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Domestic violence: the role of the practice nurse

Sue Peckover
HV RGN PhD
Lecturer/Health Visitor
Community Ageing Rehabilitation Education and Research
School of Nursing and Midwifery
University of Sheffield
E:s.peckover@sheffield.ac.uk

For many years domestic violence was seen as a private issue, something that occurred within the confines of a relationship and was of concern only  to those involved.(1) This has altered dramatically, largely as a result of research and policy changes, which have recognised the dangers posed by domestic violence and the need for women and children to be more fully supported.(2-4) As recent Department of Health guidance suggests:(2)
"All health care professionals have the opportunity and responsibility to identify people who are ­experiencing domestic violence, and to take steps to empower those women to get help and support."
 
What is domestic violence?
"Domestic violence" is the most commonly used term to describe the range of abuses experienced by people from people known to them. It has been defined as:(2)
"Any violence between current or former partners in an intimate relationship, wherever and whenever the violence occurs. The violence may include ­physical, sexual, emotional or financial abuse."
Although men can experience violence and abuse from their female partners, and domestic violence also occurs in same-sex relationships, the overwhelming majority of cases - and the most severe and chronic ­incidents - are perpetrated by men against women.(5-7)
Domestic violence is widespread and affects women of all backgrounds. We know from UK-based research that up to one in three women have suffered domestic violence at some time in their adult lives, and one in nine women have experienced physical violence during the past 12 months.(6-9) The seriousness of domestic violence is reflected in mortality rates, which indicate that on average two women per week are killed in England and Wales by their partners or ex-partners.(7)

How does domestic violence affect health?
Although domestic violence has long been a concern to women and organisations that provide support, such as Women's Aid, it has only recently become an issue for nurses and other healthcare professionals. This is surprising given the considerable negative health consequences of domestic violence. These include physical problems due to injuries such as bruises, broken bones, burns and wounds, long-term damage such as scars and chronic pain, and mental and emotional disturbances such as higher rates of anxiety, depression, stress-related illness, self-harm and attempted suicide.(10,11) Many women first experience domestic violence during pregnancy, or find that this is the time when it increases in frequency or severity. Experiencing domestic violence during pregnancy is associated with miscarriage, stillbirth, preterm and low-birthweight babies.(12)
Domestic violence also affects children. One American study suggested that 90% of incidents of domestic violence take place when a child is in the same or next room.(13) As well as witnessing or overhearing domestic violence, children are often directly abused themselves, or they may be injured because they get "caught in the crossfire". Children experiencing domestic violence may be affected in different ways, depending upon their age, their particular situation and the support they receive; problems include physical injuries, emotional disturbances such as bedwetting, nightmares and sleep disturbances, eating difficulties, self-harm, depression, weight loss and developmental delay.(4,14)

What is the role of the practice nurse?
Women affected by domestic violence are frequent users of primary-care services.(9) This is largely due to their poor health status, both when they are experiencing abuse and when they are seeking help for chronic conditions that have been caused or exacerbated by the abuse. In addition, because primary care services are easily accessed, they are often the first point of contact that women seeking help about domestic violence have with statutory agencies.(15)
The nature of consultations in primary care also gives women the opportunity to present with one complaint, and then discuss another if the consultation is appropriately managed. This means that practice nurses are extremely well placed to provide care and support to women experiencing domestic violence.
The prevalence of domestic violence means that practice nurses should consider the issue in their routine work and be prepared to ask women about the issue and respond to disclosures. Where it is suspected, it is recommended that women are directly asked.(2) Therefore it is important to offer to see women alone and in private. Talking to women about domestic violence requires considerable skills. It is important to be sensitive and empathetic, as women find domestic violence very difficult to talk about and often minimise the extent of the problem.(16) They may be in a dangerous or compromised situation, and fearful of the consequences of disclosing their experiences. For these reasons it is important to believe women and try to understand their perspectives; this requires an awareness of the difficulties women face in living with and attempting to leave violent men. This is particularly important when dealing with a disclosure, but remains important throughout the subsequent contact with the woman. In raising the issue of domestic violence with women, practice nurses must be aware of the woman's safety, and be extremely careful to ensure their own practice interventions do not jeopardise this.
Practice nurses need to be aware of local and national sources of help for women experiencing domestic violence, such as finance, housing or legal advice, telephone helplines and support groups, as well as the specialist outreach and refuge services offered by women's voluntary organisations. As well as having leaflets and contact cards available, it is also useful to display relevant posters and information sheets in the waiting rooms and toilets of GP surgeries and health centres.
It is necessary to be clear about confidentiality and professional responsibilities towards the welfare and safety of children.(3) As Department of Health guidance points out(3):
"Where there is evidence of domestic violence, the implications for any children in the household should be considered, including the possibility that the children may themselves be subject to violence or other harm."
In practice this means that domestic violence must always be taken seriously. What actions and interventions are undertaken obviously depend upon individual circumstances, but practice nurses are strongly advised to ensure that they are practising in line with current child protection policy and procedures. The principle of supporting the nonviolent parent usually represents the most effective way of promoting the welfare of the child.(3,17)
Practice nurses will also have contact with women who have previously experienced domestic violence. The period immediately following separation can be particularly dangerous for women, so anyone involved must be extremely careful about confidentiality and ensuring that their actions do not jeopardise the safety of clients.(5,18) In the longer term it is important to continue to consider this issue and its impact upon women and children, as it often underlies illnesses and complaints presented to primary care professionals. Depending upon a woman's circumstances and wishes, it may be appropriate to offer specialised support, from a psychologist or voluntary project offering support to women and children experiencing domestic violence.
As well as working individually with women, it is also important to recognise that domestic violence is a public health issue. Alongside their colleagues in primary care, practice nurses can contribute to service development and needs assessment in a number of ways. Although the ability to do this is likely to be enhanced if the issue of domestic violence is included within the local Health Improvement Programme, developments can also be undertaken as a means to tackle more established public health priorities such as mental health, coronary heart disease and health inequalities. Central to such developments is interagency working,(19,20) and practice nurses need to be aware of any initiatives, such as the provision of training, information, and policy and practice guidelines that have been developed by the interagency forum within their locality.
 
