Robin presented at the clinic with a complaint of recurring headaches. When the receptionist told her the physician was running late, Robin began to cry, explaining she could not wait, but had to see a doctor. The nurse practitioner agreed to work her in. Robin explained she had been seen twice in three weeks, and had already been sent for an MRI, but Robin denied complaints of nausea or sensitivity to light. Robin complained that the intensity and length of her headaches had increased in the past week.

When asked about the frequency of her headaches, she explained they started in the afternoon, but last weekend, began shortly after she awoke. The headache had grown so debilitating she had returned to bed and stayed there most of the weekend.

During the discussion, Robin’s cell phone rang. She jumped from the exam table and hurried to answer it. Without hesitation, she stated in a soft voice that she was at the grocery store.

When Robin walked back to the exam table, the nurse practitioner asked Robin if she was afraid of her husband.

“Sometimes,” Robin replied. “The job Denny thought he had when we moved here fell through.  His new job pays a lot less, and Denny says it’s beneath him, but he doesn’t want me to work. He’s different since we left Minnesota, always so tense. Yeah,” she said. “I guess I am afraid.”

Women like Robin have good reason to be afraid. Statistics show that abused women are at a 75% greater risk of being killed by abusers when they leave.¹ Nurses are in a unique situation to practice domestic violence advocacy and must always be alert to a woman’s safety when inquiring about possible abuse. Nurses encounter victims of domestic or intimate-partner violence (IVP) daily, regardless of where they work. And while statistics show victims of abuse to most often be women in heterosexual relationships, victims of IVP abuse are often found in same-sex relationships.

Nurses who work in offices, hospitals, clinics, or in home health must be attentive to the possibility that living with domestic violence may be part of their patients’ daily lives. It is an integral part of a nursing assessment to be aware that abuse may either complicate a patient’s diagnosis or may be the underlying catalyst for the symptoms. Simply checking off boxes as part of a screening procedure is not enough. Becoming educated about the problem and knowing how to recognize a possible victim of IVP is key. Even in this new millennium of domestic violence advocacy where CE for healthcare professionals and routine screening of patients in emergency departments (ED) are mandates, many abused people will slip through the cracks.

How great is the problem?

Seven out of 10 women killed in the world’s wealthiest countries are from the United States, and statistics show that husbands, boyfriends, or past lovers kill them. Half of those victims who are murdered are killed with a gun.² The numbers also show that of all the women who are murdered at home, only 3% are killed by strangers.³ And there is a direct correlation to the number of guns in a home and the increased incidence of women murdered during episodes of domestic violence. One study shows that a present or former partner killed 50% of all American women who were homicide victims.⁴

While domestic violence is often seen as a problem of uneducated people living in poor countries, domestic violence is not spawned by poverty. In the United States, a female is three times more likely to be murdered by an intimate partner than a female who lives in Canada, five times more likely to be murdered than a woman who resides in Germany, and eight times more likely to be killed than a women who lives in England or Wales. The female homicide rate for America is 11 times higher than homicide rates in other wealthy countries.²

Women who suffer the pain and shame of domestic violence come from all socioeconomic circles and ethnic backgrounds. A higher income and level of formal education does not protect a woman from encountering an abusive partner. According to the most current national domestic violence studies, between 22% and 25% of all women will experience domestic violence at some time within their lives.⁵

Violent crimes have decreased in the past few years, according to a 2005 U.S. Department of Justice report www.ojp.usdoj.gov/bjs/cvict_c.htm, but of those offenders victimizing females, 21% were described as intimates.⁶ Domestic violence remains the single largest cause of injury to women between the ages of 15 and 44 in the United States. Still, that number does not take into account the women who are victims of emotional abuse.¹ What begins as emotional abuse, over time, often escalates to physical violence.

