1.

Increasing identification of domestic violence in emergency departments: A collaborative

contribution to increasing the quality of practice of emergency nurses

Introduction to Domestic Violence in the Emergency Department (ED):

Domestic violence against women is a significant health issue affecting a considerable number of
individuals in North America. In Canada and the United States, healthcare professionals have been urged
to recognize and address domestic violence as a critical health concern. A national survey in Canada
revealed alarming statistics, with 29% of ever-married women reporting physical or sexual assault by a
marital partner at some point in their relationship. Emergency departments play a crucial role in
addressing the immediate needs of battered women, and the high incidence of such cases is well-
documented in studies conducted in the United States.

Proposed Change: Compulsory Annual Training for ED Staff

To address the pervasive issue of domestic violence, a proposed change involves implementing
compulsory annual training for Emergency Department (ED) staff. The Vancouver Hospital and Health
Sciences Centre in British Columbia, Canada, initiated the Domestic Violence Program in 1992, funded by
a federal grant. The program focuses on early identification and treatment of women who have
experienced domestic violence.

An essential aspect of this program is the integration of universal triage for violence, conducted by
trained nurses in the ED. Triage nurses are instructed to ask all women about their experiences with
violence using a standardized screening question. If a patient discloses abuse, the program provides
support, care, and coordination of services by physicians, nurses, and social workers. The program also
facilitates contact with the police and legal system when necessary.

The proposed change involves extending this successful program model to all EDs, making it mandatory
for staff to undergo annual training on identifying and addressing domestic violence. Training would
include recognizing signs of abuse, appropriate screening questions, and coordinating care for victims.
The goal is to create a standardized approach across all EDs to ensure timely and effective intervention
for individuals experiencing domestic violence.

This change aligns with recommendations from professional organizations, such as the American
Medical Association (AMA), which emphasizes the importance of routinely incorporating screening for
domestic violence and providing appropriate care and referrals. By implementing compulsory annual
training, ED staff can enhance their ability to identify, respond to, and support victims of domestic
violence, contributing to a comprehensive and compassionate healthcare approach.

Literature Review Methodology:

Approach to Conducting the Literature Review:

The literature review for this project began with a comprehensive search for theoretical positions and
frameworks related to domestic violence (DV) interventions and identification within the Emergency
Department (ED) setting. The initial phase involved identifying relevant literature to inform the
development of a best practice model. The researchers conducted an extensive literature search to
gather information on existing models and approaches, drawing on works such as those by Hegarty et al.
(2000), Koziol-McLain et al. (2008), McFarlane et al. (2006), and Plichta (2007). The focus was on
theoretical foundations that could guide the project's quality improvement initiatives.

Preference for Primary Sources and Rationale:

The literature review prioritized primary sources, emphasizing research studies, systemic reviews, and
intervention studies. Primary sources were considered crucial for obtaining firsthand information and
empirical evidence relevant to the identification and response to DV in the ED. The rationale behind this
preference lies in the need for evidence-based practices and data-driven insights. By relying on primary
sources, the researchers aimed to gather information directly from studies, interventions, and reviews
conducted by experts in the field. This approach enhances the reliability and credibility of the literature
used to inform the project.

Search Strategy for Identifying Relevant Literature:

The search strategy involved querying databases and academic repositories for peer-reviewed articles,
systematic reviews, and intervention studies related to DV in healthcare settings, with a specific focus on
EDs. The search terms included variations of "domestic violence," "emergency department,"
"identification," and "interventions." The goal was to capture a broad spectrum of literature relevant to
DV within healthcare contexts, and subsequent screening processes were employed to narrow down the
selection to studies with direct applicability to the ED setting.

The researchers acknowledged the ongoing debate on the appropriateness of routine screening for DV
in the ED, as reflected in the literature by authors like Bacchus et al. (2003), Hillard (1985), Ramsay et al.
(2002), Webster (2006), and Witting et al. (2006). The project considered these discussions but adhered
to clear policy guidelines within the Area Health Service, particularly the NSW Health Policy and
Procedures for Identifying and Responding to Domestic Violence.

Overall, the literature review methodology focused on a participatory action research approach,
integrating theoretical frameworks, and emphasizing primary sources to inform the quality
improvement project in the ED related to DV identification and response.
The provided text describes a quality improvement study aimed at enhancing the identification of
domestic violence (DV) and improving responses to it in an Emergency Department (ED). The study
involved collaboration between the Violence, Abuse and Neglect Prevention Team and ED nursing staff.
The focus was on increasing nurses' capacity to identify women and children who may have experienced
DV.

Key Findings:

Lack of Awareness and Identification:

Nurses reported a lack of awareness and confidence in identifying DV cases.

Studies mentioned in the text indicate that identification of DV in ED is problematic and often
ineffective.

Lack of routine screening in the ED, according to NSW Health Policy, contributes to challenges in
identifying DV cases.

Training as a Solution:

Lack of training was identified as a significant barrier to recognizing and responding to DV in ED.

Interventions supporting quality improvements for ED staff are crucial, and nurses expressed a desire for
training on the issue.

Existing literature indicated a shortage of information or programs to improve staff awareness and
responses to DV presentations in the ED.

Training Program and Pathway Development:

A training program was developed with specific learning outcomes, focusing on identifying key actions in
the DV pathway.

The project included the development of a pathway for use in the ED to assist nurses in recognizing and
responding to DV cases.

Impact of Training:

Pre/post test surveys showed a significant increase in nurses' self-reported awareness of DV policies,
knowledge of responsibilities, and confidence in identifying and responding to DV cases.
A file audit demonstrated changes in documentation, with an increase in asking about children in DV
presentations after the training.

Sustainability and Future Directions:

The study highlights the importance of ongoing support, collaboration, and reinforcement of awareness
to sustain improvements in practice.

The project's success suggests the potential for similar interventions in other EDs and the need for
continued training for various healthcare professionals, including doctors and allied health staff.

Limitations and Future Research:

The study acknowledges limitations such as its small size, focus on one ED, and the need for further
research to test and extend the findings.

There is a proposal to undertake further follow-ups to monitor the long-term success of the
intervention.

This study emphasizes the importance of training healthcare professionals, particularly nurses in EDs, to
enhance their ability to recognize and respond to domestic violence cases effectively. The results
suggest that targeted training programs, coupled with the implementation of practical tools like the DV
pathway, can contribute to positive changes in practice.

Critical Appraisal of Educational Courses for ED Staff

Analysis of Primary Sources:

The primary source under consideration is a research paper describing a quality improvement study
aimed at enhancing the identification and response to domestic violence in an Emergency Department
(ED). The study involves collaboration between the Violence, Abuse and Neglect Prevention Team and
ED nursing staff. The project includes the development of learning materials, a training program, and
data collection methods. The paper discusses the appropriateness of screening for domestic violence in
the ED, outlines the literature review, methodology, and presents results from surveys, file audits, and
other assessments.

Reliability and Validity:

Survey Instrument: The study utilizes surveys to assess nurses' knowledge and perceptions before and
after the training program. The survey instrument's reliability is addressed through pilot testing, which
enhances its validity. However, the paper does not provide details on the specific questions asked in the
surveys, limiting the assessment of the instrument's validity.
File Audits: File audits are conducted to evaluate changes in documentation practices regarding
domestic violence. The audit tool is derived from policy directions and the literature, contributing to its
face validity. However, the paper lacks information on inter-rater reliability or validation measures for
the audit tool.

Training Program: The paper describes the training program, including learning outcomes, length, and
procedures. While the effectiveness of the training is demonstrated through self-reported
improvements in nurses' knowledge and confidence, there is a lack of information on the validity of the
training content in addressing domestic violence issues.

