A scoping review of the healthcare provided by nurses to people experiencing domestic violence in primary health care settings

Abstract

Background

Domestic and family violence is a significant and growing public health concern in many communities around the world. Nurses are often the first and sometimes only point of contact for people seeking healthcare following DFV incidents and are therefore well placed to identify and support these vulnerable people. The aim of this scoping review is to examine the English language studies of healthcare provided by nurses in primary healthcare settings to people experiencing domestic and family violence.

Methods

A scoping review of the following databases was undertaken between March-June 2021: CINAHL, Medline, and PubMed. Primary studies were included if written in English, published from 2000 onwards, and focused on the care provided by primary healthcare nurses to people experiencing DFV. A critical appraisal of included studies was conducted using the Mixed Methods Appraisal Tool (MMAT). Results were synthesised narratively.

Results

Six studies were included, from the United States (n = 2), United Kingdom (n = 1), Sweden (n = 2), and Brazil (n = 1). Five studies were quantitative and one qualitative. A fundamental aspect of the healthcare provided by nurses, reported by all studies, was the screening of DFV. Other healthcare provided includes physical and mental health assessment and referral to other services, including sexual assault clinics, social supports, and law enforcement agencies. Findings suggest the level of DFV screening conducted by nurses is limited. Nurses’ knowledge of how to support people experiencing DFV was also reportedly limited. Two studies reported that nurses were unfamiliar with DFV practice guidelines and the existence and availability of support networks for people experiencing DFV.

Conclusion

Findings suggest inconsistency in primary healthcare nurses’ level of education, skill and knowledge, and detection of people experiencing DFV. As the largest healthcare professional discipline, nurses have frequent contact with people experiencing DFV. There is an urgent need for nurses to be better educationally prepared and more organisationally supported in order to adequately respond and provide healthcare to people experiencing DFV. Given that the number of people experiencing DFV has increased due to the COVID-19 pandemic, it is ever more important for nurses to be well equipped to identify and respond appropriately.

What is already known

• •Reporting of the incidence of domestic and family violence is increasing.
• •When accessing healthcare, nurses are often the first point of contact for people experiencing domestic and family violence.

What this paper adds

• •Nurses in primary healthcare settings provide screening for domestic and family violence, physical and mental health assessment, and referral to other services, including sexual assault clinics, social supports.
• •There is inconsistency in primary healthcare nurses’ level of preparedness to provide healthcare to people experiencing domestic and family violence.
• •Nurse's knowledge of how to support people experiencing domestic and family violence is reportedly limited.

1. Introduction

In this paper, a scoping review of the healthcare provided by nurses to people experiencing domestic and family violence (DFV) in primary health care settings is reported. The incidence of DFV is increasing and is likely to have been amplified by the current coronavirus pandemic (COVID-19) and the need to socially distance and isolate at home. People experiencing domestic and family violence access healthcare in both hospital and primary health care settings. This paper focuses on nurses’ role in primary health care settings, where nurses are often the first, and sometimes the only point of contact for vulnerable patients. Different from emergency and hospital settings, primary healthcare settings provide routine care for individuals and families, often over extended periods, which presents opportunities for nurses to increase access to care. To understand the contribution of nursing, this scoping review investigates the healthcare provided by nurses to people experiencing DFV in primary healthcare settings.

2. Background

2.1. Primary healthcare

Primary healthcare is defined by the World Health Organization (WHO, 2018) as a whole-of-society approach to health that focuses on people's needs as early as possible along the spectrum from health promotion and disease prevention to recovery, rehabilitation, and palliative care, and as close as possible to individuals' daily environment. Nurses practice in a range of primary health care settings in Australia such as, general or family practice, community settings, educational facilities, occupational settings, domiciliary care, residential aged care, and also sports and community groups (Australian Primary Health Care Nurses Association, 2012).

2.2. Domestic and family violence

Domestic violence can occur in many forms within family environments and is understood as a pattern of behaviour that includes the use of control and power over an intimate partner (Davis, 2008). The Australian Institute of Health and Welfare (AIHW, 2019, p. 2) defined DFV as "a subset of family violence and typically refers to violent behaviour between current or previous intimate partners". Violence can have different features such as emotional, sexual, physical, threats of action, and psychological actions (Davis, 2008). Domestic violence may cause physical trauma, psychological trauma, and fear and control issues, which can lead to mental and physical illness, disability, or death (WHO, 2013).

