Violence and the Emergency Room - Research Paper Example

 Violence and the Emergency Room Today's emergency rooms are filled with the effects of violence. Domestic violence and abuse are among the fastest growing health problems in the world. This kind of violence occurs at all racial, ethnic, and economic levels. Those that live at the higher economic levels are more financially able to hide it. Violence is a community that involves everyone. The increase in violence is not only occurring at home but in school and at the workplace. Elder abuse is increasing daily with the economy in the state it is in and the increasing numbers of elders as the baby boom generation ages. Many of these elders must be cared for in the home which puts them in harm's way when violence occurs. The stress of caring for them at home and the lack of funds increases the chance of violence and or the use of alcohol. All of these things affect the emergency room on a daily basis and many times they are fueled by alcohol which makes the encounter that much more volatile. This paper will examine domestic violence fueled by alcohol and how it might affect the emergency room. Intentional and unintentional violence and its effects take a toll on human health and the quality of life. Globally more than 5 million people die from injuries every year; violence kills more people than HIV/AIDS and malaria combined, yearly (World Health Organization, 2002). Every week in Wales and England, two women are killed by their current or former partner (Reeves & Sully, 2007) and many more are damaged for life. This is not an unusual statistic throughout the world at this time. This kind of violence in families has a very long history. It consists of a pattern of coercive control that is designed to isolate the victim (Davis, 2007). This all presents in major health issues in which the cost is high. Those in the violent situation and the communities in which they live have lost positive community participation and increased costs in healthcare. This type of violence usually manifests itself in physical, sexual, and or psychological abuse which involves fear, intimidation, and emotional depravation of not only the victim but those around them (Davis, 2007). It often engrains the victim in poverty that becomes difficult to climb out of. When fueled with alcohol, the violence can be much more sudden and heightened for the victims as well as the emergency room staff. There are some social, political, and legal context in Australia that should be considered here. In the last decade of conservative Federal government in Australia, there has been an erosion of services to women living with domestic violence. There has been a concerted move toward the consolidation of family which may force a situation in which the perpetrator is in the victims life longer. This has also caused the dismantling of policies and services that are available, including such things as child care subsidies, youth training schemes, youth allowances, legal aid, supported accommodation schemes, and movement to negotiated settlements. All of this affects programs that support women and children in trouble (Wright & Waugh, 2007). This makes it more difficult to get these women and children to safety and keep them there. When violence occurs the victims often come to the emergency room and many of them have never seen a primary physician so the violent episode may just be the tip of what is wrong with them. There is a often a revolving door situation in which the same victims come back with injuries on a regular basis. They may also keep coming back with complaints of things like headaches and stomach pain in an attempt at safety. Studies show that this may be the only safe place in which these victims can disclose or plan for escape. These same studies show that a woman's decision to expose abuse can depend on the attitude of the clinician that is caring for her as a victim (Janssen & Holt, 2002) and that nurses attitude may be the victims only hope for escape. It should be noted, however, that one in four women in Australia are abused either by their present partner or have been by a previous partner. That tells us that some emergency department nurses have been abused and some male emergency department nurses are abusers (McClennan, Worster, & Macmillan, 2008). This may be difficult in a situation where women say that the attitude of those that ask often determines whether they will disclose. Nurses in an emergency room atmosphere may have difficulty responding in a caring manner if it requires confronting their own problems with abuse (Laing, 2000). Many of the women in these studies noted that they are often treated negatively and the nurses believe their flimsy stories when they should just ask a few more questions. Women who are ask about violence are twice as likely to disclose but they want to be ask by someone who is listening, supportive, and non-judgmental and that has a good knowledge of community based support services (Davis, 2007). In one of the studies, a victim tells a story of the fact that she told a nurse about the fact that her husband had beat here. The nurse left the room to get information on a women's shelter and as she was asking another nurse, the husband overheard the conversation and she paid dearly for it when she got home. The staff in the ER must be very careful when attempting to circumvent the perpetrator. The