Skulle behöva tas upp tidigare i utbildningen

Jag tror att människor i grundutbildningen inte är tillräckligt mogna

. De säger också att de inte skulle veta hur de ska agera och göra remisser, som framtida vårdpersonal.

Also, they say that would not know how to act and make referrals, as future nursing professionals

Moreover, violence is mostly identified by physical injury

It would be difficult to identify a woman who arrives in the health service, you look at her, you see that she’s a purple arm, belly, something like that. It maybe you perceive that this is not only a bruise, you know? Realize that you have something, that has the violence behind it.

As a professional we’re not really prepared to act,

Know how to work with the measures applicable to the situation, from counseling to referral to the police, if necessary

I do not know what the agencies.

a team has to try to help [A10]; What I did when I saw this case was try to schedule a nursing consultation so they could talk to this woman, guide, listen her

Uppgifterna visade att barnmorskor begränsar IPV-frågor till gravida kvinnor som de misstänker har upplevt IPV.

. De gravida kvinnorna upplevde att det faktum att de avslöjade sanningen om IPV i sitt äktenskap kunde avslöjas av barnmorskorna för andra. Detta gjorde att de var osanna eller tysta när de tillfrågades om IPV.

Underteman är: hinder relaterade till mödrakort, arbetsbelastningsrelaterade hinder och protokollhinder.

The midwives’ own perception of culture and religion in the northern region of Nigeria came out strongly as an internal barrier to routine screening for and disclosure of IPV in pregnant women

inadequate training of midwives affected their competencies in performing screening for IPV, as illustrated

There are no questions on the antenatal card relating to intimate partner violence to ask pregnant women, so we stick to the questions on the antenatal card.

the large number of pregnant women seen by each midwife makes it exhausting to undertake screening for IPV

I am overwhelmed with work. I don’t even have time to sit and discuss one on one with my patients

“There are many patients, but few midwives because we are short staffed in this hospital

Protocol related barriers: The absence of institutional permissions, approvals, directives, and policies formalising midwives’ screening of pregnant women for IPV was also reported as a barrier to their screening practice of IPV.

“We have not been directed to ask such questions

“There is no policy in this hospital that requires us to ask our patients about intimate partner violence.

“There is no guiding procedure manual on screening pregnant women for IPV.

, there is no space to discuss private matters like IPV. Most of the things we do, like health education, we do them in groups, here in the same hall.”

“What do we do for these women after we identify them as victims of abuse. There have to be solutions or benefits for patients coming out to voice their problems. Right now, there is no resources. So we cannot screen for problems we cannot solve.

Health care professionals are not prepared to take care of women who are victims of domestic violence(11).

find difficult to provide care to families and women who are victims of violence. Further they feel powerless to overcome those difficulties

the lack of either preparatory courses or professional training in domestic violence hinders the confrontation of these issues

In addition to the lack of education and training in domestic violence

] we are very hurried, there’s no time, for example, when I think the case needs a little special attention, I tell the nurse, see this case here

I can identify some pathological risk, but not risk of violence (M6)

e. Some of those difficulties are the invisibility of the problem and lack of qualification of these professionals

Other aspects such as life history, posture and professional attitudes potentiate the difficulties of professionals to assist users who are victims of domestic violence.

You know, we can’t go deeper, we attend a lot of people […] we can’t

, this group of health care professionals was judgmental and developed moralistic attitudes towards their patients.

Dessutom känner de sig maktlösa när det gäller att övervinna dessa svårigheter. Bristen på förberedande kurser eller yrkesutbildning i våld i hemmet gör det förvisso svårt att ta itu med dessa frågor(12).

[…] we are very hurried, there’s no time, for example, when I think the case needs a little special attention, I tell the nurse, see this case here (M6).

Svårigheten att identifiera och ingripa i fall av våld mot kvinnor accentueras när kvinnor är gravida

En del av dessa svårigheter är att problemet är osynligt och att dessa yrkesgrupper saknar kvalifikationer.

