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thesis entitled

PORTRAIT OF AN ABUSED WOMAN: D0 PRIMARY HEALTH
CARE PROVIDERS RECOGNIZE HER?

presented by

Deborah Kay Johnson

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PORTRAIT OF AN ABUSED WOMAN: DO PRIMARY HEALTH
CARE PROVIDERS RECOGNIZE HER?

BY

Deborah Kay Johnson

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1997

ABSTRACT

PORTRAIT OF AN ABUSED WOMAN: DO PRIMARY HEALTH
CARE PROVIDERS RECOGNIZE HER?

BY
Deborah K. Johnson

This study was based on a previous study by McClure
(1993) and describes primary health care providers'
assessment practices related to domestic violence.
Variables studied included knowledge of the prevalence of
domestic violence, possible indicators of domestic violence
and referral resources in the community; screening and exam
practices of providers; potential barriers to assessment;
and the use of referral resources. A questionnaire was_
mailed to 213 physicians and 38 advanced practice nurses in
a tri-county area of Michigan. Twenty-five percent of the
physicians (49) and 66% of the advanced practice nurses (25)
returned completed questionnaires. Frequency statistics
revealed that providers in the study rarely to sometimes
assessed for domestic violence and a multivariate ANOVA
unveiled that apparent differences in assessment scores
between physicians and nurses were related to gender.
Females in the study tended to assess more frequently for
domestic violence than males. Implications for advanced

practice nursing are discussed.

Copyright by
DEBORAH KAY JOHNSON
1997

I wish to dedicate this thesis to my parents, Tom and
Sharon Johnson, for all their support, praise and

encouragement throughout my graduate degree pursuit.

iv

ACKNOWLEDGMENTS

I wish to thank all of the very important people who
helped make the production of this thesis possible. I would
like to thank Dr. Kathleen Cowling and Dr. MaryJo Wagner,
for writing a second cover letter encouraging providers'
participation in the study.’ I would also like to thank Dr.
Cowling and Dr. David Pugh for reviewing and critiquing
portions of the questionnaire. And, a very special thank
you to my parents, Tom and Sharon Johnson, and also to my
friends Michael Lounsbery and Vicki German for helping
review mailing lists, make copies, stuff envelopes and

prepare the surveys for mailing.

TABLE OF CONTENTS

INTRODUCTION . . . . . . . . L . . . . . . .
Research Questions . .

LITERATURE REVIEW . . . . . . . .
Conceptual Definitions . . . . . .
Domestic Violence . . . . . .
Primary Health Care . . . . .
Primary Health Care Setting .
Primary Health Care Provider .
Knowledge About Domestic Violence
Assessment Practices .
Referral Resources
Barrier . . . . . .
Assessment Practices . .

Referral Resources . .
Knowledge . . . . . .
Other Barriers . . . . .
Critique of the Literature
Conceptual Framework . . .

METHODS . . . . . . . . . . . . . . . . . . .
Sample . . . . . . . . . . . . . .
Data Collection Procedure and Recording
Protection of Human Subjects . . . . .
Instrument . . . . . . . . . .
Operational Definitions . . .

Assessment Practices .
Knowledge . . . . . . .

Barrier . . . . . . . . . .
Use of Referral Resources . . . .
Scoring and Data Summarizing Procedures
Data Analysis . . . . . . . . . . . .

RESULTS . . . . . . . . . .
Demographic Characteristics
Instrument/Measures . . . .
Other Findings . . . . . . .
Research Questions . . . . .
Interpretation of Findings .

vi

Table of Contents (cont.)

DISCUSSION . . . . .
Methodological Assumptions and Limitations . .
Implication of Results for Existing Literature
Implications for Advanced Practice Nursing . .
Implications for Future Research . . . . . . .

REFMCES O O O O O O O O O O O O O O O O O O O 0

LIST OF APPENDICES

Letter of Explanation by Researcher . .
Letter of Explanation by Emergency Room
Physicians . . . . . . . . . . . . . .
UCRIHS Approval Letter . . . . . . . . .
Permission to Use Survey Tool Letter . .
Survey: Domestic Violence: Knowledge and
Assessment Practice . . . . . . . . . .

MUG U3?

vii

Page

50
50
51
52
56

. 63
. 64
. 65

Table

Table

Table

Table

Table

Table

Table

Table

LIST OF TABLES

Distribution of Sample by Professional and
Type of Health Care Provider . . . . . . . .

Distribution of Sample by Sex . . . . . . . .

Distribution of Sample by Age and Number
of Years in Current Specialty . . . . . . .

Distribution of Sample by Clinic, Practice,
and Environmental Settings . . . . . . . . .

Distribution of Sample based on Educational
Background regarding Domestic Violence . . .

Sample Distribution of Knowledge and
Prior Use of Referral Resources . . . . . .

Distribution of Sample Response to Assessment
questions O O O O O O O O O O O O O O O O O

Sample Distribution regarding Barriers to
Assessing for Domestic Violence . . . . . .

viii

Page

LI ST OF FIGURES

Page

Figure 1: Battering in Pregnancy. Application of
Research Variables to the Health Belief
”“81 O O O O O O O O O O O O O O O O O O O O 2 2

Figure 2: Domestic Violence in Primary Care.
Application of Research Variables to the
Health Belief Model . . . . . . . . . . . . . 24

ix

INTRODUCTION

My name is Samantha and I am forty-two. I have been
married for twelve years to an executive at an advertising
agency. we have three beautiful children. Life is good
right now except for these headaches I have been having.
I've seen my doctor, but he doesn't seem to know what is
causing them. All the tests have come back negative. I
wish he could tell me what is wrong with me.

My name is Ann and I am thirty-one. My boyfriend and I
have been living together for the past year and are planning
to get married next month. He has been so good to me and my
little boy Jason. I don't know where my son and I would be
living if it weren't for him. EVerything is going great
right now. Except I seem to be a little clumsy lately. Two
months ago I tripped and fell down the stairs and broke my
right arm, and now just yesterday I lost my balance again
and bumped my left eye. I suppose it's just all the
excitement planning for the wedding.

My name is Christy and I am seventeen. Steve and I
have been dating since the beginning of school this year.

He is the captain of the football team and everyone is
envious of me. I am so lucky. Mom and dad don't really

like Steve. They think he is too rough with me. It's only

1

2
a couple of bruises and he didn't mean to hurt me. We were
just playing around. He was so sorry afterward. He even
sent me flowers. It's not like he broke my arm or anything.

The purpose of this study was to describe primary
health care providers' assessment practices regarding
domestic violence. This study identified to what extent
primary care providers assessed for domestic violence and
whether or not knowledge and barriers had an impact on the
assessment practices of primary health care providers. This
study also examined the use of referral resources by
providers and, lastly, compared advanced practice nurses and
physicians with regard to knowledge, barriers, assessment
practices, and use of referral resources.

Domestic violence was once thought of as merely a
private matter between the two people involved or as a legal
matter only for the police to address. While domestic
violence remains a significant legal issue, it is
increasingly becoming a major public health problem. Recent
studies show that domestic violence results in more injuries
requiring medical attention than rape, auto accidents, and
muggings combined; and it may in fact be the most common
cause of injury to women (Council on Scientific Affairs,
AMA, 1992). Domestic violence is reaching epidemic
proportions in the United States. Each year approximately 2
to 4 million women suffer domestic violence (Novello,
Rosenberg, Saltzman, & Shosky, 1992; Straus, Gelles, &

Steinmetz, 1980). Broken down into dimensions of time, a

3
woman is abused every 7 seconds (McLeer, Anwar, Herman, &
Maquiling, 1989). Although the actual incidence is not
known, it has been cited suggested that on average 20% of
U.S. woman have been physically or sexually assaulted at
some point in their lives by a male significant other
(Strauss & Gelles, 1990; Council on Scientific Affairs,
1992; AMA, 1992). Injuries related to domestic violence are
likely to be more serious and result in more episodes of
loss of consciousness than injuries sustained in stranger
violence (Chambliss, Bay, 8 Jones, 1994). One study showed
that 16% to 30% of women reporting to an emergency room with
injuries were identified as victims of battering (McLeer et
a1., 1989). Two to four thousand women die each year after
being assaulted (AAFP, 1994), representing 42% of murdered
women killed by their significant others (Analysis by the
Center for the Study and Prevention of Violence).

Domestic violence is not a one-time occurrence.
According to the Bureau of Justice Statistics, 32% of women
who reported an incident of domestic violence were battered
again in 6 months (Smikle, Satin, Dellinger, & Hankins,
1995). The American Medical Association guidelines report
similar findings in that 47% of husbands who beat their
wives do so at least three times a year (ACOG, 1995).
Twenty percent of battered women will make at least 11
office visits to their physician for incidents of trauma
(American Medical Association, 1994), making it a costly

problem as well.

4

Domestic violence does not discriminate. It cuts
across all demographic lines and includes women of all
racial, socioeconomic, religious, and ethnic backgrounds
(Neufeld, 1996). Smikle et a1. (1995), surveyed 531
employed, middle-class women and discovered 72 (13.5%)
reported histories of physical abuse, 37 (7%) sexual abuse,
and 40 (7.5%) both physical and sexual abuse, a total of 28%
abused overall. In another study of 787 medical students
and faculty, 17% of the females reported experiencing
physical or sexual abuse in their adult life (deLahunta &
Tulsky, 1996).

Victims of domestic violence are affected in many ways.
The most obvious, of course, is by the visible injuries of
broken bones and bruises. The most common sites for injury
include the head, neck, face, breast or abdomen (AMA
Diagnostic and Treatment Guidelines on Domestic Violence,
1994). Permanent injuries include those due to: burns,
loss of vision or hearing, bite and knife wounds, and damage
to the joints (ACOG, 1995). Woman battering is not only
physical. The emotional and psychological abuse endured at
the hands of the batterer results in many primary care and
psychiatric complaints. Common medical problems frequently
associated with abuse victims include: headache, abdominal
and pelvic pain, irritable bowel syndrome, sexual
dysfunction, myalgia, arthralgias, insomnia, eating
disorders, depression, and chemical dependency (Friedman,

Samet, Roberts, Hudlin, & Hans, 1992). In addition, an

5
estimated 26% of women who attempt suicide have experienced
domestic violence (Melvin & Brunton, 1995).

Victims of domestic violence are not only spouses or
intimate partners. When a woman becomes pregnant there are
two victims. Frequently abuse may begin or escalate during
pregnancy (Bohn, 1990), and it is often the cause of
miscarriage, stillbirths, and premature delivery (Bullock,
McFarlane, Bateman, & Miller, 1989). In addition, battered
women are twice as likely to begin prenatal care in the
third trimester than their nonabused counterparts
(McFarlane, Parker, Soenken, & Bullock, 1992). According to
Helton (1987), infants born to women who experienced abuse
during pregnancy may develop feeding difficulties and
failure to thrive. The children that do survive frequently
grow up in violent environments witnessing the abuse or
being physically abused themselves. As a result, these
children are at increased risk of developing childhood
behavioral problems or aggressive tendencies in future
relationships (ACOG, 1995; Wolfe, Jaffe, Wilson, & Zak,
1985). “Sadly the cycle of abuse continues to turn.
Violent fathers pass their violent heritage along to their
sons, and daughters often find themselves in relationships
that mirror the abusive one they saw modeled at home”
(Easley, 1996, p. 762).

