ORIGINAL RESEARCH: EMPIRICAL RESEARCH –

QUALITATIVE

Are we failing to prepare nursing and midwifery students to deal with

domestic abuse? Findings from a qualitative study
Caroline Bradbury-Jones & Karen Broadhurst

Accepted for publication 17 March 2015

Correspondence to C. Bradbury-Jones: B R A D B U R Y - J O N E S C . & B R O A D H U R S T K . ( 2 0 1 5 ) Are we failing to prepare

e-mail: [email protected] nursing and midwifery students to deal with domestic abuse? Findings from a
qualitative study. Journal of Advanced Nursing 71(9), 2062–2072.
Caroline Bradbury-Jones MA PhD RN
doi: 10.1111/jan.12666
Reader in Nursing
School of Health and Population Sciences,
University of Birmingham, UK Abstract
Aims. To investigate student nurses’ and midwives’ knowledge, confidence and
Karen Broadhurst BA PhD DipSW educational needs regarding recognition and responses to domestic abuse.
Senior Lecturer in Socio-Legal Studies Background. Domestic abuse is a serious global problem and has greater,
School of Nursing, Midwifery and Social negative effects on long-term health than more obvious diseases, such as diabetes.
Work, University of Manchester, UK
Nurses and midwives are well-placed to recognize and respond to domestic abuse
but many lack confidence in this area. There is firm evidence that training can
increase the confidence of Registered Nurses and midwives in responding to
domestic abuse. But the issue of undergraduate preparation is significantly under-
investigated.
Design. A qualitative study.
Methods. Nursing and midwifery students were recruited using purposive
sampling. We facilitated eight focus groups with a total of 55 students (student
midwives N = 32; student nurses n = 23). Data were collected between May–
November 2014.
Findings. Students in the study viewed the issue of domestic abuse as important
and they possessed sound theoretical knowledge of its nature and consequences.
However, they lacked confidence in recognizing and responding to abuse and
were concerned about the implications of this for their future practice as
registered practitioners. Interactive learning opportunities that engaged with
service users and involved experts from practice were viewed as important
educational requirements.
Conclusion. Most students in the study felt insufficiently prepared to deal with
the issue of domestic abuse. They perceived this as a cyclical state of
disempowerment that would impact negatively on their practice and on their own
ability to support nursing and midwifery students of the future.

Keywords: domestic abuse, education, empowerment, midwives, nurses, place-

ments, qualitative, student, violence

2062 © 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and
no modifications or adaptations are made.
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE Nursing and midwifery students and domestic abuse

