How family doctors perceived their ‘readiness’ and ‘preparedness’ to identify and respond to intimate partner abuse: a qualitative study

How family doctors perceived their ‘readiness’ and ‘preparedness’ to identify and respond... Abstract Background There are few existing studies which have investigated the meanings of ‘readiness’ and ‘preparedness’ among family doctors working with female patients who experience intimate partner abuse (IPA). Objectives We aimed to explore how doctors perceived the concepts of readiness and preparedness to identify and respond to IPA against female patients. Methods We adopted purposive sampling and conducted individual semi-structured interviews with 19 doctors (11 females and 8 males) practising in primary care. Thematic analysis identified dominant and associated themes, and the coding framework was transformed into a thematic map. We further applied cross-coding and code-confirming procedures in analysing the transcripts. Results Participants described differences in the meanings of readiness and preparedness when responding to IPA, though they considered that these two concepts were inter-related. The findings revealed four themes of doctors’ perceived ‘readiness’ to identify and respond to IPA: self-efficacy, emotional readiness, motivational readiness and attitudinal readiness, whereas doctors’ perceived ‘preparedness’ comprise two themes: IPA knowledge and communication skills. Conclusion Whether doctors are ready to identify and respond to IPA might be influenced by their emotional concerns as well as individual motivational beliefs and values, in addition to their attitudes and perceived self-efficacy, revealing a multidimensional concept. Besides enhancing doctors’ preparedness by means of IPA knowledge and communication skills, training and IPA research could address further their emotional readiness and legitimize doctors’ role to intervene in IPA cases. Family doctors, intimate partner abuse, perceived preparedness, perceived readiness Introduction In view of the high prevalence and serious consequences of intimate partner abuse (IPA), family doctors are often the first health professionals victims seek help from and disclose abuse to (1). Thus, doctors are in a prime position to identify and respond to IPA against women. Literature on doctors’ perceived barriers and facilitators of IPA disclosure and inquiry (2–7) suggests that research must be directed at identifying a distinct construct, for instance, perceived readiness, which may help to explain varying responses by doctors when responding to IPA. Indeed, the concept of ‘readiness’ has been broadly discussed when considering action taken by IPA victims in response to their experiences of abuse (8,9), whereas research on how doctors perceive their readiness to deal with IPA is comparatively lacking. The concept of ‘readiness’ has been described as a positive force that may motivate people to make positive changes (10,11). While the term ‘readiness’ was first used in a scale measuring doctors’ readiness to manage IPA (12), in that study, no conceptual definitions of readiness were provided and perceived preparedness emerged as a subscale. There are no agreed theoretical foundations for defining what constitutes ‘readiness’ or ‘preparedness’, resulting in some conceptual ambiguities. Indeed, some studies have used the term ‘preparedness’ (13–16), but without a clear conceptual framework. It remains unknown if ‘readiness’ and ‘preparedness’ are mutually inclusive in content properties, or whether they are distinct constructs in the context of doctors’ responses to IPA. Owing to the lack of well-defined content properties, these two terms have been used interchangeably, for example, in the work conducted by Gutmanis et al. (17), ‘feel ready’ and ‘feel prepared’ implied similar meanings. Similarly, no prior research has investigated whether doctors differentiate between the two when considering responses to patient reports of IPA. Establishing a clear conceptualization of each concept is therefore needed so as to enable valid and reliable measurements of their underlying characteristics. In light of these issues, we conducted an interview study exploring how doctors’ perceive their ‘readiness’ and their ‘preparedness’ to identify and respond to IPA. Methods Study design This qualitative study was part of a PhD project which adopted an exploratory sequential mixed-method research design (18), aiming to explore and validate doctors’ perceived readiness to identify and respond to IPA as a new and distinct construct towards scale development (19). As shown in Figure 1, we recruited a purposive sample (20) of doctors who had participated in a randomized controlled trial (WEAVE) which evaluated the effectiveness of a brief counselling intervention delivered by trained doctors (intervention group) on abused women’s safety planning, mental health and quality of life (21). The WEAVE comparison group received basic educational materials for safe practice in seeing abused women (21). The decision to recruit from the existing research sample was not merely based on convenience. We believed that recruiting doctors who were in both the intervention and comparison arms of WEAVE would result in a diversity of clinical experience in dealing with IPA enabling conceptual generalizations to be drawn. Figure 1. View largeDownload slide Recruitment of doctors for individual semi-structured interviews. Figure 1. View largeDownload slide Recruitment of doctors for individual semi-structured interviews. Data collection and analysis Between December 2012 and February 2013, a semi-structured interview schedule was reviewed by an expert panel (consisting of three research supervisors and two qualitative academic researchers), pilot-tested and subsequently refined. The interview schedule elicited doctors’ views on their readiness and preparedness to identify and respond to IPA by reflecting on their clinical experience in IPA disclosure and identification (Box 1). From March to September 2013, we sent an invitation letter to 45 WEAVE doctors who agreed to participate in this study, along with a plain language statement and a consent form by email and post; with follow-up phone calls and emails to nonresponders. Interviews were conducted with 19 GPs as it was felt that no new significant themes emerged from interviews after this point. Therefore, data collection was ceased as per guidelines for conducting qualitative studies (22). All interviews were conducted with participants individually, were audio-recorded and transcribed (Supplementary File). The average duration of the interviews was 48 minutes (range 24–68 minutes). A thematic analysis approach was adopted: the first researcher (TL) hand-coded printed transcripts into dominant (organizing) themes and associated (basic) themes (23,24), followed by data entry into NVivo software program (QSR International Pty Ltd.