The majority of 931 physicians and nurses completing a survey regarding their experience with IPV inquiry provided written responses to open-ended questions. These questions may have encouraged respondents to reflect and share their personal experiences. Perhaps respondents were also indicating that the short statements regarding barriers and facilitators included in the 43-item survey were too simplistic and did not fully capture the complexities of the issues they face related to IPV.
Overall, the top barriers to asking about IPV were lack of time, behaviours attributed to women living with abuse, lack of training, language/cultural practices and partner presence, while the facilitators cited most often included training, community resources/professional supports, and professional tools/protocols/policies. The statistically significant differences between nurses and physicians regarding both barriers and facilitators are most likely related to differences in roles and work environments.
After reviewing the comments, the study investigators were left with the impression that this is a very emotionally charged and complex practice issue for both nurses and physicians. Many nurses and physicians in this study continued to struggle with IPV inquiry. The sharing of personal stories – even in this self-administered, written format, was especially poignant and a reminder of additional burdens that some practitioners face related to IPV.
The two images of peeling off a mask
and opening a can of worms
further suggest the perceived complexities of this issue. The analogy of opening up a can of worms (or a “Pandora’s Box”), also noted by Sugg and Inui [13
] and McCauley and colleagues [27
] implies a sense of unpredictability and concern about having the necessary time and skills to deal with the many issues associated with abuse inquiry and disclosure. It is possible that for those who operate from a results-driven model of care, where actions are expected to solve problems, the inability to control a situation or the outcome, can be personally and professionally intimidating or frustrating. Understanding and accepting the lived experience of abused women, which may challenge practitioner logic, can be emotionally draining, while customizing care to unique circumstances and searching out resources may be time consuming and challenging. The image of peeling off a mask illustrates the challenges faced by some practitioners. It highlights the energy and time required of practitioners, the intensity of the experience for both abused women and practitioners and the secretiveness of IPV as a societal and practice issue. Such metaphors challenge us to explore approaches at multiple levels (i.e., practitioner, practice setting, workplace and community) and to ensure that practitioners have the necessary skill sets as well as on-going education and supports in their work environment.
Given that dealing with complex practice issues, is by definition, typically time consuming, the authors were not surprised that lack of time was the most frequently described barrier for nurses and physicians. Insufficient time is often cited as a barrier for a variety of practice issues. Lack of time is an important factor in health care environments, yet it can be a quick and almost automatic, impersonal response when asked to identify possible barriers. Even though very few nurses and physicians described personal discomfort as a barrier, focusing on lack of time may mask other barriers that may be more challenging for practitioners to address such as feelings of frustration, a sense of futility or helplessness about how best to respond.
It is noteworthy that of the barriers described by respondents in this study, 51.0% were attributed to the abused women themselves (57.8% nurses; 36.1% physicians) suggesting that practitioners described fewer barriers related to their own behaviours. Their frustration with women choosing not to accept their advice or returning to partners after leaving, in and of itself, suggests the need for more education with respect to the complex dynamics of IPV.
As noted in Table
, formal IPV training is not common and others have found that this kind of basic education is not the norm [28
]. This reported lack of formal training points to potential curriculum gaps and the need for continuous learning opportunities in the work place. Both nurses and physicians indicated that they wanted to know how to introduce the topic and what to do if the woman discloses. Challenges in engaging women in such sensitive discussions have been noted by other investigators [13
]. It is recognized that training can heighten sensitivity and enhance awareness. Hence, feelings of frustration expressed by both nurses and physicians accompanied by attitudes that appear to blame women may be consistent with low rates of formal training. Furthermore, it is not surprising that with the low rates of formal training, 30.4% of nurses had never heard a disclosure compared to only 5.0% of physicians (Table
). However, recognizing that reports of formal IPV training were low for both nurses (37.0%) and physicians (40.8%), the stark differences in disclosures between nurses and physicians may be explained by role differences, patient behaviour, the nature of the patient interaction and the practice setting, especially in terms of safe and confidential spaces for these discussions. Nonetheless, this finding is alarming given the prevalence of woman abuse and that respondents were recruited from practice areas where IPV is likely to be encountered.
The seemingly greater emphasis on training by nurses requires further inquiry. This finding is interesting considering that the proportion of physicians (58.0%) and nurses (61.5%) who had no formal IPV training is similar. Many respondents, especially nurses, recommended training during their formal educational programs, continuing professional education, the opportunity to practice such skills and the opportunity to learn from the experiences of others. Greater emphasis on training by nurses may be related to role differences in client interactions depending on the discipline, and/or lack of experience with disclosure. Although training can result in greater knowledge, confidence and skill development, it is likely overly simplistic to suggest that training without periodic refreshers, other structural supports and organizational policies will result in significant practice changes [15
]. This may be a practice issue that needs to be repeatedly addressed in a supportive practice setting to be understood and one that is very challenging to learn through simulated or theoretical experiences.