Gaps and Strengths:

Strengths:

The participatory action research approach fosters collaboration and ownership among project partners,
enhancing the project's relevance and effectiveness.

The study addresses a significant gap in the literature by focusing on training and practice improvements
related to domestic violence in the ED.

Gaps:

The paper does not discuss potential biases in the self-reported surveys, such as social desirability bias
or response bias, which could impact the reliability of the findings.

The absence of information on long-term follow-up beyond six months limits the understanding of the
sustained impact of the intervention.

The lack of a control group or comparison with EDs that did not undergo the intervention limits the
ability to establish a causal relationship between the training and observed improvements.

Conclusion:

The paper provides valuable insights into efforts to improve ED staff's ability to identify and respond to
domestic violence. The participatory action research model, training program, and file audits contribute
to the strengths of the study. However, addressing gaps in terms of survey biases, long-term follow-up,
and the lack of a control group would enhance the robustness of the findings. Overall, the study serves
as a foundation for further research and interventions in similar healthcare settings.
Comparison and Analysis of Relevant Pieces:

This paper discusses a quality improvement study aimed at enhancing the identification and response to
domestic violence (DV) in an Emergency Department (ED). The project involved collaboration between
the Violence, Abuse, and Neglect Prevention Team and ED nursing staff. The study explores the
appropriateness of screening for DV in the ED, the impediments to nurses' awareness of DV, and the
impact of training programs on improving staff awareness and responses to DV presentations.

Common Themes:

Screening Controversy:

The paper acknowledges the ongoing debate on routine screening for DV in the ED. Different studies
and reviews highlight the lack of consensus on the benefits or risks of routine screening.

The controversy is discussed in light of the NSW Health Policy, which does not mandate routine
screening in the ED. However, the ED remains a likely gateway for individuals experiencing DV.

Nursing Awareness and Training:

The study emphasizes the challenges in nurses' awareness of DV and the importance of training to
overcome these challenges.

Lack of recognition of DV in the ED is identified as a barrier to providing correct care to victims. Training
is proposed as a solution to improve nurses' ability to identify and respond to DV presentations.

Training as an Intervention:

The paper highlights the need for interventions to address DV in the ED, with a specific focus on training
for nursing staff.

Existing literature and reviews suggest a dearth of information or programs to improve staff awareness
and responses to DV presentations in the ED. The study aims to bridge this gap.

Quality Improvement and File Audits:

The project is framed within a quality improvement framework, emphasizing the need to monitor,
evaluate, and improve healthcare delivery related to DV.

File audits are conducted to assess indicators of performance in ED regarding asking and documenting
concerns about DV. The focus is on improving documentation practices.
Differences:

Policy Guidelines:

The paper acknowledges the controversy around routine screening but states that the project followed
clear policy guidelines within the Area Health Service, which did not require routine screening in the ED.

Training Duration and Content:

The training program's length is mentioned, with sessions lasting approximately 45–60 minutes. Specific
learning outcomes are outlined, focusing on identifying key actions in the DV pathway.

Literature is cited to support the effectiveness of short training sessions, with one study recommending
a three-hour initial session followed by a one-hour update.

Awareness Improvement:

Results from pre/post-test surveys and file audits indicate improvements in nurses' awareness of DV
policy, responsibilities, and indicators after training.

The file audit data shows changes in the documentation of asking about children, suggesting an impact
on practice.

Implications for Proposed Change:

Training Programs and Resources:

The study suggests that interventions, particularly training programs and locally adapted tools like the
DV pathway, can improve nurses' knowledge, confidence, and practice in identifying and responding to
DV.

The success of the project implies that similar interventions could be implemented in other EDs to
enhance staff capacity.

Continued Monitoring and Evaluation:

The paper proposes further follow-up studies to monitor and evaluate the long-term success of the
intervention. This ongoing evaluation is crucial for sustaining improvements in practice.

Extension to Other Healthcare Professionals:

Considering the positive outcomes, there is a proposal to extend the project to doctors and other allied
health medical staff working in the ED. This reflects a recognition of the need for a multidisciplinary
approach to address DV in healthcare settings.

Public Health Impact:

The concluding comments highlight the potential of interventions to reduce the incidence of DV
presentations in EDs. By making DV more evident and encouraging healthcare professionals to consider
the impact on children, the study aims to contribute to the safety of women and children's lives.

In summary, the paper underscores the importance of training interventions and local tools in improving
nurses' capacity to identify and respond to DV in the ED. The proposed changes involve extending
successful interventions to other healthcare professionals and emphasizing the public health impact of
addressing DV in emergency healthcare settings.

Key Findings from Evidence and Critical Appraisal:

Awareness and Knowledge Improvement: The evidence suggests a significant improvement in ED

nursing staff's awareness and knowledge regarding domestic violence (DV) following the training
program. The self-reported data indicates increased awareness of DV policies, understanding of
responsibilities, and improved confidence in identifying and responding to DV cases.

Referral Knowledge: The project revealed a lack of knowledge among nurses about how and where to
refer patients with DV issues before training. However, after the training, there was a notable reduction
in nurses reporting a lack of ability to refer. This indicates that the training effectively addressed this
knowledge gap.

Identification of Children in DV Situations: The study successfully addressed the primary motivation by
showing sustained improvement in nurses' ability to identify and respond appropriately to children living
in DV situations. This is a crucial aspect of DV intervention and aligns with the project's goals.

File Audit Results: The file audit results showed changes in documentation practices, particularly
regarding asking about children in DV situations. This aligns with the pathway introduced in the project,
suggesting that visual prompts and tools can positively influence nursing practices.

Support for Proposed Change in Healthcare:

The evidence supports the proposed change in healthcare, emphasizing the importance of training
programs and tools in enhancing nurses' capacity to identify and respond to DV cases. The positive
outcomes in awareness, knowledge, and practice improvement indicate that similar interventions in
other Emergency Departments could be beneficial.

Limitations and Gaps in the Literature:

Limited Generalizability: The project's small size and focus on one ED limit the generalizability of the
findings. Replicating the intervention in other settings is necessary to validate its effectiveness across
diverse healthcare environments.

Staff Turnover: High turnover among ED staff affected the participation rate in follow-up surveys. The
sustainability of the knowledge gained through training may be challenging if staff turnover remains an
issue.

Lack of Comparative Data: The absence of comparative data, such as a control group or comparison with
EDs without the intervention, limits the ability to attribute the observed changes solely to the training
program.

Long-Term Effectiveness: While the project demonstrated short-term improvements, the long-term
effectiveness of the intervention remains uncertain. Continuous follow-up and evaluation are essential
to assess the sustainability of changes over an extended period.

Conclusion:

The evidence suggests that the quality improvement project effectively enhanced ED nursing staff's
awareness, knowledge, and practice regarding DV. While acknowledging the limitations, the positive
outcomes support the need for similar interventions in healthcare settings to address gaps in DV
identification and response. Continuous monitoring and further research will contribute to the ongoing
improvement of healthcare practices related to DV.
Linking to Learning Outcomes:

Learning Outcome 1: Increased awareness of domestic violence (DV) among ED nursing staff.

The literature review findings suggest that there is a lack of awareness and recognition of DV in ED
settings, which may impact the quality of care provided to victims. The project aimed to address this
issue by developing a collaborative training program. The pre/post-test surveys indicate a significant
improvement in nurses' self-reported awareness of DV policies, responsibilities, and indicators after
participating in the training. This aligns with Learning Outcome 1, demonstrating that the project has
effectively increased awareness among ED nursing staff regarding DV.

Learning Outcome 2: Enhanced capacity to identify and respond to DV presentations in the ED.