While the Florida Department of Law Enforcement’s domestic violence figures were 3.3% lower in 2004 than in 2002, rates for 2005 were up again. Domestic violence crimes reported to the police in Florida in 2002 were 121,834 as opposed to 119,772 in 2004, and 120,836 in 2005. Crime in Florida — Florida’s uniform crime report, 2005 — advises that even when statistics reflect a drop, changes should be interpreted with caution, since in small counties with low crime numbers, even a small change in crime can produce a large change in percentage www.fdle.state.fl.us/FSAC/crime_trends/domestic_violence.

Domestic violence criminal homicides in Florida have dropped from 184 to 176, but other IVP has increased. There were 1,146 forcible rapes in 2004, which increased to 1,240. Forcible sodomy attacks show 434 reports, as opposed to 407 last year. Simple assaults increased from 90,079 to 90,455 and incidents of aggravated assaults were up from 21,494 in 2004 to 21,676 in 2005.⁷

The violence doesn’t simply exist between adults. It is often a family affair. According to the Florida Department of Child Protection Services, 111 children died in 2005 from abuse and neglect. Domestic violence may be the single major precursor to child abuse and neglect fatalities in the country.⁸

A U.S. Department of Health and Human Services survey conducted between 1986 and 1993 indicated that children of single parents have an 87% greater risk of being harmed by physical neglect and an 80% chance of suffering serious injury or harm than those from two-parent families.⁹ In 43% of the homes where domestic violence occurs, a child under the age of 12 resides, and 50% of those children living with women who are abused become victims themselves.¹⁰ Those children are particularly vulnerable to becoming trapped in the cycle of violence, and within a few years may choose a relationship with a partner who abuses them. Young women ages 16 to 24 years old experience the highest per capita rate of IVP. In a study of 724 adolescent mothers between the ages of 12 to 18, one of every eight pregnant adolescents reported having been physically assaulted by the father of the baby during the preceding 12 months. Of those, 40% also reported experiencing violence at the hands of a family member or relative. Teen mothers-to-be are at a higher risk for battering than adults.¹¹

As many as 324,000 women each year experience abuse by their partners during pregnancy.¹² For many women, abuse first begins during pregnancy, with women of all races about equally vulnerable. Of those assaulted before pregnancy, half will be attacked again afterward. Although emotional distress, low self-esteem, teen pregnancy, single status, lower education level, unemployment, and unplanned pregnancy may increase the risk of assault, every woman is potentially at risk.¹³

However, women need not be of child-bearing age to become victims of domestic violence. No comprehensive national data exists, but the best information available shows between one and two million senior Americans are abused by someone they depend on. Women suffer abuse more frequently than men, but for every case of elder abuse, neglect exploitation, or self-neglect reported, it is believed five go unreported. With a projection indicating that 86.7 million people, or 21% of the total population, will be older than 65 by 2050, nurses must remain vigilant¹⁴ http://www.census.gov/pubinfo/www/multimedia/Older2004.html.

The statistics overwhelmingly indicate nurses may be able to help reduce the number of fatalities by simply recognizing a patient may be a victim of domestic violence and offering support to the victim in terms of validation or access to community services.  The nagging persistence of domestic violence has compelled the American Nurses’ Association (ANA) to form its own domestic violence advocacy policy. The ANA supports education of nurses, healthcare providers, and women in skills necessary for prevention of violence against women, assessment of women in healthcare institutions and community settings, and research on awareness of the problems of violence against women to reduce injuries and psychological misery¹⁵ www.nursingworld.org/readroom/position/social/scviol.htm.

The ANA supports Healthy People 2010 objectives and other research that promote surveillance, prevention, and intervention for violent behavior as a priority issue for the nation.

Fiscally, the health-related cost of domestic violence, including rape, physical assault, stalking, and homicide, exceeds $5.8 billion each year, with $4.1 billion going for direct medical and mental healthcare services and 1.8 billion for indirect cost, including lost productivity and wages.¹⁶

Each year more than one million women and 1.4 million children in America are assaulted by members of their own families. And while women are mostly at risk, IVP does plague heterosexual men and is a problem in the gay community. The results of such violent attacks in all relationships often end in murder, with 17% of all murder victims killed by an intimate.¹⁷

What is abuse?

