- Email: [email protected]
Domestic violence awareness in the perianesthesia setting
Domestic Violence Awareness in the Perianesthesia Setting Barbara A. Scales, RN, CCRN, CAPA, RM
Identification of victims of domestic violence is the first phase in the intervention of stopping the cycle of violence. Phase two is acting on that information and assisting the victims to help themselves. Nurses have the unique opportunity of being “present” at the bedside for the victim of abuse. This article reviews the signs and symptoms of domestic violence. Keen patient assessment tools and support can make a world of difference in the outcome of abuse. © 2004 by American Society of PeriAnesthesia Nurses.
Case Study A female patient who was scheduled for gynecologic surgery presented with severe emotional distress. She requested that the male who had brought her to the surgery center not be allowed to come back to be with her before she went to surgery. The perianesthesia nurse talked to her and asked her if she felt up to having surgery this day because she appeared so distraught. Her anxiety was noted and documented at length, as well as her desire for separation from her “support person.” She insisted that her surgery be performed. Although the woman did not have visible bruises or cuts, the nurse suspected that she might be the victim of an abusive relationship and notified the surgeon. She also gave her a handout with the abuse hotline and notified the nursing supervisor. Three years later, the nurse was questioned by her employer about the previous case. The woman had decided to file for divorce and had summoned her records from the day of surgery. The nurse was asked briefly about whether she had witnessed any facial markings or bruises. She had no such recall but could remember that the patient had frequently gotten up from her stretcher to look at herself in the mirror. In the nurse’s notes, the nurse had documented that the patient’s face was very flushed and that she had been crying. When the nurse had asked her why she was crying, the patient had stated that she and her significant other had had a disagreeJournal of PeriAnesthesia Nursing, Vol 19, No 1 (February), 2004: pp 11-17
ment. She did not share with the nurse that he had slapped her repeatedly before their arrival to the surgery center. The nurse thought she was investigating this situation well and had even offered to call the abuse hotline for the patient. After attending a domestic violence program at a local woman’s shelter, however, the nurse now realized that she could have questioned the patient more directly. Perhaps then the patient would have divulged more information. The nurse did feel comforted that the patient had finally made the difficult decision to stop the abuse.
What Is Domestic Violence? Domestic violence is the actual or threatened physical, sexual, psychological, or economic abuse of an individual by someone with whom they have an intimate relationship.1 Although 85% of reported domestic violence is perpetrated against women, nurses must remain cognizant that both victims and abusers may be male or female.2 The use of power and control knows no gender. In some states, domestic violence is considered a crime. Nurses may Barbara A. Scales, RN, CCRN, CAPA, RM, was the Nurse Orientor in the PACU for Harrison Center Outpatient Surgery, Syracuse, NY. She currently works as a per diem staff member at the same institution. Address correspondence to Barbara A. Scales, POB 723, Tully, NY 13159; e-mail address: [email protected]. © 2004 by American Society of PeriAnesthesia Nurses. 1089-9472/04/1901-0003$30.00/0 doi:10.1016/j.jopan.2003.11.008 11
12
browse the Web site for the Family Violence Prevention Fund (http://www.fvpf.org), which displays a list of states where reporting domestic violence is mandatory.
BARBARA A. SCALES
women are at twice the risk for battering.12 Several studies indicate abuse of pregnant women reported at public clinics as 8% to 15%, whereas battered pregnant women reported at private clinics ranges from 17% to 26%.13
Statistics of Domestic Violence The New York State Division of Criminal Justice reported that domestic violence increased 117% from 1983 to 1991.3 In 1992, 7% of American women (3.9 million) who were married or living with someone as a couple were physically abused, and 37% (20.7 million) were verbally or emotionally abused by their spouse or partner.4 Every 9 seconds in the United States, a woman is physically abused by her husband.4 A 1993 poll on domestic abuse showed that 34% of Americans have witnessed domestic violence, compared to only 19% who had witnessed a mugging or a robbery. That same poll indicated that 14% of American women admitted they have been violently abused by a husband or a boyfriend.5 Domestic violence is repetitive in nature: about one in five women who were victimized by their spouse or ex-spouse reported that they had been the target of a series of at least three assaults in the last 6 months.6 In 1992, the AMA reported that as many as one in three women would be assaulted by a domestic partner in her lifetime—4 million in any given year.7 Nearly two in three female victims of domestic violence were related to or knew their attacker,8 and in 1999, 69% of all rapes were committed by a known assailant.9 Thirty percent of the women who arrive at the emergency room with injuries have battering-related injuries.10 Fortytwo percent of murdered women are killed by their intimate partners.11 Pregnancy is a risk factor for battering. Theoretically, pregnancy may add stress to an already volatile situation. The domestic partner may experience jealousy, may not have wanted children, or may think the child is not his. Forty percent of the assaults on women by their partners began during the first pregnancy. Pregnant
