Researching domestic violence and abuse in healthcare settings: Challenges and issues

Abstract

Domestic violence and abuse (DVA) is now recognised as a significant global health and societal issue. Conducting DVA research in healthcare contexts requires the consideration and understanding of a number of practical, methodological and ethical issues. Based on their experiences of working as clinicians and researchers, the authors aim to explore some of the pertinent issues and challenges associated with DVA research conducted in healthcare settings involving patients and/or healthcare professionals or both. A number of ethical, methodological and practical challenges, particularly those associated with research design and data collection, and ethical challenges related to participants and researchers, are explored.

Keywords

domestic violence and abuse ethical issues methodological challenges nursing and healthcare research

Introduction and background

After all, violence is preventable. The more we gather knowledge about it, the better we are to contribute to its minimisation in society. (Stanko and Lee, 2003: 3)

Domestic violence and abuse (DVA) is now recognised as a significant global health and societal issue (World Health Organization, 2015). Traditionally, DVA has been conceptualised as encompassing a number of different forms of harm including physical, sexual, emotional, verbal, psychological and financial abuse. However, more recently there has been a greater recognition of the inherent complexity that underlies DVA and in the UK the definition of DVA has now been revised by the UK Home Office to include:

any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse among those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. The definition also includes so called ‘honour’ based violence, female genital mutilation (FGM) [cutting] and forced marriage. (Home Office, 2013)

The potential consequences of experiencing DVA are far reaching and DVA is not defined by gender, age, social class or ethnic group. The impact of DVA on the lives and health of those affected is now well documented within the literature, and this includes increased mortality and morbidity – both physical and psychological ill-health, affecting both the short- and longer-term health and well-being of the victim or survivor (McGarry et al., 2011; Rose et al., 2011). DVA also exerts a detrimental impact on the health and well-being of wider family members, including children (Holt et al., 2008).

In the UK, DVA has recently been identified as a key national priority at a policy level for all healthcare professionals. This has been crystallised through the development and subsequent publication of The National Institute for Health and Care Excellence’s (NICE, 2014) guidance entitled ‘Domestic violence and abuse: How health services, social care and the organisations they work with can respond effectively’. A core component of the NICE (2014) guidance centres on the development of strategies to support the effective recognition and management of DVA among healthcare professionals with a key focus towards education and training.

Alongside an increasing emphasis on the role of healthcare professionals in terms of effective support and management of DVA, there has been a growing body of research which has focused on some of the key challenges associated with DVA within healthcare environments more generally. For example, research has been conducted to explore the issues related to the accurate recording of the incidence and prevalence of DVA in specific environments (Boyle et al., 2006), the identification and effective facilitation of education, training and support needs of healthcare professionals (Feder et al., 2011; Larijani and Guggisberg, 2015; Leppakoski et al., 2014), the barriers and enablers to the effective identification and management of DVA across a range of settings (Rose et al., 2011; Taft et al., 2004), the impact of DVA on the health and well-being of survivors (Campbell, 2002) and the experiences of DVA survivors within healthcare systems (Yam, 2000).

A number of methodological approaches have been utilised to investigate these phenomena within healthcare settings, ranging from surveys (Bradley et al., 2002; Leppakoski et al., 2014; Ramsay et al., 2012) to randomised control trials (Husso et al., 2012) and from thematic analysis (Rose et al., 2011) to grounded theory (Chang et al., 2005).

