Disclosing intimate partner violence to health care clinicians- What a difference the setting makes: A qualitative study

Article (PDF Available)inBMC Public Health 8(1):229 · February 2008with38 Reads
DOI: 10.1186/1471-2458-8-229 · Source: PubMed
Abstract
Despite endorsement by national organizations, the impact of screening for intimate partner violence (IPV) is understudied, particularly as it occurs in different clinical settings. We analyzed interviews of IPV survivors to understand the risks and benefits of disclosing IPV to clinicians across specialties. Participants were English-speaking female IPV survivors recruited through IPV programs in Massachusetts. In-depth interviews describing medical encounters related to abuse were analyzed for common themes using Grounded Theory qualitative research methods. Encounters with health care clinicians were categorized by outcome (IPV disclosure by patient, discovery evidenced by discussion of IPV by clinician without patient disclosure, or non-disclosure), attribute (beneficial, unhelpful, harmful), and specialty (emergency department (ED), primary care (PC), obstetrics/gynecology (OB/GYN)). Of 27 participants aged 18-56, 5 were white, 10 Latina, and 12 black. Of 59 relevant health care encounters, 23 were in ED, 17 in OB/GYN, and 19 in PC. Seven of 9 ED disclosures were characterized as unhelpful; the majority of disclosures in PC and OB/GYN were characterized as beneficial. There were no harmful disclosures in any setting. Unhelpful disclosures resulted in emotional distress and alienation from health care. Regardless of whether disclosure occurred, beneficial encounters were characterized by familiarity with the clinician, acknowledgement of the abuse, respect and relevant referrals. While no harms resulted from IPV disclosure, survivor satisfaction with disclosure is shaped by the setting of the encounter. Clinicians should aim to build a therapeutic relationship with IPV survivors that empowers and educates patients and does not demand disclosure.
BioMed Central
Page 1 of 8
(page number not for citation purposes)
BMC Public Health
Open Access
Research article
Disclosing intimate partner violence to health care clinicians - What
a difference the setting makes: A qualitative study
Jane Liebschutz*
1,2
, Tracy Battaglia
1
, Erin Finley
3,4
and Tali Averbuch
1
Address:
1
Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801
Massachusetts Ave, Boston, MA 02118, USA ,
2
Department of Social and Behavioral Sciences, Boston University School of Public Health, 801
Massachusetts Ave, Boston, MA 02118, USA ,
3
Department of Anthropology, Emory University, 115 Dickey Dr, Atlanta, GA 30322, USA and
4
The
Emory Center for Myth and Ritual in American Life, Emory University, 115 Dickey Dr, Atlanta, GA 30322, USA
Email: Jane Liebschutz* - jane.liebschutz@bmc.org; Tracy Battaglia - tracy.battaglia@bmc.org; Erin Finley - epfinley@gmail.com;
Tali Averbuch - tali.averbuch@gmail.com
* Corresponding author
Abstract
Background: Despite endorsement by national organizations, the impact of screening for intimate
partner violence (IPV) is understudied, particularly as it occurs in different clinical settings. We
analyzed interviews of IPV survivors to understand the risks and benefits of disclosing IPV to
clinicians across specialties.
Methods: Participants were English-speaking female IPV survivors recruited through IPV programs
in Massachusetts. In-depth interviews describing medical encounters related to abuse were
analyzed for common themes using Grounded Theory qualitative research methods. Encounters
with health care clinicians were categorized by outcome (IPV disclosure by patient, discovery
evidenced by discussion of IPV by clinician without patient disclosure, or non-disclosure), attribute
(beneficial, unhelpful, harmful), and specialty (emergency department (ED), primary care (PC),
obstetrics/gynecology (OB/GYN)).
Results: Of 27 participants aged 18–56, 5 were white, 10 Latina, and 12 black. Of 59 relevant
health care encounters, 23 were in ED, 17 in OB/GYN, and 19 in PC. Seven of 9 ED disclosures
were characterized as unhelpful; the majority of disclosures in PC and OB/GYN were characterized
as beneficial. There were no harmful disclosures in any setting. Unhelpful disclosures resulted in
emotional distress and alienation from health care. Regardless of whether disclosure occurred,
beneficial encounters were characterized by familiarity with the clinician, acknowledgement of the
abuse, respect and relevant referrals.
Conclusion: While no harms resulted from IPV disclosure, survivor satisfaction with disclosure is
shaped by the setting of the encounter. Clinicians should aim to build a therapeutic relationship
with IPV survivors that empowers and educates patients and does not demand disclosure.
Background
The extensive physical and mental health burden of inti-
mate partner violence (IPV) exposure has been docu-
mented in various settings [1-6]. In response, the medical
community has prioritized IPV identification. In fact, the
Joint Commission on Accreditation of Healthcare Organ-
Published: 4 July 2008
BMC Public Health 2008, 8:229 doi:10.1186/1471-2458-8-229
Received: 14 March 2008
Accepted: 4 July 2008
This article is available from: http://www.biomedcentral.com/1471-2458/8/229
© 2008 Liebschutz et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
BMC Public Health 2008, 8:229 http://www.biomedcentral.com/1471-2458/8/229
Page 2 of 8
(page number not for citation purposes)
izations hospital standards call for IPV survivor identifica-
tion and then referral to community services. In a
complementary set of guidelines, the Family Violence Pre-
vention Fund suggests clinicians inquire about IPV at
every encounter for episodic care, such as Emergency
Department visits, with higher case-finding rates as the
measure of high quality [7].