Forty-eight percent of cases are not reported to the police by battered women.14 Ninety-two percent of battered women do not discuss the abuse with their private physicians, and 57% do not discuss it with anyone at all.4 In one study of 394 women, although 22.7% reported they had been victims of abuse, only 6 of the 394 women had ever been asked by their physician about domestic violence.15 In one major metropolitan study on domestic violence, in 92% of the cases of abuse the ER physician had failed to obtain a psychological history, ask about abuse, or address the woman’s safety.16 A recent national study of the 143 accredited U.S. and Canadian medical schools revealed that 53% of the schools did not require medical students to receive instruction about domestic violence.17 The financial impact of domestic violence was presented in a study from Chicago that indicated the average cost of health care in an emergency room for a battered person is $1,633. This converts to a national cost of $857.3 million a year.18
Etiology of Domestic Violence Victims of domestic violence may be traumatized with either sexual or physical violence. Their offender may use techniques overtly or covertly; each can leave scars for life. The sexual abuser may attempt to gain control by coercion and threats. The perpetrator may withhold financial support as a means of keeping the upper hand. He/she may deny accusations of wrongdoing and shift the blame onto the victim. Isolating the victim helps the abuser to sustain an atmosphere of the victim relying solely on the abuser for all of his or her needs. The abuser may resort to other weapons to continue to dominate the victim such as intimidation and emotional harassment. Social status
DOMESTIC VIOLENCE AWARENESS
and children are powerful deterrents for the victim when trying to attempt to escape the clutches of the perpetrator. See Figure 1.
What Can Perianesthesia Nurses Do? Screening for victims of domestic abuse should begin at the pretesting interview. Perianesthesia nurses need to observe behavior, language, and appearances of the potential patient. Honing in on nervous behavior, poor eye contact, and bruises, and listening to what the patient says and does not say may lead to clues during the preoperative interview. Open-ended questions may assist the possible victim of abuse to fill in the information gap needed to make a better determination of an abusive situation. The nurse can ask, “Would you like to talk about what has happened to you?” “How do you feel about it?” It is important for the nurse to listen non-judgmentally, to allow the victim to express her situation in her own words, and to validate what the victim says. Victims are often not believed and their claims are minimized. Give support with sentences like, “You do not deserve this.” “What has happened to you is a crime.” “Help is available to you.” Nurses need to document what they see accurately by using notations that describe exactly what is seen (e.g., “her hair is a tangle,” “she has a gash on her left cheek,” “there is a bruise to the right eye in the color of purple, yellow, or green,” which is an indicator of time elapsed). Notations should be entered for abnormal laboratory findings and the presence of police. Document what the nurse is hearing by using the patient’s own words with quotation marks or write “the patient states . . .” It is proper to include descriptive words to identify the client’s demeanor such as “crying, angry, agitated.” In some courts, the word “hysterical” may be admissible.19 Nurses should avoid the use of initials or abbreviations such as DV for domestic violence. Doc-
13
ument the person’s name that the client identifies as the responsible party, but do not write that he or she is the “alleged perpetrator” because this is a legal term. Assigning the victim as “this patient is a battered woman” is considered a conclusion in a court of law, and it will not be admissible without sufficient evidence. Attempt to extract from the patient the time of day that the abusive event occurred and how much time has passed since the incident he or she is describing. Take photographs, if possible. Photographs will bring the judge and jury to the event faster than word of mouth. Be certain to date and time the photos and document who is in the photo for future reference. Last, but not least, write legibly. Documentation that cannot be read will be dismissed. Nurses are patient advocates, and the point of documentation is to assist the victim, so be sure that notes can be easily read.20 See Table 1 for patient assessment indicators. Surgery centers can establish a plan that identifies potential victims and the steps to be taken to educate the victim on how and where to seek help. Work with peers to develop a protocol on how to handle domestic violence situations. Make pamphlets with easy-to-tear-off domestic violence hotline numbers readily available in examination areas, pretesting interview areas, preparation areas, and reception areas. Prior discussion in routine clinical review meetings on how to intervene in this type of situation will assist the nurse interaction with a patient, patient’s partner, or colleague. Once a possible domestic violence patient is identified, a series of events could be set in place that could help the victim to get out of the cycle of violence. Prior to discharge, the situation must be evaluated for the victim’s safety. Adults have the right to deny assistance, but if abuse is suspected, nurses are obligated to offer help. If it is suspected that elders or children are involved in the abuse, the nurse is then considered a mandated reporter of such, and must call a hotline
BARBARA A. SCALES
14
Fig 1.