—Version 10). TL also used jotted notes, memos and content summaries in data analysis. We further undertook cross-coding and code-confirming procedures, in that research supervisors (CB and KH) independently coded four transcripts and critically scrutinized the thematic coding framework. High consistency in data coding was achieved. To affirm the data authenticity, we undertook ‘respondent validation’ (25) whereby the majority of participants had confirmed the accuracy of the transcript. Box 1. Interview schedule What has it been like seeing female patients who report being abused by their partner? (an ice-breaker) When you suspected that your female patients may have experienced partner abuse, how have you dealt with that? How have you responded when your female patients tell you about abuse? In your clinical experience, what does the term ‘readiness’ mean to you when dealing with partner abuse issues? Can you recall any cases in which you felt ‘being ready’ (or ‘not being ready’) to deal with partner abuse issues? Are ‘being ready’ and ‘being prepared’ the same thing to you? (If not, what are the differences? Could you elaborate further?) What kind of thoughts have come to mind when seeing a woman who has been abused by her partner? How does it feel seeing a female patient who presents with partner abuse? How do you cope with those (negative) feelings? Results Demographics Participants were 11 females and eight males (Fig. 1) who had been Australian family doctors for between 5 and 35 years, with an average of 19.5 years. Their average age was 48 years (range 34–61 years old), which was same as the mean age of the WEAVE sample. Meanings of ‘readiness’ and ‘preparedness’ when responding to IPA The majority of the participants clearly differentiated between the terms ‘readiness’ and ‘preparedness’; only two participants thought that these terms had more or less the same meaning. Most of the participants described doctors’ ‘readiness’ as accepting what might happen in a consultation that could be unpredictable and affected by their attitudes, beliefs, thoughts and feelings. ‘Preparedness’, on the other hand, was defined as having consultation plans, the knowledge, resources and skills to deal with IPA. Being ready is just being able to accept what comes. Being prepared is knowing what’s going to come and having a plan. (Intervention 17, Michelle, female) Readiness is an emotional response. It’s got nothing to do with how much you know [being prepared]. (Intervention 06, Sam, male) Readiness might be a more dynamic, in the moment capacity … Preparedness has got more to do with, perhaps training. (Intervention 14, John, male) I think prepared means having your resources…having the right preparation means the right resources and management strategies;…emotionally ready means…being ready to allow the patient to open up, to give them the time to talk rather than rushing the consultation. (Comparison 45, Johnny, male) Some participants further described how these terms are related. I would be prepared, but mentally, I may not be ready. (Comparison 36, Alice, female) I think once you’re ready you have to do the steps to make sure you’re prepared. (Comparison 08, Mary, female) Our findings revealed that doctors’ perceived readiness to identify and respond to IPA comprises four dominant themes (derived from 12 associated themes and 34 codes): self-efficacy, emotional readiness, motivational readiness, and attitudinal readiness. ‘IPA knowledge’ and ‘communication skills’, derived from 8 associated themes and 23 codes, represent two underlying concepts characterizing doctors’ preparedness to identify and respond to IPA (Figs. 2 and 3). It should be noted that there were no marked differences in participants’ views of ‘readiness’ and ‘preparedness’ based on age, gender, years of practice, or training received in the WEAVE trial. Figure 2. View largeDownload slide Thematic map for doctors’ perceived readiness to identify and respond to intimate partner abuse. Figure 2. View largeDownload slide Thematic map for doctors’ perceived readiness to identify and respond to intimate partner abuse. Figure 3. View largeDownload slide Thematic map for doctors’ perceived preparedness to identify and respond to intimate partner abuse. Figure 3. View largeDownload slide Thematic map for doctors’ perceived preparedness to identify and respond to intimate partner abuse. Doctors’ perceived readiness to identify and respond to IPA Self-efficacy Most of the participants perceived themselves to be able to identify and respond to IPA, and reported feeling confident in making clinical judgements on safety issues, as well as eliciting support from colleagues and other health clinicians. I think it [readiness] means that I am, most of the time, alert and I look at the patient as a whole person, rather than just a complaint that they present with. Especially if it’s the women who present frequently, or there are issues with raising children or kids, or even if they didn’t have kids … So it’s to try and give it my best shot to the consultation and to try to pick things. (Comparison 52, Kate, female) If they disclose abuse then I’m confident in my clinical skills, my access to resources, to at least assist that woman to take some steps in so far as she’s able. (Comparison 08, Mary, female) Emotional readiness Many participants stated that they need to be emotionally ready in terms of feeling comfortable to discuss IPA and respond to IPA disclosure, accepting limits of their professional roles, identifying own emotional responses and safeguarding their emotional well-being. The ability to actually feel comfortable asking the question is really important. (Intervention 09, Morgan, female) You can’t do this job if you think you have to ‘save’ everyone; I don’t blur the line between support and fixing. (Comparison 10, Dr X, male) I can support them [IPA victims] along their journey to fix things but I can’t do it for them. (Intervention 17, Michelle, female) You provide care for all, but you also need to be strong enough in yourself, not to be damaged by providing support for the others. That’s where in terms of being emotionally ready is in terms of looking after myself. (Comparison 26, Margaret, female) Motivational readiness The majority of participants emphasized that they would be there for patients experiencing IPA and point out that IPA is a violation of human rights. I think the readiness comes from an understanding that, even during difficult days, if the patient’s courageous enough to disclose this as a problem, that you really do have to be prepared, ready to understand that this patient is in need right now and there may not be another opportunity … you just have to put everything else on hold and be there for the patient. (Intervention 55, James, male) I