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Domestic violence and the role of the practice nurse

Domestic violence is not a new phenomenon, but it was only in the late 1960s that it began to be identified as a serious issue. Women's Aid has been providing services for abused women for 35 years; and individual health professionals have for a long time referred patients to these services. It is only during the last 10 years, however, that the health service has started to develop a consistent policy response to the issue.

This article summarises the extent of the problem, and suggests ways in which nurses working in primary care can help to highlight awareness, identify those at risk of abuse, and enable victims to access information and specialist service provision.

What is domestic violence?
The term "domestic violence" – sometimes called "domestic abuse" – refers to a number of different and overlapping behaviours that take place within an intimate or family-type relationship. The abuse can include physical violence, sexual assault, threats, financial or emotional abuse, and also includes forced marriage and so-called "honour crimes". Not all of these behaviours are, in themselves, inherently "violent", but together they form a pattern of coercion and control, which tends to worsen over time and to continue even after the victim's relationship with her abuser has ended.

All the available evidence shows that the vast majority of the victims of domestic violence are women and children, while men are the primary perpetrators. Women are also considerably more likely to experience repeated and severe forms of violence, to be victims of sexual violence, and to suffer permanent injury or even death as a consequence of the abuse.1 Research conducted with male respondents to the Scottish Crime Survey 2000 found that men were less likely to have been repeat victims of domestic assault, less likely to be seriously injured and less likely to report feeling fearful in their own homes. A majority of the men who said that they were victims of domestic violence were also found to be perpetrators of violence.2,3

Domestic violence is therefore most usefully seen as one extremely pervasive form of violence against women, and as a violation of women's human rights.4,5 Any woman may experience domestic violence regardless of ethnicity, religion, class, age, sexuality, disability and lifestyle. Domestic violence can also occur in a range of relationships including heterosexual, gay, lesbian, bisexual and transgender relationships, and also within extended families, and children may be both the direct and indirect victims of abuse.

How prevalent is domestic violence?
Domestic violence is extremely common: between one-quarter and one-third of all women experience it at some point in their lives, and, at any one time, as many as one in 10 women patients using primary care services may be experiencing abuse.1,4–6 On average, two women a week are killed by a violent partner or expartner.7–9 This figure has remained consistent over a number of years and constitutes nearly 40% of all female homicide victims.

Pregnancy seems to be a particular risk factor: 30% of all abuse starts during pregnancy,10–12 and between four and nine women in every 100 are abused during their pregnancies and/or immediately after the birth,13 with devastating effects on the health of the mother and child.

The impact on health
Domestic violence has an enormous impact on a woman's health. Some of the direct and indirect consequences of abuse include:

  • Physical injuries, eg, bruises, broken bones and loss of teeth.
  • Miscarriage, stillbirth and premature birth.
  • Mental health issues, eg, depression, anxiety, self-harm, eating disorders, and exacerbation of existing mental health conditions.
  • Use and misuse of alcohol, drugs and other
  • substances (including prescription medication).
  • Gynaecological disorders.
  • Other chronic health conditions.
  • Death – from suicide or murder.

Children who live with domestic violence are also affected enormously by the abuse. Some of them are also abused by the same perpetrator.14–17 All of them are to a greater or lesser extent witnesses to the violence directed at their mothers, and this will impact on their physical and mental health, their behaviour and their education.

An issue for primary care
The health service has a crucial role to play in identifying and responding to domestic violence: women may need medical treatment both immediately and in the long-term;18 and healthcare workers may be the first people to whom women disclose their abuse.19,20 Women experiencing domestic violence tend to use health services more frequently than other women; they may report a range of different health problems; they are admitted to hospital more often; and on average they are issued with more prescriptions than other people.9 Those working in primary care therefore have a vital role to play in offering support, information and validation, and signposting to specialist domestic violence services.

What can you do?
Remember that in all cases, the safety of the victim and her children is the first priority – so you must ensure you do not do anything that could jeopardise that. This means, for example, that you should never ask about possible abuse when anyone else (such as the woman's partner, friend or relative) is in the room or within earshot; and all records must be stored securely and in accordance with PCT guidelines.
These are some suggestions for how you might help:

  • Be alert to the signs that might indicate someone is being abused (see Box 1).
  • Create an environment in which victims of domestic violence feel safe and able to disclose the abuse.
  • Find out about domestic violence support services in your area and nationally.
  • Support women who disclose abuse, and let them know where they can find further help.
  • Keep accurate and detailed records of any disclosures – but never include in handheld notes, or in any other way where they might be accessible to an alleged or potential perpetrator; for example, they should never be allowed to be visible on a computer screen that might potentially be seen by other family members.
  • Ask your organisation or PCT to provide training in domestic violence awareness for all staff.
  • Take up all training opportunities provided.