Over half reported no or very little knowledge about legal reporting requirements, how to determine danger and/or how to develop a safety plan with a people experiencing DV

Extrinsic barriers to screening involved the resources available at each hospital. Most commonly, lack of single rooms, high patient load and lack of social worker availability were all cited as impediments. Patient-related barriers involved difficulties in communication rather than cultural barriers, including non-English-speaking background or dementia. Extrinsic factors commonly reported as enabling screening were access to protocols (written and online), departmental posters informing patients to expect regular DV screening, access to 24/7 social work and interpreter services and having supportive coworkers

Patientrelaterade hinder handlade om svårigheter i kommunikationen snarare än kulturella hinder, inklusive icke-engelsktalande bakgrund eller demens.

Patientrelaterade hinder handlade om svårigheter i kommunikationen snarare än kulturella hinder, inklusive icke-engelsktalande bakgrund eller demens

Yttre faktorer som vanligtvis rapporterades som möjliggörande screening var tillgång till protokoll (skrivna och online), avdelningsaffischer som informerade patienterna om att de kunde förvänta sig regelbunden DV-screening, tillgång till 24/7 sociala medierarbets- och tolktjänster och att ha stödjande arbetskamrater (se bilaga 1 på nätet).

Timmarna för utbildning i våld i nära relationer visade också ett svagt positivt samband med beredskap

Deltagarna noterade att det finns ett större behov av utbildning och stödbehov såsom utbildningstillfällen, ekonomiska resurser, organisatoriska resurser, stödgrupper för remiss från socialtjänsten och rådgivningsgrupper, för att hantera fall av IPV. Bristen på resurser tillskrevs komplexiteten och den stora mängden arbete för dem som upplevde IPV. En av deltagarna sa till exempel:

Kräver hembesöksmaterial som fokuserar på hälsosamma relationer • Behöver verktyg för att hjälpa klienter att utveckla en vision om en framtid fri från våld • Behöver kunskap relaterad till riskindikatorer för IPV och hur man tar upp frågan om potentiell exponering för våld bland klienter som inte har avslöjat • Behöver IPV-bedömningsverktyg som kan administreras flera gånger i programmet, initieras tidigt – men inte vid första besöket • För att stödja kompetensutveckling behöver man manus för hur man kommunicerar om IPV med kunder

Sjuksköterskorna uttryckte chock och skuld över att de, trots att de hade frågat om IPV-exponering, ofta inte fick reda på det förrän senare i programmet.

Participant 4 reflected on her prior experience of working in the ED, an area which has received considerable attention as a key location for disclosure of DVA. She then contrasted this to her experience of working in an in-patient environment and the time constraints of the ED

both the longevity of patient relationships within particular care settings and/or the length of stay in hospital provided the potential to build relationships of trust and to provide a ‘safe’ environment for disclosure:

And it’s having a mechanism for us to be able to seek support to help people with that.

he NS role, both the training and ongoing support had been invaluable in enabling them to speak to patients where DVA was disclosed or suspected. Participants also clearly recognised the importance of their role in terms of being a key point of contact for disclosure or identification of DVA

However, several participants also described how they ‘didn’t know’ how to initiate a conversation about DVA with patients, even when they were experienced practitioners:

while seeking the advice of the NS gave her ‘confidence’ to ask about DVA, ‘probing’ into very personal aspects of someone’s life did not feel as though it was part of her professional role:

Furthermore, the training and continued support of the NS was invaluable both in terms of the development of professional confidence to approach DVA with patients and also in terms of facilitating senior practitioners in supporting members of the nursing team themselves

I was here and we talked and is everything okay?’ So we don’t have the tools to pull out that information

Some nurses perceived that many clients responded negatively to questions about violence in their relationships because they did not define their experiences as abusive

Nurses identified that tools are required to support clients in reframing their understanding of a healthy relationship.

One of the most pressing needs identified by nurse home visitors was to receive guidance on how to understand, and then respond, to their ‘gut instinct’ or ‘gut feeling’ that a client may be experiencing abuse in her relationship

Nurses and supervisors expressed the need for additional knowledge about additional ‘clues’ that could indicate a client is experiencing abuse or at-risk of IPV.