Power and Control Wheel. Adapted from Domestic Abuse Intervention Project, 202 East Superior Street, Duluth, Minnesota 55802.
DOMESTIC VIOLENCE AWARENESS
15
Table 1. Indicators of Abuse to Consider During Patient Assessment 1. Have the body injuries occurred to multiple anatomical sites? Are the injuries bilateral? Are the injuries in various stages of healing? 2. Using a body man, identify the specific areas that have been targeted such as the face, neck, breasts, chest, or abdomen. 3. Has the woman delayed seeking medical assistance? 4. Has there been forced sexual encounter? 5. Does the woman arrive in the emergency room with medically insignificant trauma? (She may be using this as a cry for help.) 6. Does the patient react appropriately to the level of the injury? Does she appear overly anxious, depressed, or seem to be minimizing the event? 7. Does the significant other stay too close, or attempt to answer for the patient? Does the preoperative patient request that the support person not be allowed in? 8. Is the client pregnant? Does there seem to be a pattern of self-induced or therapeutic abortions? 9. Is there a history of repetitive emergency room visits and injuries? (This can be the key indicator.) 10. Suicide attempts can be an indicator of domestic violence. 11. Does the injury fit the description of how it occurred? Adapted from: Stark, Flitcraft, et al., Wife abuse in the medical setting, in Warshaw C, Ganely A (eds): Improving the health care response to domestic violence: a resource manual for health care providers (ed 2). San Francisco, CA: The Family Fund; 1996.
to report the case. Every state has laws, which vary, and each nurse is responsible to know the guidelines for practice within his/her state. Nurses can provide referrals to many agencies to get the victim assistance (see Table 2); it can be written onto a prescription pad that victims can tuck into their pockets or purses until they feel ready to act on it.
Setting Up a Plan of Action When a woman decides to leave her abusive situation, she can seek shelter and assistance to break free of her injurious cycle. Assisting her to devise a safety plan for herself and her children is important. The local shelters will encourage
the woman to fill out a form that designates an action plan. See Table 3 for highlights of an action plan from our local women’s shelter.
What If the Abused Person Denies the Need for Any Help? A client’s religion may play a role in the “why” aspect of remaining in a domestic violence situation. According to the Center for the Prevention of Sexual and Domestic Violence, a woman who has been abused often feels abandoned by God. The same center documents that pastors, priests, and rabbis may advise the woman to return home to “be a better wife.” In the Jewish religion, maintaining shalom bayit, or peace in
Table 2. Resources* ● ● ● ●
To obtain a community action kit for Domestic Violence, please call 1-800-777-1960. NATIONAL DOMESTIC VIOLENCE HOTLINE 1-800-799-SAFE National Resource Center on Domestic Violence 1-800-537-2238 Free Reconstructive Surgery for Victims of Domestic Abuse 1-800-842-4546 by the Academy of Facial Plastic and Reconstructive Surgery and the National Coalition Against Domestic Violence
*Providing these phone numbers on a prescription blank or an appointment card may help patients feel more comfortable carrying it with them.
BARBARA A. SCALES
16
Table 3. Highlights of an Action/Safety Plan The victims of domestic violence should 1. Avoid rooms in the home with the highest potential for violence (kitchen/bathroom). 2. Carry important emergency assistance numbers and have them available for the children. 3. Identify a code word that children and friends will know to indicate help is needed. 4. Teach children how to call for help. 5. Teach children how to make a collect call to the police or clergy, in the event that her partner takes them. 6. Instruct a trusted friend or neighbor to call the police if suspicious noises are heard coming from the home. 7. Provide a list of homes of friends/neighbors/family that can be refuge from violence. 8. Leave extra money and documents with a safe person or place that would be readily available when the need arises (e.g., identification [birth certificates, drivers license, photo ID, passports, benefit cards, green card]; school and medical records; money; bank book; credit card; ATM; keys to house, work, and car; car registration; medication for herself and children; address book; insurance papers; court documents of custody; order of protection, marriage certificate; tax returns; divorce papers; photos; jewelry; leases; house deeds; current unpaid bills; and children’s sentimental value items and toys). 9. List other ways to ensure personal safety. Adapted from: Vera House Incorporated Personal Safety Plan, A Personal Safety Plan, P.O. Box 365, Syracuse, NY 13209.
the home, may be a deterrent to rocking the boat and seeking help from a violent situation. In the Christian household, the concept of being submissive to the husband as found in scripture could make a woman think twice before leaving her spouse.21 The patient can choose to deny help despite all efforts of the health care provider. Provide the patient with the information needed to seek further assistance. Statistically, women are at the highest risk of serious injury when they decide to leave the abusive relationship. Homicide is a serious possibility because it has been shown that 70% of victims murdered were killed during the time they made the move to leave.2 It may take the victim a long time to determine that she is prepared to escape. Although it can be frustrating to health care workers when someone decides to stay in an abusive relationship, ultimately it is the decision of the patient.