It is not generally wise to tell a woman what she should do – that could be dangerous and is not the role of generic healthcare professionals. However, you could tell her about some of the options available (such as moving to safe alternative accommodation, eg, a refuge, or getting legal protection), and suggest she talks to a local or national specialist domestic violence service or helpline. If possible, encourage her to call them while you are with her, so that you can follow up and give support if she wants this; and if you or a colleague have been trained to provide a specialist domestic violence response, you may be able to discuss the options with her in more depth, and advise on the advantages and disadvantages of each one.

What can your GP practice or PCT do?

  • Distribute and display publicity and information so that users of services can be made aware of support and options available.
  • Engage in multiagency initiatives, eg, domestic violence forums, crime and disorder reduction partnerships, multiagency risk assessment conferences (MARACs).
  • Develop a domestic violence policy – ideally within a multiagency context.
  • Ensure that everyone working within the organisation – including reception staff – has received domestic violence training.
  • Identify one or more posts within the organisation with specific responsibility for domestic violence issues.

Indications of possible abuse
Box 1 gives some of the signs that might indicate someone is being abused. None of them automatically indicates domestic abuse, but they are suggestive – particularly if more than one is present – and should prompt you to try to see the woman alone and in private. This will give her the opportunity to disclose abuse if she wants to; and – whether she does this or not – you can give her an information leaflet or card with contact details of specialist domestic violence organisations, suggesting she passes it on to someone else if she does not need it herself.

[[Box 1_domest]]

Disclosure of abuse
A woman who is experiencing violence from a partner, expartner or family member is usually reluctant to tell anyone about it. She needs to be able to trust you, to know that it is safe to tell you, and that you will respond appropriately.
Many NHS trusts are introducing the practice of routinely asking about domestic abuse in certain healthcare settings – for example, during antenatal care. This practice is supported by the Department of Health.9

[[Box 2_domest]]

Routine enquiry – what is it, and why do it?
Routine enquiry is when everyone (or every woman) attending a particular healthcare service (such as an antenatal clinic, or accident and emergency service) is asked whether s/he is currently experiencing or has ever experienced one or more specific forms of abuse from a partner, former partner or family member. It is not primarily intended as a way of finding out how many patients are experiencing abuse. (While this is also important, it is best done as a separate procedure, and anonymously.) Nor should anyone feel pressured into disclosing.

Routine enquiry is intended to:

  • Indicate awareness, interest, concern – so that victims feel more able to disclose, and may expect a helpful response if they do.
  • Provide an opportunity to give out cards and other material with contact numbers of services – to everyone, regardless of whether they disclose abuse.
  • Avoid stigma: if every woman is asked (and you make this clear) no-one feels singled out.

It is crucial that, before routine enquiry is introduced, all staff are fully trained both to ask the question, and to respond appropriately to any disclosure. It's also important to have a safe and welcoming space – without interruptions – and take time to build up trust before asking direct questions.
Always put the woman's safety first, and only ask women about domestic violence when they are alone. The one exception is when an interpreter is needed, and in this case, you should make sure a professional interpreter is available: a family member or a friend must never be used as an interpreter for this kind of enquiry. Explain that you are asking everyone, and that domestic violence is very widespread. Ask direct questions – and record the answers.

[[Case study]]

[[disclose]]

Difficult issues
Asking about, and responding to disclosure of domestic abuse is never easy. You may be afraid you'll open up a can of worms – which you won't be able to deal with, and certainly not in the limited time you have available. You may feel it's none of your business. If the abuser is also one of your patients, there may be an apparent conflict of loyalty. And you may be concerned about whether you should inform any other agency – particularly if children are involved, or if the woman asks you not to tell anyone else.

Always adhere to your trust's policy and guidelines (including those on confidentiality and safe information-sharing, and child protection and safeguarding adults policies) – and inform women of the limits to confidentiality.21

Accept the limitations of what you as a health professional can do: while domestic violence has major implications for health, it is not in itself an "illness" which will respond to the correct "treatment". Don't take control away from the victim – she has experienced too much of that already – but instead try to empower her so she is able to make her own decisions about what is right for her and her children.