think my role as a GP is sometimes to say, ‘look, it sounds like what you’re experiencing—I would think that that’s domestic violence or I would think that that is not acceptable behaviour’. (Comparison 08, Mary, female) Attitudinal readiness There was a broad agreement among the participants that having an open-mind and not being judgmental were crucial for being ready to identify and respond to IPA. If we’re picking up a vibe, maybe being open to it rather than putting it away and ignoring. (Intervention 24, Steven, male) You’re not going to be critical or think less of them [IPA victims] or tell them what to do. (Intervention 37, Louise, female) One participant pointed out that, while doctors should not judge but respect patients’ choices in resolving IPA issues, they should be able to ‘judge’ what abusive behaviours are. That being non-judgmental doesn’t mean that there are no absolute right and wrongs … In particular, behaviours that result in intimidation or physical abuse in the home and so on. That the individual has a right to exist in their own right. (Intervention 14, John, male) Doctors’ perceived preparedness to identify and respond to IPA IPA knowledge Most of the participants demonstrated good knowledge of IPA issues, including its nature and health consequences, women’s readiness to deal with IPA, doctors’ roles to intervene, patient confidentiality issues as well as direct or indirect approaches to ask about IPA. I think you have to be guided by where the woman is and what she’s ready for. Is she really not ready to even acknowledge it or does she acknowledge it but she doesn’t want to do anything or is she getting ready to do something, and you give her different support and different help according to where she is along that road…. (Intervention 29, Marie, female) One interesting finding in relation to making sensitive inquiry was participants’ different views on asking regular patients (whom they have known for some time) and new patients about IPA. Some participants reported that they would ask about IPA in all suspicious cases, whereas a few participants stated that they would react differently to regular patients and new patients. When you know the patient already trusts you and you know a lot of their background already, it’s easier to be able to tackle that, I think. Sometimes when it presents as a new person and you don’t know their background…new people are more challenging. (Comparison 28, Jenny, female) Some women seen once—it’s almost like if you raise it [IPA] as a possibility, then that’s enough to actually allow them to start telling what’s been going on. (Comparison 36, Alice, female) Communication skills The majority of participants emphasized the significance of having good communication skills to work with IPA victims, such as rapport-building (understanding and trust), active and empathic listening, as well as validation of victims’ experience and feelings. Good communication skills resulted in ‘making a connection’ with patients. It’s all about being human, having a human interaction rather than just being clinical and academic so someone feels that you’ve got that rapport, some empathy, some warmth … every relationship in general practice, there’s got to be a warmth and a communication…. (Intervention 05, Rob, male) …to engage with them [IPA victims], so they feel that they can come back and maintain a connection with you. (Comparison 56, Sally, female) So, using mirroring and validation becomes very important to make sure that you are accessing the information in the way that they’re giving it to you, just making sure that it’s really clear. But that also reinforces for them that they can talk to you…. (Intervention 09, Morgan, female) Discussion Our study is the first to provide both a definition of doctors’ perceived readiness to identify and respond to IPA (which is different from perceived preparedness) and thematic maps for defining what constitutes ‘readiness’ or ‘preparedness’ (Figs. 2 and 3). The term readiness used by Short et al. (12) in a survey tool did not provide a conceptual framework. The sample in this study described doctors’ readiness as dealing with the moment in a consultation which involves factors relating to doctors’ attitude, beliefs, thoughts and feelings. Based on the findings, ‘readiness’ is conceptualized as ‘a psychological state that indicates the extent to which an individual is cognitively, motivationally, and emotionally inclined to embrace and respond to a phenomenon’. On the other hand, ‘preparedness’ refers to having adequate IPA knowledge and good communication skills. These two aspects have been broadly discussed in the existing IPA literature (2,4,7,8). Consistent with Gerbert and colleagues’ findings of direct and indirect approaches asking about IPA, doctors in this study reported making sensitive inquiry depending on female patients’ readiness and their understandings of the patients. Different views on asking regular patients and new patients suggest that elements in good therapeutic relationship, for instance, rapport-building, can be a facilitator for IPA disclosure and identification. As discussed below, doctors’ perceived readiness to identify and respond to IPA comprises four themes (self-efficacy, emotional readiness, motivational readiness, and attitudinal readiness). These findings have warranted the development and validation of a new multidimensional scale in a mixed-method research study (19). Age, gender, years of practice, and previous IPA training did not appear to unduly influence the participants’ responses. The doctors in this study reported perceived ‘self-efficacy’, feeling confident in identifying IPA, making clinical judgments on safety issues, as well as eliciting support from colleagues and other health clinicians. The findings are consistent with Bandura’s self-efficacy concept, doctors’ perceived self-efficacy may have been enhanced through direct experience of managing IPA (performance accomplishments), as well as vicarious experience and verbal persuasion from others (26), that is evident among the participants in the intervention group. Miller and Jaye’s study highlighted the benefits of working as part of a multidisciplinary team in IPA management (4). This further underscores the significance of experiential learning (‘learning by doing’) (27,28) in training contexts and continuous professional development (29). Future research could explore to what extent different types of clinical experience relate to doctors’ self-efficacy toward forming a causal mechanism which could explain doctors’ perceived readiness to identify and respond to IPA. Our study described how doctors perceived their ‘emotional readiness’ to deal with IPA, which is a novel finding in the literature. The participants raised their concerns about the potential impacts arising from dealing with IPA