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Abstract
Background Domestic violence (DV), also known as intimate partner violence (IPV), is one of the leading causes of serious injury among women of childbearing age. As first responders on the scene during DV calls where personal injuries have occurred, Emergency Medical Services (EMS) could routinely identify, report and assist victims of violence. Yet, little is known of the prevalence of DV calls in EMS practice, Emergency Medical Technicians' (EMT) knowledge and comfort in responding to such calls, or how they care for victims.
Method The objectives of this study were to assess EMTs' knowledge of and experience with providing care to victims of DV in the province of Ontario, Canada. Data were gathered through an online, short-answer survey. Survey data were analysed using basic frequency displays, and descriptive statistics are reported.
Results Almost 500 EMTs participated in this study, the vast majority of whom (90%) attended at least one DV call in the preceding year, with 65% attending between 10 and 20 DV calls. The majority of respondents (84.5%) wished for more education and training on the issue.
Conclusion EMTs have frequent contact with victims of DV yet have received little education about the issue. The majority of those surveyed would like specific education and training on DV.
- Domestic violence
- abused women
- emergency medical services
- prehospital care
- emergency medical technician
- paramedics
- prehospital care
- violence
- domestic
Statistics from Altmetric.com
- Domestic violence
- abused women
- emergency medical services
- prehospital care
- emergency medical technician
- paramedics
- prehospital care
- violence
- domestic
Introduction
Domestic violence (DV) is a serious public health issue affecting untold numbers of women worldwide. In Canada, 7% of women, some 653 000 individuals, experienced physical or sexual assault by their intimate partners in the 5 years preceding the most recent survey; 2% had experienced an assault in the previous 12 months.1 Of those assaulted by a current or ex-partner 44% reported receiving injuries, 13% required medical attention and 2% were hospitalised.1
The prevalence of DV in hospital Emergency Department (ED) patients has been repeatedly studied, although variability in the criteria used (eg, current or past violence, physical and sexual or physical/sexual and psychological) and the fact that women may not disclose the first time they are asked, have led to conflicting findings regarding prevalence. For example, one cross-sectional study of women presenting in American EDs reported 11.7% had injuries or stress-related issues resulting from DV,2 whereas a recent study of a hospital in the UK used narrower parameters to assess DV (acute injury or condition directly related to DV) and reported that 1% of female ED patients presented with DV-related issues.3 The most recent Canadian study conducted in a smaller, urban ED reported that 2% of female patients presented with DV-related issues.4
Given the high prevalence of DV and its associated health sequelae, it is not surprising that governmental organisations and medical governing bodies and colleges have repeatedly called for the development of DV-related policies and protocols and additional training and education for healthcare professionals. As a result, a number of education and training initiatives for medical students, residents and practitioners have been developed.5–10
Despite this focus on emergency care for victims of DV, the prehospital setting has garnered little attention. A general estimate of the prevalence of DV among Emergency Medical Service (EMS) calls was calculated by the US Centers for Disease Control in 2003; they estimated that 95 000 ambulance visits are made annually due to DV.11 Little additional research has been conducted. Just one study was found of the prevalence of DV in a specific EMS jurisdiction and those authors noted there were no other peer-reviewed English-language publications.12 In that study, Boston area ambulance run sheets from a non-consecutive, convenience sample from July to December 1995 were obtained and reviewed to assess positive, probable and negative cases of DV (N=876). The authors reported that 5.4% (N=47) of women transported by paramedics were coded by EMTs as positive for DV, whereas 10.8% (N=95) were probable cases that went unidentified. The authors concluded that EMS personnel have unique training needs and require educational programmes to increase their awareness, knowledge and documentation of the issue.
In 2005 the Sunnybrook-Osler Centre for Prehospital Care in Toronto, Canada received funding from the province of Ontario to develop a curriculum on DV specific to EMS practice. (In the present jurisdiction all EMTs who provide medical acts under the delegation of a medical director are referred to as ‘paramedics’, regardless of the sphere of practice; henceforth these providers will be referred to as paramedics.) To guide and inform curriculum content, it was desired to learn more about current practices on calls where DV was documented. It was learned, however, that DV-related calls do not have a specific code, making a chart review impossible. Instead, an online survey was developed to learn more about paramedics' current knowledge and daily practices.
