- Email: [email protected]
Women Who Return to Abusive Relationships:
0899-5885/97 $0.00 + .20 Violence Across the Lifespan: Implications for Critical Care
Women Who Return to Abusive Relationships: A Frustration for the Critical Care Nurse Gay L. Goss, PhD, NP, and Jeanne DeJoseph, PhD, CNM
Nurses who first encounter victims of domestic violence in the acute care setting are constantly frustrated when patients leave the safety of the hospital and immediately return to an intimate relationship with the perpetrator. Logic dictates that once a woman escapes from a violent environment, that she will do anything to remain free from harm. Unfortunately, just the opposite is true. The norm is more often a reconciliation of the abusive union. 13•25 How can the critical care nurse contribute to breaking this vicious cycle? The first step is to gain enough knowledge, training, and education to comprehend the nature of the dynamic that exists between the perpetrator and female victim, and to be able to initiate measures to assist the victim. Understanding the complex phenomenon of "why women stay" is crucial for the critical care nurse, whose technical skills must be augA special thank you to Dr. Marsha Fonteyn for her editorial comments in preparing this manuscript. From the Department of Family Health Care Nursing (GLG, JD), Midwifery Program QD), The School of Nursing, University of California, San Francisco, San Francisco, California
mented by the ability to ensure safety and to demonstrate compassion and professionalism. Formal preparation is one avenue for augmenting one's knowledge and skill in this area.1• 15• 33 More important is the development of empathy, and truly believing and validating a woman's experience with an abusive mate.2() The second step in this process is to learn the interpersonal skills that convey empathy and caring to the battered victim. Without these skills, a nurse may find that a victim is reluctant to discuss the true nature of her injuries, and may lack the courage needed permanently to break off from her dysfunctional and possibly life-threatening relationship with the batterer. 3 Because nurses find it difficult to envision continued cohabitation with a violent partner, they often, inadvertently or intentionally, convey this attitude to the victim. 18• 2() The nurse who fails to recognize the unseen emotional trauma inflicted on these victims, or who fails to investigate the cause of visible physical bruises and wounds, is missing a vital opportunity for meaningful nursing intervention. The failure of nurses to acknowledge the evidence of domestic violence repre-
CRITICAL CARE NURSING CLINICS OF NORTH AMERICA I Volume 9 I Number 2 I June 1997
159
160
GOSS and DEJOSEPH
sents a missed opportunity to help the victim that may actually compound the violent situation. The victim may perceive the nurse as someone who only "wants to stop the bleeding" and "get on to the next patient." 18 Thus, the cause of the problem is devalued. The perpetrator will certainly seize the chance, and take further advantage of this victim, and definitely reinforce this perceived lack of empathy by the health care system when he gets her back on his own turf. His control over the victim then escalates, further jeopardizing the well-being of the woman and her children. 5 Clearly, the critical care nurse must understand the gravity of the domestic violence dynamic, and recognize the unique opportunity that he or she has to impact this chronic problem effectively by obtaining the necessary skills needed to empower the victim. This article examines the existing literature surrounding why women stay in abusive relationships. Three themes are identified specific to the problem of domestic violence with implications for nurses in clinical practice. Understanding these concepts is important for effective interaction between the victim and the nurse. They heavily influence a woman's decision whether or not to stay in an abusive relationship.
Review of the Literature As early as 1971, in the legal literature, Trun-
inger34 described seven salient factors that explain why women stay with abusive men: • The women have negative self-concepts • They believe the perpetrator will reform • There is economic hardship • They have children who need a father's economic support • They doubt they can get along alone • They believe they are stigmatized • It is difficult for women with children to obtain employment Even though this study is more than three decades old, the problems the author identified are still prevalent and unresolved today. Gelles11 compared battered women who stayed with the perpetrator to women who
stayed and used community resources for help. He concluded that the severity of violence, childhood experiences with violence, and level of education and occupation were distinguishing factors influencing a woman's decision to stay. Pagelow,26 in an early report, surmised that diminished educational and occupational resources are the major reasons women stay in abusive relationships. Additional research substantiated these findings, indicating that economic dependence is the prevailing factor for staying with a batterer .10• 29 Secondary analysis of the data demonstrated a positive correlation between the two variables, education and economic status, as decisive factors in a woman's decision to stay. 30 Okun25 offered a plausible explanation for the repeated separations and reconciliations that characterize an abusive relationship. He believed they served as a continuation of the process of leaving, because a large portion of the abused women in his study eventually ended the relationship. He identified economics as a primary predictor in the expediency of terminating the relationship. The health care literature focusing on why women stay in an abusive relationship is more obscure. In contrast to the previously cited research, the medical and nursing studies concentrate more on the injury and treatment options for an abused victim rather than the causes, including anger and control, that led to her injuries. These reports indicate that health care providers' response to domestic violence is mired in privacy myths, their exasperation with the time allocated to victims in the practice setting, and a tendency for male providers to deliver less empathetic care. 16. 11, 31, 33 Further, injuries resulting from domestic violence have not been labeled as criminal, but rather as minor accidents caused by inadvertent actions. 12• 23• 24 Additionally, the quest for a cure is misguided when the health care system discharges a victim back to the care of the perpetrator. Hence, treatment plans and protocols for care, rather than the real crux of the problem of domestic violence, have been the focus of research in the health care literature.