These findings suggest that in order not to blame women and to better address barriers to IPV inquiry, nurses and physicians need greater understanding of the complex dynamics and contextual factors that result in women continuing to deny abuse, not following through on intended actions or returning to abusive partners. Roberts et al. cite multiple stressors that abused women frequently encounter, including financial challenges, child custody battles, a sense of fear, altered social supports and feelings associated with the loss of emotional attachments with their abusers [31
]. Furthermore, these authors suggest that abused women need to balance the rewards of leaving with the costs of this decision. Bennett and colleagues refer to the challenges that abused women often encounter when entering the justice system, such as a sense of confusion with the process, time delays, minimal information and the need for multiple appointments at a time when access to resources including child care, transportation and finances, are reduced [32
]. Moreover, Bonomi et al. refer to both subtle and blatant pressures that abusers may direct towards abused women [33
]. The impact of these cumulative stressors may be initially downplayed by abused women until experienced first-hand, resulting in the increased likelihood that women return to abusive relationships [31
The impact on abuse disclosure and practitioner behaviour of legislation, that requires practitioners to contact child protective agencies when child abuse is suspected, is an area requiring further study. While further research about how best to address barriers to IPV inquiry faced by nurses and physicians is warranted, some actions in the workplace can be instituted. The potential challenges of collaborating across sectors can be minimized by developing strong relationships and an understanding of other sector roles and responsibilities. Providing training and regular updates, facilitating quick and easy access for consultations and the opportunity to discuss individual situations are important supportive strategies rather than leaving practitioners to face such decision points alone.
Overall, the nurses and physicians cited similar barriers and facilitators; however there were important differences in responses between the two disciplines. Some differences, such as language barriers, partner presence and lack of privacy, which were described more often by nurses, may be related to differences in role expectations and work environments between nurses and physicians. Similarly, because nurses are more likely to be employees, management support and agency policy are important factors for nurses when dealing with IPV. Knowing the types of barriers experienced by practitioners can influence the need for workplace policies and the development of pre-service and in-service training materials. Such resources can be customized by discipline, while customization by practice setting is an area for future study.
Our findings are consistent with previous studies of barriers and facilitators to asking about IPV, in particular barriers such as lack of provider education, frustration, lack of time and fear of offending a patient exposed to IPV [13
]. It is disappointing that many of the barriers to abuse inquiry have not changed in the last 15
years. However, this finding suggests that approaches designed to assist practitioners in handling these commonly cited barriers may rest in the synergistic nature of the barriers and such approaches should not attempt to deal with barriers one at a time. A systems perspective that recognizes the complexity and inter-connectedness across barriers may yield more promising results.
In addition to corroborating the results of past studies, this study provides further insight into why some barriers have not changed. Lack of clinician confidence is not surprising, given the paucity of evidence-based interventions to which abused women can be referred [34
]. IPV is a complex and multidimensional issue that is not solely the domain of the health care sector. Interprofessional and cross-sectoral collaboration is required. Expressions of professional challenges in being able to adequately meet the needs of abused women, and feelings of frustration and concerns about not knowing what to do if women disclose, suggest that more is needed to support practitioners. In order to navigate the complexities that surround asking about IPV, practitioners require specific personal skills and knowledge, access to community resources and work environments that encourage the development and sustainability of these skills. Mentoring, coaching and opportunities for debriefing and reflective practice are important supports for sustaining practitioner capacity for IPV inquiry.
Although barriers and facilitators were categorized, it is evident from the analysis that there is some overlap across categories. This suggests the need for comprehensive frameworks to explore further the many issues associated with IPV inquiry and the interplay across these issues. Multifaceted i.e., practitioner, workplace, community and patient-centred, intersectoral approaches are warranted. The complexities associated with IPV inquiry require action at many levels and failing to systematically address all levels may yield less than desirable results.
These findings highlight the need for on-going rigorous research to assist in identifying best practices from the perspective of both abused women and practitioners. In addition, the needs of all women should be considered when developing patient-centred approaches that are sensitive to race, ethnicity, socioeconomic status, religious/spiritual beliefs, age, ability and sexual orientation.
Strengths and limitations of the study
This study has several strengths. Existing practice directories were used to randomly identify possible participants; responses from these participants provided rich data to explore the themes outlined above. The willingness of these respondents to provide detailed comments suggest that these practitioners were committed to IPV related issues. However, despite the high proportion of physicians (72.6%) who provided written comments among those who responded, only 32.8% (328) of physicians invited to participate in the study returned the survey. This may have limited the identification by physicians of perceived barriers and facilitators. However, while there is, in theory, a greater chance for bias when response rates are low, such response rates do not always mean biased responses [35
]. Others have noted the challenges to obtaining high response rates to mailed surveys targeting physicians [36
Furthermore, respondents may have been inclined to provide more socially acceptable and brief answers considering the sensitivity of the topic and the method of data collection, yet the volume and the richness of the written responses mitigate these limitations. Although the mailed survey offered respondents anonymity and a sense of privacy in which to share their perspectives and experiences without sanction, there was no opportunity for the researchers to seek clarification or further detail. The participants completed the open-ended questions without the benefit of interviewer prompts and without the stimulus of other participants. Future research would benefit from follow-up interviews which could provide further insights into the differences between nurses and physicians.