A curriculum to improve hospital response to violence

Victims turn first to health services

The Federal Act on Protection Against Dom­estic Violence entered into force in May 1997.[1] Since then several am­endments to it have been adopted and in 2009 a comprehensive second violence protection law package was implemen­ted.[2]

The state and its insti­tutions acknowledge that violence against women and children is a public concern and provide means for concrete pro­tection measures. The healthcare sector has in­creasingly been involved in the development of new intervention strat­egies in this field. Health workers play a key role in identifying early signs of violence and offering sup­port to abused women and children. Women who have experienced violence and are suffering from injuries or health problems are much more likely to turn to an emergency room or to general practitioners than to a counselling centre, a women’s shelter or the police. Healthcare professionals therefore have contacts with a large number of victims of domestic violence.[3] This is why in several provinces of Austria educational projects consisting of seminars, workshops and public information events for medical personnel have taken place in recent years.

To improve their response to the issue, the City of Vienna created a curriculum on how to deal with victims of domestic violence. The members of the consortium were the Vienna Women’s Health Programme, the 24-Hour Women’s Emergency Hotline of the Vienna Municipal Department of Women’s Affairs (MA57), the Youth and Family Offices of Vienna (MA11) and Vienna Hospital Association (KAV).

A five-module curriculum

The curriculum was drafted on the basis of the results of an analysis of the status quo and comprises five modules:

• forms and effects of sexual and physical violence against women
• forms and effects of sexual and physical violence against children
• securing evidence and DNA analysis
• legal information
• implementation of “victim protection groups” at Vienna hospitals

There were four stages to its planning and implementation:

Phase 1:  Establishment of the steering group, development of the education and training concept, staff survey, preparation of information material

Phase 2:  Implementation of the training programme at two model hospitals, with 20 training units of 1.5 hours each

Phase 3:  Revision of the education and training concept on the basis of an analysis of the results of phase 1: adjustment of the training structure

Phase 4:  Implementation of the training courses on four of Vienna’s municipal hospitals

The City of Vienna first launched its Violence against Women and Children curriculum in 2001 at the municipal hospital SMZ Ost with the aim of enhancing the sensitivity of health professionals in dealing with victims, by establishing victim-focused standards, ensuring ade­quate support and creating aware­ness and an effective response among providers in all the main hospitals in the city of Vienna.

The curriculum was implemented over a period of five years, and all training courses were held in the individual hospitals with an inter­disciplinary and inter-professional audience. The appropriate time frame (four years of pilot projects) allowed important results to be achieved.

Besides the curriculum, the Vienna Hospital Association, the 24-Hour Women’s Emergency Hotline, the Police and the Forensic Medicine Institute prepared a trace preserva­tion kit that ensures uniform procedures in the preservation of evidence and was established as a treatment standard in hospitals of the City of Vienna when examining victims of sexual violence.

At the Danube Hospital a group of committed staff in the accident surgery department, as a direct response to the curriculum, founded a “victims’ protection group”, motivated by the example of the existing victims’ protection group at Vienna Wilhelminen Hospital, which the curriculum presented as a good practice example.

During its first period of implementation (2001-2005), about 560 health professionals working in emergency departments, internal medicine, ophthalmology, dermatology, surgery, ENT, gynaecology and psychiatry were trained. At the end of the project a total of approximately 880 staff completed the Violence Against Women and Children training scheme in Vienna: 110 at Kaiser Franz Josef Hospital, 259 at Danube Hospital, 147 at Rudolfstiftung Hospital, 57 at Hietzing Hospital, and 200 at Vienna General Hospital. The advanced workshop on use of the trace preservation kit was attended by 110 staff of Kaiser Franz Josef Hospital, Wilhelminen Hospital and Danube Hospital. In all three hospitals, a definite trend was that more women than men took part in the training scheme, with nurses accounting for the largest occupational group: around 70% of participants worked as nurses, 15% were physicians and 15% came from other groups.