Domestic violence or IVP advocacy means helping stop the cycle of power and control that mounts a physical, sexual, and/or psychological assault against a spouse or intimate partner. IVP can involve children, partners in same-sex relations, and often includes the destruction of personal property and pets. Abuse can be physical, emotional, or sexual, or any combination of the three. What begins as name calling and belittling often escalates to physical violence. What starts as a push into a wall can lead to a broken arm or a fatal injury. A shove can be deadly when a victims tumbles down a staircase. Add weapons to the mix and the outcome generally ends in homicide. An abuser will use whatever means necessary to stay in control, but that doesn’t mean abuse occurs every day.

Not all victims of domestic violence present in an ED with physical marks of abuse. Some have pain harder to detect. Emotional abuse, degradation, and threats of violence leave invisible wounds at first, but can fulminate into depression, helplessness, and low self-esteem. Sexual abuse is more overt in forced, unwilling sexual acts, which often go unreported. For women who are first abused during pregnancy, almost half can be expected to be attacked again afterward.¹⁸

Abuse often emerges in adolescent dating because one or both of the teens have witnessed or experienced domestic violence in their families. When teens see adults abuse one another, they know no other way to solve problems or to deal with emotional issues. Boys often think a slap will keep a girl in line. If the girl comes from an abusive background, she may think that all relationships are abusive, so she remains passive.

Abuse also comes in the form of emotional pressure for teens, including threats of a breakup if sexual activity does not occur or calling a girl immature or inadequate if she does not agree to sexual activity. Emotional manipulation for sexual activity most commonly occurs with younger girls who are often insecure about their own sexuality. Sexual violence in adolescent dating can refer to forced sexual activity, rough or painful sexual activity, gang rape, and sexual exploitation of younger or intoxicated victims.¹⁹ Forced sexual activity can have long-term physical and emotional health consequences for victims, such as feelings of helplessness, powerlessness, anxiety, post-traumatic stress disorder, multiple physical complaints, and genital injuries.²⁰

Adolescents and children, simply by living in a household where domestic violence is used to control and intimidate, become victims of violence from a parent, a parent’s significant other, or another family member. Domestic violence is often family-wide with members from infants to elders victimized.

Violence works to keep loved ones under control. Perpetrators, sometimes church-going community leaders, are often charming and friendly to others. They usually only use violence to control the people they love; the violence gives them the power to control another person.

Issues of power and control

Abusers may control the money in a relationship and allow a victim no means to leave or to secure credit for a separate future. They may refuse to allow the partner to work or attend school, complaining that the family will suffer from the woman’s absence. The abused may perceive the rationale as legitimate and quit all outside activities. Through gradual or sudden separation, victims can become isolated from family and friends, which strengthens the abusers’ position of control.

Placating behavior on the part of a victim to prevent violence from recurring is a part of the power and control process. While the victim may feel responsible for the abuser’s behavior, and is often told by the abuser that she triggered the abuse, the responsibility and choice to use violence is at the heart of the power and control issue. The abuser is solely responsible.

Power and control can include threats of taking children away from their mother if she leaves, so she may never see them again. With the isolation and lack of other people to offer objectivity, fear motivates the victim to stay. She perceives the present situation as less frightening than the future, should she leave. Sometimes, she is right. When an abuser feels he has lost all power and control, he often resorts to physical violence. Often it is after that show of violence that healthcare providers first interact with victims. Yet, the abuser may have convinced the victim that she precipitated the violence, making battered women difficult for healthcare providers to identify.

