Master’s Thesis- R. Seymour; McMaster University- Nursing
NURSES’ EXPERIENCES OF INTIMATE PARTNER VIOLENCE IN HOME VISITING
NURSES’ EXPERIENCES AND DESCRIPTIONS OF HOME-VISITING SOCIALLY DISADVANTAGED PREGNANT WOMEN AND FIRST TIME MOTHERS EXPOSED TO INTIMATE PARTNER VIOLENCE
By Rebecca Seymour, BKin (Hons), BScN, RN
A Thesis Submitted to the School of Graduate Studies in Partial Fulfillment of the Requirements for the Degree Master of Science
McMaster University © Copyright by Rebecca Seymour, August, 2015
McMaster University MASTER OF SCIENCE (2015) Hamilton Ontario (Nursing)
TITLE: Nurses’ experiences and descriptions of homevisiting sociallydisadvantaged pregnant women and first time mothers exposed to intimate partner violence.
AUTHOR: Rebecca J. Seymour, BKin (McMaster University), BScN (McMaster University)
SUPERVISOR: Dr. S. Jack
NUMBER OF PAGES: XII, 244
Abstract
In the United States, intimate partner violence (IPV) is the most common cause of non-fatal injury for women. The Nurse-Family Partnership (NFP) is an evidence-based maternal and early childhood health program where nurse home visitors seek to develop therapeutic relationships and provide health promotion interventions with low-income, young pregnant women and first time mothers and their children, from early in pregnancy until the child’s second birthday. In this program, nurses have a responsibility to identify women exposed to abuse and provide supportive interventions. The purpose of this study is to understand the impact of this work on nurse home visitors’ professional and personal selves. A secondary qualitative content analysis was conducted using a sample comprised of27 nurses, 18 community partners, and 4 nurse supervisors from an original case study by Jack et al. (2012) for the development of a nurse home visitation IPV intervention. Conventional content analysis and constant comparative techniques were used to code 8 nurse focus group transcripts and 43 transcripts from face-to-face, semi-structured interviews with the community partners and supervisors. Nurses identify that clients are exposed to multiple types of violence. These experiences increase the complexity of delivering the NFP home visitation program. Nurses also experience high levels of uncertainty related to how to respond to disclosures, and how to address IPV. The presence of IPV also significantly impacts many facets of the nurse-client relationship. At times nurses struggle with wanting to “fix” the client’s relationship with her partner; yet understand this is not a healthy response. Setting boundaries and clearly defining one’s role in this work is complex, and many nurses experience high levels of anxiety, worry and fear for their clients. Supervisors and community members confirm nurses’ experiences but also provide strategies for reflective supervision and community level support. Nurse home visitors are in a unique position to provide care for women exposed to IPV and recommendations are provided for nursing education, practice and research in this field.
Acknowledgements
“Difficult roads often lead to beautiful destinations” Author Unknown
To my supervisor, Dr. Susan Jack. I truly believe that I would not have completed this Masters without you agreeing to me my supervisor when I needed you. While I know it hasn’t been easy, I cannot thank you enough for your constant and unwavering support, your accessibility, and your quick, extensive and thought provoking feedback. You have guided me through this process and I believe I have grown as an academic considerably due to your feedback and expertise. Your passion and enthusiasm for research concerning women and violence is contagious and has exposed me to a topic I have never seriously considered before. Thank you, thank you, thank you for getting me through this masters and opening up my world to new possibilities for further research.
To my thesis committee members, Dr. Michelle Butt, and Dr. Andrea Gonzalez, thank you! Michelle, thank you for following me through from beginning to end. I know this wasn’t the topic we thought we’d be doing, but I think we did alright! Thank you for providing your unique perspective and detailed feedback, especially when it reminded me to speak to a non-qualitative audience. Andrea, thank you for joining my committee and supporting me through a difficult transition to a new topic and field. Thank you for your thought provoking feedback. Michelle and Andrea, thank you. Knowing you were there to support me means more than you know.
To my fellow nursing graduate school buddies Jen and Stephanie, thank you for the emails, phone calls, coffees and support through the tears. It has been a difficult journey, thank you for being there for me.
