Abstract
Clinician family violence knowledge has traditionally been evaluated using quantitative measures via self-rating of skills. Qualitative methods have been used less frequently, in ways that require clinicians to provide specific information to demonstrate their skill base.
Objectives:
This study aimed to investigate the impact of different levels of training in family violence (no training, some training, clinical champions), on the clinician knowledge of key family violence response skills, using qualitative, survey obtained text-box responses.
Design:
A cross-sectional, online, survey of hospital clinicians in a major trauma hospital was conducted.
Methods:
The Assisting Patient/Clients Experiencing Family Violence: Royal Melbourne Hospital Clinician Survey tool was utilised and open for clinicians to complete, anonymously over a 6-week period. Free-text survey responses were analysed using an inductive thematic analysis approach.
Results:
Five hundred twenty-six clinical staff participated, 30% with no training, 52% with some training and 18% who were trained as clinical champions. A clear pattern was observed across training levels. Those with no training opted to demonstrate their family violence knowledge base less frequently. When they did, answers lacked specific information and details, showed limited knowledge of covert family violence indicators and provided a higher proportion of responses that did not align with best practice guidelines. Staff with some training showed a more sophisticated understanding in these areas. However, the quality of their responses did not match those of the clinical champions, who also provided an ongoing community of practice to further their skills.
Conclusions:
Providing some training in family violence yields a higher degree of family violence knowledge in clinicians, relative to no training. However, the extra resourcing required to train and maintain a clinical champions model in family violence provides demonstratable benefits, via a more sophisticated and nuanced understanding of indicators, enquiry and disclosure response skills, that align with best practice guidelines.
Introduction
Family violence is a global public health issue that has a significant psychological and physical impact on those affected. 1 Defined by the Family Violence Protection Act 2008 (Victoria, Australia) as behaviour that incites fear in the recipient, family violence encompasses a range of a range of behaviours in kinship structures including physical, psychological, emotional, sexual and financial abuse. 2 Whilst people of any gender or sexual orientation can experience family violence, women, children, first nations people, those from the lesbian, gay, bisexual, transgender, queer, intersex, asexual/agender plus (LGBTQIA+) community, people from culturally and linguistically diverse backgrounds and older people, are disproportionately impacted.3 –5
The perpetration of family violence is gendered; in that, it is predominantly committed by men against women, children and other vulnerable persons. 2 One in three women worldwide experience either physical and/or sexual violence in their lifetime, and nearly 40% of all murders of women are committed by their male intimate partner. 6 In Australia, one in four women have experienced physical, sexual or emotional abuse by an intimate partner; a figure in line with global trends.7,8 For women aged 15–44 years old, family violence represents the most prevalent preventable risk factor of death, disability and illness. 9 In the 2022–2023 financial year, police recorded over 93,000 family violence incidents in the Australian state of Victoria 10 representing an 2.8% rise from the previous year, reflective of the upward trend in family violence incidents over the past 5 years.
Public hospitals are a key avenue of support for people affected by family violence. Healthcare services may be one of the few settings victim-survivors can access for support without the perpetrator being present. 11 Healthcare usage is high in women in high-risk family violence situations. In a North American study, 70% of women who were killed through family violence accessed medical healthcare services in the 12 months prior to their death, and 25% accessed mental healthcare. 12 In contrast, very few (just 3%) had accessed family violence-specific services in the same period. 12 Healthcare services are clearly in an opportune position to assist in family violence situations, acting as a gateway for the provision of, and linkages to, further support.