in both personal and professional aspects. Vicarious traumatization, burnout, and compassion fatigue have been widely reported in the literature (30,31). The doctors in this study discussed the importance of identifying own emotional responses and acknowledging their roles which are not to ‘fix’ the problem. Appropriate emotional support for doctors in both training and clinical practice, by means of regular supervision, ongoing peer support or mentoring, needs to be considered. With respect to ‘attitudinal readiness’, some previous studies showed that doctors held negative or stereotypical views of IPA victims (2,6), whereas a recent study by Kohler et al. (32) revealed doctors’ openness to address IPA. Doctors in our study reported, not just being nonjudgmental, but also having a commitment to caring patients as fellow human beings (‘motivational readiness’). Participants expressed their views on IPA and humanity, placing a high value on ‘being there for the patient’, which is similar to Miller and Jaye’s findings of doctors’ willingness to provide continuity of care to patients (4). Motivational readiness being a novel finding added to the existing knowledge by giving a reason to ask patients about IPA (that is, IPA is a violation of human rights) and legitimizing the roles of doctors to identify and respond to IPA. The strength of our study is the use of purposive sampling which allowed us to explore the perspectives of doctors who had different amount of clinical experience in seeing IPA victims as well as different levels of training in addressing the needs of these patients. This study further uncovered the underlying characteristics of doctors’ perceived readiness (and perceived preparedness) to identify and respond to IPA as a unique construct for future research. The themes revealed in this research have contributed to the development of a scale to measure doctor perceived ‘readiness’ to respond to patient reports of IPA (19). Several limitations to this study should be cited. First, participants were recruited from an existing IPA study (21) and this may have inevitably introduced particular responses. The inclusion of those who were not involved in IPA research might have led to different findings. Second, the findings drawn from our study may not generalize both to doctors working in health care settings differ from primary care or to the whole population of Australian family doctors. The dominant themes identified in this study suggest the need for a larger study to investigate the phenomenon of doctors’ perceived readiness (and preparedness) to deal with IPA. Third, owing to the qualitative nature of this study, participants’ perspectives on their readiness (and preparedness) to identify and respond to IPA could not be verified as actual clinical practice. Additional research, such as, conducting patient interviews or observation of clinical consultations, could corroborate the current findings. Last, no member checking other than respondent validation (25) was employed in our study. Conclusion This study revealed that doctors’ perceived readiness to identify and respond to IPA is a multidimensional construct which is different from an interrelated concept of preparedness. These findings enhance existing knowledge about doctors’ responses towards IPA victimization by providing an operational definition and well-defined content properties of doctors’ perceived readiness to identify and respond to IPA. In particular, the themes ‘motivational readiness’ and ‘emotional readiness’ uncovered by this study are the most interesting and striking findings which have not been evident as unique concepts in the IPA literature. Our findings highlighted the significance of incorporating doctors’ motivational and emotional factors in training interventions and IPA research. Besides enhancing doctors’ ‘preparedness’ by means of increasing their IPA knowledge and improving their communication skills, well-tailored training and IPA protocols could emphasize motivational beliefs and values in the way that IPA is a violation of human rights and doctors have legitimate roles to intervene in IPA cases. Furthermore, doctors’ emotional concerns about being vicariously traumatized and their emotional needs for self-care when dealing with IPA issues should be addressed. Supplementary material Supplementary data are available at Family Practice online. Acknowledgements The authors wish to thank all the family doctors who took the time to participate in this study. Declaration Funding: none. Ethical approval: this study was undertaken by Traci Po-Yan Leung as part of her PhD project in the Melbourne School of Psychological Sciences at the University of Melbourne Health Sciences with the approval of Human Ethics Sub-Committee (HREC no. 0824166.10 and 1339631.1). Conflict of interest: none. References 1. Garcia-Moreno C , Hegarty K , Lucas d’Oliveira AF , et al. The health-systems response to violence against women . Lancet 2014 ; 385 : 1567 – 79 . Google Scholar CrossRef Search ADS PubMed 2. Hamberger LK , Patel D. Why Healthcare Professionals Are Reluctant to Intervene in Cases of Ongoing Domestic Abuse . Washington, DC : American Psychological Association , 2004 . 3. Sugg NK , Inui T . Primary care physicians response to domestic violence—opening pandora box . JAMA 1992 ; 267 : 3157 – 60 . Google Scholar CrossRef Search ADS PubMed 4. Miller D , Jaye C . GPs’ perception of their role in the identification and management of family violence . Fam Pract 2007 ; 24 : 95 – 101 . Google Scholar CrossRef Search ADS PubMed 5. Taft AJ , Broom DH , Legge D . General practitioner management of intimate partner abuse and the whole family: qualitative study . Br Med J 2004 ; 328 : 618 – 21 . Google Scholar CrossRef Search ADS 6. Wong SLF , De Jonge A , Wester F , et al. Discussing partner abuse: Does doctor’s gender really matter ? Fam Pract 2006 ; 23 : 578 – 86 . Google Scholar CrossRef Search ADS PubMed 7. Feder G , Ramsay J , Dunne D , et al. How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria . Health Technol Assess 2009 ; 13 : iii – iv , xi-xiii, 1–113, 137–347 . Google Scholar CrossRef Search ADS PubMed 8. Hegarty K , O’Doherty LJ , Gunn J , et al. A brief counselling intervention by health professionals utilising the ‘readiness to change’ concept for women experiencing intimate partner abuse: the weave project . J Fam Stud 2008 ; 14 : 376 – 88 . Google Scholar CrossRef Search ADS 9. Humphreys C , Thiara RK , Skamballis A . Readiness to change: mother–child relationship and domestic violence intervention . 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Research Design: Qualitative, Quantitative, and Mixed Method Approaches . 4th edn , international student edition . Thousand Oaks, CA : SAGE Publications, Inc ., 2014 . 