ORIGINAL ARTICLE
Nurses’ views of forensic care in emergency departments and their attitudes, and involvement of family members Josefin Rahmqvist Linnarsson, Eva Benzein and Kristofer Arestedt
Aims and objectives. To describe nurses’ views of forensic care provided for victims of violence and their families in EDs, to identify factors associated with nurses’ attitudes towards families in care and to investigate if these attitudes were associated with the involvement of patients’ families in care. Background. Interpersonal violence has serious health consequences for individuals and family members. Emergency departments provide care for victims of violence, and nurses play a key role in forensic care. However, there is limited knowledge of their views and their involvement of family members. Design. A cross-sectional design was used with a sample of all registered nurses (n = 867) in 28 emergency departments in Sweden. Methods. A self-report questionnaire, including the instrument Families’ Importance in Nursing Care – Nurses’ Attitudes, was used to collect data. Descriptive statistics, multiple linear regression and ordinal regression were used to analyse data. Results. Four hundred and fifty-seven nurses completed the questionnaire (53%). Most nurses provided forensic care, but few had specific education for this task. Policy documents and routines existed for specific patient groups. Most nurses involved family members in care although education and policy documents rarely included them. Being a woman, policy documents and own experience of a critically ill family member were associated with a positive attitude towards family. A positive attitude towards family members was associated with involving patients’ families in care. Conclusion. Many emergency department nurses provided forensic care without having specific education, and policy documents only concerned women and children. Nurses’ positive attitude to family members was not reflected in policies or education. Relevance to clinical practice. These results can inspire clinical forensic care interventions in emergency departments. Educational efforts for nurses and policies for all groups of victims of violence are needed. Emergency departments may need to rethink how family members are included in their organisation. Key words: association, attitude, emergency medical services, family, forensic nursing, nurses, victims of violence Accepted for publication: 22 April 2014
Introduction Interpersonal violence is recognised as a serious public health issue, with consequences for individuals, families and the society. It is a major health concern for countries Authors: Josefin Rahmqvist Linnarsson, RN, MSc, Doctoral student, Department of Health and Caring Sciences, Linnaeus University, Kalmar; Eva Benzein, PhD, RNT, Professor, Department of Health and Caring Sciences, Linnaeus University and Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Kalmar; Kristofer Arestedt, PhD, RN, Assistant Professor, Department of Health and Caring Sciences, Linnaeus University, Kalmar, Department of Medical
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, doi: 10.1111/jocn.12638
around the world (Krug et al. 2002). Emergency departments (EDs) are often the first point of entry for victims of violence, and health concerns related to interpersonal violence often result in multiple visits (Kothari & Rhodes 2006). Consequently, there is a need for preparedness in Health Sciences, Link€ oping University, Link€ oping and Palliative Research Centre, Ersta Sk€ ondal University College and Ersta hospital, Stockholm, Sweden Correspondence: Josefin Rahmqvist Linnarsson, Doctoral student, Department of Health and Caring Sciences, Linnaeus University, SE-391 82 Kalmar, Sweden. Telephone: +46 70 752 32 68. E-mail: [email protected]
1
J Rahmqvist Linnarsson et al.
EDs to provide care for patients who are victims of violence, that is, forensic care (McCracken 1999). Among ED staff, nurses have been especially identified as playing a key role when caring for victims of violence (Rahmqvist Linnarsson et al. 2013). However, there is limited knowledge concerning their views of the forensic care provided. Violence can also cause serious health problems for family members (Gunnels 1997, Krug et al. 2002). Despite this, little is known about the involvement of family members in forensic care.
