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Domestic violence
DOMESTIC VIOLENCE Implications for the American College of Nurse-Midwives and Its Members Patricia A. Paluzzi, CNM, MPH and Charlotte Houde-Quimby, CNM, MSN ABSTRACT Domestic violence, as well as other forms of violence against women, has received increased attention from many sectors of society in the past two decades. Estimates that one fourth to one half of all women in the United States are victims of some type of violence are startling. There exists today a broad-based recognition of and response to the impact of violence on the workplace, the health care community, and the woman survivor and her children. Public health, corporate, and government initiatives are actively seeking solutions to address this most destructive dynamic. The education of health care providers to assess women appropriately for the potential of abuse--including proper intervention, documentation, and referral--has become an essential component of health care. As a recipient of a 3-year federal grant to educate students and practicing nursemidwives in the United States about the issue of domestic violence, the Special Projects Section of the American College of Nurse-Midwives (ACNM) has joined the ranks of concemed provider organizations. The primary goal of the project is to promote and enhance universal screening of all women who present for midwifery care. The role of the certified nurse-midwife and other women's health care providers and the role of ACNM in responding to the issue of domestic violence, including future goals and expectations, are discussed.
Domestic violence (DV) is a public health problem with multiple and varied impacts on the family, workplace, and medical communities, as well as on society at large. National surveys estimate that at least 2 million women each year are battered by an intimate partner (male 9 0 95% of the time), and crime data from the Federal Bureau of Investigation records about 1,500 murders of women by male intimate partners each year (1). Domestic violence is an issue of power and control, with ever-increasing isolation playing a large part in both aiding the perpetrator in continuing the abuse and prohibiting the survivor from speaking out. This isolation may leave many women without access to the usual resources of family and friends or too ashamed to speak of the abuse to those individuals. Medical care, often in the form of obstetric or gynecologic care, will still be sought in most instances; this is Address correspondence to Patricia A. Paluzzi. CNM, MPH, American College of Nurse Midwives, 818 Connecticut Ave. NW, Ste. 900, Washington, DC 20006
430 © 1996 by the American College of Nurse-Midwives Issued by ElsevierScience Inc.
where the certified nurse-midwife (CNM) and other women's health care providers are a potential resource for women in abusive relationships. Most women will not disclose violence in their relationship without being asked. Still others may need to be asked more than once before responding candidly. Many women will respond eventually if the questioning is sensitive and caring and the environment feels safe. In addition, just being asked the question is a validating and empowering experience for the survivor and may be the first step toward making healthier choices for her life (2). It may be the first time that the presence of the violence has been acknowledged or that the woman has not been blamed. Consequently, the woman's health care provider has a unique opportunity to identify, assess, and intervene where abuse exists and to respond in a manner that empowers the woman. In a survey done for the American Medical Association (AMA), 65% of respondents stated that they would disclose violence to their health care provider before others, including clergy, family, and friends (3). A recent article in the Journal of the American Medical Association reported the results of an analysis of the various prevafence studies on DV and discerned four significant contributing factors affecting disclosure. Two of these include being asked face-to-face and the skill of the interviewer (4). This information validates anecdotal reports by providers of self-identified barriers in the assessment and intervention for abuse. These barriers have included the lack of knowledge, skills, and comfort level to address the issue or feeling unprepared to respond to a "yes" answer. To assess and intervene appropriately, the provider must have current knowledge about DV, including the knowledge, skills, and attitude necessary to ask the question, offer appropriate information for intervention and referral, assess the level of danger in the situation, assist in safety planning, and make referrals to local resources. This also requires current knowledge of legal and community options. Essentially, all of the major Americanbased health care professional organizations, including the AMA, the American College of Obstetricians and Gynecologists, the American Nurses Association, and the American College of Nurse-Midwives (ACNM), have re-
Journal of Nurse-Midwifery • Vol. 41, No. 6, November/December 1996
0091-9182/96/$15.00 PII S0091-2182(96)00064-X •
sponded to the need for education for their constituents in some manner.
sodes, and a decrease to the point of disappearance of the honeymoon phase (6). This, of course, places the woman at increased danger.
THE THREE Ds OF ABUSE Definition Domestic violence may be physical, emotional, sexual, or financial, and often more than one type of violence exists in an abusive relationship. Physical violence may include pushing, slapping, punching, shoving, or the use of weapons. Emotional violence may include name calling, withholding emotions, isolation from friends or family, criticism, and threats. Sexual violence may include either participating in or observing sexual activities without the woman's consent, including rape and derogatory remarks about women. Financial abuse may include controlling all of the money, accumulating bills in the partner's name, or threat of loss of support for the woman or children (2).