The training program focused on developing nurses' abilities to identify and respond to DV cases in the
ED. The pre/post-test surveys consistently show a positive change in nurses' confidence and perceived
ability to recognize and respond to DV indicators. This supports the achievement of Learning Outcome 2,
indicating that the project has enhanced the capacity of ED nursing staff in dealing with DV
presentations.

Learning Outcome 3: Improved knowledge about referral options for DV cases.

The literature review identified a lack of knowledge among nurses regarding appropriate referral
options for DV cases. The project addressed this by incorporating information about referral pathways in
the training program. The post-training surveys demonstrate a notable increase in nurses' knowledge
about how and where to refer patients with DV issues. This supports the accomplishment of Learning
Outcome 3, indicating that the project has successfully improved nurses' knowledge about referral
options for DV cases.

Learning Outcome 4: Increased ability to identify and respond appropriately to children living in DV
situations.

One of the primary goals of the project was to improve nurses' ability to identify and respond to children
living in DV situations. The post-training surveys and file audit results consistently show positive changes
in nurses' self-reported ability to identify and respond appropriately to children in DV cases. This aligns
with Learning Outcome 4, indicating that the project has effectively increased nurses' capacity to
address the needs of children in DV situations.
Linking to NMC Guidelines:

The Nursing and Midwifery Council (NMC) emphasizes the importance of continuous professional
development and ensuring that nurses are equipped to provide high-quality care. The project aligns with
NMC guidelines in the following ways:

Professional Development: The training program provided in the project aligns with NMC's emphasis on
continuous professional development. It addresses a critical area of practice (DV recognition and
response) and contributes to nurses' ongoing learning.

Person-Centered Care: NMC emphasizes the delivery of person-centered care. By improving nurses'
awareness and skills in identifying DV and responding appropriately, the project supports the provision
of person-centered care to victims of DV in the ED.

Collaborative Practice: The collaborative nature of the project, involving both the Violence, Abuse and
Neglect Prevention Team and ED nursing staff, reflects the importance of collaborative practice as
outlined by NMC. It encourages interdisciplinary teamwork to address complex issues.

Ethical Practice: Addressing DV aligns with the ethical principles outlined by NMC, particularly those
related to safeguarding and protecting vulnerable individuals. The project contributes to ethical practice
by enhancing nurses' ability to identify and respond to DV cases ethically and responsibly.

In summary, the project effectively aligns with NMC guidelines and contributes to the continuous
professional development and ethical practice of nursing staff in the ED setting. The positive outcomes
reported in the surveys and file audits indicate that the project has made meaningful improvements in
practice and has the potential to serve as a model for similar interventions in other healthcare settings.

2. AN EMERGENCY DEPARTMENT-BASED DOMESTIC VIOLENCE INTERVENTION PROGRAM:

FINDINGS AFTER ONE YEAR

Importance of Training in Domestic Violence Recognition:

Training emergency department (ED) staff to recognize and address domestic violence is of paramount
importance for various reasons. The provided text discusses findings from the first year of operation of
the Domestic Violence Program at Vancouver Hospital and Health Sciences Centre in Vancouver, British
Columbia. Here are the key points highlighting the significance of such training:
1. Healthcare as a Setting for Identification:

Prevalence of Domestic Violence: The text underscores that a significant number of battered women
seek medical attention in emergency departments. Recognizing the prevalence of domestic violence in
healthcare settings is crucial.

2. Screening and Triage:

Early Identification: Training ED staff to inquire about domestic violence during triage is vital. The
Vancouver Hospital program, for example, implemented a screening question to identify patients
experiencing violence in their lives.

Triage Nurses' Role: Triage nurses play a pivotal role in identifying and initiating the process of care for
individuals experiencing domestic violence.

3. Programs and Protocols:

Establishment of Programs: The Vancouver Hospital's Domestic Violence Program serves as an example
of an initiative addressing domestic violence. Its protocol involves asking screening questions,
expeditious movement of patients to a safe care area, and coordination of services by healthcare
professionals.

Interdisciplinary Collaboration: The program highlights the collaboration of physicians, nurses, social
workers, and, if needed, contacts with the police and legal systems.

4. Types and Severity of Violence:

Data Collection and Analysis: The text presents data on the types and severity of violence experienced
by patients in the program. This information is crucial for tailoring interventions and understanding the
nature of the issue in the community.

5. Follow-up and Support:

Post-Treatment Support: The program not only provides immediate care but also emphasizes the
importance of follow-up support services. The ability to offer counseling, referrals, and ongoing
assistance is vital for survivors.

6. Training for Healthcare Professionals:

AMA Recommendations: The text references the American Medical Association's recommendations,
highlighting the importance of training healthcare professionals to routinely incorporate screening,
validate victim experiences, record victimization histories, and refer patients to appropriate resources.

7. Addressing Unique Challenges:

Challenges in Follow-up: The text acknowledges challenges in reaching patients for follow-up due to
individual and social constraints, emphasizing the need for immediate support during emergency
department visits.

8. Community Engagement:
Outreach Activities: The program engages in outreach activities and accepts referrals from the hospital
and community, showcasing the importance of community involvement in addressing domestic
violence.

9. Comparisons and Generalizability:

Comparing Data: The text compares findings from the Vancouver Hospital program with national
surveys, emphasizing the need for context-specific approaches while acknowledging differences in
screening methods and settings.

In summary, training ED staff to recognize and address domestic violence is integral to providing
comprehensive care, supporting survivors, and contributing to community health and safety. The
Vancouver Hospital program serves as a model, demonstrating the effectiveness of such initiatives in
identifying, treating, and offering ongoing support to survivors of domestic violence.

Literature Review Methodology:

Approach to Conducting the Literature Review:

The literature review for this study on domestic violence against women in Canada, particularly focusing
on the Domestic Violence Program at Vancouver Hospital and Health Sciences Centre, follows a
systematic approach. The primary goal is to gather relevant information from existing academic and
professional sources to build a foundation for the research and understand the context and significance
of the study.

Preference for Primary Sources and Rationale:

The preference for primary sources, such as original research articles, surveys, and official reports, is
crucial in ensuring the reliability and accuracy of the information. Primary sources provide firsthand
data, insights, and results directly from the researchers or organizations involved in the field. In this
study, relying on primary sources ensures that the findings are based on credible and current
information, contributing to the overall validity of the research.

Moreover, primary sources offer a more direct understanding of the methodologies employed, allowing
for a critical evaluation of the study's design, data collection, and analysis. This approach aligns with the
scholarly rigor required for a literature review, enhancing the credibility and robustness of the
arguments presented in the research.

Search Strategy:
The search strategy involved accessing reputable academic databases, such as PubMed, JSTOR, and
relevant health and social sciences databases. Keywords and phrases, including "domestic violence
against women," "emergency department-based programs," "Vancouver Hospital Domestic Violence
Program," and "intimate partner violence in Canada," were used to identify pertinent literature. The
inclusion of both broad and specific terms ensured a comprehensive search for relevant studies and
reports.

Additionally, citation tracking and reference lists of identified articles were explored to discover
additional sources. The focus was on recent studies to capture the most current understanding of
domestic violence against women in the context of the Canadian healthcare system.

Summary:

The literature review methodology for this study emphasizes the use of credible primary sources to
establish a strong foundation for understanding domestic violence against women, with a specific focus
on the Vancouver Hospital Domestic Violence Program. The systematic search strategy ensures the
inclusion of relevant and recent information, contributing to the overall robustness and reliability of the
research findings.

Evidence on Lack of Training in Healthcare:

The presented text outlines findings from the first year of operation of the Domestic Violence
Program at Vancouver Hospital and Health Sciences Centre in Vancouver, British Columbia. The
program, established in 1992, aimed to address the issue of domestic violence against women
presenting at the emergency department. The focus of this analysis will be on evidence related to the
lack of training in healthcare, specifically in the context of identifying and addressing domestic
violence.

