Introduction

Partner violence is a potentially life threatening health risk factorIt is a primary cause of traumatic injury to women and one of the leading causes of death for pregnant womenHoron and Cheng (2001) found that 202% of pregnancy-associated deaths were caused by homicide during pregnancy or within 365 days of deliveryHomicide was the number one cause of death during pregnancy and during 43 - 365 days following delivery or termination of pregnancyIn contrast, among women 14 - 44 years old who are not pregnant, homicide dropped to the 5^th leading cause of deathThe number of injuries women sustained as a result of partner physical assault exceeded the total number of injuries sustained by women from car accidents, muggings, and rapes combined, making battering the most prevalent cause of traumatic injury to women in the United States (Alpert, Freund, Park, Patel, & Sovak, 1998)These findings illustrate just a fraction of the growing body of research justifying an urgent need for clinical screening, intervention, and support for victims of partner violenceThis article is a brief overview that addresses what partner violence is, why nurses are needed to clinically screen for violence, how to maximize disclosure of abuse, and appropriate actions to take when partner violence has been positively identifiedThe article concludes with suggestions for reliable sources on the Internet for professional growth as well as resources for women experiencing violence

What is Partner Violence?

The word "partner" applies to same and opposite sex couples, in married, engaged, or cohabiting relationships, and to more casual relationships such as acquaintances or dating partnersBecause of the wide range of perpetrators who can be involved, and because of the multiple forms of violence they commit, the term "partner violence" is more precise than alternatives such as domestic violence, wife beating, or wife batteringPartner violence may occur as isolated occurrences, but most typically multiple forms of abuse are occurring that create a pattern of control by one partner and generate fear and submission by the other partnerThe acts that comprise partner violence are physical, sexual, psychological, stalking, and economic abuse

• Physical assault includes but is not limited to: pushing, slapping, punching, kicking, choking, beating, assault with a weapon, tying down or restraining, leaving the woman in a dangerous place, and refusing to allow access to medical care when the woman is sick or injured
• Sexual assault includes acts such as degrading sexual comments, using coercion to compel a person to perform sexual acts when they have stated they don't want to, intentionally hurting someone during sex, including use of objects intravaginally, orally, or anally, pursuing sex when a person is not fully conscious or is afraid to say no, and coercing someone to have sex without protection against pregnancy or sexually transmitted diseasesRape, the most serious form of sexual assault, is characterized by three key elements: lack of consent, penetration, no matter how slight and independent of whether ejaculation occurred, and compelling participation by force, threat of bodily harm, or with a person incapable of giving consent due to intoxication or mental incapacitationRape is variously referred to as stranger rape, date rape, acquaintance rape, and marital rape, but under the law, rape is rape, no matter what the relationship of the victim and perpetrator
• Psychological abuse refers to acts such as humiliation, intimidation and threats of harm, intense criticizing, insulting, belittling, ridiculing, and name calling, verbal threats of harm or torture directed at the victim or family, children, friends, companion animals, stock animals, or property, physical and social isolation that separates a person from their social support networks, extreme jealously and possessiveness, accusations of infidelity, repeated threats of abandonment, divorce, having an affair if the person does not comply with abuser's wishes, monitoring movements, and driving fast and recklessly to frighten the victim (American Medical Association, 1992)
• Stalking refers to repeated harassing or threatening behaviors that an individual engages in such as following a person, appearing at a person's home or place of business, making harassing phone calls, leaving written messages or objects, or vandalizing a person's propertyThese actions may or may not be accompanied by a credible threat of serious harm, and they may or may not be precursors to an assault or murder (Tjaden & Thoennes, 2000)
• Economic abuse is restricting access to resources such as bank accounts, telephone communication, and transportation, or refusing the right to work or attend school that have the effect of keeping a victim without resources and under the control of the abuser

Clinical Screening

American Medical Association's Practice Guidelines for Physicians (1992) recommends screening for partner violence at all portals of entry to the health care systemScreening for partner violence is important because when unidentified and unameliorated, the consequences of violence are usually ongoing, escalating, and involve a wide range of general medical injuries, psychological illness, and social problemsThe Joint Commission on the Accreditation of Health Care Organizations (JCAHO) has recently required the development of partner violence protocols and this, along with proposals made by the American Medical Association (AMA), have led to a greatly improved (although still not to the degree that is necessary) level of response to partner violenceClearly, the first step in treating partner violence is to properly identify cases in which it is an issue

Barriers to Screening

There is modest cohesion in the medical community regarding the level of need for clinical intervention in cases of partner violenceBut for various reasons including the relative lack of information regarding the prevalence, incidence, duration, and severity of violence experienced by medical patients, it is difficult to definitively state the services that are needed to address these problems sufficientlyThe result of a lack of information and other barriers inherent in the pressures of today's health care environment has been a relatively low level of success in convincing health care providers to routinely screen and treat partner violence

