Family Practice Advance Access published online on February 7, 2007
Family Practice, doi:10.1093/fampra/cmm001
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GPs' perception of their role in the identification and management of family violence
a Department of Women's and Children's Health
b Department of General Practice, Dunedin School of Medicine, PO Box 913, Dunedin, New Zealand. Correspondence to Dawn Miller; Email: dawn.miller{at}otago.ac.nz
Received 6 March 2006; Revised 14 November 2006; Accepted 28 December 2006.
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Abstract |
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Objectives. To examine the following: (1) GPs' perception of their role in identification and management of family violence in New Zealand, possible barriers and how these might be overcome and (2) opinions of GPs regarding the prevalence of family violence in their practices.
Methods. Three focus group (18 participants) discussions were conducted in 2002. Participants were GPs from southern New Zealand urban and rural general practices, Student Health and one medical officer from a provincial hospital. The groups' discussions were audio taped, transcribed, then analysed and coded using qualitative methodology.
Results. Participating GPs thought they were in a good position to identify and manage family violence but estimated prevalence in their practice populations was low. Barriers included perceived difficulty, complexity and stress in dealing with family violence. Lack of time, confidence or experience in dealing with family violence, lack of information and access to referral agencies were also noted. GPs felt powerless when victims would not change their situation. Dealing with the perpetrator was difficult. Training and coordinated support and referral systems could improve GPs' involvement with identification and management of family violence.
Conclusions. The GPs' estimation of family violence prevalence in their practices is low compared to community-based research. Many issues affect the GP in identifying and managing family violence and must be considered in developing guidelines and training, referral systems and support for GPs.
Keywords. Domestic violence, family violence, focus group, GP.
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Introduction |
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Family violence is recognized as a significant health problem. People exposed to family violence are at increased risk of physical, psychological and social problems, including physical injury and death.1,2 The 2000 New Zealand Health Strategy identifies reduction in interpersonal violence as a key health objective.3
There is high incidence of family violence in New Zealand. A study of almost 3000 women who had ever been in a committed relationship and were from randomly selected households in Auckland and north Waikato reported that 33% of the Auckland participants and 39% of the Waikato participants had experienced at least one act of physical or sexual violence by an intimate partner.1 The New Zealand Ministry of Health reports that 4–10% of New Zealand children experience physical violence and up to 18% are sexually abused. Most children are abused by a family member.4 This is a worldwide problem. A World Health Organization study of over 24 000 women from 10 countries of diverse cultural and socio-economic environments reported that the lifetime prevalence of physical or sexual partner violence or both varied from 15% to 71%. Between 4% and 54% of these women had experienced violence from an intimate partner within the previous year.5
Reported rates of violence among women attending general practices are also high. A Melbourne study found that 22% of female patients currently in a relationship had experienced physical abuse from a partner in the previous year, with 10% describing the abuse as severe. Almost 40% of the patients in that study had experienced some form of sexual abuse before the age of 16 years.6 Similarly, a study of 1692 women attending general practices in Ireland reported that 39% had experienced violent behaviour from a partner.7
GPs have the opportunity to identify family violence; however, they often do not enquire about possible abuse. In a London study of 1200 women attending their GP, 41% had ever experienced physical violence from a partner but only 4% had ever been asked by their GP if they had ever been abused by a partner.8 A New Zealand study in 2000 of almost 450 000 computerized consultation records involving 140 000 patients found that only 337 consultations documented a family violence issue.9 GPs report lack of time, fear of offending the patient and inadequate knowledge of referral options as reasons for not asking about family violence.10,11
Often the victim does not readily disclose the abuse. In the Melbourne study of women attending general practices, only 27% of those who had suffered physical abuse as a child or adult and only 9% of those who had experienced sexual abuse chose to disclose this to their doctor.6 Patients may not readily disclose family violence because of shame, of fear of their partner, of confidentiality concerns or they feel they can manage the problem themselves.12
Guidelines and training for New Zealand health professionals in the identification and management of family violence have been developed in recent years.13 However, for these to be effective in general practice, the underlying difficulties that GPs face dealing with family violence need to be understood and strategies developed to support best practice and improve patient care. The present research explores the underlying issues.
For the purposes of our research, family violence is defined as physical, sexual, psychological or emotional abuse of a man, woman or child by a family member. This includes partner abuse, elder abuse and child abuse, including neglect, whether acute, longstanding or historical.
