Health practitioners’ perceptions of structural barriers to the identification of intimate partner abuse: a qualitative meta-synthesis

This theme focuses on the issues experienced ‘on the ground’ by HCPs. It was the largest theme identified in 38 papers of the 43 studies examined [21‐24, 26‐32, 34‐40, 42‐50, 52‐62]. Consistent with previous reviews, our synthesis highlighted several structural barriers at the level of the healthcare environment that impacted on HCPs’ interactions with patients.

HCPs across most healthcare settings highlighted time constraints as a major problem impeding IPA identification and response. Many participants lamented short clinic appointment times, increased workloads, and the nature of limited patient interactions, highlighting that these prevented the establishment of rapport. Although time barriers were emphasised more amongst HCPs working in settings such as the emergency department, even primary care physicians (e.g. general practitioners/family doctors) and nurses raised it as an issue.

Doctors who only have ten minutes to spend with their patients—they can’t ask about intimate partner violence. Even if they did, nobody would open up to them about a personal matter like that in ten minutes [22]. (Nurse, USA)

It’s hard to develop a feeling of trust in a short period of time [34]. (Orthopedic surgeon/trainee, Canada)

I have more than enough to do without digging too deep. The topic is big and difficult. It is big and difficult and takes time, right?... If somebody discloses things you need to make time to address it [57]. (Midwife, Norway)

For some HCPs, the lack of time was such a problem that it was preferable to discourage disclosures rather than be forced into a position where they could not address them properly. A nurse working in the sexual health setting in the UK commented that:

There are ways to ask the question to get a negative answer if you’re in a hurry [36]. (Sexual health nurse, UK)

HCPs across multiple healthcare settings highlighted lack of privacy as another critical barrier to IPA identification. HCPs pointed out that women often attended appointments with their partner, which made it inappropriate and potentially unsafe to ask about IPA.

Sometimes…I’ll ask [about IPA], just because it’s a legality issue, but a lot of times—for instance, if you’re married and you come to the ER, chances are you and your husband are both coming in the triage room. So [if I] say, “Are you a victim of domestic violence or abuse?” you’re probably not going to answer at that time honestly, if you are [24]. (Emergency department nurse, USA)

…Sometimes the husband is there too, which makes one wonder what is going to happen to the woman afterwards, will it become worse if I dig into this right now? [39]. (Midwife, Sweden)

Even when women attended alone, the physical environment within many healthcare settings was itself a barrier to sensitive inquiry. Poor design, noise, and constant interruptions made it difficult for HCPs to have sensitive discussions with women about IPA. A midwife working in the Spanish sexual and reproductive healthcare setting, for example, noted that in her clinic:

There are 3 doors, plus a telephone that rings all of the time, [but] when a woman is describing a situation like this, then nothing should interrupt her visit [45]. (Midwife, Spain)

Similarly, a study exploring the perspectives of orthopaedic surgeons and trainees in the US fracture clinic setting, described a clear example of these issues:

“There’s six other people, at least six plus learners so probably twelve people listening to every single conversation I have with patients; it’s not the appropriate place”. In addition, many fracture clinics follow an open concept model, with curtains separating exam rooms. One participant made the following analogy: “The fracture clinic is the equivalent of a family doctor seeing patients in their waiting office [34]. (Surgeons, Canada)

In the rural context, HCPs also suggested that a lack of confidentiality was a barrier to IPA identification. They pointed out that because “everybody knows everybody” [22] in a small community, that women experiencing IPA may be reluctant to disclose to a HCP they know socially or to have information recorded on their chart.

This theme, reflected in 36 of the included studies [12, 20, 21, 23, 25‐28, 30‐36, 38‐41, 43‐49, 51‐54, 56, 57, 59‐62], highlights that feeling unsupported by colleagues, the organisation and the health system more broadly was a key barrier to identifying IPA.

Participants across 35 of the studies felt that they were ill-prepared to tackle the challenging work of IPA identification and response, and perceived that the health sector did not prioritise education and training highly enough [12, 20, 21, 23, 25‐28, 30‐36, 38, 39, 41, 43‐49, 51‐54, 56, 57, 59‐62]. This neglect began early when HCPs were still studying. Practitioners emphasised that the majority of their professional training had provided limited or no content in responding to IPA [49].

I think the biggest thing is it's really not touched on a lot in school [30]. (Nurse, Australia)

I think that our education about domestic violence is somehow...lacking [53]. (Midwife, Italy)

Further, many HCPs felt that their workplaces and organisations also did not prioritise ongoing education. Participants in a variety of settings and in different countries expressed a desire to receive additional training to improve their confidence in identifying and responding to IPA but suggested that this was neither offered nor encouraged. For example, an emergency department nurse in a Turkish study suggested that:

You need to be trained for this. I don’t know, something like a course...I haven’t done anything at the moment so I don’t know how adequate I would be [61]. (Nurse, Turkey)

Similarly, a midwife in a Norwegian study by Henriksen and colleagues [57] expressed frustration that she was being asked to screen patients without being provided with any support or training.

