Thai Health Promotion Foundation

Centre for Research and

Training on
Gender and Womens Health

Title : Facilitators of and barriers to screening for intimate partner

violence and caring for women who have experienced IPV
Name

of

Authors

Kritaya

Sawangchareon*,

Somporn

Wattananukulkait*, Amornrat Sricamsuk Saito* and Ratchneewan Ross**.

*Faculty of Nursing, Khon Kaen University, Khon Kaen, Thailand.
**College of Nursing, Kent state University, Kent, Ohio, USA.
Presenter : Associate Professor. Kritaya Sawangchareon, RN, PHD
Contact details: Faculty of Nursing, Khon Kaen University. E mail :
krisaw@kku.ac.th
Sub theme preferred for presentation: Gender, culture and religion
Abstract text
Problem: Thai women are considered a vulnerable population; studies
have found that 63.4% of women were abused by their partners. Nurses,
the biggest group of health care professionals, generally do not assess
female patients who have experienced intimate partner violence (IPV),
even though IPV has been found to cause injuries, chronic problems (e.g.,
depression), and high health care costs.
Purpose: To examine facilitators of and barriers to screen, provide care
and counseling for IPV victims as perceived by registered nurses (RNs) in
Thailand.
Methods: This is an evaluation study of 32 RNs who worked at different
units and received a two, 1day training session on the assessment and

care for women with experience on IPV. The facilitators were researchers,
experts in IPV (RNs) with at least a masters degree in nursing. After
completing the training, RN participants applied their knowledge and skills
gained in their clinical settings. One month later, the participants were
asked questions regarding facilitators of and barriers to assess and care
for women who have experienced IPV.
Results: Prior to training, the RNs feared asking patients IPV questions.
They stated that they did not know what to say or what to do if the
assessment was positive. After training, they felt encouraged, however,
they reported that at work, they were too busy with their routine tasks
and had no time to screen for IPV, plus, no policies existed to support such
screening. Some RNs admitted that two day training sessions were not
adequate. They felt that facilitators to IPV assessment should provide
further training sessions, clear policies, and proper infrastructure to
support the screening.
Implications: A campaign at the national level to promote IPV screening is
crucial. IPV screening policies should be established with adequate
training for RNs. An infrastructure supporting IPV screening is necessary.
Keyword: Intimate partner violence (IPV), Screening, Counseling, Nurse,
Barriers.

Introduction
In cases of women who were sexually assaulted by male partners, 92%
did not disclose the cause to doctors and 57% did not disclose it at all
(The

Commonwealth,

1993).

Emergency

doctors

have

no

records

regarding the womens social psychology; the only records available are
the information provided by the women who has been assaulted and the
location where injured women can be kept safe (Warshaw, 1989). From
interviews with pregnant women, results have shown that at least 6%
were assaulted by their partners (Center for Disease Control and
Prevention, 1994). In Thailand, the percentage of pregnant women who

were assaulted by their partners was 4.8% (Thananowan & Heidrich,

2008) and 12% (Thanaudom, 1996). Complications of IPV include; weight
loss of infant, anemia, infection and bleeding through the vagina. These
were found a higher rate in the first and the second trimester of
pregnancy. Moreover, some pregnant women who were assaulted became
melancholia, committed suicide started smoking and drinking, and started
taking drugs (McFarlance, Parker & Soeken, 1996). Family violence is a
crime which has not been focused on. In an interview, some women said
they feel ashamed, afraid and uncomfortable to talk about the violence;
others did not want to expose it at all (Saito, Cooke, Creedy & Chaboyer,
2009). According to a report of sexual assault towards women in
Cambodia (Nelson & Zimmerman, 1996), 60% of surveyed or 1/6 of
reported women who were sexually assaulted reported that it was
committed by their husbands, more than 50% got injuries and 73.9% of
injuries were around the head. More than 7 out of 10 women and men
(59.1% of Cambodian population) who were interviewed said that they did
not get awareness family violence. In Thailand, there is the belief that
men are leaders, while women are followers. The study on perception of
how they are abused through physical, mental, emotional, social and
sexual abused up to 64.3% (Sawangchareon, 2003).All the interviewees in
this study were Buddhists, culture that only men have the right to ordain
and men have the responsibility to take care of women. Following cultural
changes, women work as hard as men.
Nurses are the ones who get closest to the victims; unfortunately,
they lack the skills necessary to deal with it. Moreover, they do not take
the problem seriously even if it leads to other diseases. In practicality,
there is a One Stop Crisis Center (OSCC) in every main provincial
hospital that serves victims of family violence, including physical and
sexual assault. The centre is outpatient section that serves the patients
passively. To prevent mental and physical problems due to family violence,
nurses need to initially screen the patients, provide the necessary help.
The amount of intimate partner violence (IPV) is associated with
depression, PTSD, suicidal thoughts and who experienced more types of

abuse. Men, who smoked, drank alcohol, and used street drugs were more
prone to IPV. According to a study, violence can be associated with
unhealthy

