Intimate partner violence (IPV) is considered the most frequent type of societal violence against women and, to a lesser extent, against men (Arroyo-Sánchez, 2016; Carmona-Torres, Recio-Andrade, & Rodríguez-Borrego, 2018). IPV is a major global problem; it is estimated that one third of women throughout the world are affected by IPV (Regueira-Dieguez, Pérez-Rivas, Muñoz-Barús, Vázquez-Portomeñe, & Rodríguez-Calvo, 2015), and the incidence rates (and associated mortality rates) have been shown to be rising (Arroyo-Sánchez, 2016; Regueira-Dieguez et al., 2015). The World Health Organization (WHO, 2013) defines IPV as “behaviour of an intimate partner that causes physical, sexual or emotional hurt, including acts of physical aggression, sexual coercion, psychological abuse and control.” Because of the physical and mental impact it has on the health of the victim, WHO considers IPV a public health priority (Loxton, Dolja-Gore, Anderson, & Townsend, 2017; WHO, 2013).
IPV occurs in all countries and areas of society (Carmona-Torres et al., 2018; García-Moreno et al., 2015). In Spain, it is estimated that 24.8% of women have experienced IPV throughout their lives and 15.1% have suffered from IPV within the past year (Ruiz-Pérez et al., 2017). These values are in line with those of the report from the Government Office for Gender Violence in 2015 (Delegación Gobierno para la Violencia de Género, 2015). According to data from the Government Office for Gender Violence (Delegación Gobierno para la Violencia de Género, 2016), since the introduction of a free telephone line 016, first introduced in Spain in 2007, 634,491 calls have been received, which is used to provide information on gender-based violence. During the first half of 2016, 70,236 reports of gender violence were registered (Delegación Gobierno para la Violencia de Género, 2016).
Given the magnitude of the problem, the Organic Law of Comprehensive Protection Measures against Gender-Based Violence (“Ley Orgánica, 2004”) was enacted in Spanish legislation, establishing that health professionals are required to carry out activities aimed at the early detection and support of victims. Furthermore, this law increased the penalties for abusers and established training programs for judges and health professionals (Regueira-Dieguez et al., 2015). This latter point is important, because healthcare systems are responsible for assisting victims of IPV and health professionals are often the first point of care (Carmona-Torres et al., 2018). In Spain, the Health Protocol for Common Action to Face Gender-based Violence, a government-commissioned report, was published in 2007 (Ministerio de Sanidad y Consumo, 2007) and updated in 2012 (Ministerio de Sanidad, Servicios Sociales e Igualdad, 2012). Subsequently, some autonomous communities established a specific protocol to confront gender-based violence. However, studies show that most health professionals are not aware of the existence of specific protocols for gender-based violence and acknowledge that they have not received training on the subject (Lozano Alcaraz et al., 2014; Ruiz Navarro, 2011).
It is well known that the victims of this type of violence use healthcare systems, although they often do not reveal the abuse or violence (WHO, 2013). In fact, studies confirm that women who experience IPV use healthcare services more frequently, with primary care and emergency services being used most often (Doran & Hutchinson, 2017; Sprague et al., 2014). Health professionals are usually the first people in contact with victims of IPV. Moreover, compared with those who do not experience violence, people who suffer violence have more chronic health problems and more frequently visit health centers (Ruiz Navarro, 2011; Varcoe et al., 2011). In general, the victims of IPV do not disclose the problem to anyone, and according to some studies, when they do, they prefer to speak with health professionals about the violence they have experienced (Feder, Hutson, Ramsay, & Taket, 2006; García-Moreno et al., 2015). Thus, health professionals are a fundamental pillar in the early detection of IPV, and healthcare systems are the natural entry point for most victims (García-Moreno et al., 2015).
In the last decade, research has focused on the prevalence of IPV in the general population and how health professionals must address the problem. However, there have been few studies focusing on the care given to health professionals who suffer IPV. To our knowledge, some studies have looked at the prevalence of IPV in nurses (Al-Natour, Gillespie, Wang, & Felblinger, 2014; Bracken, Messing, Campbell, La Flair, & Kub, 2010; McLindon, Humphreys, & Hegarty, 2018; Rodríguez-Borrego et al., 2011; Rodríguez-Borrego, Vaquero-Abellán, & da Rosa, 2012), but we are not aware of any studies that focus on the attention given to health professionals when they suffer IPV. Health professionals are important in addressing the problem of IPV; however, the abovementioned protocols (Ministerio de Sanidad, Servicios Sociales e Igualdad, 2012; Ministerio de Sanidad y Consumo, 2007) do not set out specific actions for professionals themselves who suffer IPV but rather focus specifically on professional training. To our knowledge, no studies have researched what happens with those professionals who suffer IPV. To address this, we posed the following question: Who takes care of female health professionals who suffer IPV?