abuse and the different relationship configurations where it

Why is this research or review needed? may take place.
 Domestic abuse is a global issue and it has serious, long- Accurate prevalence is difficult to ascertain because
term health and well-being consequences. domestic abuse tends to be under-reported. But a 10-coun-
 Many nurses and midwives lack confidence in recognizing try study reported that between 15-71% of women had
and responding to domestic abuse. experienced physical or sexual violence by their husband or
 How nurses and midwives are prepared to deal with partner (WHO 2009). In the UK, evidence indicates that
domestic abuse at undergraduate level is significantly
over 1
2 million women and 750,000 men in England and
under-investigated.
Wales experience domestic abuse (National Institute for
Health and Care Excellence (NICE) 2014). Domestic abuse
What are the key findings?
has serious, long-term health and well-being consequences.
 Nursing and midwifery students viewed the issue of The cumulative impact of mortality and morbidity mean
domestic abuse as important and they possessed sound the- that the health burden contributed by domestic abuse is
oretical knowledge of its nature and consequences.
greater than more commonly accepted public health priori-
 Students lacked confidence in recognizing and responding
ties, such as smoking and obesity (Vos et al. 2006, Humph-
to abuse and were concerned about the implications of this
reys et al. 2008). It is thus, considered to be a major public
for their future practice as registered practitioners.
health concern (Gutmanis et al. 2007, Bacchus et al. 2012,
 A cyclical state of disempowerment exists that students
perceive will impact negatively on their future practice and Beynon et al. 2012). Correspondingly, whereas domestic
on their own ability to support nursing and midwifery stu- abuse used to be considered a private matter (Montalvo-Li-
dents. endo 2009), it is now very much an issue that commands
public (health) attention.
How should the findings be used to influence policy/
practice/research/education?
Background
 Preparation programmes for nurses and midwives should
include the issue of domestic abuse. Nurses are well-placed to respond to domestic abuse but
 Interactive learning opportunities that engage with service there is a great deal of evidence that many health profes-
users and integrate expert knowledge are required. sionals – including Registered Nurses (RNs) and midwives
 Further research is needed at national and international – do not know how to assess accurately or respond
levels to investigate how best to prepare nurses, midwives appropriately to domestic abuse (McCloskey & Grigsby
and other health professionals to deal confidently with
2005, Lazenbatt et al. 2009, Bacchus et al. 2012). Educa-
domestic abuse in practice.
tion and training have been identified as vital in promot-
ing health professionals’ confidence in addressing this
issue (Bacchus et al. 2003, Feder et al. 2011, Beynon
et al. 2012). Mandatory domestic abuse training is now
integrated into many continuing professional development
programmes. Additionally, in the UK, NICE (2014) has
Introduction
recommended that training about domestic abuse should
Domestic abuse (also referred to as domestic violence or be part of undergraduate/pre-qualifying curricula. How-
intimate partner violence) is a universal phenomenon that ever, to date, the issue of how nurses and midwives are
indiscriminately crosses demographic and social boundaries. prepared at undergraduate level to deal with domestic
It is described as the infliction of physical, sexual or mental abuse is under-investigated.
harm, including coercion or arbitrary deprivation of liberty Of available studies, Davila (2005) reported that the
(World Health Organization (WHO) 2013) or ‘Any inci- majority of accredited nursing schools in the USA had
dent or pattern of incidents of controlling, coercive, threat- failed to integrate violence assessment and intervention
ening behaviour, violence or abuse between those aged 16 into their curricula and as a result, theoretically based
or over who are or have been intimate partners or family educational activities are underdeveloped for baccalaure-
members regardless of gender or sexuality. The abuse can ate nursing students. More recently, again in the USA,
encompass but is not limited to: psychological, physical, Connor and colleagues’ (2013) quantitative study mea-
sexual, financial [or] emotional’ (Home Office 2012). Such sured domestic abuse curriculum content exposure. They
descriptions capture the multiple manifestations of domestic found that nursing students who received training on the

© 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 2063
C. Bradbury-Jones and K. Broadhurst