19. Leung PYT , Bryant C , Phillips L , et al. General practitioners’ perceived readiness to identify and respond to intimate partner abuse: development and preliminary validation of the multidimensional scale . Aust N Z J Public Health 2017 ; 41 : 512 – 7 . Google Scholar CrossRef Search ADS PubMed 20. Patton MQ. Qualitative Research & Evaluation Methods . 3rd edn . Thousand Oaks, CA : Sage Publications , 2002 . 21. Hegarty K , Gunn JM , O’Doherty LJ , et al. Women’s evaluation of abuse and violence care in general practice: a cluster randomised controlled trial (weave) . BMC Public Health 2010 ; 10 : 1 – 11 . Google Scholar CrossRef Search ADS PubMed 22. Gibbs GR. Analysing Qualitative Data . Los Angeles, CA/London : Sage Publications , 2007 . Google Scholar CrossRef Search ADS 23. Boyatzis RE. 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New clinical and policy guidelines launched to guide health sector response . 2013 ; http://www.who.int/mediacentre/news/releases/2013/violence_against_women_20130620/en/ ( accessed on 2 December 2014 ). 30. Gerbert B , Caspers N , Bronstone A , et al. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims . Ann Intern Med 1999 ; 131 : 578 – 84 . Google Scholar CrossRef Search ADS PubMed 31. Wahlen SD . Secondary victimization: among learnear of violence issues . In Hamberger LK , Burge SK , Graham AV , Costa AJ (eds). Violence Issues for Health Care Educators and Providers . New York : Haworth Maltreatment & Trauma Press , 1997 : 307 – 19 . 32. Kohler S , Hohne A , Ehrhardt M , et al. General practitioners and managing domestic violence: results of a qualitative study in Germany . J Forensic Leg Med 2013 ; 20 : 732 – 5 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2017. Published by Oxford University Press. 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How family doctors perceived their ‘readiness’ and ‘preparedness’ to identify and respond to intimate partner abuse: a qualitative study

Family Practice , Volume Advance Article (4) – Dec 28, 2017

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Abstract Background There are few existing studies which have investigated the meanings of ‘readiness’ and ‘preparedness’ among family doctors working with female patients who experience intimate partner abuse (IPA). Objectives We aimed to explore how doctors perceived the concepts of readiness and preparedness to identify and respond to IPA against female patients. Methods We adopted purposive sampling and conducted individual semi-structured interviews with 19 doctors (11 females and 8 males) practising in primary care. Thematic analysis identified dominant and associated themes, and the coding framework was transformed into a thematic map. We further applied cross-coding and code-confirming procedures in analysing the transcripts. Results Participants described differences in the meanings of readiness and preparedness when responding to IPA, though they considered that these two concepts were inter-related. The findings revealed four themes of doctors’ perceived ‘readiness’ to identify and respond to IPA: self-efficacy, emotional readiness, motivational readiness and attitudinal readiness, whereas doctors’ perceived ‘preparedness’ comprise two themes: IPA knowledge and communication skills. Conclusion Whether doctors are ready to identify and respond to IPA might be influenced by their emotional concerns as well as individual motivational beliefs and values, in addition to their attitudes and perceived self-efficacy, revealing a multidimensional concept. Besides enhancing doctors’ preparedness by means of IPA knowledge and communication skills, training and IPA research could address further their emotional readiness and legitimize doctors’ role to intervene in IPA cases. Family doctors, intimate partner abuse, perceived preparedness, perceived readiness Introduction In view of the high prevalence and serious consequences of intimate partner abuse (IPA), family doctors are often the first health professionals victims seek help from and disclose abuse to (1). Thus, doctors are in a prime position to identify and respond to IPA against women. Literature on doctors’ perceived barriers and facilitators of IPA disclosure and inquiry (2–7) suggests that research must be directed at identifying a distinct construct, for instance, perceived readiness, which may help to explain varying responses by doctors when responding to IPA. Indeed, the concept of ‘readiness’ has been broadly discussed when considering action taken by IPA victims in response to their experiences of abuse (8,9), whereas research on how doctors perceive their readiness to deal with IPA is comparatively lacking. The concept of ‘readiness’ has been described as a positive force that may motivate people to make positive changes (10,11). While the term ‘readiness’ was first used in a scale measuring doctors’ readiness to manage IPA (12), in that study, no conceptual definitions of readiness were provided and perceived preparedness emerged as a subscale. There are no agreed theoretical foundations for defining what constitutes ‘readiness’ or ‘preparedness’, resulting in some conceptual ambiguities. Indeed, some studies have used the term ‘preparedness’ (13–16), but without a clear conceptual framework. It remains unknown if ‘readiness’ and ‘preparedness’ are mutually inclusive in content properties, or whether they are distinct constructs in the context of doctors’ responses to IPA. Owing to the lack of well-defined content properties, these two terms have been used interchangeably, for example, in the work conducted by Gutmanis et al. (17), ‘feel ready’ and ‘feel prepared’ implied similar meanings. Similarly, no prior research has investigated whether doctors differentiate between the two when considering responses to patient reports of IPA. Establishing a clear conceptualization of each concept is therefore needed so as to enable valid and reliable measurements of their underlying characteristics. In light of these issues, we conducted an interview study exploring how doctors’ perceive their ‘readiness’ and their ‘preparedness’ to identify and respond to IPA. Methods Study design This qualitative study was part of a PhD project which adopted an exploratory sequential mixed-method research design (18), aiming to explore and validate doctors’ perceived readiness to identify and respond to IPA as a new and distinct construct towards scale development (19). As shown in Figure 1, we recruited a purposive sample (20) of doctors who had participated in a randomized controlled trial (WEAVE) which evaluated the effectiveness of a brief counselling intervention delivered by trained doctors (intervention group) on abused women’s safety planning, mental health and quality of life (21). The WEAVE comparison group received basic educational materials for safe practice in seeing abused women (21). The decision to recruit from the existing research