One of the major problems facing health care today is that physicians are not taking the time to ask patients questions regarding their social environmentThere are many reasons for this backing away from the biopsychosocial approach that once guided informed health care provisionPhysicians often feel time pressures, do not want to invade an individual's privacy, believe that they do not know what to do if the individual discloses abuse, and may think that physicians cannot make a difference anywayRodriguez, Bauer, McLoughlin, & Grumbach (1999) reported that only 10% of physicians routinely screen for intimate partner abuse during new patient visits and 9% screen during periodic checkupsThe only time physicians consistently asked about intimate partner abuse was in cases that involved physical injuries (79% reported asking questions)The fear of invading patient privacy that physicians articulate flies in the face of data suggesting that most victims of partner violence are receptive to questions from medical personnel concerning abuse (Stark, 2000)Those health management facilities that have enacted a few standard questions related to partner violence in a confidential screening have shown a marked increase in disclosure and identification of cases of partner violence

The Role of Nurses in Identifying and Responding to Violence

One of us (MPK) in conjunction with her internist-husband Paul Koss, MD, as well as many other advocates across the country, have worked for over 10 years to educate physicians about why violence is a health issue, to raise consciousness of the practice guidelines, and to teach clinical screening and interventionExamining the most recent information that 10% of physicians are routinely screening suggests that the accomplishments have been modestWhen training programs are introduced, screening rates go upWhen the study ends, they go back down againWhen physicians are given resources including on-site consultants to address the excuse that they are not screening because they don't know what to do when they find abuse, their rates of screening still do not reach acceptable levelsIt is more reasonable to keep up the work, by focusing on medical students, interns and residents, who may be more receptive, than trying to alter the practice styles of mature physiciansHowever, the payback might be higher by turning to other provider groups who accord partner violence a higher priority and whose professional norms value working with the whole patientWe believe that nurses could implement a level of consistency in screening patients for partner violence

How to Ask About Partner Violence

Many of the medical, social, and behavioral problems associated with partner violence go untreated not because appropriate screening questions are omitted, but because the setting in which screening is done and the specific phrasing of the questions neither stimulated recall nor created a comfortable disclosure climateFor example, asking a woman if she is "abused at home", could elicit a response of, "no"; whereas asking the same woman whether her significant other has hit her could elicit a response of, "yes"To maximize safety and comfort it is important to interview in private, without the partner or children presentScreening for partner abuse in the presence of other family members is not only futile, it can even put the patient at risk of injury if the partner is informed and intervenes to silence the victim

The best questions to use avoid words like "domestic violence", "abused", "battered", or anything else that sounds demeaning or judgmental or is in reality a technical term that those lacking professional training may fail to understand fullyAn example of a single, comprehensive question is the following: "At any time, has a partner hit, kicked or otherwise hurt, frightened, threatened or demeaned you?" This question covers a lot of situationsIf time permits, it is better to use multiple questionsDoing so allows more opportunities for patients to disclose and offers them more details about the types of situations you want to identify

It is unwise to put any blame or judgment on the victimsRather simply ask specific questions that allow you to accurately document what has happened and make it clear that you are someone they can look to for guidance if they invest their trust in you and disclose their experiencesWeiss (2000) suggests that clinicians should be aware of the symptom presentations that are suggestive of domestic violence, such as injuries in various stages of healing, pattern injuries (where an object is outlined on the body'¦iea hand, finger, belt, etc), abdominal pain, pelvic pain, headache, dizziness, panic, and insomniaInjured patients should always be asked to explain how it happened and clinicians must be alert for answers that don't explain the injuries

Barriers to Disclosing Partner Violence

Failure to identify partner violence in medical settings stems from either a lack of adequate screening practices or hesitancy by victims to disclose acts of partner violence when askedThe barriers preventing women from disclosing are very real to the victims and must be addressed for any screening method to give accurate results

