Domestic violence presentations in the Accident and Emergency Department

Abstract: In his Annual Report for 1996 the Chief Medical Officer highlighted the problem of Domestic Violence. In Britain 40% of all murdered women were killed by their partners. Domestic Violence does affect both sexes, and victims of this "silent epidemic" often attend Accident & Emergency (A&E) for the first line treatment. (1) This article highlights the need for awareness and sensitivity when confronted with a victim (or potential victim) of Domestic Violence. We will also outline measures that have been taken in our A&E department to improve the care of these clients. 8 references.

Contents.
Introduction.
The nurse's role. Action at The Royal London.
Conclusion.
References.

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As many as 35% of women attending A&E departments may do so as a result of domestic violence. (2). Despite this chilling figure, those working in A&E may fail to make an appropriate assessment and thus miss the opportunity to intervene. Domestic violence is defined as "mental cruelty, threats, physical violence without actual bodily harm, and non consensual sex". (3) Jezierski also includes battering, murder, rape, assault, and involuntary imprisonment when defining domestic violence.(4)

Mooney reports that in North America alone in the 1980's it was estimated that 50,00 women were killed by abusive partners.(3) The NHS Executive states that the vast majority of people suffering from domestic violence are women and the perpetrators are men, however, men may also suffer, in either heterosexual, or homosexual relationships.(5) It usually occurs between cohabiting couples, but this need not be the case.

Whilst domestic violence is linked to alcohol and drug abuse, social learning and family stress, what is clear is that it's affects are far reaching, cutting-across all social, racial, and economic barriers.(6) Mooney states that if domestic violence is occurring there is a one-in-two chance that any children in the relationship are also being abused.(3)

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The nurse's role

A&E nurses often represent a key point of contact for people experiencing domestic violence. Grunfeld et al suggest that A&E nurses are in an ideal position to offer information on support agencies for women (or men) experiencing violence.(1) Domestic violence is a problem often shrouded in secrecy. The NHS Executive suggest that it is not a comfortable topic and patients do not find it easy to raise.(5) What can A&E nurses do to break this conspiracy of silence? Grunfeld et al state that identification of battered women in health care settings is impeded by nurses' adherence to societal myths.(1) There is a strong historical and cultural acceptance of domestic violence. (4) Coupled with this, there is often a reluctance to acknowledge that it is occurring, due to fear of interfering within the family unit, and the perception that domestic violence is a minor problem. (2) Other barriers to effective intervention include ignorance, lack of education, fear of client response, and the nurse's perception that "even if I help, the woman usually returns to the abuser". It is vital that nurses (and other health care providers) examine their own beliefs and values relating to domestic violence. Decisive action should also be taken at departmental and Trust levels, with training, policies and guidelines. Walsh suggests that women experiencing abuse may seek to minimise the seriousness of the problem.(7) This is partial denial which is an appropriate response to a devastating situation.

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If nurses are to maximise the chances of helping these women speak out, there are some key features that need to be in place in A and E. Sensitivity and privacy (away from other family members and friends) is needed to obtain a clear history from the woman's perspective. It is important that the nurse develops a personal repertoire of abuse related questions that are comfortable, natural and culturally sensitive. (8) When violence is indicated, the most effective way of obtaining a clear history is to use a communication model that allows the woman to talk about her problem from her point of view. (6) Documentation is vitally important in case of legal proceedings. A clear record of what the woman says has happened, and the injuries, both new and healing, must be taken. Photographs of injuries can also be vital for evidence. In 1997 the NHS Executive dispatched to all Chief Executives of NHS Trusts and Health Authorities, a helpful guide for questioning a victim of domestic violence, using recommendations from relevant professional organisations.  However, it is important to remember that it is up to the person if they want to take it further. The information should be made available so that they can be referred if that is what they want. It should be remembered that the woman may not leave the abuser on this occasion, but with the appropriate support and information women do make changes.(8)

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Action at The Royal London

• Publication of Good Practice Guidelines by the Clinical Nurse Practice Group (see attached page). This was instead of setting a standard which we felt would have been very difficult to measure.
• Training of a sister and senior staff nurse at the First Step Centre in Camden. The First Step Centre offers training, counselling, victim support, legal services and stress management, all in relation to Domestic Violence. It is free for both professionals and clients.
• In-house teaching sessions twice a week were held to increase staff awareness.
• Production of a Domestic Violence Information File -which has become an invaluable guide for issues including legal, police, housing and literature searches.
• Leaflets and posters around the department in prominent places, in Bengali, Urdu, Turkish and English.
• We programmed our computerised after care (discharge) instructions to include advice on Domestic Violence. Every patient gets an up to date telephone number and offer of help when they are discharged; regardless of their illness/injury.

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Conclusion

In conclusion it is clear from our literature reviews that domestic violence is a far reaching problem in our society which is still not being tackled or recognised by all A&E nurses are in an ideal position to be a forerunner in approaching this complex problem. This is illustrated by Walsh who stated that women experiencing violence are more likely to attend and A&E as a result of assault than if they had had a road traffic accident.(9) Education of staff and clear user friendly guidelines are paramount for the care and support that these victims need.

1.  Grunfield FA. et al (1994) Detecting domestic violence against women in the emergencv department: A nursing triage model. Journal of Emergency Nursing1994: 20.4;) 271-3.

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