Recognizing the victims

Domestic violence victims may not admit they are abused. They may also not be easy to recognize; however, to function as advocates, nurses need to look for subtle clues and historical indicators suggesting abuse. For example, look for those who experienced abuse as children, which can be predictive of later adult abuse. Regardless of the area a nurse works in, he or she comes in contact with those who are living with abuse. One study showed that 44% of women killed by intimate partners had visited an ED within two years of the homicide with approximately 93% of those women having at least one visit due to injuries.²¹ A survey of 1,931 women from four primary care practices showed that 22% of those surveyed experienced physical or sexual abuse as children and of those, half reported being abused as adults.²² Investigate further if a woman admits to injuries inflicted by a partner, past or present.

Long before questioning patients, previous admissions or ED visits, sometimes by sheer volume alone, can suggest abuse. Examine medical records for past injuries that may be clues to previous abuse. Healthcare workers often overlook abused women as “difficult patients” or “chronic complainers.” However, multiple visits for vague, somatic complaints can be triggered by brutal relationships. Chronic headaches and neck, stomach, pelvic, or abdominal pain may also be evidence of abuse.

Insomnia, a history of suicide attempts, and alcohol and drug abuse can all be the result of living with the stress of being battered or of psychological or sexual abuse. In fact, many women who abuse substances are adult or childhood victims of emotional, physical, or sexual abuse, including incest.²³ Victims of IVP may have more sexually transmitted diseases because they are often unable to negotiate condom use with their abusers.

Since physical violence often starts during pregnancy, prenatal visits are an optimal time for nurses to screen for abuse. Battering occurs to pregnant women more frequently than hypertension, gestational diabetes, or any other antepartum complication. When caring for pregnant women, watch for those who come to prenatal care late into a pregnancy, or have poor nutrition; also, low-birth weight and preterm labor are possible indicators of abuse.²⁴ Nurses should consider that some normal hormonal or emotional variations of pregnancy, such as sadness, depression, anxiety about the pregnancy, or concerns for the baby or partner, can result from increased interpersonal stress caused by abuse.²⁵

The most vulnerable mothers-to-be are teenagers. Recognizing teens who have been abused is often difficult since subtle behavioral indicators may be the only signs, and may be difficult to differentiate from normal, sometimes introverted teenage behavior. However, signs may be as severe as a history of forcing sexual acts on other children, seductive or promiscuous behavior, or prostitution. Family members and healthcare workers sometimes do not recognize the correlations between adolescents who act out and IVP, even if the teen presents with severe signs. Warning signs that must be taken seriously are teens with a history of engaging in withdrawal, fantasy, infantile behavior, extreme fear, and self-injurious behavior.

Young children often present with signs of living with abuse that are difficult to differentiate from other issues. A child lagging in physical, mental, or emotional development; with a speech disorder or failure to thrive; with consistent hunger, poor hygiene, inappropriate dress for the season, lack of supervision, unattended medical needs, or chronic truancy; or with a history of obsessions, phobias or compulsions, may be a victim of domestic violence.

In the ED, 800 to 1,200 infants a year present with subdural hematomas and other neurological injuries consistent with shaken baby syndrome. Both children and adolescents who are victims of sexual abuse may display subtle signs of stomach aches to abdominal pain, regressive bedwetting, and recurrent urinary tract and yeast infections. Drastic weight fluctuation is often noted.²⁶

Interactions between the child and a parent are often most revealing when taking a history and performing a physical assessment. Watch the parent’s reaction to the child answering questions and observe the child’s response. Some abused children cling to the abusive parent even after being injured, hoping to assure the parent that the secret is not being divulged. This behavior can also be an attempt to remain safe, to prevent further abuse, and to receive physical assurance that the abuser still loves the child. However, normal unabused children often also cling to parents in unfamiliar environments, so other indications for suspicion of abuse must be present.

At the other end of the life spectrum are some seniors who live in violent relationships. Elder abuse is often missed. Older people are often ignored, but many older women have spent a lifetime living with domestic violence. Still, to some elders, abuse is a new occurrence, one that comes with becoming dependent upon other people for daily care. Elderly are often abused or neglected by family members, whom they rely on. Cognitively impaired individuals may depend upon family members to meet their needs and personal care. Elders with dementia often have poor judgment and cannot communicate those needs, so they are higher risks for abuse.

