- Email: [email protected]
Learning to ask about domestic violence
Learning to Ask About Domestic Violence Harriet
V. Coeling,
PhD
Kent State University School of Nursing Kent, Ohio
Gloria
Harman,
Lodi Community Lodi, Ohio
PhD
Hospital
THE
PROBLEM
D
omestic violence is a prevalent and dangerous, yet hidden, condition in our society. Its prevalence is estimated at 30% of married women being abused at some point in the marriage, 12% within a given year.‘j2 In addition, unmarried women often are abused by their significant other. 3 This abuse may result in fractures, contusions, burns, internal injury, gunshot wounds, or death.4 Unfortunately, battering is seldom discussed with health care professionals who could provide assistance. i Although nearly one third of all women using emergency rooms do so because of symptoms related to domestic violence, only about 10% of these women are identified as abused. This is attributed to health care professionals’ lack of information about domestic violence or reluctance to ask the right questions5 A 1993 survey found that only 8% of physically abused women told their physicians about this abuse.6 Domestic violence is appropriately labeled the “unacknowledged epidemic.” Research has found that domestic violence escalates during pregnancy.7,8 The minimal attention to domestic violence during pregnancy is especially unfortunate because prenatal care offers one of the few opportunities that health care workers have to interact with and assist these women. Expecting mothers, being young and healthy, usually are not in the health care system unless they are pregnant. Furthermore, these mothers-to-be are more willing to disclose domestic violence while they are pregnant because of concern for the fetus. Because domestic violence may begin or escalate during pregnancy,’ health care professionals in prenatal settings have a particular responsibility to screen for actual or potential domestic violence and to provide necessary interventions for battered women. Domestic violence is a dangerous and repeated, yet preventable, problem. Hence, the Department of Health and Human Services has identified studies of women’s health-seeking behaviors related to domestic violence as a priority for research in the 1990~.~ Campbell has called case finding, which is a form of selective screening to identify individuals at risk for a specific problem, the top priority in decreasing domestic violence. 9~10McFarlane et al’i describes case
COELING
0 1997 by The Jacobs of Women’s Health Published by Elsevier 1049-3867/97/$17.00 PII SlO49-3867(97)0000,3-X
& HARMON:
Institute Science
DOMESTIC
Inc.
VIOLENCE
263
finding for domestic violence as identifying any client communication to any member of the health care team indicating physical, emotional, or sexual abuse from a male partner during the past year. Although care providers have been advised for many years to ask about domestic violence as part of the routine prenatal assessment, few professionals do SO even in the face of identified demographic risk factors for domestic violence.8 Although self-disclosure literature has identified counselor feelings and subsequent behaviors that facilitate sharing of sensitive information in general, little research has looked at the discussion of domestic violence from the perspective of the health care worker who is asking these questions, The purpose of this study was to describe how health care professionals (in this case, nurses) learn to ask sensitive questions related to domestic violence. Although the sample for this study consisted only of nurses, research suggests that all health care professionals have difficulty asking these questions.1,5,6
METHODS Sample
and Setting
Eight registered female nurses in a Midwestern county health department prenatal clinic agreed to participate in this study, for which Human Subjects Approval and agency approval was obtained. The participants attended a presentation (described below) and agreed to talk with a researcher for 5-10 minutes after each clinic session for a period of 12 weeks, describing their implementation of the in-service content. These nurses had worked in this clinic for l-8 years. One was prepared as an obstetrical/gynecological nurse practitioner and one was a midwife.