While the use of quantitative approaches to explore DVA is not uncommon, certain research questions may be best answered by qualitative approaches. Certain methodologies such as discourse analysis and ethnographic observations may prove to be very useful in exploring questions such as how healthcare professionals assess DVA risk and explore patients’ experiences in healthcare settings. Such exploration can provide useful contextual information that may not be unearthed through quantitative approaches (Gender Equality Network, 2015; Testa et al., 2011) as it is difficult to explore personal narratives (Puri et al., 2011; Santhya et al., 2007) and/or trajectories of violent incidents (Brickell, 2008). This may be the reason that many of the salient questions that DVA researchers have sought to address within healthcare settings are qualitative in nature, concerned with ‘exploring’, ‘examining’ or ‘explaining’, and are rooted in experiential knowledge or the lived experience of an individual; for example, questions which ask ‘What is the impact of DVA for survivors?’ (Sarkar, 2008; Yamawaki et al., 2012) or ‘What are the barriers to healthcare professionals undertaking enquiry about DVA?’ (Baig et al., 2012; Jenner et al., 2015; Rose et al., 2011; Sprague et al., 2012).

Given that DVA is largely hidden, these approaches are, arguably, particularly valuable. For example, as Sokoloff and Dupont (2005) highlight, in enabling otherwise marginalised or ‘silent’ voices to be heard,

although much pioneering work on domestic violence approached intimate partner violence as a monolithic phenomenon that affected all women the same, this ‘universalizing’ approach increasingly has been regarded as inadequate and inappropriate to explain the experiences or address the needs of battered women from diverse backgrounds. (Sokoloff and Dupont, 2005: 2)

Therefore, illuminating an individual’s experiences of DVA through qualitative approaches enables researchers to access a wide diversity of experiences and is invaluable to informing the development of services and support.

DVA research generally entails a number of particular opportunities and challenges for researchers. For instance, general considerations at the onset of the research may be associated with the identification and recruitment of participants, negotiating access, ensuring the safety of participants while maintaining confidentiality and anonymity, and issues related to response or recall bias (Kelmendi, 2013). This latter point has been raised as participants are required to reflect on their experiences, and their responses may depend on the ability to recall a particular experience or giving a socially desirable response due to embarrassment or feelings that they may be ‘judged’ (Bell and Naugle, 2007; Shorey et al., 2011). Other issues include the lack of an appropriate description of the context in which DVA occurs, and the impact of the research on the researcher and the researched (Dowson et al., 2012; Watts et al., 2001).

Irrespective of the methodological approach undertaken, the subject of DVA itself also warrants careful consideration and planning in terms of any safeguarding issues that may emerge during the process of enquiry (Nursing and Midwifery Council, 2015). Such issues are relevant to researchers, generally, but are particularly pertinent to researchers who are healthcare professionals themselves, such as nurses, midwives and physicians, as they are bound by the code of conduct of their respective registration regulators. As such, researchers with such dual responsibilities need to be cognisant of the range of important methodological and ethical difficulties intrinsic to investigating DVA in healthcare settings (Bacchus et al., 2003).

Aim

Utilising the existing literature alongside the collective experience of the authors in undertaking DVA research, the aim of this paper is to explore the pertinent methodological, ethical and practical challenges and responses that DVA researchers need to consider when designing and conducting DVA research in healthcare settings involving patients and/or healthcare professionals or both.

Methods

This paper was developed through a narrative review and synthesis of a range of relevant literature and is set within the broader context of our personal reflections, experiential knowledge and the learning that we have developed as a result of working as clinicians and researchers in the field of DVA. We present our findings as two main themes: i) study design and data collection; and ii) methodological challenges with associated sub-themes to support the development of the discussion.

Findings

Study design and data collection

While clinical presentations of DVA may occur across a wide range of healthcare settings, the emergency department and primary care are settings where a significant body of DVA research has been carried out. These and similar settings are often very busy with brief episodes of patient/client contact, thus making availability and engagement with participants, who could be healthcare professionals or patients, a challenge. Therefore, while planning a study in such a setting, a researcher has to clearly think about the design and research methodology. It is important to ensure that the design is appropriate to answer the research question and that the data collection instruments and tools, especially the questionnaires used, are easy to understand, efficient, relevant and not burdensome. These issues are discussed under three sub-themes – ‘defining DVA and the lack of conceptual clarity’, ‘working alongside practitioners as research partners’ and ‘engaging with survivors of DVA’ – and are presented in the following sections.

