Nurse education and understanding related to domestic violence and abuse against women: An integrative review of the literature

Abstract Aim The aim of this study was to explore previous literature related to nurses understanding of Intimate partner violence (IPV) or domestic violence and abuse (DVA) against women and to identify the gaps in nursing education so as to use the findings as a baseline to inform potential intervention strategies, curriculum development and outline implications for future nursing practice. Design An Integrative review of literature. Methods Studies were extracted through a search of the electronic databases, such as Science direct, EBSCO host and PubMed, to identify relevant evidences published between January 2000–January 2017. “Joanna Briggs Institute (JBI) tool” was used to review primary research studies. Results Seventeen empirical studies were analysed. Findings supported four themes including: educational and training experiences, identification of IPV/DVA, curriculum and communication skills of nurses. Continued efforts are further needed to highlight and address IPV/DVA in nursing education and training, to scale up nursing understanding to respond and identify IPV/DVA appropriately in a clinical environment.

of contact in healthcare services, who frequently encounter women suffering from IPV/DVA. However, in healthcare contexts, they may not be able to recognize or support women presenting with IPV/DVA (McGarry and Nairn, 2015). Nurses should essentially be equipped with the most contemporary knowledge and training to categorize concerns and manage different patients appropriately. Nurse's practice warrants psychological and physical demands everyday as they get engaged in several tasks. Therefore, other than experience, a nurse needs to have a comprehensive skill set so that health care for women does not suffer (Ghayath, Al-Sagobi, Alansari, El-Shazly, & Kamel, 2010). Given the potential impact of future nurses in reducing IPV/DVA against women, this area warrants further investigation. This study will help in influencing future research and nursing educational practice together with identifying significant gaps in care and well-being of women. Thus, an integrative review of literature was undertaken to explore past evidence related to IPV/DVA against women and to identify the gaps in nursing education to use the findings as a baseline to inform potential intervention strategies, curriculum development in addition to outlining implications for future nursing practice.

| Background
The fundamental aspects that influence nurse assessments of IPV/ DVA are reported extensively across the healthcare literature. In spite of various endorsements from the professional bodies and mandates for assessment in emergency departments internationally, studies points towards the lack of IPV/DVA enquiry in majority of the outpatient settings (Clark, Lynette, & Mary, 2017). The nursing assessment is considered to be one of the most compelling elements of communication with patients regarding domestic violence (Reis et al., 2010). Previous anecdotal experiences by nurses in different healthcare settings demonstrates that victims of domestic violence often discuss their experience related to violence if inquired about it in a non-judgmental, empathic and direct way. Previous literature also identified different factors about why intervention with reference to identification and screening with IPV/DVA victims are not performed reliably (Alvarez, Fedock, Grace, & Campbell, 2016). The primary barriers identified by nurses include language barriers, cultural differences, fear of repercussions of obligatory reporting laws, frustration is associated with the futility of the responses of healthcare systems, history of personal exposure to abuse, low confidence in inquiring questions, fear of offending victims and lack of privacy, resource knowledge available for victims, time constraints and lack of training. Perceived patient-related barriers consist of: fear of police involvement, lack of disclosure, socioeconomic factors, accessing care because of perpetrator's prevention, shame and fear of retaliation and absence of follow-up on referrals (Beynon, Gutmanis, Tutty, Wathen, & MacMillan, 2012).
Previous studies on barriers to intervene and screen with the IPV/ DVA victims are abundant (Ahmad, Ali, Rehman, Talpur, & Dhingrra, 2016;Sprague, Madden and Simunovic, 2012). Educational needs are identified to be the most prominent preceding aspect (Crombie, Hooker, & Reisenhofer, 2017). Education that starts in schools of nursing continues during the course of the nurse career that helps to prepare nurses what is required for a sustained IPV/DVA practice. Education is the basic tool or facilitator needed to influence the integration of routine screening by nurses in practical settings.
Protocols, routine screening queries included in the forms of assessments and chart prompts are some other facilitator that increases the screening process (Crombie et al., 2017).
IPV/DVA is a massive health problem globally. Domestic Violence cases are often reported and then, collected evidence is submitted for investigation. However, less attention is placed on the skills required by nurses to ensure that they are capable to properly screen women for the signs of abuse (Ramsay et al., 2012).