Domestic and family violence is a significant public health issue worldwide. An international study of 66 countries reported that 13.5% of all homicides were committed by intimate partners (Stöckl et al., 2013). It is suggested that the incidence of DFV is strongly impacted by the issue of underreporting and the majority of data is self-reported (Meyer and Frost, 2019). Global estimates of DFV indicate a gendered pattern, which disproportionately impacts women and children (WHO, 2013). The Personal Safety Survey, Australia (Australian Bureau of Statistics, 2017) reported that one in six women and one in 17 men experienced partner violence. In comparison to male perpetrators, female perpetrators of DFV are more likely to use weapons than to kick or punch, and violence is less likely to be planned or premeditated. Female perpetrated DFV is more likely to result in physical retaliation by male victims and women are more likely to use self-defence and retaliatory violence to protect themselves from an abusive partner (Boxall et al., 2020; Yates, 2018). In same-sex relationships, while women are more likely to experience emotional abuse and controlling behaviors, men are more likely to experience physical and sexual abuse from their partners (Donovan and Hester 2014; Robinson and Rowlands 2009).

The global rate of DFV varies across countries and regions (Eldoseri and Sharps, 2020). In Australia, for instance, between 2002 and 2017, the number of women being hospitalised for DFV-related assault increased from 5.3 to 6.6 hospitalisations per 100,000 population (AIHW, 2017). According to the WHO, the estimated prevalence of lifetime partner violence fluctuates between 20% in the Western Pacific to 33% in the Americas and South-East region (2021). Some of the highest rates of family and domestic-related issues were reported in Latin American and Caribbean countries (Devries et al., 2013).

Social determinants of health, including socioeconomic disadvantage, social isolation, risk of homelessness, poor health literacy, and stigma impact negatively on health service access for people experiencing DFV (AIHW, 2016). Enabling access to informal and formal healthcare support for people experiencing DFV is crucial in lowering the risk of adverse health impacts and health care costs. More specifically, effective communication between the victims of DFV and the health provider has proven to be pivotal in improving both the health and safety of the people experiencing DFV(Alvarez et al., 2016). In Australia, multiple government and non-government agencies are involved in delivering services to address DFV, with many points of entry and referral, which creates a complex and fragmented experience to navigate when seeking care (Queensland Goverment, 2016). Compounding this issue, many women experiencing DFV in Australia are from vulnerable populations including people from culturally and linguistically diverse backgrounds, First Nations peoples, young people, older adults, and people with disabilities (AIHW, 2016).

3. Domestic & family violence and COVID-19

Since the COVID-19 pandemic outbreak, there has been a global increase in DFV instances, especially in countries with a high number of COVID-19 confirmed cases, such as Singapore, France, Cyprus, Argentina, and the United States (Boserup et al., 2020). The public health directions for people to stay at home and self-isolate have led to a subsequent increase in the number and frequency of DFV incidents, at a time when people are isolated from much of their support network (Anurudran et al., 2020; Bradbury‐Jones and Isham, 2020). During the initiation of stay-at-home orders in Australia, a 5% increase in police callouts for DFV incidents occurred, along with a 75% increase in internet Google searches relating to support for DFV (Usher et al., 2020). The emergence of new forms of DFV has been reported by health practitioners, which are linked to social isolation and physical distancing associated with the COVID-19 infection. In Australia, perpetrators of domestic violence have reportedly been using the COVID-19 infection to threaten women and coerce them into cohabitation, where they are then isolated from their usual social networks (Pfitzner et al., 2020). Health practitioners are increasingly aware that many women experiencing DFV now have reduced access to support (Pfitzner et al., 2020). The situation is similar and potentially more difficult for those living in other countries. For instance, people experiencing DFV in India were unable to leave their homes and flee violent situations due to a strict lockdown for a period of many months in the early part of the pandemic, making their situation much worse (Maji et al., 2021). These reports suggest that the incidence of DFV is amplified by the COVID-19 pandemic.

4. The rationale for this review

The incidence of DFV holds implications for nursing practice, such as identifying people experiencing DFV, empowering them with essential knowledge, and addressing their health needs by designing appropriate interventions (Oweis et al., 2009). Women experiencing DFV, on average experience up to 35 episodes of violence before seeking help (Basu and Ratcliffe, 2014). Empowering people experiencing DFV to seek and receive timely care and support is critical to optimising their health outcomes and improving their access to much needed healthcare and support services. Nurses are the largest healthcare discipline and have an important role in facilitating access to services for people experiencing DFV ((Dhollande, 2021); (McGarry and Hinsliff-Smith, 2021); Alhalal, 2020). The purpose of this scoping review is to explore the healthcare provided by nurses to people experiencing DFV in primary healthcare settings.