Despite the long-term and entrenched nature of family violence in Australian society, the role of hospitals in responding to this problem has only recently been reinforced with clear clinical shortfalls in hospital preparedness to respond.13 –15 Training and education have been identified as primary interventions to improve readiness to respond in the healthcare sector.11,16 An evolving body of research has quantitatively evaluated the effectiveness of educational training programmes in improving readiness to respond and changes to clinical practice.17 –19 Whilst several studies have reported immediate improvements in clinician knowledge and skills, issues with maintaining sustained improvement from one-off training episodes have been raised.17,20
The majority of research undertaken to date has employed traditional quantitative methodologies to evaluate the effectiveness of clinician training. Whilst the outcomes of these studies are notable, uncertainty remains around the nature and extent of training required to make meaningful and sustainable clinical change. In the face of this ongoing uncertainty, the use of quantitative approaches in isolation may be limiting in the exploration of complex personal and contextual factors that contribute to training implementation success, or failure. A small number of studies have qualitatively explored training effectiveness and perceptions to date. As a broader component of a family violence screening evaluation project, 21 evaluated clinician perceptions of the utility and effectiveness of an online, time limited, family violence training module in rural health services in America.17 –19 Whilst most staff felt that the training successful in improving identification of patient experiencing family violence, a recurring theme identified through qualitative methods was the need for additional education and training to address clinician confidence, comfort and knowledge, 22 Similar qualitative support was identified by Horwood et al. for the utility of family violence identification and management training. 15 Following training, clinician participants reported prioritising inquiring into family violence, tailoring their inquiry to patient characteristics and felt comfortable providing referrals for low-risk cases. 22 However, participants highlighted the need for modifications to the training programme, regular updates and additional resourcing at a policy level to increase their sense of confidence and preparedness in family violence responding. Clinicians specifically recommended that future training sessions include the opportunity to role-play introducing family violence-related questions and responding to family violence disclosures, during a patient consultation.
This study is part of a broader project evaluating the impact of a whole-of-hospital transformation change project in family violence clinical response at a tier 1 trauma hospital in Melbourne, Victoria, Australia. Pre-initiative data were obtained at the hospital in November to December 2017 evaluating clinician skill levels in family violence.15,23,24 A follow-up survey was then conducted in November to December 2020 to evaluate the impact of the hospital wide initiative, hereafter described as the Family Safety Team (FST) project. 25 This study aimed to qualitatively evaluate the impact of family violence training by training intensity, 3-year post-implementation. Knowledge of the impact of broad-scale transformational change projects is important in establishing whether the resources required to embed these programmes result in meaningful improvements in staff skills, and whether this results in improvements in patient care, safety and well-being. Data from the quantitative survey results have been presented in a companion paper. 26
Method
The consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist information is reported in Supplemental Appendix 1. 27
Setting and participants
The study was undertaken at a large tertiary metropolitan hospital that provides acute tertiary and ancillary services. It has approximately 6000 staff, with around 4500 of these in clinical roles. Eligible participants were hospital clinical staff, including medical, nursing and allied health professionals. Inclusion criteria were all clinical staff with a known work email address (identified via the organisation’s email database, matched via job role, in this system). Beyond the inclusion criteria, there were no additional exclusion criteria.
Training intervention
A multi-faceted, system-wide approach was adopted in the design and implementation of the project, including organisational change and local level training initiatives. 28 In 2018, policies and procedures for the management of family violence in the hospital were developed. A multidisciplinary specialist family violence team (the FST) was established to train hospital staff. Training was informed by research and best practice guidelines29,30 and systematically rolled out across the hospital. Training components offered included multiple forms of shorter duration training sessions, as well as a longer duration clinical champions training model programme that also included a community of practice.
Short-duration training
The service training included: Module 1: Introducing sensitive practice (30–60 min), Module 2: Practical application of sensitive practice (30–60 min), Refresher: Recap of Modules 1 and 2 (60 min), Identifying Family violence – External (4 h), as well as training specific to particular disciplines and non-clinical or managerial staff (60 min).