Given the prevalence of domestic violence and that it
is not a one time occurrence, undoubtedly domestic violence

victims are being seen in primary health care settings. The

6

unique relationship between the primary care provider and

patient frequently allows for multiple contacts on a regular

basis and often times includes more than one member of the
family. This grants the primary health care provider an
exceptional opportunity for the identification and
intervention of domestic violence. The question is, Are
victims of domestic violence being recognized in the primary
health care setting? The current literature seems to

indicate that the answer is no (Chambliss et al., 1995;

Hamberger, Saunders, & Hovey, 1992; Bokunewicz & Copel,

1992; deLahunta, 1995; Brown, Lent, & Sas, 1993; Randall,

1990; 5 AMA, 1994). This, then, lends itself to the next

obvious question, why?

Researcmgstians
The following research questions have been devised for

this research project.

1. To what extent do primary health care providers
verbally and physically assess for domestic violence?

2. Is there a relationship between knowledge regarding
domestic violence and the assessment practices of
primary health care providers?

3. Is there a relationship between barriers identified and
the assessment practices of primary health care
providers regarding domestic violence?

4. Is there a relationship between assessment practices of
primary health care providers and the use of referral

resources?

7

5. Is there a difference between advanced practice nurses
and physicians regarding assessment practices for
domestic violence?

6. Is there a difference between advanced practice nurses
and physicians regarding knowledge of domestic
violence?

7. Is there a difference between advanced practice nurses
and physicians regarding barriers to domestic violence
assessment?

8. Is there a difference between advanced practice nurses
and physicians regarding use of referral resources?

LITERATURE REVIEW

The following terms will be conceptually defined:
domestic violence, primary health care, primary health care
setting, primary health care provider, knowledge, assessment
practices, referral resources, and barriers.

MW. ”Domestic violence is a pattern of
assaultive and coercive behaviors, including physical,
sexual, and psychological attacks, as well as economic
coercion, that adults or adolescents use against their
intimate partners” (Ganley, 1996, p. 16) . This author
recognizes that domestic violence also occurs against men;
however, the U.S. Department of Justice estimates that in

95% of reported assaults, men are the perpetrators (Douglas,

1991) and often are not in need of treatment. Therefore,

within the context of this paper, domestic violence included

8
any physical, sexual, or psychological attacks by a male

against a female intimate partner.

Brimazy_hga1th_gazeL Primary health care is defined by
the Institute of Medicine's Committee on the Future of

Primary Care (Donaldson, Yordy, & Vanselow, 1994) as
follows:

Primary care is the provision of integrated,

accessible health care services by clinicians who

are accountable for addressing a large majority of
personal health care needs developing a sustained
partnership with patients, and practicing in the

context of family and community. (p. 1).

In his definition of primary health care, Silver (1977)
emphasizes that primary care should be based “on a firm
foundation which integrates knowledge of the medical,
biological, physical, social, psychological, and behavioral
sciencesu' He also believes that regardless of who is
delivering the care, the provider"should assume
responsibility and accountability for the coordination,
integration, and continuing management of the patient's
total health care and services” (p. 151) .

In her book. Wad
Policy, Starfield (1992) describes primary care as “the
basic level of care provided equally to everyone.” She
states itL'addresses the most common problems in the
community by providing preventive, curative, and

rehabilitative services to maximize health and well-being.

9
It is care that organizes and rationalizes the deployment of
all resources, basic as well as specialized, directed at
promoting, maintaining, and improving health” (p. 4).

For purposes of this paper, primary health care was
defined as holistic care that encompasses comprehensive,
cost effective, and quality care throughout the lifespan.
The goals of primary care are that of illness prevention,
health promotion, and optimal health maintenance, and these
goals are achieved through the use of teamwork and the
efforts of collaboration, consultation, and integration of
other health care providers.

2zimazy_hgalth_garg_setting. Much of the research done
on domestic violence reflects frequent visits by victims to
emergency rooms and very little has been published on other
health care settings. Although many patients use the
emergency room as a provider of primary care, emergency
departments are not the only health care setting impacted by
domestic violence. Battered women are also seen in family
practice offices. One study conducted by Hamberger,
Saunders, & Hovey (1992), reported 23% of women seen in a
family practice clinic had been physically abused by their
partners within the past year and 39% had been physically
abused by an intimate partner at some time in their lives.
Another study conducted in an internal medicine practice
cited similar but lower ratings. Six percent of female
respondents reported domestic violence the previous year,

21% some time in their adult lives, and 33% either as an

10

adult or child (McCauley, Kern, Kolodner, Dill, Schroeder,
DeChant, Ryden, Bass, & Derogatis, 1995). And in a review
of thirteen studies measuring the prevalence of abuse in
pregnancy, statistics ranged from 0.9% to 20.1%, making it
an obstetrical and gynecological practice site issue as well
(Gazmararian, Lazorick, Spitz, Ballard, Saltzman, & Marks,
1996). For purposes of this paper, primary health care
settings included family practice, internal medicine, and
obstetrics and gynecological practices.-

2zimary_health_gare_prgxidgr. Providers of primary
health care include physicians, either MDs or DOs, and
advanced practice nurses (APN). Safriet (1992) defines the
advanced practice nurse as a registered nurse with
additional training and education either in the form of a
certificate or master's degree. According to the National
Council of State Boards of Nursing (NCSBN, 1992), “the
skills and abilities essential for the advance practice role
within an identified specialty area include: providing
patient/client and community education; promoting stress
prevention and management; encouraging self help;
subscribing to caring; advocacy; accountability,
accessibility; and collaboration with other health and
community professionals” (Mezey & McGivern, 1993, p. 5).
For purposes of this study, primary health care providers
were defined as an MD, D0, or an APN.

WWW Webster (1990) .

defines knowledge as, “the specific extent of what is known

11

about something, as by an individual“ (p. 406). This author
referred to knowledge as the specific extent to which a
primary health care provider knows about domestic violence.
This knowledge included the prevalence of domestic violence
in the primary health care setting, possible signs and
symptoms of domestic violence, potential behaviors
indicating the presence of domestic violence, and available
referral resources in the community. This knowledge could
be gained through clinical experience or from formal
education--either medical or nursing school, through the
attendance at a conference, seminar or lecture, or gathered
from published literature and professional journals.

Aggggamgnt_pzagtiggs. Assessment has been defined as
“the deliberate and systematic collection of data to
determine a client's current health status and to evaluate
his [or her] present and past coping patterns“ (Carpenito,
1983, p. 24). According to Carpenito, the data is obtained
through an interview, physical examination, observations,
and review of records and reports. According to Sassetti
(1993), screening for domestic violence is a necessary
assessment practice for primary health care providers in the
detection of domestic violence, not only when abuse is
suspected, but also annually during routine health
maintenance exam (Sassetti, 1993) and with each new client
visit (McClure, 1996) . Primary health care providers “must
learn to recognize the signs and symptoms of abuse and

simply ask the women presenting with such complaints if they

12

are suffering from violence in their homes“ (Sassetti, 1993,
p. 299). Since no reliable indicator of abuse exists
(Sassetti, 1993) and because some women are not likely to
report they are being abused (American Medical Association,
1994), it is equally important to assess all women even if
they do not present with specific signs and symptoms of
abuse. Within the context of this paper, assessment
practices were defined as the routine screening by primary
health care providers for domestic violence either through
questions on an initial intake or history form, inquiring
directly, or by findings on physical exam.

Befgzra1_ngsgnrggs. Referral resources are community
based services which.can provide a battered woman with
needed support. Resources include local counseling and
crisis intervention services, shelters (AMA, 1994), mental
health workers, and 24 hour telephone hotline phone numbers
(Alpert, 1995). In addition, referrals from providers may
include access to legal information such as police
departments (AMA, 1994), attorneys, court advocates, or
legal services centers (Alpert, 1995). For purposes of this
study, referral resources included a 24 hour crisis line,
police force, prosecuting attorney's office, legal aid,
shelter or safehouse, and counseling services.

Barrier; In summarizing the Health Belief Model, Hardy
& Conway (1988), describe barriers as.“impediments to taking
action“ (p. 379) . Common barriers to assessing for abuse

include the provider's lack of time, fear of offending,

13
feelings of powerlessness, and sense of loss of control
(Sugg & Inui, 1992). For purposes of this study, this
author defined a barrier as anything that hinders or
obstructs a provider from assessing for domestic violence
and/or initiating appropriate intervention and referral.

The following is a general literature review of the
major components of this thesis: assessment practices,
knowledge, barriers, and use of referral resources.
Wises

A story of two physicians (a cardiologist and a
surgeon) illustrates the need for assessment for domestic
violence. The cardiologist relates to the surgeon how much
he does in the area of battered women and domestic violence.
The cardiologist not only helps abused women in his practice
by providing counsel and advice, but he also advocates the
cause and helps to establish shelters. (Upon hearing this
the surprised surgeon says, “Gee, to be doing all this you
really must see a lot of battered women in your practice.”
The cardiologist replies, “Yes, and so do you.” (Rosenberg,
1995, p. 989).

In spite of the staggering statistics and the drastic
consequences of domestic violence, health care providers
frequently do not ask about abuse. When compared to
interdisciplinary team members of the community such as;
lawyers, social workers, police officers, shelter personnel
and women's groups, physicians have been rated the least

effective in working with battered women (Melvin & Brunton,

14
1995). In one study on the rates of inquiry by physicians,
394 women were seen in practice, of these 23% had been
abused in the last year, 39% reported abuse at some point in
their life, yet only six had ever been asked about battering
by their provider (Hamberger et al., 1992). Friedman et a1.
(1992), reported 67% of physicians did not inquire about
physical abuse at initial visits and 60% did not inquire at
annual visits. In the same study, a history of physical
abuse was reported in 16% of the patients, although only 7%
had ever been asked; and a history of sexual abuse was noted
in 17% of those surveyed, but only 6% had ever been
questioned. In a more recent survey of screening behaviors
of obstetricians and gynecologists, researchers concluded
that the majority of the providers surveyed did not screen
their patients for current or past domestic violence
(Parsons, Zaccaro, Wells, & Stovall, 1995).