Defining DVA and the lack of conceptual clarity

The design of a study is directly related to the methods to be utilised for the collection of data. A number of issues can arise at the outset before data collection has commenced, and include fundamental challenges around the lack of shared understanding with regard to how DVA is defined. Schwartz (2000) has succinctly highlighted this deficit by asking ‘if we want to study something called family violence, is this possible when we do not have an agreed-on definition of family and are not even close to determining the definition of violence?’ (p. 816).

There is no one clear universal definition of DVA, and the terminology that exists within the research and supporting literature includes ‘intimate partner violence’, ‘interpersonal violence’ and ‘spousal violence’. It has also been highlighted that older women, for example, have been excluded from DVA research in many instances and have been subsumed inappropriately within the discourse of elder abuse (Penhale, 1999). To avoid uncertainty, it is central that researchers are able to clearly articulate their understanding of DVA and how this is being applied within the context of their proposed research. With reference to the current UK definition (Home Office, 2013) highlighted earlier for example, it is acknowledged that the definition is arguably gender neutral and, as such, raises questions with regard to the position of DVA within the wider gender-based violence discourse, and this needs to be explored at the onset of research. This has been highlighted by Reed et al. (2010), who state that the assumptions made with regard to gender neutrality within the DVA discourse are not supported by the evidence but, more centrally, ‘the erasure of gender from the theoretical frameworks that guide public health efforts may have serious consequences, namely the development of misguided and ineffectual prevention and intervention programs’ (p. 349). While a clear definition of DVA is central for researchers in terms of study design, it is crucial that collaborating healthcare practitioners and study participants themselves are able to identify with the definition and recognise the terminology used (Schwartz, 2000).

Working alongside practitioners as research partners

A sizable proportion of DVA research in the healthcare context requires direct collaboration or working alongside practitioners and clinicians in a number of different ways, including the collection of data. There may be challenges in terms of engaging clinical staff and managers within a particular setting. This might be especially relevant where there has been little in the way of training or prior awareness-raising around the significance of DVA within a particular clinical area (Bacchus et al., 2003). In a study that explored the development and use of a screening tool for DVA within midwifery services, Bacchus et al. (2003) identified a number of practical issues associated with the execution of the study in practice. Examples of such issues included the quality of the data collection by midwives in the study who had limited research experience, and the limited commitment of midwives to research due to the demands of their everyday workload. These observations arguably highlight the possible tensions when carrying out research in healthcare contexts and are not specific to DVA research. However, such issues of engagement are of greater importance when set within the particular context of DVA research, as ‘enquiry about domestic violence takes time and if the midwife appears hurried or distracted, the woman may be alerted to this and will be less likely to reveal that she is being abused’ (Bacchus et al., 2003: 202). One way of dealing with these issues is conjoint study development with practitioners from the outset of the project. Such involvement ensures that practitioners’ concerns are listened to and a sense of ownership of the project can be developed.

DVA affects a diverse range of individuals and, as such, it may be assumed that healthcare practitioners may themselves be survivors of DVA. This was illuminated as an ‘unexpected consequence’ of a DVA training programme whereby the DVA nurse specialist was approached by staff who disclosed personal experiences of abuse (McGarry, 2016). As such, researchers also need to be cognisant of the possible personal impact of DVA research to staff who are taking part in the research.

Engaging with survivors of DVA

Within DVA research, the voice of study participants is central to the process of enquiry and may include survivors or perpetrators of abuse, healthcare professionals and specialist agencies providing services. As previously identified, there are a number of approaches to data collection that may be used; however, it is important to consider which approach will be most appropriate for any given situation. For example, the use of focus group discussions may be helpful in addressing issues relating to the asymmetry of power or discomfiture between researcher and participants, especially those who may not feel comfortable in a one-to-one interview (Wilkinson, 1998) or feel they do not have anything valuable to contribute (Kitzinger, 1995). The use of focus groups provides a safe environment for discussion (Owen, 2001) whereby the perspectives of the participants are dominant over the agenda of the researcher (Wilkinson, 1998). However, given the sensitive nature of DVA and the healthcare context, individual interviews (Liebschutz et al., 2008; Trevillion et al., 2012), participant observation (Rollans et al., 2013) or document review (Owen-Smith et al., 2008) have also been used as alternative data collection methods.