Family safety advocate training
The clinical champions programme provided in-depth training in evidence-based, best-practice responding when working with patients experiencing family violence (9+ hours in total). 31 Between 2018 and 2019, the first stage of family safety advocate (FSA) training (3 h) consisted of an internal, hospital-based training seminar based on Module 1, Module 2 and an Elder abuse training module. This included an introduction to family violence, healthcare response, hospital procedure and guidelines, family violence research findings, sensitive practice, risk assessment, safety planning, referrals, staff support and resources. The second stage (6.5 h) involved clinicians undertaking training in the Common Risk Assessment Framework Level 3 (CRAF3), which was provided by an external provider (Domestic Violence Resource Centre Australia). Training included an introduction to family violence risk assessment and management framework, shared understanding of family violence, specialist family violence risk assessment and management, safety planning, referral pathways, information sharing and networking. In 2020, due to the COVID-19 pandemic, the training format was remodelled. It involved a 1-h self-paced online learning module, followed by an 8-h (full-day) live, online interactive seminar. All of the same content as that was covered in the 2018–2019 training was included; however, from 2020 it was all provided internally by the FST educators (rather than receiving CRAF3 training through an external provider).
Additionally, monthly drop-in clinical supervision with a member of the FST (i.e. senior social worker or psychologist) were available for FSAs, as well as quarterly network meetings which involved further training (1-h seminars by guest speakers, e.g. police force, community family violence services, international initiatives), and a 6-h whole-day workshop on resisting collusion with people using violence, on an opt-in basis. These additional provisions occurred in the 15-month following commencement of FSA training.
Study design, study tool and data collection
Approval for this study was granted by the Melbourne Health Human Research Ethics Committee. Study data were collected using the online survey The Assisting Patients/Clients Experiencing Family violence: Royal Melbourne Hospital Clinician Survey (the survey) (Supplemental Appendix 2). 15 The short, targeted survey tool has been found to have good internal reliability (11 items, α = 0.83). 23 The survey was designed to collect both quantitative and qualitative information including participant demographics, prior training, perceived knowledge and confidence, estimated screening rates and perceived barriers to working effectively in the area of family violence. The survey consists of Likert-type and ordinal responses, forced choice categorical responses (e.g. Yes, No, Somewhat) and qualitative free-text response sections (eliciting further information to specifically demonstrate knowledge following a response of Yes or Somewhat on a forced choice question). The focus of this article is the qualitative analysis of the free-text box responses for three survey questions asking about knowledge of key indicators, asking clients about family violence and responding to disclosures. See Supplemental Appendix 2 for a copy of the full assessment tool, including qualitative text-box response questions.
All staff members for whom work email addresses were available (Nursing = 1829, Medical = 660, Allied Health = 549) were invited to participate. The survey was completed via an online survey platform. An invitation/reminder email was sent to staff a maximum number of three times over a 4-week period. The survey was available for completion for a total of 6 weeks; data capture occurred in November and December of 2020. No remuneration was provided upon completion of the survey, and data were collected anonymously. As approved by the Research Ethics Committee, consent was implied on submission of survey answers, and participants were unable to withdraw following submission of responses.
Data analysis/statistical analysis
Free-text survey responses were analysed using an inductive thematic analysis approach. 32 Thematic analysis has been previously employed in the field of family violence33,34 as well as in psychological research more broadly.35,36 Structured guidelines by Braun and Clarke were used to guide analysis. 37 Codes (word/phrases that categorise meaningful parts of the data that relate to the research question) were initially extracted from the data and used to identify broader conceptual patterns (themes) existing in participants’ responses. Initially, 20% of the data from each text-box response section was double-coded by two researchers (KT and CR) and compared for agreement, to establish the validity of the code-book. Inter-rater reliability was deemed acceptable for all three questions with percent agreement above 80% (84% for Q1, 90% for Q2, 87% for Q3).38,39 Discrepancies for this proportion resolved by mutual agreement. The remaining 80% of the sample was then coded by a single researcher (KT). In collaboration with the research team (four additional researchers), the identified codes were sorted into themes and sub-themes, which were then defined and labelled. In keeping with the Braun and Clarke analysis methodology, the research team considered that meaning was generated through the interpretation of the data, not excavated from it. 40 Therefore, judgements about data saturation were not considered when designing and conducting the study. However, if required to estimate qualitative data saturation, using the model outlined by Tran et al., sampling at sizes larger than 200 participants for survey-based analysis, yields very low likelihood of identifying additional themes, beyond those identified after the initial 200 responses. 41
Results
A total of 526 clinicians completed the survey. Table 1 provides participant characteristics and demographic details. Allied health professionals were the largest craft group represented, with this group also showing the strongest response rate (total sample 17.10%, Allied Health 44.63%, Nursing 11.65%, Medical 10.30%). Close to half of all respondents had been in their respective professions for 10 years or longer. The majority of participants identified as female and 30–39 was the most common age bracket. Most participants reported having some family violence training. Since the transformational change project began, 48.67% of the sample reported completing at least one specific type of family violence training at the health service. Ninety-four participants (17.87%) endorsed having completed the FSA training, providing 9 h + training, 52.47% endorsed having undertaken some training in family violence and 29.66% had undertaken no training. The majority of respondents with FSA training were from Allied Health professions, with social workers representing the largest professional group.