Dynamics The dynamic of abuse was originally described by Lenore Walker as a cycle of a tension-building phase, the acute incident, and remorse or the honeymoon phase (5). After more than two decades of studying violence, the current view of the dynamic is more longitudinal. Over time, there is a decrease in the tension-building phase, an increase in frequency and severity of acute violent epi-
Patricia A. Paluzzi is a senior technical advisor for the Special Projects Section of the American College of Nurse-Midwives. In that capacity, she serves as the project director for the Domestic Violence Education Project. Ms. Paluzzi became interested in the domestic violence arena via her work in substance abuse, where she developed and directed a midwifery service within a multidisciplinary treatment program for pregnant substance abusers. Working with women for whom the issues of early and ongoing violence had a significant impact on their lives prepared her for this current role. Ms. Paluzzi has subsequently clone extensive training, curriculum development, public speaking, advocacy, and evaluation of the issues surrounding domestic violence. Charlotte Houde-Quimby is a senior technical advisor for the Special Projects Section of the American College of NurseMidwives. In that capacity, she developed the grant resulting in the Domestic Violence Education Project and functioned as the project director for the first 5 months of the grant. During her tenure as director, she contributed to the writing of the training module and formed the Advisory Board and consultant roster. Currently, Ms~ Quimby is assigned to the Prime Project for Integrated Reproductive Health. In her current role, she is responsible for integrating domestic violence and female genital mutilation education into curriculum materials for that project. Her interest in domestic violence work began in 1993 while serving as a faculty advisor for a Dartmouth medical student project surveying primary care physicians and their clinical care of survivors of domestic violence.
Demographics Abuse occurs across all racial and ethnic groups, class structures, and sexual orientations. McCauley et al found a 5.5% rate of physical abuse in the past year among a sample of primarily white, middle-class, married, and medically insured women presenting to a primary care internal medicine practice in Baltimore (7). Abuse during pregnancy has been demonstrated to occur at rates of 9 - 2 0 % (4). Abuse in pregnancy occurs more often than does gestational diabetes, hypertension, or any other major antepartum complication (8). Another recent study by O'Campo et al has identified an increased risk of abuse in unintended pregnancies (9). Correlations regarding the social structure and support of the woman and the impact on her risk of abuse have also recently been reported (10). What is clear is that abuse is common among all women and that pregnancy and the postpartum may be higher-risk times. It is also clear that if a woman's health care provider wants to be thorough, then it is imperative to screen all women for the possibility of abuse. PUBLIC HEALTH AND SOCIETAL IMPACT
The Corporate Sector Recognizing DV as a public health issue with multiple impact has helped to increase involvement from the private sector. In 1995, Liz Claiborne, Inc., initiated a study in corporate America that showed that 57% of corporate leaders considered the issue of DV to be a major problem in society and 40% knew of at least one employee involved in an abusive relationship (10). An estimated $ 3 5 billion is lost annually in the workplace from DV-related problems, such as absenteeism, high rate of turnover, and decreased productivity (10). As a result of these findings and the general increased awareness of the seriousness of the issue, corporate initiatives meant to address the problem have been developed. The Medical Sector Under- or overutilization of the health care system may be a result of abusive relationships. An increased use of emergency medical services for injuries, sporadic attendance to prenatal care with resultant obstetric and fetal complications, and an increase in emergency psychiatric service are examples of how the medical community is impacted by the issue of DV. In May 1994, the AMA published its Diagnostic and Treatment Guideline on Do-
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mestic Violence, which claims that battered women may account for 1) 2 2 - 3 5 % of women seeking care for any reason in emergency departments, 2) 19-30% of injured women seen in emergency rooms, 3) 14% of women seen in ambulatory internal medicine clinics, 4) 25% of women who attempt suicide, 5) 25% of women using psychiatric emergency services, 6) 23% of women seeking prenatal care, 7) 4 5 - 5 9 % of mothers of abused chip dren, and 8) 58% of women over 30 years old who have been raped (11). Although the accuracy of some of this data has since been questioned, it appears to illustrate the poor fit between patient needs and health care services offered.
to see and use violence as a coping mechanism throughout life. The increase in violence among youth in America is, in part, a reflection of the exposure to abuse as a problem-solving technique in the home (12). Society Another societal impact is homelessness. An estimated 50% of homeless women and children are fleeing DV (13). The direct and indirect costs to society for the support of these families and the subsequent response of the children to their environment cannot be measured. Substance Abuse
The Legal Sector Law enforcement and the legal system face a different set of issues related to DV. These usually involve the sensitive handling of questions regarding housing, arrest, child custody, and protection. As of January 1, 1995, 29 states had some form of a mandatory arrest law (12). In some cities or states, DV courts exist where a more creative response to the issue has been developed. In many more cities, training for police, lawyers, and judges is underway. The safety of the woman and her children must be considered in each situation. Decisions of arrest, who lives where, and child custody combine to form part of what must be considered when dealing with a DV case. The ultimate safety of the woman and her children must guide each individual decision. The Next Generation The immeasurable societal impacts include the impact on children growing up in abusive households. Estimates are that 5 0 - 5 5 % of children in abusive households are themselves abused either sexually or physically. They have been shown to be at increased risk for abusive adult relationships either as batterers or survivors (12). One source estimates that boys who grow up in abusive homes are 1,000 times more likely to be abusive adults. These boys are 24 times more likely to rape and are 6 times more likely to commit suicide. Estimates are that 80% of runaways are fleeing abuse and that 63% of all boys ages 1 1 - 2 0 arrested for homicide have killed their mother's assaulter (2). Once violence has been identified in a relationship, the presence of children in the household and their safety must be addressed. Some corporations are taking a particular interest in this area, recognizing it as an important aspect of breaking the cycle of violence. It is important that providers understand the relationship of growing up with violence and the subsequent negative behaviors, such as aggression, acting out, lack of motivation in school, delinquent behavior patterns, and the potential
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There is a recognized relationship between substance abuse and DV. Both the batterer and the survivor may be involved in substance abuse or addiction. The batterer's substance abuse is often erroneously blamed for his physical or emotional abuse. These are two separate issues for the batterer and must be recognized and addressed in that manner. Women will more likely begin to abuse substances following a traumatic event (14). Thus, substance abuse for the woman may be initiated after childhood or adult abuse. Women in abusive relationships may begin to abuse substances because he demands it of her or as a method for dulling the pain of the situation. THE ACNM RESPONDS TO THE ISSUE Recognizing the significance of the issue of DV and the unique position of midwives as primary women's health care providers to respond, the Special Projects Section of the ACNM submitted a proposal to the Maternal Child Health Bureau, Department of Health and Human Services, describing a DV education project for student and practicing midwives. The start date for the 3-year project was October 1994. The primary goal of the project is to promote the concept of universal screening for violence of all women who present for care. The primary activity of the grant is to provide education to student and practicing nurse-midwives on the knowledge, skills, and attitude needed to assess and respond adequately to the issue of DV. Education The educational components include I) two training of trainers for faculty of nurse-midwifery education programs, 2) four regional workshops for CNMs and other interested health care providers, 3) two preannual meeting workshops, and 4) a home study program. The clinical content of all of the trainings includes definition and description of the issue and its impact, including proper
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assessment, intervention and referral, and the promotion of advocacy and activism. In addition, the training of trainers component provided suggestions for integration into curriculum and methods for teaching the material to students. All of the training formats provide the opportunity for continuing education credits.