To my friends and family, words are not enough. Ellie, Andrea, Miranda, Mom, Dad and James, you all believed in me when I didn’t believe in myself. Thank you for the talks, the hot chocolates, the wake-up calls, the editing, the inspirational texts and emails, the discussions about how to decrease my stress and anxiety, the dinners, the walks, the hugs, the tissues, reminding me to dance, and simply being there for me, thank you. I would not be here without all of you on my bench.
To everyone who believed in me when I didn’t believe in myself- thank you
Table of Contents
ABSTRACT…………………………………………………………………...…V
ACKNOWLEDGEMENTS……………………………………………………VI
TABLE OF CONTENTS………………………………………………...……VII
LIST OF TABLES……………………………………………………………....X
LIST OF FIGURES…………………………………………………………….XI
LIST OF ABBREVIATIONS………………………………………………...XII
CHAPTER 1……………………………………………………………………...1
INTRODUCTION…………………………………………………………...…...1
LITERATURE REVIEW…………………………………………………….….5
SEARCH STRATEGY…………………………………………………………..6
OVERVIEW OF IPV………………………………………………………….....6
WOMENS’ HEALTH AND IPV…………………………………………………………...…..8
RISK FACTORS FOR IPV………………………………………………………………...…11
PREGNANCY AND IPV……………………………………………………………………..13
CHILD EXPOSURE TO IPV…………………………………………………………………15
NURSING AND IPV……………………………………………………………20
NURSES IPV EDUCATIONAL NEEDS…………………………………………………….21
ATTITUDES…………………………………………………………………………………..24
EMOTIONS………………………………………………………………………………...…26
CHALLENGES NURSE-HOME VISITORS EXPERIENCE……………………………...... 35
ORGINZATIONAL ATTRIBUTES………………………………………………………….39
NURSING PRACTICE STRANDARDS……………………………………...... …………...41
OVERALL STRENGTHS AND LIMITATIONS OF LITERATURE……..42
SUMMARY…………...………………………………………………………...43
CHAPTER 2- METHODS……………………………………………………..45
PURPOSE STATEMENT……………………………………………………...45
RESEARCH QUESTION……………………………………………………...45
OBJECTIVES…………………………………………………………………………………46
METHODS……………………………………………………………………...46
DESIGN……………………………………………………………………………………….47
SAMPLE………………………………………………………………………………………50
DATA COLLECTION…………………………………………………………....51
DATA ANALYSIS...... 53
RIGOR…………………………………………………………………………..64
CHAPTER 3- FINDINGS……………………………………………………...69
DEMOGRAPHICS……………………………………………………………..69
THE CENTRALITY OF RELATIONSHIPS………………………………...77
THE NATURE OF IPV………………………………………………………...78
THEME 1: RELATIONSHIP WITH CLIENT………………………………82
IMPORTANCE OF THE NURSE-CLIENT RELATIONSHIP IN THE
IDENTIFICATION, ASSESSMENT AND DISCLOSURE OF IPV……………...... 83
QUALITIES OF THE NURSE-CLIENT RELATIONSHIP…………………………....84
HOW NURSES EXPERIENCE THE DISCLOSURE OF IPV…………………………99
THE INFLUENCE OF IPV ON THE PLANNING AND PROVISION OF
PROFESSIONAL NURSING CARE……………………………………………………….118
NURSES EXPERIENCE CHALLENGES WHEN ATTEMPTING TO
UNDERSTAND CLIENT THOUGHTS AND ACTIONS…………………………....118
THEME 2: RELATIONSHIP WITH SELF………………………………...126
CHALLENGES EXPERIENCED BY NURSES……………………………………………127
EMOTIONAL AND PHYSICAL WORKLOAD……………………………………..127
EXPOSURE TO VIOLENCE………………………………………………………….128
IMPACTS ON THE NURSE-CLIENT RELATIONSHIP………...………………….130
SUPPORT NEEDED…………………………………………………………………..130
MORAL DILEMMA………………………………………………..……………………….131
MANDATED REPORTER……………………………………………………………131
LEAVING A CLIENT IN A POTENTIALLY UNSAFE SITUATION……………...132
TENSION BETWEEN PERSONAL AND PROFESSIONAL SELF……………………..133
THE IMPACT OF CARING……………………………………………………….….133
CHALLENGES BASED ON PERSONAL EMOTIONS…………………………..…134
DICHOTOMY BETWEEN PERSONAL AND PROFESSIONAL SELF………………...137
THEME 3: RELATIONSHIP WITH NFP ORGANIZATION AND
COMMUNITY RESOURCES………………………………………………..140
THE ROLE OF SUPPORTS BETWEEN NURSE AND ORGANIZATION………………140
RELATIONSHIP WITH PEERS……………………………………………………...141
RELATIONSHIP WITH TEAM………………………………………………………141