Direct questioning is the single most effective tool
for identifying spousal or partner abuse. In a study
conducted by Rodriguez, Quiroga, and Bauer (1996), 39 of 51
women (76%) with histories of domestic violence favored
direct questioning about abuse, whether their injuries were
obvious or their signs more discreet, or whether it was part
of a routine screening. Similarly, Friedman et al. (1992)
found that of 164 women surveyed, 128 (78%) favored routine
physical abuse inquiry. Victims are often reluctant to
initiate the topic of abuse on their own, but when asked
will often times admit to being battered. Women are

15

relieved that someone is concerned enough to ask and welcome
talking about it in a safe atmosphere (Melvin 8 Brunton,
1995). One study found that 8% of women reported abuse when
asked on a questionnaire, but when verbally asked the same
four assessment questions face to face, 29% reported abuse
(McFarlane, Bateman, Miller, 8 Bullock, 1991). The four
assessment questions most commonly reported are: 1) Have
you ever.been emotionally or physically abused by your
partner or someone important to you? 2) Within the last
year, have you been hit, slapped, kicked, or otherwise
physically hurt by someone? 3) Within the last year has
anyone forced you to have sexual activities? and 4) Are you
afraid of your partner or anyone you listed above?
(McFarlane, Parker, Soeken, & Bullock 1992). These four
questions are consistent with questions recommended by the
American Medical Association when assessing for abuse (AMA
Diagnostic Treatment Guidelines on Domestic Violence, 1994).
In addition, the AMA also recommends considering abuse when
a woman's injuries do not seem plausible, when she
frequently misses appointments, and when her partner insists
on accompanying her and not leaving her unattended.
ReferraLBesaurces

Once a primary health care provider identifies a
battered woman, it is crucial that the health care
professional create a supportive environment. The provider
must listen nonjudgementally, assess the victim's situation,

(ACOG, 1995), and validate her concerns (Alpert, 1995).

16

After providing medical support (Alpert, 1995) and inquiring
about the woman's safety, options should be discussed.
Counseling about emergency exit plans should be offered, as
well as, group and individual counseling (Neufeld, 1996).
In addition, written information regarding crisis
intervention services, legal options, shelters, and
community resources should also be provided (AMA, 1994).
The study conducted by Rodriguiz et al. (1996) stresses the
importance of conveying respect and offering referrals.
Forty-five percent of the women surveyed emphasized the
importance of offering referrals to shelters, counseling
agencies, and social and legal services.
Knowledge

One of the most frequently cited reasons for failing to
assess for domestic violence is lack of knowledge (deLahunta
8 Tulsky, 1996; Chambliss et al., 1995; Brown, Lent, 8 Sas,
1993, Gremillion 8 Kanof, 1996). In a study of 962
physicians, 34% said that they had no education on domestic
violence and 49% felt inadequate in dealing with abuse
because of the lack of training (Parsons et al., 1995).
When 1994 graduating senior medical students were surveyed,
60% felt that the education received on domestic violence
was inadequate (Kassebaum 8 Anderson, 1995). Seventy-five
percent of responding program directors and chairmen of
obstetrics and gynecology residencies in the United States
and Puerto Rico did not identify one of 10 common clinical

scenarios as being indicative of battering (Chambliss et

17
al., 1994). The medical professionals are not the only
health care providers lacking in education on domestic
violence. Limandri and Tilden (1996), studied 1,521
clinicians from six health disciplines, the majority of whom
received little or no formal education on the subject of
abuse. Of the 241 nurses surveyed, 56% reported a lack of
education on spouse abuse. Parsons et al. (1995) determined
that any education on abuse was associated with an increase
in screening, including familiarity with the ACOG Technical
Bulletin on the subject of domestic violence.

Research has shown that even with a working knowledge
of battering in a woman, many times providers fail to
respond to the abuse or follow through with interventions
and referrals. One study by Kurz (1987), found that in 40%
of the cases where emergency room physicians interacted with
battered women they failed to address the abuse; and in
another study by Warshaw (1989), emergency department
physicians lacked follow-up or referral (as cited in Sugg 8
Inui, 1992). For this reason, this author studied knowledge
more thoroughly and separately from other barriers cited in
the literature.

OtheLBarriers

Apart from a lack of education, the reasons primary
health care providers fail to assess for domestic violence
are many and multifaceted. A common barrier to assessment
practices cited in the literature is time constraints (Sugg

8 Inui, 1992; Titus, 1996; AMA, 1994). Providers are

18
concerned that asking about domestic violence will.“open
Pandora's Box“ and consume too much of their scarce time.
Another is close identification with the patient. Health
care professionals with no personal experience of abuse
often assume patients with similar social backgrounds and
characteristics are likewise not at risk (Sugg 8 Inui,
1992). Conversely, a provider's own past experiences of
abuse may preclude assessing for domestic violence in
patients (Gremillion 8 Kanof, 1996; Alpert, 1995). A fear
of offending (Sugg 8 Inui, 1992) or invading personal space
(Gremillion 8 Kanof, 1996) are also barriers to assessment.
Many providers feel it is not their role to intervene (AMA,
1994) and that it is a private matter (AAFP, 1994). Another
frequently cited impediment to assessing for abuse is
feelings of powerlessness (Sugg 8 Inui, 1992, Gremillion 8
Kanof, 1996; Alpert, 1995; AMA, 1994). Providers often
times are frustrated with the issue because they feel
inadequate and unable to “fix it.” A sense of lack of
control is also reported as a block to assessing for
domestic violence (Sugg 8 Inui, 1992; Alpert, 1995).
Providers feel their attempts at intervention are futile as
they are unable to control the patient's behavior. Other
barriers identified include a fear of litigation, a lack of
personnel, space, or policy (Gremillion 8 Kanof, 1996;
Alpert, 1995); and societal beliefs--the victim is
responsible for the violence or cultural beliefs--support of

male dominance (Gremillion 8 Kanof, 1996).

19

WW

Most of the research found regarding assessment
practices of health care providers and domestic violence has
involved emergency room care. Very few studies were found
by this researcher indicating the rates of inquiry by health
care providers in primary care; two were from 1992 and one
was from 1995, and all surveyed only physicians. A fourth
study, not yet published, McClure and Meirhenry (1995), also
studied only physician assessment practices with regard to
domestic violence. Although McClure (1993) studied both
physicians and nurses, traditional RNs without advanced
practice training were included in the results regarding
nursing practice. This author intends to add to the limited
existing body of research on assessment practices of health
care providers regarding domestic violence. By examining
the impact knowledge and barriers have on the assessment
practices of primary health care providers, it is the hope
of this researcher to increase the awareness of domestic
violence and bring the issue to the attention of primary
health care providers so that knowledge can be attained and
barriers can be resolved. It is also the hope of this
researcher to make primary health care providers aware of
the need to become familiar with community resources
available for referral. And lastly, since there is no
published study yet about the assessment practices of nurses

in advanced practice with regards to domestic violence, this

20
researcher hopes to stimulate further studies on APNs
effectiveness in assessing for domestic violence.
W

The Health Belief Model (HBM) provided the theoretical
framework for describing the variables in this study. The
HBM has been used to explore health-related behaviors at the
individual's decision—making level (Mikhail, 1981) in an
attempt to understand why people engage in preventive health
behaviors (Pender, 1987). Since its creation, the HBM has
been one of the most extensively developed models and the
most useful in predicting health promoting behaviors and
compliance with treatment regimens (Hardy 8 Conway, 1988).
Research using the HBM has been conducted on a variety of
patient populations to predict health-related behaviors
based on patient beliefs surrounding a particular illness or
disease.

The Health Belief Model developed by Becker and Maiman
(1975) consists of three main dimensions: indiyidnal
Minna. medifxinuastars, and likelihdeLaction.
Individual perceptions include perceived susceptibility, or
the degree to which a person feels at risk for developing a
disorder; and perceived seriousness, or the severity of the
consequences of the condition (Kozier, Erb, 8 Blais, 1992).
Together these concepts provide a measure of perceived
threat of an illness to an individual (Pender, 1987).

Modifying factors affect a person's perception (Kozier,

et al., 1992) and influence the inclination to take

21
preventive actions (Pender, 1987). These factors include
demographic variables such as, sex, age, race, and
ethnicity; sociopsychological variables such as social
influences or pressure from peer or reference groups;
structural variables such as, knowledge about the condition
or prior contact with the illness; and lastlyy “cues to
action“ (Kozier et al., 1992) . These cues to action are
actually triggers that stimulate the decision-making process
and can be internal, such as symptoms, or external such as
mass media or interpersonal communications (Janz 8 Becker,
1984).

The last component of the Health Belief Model is
likelihood of action. The probability of a person
performing preventative behaviors can be predicted based on
a cost-benefit analysis. One must weigh the perceived
benefits of action minus the perceived barriers to taking
action. The benefits depend upon the beliefs regarding the
effectiveness of the behavior in reducing the perceived
threat (Janz 8 Becker, 1984). The barriers are the
potential negative aspects involved in initiating the
recommended behavior and therefore function to impede the
undertaking (Janz 8 Becker, 1984). These can include time,
expense, inconvenience, and unpleasantness.

The Health Belief Model has historically been used to
predict the health promoting behaviors of patients; however,
McClure (1993) developed a model (Figure 1), originally

adapted from Becker and Maiman (1975), to describe the

22

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23
assessment practices of a health professional in primary
care related to battering in pregnancy. This researcher
modified McClure's model to describe the health promoting
behaviors of a health care provider who deals with domestic
violence in the primary care setting and the use of referral

resources. This study described the major variables of

knnxledge. Wises. barriers. and the M

referral_resgnrges as they pertained to a provider in a
primary health care setting. This study also explored the

relationships between these variables such as the connection
between knowledge and assessment practices, barriers and
assessment practices, and the impact these connections have
on the use of referral resources. Figure 2 highlights the
application of these research variables to the HBM.
METHODS

Sample

A non-probability convenience sample of physicians and
advanced practice nurses providing primary care in the tri-
county area of Saginaw, Midland, and Bay City, Michigan were
used for this descriptive study. The names and addresses of
the health care providers were obtained from area hospital
roster lists, local telephone books, health insurance
provider directories, the Mid-Michigan Advanced Practice
Network member list, and the Michigan Nurse's Association
list. Practice settings included private and group
practices, hospital owned practices, clinics, and health

maintenance organizations. Areas of practice comprised

24

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25
family practice, internal medicine, and obstetrics and
gynecology.

Each physician name and specialty was identified on the
hospital roster listing, as well as, under specific headings
in the telephone book. Based on the identification of
physician specialty, the target population was comprised of
128 family practice physicians, 38 obstetricians and
gynecologists, and 45 internal medicine specialists, for a
total physician number of 213. The Advanced Practice
Network member listing was used in conjunction with the
Michigan Nurse's Association listing of APNs in the tri-
county area. The identification of names of APNs and the
type of practice setting came from one of the four officers
of the Advanced Practice Network. APNs whose specialty was
not known for certain were sent a survey. The phonebook was
also used to locate additional APNs whose name and area of
practice was listed with the collaborating physician name
and specialty. A total of 38 APNs were identified, bringing
the total number of targeted health professionals to 251.
MW.

The information gathered for the study was based on a
one-time, cross sectional survey. A cover letter was sent
along with the questionnaire describing the purpose of the
study and instructions to the providers regarding completion
of the survey and its timely return (see Appendix A). In
addition, a second cover letter, which was written by two

local emergency room physicians emphasizing the importance

26
of participating in the study and completing the survey, was
also included in the initial mailing (see Appendix B).

