Screening for Intimate Partner Violence in Fracture Clinics
Screening for Intimate Partner Violence in Fracture Clinics
We invited ten surgeons, ten junior residents, and ten senior residents to participate in the focus groups. Each of our three focus groups included six or seven participants, with a total of 20 surgeons or surgical trainees participating across the three focus groups. The mean age of the focus group participants was 33.9 ± 8.6 years and the majority of the focus group participants were male (75%) (Table 1). The mean length of time in practice for the orthopaedic surgeons was approximately ten years.
Four main themes were identified: contextual thoughts on IPV management, barriers to screening for IPV in fracture clinics, facilitators for screening for IPV in fracture clinics, and policy implementation for fracture clinics. Within the contextual thoughts on IPV, the following two subthemes were identified: perceptions and observations, and comparison to external models in orthopaedics. The focus group discussions yielded additional subthemes that reflected barriers to screening for IPV including fracture clinic barriers, perceived barriers for patients, perceived barriers specific to surgical trainees, and perceived barriers for surgeons. The following subthemes under the overall category of facilitators for IPV screening were identified: system-level characteristics, fracture clinic processes, and personnel resources. The policy implementation theme emerged from the analysis of the two interview transcripts.
The focus groups began by having participants share their initial thoughts on IPV and some of their personal experiences with IPV in the fracture clinic (Figure 1). One focus group began with the following example, "I have a face of intimate partner violence and murder… Two patients, one tried to have his wife killed. She became my patient because they were unsuccessful in killing her". Most participants recognized and understood the importance of screening for IPV in the fracture clinic setting with one participant noting "I think the screening is hugely important because it probably opens up a door to a certain percentage of women that would then open up and tell you about it" and another describing "I think we are the first access point for those women". The participants also discussed the need for caution when screening to ensure the safety of the patient.
(Enlarge Image)
Figure 1.
Contextual thoughts on IPV.
When discussing perceptions about common presentations of IPV within the fracture clinic setting one participated noted, "… identification is key… that's the part that I am most worried about is that I am missing people"; while another participant described: "…the biggest problem is picking it [intimate partner violence] up 'cause I think so much of it is silent". Another participant summarized current IPV screening practices: "It seems like if we are going on our intuition and our sense that something is wrong, we are doing a bad job with that from the evidence".
Surgeons and surgical trainees agreed that they are more comfortable with screening for and caring for patients who are victims of child abuse as a result of policies being in place in fracture clinics and having received appropriate training. One participant compared knowing the steps to take after screening for child abuse with not knowing the steps to take after screening for IPV: "With children we sort of know what to do, who to call. There's like a social work team we call but, you know, if you screen and then they do sort of come forth with "yes it was intimate partner violence" I wouldn't really know what to do next and so it's a little intimidating".
Participants also discussed selective screening for IPV (asking people about IPV based on pre-determined risk factors) versus universal screening for IPV (asking everyone in the fracture clinic about IPV) within the fracture clinic setting. For example, one participant said: "I think it's more ideal for screening everybody … because if not we are gonna screen people based on our certain assumptions and I don't think that's appropriate". Most participants recognized the limitations and challenges with selective screening and agreed that universal screening for IPV in fracture clinics may be appropriate, citing the success of universal screening for osteoporosis within the fracture clinic setting.
Participants described how the layout and organization of many fracture clinics makes it challenging for the orthopaedic surgeon to have privacy with their patients (Figure 2). Patients are often accompanied by someone to their appointments and it is difficult to separate the patient from this person. In addition, within the academic setting, orthopaedic surgeons rarely see their patients alone as they are usually accompanied by surgical learners when seeing their patients. One participant explained: "There's six other people, at least six plus learners so probably twelve people listening to every single conversation I have with patients; it's not the appropriate place". In addition, many fracture clinics follow an open concept model, with curtains separating exam rooms. One participant made the following analogy: "The fracture clinic is the equivalent of a family doctor seeing patients in their waiting office".
(Enlarge Image)
Figure 2.
Perceived barriers for screening for IPV in the fracture clinic.