Policy In addition, an ad hoc committee on violence against women was formed with two initial purposes, 1) to develop a position statement on violence against women for the members of the ACNM, and 2) to initiate the process of including DV in the core competencies of nurse-midwifery education programs, a unique aspect of this project, which, if accepted, will ensure sustainability. The Position Statement and Clinical Guidelines on Violence Against Women were published in the fall of 1995. As part of the current cycle of review for the core competencies, DV education material has been recommended for addition.
Technical Support Ongoing support of clinicians and educators as they integrate the content of DV into their curricula and clinical practice is another aspect of the project, and it is offered in two major ways. First, a lending library of resource materials, written and audiovisual, is available from the Special Projects Section. Secondly, the project director and expert members of the advisory committee for the DV project are available for on-site or phone consultations as requested.
Organizational Advocacy and Activism Finally, the DV project recognizes the importance of advocacy and activism when responding to this issue. The only truly effective response to DV includes working with the larger community and within multidisciplinary teams. Topics in the educational components of the project that address areas of advocacy and activism include the importance of 1) proper forensic documentation, ie, charting in a manner that advocates for the woman in both the medical and legal environments, 2) knowledge of the resources in ones' community, 3) knowledge and understanding of the laws in ones' community and their impact, and 4) understanding the effectiveness of networking within one's professional and broader communities.
Materials In addition to the original training manual provided to all participants, a separate packet of DV-related materials was produced by the project director, using a different
funding source. The packet includes six pieces of related materials that can be used independently or as a complete package: 1) a poster with a tear-off pad to be hung in bathrooms with a DV resource number stamped on the pad, 2) a stand-up card for office display to announce the safety of disclosing abuse to the office staff, 3) a panel card of patient information for use in the office, 4) a prescription pad for use in writing a phone number when it is not safe for the woman to leave the office with anything larger or more obvious, 5) a tri-fold provider-information brochure, and 6) a sheet of general DV information to augment knowledge of the issue and to assist in presenting the material for use at other sites.
ROLE OF THE NURSE-MIDWIFE AND OTHER HEALTH CARE PROVIDERS Ask the Question A woman's health care provider may be the only source of confidence and referral that an abused woman might access. Many women may not spontaneously disclose the issue of violence in their lives but often respond honestly to a sensitively asked question. Often, the question needs to be asked on more than one occasion because the fear and shame associated with abuse may prevent disclosure until some safe rapport within the relationship has been established. The June 1996 article in the Jourhal of the American Medical Association identified four factors that significantly influence the disclosure of abuse in a relationship. These are: 1) using in-person interviews rather than questionnaires to ask the question, 2) the training and skill level of the interviewer, 3) repeated questioning throughout the pregnancy, and 4) the actual wording of the question (4). In a survey sponsored by the AMA, 65% of Americans said that they would disclose violence to their physician. This is more than were willing to tell their priest, pastor or rabbi, and police officers (11). Even if the woman never discloses the abuse, asking the question has let her know that someone cares and there is a source of help. Because of the prevalence of past and current violence in women's lives and the potential health effects, assessing for violence and considering it as a possibility in any medical work-up should become the norm in every women's health care provider's practice. McCauley et al state that the risk factors for potential abuse are neither specific nor sensitive; because of the high prevalence rates, universal screening for violence of all women is appropriate (7). There appears to be fairly wide consensus that screening for the possibility of abuse as a part of every health care encounter is warranted.