Methodical challenges

Within the literature, there has been considerable discussion with regard to what constitutes sensitive research (Sampson et al., 2008). The definition of sensitive research may range from that which is defined as an intrusive topic (Renzetti and Lee, 1993) to an activity with physical and emotional consequences for both researcher and researched and which has serious implications for practice and research (Dickson-Swift et al., 2008). Many of the broader challenges surrounding researching sensitive subjects have been explored in an earlier paper within the context of undertaking nursing research around sensitive issues generally (McGarry, 2010). There are also a number of issues and challenges that are arguably specific to DVA within the context of healthcare. These issues are not only related to participants but to the researchers themselves, and these sub-themes are considered in more detail in the following.

Participants’ safety

In DVA research, the safety of the participant is of paramount importance. One such issue is the potential for so-called ‘double disempowerment’ of DVA survivors during research, ‘first as research subjects and second as part of a stigmatised and marginalised community’ (Malpass et al., 2016: 2). Such risk can potentially be minimised by ensuring ethical issues related to an individual’s capacity to consent, the right to appropriate information about purposes, processes and outcomes of the study, and the provision of enough time and space for individuals to enable them to make an informed decision about their participation are considered. As with all research, practice participants also need to be aware of their rights to privacy, confidentiality, anonymity and their right to refuse to participate or withdraw from the study at any time without any negative consequence. All of this information should be detailed in an information sheet, which (along with a copy of the consent form) is usually given to the participant to keep.

In the context of DVA, however, the potential participant may not feel safe keeping a copy of the information sheet or consent form with them. For example, if a perpetrator accesses the study information or other documents and becomes aware that a DVA survivor is taking part in a study there may be a real risk to personal safety for the survivor. At the same time, the perpetrator may also be very alert and be observing the survivor’s actions. As such, DVA researchers need to consider whether such documents are there to protect the participants or the researchers and institutions (McNutt et al., 2008; Riessman, 2005). One such example is the use of information sheets. The researcher really needs to think clearly about the need, usefulness and potential impact of giving information sheets and copies of consent forms to participants. Asking the potential participants if they feel comfortable in keeping a copy and respecting their preferences may help. Concerns for anonymity and safety are also directly related to the broader aspects of study design. For example, recruitment requires careful consideration in terms of how and where the study will be advertised so that potential study venues or other details are not made widely available or accessible to perpetrators.

Survivors may also feel more comfortable in giving verbal consent to avoid any recognition associated with written consent (Bacchus et al., 2003). In our own practical experience of conducting research, focus group participants have felt more comfortable in signing a group consent sheet or giving verbal consent. The involvement of collaborating practitioners in this regard can be helpful, as the possibility of incorporating consent requirement into existing institutional, routine consent processes can be explored.

DVA research is undoubtedly emotive and personal, and has the potential to bring up emotionally disturbing and painful memories for victims as participants (Davis et al., 2001: 337). Malpass et al. (2016), for example, use the term ‘symbolic violence’ (Bourdieu, 1999) ‘as it relates to the research process itself, something which may arise in any encounter where there is a power imbalance between the researcher and the researched’ and further highlights the need to be cognisant of ‘how we carry out any research with human beings, but particularly with vulnerable populations’ (p. 3). In a recent study that sought to explore narratives of DVA survivorship with older women, the authors worked closely with a specialist DVA agency in the development and execution of the project. This entailed specialist staff from the agency being present during the project workshops and available afterwards in terms of follow-up support for participants.