Focus group participants also identified that adequate patient histories are not readily available or quickly accessible in the fracture clinic and noted that this is a barrier. Since the patient is often initially seen at the emergency department or by a surgical trainee, the surgeon may not be aware of their full history including previous injuries and the nature of these injuries.
Orthopaedic surgeons and surgical trainees described that they spend a very limited time with individual patients and have a high number of patients to see within their fracture clinic, which makes it difficult to find the time to appropriately screen for and address IPV. One participant described: "The biggest thing is time for orthopaedic surgeons. We see 70 to 80 people in a five hour clinic so if you do the math that's less than a few minutes a person".
Both the surgeons and surgical trainees identified that there is a lack of policies on screening for and addressing IPV within the fracture clinic setting. The following exchange between the facilitator and several surgeons exemplifies this concern: Facilitator 1- "So am I right in understanding that the clinics you work in have no policies or sort of integrated mechanisms … for screening for intimate partner violence?" Several Surgeons- "None that I'm aware, that's correct".
The focus group participants were concerned that universal screening may be challenging if the patients are unable to speak, read, and/or write English. They were also concerned about responding appropriately to possible cultural differences and distinguishing cultural practices from signs of IPV.
Another perceived patient barrier identified during the focus groups was the brief interaction that the patient has with the surgeon, and that the short amount of time spent with the patient is focused on the patient's orthopaedic problem. As one participant explained, "It's hard to develop a feeling of trust in a short period of time".
The focus group participants acknowledged that IPV victims may be more comfortable disclosing to females than males, and the field of orthopaedic surgery is predominately male.
Focus group participants recognized that a patient-surgeon power imbalance may be present which could deter patients from disclosing. One participant described this imbalance: "There's already a power balance right there and then there's the body language alone and we almost always wear white coats in there. There's just a lot of overlay that would probably inhibit the patient from disclosing some information".
There was concern that patients may not want to disclose IPV, as revealed by the following comment: "If someone comes into the fracture clinic they may just want care for their physical injuries". However, one participant disagreed, stating that "patients tend to trust medical professionals and may want to open up to someone". Participants also discussed that women may not disclose due to fear of the consequences of disclosing.
In general, the surgical trainee participants felt pre-occupied with their learning and clinical activities and felt that they would not have the focus to screen for IPV. This is demonstrated by the following comment, "You are trying to do a good job at what you are, you know, at becoming a good surgeon and that's taking a lot of our energy away".
Surgical trainees have multiple demands on them, as illustrated by the following quote, "We're busy with our … patient load and our next exam coming up and our … evaluation and our fellowships and our no jobs and our everything else that we think about all the time and … that you are going into the OR the next day and you have to read this tonight…."
The surgical trainees expressed concern about IPV screening influencing their relationship with the preceptor. The focus group participants clearly indicated that their preceptor would have to be supportive and encourage IPV screening.
The focus group participants also expressed concern about the lack of education and training that they received on IPV and consequently they were unsure of what to do with a positive screen. A few participants felt fearful about being held accountable due to lack of ability to identify victims as indicated in the following comment, "you saw Mrs. Smith … she had this injury, it was obviously domestic violence cause she's dead now and this was her fourth occurrence and you didn't pick up on it, why not doctor?".
The participants felt that the orthopaedic culture, which includes short term interaction with patients and a certain personality-type, is an important barrier. One participant explained, "I think it's a lot of the perceptions of the surgeon, you know, not that orthopaedics isn't a caring profession but there are some people that, you know, don't have the best bedside manner. So I can see people feeling very reluctant to kind of share something personal". The orthopaedic surgeons also described the belief that screening for IPV falls outside of the role of the orthopaedic surgeon and that they tend to treat the injury in isolation, as opposed to treating the social and other medical issues.
Focus group participants indicated that there is lack of a champion for promoting IPV screening and effective social support for IPV victims, as described in the following comment, "There's no champion right now who actually works at the fracture clinic".
