Review: meta-analysis of qualitative studies generated recommendations for healthcare professionals meeting with women who had experienced intimate partner violence
Q How do women who have been exposed to intimate partner violence perceive the responses of healthcare professionals (HCPs) when they discuss abuse, and how would they like them to respond?
Medline, Applied Social Sciences Index and Abstracts, Social Science Citation Index, CINAHL, and PsycINFO (all up to July 2004); bibliographies of retrieved studies; and researchers.
STUDY SELECTION AND ASSESSMENT
Published, English language, qualitative studies of women ⩾15 years of age who had experienced intimate partner violence; studies had to examine abused women’s views of HCPs and include verbal interaction between researchers and participants. Analysis comprised parallel identification and examination of first order constructs (ie, understandings of women as reported in original studies) and second order constructs (ie, original study author interpretations or conclusions) and methodological appraisal of individual studies; and examination of relations between constructs. 25 studies (847 women, age range 18–78 y) met the selection criteria.
14 first order constructs were identified and grouped into 3 areas. (i) Desired characteristics of HCPs. Women wanted HCPs to be non-judgmental, compassionate, and sensitive; to maintain confidentiality; and to understand the complexity of abuse. (ii) Nature of consultation with HCPs. Women found it helpful when HCPs raised the issue in a sensitive and confident manner, did not rush the discussion, confirmed that the violence they experienced was undeserved, tried to bolster their confidence, allowed them to progress at their own pace, and respected their decisions and shared decision making. (iii) Women’s expression of their needs. Women’s feelings about abuse were complex, and women wanted HCPs to help them address these feelings.
Second order constructs (original study author conclusions) included autonomy, confidentiality, HCP behaviour, disclosure of violence, education of HCPs, cultural issues, and documentation.
7 apparent contradictions were identified; they were explained by second order constructs or resolved by creation of a third order construct. (i) Raise the issue of abuse directly or indirectly. Resolution: depends on context. (ii) Discuss abuse in front of children or not. Resolution: for women still in the abusive relationship, safety could be compromised by discussion in front of children; for women who have left the relationship, openness and honesty are more important. (iii) Women received or did not receive increased HCP contact after disclosure. Resolution: satisfaction based on receipt of practical advice or specialist support rather than increased contact. (iv) Disclosure of abuse led to positive or negative consequences. Resolution: perceived consequences affected by stage of abusive relationship and if women had children. (v) Repeated inquiry was desired or offensive. Resolution: women in later stages of an abusive relationship wanted repeated inquiry (ready for change). (vi) Women were satisfied or dissatisfied with taking medication. Resolution: depended on whether medication was appropriate to the situation or was given without counselling or advice. (vii) Women preferred male or female HCP or HCP sex did not matter. Not resolved.
Third order constructs were derived based on synthesis of first and second order constructs and were presented as recommendations to HCPs. (i) Before disclosure or questioning: have a full understanding of the issue of domestic violence; ensure continuity of care; assure women about privacy, safety, and confidentiality; place brochures and posters in medical settings to show that abuse issues can be broached; ensure a supportive, non-threatening clinical environment; develop trust using verbal and non-verbal communication skills; be compassionate, supportive, and respectful; be alert to signs of abuse, and consider domestic violence with other possibilities. (ii) When the issue of domestic violence is raised: raise the issue in the clinical consultation; be non-judgmental, caring, and comfortable when asking about domestic violence; do not pressure women to disclose; simply raising the issue can help; ask about abuse several times as women may discuss at a later date; ensure a private and confidential environment and provide adequate time. (iii) Immediate response to disclosure: respond non-judgmentally, showing compassion, support, and belief; acknowledge the complexity of the issue, respect each woman’s concerns, and put patient identified needs first; take time to listen, provide information, and offer referrals; validate women’s experiences, challenge assumptions, and provide encouragement; ensure that women feel they have control over the situation and address safety concerns; ensure that social and psychological needs are addressed. (iv) Response in later interactions: be patient and allow women to progress at their own pace; understand the chronicity of the problem and provide continued support; respect women’s wishes and do not pressure them to make decisions; be non-judgmental if women do not immediately follow up on referrals; give women an opportunity to disclose at a later date.
Meta-analysis of qualitative studies generated recommendations for healthcare professionals meeting with women who had been exposed to intimate partner violence.
- Cristina Catallo, RN, BScN
Feder et al provide insight derived from a systematic overview and synthesis of qualitative evidence on women’s disclosures of intimate partner violence to HCPs. Because the most appropriate methods for synthesising qualitative studies is disputed1,2 and no firm metasynthesis guides exist, the approach used by Feder et al was appropriate.
The metasynthesis describes women’s preferences for the discussion of intimate partner violence, verifies primary study result interpretations, and presents recommendations for HCPs. Recent systematic reviews of quantitative studies have highlighted the paucity of evidence to support routine, universal screening for violence in healthcare settings.3,4 In the absence of such research,3 Feder et al provide important recommendations for HCPs, particularly in the context of case finding and the need to respond sensitively to women’s disclosures. However, because this is a qualitative metasynthesis, it does not identify the effects of disclosure on quality of life, future violence, or the resulting risks and benefits. Until quantitative evidence exists to help address these uncertainties, the extension of these qualitative findings to issues of screening and case finding requires caution.
For correspondence: Dr G S Feder, Barts and the London, Queen Mary’s School of Medicine and Dentistry, London, UK.
Source of funding: no external funding.