WOMEN WHO RETURN TO ABUSIVE RELATIONSHIPS
More recently, nursing research has approached the problem of violence on a grass-roots level. 6 Prevalence rates, pregnancy implications, substance abuse, emotional responses, disclosure strategies, and educational programs are but a few of the issues that have been examined by nurse researchers.4· 5• 1• 15• 20• 22 In addition, other nurse researchers have explored why women stay in a more personal context, reporting a process of leaving based on factors of dependency, safety, and personal growth, as well as significant influences during the process. 19• 35 What is lacking in this literature are intervention studies and outcome research that examine the relationships of social factors in the context of the delivery of health care services to battered women.
Deconstructing the Medical Patriarchy
Historically, medical care for a battered woman was almost exclusively provided by male physicians. This care was entrenched in male values of dominance, control, and reinforcing dependence.28 The gender difference between provider and client created conflict for abused women, resulting in a disparity of experience with the health care system. For example, under this traditional patriarchal approach, Dyehouse8 identified an increased number of prescriptions and surgical interventions being offered to battered women. This approach is in direct contrast to feminist perspectives, where mutual respect, education, and participation in decision making is needed by victims to make empowerment an option. Failure to recognize these differences in treatment options reinforces the subservient role of the victim in the medical setting. Furthermore, the reluctance to engage the victim in decision-making activities fosters a perception of disbelief regarding the patient's plight, and leads to the misdiagnosis of hysteria, hypochondria, and substance abuse. 2• 28 A circular pattern is created when battered women reach out for treatment while the
161
medical system realizes the possibility of reconciliation. The woman is viewed as not truly wanting help. In tum, the male provider may assume a patriarchal posture and not consider the woman as a partner in treatment. A BandAid approach is evident because the victim is "patched up" and discharged back to the violent setting, and not seen until her next urgent visit. 28 Unfortunately, many nurses model their practice behaviors after a patriarchal medical example. Sugg and Inui's31 further exploration of the use of the medical model in the treatment of domestic violence, revealed that many physicians do not feel adequately trained to deal with the complexity of the issues associated with domestic violence, and fear "opening Pandora's Box" in their busy practice settings. Critical care nurses face a similar conflict because their initial concern is providing lifesaving interventions and later, when time permits, attacking the complex psychosocial aspects of victimization. Their practice environment is not always conducive, nor feasible, to attempt to address the societal ramifications surrounding physical assault. Perhaps they do not realize that conveying an empathetic understanding of the woman's choice to return to the batterer is as important as attending to the physical needs of the victim.
How the Victim Is Blamed An undercurrent of blaming the victim for the
violent situation exists not only in the health care arena described previously but is also pervasive in society today. Law enforcement, social service, friends, medicine, and nursing all view a battered woman with misinterpretation and impatience.v Many policemen, legislators, and judges have traditionally been men who quite likely hold a male-dominated societal attitude. In addition, the female victim often encounters a male health care provider when seeking care for her injuries. One can easily understand her hesitation when she enters the health care system. Thus, by the time the victim first encounters a critical care nurse, she is already predisposed to have feelings
162
GOSS and DEJOSEPH
of distrust, dependency, and low self-esteem. Adding these sentiments to the victim's physical trauma further compounds her feelings of hopelessness. Nurses may not directly reinforce the concept of blame as defined by male stereotyping; their participation in this process is subtler. The nurse's perception of blame may be conveyed to the battered woman in a nonverbal as well as a verbal fashion. Frequently, nurses impart a sense of exasperation for repeated use of health care services to treat their injuries through increased emergency department visits and critical care stays, with subsequent return to the perpetrator. Conversely, when battered women fail to obtain obstetric or gynecologic services, such as mammograms or prenatal care, they may be cautioned or even reprimanded at the health risk they assume. The victim receives mixed messages regarding the role of health care and her wellbeing. In essence, this unclear message translates into blame of the victim for seeking or not seeking health care. Blaming victims also occurs when nurses reinforce or add to the victim's feeling of isolation. This is evidenced by nurses' failing to confront violence, not asking for truthful explanations, or not knowing the conununity resources to offer victims. The nurse isolates and reinforces a battered woman's perception that no one understands her and that she is alone with her problem. Subsequently, the nurse and the victim become involved in a "dance" of secrecy and helplessness. The victim often perceives this interaction as blame for the violence. She often feels she has no other option but to turn to the perpetrator for support. With no other perceived option, she stays with the batterer.