sample was not merely based on convenience. We believed that recruiting doctors who were in both the intervention and comparison arms of WEAVE would result in a diversity of clinical experience in dealing with IPA enabling conceptual generalizations to be drawn. Figure 1. View largeDownload slide Recruitment of doctors for individual semi-structured interviews. Figure 1. View largeDownload slide Recruitment of doctors for individual semi-structured interviews. Data collection and analysis Between December 2012 and February 2013, a semi-structured interview schedule was reviewed by an expert panel (consisting of three research supervisors and two qualitative academic researchers), pilot-tested and subsequently refined. The interview schedule elicited doctors’ views on their readiness and preparedness to identify and respond to IPA by reflecting on their clinical experience in IPA disclosure and identification (Box 1). From March to September 2013, we sent an invitation letter to 45 WEAVE doctors who agreed to participate in this study, along with a plain language statement and a consent form by email and post; with follow-up phone calls and emails to nonresponders. Interviews were conducted with 19 GPs as it was felt that no new significant themes emerged from interviews after this point. Therefore, data collection was ceased as per guidelines for conducting qualitative studies (22). All interviews were conducted with participants individually, were audio-recorded and transcribed (Supplementary File). The average duration of the interviews was 48 minutes (range 24–68 minutes). A thematic analysis approach was adopted: the first researcher (TL) hand-coded printed transcripts into dominant (organizing) themes and associated (basic) themes (23,24), followed by data entry into NVivo software program (QSR International Pty Ltd.—Version 10). TL also used jotted notes, memos and content summaries in data analysis. We further undertook cross-coding and code-confirming procedures, in that research supervisors (CB and KH) independently coded four transcripts and critically scrutinized the thematic coding framework. High consistency in data coding was achieved. To affirm the data authenticity, we undertook ‘respondent validation’ (25) whereby the majority of participants had confirmed the accuracy of the transcript. Box 1. Interview schedule What has it been like seeing female patients who report being abused by their partner? (an ice-breaker) When you suspected that your female patients may have experienced partner abuse, how have you dealt with that? How have you responded when your female patients tell you about abuse? In your clinical experience, what does the term ‘readiness’ mean to you when dealing with partner abuse issues? Can you recall any cases in which you felt ‘being ready’ (or ‘not being ready’) to deal with partner abuse issues? Are ‘being ready’ and ‘being prepared’ the same thing to you? (If not, what are the differences? Could you elaborate further?) What kind of thoughts have come to mind when seeing a woman who has been abused by her partner? How does it feel seeing a female patient who presents with partner abuse? How do you cope with those (negative) feelings? Results Demographics Participants were 11 females and eight males (Fig. 1) who had been Australian family doctors for between 5 and 35 years, with an average of 19.5 years. Their average age was 48 years (range 34–61 years old), which was same as the mean age of the WEAVE sample. Meanings of ‘readiness’ and ‘preparedness’ when responding to IPA The majority of the participants clearly differentiated between the terms ‘readiness’ and ‘preparedness’; only two participants thought that these terms had more or less the same meaning. Most of the participants described doctors’ ‘readiness’ as accepting what might happen in a consultation that could be unpredictable and affected by their attitudes, beliefs, thoughts and feelings. ‘Preparedness’, on the other hand, was defined as having consultation plans, the knowledge, resources and skills to deal with IPA. Being ready is just being able to accept what comes. Being prepared is knowing what’s going to come and having a plan. (Intervention 17, Michelle, female) Readiness is an emotional response. It’s got nothing to do with how much you know [being prepared]. (Intervention 06, Sam, male) Readiness might be a more dynamic, in the moment capacity … Preparedness has got more to do with, perhaps training. (Intervention 14, John, male) I think prepared means having your resources…having the right preparation means the right resources and management strategies;…emotionally ready means…being ready to allow the patient to open up, to give them the time to talk rather than rushing the consultation. (Comparison 45, Johnny, male) Some participants further described how these terms are related. I would be prepared, but mentally, I may not be ready. (Comparison 36, Alice, female) I think once you’re ready you have to do the steps to make sure you’re prepared. (Comparison 08, Mary, female) Our findings revealed that doctors’ perceived readiness to identify and respond to IPA comprises four dominant themes (derived from 12 associated themes and 34 codes): self-efficacy, emotional readiness, motivational readiness, and attitudinal readiness. ‘IPA knowledge’ and ‘communication skills’, derived from 8 associated themes and 23 codes, represent two underlying concepts characterizing doctors’ preparedness to identify and respond to IPA (Figs. 2 and 3). It should be noted that there were no marked differences in participants’ views of ‘readiness’ and ‘preparedness’ based on age, gender, years of practice, or training received in the WEAVE trial. Figure 2. View largeDownload slide Thematic map for doctors’ perceived readiness to identify and respond to intimate partner abuse. Figure 2. View largeDownload slide Thematic map for doctors’ perceived readiness to identify and respond to intimate partner abuse. Figure 3. View largeDownload slide Thematic map for doctors’ perceived preparedness to identify and respond to intimate partner abuse. Figure 3. View largeDownload slide Thematic map for doctors’ perceived preparedness to identify and respond to intimate partner abuse. Doctors’ perceived readiness to identify and respond to IPA Self-efficacy Most of the participants perceived themselves to be able to identify and respond to IPA, and reported feeling confident in making clinical judgements on safety issues, as well as eliciting support from colleagues and other health clinicians. I think it [readiness] means that I am, most of the time, alert and I look at the patient as a whole person, rather than just a complaint that they present with. Especially if it’s the women who present frequently, or there are issues with raising children or kids, or even if they didn’t have kids … So it’s to try and