As the nurse with an opportunity to be on the front lines of abuse, know that women may seek help from their situations. Change can be frightening and tedious and the victim may take years to act on the information, as was the case of the patient in the case study. We as nurses can help our patients to learn to help themselves. The nurse at the bedside can assist a victim of abuse just by giving support and information. Providing a mechanism for escape from an abusive situation is the goal.
Summary Nurses in the perianesthesia setting do have a unique opportunity to identify and act on the presence of domestic violence. Perianesthesia nurses should be aware of how to identify the victims of domestic violence, resources available for those victims, and any laws pertaining to domestic violence. Perianesthesia nurses can make a difference.
References 1. Warshaw C, Ganley A: Improving the health care response to domestic violence: A resource manual for health care providers (ed 2). San Francisco, CA: The Family Fund; 1996 2. Sheehan-Berlinger J: Domestic violence: How you can make a difference. Nursing August 31:58, 2001
3. NYS Division of Criminal Justice Services. Data from 1983 and 1991. Available at: http://acog.org. Accessed October 13, 2001 4. The Commonwealth Fund: First Comprehensive National Health Survey of American Women Finds Them at Significant
DOMESTIC VIOLENCE AWARENESS Risk (News Release). New York, The Commonwealth Fund July 14, 1993 5. Family Violence Prevention Fund. Men beating women: Ending domestic violence, a qualitative and quantative study of public attitudes on violence against women. New York, EDK Associates, 1993 6. United States Department of Justice: Highlights from 20 years of surveying crime victims: The National Crime Victimization Survey 1973-92. Washington, DC, US Department of Justice, Bureau of Justice Statistics, October 1993 7. Helton A, McFarlane J, Anderson E: Prevention of battering during pregnancy: Focus on behavioral change. Am J Public Health 4:166-174, 1987 8. Lanagan P, Innes C: Preventing domestic violence against women, in Warshaw C, Ganley A (eds): Improving the healthcare response to domestic violence: A resource manual for health care providers (ed 2). Washington, DC, US Department of Justice, Bureau of Statistics, 1996 9. When violence hits home. Time 144, 1994 10. Bachman R: United States Department of Justice Bureau of Statistics, “Violence Against Women: A National Crime Victimization Survey Report,” January 1994 11. Institute for Behavioral Science, at the University of Colorado at Boulder, Colorado: Analysis by the Center for the Study and Prevention of Violence, 1991 12. National Crime Victimization Survey, 1999. Available at: http://www.4woman.org/. Accessed October 13, 2001 13. McLeer S, Anwar R: A study of battered women presenting in an emergency department. Am J Public Health 79:65-66, 1989 14. Hamberger L, Saunders D, Hovey M: Prevalence of domestic violence in community practice and rate of physician inquiry, in Warshaw C, Ganley A (eds): Improving healthcare response to domestic violence: A resource for health care
17
providers (ed 2). Washington, DC, US Department of Justice, Bureau of Statistics, 1996 15. Warshaw C: Limitations of the medical model in the care of battered women, in Warshaw C, Ganley A (eds): Improving healthcare response to domestic violence: a resource manual for health care providers (ed 2). Washington, DC, US Department of Justice, Bureau of Statistics, 1996 16. Holtz H, Hanes C: Education about domestic violence in 25 US and Canadian medical schools, 1987–88, in Warshaw C, Ganley A (eds): Improving healthcare response to domestic violence: a resource manual for health care providers (ed 2). Washington, DC, US Department of Justice, Bureau of Statistics, 1996 17. Meyer H: The billion dollar epidemic, in Warshaw C, Ganley A (eds): Improving the health care response to domestic violence: a resource manual for health care providers (ed 2). Washington, DC, US Department of Justice, Bureau of Statistics, 1996 18. National Clearing House for the Defense of Battered Women. Available at: http://www.cybergrrl.com/views/dr/stat/ statbwkill.html. Accessed October 13, 2001 19. Around the School: Harvard School of Public Health Office of Communications Researchers Look at Role of Medical Records in Domestic Violence Legal Cases. Available at: http:// www.hsph.harvard.edu/ats/aug11. Accessed August 11, 2002 20. Roache C: Researchers Look at Role of Medical Records in Domestic Violence Legal Cases, Around the School. Available at: http://www.hsph.harvard.edu/ats/aug11. Accessed August 11, 2002 21. Center for the Prevention of Sexual and Domestic Violence-domes: Domestic Violence: Religious Aspects of the Problem, Available at: http://www.cpsdv.org/dv/domestic. htm. Accessed August 15, 2002
Identification of victims of domestic violence is the first phase in the intervention of stopping the cycle of violence. Phase two is acting on that information and assisting the victims to help themselves. Nurses have the unique opportunity of being “present” at the bedside for the victim of abuse. This article reviews the signs and symptoms of domestic violence. Keen patient assessment tools and support can make a world of difference in the outcome of abuse. © 2004 by American Society of PeriAnesthesia Nurses.
