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Domestic Violence: Breaking The Silence

About the Author

Shelda L. Hudson, RN, BSN, PHN, completed her baccalaureate degree in nursing and public health certificate at Azusa Pacific University. She is a past member of the International Association of Forensic Nurses (IAFN) and an academic member of the American Botanical Council. She is the Nurse Supervisor of the Instructional Systems Development section of the National Center of Continuing Education. In this capacity, she is responsible for directing the activities of the department, selecting qualified, credentialed authors for the courses offered by the National Center as well as advising staff regarding required course design and criteria. Ms. Hudson has over 20 years of experience in publishing courses in continuing education for health care professionals with the National Center.

Carolyn Hunter, RN, MA, Nursing Education Consultant, National Center of Continuing Education. Assist with assessment, planning, implementation, and evaluation of continuing education offerings. Associate Professor Emeritus, Washington State University College of Nursing. Washington State Nursing Care Quality Assurance Commission, pro tem member.

Purpose and Goals

The goal of the enclosed course is to provide basic instruction on intimate partner violence, including identification, screening, and referral of persons with a history of being, or at risk of becoming, victims or perpetrators of intimate partner violence.

Instructional Objectives

Upon completion of this course, the learner will be able to:

1. Estimate the number of women who are likely to be victims of intimate partner violence (IPV).
2. Define dating violence and the connection with risk factors & health problems.
3. Outline the anatomy and progress of an abusive relationship and correlate with Dr. Lenore Walker's "Three Phase Theory" of domestic violence.
4. Provide information concerning characteristics of victims and perpetrators of violence.
5. Enumerate important prevention and intervention strategies the health professional can use to determine if a patient is affected by intimate partner violence.
6. Tell how power of mobile technology can be utilized to help prevent dating violence and abuse.
7. Identify important advocacy and support organizations available to the domestic violence victim/perpetrator.
8. List some preventive and treatment measures that can be used for abusive families.

Introduction

Intimate partner violence (including domestic and dating violence) is increasingly recognized as a serious and widespread public health crisis that affects individuals of all ethnic and socioeconomic backgrounds. Domestic violence, now referred to as intimate partner violence (IPV), has been defined as a pattern of coercive control consisting of physical, psychological and/or sexual assaults against current or former intimate partners. Batterers also commonly use economic abuse, isolation, and intimidation to exert power over their partners. The heart of the problem is always an imbalance of power. The abuser learns that coercion "works," that it's effective in controlling the relationship and in reinforcing the power imbalance.

This course often refers to the battering of women, since 85% of serious domestic assault victims are women, according to the U.S. Department of Justice, Bureau of Justice Statistics. However, it can also occur by women against men, and between same sex partners.

With the continued heightened awareness of acts of violence, many state boards of nursing require courses on intimate partner violence. This requirement is designed to curb the problem of violence by providing information that will help you identify the perpetrators of violence and assist you and others to avoid it.

Cries for Help ... Are We Listening?

Millions of women are battered each year by their partners – one every 15 seconds. It is so common that it is now the leading cause of injury to American women, accounting for more hospital emergency room visits than auto accidents, muggings, and rapes combined.

One in three women (35.6%) will be subjected to IPV at some point in life, and as many as 20% of pregnant women are abused by their partners (or, in pregnant adolescents), making IPV more common than preeclampsia and gestational diabetes. Pregnancy itself (particularly if unplanned), prior abuse, and delayed prenatal care are risk factors for IPV. Adverse outcomes associated with IPV before or during pregnancy include urinary tract infections, vaginal bleeding, preterm labor, and substance abuse.

Domestic violence accounts for more than 30% of female homicide cases. A surprising gallery of famous women reportedly touched by domestic abuse includes: Tina Turner, Daryl Hannah, Roseanne, Madonna, and the late Nicole Brown Simpson.

Nurses and other healthcare providers are strongly encouraged to recognize, treat, and prevent this "silent epidemic" that rages throughout our society. We are in a unique position to address this public health problem. Yet domestic violence remains extensively under-detected.

The Three-Phase Theory of Violence

In a classic study psychologist Lenore Walker, Ed.D., ABPP, completed extensive research on more than 1,000 battered women, as well as a smaller group of abused men. She found a pattern and labeled it the "Three Phase Theory" of family violence.