Materials and methods
Study design
An interactive, web-based survey was developed by an advisory committee comprising paramedics and DV experts (including physicians, nurses, researchers and survivors) to assess paramedics' practice, knowledge of the issue, mistaken assumptions and educational gaps.
Institutional Ethics Review Board approval for this project was obtained from the Sunnybrook and Women's College Health Sciences Centre.
Study population
A convenience sample of active paramedics in the province of Ontario was accessed through the Ontario Paramedic Association (OPA) website. The OPA is a voluntary association dedicated to ‘enhancing the professional image of paramedics, improving communications between paramedics, and lobbying for improvements to the standards of patient care’. During the data collection period, the OPA membership was 1326 and the website received an average 650 visits per month.
Survey
A brief, short-answer survey was developed based on the available literature and in consultation with the advisory committee. The survey was piloted with 51 paramedics during a provincial conference in September 2005. Participants completed a paper and pencil version of the survey and provided feedback on the instrument. The committee considered the pilot results and participants' feedback and made revisions as necessary; revisions primarily focused on wording and ordering of the questions.
The survey comprised 23 questions divided into three sections: A. demographic (nine questions), B. current practice and experience (seven questions) and C. knowledge about DV from the point of view of paramedic practice (four questions).
The survey was uploaded on the OPA website using a free software program (SurveyMonkey) with a banner reading, ‘We need your help!’ Under the banner a description of the curriculum development project was provided with a link to the survey. Data collection took place over a 3 month period in the winter of 2005–2006. Survey completion was anonymous. As a small incentive, participants were invited to complete and submit a separate email in order to be eligible for one of 25 available gift certificates.
Data analysis
Data were analysed using the software available through the online program. Descriptive statistics were generated and used for data reporting.
Results
On average, 650 visits were recorded on the website each month. The online survey was completed by 480 respondents; the number of participants relative to the number of website visitors is unknown. Every level of paramedic practitioner (EMT-Defibrillation, EMT-Intermediate and EMT-Paramedic) and every regional base hospital (including those in rural, remote rural and the provincial air ambulance service) were represented. (The base hospitals provide medical direction, delegation, leadership and counsel on prehospital emergency healthcare to the designated region.)
Demographics
Of the 456 respondents who provided their location, the majority (69%) were employed in urban centres of greater than 100 000 people. One-hundred (21%) worked in communities of between 10 000 and 100 000 people and 48 (10%) worked in communities with fewer than 10 000 people. One-hundred and eighty-six (40%) of the respondents had 5 years or less experience as an EMT; 49 (24%) had more than 16 years, with the remainder having between 6 and 16 years. The majority, 358, of the 477 respondents (75%) were under 40 years of age, reflective of the reported average age for paramedics in Canada (36.3 years).13
Current practice and experience
Of the 385 respondents who answered the question about the number of DV calls attended in the past 12 month period, 345 (90%) had attended at least one call in that timeframe; 93 (24%) responded to more than 10 such calls, whereas 252 (65%) responded to between one and 10 calls. Just 40 respondents (10%) had not attended, or did not remember attending, a DV call in the previous year.
When EMS providers arrive on the scene they may not know if injuries are due to assault or not, or whether or not the perpetrator is still on the scene. When a 911 call is made and DV is disclosed, or the dispatchers suspect DV, they share this information with the EMS, allowing the team to take necessary precautions to protect themselves. Of 378 respondents who described the way dispatchers identify DV calls, one-third (32%) reported that all or most of the DV calls were identified by dispatchers. Slightly more, 148 respondents, (39%) reported that few or none of their calls were so identified, whereas 107 (28%) reported that just some of the calls were identified.