Case Study A female patient who was scheduled for gynecologic surgery presented with severe emotional distress. She requested that the male who had brought her to the surgery center not be allowed to come back to be with her before she went to surgery. The perianesthesia nurse talked to her and asked her if she felt up to having surgery this day because she appeared so distraught. Her anxiety was noted and documented at length, as well as her desire for separation from her “support person.” She insisted that her surgery be performed. Although the woman did not have visible bruises or cuts, the nurse suspected that she might be the victim of an abusive relationship and notified the surgeon. She also gave her a handout with the abuse hotline and notified the nursing supervisor. Three years later, the nurse was questioned by her employer about the previous case. The woman had decided to file for divorce and had summoned her records from the day of surgery. The nurse was asked briefly about whether she had witnessed any facial markings or bruises. She had no such recall but could remember that the patient had frequently gotten up from her stretcher to look at herself in the mirror. In the nurse’s notes, the nurse had documented that the patient’s face was very flushed and that she had been crying. When the nurse had asked her why she was crying, the patient had stated that she and her significant other had had a disagreeJournal of PeriAnesthesia Nursing, Vol 19, No 1 (February), 2004: pp 11-17
ment. She did not share with the nurse that he had slapped her repeatedly before their arrival to the surgery center. The nurse thought she was investigating this situation well and had even offered to call the abuse hotline for the patient. After attending a domestic violence program at a local woman’s shelter, however, the nurse now realized that she could have questioned the patient more directly. Perhaps then the patient would have divulged more information. The nurse did feel comforted that the patient had finally made the difficult decision to stop the abuse.
What Is Domestic Violence? Domestic violence is the actual or threatened physical, sexual, psychological, or economic abuse of an individual by someone with whom they have an intimate relationship.1 Although 85% of reported domestic violence is perpetrated against women, nurses must remain cognizant that both victims and abusers may be male or female.2 The use of power and control knows no gender. In some states, domestic violence is considered a crime. Nurses may Barbara A. Scales, RN, CCRN, CAPA, RM, was the Nurse Orientor in the PACU for Harrison Center Outpatient Surgery, Syracuse, NY. She currently works as a per diem staff member at the same institution. Address correspondence to Barbara A. Scales, POB 723, Tully, NY 13159; e-mail address: [email protected]. © 2004 by American Society of PeriAnesthesia Nurses. 1089-9472/04/1901-0003$30.00/0 doi:10.1016/j.jopan.2003.11.008 11
12
browse the Web site for the Family Violence Prevention Fund (http://www.fvpf.org), which displays a list of states where reporting domestic violence is mandatory.
BARBARA A. SCALES
women are at twice the risk for battering.12 Several studies indicate abuse of pregnant women reported at public clinics as 8% to 15%, whereas battered pregnant women reported at private clinics ranges from 17% to 26%.13
Statistics of Domestic Violence The New York State Division of Criminal Justice reported that domestic violence increased 117% from 1983 to 1991.3 In 1992, 7% of American women (3.9 million) who were married or living with someone as a couple were physically abused, and 37% (20.7 million) were verbally or emotionally abused by their spouse or partner.4 Every 9 seconds in the United States, a woman is physically abused by her husband.4 A 1993 poll on domestic abuse showed that 34% of Americans have witnessed domestic violence, compared to only 19% who had witnessed a mugging or a robbery. That same poll indicated that 14% of American women admitted they have been violently abused by a husband or a boyfriend.5 Domestic violence is repetitive in nature: about one in five women who were victimized by their spouse or ex-spouse reported that they had been the target of a series of at least three assaults in the last 6 months.6 In 1992, the AMA reported that as many as one in three women would be assaulted by a domestic partner in her lifetime—4 million in any given year.7 Nearly two in three female victims of domestic violence were related to or knew their attacker,8 and in 1999, 69% of all rapes were committed by a known assailant.9 Thirty percent of the women who arrive at the emergency room with injuries have battering-related injuries.10 Fortytwo percent of murdered women are killed by their intimate partners.11 Pregnancy is a risk factor for battering. Theoretically, pregnancy may add stress to an already volatile situation. The domestic partner may experience jealousy, may not have wanted children, or may think the child is not his. Forty percent of the assaults on women by their partners began during the first pregnancy. Pregnant