Procedure A verbal presentation was given by the researchers to assist the nurses in case finding for domestic violence. Content included Parker and McFarlane’s assessment tool for use in asking about domestic violence.‘* The following questions are included in this protocol: “Within the past year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?” 0 “Since you’ve become pregnant, have you been hit, slapped, kicked or otherwise physically hurt by someone?” 0 “Within the last year, has anyone forced you to have sexual activities?” l
It was suggested that the questions be introduced by noting studies have shown that many pregnant women may be in difficult situations. Just as nurses check a client’s urine, blood pressure, and weight at each appointment, it is now recommended that nurses ask about the client’s overall situation. In addition, nurses were provided with handouts explaining that domestic violence was a crime in this state and with a diagram depicting the cycle of violence. Nurses were instructed to refer all clients responding “yes” to any of the questions to the social worker, who was an integral member of this clinic team. The social worker then closely followed the progress of these clients and shared appropriate follow-up information with all nurses, so that all involved nurses and the social worker together could continue working as a team to assist these clients. Nurses commented that the availability of the social worker was very important in their being able to ask these questions. After each clinic session, a researcher met for 5-10 minutes with each nurse who had worked that day, asking her to describe her experiences related to asking about domestic violence. Nurses were most willing to meet with the
264
WOMEN’S
HEALTH
ISSUES
VOL.
7, NO. 4 JULY/AUGUST
1997
researchers and appeared to benefit from the support these debriefing sessions provided. Both during and immediately after these debriefing sessions, the researchers jotted down the comments shared by the participants. Interviews continued for a 12-week period. Comments were content analyzed by the researchers to look for themes and patterns.
FINDINGS Previous research suggests that it is difficult for clients to discuss intimate and sensitive matters, such as those related to domestic violence, with health care professionals. What this study found was that it is equally difficult for health care professionals to engage in such conversations. The content analysis indicated that participants went through a series of stages, described below, as they became comfortable asking the domestic violence questions.
Stage One: Forgetting
to Ask
During the first 2 weeks little discussion occurred. Early on, when the researcher approached the nurses after the clinic session, the nurses would demonstrate a “taken-aback” expression and then reply that they were so sorry, but they simply forgot to ask the questions. Comments that follow are typical of responses during this stage: “I forgot. I didn’t have the sheet out and I just forgot” or “I didn’t ask. I had the prompt sheet on my left, but I’m right-handed and didn’t see the sheet.” These nurses expressed regret that they had forgotten. They were appreciative of suggestions the researchers gave regarding how they could remember to ask the questions.
Stage Two: Giving
Excuses for Not Asking
For the next week or so the nurses remembered that they had agreed to ask the questions, but found reasons for not doing so. It seemed to them that special considerations in their clients’ conditions prevented them from asking about domestic violence. During this time they often responded as follows: l
“My client was almost due and this was not an appropriate questions.“
time to ask these
or l
“It’s appropriate for the socialworker to ask. We’re more taken up with the medical
aspectbecausewe do have a social worker here.” Thus, they remembered but chose to not ask the questions.
Stage Three:
Attributing
the Need
to Ask to Others
After a few weeks, however, participants did indeed begin to ask the specified questions. During the postclinic sessions, when the researchers asked what lead-ins they had used to initiate the questions, participants said that they explained to the clients that they had been mandated to ask these questions. For example, they said (emphasized words capitalized): 0 “1 told her the STATE had identified a need to ask these questions.“ or 0 “I said this is a RESEARCH PROJECT,and we’ve been requested to ask you these questions.”
COELING
& HARMON:
DOMESTIC
VIOLENCE
265
Thus, they were asking owning the questions.
Stage Four: Establishing
the questions,
a Personal
but they were
Style When
not yet personally
Asking
Questions
At about the same time as they began asking the questions but attributing the need to so do to others, they also began experimenting to find ways they could ask the questions by using their own words and styles. During this period, they shared the following comments: 0 “What helps is fitting the questions into my routine, having developing my own phrasing and order, and asking [the questions] visit after I have established rapport with a client.”
l
a good lead-in, at the end of the
“I try to focus on my concern for them [the clients].”
One nurse described Gery specifically her way of asking the questions as follows: l
“I asked the client to read the yellow sheet about the cycle of violence. They [the clients] don’t realize violence goes in cycles. They think when the person says I’ll stop, that’s the end. She [the client] did this while I did some charting. Then I asked her the questions. Each month, I try to adapt the questionsto where the client is that month.”
At this point, these nurses were becoming quite skilled in asking the questions. They were individualizing the intervention to the specific situation.
