Domestic Violence in the Context of Nursing Practice - Essay Example

? Domestic Violence Domestic violence has been one of the primary causes of injuries among women. At the same time, it has been found to affect not just women, but children, too. Wives and their kids suffer from serious mental and physical problems that result from battering, sexual abuse, scalding, threat, and intimidation. Domestic violence escalates during pregnancy. It is the leading cause of birth defects in newborns and the major cause of miscarriages. Nurses have necessary potential and competence in supporting victims of domestic violence. They may act as advocates providing counselling services and listening to battered women. Also, they may take part in preventative actions aimed at violence neutralization or increase of awareness. Importantly, the nurse’s role is to identify, assess, and document the outcomes of violence in victims. The nurse should also be able to devise long-term strategies for women who are victims of abuse. These would either be based on advice to flee abuse or consider alternative ways of solving the problem. Domestic Violence Introduction In scholarly literature, the term “domestic violence” is used to describe instances of violent confrontation which occurs between intimate partners or a husband and a wife. Such violent confrontation typically involves rape, stalking, assault, and victims’ fear of being subject to physical abuse (Gonzalez, 2010). Some studies offer a broader understanding of domestic violence by adding here the cases of emotional abuse as well (Milner, 2010). This paper focuses on domestic violence in the context of nursing practice. It explores the question of violence during pregnancy and health outcomes of physical abuse on mothers and fetuses. After that, the principles of violence assessment by a nurse are discussed. Next, the findings about both mental and physical assessment after battering are discussed. Finally, the way nurses are supposed to approach domestic violence is examined. The paper concludes with the summary of its overall content and implications for nursing practice. Domestic Violence & Pregnancy Many women who have abusive partners hope that men will change once they learn about pregnancy. However, the reality is quite opposite. Experts warn that pregnancy will rather have an adverse effect on the partner who abuses. Ironically, one in six women who experience abuse report that they were abused when they were pregnant. Pregnancy is believed to be “a common trigger of domestic violence” (BabyCenter, 2012). According to Gazmararian et al (2000), violence from an abusive partner during pregnancy is more common than pregnancy-induced hypertension, placenta previa, and gestational diabetes. The number of pregnant women subject to violence in the United States ranges from 156, 000 to 332, 000 annually (Gazmararian et al, 2000). Up to one fifth of deaths related to pregnancy have been found to result from murder (Horon & Cheng, 2001). Violence during pregnancy is a form of Intimate Partner Violence or IBV. The latter has been defined as either physical or sexual violence or violence threat, as well as emotional abuse (psychological abuse) or coercive behaviour when the physical or sexual behaviour between partners has already taken place (Bloom, Bullock, Sharps, Laughon, and Parker, 2010). It has been observed that intimate partner violence consists of coercive and assaulting behaviours demonstrated by that partner who wants to control the other. In particular, these behaviours include inflicting physical injuries, abusing the partner emotionally and sexually, intimidation, isolation, stalking, deprivation, and threats (Family Violence Prevention Fund, 2004 in Bloom, Bullock, Sharps, Laughon, and Parker, 2010). Health consequences of violence during pregnancy affect both mothers and children (foetuses). One of the most dramatic outcomes is miscarriage. Miscarriages take away lives of mothers together with foetuses or just foetuses. Statistically, direct assaults increase the probability of lethal outcomes for mothers 19-fold. Foetal death probability through uterine rupture increases 46-fold. Other consequences of IPV during pregnancy include placenta rupture, anaemia, vaginal infections, choriamnionitis, bleeding, uterine rupture, kidney infection and poor weight gain (El-Kady, 2008). It has been found that domestic violence during pregnancy is the primary cause of birth defects in American children (Adams, 1994) Domestic Violence Assessment: Nursing Care Considerations The tasks of a nurse who deals with victims of domestic violence during pregnancy include: identification of abuse; assessment of its severity, nature, and risk of mortality; impact of the abuse on the victim’s health; planning interventions; intervention through support, referrals, safety planning, sharing information, and following-up on interventions/assessing interventions. Assessment by a nurse who deals with a victim of Intimate Partner Violence during pregnancy includes several things. First of all, nurses are supposed to do the assessment of the abuse