There is a concern that contributing to DVA research is associated with increased risk of violence if the perpetrators come to know about it. However, it has been suggested that this concern has, to some extent, been based on assumptions, anecdotal evidence (Griffin et al., 2003; Kuyper et al., 2012) or ‘… worst case scenarios of research atrocities’ (Sikweyiya and Jewkes, 2012: 1). On the contrary, such participation can be beneficial and cathartic (Edwards et al., 2009; Sikweyiya and Jewkes, 2012) and may prove empowering (Downes et al., 2014). However, the safety of participants is paramount and we have worked with specialist agencies throughout the research process to ensure that the necessary safeguards are in place. This has included seeking advice and guidance with regard to recruitment and how and where to advertise a study to ensure participants’ safety, for example seeking specialist DVA agency advice as part of the recruitment process, limiting the recruitment literature to identified women’s centres and working alongside specialist DVA workers to ensure that study participants were well supported both during and following research engagement. In a recent study which aimed to explore the experiences of DVA survivors within the context of healthcare encounters, the researchers were requested by participants not to audio-record a focus group. While this presented challenges in terms of traditional research methods and reporting, the researchers argued that to exclude these narratives from subsequent reports further ‘silences’ the voices of survivors (McGarry and Hinsliff-Smith, 2016). In order to resolve this issue, the researchers gathered detailed field notes throughout the focus group, which they were then able to compare and utilise as part of the reporting process.

Researchers’ safety

As previously identified, the intrusive and sensitive nature of DVA research means that it has the potential to bring up emotionally disturbing and painful memories to those involved (Davis et al., 2001: 337). Research participants, however, are not unique to such experiences. There is an increasing recognition that nursing and healthcare research, especially DVA research, is associated with several physical and emotional risks to researchers themselves (Taylor and Bradbury-Jones, 2011). However, the potential impact of DVA research on researchers, has not always been sufficiently accounted for by researchers, and ‘considering how many studies have been conducted on VAW [violence against women] it is remarkable how little has been written about the impact on researchers’ (Fontes, 2004: 168).

Within DVA research, and especially qualitative research, the very nature of engagement with participants or informants necessitates a degree of proximity between the researcher and the researched (McGarry, 2010).

Moreover, other challenges associated with such research have been described as including issues surrounding the maintenance of appropriate boundaries, the development of rapport, developing friendships, physical and emotional safety, managing emotions and leaving the field (leaving the physical site of the research and the process of disengagement with participants) (Dickson-Swift et al., 2007: 328).

Accounts within the wider literature include the actual physical proximity of undertaking research as described by McClennen (2008). In her paper entitled ‘Researching gay and lesbian domestic violence’, one of the key issues of proximity related to the process of ‘immersion’ and the ‘personal and professional costs of being identified with the population under study’ (p. 41), which included the potential impact in terms of being identified personally as being a member of the group in the research. The impact of physical proximity has also been highlighted in terms of issues relating to personal safety by Coles et al. (2014) in their study that explored ‘researcher trauma’ surrounding researching sexual violence.

Proximity, however, may not necessarily be defined in terms of physical proximity and there are implications for all of those involved in the research process, such as data collectors, transcribers, supervisors, readers/viewers of publications and presentations, practitioners and professionals (Downes et al., 2014; Johnson and Clarke, 2003; McCosker et al., 2001). Etherington (2007) also highlights how the process of reflexivity requires researchers to ‘emerge from behind the secure barrier of anonymity’ (p. 611) in terms of presenting their subjective position and dilemmas within the research reporting process, which again involved emotional proximity to the data.

As well as ‘reliving’ narratives there are also issues related to notions of ‘powerlessness’. Researchers are often placed in a position where they are privy to deeply personal accounts of violence, but unlike professionals such as clinicians working in a practice, they did not feel in a position to be able to provide direct support (Coles et al., 2014).