Stereotyping of Gender Roles
Violence against women is historically deep rooted. Over the centuries, it has permeated all aspects of society, culture, and religion. The historical view of the Judeo-Christian doctrine supports forms of violence against
women, as illustrated in advocating punishment of women for talking back, refusing intercourse, having miscarriages, being sodomized, masturbating, scolding and nagging, and other minor encounters. 21 In societies where women were considered to be the property of men, fit only to procreate and bear children to carry on the male family name, purity and virtuousness were the most desirable attributes of the female spouse. Historically, many cultures have supported customs that demean and mutilate women. Some examples of this degradation incl.u de foot binding of women in China; the Muslim tradition of secluding women from contact with men outside the immediate family; the custom of performing clitoridectomy in some African cultures to reduce libido in women; and the Middle Eastern and Arab custom that dictates women and girls eat separately and last (fostering malnutrition and starvation in times of famine). 21 Subtler approaches to the devaluation of women involve requiring women to relinquish their maiden names in marriage, viewing women healers as witches, and forcing women to promise to obey the male spouse in traditional marriage vows. A popular example of the debasement of women is the "rule of thumb" law that stated a man could beat his wife with an object no bigger than the width of his thumb. This law became entrenched in the British legal code until the end of the 1800s. These historical underpinnings directly influence the cultural context of the roles of women today. Western scx:iety revolves around a patriarchal model and is constructed largely on gender roles and stereotyping. Historically, male dominance and female servitude are not unique, existing in both traditional and contemporary settings. An example of this gender role definition is evident in the traditional relationship between nursing and medicine. Typically, physicians are viewed as men, and nurses are identified as women. Furthermore, this model is operationalized by the service role of women, in which performance of domestic chores serves as an opportunity for women to show appreciation for male favor. In contrast, male-dominant characteris-
WOMEN WHO RETURN TO ABUSIVE RELATIONSHIPS
tics are associated with violence, machismo, and other so-called manly qualities that reinforce control over family, home, and wife, as well as the social construction of the patriarchal influence. 14 With this perception of patriarchal power by both men and women, men have dominated the enactment of laws and the formation of social and economic policy. Until recently, virtually all decision-making authority in Western society has been under the domain of men. Nurses caring for injured women must face and overcome these discrepancies, inequalities, and stereotypes, while offering some hope to battered women.9 This task challenges even the most experienced nurse. Resources are scarce, and they must often do more with less. Additionally, cultural blinders affect almost everyone including nurses. 13 These barriers, in tandem with the strict role delineation assigned to women in society, continue to fail the battered woman and to hamper the practice of professional nursing. Given our patriarchal society and the limited choices a woman has regarding employment, education, sexuality, and patterns of socialization, the right to live without violence seems elusive. The woman stays in the relationship because society has constructed a situation in which women are dependent on men for their economic stability, social standing, and social support.
Conclusion
Domestic violence has a steadily increasing and all-pervasive presence in our society. Every day we read about this problem in our newspapers, we see reports on newscasts, and hear about it from our family and friends. Domestic violence is so commonplace that the US surgeon general declared it epidemic in our nation. 15 Despite an increasing awareness and watershed legislative changes, factions of society continue to deny the magnitude of the problem. What can account for this denial? Perhaps it is because society does not call domestic violence what it is: violence
163
against women. The health care system is overworked, and expected to do too much. Health care providers may have trouble informing patients that no cure is readily available for problems that they cannot immediately fix, as is the case with domestic violence. Instead, providers may tend to ignore these difficult diagnoses. Maybe society is unwilling to accept a change in the traditional, historical foundations and structural boundaries that socially created such vast differences between the treatment of men and women. Now is the time to develop new strategies that address these concerns and allow critical care nurses to improve the care rendered to battered victims. Unique to the critical care nurse is the opportunity for intense one-on-one interaction with the victim. It is during this personal interaction that the nurse can impart a true respect for the woman's plight. In tandem with competent physical care, the nurse can use this opportunity to convey the appropriate attitude of empathy. Empathy and a basic understanding and respect for the woman's choice-or, more important, the lack of choice-is the basic foundation that enables victims to use empowerment strategies. Nurses must realize that men batter women because society does not encourage them to stop. Until this changes, a nurse must not condemn a woman's decision to stay. As one nurse stated, "you cannot judge the victim until you've walked in her shoes." 13 Moreover, until society makes allowances for the critical issues of transportation, education, child care, and finances, women will continue to stay in an environment that is incomprehensible and uncomfortable for the nurse to confront. Nurses must realize that, until the larger societal issues are resolved, battered women will continue to return to the perpetrator time and time again. Nurses are experiencing more autonomy than ever before. The handmaiden image, whereby nurses follow strict instructions from the physician, is being replaced by an image of a collaborative provider with goals in common with the physician and the health care team. With this new dawn of responsibility
164
GOSS and DEJOSEPH
and accountability, nurses have the opportunity to introduce more interdependent activities into their practice. Sensitivity, nurturance, and a heightened awareness of helping resources are examples of the strengths nurses can bring to domestic violence situations. Relinquishing control to the victim and introducing less male-dominated constructs into the health care setting will allow the battered woman to feel free to disclose the presence of violence and to gain the confidence to challenge the gender delineations imposed by society. This posture will enhance the possibility of realistic empowerment for the victim of domestic violence. The practice of professional nursing is changing at an unparalleled pace. The nurses' role refinement, agency involvement, mandatory reporting laws, and revisions in health care administration describe many of the influences affecting practice. The new health care agenda is the forum the nurse can use to reconstruct the obsolete health care model often associated with domestic violence. Reframing issues within a feminist framework, accompanied by collaborative efforts with our multidisciplinary partners, is an excellent venue for change. As health care reform becomes a pennanent part of the public and private sector, more regulations are inevitable. Domestic violence is in the forefront of these current revisions across the country. Critical care nurses providing care to battered woman and their children should seize the opportunity to provide empathy; impart understanding; discard myths surrounding domestic violence; and, finally, encourage our society to value women.
