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Domestic Violence in America: Challenges and Solutions

By Judith Shannon Lynch, MS, MA, APRN, FAANP
Originally published in Medscape, August 2001

Introduction

There is no longer any doubt that domestic violence has taken a great toll on the women and children of America. Each year, an estimated 1 million women and 1.4 million children are assaulted by members of their own families.1 Similar trauma occurs among men, those in gay or lesbian relationships, and among people in all age and socioeconomic groups. The outcome of these assaults is deadly: 17% of all murder victims are killed by family members and more than 50% of all American women who are victims of homicide are murdered by a current or former partner.2

Current estimates that 3-4 million women are physically abused by a family member means that 1 woman is beaten every 7 seconds in the United States.3 Prevention and intervention of this problem has become a major public health priority.

What constitutes domestic violence? Domestic violence can be defined as any relationship of unequal power and control where there is coercion, threats, intimidation, emotional abuse, isolation, minimizing, denying of freedoms, blaming, use of male privilege including spousal rape, or economic denial.

Domestic Violence and Health

Each year, survivors of domestic violence make thousands of visits to their primary care providers. At least 700,000 women present with overt injuries caused by physical abuse alone.4 However, this immediate and apparent trauma is only the tip of the iceberg. Intimate violence also has profound psychological effects on health. Chronic pain, depression and anxiety states, alcohol and substance abuse, and various somatization disorders are but a few of the long-term health problems encountered by trauma survivors. Domestic violence may also complicate pregnancy and common chronic disease management in health problems such as asthma, seizure disorders, diabetes, and hypertension.5

Current Challenges to Care

Several hundred nurse practitioners, educators, and researchers met at the American Academy of Nurse Practitioners 16th Annual National Conference. The purpose of this special interest group was to identify current challenges to care for survivors of domestic violence. The group was primarily concerned that trauma victims be quickly identified in all primary care settings so that safety goals can be swiftly implemented for both victims and dependent children.

Despite a growing awareness of the problem, few clinicians routinely screen patients for domestic abuse. Gagan6 found the most frequently reported barrier to assessing for or intervening with suspected domestic violence was time. Adult and family nurse practitioners believed they did not have enough time to inquire about problems surrounding violence because discovery would require interventions involving large amounts of time. In other words, once patients were identified, there was inadequate time in the clinical setting to set up safety plans and other interventions.

Likewise, Rodriguez and colleagues found that only 10% of primary care physicians (family physicians, internists, and obstetrician/gynecologists) screened new patients for domestic violence and only 11% asked about any abuse during a first prenatal visit.7

The group discussion culminated in a request that the Academy form an expert panel. This panel will generate a position paper on the importance of quick and precise methods of identifying domestic violence victims in all primary care settings.

Roles of Advanced Practice Nurses (APNs) in Clinical Settings

In a clinical session, Doris Williams Campbell, ARNP, PhD, FAAN, from the University of South Florida, Tampa, Florida, addressed similar concerns around assessment and intervention with victims of domestic violence.8 She offered guiding principles that APNs should use in their clinical settings when responding to patients. These included:

Campbell emphasized that universal screening of all patients, adult and pediatric, male and female, is the key to effective identification. As long as the question is not asked, the problem will go on and the victim and family will continue to suffer. Campbell also reminded her colleagues that the 2 groups at highest risk for domestic violence are women whose partners have a weapon in the home and women who have substance-abusing partners.

Research on Educating Future APNs in Violence Care

Clinicians are not the only nurses concerned with the identification and treatment of domestic violence victims. It is essential that students be adequately prepared to address these health problems through their educational programs. Eileen T. Breslin, PhD, RN, Dean and Professor of the School of Nursing, University of Massachusetts, Amherst, Massachusetts, and Ann Woodtli, PhD, RN, FAAN, Professor of the College of Nursing, University of Arizona, Tucson, Arizona, recently completed a study that examined the extent to which graduate advanced nurse practitioner programs incorporated into their curricula those competencies necessary to provide high quality care to victims of domestic violence.9 These competencies, described in the American Association of Colleges of Nursing (AACN) Position Statement, Violence as a Public Health Problem,10 are as follows:

Are Students Being Prepared?

Christiane Puz, a graduate student associated with the project, discussed study results in a research session.9 Faculty members from 308 nursing schools answered a questionnaire that asked how relevant and important the above competencies were in preparing students to care for victims of domestic violence. Although competencies were deemed relevant to practice, importance in the overall curriculum was challenging, and many faculty members felt dissatisfied with the amount of content currently being offered to their students.

This study found that both factual information in the classroom and planned clinical experiences related to violence content are essential for nurse practitioners to provide expert competent nursing care. In fact, there is no question that nurse practitioners must provide expert care in the areas described in the AACN competencies.

It remains challenging to provide curriculum time for violence care content but, given its relevance, faculty members should look for innovative ways to include such material, perhaps in the core curriculum.

Conclusions of this study are important as they can serve as baseline data for future studies looking at improving the quality of nurse practitioner education in the area of violence care.