RELATIONSHIP WITH SUPERVISOR……………………………………………...142
RELATIONSHIP WITH NFP ORGANIZATION…………………………………….144
SUPPORTS BETWEEN NURSE AND COMMUNITY RESOURCES…………………...149
SUMMARY……………………………………………………………………152
CHAPTER 4- DISCUSSION…………………………………………………153
THE CENTRALITY OF RELATIONSHIPS IN THE NFP ………………153
THEME 1: THE NURSE-CLIENT RELATIONSHIP: THE NATURE
AND IMPACT OF IPV……………………………………………………….154
THE NURSE-CLIENT RELATIONSHIP…………………………………………………..156
DISCLOSURE, PLANNING AND PROVIDING CARE…………………………………..157
SAFETY……………………………………………………………………………………..159
BOUNDARIES……………………………………………………………………………...160
THEME 2: RELATIONSHIP WITH SELF………………………………...162
COMPASSION SATISFACTION…………………………………………………………..163
BURNOUT AND COMPASSION FATIGUE……………………………………………...165
VICARIOUS TRAUMA…………………………………………………………………….166
BEING A MANDATED REPORTER……………………………………………………....167
THEME 3: RELATIONSHIP WITH NFP ORGANIZATION ANDCOMMUNITY RESOURCES………………………………………………..169
PEER-TO-PEER COMMUNICATION WITHIN THE NFP ORGANIZATION…………..170
NURSE AND TEAM………………………………………………………………………..170
NURSE AND SUPERVISOR…………………………………...…………………………..171
NURSE AND ORGANIZATION………………………………………………………...…176
NURSE AND COMMUNITY………………………………………………………………177
STRENGTHS AND LIMITATIONS………………………………………...179
PRACTICE, EDUCATION AND RESEARCH
RECOMMENDATIONS…………………………………………………...…181
IMPLICATIONS FOR NURSE-HOME VISITING PRACTICE…………………………..182
IMPLICATIONS FOR NURSING EDUCATION…………………………………….……185
IMPLICATIONS FOR FURTURE RESEARCH…………………………………...………187
CONCLUSION………………………………………………………………...188
REFERENCES………………………………………………………………...190
APPEDICES…………………………………………………………………...212
List of Tables
Table Number / Table Title / Page3.1 / Summary of Demographics / 72
3.2 / Summary of Findings / 75
4.1 / Assessment of Trustworthiness / 181
4.2 / Summary of Recommendations / 182
List of Figures
Figure Number / Figure Title / Page3.1 / Nurses Experiences Caring for Women Exposed to IPV / 78
List of Abbreviations
CNO / College of Nurses Of OntarioIPV / Intimate Partner Violence
NHV / Nurse Home Visitor
RNABC / Registered Nurses Association of British Columbia
RNAO / Registered Nurses Association of Ontario
STAKE / Community Partner (Stakeholder)
SUPER / Supervisor
1
Master’s Thesis- R. Seymour; McMaster University- Nursing
CHAPTER 1
INTRODUCTION AND LITERATURE REVIEW
The Nurse-Family Partnership (NFP) is an evidence-based maternal and early childhood health program where nurse home visitors seek to develop therapeutic relationships and provide health promotion interventions with low-income, young pregnant women and first time mothers and their children (Olds, Sadler & Kitzman, 2007). The NFP program seeks to promote long-term achievement for vulnerable first time mothers, their children,their communities and society (Nurse-Family Partnership, 2011). The program’s overarching purpose is to provide the child with the best possible start to life, which it achieves by focusing on three major goals. It seeks to: 1) improve pregnancy outcomes through helping mothers engage in preventative health practices; 2) increase child health and development by helping parents provide responsible and competent care for their children; and 3) increase the economic self-sufficiency of the family by supporting parents in the development of a plan for their own future (NFP; Olds et al.). These goals are supported through the work of the nurse home visitors who focus on six content domains with their clients: personal health, environmental health, friends and family, the maternal role, use of health care and human services, and maternal life course development, which includes planning for future pregnancies, education and employment (Dawley, Loch & Bindrich, 2007).