Why is this research or review needed?
• IPV/DVA is a global health problem mainly perpetrated against women of all ages from every society.
• Most of the nurses lack adequate knowledge in reacting to and identifying IPV/DVA against women.
• How nurses should be prepared to deal with IPV/DVA against women during their educational tenure is yet to be investigated.
What are the key findings?
• Nurses play a crucial role in recognizing IPV/DVA against women and in providing them practical, emotional and psychological support.
• Collected evidences indicate that nurses during their education do not receive sufficient instructive training about IPV/DVA, in their advanced education curriculum, to permit them to deal with, recognize and identify IPV/ DVA in their future specialized practice.
• Nurse usually lack confidence in responding to IPV/DVA mainly due to limited training and educational experience, fear of offending, lack of effective interventions and communication skills.
How should the findings be used to influence policy/practice/research/education?
• Nurses should consider routine screening for women suffering IPV/DVA as a standard of care.
• The study supports the need for undergraduate nurses to receive interactive learning opportunities engaging the victims and training on IPV/DVA against women at multi-agency levels to raise awareness and identify suitable interventions.
• Future research is needed to influence the nurse education by integrating post-and pre-registration courses and preparation programs in the nursing curriculum related to the issues of IPV/DVA against women.
Registered nurses have an imperative role to play in identification, responding, intervention and referral of women with current or past histories of IPV/DVA, however, more than one-third of nurses have been found to have no formal education on IPV/DVA. Furthermore, research has found that there has been a shortage of content in nursing curriculum that is related to domestic abuse and violence against women. There is a dire need for educational intervention to ensure that nurses are provided appropriate training to equip them with adequate skills and knowledge in dealing with abused women. Since, limited or no medical curricula comprehensively covers DV-related issues such as intervention strategies, medical consequences of DV and legal rights of females, therefore, this study will help to explore the gaps in nursing education with respect to IPV/DVA.

| THE RE VIE W/AIM
To explore previous literature related to nurses understanding with regard to IPV/DVA against women and to identify the gaps in nursing education to use the findings as a baseline to inform potential intervention strategies, curriculum development in addition to outlining implications for future nursing practice.

| Design
We conducted an integrative review using the theoretical framework espoused by Whittemore and Knafl (2005) to examine literature, including all methodological approaches and allow non-experimental and experimental studies to inclusively comprehend the phenomenon being investigated. We used systematic and explicit process to reduce the risk of bias, improve the reliability of results together with usefully pooling data from both the empirical and theoretical evidences. This type of review is appropriate for our research because limited knowledge of nurses exists around this topic, therefore, the past theoretical or empirical literature will be reviewed that might lead to the conceptualization of a preliminary or initial topic (Torraco, 2005).

| Search methods
Electronic databases including Science direct, EBSCO host, PubMed Ovid Medline database and Social Science Index were searched to extract relevant articles. The key word domestic violence/Intimate partner violence was combined with some other key terms such as "nurse", "abuse" "knowledge", "perception", "understanding" "integrative review", "education", "curriculum" and "women" and the phrases used included "nurses and domestic violence", "nurse education and domestic violence", "nurses training and domestic violence" and "relationship between nurses and abused women". Boolean connectors and truncation symbols "OR", "AND" were used to merge terms for focusing and broadening the search.

| Search outcomes
Findings of the papers written in English language published from the year January 2000-January 2017 were included, as majority of the studies related to nurse education on IPV/DVA were conducted over the last 17 years and is also considered as a golden period. This integrative review included both qualitative, quantitative and mixed TA B L E 1 Summary of integrative review databases, search terms, and inclusion criteria Search terms "Nurse", "battering", "abuse" "knowledge", "perception", "understanding" and "women" and the phrases used included "nurses and domestic violence", "health care system and domestic violence", "nurses training on domestic violence" and "relationship between nurses and abused women".

| Quality appraisal
To ensure external and internal validity of the selected studies, Joanna Briggs Institute (JBI) critical appraisal tool/Briggs institute checklist was used to examine the methodological quality of the qualitative and quantitative articles based on the level of evidence (Tables 2-5). While for mixed method articles (Table 5), O'Cathain (2010) critical appraisal framework was used. These tools were used to characterize the strengths, limitation and impact of pertinent data with an intention of addressing the research aims/objectives and the quality of evidence being provided, mainly extracted in line with the specific objectives and review aims. We used this tool to lessen the risk of error/bias while pulling out data from each article individually. Hart (2000) demonstrated that analysis in any study is an aspect of systematically breaking down relevant data into different components and discussing how it relates with each other. Therefore, this study made use of thematic analysis as recommended by Aveyard (2010). It required to control the frequency of theme appearance or data type. To accomplish this, the investigator should be accustomed with the already collected data and must read the evidence being examined. Thematic analysis is considered to be the most suitable approach because it is an aspect of moving closer to the extracted data and mounting even deeper appreciation of the content (Fink, 2010). Thematic analysis was done based on the content similarity in addition to patterns observed in the chosen articles. Hart (2000) indicated that data synthesis is an aspect of creating connections between the components being identified during analysis.