Nurses found it challenging to know what to do when they suspected a client was experiencing abuse,

nurses identified that they specifically needed guidance about when and how to take the initiative in raising the issue of abuse again with clients

To organise their assessments and subsequent plan of care, nurses requested a clinical pathway or at least detailed instructions on ‘what to do next’ or how to respond to IPV disclosures

Communication challenges may also be due to an inability to establish rapport with the patient. This may be due to the provider’s personal feelings and beliefs about IPV or patients shutting down or not returning if IPV questions are not asked appropriately. Often, however, it is due to a lack of time during which providers can establish a relationship with the patient

So that is one of the reasons why it gets overlooked. Because it takes a little bit of time and meandering to get it out.

Several operational/facility challenges were also noted, primarily stemming from issues related to current procedures in place for screening and responding to IPV as well as facility infrastructure concerns. Participants noted a lack of confidence in the current screening questions and response resources available at their facility.

feeling that the current procedures seemed ineffective

The most common operational concern was related to insufficient time to inquire about IPV

EDs noted that a major challenge is a lack of follow-up visits, whereas clinics stated that too much time elapses between visits.

‘We have numerous types of screenings that go on in the electronic health record (EHR). And so it pulls you away from actually being compliant with all of them cause there’s quite a few lately’ (nurse, ED, 01). Lack of privacy was also noted as a barrier to screening, particularly among emergency departments.

‘We review policies and the hardest thing is between us, in the entire community, is for the hospitals to express themselves and where their policies are at. No one wants to share their policy. No one wants to do a transfer policy. No one wants to give us anything, not even a little bit because of the competition between them.

operational/facility issues. Several communication promoters were noted including those that serve to increase the comfort of patients and improve self-awareness of both patients and providers

Participants also noted there are times in which a particular provider may have difficulty establishing trust and rapport

One participant also discussed the importance of dress (‘not having the white coat on’) and demeanour in helping patients feel more comfortable. The way in which questions related to IPV are framed can also help build trust and rapport. Strategies for framing questions included asking all patients IPV questions rather than those ‘suspected’ of experiencing IPV; asking less sensitive questions first; using straight forward, plain language; and asking questions conversationally as opposed to reading directly from a questionnaire.

it is not specifically for issues related to abuse. For providers, education and training are critical for raising awareness and improving communication about IPV. B

For operational/facility promoters, participants discussed the importance of strong partnerships, access to resources and being available to patients. Having partnerships with mental health providers, social service agencies, rape treatment centre/emergency services and law enforcement are considered necessary for effectively responding to IPV

Participants also noted that receiving specific instruction on what questions to ask has been instrumental in establishing their IPV procedures.

To be available to patients, it is important that sufficient time is allotted during patient visits

n average patient visits are 15 minutes, but 30 minutes is really needed to appropriately screen for IPV and even more time is required if the patient needs help accessing resources.

ability included ensuring patient visits are conducted in private locations so patients have the opportunity to say something if they want to and providing the patient with access to the provider’s phone and/or email address

IPV screening and response programmes. Participants identified a need for more procedural guidance related to IPV screening and response

. Participants also requested additional education for both patients (e.g. brochures, posters) and providers (e.g. in-services, trai

the need for local resources was also noted. This included lists of local referral contacts, opportunities to develop better relationships with local IPV service agencies and more prevention programmes within the community

Several midwives mentioned the challenges of determining “if it [violence] is physical, or economical, or psychological, or emotional

Midwives expressed lack of sufficient time to discuss IPV with patients and screen them during appointments. They often felt that they had to compromise their attention to the patient; in the case of the Haitian patients, this was due to needing a translator, which slowed down examinations and lengthened discussions between patient and provider. Other times, the need to document the events of the encounter and update patient progress notes and examination findings took away attention from the patient.

Language was a very salient issue for the midwives concerning their Haitian patients who did not speak Spanish; either the midwives had seriously limited communication due to inadequate translated resources or unavailable translators, or they felt conflicted by the ethical concern in using a partner as a translator.

Additionally, midwives found that coordinating schedules with the translator proved challenging when patients needed a referral to the psychologist or other members of the health care team.