Background Health consequences of interpersonal violence comprise both physical and mental sequelae (Singer et al. 1995, Coker et al. 2002, Carbone-Lopez et al. 2006), such as injuries, chronic pain, depression and post-traumatic stress disorder (Campbell 2002). Around 1% of Sweden’s population report being victims of interpersonal violence. International comparison shows that between 01–18% of the population in 30 surveyed countries report victimisation from violent crime (Van Dijk et al. 2008). According to the latest Swedish crime survey, only one-third of interpersonal crimes committed are reported to the police (The Swedish National Council of Crime Prevention 2012). Even though EDs often provide forensic care, preparedness seems to vary in different groups of forensic patients as protocols and routines often only concern women, children and sexual assault (Bell et al. 1994). EDs in Sweden also seem to lack a general preparedness to provide forensic care regardless of the victim’s gender or age (Rahmqvist Linnarsson et al. 2013). Previous studies also point to a need for education in forensic care among ED staff (Wilkinson et al. 2005, Abdool & Brysiewicz 2009, Henderson et al. 2012), especially among nurses who seem to be in a key position to provide such care (Rahmqvist Linnarsson et al. 2013). Interpersonal violence also affects family members and can cause health problems for them as well (Gunnels 1997, Krug et al. 2002). Care provided at the ED following a stressful event is crucial to reduce the risk of adjustment disorders such as post-traumatic stress disorder (Kercher 1991). Involving family members in various care contexts can strengthen the family unit and alleviate suffering and emotional distress (Eggenberger & Nelms 2007). When involved in care, family members can also be an important support for the patient (Engstrom & Soderberg 2007, Paavilainen et al. 2009). Previous studies of families in critical care are mostly from intensive care units and not from EDs (Obringer et al. 2012, Al-Mutair et al. 2013). The
2
published studies that were found about families in EDs focused on presence during resuscitation or sudden bereavement (Compton et al. 2011, Leung & Chow 2012). Despite knowledge of the importance of family members in critical care, no studies were found concerning the involvement of patient’s families in forensic care in EDs. An underlying assumption in this study is that quality of care for family members is influenced by the nurses’ attitudes towards the importance of families in nursing care. Nurses have been shown to be in a unique position to care for family members in critical care (Rahmqvist Linnarsson et al. 2010). A previous study with nurses from different care contexts showed that gender, years working as a registered nurse and general approach at the workplace influenced nurses’ attitudes (Benzein et al. 2008b). However, there are to our knowledge no published studies regarding possible factors associated with nurses’ attitudes to families in an acute care context. It is also unknown whether nurses’ attitudes are associated with the involvement of patients’ families in care. The aims of this study were therefore (1) to describe nurses’ views of forensic care provided for victims of violence and their families in EDs, (2) to identify factors associated with nurses’ attitudes towards families in care and (3) to investigate whether these attitudes were associated with the involvement of patients’ families in care.
Methods Design and sample A cross-sectional, multicentre design was used in this study. All registered nurses (n = 867) currently working at 28 EDs in Sweden were included. The EDs were derived from a previous study aiming to describe preparedness to provide care for victims of violence and their families in EDs from the perspective of the heads of departments (Rahmqvist Linnarsson et al. 2013). These EDs were contacted once again for the present study for inclusion of all nurses working there. Both larger university hospital EDs and smaller regional hospital EDs in 14 of 21 county councils were represented in the sample. The head of department at each ED provided contact information for employed nurses and approved this study to be conducted at their department. According to current Swedish ethics legislation, formal ethical approval was not required for this study. The study adheres to the principles of the Declaration of Helsinki (World Medical Association 2008). The participants were informed of the voluntary nature of their participation and that individual responses were confidential. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing
Original article
Data collection A web-based self-report questionnaire was composed on the basis of a previous study (Rahmqvist Linnarsson et al. 2013) and a thorough review of relevant literature. To ensure content validity, the questions were evaluated by an expert group of clinicians and researchers (Streiner & Norman 2008). The questionnaire was sent to the sample of nurses as a secure hyperlink embedded within an informational e-mail in the fall of 2012. Two reminders were sent to those who did not respond. The questionnaire included background information such as gender, age, years working as a RN and specialist nursing degree. It also included questions concerning ED policy documents, routines and education for care of victims of violence and their families (nine items), as well as nurses’ own work and personal experiences (six items). The questions were closedended followed by some open-ended questions for free text responses (Streiner & Norman 2008). All questions needed to be answered before submission was enabled. Together with the questionnaire, the nurses also received the instrument Families’ Importance in Nursing Care – Nurses’ Attitudes (FINC-NA), which measures nurses’ attitudes to the importance of families in nursing care (Benzein et al. 2008a). In this study, a revised version of the instrument FINC-NA, which has shown good measurement properties in terms of validity and reliability, was used (Saveman et al. 2011). It consists of 26 items with a fivepoint Likert response scale (from ‘totally agree’ to ‘totally disagree’). The higher the score, the more the positive attitude towards families in nursing care. FINC-NA is a multidimensional instrument and comprises of four subscales (Benzein et al. 2008a): family as a resource in nursing care (Fam-RNC, ten items), family as a conversational partner (Fam-CP, eight items), family as a burden (Fam-B, four items) and family as its own resource (Fam-OR, four items). Internal consistency in this study sample estimated using Cronbach’s alpha was a = 090 for the FINC-NA total scale and for Fam-RNC a = 089, Fam-CP a = 080, Fam-B a = 059 and Fam-OR a = 079. ‘Family members’ and ‘families’ were used as terms for a self-defined group of individuals considered significant for the patient regardless of blood ties or law.