1. Tension-Building Phase: Tension is a normal factor in everyone's life and indeed, in all relationships. However, for a variety of reasons, some people react to tensions violently. Once violence occurs within a relationship, it compounds the normal tensions.

During the tension-building phase of a violent relationship, the woman will sense her partner's increasing tension. She may or may not know what is wrong. The man often is edgy, lashes out in anger and challenges her, tells her she is stupid, incompetent and unconcerned about his welfare. In a violent relationship, the woman generally lets the batterer know she accepts his blame of her. She tries hard not to make any "mistakes" that may upset him. She takes the responsibility for making him feel better and thus begins to set herself up to feel guilt when he eventually explodes in spite of her best efforts to calm and please him.

During the increasing tension, the woman is rarely angry even at the most unreasonable demands or blame. Rather, she internalizes her appropriate anger at the man's unfairness, and instead feels depression, anxiety, and a sense of helplessness. She may suffer physical symptoms related to her emotional distress, such as headaches, upset stomach, difficulty sleeping, weakness and fatigue. These problems increase the woman's sense of worthlessness and loss of control and make her more vulnerable to the man's criticisms.

The woman may often deny her fear in an attempt to minimize the seriousness of the threat, believing she can control the situation. Even if she acknowledges her fear and danger, she often may not seek help. She usually feels ashamed of her failure to please her partner and believes, often correctly, that if other people know about the violence they will blame her for it.

As the tension in the relationship increases, seemingly minor episodes of violence, such as pinching, tripping, slapping, or shoving occur. The batterer knows his behavior is inappropriate, and he fears the woman will leave him. The fear of rejection and loss only serve to increase his rage at the woman and his intense need to control her.

2. Acute Battering Incident Phase: The tension-building phase ends in an explosion of violence. The incident that sets off the man's violence is often trivial or unknown, leaving the woman desperately confused and feeling very helpless. The woman may or may not fight back. She often attempts to escape the violence, or calls for help. If she cannot escape the beatings, she may make herself feel as if the beatings are happening in a dream. She may not be aware how badly she is hurt.

Following the battering, the woman is in a state of physical and psychological shock. She may be passive and withdrawn, or incoherent. She may not appreciate the seriousness of her injuries and may resist getting treatment. The man may discount the episode, and he usually underestimates the woman's injuries. He may refuse to summon medical help even when her injuries are obviously life threatening.

3. Loving Reconciliation Phase: Loving reconciliation may begin within a period of a few hours to several days following the acute battering incident. Both the man and the woman have a profound sense of relief the incident "is over." While the woman may be initially angry with the man, he begins an intense campaign to "win her back." Just as his tension and violence were overdone, his apologies, gifts and gestures of love may also be excessive. He showers her with love and praise that helps to repair her shattered self-esteem. It is nearly impossible for her to leave him during this phase as he is meeting her desperate need to see herself as a competent and lovable woman.

It is during this phase that the woman's feelings of power and her romantic ideals are nurtured. She believes that this gentle, loving person is her "real" man. She believes if only she can find the key, she can control him and prevent further violent episodes. No matter how often it has happened, somehow this episode seems different and she really believes it will never happen again. During the loving reconciliation, a strong bond develops between the couple, isolating both of them from reality and from anyone who might try to intervene in their destructive relationship. Anyone who has attempted to support the woman and urged her out of the violent relationship may now be seen as "the enemy" trying to separate the loving couple.

Loving reconciliation is a period of intense pleasure and reassurance for the couple. It convinces them there is nothing wrong with their relationship and discourages them from seeking assistance from other people or agencies. It is also isolating and provides them a time of being alone. When the violence recurs, the woman finds she has fewer and fewer places to turn for support.

Loving reconciliation also becomes a kind of reward for the violence. Psychologists have found that any behavior followed by a positive reward will occur more frequently. The more often the periods of uncomfortable tension that end in a violent explosion are followed by loving closeness, the less likely the couple will seek alternatives for handling tension and stress. To end the episodes of violence, this cycle must be broken and new alternatives for handling their tension must be developed by the couples that are caught up in the battering relationship.

Causes of Violence Between Partners

Violence between partners may be triggered by numerous factors. Some of these triggering factors are:

1. Stress situations such as job loss, financial problems, pregnancy or role changes.
2. Frustrations: Underachieving or not achieving goals.
3. Alcohol and/or other substance abuses.
4. Abuse-prone attitudes and beliefs: "Show the woman who's boss," or "I wouldn't hit her if she didn't deserve it."
5. Childhood experiences of abuse and/or parental violence.
6. Psychological or physical disorders.