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Methods |
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Three focus group discussions with GPs (18 participants in total) were undertaken between April and October 2002. Existing GP peer support groups in the province of Otago, New Zealand, were purposively selected and focus group discussions conducted in these forums. GP peer groups meet monthly for support, often including discussion around difficult consultations. The group members have usually developed trust in each other and the confidences they share, an advantage for focus group discussions around the sensitive issue of family violence.
The doctors were purposively sampled for this study, with both urban and rural practitioners included, from private practice and Student Health, to give a cross-section of GPs in the local community.
The first focus group included two male and five female GPs. Three doctors were in rural general practice, three were urban GPs and one doctor worked full time at Student Health. Two of the urban GPs also worked part time at Student Health. The second group comprised four rural GPs (two men and two women) and one male hospital medical officer in a small provincial town of 3000 people. The six female participants of the third focus group included five urban GPs and one Student Health doctor. Further demographic information is included in Table 1.
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The first and third focus group discussions were held at the home of a peer group member. The rural focus group was held at the local provincial hospital. All participants received a small contribution towards costs in participating.
Prior to each focus group, participants were reminded of the project protocol for safeguarding confidentiality, and written consent was gained. Each participant was given a copy of the focus group guide (Appendix) to consider prior to the focus group meeting in order to facilitate reflection upon what was considered to be a sensitive topic. This guide was developed from a review of the literature including the Family Violence Intervention Guidelines13 and discussions with other researchers. The facilitators encouraged free-ranging discussion around all the issues that emerged during the focus group meetings. The guide was used to ensure that certain topics were discussed in all focus groups. A phenomenological approach was used where the researchers sought to understand the experiences and perspectives of the participant GPs in dealing with family violence.
All participants were encouraged to contribute and did so readily as these groups were already effectively functioning peer groups of professional colleagues used to discussing sensitive and difficult issues. When discussion slowed, the facilitator paraphrased and summarized issues raised and asked if anyone had any further comments to make. Each focus group discussion lasted for approximately 90 minutes.
The audio tapes of all focus group discussions were transcribed verbatim and reviewed for accuracy prior to their analysis. The transcripts were initially examined and coded independently by the authors, who then met to compare and review their interpretations. Data were organized initially according to a template coding style. Additional categories can emerge and old ones change in this analytical process.14 In this case, the template was concordant with the focus group guide areas of enquiry, the literature and issues of identification and management of family violence previously identified.13 In accordance with qualitative analysis, the transcripts from each group were the initial focus of a holistic analysis. Subsequently, the focus shifted to individuals' contributions and emergent themes were identified. The facilitators (DM and CJ) are experienced in qualitative research including conducting focus groups interviews.
This research was approved by the Otago Ethics Committee.
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Results |
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Demographics
The 18 doctors who participated in focus group discussions ranged in age from 30 to over 60 years old, with 11 doctors aged between 40 and 49 years. Fourteen doctors were New Zealand European, two European but not New Zealanders and two were Asian. They had been practising medicine for between 6 and 37 years, with the average time in practice of 17 years. In all, 12 of the 18 participating doctors had a postgraduate medical qualification. Twelve doctors had previously attended a continuing medical education session on family violence, one had attended a workshop on the topic, one had read the Ministry of Health guidelines on family violence published in 2002 and one had taught medical students on family violence.
Identifying family violence
Participating GPs thought that they were in a good position to identify family violence as they are usually accessible, trusted by patients, deal regularly with patient confidences and provide continuity of patient care. However, most respondents could identify only a small number of their patients, ‘may be five or six (in a practice population of 1500)’, who were affected by family violence, although one GP working at Student Health estimated that up to 50% of her patients had discussed violence and abuse issues.
All the doctors reported that they had considered family violence when patients presented with obvious injuries or cues such as frequent attendances with ongoing symptoms, though the patient may not readily disclose the problem. Some respondents were prepared to ask patients directly if suspicious of family violence and reported that this approach was often well received.
I have been surprised at how well people have reacted to being asked more directly and it's a bit like thinking about are they smoking, ... are they on drugs?
Other doctors felt that just asking about violence and abuse could be painful, potentially abusive for the victim as well as shameful.
However, participants also noted that GPs may not think to ask or chose not to ask about the possibility of family violence because of lack of time, lack of confidence or experience in how to deal with these issues and lack of information on referral agencies.
One focus group discussed the difficulty of acknowledging the possibility of family violence as this would change their view of the particular family.