Demographic characteristics of participants according to training intensity level.
FSA: family safety advocate.
With 526 total survey responses of between 323 and 367 responses provided for each qualitative text-box response question, data saturation was achieved, based on the predicting data saturation model proposed by Tran et al. 41
Clinician knowledge of indicators of family violence (question 1)
Most clinicians responded Yes (28.52%) or Somewhat (42.40%) when asked if they were aware of the key indicators that a patient may be experiencing of family violence. The remaining participants (29.08%) indicated having no knowledge of indicators (i.e. responded No). Those who indicated awareness of family violence indicators were asked to provide additional information to demonstrate their knowledge in a free-text response box. Of the 464 participants who responded Yes or Somewhat, 323 (i.e. 69.61%) provided further qualitative text-box information when prompted to demonstrate their knowledge.
When describing factors that may indicate a patient is at risk of family violence, three main themes emerged from the clinician responses: Patient behaviours, Contextual factors and Lived experience of family violence. See Supplemental Appendix 3, for themes, subthemes, descriptions and example responses. The first theme, Patient behaviours, involved observable or disclosed patient factors. This included patients’ difficulty answering questions, patients disclosing experiences of family violence, observable patient behaviour and staff observations of interactions between patient and perpetrator. The second theme, Contextual factors, were patient and perpetrator-related factors that increase the likelihood of family violence. These include sociocultural factors, a history of family violence, substance abuse and having gone undergone recent stress life changes. The third theme, Lived experience of family violence, involved patient and perpetrator factors that have been found to increase the likelihood of family violence. These include observed or disclosed controlling behaviours, psychological symptoms, patient dependence and isolation. An additional sub-theme – Red flags – emerged, underpinning all indicators, for situations that suggested a family violence situation was at high risk for significant harm to occur. Described red flags included recent life changes, patient vulnerabilities (e.g. female gender) and perpetrator access to weapons. The main themes and practices identified for all qualitative questions are shown in Figure 1.
Diagrammatical representation of response themes across survey text-box questions.
As a broad trend, free-text responses from participants with No Training in family violence (9.68% of the response set) were shorter, less detailed and included fewer indicators. These participants often referred to more obvious physical indicators (e.g. bruising) and observed family dynamics and demonstrated limited awareness of Contextual factors that increase the likelihood of family violence. Those participants who demonstrated awareness of additional indicators listed them as key words. For example, ‘Withdrawn, physical financial control, psychological, emotional’ or ‘red flags’. Such responses indicate surface level awareness of more obvious indicators, with less in-depth knowledge or consideration of the context in which these indicators may occur.
Free-text responses from participants with Some Training in family violence (57.66% of the response set) generally made greater reference to indicators of family violence from all three themes, including reference to Contextual factors. These participants most often referred to Patient behaviours (e.g. patient withdrawn when around partner) and physical indicators of family violence (e.g. injuries). These responses provided more frequent reference to covert indicators that family violence may be occurring (compared to respondents with no family violence training responses). For example, ‘Hx of family violence/controlling behaviour/vulnerable situation/recent stressful events/recent change in circumstances (pregnancy, loss of job, birth of child, etc.)/External emergencies’. Whilst having undertaken some family violence training appears to increase clinician awareness of covert indicators of family violence, participant responses from this group also highlighted the need for further training to expand their knowledge (e.g. ‘Could learn more indicators’).
