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Emerg Med J 30:198-201 doi:10.1136/emermed-2012-201127
  • Original article

Preparedness to care for victims of violence and their families in emergency departments

  1. Christen Erlingsson1
  1. 1Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden
  2. 2Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
  1. Correspondence to Josefin Rahmqvist Linnarsson, Department of Health and Caring Sciences, Linnaeus University, SE-391 82 Kalmar, Sweden; josefin.rahmqvist.linnarsson{at}lnu.se
  1. Contributors JRL designed the study, collected and analysed the data and prepared the manuscript. EB participated in planning and supervising the study and revising the manuscript. KÅ contributed to the study design, data analysis and revision of the manuscript. CE participated in the planning of the study and revision of the manuscript.

  • Accepted 28 February 2012
  • Published Online First 20 March 2012

Abstract

Objective To describe the preparedness to provide care for victims of violence and their families in emergency departments (EDs) in Sweden.

Methods A web-based questionnaire was sent to all hospital EDs in Sweden (N=66).

Results A total of 46 out of 66 (70%) heads of EDs completed the questionnaire. The results show that most of the EDs are prepared to care for women and children who are victims of violence. However, there seems to be a lack of preparedness to care for other groups of patients, such as victimised men. Very few EDs have routines to identify victims of violence among patients. Results also indicate that nurses play a key role in the care for victims of violence; however, family members are rarely included in care.

Conclusions A lack of general preparedness in EDs to care for all victims of violence, regardless of gender and age, can lead to many patients not receiving appropriate care and treatment. To correct this there is a need to implement guidelines and routines about the care for victims of violence. Further research can shed more light on which measures are needed to improve quality of care for these patients and their families.

Interpersonal violence is a leading cause of suffering and untimely death worldwide.1 It has been recognised as a critical problem with immediate and long-term implications for health and well-being for both individuals and their families.1 ,2 Violent crime trends have a similar pattern in the majority of countries worldwide. In an international comparison of victimisation, between 0.1 and 1.8% of the population in the surveyed countries reported being victims of sexual offences or assault.3 In Sweden the figure is just above 1%. A majority of the victims are men, about one-third are women and just over a tenth are children.4 Violence against women has been highlighted as an area of special concern and there are official national guidelines for women being implemented in Sweden within the healthcare organisation.5 However, there are no national guidelines for victims of violence generally. Regardless of the gender of the victim an important part of providing care is the inclusion of their families. This could prevent negative health consequences for the family members such as severe stress and anxiety syndromes.1 ,6

For victims of violence who seek medical care, emergency departments (EDs) are often the first point of entry. However, they do not readily identify themselves as being victims and therefore the onus of such identification lies on ED staff.7 The staff might be uncertain about posing inappropriate questions, but patients attending EDs seem to prefer routine questioning about violence.8 Failure to identify victims of violence can contribute to misdiagnosis, inappropriate treatment and care as well as neglect of legal evidence.9 Thus, asking questions is a first step in recognising those patients who are victims of violence. However, to intervene and interact effectively with these patients, the EDs need to train ED staff in this area.10 Specific formalised programmes, guidelines, training for ED staff and routines for referrals have been suggested to contribute to such a preparedness.11 However, data about EDs' general preparedness for victims of violence and their families, reflected in clinical policies, practice guidelines and routines, are limited. The aim of this study was to describe the preparedness to provide care for victims of violence and their families in EDs in Sweden.

Methods

Study design and population

A descriptive cross-sectional design was used and data were collected with a national survey of the heads of departments from all hospital EDs in Sweden (N=66). The web-based questionnaire was sent in spring 2011 and included three reminders. The 42-item questionnaire was developed by the authors of this study and included closed-ended questions (22 items) followed by open-ended questions (20 items). The questions were formulated to elicit responses regarding regulating documents and routines (15 items), organisation of care (11 items), education and further development of care for victims of violence and their families in the EDs (10 items). The questionnaire also gathered demographic data of the EDs (6 items). The questions were developed after a review of relevant literature and other related questionnaires. An expert group of clinicians and researchers evaluated the questionnaire. It was then revised guided by their comments.12

Data analysis

Quantitative data were analysed using descriptive statistics with SPSS V.19 for Windows (SPSS, Inc). Qualitative data were categorised using content analysis, identifying frequently used words and categories of groups of words with similar content.13 Formal ethical approval was not required for this study according to ethics legislation in Sweden. The study adheres to the ethical standards of the Helsinki declaration. The participants were informed that participation was voluntary and that their individual responses were confidential.14

Results

Demographics

The response rate in this study was 70% (n=46) and 17 out of 21 county councils were represented, thus covering the nation geographically. All respondents were physicians and the sizes of the EDs in this sample are shown in table 1.