The participants indicated that trust of the medical profession was an important facilitator, as patients often open up to medical professionals (Figure 3). One of the participants commented, "I'm sometimes surprised at how open and forthcoming patients are in the short time you get to know them the things that they'll tell you. I mean I think there is a sort of inherent trust in the medical profession".
(Enlarge Image)
Figure 3.
Facilitators for screening for IPV.
The focus group identified education for surgeons and surgical trainees as an important facilitator, as described in the following comment, "I think the next step would be towards education and make it not just completely academic but with these things I think you have to have case scenarios…"
The focus group participants suggested numerous changes to the fracture clinic environment to facilitate IPV screening and care for IPV victims. Examples described included having a private area where surgeons could talk to patients about confidential issues and having posters and pamphlets on IPV available within the fracture clinic to potentially help patients feel more comfortable with the topic.
Participants noted that having a prepared information package for surgeons would greatly assist in screening for IPV. One participant suggested "having something like a preprinted order pack, an abuse care package so that I know, not just academically what resources are available … it has resources for the patient that has a set of orders".
Another idea that was raised during the focus groups with having a screening form which the patient would complete upon presentation to the fracture clinic which could help to identify high risk patients for the orthopaedic team to follow-up with.
The focus group participants suggested that they could flag the charts of potential IPV victims. The following participant describes this suggestion: "They can stick like a red dot on the chart or something and then we go okay maybe that red dot means that we should ask them …"
The focus group discussions included suggestions for changing the infrastructure within the fracture clinic to facilitate screening for IPV. These suggestions include ensuring that there is adequate support from all fracture clinic staff and the hospital.
Focus group participants suggested that surgical trainees have the opportunity to spend more time with patients so that they can effectively screen for IPV, as suggested in the following comment: "I think sometimes …patients might actually disclose [IPV] to surgical trainees more than surgeons because surgical trainees tend to spend more time with the patient in the fracture clinic in terms of taking the history and doing the physical exam".
There was a great deal of discussion on the need for a dedicated person within the fracture clinic setting to screen for and manage IPV. The following quote from a surgical trainee demonstrates this: "When we were doing the screening for the IPV Prevalence study we had, you know, students coming in and asking every patient "can I talk to you in private?" That did it quite effectively".
Facilitators for caring for IPV victims included having a simple plan in place for the fracture clinic including the availability of a crisis team. A participant noted, "You should give them a simple plan that this is a person to contact when these are the problems in the fracture clinic or this is the person coming to the clinic every day three four hours and in case you find some clue you don't need to waste much time because you are busy".
Both opinion leaders were asked about the need for local and national champions to promote the need for IPV screening and care for victims within the fracture clinic setting (Figure 4). Both believed that a champion would be invaluable, as evident from the following quote: "I think, you always need a champion not only to develop the policy but also to implement the policy".
(Enlarge Image)
Figure 4.
Implementation of policies for IPV screening.
The interviewees identified a need to increase awareness about IPV among all health care professionals working within the fracture clinic setting. One opinion leader explained, "…the data that shows in the last year 30% of women that present to a fracture clinic have been subject to some type of IPV and I'm not so sure that that people even know those numbers so I think, you know, getting the information out there that it impacts a huge segment of the population, that the impact is substantial …"
The interviewees agreed that local policy on IPV would be beneficial in assisting patients who experience abuse. As one opinion leader stated, "…it's easier taking a grassroots approach, you know, go to a smaller entity like a hospital or clinic…if you have enough you know clinics that a or hospitals that are sort of buying into this program which is being run more at a grassroots level then maybe at the sort of provincial or systemic level someone might so oh this is working really well or seems to be really important, what we need to do is formalize this".
The need for research to inform policy was also discussed and both opinion leaders believed that the implementation of an IPV screening program should be evidence-based and they supported future research to better inform the decision makers.
Results
Participants
We invited ten surgeons, ten junior residents, and ten senior residents to participate in the focus groups. Each of our three focus groups included six or seven participants, with a total of 20 surgeons or surgical trainees participating across the three focus groups. The mean age of the focus group participants was 33.9 ± 8.6 years and the majority of the focus group participants were male (75%) (Table 1). The mean length of time in practice for the orthopaedic surgeons was approximately ten years.