5. Methods

This scoping review investigated the following research question:

What healthcare is provided by primary healthcare nurses to people presenting following domestic and family violence?

The population of interest was nurses practising in any country. The core concept examined was the provision of healthcare to people experiencing DFV and the context was primary healthcare. For the purpose of this review, the following broad definition of healthcare is adopted ‘…various services for the prevention or treatment of illness and injuries…’ (Collins Dictionary, 2021, p. 113) within the scope of practice of a registered nurse.

5.1. Protocol and search strategy

To answer this broad research, question a scoping review of the literature was conducted between 1 March and 4 June 2021, to identify research on primary healthcare nurses’ provision of care to people presenting with DFV.  The scoping review is reported here in accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses Scoping Review extension (PRISMA-ScR) guidelines a(McGowan et al., 2020).

A review protocol was developed by the first author (HA), who is a registered nurse experienced in primary healthcare, in consultation with a clinical nurse practitioner and academic (JC), and a research librarian. After the review protocol was established, an electronic search of three databases was conducted, CINAHL, Medline, and PubMed. The initial search phases were completed between 16 March 2021 and 9 April 2021. Several search terms were arranged in three main Boolean/phrases and combined with “AND” as follows, “Domestic violence OR domestic abuse OR intimate partner abuse OR family abuse OR family assault” AND “nurse OR nurses OR nursing” AND “primary health care OR primary healthcare”. The following limiters were applied in both the CINAHL, PubMed, and Medline databases: full text, published between 2000 and 2021, and written in the English language. The papers identified through the search were uploaded to Endnote X10 (Clarivate Analytics) for citation management and eligibility assessment. To ensure its comprehensiveness, the search was re-run on the 5th January 2022, adding the search terms “family violence”, “medical clinic OR medical practice OR health clinic" because the authors became aware that these terms are also used to describe domestic and family violence and primary healthcare settings.

5.2. Eligibility assessment

The articles were assessed independently by two authors (HA, JC) against the inclusion and exclusion criteria (Table 1). There was disagreement of six studies, and this was resolved through discussion. The remaining articles were then read in full independently by two authors and there were no disagreements on the final included sample.

Table 1.

Inclusion & exclusion criteria.

Inclusion criteria	Exclusion criteria
English language 2000–2021	Focus on dating violence
Peer-reviewed primary research	Hospital setting
Any study design	Focus not on primary healthcare nursing Focus on maternal health, child health
Nurses practising in a primary healthcare setting	Conference proceedings/ papers/ abstracts, interviews, thesis, letters to the editor
Nurses providing care to adults experiencing domestic and family violence	Commentaries, editorials, discussion papers, reports, books, book reviews
Healthcare provided by nurses is reported	Research protocols, literature reviews

5.3. Critical appraisal of individual sources of evidence

The Mixed Methods Assessment Tool (MMAT) was applied to provide an appraisal of the design of included studies (Hong, 2018, p,114). Since there was no limitation on the research design of included studies, the MMAT enabled appraisal of any type of design approach. The MMAT includes seven questions for each research design. The authorship team reviewed the included studies (n = 6) independently. There was unanimous agreement between the authors on their appraisal.

5.4. Data charting

A data extraction table was developed by two authors (HA, JC). The following data were extracted by one author independently (HA) and then reviewed and confirmed by another author (JC), author, year, country, aim, design, results relating to the scope of practice.

6. Results

6.1. Selection of sources of evidence

The search yielded n = 3604 articles, and after removing duplicates (n = 217), the titles and abstracts screened for eligibility, and a further n = 3356 articles excluded. The full text of the remaining 31 articles were read and n = 25 articles were removed leaving a final sample of n = 6 included articles. Additional studies were identified from the references lists of included papers and online library searching (n = 3) and screened for eligibility. No new records were included in the review. The search strategy and screening are summarised in a PRISMA-ScR diagram, in Fig. 1.

Fig. 1.

PRISMA flow diagram.