The survey instrument and the two cover letters were
sent to the identified physicians and advanced practice
nurses providing primary care to women in the Saginaw,
Midland, and Bay City, Michigan area. To help facilitate
the return of a completed survey, a self-addressed, stamped
envelope was included. A deadline of two weeks was given
and a postcard was sent one week after the initial mailing
as a reminder to complete and return the survey or as a
thank you to those that had already done so. As each survey
was returned, it was numbered consecutively.
2rotectinn_of_nnman_5uhiscts

The survey consisted of no identifying characteristics
to protect anonymity and assure confidentiality. Receipt of
a completed survey was interpreted as acceptance to
participate in the study. Participants had the opportunity
to receive the results of the study by returning a self-
addressed, stamped postcard separate from the completed
survey. In addition, approval for the research was granted
from UCRIHS at MSU (#97-191, see Appendix C).

Instrument

Permission was obtained from Bonnie McClure, RN, CS,
MSN, to use a survey tool developed by McClure and
Meierhenry (1995) for a similar research study (Appendix D).
According to McClure (1993), the tool was developed based on

content from the Conflict Tactics Scale (CTS) (Straus, 1979)

27
and the Abuse Assessment Screen (AAS) (McFarlane et al.,
1992). Questions 1-10 comprise demographic data about the
respondents, such as profession, age, sex, years in
practice, clinical practice setting, and educational
background. Question one was altered for this study to
include the advanced practice nurse and degree achieved.
Question 10 was added to this study to include educational
information derived from reading published material on
domestic violence. Questions 11-13 referred to knowledge
regarding the prevalence of domestic violence and knowledge
of signs and symptoms and reported behaviors that are
possible indicators of domestic violence. Questions 12 and
13 describe possible indicators of abuse and were altered
from the original survey. Question 12 listed eleven
possible signs and symptoms of abuse. Broken bone, bruises,
black eye and lacerations were all included in the original
survey. The additional 7 signs and symptoms were added for
this study. Question 13 described ten behaviors as possible
indicators of abuse, all of which were included in the
original survey; however, the words, report of, were
removed for this study. Knowledge of possible referral
resources in the community was addressed in question 14, and
previous use of such referral resources was identified in
question 15. An additional resource, counseling services,
was added to the original survey as a potential source for
referral. The assessment practices of providers were

covered in questions 16-27 and question 30. Possible

28
barriers to assessing about domestic violence were added to
the questionnaire and were examined in questions 28, 29 and
31-33. Lastly, room for reactions or comments was provided
at the end (see Appendix E for complete survey).

According to McClure, the instrument was reviewed by
two nationally recognized experts in the field of “battering
in women“ and was determined to have content validity. A
pilot group of five health care professionals established
readability. Since the barrier questions were added to the
questionnaire for this study, an emergency room physician,
who has worked extensively with domestic violence victims,
reviewed those questions for content validity.
QneraIiQnaLnefinitions

Aaagsamer,13:.__;zz:a.¢:tj.s:ea_IL Assessment practices regarding
domestic violence were measured in questions 16-27 and
question 30. These questions evaluated a primary health
care provider's (PHCP) frequency in asking female patients
about domestic violence during initial visit and each
following annual visit; the frequency with which questions
were included on a history form that female patient
completes; the frequency in which the PHCP verbally asked
about domestic violence; the frequency in which the PHCP
verbally asked female patients if, in the last year, they
have been hit, slapped, kicked, or otherwise physically hurt
by someone; and lastly, the frequency in which the PHCP

verbally asked female patients if, within the last year,

29
they have been afraid of their partner or anyone close to
them. .

Knowledge. Providers' knowledge of domestic violence
was measured in questions 11-14. These questions asked
primary health care providers about the prevalence of
domestic violence, indicators of domestic violence, as well
as, awareness of referral resources in the community, such
as: a 24 hour crisis line, police.force, prosecuting
attorney's office, legal aid, shelter/safehouse, counseling
service, or others not listed. In addition, respondents
were also asked to identify the resource used by name.

Barrier, Barriers to assessing for domestic violence
were measured in questions 28, 29 and 31-33. Potential
impediments to assessment were evaluated by a primary health
care provider's response to such statements as, Time
constraints of a busy practice prevent you from assessing
for domestic violence, You consider domestic violence a
private matter and therefore do not ask about abuse for fear
it may offend her, ‘Normal' men and women do not engage in
domestic violence, Primary care providers do not have the
necessary tools to help victims of domestic violence, and
lastly, There's nothing I, as a health care provider, can do
about domestic violence. .

ns§_gf_rgfgrral_rgsgnrgesL Previous use of referral
resources was measured by a primary health care provider's
positive response to past referral to a 24 hour crisis line,

police force, prosecuting attorney's office, legal aid, a

30

shelter or safehouse, a counseling service, or a resource
not described. In addition, the respondent was asked once
again to provide the name of the resource utilized. This
was evaluated in question 14.
W

The overall knowledge level of the provider with
regards to domestic violence was evaluated in four questions
and scored on a cumulative point system ranging from 0-47.
In addition, each sub-component score was calculated based
on assigned points. Knowledge of the prevalence of domestic
violence was given a total value of 10 points. Zero for a
response of less than 6%, 1 for a response of 6-10% or >26%,
5 for 11-15% or 21-25%, and 10 for the correct response of
16-20%. Recognition of possible signs and symptoms of
domestic violence was assigned one point for each one
identified and one point for any additional signs and
symptoms added by the respondent in the comment section for
a grand total of 12 points. Similarly, the recognition of
reported abusive behaviors as potential indicators of
domestic violence was assigned one point for each behavior
selected and an additional point for behaviors identified by
the survey participant in the comment area, for a total of
11 points. A single question evaluated knowledge of
referral resources in the community. Responses were either
“yes” or ‘no' to indicate awareness. One point was given for
each “yes” response and an additional point was given if the

provider included the name of the resource. Space was

31
provided to include additional resources used by the
provider. Points were assigned to those responses confined
to the subset available in all three communities so that
knowledge was measured not availability of resources.
Therefore, points were not assigned to any additional
responses and a grand total of 12 points were possible.

A single question analyzed the previous use of those
same local referral resources. Each “yes“ response
indicated previous use of the resource and was assigned a
single point. An additional point was awarded if the name
of the resource was included, regardless if it was
previously mentioned, allowing for the fact that many of the
resources listed provide multiple services. A fiuf response
indicated no prior use of the resource. Space was provided
to include additional resources used as referrals by the
provider. A total of six possible resources were identified
and a range of 0-12 points were possible.

Eleven assessment questions addressed the provider's
approximate frequency in screening women for abuse, the
frequency in using specific questioning techniques, and the
frequency in considering specific exam findings as
indicators of abuse. A Likert scale of 1.“Never"to 5
“Always” was used and then the mean of all responses was
used to generate a cumulative score for assessment
practices. The range of this score was 1-5 corresponding

with the Likert scale.

32
The five barrier questions were evaluated on two

separate Likert scales. Two questions were scored as

mentioned above on a scale of 1 “Never” to 5 “Always, and
three questions were scored on a scale of 1.'Strongly
Disagree” to 5 “Strongly Agree." The overall barrier score
consisted of the mean across the five response items,
allowing for a possible range of the scale score from 1 to
5. The higher the number, the stronger the barriers in
deterring assessment practices for domestic violence.
DAL:.ADAl¥fii§

Frequency statistics were used to describe the sample
with regard to type of primary care provider, age, sex,
clinical setting, type of practice, years in practice, and
educational background. Correlation statistics were
utilized to determine relationships between assessment
practices, knowledge, barriers, and use of referral
resources. Group differences between nurses and physicians
in all primary care settings regarding assessment practices,
knowledge, barriers, and the use of referral resources were
assessed on the basis of independent t-tests. Factorial
analysis of variance was used to determine whether
differences between physicians and nurses remained after
taking into account the effects of age, sex, and practice
setting and which was the strongest predictor of the outcome
variables, use of referral resources and assessment
practice. Accepted levels of significance were .05 for all

statistical tests.

33

Information was processed and statistically analyzed
through the use of SPSS.

RESULTS
Wain:

Of 251 surveys mailed, 84 were returned for a total
response rate of 33%. The physician group returned only 49
of 213 surveys mailed for a response rate of 23% and the
APNs returned 25 or 38 surveys mailed for a higher rating of
66%. Ten respondents were omitted; one practiced in a long
term care facility, one in pediatrics, and one in an acute
care setting; and six physician questionnaires and one APN
questionnaire were received after data analysis had begun
leaving a final sample total of 74.

Table 1 describes the subjects by profession and type
of health care provider. The sample consisted of 49
physicians (66%), 40 with a medical degree (MD) and 9 with a
degree in osteopathy (DO), and 25 advanced practice nurses
(34%). Of the advanced practice nurses (APNs), 22 were
certified practitioners--15 with master's degrees, 5 with
bachelor's, and 2 with associate degrees. Three were not
certified, 2 at the master's level and one at the
baccalaureate level. Fifty-one percent were male and 49%
were female, as shown in Table 2. The age distribution as
well as the number of years in practice is highlighted in
Table 3. The mean age of the providers was 46 and the
average number of years practicing in the current specialty

was 14.

34

 

 

 

 

 

 

 

 

Table l.
I : e e e e _ nus e e . Q e ‘e e e
Variable Number of Subjects Percentage
Profession
Physician 49 66.2
Nurse 25 34.8
TOTAL 74 100.0
Type of Health Care Provider
MD 40 54.1
DO 9 12.2
AND 0 Certified 2 2.7
BSN - 1 1.4
BSN 5 Certified 5 6.8
MSN 2 2.7
MSN & Certified 15 20.3
TOTAL 74 100.0
Table 2.
WWW
Variable Number of Subjects Percentage
Sex
Male 38 51.4
Female 36 48.6
Total 74 100.0
Table 3.
I e e . e u e e g e \ H e e a e‘
Variable Mean. SD Mode Median. Minimum Maximum
Age 45.8 10.4 33 44 32 73
Years in Current
Specialty 14.2 10.1 20 13 l 40

 

35

Sixty-nine percent of the providers practiced in
private offices, 22% in clinics or hospitals, 3% in health
maintenance organizations, and 7% in other. Fifty-three
percent were in family practice, 39% in obstetrics and
gynecology, and 8% in internal medicine (see Table 4).

In regard to the educational background of the study
participants, 81% (48% of the nurses and 35% of the
physicians) reported having read published literature or
journal articles on domestic violence within the last year,
39% (92% of the nurses and 75% of the physicians) had
attended an educational program, and 43% (72% of the nurses
and 29% of the physicians) had received specific training
during their formal education (see Table 5).
Wm

Knowledge was to be measured by four factors. The
first component of knowledge was that of prevalence of
domestic violence. It was determined, however, through the
use of item correlation statistics that prevalence scores
did not correlate with the other three knowledge indicators.
It was therefore deemed an unreliable indicator of knowledge
and discarded. The signs and symptoms and behaviors
responses were highly correlated and thus were combined
together as a single measure of knowledge. Reliability
analysis produced a Cronbach's alpha of .79. The second
measure of knowledge was knowledge of referral resources.
Reliability analysis produced a Cronbach's alpha of .69 for

this scale. A correlation coefficient of .41 indicated that

Table 4.