Neglect may be a factor if, for example, an elderly woman indicates she needs glasses or dentures and does not have access to them, admits she feels unsafe in her residence, cannot get help when needed, or states she is left alone for long periods of time.²⁷

Caregivers who seem uncooperative with healthcare providers or who demonstrate anger or indifference toward the older person should alert professionals to a potentially dysfunctional situation. The law requires both child and elder abuse or neglect to be reported.

Searching for physical evidence

No single sign usually marks patients as victims. Nurses need to be vigilant for subtle physical and psychological clues while performing assessments. Observe for the markers that may indicate abuse. Many abusers injure women in a “bathing-suit pattern” by pinching, punching, and burning soft fleshy tissue normally covered by clothing and only revealed during a medical examination. Look for symmetrical bruises on the upper arms, wrists, and neck where a person might physically attempt to stop the victim from walking away. Check for nail marks or a swatch of hair missing from the woman’s head, which she might try to hide under a hat. Use of makeup, clothing, or hair to cover injuries is also indicative of possible abuse.

Victims of all ages often have bruises in various stages of healing. Old fractures and injuries inconsistent with an explanation of how they occurred should trigger suspicion, for example, a patient reporting that symmetrical injuries resulted from “bumping into the bathroom sink.” Fractured mandibles, black eyes, ruptured tympanic membranes, lacerations around the eyes and lips, and subdural hematomas, as well as rib fractures and bruises on the breasts or genitalia, are suspect of abuse.

In the elderly, malnutrition, dehydration, poor personal hygiene, skin ulcers, and extreme agitation or withdrawal may be signs of neglect, while unexplained venereal disease or genital infection may signal sexual abuse. Should these individuals be in abusive situation, they often cannot or will not tell anyone.²⁸

Observation is key to recognizing patterns of abuse. In abusive relationships, subtle clues are normally present if the nurse knows the signs.  Minor injuries often become extreme emergencies to a victim of abuse, while severe trauma may barely raise a concern. A victim may watch a partner for signs of approval before answering questions, or edge toward the opposite side of the stretcher when her partner walks near. An abuser may interrupt a victim while she is talking with the nurse or may talk over the victim in an attempt to dominate the conversation and provide all the pertinent information. A nurse may notice the patient’s heart rate accelerate when the abusive partner enters the room and moves closer. None of these observations alone indicate abuse, but their presence warrants further exploration.

A systematic approach to the woman during pregnancy can increase the reporting of prenatal violence. One study found that the use of abuse screening during the initial prenatal visit, followed by multiple assessments during subsequent visits, augmented reporting of abuse by 22 times, compared with questioning about abuse solely at the initial visit.²⁹ Complications of pregnancy are anemia, infections, symptoms of preterm labor, inadequate weight gain, poor nutrition, low-birth weight, or fetal-maternal injury. Any could indicate abuse.

Second trimester bleeding is significantly higher for abused women. So too are maternal instances of depression, suicide attempts, and tobacco, alcohol, and illicit drug use. Although abuse may begin or accelerate during the prenatal period, few women ever report the phenomenon to their providers.³⁰

When working with pregnant teenagers, developing trust and establishing rapport from the onset of pregnancy counseling is important since teenagers do not often disclose abuse.³¹ Screening for abuse in both adults and teens is also advised during well-baby care visits.

Obvious physical signs of abuse in children are bruises in the shape of handprints, belt buckles, welts, and other pattern injuries. Observe and be suspicious of round burns suggestive of a cigarette burn, long burns that mimic curling irons, and contusions with an imprint from a ring. Often an abused child will present with burns on his or her buttocks and genitalia. Linear and loop marks may suggest the use of an electrical cord or belt. Blunt trauma can affect the GI tract, cardiopulmonary, or central nervous systems. Fractured ribs can precipitate a pneumothorax, heart contusion, and pericardial tamponade. Infants or children with altered mental states, unresponsiveness, convulsions, or other neurological deficits may be victims.

