Intimate partner violence screening and treatment: the importance of nursing caring behaviors
Brenda J. Johnston
Intimate partner violence (IPV) is a major health concern worldwide. It is the primary cause of traumatic injury to women and one of the leading causes of death for pregnant women. Emergency department (ED) nurses are in a unique position to identify IPV victims, however, many hospital EDs do not perform routine screenings. This article reviews the literature associated with barriers to screening for IPV and victim’s experiences when seeking care in an ED following IPV.
Key words: intimate partner violence, domestic violence, abuse screening, barriers, caring, forensic nursing
Approximately 4.9 million intimate partner rapes and physical assaults occur annually in the United States (Tjaden & Thoennes, 2000). Intimate partner violence (IPV) is defined as threatened or actual physical, psychological, emotional, or sexual abuse directed toward a current or former intimate partner (National Center for Injury Prevention and Control [NCIPC], 2003). It is a major health concern worldwide, the primary cause of traumatic injury to women, and one of the leading causes of death for pregnant women (Griffin & Koss, 2002). Women experience more IPV than men and are often repeatedly victimized by the same partner (Tjaden & Thoennes, 2000). According to Rennison, Bureau of Justice Statistics (2003), IPV makes up 20% of violent crime against women compared to 3% against men.
IPV victims experience far more ill effects than the visible physical trauma. Adverse health outcomes have been well documented in the literature and include conditions such as chronic pelvic pain, spastic colon, migraines, stomach ulcers, sexually transmitted diseases, frequent diarrhea, indigestion, and constipation (Coker, Smith, Bethea, King, & McKeown, 2000).
A wide array of psychological problems is also connected to a history of IPV and includes depression, sleep problems, anxiety, and post-traumatic stress disorder (PTSD) (Walton-Moss & Campbell, 2002). According to the NCIPC (2003) the adverse effects of IPV have an estimated annual price tag of $5.8 billion. This cost estimate is based on total health care expenditures and victims’ lost productivity wages. This astounding cost, along with the untold intangible costs, proves IPV is a substantial health problem.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (1992) established guidelines that required accredited hospitals to implement policies and procedures in their emergency departments and ambulatory care settings for identifying, treating, and referring victims of abuse. The American Medical Association (AMA) has also established diagnostic and treatment guidelines on domestic violence and recommends that physicians be willing to ask all female patients about abuse and know how to respond to positive screens (AMA, 1992). The American Nurses Association (ANA) (2000) has also recognized the prevention of violence against women as a priority and has made specific recommendations for universal screening, routine assessment, and documentation of abuse.
Although the recommendations from ANA, AMA, and JCAHO are clear in regard to screening and treatment for IPV victims, the United States Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against routine screening of women for a history of IPV (Nelson, Nygren, McInerney, & Klein, 2004). The extensive review of the research by USPSTF found that no studies determined the accuracy of screening tools or the effectiveness of interventions (Nelson et al., 2004). In addition, studies have also not addressed the possible harmful aspects of screening and interventions for IPV which may include loss of contact with support systems, psychological distress, and an escalation of abuse (Sachs, Koziol-McLain, Glass, Webster, & Campbell, 2002).
As a result the USPSTF could not determine the balance between the benefits and risks of screening for family and intimate partner violence among children, women, or older adults (Nelson et al., 2004). These recommendations may seem contradictory, however including questions about abuse in the routine patient history could be recommended based on the prevalence of abuse among adult women and the potential value of information for clinicians (Nelson et al., 2004).
Purpose and Methodology
The purpose of this article is to provide an overview of the scientific basis for the nursing care of people seeking treatment for IPV, rather than providing an exhaustive review of the literature. With that purpose in mind the following studies were selected based on their applicability to current nursing practice. What follows is a review of selected literature associated with barriers to screening and treating victims of IPV. The role of ED nurses in caring for victims, barriers to providing care, and the victim’s experiences when seeking care will also be addressed. Specific caring behaviors are identified using Swanson’s Theory of Caring (1991) which can play a vital role in easing the fear and anxiety of IPV victims.
