven-
tion is required but they were reluctant to screen for DA
due to a lack of condence. Lundh et al. (2022) identied
that nurses priorities may conict with a patient’s needs,
and the resources in ED’s, resulting in feelings of power-
lessness for both them and women su󰀨ering DA.
Systemic support
A contributing factor to the ‘moral distress’ theme dis-
cussed above is a lack of structured support for nurs-
es and other healthcare professionals assisting women
victims of DA. Duchesne et al. (2022) found one of the
negative experiences commonly encountered by DA
victims in receiving ED care is repeated questioning
from professionals who could not meet their needs fur-
ther, leading to feelings of hopelessness. Dawson et al.
(2019) identied a three-fold issue: identifying those at
risk, knowing there was a policy in place, and knowing
how to implement that policy. Healthcare professionals
reported having the skills to identify victims, but due to
poor referral systems, there were limited options avail-
able to them (Basu & Ratcli󰀨e, 2012). Vonkeman et al.
(2019) stressed that where policies and documentation
were in place, the absence of appropriate training and
education undermined such initiatives, whilst Ritchie et
al. (2013) found that sta󰀨 training had no impact on the
numbers of DA victims identied, unless accompanied by
robust procedures and documentation.
Identifying which healthcare professional should
screen for DA is an issue. The assessment of the im-
plementation of a new screening tool by Spangaro et al.
(2021) found that 87% of clinical sta󰀨 were in favour of
DA screening in ED’s. Saberi et al. (2017) found that 82%
of ED healthcare professionals surveyed believed that
screening for DA should be routine, whilst 83% stated
they had received little to no DA training. Vonkeman et al.
(2019) reported the same positive sta󰀨 attitude, accom-
panied by the same lack of condence- in this case, 81%
of sta󰀨 had received no training. Dawson et. al (2019)
also found that, although sta󰀨 requested training and role
clarication, ED healthcare professionals were consist-
ently committed to keeping women safe. Dawson et al.
(2019), Saberi et al. (2016), and Spangaro et al. (2021).
all found that both nurses and medical sta󰀨 viewed
screening and responding to DA as part of their role re-
sponsibility. Basu and Ratcli󰀨e (2012) found medical sta󰀨
were resistant to screening at the outset of a DA trial pro-
gramme, believing this job should fall to nurses, although
this attitude changed over time. There was some dispar-
ity between nurses and medical sta󰀨 when it came to
who should be screened, with nurses believing screening
should be targeted whilst medical sta󰀨 favoured a routine
enquiry tool (Saberi et al., 2017). Nurses also reported
fewer DA training opportunities and less condence than
medical sta󰀨 (Spangaro et al., 2021). At the same time,
nurses reported time constraints prevented DA screening
at more than triple the rate that medical sta󰀨 did (Vonke-
man et al., 2019).
The WHO (2013) recommend healthcare profession-
als ask about DA when assessing health conditions
caused by DA, such as termination of pregnancy or sex-
ually transmitted diseases, but the WHO does not ad-
vocate for universal screening. NICE guidelines (2016)
suggest training for all frontline clinical sta󰀨 at level 1 (re-
sponding to a disclosure) and level 2 (the skills required
in screening for DA) and identify people presenting with
indicators of DA. However, the indicators that NICE
(2016) suggest are broad and open to interpretation; who
is ‘at risk’ is therefore a decision made by the healthcare
practitioner who may have preconceived, cultural or ste-
reotypical ideas of victimhood and may fail to act (Saberi
et al., 2017).
Victims of DA do not necessarily present with obvious
deliberate injuries; exposure to DA has many long-term
physical and psychological health implications asso-
ciated with post-traumatic stress disorder, anxiety, and
suicidality (WHO, 2013). Therefore, it is not clear how
women could be identied as ‘at risk’ and in addition,
Warren-Gash et al. (2016) suggest use of universal
screening may remove the stigma of being asked if suf-
fering with DA. If applied to all women and deemed a
waste of time in most instances, the counter perspec-
tive is that time-pressured health and social care prac-
titioners might overlook screening altogether (Dawson
et al., 2019). Training should therefore pay attention to
dispelling the common myths that surround DA so that
healthcare professionals feel empowered to use both
JNTP Vol.1 No.1 (April 2025) 001001a615J. Goldie, P. Regan

22
their clinical judgement and experience alongside WHO
(2013), NICE guidelines (2016) and local Trust policy, to
determine who needs screening.