Sexually abused children may present with sexually transmitted diseases; rectal bleeding and bruises; bite marks; or bruises in the soft palate or the rectal, thigh, or genital areas. You may find torn, stained, or bloody underclothing. Less obvious signs are pain or itching in the genital area, painful discharge of urine, and/or repeated urinary tract infections.³²

While children can enter the ED or clinic with signs and symptoms that suggest abuse, it may be that no abuse has occurred; for example, an infant who sustained a fracture from a fall while being diapered or dressed. A child not yet diagnosed with osteogenesis imperfecta — a brittle bone disease characterized by bones that break easily — could also present a profile of a child who has been abused.³³

A nurse’s intuition, careful physical assessment, and attention to subtle clues are the often first steps to recognizing the abuse exists. Laws vary from state to state, but all cases of suspected child abuse must be reported to Child Protective Services.

To assist in the education of nurses, the Centers for Disease Control and Prevention (CDC) has a list of training material covering many areas of patient care.³⁴ See Intimate Partner Violence and Sexual Assault: A Guide to Training Materials and Programs for Health Care Providers.

Perpetrators of domestic violence use power and control to manipulate partners and family at home and often continue with a subdued version in public. An abuser may object to a male nurse caring for his partner. He may interrupt questions and answer for his partner. Many abusers refuse to let their victims be alone with nurses, therapists, or physicians, even for a few minutes. Strong objections to leaving the patient alone in your care by the partner, when you already suspect abuse, is a warning signal.

Dating violence

Violence occurs in about 33% of the dating relationships of adolescents. Common reasons adolescents give for violence in a relationship is real or perceived betrayal and jealousy. Many adolescents believe that abuse is justified if one feels betrayed.

Although it may seem obvious, many teens do not think of occasional slapping, pushing, hair pulling, pinching, or even threats with weapons as violence. While dating does not involve the legal and financial commitments of marriage, society affords interpersonal relationships privacy, which contributes to the hidden nature of adolescent dating violence.

Personal factors identified in victims and perpetrators include an attitude that justifies the use of aggression, substance abuse, and a history of violence. Teens are at risk for being victims of dating violence if they are involved with an individual who demonstrates dominance, jealousy, poor anger management skills, and controlling behavior.

Often adolescents believe aggression in relationships is normal, that all couples use violence. They may even minimize the effect of the abuse. Some teens come from abusive homes where control over another partner is a regular occurrence; the culture they have grown up in may even condone such practices. A teen may feel afraid, yet not trust his or her instincts.

Victims who grew up with belittling remarks are often used to being ignored and disrespected. They are accustomed to having their opinions dismissed. Those individuals often slip into adult relationships with abusers who use controlling behavior, extreme jealousy, and possessiveness, which all tend to isolate the victim and foster dependence on the abuser.³⁵

Asking the questions

All patients should be routinely questioned for abuse. Victims may not spontaneously offer information, but many will admit to being in abusive relationships, if asked. Close the door before starting the physical assessment or history, so that the patient’s safety is not compromised. An abuser may be outside the door listening and asking about abuse may well trigger a violent episode. Even if there is no retaliation at the time, the abuser may punish the victim later.

Questions can be incorporated with routine procedures, in an elevator if the nurse is alone with the woman, or in a private room to which the abuser has no access. Broach the subject as routine, showing no more emotion than one would asking any question regarding the patient’s care. Tell the woman such questions are routine, simply part of the history taking process. Incorporating questions regarding the possibility of abuse into the physical assessment process may help assure a woman of the routine nature of the questions. While the questioning is important, so too is respecting the dignity of every individual and his or her culture.

Many nurses shy away from asking about abuse because of a lack of time, because of their own beliefs about asking such personal questions, or because some nurses themselves might have been in a similar situation. While questioning a patient about abuse must be carried out in a private manner, the questioning itself must become as routine during history taking as asking questions about a patient’s bowel habits — delicate subjects, but essential information to caring for the whole person. Inquiring about the possibility of abuse is primary to a patient’s safety and to offering good healthcare. Not broaching the topic of abuse is costly, both in lives and in terms of healthcare dollars.