Stage Five: Becoming
Comfortable
When
Asking
Toward the end of the 12 weeks, the researchersnoted the participants’ increasing comfort asking these questions. This became evident in responsessuch as l l l l
“It’s not a problem now becauseI phrase the questions in a way I’m comfortable with.” “I’m more comfortable than when I first did this.” “They [the questions] have become common questions.” “It’s easier once you get familiar with the clients and they get familiar with the question.”
At this point, the nurses shared their confidence in talking with clients about domestic violence and began to expect that clients would share these concerns with them.
Stage Six: Accepting
Personal
Responsibility
for Asking
During the previous few weeks, the researchers noted that many nurses were still telling clients they were asking these questions because someone else had told them to do so. Researchers then asked each nurse whether she was ready to explain to clients that she was asking the questions because she believed the questions were important. Almost all participants, after thinking about this suggestion, indicated that they were ready to do so. Subsequent explanations to clients were described as follows: “I start by saying [to the client] we check many things on our patients and one of these things is whether. . . [nurse then verbalized the specified questions].” So, during the course of the study, these nurses appeared to move from forgetting to ask the recommended questions about domestic violence to high levels of comfort in asking these questions. After the researchers further analyzed the data, they arranged a time at which they could go back to the agency and share their findings with these nurses. When the researchers presented the different stages, the participants
266
WOMEN’S
HEALTH
ISSUES
VOL.
7, NO. 4 JULY/AUGUST
1997
expressed momentary surprise because they were not conscious of going through these stages. However, they almost immediately agreed with the stages and confirmed that they could remember going through these stages. In addition, nurses mentioned several factors that encouraged clients to respond to the questions. Having time alone, in private, with the client during each visit was mentioned as very important. Asking the questions toward the end of the visit, after rapport had been established with the client, assigning the same nurse to a client for each visit, being supportive and nonthreatening, and communicating to clients that the nurses were there to help them were other strategies mentioned by nurses. One nurse commented that the questions had to be asked again and again “so the clients can share when they feel ready”; another nurse said, “we have to keep emphasizing that violence is not normal; they think some of this is normal.”
IMPLICATIONS
FOR RESEARCH
Because the sample in this study was small in size and was limited to one clinical agency, it is recommended that this process of observing health care professionals as they learn to ask about domestic violence be repeated both in different settings and in settings that include both male and female nurses to determine the generalizability of this process. Although, as noted previously, there is no reason to expect that nurses have either more difficulty or less difficulty asking these questions than do other disciplines, it is recommended that the study be repeated with other disciplines to determine whether similar learning stages are noted. Also, some participants asked whether it was necessary to ask all three questions and to ask them in such a specific manner. Research is needed to determine whether this is indeed necessary. It should be noted, however, that Fishwick’s research and that of Loring and Smith did find that the use of general questions allowed the client to offer only incomplete information or a fabricated story. 13,14Answering these questions will assist health care professionals to be more effective case finders for domestic violence.
IMPLICATIONS
FOR PRACTICE
The findings from this study suggest that, although it is difficult for health care professionals to ask sensitive questions related to domestic violence, they can learn to do so. Having the time to learn to ask these questions and the opportunity to practice doing so was considered to be very important by the nurses. Learning to ask these three questions is a more complex task than first imagined. Professional training in this area is essential.i5 In addition, health care professionals need to develop a personal comfort level in asking these questions. This takes time, practice, and encouragement. The process involves rethinking how we show concern for our clients. It is easy to assume that the best way to show concern for our clients, or any woman, is to avoid asking embarrassing or personal questions. However, research has shown that concern resulting in client safety is best shown by courageously and kindly asking what may first appear to be a difficult question.2 Policy often is thought to come from the top down. Standards of care are established by experts, then workers are instructed to carry them out. We must realize, however, that a “bottom-up” approach is also needed. Health care professionals must be empowered to carry out recommendations, such as asking about domestic violence, by having the opportunity to first learn the skill. This learning process is a time-consuming but important step. The importance of taking time for this learning process is reflected in these
COELING
& HARMON:
DOMESTIC
VIOLENCE
267
concluding comments, which the last week of the study: l
were
made by two participating
“This whole project has opened my eyes to things that I had blinders started.”
nurses
during
on to before it
and l
“Today, one patient told me she had an argument with her husband last week. She got mad and punched the wall. We talked about anger and how this can escalateto violence and what shecould do to prevent violence. It mademe feel like a real public health nurse-like I was preventing a serious problem from happening.”