history and abuse course with special focus on length of occurrence of domestic violence during pregnancy. Next, the severity of the abuse and its frequency need to be assessed. This typically applies to injuries as well as other health conditions that, women believe, come as a result of violence. It is also important to assess the level of the abuse, i.e. whether it is escalating. Apart from physical abuse, the nurse should assess sexual and emotional abuse. Victims of abuse should be inquired about their use of special resources for women who face abuse (shelters, members, clergy, and the police) and about the effectiveness of these organizations/people (Bloom, Bullock, Sharps, Laughon, and Parker, 2010). This assessment should be carefully documented by the nurse. While this may be a time-consuming activity, the recorded data may be invaluable for the victim’s probable legal procedures in the future (for example, in the issues of custody). The details need to be documented the way the woman is telling them; if possible, photos and body maps should be enclosed (See Appendix 2). Battering: Impact on Individuals, Newborns, and Families Violent partners are the major source of injuries that adult women get in the United States. The United States Department of Justice Bureau of Justice Statistics reports that “women are six times more likely than men to be the victim of a violent crime committed by an intimate” (Adams, 1994). In addition, official statistics says that every fifteen seconds an American woman is battered at home. Besides, as many as 4 million women are battered annually in the U.S. This fact needs to be considered along with the information that in the States a woman is much more likely to be injured, killed, raped, or assaulted by her partner than by other assailants. As many as 40% of all homeless children and women are victims of violence who fled abuse (Adams, 1994). To identify the impact of battering on a person, one needs to consider physical consequences first. Common sense suggests that battering is life-threatening. Just one attack may lead to lethal outcome or severe injury. Of all U.S. women who are killed, 30% are killed by their partners, current or former. Besides, up to 35 per cent of all female visits to an emergency room are related to injuries inflicted by their partners (Adams, 1994). Battering is no less grim psychologically. The term Battered Woman Syndrome has been used to describe the psychological effects of battering on women. Lucy Walker, the author of the further described Walker’s cycle of violence, observes that BSW is about a group of psychological symptoms which are typically transient and come in a specific, well recognizable pattern in females that report having been subject to abuse: physical, emotional, or sexual (Myers, 1997). This syndrome is recognized to be a subcategory of Posttraumatic Stress Disorder. It is found in women who have been exposed to battering in home for a long time. To be labelled this way (“battered woman”), a woman typically has to go through at least two cycles of violence (Self-Defense-4-Women.com). Let us focus on the concept of the ‘cycle of violence’. Generally speaking, as Karen Kenney notes, violent behavior in real life is not continually violent. It consists of distinct times when everything is calm, as well as of times characterized by excessive violence, combined with periods of the perpetuator’s remorse (Kenney, 2011). Typically, this cycle is found to be self-feeding. It is known to thrive in relationships where one spouse acts as a batterer. On a closer look, three key phases were distinguished with Walker’s Cycle Theory of Violence developed back in 1984. The first of them is tension building (tension is developed in an abuser). The second phase is conflict itself, or, in other words, battering (the abuser beats his victim). The third phase is the so-called honeymoon: the abuser promises to stop battering his victim, seems ashamed and usually asks for forgiveness. After the honeymoon phase, the abuse cycle enters again the phase of tension-building (Davhana-Maselesele, 2011) (See Appendix 1). Having experienced at least two phases of this cycle, women develop BSW. It means that a woman experiences “a breaking down of […] self-confidence and self-respect to a point where she no longer knows whether she is crazy or not” (Self-Defense-4-Women.com). Importantly, when this woman gets out of the abusive relationship she is likely to overcome helplessness and inadequacy she feels. The effects of violence are especially dramatic on children. By estimate, more than half of battered women come from households with children aged under 12. Overall, more than 3 million of children in the United States are exposed to abuse at home annually. Small children are more likely to witness domestic violence (Adams, 1994). Being a witness of battering and being raised in homes where domestic violence is a regular occurrence, children start to perceive violence as normal. Fathers become important role models for boys. Yet, before this boys go through stages of severe psychological sufferings. It