Evidence to support IPV screening interventions includes
surveys of patients who report expectations that a clini-
cian inquire about IPV and increased satisfaction with the
visit after being asked regardless of disclosure [8,9]. In a
meta-analysis of the qualitative literature, Feder and col-
leagues found women IPV survivors value support and
education whether or not they are ready to talk about the
abuse, and consider most helpful relationships with phy-
sicians characterized by respectful support [10].
The most recent guidelines of the United States Preventive
Services Task Force found insufficient evidence for screen-
ing for family violence due to lack of studies showing that
a primary care based screening intervention helps reduce
harmful outcomes [11]. In addition, the potential for neg-
ative outcomes of screening has not been examined [8,11-
14]. Rather, the success of screening interventions tends to
be measured in number of disclosures rather than in
improvement of the survivor's overall condition [15-17].
Most studies of screening either lack a measure for the
potential harm of disclosure or minimize such potential
in written reports [15,17-19]. Although studies have
shown higher disclosure in certain specialties [20], the dif-
ference in outcomes by specialty have not been well
described. Rhodes and colleagues reported that many
inquiries about IPV in an emergency room setting by phy-
sicians were perfunctory and did not lead to documenta-
tion or referral for other help [8,21].
Previously we reported results from a qualitative study of
IPV survivors in which we examined those qualities of the
patient-provider relationship that facilitate a safe and pro-
ductive disclosure [22]. In that study, participants identi-
fied important provider characteristics, including: the
ability to communicate a sense of personal concern; open
communication; willingness to negotiate issues of con-
trol; confidentiality of medical information; shared deci-
sion-making; competency in medical care; careful
listening; and taking ample time to address participant
concerns [22]. Because of the reports of challenges to
communication about IPV in emergency room settings
and the emphasis on trust and communication in the
patient-provider relationship, we hypothesized that the
setting of disclosure of IPV might be important to the
patient experience. Furthermore, such differences might
inform clinical practice in varied medical settings.
In this paper we present the results of a re-analysis of par-
ticipants' descriptions of patient-provider encounters to
examine potential harms and benefits of IPV disclosure.
We explored whether the specialty of care was related to
the outcomes of disclosure, and identified a series of fac-
tors affecting these outcomes across primary care, obstet-
rics/gynecology and emergency department specialties.
Methods
Study Design
Ethnographic interviewing elicited IPV survivors' experi-
ences interacting with both physician and non-physician
health care providers. Grounded theory, a method of
qualitative analysis [23], was used to elucidate views on
patient-provider encounters revealed in the narrative data.
Study Participants
Twenty-seven IPV survivors were recruited from commu-
nity-based domestic violence counseling or sheltering
programs in eastern Massachusetts. They were recruited
either through referral by local shelter staff or through a
flier sent to all domestic violence programs in eastern
Massachusetts. Eligible participants were female, ages 18
to 64, English-speaking, with a history of an abusive inti-
mate partner relationship within the past 3 years. Each
participant provided written informed consent and was
compensated $25.
Interview Technique
After approval by the Boston University Medical Center
Institutional Review Board, data were collected from
October 1996 through November 2000. Open-ended, in-
depth interviews, conducted by 1 of 2 authors (JL, TB),
both primary care physicians, were audio-taped and lasted
1–2 hours.
Using an interview guide, the interviewer asked partici-
pants to describe encounters with health care clinicians
both related and unrelated to the abusive relationship
after the onset of the abuse. While most participants
related to the onset of the adult intimate partner violence,
others spontaneously mentioned experiences with health-
care providers during adolescence or relating to childhood
abuse. The participants were asked to provide information
on perceived barriers to care and the abusive relationship
over the past three years. Interviews were iterative; partic-
ipants enrolled later in the data collection interval were
questioned about themes revealed in previous interviews.
Analysis
Each audio-taped interview was transcribed verbatim by a
professional transcriber, reviewed for accuracy and de-
identified. Authors independently reviewed transcripts to
identify common themes which were developed into a
preliminary coding scheme with the first 10 interviews.
BMC Public Health 2008, 8:229 http://www.biomedcentral.com/1471-2458/8/229
Page 3 of 8
(page number not for citation purposes)
An advisory group of domestic violence advocates and
survivors helped revise this scheme and suggest new con-
cepts. The authors then independently coded the inter-
views using this revised coding scheme. Coding was
compared and differences of opinion resolved through
examination of the text.