Know the Response Once the question has been asked, an appropriate response must follow. The provider should be prepared to
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accept what she/he hears without judgment, have knowledge of current community resources available for referral, understand that leaving does not constitute the only option, conduct a sensitive danger assessment, develop a safety plan, and, most importantly, meet the woman in her current stage with the abuse and work with her from that place. An appropriate response should validate the experience for the woman (name the violence), empathize with her (no one deserves this), generalize the problem so as not to give the impression that she is alone (many women are in the same situation, you are not alone), and empower her (you know what is best for you). Knowing that violence is an issue of power and control and that the batterer seeks collusion for his own validation, we must be careful never to supply him with that collusion, such as, responding in a manner that would imply disbelief or other judgments. Believing the woman and remaining nonjudgmental are essential components in fostering trust and establishing a positive rapport with the abused woman. Naming the violence is often the first step of empowerment that will aid the woman in future decisions about her relationship.
the fall of 1994, President Clinton signed into law the Violence Against Women Act to provide funding and an office to address the issue of violence against women in the United States. The office was established, with Bonnie Campbell named as the director, in the spring of 1995. The original monies were allocated to increase the number of shelters and other community resources, as well as to establish a national toll-free hot line. By the summer of 1995, almost all of the money was cut from the original budget. A campaign of phone calling, letter writing, and testimony has restored the budget to near its original amount. Violence against women is a political issue, and if we are to support its eradication we must assume the role of activist. This role may include 1) writing to our senators and representatives to educate them and express our views on their responses to issues, 2) aiding the local shelter by volunteering time or money, 3) educating corporations and others outside our communities about the issue and supporting any positive responses, and 4) adopting a policy of zero tolerance for violence in our personal and professional lives.
Taking Care of Ourselves Forensic Documentation The importance of proper forensic documentation and how that may vary from state to state is discussed in detail in a separate article in this module (Sheridan, page 467). It is an essential part of providing appropriate and safe care to abused women and must be fully understood by every clinician.
Individual Advocacy Supporting the survivor may take many different forms with different women or the same woman over time. Acting on the woman's behalf includes knowing the resources in your area and making appropriate referrals; knowing the laws in your state and educating the woman properly; documenting in a manner that will support her in both the medical and legal communities, possibly including court testimony; forming or participating in multidisciplinary teams to respond better to the problem; knowing how to assess for danger and do safety planning; acknowledging and accepting where the woman is in her process and working with her from that place; and, perhaps most importantly, just asking the question and validating the experience.
Individual Activism Activism has always played a significant role in any issue requiring a nationwide response. The issue of violence against women affects us all and that has been recognized by many, including the current administration. In
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Working with women in abusive relationships can be both personally and professionally challenging. As providers, it may remain difficult to accept a woman's choices unconditionally and support her in those choices while balancing our fears for her safety. Domestic violence is not something that can be "fixed." Watching another be hurt and feeling powerless to help can be a frustrating situation and one we may be in repeatedly once we uncover the violence affecting those in our care. Women in abusive relationships may consume a lot of resources, which, in today's medical world, are very limited. It may feel frustrating to attempt to address the very real concerns of the woman in front of us while meeting the very real demands of the clinical setting. Given the large numbers of women who are exposed to abuse, there will be many providers who are also survivors. Some may still be in the abusive relationship, whereas others will span the full range of sequelae. If patient abuse histories touch the personal history of the provider, it may be difficult to remain objective and nonjudgmental. Responding to women effectively requires taking care of ourselves. This may include seeking support within or outside our community through a friend, therapeutic intervention, or group. THE FUTURE ROLE OF ACNM AND NURSEMIDWIVES
Ongoing aspects and future endeavors of the DV education project include 1) site visits to midwifery education programs and clinical sites to support their work in this
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area, 2) the production of a video with a training manual for future education, 3) continuing to offer trainings for the next annual meeting and as requested, 4) continued advocacy within and outside of the medical community, and 5) evaluation of the effectiveness of the project with dissemination to other groups w h o m a y wish to replicate all or parts of the project. T h e A C N M , as an agency, has a d o p t e d a policy of zero tolerance for violence. T h e ultimate goal of the DV education project is to e n c o u r a g e all midwives to a d o p t this s a m e policy in their personal and professional lives. This includes universal screening for all w o m e n w h o present for care. This will only be accomplished if nurse-midwives acknowledge the issue of DV as a serious o n e and a c c e p t the responsibility of responding to it both clinically and politically. Continued advocacy and activism are key c o m p o n e n t s to a successful r e s p o n s e to this m o s t destructive p h e n o m e n a . It will require the efforts of all of us to break the cycle and m a k e the h o m e and c o m m u n i t y a safer place for w o m e n and children.
REFERENCES I. Federal Bureau of Investigation. Uniform crime reports. Washington, DC: U.S. Department of Justice, 1993. 2. Escape the abuse, leaving Smart. Seattle: |ntermedia, 1995.
3. Center for Disease Control and Prevention. MMWR 1994;43:132-7. 4. Gazmararian J, Lazofick S, Spitz A, BaUard T, Saltzman L, Marks J. Prevalence of violence against pregnant women. JAMA 1996;275:1915-20. 5. Walker L. The battered woman. New York: Harper and Row, 1979. 6. Dutton MA. Understanding women's response to domestic violence: a redefinition of battered women's syndrome. Hofstra Law Rev 1993;21:1191-242. 7. McCauley J, Kern DE, Kolodner K, Dill L, Schroeder AF, De Chant HK, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995; 123:737-46. 8. Bohn D, Parker B. Domestic violence and pregnancy, health effects and implications for nursing practice. In: Nursing care of survivors of family violence. Mosby, 1993:156-72. 9. O'Campo P, Gielen AC, Faden RR, Xue X, Kass N, Wang M~C, Violence by male partners against women during the childbearing years: a contextual analysis." Am J Public Health 1995;85:1092-7. 10. Survey conducted by Roper Starch Worldwide on behalf of Liz Claiborne, Inc. In: Family Violence Prevention Fund. News from the homefront. Fall/Winter 1994. 11. Diagnostic and treatment guidelines on domestic violence. American Medical Association 1994:b. 12. Myers T, Wright L. Raised in violence. Presented at the 32nd annual meeting of the American Association of Psychiatric Services for Children, November 1980. 13. Bassuk EL, Rosenberg L, Why does family homelessness occur? a case-control study. Am J Public Health 1988; 78:783-8. 14. Nelson-Zlupko L, Kauffman E, Dore MM. Gender differences in drug addiction and treatment: implications for social work intervention with substance abusing women. Social Work 1995;40:45-55.