In general, FSA-trained participants (clinical champions) who supplied free-text responses (33.47% of the response set) provided greater detail, longer responses and information more closely aligned with clinical best-practice guidelines. Respondents referred to indicators of family violence across all themes and made particular reference to contextual and lived experience factors. For example, ‘Hx [history] of controlling behaviour, isolating from support network, stalking, patient feeling intimidated/frightened of family member, patient/client pregnant, patient/client wanting to end relationship; change in circumstances leading to financial strain; family member misuses alcohol/substance affected; family member behaves in a threatening manner’. Such responses make specific reference to knowledge of ‘red flag’ indicators of family violence, in line with clinical best-practice guidelines. It is important to note that, despite having undergone over 9 h of instruction in family violence identification and response, some participants responded vaguely or with little detail. For example, ‘Again, I am reasonably confident but would double check my resources if unsure’ and ‘5 core indicators of family violence’. Such responses may indicate a lack of certainty and specifics in clinician knowledge of family violence indicators, even in some trained clinical champions.
Clinician knowledge of how to ask about family violence (question 2)
When asked if they knew how to ask patients about family violence, just over a quarter of participants responded Yes (27.38%), just over a 40% responded Somewhat (42.58%), with the remaining participants (30.03%) indicating that they would not know how to ask patients about FV. The proportion of clinicians who responded affirmatively (Yes or Somewhat) to this question, that also provided a qualitative text-box response to demonstrate their knowledge, when promoted, was 69.71% (i.e. 367 participants).
When asking patients about family violence, three main themes emerged: Laying the framework, Asking and Patient outcomes. See Supplemental Appendix 4. The first theme, Laying the framework, involved the sub-theme of patient and clinician factors leading to the clinician’s decision to ask about family violence, including professional judgement, physical indicators and patient history. A second sub-theme involved procedural considerations the clinician would take when asking about family violence (e.g. ensuring adequate time and privacy/confidentiality). The third sub-theme encompassed ways in which the clinician would provide emotional support, including assuring patient safety and conveying understanding to the patient. The second theme, Asking Questions, included establishing a platform for an effective discussion about family violence and specific approaches to asking questions (e.g. open-ended or direct questioning, encouraging elaboration). The third theme, Patient outcomes, involved actions clinicians would take upon patient disclosure, including documentation, safety planning and offering practical support. Two additional sub-themes – Sensitive inquiry and Emotional support – were identified as approaches that underpinned interactions with patients when asking about family violence and include factors such as discretion, validation, empathy and reassurance.
Free-text responses from those with No Training in family violence (11% of the response set) mostly did not align with clinical best-practice guidelines, as per the FST training modules. For instance, ‘refer them to helpline’. At a broad level, their responses suggested a superficial understanding of how to ask about family violence. Participants with Some Training in family violence who provided free-text responses (57% of the response set) made some reference to information contained under the themes of Laying the framework and Patient outcomes, which is more reflective of clinical best-practice guidelines. However, a lack of detail in responding again indicated superficial understanding. For example, whilst responses such as ‘look up policy/procedure’ or ‘document’ are somewhat in line with clinical guidelines, the lack of specifics indicates potentially less thorough knowledge on how to ask most effectively about family violence, or of knowing the information inherently to be able to utilise it quickly in ‘on the spot’ situations.
At a broad level, FSA-trained participants who provided responses (32% of responses) included a greater proportion of information that aligned with clinical best-practice guidelines. For example, whilst reference to ‘assessment’ was made across all training groups, those with full FSA training often provided a richer, more specific response (e.g. ‘Complete psychosocial assessment which subsequently flags risk. From there, explore further with patients utilising open and closed questions to clarify situation’).