For many years, intimate partner violence was largely viewed as simply a "family problem." In numerous instances the police, courts and hospitals, as well as most social service organizations, were hesitant to intervene. However, as a result of the growing issue with violence in general, persons from these agencies and other community groups have become more outspoken and active in the causes of violence within the home.

The Abuser: Often Called the Offender

Just what kind of man is the person who abuses women? Research reveals that batterers come from every walk of life. They are as varied as the circumstances in which they live. Batterers are usually men who were physically or psychologically abused in their homes when they were children. Often they grew up in homes where episodes of violence were common, and their father either beat or completely dominated their mother.

Batterers are also manipulative and often will exhibit a dual personality that is convincingly charming one minute and violent or aggressive the next. The batterer's victim will never know which behavior he will exhibit the next moment, hour, day or week. To protect herself she must be constantly on the alert to ensure he is kept calm.

The majority of battering men will refuse to admit they have a problem. This is true in the sense that what they are seeking is control of the woman, and they want their control to be absolute and complete. Often because of his larger size, the batterer is in little danger of physical harm from his victim. Frequently if the battered woman attempts to protect herself by fighting him, he will become more enraged and the battering more intense. The batterer will not usually volunteer himself for help and treatment until after the woman has left him and the battering environment and sought help on her own. When the victim is unwilling or unable to leave and seek help, the batterer really has no incentive to change his behavior.

The abuser will often refuse to take responsibility for his destructive behavior. He may use excuses such as, "I was drunk," "I didn't know what I was doing," or "It just happened." He may, in fact, believe his abuse and violence are justified; in any case, the assaults will continue to occur.

Recognizing the Battered Woman

If you suspect that someone is the victim of domestic/family violence, what are some of the signs to confirm your suspicions? You should be especially suspicious if the woman is frequently absent from work or social activities. If she reappears wearing long sleeves in warm weather, sunglasses indoors, scarves around her throat, or in extremely heavy makeup, this should raise questions in your mind.

If the woman is often absent from work or otherwise is homebound as a result of a high incidence of sickness, surgeries or other ailments, you should suspect she is a victim of battering. Suspect abuse if she is unable to hide blackened eyes, broken limbs or bruises; and when asked about them, says she was in an accident or experienced a fall, is really clumsy or some other excuse. If she seems to be excessively private, avoids old friends, or if her personality suddenly changes drastically, it is not unreasonable for you to suspect she is a battered woman.

Whenever you suspect battering and the woman victim either will not or cannot admit she is in danger, keep in mind she is suffering from a learned helplessness. Often, her state of mind is such that she believes she must rely totally on the batterer to survive. She is also worried about her health and well- being because she is aware of the fact he might harm her if she attempts to leave. If children are involved, she will also be concerned about their welfare. This is your opportunity to share some kindness with her and respect whatever she decides to do. Clinicians should aim to build a therapeutic relationship with IPV survivors that empowers and educates patients and does not demand disclosure.

Children – The Silent Victims of Domestic Violence

Children who witness domestic violence are themselves victims of abuse. Unless directly abused, they are often overlooked and do not receive adequate services. The children of battered women must contend with the same myths and untruths about battering which confront their mothers. They must also deal with adult prejudice which tells them, "It's not so bad...don't worry. Everything will be all right." Meanwhile, everything they feel and have experienced is bad.

Many parents minimize or deny the presence of children while the mothers are being assaulted. However, interviews with children of battered women reveal they have seen and heard, and can give detailed accounts of violent behavior that their mother or father never realized they had witnessed. Events can be witnessed in many ways, not just by sight. Children may hear their mother's screams and crying; the abuser's threats; sounds of fists hitting flesh, glass breaking, and wood splintering; cursing and degrading language. Children also witness the consequences of the abuse after it has occurred – their mother's bruises and torn clothes, holes in walls, broken furniture, their mother's tears. They sense the tension in the house, and in their mother.