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Domestic violence (DV) is a public health problem with multiple and varied impacts on the family, workplace, and medical communities, as well as on society at large. National surveys estimate that at least 2 million women each year are battered by an intimate partner (male 9 0 95% of the time), and crime data from the Federal Bureau of Investigation records about 1,500 murders of women by male intimate partners each year (1). Domestic violence is an issue of power and control, with ever-increasing isolation playing a large part in both aiding the perpetrator in continuing the abuse and prohibiting the survivor from speaking out. This isolation may leave many women without access to the usual resources of family and friends or too ashamed to speak of the abuse to those individuals. Medical care, often in the form of obstetric or gynecologic care, will still be sought in most instances; this is Address correspondence to Patricia A. Paluzzi. CNM, MPH, American College of Nurse Midwives, 818 Connecticut Ave. NW, Ste. 900, Washington, DC 20006
430 © 1996 by the American College of Nurse-Midwives Issued by ElsevierScience Inc.
where the certified nurse-midwife (CNM) and other women's health care providers are a potential resource for women in abusive relationships. Most women will not disclose violence in their relationship without being asked. Still others may need to be asked more than once before responding candidly. Many women will respond eventually if the questioning is sensitive and caring and the environment feels safe. In addition, just being asked the question is a validating and empowering experience for the survivor and may be the first step toward making healthier choices for her life (2). It may be the first time that the presence of the violence has been acknowledged or that the woman has not been blamed. Consequently, the woman's health care provider has a unique opportunity to identify, assess, and intervene where abuse exists and to respond in a manner that empowers the woman. In a survey done for the American Medical Association (AMA), 65% of respondents stated that they would disclose violence to their health care provider before others, including clergy, family, and friends (3). A recent article in the Journal of the American Medical Association reported the results of an analysis of the various prevafence studies on DV and discerned four significant contributing factors affecting disclosure. Two of these include being asked face-to-face and the skill of the interviewer (4). This information validates anecdotal reports by providers of self-identified barriers in the assessment and intervention for abuse. These barriers have included the lack of knowledge, skills, and comfort level to address the issue or feeling unprepared to respond to a "yes" answer. To assess and intervene appropriately, the provider must have current knowledge about DV, including the knowledge, skills, and attitude necessary to ask the question, offer appropriate information for intervention and referral, assess the level of danger in the situation, assist in safety planning, and make referrals to local resources. This also requires current knowledge of legal and community options. Essentially, all of the major Americanbased health care professional organizations, including the AMA, the American College of Obstetricians and Gynecologists, the American Nurses Association, and the American College of Nurse-Midwives (ACNM), have re-
Journal of Nurse-Midwifery • Vol. 41, No. 6, November/December 1996
0091-9182/96/$15.00 PII S0091-2182(96)00064-X •
sponded to the need for education for their constituents in some manner.
sodes, and a decrease to the point of disappearance of the honeymoon phase (6). This, of course, places the woman at increased danger.
THE THREE Ds OF ABUSE Definition Domestic violence may be physical, emotional, sexual, or financial, and often more than one type of violence exists in an abusive relationship. Physical violence may include pushing, slapping, punching, shoving, or the use of weapons. Emotional violence may include name calling, withholding emotions, isolation from friends or family, criticism, and threats. Sexual violence may include either participating in or observing sexual activities without the woman's consent, including rape and derogatory remarks about women. Financial abuse may include controlling all of the money, accumulating bills in the partner's name, or threat of loss of support for the woman or children (2).
Dynamics The dynamic of abuse was originally described by Lenore Walker as a cycle of a tension-building phase, the acute incident, and remorse or the honeymoon phase (5). After more than two decades of studying violence, the current view of the dynamic is more longitudinal. Over time, there is a decrease in the tension-building phase, an increase in frequency and severity of acute violent epi-
Patricia A. Paluzzi is a senior technical advisor for the Special Projects Section of the American College of Nurse-Midwives. In that capacity, she serves as the project director for the Domestic Violence Education Project. Ms. Paluzzi became interested in the domestic violence arena via her work in substance abuse, where she developed and directed a midwifery service within a multidisciplinary treatment program for pregnant substance abusers. Working with women for whom the issues of early and ongoing violence had a significant impact on their lives prepared her for this current role. Ms. Paluzzi has subsequently clone extensive training, curriculum development, public speaking, advocacy, and evaluation of the issues surrounding domestic violence. Charlotte Houde-Quimby is a senior technical advisor for the Special Projects Section of the American College of NurseMidwives. In that capacity, she developed the grant resulting in the Domestic Violence Education Project and functioned as the project director for the first 5 months of the grant. During her tenure as director, she contributed to the writing of the training module and formed the Advisory Board and consultant roster. Currently, Ms~ Quimby is assigned to the Prime Project for Integrated Reproductive Health. In her current role, she is responsible for integrating domestic violence and female genital mutilation education into curriculum materials for that project. Her interest in domestic violence work began in 1993 while serving as a faculty advisor for a Dartmouth medical student project surveying primary care physicians and their clinical care of survivors of domestic violence.