give it my best shot to the consultation and to try to pick things. (Comparison 52, Kate, female) If they disclose abuse then I’m confident in my clinical skills, my access to resources, to at least assist that woman to take some steps in so far as she’s able. (Comparison 08, Mary, female) Emotional readiness Many participants stated that they need to be emotionally ready in terms of feeling comfortable to discuss IPA and respond to IPA disclosure, accepting limits of their professional roles, identifying own emotional responses and safeguarding their emotional well-being. The ability to actually feel comfortable asking the question is really important. (Intervention 09, Morgan, female) You can’t do this job if you think you have to ‘save’ everyone; I don’t blur the line between support and fixing. (Comparison 10, Dr X, male) I can support them [IPA victims] along their journey to fix things but I can’t do it for them. (Intervention 17, Michelle, female) You provide care for all, but you also need to be strong enough in yourself, not to be damaged by providing support for the others. That’s where in terms of being emotionally ready is in terms of looking after myself. (Comparison 26, Margaret, female) Motivational readiness The majority of participants emphasized that they would be there for patients experiencing IPA and point out that IPA is a violation of human rights. I think the readiness comes from an understanding that, even during difficult days, if the patient’s courageous enough to disclose this as a problem, that you really do have to be prepared, ready to understand that this patient is in need right now and there may not be another opportunity … you just have to put everything else on hold and be there for the patient. (Intervention 55, James, male) I think my role as a GP is sometimes to say, ‘look, it sounds like what you’re experiencing—I would think that that’s domestic violence or I would think that that is not acceptable behaviour’. (Comparison 08, Mary, female) Attitudinal readiness There was a broad agreement among the participants that having an open-mind and not being judgmental were crucial for being ready to identify and respond to IPA. If we’re picking up a vibe, maybe being open to it rather than putting it away and ignoring. (Intervention 24, Steven, male) You’re not going to be critical or think less of them [IPA victims] or tell them what to do. (Intervention 37, Louise, female) One participant pointed out that, while doctors should not judge but respect patients’ choices in resolving IPA issues, they should be able to ‘judge’ what abusive behaviours are. That being non-judgmental doesn’t mean that there are no absolute right and wrongs … In particular, behaviours that result in intimidation or physical abuse in the home and so on. That the individual has a right to exist in their own right. (Intervention 14, John, male) Doctors’ perceived preparedness to identify and respond to IPA IPA knowledge Most of the participants demonstrated good knowledge of IPA issues, including its nature and health consequences, women’s readiness to deal with IPA, doctors’ roles to intervene, patient confidentiality issues as well as direct or indirect approaches to ask about IPA. I think you have to be guided by where the woman is and what she’s ready for. Is she really not ready to even acknowledge it or does she acknowledge it but she doesn’t want to do anything or is she getting ready to do something, and you give her different support and different help according to where she is along that road…. (Intervention 29, Marie, female) One interesting finding in relation to making sensitive inquiry was participants’ different views on asking regular patients (whom they have known for some time) and new patients about IPA. Some participants reported that they would ask about IPA in all suspicious cases, whereas a few participants stated that they would react differently to regular patients and new patients. When you know the patient already trusts you and you know a lot of their background already, it’s easier to be able to tackle that, I think. Sometimes when it presents as a new person and you don’t know their background…new people are more challenging. (Comparison 28, Jenny, female) Some women seen once—it’s almost like if you raise it [IPA] as a possibility, then that’s enough to actually allow them to start telling what’s been going on. (Comparison 36, Alice, female) Communication skills The majority of participants emphasized the significance of having good communication skills to work with IPA victims, such as rapport-building (understanding and trust), active and empathic listening, as well as validation of victims’ experience and feelings. Good communication skills resulted in ‘making a connection’ with patients. It’s all about being human, having a human interaction rather than just being clinical and academic so someone feels that you’ve got that rapport, some empathy, some warmth … every relationship in general practice, there’s got to be a warmth and a communication…. (Intervention 05, Rob, male) …to engage with them [IPA victims], so they feel that they can come back and maintain a connection with you. (Comparison 56, Sally, female) So, using mirroring and validation becomes very important to make sure that you are accessing the information in the way that they’re giving it to you, just making sure that it’s really clear. But that also reinforces for them that they can talk to you…. (Intervention 09, Morgan, female) Discussion Our study is the first to provide both a definition of doctors’ perceived readiness to identify and respond to IPA (which is different from perceived preparedness) and thematic maps for defining what constitutes ‘readiness’ or ‘preparedness’ (Figs. 2 and 3). The term readiness used by Short et al. (12) in a survey tool did not provide a conceptual framework. The sample in this study described doctors’ readiness as dealing with the moment in a consultation which involves factors relating to doctors’ attitude, beliefs, thoughts and feelings. Based on the findings, ‘readiness’ is conceptualized as ‘a psychological state that indicates the extent to which an individual is cognitively, motivationally, and emotionally inclined to embrace and respond to a phenomenon’. On the other hand, ‘preparedness’ refers to having adequate IPA knowledge and good communication skills. These two aspects have been broadly discussed in the existing IPA literature (2,4,7,8). Consistent with Gerbert and colleagues’ findings of direct and indirect approaches asking about IPA, doctors in this study reported making sensitive inquiry depending on female patients’ readiness and their understandings of the patients. Different views on asking regular patients and new patients suggest that elements in good therapeutic relationship, for instance, rapport-building, can be