Above all, don't expect to solve the problem immediately. The victim will almost certainly have been experiencing abuse for some time before she discloses to anyone. She has taken the first step, and – following an appropriate response from you or another healthcare professional – she is likely to take further steps towards safety for herself and her children in the near future.

[[case study 2]]

References
1. Walby S, Allen J. Domestic violence, sexual assault and stalking: findings from the British Crime Survey. Home Office Research Study No. 276. London: Home Office; 2004.
2. Scottish Executive Central Research Unit. Domestic abuse against men in Scotland. Crime and Criminal Justice Research Findings No. 61. Edinburgh, SECRU; 2002.
3. Coulter M. Male victims and national standards for domestic and sexual violence. Safe 2007; Spring:22-4.
4. Council of Europe. Recommendation Rec(2002)5 of the Committee of Ministers to member States on the protection of women against violence and explanatory memorandum. Available from: http://www.coe.int/t/dg2/equality/domesticviolencecampaign/Aboutdomestic...
5. Coy M, et al. Realising rights, fulfilling obligations: a template for an integrated strategy on violence against women for the UK. London: EVAW; 2008.
6. Donaldson A, Marshall LA. Argyll and Clyde Domestic Abuse Prevalence Study. Scotland: NHS Argyll & Clyde; 2005.
7. Povey D, editor. Crime in England and Wales 2003/2004. Supplementary Volume 1: Homicide and Gun Crime. Home Office Statistical Bulletin No. 02/05. London: HO; 2005.
8. Home Office. Criminal statistics. London: HO; 1999.
9. Department of Health. Responding to domestic abuse. London: DH; 2005.
10. Lewis G, Drife J. Why mothers die: report from the confidential enquiries into maternal deaths in the UK, 1997-99. London: RCOG Press; 2001.
11. Lewis G, Drife J. Why mothers die: Report on confidential enquiries into maternal deaths in the UK, 2000–02. London: RCOG Press, 2005.
12. McWilliams M, McKiernan J. Bringing it out into the open: domestic violence in Northern Ireland. London: HMSO; 1993.
13. Taft A. Violence against women in pregnancy and after childbirth: Current knowledge and issues in healthcare responses. Australian Domestic and Family Violence. 2002 Available from: http://www.austdvclearinghouse.unsw.edu.au/PDF%20files/Issuespaper6.pdf
14. Hester M, et al. Making an impact: children and domestic violence. London: Jessica Kingsley; 2000 (new edition 2007).
15. Edleson J. The overlap between child maltreatment and woman abuse. 1999. Available from: http://new.vawnet.org/category/Main_Doc.php?docid=389
16. Humphreys C, Thiara R. Routes to safety: protection issues facing abused women and children and the role of outreach services. Bristol: Women's Aid Federation of England; 2002.
17. Mullender A, Morley R, editors. Children living through domestic violence: putting men's abuse of women on the child care agenda. London: Whiting and Birch; 1994.
18. Crisp D, Stanko B. Domestic violence: a healthcare issue. In: Shepherd J, editor. Violence in health care: understanding, preventing and surviving violence: a practical guide for health professionals. Oxford: OUP; 2001.
 19. Mezey G, et al. Victims of violence and the GP. Br J Gen Pract 1998;48:906-8.
20. Davidson L, et al. What role can the health service play? In: Taylor-Browne J, editor. What works in reducing domestic violence? London: Whiting and Birch; 2001.
21. Douglas N, et al. Safety and justice: sharing personal information in the context of domestic violence – an overview. London: Home Office Development and Practice Report; 2004.

Resources
Responding to domestic abuse
A DH handbook for health professionals
W: www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH_4126161

Home Office guidance on safe information sharing
W: www.eurowrc.org/01.eurowrc/04.eurowrc_en/GB_UNITED%20KINGDOM/Sharing%20p...
information%20-%20 domestic%20violence.pdf

The Survivor's Handbook
W: www.womensaid.org.uk/domestic-violence-survivors-handbook.asp?section=00...
00001&itemTitle=The+Survivor%27s+Handbook

Women's Aid
W: www.womensaid.org.uk
Freephone 24-hour Domestic Violence Helpline
T: 0808 2000 247

The Women's Aid Domestic Abuse Directory
W: www.womensaid.org.uk/azrefuges.asp?section=00010001000800060002&
region_code=&x=5&y=5