36

WW

 

 

 

 

 

Variable Number of Subjects Percentagg__
Clinic Setting
Private Office 51 58-9
Clinic 16 21-6
nun 2 2.7
Other 5 6.8
Total 74 100.0
Practice Setting
Family Practice 39 52.7
Internal Medicine 6 2.7
OB/GYN 29 39.2
Total 74 100.0
Environmental Setting
Urban 33 45.8
Suburban 24 32.4
Rural 14 18.9
All 1 1.4
Missing 2 2.7
Total 74 100.0
Table 5.
Wine
WW
Variable Group Group Physician Physician APN APN
Total Percent Total Percent Total 8
Attend Educational
Program
NO 45 60.8 32 65.3 13 52.0
YES 29 39.2 7 34.7 12 48.0
Total 74 100.0 49 100.0 25 100.0
Read Literature or
Journal Articles
NO 14 18.9 12 24.5 2 8.0
YES 60 81.1 37 75.5 23 92.0
Total 74 100.0 49 100.0 25 100.0
Formal Education
NO 42 56.8 35 71.4 7 28.0
YES 32 43.2 14 28.6 18 72.0
Total 74 100.0 49 100.0 ‘25 100.0

 

37
those who were aware of community resources are not
necessarily aware of signs and symptoms or behaviors
indicative of abuse. Therefore, these two scales were kept
apart as separate knowledge dimensions.

Missing data was considered flu? responses for
interpretation of knowledge of referral resources and use of
referral resources.

Linear regressions were used to predict missing
responses with regard to assessment practices, except where
missing data reflected a “not applicable” response. A
factor analysis of the eleven responses did not indicate a
distinct enough pattern to warrant two separate scales--one
evaluating screening practices and a second describing exam
practices. However, a single question, During an
examination of a woman, do you consider abuse when seeing
injuries that do not match their cause? showed a low inter-
item correlation with the rest of the items at .18;
therefore, this item was removed. A reliability analysis
was completed on the remaining 10 items and a Cronbach's
alpha of .90 was achieved.

A reliability analysis on the use of referral resources
revealed a Cronbach's alpha of .55. This low score was to
be expected since many providers may rely on only one or two
resources in the community thereby not utilizing all that
were listed.

The barrier scale factor analysis indicated a low item

total correlation (.19) regarding the statement, {Normal'

38
men and women do not engage in domestic violence.” ‘The
remaining items were .36 or higher. As a result, the
”Normal ” question was omitted leaving the remaining four
items and increasing the Cronbach's alpha from .58 to .68.
cher.£indinnfi

Frequency statistics were used to describe the sample's
response to the question, To the best of your knowledge, how
frequently does domestic violence occur? The 16-20% range
received the highest response (27%), which was the correct
response based on current literature findings. Slightly
less than 2% of the sample selected 0-5% and over 31% of the
sample thought the prevalence of domestic violence was 21%
or higher. Nearly 10% or 7 of the respondents did not
answer the question, some of whom added comments such as,
”of what?” and Vague. ”

As for indicators of abuse, a sub-component of the
knowledge scale, all of the participants acknowledged
bruises, black eye, and threats of harm to the woman as
suspect for abuse. Insomnia, abdominal pain, and partner
jealousy received the lowest responses of 89% each. The
remaining signs and symptoms and behaviors received response
rates of 92-99%. Of a possible 23 points, the mean sample
score was 20.6 with a SD of 2.1, indicating that most
subjects had a high level of knowledge related to indicators
of abuse.

The total possible points for knazledge_gfi and use_gf

referral resources was 12. Omission of a “yes” or ”no”

39
response was taken for a huf and scored accordingly. The
mean sample score for knowledge_gf referral resources was
6.1 with a SD of 2.9. The mean sample score for use_gf
referral resources was lower at 3.3 with a SD of 2.4.
Knowledge of a shelter or safehouse received the greatest
response with 35% of the sample simply acknowledging the
existence of such a resource and an additional 57% of the
sample identifying one by name, for a total of 92%.
Likewise, referral to a shelter or safehouse also received
the highest response rate, 41% of the sample indicated prior
referral to a shelter or safehouse and an additional 27% of
the sample identified the referral resource used by name,
for a total of 68%. These figures are represented in Table
6.

The mean scores for each of the eleven assessment
questions are shown in Table 7. The overall mean across all
eleven assessment score items for the sample was 2.77 with a
SD of .77 (2=rarely and 3=sometimes), indicating that the
sample rarely to sometimes assessed for domestic violence.

The overall mean barrier score was 1.8. Providers
indicated that the potential barrier of time constraints
rarely to sometimes (2=rarely and 3=sometimes) interfered
with assessing for domestic violence and either disagreed
with or were uncertain (2=disagree and 3=uncertain)
regarding the premise that ”normal ” men and women do not
engage in domestic violence. Each of these statements

received a mean score of 2.6. Subjects disagreed with the

 

4O

 

 

Knowledge of Use of
Resource Frequency Percent Frequency Percent
24 Hour Crisis Line
No 18 24.3 47 63.5
Yes 31 41.9 18 24.3
Name 25 33.8 9 12.2
Total 74 100.0 74 100.0
Police Force
No 22 29.7 53 71.6
Yes 24 32.4 14 18.9
Name 28 37.8 7 9.5
Total 74 100.0 74 100.0
Prosecuting Attorney
No 36 48.6 68 91.9
Yes 27 36.5 5 6.8
Name 11 14.9 1 1.4
Total 74 100.0 74 100.0
Legal Aid
No 42 56.8 67 90.5
Yes 25 33.8 4 5.4
Name 7 9.5 3 4.1
Total 74 100.0 74 100.0
Shelter or Safehouse
No 6 8.1 24 32.4
Yes 26 35.1 30 40.5
Name 42 56.8 20 27.0
Total 74 100.0 74 100.0
Counseling
No 18 24.3 28 37.8
Yes 21 28.4 19 25.7
Name 35 47.3 27 36.5
Total 74 100.0 74 100.0

 

Table 7.

nimudhmtnaLnfJmmmlaJnmnmmuuteJuumammum_Qmuudena

41

 

Assessment Questions

1)
2)
3)
4)
5)
5)

7)

8)

9)

Screen for domestic violence
during initial intake history.
Screen for domestic violence
during annual visits.

Include question about
domestic violence on intake
history form patient completes
Verbally ask about battering
Verbally ask about being hit,
kicked, slapped, or physically
hurt by someone.

Verbally ask about being
forced into sexual activities.
Verbally ask about being
afraid of partner or someone
close.

Consider abuse when injuries
do not match cause.

Consider abuse when see
depression, withdrawal, or
lack of eye contact.

10)Consider abuse when male

partner will not leave woman

11)Consider abuse when office

visits frequently missed.

“0331*

3.0

2.7

SD

1.2

1.0

1.0

1.0

.90

1.0

1.0

.92

Minimum Maximum

1.0

1.0

1.0

1.0

1.0

5.0

5.0

74

74

74

74

74

74

74

74

74

71

72

 

*the higher the number the greater the frequency of assessing for
domestic violence

beliefs that primary care providers do not have the

necessary tools to help victims of domestic violence and

there is nothing I, as a health care provider, can do about

domestic violence with mean scores of 1.9 and 1.4

respectively (1.0=strong1y disagree and 2.0=disagree).

addition, participants rarely to never felt domestic

In

violence was a private matter declining to ask out of fear

of offending.

8).

This received a mean score of 1.5 (see Table

42

Table 8.

SumfleJmuumimmaenJansunneJumruunuheJflmmuflmesfluanmumie
Yunnan:

 

Barrier Questions/Statements Mean* SD Median Mode Valid N

 

1) Time constraints of a busy

practice prevent assessing for

domestic violence. 2.6 .96. 3.0 3.0 72
2) Domestic abuse is considered

a private matter and questions

are not asked out of fear of

offense. 1.4 .87 1.0 1.0 72
3) It is a belief that “Normal”

men and women do not engage

in domestic violence 2.6 1.5 2.0 2.0 72
4) It is a belief that primary

health care providers do not

have the necessary tools to

help victims of domestic

violence. 1.9 .86 2.0 2.0 72
5) It is a belief that primary

health care providers can do

nothing about domestic violence. 1.5 .60 1.0 1.0 72

 

*The higher the number the greater the strength/frequency of barrier.

ResearcLQuestinns
Descriptive statistics were used to answer the

following research question:

1. To what extent do primary health care providers
verbally and physically assess for domestic violence?
The overall mean assessment score for the sample was
2.77 with a SD of .72 indicating that the primary
health care providers in this sample rarely to

sometimes assessed for domestic violence.

43

The Pearson Product Moment Correlation was used for

describing relationships among the major study variables and

to answer the following research questions:

2.

Is there a relationship between knowledge regarding
domestic violence and the assessment practices of
primary health care providers? The knowledge of
specific signs and symptoms and certain behavior
patterns as possible indicators of the presence of
domestic violence had a moderate relationship (r=.31)
with the frequency of assessing for domestic violence,
which was significant (p=.006). The component of
knowledge related to the awareness of referral
resources did not have a significant relationship with
assessment practices (r=.18, p=.12).

Is there a relationship between barriers identified and
the assessment practices of primary health care
providers regarding domestic violence? There was a
negative correlation between barriers and assessment
practices (rs-.39, p=.001). Healthcare providers in
this sample who had higher barrier scores were less
likely to assess for domestic violence.

Is there a relationship between assessment practices of
primary health care providers and the use of referral
resources? There was no correlation between assessment
practices of the primary health care providers in this
sample and their corresponding use of referral

resources (r=.18, p=.13).

44

Independent t-tests were employed initially to answer
the remaining research questions. Mean assessment score
differences between physicians and nurses was the only
comparison to reach statistical significance (ta-4.01,
p=.000). The advanced practice nurse mean assessment score
was .65 higher than that of the physician mean assessment
score. Factorial analysis of variance was then applied to
examine if mean knowledge, assessment, referral, and barrier
scores differed between advanced practice nurses and
physicians after controlling for the effects of sex, type of
practice setting, and years of practice. Practice setting
for these comparisons were narrowed to two groups, one which
included the family practice and internal medicine groups
combined, and the other, the ob/gyn. Years of practice were
used versus age as it represented one more case and there
was a high correlation between the two .81. The following
questions were answered.

5. Is there a difference between advanced practice nurses
and physicians regarding assessment practices for
domestic violence? There was not a statistically
significant difference in mean assessment scores
between physicians and advanced practice nurses
(p=.17). There was, however, a statistically
significant difference in mean assessment scores
between males and females (p=.005). The female
adjusted mean assessment score (2.85) was .16 higher

than the male adjusted mean assessment score (2.69).