a facilitator for IPA disclosure and identification. As discussed below, doctors’ perceived readiness to identify and respond to IPA comprises four themes (self-efficacy, emotional readiness, motivational readiness, and attitudinal readiness). These findings have warranted the development and validation of a new multidimensional scale in a mixed-method research study (19). Age, gender, years of practice, and previous IPA training did not appear to unduly influence the participants’ responses. The doctors in this study reported perceived ‘self-efficacy’, feeling confident in identifying IPA, making clinical judgments on safety issues, as well as eliciting support from colleagues and other health clinicians. The findings are consistent with Bandura’s self-efficacy concept, doctors’ perceived self-efficacy may have been enhanced through direct experience of managing IPA (performance accomplishments), as well as vicarious experience and verbal persuasion from others (26), that is evident among the participants in the intervention group. Miller and Jaye’s study highlighted the benefits of working as part of a multidisciplinary team in IPA management (4). This further underscores the significance of experiential learning (‘learning by doing’) (27,28) in training contexts and continuous professional development (29). Future research could explore to what extent different types of clinical experience relate to doctors’ self-efficacy toward forming a causal mechanism which could explain doctors’ perceived readiness to identify and respond to IPA. Our study described how doctors perceived their ‘emotional readiness’ to deal with IPA, which is a novel finding in the literature. The participants raised their concerns about the potential impacts arising from dealing with IPA in both personal and professional aspects. Vicarious traumatization, burnout, and compassion fatigue have been widely reported in the literature (30,31). The doctors in this study discussed the importance of identifying own emotional responses and acknowledging their roles which are not to ‘fix’ the problem. Appropriate emotional support for doctors in both training and clinical practice, by means of regular supervision, ongoing peer support or mentoring, needs to be considered. With respect to ‘attitudinal readiness’, some previous studies showed that doctors held negative or stereotypical views of IPA victims (2,6), whereas a recent study by Kohler et al. (32) revealed doctors’ openness to address IPA. Doctors in our study reported, not just being nonjudgmental, but also having a commitment to caring patients as fellow human beings (‘motivational readiness’). Participants expressed their views on IPA and humanity, placing a high value on ‘being there for the patient’, which is similar to Miller and Jaye’s findings of doctors’ willingness to provide continuity of care to patients (4). Motivational readiness being a novel finding added to the existing knowledge by giving a reason to ask patients about IPA (that is, IPA is a violation of human rights) and legitimizing the roles of doctors to identify and respond to IPA. The strength of our study is the use of purposive sampling which allowed us to explore the perspectives of doctors who had different amount of clinical experience in seeing IPA victims as well as different levels of training in addressing the needs of these patients. This study further uncovered the underlying characteristics of doctors’ perceived readiness (and perceived preparedness) to identify and respond to IPA as a unique construct for future research. The themes revealed in this research have contributed to the development of a scale to measure doctor perceived ‘readiness’ to respond to patient reports of IPA (19). Several limitations to this study should be cited. First, participants were recruited from an existing IPA study (21) and this may have inevitably introduced particular responses. The inclusion of those who were not involved in IPA research might have led to different findings. Second, the findings drawn from our study may not generalize both to doctors working in health care settings differ from primary care or to the whole population of Australian family doctors. The dominant themes identified in this study suggest the need for a larger study to investigate the phenomenon of doctors’ perceived readiness (and preparedness) to deal with IPA. Third, owing to the qualitative nature of this study, participants’ perspectives on their readiness (and preparedness) to identify and respond to IPA could not be verified as actual clinical practice. Additional research, such as, conducting patient interviews or observation of clinical consultations, could corroborate the current findings. Last, no member checking other than respondent validation (25) was employed in our study. Conclusion This study revealed that doctors’ perceived readiness to identify and respond to IPA is a multidimensional construct which is different from an interrelated concept of preparedness. These findings enhance existing knowledge about doctors’ responses towards IPA victimization by providing an operational definition and well-defined content properties of doctors’ perceived readiness to identify and respond to IPA. In particular, the themes ‘motivational readiness’ and ‘emotional readiness’ uncovered by this study are the most interesting and striking findings which have not been evident as unique concepts in the IPA literature. Our findings highlighted the significance of incorporating doctors’ motivational and emotional factors in training interventions and IPA research. Besides enhancing doctors’ ‘preparedness’ by means of increasing their IPA knowledge and improving their communication skills, well-tailored training and IPA protocols could emphasize motivational beliefs and values in the way that IPA is a violation of human rights and doctors have legitimate roles to intervene in IPA cases. Furthermore, doctors’ emotional concerns about being vicariously traumatized and their emotional needs for self-care when dealing with IPA issues should be addressed. Supplementary material Supplementary data are available at Family Practice online. Acknowledgements The authors wish to thank all the family doctors who took the time to participate in this study. Declaration Funding: none. Ethical approval: this study was undertaken by Traci Po-Yan Leung as part of her PhD project in the Melbourne School of Psychological Sciences at the University of Melbourne Health Sciences with the approval of Human Ethics Sub-Committee (HREC no. 0824166.10 and 1339631.1). 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All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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Family PracticeOxford University Press

Published: Dec 28, 2017

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