Demographics Abuse occurs across all racial and ethnic groups, class structures, and sexual orientations. McCauley et al found a 5.5% rate of physical abuse in the past year among a sample of primarily white, middle-class, married, and medically insured women presenting to a primary care internal medicine practice in Baltimore (7). Abuse during pregnancy has been demonstrated to occur at rates of 9 - 2 0 % (4). Abuse in pregnancy occurs more often than does gestational diabetes, hypertension, or any other major antepartum complication (8). Another recent study by O'Campo et al has identified an increased risk of abuse in unintended pregnancies (9). Correlations regarding the social structure and support of the woman and the impact on her risk of abuse have also recently been reported (10). What is clear is that abuse is common among all women and that pregnancy and the postpartum may be higher-risk times. It is also clear that if a woman's health care provider wants to be thorough, then it is imperative to screen all women for the possibility of abuse. PUBLIC HEALTH AND SOCIETAL IMPACT
The Corporate Sector Recognizing DV as a public health issue with multiple impact has helped to increase involvement from the private sector. In 1995, Liz Claiborne, Inc., initiated a study in corporate America that showed that 57% of corporate leaders considered the issue of DV to be a major problem in society and 40% knew of at least one employee involved in an abusive relationship (10). An estimated $ 3 5 billion is lost annually in the workplace from DV-related problems, such as absenteeism, high rate of turnover, and decreased productivity (10). As a result of these findings and the general increased awareness of the seriousness of the issue, corporate initiatives meant to address the problem have been developed. The Medical Sector Under- or overutilization of the health care system may be a result of abusive relationships. An increased use of emergency medical services for injuries, sporadic attendance to prenatal care with resultant obstetric and fetal complications, and an increase in emergency psychiatric service are examples of how the medical community is impacted by the issue of DV. In May 1994, the AMA published its Diagnostic and Treatment Guideline on Do-
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mestic Violence, which claims that battered women may account for 1) 2 2 - 3 5 % of women seeking care for any reason in emergency departments, 2) 19-30% of injured women seen in emergency rooms, 3) 14% of women seen in ambulatory internal medicine clinics, 4) 25% of women who attempt suicide, 5) 25% of women using psychiatric emergency services, 6) 23% of women seeking prenatal care, 7) 4 5 - 5 9 % of mothers of abused chip dren, and 8) 58% of women over 30 years old who have been raped (11). Although the accuracy of some of this data has since been questioned, it appears to illustrate the poor fit between patient needs and health care services offered.
to see and use violence as a coping mechanism throughout life. The increase in violence among youth in America is, in part, a reflection of the exposure to abuse as a problem-solving technique in the home (12). Society Another societal impact is homelessness. An estimated 50% of homeless women and children are fleeing DV (13). The direct and indirect costs to society for the support of these families and the subsequent response of the children to their environment cannot be measured. Substance Abuse
The Legal Sector Law enforcement and the legal system face a different set of issues related to DV. These usually involve the sensitive handling of questions regarding housing, arrest, child custody, and protection. As of January 1, 1995, 29 states had some form of a mandatory arrest law (12). In some cities or states, DV courts exist where a more creative response to the issue has been developed. In many more cities, training for police, lawyers, and judges is underway. The safety of the woman and her children must be considered in each situation. Decisions of arrest, who lives where, and child custody combine to form part of what must be considered when dealing with a DV case. The ultimate safety of the woman and her children must guide each individual decision. The Next Generation The immeasurable societal impacts include the impact on children growing up in abusive households. Estimates are that 5 0 - 5 5 % of children in abusive households are themselves abused either sexually or physically. They have been shown to be at increased risk for abusive adult relationships either as batterers or survivors (12). One source estimates that boys who grow up in abusive homes are 1,000 times more likely to be abusive adults. These boys are 24 times more likely to rape and are 6 times more likely to commit suicide. Estimates are that 80% of runaways are fleeing abuse and that 63% of all boys ages 1 1 - 2 0 arrested for homicide have killed their mother's assaulter (2). Once violence has been identified in a relationship, the presence of children in the household and their safety must be addressed. Some corporations are taking a particular interest in this area, recognizing it as an important aspect of breaking the cycle of violence. It is important that providers understand the relationship of growing up with violence and the subsequent negative behaviors, such as aggression, acting out, lack of motivation in school, delinquent behavior patterns, and the potential
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There is a recognized relationship between substance abuse and DV. Both the batterer and the survivor may be involved in substance abuse or addiction. The batterer's substance abuse is often erroneously blamed for his physical or emotional abuse. These are two separate issues for the batterer and must be recognized and addressed in that manner. Women will more likely begin to abuse substances following a traumatic event (14). Thus, substance abuse for the woman may be initiated after childhood or adult abuse. Women in abusive relationships may begin to abuse substances because he demands it of her or as a method for dulling the pain of the situation. THE ACNM RESPONDS TO THE ISSUE Recognizing the significance of the issue of DV and the unique position of midwives as primary women's health care providers to respond, the Special Projects Section of the ACNM submitted a proposal to the Maternal Child Health Bureau, Department of Health and Human Services, describing a DV education project for student and practicing midwives. The start date for the 3-year project was October 1994. The primary goal of the project is to promote the concept of universal screening for violence of all women who present for care. The primary activity of the grant is to provide education to student and practicing nurse-midwives on the knowledge, skills, and attitude needed to assess and respond adequately to the issue of DV. Education The educational components include I) two training of trainers for faculty of nurse-midwifery education programs, 2) four regional workshops for CNMs and other interested health care providers, 3) two preannual meeting workshops, and 4) a home study program. The clinical content of all of the trainings includes definition and description of the issue and its impact, including proper
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assessment, intervention and referral, and the promotion of advocacy and activism. In addition, the training of trainers component provided suggestions for integration into curriculum and methods for teaching the material to students. All of the training formats provide the opportunity for continuing education credits.