6.2. Critical appraisal of individual sources of evidence

The six included studies were assessed using the Mixed Methods Appraisal Tool (MMAT) (Hong et al., 2018), as shown in Table 2. The score awarded for each of the seven assessment questions in the MMAT was converted to a percentage for each study; an approach used previously by others (h(Khosravi et al., 2014); (Pluye et al., 2009)). Four of the included studies were considered to have an appropriate and rigorous design, in so far as they met over 85% of the MMAT criteria. Two of the studies met only half the criteria because it was unclear whether the sampling strategies were appropriate and whether the final samples were representative of the target population. The studies were scored as follows: Ramsay et al., 2012= 86%; Soglin et al., 2009= 86%; Sundborg et al., 2012=57%; Sundborg et al., 2018= 86%; Tschirch et al., 2006= 57%; Visentin et al., 2015= 100%.

Table 2.

Quality assessment of sources of evidence retrieved from (Hong et al., 2018).

Authors/year/study design	Methodological quality criteria (Hong et al., 2018)	Response
		Yes	No	Can't tell
Ramsay et al., 2012 Quantitative descriptive	Are there clear research questions?	√
	Do the collected data allow to address the research questions?	√
	Is the sampling strategy relevant to address the research question?	√
	Is the sample representative of the target population?	√
	Are the measurements appropriate?	√
	Is the risk of nonresponse bias low?		√
	Is the statistical analysis appropriate to answer the research question?	√
Soglin et al., 2009 Quantitative descriptive	Are there clear research questions?	√
	Do the collected data allow to address the research questions?	√
	Is the sampling strategy relevant to address the research question?	√
	Is the sample representative of the target population?			√
	Are the measurements appropriate?	√
	Is the risk of nonresponse bias low?	√
	Is the statistical analysis appropriate to answer the research question?	√
Sundborg et al., 2012 Quantitative descriptive	Are there clear research questions?	√
	Do the collected data allow to address the research questions?	√
	Is the sampling strategy relevant to address the research question?	√
	Is the sample representative of the target population?		√
	Are the measurements appropriate?			√
	Is the risk of nonresponse bias low?			√
	Is the statistical analysis appropriate to answer the research question?	√
Sundborg et al., 2018 Quantitative non-randomized	Are there clear research questions?	√
	Do the collected data allow to address the research questions?	√
	Are the participants representative of the target population?	√
	Are measurements appropriate regarding both the outcome and intervention (or exposure)?	√
	Are there complete outcome data?	√
	Are the confounders accounted for in the design and analysis?			√
	During the study period, is the intervention administered (or exposure occurred) as intended?	√
Tschirch et al., 2006 Quantitative descriptive	Are there clear research questions?	√
	Do the collected data allow to address the research questions?	√
	Is the sampling strategy relevant to address the research question?			√
	Is the sample representative of the target population?			√
	Are the measurements appropriate?	√
	Is the risk of nonresponse bias low?			√
	Is the statistical analysis appropriate to answer the research question?	√
Visentin et al., 2015 Qualitative	Are there clear research questions?	√
	Do the collected data allow to address the research questions?	√
	Is the qualitative approach appropriate to answer the research question?	√
	Are the qualitative data collection methods adequate to address the research question?	√
	Are the findings adequately derived from the data?	√
	Is the interpretation of results sufficiently substantiated by data?	√
	Is there coherence between qualitative data sources, collection, analysis and interpretation?	√

6.3. Characteristics of sources of evidence

Of the six included studies, shown in Table 3, one was qualitative (Visentin et al., 2015) and the remainder quantitative. The articles included a total of 1404 participants: general practitioners (n = 183), primary healthcare nurses (n = 836), and patients (n = 385). The included studies were published between 2006 and 2018, in Sweden (Sundborg et al., 2012, 2018), the United States (US) (Soglin et al., 2009; Tschirch et al., 2006), the United Kingdom (UK) (Ramsay et al., 2012) and Brazil (Visentin et al., 2015).

Table 3.

Summary of the included studies.