Prevention is our goal. This study suggests that it is best achieved by paying attention not only to the needs of clients but also to the needs of the health care providers caring for the clients.
ACKNOWLEDGMENTS Appreciation is expressed to the prenatal clinical nurses of the Summit County Health Department (Ohio) for the help they provided in this study and to the Kent State University Research Council for providing partial funding for this project.
REFERENCES 1. Reidy R, VonKorff M. Is battered women’s help seekingconnected to the level of their abuse?Public Health Rep 1991;106:360-3. 2. McFarlane J, Christoffel K, Bateman L, Miller V, Bullock L. Assessingfor abuse: self-report versus nurse interview. Public Health Nursing 1991;8:245-50. 3. United States Department of Health and Human Services, Public Health Service. Healthy people: national health promotion and disease prevention objectives. Washington (DC): DHHS, 1990, Pub. No. PHS 91-50212. 4. Bullock L, McFarlane J, Bateman LH, Miller V. The prevalence and characteristics of battered women in a primary care setting. Nurse Practitioner 1989;14:47-56. 5. Henderson AD. Why is it important for critical care nurses to know anything about wife abuse? Crit Care Nursing 1992;12:27-30. 6. Shalala: Domestic violence. Nation’s Health 1994;May/June:6. 7. Campbell JC. A review of nursing research on battering. Violence against women: nursing research, education, and practice issues. New York Hemisphere Publishing 1992. 8. Sampselle CM, Petersen BA, Murtland TL, Oakley DJ. Prevalence of abuse among pregnant women choosing certified nurse-midwife or physician providers. J NurseMidwifery 1992;37:269-73. 9. Campbell JC. Just like me: the dynamics of battering. Paper presented at Breaking the Cycle of Family Violence Conference, Northeast Ohio University College of Medicine, Rootstown, OH, 1992. 10. Stanhope M, Lancaster J. Community health nursing: process and practice for promoting health. St. Louis: Mosby, 1992. 11. McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy. JAMA 1992;267:3176-8. 12. Parker B, McFarlane J. Identifying and helping battered pregnant women. Maternal Child Nursing 1991;16:161-4. 13. Fishwick NJ. Health care encounters of women in abusive relationships: a process of protecting personal integrity. Unpublished doctoral dissertation. Cleveland (OH): Case Western Reserve University, 1993. 14. Loring MT, Smith RW. Health care barriers and interventions for battered women. Public Health Rep 1994;109:328-38. 15. Tilden VP, Schmidt TA, Limandri BJ, Chiodo GT, Garland MJ, Loveless PA. Factors that influence clinicians’ assessment and management of family violence. Am J Public Health 1994;84:628-33.
L 268
WOMEN’S
HEALTH
ISSUES
VOL.
7, NO.