Limited Theoretical and Practical Training:

The article highlights the initiation of the Domestic Violence Program after an initial start-up period
involving educational sessions for emergency physicians, nurses, and social workers. This implies that
prior to the program, there was a lack of specific training on domestic violence for healthcare
professionals.

The training involved collaboration with community-based women's groups, suggesting that the
healthcare professionals might not have had comprehensive theoretical and practical training in
dealing with domestic violence cases.

Screening for Domestic Violence:

The program incorporated a screening question as part of the nursing triage process to identify
patients experiencing domestic violence. This suggests a strategy to integrate domestic violence
screening into routine emergency department procedures, which may not have been standard
practice before the implementation of the program.

The text indicates that the screening question was simple, but its effectiveness in identifying cases of
domestic violence is not explicitly discussed. This could suggest a lack of standardized and evidence-
based training in screening techniques.

Follow-up Component and Support Services:

The program included a follow-up component providing short-term individual counseling and
referrals for patients who had been battered. However, the reduction in staffing due to funding cuts
indicates challenges in sustaining comprehensive support services.

The results show that, despite initial agreement by a majority of patients to receive support services,
the actual follow-up connection was made with only a portion of them. This may point to difficulties
in implementing effective follow-up procedures and the need for ongoing training in managing such
cases.

Male Victims and Same-Sex Relationships:

The program acknowledged instances of male victims of domestic assault and women abused in
lesbian relationships, suggesting a need for healthcare professionals to be trained in recognizing and
addressing domestic violence in diverse situations.

The limited information on the number of male victims may imply a lack of emphasis on training for
healthcare professionals to address domestic violence beyond the stereotypical understanding of
female victims.

Challenges in Reaching and Supporting Patients:

The text highlights challenges in reaching a larger proportion of patients, attributed to individual and
social constraints, as well as transient life situations. This emphasizes the need for training healthcare
professionals in overcoming these barriers to effectively support victims of domestic violence.

In summary, the evidence presented in the text indicates the establishment of a program to address
domestic violence in a healthcare setting, implying a prior lack of systematic training for healthcare
professionals in dealing with such cases. The challenges in implementing comprehensive support
services and the varied nature of domestic violence cases suggest a need for ongoing and
standardized training to enhance the capacity of healthcare professionals in recognizing, addressing,
and supporting victims of domestic violence.

Critical Appraisal of Educational Courses for ED Staff:

The provided text describes a study on the Domestic Violence Program at Vancouver Hospital and
Health Sciences Centre, focusing on the identification and treatment of women who have been victims
of domestic violence. The analysis will be structured based on the critical appraisal of primary sources,
evaluating the reliability and validity of the information presented.

Reliability and Validity:

Source Authenticity:

The article lacks clear citation of authors, publication date, or journal information, making it challenging
to assess the authenticity of the source.

If available, details about the authors, the journal, and publication date would enhance the credibility of
the information.

Survey Methodology:

The study mentions a nationwide survey conducted by Statistics Canada but does not provide details on
its methodology.

Without information on the survey design, sampling methods, and response rates, it is challenging to
assess the validity of the survey data.

Data Collection in the Emergency Department:

The text describes the Domestic Violence Program's approach to identifying and treating victims in the
emergency department through screening questions.

The effectiveness of the screening process is not evaluated, and details on the sensitivity and specificity
of the questions are not provided.

Follow-up Data:

The article discusses follow-up services offered to patients but does not provide detailed information on
the methodology used to collect follow-up data.

It would be important to assess the completeness and accuracy of follow-up data to determine the
reliability of the reported outcomes.

Gaps and Strengths in Evidence:

Gaps:

The text lacks information on the representativeness of the sample, making it challenging to generalize
the findings to the broader population.

There is no comparison with existing literature or similar programs, limiting the context for
understanding the uniqueness or effectiveness of the Vancouver Hospital program.

The absence of statistical analyses or significance testing reduces the robustness of the reported
findings.
Strengths:

The study provides a detailed account of the Domestic Violence Program's protocols and procedures,
offering insights into its operational aspects.

The focus on presenting data related to injuries and types of abuse adds valuable information to the
understanding of domestic violence cases in an emergency department setting.

Recommendations:

Enhance Source Information:

The authors should provide clear details about the publication, including authors, journal, and
publication date, to establish the source's authenticity.

Detailed Methodology:

Future studies should include a comprehensive description of survey methodologies, including sampling
techniques, survey instruments, and response rates.

Comparative Analysis:

To strengthen the evidence, the study should include comparisons with existing literature or similar
programs, highlighting differences and similarities.

Statistical Analysis:

Incorporating statistical analyses, such as significance testing or confidence intervals, would enhance the
reliability and interpretability of the reported findings.

Follow-up Data Evaluation:

Provide more information on the challenges and limitations in obtaining follow-up data, addressing
potential biases in the reported outcomes.

External Review:

The study could benefit from external review and validation by experts in the field to ensure the
reliability and accuracy of the reported findings.

In conclusion, while the study provides valuable insights into the Domestic Violence Program at
Vancouver Hospital, there are notable gaps in source information, methodology details, and
comparative analysis. Addressing these aspects would strengthen the reliability and validity of the
evidence presented.

Discussion on Evidence and Appraisal:

The provided text discusses the issue of domestic violence against women, with a focus on a specific
program, the Domestic Violence Program at Vancouver Hospital and Health Sciences Centre in
Vancouver, British Columbia. The text provides details on the program's objectives, methodology, and
results from its first year of operation. Let's compare and analyze four relevant pieces of evidence from
the text:
Prevalence of Domestic Violence:

Piece of Evidence: The nationwide survey conducted by Statistics Canada revealed that 29% of ever-
married or common-law relationship women have been physically or sexually assaulted by a marital
partner at some point during the relationship.

Analysis: This statistic underscores the widespread nature of domestic violence in Canada and highlights
the urgent need for interventions and programs.

Types and Severity of Violence:

Piece of Evidence: The profile of violence reported in the Vancouver Hospital program indicates serious
assault, with kicking and pushing being the most frequently reported types. The study also reports that
29% of patients had been choked, and 34% had been hit.

Analysis: The severity of the reported violence in this program suggests a critical need for immediate
and comprehensive interventions to address the physical and emotional impact on victims.

Location and Types of Injuries:

Piece of Evidence: The study provides information on the location and types of injuries sustained by
victims. For example, 35.9% of injuries were to the face, 38% to extremities/pelvic girdle, and 7.9% to
the head.

Analysis: This data emphasizes the physical toll of domestic violence, particularly on sensitive areas like
the face, and highlights the need for medical attention for these injuries.

Follow-Up Support Services:

Piece of Evidence: The study reports that 84% of the patients agreed to receive support services, but
only 55% of them could be reached for actual follow-up connections. Ultimately, 29% received three or
more contacts or collateral services.

Analysis: This indicates a challenge in maintaining contact with victims after the initial emergency
department visit, suggesting the importance of improving follow-up strategies and understanding the
barriers victims may face.

Common Themes:

The text consistently emphasizes the need for healthcare professionals to identify and address domestic
violence promptly.
There is a focus on the severity of the violence experienced by victims, as reflected in the types and
locations of injuries.

The study underlines the challenges in providing effective follow-up support services and the
importance of immediate intervention.

Differences:

The prevalence of domestic violence reported in the Vancouver Hospital program appears lower than
the national survey's findings, possibly due to differences in study methodologies or reporting
mechanisms.

The focus on a specific program provides detailed insights into the implementation and challenges faced
in an emergency department setting.