Author(s), year and location	Title	Aim of the study	Methodology	Participants	Result relating to healthcare provided by nurses
Ramsay et al. (2012) UK.	Domestic violence: Knowledge, attitudes, and clinical practice of selected UK primary healthcare clinicians	To examine the current levels of competency of clinicians regarding DFV against women.	Cross-sectional survey as a phase of a randomised controlled trial. Survey Instrument: Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS). (Stata, version 10.1).	Primary healthcare clinicians in urban primary care trusts. Nurses n = 89 General Practitioners n = 183 Mean age of nurses was 46 (SD 8.1) years. Number of years of experience as a nurse: median 7 years (Interquartile range 4–12).	78.2% nurses had not diagnosed new DFV cases in the last 6 months. 80.9% nurses did not routinely ask patients about DFV. 45.1% of nurses provided women with DFV education or material resources, 55.4% did not have sufficient knowledge of referral resources and 87.3% were not familiar with a specific guideline. 62.5% nurses were unsure if they had a protocol to guide their DFV practice, and 40.5% were unsure if they had access to a camera for photographing DFV injuries. Over half (54.2%) of the nurses were unsure if they had adequate referral resources.
Soglin et al., 2009. US	Detection of Intimate Partner Violence in a General Medicine Practice	To examine the ability of a multifaceted approach to education linked with enhanced workers resources to promote identification of DFV.	Two-phase study, 1) prevalence of DFV was contrasted with physician identification of DFV in patient charts. 2) Evaluation of screening rates of the presence of DFV in all female patients (unaccompanied), pre/post a physician educational DFV intervention, and nurse-focused routine enquiry of 25% of female patients (when taking vitals, nurses asked patients two previously validated DFV screening queries). Screening rates were compared with those of the other 75% of patients.	Patient records of n = 306 women with a mean age of 40.5 years, of theses 99% had valid health insurance and 69% had an income between 25,000 and 100,000 USD. Number of nurse and physician participants not provided.	Review of patient records: Most (73%) women reported no history of DFV at baseline, and 27% reported a lifetime history of DFV, while current experience of DFV was reported by 4.2%. Introduction of routine enquiry (screening) by nurses showed a significant increase in reports of lifetime DFV (17.6%) when compared to usual care (2%), but there was no significant change (1% vs 1.3%) in current DFV identification.
Sundborg et al., 2012. Sweden.	Nurses’ preparedness to care for women exposed to intimate partner violence: A quantitative study in primary healthcare	To examine the preparedness of primary healthcare nurses to identify and care for women who were exposed DFV.	Questionnaire, 29-items, to examine nurses' preparedness, nurses' knowledge and personal attitudes toward DFV.	N = 192 nurses from n = 39 primary healthcare centres across rural and urban areas. Mean age 49 years (SD = 11.22). Number of years working as a nurse mean = 21 (SD = 10.37). Number of years working as a district nurse mean of 12 (SD = 6.44).	Most (70%) nurses were unaware of how to collaborate with specialised authorities when supporting patients experiencing DFV. 80% of nurses stated that they did not receive any vocational training about DFV, and 92% had not receive training about DFV within the last three years in their professional work. 82% of nurses were eager to be trained. 52% of nurses reported asking direct questions when DFV was suspected. Several nursing interventions were used when encountering suspected or identified abused women, such as, offering them appointments with doctors and providing them with information about volunteer organisations.
Sundborg et al., 2018. Sweden	Impact of an educational intervention for district nurses about preparedness to encounter women exposed to intimate partner violence	To evaluate the preparedness of primary healthcare nurses to encounter females exposed to DFV using an educational intervention	Observational quasi-experimental. Groups: intervention, control and national. Educational intervention methods: lectures, PowerPoint and group discussion. A survey was completed by all groups before the intervention and repeated by the intervention and control groups after a year.	A total of n = 538 district nurses were recruited in three groups: Intervention group n = 117 (80% aged ≥ 40 years; 43% worked as district nurses for ≥ 10 years) Control group n = 204 (91% aged ≥ 40 years; 64% worked as district nurses for ≥ 10 years) National group n = 217 (93% aged ≥ 40 years; 88% worked as district nurses for ≥ 10 years)	The educational intervention had a low impact on district nurses’ preparedness. Most significant finding was in the post-intervention group survey, nurses no longer perceived DFV as a private matter not to be discussed with patients (p= 0.003; 95% CI = 0.64; 2.78). Professional support by co-workers showed a decrease in the post-intervention survey (p= 0.032; 95% CI = 141; 0.03) suggesting that the nurses searched for support in their workplace and didn't find it.
Tschirch et al., 2006. US.	Nursing in tele-mental health	To provide women experiencing DFV with an assessment, referral, and recovery program.	A project of tele-mental health network. A classroom at a nursing school was used as a telemedicine clinic. The project was implemented by a collaborative team including a psychiatric nurse practitioner (PNP), family nurse practitioner (FNP), patient's shelter liaison and nursing school director. Mental health assessment tools included Symptom Checklist-90-R to measure treatment response and the Global Severity Index to measure level of distress.	N = 79 women who had experienced DFV, living in a women's shelter. Participants’ mean age 33 years. N = 38 women were referred for psychiatric evaluations, and n = 34 initiated treatment, with n = 25 being treated successfully. A total of 110 telemedicine visits were conducted.	Nurses were instrumental in identifying women experiencing DFV. 29% of the women had not received mental health assessment previously by a healthcare provider. A nurse practitioner provided a physical and mental health assessment including metabolic pathology investigations and alcohol and other drug screening. The nurse practitioner was female which was important for many of the women. The highest four symptoms identified by the SCL-90-R screening tool were psychosis, anxiety, somatisation and depression. 97% experienced mood and anxiety disorders. Major depression (49%) and posttraumatic stress (54%) were the most frequently occurring diagnoses. The service was rated extremely highly by the women receiving telemedicine.
Visentin et al., 2015. Brazil.	Women's primary care nursing in situations of gender violence	To identify the interventions conducted by nurses in primary healthcare settings for women experiencing DFV.	Exploratory-descriptive approach. Qualitative data collection through semi-structured interviews.	N = 17 primary healthcare nurses working in a community health unit, aged between 25 and 57 years, n = 14 female. Clinical experience ranged from 4 months to 21 years.	Building a relationship and connection with women to enable them to verbalise the violence was key. Referrals to specialist services were an integral part of care. Nurses identified their limitations when caring for people experiencing DFV, including lack of professional training, lack of time, feeling unprepared and difficulty recognising the presence of DFV and dealing with the situation of violence.