Using NUD*ST qualitative research software (QSR Inter-
national, Pty., Ltd., Melbourne, Australia) for data organ-
ization and coding, separate narratives representing a
single patient-clinician relationship were identified and
labeled as encounters. Encounters, which could be com-
posed of a single interaction or continued contact over a
period of years, were first categorized into "related to
abuse" or "unrelated to abuse". As we did reiterative cod-
ing and analysis to understand the specific effect of dis-
closing (or not-disclosing) IPV, these unrelated
encounters did not offer relevant material to allow catego-
rization into a specific outcome (disclosure, discovery/
discussion, nondisclosure) and were thus dropped from
the analyses. Each medical encounter related to abuse was
then coded according to three characteristics: outcome,
specialty and attribute.
The first of these, outcome, described three mutually
exclusive types of encounters: disclosure, discovery, and
non-disclosure. A disclosure occurred when a participant
reported telling her clinician about IPV. When a partici-
pant perceived her clinician knew of the abuse when she
had not made an explicit disclosure, the outcome was
labeled discovery. To be labeled discovery, the partici-
pants made explicit reference that the provider discussed
some aspect of IPV, such as counseling or referral, even
without explicit disclosure of IPV. All other encounters
that did not fall into disclosure or discovery were labeled
non-disclosure. To qualify for non-disclosure, one of two
circumstances had to apply. First, the provider asked but
the participant purposely did not disclose. Second, the
participant was in an actively abusive relationship but did
not spontaneously disclose, such as during treatment for
injury, or during medical or pregnancy related care.
Each encounter was also coded for its specialty: Emergency
Department (ED), Obstetrical or Gynecological Care (OB/
GYN), Primary Care (PC) or other. PC included pediatri-
cians and family physicians identified as the primary care
provider but who may have also provided obstetrical care.
Encounters occurring in other specialties (e.g. mental
health, surgery) were excluded from this analysis because
there were too few of any single type.
The final category, attribute, described the participant's
level of satisfaction with the encounter as a result of
whether she perceived the interaction as beneficial, harm-
ful or unhelpful. For example, if an unpleasant interaction
ended in the participant accepting help or receiving infor-
mation that she found useful, we labeled it beneficial.
Harmful interactions were ones resulting in injury to self,
child or direct worsening of abuse. We classified negative
reports not resulting in actual harm as unhelpful. When
we were unable to categorize attribute due to a lack of
information or contradictory descriptions, we excluded
that encounter from analysis. Finally, we conducted a
comparative analysis to explore the characteristics of
encounters across outcomes, specialties and attributes.
Results
We interviewed 27 women; 12 were black, 10 Latina, and
5 White. Fourteen were recruited by domestic violence
staff, and thirteen contacted the authors in response to the
informational flier. Sixteen were living in a residential
program at the time of the interview. Participant ages
ranged from 18–56 years; median age was 31 years.
Twenty-three participants had at least one child.
A total of 185 health care encounters were described. The
number of encounters per participant ranged from 3–12;
median number of encounters was 7. Although it was fre-
quently difficult to determine the professional designa-
tion (physician, nurse, therapist) of an individual
provider, specialty was clear in 175 encounters. The thirty-
one mental health encounters were excluded because
most were visits specifically related to the IPV. Twenty-two
were nurses from different treatment settings (inpatient,
public health, etc.). Of the twenty-nine other encounters,
there were two few (<5) of any single type and could not
be easily combined into categories- such as radiology
technicians, surgeons, ambulance drivers, physical thera-
pist, child protective service worker, medical subspecialist,
etc. Thirty-one were excluded because they were unrelated
to abuse, and did not contribute to the analysis presented
in this paper, the impact of IPV disclosure. Another three
were unable to be classified by attribute, leaving a sample
pool of 59 encounters (23 primary care, 17 ED, 19 OB/
GYN) representing 25 participants (Figure 1).
Thirty-five (59%) of these encounters involved IPV disclo-
sure to the clinician, 7 (12%) in discovery, and 17 (29%)
in non-disclosure. Of the disclosures, 25 (71%) were ben-
eficial. Among discoveries, 4 were beneficial (57%), while
among non-disclosures, 6 (35%) were beneficial. Setting
of care was associated with reported satisfaction from dis-
closure. In the ED, 2 (22%) disclosures were beneficial. Of
OB/GYN disclosures, 9 (75%) were beneficial. In primary
care, all 14 disclosures were beneficial (Figure 2). There
were no harmful disclosures in any specialty, and the
remaining disclosures were unhelpful. We discuss these
findings further in the paragraphs below.
BMC Public Health 2008, 8:229 http://www.biomedcentral.com/1471-2458/8/229
Page 4 of 8
(page number not for citation purposes)
Consequences of Unhelpful Disclosures: Fear and
Avoidance of Healthcare
The most serious negative consequences of disclosure
occurred in two participants who reported feeling endan-
gered because of the disclosure, both after treatment for
acute injuries in the ED. However, neither experienced
any actual increase in violence. In two OB/GYN visits, par-
ticipants found disclosure experiences so problematic
they ultimately left their providers. The remaining 5
unhelpful disclosure experiences resulted in dissatisfac-
tion without cessation of the clinical relationship.