Here, we aimed to investigate who assists women working as health professionals in the Spanish Public Health System (SPHS) when they suffer IPV.
Design and Participants
We conducted a descriptive, cross-sectional, multicenter study. The participants were female health professionals (physicians, nurses, or nursing assistants) who worked in the SPHS. The sample consisted of 794 cases collected from October 2014 to April 2015. To calculate the sample size, we used the Grammo program (Version 7.11, March 2011) by means of a population estimate. We used an expected prevalence of 33%—the rate found in female nurses in the Andalusian population (Rodríguez-Borrego et al., 2011)—as a reference, with an accuracy of 3%, a 95% confidence level, and a 10% replacement rate. This necessitated a minimum of 517 female health professionals.
The data collection instrument used was a single questionnaire consisting of the following:
- A scale to measure ill-treatment of women developed by Delgado, Aguar, Castellano, and Luna del Castillo (2006), validated for women (reliability of 0.8688 and 0.7072), with modifications by Rodríguez Borrego, Vaquero Abellán, Bertagnolli, Redondo Pedraza, and Muñoz Alonso (2009) because of the detection of an error in the recoding process. In our study, the internal consistency reliability was 0.496. The questionnaire consisted of closed-ended questions focusing on the detection of physical, emotional, and sexual violence. Five possible answers were available: “never,” “rarely,” “sometimes,” “quite a lot,” and “often.” Questions 1–5 referred to psychological abuse; Questions 6, 7, 9, and 10, to physical abuse; and Question 8, to sexual abuse. The measurement scale used was that used by Rodríguez Borrego et al. (2009).
- As additional sociodemographic data, those surveyed were asked if they were suffering from violence. They were asked the following questions: Have you discussed the subject with any person—psychologist, health professionals, trusted people (person close to your social network, sometimes close family member or friend, which is usually useful if you need help), both (health and trusted), and other? Are you receiving any kind of support or treatment? Would you grant a personal interview in a safe and anonymous environment? If the last question was answered in the affirmative, an email address was offered to victims of IPV to contact the main researcher for an in-depth interview.
This study is part of a larger research project that aimed to study IPV among health professionals who work in the SPHS. The present work uses a quantitative approach, focusing on the attention given to health professionals suffering IPV. Participants received an email from their work center inviting them to participate in a study through a Web link. The text of the institutional email included a link to directly access a self-administered, closed-response, online questionnaire, which was completed anonymously. Once they clicked on the study link, an information sheet was provided; they had to give their informed consent to proceed with the questionnaire. That link contained a unique code to avoid double participation.
The study received a favorable report from the Research Ethics Committee of the Hospital in the South of Spain, Reference 2462 and Certificate No. 226. The research respected the basic principles of the Helsinki Declaration and the UNESCO Universal Declaration. Data were treated confidentially, according to the Organic Law 15/1999 of 13 December about the Protection of Personal Data and Royal Decree 994/99 of the Spanish State.
Statistical analysis of the data was performed using SPSS 22.0 (IBM Corp., Armonk, NY) and consisted of a descriptive analysis through the calculation of counts (n) and proportions (%) for qualitative variables and through the calculation of mean (M) and standard deviation (SD) for quantitative variables. Proportions of categorical variables were compared using chi-square tests for contingency tables. When there was frequency ≤ 5, the Fisher test was used. All hypothesis tests were bilateral. For all statistical tests, a confidence value of 95% (p < 0.05) was considered statistically significant.
Of the total sample population (N = 794), 51.9% were nurses, 44.6% were physicians, and 3.5% were nursing assistants. Most were working in urban areas (82.7%), and 68.4% were working in primary care. Most of the participants had children or dependent people under their care (64.2%), with an average of 1 ± 1. The most frequent civil status was married (77.7%), and most lived with their current or last partner (71.7%). The most common economic livelihood (73.3%) was the income of both partners. These data are shown in Table 1, tabulated according to whether or not they were suffering IPV.