The studies focused on the performance and knowledge of nurses (Ramsay et al., 2012; Sundborg et al., 2012), the impact of education on practice (Soglin et al., 2009; Sundborg et al., 2018), and patient care (Tschirch et al., 2006; Visentin et al., 2015). Four studies used surveys to collect data, one used semi-structured interviews (Visentin et al., 2015), and one used patient records and clinical charts (Soglin et al., 2009). The primary healthcare settings included ‘primary healthcare centres’ (Ramsay et al., 2012; Sundborg et al., 2012, 2018; Visentin et al., 2015), a women's shelter (Tschirch et al., 2006), and a general medicine practice (Soglin et al., 2009). The major themes that arose from this review included the 1) healthcare provided by nurses, 2) screening for DFV, and 3) nurses’ educational preparedness to provide healthcare for people experiencing DFV, discussed below. All included studies focused on women experiencing DFV, none of the studies related to men experiencing DFV.

6.4. Healthcare and screening provided by nurses to people experiencing domestic and family violence

A key priority of primary healthcare nurses’ practice, reported in each of the studies, was to screen people for DFV. There was variation in the reported frequency of DFV screening conducted by the nurses. For example, one study reported that 80.9% of nurses did not routinely include queries about DFV in patients’ assessments, and only 27.0% of nurses asked patients who displayed signs or symptoms of violence, whether they had experienced DFV (Ramsay et al., 2012). In this same study, most nurses had not detected any cases of DFV within a period of six months (78.2%) (Ramsay et al., 2012). The study by Sundborg et al. (2012) noted that 52.0% of nurses asked patients directly about DFV only when DFV was suspected.

Nurses who reportedly asked direct or indirect questions to patients regarding DFV were aware of barriers that could prevent patients from verbalising information about the occurrence of DFV (Visentin et al., 2015). Nurses perceived that women's feelings of isolation, shame, and guilt were often significant barriers (Visentin et al., 2015 p. 59). To overcome these barriers, nurses sought to build rapport and trust with those they encountered to encourage them to report incidences of violence (Visentin et al., 2015). In the Soglin et al., study, nurses asked all female patients two validated questions about domestic and family violence whilst recording each patient's vital signs. This routine screening intervention for domestic and family violence resulted in an increase in detection (17.6%) of women who had experienced domestic and family violence at some point in their lifetime, when compared to usual (no routine screening) nursing care (2.0%). In terms of identifying current domestic and family violence, the routine screening did not increase detection compared to usual care (1.0% vs.1.3%).