REFERENCES 1. Bokunewicz B, Copel L: Attitudes of emerge ncy nurses before and after a 6o minute educational presentation on partner abuse. J Emerg Nurs 18:2427, 1992 2. Bowker L, Mauser L: The effectiveness of counseling services utilized by battered women. Women and Therapy 5:65-82, 1986 3. Brendtro M, Bowker L: Battered women: How can the nurse help? Issues in Mental Health Nursing 10:169- 180, 1989
4. Bullock L, McFarlane J: The lowbirth weight/battering connection. AmJ Nurs 89:1153-1155, 1988
5. Campbell J: Nursing assessment of risk of homicide
6. 7.
8.
9.
10.
11. 12.
13. 14. 15.
16. 17. 18. 19. 20.
21. 22.
23.
24.
25. 26. 27.
with battered women. Advances in Nursing Science 8:36--51, 1986 CampbellJ: Women abuse and public policy: Potential for nursing action. Clinical Issues in Women's Health Nursing 4:503-512, 1993 Campbell J, Poland M, Waller J, Ager J: Correlates of battering during pregnancy. Res Nurs Health 15:219226, 1992 Dyehouse J: Abuse of women in the health care system. In Dyehouse J (ed): Violence Against Women. New York, Hemisphere Publishing, 1992 Ewing C, Aubrey M: Battered woman and public opinion. Some realities about the myths. Journal of Family Violence 2:257-264, 1987 Fagen J, Stewart D, Hanson K: Violent men or husbands. In Finkelhor, Hoatling, Straus (eds): Dark Side of Families. Beverly Hills, Sage Publications, 1986 Gelles R: Abused wives: Why do they stay? Journal of Marriage and the Family 38:659-688, 1976 Goldberg W, Tomlanovich M: Domestic violence victims in the emergency department: New findings. JAMA 267:3259-3264, 1984 Goss G: The process of facilitating disclosure of physical abuse: The role of the nurse clinician. Disseration Abstracts, UCSF, 1996 Hansen M, Haraway, M: Battering and Family Therapy. Newbury Park, CA, Sage Publications, 1993 Helton A: The Prevention of Battering During Pregnancy: A Protocol for Care. New York, March of Dimes, 1986 Jecker N: Privacy beliefs and the violent family.JAMA 269:776-780, 1993 King C, Ryan J: Abused women: Dispelling myths and encouraging intervention. Nurse Pract 14:4758, 1989 Kurz D: Emergency department responses to battered women: Resistance to medicalization. Social Problems 34:69-81, 1987 Landenburger K: A process of entrapment in and recovery from an abusive relationship. Issues in Mental Health Nursing 10:209-227, 1989 Limandri B: The therapeutic relationship with abused women. Journal of Psychosocial Nursing 25:9-16, 1987 Martin D: Battered Wives. New York, Pocket Books, 1976 McFarlaneJ, Christoffel R, Bateman L, et al: Assessing for abuse: Self report versus nurse interview. Public Health Nurs 8:242-250, 1991 McLeer S, Anwar R: The role of the emergency physician in the prevention of domestic violence. Ann Emerg Med 16:115- 161, 1987 McLeer S, Anwar R: A study of women presenting in an emergency department. Public Health Beliefs 79:65- 66, 1989 OkunL: Woman Abuse. New York, SUNYPress, 1986 Pagelow M: Woman Battering: Victims and Their Experiences. Beverly Hills, Sage Publications, 1981 Snell J, Rosenwold R, Roby A: The wifebeater's wife reconsidered. Arch Gen Psychiatry 2:107-112,
1964
WOMEN WHO RETURN TO ABUSIVE RELATIONSHIPS 28. Stark A, Flitcraft A, Frazier W: Medicine and patriarchal violence: The social construction of a "private event." IntJ Health Serv 9:461-493, 1979 29. Strube M, Barbour L: The decision to leave an abusive relationship: Economic dependence and psychological commitment. Journal of Marriage and the Family 45:785-793, 1983 30. Strube M, Barbour L: Factors relating to the decision to leave an abusive relationship. Journal of Marriage and the Family 46:837-844, 1984 31. Sugg N, Inui T: Primary care physician's response to domestic violence. JAMA 267:3157-3160, 1992
165
32. Tilden V: Response of the health care delivery system to battered women. Issues in Mental Health Nursing 10:309-320, 1989 33. Tilden V, Shepherd P: Increasing the rate of identification of battered women in an emergency department: Use of a nursing protocol. Research in Nursing 10:209-215, 1987 34. Truninger E: Marital violence: The legal solutions. Hastings Law Review 23:259-276, 1971 35. Ulrich Y: Women's reasons for leaving abusive spouses. Health Care for Women International 12:465-473, 1991
Address reprint requests to Gay L. Goss PhD, NP 7320 Beltis Drive Modesto, CA 95356
Women Who Return to Abusive Relationships: A Frustration for the Critical Care Nurse Gay L. Goss, PhD, NP, and Jeanne DeJoseph, PhD, CNM
Nurses who first encounter victims of domestic violence in the acute care setting are constantly frustrated when patients leave the safety of the hospital and immediately return to an intimate relationship with the perpetrator. Logic dictates that once a woman escapes from a violent environment, that she will do anything to remain free from harm. Unfortunately, just the opposite is true. The norm is more often a reconciliation of the abusive union. 13•25 How can the critical care nurse contribute to breaking this vicious cycle? The first step is to gain enough knowledge, training, and education to comprehend the nature of the dynamic that exists between the perpetrator and female victim, and to be able to initiate measures to assist the victim. Understanding the complex phenomenon of "why women stay" is crucial for the critical care nurse, whose technical skills must be augA special thank you to Dr. Marsha Fonteyn for her editorial comments in preparing this manuscript. From the Department of Family Health Care Nursing (GLG, JD), Midwifery Program QD), The School of Nursing, University of California, San Francisco, San Francisco, California