Clinician knowledge of how to respond to family violence disclosures (question 3)
Most survey respondents indicated having some knowledge of what to do if a patient discloses experiences of FV, with just under half responding Somewhat (45.82%) to this question, and another third responding definitively Yes (34.98%). A total of 323 of these 425 respondents (76%) provided additional information when prompted to demonstrate their knowledge in the qualitative text-box section.
When considering what to do if a patient discloses an experience of family violence, three main themes emerged: Sensitive inquiry, Procedural response and Active response with patient (see Supplemental Appendix 5). Sensitive inquiry involved a range of clinician behaviours and approaches to support and validate the patient. This included active listening, emotional support and adopting a non-judgemental approach. Procedural response encompassed clinician responses in line with hospital policy, including documentation of disclosure, mandatory reporting and patient referral to other services. Active response with patient involved clinician responses that involve patient participation. These included engaging the patient with education about family violence, developing a safety plan in collaboration with the patient, offering practical support and encouraging further discussion following the disclosure.
Free-text respondents with No Training in family violence (18.58% of response set) most often provided responses under the theme of Procedural response, indicating that they would respond to a disclosure of family violence by referring the patient to another clinician (i.e. social work). Those with Some Training who provided responses (54.80% of responses) highlighted their awareness of the existence of the FST and indicated that they would access resources and consult with an FSA as needed. However, a lack of specific details may indicate reduced knowledge on how to best respond to disclosures immediately. For example, ‘We have been provided with information re resources for family violence and I would refer to these to check that I have the correct information’. Whilst there was also more reference to responding to patients sensitively (e.g. ‘Proceed carefully’, ‘Provide reassurance’), respondents most often indicated that their response would be to refer the patient to the Social Work team and document the disclosure.
Participants who had received FSA Training (26.63% of responses) commonly indicated that, before referring to social work or external service providers, they would spend time engaging and supporting the patient themselves. For example, ‘establish rapport and gain consent to ask further questions. . . undertake a risk assessment. . . gain an understanding of where the person is at in terms of their readiness to leave. . . I would understand what strategies the person is already using to keep safe. . .’. Those with FSA training often reported that they would adopt a patient-led approach, including seeking patient consent before referrals or reports were made. Inclusion of specific support options highlights that those with FSA training may have greater confidence and effectiveness at responding to disclosures of family violence than those with less training.
Discussion
The present study aimed to evaluate the impact of family violence clinician training intensity, delivered as a component of a broader transformational change project. A clear pattern was observed across training levels, from the qualitative data analysed, in relation to clinician knowledge of key family violence information and clinical response skills. Those with no training provided qualitative responses demonstrating their family violence knowledge base less frequently. Notably, their qualitative responses lacked specific information and details, showed limited understanding knowledge of covert indicators and provided a higher proportion of responses that did not align with best practice guidelines. Staff with some training showed a more sophisticated understanding in these areas. However, the quality of their responses did not match those of the FSAs who had been trained under the hospital’s family violence clinical champions model and were also provided an ongoing community of practice to further their skills. The FSA group provided the highest proportion of responses that demonstrated their knowledge base. Responses tended to be more detailed, specific, nuanced and aligned with best practice guidelines.
The results were consistent with existing literature indicating that longer duration and multi-dimensional training that incorporates ongoing structural support (e.g. regular clinical supervision or follow-up services for staff) transfers to higher levels of family violence knowledge and skills in health professionals.18,20,22,42 The findings presented in the current study are promising. They indicate that the in-depth training and ongoing support provided to clinicians in the FSA network was effective in improving reportable family violence knowledge and skills among clinical staff. They also indicate that staff who have completed short duration training show greater knowledge and awareness than those who have received no training. These findings indicated that with appropriate resourcing, multiple training types and opportunities and a comprehensive transformational change project plan, health services can upskill staff in family violence knowledge and clinical response skills.