The Prevalence of IPV Among Health Professionals
Of the 794 women who participated in the study, 270 (34%) suffered from IPV. Emotional violence was the most common type of IPV (70.7%), followed by a combination of emotional and sexual (12.6%); emotional and physical (7%); emotional, physical, and sexual (5.6%); solely sexual (3%); and solely physical (1.1%).
Attention Given to IPV Victims
Among the respondents, 25.9% had spoken with someone other than the perpetrator about the violence. Those victims reported that they had discussed the violence with a trusted person (24.3%), a psychologist (24.3%), a health professional (20%), others (20%), or both a health professional and a trusted person (11.4%; see Table 2). We found that 11.1% of those participants who disclosed IPV were receiving support or treatment, and 17.8% were willing to grant a personal interview in a safe and anonymous environment (see Table 2).
Considering whether the respondents had discussed their IPV with someone, we detected significant differences according to their civil status (p < 0.001), with married women being less likely to speak about the problem. Women who were living with their last/current husband/partner were also less likely to speak about the problem than those not living with a partner (p = 0.002). Women living in an urban area were also less likely to speak about the problem (p = 0.033). In terms of economic livelihood (p < 0.001), those women relying on a combined income did not usually speak about the problem (see Table 3).
Finally, when analyzing female health professionals to understand with whom they had discussed their IPV, we detected significant differences with respect to civil status and profession (see Table 4): Nurses were more likely to have discussed their IPV with a psychologist (11/41); and physicians, with a trusted person (8/27).
We found that female health professionals tend to resort to trusted people and psychologists to talk about their IPV problem. This is different from the findings of previous studies carried out in Spain for the general population, where it was observed that women first consult psychologists (29.2%), followed by health professionals (22.4%) and legal services (16%), with the health professionals being the best-rated service among the available resources (Delegación Gobierno para la Violencia de Género, 2015). The difference may be because the trusted people whom female health professionals resort to might be fellow health professionals, which would be consistent with previous studies that reported that healthcare services are the main resource for IPV victims (Feder et al., 2006; Garcia-Moreno et al., 2015).
The findings on the prevalence of IPV among health professionals in this study are similar to those in previous research performed in Spain (Rodríguez-Borrego et al., 2011) and in other countries (Al-Natour et al., 2014; Bracken et al., 2010). In addition, the prevalence of IPV found in this study is higher than that for women in Spain in general, which was 24.4% according to the Government Office for Gender-Based Violence in 2015 (Delegación Gobierno para la Violencia de Género, 2015). However, data from Spanish studies regarding the general female population and women who are health professionals show a lower percentage of IPV than is reported in other European studies, where it is estimated that 43% of female participants have suffered emotional violence from their previous or current partner and 33% have suffered physical or sexual violence in their lives at some point since the age of 15 years (European Union Agency for Fundamental Rights, 2014). Other global studies have estimated the prevalence of IPV at 33% (Devries et al., 2013). Despite differences between studies, there seems to be a trend of higher prevalence of IPV among female health professionals in Spain than for women in general (Delegación Gobierno para la Violencia de Género, 2015, 2016; Ruiz-Pérez et al., 2017).
Social norms and societal beliefs about traditional gender roles can lead to the transfer of attitudes toward IPV being passed on from generation to generation (Flood & Pease, 2009; Tran, Nguyen, & Fisher, 2016). In addition, suffering or witnessing violence increases tolerance toward IPV (Heise, 1998). Research has reported that nurses' frustration at not being able to help victims of IPV motivates them to train and seek solutions (Yamada & Kato, 2015). Therefore, the performance of health professionals in respect to IPV will depend on their level of recognition, the type of violence, and their experience (García-Moreno et al., 2015; Tran et al., 2016). Health professionals who suffer IPV might not recognize cases of IPV among the people whom they assist because they may not recognize particular types of behavior as signs of abuse (Carmona-Torres et al., 2018). Thus, vocational training on this issue is necessary at all levels of health care, because most studies report that health professionals need greater training to be able to deal with IPV cases, including training on the availability of social and local services (Blumling, Kameg, Cline, Szpak, & Koller, 2018; DeBoer, Kothari, Kothari, Koestner, & Rohs, 2013; Lozano Alcaraz et al., 2014; Ruiz Navarro, 2011; Umubyeyi, Persson, Mogren, & Krantz, 2016).