I feel that this is something we just have to deal with without anyone telling us how to do it. So I think that I feel provoked that they [the organization] have just decided this without training us properly [57]. (Midwife, Norway)

In addition to a lack of training opportunities, HCPs lamented the absence of comprehensive IPA policies and protocols to guide practitioners in identification and response. This led to feelings of uncertainty and confusion. One practitioner from a study by Rahmqvist and colleagues [40] in the Swedish emergency department setting commented that:

I would like to know exactly what to do, with clear routines so that when it comes up, that they have been victimized, I know what to do. How can I help? Where can I refer the patient for follow up care?... sometimes it hasn’t worked out before, so I hesitate to ask or engage because I don’t know what to do or what will happen if I try to refer [40]. (Emergency department nurse, Sweden)

A sexual health nurse in an American study by Ramachandran and colleagues [27] described similar sentiments, suggesting that even when practitioners were trained to ask, there were no policies to guide them in what to do next:

We’re trained to ask the questions, we’re trained to make sure, are you feeling safe, blah, blah, blah. But then someone says ‘yes’ and then you’re like, oh no, because now I really have no idea what to do with them… I’ve never had any real sense of, OK, now what’s the appropriate follow-up? And obviously, I know that you need it, but do I tell them they can call a hotline? Are they really going to do that? Do I make them an appointment while I’m in the office with them to speak with someone? It’s really hard to know, what we do now… [27]. (Sexual health nurse, USA)

Data from five studies suggested that a further barrier to addressing IPA in health settings was a lack of collaboration amongst the different professions and no sense of working together as a team to address IPA. Many HCPs stated that they thought the responsibility for identifying and responding to IPA ought to sit with a different specialty or profession, either because they felt that the other professions (such as social work) were better equipped or because their own role description actively discouraged screening.

I think they’re [patients] being screened as they come through the emergency department, so I don’t think that screening them again in the fracture clinic adds anything [32]. (Fracture clinic, Canada)

Not us, I think the doctor is the one who [is] supposed to refer them to the social workers, because we can’t refer patients as nurses. We don’t refer [47]. (Emergency nurse, South Africa)

Screening for IPV is not our role as nurses and it is not written in the job description, so I have no authority for IPV screening, and could be fired if taking the responsibility for doing that [20]. (Nurse, Jordan)

Lastly, HCPs across multiple healthcare settings highlighted a structural disconnect between healthcare settings and social agencies that support people affected by IPA. HCPs did not feel confident in knowing what referral options were available and how services could help:

…What would I do if all these people disclosed abuse? Where would I send them for help? Such things can’t work without appropriate mechanisms within the health care system [52]. (Primary care physician, Greece)

Unfortunately, the referral system is terrible, so I didn't know where to refer her to [47]. (Emergency nurse, South Africa)

In extreme cases, not knowing where to refer individuals encountering IPA for support and feeling cut off from the service sector meant that some HCPs felt it was ‘better not to know’ about IPA. As a family physician in an American study commented:

If you don’t have the resources... sometimes it makes you reluctant to screen for it. Sometimes you’d rather not know. I mean now all of a sudden they’ve got this woman who is being abused and you can’t do anything and you don’t have the resources to be able to offer her care...that may be a barrier [26]. (Family physician, USA)

The final theme, reflected across 20 of 43 studies [22, 24‐26, 29, 30, 37, 38, 40‐42, 44, 47, 53, 54, 57‐60, 62], suggests that, in part, the low priority given to the issue of IPA within healthcare settings stems from problematic attitudes and beliefs in wider society that put the reason for not asking or disclosing onto the victim. This includes a perception that women will not disclose due to normalisation of IPA, that IPA only presents in certain types of women, that women will lie or are not reliable patients.

One example of this is the perception that women do not want to disclose IPA to a HCP and are likely to deny it if asked, which was mentioned in seven studies. In low-and-middle-income countries, this perceived reluctance to disclose was linked to patriarchal gender roles and the normalisation of violence. For example, a nurse in a Jordanian study [20] explained that:

In our culture, women are expected to not disclose IPA, and will not tell the truth. They will tolerate and accept violence for the sake of their own and family dignity and reputation [62]. (Nurse, Jordan)

However, the perception that it is pointless to ask women about IPA was also held by HCPs.

They are afraid they will not be able to escape, that the situation cannot be resolved, that nothing can be done. No one can help, they are powerless and trapped in it. These people probably do not have an alternative: if they could, they would probably put things in order and leave [58].(Doctor, Slovenia)

A further perceived barrier to addressing IPA are societal assumptions regarding the types of people affected. HCPs described the belief that IPA is something that happens to ‘other’ people, not their patient cohort:

Domestic violence is not that common in the group of patients I see because I usually see girls from good, educated, well off families...but in lower classes, less educated, less resources, yes I would say there it is a problem [37]. (Doctor, Pakistan)

Well, you can find violence in all parts of society, but I do not feel that our women are among the most deprived people. Thus, it’s not … These are not people who have a lot of issues, neither economic nor other problems [57]. (Midwife, Norway)

You have people who. . . you know very well, you know who their partners are, you see them in the practice. . . it may not even occur to you that person could be violent, so that’s probably why you may not [ask]—I may not so much for somebody I know well [38]. (General practitioner, UK)

A further societal belief that acts as a barrier to IPA identification is that women fabricate or provoke violence. Some HCPs suggested that women are not reliable patients; in particular, those who are intoxicated or mentally ill were highlighted as patients difficult to believe. Additionally, it was suggested that women use allegations of IPA for attention-seeking behaviour:

While I understand that there are lots of people out there who are abused and we need to screen them and get them help if they want it, at the same time, when you ask the same questions to everyone, sometimes it just offers an invitation for more attention-seeking behaviors [24]. (Emergency department nurse, USA).