After the pilot project had been completed in all the hospitals of the City of Vienna, the hospitals of the Vienna Hospital Asso­ciation agreed to offer internal training events on victim protection for their staff at regular intervals, modelled on the curri­culum. This is an import­ant step in creating sustainable support for staff in their key role with regard to early detection of domestic violence. Nowadays, permanent interdisciplinary groups on domestic violence have been set up in all of Vienna’s hospitals, includ­ing gynaecology and emergency depart­ments. The cooperation between hos­pitals and extramural institutions has greatly improved within the Vienna-wide network of the groups on domestic violence, the Vienna Women’s Health Programme and the 24-Hour Women’s Emergency Hotline of the City of Vienna.

Satisfied participants

The Vienna Hospital Association conducted an anonymous post-training survey among the curriculum participants at two hospitals. The feedback showed that participants were particularly satisfied of the training course with regard to the presentation of the subject matter as well as its practicability. Three months after the training, they said that the know-how they had acquired was very useful in their daily work and that the information materials provided were of great help. Many of them said they were interested in further training events on domestic violence, in developing better links among departments as well as other institutions and more active participation by physicians.

Two improvements could have been made: external evaluation of the results would have enhanced the curriculum’s potential for transfer, and the formalisation of agreements among all the institutions participating in the training would have enhanced its sustainability over time.

Victim protection groups made mandatory

The project’s efficiency was guaranteed through a low-cost-approach: existing staff were activated as trainers: employees of the City of Vienna, of the women’s shelter association, of the Vienna Federal Police and of the University Institute of Forensic Medicine trained the hospital staff. Its sustainability has been ensured by the Vienna Women’s Health Prog­ramme and by the involvement, since its start, of the City Coun­cillors for Health, Women, and Children/Youth. More broadly, in January 2012 a federal law on mandatory children’ and victims’ pro­tection groups in Austrian hospitals has entered into force.[4]

These groups should contribute to the early det­ection of domestic vio­lence and raise hospital staff’s awareness of violence against women and children, thus con­tributing to the sustain­ability of similar actions in the future.

The curriculum has long-term effects and the global approach adopted was to move from a preliminary analysis of the specific training needs of health personnel to the design of a training curriculum and the implementation of training activities. It has made hospital staff aware of domestic violence. Post-training questionnaires indicate that the training was considered by participants as a good opportunity to enhance their knowledge and skills in dealing with victims.

A basis for better prevention

The practice was effective in terms of the number of trained professionals, thus increasing the detection of early warning signals and ensuring that domestic violence victims receive immediate and specialised support. It also produced an impact on the wider environment through the involvement of health institutions on the topic of domestic violence, and by increasing the coordination amongst agencies that support victims.

The elements that work particularly well are improving responses to victims of domestic violence through early detection, establishing treatment standards, streamlining internal communication processes, defining an emergency treatment plan, communicating know-how to extramural assistance resources and establishing victims’ protection groups in hospitals.

These successes were achieved on a basis of close multiagency cooperation among healthcare institutions, abuse intervention centres, women’s shelters, police and welfare offices; an appropriate length and time frame; and the provision of both training materials and a checklist for early warning signals.

A particularly difficult obstacle the project faced was the rigid time constraints that health workers are under. A great deal of effort was necessary to fit the training agenda inside their working hours. Also, the mixed top-down strategy adopted to involve the hospital staff was successful but very costly in terms of time and energy.

The Viennese training programme was the first in Austria to sensitise hospital staff. Many other cities followed the Viennese example.

The lessons learned from the process are that:

The development of the curriculum and the establishment of a capacity-building process was particularly important in improving the response of the health sector.

The multi-sector collaboration generated through the curriculum development process presented provide a good basis for strengthening prevention as well as providing assistance and care to those who are already in situations of violence.

Although the training programme has been implemented with the support of all hospital directors in a top-down strategy, finally sustainability depends on the personal commitment of individual staff members.

[1] Logar 2005

[2] Initiated by Women’s Minister Johanna Dohnal in close cooperation with Caspar Einem, Minister of the Interior, an interministerial working group was convoked, composed of staff of women’s shelters, police officers, judges and lawyers and resulting in the Federal Act on Protection Against Domestic Violence. (Federal Chancellery – Federal Minister for Women and Civil Service 2008, 12ff.)

[3] Federal Chancellery – Federal Minister for Women and Civil Service 2008, 121

[4] 69th Federal Law: Change of the Federal Law on Hospitals and Convalescent Homes, § 8e, Children’s and Victims’ Protection Groups