Forty-eight percent of cases are not reported to the police by battered women.14 Ninety-two percent of battered women do not discuss the abuse with their private physicians, and 57% do not discuss it with anyone at all.4 In one study of 394 women, although 22.7% reported they had been victims of abuse, only 6 of the 394 women had ever been asked by their physician about domestic violence.15 In one major metropolitan study on domestic violence, in 92% of the cases of abuse the ER physician had failed to obtain a psychological history, ask about abuse, or address the woman’s safety.16 A recent national study of the 143 accredited U.S. and Canadian medical schools revealed that 53% of the schools did not require medical students to receive instruction about domestic violence.17 The financial impact of domestic violence was presented in a study from Chicago that indicated the average cost of health care in an emergency room for a battered person is $1,633. This converts to a national cost of $857.3 million a year.18
Etiology of Domestic Violence Victims of domestic violence may be traumatized with either sexual or physical violence. Their offender may use techniques overtly or covertly; each can leave scars for life. The sexual abuser may attempt to gain control by coercion and threats. The perpetrator may withhold financial support as a means of keeping the upper hand. He/she may deny accusations of wrongdoing and shift the blame onto the victim. Isolating the victim helps the abuser to sustain an atmosphere of the victim relying solely on the abuser for all of his or her needs. The abuser may resort to other weapons to continue to dominate the victim such as intimidation and emotional harassment. Social status
DOMESTIC VIOLENCE AWARENESS
and children are powerful deterrents for the victim when trying to attempt to escape the clutches of the perpetrator. See Figure 1.
What Can Perianesthesia Nurses Do? Screening for victims of domestic abuse should begin at the pretesting interview. Perianesthesia nurses need to observe behavior, language, and appearances of the potential patient. Honing in on nervous behavior, poor eye contact, and bruises, and listening to what the patient says and does not say may lead to clues during the preoperative interview. Open-ended questions may assist the possible victim of abuse to fill in the information gap needed to make a better determination of an abusive situation. The nurse can ask, “Would you like to talk about what has happened to you?” “How do you feel about it?” It is important for the nurse to listen non-judgmentally, to allow the victim to express her situation in her own words, and to validate what the victim says. Victims are often not believed and their claims are minimized. Give support with sentences like, “You do not deserve this.” “What has happened to you is a crime.” “Help is available to you.” Nurses need to document what they see accurately by using notations that describe exactly what is seen (e.g., “her hair is a tangle,” “she has a gash on her left cheek,” “there is a bruise to the right eye in the color of purple, yellow, or green,” which is an indicator of time elapsed). Notations should be entered for abnormal laboratory findings and the presence of police. Document what the nurse is hearing by using the patient’s own words with quotation marks or write “the patient states . . .” It is proper to include descriptive words to identify the client’s demeanor such as “crying, angry, agitated.” In some courts, the word “hysterical” may be admissible.19 Nurses should avoid the use of initials or abbreviations such as DV for domestic violence. Doc-
13
ument the person’s name that the client identifies as the responsible party, but do not write that he or she is the “alleged perpetrator” because this is a legal term. Assigning the victim as “this patient is a battered woman” is considered a conclusion in a court of law, and it will not be admissible without sufficient evidence. Attempt to extract from the patient the time of day that the abusive event occurred and how much time has passed since the incident he or she is describing. Take photographs, if possible. Photographs will bring the judge and jury to the event faster than word of mouth. Be certain to date and time the photos and document who is in the photo for future reference. Last, but not least, write legibly. Documentation that cannot be read will be dismissed. Nurses are patient advocates, and the point of documentation is to assist the victim, so be sure that notes can be easily read.20 See Table 1 for patient assessment indicators. Surgery centers can establish a plan that identifies potential victims and the steps to be taken to educate the victim on how and where to seek help. Work with peers to develop a protocol on how to handle domestic violence situations. Make pamphlets with easy-to-tear-off domestic violence hotline numbers readily available in examination areas, pretesting interview areas, preparation areas, and reception areas. Prior discussion in routine clinical review meetings on how to intervene in this type of situation will assist the nurse interaction with a patient, patient’s partner, or colleague. Once a possible domestic violence patient is identified, a series of events could be set in place that could help the victim to get out of the cycle of violence. Prior to discharge, the situation must be evaluated for the victim’s safety. Adults have the right to deny assistance, but if abuse is suspected, nurses are obligated to offer help. If it is suspected that elders or children are involved in the abuse, the nurse is then considered a mandated reporter of such, and must call a hotline
BARBARA A. SCALES
14
Fig 1.
Power and Control Wheel. Adapted from Domestic Abuse Intervention Project, 202 East Superior Street, Duluth, Minnesota 55802.