The NFP is a targeted public health intervention; and women who are eligible to participate must meet a specific set of criteria. This includes: no previous live births, demonstrate low income, and are enrolled prior to the end of the 28th week of pregnancy (NFP, 2011). The program consists of approximately 64 planned home visits over a two and a half year period (14 prenatal home visits and 50 home visits after the infant is born), and the visits continue until the child’s second birthday (NFP; Olds et al., 2007). Outlined in the recommended schedule of visits, it is suggested that nurses visit bi-weekly except during the first month of the program, and the first month post-partum where they visit weekly (Kurtz- Landy, Jack, Wahoush, Sheehan, & MacMillan, 2012). In the last three months of the program, the nurse home visitor meets with the family monthly. However, nurse home visitors can use their professional clinical judgment to adapt the home visitation schedule to meet the needs of the client. The infant’s father and other family members are encouraged to participate in the home visits (Olds et al.). Nurses try to establish trusting relationships that make a measurable impact (NFP).
Over the last 35 years in the United States (US), three randomized control trials (RCT) have been conducted to measure the effectiveness of the NFP on a series of maternal and infant health outcomes (Olds et al., 2007). Consistent and repeated outcomes of the program include an improvement in prenatal health, increased intervals between 1st and 2nd pregnancies and births, reduced rates of subsequent pregnancies and births, increased maternal employment, a decrease in women’s use of welfare, improvement in the quality and safety of the home environment, an increase in children’s readiness and academic achievement, a reduction in childhood injuries, a decrease in the injuries detected in the medical record, reduction in children’s mental health problems, and reduced costs to government and society (Olds et al.). Using a sample from the RCT conducted in Elmira, New York, a 15-year follow-up was also conducted by Olds et al. (1998) to assess whether there were any differences in nurse-visited mothers versus a comparison group of mothers. Results showed adolescents from the nurse-visited group reported fewer instances of running away, arrests, convictions and violations of probation, lifetime sexual partners, cigarettes smoked per day, and days having consumed alcohol in the past 6 months (Olds et al.). Parents of the nurse-visited adolescents reported fewer behavioral problems related to drug or alcohol use (Olds et al.).
The NFP values ongoing program improvement and follows a five-step framework to implement enhancements when needed: understanding program challenges, formative development of innovations, piloting innovations, rigorous testing of innovations and translating learning into NFP practice (Olds et al., 2013). Specific priority topics with the NFP that have been identified as requiring enhancement include supporting nurses to identify and address maternal mental illness and intimate partner violence (IPV) in the home (Olds et al., 2007). For this study, IPV is defined as any physical, sexual or psychological harm done to a person by a partner or former partner (CDC, 2013a).
As part of the 15-year follow-up study to the first NFP RCT conducted in Elmira, NY, Eckenrode and colleagues (2000) led the analysis to determine the impact of exposure to IPV on the effectiveness of NFP in reducing the number of substantiated cases of child abuse and neglect. In this analysis, of the 400 women who enrolled in the primary NFP RCT, 324 of these women and their children participated in the follow-up study (Eckenrode et al.). In the RCT, one group was visited by a nurse from pregnancy until the child’s second birthday (plus routine prenatal care), another was visited by a nurse during pregnancy (plus routine prenatal care), and the other group who received routine prenatal care only served as a control. The cohort was followed for 15 years and a large number of parameters were measured including those related to IPV.