• Fear is the first of the barriers most victims must overcome when making the choice to disclose partner violenceThis fear is multidimensional in that, not only is the victim usually fearful of the abuser retaliating against her for telling family secrets, but she is also often afraid of involving the clinician or the police in her personal situationShe may fear if she discloses, she will lose whatever control she has over the situation, or be blamed or stigmatized by the authorities or the clinician inquiring about the abuseMany women have learned from unfortunate encounters with police responding to domestic violence calls that assertions of partner violence still too often meet a high level of skepticismIn legal proceedings skepticism may continue even in the presence of physical evidence supporting the claimThus, many women try to avoid involving others, believing that they cannot or will not help them
• Cultural Differences is a second barrier many women face when deciding whether to disclose partner violenceThey may feel the clinician would not understand their specific culture or may have a culturally shaped worldview that accepts the partner's behavior as normativeCulture shapes what people define as acceptable and unacceptable in intimate relationships, what they feel causes violence that goes beyond minimal levels, what the appropriate response to violence is, and who is in the best position to help resolve the situationWhat is not considered acceptable in one culture may be normative in another cultureFor example, Heise, Ellsberg, & Gottemoeller, (1999) recounted that, "a study of female homicide in Alexandria, Egypt, found that 47% of all women killed were murdered by a relative after they had been raped" (p10)Such "honor killings" are essentially tolerated where cultural practices dictate that murdering the woman is the only way to reclaim the family name after a rape has occurredHowever, in many other societies the idea of killing a family member because she was raped is unspeakableAlthough the cultural issues are not always so extreme, there are different expectations within different households, and many victims of partner violence maintain a culturally based world-view that minimizes the abuser's behavior
• Dependence on the abuser is a third barrier that a woman may face when deciding whether to disclose partner violenceDependence can be economic, social, psychological, or any combination of these types of relianceWhere will she live if she discloses violence to the physician or authorities? Perhaps her abuser prevented her from getting a job and therefore she has no money of her own to meet her basic needs and those of her childrenWho will support her decision to leave if her abuser has forced her to cutoff or avoid her family and former friends? These are just a few examples of fears that may go through the victim's mind as she contemplates placing her trust in a medical provider
• Feelings of failure are common for victims of partner violence who often feel responsible for the abuseThis belief can arise from the abuser blaming the victim, the authorities asking questions that imply blame (eg"What did you do to provoke the attack?" or "Why don't you leave your abuser?"), or even from internalized scripts that cast women as responsible for harmony in the homeIf a victim is experiencing feelings of failure related to abuse, she may not feel comfortable confiding in anyone else, preferring to work harder to try and change what is happening
• Promise of change or hope is the final barrierPerhaps the abuser acts remorseful and seems greatly apologetic for the abuse, making excuses and explaining why it will never happen again, bringing gifts or offering to work extra hard to make up for what he has doneAlthough abusers may be sincere at the time, few are able to cease their violence without outside help (for a list of Web sites with state-certified programs for batterers go to wwwncadvorg/)The majority of perpetrators, however, use remorse as one more tool to manipulate their victims into putting up with more abuse, staying with them, and not reporting the crime to the authorities

Following Up Positive Identifications

It is important to listen nonjudgementally and validate the disclosure by telling the patient how sorry you are about what is happening and that no one has the right to treat another person that wayThese steps in and of themselves are healing and empowering, but they are not enoughJudith Alpert and her colleagues (1998) developed a guide to recognize and treat victims of partner violenceThis resource uses the acronym "RADAR" to summarize the clinical tasks requiredThe acronym "RADAR" stands for Remember, Ask, Document, Assess, and ReviewIf followed, the RADAR action steps greatly increase the quality of careBoth remembering to routinely ask patients about partner violence and asking them directly with specific questions increase the success of screening for abuseThe next three steps of the RADAR system structure clinical response and include documenting the injuries, assessing the victim's safety, and reviewing possible options with the woman

Document Findings in Medical Records

Document your findings in the medical records when taking information from someone whom you suspect has been a victim of partner violenceStark (2000) points out that documentation can serve multiple purposes including:

1. Alerting other health care providers of ongoing domestic violence in a patient's life

2. Serving as objective documentation that injuries not consistent with accidental origin have been observed

3. Assisting those who monitor quality of care to determine the rates of screening that is occurring

4. Contributing data to hospital and clinic policy decisions so that scarce resources are allocated to the problems that patients are most typically presenting

The clinician may consider taking photographs of the injury on a Polaroid or digital camera to place in the victim's file, providing visual evidence to support the written documentationThis is one of the most important steps medical providers can take to increase the safety of victimsPatients may not be ready to take legal steps initially or even for a substantial length of timeBut when and if that point is reached, the documentation will be there to lend credibility

Assess Perpetrator Lethality

Assessing your patient's safety is a vital role in responding to disclosures of partner violenceAlpert and colleagues (1998) suggest asking the woman if there are weapons in the house, if the violence is increasing with time, or if the children are in dangerAnother factor that should be taken into consideration is the level to which the woman feels like she is entrappedBeing isolated from support other than the abuser can interfere with medical access and complicate discovery of future injuries or abuse to the womanGaining a better picture of what the situation is at home is important in offering resources such as specialized community services or support groups

Like many ongoing health issues that providers address, partner violence cannot be resolved in a single appointmentIt is important to not pressure the woman to do what she does not want to doEach visit offers a new opportunity to take stock of the violence and move the patient along the change continuumHowever, if there is eminent danger, clinicians may offer to telephone the police or shelter to arrange for protection and transportationSome states such as California and many tribal nations mandate that authorities must be notified if a health care provider suspects partner violence has occurredIt is important to inform yourself of what is required of you as a health care provider in your state