Table 1

Sizes of the EDs as estimated by the respondents (n=46)

A vast majority of the respondents (n=36; 78%) did not know how many patients seeking care in their department were victims of violence. Ten EDs (22%) provided an estimate of how many patients were victims of violence. The estimates ranged from 30 patients/year in the smaller hospitals to 3500 patients/year in larger hospitals, which implies between 0.2% and 30% of patients seeking care at the ED annually.

Regulating documents regarding care for victims of violence

Most of the respondents (n=28; 61%) stated that there were policy documents in their county council regulating healthcare providers' specific care for victims of violence. These policy documents focused on violence against women and children. Nine of the respondents (20%) stated that there were no policy documents available in their county council and just as many did not know whether or not such documents existed. In the free-text responses some respondents stated that this was an area under development in their county council. At department level, a majority of the EDs (n=38; 83%) had specific documents regulating the care of victims of violence. Examples of such documents were: checklists, contact lists, routine descriptions, care plans and action plans. These documents focused solely on violence against women and children. Some of the respondents also stated in the free-text responses that such regulating documents were under development.

Specific routines in the EDs

The respondents were asked if they had routines in their ED for asking patients about experiences of violence (physical, sexual or/and emotional). Very few of them (n=4; 9%) had routines to ask all of the patients about experiences of violence. In the free-text responses some respondents said that it was not always possible to ask patients about violence and that it was a possibility rather than a routine. Half of the respondents (n=23; 50%) answered that ED staff asked about violence only when they suspected that there was violence behind the injury. Examples mentioned were in cases of suspected rape or sexual violence. Two respondents (4%) stated that their ED staff asked about violence only for some groups of patients, specifically women and children. Sixteen of the EDs (35%) did not have any routines to ask patients about violence and one (2%) did not know if such routines existed.

Written routines regarding medical and psychosocial care, documentation and evidence collection in the cases of assault and sexual abuse existed in the majority of the departments (table 2). However, when looking at the two groups in more detail, a larger number of EDs had written routines for medical care, psychosocial care and collecting evidence in cases of sexual abuse compared to cases of assault. Most of the departments (n=34; 74%) had general routines for photographing all injuries caused by violence as a part of documentation. Some respondents stated that this was only done for special groups of patients (n=6; 13%) and some had no routines for photography as a part of documentation (n=6; 13%).

Table 2

Written routines for care of victims of violence in cases of assault or sexual abuse

Organisation and further development of care for victims of violence in the EDs

Most departments (n=29; 63%) had a designated person on the staff or a group assigned specifically to the care for victims of violence. The staff assigned for this task were mostly registered nurses and sometimes counsellors or assistant nurses. In some EDs, groups were formed that included personnel representing these different professions. These groups were specifically responsible for victims of violence and had a multidisciplinary role in working together with other professionals. The majority of EDs (n=29; 63%) cooperated in networks or groups with other authorities or organisations such as police, district attorney, social services, other healthcare facilities and schools. The main focus of this multidisciplinary involvement was care for women and children.

ED staff with specific responsibility for victims of violence were those receiving further education in the area. These were mostly registered nurses and only a few respondents named physicians, counsellors or assistant nurses in the free-text responses. The majority of EDs (n=32; 70%) had offered some kind of further education or training which focused on recognition of injuries caused by violence, care for women and children who are victimised, available support/help and multidisciplinary cooperation and the normalisation process. Fifteen (33%) of the EDs reported participating in, or having organised, a project during the previous 12 months that focused on caring for victims of violence. These projects included further education, revising or formulating new regulating documents. The projects described focused on violence against women, domestic violence or honour related violence. Most of the EDs had not participated in or organised any projects in the past year or were unaware whether such projects existed (n=31; 67%).

Continued support and care offered

Thirty-five (76%) of the EDs offered written information to the victims of violence about available support and help both during the hospital stay and after being discharged. In most of the EDs (n=31; 67%), this information was also available in public access areas such as waiting rooms. Concerning continued care, 41 (89%) of the respondents answered that victims of violence were offered contact information to other care providers or organisations. Mostly, victims of violence were referred to a counsellor at the hospital. Some mentioned other options such as referral to social services, psychiatric department, primary care or other emergency help organisations. Women's organisations were especially mentioned as a contact for continued care.