Several participants were concerned by practitioners' ten-
dency to encourage extreme "solutions" to the violence,
like telling women to file a police report immediately.
While in the ED, one participant reported being told, "Just
tell me the name and where he's at and we'll send the
police at him right now." She recalled thinking: "But what
makes them think he won't come back and kill me?" The
participant did not contact the police, and returned home
in fear.
A number of participants indicated the cumulative effect
of unhelpful disclosure experiences was avoidance of
health care encounters. One participant noted:
"I used to go without medical treatment... I'd wait until it
wasn't a choice anymore. And I'd wind up having to go to
the emergency room."
Another participant revealed:
"Somebody would find out something was happening in my
house, like a social worker, a doctor, a nurse or whatever, I
would stop going there and go somewhere else."
The lack of an emotional connection with the clinician
was a prominent feature in participants' discussion of
unhelpful disclosures. Describing an ED visit, one partici-
pant commented:
"He checked me, he didn't ask any questions, nothing, and
they took x-rays and pulled out of there... Maybe I was hop-
ing... that they would talk to me? I mean, they checked me
out... but I didn't feel like... emotionally? Like maybe talk,
some kind of comfort?"
The lack of effective communication on safety assessment,
referrals, and follow-up for IPV was also a consistent prob-
Encounter Classification Flow ChartFigure 1
Encounter Classification Flow Chart.
185 Encounters Discussed
93 OB, ED or PC Encounters
31 Mental Health Clinicians
29 Multiple Settings and Provider Type
22 Nurses Miscellaneous Settings
10 No Specialty Noted
31 Unrelated to Abuse
3 No attribute
59 Encounters Analyzed
23 Primary Care
17 Emergency Department
19 Obstetrics/Gynecology
Encounter Attribute by SpecialtyFigure 2
Encounter Attribute by Specialty.
0
5
10
15
20
25
30
B-GYNED O PC
Helpful Disclosur e
Unhel pful Disclosure
Discovery
Non-disclos ure
BMC Public Health 2008, 8:229 http://www.biomedcentral.com/1471-2458/8/229
Page 5 of 8
(page number not for citation purposes)
lem in unhelpful disclosures. During her prenatal intake
visit, for example, one participant disclosed ongoing vio-
lence, the name of her abusive partner, and his status as an
undocumented foreigner. Not understanding what fol-
low-up would occur, she became petrified that her hus-
band would assault her for revealing his status. She
subsequently switched to another prenatal care provider,
where she lied about her home life. Several participants
disclosed abuse but reported receiving little helpful advice
from the clinician. The woman encouraged to contact the
police above did not remember being offered contact
information for safe houses in the area. Similarly, after
treatment for acute injuries, one participant reported: "I
don't recall ever getting information about a shelter... or
an advocate speaking to me. Any of that."
Benefits of Disclosure: Making Changes, Improving Self-
Esteem, Building Relationships
Eleven of the 25 beneficial disclosure experiences led
directly to a change in the participant's circumstances,
such as leaving the abusive spouse, entering a detoxifica-
tion program or filing a police report. For example, one
participant with newborn twins and a toddler reported
that after disclosing her husband's assaults,
"I started off in a shelter in [a distant town] because I
couldn't find one that would take all of us right away... My
[OB] got on the phone with Social Service to try and get me
all the help that I needed."
In others, changes resulted after a clinician worked with a
participant over a period of time. One participant
described the effect of the close relationship she devel-
oped with her midwife:
"She was real supportive through my pregnancy, and told
me 'everything will be okay,' and I'll be a good mother. And
I am a good mother. 'Cause it made me realize a lot of
things... that I was thinkin', and I had my whole life to live,
but now I could do better with myself, as well as with my
daughter... I'm workin' on gettin' housin', takin' care of my
schoolin', just bein' responsible."
Instead of an immediate end to the abuse, these patient-
clinician encounters resulted in a shift in the participant's
self-esteem, perception of the violent relationship, or
awareness of alternatives, eventually empowering her to
seek help for the abuse on her own. For example, clini-
cians' assurances that relationship violence was unaccept-
able resonated with several participants. One participant
reported her primary care doctor's sympathetic insistence
that the batterer's behavior was wrong set the stage for her
to take action:
"She was like, 'No... no one who loves you will put their
hands on you.' You know, it's not right. 'That's not real
love.'...After [he broke] the wrist, I said, 'No more.'"
After being treated in the ED for IPV-related injuries,
another participant left with information on local safe
houses that she later consulted when she was ready to
leave her abuser.
Some of the beneficial disclosure experiences resulted in a
more positive attitude toward health care in general, as in
5 instances where participants reported feeling a greater
closeness with their clinicians despite no other change in
their circumstances. Whether or not disclosure led to
change, analysis revealed three common characteristics of
provider behavior in beneficial disclosures: 1) explicit
acknowledgement of the content of the disclosure (all
cases), 2) demonstration of a caring attitude after disclo-
sure (most cases) and 3) specific referral to other resources
(some cases). For example, one participant said an ED cli-
nician explicitly acknowledged her abuse and demon-
strated concern:
"He said, well, 'I hear you're in a battered women's shelter.