behavior,

adverse

health

effects

and

comorbid

health

conditions (Rhodes et al, 2009). Provision of appropriate knowledge to

health officers and midwifery nurses, would assist families with domestic
violence. They can use the knowledge obtained to deal and solve the
issues in a safe matter (Varcarolis, & Halter,2010). Moreover, they can
encourage the relatives of the victims to help solving the problems.
The structure of the screening process needs to be safe for the
victims and make rapport, Nurses on the other hand need to have the
necessary skills to determine suicidal signs and emotional disturbances,
information gathering ability, and a way to provide follow up (Punyayong,
2003). Nurses also need appropriate interviewing techniques with basic
counseling to be part of nursing care. (Sawangchareon & Sadthapoomirin,
2001). A way to evaluate the ability of nurses includes; assessment of the
reaction-thoughts, experiences, satisfaction, learn-knowledge, attitude
and skills, and behavior, prior and post training in the workplace by
observation. (Eseryel, 2002). These will assist nurses to gain relevant
experience in helping those with domestic violence, nurses will be able to
appropriate screen and reduce the effects from violence. Furthermore it
could lead to solutions to problems. During screening, nurses have to use
their abilities learned to assist patients and the proper sections in order to
avoid obstacles and do their work properly.
Objective To examine facilitators of and barriers to screening and
caring for IPV as perceived by registered nurses (RNs) after training.
Methods This is an evaluation study of 32 RNs who worked at
different units and received a two, 1day training session on the
assessment and care for women with experience on IPV. The facilitators
were researchers, experts in IPV (RNs) with at least masters degree in
nursing. A workshop was held to 83 nurses with the aim to:
1) Evaluate current knowledge, attitude and skills.

2) Provide nurses the knowledge and a way to self-evaluate using

psychological materials, explain the manual, practice to interview and to
give advise using screening materials.
3) Provide follow up and further training in a months time.
A total of 65 nurses evaluated the pre-test questionnaires. After training,
RN participants applied their knowledge and skills gained into their clinical
settings. One month later, only 32 out of the initial 65 participants
attended the session, filled post-test questionnaire and participated in
focus group discussion. They were asked questions regarding facilitators
of and barriers to assess and care for women with IPV.
Settings The training was set in the Faculty of Nursing of a
nursing institute for 2 days. The facilitators were psychological nurse
researchers with expertise in IPV. The training program was developed by
IPV expertise and has been previously used to train 17 RNs. The document
are written in detail and includes: 1) an introduction to IPV; 2) nursing care
for domestic violence; 3) IPV screening and psychological test for
depression and coping strategies; 4)interview methods and counseling for
IPV; 5) Law and social networks in Thailand; and 6) model for IPV
prevention. During practice, participants got were supervised (All of work
in Muang District, Khon Kaen Province). Due to the emergency situation in
Thailand, the workshop split with a one month in between sessions. The
first training session was held on28 May and second only on 28 June 2010.
During this one month between workshops, participants had time to
practice the knowledge and skills learned using their workplace as
settings. The researcher followed up by telephone during the one month
practice and one month after the second day workshop.
Sample: 83 RNs in primary care unit (PCU), maternity departments, and
nurse instructors was registered in training. 66 nurses evaluated in the pre
test questionnaires. 32 RNs attended the following training session,
evaluated the post test questionnaires, and took part in the focus group
discussion.

Data analysis: the researcher evaluated knowledge, attitude, skills and

problems using questionnaires. Independent t-tests for pre-post test
analysis and focus group discussions were analyze by coding important
issues.
Result
A total of 83 RNs in PCU, maternity departments, and nurse
instructors registered the 2 days workshop (See table 1). A total of 66
people answered the questionnaire the first day, however only 32 people
attended the workshop the second day due to the emergency situation in
Thailand and working duties. All of the participants were women; 19 of
them were 31-40 years old and most married. Ten nurses were working in
maternity departments, 15 in PCU and 15 in OPD. Twenty-four people had
working experience between 1-30 years. A total of 29 had a Bachelors
degree; while only 3 had a Masters degree on adult heath nursing. Twenty
did not have experience as counseling while 8 had experience on HIV
consulting, however they never attended specific training on IPV. After
taking part in the workshop, the participants knowledge did not change
significantly, since they were not able to study or practice during the
workshop. However, their change in attitude was statistically significant
(p<.05).

Table 1: Personnel information of RNs involved the workshop

General Information

Number

Pre-test
Sex
Female
65
Male
1
Age between 24 -57 years

Number
Post-test
32
-

old
24-30
31-40
40-50
51-57
Total
Marital status
Single
Married
Divorce
Position
General nurses
Head of nurses
Nurse instructor
Specialist nurse
Work duration in PCU
Never
1-5 years
6-10 years
11-20 years
21-30 years
Working experience

13
32
16
5
66

5
19
1
32

13
49
4

7
22
3

21
1
7
37

6
26

19
13
10
17
7

8
3
4
12
5

Number

Number

Pre-test
8
6
7
25
17
3

Post-test
5
1
18
8
-

53
11
2

29
3
-

39
16
5
6

20
6
5
1

on

nursing
From 2 to 33 years

General Information
No answer
2-5 years
6-10 years
11-20 years
21-30 years
Over 30 years
Education
Bachelors degree
Masters degree
Doctors degree
Consultant experience
None
1-5 years
6-10 years
11-20 years
Consultant experience on
violence

Yes
No
Workplace
PCU
Maternity departments
OPD
IPDmidwifery
Instruction
Total

17
49

8
24

15
10
15
16
10
66

11
10
4
6
1
32

Table 2: Differences between knowledge and attitude before and after the
workshop (Independent Samples test)
Informati
on
Knowled
ge
Attitude

Average scores/SD
N66
N32

T=Test

10.42(1.