The difficulty in trying to screen for violence is compounded because often the partner was the one who would come to translate for the patient

Another barrier was the dual complexity of language and culture.

Partly because the midwives did not have a good understanding of Haitian culture and respective interpersonal dynamics, the midwives struggled to determine if the partner translating for the woman was an indication of a risk factor for IPV

The midwives frequently expressed a need among the health care team for intercultural training, one that would be both in-depth and relevant, so they might better understand their patients and their circumstances before judging behaviors or trying to impose their own cultural expectations

By understanding a patient’s cultural beliefs and customs, a midwife may be prepared to better communicate with and assist her patients.

The midwives desired better training to manage this cultural difference and ambivalent sexism so they would feel more equipped to serve their patients.partner behaviors that could increase their risk for adverse outcomes related to IPV, and where they can go to receive support if they experience IPV

Some midwives expressed that what might be most important would be knowledge of where the victims could seek help and providers could seek resources,

Even though the midwives could refer women to the clinic psychologist, they did not have immediate awareness or knowledge about the referral process to the government ministry for women

Flera barnmorskor nämnde utmaningarna med att avgöra "om det [våldet] är fysiskt, eller ekonomiskt, eller psykiskt, eller emotionellt". Ekonomiskt våld kan visa sig genom att begränsa en kvinnas förmåga att arbeta utanför hemmet och ha en egen inkomst som kan främja självständighet.

Barnmorskor uttryckte brist på tillräckligt med tid för att diskutera IPV med patienter och screena dem under besök.

I fallet med de haitiska patienterna berodde detta på att de behövde en tolk, vilket fördröjde undersökningarna och förlängde diskussionerna mellan patient och vårdgivare. Andra gånger tog behovet av att dokumentera händelserna under mötet och uppdatera anteckningar om patientens framsteg och undersökningsresultat uppmärksamheten från patienten.

eller så kan hon sakna tid med en patient om hon gick över den tilldelade tiden med en tidigare patient.

Endast en barnmorska sa uttryckligen att om en patient behöver mer uppmärksamhet relaterat till sin risk för våld, så kommer hon att kompromissa och förkorta tiden med sina andra patienter.

Svårigheten med att försöka screena för våld förvärras av att partnern ofta var den som kom för att översätta åt patienten.

Detta skapade ett etiskt problem för barnmorskorna, eftersom screening för våld genom en partner kunde öka en kvinnas risk för framtida våld, och det är osannolikt att hon skulle rapportera det när en potentiell förövare är närvarande (Waalen et al., 2000).

Detta verkade göra barnmorskorna obekväma, då de flesta uttryckte frustration över att vilja kommunicera direkt med kvinnan men inte kunna göra det.

En barnmorska menade att det var för trubbigt och okänsligt att fråga direkt om patienten utsatts för våld, vilket menade att barnmorskans beteende och förhållningssätt till ämnet våld spelade roll och kunde påverka patientrapporteringen. Barnmorskorna upplevde att genom att ha en nära relation till patienten, eller åtminstone kunna känna empati med dem, kan patienten känna att de kan lita mer på dem. Önskan att vinna en patients förtroende och förtroende

Generellt önskade barnmorskorna mer resurser för sina patienter på det språk som patienterna förstår: information om vad de kan förvänta sig under graviditeten, hur en patient ska ta hand om sig själv under graviditeten, partnerbeteenden som kan öka risken för negativa utfall relaterade till IPV och vart de kan vända sig för att få stöd om de upplever IPV.

Jag tror att det som saknas är kunskapen om de platser som vi kan vända oss till.

Men när det inte finns några tecken på fysiska blåmärken till följd av aggressionen finns det svårigheter för denna skada, därför krävs större uppmärksamhet från hälso- och sjukvårdsteamens sida och en noggrann övervakning i varje enskilt fall(12).

älso- och sjukvårdspersonal känner till fördelarna med mödravården som VIP-personen omfattar, men att de inte kan utföra dessa specifika besök rutinmässigt, eftersom partnern är närvarande

Att etablera en relation av tillit och att kunna förstå vad hälsoanvändaren inte verbaliserar, utan uttrycks i sin kropp och sitt beteende, var de medel som hälso- och sjukvårdspersonalen använde för att underlätta identifieringen av VIP-personen(13).