Data analysis Descriptive statistics were calculated for the sample demographics and were also used to describe the nurses’ views of forensic care provided for victims of violence and their families in EDs (Altman 1990). © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing
Nurses’ views of forensic care and families
Multiple linear regression analyses were applied to identify factors associated with nurses’ attitudes to families in care. The FINC-NA scales were used as dependent variables, whereas independent variables included gender (women/men), years working as a RN, specialist nursing degree (yes/no), knowledge of documents concerning care for family members (yes/no), received education on care for family members (yes/no) and own experience of having a critically ill family member (yes/no). The regression analyses were based on robust standard errors as the assumption of normality was violated. Multicollinearity was assessed with variance inflation factor (VIF). No problems were detected, and the variables had VIF values between 100– 136 (Cohen et al. 2003). Ordinal regression analyses in two steps were used to investigate whether nurses’ attitudes were associated with the involvement of patients’ families in care. The question ‘Do you involve family members of victims of violence in care?’ (yes, always/yes, sometimes/no) was used as the dependent variable. Nurses in the sample who did not provide care for victims of violence were excluded in these analyses (n = 13). In the first step, an initial regression model was used with the FINC-NA scales as single independent variables. In the second step, a full regression model was created with the FINC-NA scales together with the covariates that were significantly associated with FINCNA in the multiple linear regression model: gender, own experience of having a critically ill family member and knowledge of documents concerning care for family members (Cohen et al. 2003). For each analysis, a p-value of
Nurses’ views of forensic care in emergency departments and their attitudes, and involvement of family members Josefin Rahmqvist Linnarsson, Eva Benzein and Kristofer Arestedt
Aims and objectives. To describe nurses’ views of forensic care provided for victims of violence and their families in EDs, to identify factors associated with nurses’ attitudes towards families in care and to investigate if these attitudes were associated with the involvement of patients’ families in care. Background. Interpersonal violence has serious health consequences for individuals and family members. Emergency departments provide care for victims of violence, and nurses play a key role in forensic care. However, there is limited knowledge of their views and their involvement of family members. Design. A cross-sectional design was used with a sample of all registered nurses (n = 867) in 28 emergency departments in Sweden. Methods. A self-report questionnaire, including the instrument Families’ Importance in Nursing Care – Nurses’ Attitudes, was used to collect data. Descriptive statistics, multiple linear regression and ordinal regression were used to analyse data. Results. Four hundred and fifty-seven nurses completed the questionnaire (53%). Most nurses provided forensic care, but few had specific education for this task. Policy documents and routines existed for specific patient groups. Most nurses involved family members in care although education and policy documents rarely included them. Being a woman, policy documents and own experience of a critically ill family member were associated with a positive attitude towards family. A positive attitude towards family members was associated with involving patients’ families in care. Conclusion. Many emergency department nurses provided forensic care without having specific education, and policy documents only concerned women and children. Nurses’ positive attitude to family members was not reflected in policies or education. Relevance to clinical practice. These results can inspire clinical forensic care interventions in emergency departments. Educational efforts for nurses and policies for all groups of victims of violence are needed. Emergency departments may need to rethink how family members are included in their organisation. Key words: association, attitude, emergency medical services, family, forensic nursing, nurses, victims of violence Accepted for publication: 22 April 2014
Introduction Interpersonal violence is recognised as a serious public health issue, with consequences for individuals, families and the society. It is a major health concern for countries Authors: Josefin Rahmqvist Linnarsson, RN, MSc, Doctoral student, Department of Health and Caring Sciences, Linnaeus University, Kalmar; Eva Benzein, PhD, RNT, Professor, Department of Health and Caring Sciences, Linnaeus University and Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Kalmar; Kristofer Arestedt, PhD, RN, Assistant Professor, Department of Health and Caring Sciences, Linnaeus University, Kalmar, Department of Medical
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, doi: 10.1111/jocn.12638
around the world (Krug et al. 2002). Emergency departments (EDs) are often the first point of entry for victims of violence, and health concerns related to interpersonal violence often result in multiple visits (Kothari & Rhodes 2006). Consequently, there is a need for preparedness in Health Sciences, Link€ oping University, Link€ oping and Palliative Research Centre, Ersta Sk€ ondal University College and Ersta hospital, Stockholm, Sweden Correspondence: Josefin Rahmqvist Linnarsson, Doctoral student, Department of Health and Caring Sciences, Linnaeus University, SE-391 82 Kalmar, Sweden. Telephone: +46 70 752 32 68. E-mail: [email protected]
1
J Rahmqvist Linnarsson et al.