| Data synthesis
It is referred to as an aspect where an investigator approaches literature as soon as it is assembled. The synthesis should be performed in a "step by step manner" to make the data more manageable. It is therefore imperative to have comprehensive subject knowledge and an aptitude to think in a broader context. It is undertaken by fetching together different studies as well as other pieces of information so as to discern new meanings. The final review yielded 17 studies as shown in Figure 1. The quantitative studies were dominated TA B L E 3 JBI critical appraisal checklist for analytical cross-sectional studies  (N = 8) (Table 6), only two studies used mixed method approach (N = 2) ( Table 7) and seven were qualitative studies (N = 7) (Table 8).
Moreover, themes were identified manually by the author (Table 9).

| Ethics
Ethical approval was not required.

| RE SULTS
An initial search from the selected databases was performed to identify potentially relevant articles. This was followed by the abstract and title screening, after which full texts of potential studies were assessed and retrieved. A total of (N = 321) and (N = 5) studies were identified and examined for the construction of this paper.
A total of 192 duplicate records were excluded to reduce repetition of similar information while full text of 26 were not available.
After abstracts/title review, 107 full articles were reviewed for inclusion. 62 research papers were dated between 2000-2017. After thorough review of the full text; 45 articles were excluded from this investigation because it did not meet the inclusion criteria for instance, these were midwives studies or focused on children or males. The conduction of research strategy through MeSH terms, was performed that produced studies focused on midwives as well.
These studies were excluded due to the lack of relevance to our proposed research question. We excluded midwives research studies with midwife participants because routine enquiry by midwives into domestic violence in UK is compulsory. The final review yielded 17 studies.
Evaluation of these articles found that the body of evidence on nurse knowledge on IPV/DVA was limited. The data were recategorized as well as recorded as essential to fit under more suitable headings as well as eventually, the categorized data were aggregated into four themes: educational and training experiences of nurses, identification of IPV/DVA, curriculum and communication skills of nurses.

TA B L E 4 JBI Critical Appraisal
Checklist for Quasi-Experimental Studies (Non-randomized experimental studies) (Schoening et al., 2004) and included a convenience sample of 52 nurses.

| Identification of IPV/DVA
The identification of girls and women who are subjected to IPV/DVA is considered to be a criterion for adequate care and treatments along with specialized referral to services. IPV/DVA identification in healthcare hospitals can be improved if women are inquired about it, whereas, it is safe and effective only if followed by a suitable response (Al-Natour, Gillespie, Felblinger, & Wang, 2014;Beccaria et al., 2013;Davidov, Nadorff, Jack, & Coben, 2012;Davila, 2006;Guruge, 2012;Schoening et al., 2004). This type of disclosure is relatively low to best predict the prevalence of IPV, while some studies indicate that in spite of training for universal screening, majority of the providers inquire about it selectively (Beccaria et al., 2013;Schoening et al., 2004).
Studies indicate that nurses needs to be knowledgeable and Furthermore, in countries or settings where prevalence of IPV/DVA is high and scare referral choices are found, maybe a universal enquiry bring around limited advantage for women along with overwhelming health professionals (Bryant & Spencer, 2002).
Another study demonstrated that majority of women find queries regarding IPV/DVA tolerable (Schoening et al., 2004 1. Qualitative element/study has qualitative objective or question 2. Qualitative element/study has appropriate design or method context for qualitative element/study is described 3. Sampling approach and participants in qualitative element/study are described 4. Approach to data collection and analysis in qualitative element/study is described 5. Researcher reflexivity in qualitative element/study is discussed Sequence generation or randomization in quantitative experimental element/study is appropriate 6. "Blinding" in quantitative experimental element/study is appropriate 7. Data sets are complete or largely complete in quantitative experimental element/study 8. Sampling and sample is appropriate to quantitative observational study/element 9. Choice of measurements in quantitative observational study/element is justified 10. Confounding variables are properly controlled in quantitative observational study/element 11. Mixed methods element/study is justified 12. Mixed methods element/study combines qualitative and quantitative data collection methods and/or analysis techniques 13. Mixed methods element/study integrates data or results from qualitative and quantitative elements

