Chang et al.'s [22
] methods for mapping provided an innovative way to explore abused women's movements through the stages of change. This mapping exercise gave a visual representation for the series of decisions and small actions toward IPV disclosure in the emergency department. Similar to the findings of Chang et al. [22
], the majority of change maps for participants lacked linearity and included the multiple interruptions over time by external factors. These authors found that some participants skipped some of the stages of the TTM due to factors beyond their control like pregnancy, illness, and substance use. Likewise in our study, participants identified “turning point” events that served as catalysts for change. “Turning point” events served to initiate action, for example, self-initiated IPV disclosure. Some significant turning points that arose from this study were the fear of being killed by the perpetrator, fearing harm to an unborn baby or other children, needing emergency care for injuries related to violence, and feeling pressured to disclose IPV when asked by health care providers. This analysis provides new insights regarding participants who “weighed options” and considered their perceived risks of disclosing IPV with their perceived benefits. Despite a presentation of what appears to be a simplistic diagram of action steps, this exercise demonstrated that IPV disclosure in the emergency department is a complex process influenced by factors within and beyond the participant's control. For most of the women in this study, movement through the various stages of change took years and many visits to the emergency department that included treatment of injuries related to IPV. This exercise emphasized the role that clinicians can play in fostering client trust through communication and supporting a client's readiness for IPV disclosure.
There are many important clinical implications that arise from this mapping exercise. Nurses who encounter abused women can consider the processes that women undertake when deciding to disclose IPV in the emergency department setting. Wong et al. [33
] stated that health care providers undervalued the crucial role they can play in the response to women exposed to IPV. Among the participants of this study, IPV disclosure was found to be a positive experience when the nurse and other health care providers offered non-judgmental and empathic support. Considering how abused women move through the stages of the TTM can help guide nurse's conversations regarding IPV and work towards establishing the client's trust.
This mapping exercise could be used in future research to identify appropriate interventions that best fit with the TTM stage of change. Several authors recommended patterning IPV-related intervention with the client's stage of change [24
]. For example, when a nurse might suspect that a client is exposed to IPV, she or he could include a discussion of the TTM and attempt to identify which stage of change is most applicable [26
]. These authors stated that a woman's response to IPV-related questions indicated their stage within the TTM from denial of IPV (precontemplators) to describing strategies for how to deal with IPV (action). Authors recommended that nurses and other health care providers conduct “consciousness-raising” whereby the clinician educates abused women on the risks associated with IPV and expresses concern about their client's safety [25
]. For the participants of this study, consciousness raising might have been helpful if it was provided over multiple occasions to the women who disclosed IPV. These women drew on any information or support from nurses and health care providers when they were actively preparing for disclosure.
Among the women in earlier stages such as precontemplation and contemplation, however, this intervention by nurses could have been interpreted as invasive and created further feelings of shame among women seeking treatment in the emergency department. This was especially of concern among those participants who perceived their interactions with health care providers as invasive. These participants continued to be in a place of denial and perceived judgement for their decision to remain in an abusive relationship. Strategies to provide information about IPV in a noninvasive manner might assist participants concerned about further invasion from the health care provider.
This mapping technique may help explain issues that challenge health care provider such as frequent and multiple visits to the emergency department by abused women [34
]. These authors argued that nurses and health care providers frequently misunderstand client behaviours and become frustrated when women seek emergency care on multiple occasions. Women are often marginalized by the health care provider for the decisions they make in their relationships [34
]. This lack of understanding of the strategies that women use to mitigate the risks that they associate with IPV disclosure could serve as a barrier to women attempting to establish the nurse's trustworthiness and, ultimately, their own internal readiness for IPV disclosure. This mapping activity can also support health care provider education by addressing the lack of education—or skills—barrier related to IPV frequently cited by participants [16
]. Use of change maps illustrates how taking action towards IPV disclosure is a long process involving multiple visits to the emergency department. Understanding this can help nurses to recognize the complexity of IPV disclosure, which is often a slow process towards change. Awareness of the factors that facilitate and impede IPV disclosure may help ease judgments against a client for her decision not to disclose IPV. In the absence of evidence for effective interventions related to IPV disclosure, the research provided by authors on stage-based approaches related to IPV can help shift nurses and other health care providers attitudes to women exposed to IPV from one of judgment to one of neutrality.
One limitation of this study is its reliance on one set of informants—women exposed to IPV—to describe events and circumstances related to IPV disclosure. It would have been useful to include perspectives from nurses and other health care providers. It is difficult to discern whether participants shared all events related to the disclosure process or may have had difficulty recalling their experiences related to IPV disclosure. Future research could include women who had recently disclosed IPV within a specified time period, as opposed to participants who had disclosed over varied time periods.
In conclusion, these findings suggest that few women followed a linear pattern using the Transtheoretical Model of Change. The mapping technique can be a useful for emergency department nurses working with abused women to begin and guide conversations related to IPV. Consideration of the complex process of change and conveying a willingness to discuss IPV may promote trust and engagement between client and nurse.