A Nurse Practitioner-Run Clinic

At a podium presentation, Charlotte M. Covington, MSN, RN, CS, FNP,11 Assistant Professor, Vanderbilt University School of Nursing, Nashville, Tennessee, and Family Nurse Practitioner, The YWCA Starting Point, a Domestic Violence Center, Nashville, Tennessee, described the evolution of a nurse practitioner-managed clinic in a women's domestic violence center. This clinic was created to provide acute and preventive healthcare to shelter residents and their children (a vulnerable population with poor access to any healthcare). Previous to the inception of this clinic, all care was off-site, primarily offered in the emergency rooms of local hospitals.

A Joint Partnership

Nashville has long recognized the needs of its citizens who suffer from domestic violence. There has been a crisis line in operation since 1979 and an identified shelter for women since 1981. In 2000, a new shelter was built to accommodate a growing population of women in need and their dependent children. Current shelter services include residential staff, a 24-hour crisis line, presence of case managers for long-term planning needs, a children's support group, legal assistance, and access to mental health services.

Financing is through the local YWCA, which was awarded a grant from the Junior League to create an on-site health clinic. The YWCA, in turn, contracted with Vanderbilt University's School of Nursing to provide 12 hours of nurse practitioner faculty coverage for primary care needs. Covington is the first nurse practitioner to hold this position.

Residents of the Shelter

In a census that numbers between 40 and 85 persons on any given day, 33% of residents are children. White women represent 50% of the adult population, African-American women 40%, and Hispanic women 10%. The average length of stay is 35 days, although residents may stay as long as 6 months. This is unusual in a country where most women are only allowed to stay in a shelter for a period of 30 days. A prolonged residency certainly makes healthcare more accessible to patients.

Healthcare Needs

Covington finds that acute care takes up most of her time with patients. Ear, nose, and throat problems, low back pain, and various gynecologic maladies are the most common presentations, along with depression and anxiety, often in the form of posttraumatic stress disorders. There is some difficulty with follow-up care because of resident turnover. One of Covington's biggest frustrations is caring for women who choose to return to their abusing partners, even though some have previously left their homes more than 3 times.

The most pressing need identified by Covington is that of better addressing the cultural diversity inherent in identifying and treating domestic violence victims. What may seem abusive in one culture may be accepted as the norm in another culture. Patient perceptions and beliefs are paramount, even when these ideologies do not match with the clinician's own belief system.

This observation is congruent with another of the domestic violence special interest group's challenges to the Academy—to better identify vulnerable populations at risk for domestic violence. Included in these populations are persons with cultural constraints, those living in poverty, and people with various sexual orientations.

The development and implementation of this innovative shelter environment, complete with healthcare access, stands as a striking example of what can be accomplished when the community and university stand together to protect vulnerable women and children.

Conclusions

The inclusion of questions to identify abuse in all primary care settings will significantly increase the identification of victims of domestic violence. APNs have a significant opportunity for this early identification because of their gatekeeper positions within the healthcare delivery system and their focus on continuity of care.

If APNs are to participate in the universal screening of patients, they must be properly educated in the theories of domestic violence as well as in common ways that patients will present in various settings. Nursing educators must integrate violence care into formal classroom education and clinical practice settings.

APNs are adept at creating new roles in diverse environments. Funding and community partnerships must be forged to bring quicker and better healthcare to all domestic violence victims and their families. Violence is pervasive in our culture but is seldom discussed. APNs must be highly visible in the design of a marketing campaign that uses the media to fight against trauma of all types.

References

  1. Feldhaus KM, Koziol-McClain J, Amsbury HL, et al. Accuracy of 3 brief screening questions for detecting partner violence in the emergency room. JAMA. 1997;277:1357-1361.
  2. Clinical update. Domestic violence: ending the cycle of abuse. Clin Rev. 1998;18:55-69.
  3. Hinterliter D, Pitula CR, Delaney KR. Partner violence. Am J Nurse Pract. 1998;32-40.
  4. National Institute of Justice and Centers for Disease Control and Prevention. Prevalence, incidence, and consequences of violence against women: findings from the national violence against women survey. Washington, DC: NIJ/CDC; 1998.
  5. McCauley J, Dern DE, Kolodner L, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med. 1995;123:737-746.
  6. Gagan MJ. Clinical implications of a study of nurse practitioner performance with suspected domestic violence victims. J Am Acad Nurse Pract. 1999;11:467-470.
  7. Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA. 1999;282:468-474.
  8. Campbell DC. The role of advanced practice nurses in domestic violence: assessment and intervention. Program and abstracts of the American Academy of Nurse Practitioners 16th Annual National Conference; June 28-July 1, 2001; Orlando, Florida. Clinical Presentation.
  9. Breslin E, Woodtli A, Puz C, et al. Assessment of violence-related competencies in advanced practice nursing curricula. Program and abstracts of the American Academy of Nurse Practitioners 16th Annual National Conference; June 28-July 1, 2001; Orlando, Florida. Invited Research Session.
  10. American Association of Colleges of Nursing. Violence as a public health problem. Washington, DC: AACN; 1999.
  11. Covington CM. Development of a nurse practitioner practice at a woman's domestic violence shelter. Program and abstracts of the American Academy of Nurse Practitioners 16th Annual National Conference; June 28-July 1, 2001; Orlando, Florida. Podium Presentation.

Copyright © 2001 Medscape, Inc.