The reluctance in me to want to believe that there is this violence going on in the family ... one that you thought was safe and good suddenly becomes ugly and bad and destructive ... you are almost in the same situation as the victim in dealing with that.
All groups mentioned that dealing with family violence could raise personal issues about their own experience of such violence.
There has to be support ... it could be the things we hear ... actually stirs stuff up in the GPs who have to deal with it.
The patient's willingness to disclose violence or abuse could be influenced by kinship bonds, the sense of betraying a family member and the victim's fear and guilt. Abuse could also become the cultural norm for a family, especially for children.
[they] just accept what is going on because that is what their lot is and therefore they don't disclose.
Two groups discussed the GP's role in early intervention of family violence.
The mother feels that she could get very angry at the children. Sometimes there has been ... a blow or something that has frightened her ... and said I need some help with this.Is it different if a person says they feel they have the potential to cause violence but they haven't actually done anything ... what options would you provide?
Managing family violence
Many participants described asking about family violence as ‘opening a can of worms’ and managing family violence as ‘walking a tightrope’. They reported feeling powerless when patients acknowledged family violence but would not take any action to change the situation or consider referral. One participant described the challenge of providing support and empowerment for victims of family violence. For example, it was tempting to pressure the victim to make changes out of concern for the patient's health and safety but this could make the situation worse. The patient could remain at risk and the GP had to live with that concern.
... She had a black eye and she told me that her husband had hit her ... . she just didn't want to make any changes, I probably pushed her quite hard because I was concerned about her safety ... she didn't come back to me for about three years ... it told me that she felt threatened by the stance I had taken which was very proactive for her health and safety but it didn't meet where she was at, ... you are then left in the situation of harm that you are powerless to intervene ...Other doctors reported similar experiences:
If you turn them away the minute you are suspicious of something, where do they go, what happens, are the kids then even less protected ... or is the wife less protected?
Participants were concerned at ‘messing up’, making the situation worse, and a previous bad experience in dealing with family violence could deter the doctor from getting involved again.
This child was being abused by the mother ... I did something about that ... it all back fired ... that experience of things going wrong puts you off as well.
The victim's family could also compound the abuse leaving the GP and others powerless.
[the] girl had been belted by her brother ... we called in the police ... with the girl's consent, she wanted that ..., then the family persuaded her that she was at fault and that the brother (wouldn't be able to go overseas as planned if she laid a complaint) .... so the police were totally frustrated and unable to do anything.
When the perpetrator is a patient
Dealing with the perpetrator as a patient was particularly difficult at times, especially when the GP had responsibility for his/her ongoing care.
There is violence towards kids ... you think this is horrible, this is terrible, how can this person do that, but I have still got to look after this person ... and if I don't, he will go to the Medical Council.
One GP had found it difficult to extricate himself from caring for the perpetrator.
This woman who tried to run her husband over in the car ... I said I don't think I am the right person here—you might need to talk to someone else and she just hit the roof.
All groups discussed issues involved in dealing with both the victim and perpetrator as patients. Sometimes it was helpful knowing others involved, but most doctors found this situation difficult. Confidentiality was also an issue:
How do you bring it up? [discussing family violence with the perpetrator] I mean it is easy enough if you have got the broken knuckle from the injury but if you know that the wife has complained that something has been happening or been to see you earlier in the week, well you can't.
There was also concern for the partner's safety if raising the issue of violence with the perpetrator.
Doctors in all groups talked of being at risk themselves because of the stress involved in dealing with the perpetrators of violence, including family violence.
I have had murderers I have examined for the police. After one of them I crashed my car on the way home, I just lost it.Or the perpetrator can manipulate the situation.
... we get sucked into that ... this person is actually very nice, I can't believe he is going to do that ...
Improving management of family violence
All groups felt that working and communicating well as a team, with the GPs, practice nurses and receptionists within their own practice and with public health nurses, teachers, police and other agencies, was very important in the identification and management of family violence. However, experience of this was variable. All groups had limited knowledge of agencies in the community and the services they offered. The rural group had a good community-based team but referral options were limited.
Delays in the patient being seen after referral to an agency were frustrating. One group discussed the difficulty in entrusting care of their patient who was a victim of family violence to an agency because they often then lost contact with that person, were not included in ongoing care and did not have ongoing communication with the agency about progress.
There was also concern that the agencies could have an aggressive approach to the problems, and the victims were not always in a position to be assertive in getting across their wishes in the process.