On their most recent DV call, 79% (294) of the respondents informed the police. (Calls made to 911, the emergency phone number, are automatically patched through the police services and those identified by the caller as involving DV would also automatically result in police at the scene; however, calls for medical aid where there is no disclosure of DV would not automatically result in police attending the scene.) Upon transporting the patient to the hospital, 58% of respondents (217) reported their assessment of DV to the hospital's ED staff, 18% (69) reported the case to their supervisor and 7% (25) told no one. Child protection services were notified by 8% of respondents (31). Twenty-three per cent (106) of the respondents left this field blank. Totals add up to more than 100% as respondents could select more than one response.
In response to the question ‘How frequently are DV patients transported to hospital?’, the majority of the 375 respondents, 64.3% (241), reported that DV patients are transported to hospital ‘some of the time’, whereas 29.3% (110) said such patients are transported ‘most of the time’. When patients were not transported to hospital the most frequently cited reason for non-transport, was because the patient refused 83.5% (303). In only 6.3% (23) of the cases was the absence of injuries the reason for non-transport. One-hundred and seventeen respondents (31%) left this field blank.
Knowledge and attitudes
Most of the 381 respondents had some prior education about DV, obtained through a variety of means. The largest percentage (58.3% or 222) described their prior learning as ‘informal education including personal learning’; 35.7% (136) attended a conference or other continuing medical education initiative, whereas 17.6% (67) received some formal academic education. Although a ‘no training’ option was not available, there was an ‘other’ option with space provided for comments. Thirteen respondents noted that they had no prior training or education; some indicated this with multiple exclamation marks. In this same section, three respondents said they knew about the issue from ‘personal experience’. (Totals equal more than 100% as respondents could select more than one response.) Ninety-nine respondents left this field blank. Fully 84.5% of respondents (321) expressed the wish for more formal training on the topic.
Current knowledge about DV and paramedic practice was assessed through a series of questions beginning with ‘To your knowledge, does the law require mandatory reporting of DV?’. Twenty-two per cent (84) of 378 respondents correctly identified that in Ontario mandatory reporting was required only when children had witnessed or heard the assault; however, 43% (163) believed the law required them to file a report when they attended victims of DV.
Two additional questions focused on perceived risk factors for victimisation and perpetration of violence. Two-hundred and eighty respondents wrote detailed answers describing factors that put a woman at risk for victimisation. Risk factors for increased victimisation were noted to be: women and children, low income and education, isolation, a history of past violence, recent immigrants and involvement of alcohol or drugs. A number of respondents declared that all women were equally at risk of victimisation; one person noted that wealthier victims may be more adept at concealing DV. Factors related to increased risk of perpetration were identified by 236 respondents. Specific risk factors for perpetration were: former victimisation or witnessing family violence, alcohol or drug use, anger issues, personality traits and behaviours such as manipulation, and mental illness.
Discussion
To the authors' knowledge, this is the first large, population-based survey of paramedics' experience and knowledge of DV and a first effort to estimate the prevalence of DV calls in the EMS environment. Close to 500 paramedics from across the province responded to the survey, providing the first ever, broad-based data on the prevalence of DV in paramedics' practice, their knowledge of the issue, mistaken assumptions and educational gaps. As such, this research represents an important contribution to the scant literature on domestic violence in the prehospital environment.
EMS providers working in the prehospital environment encounter significant numbers of women who experience DV. In fact, almost one-quarter of the present study's respondents attended more than 10 such cases in the previous year, whereas 9% reported seeing more than 20 DV cases in a 1 year period. These numbers most likely refer to those cases where either the woman has disclosed or the circumstances have made identification of DV evident. Based on experience in other domains, it may be conjectured that an additional substantial number of cases go undetected.
Despite the volume of DV calls reported by EMS providers, it is surprising how little formal education or training has been developed for the sector. Most study respondents had only informal, personal education or a conference/CME session on the topic. A scan of the literature revealed little in the way of specific training for EMTs on the topic, although the latest version of one of the standard texts addresses the topic somewhat, and the latest edition of the textbook published by the National Association of EMS Physicians includes a section on DV.14 A review of the prehospital syllabus for Ontario paramedics revealed a broad section on the topic of abuse; however, nothing specific concerning DV (http://www.health.gov.on.ca/english/public/program/ehs/edu/pdf/pcp_syllabus.pdf).