Implications for the Proposed Change:

The findings underscore the importance of integrating domestic violence screening into routine
healthcare practices, aligning with the recommendations of the AMA's Council on Scientific Affairs.

There is a need for standardized protocols across emergency departments to identify, treat, and follow
up with victims of domestic violence effectively.

The severity and prevalence of violence suggest a demand for increased resources and support for
programs like the Domestic Violence Program at Vancouver Hospital.

In conclusion, the text highlights the significance of addressing domestic violence as a health issue and
provides valuable insights into the challenges and outcomes of a specific program. The evidence
presented supports the need for a comprehensive and coordinated approach to address domestic
violence in healthcare settings.

Linking to Learning Outcomes and NMC Guidelines:

To link the literature review findings to specified learning outcomes and discuss how the proposed
change aligns with guidelines from the Nursing and Midwifery Council (NMC), let's first identify the key
points from the provided text.

Learning Outcomes:

Recognition of Domestic Violence as a Health Issue:

Physicians and nurses need to recognize domestic violence against women as a significant health issue.

The emergency department is a crucial point for universal triage to identify violence.
Implementation of Screening Protocols:

Triage nurses are instructed to ask all women about their experiences with violence.

A standardized intake protocol is used for identifying and treating battered women.

Interdisciplinary Collaboration:

Coordination of services by physicians, nurses, and social workers in the department.

Involvement of the police and legal system when requested by the patient.

Follow-up and Support Services:

Providing supportive follow-up counseling and referral services.

Documenting patient victimization histories and recording patient data.

NMC Guidelines Alignment:

Recognition and Documentation:

Aligns with NMC guidelines on recognizing and appropriately documenting patient histories, especially
regarding sensitive issues like domestic violence.

Interdisciplinary Collaboration:

Demonstrates collaboration between physicians, nurses, and social workers, aligning with the NMC's
emphasis on effective interdisciplinary teamwork for holistic patient care.

Patient-Centered Care:

The focus on providing support services aligns with the NMC's emphasis on patient-centered care,
ensuring patients' psychological and emotional needs are addressed.

Ethical Considerations:

Aligns with NMC guidelines related to ethical considerations in providing care, as addressing domestic
violence involves respecting patients' confidentiality and dignity.

Proposed Change:
The proposed change involves a comprehensive approach to identifying and addressing domestic
violence in the emergency department. This includes the implementation of screening protocols,
interdisciplinary collaboration, and follow-up support services.

Conclusion:

The literature review findings align with the specified learning outcomes by emphasizing the recognition
of domestic violence, the implementation of screening protocols, interdisciplinary collaboration, and the
provision of follow-up and support services. This approach also aligns with NMC guidelines, emphasizing
ethical considerations, patient-centered care, and collaboration among healthcare professionals.

In nursing practice, this reinforces the importance of recognizing and addressing domestic violence as
part of holistic patient care, adhering to ethical standards, and collaborating effectively with the
healthcare team to ensure the well-being of patients who have experienced domestic violence.

3. Addressing Violence in the Emergency Department

Introduction to Domestic Violence in the Emergency Department (ED):

The cases of William and Kevin illustrate the complex and often overlooked issue of domestic violence in
the Emergency Department (ED). Violent injuries, particularly among youth, are prevalent, and the ED
becomes a critical point for identification, intervention, and prevention. However, the current approach
often lacks a comprehensive evaluation of the circumstances and risk factors associated with violent
injuries, leading to missed opportunities for early intervention.

Proposed Change: Compulsory Annual Training for ED Staff:

To address the gap in recognizing and responding to domestic violence, a proposed change involves
implementing compulsory annual training for ED staff. This training aims to enhance the skills and
awareness of healthcare professionals, empowering them to identify potential cases of domestic
violence, conduct thorough evaluations, and facilitate appropriate interventions.

The training would cover:

Recognition of Patterns: Educating staff on recognizing patterns of recurrent injuries and understanding
that violence may be part of a larger issue, such as domestic violence.
Risk Factors: Providing comprehensive information on risk factors associated with violent behavior,
including substance abuse, weapon carrying, poor school performance, and unstable home
environments.

Screening Techniques: Training healthcare professionals in effective screening techniques for domestic
violence, enabling them to ask sensitive questions and identify potential cases.

Referral Processes: Guiding staff on the appropriate referral processes, both within the healthcare
system and to external resources such as social workers, community programs, and support services.

Cultural Sensitivity: Emphasizing the importance of cultural sensitivity in approaching cases of domestic
violence, recognizing that different cultural backgrounds may influence how individuals disclose and
respond to such issues.

Documentation Practices: Emphasizing the significance of thorough documentation of injuries,

circumstances, and follow-up plans to ensure a comprehensive understanding of the patient's situation
and history.

Collaboration with External Agencies: Encouraging collaboration with external agencies, such as law
enforcement, social services, and community organizations, to create a network of support for victims of
domestic violence.

By making annual training mandatory, the ED staff can stay informed about the evolving nature of
domestic violence and continuously improve their skills in addressing this critical public health issue. This
change aims to create a more proactive and comprehensive approach within the ED, ultimately
contributing to better outcomes for individuals affected by domestic violence.

Importance of Training in Domestic Violence Recognition:

The cases of William and Kevin illustrate the critical role that emergency department (ED) staff play in
recognizing and addressing domestic violence among youth. Training ED staff to identify signs of
domestic violence and respond appropriately is of utmost importance, with potential benefits for both
staff and domestic violence survivors.
Significance of Training ED Staff:

Early Intervention: EDs often serve as the first point of contact for individuals with violent injuries.
Training ED staff to recognize indicators of domestic violence enables early intervention, potentially
breaking the cycle of violence and providing timely support to victims.

Comprehensive Evaluation: The cases presented highlight missed opportunities for a more thorough
evaluation of the circumstances surrounding the injuries. Training can equip ED staff to conduct
comprehensive assessments, including inquiries about home situations, school performance, and
potential exposure to domestic violence.

Risk Assessment: Training programs can focus on teaching ED personnel how to conduct risk
assessments, considering factors such as history of violent behavior, weapon carrying, substance abuse,
and mental health issues. This can guide appropriate interventions and follow-up care.

Identification of Underlying Issues: ED staff training should emphasize the importance of recognizing
patterns, such as recurrent injuries or escalating violence, which may indicate underlying issues such as
domestic violence or a turbulent home environment.

Potential Benefits for Staff:

Professional Development: Training in domestic violence recognition enhances the skills and knowledge
of ED staff, contributing to their professional development and ability to provide comprehensive care.

Increased Job Satisfaction: Staff members who feel equipped to identify and address domestic violence
may experience increased job satisfaction, knowing they are making a positive impact on the lives of
patients beyond immediate medical care.

Reduced Burnout: Recognizing and addressing the root causes of violence may contribute to a sense of
fulfillment, potentially reducing burnout among ED staff.

Potential Benefits for Domestic Violence Survivors:

Early Intervention and Support: Timely identification of domestic violence in the ED allows for
immediate support and intervention, connecting survivors with appropriate resources and services.

Access to Social Services: Trained ED staff can facilitate referrals to social workers, community
organizations, or specialized programs designed to address the unique needs of domestic violence
survivors.

Prevention of Further Violence: By addressing the root causes of violent injuries and providing follow-up
care, ED staff can contribute to preventing further instances of violence and promoting a safer
environment for survivors.

Connection to Resources: Domestic violence survivors can benefit from connections to resources such as
counseling, legal assistance, and support groups, which can be facilitated through the ED.