Det var under omfamningen, efter att ha identifierat att patienten hade ett mycket sorgset ansikte. Under omfamningen måste den professionella vara öppen för att lyssna, eftersom kvinnor i allmänhet skäms för att tala, de känner sig skyldiga. (E1

skulle vilja ha mer utbildning och att det fanns professioner på FHSC så att vi skulle kunna diskutera fallen. Vi saknar mycket vägledning i frågan. (E5)

The continuity of care for pregnant women (...) runs into the lack of training and in the lack of a network of services with good communication. (E13)

, reporting and internal referrals provide protection for the professional as well, since there are other devices involved. So I would send it to the network, even though it does not work as it should, but it is a protection for the professional that it does not just stay inside the unit.

would have to have more property to know where to referral. If you direct her to the wrong place, she stays in that go and returns all the time, and it ends up discrediting the situation of the woman

The continuity of care for pregnant women (...) runs into the lack of training and in the lack of a network of services with good communication

We are not prepared to meet and have a network of services to give us this support

Many professionals are afraid to make the notification; there is the question of the identification, which we know is not something that needs to be identified

Be it any kind of violence, we would have to have more security as a professional

Most of the participants felt that routine screening is a time-consuming process, it is not their job, lack of time, lack of privacy, increased workload, et

We have an acute shortage of staff and increased workload, so we are mainly focusing on the routine activities of the unit, for example, giving medicines, meeting hygiene needs of the patients

“We don't have checklist or SOP to screen abuse routinely, we should get instructions on how to ask and what to ask about abuse...”. (N2) “If any format is available, nurses can ask the educated women to fill and give…. because directly asking about abuse won't be good. In the case of illiterate women, nurses have to ask in such a way that, they should not get hurt and fill the form

All the participants agreed that though they are confident in providing physical care to abused women, they lack confidence in screening routinely for abusive experiences. They also expressed that their training on this issue was insufficient.

While all the participants agreed that they had insufficient training on domestic violence they lack the opportunities to learn much about violence against women. They were less aware of conferences, workshops, and Continuous Nursing Education (CNE) programs on this sensitive issue

“Yes ...I need further education on this issue…. Because whenever patients disclose, I become emotional and I don't know how to handle my emotions

Because sometimes, the way how we are asking the question itself will traumatize them. If we are trained about this, we will be able to do this successfully

Undertema 9: Arbetsrelaterade hinder De flesta av deltagarna ansåg att rutinmässig screening är en tidskrävande process, att det inte är deras jobb, brist på tid, brist på integritet, ökad arbetsbelastning etc. "Tidskrävande...". (N1) "Vanligtvis är det psykosociala perspektiv som behandlas av socialsekreteraren." (N3) "Brist på integritet...". (N3) "Brist på tid för att fråga om övergrepp hos kvinnor och reagera på det...".

"Vi har en akut brist på personal och ökad arbetsbelastning, så vi fokuserar främst på enhetens rutinaktiviteter, till exempel att ge mediciner, tillgodose patienternas hygienbehov". (N5)

De ansåg också att om det finns några blanketter tillgängliga kan de be de utbildade kvinnorna att fylla i blanketterna eftersom det är en känslig fråga. "Vi har ingen checklista eller SOP för att screena missbruk rutinmässigt, vi borde få instruktioner om hur man frågar och vad man ska fråga om övergrepp...". (N2)

saknar de förtroende för att rutinmässigt screena för övergreppsupplevelser. De uttryckte också att deras utbildning i denna fråga var otillräcklig. Få av illustrationerna finns med. "Till viss del kan jag prata med kvinnorna... men jag är inte helt säker på att hantera den här frågan".

"Nej... Jag vet inte hur jag ska prata med en kvinna som har utsatts för övergrepp. Jag blir väldigt känslosam.

Även om alla deltagare var överens om att de hade otillräcklig utbildning om våld i hemmet, saknar de möjligheter att lära sig mycket om våld mot kvinnor. De var mindre medvetna om konferenser, workshops och program för kontinuerlig sjuksköterskeutbildning (CNE) om denna känsliga fråga.