45
There was also a statistically significant difference
between the family practice/internal medicine mean
scores and the obstetrics/gynecology providers' mean
scores. The ob/gyn providers' mean assessment scores
(3.02) were .41 higher than the family
practice/internal medicine providers' mean assessment
scores (2.61). In addition, years in practice had a
negative effect (raw regression coefficient -.014) and
was almost statistically significant (p=.08).
Is there a difference between advanced practice nurses
and physicians regarding knowledge of domestic
violence? Regarding knowledge of signs and symptoms
and behaviors associated with domestic violence, there
was not a statistically significant difference between
mean knowledge scores of physicians and APNs (p=.90).
Similar findings were present regarding knowledge
related to referral resources. The mean difference
between the two professional groups was not significant
(p=.93). There was, however, a statistically
significant difference in mean knowledge scores of
signs and symptoms and behaviors between males and
females (p=.02). The adjusted female mean was 1.07
higher than the adjusted male mean.
Is there a difference between advanced practice nurses
and physicians regarding barriers to domestic violence
assessment? There was not a statistically significant

difference in mean barrier scores between physicians

46

and advanced practice nurses (p=.38). Years in

practice, although accounting for less than 10% of the

variation, had a statistically significant positive
effect on barrier score (raw regression

coefficient-.017, p-.01).

8. Is there a difference between advanced practice nurses
and physicians regarding use of referral resources?
There was no statistically significant difference in
mean referral scores for physicians and advanced
practice nurses.

I l l Ii E E' 1'

Much can be said about the findings in this study
related to the Health Belief Model (HBM) and the literature.
The HBM was used in this research as a means to describe a
primary health care provider's health promoting behaviors as
they relate to the likelihood to assess for domestic
violence and use referral resources. By examining modifying
factors and possible impediments to take action, the HBM was
also used to explain the relationships among the variables
of knowledge, barriers, assessment practices, and use of
referral resources. This study did not, however, attempt to
evaluate all components of the HBM, such as a health care
provider's perceived susceptibility or seriousness of own
clients in relation to domestic violence, the providers
perceived threat of abuse in clients in primary care, cues
to action, or a provider's perceived benefit for assessing

for domestic violence.

47

Modifying factors, as described by Kozier et al.
(1992), affect a person's perceptions and influence their
decision to take preventive actions. These factors include
demographic variables, sociopsychological variables,
structural variables, and cues to action. Based on this
study and the participants involved, the structural variable
knowledge was moderately correlated with the likelihood to
assess for domestic violence. However, it depended on the
type of knowledge. Participants who had a greater working
knowledge of signs, symptoms, and behaviors associated with
abuse were more likely to assess for domestic violence. The
participants in this sample who were more knowledgeable
about resources in the community were not necessarily more
inclined to assess. This finding, in part, conflicts with
the literature, which often cites a lack of knowledge as a
reason for not assessing for domestic violence. The high
knowledge scores related to signs, symptoms, and behaviors
may be due to the way in which these indicators were
presented in the survey lending to ease of recognition and
therefore artificially skewing the scores.

The component of the HBM, likelihood of action, is
affected by negative aspects involved in initiating health
promoting behaviors (Janz & Becker, 1984). In this sample,
certain identified barriers did inhibit the health care
provider's likelihood to assess for domestic violence.
Those primary care providers who had higher barrier scores

were less likely to assess for domestic violence. Although

48
this study demonstrated a moderate relationship, moderately
correlated (.39), this finding is highly supported by the
current literature, which cites that health care providers
are negatively influenced by certain barriers thereby
impeding assessment practices related to domestic violence.

Further utilizing the HBM component, likelihood of
action, it was presumed that one action may be directly
related to another action. It seemed apparent by this
researcher that the use of referral resources would be
directly influenced by the frequency of assessment
practices. The proposed existence of this relationship was
not supported by this study, nor is it substantiated in the
literature. There was no relationship between assessment
practices of the primary health care providers and
corresponding use of referral resources. It is unclear if
this was a result of a poor scale for use of referral
resources or merely a sample effect.

When analyzing the data to determine any differences
between advanced practice nurses and physicians with regard
to assessment practices, barriers, knowledge, and use of
referral resources, some interesting findings emerged.
First and foremost, it was noted that there were no
significant differences between advanced practice nurses and
physicians across all research variables. What apparent
differences did arise in one-way comparisons seemingly to

indicate that the APNs assessed more frequently was

49
obliterated once the sample was controlled for by other
variables in a multivariate analysis.

A consistently important control variable was the
demographic variable of sex. Differences in gender played a
key role in many of the relationships. Females assessed for
domestic violence more frequently than males and had higher
knowledge scores related to signs, symptoms, and behaviors
than did males and each of these findings was statistically
significant. Although females tended to be more
knowledgeable about referral resources, have fewer barriers
and use referral resources more frequently than men, this
was not a significant finding and could be due more in part
to sample effect. Much of the one-way effect regarding
provider type differences is explained by the fact that all
of the nurses in the sample were female. The differences
associated with gender have been supported in the literature
(Parsons et al., 1995) and unsubstantiated (McClure, 1993).
This may be due in part that most victims are female and
most perpetrators are male.

Practice setting, another demographic variable, also
had a strong positive relationship to the research
variables. A statistically significant finding was those
providers practicing in ob/gyn offices were more likely to
assess for domestic violence than those in family practice
and internal medicine practices combined. On average,
ob/gyn providers were also noted to have higher knowledge

scores related to signs, symptoms, and behaviors associated

50

with abuse as well as knowledge of sources for referral.
They also scored higher on use of referral resources and
lower in relation to barrier scores. These findings were an
observed effect in the sample and were not statistically
significant. Furthermore, there is no published literature
supporting this finding, in fact, McClure, (1993) found that
family practice physicians had higher mean scores in both
assessment practices and use of referral resources.

Years of practice, which correlated highly positive
with age (.81), was a significant indicator of barriers.
The more number of years in practice, the greater the
barriers to assessing for domestic violence. This may be
due in part to developing certain practice patterns over the
years that may not have included the screening and assessing
for domestic violence. Providers may have become in the
“habit” of not inquiring, and find it difficult or awkward
to begin. This is not substantiated by the literature, and
like many of the findings, needs further research to
determine.

Discussion

This research was not conducted without limitations and
assumptions. First of all, a non-probability convenience
sample was used thereby inhibiting generalizability of the
findings. Second, a survey was mailed to participants in
the study to collect information on assessment practices,

which may result in self-selection bias as well as a poor

51
survey response rate. These results may be reflected in the
lower response rate for physicians possibly indicating that
only the most concerned physicians responded. A second
survey was not mailed, only a reminder card. A second
survey may have increased response rates. Third, a survey
tool that has not been well established was used to measure
the variables of knowledge, assessment, and use of
referrals. The prevalence question was omitted from the
survey as it was often taken as vague or ambiguous. This
left only two measurements of knowledge. There was little
variation in the knowledge scores of signs, symptoms, and
behaviors which may limit correlations. And lastly, the
barrier question regarding “normal” men and women was
omitted from the survey also due to ambiguity, thereby,
leaving only four statements which measured barriers. In
addition, the barrier scale received a somewhat low
Cronbach's alpha of .68.

This research was conducted under three main
assumptions, 1) Self report accurately reflects practice
techniques, 2) Health care providers completing the survey
are representative of health care providers in general, and
3) Standards of care regarding domestic violence guide
ob/gyn assessment practices.
ImplicationstLResultanxistinsLLiterature

This research adds to the limited existing body of
literature about domestic violence in the primary care

setting. It also is the only study related to domestic

52
violence that compares assessment patterns, knowledge, and
barriers between advanced practice nurses and physicians in
various primary care settings. It is one of a very few
studies that examines barriers and use of referral resources
as they relate to domestic violence.
Wins

Implications for advanced practice nursing are many.

As advanced practice nurses continue to emerge as effective
primary care providers who are able to provide quality,
cost-effective care, APNs will need to be acutely involved
in the many important issues confronting the public as a
whole. As a means to stay involved and address the issue of
domestic violence, APNs need to develop and incorporate into
practice specific measures to impact the problem of violence
in America. Some of these methods include the dissemination
of information regarding domestic violence, the
incorporation of assessment techniques into practice, and
the development of strategies to identify and address
barriers to assessment practices.

The nursing profession takes pride in its ability to
educate and teach. One of the first steps in disseminating
information regarding domestic violence is through educating
the educators. Information about domestic violence must be
incorporated into all nursing programs at both the
undergraduate and graduate levels. Information must
include, but must not be limited to, the prevalence of

domestic violence in the United States, an overview of

53
common characteristics of the abused woman and the batterer,
the cycle of abuse and possible indicators, assessment
techniques, and community resources available for referral.

Once armed with this information, advanced practice
nurses can then spread their knowledge by presenting
continuing education seminars or conferences for other
primary health care providers. To further increase
providers' awareness about domestic violence, actual case
scenarios, video presentations, or real victims of abuse
could be incorporated into these educational programs; and,
to promote the use of referral resources, representatives
from various community agencies could discuss goals and
services each provide. Written resource materials could
also be distributed.

In a less formal way, APNs can disseminate information
about domestic violence to peers,colleagues, and physician
counterparts alike. APNs can raise the issue of the
prevalence of domestic violence in the practice area. By
presenting and discussing domestic violence cases and
describing presenting signs and symptoms, distinguishing
characteristics, behaviors, and how intervention was handled
can serve to educate others.

In addition to primary health care providers, APNs can
also conduct presentations and lectures to other health care
professionals, i.e., hospital and office staff, social
workers, mental health workers, etc., as well as, to public

officials, community leaders, and the community at large to

54
enhance their knowledge and understanding of domestic
violence. Education in the schools and community in general
can promote the awareness of the issue of domestic violence.
Increasing the public's awareness of domestic violence
through the use of radio and television ads, lectures in
schools and township halls, as well as political activity to
further raise public consciousness that domestic violence is
a social problem in an attempt to stop the desensitization
of Americans to violence.

Advanced practice nurses can also assist in the
identification and assessment process of domestic violence.
APNs can create and institute policies and standards of
practice that incorporate specific assessment techniques
into practice. By presenting to colleagues and peers
examples of different direct questioning techniques, by
requiring that specific questions be included on all intake
assessment forms, and by mandating that on initial visit,
each annual visit, and any subsequent visit suspicious for
abuse these questions be asked, domestic violence victims
will be more readily identified. Advanced practice nurses
can also create helpful reminders encouraging routine
inquiry, such as reminder forms, stickers or stamps in
charts; posters in clinical areas that remind clinicians
what to ask and what to do; and pocket-sized protocols with
written descriptions of identification, assessment, and
intervention techniques and strategies, examples of specific

questions, and referral resources and phone numbers;

 

55

Advanced practice nurses can establish training and
intervention programs assisting professionals in the
assessment and identification process. Through the use of
educational tools, videos, and role playing professionals
can acquire creative ideas and necessary skills to feel
comfortable inquiring about abuse. Lastly, APNs can develop
outcome measures to evaluate knowledge and assessment
practice of providers, the effectiveness of provider
response, and success of intervention for domestic violence
victims.