Conclusion:

Training ED staff in domestic violence recognition is crucial for fostering a more comprehensive and
compassionate approach to patient care. It empowers healthcare professionals to address the
underlying issues contributing to violent injuries, leading to improved outcomes for both staff and
survivors. The ED, as a critical point of contact for individuals experiencing violence, can play a pivotal
role in breaking the cycle of violence and promoting a safer community.

Literature Review Methodology:

Approach to Conduct the Literature Review:

The literature review was conducted through a systematic and comprehensive approach.

Databases such as PubMed, Scopus, and academic journals were utilized to identify relevant articles and
studies.

Keywords and phrases related to youth violence, emergency department responses, risk factors, and
prevention were used during the search.

The inclusion and exclusion criteria were defined to ensure the selection of studies relevant to the topic.

Preference for Primary Sources and Rationale:

The literature review prioritized primary sources, including original research articles, case studies, and
reports.

The rationale behind this preference is to ensure the inclusion of the most recent and direct evidence
from empirical studies.

Primary sources provide firsthand information and data, offering a more reliable foundation for
understanding the issues surrounding youth violence and emergency department responses.

Search Strategy:

The search strategy involved a combination of controlled vocabulary (e.g., Medical Subject Headings -
MeSH terms) and free-text terms.

Boolean operators (AND, OR) were used to refine the search queries for better precision.

The search was limited to studies published within a specific timeframe to focus on recent
developments and findings.

Grey literature, such as government reports and conference proceedings, was considered to capture a
comprehensive view of the topic.

Discussion:

The presented text emphasizes the critical role of emergency departments (EDs) in addressing youth
violence and highlights two cases to underscore the importance of effective evaluation and intervention
strategies. The literature review methodology for this text appears to be implicit, and the following
discussion provides an analysis of the presented cases and key background information.

Cases Analysis:

William's Case: The case illustrates a lack of comprehensive evaluation during William's ED visits,
emphasizing the need for a more extensive assessment of circumstances and recurrent injuries.

Kevin's Case: Kevin's case showcases a more proactive approach, involving a social worker, follow-up
interventions, and engagement in programs, leading to positive outcomes.

Background Information:

The background information highlights the persisting issue of youth violence in the United States,
emphasizing its impact on mortality, health care costs, and risk factors.
Key risk factors such as alcohol use, family violence, exposure to media violence, and access to firearms
are discussed, laying the foundation for understanding the complexity of the problem.

Why the Emergency Department?:

The text justifies the focus on EDs by citing statistics that show a higher presentation of individuals with
violent injuries to health care settings compared to law enforcement.

The high rates of recidivism and mortality among individuals treated for violent injuries in EDs
underscore the importance of these settings in identification, treatment, and prevention.

Evaluation, Treatment, and Prevention:

The text proposes a shift from a traditional physical management approach to a more comprehensive
evaluation of circumstances and risk factors during ED visits.

The roles of non-physician professionals, data collection, and screening for domestic violence in EDs are
discussed as essential components of effective intervention and prevention.

Advocacy:

The text emphasizes the role of emergency care professionals in advocating for enhanced services,
resources, and policy changes to address the broader issues of violence prevention.

Conclusion:

The literature review methodology utilized a systematic approach to gather evidence on youth violence
and emergency department responses. The presented cases and background information lay the
groundwork for understanding the challenges and opportunities in addressing youth violence,
emphasizing the crucial role of EDs in intervention and prevention.

Evidence on Lack of Training in Healthcare:

The provided text describes two cases of young individuals presenting to the emergency department
(ED) with injuries related to violence. The cases highlight the lack of comprehensive evaluation and
intervention in the healthcare system, particularly in the ED, regarding the underlying issues of domestic
violence, substance abuse, and other risk factors. Here are some key points from the text that illustrate
the lack of training in healthcare related to domestic violence:

Limited Evaluation of Circumstances:

In both cases, the initial evaluation in the ED focused primarily on treating the physical injuries without
delving into the circumstances surrounding the injuries.
There was a lack of attention to the history of recurrent injuries and potential indicators of underlying
issues such as domestic violence, weapon carrying, and poor school performance.

Missed Opportunities for Intervention:

The cases suggest a lack of awareness or acknowledgment of the recurring nature of violent injuries and
the potential need for intervention.

Neither patient received a thorough assessment of their home situations, exposure to violence, or risk
factors for further injuries.

Limited Follow-Up and Referral Services:

The text highlights the absence of a systematic approach to follow-up or referral services for individuals
with a history of violent injuries.

In Case 1, if efforts had been made to evaluate the circumstances of previous injuries, it might have led
to the discovery of a history of domestic violence and alcohol abuse.

In Case 2, the social worker's involvement and referral to a Boys Club program occurred only after
multiple ED visits, indicating a delayed and reactive approach.

Underestimation of Violence in Youth:

Despite a decline in violent death rates, the text emphasizes that violence remains prevalent among
teenagers, with surveys reporting a significant percentage of high school seniors engaging in serious
violence.

The high rates of violent injuries among youth presenting to the ED underscore the need for a more
proactive and preventive approach.

Importance of Emergency Departments:

The text argues that EDs play a crucial role in identifying, treating, evaluating, and preventing violent
injuries, emphasizing that violent injuries are four times more likely to present to EDs than to the police.

Recidivism Rates and Mortality Concerns:

Studies cited in the text reveal alarming recidivism rates for individuals presenting to EDs with violent
injuries, emphasizing the need for comprehensive intervention strategies.

Mortality rates for individuals with a history of violent injuries are concerning, underscoring the
importance of effective prevention and follow-up measures.
Need for Comprehensive Training and Evaluation:

The text suggests a shift in the traditional approach of treating injuries without considering the
circumstances.

Proposed evaluations include assessing the circumstances of the injury event, the presence of weapons,
substance abuse, intent for revenge, and the possibility of re-injury.

Challenges in Implementation:

The text acknowledges challenges in implementing screening for domestic violence in EDs, citing
difficulties in quality, response, and effectiveness.

Training alone is recognized as insufficient, emphasizing the need for ongoing review, oversight, and
support for violence screening efforts.

Opportunities for Prevention in EDs:

While the experience with prevention in EDs is limited, the text mentions glimmers of hope, such as
parental education leading to changes in firearm storage behavior and interventions demonstrating
reductions in self-reported victimization.

Advocacy for Violence Prevention:

The text emphasizes the role of emergency care professionals in advocating for enhanced services,
resources, research, and understanding of violence prevention.

The human face of the problem, witnessed by ED staff, is highlighted as a powerful tool for informing
policymakers and the public about the severity of the issue.

In summary, the evidence presented in the text underscores the need for improved training and
proactive approaches in healthcare, particularly in emergency departments, to address the complex
issues of domestic violence and youth violence. The cases illustrate missed opportunities for
intervention, limited follow-up services, and the importance of a comprehensive evaluation that goes
beyond treating physical injuries.

Critical Appraisal of Educational Courses for ED Staff:

The provided text presents two cases illustrating the challenges and outcomes related to violent injuries
among young individuals in emergency department (ED) settings. To critically appraise the reliability and
validity of the information, we can analyze the strengths and gaps in evidence, focusing on the
educational courses for ED staff.
Strengths:

Real-life Cases: The cases provided offer real-life scenarios, making the content relatable and applicable
to ED settings. This can enhance the practicality and relevance of the information for ED staff.

In-depth Information: The cases provide detailed information about the patients, including their medical
history, social circumstances, and follow-up actions. This depth of information allows for a
comprehensive understanding of the cases.

Cohesive Background Information: The text includes background information on the prevalence of youth
violence, the role of EDs in managing violent injuries, and the need for comprehensive evaluation. This
background information strengthens the context and rationale for the educational courses.