Clinician responses about indicators of family violence demonstrated knowledge of broad range of indicators across the staff cohort. Patient behaviours, contextual factors and lived experiences of family violence were all identified, although the breadth and depth of this knowledge was variable depending staff family violence training levels, with more training aligning with stronger demonstratable knowledge bases. Existing research indicates women commonly experience emotional, psychological and financial abuse, with these more covert forms of family violence occurring at higher rates than their physical counterparts. 43 Thus, it is vital for clinicians to be aware of less obvious features of family violence, given that they are likely to engage with patients experiencing non-physical forms of family violence. Appropriate identification is the first step to management and failure to identify the spectrum of presenting indicators represent a missed opportunity to support patients presenting with family violence concerns. Importantly, whilst clinicians with full FSA training demonstrated greater knowledge of family violence indicators, some still described a lack of confidence in identification. Thus, ongoing, and continued, training opportunity to reinforce less obvious indicators is likely to be required to build confidence and solidify knowledge.
Three main themes emerged when clinicians provided their knowledge on asking clients about family violence, which included laying the framework, asking and patient outcomes. Participant responses indicated that many clinicians are aware to use sensitive enquiry practices, consider procedural issues for where, when and how they ask and pre-emptively think about how to provide emotional support to patients, should a disclosure arise from their enquiry. This knowledge-base, particularly in clinicians with higher levels of training, was encouraging to see, and aligns with best practice recommendations. 44 Inquiring into patients’ experiences of family violence in a sensitive, informed and thoughtful way provides victim-survivors with the opportunity to disclose, access supports and increases the likelihood of future disclosures. 45 Previous research indicates that clinicians who are not confident or skilled in asking about family violence are less likely to ask their patients about these experiences. 46 This occurs particularly when the clinician feels uncomfortable, rushed, unsupported by the healthcare setting or are unaware of available supports. 46 Furthermore, clinicians are less likely to enquire if the patient does not raise the issue first. 46 Parallel to this, victim-survivors are unlikely to disclose family violence experiences in the absence of clinician inquiry or if they perceive clinician discomfort, reluctance or disinterest in their experiences.15,47 Thus, it is important that all clinicians within a service have an adequate understanding of enquiry skills, not just those with advanced training, as clarity and confidence in asking assists to build a sense of trust and safety and an opportunity to disclose for victim-survivors.
When asked to outline how they respond to disclosures, sensitive inquiry and procedural responses were also prominent theme in this dataset, along with an active response with patient. Clinicians with less family violence training were more likely to indicate their primary response would be to refer the patient to another department (e.g. social work). Whilst this is not an inappropriate response from a clinical perspective, it indicates a diffusion of responsibility away from the individual clinician, to provide a supportive response, to another member of the treating team. This form of response was identified frequently in a study assessing family violence knowledge in clinicians at the hospital, prior to the role out of the family violence transformational change project. 24 FSA clinicians identified the importance of a patient-led response and emotional support before considering referral to another department or service. This finding reflects a greater sense of individual clinician responsibility to engage in family violence identification and response among those who have undertaken greater levels of training. This is unsurprising, given that part of family violence training includes education on role responsibility. An empathetic response from a healthcare provider conveys an important message: that they are fundamentally deserving of healthy relationships that are free of violence. 48 Appropriate responses to disclosures of family violence may not only empower victim-survivors but also improve health outcomes.49 –51
For complex healthcare practices, such as family violence response, a multifaceted intervention approach that incorporates local opinion leaders, educational outreach, audit and feedback loops and reminders, is likely to be most effective in maintaining organisational behaviour change.18,52 This theme was also reinforced in the current study from by comments from clinicians across all training levels. Clinicians consistently indicated that they would like more training/knowledge, and they would continue to use secondary consultation with clinicians and teams skilled in the area (i.e. FSAs, FST, social work). Our study findings dovetail with organisational behaviour change theories, which denote that for practitioner behaviour change to be sustained, organisational interventions should include normative restructuring of practice, modification of group norms and expectations (e.g. via educational outreach) and reinforcement of norms by highlighting expectations of reference groups. 53 Taken together, despite the promising nature of the results of this study, the findings highlight the need for further and ongoing resourcing, such as ongoing access to refresher training and a permanently funded family violence team that is available to support clinicians when needed.