issue prior to graduate school had significantly higher

The study
perceived preparation and perceived knowledge ratings,
than those who had no training (Connor et al. 2013).
Aims
Tufts et al. (2009) investigated domestic abuse in relation
to nurse educators – suggesting that it is educators who The aim was to investigate students’ knowledge, confidence
need knowledge and skills regarding domestic abuse to and educational needs regarding recognition and responses
teach students effectively. While such studies provide to domestic abuse. We sought to answer the following
some insights into the issue, there is a great deal that questions:
remains unknown.
Q.1. What do students understand about the nature and mani-
As yet we do not fully understand through empirical
festations of domestic abuse?
enquiry, how empowered nursing and midwifery students
are (from now on referred to as ‘students’, except where a Q.2 What are students’ experiences of recognising and respond-
distinction is required between the two groups) in dealing ing to domestic abuse in clinical practice?
with domestic abuse and what educational preparation they
Q.3. How confident are students in dealing with domestic abuse
require to deal confidently and competently with the issue.
in clinical practice?
The study reported in this paper sought to address this gap
in knowledge. Q.4. What are the educational needs of students to empower
them to deal confidently and competently with domestic abuse?
Theoretical framework
Q.5. What are students’ perceptions of the importance and rele-
Theoretically we drew on a model of empowerment pro-
vance of domestic abuse to their practice?
posed by Bradbury-Jones et al. (2010): the ‘Spheres of Influ-
ence’ model. The model (Figure 1) emphasizes the
centrality of knowledge and confidence in determining stu-
Design
dents’ empowerment in clinical practice. It shows a range
of factors that can influence these, including for example, This was an exploratory study in an area where there is
directly related influences such as being recognized as a limited evidence and for this reason a qualitative approach
learner, being part of a team and being respected as a per- was adopted. This is congruent with the Medical Research
son, having a supportive clinical mentor and a high quality Council (MRC) (2008) guidance on developing and evaluat-
placement, through to broader organizational and political ing complex interventions, where qualitative studies have
influences. We chose this particular model to theoretically considerable value in the development phase.
underpin the study because it is empirically grounded in
research with nursing students. Its focus on knowledge and
Sample/participants
confidence aligns with the aims of the study and moreover,
it allowed us to take account of the multiplicity of issues The study took place in one university in the UK. We
that might influence students’ knowledge and confidence aimed for a heterogeneous sample of students to capture a
and thus their empowerment, regarding recognition and range of perspectives and experiences and to arrive at a full
responses to domestic abuse. understanding of the issue. Using purposive sampling, we
recruited third year students from the Bachelor of Nursing
(from adult, mental health and child fields) and Bachelor of
Midwifery programmes. Sample size in qualitative research
L PO
A CTURAL/OR has been a long-standing issue of debate, but as Sandelow-
IC STRU GA
L
IT
ski (1995) observed, it is a matter of quality rather than
G

NI
S
LO

IC

R
RVISO quantity. We planned for a sample of 36 because we con-
PE
AT

PL
A
O

U A
L
IO
L

S MEMB sidered that this would be sufficient to answer our research

CI

RA

EAM E
NA
/

T R
CE
OR

(extrinsic)
TU
SO

question and would ensure sufficient variation in the groups

ME

L
NT

PE
CUL

NE

CONFIDENCE
RS

NT
ME

recruited. The inclusion criteria were for students to be in

AR

ON

KNOWLEDGE
LE

(Intrinsic) the third (final) year on either of the programmes. The

exclusion criteria were students on other educational pro-
Figure 1 Empowerment of nursing students in clinical practice: grammes who were not in the third year. We deliberately
spheres of influence. recruited final year students because of their extensive

2064 © 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE Nursing and midwifery students and domestic abuse

