Objective—To evaluate and refine an assault patient questionnaire to facilitate the contribution of accident and emergency (A&E) departments to Crime and Disorder Act local crime audits.
Method—A brief nine item questionnaire was devised in collaboration with the authors of the Home Office British Crime Survey. A prospective sample of 46 consecutive assault patients who attended Cardiff Royal Infirmary A&E department were interviewed by either reception staff or triage nurses. The questionnaire was revised appropriately.
Results—The collection of information in A&E departments about the circumstances of violence was straightforward. Questions about motive for violence and about relationships between the injured and their assailants were problematic.
Conclusion—The collection of information relevant to Crime and Disorder Act crime audits was possible without extra resource. Receptionists were found to be the most appropriate staff to record information.
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In Britain only about 25% of offences that result in accident and emergency (A&E) treatment are recorded by the police,1–3 for some categories of violence, such as domestic violence and violence in licensed premises, the proportion is even lower. This means that a large number of these offences are not being investigated leaving assailants to continue their violent behaviour in the community. This finding resulted in the NHS (Health Authorities) being included in the 1998 Crime and Disorder Act4 as bodies with whom police authorities and local authorities must collaborate to tackle crime. The Crime and Disorder Act includes legislation on the application to Scotland, criminal law, the criminal justice system and dealing with offenders in England, Wales and Scotland. Importantly the Act requires the partnership of the police authority, local authority and health authority to perform local crime audits and subsequently to base crime management strategies upon them. This therefore brought about the need for Health Authorities to develop a method of contributing to these local crime audits. Although A&E departments are not mentioned specifically they are the key source of data concerning violence available to the health authority.
This new legislation came shortly after the General Medical Council stated that doctors can disclose information without patient consent if necessary where it is key to the prevention or detection of serious crime.5 The project reported here describes the development with the Home Office and A&E personnel, of a questionnaire for use in A&E departments.
A questionnaire was devised with the authors of the British Crime Survey (BCS)6 (fig 1), to collect demographic information about the injured and information about the circumstances of violence. Questions focused on numbers and sex of alleged attackers, patient's relationship with their assailant(s), the motive for attack and whether the assault had been reported to the police.
The questionnaire was completed by all patients who reported injury in assaults in a two week period in the A&E department, Cardiff Royal Infirmary (22 January and 5 February 1999 inclusive). The answers were recorded by reception staff during the first week and triage nurses in the second week. The completed questionnaires were put in a labelled box in the reception area.
At the end of the two week period the questionnaires were evaluated. Information was also obtained from two sets of interviews. The senior receptionist and the senior triage nurse interviewed each person from their team and asked them about any problems they had encountered with individual questions on the questionnaire. After they had spoken to their staff an interview was arranged with both the senior triage nurse and senior receptionist to obtain feedback from the initial questionnaire. The questionnaire was amended to take account of results of these interviews.
Forty six questionnaires were completed during the two week period, 17 in the first week and 29 in the second week. There were problems with two of the nine questions.
Reception staff found it difficult to ask the question, “What was the motive for the attack?” They found it too personal to ask in a busy waiting room. They therefore asked the triage nurses to ask this question. However, 24 of 46 patients did not know the motive and five refused to answer the question. The question, “What is your relationship with your attacker?”, was also felt to be too personal to ask in the waiting room. Some female patients thought they were being asked if they were having a sexual relationship with their attacker. The rest of the questions posed no problems. Twenty five patients said they had already reported the assault to the police: 19 said they had not and two did not answer the question.
Feedback from triage nurses indicated that completing the forms increased triage time during busy shifts, to the extent that it would increase triage time beyond National Triage limits. The only question they had problems with was, “What was the motive for the attack?” It was found that once the questionnaires left the reception area they were more likely to be lost. Several of the forms were left in treatment rooms and one was eventually found in the plaster room.
There are several important reasons why information about violence should be collected in A&E departments: to contribute to Crime and Disorder Act local crime audits; to inform local crime prevention strategy; and to drive appropriate referrals and action in A&E departments, for example, to refer victims to a place of safety, or to Victim Support groups and to give patients opportunities if they wish to report the offence to the police. This is reflected in the statutory responsibility of health authorities to contribute to local efforts to tackle community violence.
The overall format of the questionnaire was acceptable. However, there were problems with two questions. The question on the motive for the attack was difficult to ask in a crowded waiting room and the answer generally not given when this question was asked in a quiet triage room. It was therefore decided to delete this question. The question, “What was your relationship with your attacker?” was re-worded to, “Did you know your attacker: if so were they a partner, ex-partner, family member, acquaintance/friend, bouncer, stranger, workmate/colleague, work client or customer”.
Only 25 of 46 patients had reported their assault to the police. It would have been useful to know whether the patients who had not reported the assault were intending to do so in the future. Therefore a further question was added after the question, “Have you reported this assault to a police officer? (Yes/No)”, “If no, would you like this assault to be reported? (Yes/No)”
Receptionists were the most appropriate staff to complete the questionnaire: there was sufficient time, whereas this was not the case for triage nurses. Triage nurses were able to ask more personal questions as the surroundings were more private, but triage time was increased unacceptably and there was an increased risk of lost forms. Both receptionists and triage nurses interviewed agreed that the receptionists had more time than the triage nurses to ask the questions and this was supported by past research that has also demonstrated that reception staff have time to record data, particularly computerised data7 and that only about 5% of new A&E patients report injury in assault.8
Initially it was planned that during one week SHOs would complete the forms. Because of the number of forms mislaid between reception and triage it was felt that the introduction of a third group would increase this loss.
The questionnaire has been incorporated into A&E department software for computerised data capture.
Because Crime and Disorder Act crime audits are local exercises to take account of local circumstances, it is important that questions additional to this core dataset can be incorporated. The collection of this standard information would facilitate the study of violence from a national A&E perspective to complement national police and BCS statistics, which both have disadvantages.
Victoria Goodwin carried out the survey, collaborated with all the staff groups (triage nurses, receptionists and SHOs) and collated and analysed the data. Jonathan Shepherd devised and supervised the project and collaborated with the Home Office. Both authors drafted and revised the paper.
Conflicts of interest: none.
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