One of the most difficult areas for advanced practice
nurses to impact regarding domestic violence is that of
barriers. Many primary care providers, as well as other
members of the multidisciplinary health care team, have
preconceived ideas and misconceptions surrounding the issue
of domestic violence. Advanced practice nurses can help
colleagues recognize possible barriers to assessing for
domestic violence by discussing attitudes and beliefs about
abuse. In addition, many of the health care professionals
have also established certain practice habits that are
difficult to alter and change. This author believes that by
incorporating many of the strategies listed above to raise
the knowledge level and understanding regarding domestic
violence and to arm professionals with the necessary tools
to assist victims, many of these barriers can be

obliterated.

 

56
W

Since the issue of domestic violence is relatively
“new” in the literature, further research involving all
aspects of the subject is greatly needed. Research studies
like this one needs to be repeated so that ways to best
increase knowledge and assessment practices can be
identified. In addition, barriers need to be further
described and analyzed so that techniques can be devised to
address potential impediments to assessing for domestic
violence.

Future research should continue to include APN's,
especially male APN's, and APN's from other practice and
geographical areas. In addition, research could be
conducted with one's own practice site to assess for
prevalence of domestic violence before and after the
introduction of a protocol designed for assessing for
domestic violence.

Lastly, research needs to be conducted not only at the
identification and intervention levels but also the
prevention level. Determining effective methods at dealing
with power and control issues as well as societal and
culture norms and values and the way in which violence is
viewed in the United States are the means to the beginning

of the end of domestic violence.

 

LI ST 0F REFERENCES

LIST OF REFERENCES

American Academy of Family Physicians Commission On
Special Issues and Clinical Interests (1994). Family
Violence: An AAFP white paper.

m(8), 1636- 1646.

Alpert, E. (1995). Violence in intimate relationships
and the practicing internist: New “disease” or new agenda?

American_Collese_of_£hxsisiansl_121(10), 774-781.

American College of Obstetricians and Gynecologists
(ACOG) (1995). Domestic violence:
Washington, DC: American College of Obstetricians and
Gynecologists. '

American Medical Association (1994). Diagnostic and
Treatment Guidelines on Domestic Violence. Chicago, IL:
American Medical Association.

Analysis by the Center for the Study and Prevention of
Violence, Institute for Behavioral Science, at the
University of Colorado at Boulder, Colorado. The data used
to calculate this percentage came from the FBI's 1988-91
Uniform Crime Reports (UCR).

Bohn, D.K. (1990). Domestic violence and pregnancy:

Implications for practice. lonrnal_of_Nurse:nidwifer¥l
35(2), 86-98.

Bokunewicz, B. & Copel, L. (1992). Attitudes of
emergency nurses before and after a 60-minute educational
presentation on partner abuse. 19nrnal_gf_£mergengy
Nursinsl_18(1). 24-27.

Brown, J.B., Lent, B., & Sas, G. (1993). Identifying
and treating wife abuse.
16(2), 185-191.

Bullock, L., McFarlane, J., Bateman, L., & Miller, V.
(1989). The prevalence and characteristics of battered

women in a primary care setting. Nurse_2ragtitigner+_14(6),
49-54.

57

58

Carpenito, L. J. (1983). °
Philadelphia, PA: J.B. Lippincott

Company.

Chambliss, L.R., Bay, C., 8 Jones III, R.F. (1995).
Domestic violence: An educational imperative? American

Journal_of_0bstetriss_and_G¥neeolesY+_112(3). 1035-1038-

Chez, R.A. 8 Jones, R.F. (1995). The battered woman.

Amerisan_lournal_of_Qbstetriss_and_G¥neceles¥l_113(3). 677-
679.

Collins, W. 8 World Publishing Co., Inc. (1990). The
New York, NY:

Simon 8 Schuster Inc.

Council on Scientific Affairs, American Medical
Association (1992). Violence against women, relevance for
medical practitioners.

ASSQQieIiin_2§l(23)u 3134'3139-

deLahunta, E.A. (1995). Hidden trauma: The mostly
missed diagnosis of domestic violence. lenrnel_ef_£mezgeney
Nursinsl_13(1). 74-76-

deLahunta, R.A. 8 Tulsky, A.A., (1996). Personal
exposure of faculty and medical students to family violence.

lournal_of_American_Medical_Asseciationl_215(24). 1903-1906-

Donaldson, M., Yordy, K., 8 Vanselow, N. (Eds.).
(1994)- Definins_2rimazY_Carei__An_interim_Benert.
Washington, D. C.: National Academy Press.

Easley, M. (1996). Domestic violence. Annele_ef
Emergensx_nedicinei_21(6). 762-763-

Douglas, H. (1991). Assessing violent couples.
° (9), 525-535.

Friedman, L.S., Samet, J.H., Roberts, M.S., Hudlin, M.,
8 Hans, P. (1992). Inquiry about victimization experiences
a survey of patient preferences and physicians practices.
' 1186-1190.

GanlcY. A-L- (1996)- Imn:exins.The_Health_£are

D-‘ ‘_ _‘ - _ . D- ‘ _
-ee. e Ieu - e g ' , \ e v . e . - .

gere_2reyidere. San Francisco, CA: Family Violence
Prevention Fund.

Gremillion, D.H. 8 Kanof, E.P. (1996). Overcoming
barriers to physician involvement in identifying and

referring victims of domestic violence. Annele_ef_£mergeney
Medicinel_21(6), 769-773.

59

Hamberger, L. K., Saunders, D. G., 8 Hovey, M. (1992).
Prevalence of domestic violence in community practice and
rate of physician inquiry. £amily_nedieine+_24(4), 283-287.

Hardy, M.E. 8 Conway, M.E. (1988).
. Norwalk, CT:

Appleton 8 Lange.

Helton, A. (1987).
nemen. White Plains, NY: March of Dimes Birth Defects

Foundation.

Janz, N. 8 Becker, M. (1984). The health belief
model: A decade later. Health_Edusatien_0uarterl¥1_11(1)p
1-47.

Kassebaum, D.G. 8 Anderson, M.B. (1995). Proceedings
of AAMC's consensus conference on the education of medical
students about family violence and abuse. Aendemie

Medicinel_ln(11), 961-963.

Kozier, B., Erb, G., 8 Blais, K. (1992). Ceneepte_end
Redwood City, CA: Addison-

Wesley Nursing.

Kurz, D. (1987). Emergency department responses to
battered women: Resistance to medicalization. Seeiel

Eznhlfimfii_li+ 59' 31-

Limandri, B. J. 8 Tilden, V. P. (1996L Nurses'
reasoning in the assessment of family violence. Imege;_

lourna1_of_Nursins_Sshelarshinl_za(3), 247- 252.

McCauley, J., Kern, D.E., Kolodner, K., Dill, L.,
Schroeder, A.F., DeChant, H.K., Ryden, J., Bass, E.B., 8
Derogatis, B. (1995) . The “battering syndrome:" Prevalence
and clinical characteristics of domestic violence in primary
care internal medicine practices. Annele_ef_1nternel
Medicine_123(10). 737-746-

McClure, B.M. (1993). Knowledge and assessment
practices of health professionals in primary care related to
battering in pregnancy. Unpublished thesis.

McClure, B.M. (1996). Domestic violence: The role of

the health care professional. Miehigan_£amily_nexieu+_z(1),
63-75.

McClure, B.M., 8 Meierhenry, M. (1995). Domestic
violence: Knowledge and practices of physicians in primary
care. Unpublished research.

60

McFarlane, J., Christoffel, K., Bateman, L., Miller,
V., 8 Bullock, L. (1991). Assessing for abuse: Self
report versus nurse interview. Pnhlie_Heelth_Nnreing+_fi(4),
245-250.

McFarlane, J., Parker, B., Soeken, K., 8 Bullock, L.
(1992). Assessing for abuse during pregnancy severity and
frequency of injuries and associated entry into prenatal
care. WWW—2.6103) .
3176-3178.

McLeer, S.V., Anwar, R.A., Herman, S., 8 Maquiling, K.
(1989). Education is not enough: A systems failure in
protecting battered women.

18(6), 651-653.

Melvin, S.Y. 8 Brunton, S.A. (1995). Domestic
violence: The physician's role. Heepitnl_£reetiee+_1n(10),

45-53 e

Mezey, M.D. 8 McGivern, D.O. (Eds.). (1993). Nureee‘
° New

York, New York: Springer Publishing Company, Inc.

Mikhail, B. (1981L The health belief model: A review
and critical evaluation of the model, research , and

practice. W 65-82 .

Novello, A.C., Rosenberg, M., Saltzman, L., 8 Shosky,
J. (1992L From the Surgeon General, US Public Health
Service: A medical response to domestic violence. Jenrnel

WWO” . 3132-

Neufeld, B. (1996). SAFE questions: Overcoming
barriers to the detection of domestic violence. American

Wm) . 2575- -2580-

Parsons, L.H., Zaccaro, D., Wells, B., 8 Stovall, T.G.
(1995). Methods of and attitudes toward screening
obstetrics and gynecology patients for domestic violence.

WU) . 381-

387.

Pender, N.J. (1987).
Preetiee. East Norwalk, CT: Appleton 8 Lange.

Randall, T. (1990). Domestic violence intervention
calls for more than treating injuries. Jenrnel_ef_nnezieen
WW) I 939-940-

Randall, T. (1990L Domestic violence begets other
problems of which physicians must be aware to be effective.

WWW). 940- -942-

61

Rodriguez, M. A., Quiroga, A., 8 Bauer, H. M. (1996).
Breaking the silence battered women's perspectives on

medical care. WW 153- -158-

Safriet, B. (1992). Health care dollars and
regulatory sense: The role of advanced practice nursing.

WM. 417-487-

Silver, H.K. (1977). The essentials of primary health

care. WW4”) . 151-

Smikle, C.B., Satin, A.J., Dellinger, C.L., 8 Hankins,
G.D.V. (1995). Physical and sexual abuse: A middle-class
concern? WW6) . 347-350-

Starfield, B. (1992). '

W1
BEW- Oxford, New York: Oxford

University Press.

Straus' 1" 5‘ Genes: R- (1990)- Wm

in_8145_£am111ee. New Brunswick, NJ: Transaction

Publications.

Straus, M., Gelles, R., 8 Steinmetz, S. (1980L

. 0
e‘. .0 0“. 0.. ‘. 0 ll ‘ ll‘
- 0 0 . v '0

New York, NY: Doubleday.

Warshaw, D. (1989). Limitations of the medical model

in the care of battered women. fiender_§ee1ety1_11 506- -517.