Although a few earlier studies have addressed EMS providers and the issue of domestic violence, for example, Singleton et al15 investigated public attitudes about the roles of EMS, and Jezierski,16 as well as Hall and Becker,17 published descriptions of curricula, there have been remarkably few studies of EMS providers' knowledge, attitudes and experience with the issue. In a review of the literature, just one evaluation of an educational intervention on DV developed specifically for workers in the prehospital environment was found.18 In that study, 46 EMTs completed a 12 item paper and pencil survey prior to a 3 h mandatory lecture. A post-test was administered 4- 6 months after the lecture. Although the post-test sample was small (n=19), significant improvements in knowledge were reported on most measures. In commenting on the small sample size, the authors note that the EMT population is a highly mobile one as providers move in and out of service. Despite this, the results suggest that instruction on the topic is useful.
With education on DV tailored to the EMS sphere of practice, EMTs may find there are opportunities to speak to an abused woman, reduce the shame and isolation many abused women experience, and provide her with much needed resource and referral information.
Limitations
There are some clear limitations to this study, the first being a cautionary note about the generalisability of these findings to all EMTs or paramedics based on the low response rate. However, the demographic of respondents does reflect the diversity of the present large jurisdiction.
A second limitation of the study is its reliance on paramedics' recall of past events, in particular the number of DV-related calls each paramedic answered in the past year.
It should also be noted that our jurisdiction employs a mix of EMT-Defibrillation, EMT-Intermediate and EMT-Paramedic providers. There was no differentiation between these categories of EMTs for the purposes of this study. Therefore, it is not known whether the level of training, as distinguished from the years in practice, is associated with recognition and knowledge of DV, although it is known that there is no curriculum on DV offered in any of the higher level training courses.
Finally, conducting research with healthcare professionals is particularly challenging and low response rates are frequently noted. As little survey research has been conducted with EMTs and paramedics, an ‘average’ response rate has yet to be determined. However, in mail survey research of healthcare professionals, response rates of 36% are typical.19 Physicians are known to be particularly resistant to completing surveys in any form.20 Kellerman and Herold in a review of 25 studies of physicians that employed mailed surveys reported response rates ranging between 14% and 38%.21 Online surveys have been used with health professionals with varying degrees of success (response rates ranging from 9% to 94%).22 Although the number of studies using the web or email to collect data has been increasing over the past 15 years, response rates appear to be decreasing. In a review of electronic surveys conducted between 1986 and 1998, the author notes: ‘On average, the 31 studies report a mean response rate of 36.83%…The 1998/9 period, in contrast, showed thirteen studies using email surveys with an average response rate of about 31%’.23
Conclusion
To date, little research has been conducted with EMS providers' about their experiences with and responses to DV calls. Yet, DV is a common phenomenon that frequently results in injuries requiring emergency medical attention. EMS providers are, therefore, uniquely positioned to help abused women by both treating the injuries they may have sustained and providing them with support, resources and information; or when that is not possible, by alerting hospital ED staff. EMS providers currently receive little formal education about DV and have stated that they would like more training on the topic geared to their specific sphere of practice.
Future directions
It is to be hoped that in the near future all EMS providers will receive specific education and training on DV designed for their particular practice. Evaluating these programmes will be important with a prime consideration being whether or not increased education leads to improved patient outcomes. To assist in analysing patient outcomes, as well as to improve patient documentation, consideration should be given to developing a standardised DV code to appear in EMS records. With a DV code in place, future research could include pretest and post-test measures as well as a review of patient records to note whether or not DV had been detected or suspected, and whether or not support and resources were offered to the abused woman.
References
Footnotes
Funding Partial support for this project was provided by the province of Ontario
Competing interests None.
Ethics approval This study was conducted with the approval of the Sunnybrook Health Sciences Centre, Toronto.
Provenance and peer review Not commissioned; externally peer reviewed.