Make a Safety Plan With the Victim and With Children

A safety plan is something that goes beyond just making sure that a woman is safe in her current home environmentAbove and beyond assessing whether a woman or her children are in danger in the home, it is important to have a plan that they can follow if placed in a dangerous situation by the abuserSafety plans include a myriad of things, such as having a place to stay or housing available should they need to leave the home suddenly; having access to a separate bank account; always keeping a bag packed with copies of important documents or immigration papers, as well as a change of clothes; having access to legal services; having an understanding with the school regarding who specifically is allowed to pick up the children; and any other number of things that must be addressed in individual cases to insure that a woman and the children can leave on a moments notice

Make Appropriate Referrals

Finally, reviewing the many options your patient has is critical in supporting her through this difficult situationIt is helpful if you have a working knowledge of the different types of community resources including shelters, support groups, and legal advocacyIt is advisable to keep a list of contact numbers in the clinical areaDisplaying brochures or pamphlets with contact numbers in the office not only sends the message that the clinician is comfortable working with the issues, but also provides information for patients who are not yet ready to discloseIf you are giving an abused woman literature or telephone numbers, make sure that she will be safe in taking themSome partners could react with increased violence to the threat they feel over their partner speaking to outsidersIf it is safe for the woman to take these materials, they can prove very useful as she is given the choice of using this information, but does not need to feel pressured into contacting support groups that she is not yet ready to embraceThere are also Internet resources available; but before recommending them to patients, make sure that they realize that most internet browsing software creates a list of recently visited sites that are accessible to anyone who sits down to the computerElectronic footprints are left in multiple places on a computer after visiting any website on the InternetTo maintain safety, these sites must be deleted before shutting down (see Fremantle Regional Domestic Violence Coordinating Committee, 2001)There are also programs that delete records from a computer, preventing the abuser from tracking which websites the victim has visited (see Historykill, 2001)

Where to Learn More

Nurses who are interested in learning more about working with partner violence can readily find resources on the InternetSome websites have information that is directly geared to victims of partner violence such as the National Coalition Against Domestic Violence (NCADV) (wwwncadvorg or 303-839-1852), the National Domestic Violence Hotline (NDVH) (wwwndvhorg or 800-799-SAFE), or the Family Violence Prevention Fund (FVPF) (wwwfvpforg or 415-252-8900)The NDVH specializes in helping women with immediate needs and the FVPF serves as a resource for a varying range of support for different forms of partner violenceCAVNET's online forum (wwwcavnet2org) for survivors is also an excellent resourceThe forum takes place between 8-10 PM Eastern Standard Time Sundays and Wednesdays and addresses sexual assault, stalking, incest and domestic violence

Other websites offer professional resources for upgrading skills including, the Minnesota Center Against Violence and Abuse (MCAVA) (wwwmincavaumnedu or 612-624-0721), or wwwvawnetorgThe American College of Obstetrics and Gynecology has a helpful website that can be found at wwwacogorgOther valuable locations on the Internet with items of local and national of interest may be easily accessed through links found on either the NCADV or the MCAVA sites

Conclusion

Partner violence is a serious health risk that must be addressed more reliably than it has been to this pointWomen are being killed, beaten, raped, and abused in a wide range of other ways without having a strong base of support in the medical care system to which they can turn to seek helpWomen have more frequent contact with their health care providers than with any other formal system including law enforcement, prosecution, social service, or mental healthThe nursing profession has potential for having enormous impact on the health and safety of women by taking up the challenge of routinely performing violence assessmentNurses enjoy high patient trust, and their training in empathy and clinical rapport make them ideal receivers for the disclosure of partner violenceIt is important to recognize that there are many barriers to a woman reporting partner violence and, with those in mind, use your RADAR

Authors

Michael PGriffin, MA
E-mail - griffin@emailarizonaedu

Michael PGriffin is currently working as a Research Assistant in the College of Public Health at the University of ArizonaHe has a BAwith a major in psychology from Loyola College in Maryland and an MAin experimental psychology from the College of William & Mary in Williamsburg, VAMichael has completed a Family Group Decision Making workshop and participated in several investigations into the topic of domestic violence, psychology and law, aggression, and victimization

Mary PKoss, PhD
E-mail - mpk@uarizonaedu

Mary PKoss is a Professor of Public Health, Family and Community Medicine, Psychiatry and Psychology, in the University of Arizona College of Public HealthShe has worked in the field of violence against women for 25 yearsIn 1991 she published the first study of the impact of sexual and physical violence on women's health and medical utilizationShe received the 2000 American Psychological Association Award for Distinguished Contributions to Research in Public PolicyMuch of her current work is in collaboration with the Southern Arizona Center Against Sexual Assault

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