Other healthcare provided by nurses included mental and physical health assessments (Tschirch et al., 2006), education (Ramsay et al., 2012; Tschirch et al., 2006) referral to other health services (Visentin et al., 2015; Sundborg et al., 2012; Ramsay et al., 2012) including sexual assault services (Visentin et al., 2015), and referral to social and law enforcement agencies (Visentin et al., 2015; Sundborg et al., 2018; 2012). Tschirch et al. (2006) reported on a telehealth network to care for underserved women experiencing DFV. The nurse practitioner supporting the service screened all patients with the Symptom Checklist-90-R (SCL-90-R), assessed their mental health, and undertook a physical assessment, including blood investigations. Tschirch et al. (2006) reported that many of the women experienced post-traumatic stress disorder and many were unaware that their symptoms could relate to the trauma they had experienced. Here, the nurse practitioner had a critical role in providing education to the women to normalise and understand the origin of their symptoms. This study also highlighted that many of the women preferred care provided by a female. The psychiatrist in the telehealth service was male and for some women, this was perceived as confronting (Tschirch, 2006 p.17).

Sundborg et al. (2012) reported that in cases where DFV was suspected, most nurses arranged an appointment with a physician (68.0%), met the woman without her partner (60.0%), and provided her with information on volunteer support agencies (56.0%). In cases where DFV was disclosed, nurses also spent time listening to the women's descriptions of their DFV experience (70.0%), and advised them to inform the police (60.0%) (Sundborg et al., 2012).

6.5. Educational preparedness of nurses

Preparedness to provide care for people experiencing DFV was discussed in all six studies, and the level of preparedness reported was mixed. The exploratory-descriptive study by Visentin et al. (2015), concluded that nurses were not sufficiently prepared to care for people experiencing DFV. In Ramsay et al. (2012) study, the test of nurses’ actual knowledge showed their ability to identify warning signs of violence, including frequent injuries (86.5%), anxiety (79.8%), and depression (79.8%), but the identification of substance abuse related to DFV was low (37.1%). In the tele-mental health trial by Tschirch et al. (2006), as members of a collaborative multidisciplinary team, nurses identified four frequently prevalent symptoms, including psychosis, anxiety, somatisation, and depression. The authors reported that 29% of the women experiencing DFV had not previously received mental health assessment or treatment from primary care providers and noted that early intervention for people experiencing DFV with mental health symptoms could prevent more serious illnesses that later required acute hospitalisation (Tschirch et al., 2006).

Limitation in knowledge was also identified in the study by Sundborg et al. (2012), in which 70% of nurses claimed that they were unaware of any collaboration with external organisations in combating DFV. Although unaware of collaboration, most nurses reported that collaboration with external organisations was needed (92%). Only 30% of participants acknowledged the existence of collaborations and could provide the names of partner volunteer agencies. Visentin et al. (2015) stated that nurses considered the DFV referral network as challenging. Despite this, nurses acknowledged the need to collaborate with other sectors to make public safety and social welfare decisions and seek appropriate resolutions for people experiencing DFV (Visentin et al., 2015 p.59).

Lack of training in providing healthcare to people experiencing DFV was a significant issue for nurses (Visentin et al., 2015; Ramsay et al., 2012; Sundborg et al., 2012). In one study, 80% of nurses had not received vocational training in DFV, and 92% of them had not received training during their professional work within the last three years, yet the majority (82%) had an appetite for learning about DFV (Sundborg et al., 2012). Over half (55.4%) of the participants in the UK based study by Ramsay et al. (2012), indicated they did not have sufficient knowledge of referral resources, 87.3% were not familiar with a specific DFV guideline, and 62.5% were unsure if they had a protocol for DFV healthcare provision (Ramsay et al., 2012).

One study assessed the impact of an educational intervention for district nurses on their preparedness to provide healthcare for women experiencing DFV (Sundborg et al., 2012). This study used a cascade teaching methodology, where a group of district nurses received a short lecture on DFV, who then shared that knowledge by replicating the same lecture to their work colleagues. Findings indicated that the short intervention had a low impact on district nurses’ preparedness. There are limitations to this approach as it relies heavily on the skills of the district nurses to impart their knowledge accurately and effectively. One of the significant findings was that the district nurses’ perception of DFV changed following the education intervention, in so far as they no longer perceived DFV as a private matter not to be discussed with patients (Sundborg et al., 2012).

7. Discussion

7.1. Summary of evidence

In this paper, a scoping review to explore the healthcare provided by nurses in primary healthcare settings to people experiencing DFV is reported. The findings hold translational implications for nurses’ screening of people experiencing DFV and nurses’ educational preparedness to provide healthcare to people experiencing DFV.

