Chains of Love
As the most frequent contact of patients, nurses are at the forefront of breaking the cycle of domestic violence against women

By Donna Hemmila
June 11, 2004

Imagine changing — maybe even saving — a woman’s life by spending less than an hour on the phone.

Inspired by the belief that nurses can make a difference in the struggle to end family violence, researcher and educator Judith McFarlane, RN, DrPH, FAAN, set out to test a way nurses could help women break free of their abusers. McFarlane designed a clinical trial that looked at the effectiveness of nurses performing a telephone intervention to encourage safer behaviors among women with abusive partners.

The interventions took place in six nine-minute phone calls totaling only 54 minutes, and McFarlane believes the process can easily fit into any clinic or hospital setting with minimal costs.

In a study titled “Increasing the Safety-Promoting Behaviors of Abused Women” published in the March issue of the American Journal of Nursing, McFarlane details the success of the intervention: Abused women who received the phone calls were more likely to take steps to enhance their safety.

For health care providers, the study proves something else: Nurses can play a vital role in combating family violence.

“This is a nursing issue,” McFarlane said. “It’s not a medical issue. There is no prescription you can write to end domestic violence.”

Epidemic proportions

In the United States, McFarlane says in her study, 1 million women a year report being abused by an intimate partner, and half of them suffer physical injuries.

The National Violence Against Women Survey, conducted in 2000 by the national Centers for Disease Control and Prevention and the National Institute of Justice, concluded that intimate-partner violence is pervasive in the United States, with 25% of women contacted and 7.6% of men saying they’d been raped or physically assaulted in their lifetime by a date or an intimate.

Of the 4.8 million incidents of abuse against women, the survey estimated that 2 million resulted in an injury and more than 552,000 required medical treatment.

The abuse is an epidemic, McFarlane said, and not all cases are detected. She’d like to see screening for signs of domestic violence as a normal part of patient contact like taking someone’s blood pressure.

“No one deserves to be hit,” she said. “We can end this. I think nurses are in a pivotal position to end this.”

McFarlane’s study involved women who had sought a protective order against an abusive partner. Working through the family violence unit in the county district attorney’s office in Houston, the researchers — five nurses and one caseworker — found 154 eligible women. All but four agreed to participate in the study.

Those 150 women were divided equally into a control group and those targeted for the interventions. One woman died by suicide three weeks into the study, but the others all continued with the 18-month study.

Women in both study groups received the usual services from the DA’s office including discussion of safety-promoting behavior.

Women in the intervention group received phone calls within 48 to 72 hours after the initial contact. The researchers asked questions such as, “Have you ever hidden money?” and “Have you ever had available birth certificates (yours and children)?” Five more phone calls followed at intervals of one, two, three, five, and eight weeks. During these calls, the nurses asked the same questions, changing the beginning to “Since the last time we talked, have you 85 ?”

The intervention calls were conducted in either Spanish or English, and investigators would make suggestions, such as hiding money and documents in an empty tampon container.

Some of these simple acts, like buying a spare car key, required great effort and courage from the women, McFarlane said. Women told her of sneaking car keys off the abuser’s key chain while he slept and taking a bus to have a duplicate made and then returning the key without the man noticing. Some women had been so controlled by the abusive partner that they had no idea how to find their way around the city and had to learn how to use the bus schedules.

All the women in the study were contacted at three, six, 12, and 18 months to determine what safety strategies they had adopted and retained. Those in the intervention group had performed on average two more safety behaviors than women in the control group and had retained the behaviors for 18 months.

Researchers concluded that the interventions could work if offered in a routine health assessment if a woman had experienced a recent violent episode — a time when she would be most open to seeking help to stop the abuse. McFarlane recommends further research to determine the effectiveness of such interventions in relation to the time that has passed since the women’s last violent episode. More research is needed to see if the safety measures prevent future trauma and subsequent health care costs.

McFarlane started her research into domestic violence more than 25 years ago when a nursing student asked her if women were abused when they were pregnant.

The question came up during a one-hour domestic violence class McFarlane was teaching. She knew that women were abused during pregnancy, but there was no research to back up her instinctual knowledge. So she and the student embarked on a research project to document intimate-partner violence against pregnant women.

“That’s what nurses do,” McFarlane said. “We ask questions to improve care and then we do the research.”

Since then, she’s been involved in dozens of domestic violence studies and seen the research focus shift from documenting the existence of intimate-partner abuse to looking at ways to diagnose and intervene in the cycles of violence.

Stop the abuse

Nursing programs now include courses in family violence. At Texas Woman’s University College of Nursing, where McFarlane holds the Parry Chair in Health Promotion and Disease Prevention, students learn about family violence at all of life’s stages, from child abuse and neglect to
elder abuse.

“We have come a long way,” McFarlane said. “Our new nurses are trained. We want to get the word out to practicing nurses.”

The U.S. Department of Health and Human Services would like to reduce incidents of intimate-partner abuse by 20% by 2010. Many health plans, hospitals, nursing associations, and public agencies have made intimate-partner violence detection and treatment a high priority.

The Emergency Nurses Association’s policy on domestic violence encourages emergency nurses to take an active role in domestic violence programs and supports mandatory training and continuing education for all health professionals.

Although training alone won’t end domestic violence, an emphasis on training for health professionals can deliver results.

STAND! Against Domestic Violence, a nonprofit advocacy agency based in the San Francisco Bay area, saw a jump in referrals from health care providers after it started offering training for health plans and facilities.

In 1999, 28 women were referred and, in 2002, the number nearly tripled to 79, said David Lee, STAND!’s Central County regional director.

“Frequently, we have people coming forward, and it’s the first time anyone had ever asked about it,” he said in describing the impact a practitioner
can make.

Violence detectors

Nurses, who often have the most frequent patient contact, have always been on the forefront of treating abuse, Lee said, but a multidisciplinary approach to training works best. Physicians, nurses, social workers, and patient educators all need to be involved.

That is the approach taken at Kaiser Permanente’s Northern California Region medical centers, said Brigid McCaw, MD, MS, MPH, clinical leader of the health organization’s Family Violence Prevention Services. Kaiser is making an effort to detect intimate-partner abuse.

Patients diagnosed with domestic violence in the Northern California region in 2000 totaled 761. In 2003, the number rose to 2,500. The highest number of cases was diagnosed in behavioral health departments followed by primary care units and, lastly, emergency departments.

“We’re increasing screening and referral wherever the patient connects with the health plan,” McCaw said.

Kaiser has stepped up patient outreach with strategies like placing domestic violence awareness posters and brochures inside restrooms where victims can stealthily collect the information. A traveling display called “Silent Witness” documents the experiences of Kaiser employees, including nurses and physicians who have suffered and survived partner abuse. And the organization continues training and education for staff.

Routine screening

In spite of all the education and screening efforts, more routine screening and more comprehensive education still need to be done, said April Gerlock, ARNP, APRN, PhD, who works with both victims and perpetrators of intimate-partner violence at the Veterans Administration Puget Sound Health Care System in Tacoma, Wash. More routine screening in all health care settings needs to happen, she said, and facilities need to make time for more domestic violence training.

“I think we’re always trying to get the quick-and-dirty 30-minute training,” Gerlock explained. “It’s so hard to deal with domestic violence in 30 minutes.”

At the same time, any training or intervention is better than remaining passive. When Gerlock suspects that she is dealing with a victim or perpetrator, she follows up on the next visit. “Just checking can make a difference,” Gerlock said.

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