Screening for domestic and family abuse in Australian public hospital emergency departments: extent, models and impacts

In Australia at least one woman is killed every week as a result of abusive and controlling behaviours by a current or former partner (Bricknell 2020). Accurate statistics on prevalence and mortality are difficult to obtain as all states and territories have their own legislation with different definitions and diverse record keeping procedures (AIHW 2018). Despite these challenges, data compiled and compared from 20 major sources demonstrates that domestic and family abuse is the third greatest health risk for women in Australia between 25 and 44 years of age (AIHW 2021), and the consequences of this result in many presentations to health settings for assistance. It is estimated that up to ten women a day are hospitalised as a result of an assault by a current or former partner (AIHW 2021). Research indicates that women living with or recovering from domestic and family abuse will present to emergency departments three times more often than other women and are more likely to present frequently (Power, Bahnisch and McCarthy 2011). However, these statistics are likely to be an underestimate because there is under-identification of domestic abuse related health issues in presentations to hospitals in Australia (State of Victoria 2016c). This thesis examines contemporary screening programs within Australia and internationally and explores the nature of and extent to which emergency departments of public hospitals within Australia screen, identify and respond to women who present with health issues resulting from domestic and family abuse. The experiences of women victim/survivors upon presentation to emergency departments, are central to this exploration. This thesis draws on qualitative and quantitative methodologies in order to gain information from various sources in this area. This research included an online survey completed by 35 emergency department social workers in order to gain insight into their understanding and practice knowledge around domestic and family abuse and screening programs to address this issue. This research also included the facilitation of four focus groups comprising in total 25 women victim/survivors of domestic and family abuse, alongside interviews with ten emergency department social workers and five family violence agency managers from organisations across Australia. These qualitative methods provided in-depth information from well-informed participants. In Australia and internationally, there are many debates within hospitals and health settings arguing the usefulness and integrity of universal screening programs to identify and manage women presenting with health impacts resulting from domestic and family abuse. This research acknowledges those debates, examines good practice in screening programs, and argues for the implementation of universal screening in the Australian context. A review of screening programs in emergency departments found a preference in Australia for selective screening models where women are screened in health areas known for elevated risk of domestic and family abuse, or upon the presence of clinical indicators. The social work participants in this research nominated several clinical indicators that would lead them and/or their colleagues to ask screening questions of women presenting to the emergency department. The experiences of the women victim/survivor participants validated information from the literature review which found that domestic and family abuse impacts on the health of victim/survivors, who present to a variety of health sites for assistance (including emergency departments) but are unlikely to disclose during these presentations. The women in this research presented with many of the clinical indicators nominated by the emergency department social workers, yet did not have their abuse identified, even in situations where there was a selective screening program in place. Further to this, the responses and treatment received by the women focussed on the individual mental health of the women, rather than understanding presentations in the context of responding to gendered violence. These actions worked to strengthen the accounts often provided by perpetrators and led to increased risk for the women and their children. This research is based on a feminist critical social work approach, and as such was committed to a gendered structural analysis of current practice and participant responses. Therefore, barriers to disclosure on behalf of the women victim/survivors were viewed through the lens of perpetrator tactics to ensure that the focus was on the perpetrators’ abuse and violence. Similarly, the reluctance or inability of health professionals to enquire or identify domestic and family abuse, and evidence of collusion with the perpetrator, was also seen through the lens of perpetrator tactics, alongside the influence of macro structures such as gender-blind medical practices and internalisation of gendered community beliefs within health professionals. This research concludes by arguing the case for implementation of universal screening in emergency departments and proposes a framework for good practice.