Policy In addition, an ad hoc committee on violence against women was formed with two initial purposes, 1) to develop a position statement on violence against women for the members of the ACNM, and 2) to initiate the process of including DV in the core competencies of nurse-midwifery education programs, a unique aspect of this project, which, if accepted, will ensure sustainability. The Position Statement and Clinical Guidelines on Violence Against Women were published in the fall of 1995. As part of the current cycle of review for the core competencies, DV education material has been recommended for addition.
Technical Support Ongoing support of clinicians and educators as they integrate the content of DV into their curricula and clinical practice is another aspect of the project, and it is offered in two major ways. First, a lending library of resource materials, written and audiovisual, is available from the Special Projects Section. Secondly, the project director and expert members of the advisory committee for the DV project are available for on-site or phone consultations as requested.
Organizational Advocacy and Activism Finally, the DV project recognizes the importance of advocacy and activism when responding to this issue. The only truly effective response to DV includes working with the larger community and within multidisciplinary teams. Topics in the educational components of the project that address areas of advocacy and activism include the importance of 1) proper forensic documentation, ie, charting in a manner that advocates for the woman in both the medical and legal environments, 2) knowledge of the resources in ones' community, 3) knowledge and understanding of the laws in ones' community and their impact, and 4) understanding the effectiveness of networking within one's professional and broader communities.
Materials In addition to the original training manual provided to all participants, a separate packet of DV-related materials was produced by the project director, using a different
funding source. The packet includes six pieces of related materials that can be used independently or as a complete package: 1) a poster with a tear-off pad to be hung in bathrooms with a DV resource number stamped on the pad, 2) a stand-up card for office display to announce the safety of disclosing abuse to the office staff, 3) a panel card of patient information for use in the office, 4) a prescription pad for use in writing a phone number when it is not safe for the woman to leave the office with anything larger or more obvious, 5) a tri-fold provider-information brochure, and 6) a sheet of general DV information to augment knowledge of the issue and to assist in presenting the material for use at other sites.
ROLE OF THE NURSE-MIDWIFE AND OTHER HEALTH CARE PROVIDERS Ask the Question A woman's health care provider may be the only source of confidence and referral that an abused woman might access. Many women may not spontaneously disclose the issue of violence in their lives but often respond honestly to a sensitively asked question. Often, the question needs to be asked on more than one occasion because the fear and shame associated with abuse may prevent disclosure until some safe rapport within the relationship has been established. The June 1996 article in the Jourhal of the American Medical Association identified four factors that significantly influence the disclosure of abuse in a relationship. These are: 1) using in-person interviews rather than questionnaires to ask the question, 2) the training and skill level of the interviewer, 3) repeated questioning throughout the pregnancy, and 4) the actual wording of the question (4). In a survey sponsored by the AMA, 65% of Americans said that they would disclose violence to their physician. This is more than were willing to tell their priest, pastor or rabbi, and police officers (11). Even if the woman never discloses the abuse, asking the question has let her know that someone cares and there is a source of help. Because of the prevalence of past and current violence in women's lives and the potential health effects, assessing for violence and considering it as a possibility in any medical work-up should become the norm in every women's health care provider's practice. McCauley et al state that the risk factors for potential abuse are neither specific nor sensitive; because of the high prevalence rates, universal screening for violence of all women is appropriate (7). There appears to be fairly wide consensus that screening for the possibility of abuse as a part of every health care encounter is warranted.
Know the Response Once the question has been asked, an appropriate response must follow. The provider should be prepared to
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accept what she/he hears without judgment, have knowledge of current community resources available for referral, understand that leaving does not constitute the only option, conduct a sensitive danger assessment, develop a safety plan, and, most importantly, meet the woman in her current stage with the abuse and work with her from that place. An appropriate response should validate the experience for the woman (name the violence), empathize with her (no one deserves this), generalize the problem so as not to give the impression that she is alone (many women are in the same situation, you are not alone), and empower her (you know what is best for you). Knowing that violence is an issue of power and control and that the batterer seeks collusion for his own validation, we must be careful never to supply him with that collusion, such as, responding in a manner that would imply disbelief or other judgments. Believing the woman and remaining nonjudgmental are essential components in fostering trust and establishing a positive rapport with the abused woman. Naming the violence is often the first step of empowerment that will aid the woman in future decisions about her relationship.
the fall of 1994, President Clinton signed into law the Violence Against Women Act to provide funding and an office to address the issue of violence against women in the United States. The office was established, with Bonnie Campbell named as the director, in the spring of 1995. The original monies were allocated to increase the number of shelters and other community resources, as well as to establish a national toll-free hot line. By the summer of 1995, almost all of the money was cut from the original budget. A campaign of phone calling, letter writing, and testimony has restored the budget to near its original amount. Violence against women is a political issue, and if we are to support its eradication we must assume the role of activist. This role may include 1) writing to our senators and representatives to educate them and express our views on their responses to issues, 2) aiding the local shelter by volunteering time or money, 3) educating corporations and others outside our communities about the issue and supporting any positive responses, and 4) adopting a policy of zero tolerance for violence in our personal and professional lives.