What's the deal? I take a special interest in domestic vio-
lence and what happens,' and he sat and talked to me. I felt
comfortable in talking to him because he was showing this
special interest in what was going on with me."
Also of note, in all but two beneficial disclosures the par-
ticipant reported familiarity with the clinician. In primary
care, these relationships involved getting to know the cli-
nician through a variety of contacts both related and unre-
lated to the IPV. In OB/GYN, these relationships generally
formed during prenatal care, or in the peri-partum period
when the participant had daily contact with hospital clini-
cians. Such familiarity can also occur in the ED setting, as
in one case where the participant accepted advice from a
nurse who had treated her a few weeks earlier for IPV-
related injuries. When the participant returned to the ED
with more injuries, the nurse recognized her:
"And I started crying, and she's like, 'Two weeks ago you
was here, now you're back here again today and it's for the
same thing. Your face isn't all bruised up like it was two
weeks ago, but you're hurtin'. What's goin' on?' I broke
down and told her...She was like, 'Well, you don't need to
be in a relationship like that."'
The participant acted on referrals and left her abusive part-
ner as a result of this encounter.
Potential Benefits and Problems without Disclosure
The common thread to benefits and problems without
verbal disclosure by the participant included explicit clini-
BMC Public Health 2008, 8:229 http://www.biomedcentral.com/1471-2458/8/229
Page 6 of 8
(page number not for citation purposes)
cian acknowledgement of potential abuse (or lack
thereof). In particular, participants reported being upset
by health care providers who they felt should have recog-
nized IPV but did not acknowledge it. This, in turn, led to
avoidance of healthcare. One participant reported that
healthcare personnel failed to bring up IPV even after her
husband yelled at her in the ED during two separate visits.
She interpreted this lack of acknowledgement as an indi-
cation that clinicians did not care to get more involved.
Another participant was particularly disappointed that her
primary care clinician did not address the abuse with her,
given that she had received counseling about it from his
nursing staff: "He never gave me any type of indica-
tion...he didn't talk to me about it. That's why I left
him...because he wasn't really direct with me."
Several participants reported benefit when the clinician
spoke openly with the participant about IPV but did not
insist upon disclosure. Furthermore, clinicians in these
encounters used verbal and non-verbal cues to convey
concern, and offered options for intervention while not
forcing the participant to take action. The aftermath of
acute injury was a particularly vulnerable time, as survi-
vors were emotionally and physically exhausted as well as
fearful of more injury.
"They asked me, 'How did it happen?' 'What happened to
you?' 'Who did that?' I was in so much pain that I really
didn't want to talk about it."
A critical component of beneficial non-disclosure experi-
ences was consideration of the patient's safety, as in this
ED visit:
"She realized that I had other bruises on me. I thought he
might hear her and I was like, 'No. Let's just drop the con-
versation. Let's just get me stitched up.' My husband came
in so there was no more talk about it. When I left, she called
me apart, and she [said]: 'you could call here in an emer-
gency and we could get you some help."'
Another example included ED staff suggestion that a par-
ticipant treated for acute injuries continue care in PC:
"and they gave me a choice, 'would you rather go to your
doctor and tell them what happened?"' As a result of that
referral, she revealed the abuse to her primary care clini-
cian.
Discussion
Narratives of intimate partner violence survivors reveal no
actual harms occurred as a result of disclosure of abuse to
health care clinicians. However, some negative disclosure
experiences did impair subsequent interactions with the
health care provider as well as increase emotional distress.
The benefits included immediate changes (e.g. filing a
restraining order), improvement in self-esteem to facili-
tate long term changes, and relationship building with
health care clinicians. The setting of care appeared to
influence these outcomes, impacted strongly by patient
familiarity with the clinician.
This study reinforces insights from prior studies that ask-
ing about IPV in longitudinal care specialties offers the
greatest opportunity for disclosure [20]. Indeed, partici-
pants valued clinicians who knew them well over time
and were thus more likely to find disclosure in such set-
tings beneficial. The benefits of disclosure reported here
went beyond simply providing information, as might
have been expected, but suggest an impact on patient self-
worth and empowerment. This suggests that the relation-
ship between clinician and patient can itself be a point of
healing, and should reassure clinicians that extensive
training in domestic violence or counseling is not as
important as nurturing the relationship with a patient
[24,25].
In all specialties, participants were more likely to disclose
IPV and find disclosure beneficial if clinicians respectfully
addressed the abuse, ensured participants' physical safety
after an assault, assured participants of confidentiality
regarding disclosed information, gave patient choices for
action and demonstrated emotional support. Indeed, our
study demonstrates that inquiry and discussion of IPV in
the right setting can be a powerful tool for change.
Despite the increased potential to identify and refer a vic-
tim of IPV in the aftermath of an acute injury [26,27], par-
ticipants in this study had mixed experiences with
disclosure in the ED. Someone being treated for an acute
injury as a direct result of IPV is likely to be in a highly
charged state from the physical and emotional pain [28].