The cost of not asking the question is tremendous with more than 500,000 women injured as a result of domestic violence requiring medical treatment. The trauma seen from domestic violence does not take into consideration chronic pain, depression, anxiety states, and other long-term health problems suffered by domestic violence survivors. IVP is a major public health concern. The healthcare costs of intimate-partner rape, physical assault, and stalking have been estimated to exceed $5.8 billion each year, of which nearly $4.1 billion is for direct medical and mental healthcare services. When updated to 2003 dollars, the cost exceeded $8.3 billion³⁶ www.cdc.gov/ncipc/pub-res/ipv_cost/04_costs.htm.

Although asking the question is central to helping end violence, sometimes a victim feels relief just confiding in someone about the situation. Listening and assuring the victim that no one deserves to be abused may be the first step toward a patient choosing to live violence free, and that requires little time from a nurse’s schedule. Domestic violence advocacy isn’t strictly a nurse’s role. The social service department, local domestic violence shelter, or police victim advocate’s office can be contacted for further information, if the patient desires.

Nurses should choose the type of question that makes them most comfortable. Direct and indirect questions produce the same results. “Does your partner hit you?” or “Have you ever been or are you now in an abusive situation?” are direct questions. If that approach feels uncomfortable, try indirect questions. “We see many women with injuries or complaints like yours and often they are being abused — has that ever happened to you?” or “Have you and your partner ever gotten physical with one another during an argument?” Or “Many women in our community experience abuse from their partners. Is anything like that happening in your life?” Or “How do you and your partner handle situations when you don’t agree on important issues?”

Asking about violence in an adolescent relationship is just as important as inquiring about adult abuse. Building trust and not using loaded words such as “rape” and “violence” may help to open the lines of communication, since many teens are confused about the definition of date rape and what constitutes intimate partner violence. Communicating may be challenging, but often simply asking, “Does your partner always blame you for his or her problem?” or “Does your partner try to make decisions about whom you see or what you wear?” will jump start a conversation. The inquiry should also focus on whether the teen changes his or her behavior to avoid an argument, how conflict is handled, and the adolescent’s perception of violence. Ask if the teen feels hitting or slapping is okay, for instance, if she flirted with someone, or had threatened to break up with her boyfriend or girlfriend. Gay, lesbian, bisexual, and transgendered teens are also at risk for abuse in their relationships³⁷ www.ndvh.org/educate/teen.html. Disclosure can be emotionally upsetting, so trust and rapport are essential for effective intervention and the support of victims with lowered self-esteem.

While more women than in the past are being screened for abuse, most still are not. One major research project found less than 25% of women presenting in the ED were asked about IVP.³⁸

Maintain a nonjudgmental acceptance of whatever answer the patient offers. If a nurse truly has a problem asking about abuse, another nurse should broach the subject. Any hint of disapproval may keep a victim silent.

Should I stay or should I go?

Nurses cannot choose a life of nonviolence for their patients. They can offer choices, but the responsibility and risks belong to the victim. Many women will leave their abusers (who are also often their life-partner, father of their children, their lover, and financial supporter) as many as seven to eight times before they leave for good. The decision cannot be taken lightly, as the time when a victim leaves is also the time many women and their children are murdered.

Starting a new life is not easy, especially if the victim has repeatedly been told she is ignorant, fat, and lazy or that no one else could ever love her. There is also the fear created by many abusers who claim that the children will be taken away, if she leaves.

Nurses must guard against the feeling of failure, should a victim choose to remain in the abusive relationship. Domestic violence advocacy means giving a woman the choice to leave, but a nurse must remember the choice to leave a violent relationship is strictly up to the victim, and her decision should not diminish the nurse’s efforts. Nurses must also guard against becoming apathetic or judgmental, should the person return numerous times for injuries sustained from abuse. Offer support and assistance, tell victims what community services are specific to them, and exhibit a nonjudgmental attitude.