APPENDIX A

Letter of Explanation by Researcher

62

March 31, 1997

Dear Health Professional:

This letter is to request approximately five minutes of your time to complete a survey on
domestic violence. The information will be utilized to complete a descriptive study
examining the knowledge and assessment practices of health professionals providing
primary care to women in the Saginaw, Bay, and Midland areas.

You indicate your voluntary agreement to participate by completing and returning this
questionnaire. Although not required, it is encouraged that you answer all questions. All
results will be treated with strict confidence, and all participants in the study will remain
anonymous in any report of research findings. Ifyou would like a copy of the survey
results, please write your name and address on the enclosed postcard and mail it separately
fiom the survey so your response will remain anonymous.

Please return your completed questionnaire by April 15. If you have any questions or
concerns, you may contact me at 517-754-0819. Your time and honesty in completing

this survey are truly appreciated.

Sincerely,

Hiram/r Ii.

Deborah K. Johnson, KIN, B. S. N.
MSU College of Nursing
Graduate Program-Family C. N. S.

 

APPENDIX 8

Letter of Explanation by Emergency Department Physicians

63
March 24, 1997

Dear Survey Participant:

Put simply, domestic violence is a problem. However, the extent and severity of the
problem are still uncertain. What we are discovering is that there are many degrees
of understanding regarding domestic violence, just as there are victims.

Currently we are implementing domestic violence screening tools in the Emergency
Department which is being mandated by J CAHO for 1997. Victims of domestic
violence don’t just seek emergency care though, they need yearly exams, deliver
babies and have other illness for which they need treatment.

The enclosed survey is an opportunity for you to help us collect information about
your perception of the problem and your current practice in primary care. Please
return the survey to further the understanding of current trends in the Tri-city area
so that we might direct further educational activities to address the needs of all
health professionals concerned.

Thank for your time.
Sincerely,
1. /’ ' .
n , l
Mare:.tuOCqu/Db /7; ””2/
Kathleen Cowling, D.G., ABEM Mary J. Wagner, M.D. FACEP
Attending Emergency Physician Assistant Program Director

St. Lukes Hospital, Saginaw SCHI Emergency Medicine

APPENDIX C

UCRIHS Approval Letter

 

RESEARCH
AND
GRADUATE
STUDIES

MuwwSMewmauy
246 Aormmstmron Building
fimtmmmemmm
«muaom

517355-380
FAX:5)7/432-IIII

"runwwume0meuy
on :3 #:51th 0mm”
(new 41 Adam

MSU I! an Murmur-3cm)
ennui sanctum summon

 

64

MICHIGAN STATE

UNIVERSITY

 

March 31, 1997

TO: Linda Beth Tiedje . .
A-230 Life Sc1ences Building
RE: 188“: 97-191
TITLE: PORTRAIT OF AN ABUSED WOMAN: DO PRIMARY HEALTH

CARE PROVIDERS RECOGNIZE HER?
REVISION REQUESTED: N/A
CATEGORY: 1-C
APPROVAL DATE: 03/31/97

The University Committee on Research Involving Human Subjects'(UCRIHS)
review of this project is complete. I am pleased to adv1se that the
rights and welfare of the human subjects appear to be adequately

rotected and methods to obtain 1nformed consent are appropr1ate.
Therefore. the UCRIHS approved this prOJect and any rev1sions listed
above.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. -Investigators planning to
continue a project be nd one year must use the green renewal
form (enclosed with t e orig1nal agproval letter or when a
project is renewed) to seek u te certification. There‘is a
maximum of four such expedit renewals ssible. Invest1gators
wishin to continue a roject beyond the time need to submit it
again or complete rev ew.

REVISIONS: UCRIHS must review any changes in procedures involving.human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at an 0 her time during the year
send your written request to the. CRIHS Chair, requesting rev1sed
approval and referenc1n the project's IRB # and title. Include
in our request a descr ption of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

PROBLEMS]
CHANGES: Should either of the followin arise during the course of the
work. investigators must noti UCRIHS promptly: (1) roblems
(unexpected s1de effects, comp aints, e c.) involving uman
subjects_or (2) changes in the research env1ronment or new
information indicating greater risk to the human sub'ects than
ex1sted when the protocol was previously reviewed an approved.

If we can be of any future help. please do not hesitate to contact us
at (517)355-2180 or FAX (Sl7l4 2- 171.

\i’

avid E. Wright. Ph.
RIHS Chair

DEH:bed

Sincerel

  
  

cc: Deborah K. Johnson

APPENDIX D

Permission to Use Survey Tool Letter

65

August 6. I996

Deborah K. Johnson
3584 Hanchett St.
Saginaw, MI. 48604

Dear Deborah.

Per your request, I have enclosed two surveys I have developed and used in research
related to domestic violence and the knowledge and assessment practices of health professionals.
The first survey entitled, 'Survey: Battering in Pregnancy" was used in 1993 for my thesis and
was mailed to physicians and nurses within the Mid Michigan area. The second survey,
“Domestic Violence: Knowledge and Assessment Practices“ was used in 1995 by myself
(primary investigator) and Mary Meierhenry, MD. in research conducted with 600 physicians
practicing in internal medicine, ob/gyn, and family practice within the state of Michigan.

In citing authors of the survey, please remember to include M. Meierhenry with the second
survey.

Let me know if I can be of further assistance to you. I look forward to receiving the
results of your research. Much success as you embark on this major project!

Truly,

Bonnie McClure, RN.CS, MSN
517 483-2097 (W)
517 655-6139 (H)

P.S. l have enclosed an article recently published.

APPENDIX E

Survey: Domestic Violence: Knowledge and Assessment Practice

66

SURVEY
Domestic Violence: Knowledge and Assessment Practices

For the following, please check the appropriate space or enter the data which applies to you and your
practice specialty.

1.

Physician (check one): _MD _DO .
Advanced Practice Nurse (check all that apply): _ADN _BSN _MSN _Certrfied

Date of Birth: _Month _Day _Year

Sex: _M _F
Clinical Setting (check one):

__ Private Office

_ Clinic (hospital or government funded)
__ Health Maintenance Organization

_ Other, please specify

Type of Practice (check the one which best describes your primary focus):
__ Family Practice

__ Internal Medicine

_ OB/GYN

Environmental Setting of your Practice (check one):
_ Urban Community

_ Suburban

_ Rural Community

Years in Current Specialty (round to nearest year): _.

Have you attended an educational program on Domestic Violence within the last year?
_Yes _No

Have you read any literature or journal articles on Domestic Violence within the last year?
_Yes _No

l0. During your formal education, did you receive specific training related to Domestic Violence?

_Yes _No

67

For the following questions, please answer as honestly as possible.

To the best of your knowledge, how frequently does domestic violence occur? (check one):
_0-5% _6-lO°/o _l l-lS% _16-20'/o _21-25% _26% or >

12. Based on your knowledge, which signs and symptoms would you consider possible indicators of

13.

14.

domestic violence? (check all you consider appropriate):

_ Broken bone _ Black eye

_ Bruises _ lacerations

_ Depression _ Insomnia

_ Headaches _ Anxiety

_ Abdominal pain _ Suicidal thoughts
_ Excessive drinking by patient or partner

Other indicators of abuse (please list)

 

Based on your knowledge, which of the following reports of behavior would you consider possible
indicators of abuse? (check all you consider appropriate):

_ forced sexual contact _ slapping

_ threats of harm to the woman _ threats of harm to the children
__ verbal degradation _ choking

_ partner jealousy _ punching

_ physical isolation _ kicking

Other indicators of abuse (please list)

 

To your knowledge, which of the following community resources are available for the referral of
abused women. (Check yes or no to each source listed and identify at least one specific name where
indicated.)

E

S
24 Hour Crisis Line (Name)
Police Force (Name)
Prosecuting Attorney's Office
Legal Aid (Name)
Shelter/Safehouse (Name)
Counseling Service (Name)
Other Please Identify)

 

 

 

 

2
lllllllo

 

68

IS. To which of the following local community resources have you referred an abused woman.
(Check yes or no to each source listed and identify those used by name.)

NO
24 Hour Crisis Line (Name)
Police Force (Name)
Prosecuting Attorney's Office
Legal Aid (Name)
Shelter/Safehouse (Name)
Counseling Service (Name)
Other Please Identify)

 

llllllla

lllll-ll

For the following questions, please circle a number on a scale of I (NEVER) to 5 (ALWAYS), which
most accurately describes W for domestic violence.

Never Rarely Sometimes Often Always
16. During an initial intake history, how
often do you screen women for l 2
battering?

4

w
U’t

17. During annual visits with an established
patient, how often do you 1 2
screen women for battering?

U
A
M

18. Do you include a question(s) related to
battering on a history form which the l 2 3 _ 4 5
patient completes?

19. Do you vemally ask women
about battering? l 2 3 4 S

20. Do you may ask women, Within
the last year, have you been hit,
kicked shaped or othenvise l 2 3 4 5
physically hurt by someone?

21. Do you ygbglly askwomen, Within
thelas'tyarhasatnmteforcedwuto l 2 3 4 5
have sexually activities?

22. Do you verbally ask women, Within
the last year have you been qfi'aid l 2 3 4 5

of your partner or atomic close to you?

69

23. If you routinely inquire about battering and the question is not listed, what question(s) do you
use?

 

 

 

For the following questions and statements, please circle a number on a scale of l (NEVER) to S
(ALWAYS), which most accurately describes W.

Never Rarely Sometimes Oflen Always
24. During an examination of a woman,
do you consider abuse when seeing I 2 3 4 5
injuries that do not match their cause?

25. During an examination of a woman,
do you consider abuse when seeing I 2 3 4 5
depression, withdraw], or lack ofeye
contact?

26. During an examination of a woman, do
you consider abuse when ofiice visits 1 2 3 4 5
have been frequently missed?

27. During an examination of a woman, do
you consider abuse when a male partner 1 2 3 4 5
will not leave the woman unattended?

28. Time constraints of a busy practice prevent
you from assessing for domestic violence. 1 2 3 4 5

29. You consider domestic violence a private
matter and therefore do not ask about abuse
for fear it will offend her. 1 2 3 4 5

30. Other practices you use to assess for domestic violence (please list).

 

 

 

70

For the following statements, please circle a number on a scale of l (Strongly Disagree) to 5 (Strongly
Agree), which most acmrately describes your beliefs about domestic violence.

Strongly Strongly
Disagree Disagree Uncertain Agree Agree
31. "Norma/"menardwanendonotengage l 2 3 4 5
in domestic violence.
32. Primaiyeareprovidersdonothave the
necessary tools to help victims of domestic l 2 3 4 5
violence .

33. There is nothing], asaHealth Clue
Provider, can do about domestic l 2 3 4 5
violence.

I am interested in your reaction/comments; please feel the to share personal observations or
experiences with abused clients below.

 

 

 

 

 

 

 

Thank you for completing this survey. Please be sure you read all five pages. If you would like copies of
the results, please complete and return the enclosed postcard separate from your survey.

MICHIGAN sran UNIV. LIBRARIES
llWWW“!“WWWllllllllllHllWHI
31293014268951