Bruised All Over

Although October is domestic violence awareness month, this crucial topic should be at the forefront of everyone’s minds all year. At the TRENDS Critical Care Nursing conference earlier this month, one of the speakers touched on how such violence impacts the community, and how healthcare professionals can take a stand.

Linda N. Hagan, RN, BSN, domestic violence liaison for Aria Health, Philadelphia presented “Bruised All Over: Domestic Violence Awareness.”

Hagan is trained by the Delaware Valley Healthcare Council on domestic violence awareness. As former emergency department nurse and trauma case manager, she was a natural choice for such education. Victims of domestic violence typically enter the healthcare system through the emergency department, so ED nurses are often the first line of defense.

“Domestic violence is a public health phenomenon,” Hagan said. Historically, that attitude is a novel way of thinking. The old “rule of thumb law” allowed men to beat their wives, even to death, without fear of punishment, so long as the object used to beat them was no larger than the man’s thumb. In the 1870’s, the first laws against wife-beating in America hit the books. It wasn’t until the 1960’s that the first shelter for victims of domestic violence opened. In the 1980’s, the surgeon general said that all healthcare providers should be involved in domestic violence awareness.

Under the Violence Against Women Act of 1994, money was earmarked for both shelters and education of both healthcare providers and the general public.

Together with the Bensalem Police Department, Bucks County Government, Bucks County Health Department, Network of Victim Assistance, Planned Parenthood of Bucks County, and five other hospitals, Hagan’s employer Aria Health is a member of a county-wide taskforce addressing domestic violence in the region. The taskforce developed consistent practices across the six hospitals and created awareness campaigns for the community. It is part of a larger group BCHIP-Bucks County Health Improvement Partnership, a collaboration of the seven county hospitals and victim’s assistance programs and A Woman’s Place, the county’s only women’s shelter.

Scary Statistics
The taskforce knows their work is an uphill climb. Domestic violence is the leading cause of non-fatal injuries in women. The issue is not gender-neutral, though. “Domestic violence affects men and women,” said Hagan. In 2013, 1 in 3 women and 1 in 9 men were victims of domestic violence.

While we might think of a domestic violence victim as the stereotypical battered woman (like photos of abuse victims Hagan showed the audience), it encompasses intimate partner violence, child abuse and elder abuse, all of which can be dangerously linked. “Domestic violence is a cycle,” Hagan explained. “Children who witness it often become victims or perpetrators themselves.”

Within the healthcare system, domestic violence causes 100,000 hospitalization days each year. Twenty-five to thirty-five percent of patients treated in emergency departments are victims of some form of domestic violence. Women with a history of intimate partner violence are more likely to develop chronic conditions like heart disease and asthma. Annual medical costs for issues surrounding domestic violence are $5.8 billion or greater.

Opening a Conversation
The first and often most difficult task in a nurse’s care of a victim of intimate partner violence is to get them to admit it occurred in the first place. Directly asking, “Are you a victim of domestic violence?” typically leads to a negative response. To get a narrative from a patient, a nurse can ask “What happens when you and your husband argue?” Remaining non-judgmental is crucial. At Aria, staff has been trained to ask, “Have you ever been hit, kicked, punched or otherwise threatened for your life?”

According to Hagan, emergency department nurses may need to ask seven to twelve times before getting an affirmative response.

Aria Hospitals have signs in the triage areas reminding staff to ask patients about domestic violence. Policies support asking all patients if they have been involved in a domestic violence incident, so they will not be construed as profiling. These conversations must take place in a private space to protect women’s safety.

Besides the obvious physical traumas, indications of intimate partner violence include headaches, overdoses, anxiety and depression and miscarriages. With physical violence, Hagan reminded, “You have a lot of covered territory,” meaning people can hide bruises with clothes.

And yet, domestic violence is not solely a physical act. Verbal and emotional abuse and intimidation often start the chain, followed by isolation, economic abuse and sexual abuse. Separating victims from their support system and controlling their money are two ways abusers keep them under their control.

SEE ALSO: Earn CE: Domestic Violence

“We need to empower the women,” Hagan said. In a dangerous catch-22, there is a 75% greater chance of a victim being killed when they choose to leave the abusive relationship. Legally, healthcare professionals are not mandated to report intimate partner violence, unless there was a severe crime, like a stabbing or shooting. With child and elder violence, however, healthcare workers are mandated to report it. So, the best defense nurses can provide is continuous education.

Encouraging Change
Nurses encourage suspected victims to develop an emergency plan. Such plans include bringing cash, clothes and copies of important papers to a trusted non-family member. It’s important to share these with someone the perpetrator would not think off as the first line of contact, so perhaps a colleague or someone else they do not know. Victims should plan the safest way to get away and also set a code word with friends and neighbors to alert them to dangerous situations.

To reassure them, nurses should tell the patients, “It’s not your fault. No one deserves to be treated that way” or “I’m sorry that happened to you but I am glad you told me.”

Outcomes will not always turn out the way nurses expect. Hagan encouraged her fellow healthcare professionals to also take care of themselves. Talking to people, getting enough sleep, eating healthy, and importantly, remembering you did the right thing with supporting victims intimate partner violence are key to nurses’ own mental health.

No one can stop this cycle alone. Nurses play a key role in recognizing the signs of abuse in emergency department patients and starting calls to action to get them the help they need.

Danielle Bullen is on staff at ADVANCE. Contact: dbullen@advanceweb.com

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