10.65(1.

-.73

52)
56.36(4.

35)
58.34(5.

-2.03

09)

34)

Sig.

95% CI
Lower

Upper

.46

-.86

-.39

.04

-3.92

-.03

Prior to training, the RNs feared asking patients IPV questions. They stated
that they did not know what to say or what to do if the assessment was
positive. After training, they felt encouraged, however, they reported that
at work, they were too busy with their routine tasks and had no time to
screen for IPV, plus, no policies existed to support such screening. Some
RNs admitted that two day training sessions were not adequate. They felt
that facilitators to IPV assessment should provide further training
sessions, clear policies,

and

proper

infrastructure

to support

the

screening.
Problems on the use of knowledge post focus groups discussions were;
1. Knowledge and skill
- From the workshop, the sample group did not have enough experience
and skill to take care of patients; therefore better understanding is
questions, such as: are we required to send the patients to OSCC? Is it
repeated work?
- RN lacked counseling skills for the abused and their family; they could
only provide limited information and listen to them. The RN expected the

family to be happy after providing information; however, Nurses did not

use the assessment tool stating that it was too complicated to do so.
2. Time
At Emergency room(ER), some of the nurses stated that they
do not have enough time to take care of IPV cases, then in some
ERs nurses have sent complicate cases to be further monitored and
observe department.
3. Policy
Each hospital has different policies towards family violence; it
depends on the administrators/responsible officers who support such
cases to be more successful. Some hospital policies did not support
specific cases.
4. Care system
In ANC, the process of follow up was not smooth was no data system
for shifting patients to OSCC. Furthermore, some areas within hospitals did
not follow up such cases stating that it was not their duty.
Recommendations
1.

The training could help provide a systematically interviewing

process to understand the problems and causes, and to assist in providing

prevention and solution for domestic violence.
2.

Nursing process should be applied in every case to attempt to

solve domestic violence issues.

3.

Clear policy on caring for women who experienced IPV should

be developed and cooperated into hospital care.

4.

In some PCU, nurses could cooperate with the community and

the violence care network to support family health and protect them from
domestic violence.
5.

Nurses should be more involved in training and consultation.

Academic trips on family violence care units should be also conducted so

that nurses can learn from other organizations that are responsible for
caring for women who have been abused.

Discussion
Using IPV knowledge is a new skill in nursing, nurses working in
many

units

are

interested

to

adopt

this

knowledge

within

their

organizations. Policies were not clear enough to support and help IPV
victims; only campaigns against women violence are currently available.
Everyone who attended the training realize that IPV is a serious problem,
but are unaware on how to help and solve them. It is necessary to
encourage nurses or health professionals to realize the risk of hidden
domestic violence related to women health (Ross, et al, 2010). Better
knowledge and attitude of nurses can help them have a better
relationship with patients to screen and care for IPV victims (Hall &
Becker, 2002).
Since training was conducted, nurses attitude toward helping IPV
victims has significantly changed. However, nurses still need further
knowledge and skills on specific consultant skills. These training sessions
showed no significant difference changes towards their knowledge,
acknowledging the need of more training from specialists. During the
screening process nurses had their normal daily working duties and
therefore did not have time to carry out the IPV screening. On follow up,
the researcher found that most nurses still see the importance of IPV
consulting and tried to use as much as possible. Knowledge on screening
and caring for IPV can be integrated into nursing process. Education in
nursing curriculum can support proper role of nurses to prevent and
reduce domestic violence (Friedberg, 2008).
Implication
Other nurses groups can use the IPV workshop as a way of training on
hidden family violence problems. Nurses will help abused-women to be
stronger and take care of themselves and family members efficiently. In
some cases, husband were unaware they abused their partner if it were not
for the intervention of nurses. After getting assistance from nurses, family
violence problems are better; however, more complicated violence cases will
be shifted to specialists for care. A campaign at the national level to promote

IPV screening is crucial. IPV screening policies should be established with

adequate training for RNs. An infrastructure supporting IPV screening is
necessary.
Acknowledgment
The authors would like to thank the Health Promotion Nursing Network
(HPNN) to provide financial support for conducting this study and the
Centre for Research and Training on Gender and Womens Health
(CRTGWH) for financial support to attend the 2 nd CAAWS. The authors also
wish to thank the participants, the Faculty of Nursing, Khon Kaen
University, colleagues, and master degree students in the Mental Health
and Psychiatric Nursing Program to make this study possible.
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