core ethical concepts of nursing is the duty to care. This duty incorporates the core ethical concepts of beneficence and malficence (Davis, 2007). Failure to act in a manner that promotes the interests of women as victims breaches the duty to care, even if it is difficult and we have been victims ourselves, there must be a caring attitude toward the victim as well as the perpetrator and family. Women inside an abusive situation are unable to advocate for themselves and they often find that there are nurses who are "not seeing, seeing but not seeing, seeing but acting ineffectively and seeing for effective action"(Davis, 2007 pg. 13). Each victim hopes to get the nurse who is seeing for effective action. Caring and advocacy are the cornerstones of nursing and we must all be able to use those to the benefit of our patients, especially in an emergency room situation that is labile at best. There are many barriers to disclosure in the emergency room. One of those may be that there are other victims there in the same ER. It may very well be that the victims family is there or the perpetrator. There are feelings of shame, fear of blame by the healthcare workers, denial and fear of reaction from those around them. There is fear that their family will not understand and the fear of retaliation from the perpetrator (Davis, 2007). They might even fear receiving a medication that may dull their senses and make it difficult to protect their children or themselves. Many of the victims interviewed felt that the lack of privacy prevented them from saying anything, especially when the perpetrator or family were close enough to hear. Many emergency rooms today have firm policies in place that disallow family and especially husbands from being in the exam room when being seen by the nurse or physician. This allows for the possibility of the victim feeling less fearful and possibly disclosing. Screening and intervening becomes the greatest ER issue. In order to help, it must be known that there is a problem. Up to 35% of ED patients are victims of domestic violence and 95% of those are women. A full 50% of victims murdered by a spouse or lover were seen in an ED without being screened for domestic violence, not long before they were killed (Rhodes, Frankel, & Loventhal, 2007). Many slip through the cracks as the traumatic injuries are taken care of. Sometimes the trauma keeps us from seeing what we really need to see. Nursing must learn how to effectively screen for abuse (Gerard, 2000). Universal screening has been recommended in the ER for quite some time, yet less than 30% of the EDs in the world are compliant with screening (Gerard, 2000).Yet screening is the one thing that is proven to save lives in this case. Many victims visit the ED for other than the battery hoping that someone will ask them. They are hoping someone will not believe them when they say they ran into the door. What can an ED nurse do? There are many things and most of them come down to caring, listening, and advocating. Getting through the barriers to disclosure are not easy and then knowing what to do next can be even more difficult. The ABCDE plan for domestic violence can help: A-Ask and assess for safety B-Believe what a woman says and be supportive C-Collect resources and have them available for use. D-Document the intervention so someone else will know. E-Ensure safety for the client and yourself (McClennan, Worster & MacMillan, 2010). Nurses in the ED should be sure that they are well aware of community resources that provide assistance and support for women. There is also a great need for collaboration with other departments in the hospital in preparation for these victims. The health and welfare staff as well as case management and social services should be involved and ready to act. The formulation of this kind of collaborative team has been difficult in the past because of boundary infringements and a lack of understanding of the others roles which limited communication and caused poorly co-ordinate teamwork which prevents a good interdisciplinary approach (Reeves & Sully, 2007). This kind of coordination of resources can either help a victim or compromise her position based on how well it is put together. Prior planning by a multidisciplinary service group is essential to success of any victim program designed for use in the ER. The ED nurse should also begin to understand the stages of an abusive relationship as it will help her understand what she might be able to do at each stage. For example, if this is a new relationship, the victim is likely to be at a forgiving stage with less fear, and less need to escape from the situation. "He didn't mean to hit me" or "He is so sorry he did this". The approach that the nurse should make under this circumstance is to be sure to explain the cycle of abuse and how the apologetic stage is often followed by another abuse. If she understands what to expect next, she may act fast enough. In the case of an older relationship, the victim better understands the situation she is in. At this stage though, she may have no friends due to her isolation and there are likely children involved. She may also be totally isolated monetarily and have nothing to run with. It becomes a very frightening and possibly dangerous situation for her to disclose or plan to escape. She will need much help and planning as well as support and understanding. The ED nursing