In this analysis, among the group of women who reported 28 situations of exposure to IPV, participants who received the long-term NFP home visits compared to women in the other groups had fewer reports of child abuse and neglect in the 15-year follow up period (Eckenrode et al.). However, when women reported exposure to >28 events of IPV, engagement in the NFP home visits did not reduce reports of child maltreatment. Based on these findings, the authors concluded that the presence of IPV may attenuate the effectiveness of the NFP home visits to reduce the incidence of child abuse and neglect; however exposure to IPV did not affect other NFP program outcomes that were measured. In a paper summarizing the findings from the first 25 years of evaluating the NFP, with a specific focus on the RCT studies conducted in Elmira NY and Memphis, TN, Olds (2002) identified the need to augment and improve the program so that nurses can better support women exposed to moderate to high levels of IPV.
With an identified need to enhance the NFP guidelines with respect to how IPV is assessed and responded to within the program, Jack and colleagues (2012a) conducted a qualitative case study and utilized findings to inform the development of the NFP IPV intervention. In this case study, the researchers interviewed NFP clients who self-reported exposure to moderate to severe IPV, nurse supervisors and community stakeholders, as well as conducting focus group interviews with NFP nurses; and sought to develop a nurse home-visitation intervention for IPV (Jack et al.).
Based on findings from these interviews, a five component NFP IPV enhancement was created and included: 1) a comprehensive nurse education program on IPV; 2) a manualized intervention and clinical pathway for identifying, assessing and responding to IPV within the home visit context; 3) guidelines for implementing NFP agencies to support nurses and supervisors in delivering an IPV intervention; 4) supervisor guidelines for reflective supervision; and 5) a clinical consultation or coaching support system.
Literature Review
The following literature review begins with an overview of the search strategy used, followed by an in-depth discussion of IPV, including definitions, global prevalence rates, women’s mental and physical health and IPV, risk factors and outcomes for IPV during pregnancy. The impact of IPV exposure on child-related outcomes will also be briefly summarized. I will conclude this review by summarizing the literature related to how the profession of nursing has responded to the issue of IPV, including nurses’ educational needs, attitudes, and emotional responses to working with women who have experienced abuse and their families, as well as the organizational barriers and facilitators that influence nurses’ capacity to work with this population. Please refer to Appendix A for a comprehensive review of the quality of the literature presented.
Search Strategy
Databases were searched with the objectives of gaining general knowledge about IPV, nursing practice standards, nurses’ experiences working with women exposed to IPV, and nurses’ experiences of conducting home visits with women experiencing IPV. Databases searched included: Web of Science, CINAHL, PubMed, Sociological Abstract and Ovid. Searches were restricted to the years 1994-2014. Search terms used included: domestic violence, battered women, nurs*, nurs* experience*, intimate partner violence, violence towards women, home visiting, nurs* home visiting and partner abus*. Reference lists from relevant articles were hand searched for further relevant sources. A search for key authors was also conducted.
Intimate Partner Violence
The Centers for Disease Control and Prevention (CDC) defines IPV as any physical, sexual or psychological harm done to a person by a partner or former partner (CDC, 2013a). Due to the sensitive and controversial nature of this topic, gathering prevalence and incidence rates on IPV can be difficult. Many women do not want to report IPV for fear of retaliation, or because they think they are at fault (WHO, 2012). In other cases, cultural norms, such as gender inequitable norms and those that connect manhood and aggression can hinder reporting IPV rates (WHO, 2012). Another challenge when searching for the prevalence of IPV is the definition used by the researcher to describe the exposure. Specifically, terms such as “battering,” “domestic violence” and “intimate partner violence” are at times used interchangeably. Though many definitions exist, the consensus on the difference is domestic violence can include elder and child abuse, while IPV is strictly abuse between spouses, boyfriends, girlfriends or ex-partners (WHO, 2011). Due to these issues, prevalence rates vary by country and reporting method used. Global, US and Canadian Statistics are discussed to give the reader a general overview of the issue.