Due to the nature of DVA research, especially qualitative research, it can be difficult to anticipate fully the way in which the research will unfold. This includes possible disclosure beyond the original scope of the study. For example, during a recent study one of the authors of this paper encountered a deeply personal disclosure of historical rape by a participant. This disclosure was unexpected within the context of the discussion. However, the participant felt that this was a safe space to disclose and the researchers were able to offer support and to also ensure that they, as team members, were well supported. This raises clear issues with regard to ensuring that adequate support mechanisms are in place for both participants and researchers. These strategies include recognising the need to build, in time for appropriate debriefing exercises, discussions and reflections in order to support researchers and the research team to manage the emotional and psychological impact of DVA research. This may follow on directly after a focus group for example, but will also be acknowledged as a regular feature of project management. However, it is important to recognise the possible emotional impact of a study at the onset and to ensure that mechanisms are planned and in place to support all members of the research team as a matter of good research practice. While this experience has been considered within the context of ‘researcher safety’, it is also important to recognise and anticipate unexpected disclosure while undertaking DVA research and possible responses. It is also paramount to ensure that the physical safety of participants and researchers is considered as a key facet of the research process, for example, for researchers to be aware of ‘lone worker’ policies within their organisations when conducting interviews in participants’ own homes or other community venues. For participants, ensuring that the venue is safe and is sufficiently anonymous, through considering the recruitment advertising of venues and how this may need to be limited so that perpetrators do not have access to details of events, is also of central importance in terms of safety. In a recent study, for example, we limited the information recorded on a recruitment poster and only disclosed the venue details to participants themselves.

Conclusion and implications for nursing research and practice

DVA is now clearly acknowledged as a significant concern for those working across a range of healthcare settings. As healthcare professionals continue to develop their professional interest and active engagement in DVA research it is crucial to consider some of the key methodological and practical issues that impact on the design and delivery of DVA research for all participants, both researcher and researched. The aim of this paper, therefore, has been to explore in depth some of the key issues and challenges that DVA researchers need to consider when designing and conducting healthcare research, and this includes the dual ethical responsibilities of healthcare professionals both as registered practitioners and as researchers. The areas covered in our study are by no means exhaustive, but are intended to provide a starting point for further consideration and exploration. As highlighted in this paper there are a number of particular challenges for those researching DVA within healthcare contexts, and while these should not be underestimated, neither should they deter the continued pursuit of empirical enquiry around DVA.

Key points for policy, practice and/or research

DVA exerts a significant impact on the health of those who experience abuse and is a national and global concern.

Effective recognition, management and support are now acknowledged as key priorities for healthcare professionals at a policy level.

As DVA research continues to evolve within healthcare it is important that all healthcare professionals are able to recognise the tensions that are inherent in carrying out research in this field.

Consideration of the ethical, practical and methodological challenges to DVA research enables nurses and healthcare researchers to develop research processes that are both rigorous and cognisant of the safety of all participants.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Julie McGarry is Associate Professor within the School of Health Sciences, University of Nottingham, UK. Julie’s clinical background is in adult and mental health fields of nursing practice working with vulnerable adults both in hospital and community settings. Julie’s field of research expertise centres on DVA – her recent work has included exploring narratives of abuse among older survivors, barriers to the recognition of DVA among healthcare professionals and the development of effective health and social care professionals’ working practices with survivors and families. Julie’s work synthesises research, education and practice and she has recently been awarded the title of Senior Fellow of the Higher Education Academy.

Parveen Ali is a Lecturer within the School of Nursing and Midwifery, University of Sheffield. Parveen is a Registered Nurse, Registered Nurse Teacher and a Fellow of the Higher Education Academy. Her research interests include gender-based violence, inequalities in healthcare experiences and health outcomes and nursing education. Parveen has been involved in studies exploring how the preparation and training of healthcare professionals such as doctors, nurses and allied health professionals can contribute to tackling such inequalities and improving patient experience.

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