has been found that they often construe themselves as the reason for battering. They also feel guilty about inability to intervene. Other feelings include fear, loss of security, excessive anxiety, isolation, shame, anger, and lost respect for the battered mother (Self-Defense-4-Women.com). Physical reactions in children that stem from constant stress include headaches, rashes, asthma, constipation, developmental delays, ulcers, problems of hearing and speech, and pain in the abdomen. Babies have been found to have attachment problems, while preschoolers are especially subject to worry, sleeping problems, and nightmares (Myers, 1997). Adolescents who grew up in abusive environments demonstrate increased violence. Their behavior gets aggressive and disruptive; girls become withdrawn, anxious, passive, and clinging. Children may also have impaired concentration and often demonstrate poorer academic skills (Berman et al, 2010; Adams, 1994). According to recent research, those children who grew in abusive homes are more likely to become alcoholics, drug abusers, and smokers. Besides, they are more prone to such diseases as skeletal fractures, ischemic heart disease, and cancer in adulthood (Berman et al, 2011). In terms of mental health, such children are likely to grow into adults subject to depression, with low-esteem, and anxiety disorders (Berman et al, 2011) Often children become victims of violent behaviour demonstrated by a battering parent. In this case, children get injuries, which may be very dangerous. Children get hurt by objects that are being thrown or when the abuser uses weapon. Babies suffer as they appear to be in the hands of their mothers while she is being abused, while older kids often get hurt as they try to defend their mothers. However, most often children become the objects of violence. Research shows that “over fifty per cent of wife abusers beat their children, with some studies placing the rate as high as seventy to eighty per cent” (Adams, 1994). To make the matters worse, mothers who get battered may start battering their children, too. In any case, children lose their childhood (Myers, 1997) Physical and Mental Assessment Findings about Battering Battered women who have experienced two or more cycles of violence may develop Battered Women Syndrome. This is a type of Posttraumatic Stress Disorder. This condition is characterized by helplessness, loss of self-esteem, loss of self-respect and self-confidence, as well as the feeling of inadequacy. Humphreys et al (2001) found that among 50 sheltered women 19 had PTSD. This accounts for almost 40 per cent. At the same time, it has been found that the specific features of PTSD or BWS may wear off once women get away from their abusers. PTSD-related mental health problems include suicidal intentions and substance abuse (Hughes & Jones, 2000). Physical assessment findings allow locating places most likely to be injured in women during domestic violence acts. These are head, abdomen, thorax, neck, and face (Muelleman et al, 1996). Common types of injuries, as listed in the study Sutherland, Bybee, and Sullivan (2002) are cuts, dislocated joints, fractures, knife wounds, scrapes, gunshot wounds, bruises, and broken bones. Frequently reported health problems in abused women are high blood pressure, sensations of choking, and pelvic pain. Sutherland and his colleagues also found that the majority of women who suffer from domestic violence are likely to experience fatigue and pain symptoms. Specifically, 93% reported feeling low in terms of energy, 88% said they had sleep problems, 84% reported having headaches, 81% said they had muscle tension/soreness, 80% complained about back pain, and 75% indicated that they experienced fatigue. Nursing Approach to Domestic Violence Humphreys and Campbell (2010) define the following nursing roles in relation to domestic violence. It is stated that the primary role of a nurse who deals with victims of domestic violence is that of advocate. This includes helping an injured woman to decide on the basis of the provided information and continually supporting the victim irrespective of the choices and decisions made by her. Other tasks of a nurse include 1) identification of the abuse presence; 2) assessment of the nature, level of severity and potential lethal consequence of the abuse, as well as the outcome of the abuse on the woman’s health; 3) planning of intervention strategies; 4) intervention via referrals, sharing of information, support, and safety planning; 5) following-up / assessing interventions effectiveness. Bonnie McClure, a Family Nurse Practitioner, RN, speaks of the following role of a nurse: assessment and intervening in violence in homes. McClure distinguishes three types of interventions that should be performed. First of all, this is primary intervention. It refers to preventing “a detrimental health effect from occurring” (McClure, 1996). Nurses may get involved in primary intervention through participation in political actions, education of communities, and colleagues. For example, in offices, nurses may place posters or distribute resource