Barriers to Screening and Treatment of IPV
Education about IPV identification is available to all health care professionals with direct access to patients, however information regarding screening concludes that ED patients are not routinely screened for IPV (Rodriguez, Bauer, McLoughlin, & Grumbach, 1999; Wilson et al., 2001). Glass, Dearwater, & Campbell (2001) indicated that of 11 EDs surveyed, fewer than 25% of women who sought treatment were questioned about a history of IPV.
Reasons cited by nurses for lack of screening included lack of privacy in the health care setting, insufficient time to question patients, and difficulty knowing how to inquire about domestic violence (Ellis, 1999). Other barriers include lack of interest, fears of legal involvement, and concerns about confidentiality (Ellis, 1999; Glass, Dearwater, & Campbell, 2001). These barriers to screening create an environment that makes it difficult for IPV victims to obtain effective care and treatment.
Nurses are often caught off-guard when patients disclose a history of abuse. Most hospital EDs lack clear documentation guidelines and appropriate intervention policies, which leaves nurses ill-prepared (Dienemann, Campbell, Wiederhorn, Laughon, & Jordan, 2003). Poor documentation and a lack of interventions for victims can lead to failed offender prosecutions and the continuation of the abuse cycle (Isaac & Enos, 2001). Using protocols that incorporate danger assessment tools, developing safety plans, and providing information about community services is supported in the literature (Dienemann et al., 2003; Ellis, 1999; Feldhaus, 2001; Glass, Dearwater, & Campbell, 2001; Walton-Moss & Campbell, 2002). These interventions are crucial to the care of IPV victims.
Victims’ Perceptions of Care
IPV victims’ perceptions about screening questions and interventions have many commonalities. A lack of privacy, concerns regarding continuity of care, and time constraints have been consistently cited as reasons that prevent them from disclosing IPV (Baccchus, Mezey, & Bewley, 2003; Glass, et al., 2001). Women also express fears about the legal system, losing their children, possible retribution by their abuser, and being judged harshly by health care providers (Chang et al., 2003; Glass, et al., 2001; Petersen, Moracco, Goldstein, & Clark, 2003). There is also concern that in areas where health care providers are mandated to report IPV, victims are less likely to disclose (Rodriquez, Sheldon, & Rao, 2002). Victim’s perceptions of their care in the ED indicate that many nurses appear unconcerned and disinterested; this leaves victims feeling isolated and choosing silence (Yam, 2000).
A major theme in caring for IPV victims includes the need for a supportive environment where women are encouraged to make choices for their future (Bates, Hancock, & Peterkin, 2001). The victims often express disappointment because they are provided little emotional support or follow-up services after disclosing a history of IPV (Peckover, 2003). Petersen, Moracco, Goldstein, & Clark (2003) found that IPV victims felt the current health care system could not adequately provide the level of assistance they needed. Women felt that nurses were unaware of community resources that could help them become more self sufficient. IPV victims were interested in advocacy, job training, and financial support. They were interested in developing skills and obtaining the resources necessary to gain a life free from violence (Peterson et al., 2003).
Nursing’s Role in IPV Screening and Treatment
EDs are the third most common resource cited by women seeking treatment for IPV next to law enforcement and family and friends (Pakierser, Lenaghan, & Muelleman, 1998). This fact places ED nurses in an advantageous position to identify victims. Giffin and Koss (2002) urged IPV educators to turn to the nursing profession because of its focus on the whole patient as well as its recognition of IPV as a high priority. It is of critical importance that nurses become aware of how to identify and treat the complexities of this condition.
Giffin & Koss (2002) recommend that nurses screen all patients for a history of IPV in a private area away from their partner or children. They also suggest avoiding such terms as “domestic violence,” “abused,” or “battered” because these words can sound demeaning or judgmental. It is important to ask questions that are comprehensive, such as “At any time, has a partner hit, kicked or otherwise hurt, frightened, threatened, or demeaned you?” (Giffin & Koss, 2002, p. 5). Although specific screening questions can be helpful in improving identification of victims, a broader approach encompassing all aspects of care and treatment can be useful and may be achieved by incorporating some fundamental nurse caring behaviors.