DOMESTIC VIOLENCE AWARENESS
15
Table 1. Indicators of Abuse to Consider During Patient Assessment 1. Have the body injuries occurred to multiple anatomical sites? Are the injuries bilateral? Are the injuries in various stages of healing? 2. Using a body man, identify the specific areas that have been targeted such as the face, neck, breasts, chest, or abdomen. 3. Has the woman delayed seeking medical assistance? 4. Has there been forced sexual encounter? 5. Does the woman arrive in the emergency room with medically insignificant trauma? (She may be using this as a cry for help.) 6. Does the patient react appropriately to the level of the injury? Does she appear overly anxious, depressed, or seem to be minimizing the event? 7. Does the significant other stay too close, or attempt to answer for the patient? Does the preoperative patient request that the support person not be allowed in? 8. Is the client pregnant? Does there seem to be a pattern of self-induced or therapeutic abortions? 9. Is there a history of repetitive emergency room visits and injuries? (This can be the key indicator.) 10. Suicide attempts can be an indicator of domestic violence. 11. Does the injury fit the description of how it occurred? Adapted from: Stark, Flitcraft, et al., Wife abuse in the medical setting, in Warshaw C, Ganely A (eds): Improving the health care response to domestic violence: a resource manual for health care providers (ed 2). San Francisco, CA: The Family Fund; 1996.
to report the case. Every state has laws, which vary, and each nurse is responsible to know the guidelines for practice within his/her state. Nurses can provide referrals to many agencies to get the victim assistance (see Table 2); it can be written onto a prescription pad that victims can tuck into their pockets or purses until they feel ready to act on it.
Setting Up a Plan of Action When a woman decides to leave her abusive situation, she can seek shelter and assistance to break free of her injurious cycle. Assisting her to devise a safety plan for herself and her children is important. The local shelters will encourage
the woman to fill out a form that designates an action plan. See Table 3 for highlights of an action plan from our local women’s shelter.
What If the Abused Person Denies the Need for Any Help? A client’s religion may play a role in the “why” aspect of remaining in a domestic violence situation. According to the Center for the Prevention of Sexual and Domestic Violence, a woman who has been abused often feels abandoned by God. The same center documents that pastors, priests, and rabbis may advise the woman to return home to “be a better wife.” In the Jewish religion, maintaining shalom bayit, or peace in
Table 2. Resources* ● ● ● ●
To obtain a community action kit for Domestic Violence, please call 1-800-777-1960. NATIONAL DOMESTIC VIOLENCE HOTLINE 1-800-799-SAFE National Resource Center on Domestic Violence 1-800-537-2238 Free Reconstructive Surgery for Victims of Domestic Abuse 1-800-842-4546 by the Academy of Facial Plastic and Reconstructive Surgery and the National Coalition Against Domestic Violence
*Providing these phone numbers on a prescription blank or an appointment card may help patients feel more comfortable carrying it with them.
BARBARA A. SCALES
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Table 3. Highlights of an Action/Safety Plan The victims of domestic violence should 1. Avoid rooms in the home with the highest potential for violence (kitchen/bathroom). 2. Carry important emergency assistance numbers and have them available for the children. 3. Identify a code word that children and friends will know to indicate help is needed. 4. Teach children how to call for help. 5. Teach children how to make a collect call to the police or clergy, in the event that her partner takes them. 6. Instruct a trusted friend or neighbor to call the police if suspicious noises are heard coming from the home. 7. Provide a list of homes of friends/neighbors/family that can be refuge from violence. 8. Leave extra money and documents with a safe person or place that would be readily available when the need arises (e.g., identification [birth certificates, drivers license, photo ID, passports, benefit cards, green card]; school and medical records; money; bank book; credit card; ATM; keys to house, work, and car; car registration; medication for herself and children; address book; insurance papers; court documents of custody; order of protection, marriage certificate; tax returns; divorce papers; photos; jewelry; leases; house deeds; current unpaid bills; and children’s sentimental value items and toys). 9. List other ways to ensure personal safety. Adapted from: Vera House Incorporated Personal Safety Plan, A Personal Safety Plan, P.O. Box 365, Syracuse, NY 13209.
the home, may be a deterrent to rocking the boat and seeking help from a violent situation. In the Christian household, the concept of being submissive to the husband as found in scripture could make a woman think twice before leaving her spouse.21 The patient can choose to deny help despite all efforts of the health care provider. Provide the patient with the information needed to seek further assistance. Statistically, women are at the highest risk of serious injury when they decide to leave the abusive relationship. Homicide is a serious possibility because it has been shown that 70% of victims murdered were killed during the time they made the move to leave.2 It may take the victim a long time to determine that she is prepared to escape. Although it can be frustrating to health care workers when someone decides to stay in an abusive relationship, ultimately it is the decision of the patient.