experiential knowledge of student-hood and because we the end of each focus group for debrief and informal discus-
were interested in their perceptions of preparedness for sion. Also, participant information sheets contained contact
their forthcoming role as professional registrants. information for domestic abuse and child abuse help-lines.
Two students did disclose a personal history of abuse dur-
ing the focus group discussions (participants in some of our
Data collection
previous studies have made similar disclosures). For both
Eight focus groups were conducted between May–Novem- students, the abusive relationship had ceased and they were
ber 2014. Seven focus groups were audio recorded with the no longer experiencing abuse. However, they were both
full, written consent of participants and transcribed verba- contacted after the discussion by (CB-J) to ensure that they
tim. One focus group preferred the researcher to take ver- were emotionally and physically safe.
batim notes. We aimed for fluid discussion rather than
question and answer format, but to ensure that the focus
Data analysis
groups were conducted consistent with the aim of the
study, they were organized around a discussion guide Data were analysed using thematic content analysis. CB-J
(Table 1). undertook an initial analysis independently of KB. The
analysis was then shared and the two researchers made
some minor moderations to the initial analysis until the
Ethical considerations
final themes were agreed. As indicated in Table 1, we had
Ethics committee approval was obtained from the Univer- closely adhered to the research questions in the focus group
sity Research Ethics Committee, at the selected study site discussion guide and as a result, we found that the induc-
(Ref 14079). The two principal ethical considerations tively derived themes mapped neatly to our questions,
related to: (1) the relative power of the two researchers in which assisted in the organization and presentation of data.
relation to the student participants; and (2) the sensitive Analysis of focus group data can be conducted in a simi-
subject area. To address the first, participants were lar manner to analysis of other qualitative, self-report data.
recruited by an open verbal invitation to participate, However, the distinct feature of focus groups, is attention
accompanied by written information about the project. To to group dynamics (Kitzinger 2005). For this reason,
overcome potential issues related to coercion, this was via a although some of the data presented in this paper are from
third party (an academic colleague who was not connected invididual participants, where possible we have retained
to the study). Prior to the formal start of the focus group, strings of discussion to highlight interaction.
the two researchers explained the purpose of the study and
expectations about participation. All students signed a con-
Rigour
sent form that made explicit their right to exit the focus
group at any stage. Evaluating the quality of qualitative research is a conten-
In relation to the second ethical issue, Connor et al. tious issue and some have argued that it is simply a matter
(2013) reported that 40% of nursing students surveyed had of taste (Sandelowski 2014). However, it is important to
personally experienced some type of domestic abuse. So, undertake high quality, rigorous research, irrespective of
there was a considerable chance that some participants in how others choose to judge it. We attended to rigour in
our study may have experienced domestic abuse, resulting two ways: methodologically and theoretically. Methodolog-
in distress and upset. We put in place supportive mecha- ically we drew on Lincoln and Guba (1985) work on trust-
nisms to overcome these, for example, we allowed time at worthiness. Cognizant of their four criteria of credibility,
transferability, dependability and confirmability, we incor-
Table 1 Focus group discussion guide.
porated several strategies into the research design. For
Prompt questions: example, providing meaningful excerpts of data means that
Q.1. What do you understand by the term ‘domestic abuse’?
readers can judge the believability or credibility of the find-
Q.2 While on placement, have you encountered any people
who have experienced domestic abuse? ings. Analysing data independently was considered an
Q.3. How confident do you feel in dealing with domestic abuse important measure about dependability and gives us confi-
in clinical practice? dence that the findings reflect an ‘accurate’ interpretation of
Q.4. What do you think is required educationally to equip you the data. Similarly, although the notion of confirmation in
to deal confidently and competently with domestic abuse?
qualitative research is contentious (Ashworth 1993), the
Q.5. How important is it for us to investigate this issue?
two final focus groups were a means of checking that our

© 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 2065
C. Bradbury-Jones and K. Broadhurst