EDs to provide care for patients who are victims of violence, that is, forensic care (McCracken 1999). Among ED staff, nurses have been especially identified as playing a key role when caring for victims of violence (Rahmqvist Linnarsson et al. 2013). However, there is limited knowledge concerning their views of the forensic care provided. Violence can also cause serious health problems for family members (Gunnels 1997, Krug et al. 2002). Despite this, little is known about the involvement of family members in forensic care.
Background Health consequences of interpersonal violence comprise both physical and mental sequelae (Singer et al. 1995, Coker et al. 2002, Carbone-Lopez et al. 2006), such as injuries, chronic pain, depression and post-traumatic stress disorder (Campbell 2002). Around 1% of Sweden’s population report being victims of interpersonal violence. International comparison shows that between 01–18% of the population in 30 surveyed countries report victimisation from violent crime (Van Dijk et al. 2008). According to the latest Swedish crime survey, only one-third of interpersonal crimes committed are reported to the police (The Swedish National Council of Crime Prevention 2012). Even though EDs often provide forensic care, preparedness seems to vary in different groups of forensic patients as protocols and routines often only concern women, children and sexual assault (Bell et al. 1994). EDs in Sweden also seem to lack a general preparedness to provide forensic care regardless of the victim’s gender or age (Rahmqvist Linnarsson et al. 2013). Previous studies also point to a need for education in forensic care among ED staff (Wilkinson et al. 2005, Abdool & Brysiewicz 2009, Henderson et al. 2012), especially among nurses who seem to be in a key position to provide such care (Rahmqvist Linnarsson et al. 2013). Interpersonal violence also affects family members and can cause health problems for them as well (Gunnels 1997, Krug et al. 2002). Care provided at the ED following a stressful event is crucial to reduce the risk of adjustment disorders such as post-traumatic stress disorder (Kercher 1991). Involving family members in various care contexts can strengthen the family unit and alleviate suffering and emotional distress (Eggenberger & Nelms 2007). When involved in care, family members can also be an important support for the patient (Engstrom & Soderberg 2007, Paavilainen et al. 2009). Previous studies of families in critical care are mostly from intensive care units and not from EDs (Obringer et al. 2012, Al-Mutair et al. 2013). The
2
published studies that were found about families in EDs focused on presence during resuscitation or sudden bereavement (Compton et al. 2011, Leung & Chow 2012). Despite knowledge of the importance of family members in critical care, no studies were found concerning the involvement of patient’s families in forensic care in EDs. An underlying assumption in this study is that quality of care for family members is influenced by the nurses’ attitudes towards the importance of families in nursing care. Nurses have been shown to be in a unique position to care for family members in critical care (Rahmqvist Linnarsson et al. 2010). A previous study with nurses from different care contexts showed that gender, years working as a registered nurse and general approach at the workplace influenced nurses’ attitudes (Benzein et al. 2008b). However, there are to our knowledge no published studies regarding possible factors associated with nurses’ attitudes to families in an acute care context. It is also unknown whether nurses’ attitudes are associated with the involvement of patients’ families in care. The aims of this study were therefore (1) to describe nurses’ views of forensic care provided for victims of violence and their families in EDs, (2) to identify factors associated with nurses’ attitudes towards families in care and (3) to investigate whether these attitudes were associated with the involvement of patients’ families in care.