Discussion
NICE guidelines (2016) require NHS commissioners to
commission services in which frontline sta󰀨 are trained
to respond appropriately to disclosures of DA, and that
referral pathways and specialist services are accessible.
Although stated in the search strategy section, research
studies focusing solely on independent domestic vio-
lence advisors (IVDA’s) were excluded, but if they were
available in ED’s, then DA support could be improved.
Some IVDA’s are based in ED’s, develop timely referral
process, protect victims from violent partners or ex part-
ners, be proactive in developing safety plans and be the
primary contact (HM Government, 2009). The evidence
suggests IVDA’s in hospital’s work well and have devel-
oped a close working relationship with community IVDA
services, MARAC, and integrated referrals (Mason et al.,
2020). ED sta󰀨 highly value hospital based IVDA’s due
to the increased ED attendance of DA victims prior to
referral (Dheensa et al., 2020; Mason et al., 2020). One
suggestion is IVDA’s become permanent members of
hospital sta󰀨 and be based in ED’s (Mason et al., 2020).
NICE (2016) recommend routine enquiry about DA in
ED’s but it remains inconsistent (Dheensa et al., 2020).
Despite IVDA’s in hospitals being found to be highly ef-
fective and supportive of women, they are not universally
found in UK ED’s (Mason et al., 2020). A study by Baird
et al. (2019) highlighted that sta󰀨 continued to feel ill-
equipped to deal with DA, and they requested specialist
training, education, and tailored policy. Due to a lack of
consistent training and screening tools (Fang & Donlie,
2021), healthcare professionals in ED felt they were left
to assess DA related safeguarding concerns in an ad-hoc
manner (Duchesne et al., 2022). This ad hoc approach
resulted in missed opportunities for intervention, leading
to half of women murdered by an intimate partner within
24 months of their deaths after attending ED (Duchesne
et al., 2022). In Christensen et al. (2021), the literature
review focused on the experiences of ED nurses deal-
ing with DA and revealed the depth to which the nurses
themselves were a󰀨ected by the abuse they witnessed,
such as recurring themes of feeling grief, despair, and
hopelessness. This is a complex cultural landscape, and
it is important that ED training is woman-focused and
with specialist knowledge of DA.
The moral distress that healthcare practitioners have
experienced when caring for victims of DA should not be
underestimated, and the range of emotions experienced
by those providing care to victims of DA must be con-
sidered in the training. Healthcare practitioners describe
feelings of helplessness, sorrow, and grief, tied to think-
ing there is little they can do to help and worry about the
danger a women may be in following disclosure of DA
(Lundh et al., 2022). Their concern is not without foun-
dation because women are statistically at greatest risk
from their abuser when they seek help (WHO, 2013).
In her groundbreaking 1995 book ‘what makes women
sick’ Lesley Doyal discussed the ’learned helplessness’
common of DA victims, in which a sense of personal
worthlessness, combined with economic dependence,
often caused women to return to an abusive situation.
The evidence suggests this is still the case and so any
training programmes must include the reasons women
may return to an abusive relationship, emphasise shared
decision making and highlight the negative outcomes for
women who experience coldness, paternalism, or pity
when disclosing DA in the ED (Duchesne et al., 2022).