interpretation of data aligned with the actual experiences of [Domestic abuse is] when someone has been either verbally, physi-
nursing and midwifery students. In terms of theory, a sound cally or sexually abused, generally within the home by a member
theoretical base in qualitative research has been advocated of the family. (SM1)
as an important marker of rigour (Bradbury-Jones et al.
2014). So arguably, the model of empowerment used in the When people talk about domestic abuse that’s kind of the first
study contributed to rigour by providing structure, clarity assumption, it’s someone with black eyes, oh I walked into
and strong theoretical and empirical underpinnings. the cupboard again thing. But I think that there are other
forms, like financial control or like psychological fear as well.
(SN 1)
Findings
Student nurses in the second focus group debated the
Fifty five students took part (representing over-recruitment
types of abuse and identified some of the typical assump-
in relation to our intended sample size of 36). All partici-
tions surrounding the issue:
pants were female; we did not collect data relating to age.
In the UK, student nurses chose a ‘field’ where they subse- Student 1 People just think it’s physical don’t they? But it’s
quently specialize as a Registered Nurse. Along with the: more than that, it’s emotional and financial
32 student midwives, the 23 student nurses were on the fol- and. . .
lowing fields: 16 adult; four child; and three mental health. Student 5 I think there is a lot of assumptions when people
We had hoped to achieve maximum variation in the sample say domestic violence, you usually think it’s a
and we are confident that this was achieved. Composition man doing it to a woman, whereas it’s like, I
of the focus groups is shown in Table 2 with a code allo- think research kind of shows a lot more the other
cated to each to represent whether it was with student way round now.
nurses (SN) or student midwives (SM). Findings are pre-
sented in response to the research questions. Illustrative Student 2 Oh yeah, ‘cause you could just be being
excerpts have been selected on account of their typicality to controlled, there might not be an element of like
substantiate key findings. physical violence, but you could be being
controlled and you might think that’s perfectly
normal, until someone points out that that’s not
Students’ understandings of the nature and the way it should be. They might not realize
manifestations of domestic abuse themselves that that’s what’s happening. . . (SN2)
In our study, students had a clear awareness of the different It was clear from such discussions, that most students
manifestations of abuse: demonstrated sophisticated knowledge of the range and
various manifestations of domestic abuse.
Table 2 Focus group composition.
No. of stu- Students’ experiences of recognising and responding to
Student group Field specific Code dents
domestic abuse in clinical practice
Student N/A SM1 10
Interesting differences were seen in perceptions of exposure
midwives
Student N/A SM2 8 between students, with programme and field specific varia-
midwives tions. Student midwives were clear about the extent to
Student N/A SM3 8 which they encounter domestic abuse:
midwives
Student N/A SM4 6 Interviewer
midwives Have you encountered women who feel. . . you’ve been
Student nurses 6 adult & 1 mental SN1 7 worried about?
health
Student nurses 3 adult & 4 child SN2 7 Student 1 Yes.
Student nurses 2 adult SN3 2
Student nurses 5 adult & 2 mental SN4 7
Student 2 Yes.
health Interviewer Yes, all of you?
Total 55
participants All Yes. (SM2)

2066 © 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE Nursing and midwifery students and domestic abuse

Similarly, nursing students from the child field reflected following section, this contributed to their lack of confi-
on their experiences as captured in the following discus- dence in responding in practice to this issue.
sion:

In my first year it [my clinical placement] was in quite a deprived Students’ confidence in dealing with domestic abuse in
area and there were days when literally every single meeting was clinical practice
about domestic violence. Like that was all we did every day was
children that were looked after because of present domestic vio-
lence or past domestic violence, or the risk of domestic violence. So I think we’ve had really good lectures on theory around domestic
yeah sometimes it would be all we would do all week. (SN2) abuse but I don’t think we’ve had such good preparation for
practical. . . especially around if somebody discloses, I don’t
Although many of the students from the adult field also
know. . .I feel like I am not very well prepared for if it had been
shared experiences of encountering domestic abuse, two
disclosed directly to me. (SM2)
students considered that they had never come across it:
In this first illustrative extract, the student confirms lack
I don’t think you get to see it in adult field really. Like you don’t
of opportunity to translate theoretical learning into applied
hear of domestic violence, you don’t get to see a police report. I
skills for frontline practice. Student nurses in the first focus
haven’t in 3 years. . .I don’t remember seeing it. People hide it don’t
group were able to expand considerably, on the specific
they? (SN2)
gaps in their knowledge and confidence. The theme of feel-
ing uncertain and ill equipped to respond to situations of
From a practice point of view, during my training I haven’t. . .I
domestic abuse in practice was pervasive:
don’t think I’ve came across anyone in these situations, but obvi-
ously there’s always the opportunity that it might arise. (SN1) I don’t think through the training that we’ve had massive amounts
of teaching on how actually we would deal with it. Because it’s
Even when students had encountered domestic abuse on
one thing someone telling us that they’ve been involved in domestic
placement, their opportunities to engage with the care of
violence, but it’s another that we actually know how to react and
those who had experienced it varied considerably:
support them in that. And like what kind of referrals that we
It gets moved to the specialists. I’ve spoken to my mentors and they would need to be doing as well. (SN1)
feel a bit like they get deskilled now, because all they do is sign-
The student midwives identified similar gaps:
post. . .and now it’s like ‘oh I don’t know what to do’, you know?
(SM1) Student 2 They [midwives in practice] assume that we’ve
been learning it in university – had a lecture.
Student 3 From my experience, as soon as there’s like a
Student 1 The problem is you don’t learn that much [about
safeguarding issue or a domestic violence,
domestic abuse] in university (SM2)
students weren’t allowed to be involved. . .I think
for the family being involved, fair enough, they Students were encouraged to think ahead to their
don’t need extra people. But for our learning we impending status as registered practitioners and consider
don’t get provided it, so it’s like something that their level of preparedness. One nursing student captured
when we’re qualified nurses we’re expected to the position well:
do, but we don’t get it as students. . . It’s a tricky one. . .I am confident in the sense that I am confident
Student 6 Yes but it varies though. When I was with health that it should be part of the care I deliver. So I have full confidence
visitors [public health nurses], I always went to of it being important. . . but I am less confident as to what to actu-
the safeguarding and domestic violence things ally do! SN3
and there was only maybe one when I didn’t.
Some of them [RNs] are just like: ‘Oh no, you
can’t come’. (SN2) Educational considerations to increase students’
confidence and competence in dealing with domestic
Students did not consistently describe field placements as
abuse
providing opportunities to apply their formal knowledge.
More often than not, they felt removed from situations Third year students are well-placed to make recommenda-
when domestic abuse was manifest. As described in the tions about how educational and placement opportunities