mented by the ability to ensure safety and to demonstrate compassion and professionalism. Formal preparation is one avenue for augmenting one's knowledge and skill in this area.1• 15• 33 More important is the development of empathy, and truly believing and validating a woman's experience with an abusive mate.2() The second step in this process is to learn the interpersonal skills that convey empathy and caring to the battered victim. Without these skills, a nurse may find that a victim is reluctant to discuss the true nature of her injuries, and may lack the courage needed permanently to break off from her dysfunctional and possibly life-threatening relationship with the batterer. 3 Because nurses find it difficult to envision continued cohabitation with a violent partner, they often, inadvertently or intentionally, convey this attitude to the victim. 18• 2() The nurse who fails to recognize the unseen emotional trauma inflicted on these victims, or who fails to investigate the cause of visible physical bruises and wounds, is missing a vital opportunity for meaningful nursing intervention. The failure of nurses to acknowledge the evidence of domestic violence repre-
CRITICAL CARE NURSING CLINICS OF NORTH AMERICA I Volume 9 I Number 2 I June 1997
159
160
GOSS and DEJOSEPH
sents a missed opportunity to help the victim that may actually compound the violent situation. The victim may perceive the nurse as someone who only "wants to stop the bleeding" and "get on to the next patient." 18 Thus, the cause of the problem is devalued. The perpetrator will certainly seize the chance, and take further advantage of this victim, and definitely reinforce this perceived lack of empathy by the health care system when he gets her back on his own turf. His control over the victim then escalates, further jeopardizing the well-being of the woman and her children. 5 Clearly, the critical care nurse must understand the gravity of the domestic violence dynamic, and recognize the unique opportunity that he or she has to impact this chronic problem effectively by obtaining the necessary skills needed to empower the victim. This article examines the existing literature surrounding why women stay in abusive relationships. Three themes are identified specific to the problem of domestic violence with implications for nurses in clinical practice. Understanding these concepts is important for effective interaction between the victim and the nurse. They heavily influence a woman's decision whether or not to stay in an abusive relationship.
Review of the Literature As early as 1971, in the legal literature, Trun-
inger34 described seven salient factors that explain why women stay with abusive men: • The women have negative self-concepts • They believe the perpetrator will reform • There is economic hardship • They have children who need a father's economic support • They doubt they can get along alone • They believe they are stigmatized • It is difficult for women with children to obtain employment Even though this study is more than three decades old, the problems the author identified are still prevalent and unresolved today. Gelles11 compared battered women who stayed with the perpetrator to women who
stayed and used community resources for help. He concluded that the severity of violence, childhood experiences with violence, and level of education and occupation were distinguishing factors influencing a woman's decision to stay. Pagelow,26 in an early report, surmised that diminished educational and occupational resources are the major reasons women stay in abusive relationships. Additional research substantiated these findings, indicating that economic dependence is the prevailing factor for staying with a batterer .10• 29 Secondary analysis of the data demonstrated a positive correlation between the two variables, education and economic status, as decisive factors in a woman's decision to stay. 30 Okun25 offered a plausible explanation for the repeated separations and reconciliations that characterize an abusive relationship. He believed they served as a continuation of the process of leaving, because a large portion of the abused women in his study eventually ended the relationship. He identified economics as a primary predictor in the expediency of terminating the relationship. The health care literature focusing on why women stay in an abusive relationship is more obscure. In contrast to the previously cited research, the medical and nursing studies concentrate more on the injury and treatment options for an abused victim rather than the causes, including anger and control, that led to her injuries. These reports indicate that health care providers' response to domestic violence is mired in privacy myths, their exasperation with the time allocated to victims in the practice setting, and a tendency for male providers to deliver less empathetic care. 16. 11, 31, 33 Further, injuries resulting from domestic violence have not been labeled as criminal, but rather as minor accidents caused by inadvertent actions. 12• 23• 24 Additionally, the quest for a cure is misguided when the health care system discharges a victim back to the care of the perpetrator. Hence, treatment plans and protocols for care, rather than the real crux of the problem of domestic violence, have been the focus of research in the health care literature.
