Domestic Violence: What Can Nurses Do?

"Safety and security don't just happen: they are the result of collective consensus and public investment. We owe our children—the most vulnerable citizens in any society—a life free from violence and fear. In order to ensure this, we must become tireless in our efforts not only to attain peace, justice and prosperity for countries, but also for communities and members of the same family. We must address the roots of violence."
—Nelson Mandela

Introduction

It is now 30 years since domestic violence first began to emerge as a significant issue. Initially efforts focused on ensuring safety for women and children fleeing violent partners.

Over the years, this focus has broadened to include the serious effects of domestic violence on children, what can be done to assist perpetrators of abuse, and the needs of those affected by abuse in all areas including social services, housing, legal and most recently, health services.

While an enormous amount of work has been done to improve the safety of women and children in our community, there is now a heightened concern about the many aspects of interpersonal violence that have an impact on the basic human right to live a life free of violence and abuse, with recent data indicating violence against women remains a substantial problem within our community.

A role for nurses

Nurses are a large group of service providers who have a central ethic of caring and an agenda of early intervention and health promotion in their work to improve the health status of communities.

As a group of health workers, nurses traditionally have been reluctant to consider domestic violence as a health issue, preferring instead to consider it to be the domain of social workers, psychologists and psychiatrists. Nurses have also been reluctant to embrace this issue in hospital settings.

Despite this, nurses have an important role to play in their work in hospital and community settings, to assist women (and their children) who are victims of abuse/violence in a domestic situation.

Evidence shows the effects of abuse/violence have a profound impact on women's and children's health, and that women regularly seek services from health care workers, including nurses, for health concerns related to this abuse/violence.

While domestic violence remains a serious and frequent aspect of women's intimate relationships, and women and children suffer health consequences as a result, nurses have a significant role to play in working toward the prevention and early intervention of domestic violence.

Imagine what could be achieved if all nurses were as informed about domestic violence as they are about wound care, or diabetes management, for example?

What would it mean to nurses who are themselves living in abusive/violent relationships, or other women living with abuse/violence whom nurses meet in the course of their work, if this topic could be discussed in informed and supportive ways?

It is imperative that nurses are prepared to educate themselves, and confront their fears, values and beliefs, while working towards creating an environments for this to occur.

Definitions of domestic violence

These days it is common for the term 'intimate partner violence' to be used. Others include 'family violence' (particularly in the context of violence in Aboriginal and Torres Strait Islander communities) or 'relationship violence'.

All of these terms refer to violence that occurs between people who are, or were formerly, in an intimate relationship.

This violence can occur on a continuum of economic, psychological and emotional abuse, through to physical and sexual violence.

Men can also be victims of this violence, but evidence indicates the majority of victims are women, and it is women who are more likely to suffer health consequences.

It is also known that such violence occurs across all cultural and socio-economic groups.

But as well as understanding what domestic violence is, nurses require some insight into the nature of these relationships. Such relationships are not about isolated incidents of physical violence followed by long periods of harmony. Rather, they are extremely stressful, with women investing significant energy in preventing violent episodes, maintaining peace and harmony, caring for children while protecting them from the impact of the abuse/violence, as well as living with the fear of precarious personal safety.

Very often women do not share this aspect of their relationship with others, or if they do, are often not believed and therefore unable to get the help and support they need. Significantly, many women do not want the relationship to end; but they do however want the violence to stop.

Occurrence

It is important for nurses to appreciate the scope of this problem. A national survey conducted by the Australian Bureau of Statistics found the prevalence of domestic violence in Australia is alarmingly high, with one in five women reporting being subjected to violence at some time in their adult life.

Health impact of violence

A recent review of international literature on abuse/violence identified a wide range of associated physical, neurological, psychological and psychogenic health problems.

Women who have been assaulted by their partner generally have worse heath than other women. Health issues include chronic problems with digestion, stomach, kidney and bladder function and headaches, poorer pregnancy outcomes and lower birthweight babies.

Recognition by nurses about the extent of these health consequences is central to their commitment to working with women to address the underlying cause of poor health.

Strategies and skills for nurses

Research suggests women who have been subjected to violence tend not to ask professionals directly for help. In a recent women's safety survey, 79% of women who had experienced physical assault and 81.25% who had experienced sexual assault had not sought any professional help.

The range of barriers to disclosing domestic violence include:

Fear for own safety, or safety of children or other family;
Denial or disbelief;
Emotional attachment to, or love for partner;
Commitment to relationship;
Hope the behaviour would change;
Shame and embarrassment;
Staying for the sake of the children;
Depression and stress;
Isolation;
Lack of faith in other people's ability to help; and
Belief in the value of self-reliance and independence.

When women do tell someone about the violence, few approach domestic violence services of the police. They are more likely to approach friends, family or the helping professions, and the response to disclosure is significant in determining the woman's subsequent help seeking behaviour.