Domain 8: Utility
Findings are useful to "target audience" e.g., policy makers and consumers

TA B L E 5 (Continued)
TA B L E 6 Summary of Quantitative articles identified for data extraction and included in the integrative review

| D ISCUSS I ON
The findings from the studies reviewed in this integrative literature review, evidenced nurses understanding with regard to domestic violence against women and identified the gaps in nursing education. These new insights will enable the findings to be used as a baseline to inform suitable intervention strategies and curriculum development (Beccaria et al., 2013;Bessette & Peterson, 2002;Cho et al., 2015;Davila, 2006;Dedavid da Rocha et al., 2015;Häggblom & Möller, 2006 TA B L E 9 Some of the common themes extracted from the articles analysed as described in the findings are as follows: women make attempts to hide such violence due to the feelings of shame and being stigmatized (Spangaro, Poulos, & Zwi, 2011 (Cho et al., 2015;Schoening et al., 2004). This review also provides insights into undergraduate nursing opinions and attitudes regarding DVA. The findings highlights concern areas that are often comparable to the problems identified in the broad literature. These findings also has implications for nursing education ensuring that graduates are well equipped to suitably respond to and identify DVA/IPV in the clinical settings. Our findings also resonate with the WHO "Clinical and Policy Guidelines (2013) for Health Sector Response to Violence against Women" that mainly focused on the need for training at "pre-qualification level." These guidelines aims to raise awareness about the DVA/IPV against women among policy makers together with health professionals so that they can adequately comprehend the necessity for suitable responses in a healthcare environment. A standard offered in a certain guideline can be incorporated into the education of nurse professionals.

| Strengths and limitations
The integrative review was strengthened using a specific framework for guidance. Our review was enhanced by implementation of a widely accepted critical appraisal tool "JBI" to assess the quality of each study and huge number of international studies counted in our analysis. This review has numerous limitations which may lead to limit the generalizability of the findings. For example, grey literature was not searched. The exclusion of studies in languages other than English language also served as a limitation that resulted in exclusion of some substantial and important evidence. Although this review was systematic in our review steps and processes, but was not a systematic review. Adoption of a systematic review approach would have enhanced the scientific rigour of review, however, limited financial and personnel resources prevented us from adopting this approach.

| CON CLUS ION
Intimate partner violence (IPV) or domestic violence and abuse (DVA) often has a huge psychological or physical impact on the lives of women. Major success for implementation of a DVA enquiry is based on the developmental needs and training of the nurses involved. Nurses tend to play a statistically significant role in recognizing individuals who are DVA victims, boosting the developments of safety plan as well as expediting access to support on top of assistance. Courses at undergraduate level in a nursing university is an ultimate opportunity to bring changes in the attitudes concerning DVA, also equip nurses with an inclusive understanding of IPV/DVA. This review offers insights into the opinions of nurses on IPV/DVA as well as identifies a need for constant consideration to address persistent educational needs to identify DVA against women. This review draws attention to the need for future research to influence the nurse education on shaping suitable professional attitude towards IPV/DVA as well as influence clinical practices.

| Implications for practice, education and research
The findings of this review may be of significance to nursing practice, as nursing staff caring for women suffering from DVA can be facilitated in developing a positive attitude towards the use of screening questions, better communication methods and advanced training during the course of their study. Nurses often have a duty of care towards their patients/clients, yet IPV/DVA is thought to be largely unreported or unasked, with many of the women going home with the DVA perpetrator. It is important to consider that nurses are professionals who are often involved with the care of patients, which may create a safe environment for a disclosure to happen. Hence, there lies a need for mandatory collaboration between secondary and primary health care along with trainings, liaising with some local agencies, to provide support to women who experience DVA. It is essential to include post-and pre-registration courses in nursing curriculum. Cooperative networking are required for establishing the multi-agency guidelines and trainings, all of which tends to influence the DVA identification. Referral channels and information sharing need to be established in secondary and primary sectors for providing assistance in this process. Training at multi-agency levels are needed to: raise awareness, identify, estimate risk levels, document as well as identify suitable intervention levels.

ACK N OWLED G EM ENTS
None.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the author(s).