WOMEN WHO RETURN TO ABUSIVE RELATIONSHIPS
More recently, nursing research has approached the problem of violence on a grass-roots level. 6 Prevalence rates, pregnancy implications, substance abuse, emotional responses, disclosure strategies, and educational programs are but a few of the issues that have been examined by nurse researchers.4· 5• 1• 15• 20• 22 In addition, other nurse researchers have explored why women stay in a more personal context, reporting a process of leaving based on factors of dependency, safety, and personal growth, as well as significant influences during the process. 19• 35 What is lacking in this literature are intervention studies and outcome research that examine the relationships of social factors in the context of the delivery of health care services to battered women.
Deconstructing the Medical Patriarchy
Historically, medical care for a battered woman was almost exclusively provided by male physicians. This care was entrenched in male values of dominance, control, and reinforcing dependence.28 The gender difference between provider and client created conflict for abused women, resulting in a disparity of experience with the health care system. For example, under this traditional patriarchal approach, Dyehouse8 identified an increased number of prescriptions and surgical interventions being offered to battered women. This approach is in direct contrast to feminist perspectives, where mutual respect, education, and participation in decision making is needed by victims to make empowerment an option. Failure to recognize these differences in treatment options reinforces the subservient role of the victim in the medical setting. Furthermore, the reluctance to engage the victim in decision-making activities fosters a perception of disbelief regarding the patient's plight, and leads to the misdiagnosis of hysteria, hypochondria, and substance abuse. 2• 28 A circular pattern is created when battered women reach out for treatment while the
161
medical system realizes the possibility of reconciliation. The woman is viewed as not truly wanting help. In tum, the male provider may assume a patriarchal posture and not consider the woman as a partner in treatment. A BandAid approach is evident because the victim is "patched up" and discharged back to the violent setting, and not seen until her next urgent visit. 28 Unfortunately, many nurses model their practice behaviors after a patriarchal medical example. Sugg and Inui's31 further exploration of the use of the medical model in the treatment of domestic violence, revealed that many physicians do not feel adequately trained to deal with the complexity of the issues associated with domestic violence, and fear "opening Pandora's Box" in their busy practice settings. Critical care nurses face a similar conflict because their initial concern is providing lifesaving interventions and later, when time permits, attacking the complex psychosocial aspects of victimization. Their practice environment is not always conducive, nor feasible, to attempt to address the societal ramifications surrounding physical assault. Perhaps they do not realize that conveying an empathetic understanding of the woman's choice to return to the batterer is as important as attending to the physical needs of the victim.
How the Victim Is Blamed An undercurrent of blaming the victim for the
violent situation exists not only in the health care arena described previously but is also pervasive in society today. Law enforcement, social service, friends, medicine, and nursing all view a battered woman with misinterpretation and impatience.v Many policemen, legislators, and judges have traditionally been men who quite likely hold a male-dominated societal attitude. In addition, the female victim often encounters a male health care provider when seeking care for her injuries. One can easily understand her hesitation when she enters the health care system. Thus, by the time the victim first encounters a critical care nurse, she is already predisposed to have feelings
162
GOSS and DEJOSEPH
of distrust, dependency, and low self-esteem. Adding these sentiments to the victim's physical trauma further compounds her feelings of hopelessness. Nurses may not directly reinforce the concept of blame as defined by male stereotyping; their participation in this process is subtler. The nurse's perception of blame may be conveyed to the battered woman in a nonverbal as well as a verbal fashion. Frequently, nurses impart a sense of exasperation for repeated use of health care services to treat their injuries through increased emergency department visits and critical care stays, with subsequent return to the perpetrator. Conversely, when battered women fail to obtain obstetric or gynecologic services, such as mammograms or prenatal care, they may be cautioned or even reprimanded at the health risk they assume. The victim receives mixed messages regarding the role of health care and her wellbeing. In essence, this unclear message translates into blame of the victim for seeking or not seeking health care. Blaming victims also occurs when nurses reinforce or add to the victim's feeling of isolation. This is evidenced by nurses' failing to confront violence, not asking for truthful explanations, or not knowing the conununity resources to offer victims. The nurse isolates and reinforces a battered woman's perception that no one understands her and that she is alone with her problem. Subsequently, the nurse and the victim become involved in a "dance" of secrecy and helplessness. The victim often perceives this interaction as blame for the violence. She often feels she has no other option but to turn to the perpetrator for support. With no other perceived option, she stays with the batterer.