As the nurse with an opportunity to be on the front lines of abuse, know that women may seek help from their situations. Change can be frightening and tedious and the victim may take years to act on the information, as was the case of the patient in the case study. We as nurses can help our patients to learn to help themselves. The nurse at the bedside can assist a victim of abuse just by giving support and information. Providing a mechanism for escape from an abusive situation is the goal.
Summary Nurses in the perianesthesia setting do have a unique opportunity to identify and act on the presence of domestic violence. Perianesthesia nurses should be aware of how to identify the victims of domestic violence, resources available for those victims, and any laws pertaining to domestic violence. Perianesthesia nurses can make a difference.
References 1. Warshaw C, Ganley A: Improving the health care response to domestic violence: A resource manual for health care providers (ed 2). San Francisco, CA: The Family Fund; 1996 2. Sheehan-Berlinger J: Domestic violence: How you can make a difference. Nursing August 31:58, 2001
3. NYS Division of Criminal Justice Services. Data from 1983 and 1991. Available at: http://acog.org. Accessed October 13, 2001 4. The Commonwealth Fund: First Comprehensive National Health Survey of American Women Finds Them at Significant
DOMESTIC VIOLENCE AWARENESS Risk (News Release). New York, The Commonwealth Fund July 14, 1993 5. Family Violence Prevention Fund. Men beating women: Ending domestic violence, a qualitative and quantative study of public attitudes on violence against women. New York, EDK Associates, 1993 6. United States Department of Justice: Highlights from 20 years of surveying crime victims: The National Crime Victimization Survey 1973-92. Washington, DC, US Department of Justice, Bureau of Justice Statistics, October 1993 7. Helton A, McFarlane J, Anderson E: Prevention of battering during pregnancy: Focus on behavioral change. Am J Public Health 4:166-174, 1987 8. Lanagan P, Innes C: Preventing domestic violence against women, in Warshaw C, Ganley A (eds): Improving the healthcare response to domestic violence: A resource manual for health care providers (ed 2). Washington, DC, US Department of Justice, Bureau of Statistics, 1996 9. When violence hits home. Time 144, 1994 10. Bachman R: United States Department of Justice Bureau of Statistics, “Violence Against Women: A National Crime Victimization Survey Report,” January 1994 11. Institute for Behavioral Science, at the University of Colorado at Boulder, Colorado: Analysis by the Center for the Study and Prevention of Violence, 1991 12. National Crime Victimization Survey, 1999. Available at: http://www.4woman.org/. Accessed October 13, 2001 13. McLeer S, Anwar R: A study of battered women presenting in an emergency department. Am J Public Health 79:65-66, 1989 14. Hamberger L, Saunders D, Hovey M: Prevalence of domestic violence in community practice and rate of physician inquiry, in Warshaw C, Ganley A (eds): Improving healthcare response to domestic violence: A resource for health care
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providers (ed 2). Washington, DC, US Department of Justice, Bureau of Statistics, 1996 15. Warshaw C: Limitations of the medical model in the care of battered women, in Warshaw C, Ganley A (eds): Improving healthcare response to domestic violence: a resource manual for health care providers (ed 2). Washington, DC, US Department of Justice, Bureau of Statistics, 1996 16. Holtz H, Hanes C: Education about domestic violence in 25 US and Canadian medical schools, 1987–88, in Warshaw C, Ganley A (eds): Improving healthcare response to domestic violence: a resource manual for health care providers (ed 2). Washington, DC, US Department of Justice, Bureau of Statistics, 1996 17. Meyer H: The billion dollar epidemic, in Warshaw C, Ganley A (eds): Improving the health care response to domestic violence: a resource manual for health care providers (ed 2). Washington, DC, US Department of Justice, Bureau of Statistics, 1996 18. National Clearing House for the Defense of Battered Women. Available at: http://www.cybergrrl.com/views/dr/stat/ statbwkill.html. Accessed October 13, 2001 19. Around the School: Harvard School of Public Health Office of Communications Researchers Look at Role of Medical Records in Domestic Violence Legal Cases. Available at: http:// www.hsph.harvard.edu/ats/aug11. Accessed August 11, 2002 20. Roache C: Researchers Look at Role of Medical Records in Domestic Violence Legal Cases, Around the School. Available at: http://www.hsph.harvard.edu/ats/aug11. Accessed August 11, 2002 21. Center for the Prevention of Sexual and Domestic Violence-domes: Domestic Violence: Religious Aspects of the Problem, Available at: http://www.cpsdv.org/dv/domestic. htm. Accessed August 15, 2002