Assessment

When assessing women, nurses should be aware that some of the following physical signs of injuries might be related to domestic violence:

Bruising in the chest and abdomen;
Multiple injuries;
Minor lacerations;
Ruptured eardrums;
Delay in seeking medical attention; and
Patterns of repeated injury.

However it is unlikely women will present with a physical injury. They will more likely present with issues such as:

A stress-related illness;
Anxiety, panic attacks, stress and/or depression;
Drug abuse including tranquilisers and alcohol;
Chronic headaches, asthma, vague aches and pains;
Abdominal pain, chronic diarrhoea;
Sexual dysfunction, vaginal discharge;
Joint pain, muscle pain;
Sleeping and eating disorders;
Suicide attempts, psychiatric illness; or
Gynecological problems, miscarriages, chronic pelvic pain.

The woman may also:

Appear nervous, ashamed or evasive;
Describe her partner as controlling or prone to anger;
Seem uncomfortable or anxious in the presence of her partner;
Be accompanied by her partner, who does most of the talking;
Give an unconvincing explanation of the injuries;
Be recently separated or divorced;
Be reluctant to follow advice.

If nurses think a woman in their care may be experiencing domestic violence, the detail of questioning will depend on how well they know the woman and what indicators they have observed. Nurses should begin with broad questions, such as:

'How are things at home?'
'How are you and your partner relating?'
'Is there anything else happening that may be affecting your health?'

Specific questions linked to clinical observations could include:

'You seem very anxious and nervous. Is everything all right at home?'
'When I see injuries like this, I wonder if someone could have hurt you?'
'Is there anything else that we haven't talked about that might be contributing to this condition?'

How to respond

The response of nurses to women in these circumstances can have a profound effect on their willingness to open up or to seek help. Some responses to assist successful communication in these circumstances could include:

Listening: Being listened to can be an empowering experience for a woman who has been abused.
Communicating belief: "That must have been very frightening for you."
Validating the decision to disclose: "It must have been difficult for you to talk about this." "I'm glad you were able to tell me about this today.'
Emphasising the unacceptability of violence: "You do not deserve to be treated this way."

What not to say

Nurses should avoid responses that undermine the woman's actions, such as:

"Why do you stay with a person like that?"
"What could you have done to avoid the situation?"
"Why did he hit you?"

Assisting safety

It is also imperative to assist the woman by assessing her safety and the safety of her children. To do so, speak to the woman alone and ask her:

Does she feel safe going home after the appointment?
Are her children safe?
Does she need an immediate place of safety?
Does she need to consider an alternative exit from your building?
If immediate safety is not an issue, what about her future safety? Does she have a plan of action if she is at risk?
Does she have emergency telephone numbers (i.e. police, women's refuges)?
Help make an emergency plan: Where would she go if she had to leave? How would she get there? What would she take with her? Who are the people she could contact for support?
Document these plans for future reference.

Act now

Nurses can play an important role in working toward the creation of a violence free community but they must first become informed. They must then insist the organisations in which they work accept this responsibility and work together to create environments that support people experiencing domestic violence.

There is a growing awareness and commitment at health department level to address the personal, social and economic costs of abuse/violence, so the time is ripe for nurses to act and ensure serious inroads are made in improving the health of all communities.

Charmaine Power, RN, Ph.D. is a senior lecturer in the school of nursing and midwifery at Flinders University, South Australia.

References

WHO, World Report on Violence and Health, World Health Organisation, Geneva, 2002.
ABS, Women's Safety Australia, Australian Bureau of Statistics, Canberra, 1996.
VicHealth, The health costs of violence: Measuring the burden of disease caused by intimate partner violence, State Government of Victoria, 2004.
Power, C. Reconstituting Self: A feminist post-structural analysis of women's narratives of domestic violence. Unpublished PhD Thesis, Flinders University, Adelaide, 1998.
ABS, op cit.
Campbell, J. Health consequences of intimate partner violence, The Lancet, 359, 2002, pp. 331-336.
Renker, P. Keep a blank face. I need to tell you what has been happening to me: Teen's stories of abuse and violence before and during pregnancy, The American Journal of Maternal Child Nursing, 27:2, 2002, pp. 109-116.
McFarlane, J., Malecha, A., Gist, J., Watson, K., Batten, E., Hall, I. and Smith, S. An intervention to increase safety behaviours of abused women: Results of a randomised clinical trial, Nursing Research, 51:6, 2002, pp. 347-354.
ABS, op cit.
The Domestic Violence and Incest Resource Centre and Women's' Health West, Identifying Family Violence, Partnerships Against Domestic Violence, Canberra, 2002, p. 15.
Keys, Young. Against the odds: How women survive domestic violence—the needs of women and children experiencing domestic violence who do not use domestic violence and related crisis services, Office of the Status of Women, Canberra, 1998.
The Domestic Violence and Incest Resource Centre and Women's' Health West, op. cit. p. 16. ibid. pp. 16-17. ibid. p. 18. ibid. p. 18.

Reprinted with permission of the ANJ. Power, C. Domestic violence: What can nurses do? Australian Nursing Journal, 12:5, 2004, pp. 21-23.