Nurse Caring Behaviors
The barriers addressed regarding IPV screening and treatment challenge nurses to examine the practice and goals of nursing care. Caring for patients may not always involve alleviating suffering or curing disease, and momentous changes may not be observable as a direct result of care. Watson (1988) viewed caring as a moral ideal. She suggested that both nursing and medicine are moving out of a time when cure is critical into one where care takes precedence but she also noted that much more is known about curing illness than is known about healing and caring processes. Caring may be easiest to describe in the context of actions that convey understanding and involvement in other people’s experiences.
Swanson’s Theory of Caring
Nurse caring behaviors as outlined in Swanson’s Theory of Caring may provide the approach necessary to improve the practice of screening and treating IPV victims. Swanson’s middle range theory of caring (1991, p. 162) defined caring as “a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility.”
This definition embraces a belief that nursing is informed caring for the well-being of others and rests on five key concepts: Maintaining belief, knowing, being with, doing for, and enabling (Swanson, 1993). Swanson emphasizes that these concepts are not mutually exclusive but are instead overlapping processes with one overarching phenomenon: caring. An understanding of the following concepts and how they can be applied to IPV victims may help nurses caring for this population. Table 1 illustrates each key concept and its proposed usage in caring for IPV victims.
Maintaining Belief. An underlying belief in the capacity of others to make it through difficult transitions and events and to face a future with meaning is fundamental. Faith in persons is essential for nurses to be able to define what is important and know where and how to address care (Swanson, 1993). The capacity to recognize the strength of all persons to overcome adversity is essential for nurses providing care to IPV victims. Without this capacity nurses may express frustration and powerlessness when faced with women who stay in abusive relationships, refuse to report abuse to police, or deny that injuries were inflicted by a significant other. Nurses with a belief in persons will convey to victims faith in their ability to recover and to ultimately have a life free from violence. This belief in persons breeds optimism and creates an environment where victims can feel safe disclosing abuse and assured that their needs will be addressed and understood.
Knowing. Swanson (1993) defines knowing as “striving to understand events as they have meaning in the life of another” (p. 355). Knowing involves objective assessments that focus on all aspects of the person’s condition and reality. It avoids assumptions and sets the stage for a caring transaction.
Nurses working with IPV victims practice knowing when they attempt to understand these patients’ daily reality. This can be accomplished through an understanding of the cycle of violence and by assessing the patient’s level of dependency on the abuser. It can also be achieved through an acknowledgement of the physical, cultural, and spiritual effects of IPV on victims. Nurses can become more knowledgeable about IPV through continuing education programs and community agencies such as shelters for abused women. Equipped with increased knowledge of the effects of IPV, nurses can communicate a willingness to provide care that is based on the lived reality of victims. This awareness helps allow open disclosures of abuse histories without fear of judgment or criticism.
Being With. Being with is demonstrated by being emotionally present to another and conveying to people that their experiences are important. This caring category is made obvious when the nurse shares in the meanings, feelings, and lived experiences of the patient (Swanson, 1993). Being with does not simply involve a side-by-side physical presence but an open communication which demonstrates availability and commitment to the needs of another. Comforting messages that convey to patients that they are not alone, and that what happens to them matters, are essential (Swanson, 1993). Nurses caring for victims can demonstrate the being with caring process by acknowledging victims and allowing them to share the details of their abuse history in private with attentive listening. Emphasizing that the abuse is the fault of the abuser, giving phone numbers of essential emergency services, and providing information about safety planning conveys a caring attitude and a sense of responsibility.