One group suggested the establishment of a community-based group, not linked to any particular agency, who could be contacted by GPs for advice and support on family violence-related issues. They felt that GPs could be more enthusiastic about getting involved in the identification and management of family violence if there was a coordinated referral system with well-established infrastructure and good communication systems. This would need to include appropriate, free and accessible services required for ongoing support and management of victims and perpetrators.
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Discussion |
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GPs in this study felt that they were in a good position to identify family violence as they are accessible, trusted and provide continuity of patient care. The community, the patients and the policymakers recognize this.3,15
The prevalence of family violence in the community1 and among patients attending general practice is high.6 Fanslow and Robinson1 also showed that victims of partner abuse were two times more likely than those not abused to have attended a health care provider in the previous 4 weeks. This indicates that victims of family violence are presenting to their GPs.
Despite the above findings, our participants estimated that the prevalence of family violence in their practices was small. This is consistent with findings in UK-based research8 and supported by the New Zealand study showing low documentation rates of family violence issues in general practice consultation records.9 Interestingly in the present research, a Student Health doctor reported a high number of violence-related consultations, perhaps indicating a particularly at risk community or patients who disclose these issues more readily. This suggests that further study of the tertiary student community is warranted.
While there is currently a lack of evidence on the benefit of screening for family violence,16 there is strong evidence about the risks of physical, psychological and social problems for people exposed to family violence.1,2 Health professionals such as GPs are in a good position to identify patients at risk so why are they not identifying them?
The impact that dealing with family violence had on the doctor, both personally and professionally, was raised repeatedly in all focus groups. Family violence issues were described as very difficult, complex and time consuming, and respondents felt powerless and fearful for their patients' safety when patients would not disclose obvious abuse.11 Gerbert17 identifies physicians’ ‘burnout' due to lack of disclosure as a barrier to identification of family violence. The doctor can give up asking in the face of the patient's reluctance to disclose.
Our participants were also fearful that raising the possibility of family violence may have negative repercussions; in particular, that it may cause offence, pain or shame to the patient or exacerbate the abuse. Similar sentiments were expressed in Sugg's11 study of American family physicians. The 2002 Irish study of over 1800 women attending general practices found that 77% were in favour of routine enquiry about family violence.7 However, a 2006 English study of three different health care settings, including general practice, found that while the acceptability of routine enquiry about family violence was high, it was reduced significantly among those women who had been abused within the previous year.18 This may be a reason to enquire about family violence.
GPs in our study also had difficulty in acknowledging the possibility of family violence in a family they had always considered good and safe. Sugg11 found that where the physician was of a similar background to the patient the possibility of family violence was difficult for the doctor to consider. The doctor can get drawn into the deceit, the unwillingness to disclose.
The doctors may have personal issues related to family violence which could affect their willingness to get involved. In Sugg's11 study of 38 physicians, 14% of male doctors and 31% of female doctors had a personal history of child abuse or physical violence with an intimate partner. Appropriate support for the doctor in both training and clinical practice needs to be readily available. This could include support from practice colleagues, peer groups and regular organized supervision.
Respondents also felt powerless and fearful for their patients' safety when patients would not make any changes when violence had been identified or when other family members stepped in to defend the perpetrator. They described the difficult and stressful path as 'walking a tightrope' in supporting and empowering the patients while resisting the temptation to direct, even when concerned for the patients' safety. Other studies reported similar findings.11,17,19 A previous bad experience in dealing with family violence could deter a GP from getting involved again. Rather than expecting to fix the problem, Gerbert17 suggests that asking a patient about abuse is in itself a successful consultation, giving the message that abuse is wrong and that the doctor cares. Sugg11 suggests that GP education programmes on family violence should discourage the ‘fix it’ approach. The time course for change is often prolonged.
Participants in our study were also fearful that their intervention could make the patients' situation worse.
Most doctors found dealing with the perpetrator as a patient difficult at times. Some found that adverse feelings towards this patient could compromise the doctor–patient relationship, but the GP was still responsible for the patient's ongoing medical care. The GPs in Taft's19 study had similar experiences. However, GPs in our study commented that if they tried to extricate themselves from caring for a patient, the patient was not always willing to let go. GPs can be at risk of being drawn into the power dynamics of the violence. The participant doctor's fear of a violent patient, or of the violent partner of a patient, was also expressed in Brown's study.10 Midwives had similar fears about irate partners, and the underlying power dynamics, when asking pregnant women about family violence.20
Our study highlights the challenges a GP faces in having both the victim and the perpetrator as patients, including the confidentiality issues that can ensue.