Dawson et al. (2019) found that female healthcare
practitioners were more likely to have higher awareness
and empathy of DA than their male counterparts, and that
abused women were more likely to disclose to female
sta󰀨. The systematic review by Duchesne et al. (2022)
discovered that between one fth and one third of ED
sta󰀨 had personally experienced partner violence- statis-
tically, the majority of these were women. As the nursing
workforce in the UK is 88.6% female (NHS, 2021), it is
likely to conclude that victims of DA are over-represented
among nursing sta󰀨. Therefore, it is disappointing that
nurses receive the least DA training of professional ED
sta󰀨, and as a result, report the lowest levels of con-
dence in this area (Dawson et al., 2019; Vonkeman at
al., 2019). The Department of Health (2017) and NICE
(2016) guidelines make no distinction between nurses
and medical sta󰀨 in their training recommendations, and
both professions have a small element of DA awareness
in their undergraduate training programmes, so the dis-
crepancy in knowledge must arise from Trust-level train-
ing priorities. Nurses have more patient contact, for more
prolonged periods than medical sta󰀨, combined with the
suggestion that women nd it easier to disclose to other
women, reinforces the need for nurse DA education to be
as thorough and robust as that of medical sta󰀨 (Ullman &
Davidson, 2021). The training provided should therefore
ensure that it acknowledges the impact that subjective
experiences have on those providing care to victims of
DA.
Limitations
These ndings should be considered alongside the limi-
tations of this literature review. Only n=5 databases were
searched via the University portal and inevitably some
studies will be missing. The search was also limited to
studies in English, so some European research which
met all other inclusion criteria but were not in English,
were excluded. The search parameters were quite nar-
row, focussing specically on ED’s and experiences and
behaviours of nurses. Although careful consideration
was given to geographical exclusion, only n=1 of the n=7
research studies reviewed was produced exclusively in
the UK. Cultural caution should therefore be taken when
JNTP Vol.1 No.1 (April 2025) 001001a615J. Goldie, P. Regan

23
applying these ndings to UK ED’s.
Conclusion
Currently, and contrary to WHO (2021) recommenda-
tions, the evidence suggests DA screening in most ED’s
is happening on an ad-hoc basis and subject to the ex-
perience and condence of individual healthcare profes-
sionals (Dawson et al., 2019; Lundh et al., 2022; Saberi et
al., 2017; Spangaro et al., 2021; Vonkeman et al., 2019).
NICE guidelines (2016) state that healthcare profession-
als should deliver a trauma-informed approach, and that
Trusts should make policies and procedures clear. Trau-
ma informed care seeks to recognise the widespread
impact of trauma, to recognise the signs and symptoms
of DA, to promote a sense of safety and to actively pre-
vent re-traumatisation (O󰀩ce for Health Improvement &
Disparities, 2022). Emergency departments present a
uniquely challenging environment to deliver trauma-in-
formed care, but despite this changeable environment it
is possible to improve assessment, referral and support
to women attending ED with DA induced injuries. Health-
care professionals training should seek to ‘myth bust’
and empower them to identify women most at risk based
on the best evidence and recognise the often-overlooked
issue of coercive control (CPS, 2017). Any assessment
tool adopted should be user friendly, quick to complete
and integrated within the referral process to IVDA’s in
ED’s (Warren-Gash, 2016). Training alone is not enough,
because a shift in attitudes at a systemic level is required
so that ED healthcare professionals feel supported and
empowered to respond appropriately to women present-
ing with DA symptoms in ED (Saberi et al., 2017).
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Author Biographies
Jess Goldie
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25
JNTP Vol.1 No.1 (April 2025) 001001a615J. Goldie, P. Regan
https://orcid.org/0009-0002-8269-1492
East Lancashire Hospitals NHS Trust, Blackburn, UK.
Jess Goldie studied for a BSc Hons degree, adult eld at
the University of Central Lancashire. Jess is now working
at Royal Bolton Hospital emergency department full time.
Paul Regan
https://orcid.org/0000-0002-8775-933x
Senior Lecturer in adult nursing, School of Nursing and Midwifery, Uni-
versity of Central Lancashire.
Before joining the pre-registration team at the Univer-
sity of Central Lancashire in 2010, Paul worked in the
NHS for 28 years from 1982-2010. Paul has clinical ex-
perience of adult nursing, acute mental health nursing
and as a generic health visitor.