Nurses across all studies were enthusiastic in their desire to support people experiencing domestic violence and recognised that it was an area of need in the community. Despite this drive, the study findings suggest that primary healthcare nurses are reluctant to ask people about DFV. International statistics indicate that up to 80% of nurses who are untrained in the care of patients presenting with DFV feel uncomfortable approaching the topic of DFV (Oktay, 2013). An important factor in initiating conversations relating to DFV is gaining the trust of patients (Visentin et al., 2015). Adopting a trauma informed approach, in which a person acknowledges the impact of trauma and emphasises psychological and physical safety, is important to create opportunities for healing and develop a sense of empowerment p(Hopper et al., 2010).

Only 28% of all women who have experienced DFV seek help ((Biroscak et al., 2006); (Hooker et al., 2016)). Of that group, 48% will seek help from their general practitioner and 50% will seek help at an emergency department (ED) ((Van Der Wath et al., 2013); (Yonaka et al., 2007); (Svavarsdottir and Olafsdottir, 2008)). As frontline healthcare professionals, it is critical that nurses feel educationally prepared and organisationally supported to provide care to people experiencing DFV. A recent discourse analysis of two (n = 10/n = 6) focus groups with emergency department nurses reported variation in nurses’ self-perception of their capacity to provide healthcare to people experiencing DFV (Venkataraman et al., 2021). These study findings suggest that preparing the nursing workforce to provide effective assessment and intervention is fundamental to improving access to care for people experiencing DFV ((Venkataraman et al., 2021)).

The findings of this review suggest a lack of vocational and professional training, which reduces the preparedness of nurses to care for people experiencing DFV. Of the nurses who participated in two of the included studies, most perceived that they had received insufficient training to provide healthcare to people experiencing DFV (Ramsay et al., 2012; Visentin et al., 2015). A recent Australian study reported that training for midwives, neonatal intensive care nurses, and community child health nurses improved their awareness of DFV (87.6%) (Baird et al., 2018). After exposure to a series of educational sessions about DFV, more than 60% of the nurses and midwives reported improved knowledge of screening and ways to ask about DFV, responding to individual disclosures, collaborating with support agencies, and using appropriate referral pathways (Baird et al., 2018).

Improving undergraduate curricula offers an opportunity to empower nurses to respond to DFV, by equipping them with a comprehensive understanding of potential challenges and approaches (Doran et al., 2019 p. 99). A recent national independent review of nursing education in Australia identified the acute care focus of most pre-registration nursing curricula (Schwartz, 2019) and the need to ensure that nurses are well prepared to provide healthcare in a range of environments, particularly community settings. It is important to highlight that any attempt in integrating DFV training into undergraduate curricula must not be limited to acute care settings.

7.2. Implication for nursing

Domestic and family violence is the leading cause of homelessness for women and children in Australia (Equity Economics 2021). Over fifty percent of women experiencing DFV have children in their care. The 2016 Personal Safety Survey in Australia, reported that 80,000 women experiencing DFV who had previously left a violent partner, returned to their partner. Reasons for returning include having nowhere else to go, fear for the safety and wellbeing of children, and a desire to try and work things out within families (Equity Economics 2021). Optimising every opportunity to improve access to healthcare for people experiencing DFV is critical to ensure people receive appropriate help. Providing DFV screening, assessment and, appropriate referrals are fundamental nursing roles that can improve access to care for people experiencing DFV. As frontline health workers, nurses are perfectly placed to provide initial care and connect this vulnerable population with further support. Findings of this review suggest that while primary healthcare nurses are motivated to support their patients, they do not perceive they are well prepared to provide healthcare to people experiencing DFV. The rapidly growing incidence of DFV means it is critical that nurses are educated and ‘ready’ to provide healthcare to people experiencing DFV.

8. Limitations

This scoping review has some limitations. The search was limited to articles published in the English language, and peer reviewed publications, focused on adults experiencing domestic and family violence. A search of the so called ‘grey literature’ was beyond the scope of this review. All included studies focus on women experiencing DFV, no studies were identified that provided data on nurses’ provision of care to female perpetrators of DFV or DFV within same-sex relationships.

9. Conclusion

This scoping review explored the healthcare provided by primary health care nurses to people experiencing DFV. Nurses reported various interventions for women experiencing DFV. Few nurses routinely screen women for DFV because they feel ill prepared and uncomfortable. In addition, few nurses receive regular education/training in screening and providing healthcare to women experiencing DFV and are therefore unfamiliar with their local protocols and guidelines. Given the growing incidence of DFV, ensuring nurses are educationally well prepared to provide healthcare to people experiencing DFV is important because it is likely to improve access to care for the rising number of people experiencing DFV.

Funding

No external funding.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.