Limitations
The current data were collected during the COVID-19 pandemic, several weeks after a 4-month, government-imposed lock-down. The survey tool completion window occurred during a period of clinician burnout and fatigue, which likely impacted level of engagement with professional developing training opportunities. The [Hospital Name] FST were partially re-deployed to clinical and staff support roles, during the pandemic period, reducing the training provided and number of attendees at training sessions, in 2020 relative to preceding years. 54 With the level of training reduced, family violence skills may not have been maintained, or at front-of-mind for clinicians. It is likely that, with normal provision of training and attendance during the final year of the 3-year initiative, additional clinician knowledge improvements may have been observed.
Another limitation of the present study is the overall survey response rate of 17.31%. Whilst a small response rate typically makes it difficult to confidently generalise study findings to the broader hospital clinician context, this rate is much higher than most family violence surveys in clinicians, 55 and equivalent to the survey response rate observed during data collection in the baseline study. 56 The response rate was also higher than other research featuring surveys provided via email to a large (>2000) participant pool of healthcare workers. 57
The present study also does not evaluate actual practice change. Whilst it is useful to survey clinicians’ perceptions, improvements in clinician knowledge and confidence do not necessarily indicate improvements in clinical practice. However, evidence of practice change has been collected at the health service. At the onset of the initiative in 2017, there was no way of monitoring tracking or evaluating the number of clients presenting to the service with current family violence experiences. Five years on, a family violence screening clinical workflow is embedded in the hospital’s new electronic medical record system. Audits indicate a steady increase in usage of this tool, year on year since it was implemented in a stepped roll out from mid-2019, such that it was utilised on average more than 4000 times a month in 2023 (internal audit data). Data analysis is currently underway to further, extract, collate and publish this data in a future research article.
Conclusion
Family violence is a widespread public health issue. Healthcare settings are part of the frontline in identifying and respond to family violence; however, many clinicians are limited in their capacity to engage in best-practice clinical response. The findings of the present study indicate that family violence knowledge and skills were stronger in healthcare clinicians when a comprehensive transformational change project was undertaken at a large, well-resourced adult hospital. It is clear that, in addition to longer duration training, continued service improvement, a community of practice and ongoing supports are required to maintain and consolidate knowledge and practice change.
Supplemental Material
sj-docx-1-whe-10.1177_17455057241305264 – Supplemental material for Impact of a 3-year transformational change project in family violence clinical response: Qualitative evaluation of the depth and breadth of knowledge in hospital clinicians by training level
Supplemental material, sj-docx-1-whe-10.1177_17455057241305264 for Impact of a 3-year transformational change project in family violence clinical response: Qualitative evaluation of the depth and breadth of knowledge in hospital clinicians by training level by Kirsty Troy, Catherine Rushan, Toni D Withiel, Kim L Felmingham and Caroline A Fisher in Women’s Health
Supplemental Material
sj-docx-2-whe-10.1177_17455057241305264 – Supplemental material for Impact of a 3-year transformational change project in family violence clinical response: Qualitative evaluation of the depth and breadth of knowledge in hospital clinicians by training level
Supplemental material, sj-docx-2-whe-10.1177_17455057241305264 for Impact of a 3-year transformational change project in family violence clinical response: Qualitative evaluation of the depth and breadth of knowledge in hospital clinicians by training level by Kirsty Troy, Catherine Rushan, Toni D Withiel, Kim L Felmingham and Caroline A Fisher in Women’s Health
Supplemental Material
sj-docx-3-whe-10.1177_17455057241305264 – Supplemental material for Impact of a 3-year transformational change project in family violence clinical response: Qualitative evaluation of the depth and breadth of knowledge in hospital clinicians by training level
Supplemental material, sj-docx-3-whe-10.1177_17455057241305264 for Impact of a 3-year transformational change project in family violence clinical response: Qualitative evaluation of the depth and breadth of knowledge in hospital clinicians by training level by Kirsty Troy, Catherine Rushan, Toni D Withiel, Kim L Felmingham and Caroline A Fisher in Women’s Health
Footnotes
References
Supplementary Material
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