Many fathers inadvertently injure their children while throwing furniture or other household objects when abusing their partners. The youngest -children sustain the most serious injuries, such as concussions, or broken shoulders and ribs. These children also suffer poor health, low self-esteem, poor impulse control, sleeping difficulties, and feelings of powerlessness. They are at high risk for alcohol and drug use, sexual acting out, running away from home, isolation, loneliness, fear and suicide. Who will speak for them?

Victims of Intimate Partner Violence

All individuals with evidence of trauma need to be questioned directly about the potential for domestic abuse using a structured, nonjudgmental, confidential interview conducted in privacy and safety. Current recommendations include routine screening of all female patients over age 14.

Recognizing Signs & Symptoms

In addition to the obvious signs listed below, be alert to the presentation of stress-related complaints such as headaches, or stress-enhanced conditions such as chronic upper respiratory problems or bronchitis.

• Physical Abuse: Trauma/pattern of injury inconsistent with event history; delay in presentation.
• Emotional or Sexual Abuse: Adults frequently present with complaints associated with long-term stress and chronic anxiety. Children or adolescents may present with behavioral problems. The elderly may present as withdrawn or fearful of authority.
• Neglect: Lack of attention to person or environment.
• Patterned Injuries: Central injuries to the face, head, neck, breasts, abdomen, and genitals are prevalent in contrast to accidental injuries affecting the periphery or extremities. A pattern of multiple non-life threatening injuries at varying stages of healing is highly suspicious. In children and the elderly, spiral fractures may be indicative of abuse.
• Pregnancy: Escalation of domestic violence is seen in pregnant women with up to 35% of obstetric patients suffering some type of physical assault.
• Screen for batterers, too: The batterer may be our patient in some circumstances, and treating contributing factors can help stop abuse. A batterer may suffer from depression, chemical dependency, or post-traumatic stress disorder, for example. Past head injuries have also been associated with pathological jealousy and violence. Empathy, rather than a confrontational approach, may make the batterer more amenable to treatment.

Prevention and Intervention Strategies

• Recognize potential victims; take your time to establish rapport, and ask direct questions about domestic battering. Simple and specific is best.
• Implement your agency's DV protocol if domestic violence is suspected
• Triage for immediacy of need for treatment
• If injuries do not require immediate trauma or surgical care, take history from patient alone in private room
• If injuries require immediate trauma or surgical care, call security, local police, or both if partner seems disruptive or dangerous
• Contact victim's advocacy representative and offer services to client as available

What Should You Do if Clinical Signs are Evident?

If any of the clinical signs are evident, and there are negative responses to the screening questions, it is appropriate to ask additional questions to prompt information such as:

• Sometimes when I see an injury like yours, it is because someone hit them. Did that happen to you?
• I don't know if this is a problem for you, but many women I see are dealing with an abusive relationship, so I've started asking about domestic violence routinely.

Help for Victims of Domestic Violence

The violence your patient is experiencing will not simply go away no matter how often she wishes or prays it will. Neither will it simply get better. Once it has started, it will recur more often and each time it will get progressively worse. It does not matter how much she loves her partner. She must know that she is in danger of losing her life and needs to take steps to assure her own safety.

If she wants protection, she must take the first step. There are many people and places she can call, so she must gather her courage and make a call for help. She can call a friend, family, or the police. She can also call her church, a physician, or a counselor. There are also women's centers, shelters and family crisis centers. They are always open and she will be able to reach them by phone. Family crisis centers have hotlines and are open 24 hours a day, every day. In spite of what she may have been told, these shelters and family crisis centers do not act to break up families. Rather, they work to save lives and often provide counseling services to the batterer as well as the victim, or have information to direct them to sources of assistance. If she is unable to find the family crisis center, call the police, sheriff, district attorney, public library, or Salvation Army. The Salvation Army has kind and caring people who will help without regard to color, religion or ethnic background. They will put her in touch with people who offer exactly the assistance needed. She must not stop until help is obtained. Her very life depends on it.

Dating Violence

1 is 2 Many

Despite the significant progress made in reducing violence against women, there is still a long way to go. Young women still face the highest rates of dating violence and sexual assault. In the last year, one in 10 teens have reported being physically hurt on purpose by a boyfriend or girlfriend. One in five young women have been sexually assaulted while they're in college.

In response to these alarming statistics, healthcare professionals must focus on reducing violence against women specifically on teens and young women ages 16-24. By targeting the importance of changing attitudes that lead to violence and educating the public on the realities of abuse, we can lead the way in an effort to stop violence against women before it begins.