cards that increase people’s awareness and provide useful contacts. Besides, community forms may be held in offices and schools to educate people. As for secondary intervention, it aims to identify and intervene at an early stage of violent behaviour. This may be done through interview (asking questions directly) or through the use of self-reported history forms (less effective) (McClure, 1996). The secondary intervention also includes preparing documentation which covers the history of the abuses and fixes health outcomes. This one should be complemented by photos. Finally, tertiary intervention is about long-term planning with reference to the health problem experienced by a battered woman. Tertiary intervention is about supporting the woman in her decisions whether she decides to leave or chooses to stay. It should be taken into consideration that many women will choose to stay because of religious, financial, or family constraints. The nurse is supposed to provide support in either case, continue to listen, and attempt to find alternative methods of solving the dilemma. Conclusion In summary, nurses need to get actively involved into solving problems related to domestic violence both through prevention, treatment, and psychological support of victims. It is important to develop an adequate knowledge base of various aspects of domestic violence (domestic violence during pregnancy, effects on women and children’s health, causes and nature of domestic violence, etc). Importantly, nurses should be able to proficiently identify and assess victims’ physical and mental conditions, and intervene through support, information sharing, and treatment. Appendix 1 The Cycle of Violence (Fisher, 2001) Appendix 2 Body Map (Fisher, 2001) References Adams, C. (1994). Woman battering. Fortress Press. Baby Center (2013). Domestic violence during pregnancy. Baby Center. Retrieved February 14, 2013 from http://www.babycenter.com/0_domestic-violence-during-pregnancy_1356253.bc. Berman, H., Hardesty, J., Lewis-O’Connor, A., & Humphreys, J. (2010). Childhood exposure to intimate partner violence. In J. Humpreys & J. Campbell (Eds). Family violence and nursing practice. Springer Publishing Company, 279-317. Bloom, T., Bullock, L., Sharps, P., Laughon, K., & Parker, B. (2010). Intimate partner violence during pregnancy. In J.Hamphrey & J.Campbell (Eds). Family violence and nursing practice. Springer Publishing Company. Davhana-Maselesele, M. (2011). Trapped in the Cycle of Violence: A phenomenological study. Describing the stages of coping with domestic violence. J Soc Sci, 29 (1), 1-8. El Kady, D. (2008). Perinatal outcomes in traumatic injuries during pregnancy. Clinical Obstetrics and Gynecology, 50 (3), 582-591. Fisher, M. (2001). Working with battered women: A handbook for healthcare professionals. Retrieved from http://www.hotpeachpages.net/canada/air/medbook/medbook.pdf Horon, I. & Cheng, D. (2001). Enhanced surveillance for pregnancy-associated mortality – Maryland 1993-1998. Journal of the American Medical Association, 285 (11), 1455-1459. Hughes, M. & Jones, M. (2000). Women, domestic violence, and Posttraumatic Stress Disorder (PTSD). Retrieved from http://www.csus.edu/calst/government_affairs/reports/ffp32.pdf Humphreys, J., Lee, K., Neylan, T., & Marmar, C. (2001). Psychological and physical distress of sheltered battered women. Health Care Women Int, 22 (4), 401-414. Humphreys, J. & Campbell, J. (2010). Family violence and nursing practice. Springer Publishing Company. Gazmararian, J., Petersen, R., Spitz, A., Goodwin, M., Saltzman, L., &Marks, J. (2000). Violence and reproductive health: Current knowledge and future research directions. Maternal and Child Health Journal, 4 (2), 79-84. Gonzalez, J. (2010). The battered woman experience: a phenomenological study exploring the lives of Latina women and their experience with domestic violence (Doctor’s thesis, University of Nebraska). Retrieved from http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1068&context=cehsdiss. Kenney, K. (2011). Domestic violence Ebook. ABDO. McClure, B. (1996). Domestic violence: The role of the health care professional. Attacking Violence: Prevention and Intervention, 2 (1). Retrieved from http://hdl.handle.net/2027/spo.4919087.0002.105 Milner, B.-A. (2010). Recognizing children and young people living in the context of domestic violence. Internet Journal of Criminology, 1-43. Retrieved from http://www.internetjournalofcriminology.com/Milner_Children_Young_People_and_Domestic_Violence_Oct_2010.pdf. Myers, J. (1997). Myers on evidence in child, domestic, and elder abuse. Aspen Publishers Online. Muelleman, R., Lenghan, R., & Pakieser, R. (1996). Battered women: Injury locations and types. Annals of Emergency Medicine, 28 (5), 486-492. Self-Defense-4-Women.com (2013). Battered Woman Syndrome. Retrieved from http://www.selfdefense-4-women.com/battered-woman-syndrome.html Sutherland, C., Bybee, D., Sullivan, C. (2002). Beyond Bruises and Broken Bones: The Joint Effects of Stress and Injuries on Battered Women’s Health, American Journal of Community Psychology, 30 (5), 609-636. Read More