Themes
Four main themes were identified: contextual thoughts on IPV management, barriers to screening for IPV in fracture clinics, facilitators for screening for IPV in fracture clinics, and policy implementation for fracture clinics. Within the contextual thoughts on IPV, the following two subthemes were identified: perceptions and observations, and comparison to external models in orthopaedics. The focus group discussions yielded additional subthemes that reflected barriers to screening for IPV including fracture clinic barriers, perceived barriers for patients, perceived barriers specific to surgical trainees, and perceived barriers for surgeons. The following subthemes under the overall category of facilitators for IPV screening were identified: system-level characteristics, fracture clinic processes, and personnel resources. The policy implementation theme emerged from the analysis of the two interview transcripts.
Contextual Thoughts About IPV Screening in the Fracture Clinic Setting
The focus groups began by having participants share their initial thoughts on IPV and some of their personal experiences with IPV in the fracture clinic (Figure 1). One focus group began with the following example, "I have a face of intimate partner violence and murder… Two patients, one tried to have his wife killed. She became my patient because they were unsuccessful in killing her". Most participants recognized and understood the importance of screening for IPV in the fracture clinic setting with one participant noting "I think the screening is hugely important because it probably opens up a door to a certain percentage of women that would then open up and tell you about it" and another describing "I think we are the first access point for those women". The participants also discussed the need for caution when screening to ensure the safety of the patient.
(Enlarge Image)
Figure 1.
Contextual thoughts on IPV.
When discussing perceptions about common presentations of IPV within the fracture clinic setting one participated noted, "… identification is key… that's the part that I am most worried about is that I am missing people"; while another participant described: "…the biggest problem is picking it [intimate partner violence] up 'cause I think so much of it is silent". Another participant summarized current IPV screening practices: "It seems like if we are going on our intuition and our sense that something is wrong, we are doing a bad job with that from the evidence".
Surgeons and surgical trainees agreed that they are more comfortable with screening for and caring for patients who are victims of child abuse as a result of policies being in place in fracture clinics and having received appropriate training. One participant compared knowing the steps to take after screening for child abuse with not knowing the steps to take after screening for IPV: "With children we sort of know what to do, who to call. There's like a social work team we call but, you know, if you screen and then they do sort of come forth with "yes it was intimate partner violence" I wouldn't really know what to do next and so it's a little intimidating".
Participants also discussed selective screening for IPV (asking people about IPV based on pre-determined risk factors) versus universal screening for IPV (asking everyone in the fracture clinic about IPV) within the fracture clinic setting. For example, one participant said: "I think it's more ideal for screening everybody … because if not we are gonna screen people based on our certain assumptions and I don't think that's appropriate". Most participants recognized the limitations and challenges with selective screening and agreed that universal screening for IPV in fracture clinics may be appropriate, citing the success of universal screening for osteoporosis within the fracture clinic setting.
Fracture Clinic Barriers to Screening for IPV
Participants described how the layout and organization of many fracture clinics makes it challenging for the orthopaedic surgeon to have privacy with their patients (Figure 2). Patients are often accompanied by someone to their appointments and it is difficult to separate the patient from this person. In addition, within the academic setting, orthopaedic surgeons rarely see their patients alone as they are usually accompanied by surgical learners when seeing their patients. One participant explained: "There's six other people, at least six plus learners so probably twelve people listening to every single conversation I have with patients; it's not the appropriate place". In addition, many fracture clinics follow an open concept model, with curtains separating exam rooms. One participant made the following analogy: "The fracture clinic is the equivalent of a family doctor seeing patients in their waiting office".
(Enlarge Image)
Figure 2.
Perceived barriers for screening for IPV in the fracture clinic.
Focus group participants also identified that adequate patient histories are not readily available or quickly accessible in the fracture clinic and noted that this is a barrier. Since the patient is often initially seen at the emergency department or by a surgical trainee, the surgeon may not be aware of their full history including previous injuries and the nature of these injuries.