© 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 2067
C. Bradbury-Jones and K. Broadhurst

might prepare them more fully for responding in practice to Student 5 Maybe we should be working with social
domestic abuse: workers? That would be more beneficial. (SM2)

Student 1 I think maybe a collection of really different

stories from really different people [who have Students’ perceptions of the importance and relevance of
experienced domestic abuse], you know people domestic abuse to their practice
who are really successful and seem to be
The fact that we over-recruited to this study may serve as
powerful, strong women who are in a situation.
an indicator of how students view the issue of domestic
And kind of break the stereotype and have a
abuse. Many said that they had attended the focus group
few. . .I don’t know, just have stories from real
specifically to learn more about the issue. During the dis-
people.
cussions, the students highlighted the cyclical nature of lack
Student 4 I think it would be really nice to actually sit like of educational preparation:
this with people and see them and speak to them.
I think it perpetuates itself because if we leave not being pre-
But equally, if that person is not willing to do
pared, then we’re going to feel embarrassed or not sure how to
that, then obviously a written format would give
talk to our students about it. And then that’s probably why
us something, just to refer to. (SN1)
they don’t want to talk about it, because they [RNs] feel that
Integration of patients/service users into formal educa- ‘oh it’s this thing that I should know stuff about – but I don’t’.
tion was firmly recommended by students across the disci- (SN2)
plines of nursing and midwifery. As illustrated, students
wanted ‘solid practical’ learning experiences and to engage We’ve got to the end nearly [of our programme] and like my big-
with real life stories from survivors of domestic abuse. Stu- gest concerns are how my training has prepared me – or hasn’t pre-
dents’ responses to focus group questions clearly indicated pared me – and the feelings of anxiety that I’ve got. And so it was
that domestic abuse is an unsettling topic and disclosure productive use of my time to come to something like this [focus
can prompt fear and panic in students. In the absence of group], than to just complain and moan and internalize worries
adequate preparation, students are left not knowing how that I might have had about the 3 years that have gone already.
to respond. As indicated in the following excerpt, students (SN1)
struggled to marry up a clear message in policy that safe-
guarding is the business of all professional groups:
Discussion
Student 1 I think we could have been trained a little bit
better in how to deal with someone disclosing The ‘Spheres of Influence’ model (Bradbury-Jones et al.
domestic abuse. But can you really prepare for 2010) holds that knowledge and confidence are essential
that, I think. elements of student empowerment. Our findings show that
students have a good theoretical understanding of the issue
Student 2 I’m wondering whether it would be good, I don’t
of domestic abuse, including the different types and its neg-
know if it’s possible, to get women who have
ative impacts. In fact, they were able to challenge some of
been in that situation to come and talk to us.
the commonly held stereotypes about abuse, for example,
Interviewer that it only occurs among certain groups and contexts (Tay-
Service users? lor et al. 2013). Most of the midwifery students reported
that they had encountered women in practice who had
Student 2 Yes because I’m always terrified of saying the
experienced domestic abuse but we were surprised that
wrong thing, which can prevent you saying
some of the adult nursing students believed that they had
anything, you know, you can be a bit hesitant
never encountered anyone in practice where domestic absue
about it. So if you could have a real honest
was an issue. Given the prevalence of domestic abuse this is
conversation. . .I know everybody’s individual and
highly unlikely and may represent an inability of students
one service user can’t speak for everybody, but it
to link theory to practice or to pick up on potential clues
might, as students, give us a bit of confidence
and indicators of abuse. This points to the need for greater
about what would feel comfortable with us. . .
support and education in this area.
Student 1 And make us more aware of what services are Confidence in recognizing and responding to domestic
available. abuse was a pervasive concern for the majority of students