department should have a plan for screening all women above the age of 14. There should be a policy in place that denies access to the exam room by family members while the nurse or physician are examining the patient. Every screened woman should be ask about abuse and the nursing staff should understand domestic violence in such a way that they are caring advocates for the victims involved (Yonaka, Yoder & Darrow, 2007). They should also be prepared to take action when necessary which may mean involving a safe house and the police to remove the perpetrator so that the victim and/or her children can be removed to a safe place. This is a difficult process but when the perpetrator has alcohol on board, it is even more difficult because that person is more than likely going to be belligerent in actions which may put the staff as well as the victim at risk (Cocoran & Allen, 2010). Planning for that risk should happen as part of the planning for this team to deal with victims. Many emergency rooms now have policemen on duty all the time to help with this very kind of situation. In conclusion, nurses have a critical role in preventing, recognizing, and intervening where families, women and children are caught in violent situations. Nurses have a duty to care and to advocate which may not always be easy for them. Screening must be incorporated into their practice like CPR. It saves lives and must be learned well (Janssen & Sugg, 2002). Awareness of culture, resources, safety issues and the development of policies and clear procedures that support nursing practice are necessary parts of emergency room nursing. The emergency room nurse is uniquely situated to take advantage of that window of opportunity and to have the courage to ask questions and act accordingly. Emergency room staff must take a collaborative approach in developing protocols meant to protect all involved in a violent situation, including the risk they themselves take (Retallick & McCarthy, 2008). These protocols must be already developed and ready to use at a moments notice. Whether supporting or rescuing, the nurse must absolutely understand what her role is, who to involve, and how to carry it out safely for all of those involved. References Corcoran, J., & Allen, S.( 2005). The effects of a police/victim assistance crisis team approach to domestic violence. Journal of Family Violence. 20(1). [ Accessed March 14, 2010.] Davis, G. 2007. Family violence in New Zealand: A primary health care nursing perspective. Whitireia Nursing Journal. 14. 7-12. [ Accessed March 10, 2010.] Gerard, M. 2000. Domestic violence: how to screen and intervene. Critical Care Nurse. 63(12). 58. [ Accessed March 10, 2010]. Harris, M. 1992. Domestic violence is very unhealthy. Fortum. 21(6). [Accessed March 16, 2010.] Janssen, P., Holt, V., Sugg, N. 2002. Introducing domestic violence assessment in a postpartum clinical setting. Maternal and Child Health Journal. 6(3). 195. [Accesses March 14, 2010]. Laing, L. 2000. Children, young people and domestic violence. Australian Domestic and Family Violence Clearinghouse: Kensington. [ Accessed March 20, 2010.] Luck, L., Jackson, D., & Usher, K. 2007. Innocent or culpable? Meanings that emergency department nurses ascribe to individual acts of violence. Journal of Clinical Nursing. .[ Accessed March 14, 2010.] Martin, S. 2002. Children exposed to domestic violence: psychological considerations for health care practitioners. Holistic Nursing Practice. 16(3). [Accessed March 19, 2010.] McClennan, S., Worster, A., MacMillan, H. 2008. Caring for victims of intimate partner violence: a survey of Canadian emergency departments. CJEM. 10(4). 325-8. [Accessed March 13, 2010.] Nancarrow, H., & Struthers, K. 1995. The growth of domestic violence responses in Australia: A flash in the pan or a sustainable program for change? Social Alternatives. 14(1).[ Accessed March 12, 2010.] Olive, P. 2006. Care for emergency department patients who have experienced domestic violence: a review of the evidence base. Journal of Clinical Nursing 16. 1736-1748. [Accessed March 20, 2010.] Reeves, S., & Sully, P. 2007. Interprofessional education for practitioners working with the survivors of violence: Exploring early and longer-term outcomes on practice. Informa Healthcare. 21(4). 401-412. [Accessed March 20, 2010.] Retallick, N., & McCarthy D. 2008. Collaborative team approach to the early identification of domestic and family violence in an ED. Australasian Emergency Nursing Journal. 11(4). 198. [Accessed March 12, 2010.] Rhodes, K., Frankel, R., Lovinthal, N. et.al. 2007. You're not a victim of domestic violence, are you? Annals of Internal Medicine. 147(9). [Accessed March 14, 2010.] Schimanski, K., Hedgecock, B. 2009. Factors to consider for family violence screening implementation in New Zealand emergency departments. Australasian Emergency Nursing Journal. 12(2). 50-4. [Accessed March 12, 2010.] Thomson, T., Robinson, K., Russell, M. 1999. Domestic violence. Topics in Emergency Medicine. 21(2). 70-79.[ Accessed March 20, 2010.] Wright, I & Waugh, I. Domestic violence: A priority in child protection in New South Wales, Australia. Child Abuse Review. 16. 311-322. [Accessed March 14, 2010.] Yonaka, L., Yoder, M., Darrow, J. 2007. Barriers to screening for domestic violence in the emergency department. The Journal of Continuing Education for Nursing. 38(1).[ Accessed March 19, 2010.] http://www.who.org Read More