The doctors in our study felt it was important to work as part of a team in both the identification and management of family violence. They worked well with other professionals in their practices and the community but had limited knowledge about referral agencies and how to access them. Some GPs lacked confidence in the agencies available for referral, especially if the doctor had an adverse experience with a particular group. Taft19 also found that GPs were not familiar with or were distrustful of agencies, and this could lead to the GPs being reluctant to identify family violence. Information on agencies is now included in New Zealand general practice guidelines, and training in family violence will often include meeting with agency representatives.
Improvement in the relationship between GPs and referral agencies, development of better communication systems and keeping everyone informed of progress could help in establishing a more coordinated team approach to dealing with family violence. The suggestion of a neutral coordinating group to support and advise all involved in this process could help with coordination. According to the doctors in our study, GPs may be more enthusiastic about identifying family violence if such a support service was available.
Most participants in our focus group discussions had some training in the identification and management of family violence. However, they still raised many issues and had significant difficulties in this area. Initial and ongoing training and support is important if GPs are to deal effectively with the many issues that can arise with family violence.
The limitations to this study include the number of focus group participants, 13 of the 18 participants were women and all participant doctors practised in Otago, New Zealand, which has a predominantly European population. The number of women participants reflects the composition of the peer groups recruited, not a wider demographic trend. It is not possible to generalize the findings to all New Zealand GPs. The important issues identified in this study suggest the need for a larger study that achieves saturation of themes and explores identified issues further.
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Conclusions |
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The GPs in this study thought that they were in a good position to identify family violence; however, the rate of identification in their general practices is low. Dealing with family violence can be very difficult, complex and stressful. This can deter a GP from getting involved. Consideration of these issues should be included in the training, guidelines and ongoing support for GPs in dealing with family violence. A well-coordinated system of referral and support could encourage GPs to get more involved in the identification and management of family violence.
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Declaration |
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Funding: None.
Ethical approval: None.
Conflicts of interest: None.
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Appendix |
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Focus group questions
- Identification issues
- What factors facilitate identification and support of victims of family violence by GPs?
- What are the barriers to identification and support of victims of family violence?
- When should GPs ask patients about family violence? Should this be included routinely as part of a screening-related consultation?
- What is the possible impact for GPs dealing with family violence? Does this affect identification and management of family violence?
- What is the role of the practice nurse in identification and support of victims of family violence?
- What are the barriers to identification and support of victims of family violence?
- What factors facilitate identification and support of victims of family violence by GPs?
- Documentation issues
- Why ‘do’ GPs document details of family violence?
- Why do GPs ‘not’ document details of family violence?
- How often would you decide not to document details of family violence?
- Why do GPs ‘not’ document details of family violence?
- Why ‘do’ GPs document details of family violence?
- Prevalence
- What is your perception/estimation of the prevalence of family violence in your practice?
- What is your perception/estimation of the prevalence of family violence in your practice?
- Suggestions for improvement
- How could identification and support of victims of family violence by GPs be improved?
- Would guidelines and specific training on dealing with identification and management of family violence improve clinical practice related to family violence?
- Would guidelines and specific training on dealing with identification and management of family violence improve clinical practice related to family violence?
- How could identification and support of victims of family violence by GPs be improved?
- The perpetrator
- Much of the emphasis is on dealing with the victims of family violence.
- What is the role of the GP in dealing with the perpetrator?
- What is the role of the GP in dealing with the perpetrator?
- Much of the emphasis is on dealing with the victims of family violence.
- Overall
- Is general practice the right place to deal with family violence?
- What role should general practice play in the identification, referral and management of victims of family violence?
- Should there be mandatory reporting of family violence?
- What role should general practice play in the identification, referral and management of victims of family violence?
- Is general practice the right place to deal with family violence?
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Acknowledgments |
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The authors wish to thank all the doctors who participated in the focus group discussions and Roz McKecknie for transcribing the audio tapes. This research was funded by the Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
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Notes |
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Miller D and Jaye C. GPs' perception of their role in the identification and management of family violence. Family Practice 2007; Pages 1–7 of 7.
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References |
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17 Gerbert B, Caspers N, Bronstone A, Moe J, Abercrombie P. (1999) A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med 131:578–584.
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20 Mezey G, Bacchus L, Haworth A, Bewley S. (2003) Midwives’ perceptions and experiences of routine enquiry for domestic violence. Br J Obstet Gynecol 110:744–752.
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