These women may feel particularly vulnerable and sensi-
tive to any perceived failure of empathy on the part of the
clinician. Furthermore, the probability of a beneficial dis-
closure in the ED may be lower with lack of familiarity
with the clinician, a key element in many helpful disclo-
sures. There may also be organizational barriers [29], such
as lack of stretches of time to spend with any one patient
while trying to manage an emergency department with
multiple patients with differing levels of acuity. Rhodes's
analysis of audio-taped encounters between physicians
and IPV survivors confirms the difficulty exhibited by
many clinicians' attempting to address this issue [21].
Thus, the ability to process and receive help related to IPV
may be higher if it is done outside the context of emer-
gency care. Treatments for acute injury related to IPV
should also be viewed by clinicians as opportunities to
educate and empower the patient, leaving her with
options to exercise when she is ready. This may empower
clinicians as well if they feel they have a task in helping the
BMC Public Health 2008, 8:229 http://www.biomedcentral.com/1471-2458/8/229
Page 7 of 8
(page number not for citation purposes)
patient rather than just uncovering a painful problem.
Because ongoing relationships were more likely to lead to
helpful disclosure experiences in this study, acute care
providers should, with the patient's permission, inform
her regular clinician of her visit [30].
IPV case-finding may satisfy the need for a quantifiable,
appropriate quality improvement measure. However,
measuring case finding alone may obscure whether the
inquiry is occurring in an empowering and safe manner
that benefits survivors. In settings such as the ED or even
inpatient hospital care, where the risks of disclosure may
be higher, other measures of quality could include surveys
of patients at high risk for IPV to assess whether they
received any education about resources or options for IPV.
Future studies of intervention for IPV could consider
measuring empowerment and trust around IPV disclosure
in the health care setting. Outcome measures often deter-
mine the emphasis of clinical care [31,32]. If an organiza-
tion such as the Joint Commission chose a process
measure of IPV education and patient empowerment, it
might spur clinical practice to change.
There are several limitations to this study. First, we were
not always able to determine the exact nature of the visit
or specialty. Furthermore, participants were not directly
asked to compare their experiences; differences were
gleaned from the stories they told. This is typical of quali-
tative research studies in which unexpected themes
emerge from close examination of the data. Self-report is
subject to recall bias, which may be particularly affected
by any post-traumatic stress disorder related to abuse. The
interviews occurred almost 10 years ago and clinician
response might have improved since then, given the edu-
cational efforts with medical students and residents. How-
ever, this has not been demonstrated in more recent
studies [21]. Finally, we only interviewed women who
had used community resources and may not represent all
IPV survivors.
Conclusion
Our results reveal that whether or not disclosure of abuse
is achieved, clinician conversations with survivors about
IPV have a powerful impact on both positive and negative
outcomes. When these conversations occur in the context
of a supportive relationship with that clinician, positive
outcomes are more likely. Although these findings will
need to be replicated in other settings, this study suggests
a need to tailor interventions for women who experience
IPV to the nature of the clinical specialty, particularly
treatment of acute injury. Our findings indicate that it is
not enough for health care providers to simply ask about
abuse. Clinicians should aim for a therapeutic relation-
ship with IPV survivors that does not demand disclosure
or action, but instead empowers and educates the patient.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
JL designed the study. JL and TB conducted the interviews.
All coauthors helped analyze data and reviewed the man-
uscript drafted by JL for important intellectual content. All
coauthors approved the final draft.
References
1. Coker AL, Davis KE, Arias I, Desai S, Sanderson M, Brandt HM, Smith
PH: Physical and mental health effects of intimate partner
violence for men and women. Am J Prev Med 2002,
23(4):260-268.
2. Coker AL, Smith PH, Bethea L, King MR, McKeown RE: Physical
health consequences of physical and psychological intimate
partner violence. Arch Fam Med 2000, 9(5):451-457.
3. Liebschutz JM, Mulvey KP, Samet JH: Victimization among sub-
stance-abusing women: worse health outcomes. Arch Intern
Med 1997, 157:1093-1097.
4. Frayne SM, Skinner KM, Sullivan LM, Tripp TJ, Hankin CS, Kressin NR,
Miller DR: Medical profile of women Veterans Administration
outpatients who report a history of sexual assault occurring
while in the military. J Womens Health Gend Based Med 1999,
8(6):835-845.
5. Campbell J, Jones AS, Dienemann J, Kub J, Schollenberger J, O'Campo
P, Gielen AC, Wynne C: Intimate partner violence and physical
health consequences. Arch Intern Med 2002, 162(10):1157-1163.
6. Lipsky S, Caetano R: Impact of Intimate Partner Violence on
Unmet Need for Mental Health Care: Results From the
NSDUH. Psychiatr Serv 2007, 58(6):822-829.
7. Family Violence Prevention Fund: National Consensus Guidelines
on Identifying and Responding to Domestic Violence Victim-
ization in Health Care Settings. San Francisco CA, The Family
Violence Prevention Fund; 2004.