Stereotyping of Gender Roles
Violence against women is historically deep rooted. Over the centuries, it has permeated all aspects of society, culture, and religion. The historical view of the Judeo-Christian doctrine supports forms of violence against
women, as illustrated in advocating punishment of women for talking back, refusing intercourse, having miscarriages, being sodomized, masturbating, scolding and nagging, and other minor encounters. 21 In societies where women were considered to be the property of men, fit only to procreate and bear children to carry on the male family name, purity and virtuousness were the most desirable attributes of the female spouse. Historically, many cultures have supported customs that demean and mutilate women. Some examples of this degradation incl.u de foot binding of women in China; the Muslim tradition of secluding women from contact with men outside the immediate family; the custom of performing clitoridectomy in some African cultures to reduce libido in women; and the Middle Eastern and Arab custom that dictates women and girls eat separately and last (fostering malnutrition and starvation in times of famine). 21 Subtler approaches to the devaluation of women involve requiring women to relinquish their maiden names in marriage, viewing women healers as witches, and forcing women to promise to obey the male spouse in traditional marriage vows. A popular example of the debasement of women is the "rule of thumb" law that stated a man could beat his wife with an object no bigger than the width of his thumb. This law became entrenched in the British legal code until the end of the 1800s. These historical underpinnings directly influence the cultural context of the roles of women today. Western scx:iety revolves around a patriarchal model and is constructed largely on gender roles and stereotyping. Historically, male dominance and female servitude are not unique, existing in both traditional and contemporary settings. An example of this gender role definition is evident in the traditional relationship between nursing and medicine. Typically, physicians are viewed as men, and nurses are identified as women. Furthermore, this model is operationalized by the service role of women, in which performance of domestic chores serves as an opportunity for women to show appreciation for male favor. In contrast, male-dominant characteris-
WOMEN WHO RETURN TO ABUSIVE RELATIONSHIPS
tics are associated with violence, machismo, and other so-called manly qualities that reinforce control over family, home, and wife, as well as the social construction of the patriarchal influence. 14 With this perception of patriarchal power by both men and women, men have dominated the enactment of laws and the formation of social and economic policy. Until recently, virtually all decision-making authority in Western society has been under the domain of men. Nurses caring for injured women must face and overcome these discrepancies, inequalities, and stereotypes, while offering some hope to battered women.9 This task challenges even the most experienced nurse. Resources are scarce, and they must often do more with less. Additionally, cultural blinders affect almost everyone including nurses. 13 These barriers, in tandem with the strict role delineation assigned to women in society, continue to fail the battered woman and to hamper the practice of professional nursing. Given our patriarchal society and the limited choices a woman has regarding employment, education, sexuality, and patterns of socialization, the right to live without violence seems elusive. The woman stays in the relationship because society has constructed a situation in which women are dependent on men for their economic stability, social standing, and social support.
Conclusion
Domestic violence has a steadily increasing and all-pervasive presence in our society. Every day we read about this problem in our newspapers, we see reports on newscasts, and hear about it from our family and friends. Domestic violence is so commonplace that the US surgeon general declared it epidemic in our nation. 15 Despite an increasing awareness and watershed legislative changes, factions of society continue to deny the magnitude of the problem. What can account for this denial? Perhaps it is because society does not call domestic violence what it is: violence
163
against women. The health care system is overworked, and expected to do too much. Health care providers may have trouble informing patients that no cure is readily available for problems that they cannot immediately fix, as is the case with domestic violence. Instead, providers may tend to ignore these difficult diagnoses. Maybe society is unwilling to accept a change in the traditional, historical foundations and structural boundaries that socially created such vast differences between the treatment of men and women. Now is the time to develop new strategies that address these concerns and allow critical care nurses to improve the care rendered to battered victims. Unique to the critical care nurse is the opportunity for intense one-on-one interaction with the victim. It is during this personal interaction that the nurse can impart a true respect for the woman's plight. In tandem with competent physical care, the nurse can use this opportunity to convey the appropriate attitude of empathy. Empathy and a basic understanding and respect for the woman's choice-or, more important, the lack of choice-is the basic foundation that enables victims to use empowerment strategies. Nurses must realize that men batter women because society does not encourage them to stop. Until this changes, a nurse must not condemn a woman's decision to stay. As one nurse stated, "you cannot judge the victim until you've walked in her shoes." 13 Moreover, until society makes allowances for the critical issues of transportation, education, child care, and finances, women will continue to stay in an environment that is incomprehensible and uncomfortable for the nurse to confront. Nurses must realize that, until the larger societal issues are resolved, battered women will continue to return to the perpetrator time and time again. Nurses are experiencing more autonomy than ever before. The handmaiden image, whereby nurses follow strict instructions from the physician, is being replaced by an image of a collaborative provider with goals in common with the physician and the health care team. With this new dawn of responsibility
164
GOSS and DEJOSEPH
and accountability, nurses have the opportunity to introduce more interdependent activities into their practice. Sensitivity, nurturance, and a heightened awareness of helping resources are examples of the strengths nurses can bring to domestic violence situations. Relinquishing control to the victim and introducing less male-dominated constructs into the health care setting will allow the battered woman to feel free to disclose the presence of violence and to gain the confidence to challenge the gender delineations imposed by society. This posture will enhance the possibility of realistic empowerment for the victim of domestic violence. The practice of professional nursing is changing at an unparalleled pace. The nurses' role refinement, agency involvement, mandatory reporting laws, and revisions in health care administration describe many of the influences affecting practice. The new health care agenda is the forum the nurse can use to reconstruct the obsolete health care model often associated with domestic violence. Reframing issues within a feminist framework, accompanied by collaborative efforts with our multidisciplinary partners, is an excellent venue for change. As health care reform becomes a pennanent part of the public and private sector, more regulations are inevitable. Domestic violence is in the forefront of these current revisions across the country. Critical care nurses providing care to battered woman and their children should seize the opportunity to provide empathy; impart understanding; discard myths surrounding domestic violence; and, finally, encourage our society to value women.
