A GROUNDED THEORY STUDY OF NURSES WHO CARE FOR PATIENTS WHO ARE VICTIMS OF SEXUAL VIOLENCE DISSERTATION Presented in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in Nursing Barry University Dara M. Whalen 2016 A GROUNDED THEORY STUDY OF NURSES WHO CARE FOR PATIENTS WHO ARE VICTIMS OF SEXUAL VIOLENCE DISSERTATION by Dara M. Whalen 2016 APPROVED BY: _________________________________________ Jessie M. Colin, PhD, RN, FRE, FAAN Chairperson, Dissertation Committee Program Director, College of Nursing and Health Sciences _________________________________________ Mary Colvin, PhD, RN Member, Dissertation Committee _________________________________________ Claudette R.
Chin, PhD, ARNP Member, Dissertation Committee ___________________________________________ John P. McFadden, PhD, CRNA Dean, College of Nursing and Health Sciences Copyright by Dara M. Whalen, 2016 All Rights Reserved Abstract Background: Sexual violence is a widespread traumatic event that has physical, psychological, financial, and spiritual implications for victims, their friends and family, and the community. The negative and long-term effects include poor health outcomes, depression, substance abuse disorders, and post-traumatic stress disorder.
Many nurses who treat these patients are inadequately trained. Purpose: The treatment of nurses towards patients who are victims of sexual violence can mitigate or contribute to perceived revictimization of patients. The purpose of this qualitative study was to identify the processes and uncover the attitudes and behaviors of nurses without specialized training who care for patients who are victims of sexual violence. Additionally, the purpose was to generate a theory that describes the process that these nurses use to make decisions about how to provide proper care.
Philosophical Underpinnings: This qualitative constructivist grounded theory study was guided by symbolic interactionism and pragmatist philosophy. Method: Charmaz’s grounded theory method of inquiry was used for this qualitative study. Data were collected with semistructured interviews with 13 emergency department nurses without specialized training in treating sexual violence victims and a focus group of five Sexual Assault Nurse Examiners. Data analysis took place with a constant comparative process to reveal the conceptual categories and themes.
The focus group confirmed the categories. Findings: Four themes emerged: Avoiding, Attempting, Analyzing, and Adjusting. The basic social process and substantive theory that emerged was Apprehending an Unknown iv Phenomenon. This framework provides an in-depth understanding of the decision making process of nurses caring for victims of sexual violence.
Conclusion: This study provided deeper understanding of nurses’ perceptions and experiences in decisions to treat patients who experienced sexual violence. The theory developed can be used to guide nurses’ decision making when they have little or no training on which to base their decisions. With further development of an evidence-based model, study findings should help improve outcomes for patients and reduce stress and anxiety in nurses who treat patients who have experienced traumatic sexual violence. v ACKNOWLEDGMENTS To acknowledge all of those who helped me along this journey would take more pages than I am allowed.
To Mom, you never gave up and have always had my back. I am so blessed to have you with me, forever cheering me on. To my fabulous sisters Dana and Dawn, the laughter, the tears, the encouragement, and support you share with me are truly appreciated. Thank you to all of my family including my brother Jon for forgiving my absences, cheering me on, never giving up on me, and always being by my side.
I could not be where I am today without you. A sincere thank you to my chair, Dr. Jessie Colin, who pushed me, checked in on me, inspired me, and never, ever gave up on me. I am grateful for your gentle yet persistent nudges; they helped to propel me to this point.
To my committee members, Dr. Mary Colvin and Dr. Claudette Chin, your kind words and enthusiasm for my work is greatly appreciated. To my classmates and colleagues who held me up during those times I was weighed down by the struggle, thank you for your strong hands and hearts.
And to my friends who remained in my life even when I disappeared behind my work, I am coming out to play soon. To the kind, supportive and talented Mureen Shaw, you are an amazing friend, and I thank you with all my heart for your friendship and support. I want to acknowledge my students—you have inspired me to be my best. To the nurses of the world, I ask you to remember how blessed we are to be part of a noble and trusted profession.
I am honored to be among your ranks. vi My final acknowledgement is as important as all the others. For those of you who have been touched by violence, I promise to continue to work to help you heal and assure that you feel valued and important. You are not alone.
vii DEDICATION I dedicate this work to my wonderful son Darrion. Since the day I became your mom I wanted to make the world a better place for you. You are the best man I know and I am truly blessed to be your mother. Thank you for forgiving my absences and tolerating my wandering path.
And of course, thank you for my magnificent grandson Owen and his mom Kim. You all keep me smiling and make my world a better place. Thank you for being my family. viii TABLE OF CONTENTS TITLE PAGE.
ii COPYRIGHT PAGE. viii TABLE OF CONTENTS. ix LIST OF TABLES. xiii LIST OF FIGURES.