8. Rhodes KV, Drum M, Anliker E, Frankel RM, Howes DS, Levinson W:
Lowering the threshold for discussions of domestic violence:
a randomized controlled trial of computer screening. Arch
Intern Med 2006, 166(10):1107-1114.
9. Friedman LS, Samet JH, Roberts MS, Hudlin M, Hans P: Inquiry
about victimization experiences. Arch Intern Med 1992,
152:1186-1190.
10. Feder GS, Hutson M, Ramsay J, Taket AR: Women Exposed to
Intimate Partner Violence. Arch Intern Med 2006, 166:22-37.
11. United States Preventive Services Task Force: Screening for Fam-
ily and Intimate Partner Violence: Recommendation State-
ment.
Ann Intern Med 2004, 140:382-386.
12. Anglin D, Sachs C: Preventive care in the emergency depart-
ment: screening for domestic violence in the emergency
department. Academic Emergency Medicine 2003,
10(10):1118-1127.
13. Thompson RS, Rivara FP, Thompson DC, Barlow WE, Sugg NK,
Maiuro RD, Rubanowice DM: Identification and management of
domestic violence: a randomized trial. Am J Prev Med 2000,
19(4):253-263.
14. Plichta SB: Intimate partner violence and physical health con-
sequences: policy and practice implications. Journal of Interper-
sonal Violence 2004, 19(11):1296-1323.
15. Wathen CN, MacMillan HL: Interventions for violence against
women: scientific review. JAMA 2003, 289(5):589-600.
16. Rhodes KV, Lauderdale DS, He T, Howes DS, Levinson W:
"Between me and the computer": increased detection of
intimate partner violence using a computer questionnaire.
Ann Emerg Med 2002, 40(5):476-484.
17. MacMillan HL, Wathen CN, Jamieson E, Boyle M, McNutt LA,
Worster A, Lent B, Webb M, McMaster Violence Against Women
Research G: Approaches to screening for intimate partner
violence in health care settings: a randomized trial. JAMA
2006, 296(5):530-536.
18. McCloskey LA, Lichter E, Williams C, Gerber M, Wittenberg E, Ganz
M: Assessing intimate partner violence in health care set-
tings leads to women's receipt of interventions and
improved health. Public Health Reports 2006, 121(4):435-444.
Publish with Bio Med Central and every
scientist can read your work free of charge
"BioMed Central will be the most significant development for
disseminating the results of biomedical research in our lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central
yours — you keep the copyright
Submit your manuscript here:
http://www.biomedcentral.com/info/publishing_adv.asp
BioMedcentral
BMC Public Health 2008, 8:229 http://www.biomedcentral.com/1471-2458/8/229
Page 8 of 8
(page number not for citation purposes)
19. McCord-Duncan EC, Floyd M, Kemp EC, Bailey B, Lang F: Detecting
Potential Intimate Partner Violence: Which Approach do
Women Want? Fam Med 2006, 38(6):416-422.
20. McCloskey LA, Lichter E, Ganz ML, Williams CM, Gerber MR, Sege
R, Stair T, Herbert B: Intimate partner violence and patient
screening across medical specialties. Academic Emergency Medi-
cine 2005, 12(8):712-722.
21. Rhodes KV, Frankel RM, Levinthal N, Prenoveau E, Bailey J, Levinson
W: "You're not a victim of domestic violence, are you?" Pro-
vider patient communication about domestic violence. Ann
Intern Med 2007, 147(9):620-627.
22. Battaglia T, Finley E, Liebschutz J: Survivors of intimate partner
violence speak out: Trust in the patient-provider relation-
ship. JGIM 2003, 18(8):.
23. Glaser B, Strauss A: The Discovery of Grounded Theory. Chi-
cago , Aldine; 1967.
24. Kelly U: "What will happen if I tell you?" Battered Latina
women's experiences of health care. Can J Nurs Res 2006,
38(4):78-95.
25. Bates L, Hancock L, Peterkin D: "A little encouragement":
health services and domestic violence. Int J Health Care Qual
Assur Inc Leadersh Health Serv 2001, 14(2-3):49-56.
26. Abbott J, Johnson R, Koziol-McLain J, Lowenstein SR: Domestic vio-
lence against women: Incidence and prevalence in an emer-
gency department population. JAMA 1995, 273(22):1763-1767.
27. Ernst AA, Nick TG, Weiss SJ, Houry D, Mills T: Domestic violence
in an inner-city ED. Ann Emerg Med 1997, 30(2):190-197.
28. Yam M: Seen but not heard: battered women's perceptions of
the ED experience. Journal of Emergency Nursing 2000,
26(5):464-470.
29. Gerbert B, Johnston K, Caspers N, Bleecker T, Woods A, Rosen-
baum A: Experiences of battered women in health care set-
tings: a qualitative study. Women Health 1996, 24(3):1-17.