2068 © 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE Nursing and midwifery students and domestic abuse

in the study. Many were particularly worried about how to achieve to become registered practitioners: these include
talk about the issue of abuse with patients and service explicit statements about abuse. The Nursing and Mid-
users. The issue of disclosure is a fearful process for people wifery Council (NMC), states that on entry to the register,
who have been abused (Montalvo-Liendo 2009, Catallo all nurses must be able to recognize when a person is at risk
et al. 2013), but it is also something feared by many health and in need of protection and take reasonable steps to pro-
professionals. Complex assessments need to be made by tect them from abuse (NMC 2010). Similarly, in relation to
health professionals in relation to domestic abuse (Davidov midwifery:
& Jack 2014) and previous studies have highlighted how To be admitted to the register, student midwives need to
many RNs and midwives lack confidence in dealing with demonstrate that they are competent in: ‘providing the
the issue (Taylor et al. 2013). Students in the study were opportunity to women to disclose domestic abuse and. . .
concerned about the implications of their lack of prepared- able to respond appropriately (NMC 2009, p. 44).
ness. They described this as cyclical, perceiving that if they The Willis Commission that reported in 2012, was set up
remained unprepared as RNs and midwives, they would be to investigate the essential features of pre-registration nurs-
unable to suitably support the next generation of students ing education in the UK and the types of support for newly
and so on. registered practitioners that are needed to create a compe-
The next two concentric layers of the spheres of influence tent and compassionate workforce. The review recom-
model are concerned with how students are treated in prac- mended that nurse education should embed patient safety
tice as learners, team members and as respected people. as its top priority. It also emphasized the imperative for
These spheres highlight the place of supportive mentors and nurses to be provided with the necessary education and
placements in facilitating students’ learning. Some students skills to equip them for their roles (Willis Commission
in our study were able to learn about domestic abuse in 2012). Based on the findings of our study, however, we
practice and were actively engaged in cases where domestic question whether the NMC competences of the recommen-
abuse was an issue. However, most lacked such exposure dations from the Willis Commissions are always achieved.
and were excluded from care where domestic abuse was an All students in the study were at the point of registration.
issue. Although this is invariably to protect individuals and The transition from nursing student to practising nurse has
families from yet another person involved with their care, it been identified as a challenging and stressful time (Missen
does present a conundrum. When and where will students et al. 2014). The student midwives had received some cov-
ever be able to gain the required experiential knowledge erage of the issue of domestic abuse as theoretical prepara-
that can assist in translating knowledge into practice? tion in university and many had exposure to the issue
In our study, students indicated the value of inter-profes- during clinical practice. But the nursing students had
sional learning – a consistent theme in messages from Seri- received no educational input into the issue of domestic
ous Case Reviews (Brandon et al. 2008) is that abuse and most had been excluded from learning opportu-
professionals struggle to work across professional bound- nities in practice. Connor et al. (2013) reported that educa-
aries. The foundation for reciprocal learning could be laid tional preparation of nursing students regarding domestic
down in undergraduate education, particularly where facul- abuse is required to enable them to enter the nursing pro-
ties house multi-professional groupings. In addition to fession with the capacity to directly impact on the care of
inter-professional learning, students in our study wanted people with domestic abuse experiences. We agree. But our
interactive sessions that engage with service users. This is study highlights a considerable gap in preparation at under-
congruent with recent NICE guidelines (2014), where part- graduate level, particularly for nursing students.
nership with local specialist domestic abuse services and
face-to-face contact are considered to be important consid-
Limitations
erations for domestic abuse education and training. These
can be considered as part of the recommendations for edu- There are some theoretical and methodological limitations
cation arising from our study. of the study. Theoretically we drew on a model that was
The outer layers of the spheres of influence model are developed from work with nursing students and not mid-
concerned with the broader influences on students’ knowl- wifery students. Although there are some generic issues of
edge and confidence. The policy context is particularly rele- educational preparation that might transcend the disciplin-
vant here. In the context of nursing and midwifery ary differences in these two groups, the context of practice
preparation, in the UK where the study was conducted, is different. This might mean that a model developed from
there are several competences that nursing students need to within nursing was unfitting to frame a study that also