Taking Care of Ourselves Forensic Documentation The importance of proper forensic documentation and how that may vary from state to state is discussed in detail in a separate article in this module (Sheridan, page 467). It is an essential part of providing appropriate and safe care to abused women and must be fully understood by every clinician.
Individual Advocacy Supporting the survivor may take many different forms with different women or the same woman over time. Acting on the woman's behalf includes knowing the resources in your area and making appropriate referrals; knowing the laws in your state and educating the woman properly; documenting in a manner that will support her in both the medical and legal communities, possibly including court testimony; forming or participating in multidisciplinary teams to respond better to the problem; knowing how to assess for danger and do safety planning; acknowledging and accepting where the woman is in her process and working with her from that place; and, perhaps most importantly, just asking the question and validating the experience.
Individual Activism Activism has always played a significant role in any issue requiring a nationwide response. The issue of violence against women affects us all and that has been recognized by many, including the current administration. In
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Working with women in abusive relationships can be both personally and professionally challenging. As providers, it may remain difficult to accept a woman's choices unconditionally and support her in those choices while balancing our fears for her safety. Domestic violence is not something that can be "fixed." Watching another be hurt and feeling powerless to help can be a frustrating situation and one we may be in repeatedly once we uncover the violence affecting those in our care. Women in abusive relationships may consume a lot of resources, which, in today's medical world, are very limited. It may feel frustrating to attempt to address the very real concerns of the woman in front of us while meeting the very real demands of the clinical setting. Given the large numbers of women who are exposed to abuse, there will be many providers who are also survivors. Some may still be in the abusive relationship, whereas others will span the full range of sequelae. If patient abuse histories touch the personal history of the provider, it may be difficult to remain objective and nonjudgmental. Responding to women effectively requires taking care of ourselves. This may include seeking support within or outside our community through a friend, therapeutic intervention, or group. THE FUTURE ROLE OF ACNM AND NURSEMIDWIVES
Ongoing aspects and future endeavors of the DV education project include 1) site visits to midwifery education programs and clinical sites to support their work in this
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area, 2) the production of a video with a training manual for future education, 3) continuing to offer trainings for the next annual meeting and as requested, 4) continued advocacy within and outside of the medical community, and 5) evaluation of the effectiveness of the project with dissemination to other groups w h o m a y wish to replicate all or parts of the project. T h e A C N M , as an agency, has a d o p t e d a policy of zero tolerance for violence. T h e ultimate goal of the DV education project is to e n c o u r a g e all midwives to a d o p t this s a m e policy in their personal and professional lives. This includes universal screening for all w o m e n w h o present for care. This will only be accomplished if nurse-midwives acknowledge the issue of DV as a serious o n e and a c c e p t the responsibility of responding to it both clinically and politically. Continued advocacy and activism are key c o m p o n e n t s to a successful r e s p o n s e to this m o s t destructive p h e n o m e n a . It will require the efforts of all of us to break the cycle and m a k e the h o m e and c o m m u n i t y a safer place for w o m e n and children.
REFERENCES I. Federal Bureau of Investigation. Uniform crime reports. Washington, DC: U.S. Department of Justice, 1993. 2. Escape the abuse, leaving Smart. Seattle: |ntermedia, 1995.
3. Center for Disease Control and Prevention. MMWR 1994;43:132-7. 4. Gazmararian J, Lazofick S, Spitz A, BaUard T, Saltzman L, Marks J. Prevalence of violence against pregnant women. JAMA 1996;275:1915-20. 5. Walker L. The battered woman. New York: Harper and Row, 1979. 6. Dutton MA. Understanding women's response to domestic violence: a redefinition of battered women's syndrome. Hofstra Law Rev 1993;21:1191-242. 7. McCauley J, Kern DE, Kolodner K, Dill L, Schroeder AF, De Chant HK, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995; 123:737-46. 8. Bohn D, Parker B. Domestic violence and pregnancy, health effects and implications for nursing practice. In: Nursing care of survivors of family violence. Mosby, 1993:156-72. 9. O'Campo P, Gielen AC, Faden RR, Xue X, Kass N, Wang M~C, Violence by male partners against women during the childbearing years: a contextual analysis." Am J Public Health 1995;85:1092-7. 10. Survey conducted by Roper Starch Worldwide on behalf of Liz Claiborne, Inc. In: Family Violence Prevention Fund. News from the homefront. Fall/Winter 1994. 11. Diagnostic and treatment guidelines on domestic violence. American Medical Association 1994:b. 12. Myers T, Wright L. Raised in violence. Presented at the 32nd annual meeting of the American Association of Psychiatric Services for Children, November 1980. 13. Bassuk EL, Rosenberg L, Why does family homelessness occur? a case-control study. Am J Public Health 1988; 78:783-8. 14. Nelson-Zlupko L, Kauffman E, Dore MM. Gender differences in drug addiction and treatment: implications for social work intervention with substance abusing women. Social Work 1995;40:45-55.
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