REFERENCES 1. Bokunewicz B, Copel L: Attitudes of emerge ncy nurses before and after a 6o minute educational presentation on partner abuse. J Emerg Nurs 18:2427, 1992 2. Bowker L, Mauser L: The effectiveness of counseling services utilized by battered women. Women and Therapy 5:65-82, 1986 3. Brendtro M, Bowker L: Battered women: How can the nurse help? Issues in Mental Health Nursing 10:169- 180, 1989
4. Bullock L, McFarlane J: The lowbirth weight/battering connection. AmJ Nurs 89:1153-1155, 1988
5. Campbell J: Nursing assessment of risk of homicide
6. 7.
8.
9.
10.
11. 12.
13. 14. 15.
16. 17. 18. 19. 20.
21. 22.
23.
24.
25. 26. 27.
with battered women. Advances in Nursing Science 8:36--51, 1986 CampbellJ: Women abuse and public policy: Potential for nursing action. Clinical Issues in Women's Health Nursing 4:503-512, 1993 Campbell J, Poland M, Waller J, Ager J: Correlates of battering during pregnancy. Res Nurs Health 15:219226, 1992 Dyehouse J: Abuse of women in the health care system. In Dyehouse J (ed): Violence Against Women. New York, Hemisphere Publishing, 1992 Ewing C, Aubrey M: Battered woman and public opinion. Some realities about the myths. Journal of Family Violence 2:257-264, 1987 Fagen J, Stewart D, Hanson K: Violent men or husbands. In Finkelhor, Hoatling, Straus (eds): Dark Side of Families. Beverly Hills, Sage Publications, 1986 Gelles R: Abused wives: Why do they stay? Journal of Marriage and the Family 38:659-688, 1976 Goldberg W, Tomlanovich M: Domestic violence victims in the emergency department: New findings. JAMA 267:3259-3264, 1984 Goss G: The process of facilitating disclosure of physical abuse: The role of the nurse clinician. Disseration Abstracts, UCSF, 1996 Hansen M, Haraway, M: Battering and Family Therapy. Newbury Park, CA, Sage Publications, 1993 Helton A: The Prevention of Battering During Pregnancy: A Protocol for Care. New York, March of Dimes, 1986 Jecker N: Privacy beliefs and the violent family.JAMA 269:776-780, 1993 King C, Ryan J: Abused women: Dispelling myths and encouraging intervention. Nurse Pract 14:4758, 1989 Kurz D: Emergency department responses to battered women: Resistance to medicalization. Social Problems 34:69-81, 1987 Landenburger K: A process of entrapment in and recovery from an abusive relationship. Issues in Mental Health Nursing 10:209-227, 1989 Limandri B: The therapeutic relationship with abused women. Journal of Psychosocial Nursing 25:9-16, 1987 Martin D: Battered Wives. New York, Pocket Books, 1976 McFarlaneJ, Christoffel R, Bateman L, et al: Assessing for abuse: Self report versus nurse interview. Public Health Nurs 8:242-250, 1991 McLeer S, Anwar R: The role of the emergency physician in the prevention of domestic violence. Ann Emerg Med 16:115- 161, 1987 McLeer S, Anwar R: A study of women presenting in an emergency department. Public Health Beliefs 79:65- 66, 1989 OkunL: Woman Abuse. New York, SUNYPress, 1986 Pagelow M: Woman Battering: Victims and Their Experiences. Beverly Hills, Sage Publications, 1981 Snell J, Rosenwold R, Roby A: The wifebeater's wife reconsidered. Arch Gen Psychiatry 2:107-112,
1964
WOMEN WHO RETURN TO ABUSIVE RELATIONSHIPS 28. Stark A, Flitcraft A, Frazier W: Medicine and patriarchal violence: The social construction of a "private event." IntJ Health Serv 9:461-493, 1979 29. Strube M, Barbour L: The decision to leave an abusive relationship: Economic dependence and psychological commitment. Journal of Marriage and the Family 45:785-793, 1983 30. Strube M, Barbour L: Factors relating to the decision to leave an abusive relationship. Journal of Marriage and the Family 46:837-844, 1984 31. Sugg N, Inui T: Primary care physician's response to domestic violence. JAMA 267:3157-3160, 1992
165
32. Tilden V: Response of the health care delivery system to battered women. Issues in Mental Health Nursing 10:309-320, 1989 33. Tilden V, Shepherd P: Increasing the rate of identification of battered women in an emergency department: Use of a nursing protocol. Research in Nursing 10:209-215, 1987 34. Truninger E: Marital violence: The legal solutions. Hastings Law Review 23:259-276, 1971 35. Ulrich Y: Women's reasons for leaving abusive spouses. Health Care for Women International 12:465-473, 1991
Address reprint requests to Gay L. Goss PhD, NP 7320 Beltis Drive Modesto, CA 95356