Orthopaedic surgeons and surgical trainees described that they spend a very limited time with individual patients and have a high number of patients to see within their fracture clinic, which makes it difficult to find the time to appropriately screen for and address IPV. One participant described: "The biggest thing is time for orthopaedic surgeons. We see 70 to 80 people in a five hour clinic so if you do the math that's less than a few minutes a person".
Both the surgeons and surgical trainees identified that there is a lack of policies on screening for and addressing IPV within the fracture clinic setting. The following exchange between the facilitator and several surgeons exemplifies this concern: Facilitator 1- "So am I right in understanding that the clinics you work in have no policies or sort of integrated mechanisms … for screening for intimate partner violence?" Several Surgeons- "None that I'm aware, that's correct".
Perceived Barriers for Injured Patients Regarding Screening for IPV
The focus group participants were concerned that universal screening may be challenging if the patients are unable to speak, read, and/or write English. They were also concerned about responding appropriately to possible cultural differences and distinguishing cultural practices from signs of IPV.
Another perceived patient barrier identified during the focus groups was the brief interaction that the patient has with the surgeon, and that the short amount of time spent with the patient is focused on the patient's orthopaedic problem. As one participant explained, "It's hard to develop a feeling of trust in a short period of time".
The focus group participants acknowledged that IPV victims may be more comfortable disclosing to females than males, and the field of orthopaedic surgery is predominately male.
Focus group participants recognized that a patient-surgeon power imbalance may be present which could deter patients from disclosing. One participant described this imbalance: "There's already a power balance right there and then there's the body language alone and we almost always wear white coats in there. There's just a lot of overlay that would probably inhibit the patient from disclosing some information".
There was concern that patients may not want to disclose IPV, as revealed by the following comment: "If someone comes into the fracture clinic they may just want care for their physical injuries". However, one participant disagreed, stating that "patients tend to trust medical professionals and may want to open up to someone". Participants also discussed that women may not disclose due to fear of the consequences of disclosing.
Perceived Barriers Specific to Surgical Trainees Screening for IPV
In general, the surgical trainee participants felt pre-occupied with their learning and clinical activities and felt that they would not have the focus to screen for IPV. This is demonstrated by the following comment, "You are trying to do a good job at what you are, you know, at becoming a good surgeon and that's taking a lot of our energy away".
Surgical trainees have multiple demands on them, as illustrated by the following quote, "We're busy with our … patient load and our next exam coming up and our … evaluation and our fellowships and our no jobs and our everything else that we think about all the time and … that you are going into the OR the next day and you have to read this tonight…."
The surgical trainees expressed concern about IPV screening influencing their relationship with the preceptor. The focus group participants clearly indicated that their preceptor would have to be supportive and encourage IPV screening.
The focus group participants also expressed concern about the lack of education and training that they received on IPV and consequently they were unsure of what to do with a positive screen. A few participants felt fearful about being held accountable due to lack of ability to identify victims as indicated in the following comment, "you saw Mrs. Smith … she had this injury, it was obviously domestic violence cause she's dead now and this was her fourth occurrence and you didn't pick up on it, why not doctor?".
Perceived Barriers Specific to Orthopaedic Surgeons Screening for IPV
The participants felt that the orthopaedic culture, which includes short term interaction with patients and a certain personality-type, is an important barrier. One participant explained, "I think it's a lot of the perceptions of the surgeon, you know, not that orthopaedics isn't a caring profession but there are some people that, you know, don't have the best bedside manner. So I can see people feeling very reluctant to kind of share something personal". The orthopaedic surgeons also described the belief that screening for IPV falls outside of the role of the orthopaedic surgeon and that they tend to treat the injury in isolation, as opposed to treating the social and other medical issues.
Focus group participants indicated that there is lack of a champion for promoting IPV screening and effective social support for IPV victims, as described in the following comment, "There's no champion right now who actually works at the fracture clinic".