4 JULY/AUGUST
1997
V. Coeling,
PhD
Kent State University School of Nursing Kent, Ohio
Gloria
Harman,
Lodi Community Lodi, Ohio
PhD
Hospital
THE
PROBLEM
D
omestic violence is a prevalent and dangerous, yet hidden, condition in our society. Its prevalence is estimated at 30% of married women being abused at some point in the marriage, 12% within a given year.‘j2 In addition, unmarried women often are abused by their significant other. 3 This abuse may result in fractures, contusions, burns, internal injury, gunshot wounds, or death.4 Unfortunately, battering is seldom discussed with health care professionals who could provide assistance. i Although nearly one third of all women using emergency rooms do so because of symptoms related to domestic violence, only about 10% of these women are identified as abused. This is attributed to health care professionals’ lack of information about domestic violence or reluctance to ask the right questions5 A 1993 survey found that only 8% of physically abused women told their physicians about this abuse.6 Domestic violence is appropriately labeled the “unacknowledged epidemic.” Research has found that domestic violence escalates during pregnancy.7,8 The minimal attention to domestic violence during pregnancy is especially unfortunate because prenatal care offers one of the few opportunities that health care workers have to interact with and assist these women. Expecting mothers, being young and healthy, usually are not in the health care system unless they are pregnant. Furthermore, these mothers-to-be are more willing to disclose domestic violence while they are pregnant because of concern for the fetus. Because domestic violence may begin or escalate during pregnancy,’ health care professionals in prenatal settings have a particular responsibility to screen for actual or potential domestic violence and to provide necessary interventions for battered women. Domestic violence is a dangerous and repeated, yet preventable, problem. Hence, the Department of Health and Human Services has identified studies of women’s health-seeking behaviors related to domestic violence as a priority for research in the 1990~.~ Campbell has called case finding, which is a form of selective screening to identify individuals at risk for a specific problem, the top priority in decreasing domestic violence. 9~10McFarlane et al’i describes case
COELING
0 1997 by The Jacobs of Women’s Health Published by Elsevier 1049-3867/97/$17.00 PII SlO49-3867(97)0000,3-X
& HARMON:
Institute Science
DOMESTIC
Inc.
VIOLENCE
263
finding for domestic violence as identifying any client communication to any member of the health care team indicating physical, emotional, or sexual abuse from a male partner during the past year. Although care providers have been advised for many years to ask about domestic violence as part of the routine prenatal assessment, few professionals do SO even in the face of identified demographic risk factors for domestic violence.8 Although self-disclosure literature has identified counselor feelings and subsequent behaviors that facilitate sharing of sensitive information in general, little research has looked at the discussion of domestic violence from the perspective of the health care worker who is asking these questions, The purpose of this study was to describe how health care professionals (in this case, nurses) learn to ask sensitive questions related to domestic violence. Although the sample for this study consisted only of nurses, research suggests that all health care professionals have difficulty asking these questions.1,5,6
METHODS Sample
and Setting
Eight registered female nurses in a Midwestern county health department prenatal clinic agreed to participate in this study, for which Human Subjects Approval and agency approval was obtained. The participants attended a presentation (described below) and agreed to talk with a researcher for 5-10 minutes after each clinic session for a period of 12 weeks, describing their implementation of the in-service content. These nurses had worked in this clinic for l-8 years. One was prepared as an obstetrical/gynecological nurse practitioner and one was a midwife.
Procedure A verbal presentation was given by the researchers to assist the nurses in case finding for domestic violence. Content included Parker and McFarlane’s assessment tool for use in asking about domestic violence.‘* The following questions are included in this protocol: “Within the past year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?” 0 “Since you’ve become pregnant, have you been hit, slapped, kicked or otherwise physically hurt by someone?” 0 “Within the last year, has anyone forced you to have sexual activities?” l
It was suggested that the questions be introduced by noting studies have shown that many pregnant women may be in difficult situations. Just as nurses check a client’s urine, blood pressure, and weight at each appointment, it is now recommended that nurses ask about the client’s overall situation. In addition, nurses were provided with handouts explaining that domestic violence was a crime in this state and with a diagram depicting the cycle of violence. Nurses were instructed to refer all clients responding “yes” to any of the questions to the social worker, who was an integral member of this clinic team. The social worker then closely followed the progress of these clients and shared appropriate follow-up information with all nurses, so that all involved nurses and the social worker together could continue working as a team to assist these clients. Nurses commented that the availability of the social worker was very important in their being able to ask these questions. After each clinic session, a researcher met for 5-10 minutes with each nurse who had worked that day, asking her to describe her experiences related to asking about domestic violence. Nurses were most willing to meet with the
264
WOMEN’S
HEALTH
ISSUES
VOL.
