NurseWeek: Reading the signs

Reading the signs
Nurses play pivotal role in identifying and helping victims of domestic violence

By Melissa Gaskill
February 5, 2001
Photo: Photodisc

Women are frequently the victims of violence, but so are people with disabilities, the elderly and children. Nurses need specific training to successfully intervene in this complicated issue.


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In rural Iowa, homes are far apart, not everyone has a telephone and weeks may go by without neighbor seeing neighbor. So no one missed the young woman and her newborn – until she brought the child to a physician and whispered to the nurse practitioner that her boyfriend, the baby’s father, nailed all the doors shut every day on his way out to work.

The crack in the door
That nurse was Perle Slavik Cowen, Ph.D., RN, an associate professor at the University of Iowa’s College of Nursing who oversees a grant program that covers the monthly well-child exams in which the young mother participated. Cowen accompanied the local sheriff to the woman’s home the next day.

"As we were prying the nails out of the door, the man showed up. Someone had seen the sheriff’s car at the house and called him," Cowen said. "He became agitated and threatening to all of us – the mother, the nurse, even the sheriff – and so was taken to jail."

It is no accident that this young mother chose to confide in a nurse.

"Nurses generally are the ones invading the patient’s physical boundaries, by virtue of their role in physical assessment. This allows them to approach emotional boundaries in an acceptable way, too," said Glenda Walker, DSN, RN, a professor and director of the division of nursing at Stephen F. Austin University in Texas. "Nurses get that crack in the door that other professionals don’t."

The ability of nurses to successfully intervene in domestic violence is borne out by a number of studies.

For example, Barbara Parker, Ph.D., director of the Center for Nursing Research at the University of Virginia’s School of Nursing, found that pregnant women who receive one-on-one counseling from a trained nurse reported less abuse six months to one year later.

A complicated issue
Women are frequently the victims of violence, but so are people with disabilities, the elderly and children. In short, domestic violence is a complicated issue. Even defining it can be difficult. Therefore, nurses need specific training to successfully intervene, said Christina Walsh, technical assistance coordinator for the National Training Center on Domestic and Sexual Violence, based in Austin, Texas.

Walker agreed. "There are ways to ask the question where you make it OK to answer." Ask a woman if she is abused and she’ll most likely say no, but ask whether she’s afraid of her partner and she may say yes.

Intervention also must take place where a woman feels safe, Walsh said, places where she is allowed to go alone, such as a hair salon, the grocery store or work.

The health care system sees many of the nearly one-third of American women who report being physically or sexually abused by a husband or boyfriend, said Debbie Lee, director for health at the Family Violence Prevention Fund in San Francisco. That contact may not necessarily be a direct result of the violence, either. So all health care providers need to know how to screen for and assess domestic violence situations.

In addition, information about shelters, counseling and other services for victims of domestic violence must be provided in such a way that it is safe for the woman to take it. Many hospital emergency rooms, for example, leave materials in the women’s restrooms. Or one nurse occupies the partner while another questions the woman.

Spotting the signs
Many times, successful intervention takes place in the home. A study at the Cornell University Family Life Development Center found that home nurse visits in the two years after the birth of a child significantly reduced the rate of child abuse. Child abuse and domestic violence are intertwined issues, with experts increasingly recognizing the effect of domestic violence on children even when they are not direct victims.

"I’m a firm believer in home visits," Walker said. "You can get phenomenal cues about the potential for violence. How does the child deal with a stranger in the home? How does a parent deal with interruptions? How does the parent handle discipline? Can a nurse talk to the woman without the husband present? That is data to put a pattern together. Abuse isn’t any one thing; it is a pattern."

"A visiting nurse can see things with an outside perspective that others don’t see," Walsh said, "and can say things that others couldn’t say. That nurse also can establish a relationship."

A relationship is critical because it usually takes many offers before help is accepted. "It is important for nurses to not turn aside when a person doesn’t take your recommendation the first five times, and not to withhold it the sixth time," Cowen said. "That sixth time may be when they are ready."

Don’t give up
Walker tells nurses not to feel as if they have failed if an offer of help is refused. "You have opened the door to something that woman will carry with her – the fact that someone cared enough to listen. You may not see the fruit of that effort for months or years. Family violence is a very complicated phenomena."

Assessment alone can serve as intervention, Parker’s study showed, because it acknowledges abuse as a serious issue.

Like the young mother nailed into her home, most victims of domestic violence are separated from other people by their abuser. Nurses often have legitimate reasons to get past the barriers and to develop rapport and trust with the victim. "You are breaking the secrecy," Walker said. "That provides the avenue for a positive outcome."

"We hear story after story where a police officer gave a woman a card with a list of services and a phone number, and after the fifth or sixth offer, they finally call," Walsh said. "They still have that crumpled card. It represents the idea that someone said, ‘You don’t have to put up with this.’ "

"Domestic violence is something that seldom remedies itself on its own," Cowen said. "These situations only get worse without intervention. Nurses need to understand that it is their job to intervene."