30. Glass N, Dearwater S, Campbell J: Intimate partner violence
screening and intervention: data from eleven Pennsylvania
and California community hospital emergency departments.
Journal of Emergency Nursing 2001, 27(2):141-149.
31. Burke SM: Continuous compliance in the environment of
care. J Healthc Prot Manage 2005, 21(2):6-14.
32. Mobley D, Bodin S: Joint Commission preparation in a large
academic medical center: a framework for success. J Healthc
Qual 1998, 20(5):8-14.
Pre-publication history
The pre-publication history for this paper can be accessed
here:
http://www.biomedcentral.com/1471-2458/8/229/pre
pub
    • "When patients do disclose IPV to health care providers, there is wide variation in clinicians' responses ( Gerber, Leiter, Hermann, & Bor, 2005; Liebschutz et al., 2008; Rhodes et al., 2007). Responses range from those that patients may find unhelpful, alienating, and/or distressing (Liebschutz et al., 2008), such as not acknowledging a disclosure or telling patients that they must report the violence and/or leave the relationship, to those that meet the standards of best practices (Family Violence Prevention Fund, 2004), including validation, further assessment, safety planning, and link to needed health care and social services (Liebschutz et al., 2008; Rhodes et al., 2007). As an integrated health care system providing both primary and specialty care for medical and mental health needs, as well as a range of social services and VA-related benefits, there may be unique characteristics of the VHA system that influence IPV detection and response. "
    [Show abstract] [Hide abstract] ABSTRACT: Women veterans experience high rates of intimate partner violence (IPV), with associated negative health impacts. The Veterans Health Administration (VHA) has recently developed plans to implement routine IPV screening and provide IPV-related follow-up services for VHA patients. Previous research has examined barriers and facilitators to health care provider screening for IPV. The next step is to examine patients' disclosure of IPV experiences to health care providers and effective response to such disclosures. We sought to identify VHA patients' and providers' perspectives on how to facilitate effective IPV detection and care in VHA. We conducted semistructured, qualitative interviews with 25 female veteran patients and 15 VHA health care providers. We used an inductive approach to analyzing interview transcripts and identifying themes that constituted study findings. Themes fell in to two broad categories: 1) barriers to disclosure and 2) barriers to an adequate response to disclosure and providing follow-up care. Barriers to disclosure of IPV to health care providers included lack of provider inquiry, lack of comfort, and concerns about the consequences of disclosure and lack of privacy. Patients and providers both indicated a need for expanded resources to respond to IPV in VHA. Findings support current plans for IPV program implementation in VHA and point to recommendations for practice and implications for further research. Published by Elsevier Inc.
    Full-text · Article · Jul 2015
    • "rd health care providers, and enabled victims to make a safe decision regarding staying with or leaving their abusers. Conversely, victims of IPV reported frustration, disappointment , and anger when their IPV was recognized by health care providers, but not addressed. This lack of health care provider action led to future avoidance of health care. [7] Nurses are an important professional group concerned with women's health and have close interpersonal contact with women in community health settings. Screening for IPV is a crtical nursing function that can be done at first contact with women in community health settings. Guruge has shown that nurses perceived their roles toward IPV as"
    Full-text · Article · May 2015
    • "These positive sides of screening were also identified by women in a review by Feder et al. (2009) but, despite their recognition of the benefits of using a screening test, Lanzenbatt et al. discovered that only 50% of their midwives were in favour of routine screening for all pregnant women (Lazenbatt et al., 2009). The midwives considered their relationship with the women as a key factor in the effectiveness of screening, and this is supported by the conclusions of other qualitative studies of midwives' perceptions of screening (Hindin, 2006; Jack et al., 2008; Liebschutz et al., 2008; Feder et al., 2009; Sprague et al., 2012). Studies of battered women's views of domestic violence screening have also found that, when a health professional can sensitively and non-judgementally ask about violence in a confidential environment, women feel supported, cared for and understood, and relieved that someone is finally talking to them about it (Feder et al., 2009). "
    [Show abstract] [Hide abstract] ABSTRACT: the aim of this qualitative study was to explore midwives׳ knowledge and clinical experience of domestic violence among pregnant women, with particular emphasis on their perceptions of their professional role. the data collected for this phenomenological-hermeneutical qualitative study were collected using semi-structured interviews, and analysed according to Denzin and Lincoln (2011). fifteen hospital and community midwives working in the local health district of Monza and Brianza in northern Italy were recruited between July and October 2012. three main themes emerged: 'it is difficult to recognise domestic violence' because of a limited knowledge of the most common signs and symptoms of violence, a lack of training, cultural taboos, and the women׳s unwillingness to disclose abuse; 'we have a certain number of means of identifying violence', such as relationships with the woman, specific professional training and screening tools, which have advantages and disadvantages; 'the professionals involved' in identifying and managing family violence highlight the importance of a interdisciplinary approach. midwives acknowledge their crucial role in identifying and managing domestic violence but are still unprepared to do so and indicate various barriers that need to be overcome. There is a need to implement basic university education on the subject and provide specific professional training. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · Feb 2015
Show more