Whether a victim decides to leave or not, she needs a safety plan in place, should she choose to leave or need to escape at a later time. The optimum circumstance is if the woman has someone outside the house to offer support, a friend, a family member, or neighbor, but this often is not the case. Friends, family, and neighbors who have helped victims leave abusive situations before often refuse to help and withdraw support if the woman returns to the abuser. A safety plan is an important tool, and should include a bag kept somewhere outside the house with money for a bus or cab, phone numbers to call for assistance, a change of clothes for her and her children, and copies of important documents, such as children’s birth certificates, driver’s license, and Social Security cards. These are necessary tools for starting a life away from an abuser.

Of course, nurses should only give out the phone numbers or hotlines of local abuse shelters if the patient wishes to accept them. Many local shelters also have support groups for women who remain in abusive relationships. Often times shelters provide day care facilities during the scheduled time, and the group is helpful to women who choose to stay since the members all live with abuse and understand what each other endures. For victims who may be interested in help, but not at the present time, let them know where the numbers are listed in the phone book. Those emergency numbers should already be posted in areas where women go without their abusers, such as X-ray dressing rooms and restrooms.

There is a toll-free hotline in Florida for English-, Spanish-, and Creole-speaking callers at (800) 500-1119 and a national hotline at (800) 799-SAFE (800/787-3224) for the hearing impaired. The national hotline has interpreters available to translate an additional 139 languages. For women who choose to stay at home, there are many support groups geared to their situation, complete with childcare.

Medical-legal issues

In Florida, the law requires healthcare workers to call the police for adults who are injured from knives, firearms, or other deadly weapons, or that present life-threatening emergencies, all suspected child abuse or neglect,³⁹ and elder abuse and neglect (Elder abuse hot line 1-800-962-2873 or TDD 1-800-453-5145) www.dcf.state.fl.us/as/reporting.shtml.

Before screening for abuse, providers can explain exceptions to confidentiality by saying, “While you are here, if you tell me about a child or elder who is abused, I am required by law to report it.” Since 1992, guidelines from the Joint Commission on Accreditation of Healthcare Organizations have required EDs to maintain lists of community referral agencies specific to domestic violence victims.⁴⁰ Local police department victims’ advocate services provide information about local laws and regulations. Those resources and advocates from local domestic violence shelters can assist nurses to support victims and inform women of their rights and services available.

The legal system has set out to make changes in the way domestic violence is handled in our courts, and nurses and their charting are an important part of that process. Assessment observations, including injuries, signs and symptoms of possible abuse, and statements that victims and alleged abusers make, should be charted. Be specific about shapes and sizes of bruises, for instance, if an injury appears in the shape of a horseshoe ring. Injury maps are perfect tools for pinpointing sites. Always place patients’ words or any statement made by a partner in quotation marks. Should the record be subpoenaed, the nurse cannot be held liable for recording actual statements.

One way to break the cycle of violence is to document injuries with a photograph, but be sure to have patients sign a consent form before taking photographs. Let victims know that like any medical photograph, the photo will stay with the medical record. Should the record be brought into court, the photos may provide the only legal evidence of abuse. There are special cameras for injury documentation in suspected domestic violence cases,⁴¹ but any quality camera will work. When taking photos, move in close to the wound or bruise and fill the frame with the area you are documenting. If possible, take photographs at time of admission and during the next few days, since the area of injury often becomes more visible a day or two later. Both the patient and photographer should sign and date each photo. One of the best domestic violence advocacy tools a nurse has access to is a camera to document injuries.

Place evidence related to an assault, such as torn or blood- or semen-stained clothing, in a sealed paper bag or an envelope to present to the proper authorities.

Nurses are on the front lines for incoming victims of abuse and those who ask the right questions and provide knowledge of community domestic violence resources have the power to become advocates.