xiv CHAPTER ONE: THE PROBLEM .1 Background of the Study .13 Purpose of the Study .18 Significance of the Study .19 Implications for Nursing Education.19 Implications for Nursing Practice .20 Implications for Nursing Research .21 ix Implications for Health/Public Policy .21 Scope and Limitations of the Study .23 CHAPTER TWO: REVIEW OF THE LITERATURE .25 Victims of Sexual Violence .26 Attitudes Towards Victims.47 CHAPTER THREE: METHODS .48 Sample and Setting .50 Access and Recruitment .53 Ethical Considerations/Protection of Human Subjects .53 Data Collection Procedures .65 CHAPTER FOUR: FINDINGS .77 Phase I: Individual Interview Group Participants .86 Personally directed care .96 Phase 2: Focus Group Participants .103 Confirmation of the Conceptual Categories by the Focus Group .105 The Basic Social Process: Apprehending an Unknown Phenomenon .116 Harm to the legal case.120 Restatement of the Research Questions .122 Connection to Theory .123 CHAPTER FIVE: DISCUSSION AND CONCLUSION .125 Exploration of the Meaning of the Study .125 Interpretive Analysis of the Findings .137 Apprehending an Unknown Phenomenon.142 Significance of the Study for Nursing .145 Implications for Nursing Education.146 Implications for Nursing Practice .147 Implications for Nursing Research .148 Implications for Health/Public Policy .149 Strengths and Limitations.149 Recommendations for Further Study .151 Summary and Conclusions. LIST OF TABLES Table 1. Demographics of the Individual Interview Group (n = 13). Demographics of the Focus Group (n = 5).76 xiii xiv LIST OF FIGURES Figure 1.
Grounded theory method. Conceptual model of Apprehending an Unknown Phenomenon .123 xv 1 CHAPTER ONE THE PROBLEM Attitudes of nurses towards patients who are victims of sexual violence can mitigate or contribute to perceived revictimization that is common in people who experience such a traumatic event. Inadequate and insensitive initial care combined with nonexistent or disorganized follow-up support and evaluation may leave patients to deal with the physical and emotional consequences of the violence on their own (Campbell, 2006). An informed and purposeful approach to the care of these patients by nurses is necessary to the formation of a trusting and therapeutic relationship, which can improve the patients’ psychological and physical health outcomes.
Nurses practice within the context of a social contract that is designed to meet the needs of society and requires the “provision of a caring relationship that facilitates health and healing” (American Nurses Association [ANA], 2010, p. To meet the obligation of that contract, nurses must be aware of their own values and belief systems that contribute to the process of providing care to the populations they serve. This qualitative study will use a grounded theory approach to gain understanding about the process that nurses use to decide how to care for patients who experience sexual violence. Background of the Study Violence is a complex worldwide phenomenon that is often considered an inevitable part of the human condition (Dahlberg & Krug, 2002).
Violence has a significant impact on the physical and psychosocial health of individuals, communities, and society in general. In the 2002 World Health Organization’s (WHO) World Report on Violence and Health (Krug, Dahlberg, Mercy, Zvi, & Lozano, 2002), it was reported that 2 an estimated 1.6 million people worldwide died from violence. Approximately, “half of those deaths were suicides, nearly one third were homicides and about one fifth were casualties of armed conflict” (Dahlberg & Krug, 2002, p. Violence is one of the leading causes of death worldwide for people ages 15-44.
accounting for “14% of deaths among men and 7% of deaths among women” (Dahlberg & Krug, 2002, p. Deaths related to violence are nearly twice as likely to occur in countries classified as low- to middle-income as in countries considered high-income. Within countries, variations are evident between rural versus urban populations, rich versus poor communities, and between ethnic and racial groups (Dahlberg & Krug, 2002). Death is not the only consequence of acts of violence.
Physical, sexual, and psychological violence occur in every community on a daily basis and severely affect the overall health of multiple millions of people throughout the world (Dahlberg & Krug, 2002). The economic costs of the immediate and long-term effects of violence are compounded by victims’ continued disability and loss of productivity (Dahlberg & Krug, 2002). In addition, victims of violence are at higher risk than others for psychological disturbances, including depression, anxiety disorders, and post-traumatic stress disorder (PTSD). These victims may also engage in harmful self-medicating behaviors utilizing alcohol and drugs (Dahlberg & Krug, 2002).
Reliable statistics that accurately measure violence are vital. Challenges to an accurate assessment of the problem include variations in the definition of violence, disorganized reporting systems, underreporting of violent acts by victims, and reluctance of governments/institutions to disclose the prevalence of the problem (Dahlberg & Krug, 3 2002). Mortality rates gathered from death certificates, coroner reports, and registries contribute to the statistics but do not reflect a comprehensive or accurate picture of the problem. Instances of physical and psychological harm from violence are much more common than death and are severely underestimated with existing reporting methodologies (Dahlberg & Krug, 2002).
Defining violence can be difficult when the wide variation of beliefs worldwide is considered that govern cultural, legal, and societal rules and mores. Behaviors that are considered culturally acceptable in one part of the world may be considered illegal in a neighboring country or community (Dahlberg & Krug, 2002). Towards a consensus, WHO developed this definition of the term violence (Dahlberg & Krug, 2002): Violence is defined as the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopement or deprivation. 5) Moreover, legal definitions of violence may vary between communities due to the need for language that is specific to the national formation of statutes, regulations, and legislative mandates.
The definitions may not include the wide range of intention and consequences included in the WHO definition. The WHO categorizes violence according to the individual or entity committing the act: self-directed, collective, and interpersonal violence. Self-directed violence refers to suicide and self-abuse, including self-mutilation. This category includes suicide intent and suicidal action without completion as well (Dahlberg & Krug, 2002).
4 Collective violence is the use of violence by people who identify themselves as members of a group in which the violence is used against another group or individual to achieve a political, economic, or social objective. This category includes a variety of forms including “armed conflict within or between states; genocide, repression and other human rights abuses; terrorism; and organized violent crime, physical, sexual, or psychological” (Zwi, Garfield, & Loretti, 2002, p.