Care for families of victims of violence

Nineteen (41%) of the respondents did not know whether care for families was included in policy documents for victims of violence in their county council (table 3). The respondents that did describe how family members were included in policy documents stated that it included only children. Most of the respondents (n=27; 59%) had no knowledge about any specific documents at their EDs that included the care for families of victims of violence (table 3). The EDs that had such documents described these as focusing on children and care for family members only in cases of domestic abuse towards women. When answering questions on specific further education and training, the majority of respondents (n=35; 76%), either stated that family members were not included or that they had no knowledge about their inclusion (table 3). Most of the EDs had no written routines for care of family members who accompany victims of violence to the ED in cases of assault (n=24; 52%) or sexual abuse (n=18; 39%). Half of the respondents (n=21; 46%) stated that family members in the EDs were given written information about available support within and/or outside the hospital. However, 26 (57%) of the respondents answered that they did not offer a contact with another care provider or organisation for further support or help nor did they know if this was something that was offered to family members (table 3).

Table 3

Questions concerning care for families of victims of violence

Discussion

This study gives unique insights into preparedness in Swedish EDs about care for victims of violence and their families. The main findings were that preparedness for some specific populations exists—that is, women and children leaving others unaddressed, such as victimised men. Results point towards uncertainty about how many of those who seek care in the EDs are victims. Among ED staff, registered nurses are often the ones given special responsibility for specific issues regarding victims of violence but family members are rarely included.

In most of the EDs there is a preparedness to care for women and children who are victims of domestic violence. This preparedness includes regulating documents and written routines, organisation of education for personnel, delegation of specific responsibility to ED staff and provision of information about continued support and care. This preparedness for special groups might be a result of the efforts made in Sweden as well as worldwide in this area.5 ,15 ,16 However, this emphasis only on special groups seems to have resulted in a lack of preparedness to care for others such as men. This especially raises concerns in light of violent crime statistics, confirming assault on men as the most reported offence.1 ,3 ,4 Readiness to provide continued support and care for victims of violence in this study was especially high. Consistently with this, Sweden is considered to have one of the most highly developed victim-support systems in the world. This holds especially true for victims of sexual assault, who are most likely to receive such support; a finding seen in this study and also in previous international comparisons.3

A notable finding was that most of the heads of EDs were unable to report how many victims of violence were seen in their departments annually. Very few EDs have routines to identify victims of violence. Previous studies have shown that screening for violence varies among EDs and many do not screen in a standardised way.17 The estimates of victims of violence in EDs might therefore be underestimates. Also, if existing routines for asking about violence are exclusively for women or children there is an inherent risk that other victims of violence may remain unidentified.

Most ED staff with specific responsibility for victims of violence were registered nurses. Many EDs offer some education and training for the nurses in this area. Although forensic nursing is not yet a recognised specialty or a part of the nursing curriculum in Sweden, registered nurses are reported as those with this specific responsibility. In previous research, registered nurses in EDs have also been recognised as well placed with a distinct opportunity to care for victims of violence and their families.18 ,19 On the other hand, studies also show that registered nurses express a need for education and structure to include forensic tasks, something that is not always sufficiently provided.20

Furthermore, the results of this study show that the families of victims of violence in EDs are often not included in care. They are rarely a part of any written policies/routines or education. However, the victim's family has been described as an important part of forensic care.1 ,6 And for ED patients in general, studies have shown the importance of including family members in care.21 The presence of family members has also been shown to be beneficial for the patient22 as well as for the whole family in coping with emotional distress23 in an emergency.

Methodological issues

This national survey and descriptive study design is a beneficial approach to setting ‘the map’ and providing clues for future studies.24 The questionnaire used was developed specially for this study, which makes it specific for the sampled population. The response rate was high (70%) and the respondents were also well spread geographically, covering both small and large hospitals. Work environment and organisation of healthcare can vary considerably between countries, which may limit the generalisation of these findings. The results consist of self-reports and no attempt was made to externally validate the reported data. A problem with such self-reports is the potential risk of a social desirability bias. However, the use of factual questions and assurance of confidentiality, should have limited the risk of such bias.12

The results show the need for more research about care in EDs for victims of violence. Further research is needed to assess the usefulness of existing structure and content in clinical practice. The views of ED staff, especially, registered nurses, of their resources and knowledge when caring for victims of violence as well as for their families are an important perspective for further research. Furthermore, research into victim or family perspectives of the care offered at the EDs could shed even more light on areas of improvement.

Acknowledgments

We are most grateful to all the heads of departments who participated in this study. We would also like to thank Peter Diedrichs for valuable assistance and support with the web-based survey tool.

Footnotes

  • Funding This study was funded by Linnaeus University.

  • Competing interests None.

  • Ethics approval Formal ethical approval was not required for this study according to current ethic legislation in Sweden. The study adheres to the ethical standards of the Helsinki-declaration. The participants were informed that participation was voluntary and that their individual responses were confidential.

  • Provenance and peer review Not commissioned; externally peer reviewed.

References


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0.5% - 43% response rate
3% - 41% response rate
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