Governments have invested many resources in mitigating the problem of IPV: Its continued existence therefore suggests that the current programs are ineffective (Ocampo Otálvaro & Amar, 2011). Perhaps, this is because of the fact that the protocols, laws, and so forth existing in Spain (Delegación Gobierno para la Violencia de Género, 2015; García-Moreno et al., 2015; Ministerio de Sanidad y Consumo, 2007, 2012; Ruiz Navarro, 2011) have not approached the problem that female health professionals, who are key for the care of violence victims, may themselves be victims of IPV and thus may not offer an effective professional response to others. Health policymakers must devise an effective response to health professionals suffering IPV. They should establish specific programs for prevention and support health professionals experiencing IPV to reduce their health consequences.
Strengths and Limitations
One of the fundamental strengths of this study is that it is the first study with a large sample that analyzed who attended to the health professionals experiencing IPV.
Among the limitations of this study, it should be noted that, because of the mode of dissemination of the questionnaire, it was not possible to calculate the rate of nonresponse. Another limitation is that female health professionals suffering IPV might be more motivated to answer the survey, but this limitation could be a strength for this study. If it is assumed that victims were more predisposed to answer the questionnaire, the data referring to the limited attention or assistance they receive, and their silence are even more startling.
In addition, to complete the questionnaire, the respondents needed an electronic device with an Internet connection. Finally, another limitation is the low internal consistency reliability (0.496): The results obtained must therefore be considered with caution, and more studies are necessary to strengthen the results.
Implications for Forensic Nursing Practice
We show that female health professionals suffer IPV but are not included in the existing protocols for IPV in their institutions in Spain. For this reason, health institutions should include in their action plans the detection and management of IPV among their professionals. Healthcare administrators and managers should support and assist health professionals who suffer IPV and provide training about IPV issues and proper interventions to help victims. Unless health professionals care for themselves, it may be difficult for them to provide similar care for their patients (Al-Natour et al., 2014). In addition, it is necessary to establish screening approaches that can detect IPV within health institutions (Dichter, Wagner, Goldberg, & Iverson, 2015).
The absence of scientific production related to this topic of study not only presents a contrast with other studies about professionals who suffer IPV but also highlights the need to conduct more research in this area. It is important to emphasize that healthcare professionals play a very important role when caring for IPV victims (Feder et al., 2006; García-Moreno et al., 2015; Umubyeyi et al., 2016).
Recommendations for Future Research
This study shows that health professionals are not immune to the problem of IPV and sometimes resort to talking to trusted people rather than seeking help from formal sources that are available. This problem is not unique to Spain: Studies have recently identified the problem in other countries such as Australia and Jordan (Al-Natour et al., 2014; McLindon et al., 2018).
To properly address the problem of IPV, further studies will be needed. This research should be conducted in other countries and cultures where women work as health professionals. Health professionals are sometimes the first point of contact for IPV victims and must be able to respond effectively to the problem. Healthcare organizations rarely contemplate what it means if the health professional is impacted by IPV in their home and are asked to intervene sensitively with patients affected by the same issue. If health professionals suffer IPV, they may not respond effectively to others' problems, because there may be certain signs of violence that they do not recognize as such (Carmona-Torres et al., 2018). Therefore, it is necessary that future research focuses on studying the prevalence of IPV among health professionals and who attends to them, as well as on establishing effective measures to prevent it. As McLindon et al. (2018) explain, more research is required to better understand the needs of female health professionals during and after IPV, including the role of the workplace in responding effectively to health professionals suffering IPV and their care of other victims. It is also necessary that future research address IPV among male health professionals: Although the percentage of IPV is lower among men, they can also suffer this problem.
In conclusion, women working as health professionals and who suffer IPV often discuss the problem with trusted people (informal resources) instead of health professionals. This suggests that the problem could remain in the private sphere, which might deprive the victim of the help that she needs. This trend might also affect the professional activities and functions of these health professionals when attempting to help other victims of IPV. Further studies are needed to explore IPV among health professionals and who attends to them as well as to establish effective measures to prevent it and improve assistance.
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