Methods Design and sample A cross-sectional, multicentre design was used in this study. All registered nurses (n = 867) currently working at 28 EDs in Sweden were included. The EDs were derived from a previous study aiming to describe preparedness to provide care for victims of violence and their families in EDs from the perspective of the heads of departments (Rahmqvist Linnarsson et al. 2013). These EDs were contacted once again for the present study for inclusion of all nurses working there. Both larger university hospital EDs and smaller regional hospital EDs in 14 of 21 county councils were represented in the sample. The head of department at each ED provided contact information for employed nurses and approved this study to be conducted at their department. According to current Swedish ethics legislation, formal ethical approval was not required for this study. The study adheres to the principles of the Declaration of Helsinki (World Medical Association 2008). The participants were informed of the voluntary nature of their participation and that individual responses were confidential. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing
Original article
Data collection A web-based self-report questionnaire was composed on the basis of a previous study (Rahmqvist Linnarsson et al. 2013) and a thorough review of relevant literature. To ensure content validity, the questions were evaluated by an expert group of clinicians and researchers (Streiner & Norman 2008). The questionnaire was sent to the sample of nurses as a secure hyperlink embedded within an informational e-mail in the fall of 2012. Two reminders were sent to those who did not respond. The questionnaire included background information such as gender, age, years working as a RN and specialist nursing degree. It also included questions concerning ED policy documents, routines and education for care of victims of violence and their families (nine items), as well as nurses’ own work and personal experiences (six items). The questions were closedended followed by some open-ended questions for free text responses (Streiner & Norman 2008). All questions needed to be answered before submission was enabled. Together with the questionnaire, the nurses also received the instrument Families’ Importance in Nursing Care – Nurses’ Attitudes (FINC-NA), which measures nurses’ attitudes to the importance of families in nursing care (Benzein et al. 2008a). In this study, a revised version of the instrument FINC-NA, which has shown good measurement properties in terms of validity and reliability, was used (Saveman et al. 2011). It consists of 26 items with a fivepoint Likert response scale (from ‘totally agree’ to ‘totally disagree’). The higher the score, the more the positive attitude towards families in nursing care. FINC-NA is a multidimensional instrument and comprises of four subscales (Benzein et al. 2008a): family as a resource in nursing care (Fam-RNC, ten items), family as a conversational partner (Fam-CP, eight items), family as a burden (Fam-B, four items) and family as its own resource (Fam-OR, four items). Internal consistency in this study sample estimated using Cronbach’s alpha was a = 090 for the FINC-NA total scale and for Fam-RNC a = 089, Fam-CP a = 080, Fam-B a = 059 and Fam-OR a = 079. ‘Family members’ and ‘families’ were used as terms for a self-defined group of individuals considered significant for the patient regardless of blood ties or law.
Data analysis Descriptive statistics were calculated for the sample demographics and were also used to describe the nurses’ views of forensic care provided for victims of violence and their families in EDs (Altman 1990). © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing
Nurses’ views of forensic care and families
Multiple linear regression analyses were applied to identify factors associated with nurses’ attitudes to families in care. The FINC-NA scales were used as dependent variables, whereas independent variables included gender (women/men), years working as a RN, specialist nursing degree (yes/no), knowledge of documents concerning care for family members (yes/no), received education on care for family members (yes/no) and own experience of having a critically ill family member (yes/no). The regression analyses were based on robust standard errors as the assumption of normality was violated. Multicollinearity was assessed with variance inflation factor (VIF). No problems were detected, and the variables had VIF values between 100– 136 (Cohen et al. 2003). Ordinal regression analyses in two steps were used to investigate whether nurses’ attitudes were associated with the involvement of patients’ families in care. The question ‘Do you involve family members of victims of violence in care?’ (yes, always/yes, sometimes/no) was used as the dependent variable. Nurses in the sample who did not provide care for victims of violence were excluded in these analyses (n = 13). In the first step, an initial regression model was used with the FINC-NA scales as single independent variables. In the second step, a full regression model was created with the FINC-NA scales together with the covariates that were significantly associated with FINCNA in the multiple linear regression model: gender, own experience of having a critically ill family member and knowledge of documents concerning care for family members (Cohen et al. 2003). For each analysis, a p-value of