Conclusion
Increased awareness about the nature and extent of domestic violence can leave practice nurses in no doubt that this is a serious issue, and one that is associated with a range of negative consequences. Practice nurses have a crucial role in recognising domestic violence and facilitating the provision of support and protection for women and children. For this to be achieved safely and effectively, good practice needs to be underpinned by appropriate training and supervision, and undertaken using a team approach, working in partnership with women and other agencies who contribute to the support and protection of women and children affected by domestic violence.

References

  1. Dobash RE, Dobash RP. Women, violence and social change. London: Routledge; 1992.
  2. Department of Health. Domestic violence. A resource manual for health care professionals. London: Department of Health; 2000.
  3. Department of Health. Working together to safeguard children. London: Department of Health; 1999.
  4. Mullender A, Morley R, editors. Children living with domestic violence: putting men's abuse of women on the child care agenda. London: Whiting and Birch; 1994.
  5. Kelly L. Surviving sexual violence. Cambridge: Polity Press; 1988.
  6. Mooney J. The hidden figure: ­domestic violence in North London. London: Islington Council; 1993.
  7. Mirlees-Black C, Byron C. Domestic violence: findings from the BCS self-completion questionnaire. Research Findings 86. London: Home Office Research Development and Statistics Directorate; 1999.
  8. Mama A. The hidden struggle: ­statutory and voluntary sector responses to violence against black women in the home. London: The London Race and Housing Research Unit; 1989.
  9. Stanko E, Crisp D, Hale C, Lucraft H. Counting the costs: estimating the impact of domestic violence in the London Borough of Hackney. London: Children's Society, and Hackney Safer Cities; 1998.
  10. British Medical Association. Domestic violence: a health care issue. London: BMA; 1998.
  11. Williamson E. Domestic violence and health: the response of the medical ­profession. Bristol: The Policy Press; 2000.
  12. Bewley S, Friend J, Mezey G, editors. Violence against women. London: Royal College of Obstetricians and Gynaecologists Press; 1997.
  13. Hughes H. Impact of spouse abuse on children of battered women. Implications for practice. Violence Update 1992;1 Aug:9-11.
  14. Hester M, Pearson C, Harwin N. Making an impact: children and ­domestic violence. A reader. London: Department of Health; 1998.
  15. Pahl J, editor. Private violence and public policy: the needs of battered women and the response of the public services. London: Routledge; 1985.
  16. Kelly L, Radford J. "Nothing really happened": the invalidation of women's experience of sexual violence. Crit Soc Policy 1991;30:39-53.
  17. Kelly L. The interconnectedness of domestic violence and child abuse: challenges for research, policy and practice. In:  Mullender A, Morley R, editors. Children living with domestic violence: putting men's abuse of women on the child care agenda. London: Whiting and Birch; 1994. p. 43-56.
  18. Hester M, Radford L. Domestic violence and child contact arrangements in England and Denmark. Bristol: Policy Press; 1996.
  19. Home Office. Domestic violence: break the chain. Multi-agency guidance for addressing domestic violence. London: Home Office; 2000.
  20. Home Office. Living without fear:an integrated approach to tackling violence against women. London: Home Office; 1999.

Further reading
British Medical Association. Domestic violence: a health care issue. London: BMA; 1998.
Department of Health. Domestic violence. A resource manual for health care professionals. London: Department of Health; 2000.

Internet resources
Women's Aid
W:www.womens aid.org.uk
Domestic Violence Data Source
W:www.domestic violencedata.org

Training materials
Peckover S, Marshall K, Kendall S. Understanding domestic violence: a ­training pack for community ­practitioners. London: Community Practitioner and Health Visitors Association; 2001.
For more ­information visit the CPHVA ­bookshop website
W:www.cphva bookshop.com