System-level Characteristics That are Facilitators for Screening for IPV in the Fracture Clinic Setting
The participants indicated that trust of the medical profession was an important facilitator, as patients often open up to medical professionals (Figure 3). One of the participants commented, "I'm sometimes surprised at how open and forthcoming patients are in the short time you get to know them the things that they'll tell you. I mean I think there is a sort of inherent trust in the medical profession".
(Enlarge Image)
Figure 3.
Facilitators for screening for IPV.
The focus group identified education for surgeons and surgical trainees as an important facilitator, as described in the following comment, "I think the next step would be towards education and make it not just completely academic but with these things I think you have to have case scenarios…"
Changes to Fracture Clinic Processes that Would Facilitate Screening for IPV in the Fracture Clinic
The focus group participants suggested numerous changes to the fracture clinic environment to facilitate IPV screening and care for IPV victims. Examples described included having a private area where surgeons could talk to patients about confidential issues and having posters and pamphlets on IPV available within the fracture clinic to potentially help patients feel more comfortable with the topic.
Participants noted that having a prepared information package for surgeons would greatly assist in screening for IPV. One participant suggested "having something like a preprinted order pack, an abuse care package so that I know, not just academically what resources are available … it has resources for the patient that has a set of orders".
Another idea that was raised during the focus groups with having a screening form which the patient would complete upon presentation to the fracture clinic which could help to identify high risk patients for the orthopaedic team to follow-up with.
The focus group participants suggested that they could flag the charts of potential IPV victims. The following participant describes this suggestion: "They can stick like a red dot on the chart or something and then we go okay maybe that red dot means that we should ask them …"
The focus group discussions included suggestions for changing the infrastructure within the fracture clinic to facilitate screening for IPV. These suggestions include ensuring that there is adequate support from all fracture clinic staff and the hospital.
Personnel Resources for Facilitators for Screening for IPV in the Fracture Clinic Setting
Focus group participants suggested that surgical trainees have the opportunity to spend more time with patients so that they can effectively screen for IPV, as suggested in the following comment: "I think sometimes …patients might actually disclose [IPV] to surgical trainees more than surgeons because surgical trainees tend to spend more time with the patient in the fracture clinic in terms of taking the history and doing the physical exam".
There was a great deal of discussion on the need for a dedicated person within the fracture clinic setting to screen for and manage IPV. The following quote from a surgical trainee demonstrates this: "When we were doing the screening for the IPV Prevalence study we had, you know, students coming in and asking every patient "can I talk to you in private?" That did it quite effectively".
Facilitators for caring for IPV victims included having a simple plan in place for the fracture clinic including the availability of a crisis team. A participant noted, "You should give them a simple plan that this is a person to contact when these are the problems in the fracture clinic or this is the person coming to the clinic every day three four hours and in case you find some clue you don't need to waste much time because you are busy".
Policy Implementation
Both opinion leaders were asked about the need for local and national champions to promote the need for IPV screening and care for victims within the fracture clinic setting (Figure 4). Both believed that a champion would be invaluable, as evident from the following quote: "I think, you always need a champion not only to develop the policy but also to implement the policy".
(Enlarge Image)
Figure 4.
Implementation of policies for IPV screening.
The interviewees identified a need to increase awareness about IPV among all health care professionals working within the fracture clinic setting. One opinion leader explained, "…the data that shows in the last year 30% of women that present to a fracture clinic have been subject to some type of IPV and I'm not so sure that that people even know those numbers so I think, you know, getting the information out there that it impacts a huge segment of the population, that the impact is substantial …"
The interviewees agreed that local policy on IPV would be beneficial in assisting patients who experience abuse. As one opinion leader stated, "…it's easier taking a grassroots approach, you know, go to a smaller entity like a hospital or clinic…if you have enough you know clinics that a or hospitals that are sort of buying into this program which is being run more at a grassroots level then maybe at the sort of provincial or systemic level someone might so oh this is working really well or seems to be really important, what we need to do is formalize this".
The need for research to inform policy was also discussed and both opinion leaders believed that the implementation of an IPV screening program should be evidence-based and they supported future research to better inform the decision makers.