Doing For. Doing for includes providing care and comfort for a person and doing for another what they would otherwise do for themselves if it were at all possible. It includes the anticipation of another’s needs and the performance of competent, skillful tasks, protecting from harm, and preserving the dignity of the one cared for (Swanson, 1993). Nurses treating victims employ this caring process each time they sit with a patient and work on a safety plan or document their injuries. Each time a nurse discusses protective orders and helps the patient contact the appropriate law enforcement agency to report abuse, this caring behavior is demonstrated. Placing the victim in contact with a local women’s shelter and providing information about legal services is also important. Doing for IPV victims involves employing interventions that can help the patient heal and move toward a violence-free life.
Enabling. Enabling involves helping others practice self care and is defined as “facilitating the other’s passage through life transitions and unfamiliar events” (Swanson, 1991, p. 164). The ultimate goal of nursing care is to help patients achieve well-being and this achievement may involve creating an environment where self-healing can occur (Swanson, 1993).
IPV victims struggle with many issues including self-blame, low self-esteem, and fear. If their situation involves the end of a relationship, they may also be facing an uncertain financial future.
Nurses providing care to this population must have an awareness of these complex issues and realize that care for these victims must not end with discharge from the ED. Appropriate referrals to advocacy services, affordable counseling, and legal assistance are essential. With these services victims can have an opportunity to rebuild their lives and lay responsibility for their abuse at the hands of the abuser.
Although many associations recommend routine screening for IPV and have treatment guidelines established, research is conflicting in regard to the benefits of these practices. To reach a consensus on care for victims, more data are needed that reflect patient outcomes that can be directly related to screening and treatment interventions. Outcomes data such as this will only become available when clinicians cultivate consistent practices for screening and treating IPV victims.
The literature review exposed many barriers to screening and treating IPV victims in EDs. Barriers included fear, a lack of privacy, lack of concern, and few policies and procedures addressing screening. Other barriers included a lack of knowledge regarding appropriate interventions for positive IPV screens. These barriers leave victims feeling isolated, without support, and wishing someone would provide services that would enable them to stand on their own and have a life free from abuse.
Nurses, being ideally suited to identify victims and provide assistance, may find the appropriate interventions in the five caring processes identified by Swanson’s Theory of Caring. These five processes are maintained by a belief in persons grounded in knowing their reality and communicated by being with, doing for, and enabling. These processes provide a structure of caring that can ultimately create an environment where IPV victims can begin to transition from victim to survivor.
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Brenda J. Johnston, MSN, RN, CEN, SANE-A, is the Coordinator of the Forensic Nurse Examiner Program, Winchester Medical Center, Winchester, VA.
Table 1. Nursing Caring Behaviors
Key Concept Proposed Usage
Maintaining Belief: Sustaining * Inquire about a history of violence
belief in the other’s capacity * Communicate concern with body
to get through an event or language, eye contact, and attentive
transition and face a future of listening
fulfillment (Swanson, 1993). * Discuss the victim’s strengths and
* Commend them for having the courage
to discuss a history of IPV
Knowing: Striving to understand * Communicate an understanding of the
an event as it has meaning in cycle of violence
the life of another (Swanson, * Assess the victim’s level of
1993). dependency on the abuser
* Communicate awareness of the
physical, cultural, and spiritual
effects of IPV
* Share knowledge of community agencies
that provide services to victims
Being With: Being emotionally * Be available and unhurried
present to the other and * Show empathy and compassion
conveying to persons that their * Provide privacy and a safe
experiences are important environment to facilitate
(Swanson, 1993). communication
* Do not be critical or judgmental
* Emphasize that the abuse is the fault
of the abuser
* Show concern for the victim’s safety
Doing For: Doing for the other * Document injuries with photographs,
as he/she would do for the self diagrams, and written descriptions
if it were at all possible * If applicable collect any biomedical
(Swanson, 1993). and trace evidence
* Provide treatment for injuries
* Assist with the development of a
* Discuss reporting options and the
need for protective orders
Enabling: Assisting others to * Assist with contacting appropriate
practice self care and law enforcement agencies
facilitating passage through * Provide written information regarding
life transitions and unfamiliar protective orders
events (Swanson, 1993). * Provide written information about
victim witness programs and other
* Arrange discharge to include a safety
plan and referral to shelter and
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