7, NO. 4 JULY/AUGUST
1997
researchers and appeared to benefit from the support these debriefing sessions provided. Both during and immediately after these debriefing sessions, the researchers jotted down the comments shared by the participants. Interviews continued for a 12-week period. Comments were content analyzed by the researchers to look for themes and patterns.
FINDINGS Previous research suggests that it is difficult for clients to discuss intimate and sensitive matters, such as those related to domestic violence, with health care professionals. What this study found was that it is equally difficult for health care professionals to engage in such conversations. The content analysis indicated that participants went through a series of stages, described below, as they became comfortable asking the domestic violence questions.
Stage One: Forgetting
to Ask
During the first 2 weeks little discussion occurred. Early on, when the researcher approached the nurses after the clinic session, the nurses would demonstrate a “taken-aback” expression and then reply that they were so sorry, but they simply forgot to ask the questions. Comments that follow are typical of responses during this stage: “I forgot. I didn’t have the sheet out and I just forgot” or “I didn’t ask. I had the prompt sheet on my left, but I’m right-handed and didn’t see the sheet.” These nurses expressed regret that they had forgotten. They were appreciative of suggestions the researchers gave regarding how they could remember to ask the questions.
Stage Two: Giving
Excuses for Not Asking
For the next week or so the nurses remembered that they had agreed to ask the questions, but found reasons for not doing so. It seemed to them that special considerations in their clients’ conditions prevented them from asking about domestic violence. During this time they often responded as follows: l
“My client was almost due and this was not an appropriate questions.“
time to ask these
or l
“It’s appropriate for the socialworker to ask. We’re more taken up with the medical
aspectbecausewe do have a social worker here.” Thus, they remembered but chose to not ask the questions.
Stage Three:
Attributing
the Need
to Ask to Others
After a few weeks, however, participants did indeed begin to ask the specified questions. During the postclinic sessions, when the researchers asked what lead-ins they had used to initiate the questions, participants said that they explained to the clients that they had been mandated to ask these questions. For example, they said (emphasized words capitalized): 0 “1 told her the STATE had identified a need to ask these questions.“ or 0 “I said this is a RESEARCH PROJECT,and we’ve been requested to ask you these questions.”
COELING
& HARMON:
DOMESTIC
VIOLENCE
265
Thus, they were asking owning the questions.
Stage Four: Establishing
the questions,
a Personal
but they were
Style When
not yet personally
Asking
Questions
At about the same time as they began asking the questions but attributing the need to so do to others, they also began experimenting to find ways they could ask the questions by using their own words and styles. During this period, they shared the following comments: 0 “What helps is fitting the questions into my routine, having developing my own phrasing and order, and asking [the questions] visit after I have established rapport with a client.”
l
a good lead-in, at the end of the
“I try to focus on my concern for them [the clients].”
One nurse described Gery specifically her way of asking the questions as follows: l
“I asked the client to read the yellow sheet about the cycle of violence. They [the clients] don’t realize violence goes in cycles. They think when the person says I’ll stop, that’s the end. She [the client] did this while I did some charting. Then I asked her the questions. Each month, I try to adapt the questionsto where the client is that month.”
At this point, these nurses were becoming quite skilled in asking the questions. They were individualizing the intervention to the specific situation.
Stage Five: Becoming
Comfortable
When
Asking
Toward the end of the 12 weeks, the researchersnoted the participants’ increasing comfort asking these questions. This became evident in responsessuch as l l l l
“It’s not a problem now becauseI phrase the questions in a way I’m comfortable with.” “I’m more comfortable than when I first did this.” “They [the questions] have become common questions.” “It’s easier once you get familiar with the clients and they get familiar with the question.”
At this point, the nurses shared their confidence in talking with clients about domestic violence and began to expect that clients would share these concerns with them.