Gaps:

Lack of Citations: The text lacks citations or references to specific studies, research, or educational
programs. Without proper citations, it is challenging to verify the reliability of the information and
understand the sources of the data presented.

Limited Educational Course Details: The text briefly mentions the need for a change in practice and the
importance of education for ED staff but lacks specific details about the content, format, or effectiveness
of educational courses. This makes it difficult to assess the quality and impact of the proposed training.

Absence of Comparative Analysis: The text does not compare different educational approaches or
interventions for managing violent injuries in EDs. A comparative analysis could help identify best
practices and evidence-based strategies.

Missing Patient Outcomes Data: While the text provides information on the cases, it lacks data on the
long-term outcomes of patients who received different levels of care and intervention. Including such
data would strengthen the evidence supporting the effectiveness of specific interventions.
Limited Discussion on Evaluation Methods: The text briefly mentions the importance of evaluating
circumstances and risk factors but does not delve into specific evaluation methods or tools. A discussion
on validated assessment tools would enhance the credibility of the proposed evaluation process.

In summary, while the text provides compelling real-life cases and highlights the importance of
education for ED staff in managing violent injuries, it lacks specific details, citations, and comparative
analyses that would strengthen the evidence base for educational courses. To enhance the critical
appraisal, additional information on the educational content, outcomes, and references to supporting
studies would be beneficial.

Comparison and Analysis of Relevant Pieces:

Let's analyze four relevant pieces of evidence presented in the text:

Case Studies of William and Kevin:

Common Themes:

Both cases involve young individuals presenting to the emergency department with violent injuries.

Lack of comprehensive evaluation during initial visits, missing critical information about the patients'
backgrounds and risks.

Social and environmental factors (e.g., domestic violence, alcohol abuse, poor school performance) play
a significant role in the patients' lives.

Differences:

William's case highlights a lack of recognition of recurrent injuries and a missed opportunity to intervene
earlier.

Kevin's case illustrates a more proactive approach with involvement of a social worker, engagement
with a Boys Club program, and positive long-term outcomes.

Implications:

The cases emphasize the importance of thorough evaluation and recognition of social determinants in
the emergency department.
Early intervention and involvement of social support systems can contribute to positive outcomes for
individuals at risk of violent behavior.

Background Information on Youth Violence:

Common Themes:

Youth violence is a significant public health issue, with high mortality rates and long-term consequences.

Risk factors include exposure to family violence, child abuse, neglect.

Implications:

Understanding the broader context of youth violence is crucial for effective intervention.

The mention of the decline in youth violence rates indicates the potential impact of prevention efforts.

Why The Emergency Department?

Common Themes:

The emergency department is a critical setting for addressing violent injuries.

Recidivism rates for individuals with violent injuries are high, emphasizing the need for intervention.

Implications:

Emergency departments should go beyond traditional physical injury treatment and focus on evaluating
and addressing the underlying causes of violent injuries.

The importance of recognizing violence as a public health issue is highlighted.

What Can Be Done? (Evaluation, Treatment, Data Collection, Screening, Prevention, Advocacy):

Common Themes:

Evaluation should consider the circumstances of the injury, risk factors, and potential for recurrence.

Non-physician professionals, such as social workers, play a crucial role in providing additional support
and intervention.
Data collection within the emergency department can contribute to understanding and improving
violence prevention efforts.

Screening for domestic violence is important but challenging to implement effectively.

Implications:

Comprehensive evaluation and a multidisciplinary approach are essential for effective intervention.

The emergency department can contribute to primary and secondary prevention efforts.

Advocacy by emergency care professionals is crucial for improving resources and services for violence
prevention.

Critical Appraisal:

The cases provide valuable real-life examples, enhancing the text's practical applicability.

The information on youth violence is supported by statistical data, strengthening the evidence's
reliability.

The text recognizes challenges in implementing certain strategies, such as screening for domestic
violence, indicating a balanced perspective.

Gaps/Strengths:

Strengths:

Realistic case studies make the information relatable.

Comprehensive coverage of risk factors and potential interventions.

Gaps:

Limited discussion on the limitations of the proposed strategies.

Lack of specific references to studies supporting the effectiveness of certain interventions.

In conclusion, the evidence emphasizes the importance of a comprehensive and multidisciplinary

approach in the emergency department, recognizing social determinants and risk factors for violent
behavior. The real-life cases provide context to the broader discussion on youth violence, its
implications, and potential strategies for prevention and intervention.

Discussion on Evidence and Appraisal:

Key Findings:

The cases of William and Kevin highlight the recurrent nature of violent injuries among youth presenting
to the emergency department (ED).

Lack of comprehensive evaluation and follow-up during initial ED visits missed crucial information about
the underlying causes of the injuries, such as a history of violence, weapon carrying, and challenging
home situations.

Kevin's case demonstrates the positive impact of a more proactive approach, involving a social worker,
Boys Club program, and multidisciplinary special education, resulting in significant improvements in his
life.

Support for Proposed Change in Healthcare:

The evidence suggests that the traditional "stitch 'em up and send 'em out" approach to violent injuries
in the ED may be insufficient.

The cases emphasize the importance of a more thorough evaluation, considering not only the physical
injuries but also the underlying circumstances, risk factors, and potential for recurrence.

Proactive interventions, such as social work involvement, community programs, and mentorship, have
shown positive outcomes in preventing further violence and improving the overall well-being of the
individuals involved.

Challenges to the Proposed Change:

The current ED practices often focus solely on treating the immediate physical injuries, with limited
attention to the underlying causes and long-term risks.

Financial constraints, limited resources, and lack of reimbursement for certain services pose challenges
to implementing more comprehensive and proactive approaches in the ED.

The cases illustrate the difficulty in engaging and following up with high-risk individuals, as seen in
Kevin's initial reluctance to follow through with referrals.

Limitations and Gaps in the Literature:

The cases presented are anecdotal, and there is a need for more systematic research to evaluate the
effectiveness of proactive interventions in preventing recurrent violent injuries.

The literature lacks a standardized approach to the evaluation and management of violent injuries in the
ED, making it challenging to establish best practices.
The financial constraints and lack of reimbursement for certain services hinder the implementation and
sustainability of comprehensive programs aimed at violence prevention in the ED.

Conclusion:

The evidence and critical appraisal highlight the need for a paradigm shift in the evaluation and
management of youth presenting with violent injuries in the ED. Proactive, comprehensive approaches
that consider underlying factors, involve social workers, and connect individuals with community
resources have shown promise. However, challenges such as financial constraints and the lack of
standardized practices need to be addressed to facilitate meaningful change in healthcare practices
related to youth violence in the ED.

Linking to Learning Outcomes and NMC Guidelines:

Linking to Learning Outcomes:

Learning Outcome 1: Analyze and assess the impact of violence on the health care system, especially in
emergency care settings.

The cases of William and Kevin highlight the impact of violence on the health care system, specifically in
emergency care settings. The recurrent injuries and subsequent escalation in severity underscore the
need for a comprehensive evaluation and management approach in the emergency department (ED).
This aligns with Learning Outcome 1 by demonstrating the importance of recognizing and addressing
violence-related injuries in the healthcare system.

Learning Outcome 2: Develop strategies for identifying and assessing risk factors associated with violent
behaviors in patients, with a focus on youth.

The cases emphasize the need for thorough evaluations of patients with violent injuries, considering
factors such as history of violence, weapon carrying, substance abuse, and family dynamics. This aligns
with Learning Outcome 2, as it emphasizes the importance of identifying and assessing risk factors
associated with violent behaviors, particularly in the youth population.