© 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 2069
C. Bradbury-Jones and K. Broadhurst

involved student midwives. Also, the model was developed attended the focus group specifically to learn more about
in relation to students’ empowerment in clinical practice the issue. Since undertaking the study, we have begun to
generally – it was not focused on a specific issue. Applying integrate coverage of domestic abuse into the nursing cur-
it to explore an issue such as domestic abuse may have riculum locally. This is a small step in the right direction,
therefore been inappropriate. Overall though, while accept- but it needs to be more widespread if we are to avoid the
ing these theoretical limitations, the structure and organiza- culpability of producing future generations of graduates
tion of the model served as a useful framework for the who are ill-prepared to deal with such an important area of
study. nursing practice.
Methodologically, this was a small, study undertaken in
one university in the UK. For this reason caution needs to
Acknowledgements
be exercised in over-claiming transferability to other coun-
tries and contexts. We know, however, that domestic abuse We would like to thank the University of Manchester for
is an issue that crosses geographical boundaries and it is funding the study. Our thanks also to the student nurses
likely therefore, that students in many countries (and those and midwives who gave up their time to participate in the
from disciplines other than nursing and midwifery) will research.
have similar experiences to those included in this study. For
these reasons we believe that the findings have transferabil-
ity internationally.
Funding
This study was funded by University of Manchester, School
of Nursing, Midwifery and Social Work, Education Innova-
Conclusion
tion and Evaluation Unit.
The study reported in this paper was underpinned theoreti-
cally by the ‘Spheres of Influence’ model; the limitations of
which have already been discussed. Overall, however, we
Conflict of interest
found that the model’s focus on knowledge and confidence No conflict of interest has been declared by the author(s).
gave direction to the study and ensured that the study was
conducted inline with the intended aims. As a result, this
small study has generated robust evidence for practice,
Author contributions
albeit in need of further exploration. All authors have agreed on the final version and meet at
In terms of education, nursing and midwifery curricula least one of the following criteria [recommended by the IC-
are already squeezed in terms of content. It is impossible to MJE (http://www.icmje.org/recommendations/)]:
include all health-related issues and there are perennial ten-
sions between what needs to be included; to what extent; • substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
and where. All students in this study wanted domestic
data;
abuse to be covered in their curricula. The midwifery stu-
dents had received some educational preparation, but for • drafting the article or revising it critically for important
intellectual content.
the nursing students it is evident that domestic abuse had
not hit the threshold as an issue to be included in their cur-
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© 2015 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 2071
C. Bradbury-Jones and K. Broadhurst

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