Deltema 13: Behov av vidareutbildning Samtliga deltagare uppgav att de saknar förtroende för hur man screenar rutinmässigt och bemöter kvinnor med övergrepp.

De uttryckte också att de är intresserade av att delta i CNE-program, workshops och konferenser för att lära sig om denna viktiga fråga.

Vidare föreslog de att inkludera ett ämne om våld i hemmet och sjuksköterskors roll i deras sjuksköterskeutbildning. De ansåg också att administrationen borde stödja dem genom att ta fram riktlinjer, policys för att rutinmässigt screena övergrepp bland kvinnor med psykisk ohälsa.

"Ja, ... Jag behöver ytterligare utbildning i denna fråga .... För varje gång föräldrarna avslöjar det blir jag känslosam och jag vet inte hur jag ska hantera mina känslor...". (N1) "Detta är en mycket viktig och mycket vanlig fråga. Till och med patinen

I feel I need more training and updating in issues around domestic violence. Like all trusts, education needs are not priority for staff-financial constraints

Although, some of the participants noted that few resources are available, they were also concerned about the delays in building a case for IPV.

I referred a woman last month and the social services referral was disheartening. I ended up being passed around and giving the details to four different individuals and when I rang back the next day, they had no details of hers on file! I had to start the process again. This took time.. I ended up staying three hours late to sort it out

. The willingness of social care agencies needs to improve because at the moment, the whole referral process demands more time than we can give it, and still give safe care to other women we are caring for (for example, on busy hospital wards).

. Although policies are available, they are inadequate and at times “inappropriate/insensitive” to the reality of what staff can do with the limitations of times and resources

Improved training is definitely needed in this sensitive area for all midwives in my opinion.

Jag känner att jag behöver mer utbildning och uppdatering i frågor som rör våld i nära relationer. Liksom alla stiftelser är utbildningsbehov inte prioriterade på grund av personalens ekonomiska begränsningar.

En av deltagarna ger till exempel en tydlig redogörelse för arbetets komplexitet, behovet av resurser och fördröjningarna i handläggningen av ärenden och intressebevakningen:

Det tar lång tid att skicka akuta remisser till socialtjänsten

Det var uppenbart att deltagarna var motiverade att hantera fall av våld mot våld på ett effektivt sätt, men att de inte hade utbildning och resurser. Därför ägnade de sig åt att lära sig genom rättegångar och misstag

Det behövs definitivt en förbättrad utbildning inom detta känsliga område för alla barnmorskor enligt min mening

Screening was also significantly associated with certain organizational factors inherent to the clinic setting. Providers employed by clinics that had instituted clear protocols for addressing IPV (c2 [3, 134] ¼ 23.19; p ¼ .01), those with high levels of perceived knowledge of these protocols (c2 [3, 134] ¼ 24.73; p ¼ .01), and those who felt they had adequate referral sources for their abused patients (c2 [3, 134] ¼ 12.35; p ¼ .01) screened for IPV more often and among more patient categories.

Specific Screening scores were inversely correlated with knowledge scores (r ¼ 0.55; p < .01) and scores from two attitudes subscales, “staff preparation” (r ¼ 0.52; p < .01) and “victim understanding” (r ¼ 0.57; p < .01). Higher mean scores on the specific screening measure were associated with clear clinic protocols for addressing IPV (t [117] ¼ 5.09, p < .01 [“yes” ¼ 4.02 vs. “no” ¼ 2.68]), having adequate referral resources on-site to provide patients

The organizational factors that significantly predicted these patient counseling and safety assessment/safety planning were clinic protocols to address IPV (c2 [6, 134] ¼ 32.41; p < .01), community resources knowledge (c2 [6, 134] ¼ 22.34; p < .01), and adequate referral resources on site (c2 [6, 134] ¼ 36.19; p < .01).

Thirteen respondents stated they were unaware of any community resources for survivors and thus could not refer abused patients at all. One-half of providers responding to the survey indicated they were personally or socially acquainted with their patients outside of their practic