Stage Six: Accepting
Personal
Responsibility
for Asking
During the previous few weeks, the researchers noted that many nurses were still telling clients they were asking these questions because someone else had told them to do so. Researchers then asked each nurse whether she was ready to explain to clients that she was asking the questions because she believed the questions were important. Almost all participants, after thinking about this suggestion, indicated that they were ready to do so. Subsequent explanations to clients were described as follows: “I start by saying [to the client] we check many things on our patients and one of these things is whether. . . [nurse then verbalized the specified questions].” So, during the course of the study, these nurses appeared to move from forgetting to ask the recommended questions about domestic violence to high levels of comfort in asking these questions. After the researchers further analyzed the data, they arranged a time at which they could go back to the agency and share their findings with these nurses. When the researchers presented the different stages, the participants
266
WOMEN’S
HEALTH
ISSUES
VOL.
7, NO. 4 JULY/AUGUST
1997
expressed momentary surprise because they were not conscious of going through these stages. However, they almost immediately agreed with the stages and confirmed that they could remember going through these stages. In addition, nurses mentioned several factors that encouraged clients to respond to the questions. Having time alone, in private, with the client during each visit was mentioned as very important. Asking the questions toward the end of the visit, after rapport had been established with the client, assigning the same nurse to a client for each visit, being supportive and nonthreatening, and communicating to clients that the nurses were there to help them were other strategies mentioned by nurses. One nurse commented that the questions had to be asked again and again “so the clients can share when they feel ready”; another nurse said, “we have to keep emphasizing that violence is not normal; they think some of this is normal.”
IMPLICATIONS
FOR RESEARCH
Because the sample in this study was small in size and was limited to one clinical agency, it is recommended that this process of observing health care professionals as they learn to ask about domestic violence be repeated both in different settings and in settings that include both male and female nurses to determine the generalizability of this process. Although, as noted previously, there is no reason to expect that nurses have either more difficulty or less difficulty asking these questions than do other disciplines, it is recommended that the study be repeated with other disciplines to determine whether similar learning stages are noted. Also, some participants asked whether it was necessary to ask all three questions and to ask them in such a specific manner. Research is needed to determine whether this is indeed necessary. It should be noted, however, that Fishwick’s research and that of Loring and Smith did find that the use of general questions allowed the client to offer only incomplete information or a fabricated story. 13,14Answering these questions will assist health care professionals to be more effective case finders for domestic violence.
IMPLICATIONS
FOR PRACTICE
The findings from this study suggest that, although it is difficult for health care professionals to ask sensitive questions related to domestic violence, they can learn to do so. Having the time to learn to ask these questions and the opportunity to practice doing so was considered to be very important by the nurses. Learning to ask these three questions is a more complex task than first imagined. Professional training in this area is essential.i5 In addition, health care professionals need to develop a personal comfort level in asking these questions. This takes time, practice, and encouragement. The process involves rethinking how we show concern for our clients. It is easy to assume that the best way to show concern for our clients, or any woman, is to avoid asking embarrassing or personal questions. However, research has shown that concern resulting in client safety is best shown by courageously and kindly asking what may first appear to be a difficult question.2 Policy often is thought to come from the top down. Standards of care are established by experts, then workers are instructed to carry them out. We must realize, however, that a “bottom-up” approach is also needed. Health care professionals must be empowered to carry out recommendations, such as asking about domestic violence, by having the opportunity to first learn the skill. This learning process is a time-consuming but important step. The importance of taking time for this learning process is reflected in these
COELING
& HARMON:
DOMESTIC
VIOLENCE
267
concluding comments, which the last week of the study: l
were
made by two participating
“This whole project has opened my eyes to things that I had blinders started.”
nurses
during
on to before it
and l
“Today, one patient told me she had an argument with her husband last week. She got mad and punched the wall. We talked about anger and how this can escalateto violence and what shecould do to prevent violence. It mademe feel like a real public health nurse-like I was preventing a serious problem from happening.”
Prevention is our goal. This study suggests that it is best achieved by paying attention not only to the needs of clients but also to the needs of the health care providers caring for the clients.
ACKNOWLEDGMENTS Appreciation is expressed to the prenatal clinical nurses of the Summit County Health Department (Ohio) for the help they provided in this study and to the Kent State University Research Council for providing partial funding for this project.
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1997