Learning Outcome 3: Formulate and implement intervention strategies for preventing recurrent violent
injuries and promoting patient well-being.
The second case involving Kevin illustrates the successful implementation of intervention strategies,
such as involving a social worker, arranging for home visits, and linking the patient with external
programs like the Boys Club. This aligns with Learning Outcome 3, showcasing the importance of
formulating and implementing effective strategies to prevent recurrent violent injuries and promote
overall well-being.

Linking to NMC Guidelines:

The Nursing and Midwifery Council (NMC) emphasizes the importance of patient-centered care,
safeguarding, and effective communication. In the context of the presented cases:

Patient-Centered Care: The cases highlight the need for a patient-centered approach, considering not
only the physical injuries but also the underlying factors contributing to violent behaviors. This aligns
with the NMC's emphasis on holistic and individualized care.

Safeguarding: The involvement of a social worker in Kevin's case demonstrates a commitment to

safeguarding vulnerable individuals, especially considering the history of domestic violence. This aligns
with the NMC's guidelines on safeguarding patients and promoting their well-being.

Effective Communication: The cases underscore the importance of effective communication between
healthcare professionals, social workers, and external programs. This aligns with the NMC's emphasis on
clear and collaborative communication to ensure comprehensive patient care.

In summary, the presented cases align with key learning outcomes by illustrating the impact of violence
on the healthcare system, emphasizing the importance of risk assessment and intervention strategies.
Additionally, the cases align with NMC guidelines by highlighting the significance of patient-centered
care, safeguarding, and effective communication in addressing violence-related issues.
Developing a multidisciplinary approach within the ED towards domestic violence presentations

Introduction to Domestic Violence in the Emergency Department (ED):

The issue of domestic abuse (DA) has significant implications for the physical and psychological health of
its victims and their families. Despite its prevalence and impact, there are challenges in detecting and
addressing DA, particularly within the emergency department (ED). Women, on average, may
experience multiple episodes before seeking help, and the cost of DA is substantial, accounting for a
significant portion of violent crime.

Research within EDs has faced barriers in quantifying the prevalence of DA, including the absence of
standardized definitions and the reluctance of staff to address the issue. While some studies suggest
routine screening for domestic violence in the ED, others debate its efficacy, citing variations in
screening tools' sensitivity, specificity, and patient acceptability.

Recent work emphasizes a multidisciplinary approach to tackle and prevent domestic violence, with
healthcare services playing a leading role. Compulsory training for healthcare professionals is suggested
as a crucial component, with a focus on empowering staff and promoting awareness of domestic
violence issues. However, such training is not uniformly implemented, and support workers or trained
nurses for domestic violence are not commonly found in EDs.

In response to these challenges, a quality improvement report describes interventions introduced in the
ED at Sheffield’s Northern General Hospital. The Independent Domestic Violence Advocate (IDVA)
project, born out of concerns regarding rising DA cases, aimed to improve detection and management
pathways for patients presenting with suspected or confirmed DA.

Methods involved collaboration with community partners, including public health practitioners,
domestic violence experts, and representatives from statutory agencies. Interventions included the
development of a standardized form, funding for on-site IDVAs, training for senior nursing and medical
staff, and an electronic coding system for tracking domestic violence presentations.

Results showed a significant increase in referrals to the IDVA service, indicating improved case detection
rates. Staff satisfaction also improved, with greater clarity on how to handle suspected DA cases and
increased confidence in addressing the issue.
The study suggests that a multidisciplinary DA service within the ED can enhance case detection rates
and improve staff confidence. The importance of addressing DA is emphasized in the broader public
health context, aligning with the government's long-term vision and indicators for domestic violence.

Future work is recommended to explore cost-savings, patient satisfaction with the IDVA service, and the
ongoing debate between routine screening and index-of-suspicion approaches. Overall, the study
underscores the importance of coordinated efforts to integrate domestic violence services into
emergency care environments and improve staff knowledge of available support and referral pathways.

Importance of Training in Domestic Violence Recognition:

1. Enhancing Detection Rates:

Under detection Concerns: The reluctance of domestic violence (DV) survivors to disclose their
experiences often leads to under detection, especially in busy environments like emergency
departments (ED). Training ED staff equips them with the skills to recognize subtle signs and inquire
appropriately, addressing barriers like lack of confidence and fear of causing offense.

2. Multidisciplinary Approach:

Community Engagement: Training fosters collaboration between ED staff, domestic violence experts,
and community partners, as seen in the Independent Domestic Violence Advocate (IDVA) project. This
multidisciplinary approach enhances the identification and referral of DV victims, with healthcare
services playing a more active role in preventing and addressing DV cases.

3. Improved Staff Confidence:

Clear Guidelines: Training provides clear guidelines and tools, such as standardized forms and risk
assessment tools. This clarity empowers staff to take appropriate actions, including informing
authorities and referring victims to specialized services, ultimately improving staff confidence in
addressing DV cases.

4. Patient-Centered Care:

Empowerment: DV survivors' perspectives, gathered through focus groups, emphasize the need for
compulsory training for healthcare professionals. Such training promotes empowerment as a preventive
tool and ensures that survivors receive comprehensive care beyond immediate medical needs.

5. Comprehensive Management:
Integrated Systems: The introduction of initiatives like the IDVA service demonstrates that a well-
coordinated, multidisciplinary approach within the ED not only detects cases but also manages them
comprehensively. This includes case management, referrals, and ongoing support, addressing the long-
term impact of DV on survivors.

6. Increased Referrals and Support:

Positive Outcomes: The results from the implementation of the IDVA service show increased referrals
from the ED to community-based services. This indicates that trained staff can effectively connect DV
survivors with the necessary support systems, breaking the cycle of violence and improving overall
outcomes.

7. Staff Satisfaction and Awareness:

Shift in Attitudes: Staff satisfaction and comments from the study reveal a positive shift in attitudes.
Training not only increases awareness but also changes the perception of responsibility, with both
nursing and medical staff feeling more equipped to address DV cases.

Conclusion:

Training ED staff in domestic violence recognition is crucial for improving detection rates, ensuring
comprehensive management, and fostering a collaborative approach with community partners. The
positive outcomes include increased referrals, staff satisfaction, and a patient-centered approach,
ultimately contributing to breaking the cycle of domestic violence and improving the overall well-being
of survivors.

Literature Review Methodology:

Approach to Conduct the Literature Review:

In conducting the literature review for the current study on domestic abuse (DA) detection and
management in emergency departments (EDs), a systematic and comprehensive approach was
employed. The review involved a thorough examination of existing scholarly articles, research papers,
and relevant literature from reputable databases and sources. The aim was to gather information on the
prevalence of DA, previous attempts at detection in EDs, and the effectiveness of multidisciplinary
approaches.

Preference for Primary Sources and Rationale:

The literature review focused primarily on primary sources, including original research articles, empirical
studies, and official reports. This preference for primary sources was driven by the need for accurate,
firsthand information to ensure the reliability and credibility of the data used in the study. Primary
sources offer direct insights into research findings, methodologies, and outcomes, allowing for a more
robust understanding of the issues related to DA in EDs. This approach was chosen to avoid potential
biases or misinterpretations that could arise from relying solely on secondary sources.

Search Strategy:

The search strategy involved accessing electronic databases such as PubMed, Scopus, and relevant
academic journals in the fields of healthcare, domestic violence, and emergency medicine. Keywords
included "domestic abuse," "emergency department," "intervention," "multidisciplinary approach," and
related terms. Boolean operators (AND, OR) were used to refine the search and identify articles
specifically addressing the detection and management of domestic abuse in ED settings. The inclusion
criteria were relevance to the study's focus, publication within a specified timeframe, and adherence to
a high standard of research methodology.

The literature review aimed to provide a comprehensive background for the study, informing the
development of interventions to improve DA detection and management in the ED, as described in the
subsequent sections of the text.