Dating violence is defined as the physical, sexual, or psychological/emotional violence within a dating relationship, as well as stalking. It can occur in person or electronically and may occur between a current or former dating partner. Adolescents and adults are often unaware that teens experience dating violence. In a nationwide survey, 9.4 percent of high school students report being hit, slapped, or physically hurt on purpose by their boyfriend or girlfriend in the 12 months prior to the survey. (Centers for Disease Control and Prevention, 2011 Youth Risk Behavior Survey). About 1 in 5 women and nearly 1 in 7 men who ever experienced rape, physical violence, and/or stalking by an intimate partner, first experienced some form of partner violence between 11 and 17 years of age. Many of these cases can be prevented by helping adolescents develop skills for healthy relationships.

What are the consequences of dating violence?

As teens develop emotionally, they are heavily influenced by their relationship experiences. Healthy relationship behaviors can have a positive effect on a teen's emotional development. Unhealthy, abusive or violent relationships can cause short term and long-term negative effects, or consequences to the developing teen. Victims of teen dating violence are more likely to do poorly in school, and report binge drinking, suicide attempts, and physical fighting. Victims may also carry the patterns of violence into future relationships.

Why Does Dating Violence Happen?

Communicating with your partner, managing uncomfortable emotions like anger and jealousy, and treating others with respect are a few ways to keep relationships healthy and non-violent. Teens receive messages about how to behave in relationships from peers, adults in their lives, and the media. All too often these examples suggest violence in a relationship is okay. Violence is never acceptable. But there are reasons why it happens. Violence is related to certain risk factors. Risks of having unhealthy relationships increase for teens who:

• Believe it's okay to use threats or violence to get their way or to express frustration or anger.
• Use alcohol or drugs.
• Can't manage anger or frustration.
• Hang out with violent peers.
• Have multiple sexual partners.
• Have a friend involved in dating violence.
• Are depressed or anxious.
• Have learning difficulties and other problems at school.
• Don't have parental supervision and support.
• Witness violence at home or in the community.
• Have a history of aggressive behavior or bullying.
• Dating violence can be prevented when teens, families, organizations, and communities work together to implement effective prevention strategies.

Choosing Respect: Developing Healthy Relationships to Prevent Dating Violence

Dating violence can be prevented. Adolescence has been characterized as a "window of opportunity" - a time for adolescents to prepare for future relationships by learning healthy relationship skills such as negation, compromise, and conflict resolution. That's why adults need to talk to adolescents now about the importance of choosing respect and developing healthy relationships.

• Several studies suggest that adolescents do not see the negative consequences of dating violence and violence in their friends' lives
• 31% of adolescents report having at least one friend who is in a violent relationship.
• Acceptance of dating violence among friends is one of the strongest links to future involvement in dating violence.
• Adolescents often believe that unhealthy relationships are the norm. Many relationships seen on TV, in the movies, and in magazines are unrealistic or unhealthy examples of relationships.
• Qualities like respect, good communication and honesty are absolute requirements for a healthy relationship. Adolescents that do not have this part down before they begin to date may have trouble forming healthy, nonviolent relationships with others.

Choose Respect is a nationwide effort to prevent dating violence before it starts. It encourages adolescents to form healthy relationships with others-before they even start to date.

Apps Against Abuse

Harness the power of mobile technology to help prevent dating violence and abuse. This can be done by keeping young adults connected to trusted friends and provides easy access to important resources for help including local police and abuse hotlines. Here are a few to consider:

Circle of 6

This iPhone app makes it quick and easy to reach your circle of supporters and let them know where you are and what you need. It takes two touches to get help. The app uses text messaging to contact your circle, uses GPS to locate you when needed, connects to reputable domestic violence organizations, and asks contacts to take a pledge on Facebook to stop violence before it happens.

On Watch

On Watch is an iPhone app that lets you transmit critical information by phone, email, text, and social media to your support network. You can check in with friends, call 911 or campus police with two touches of a button, set countdown timers that send messages and GPS information automatically if events or activities don't go according to plan, and connect to sexual assault, dating violence and domestic abuse hotlines.

Domestic Violence–Breaking the Silence

For the past eight years Sally has been a hard-working, reliable employee. She is pleasant with patients and coworkers and rarely makes a mistake. Recently, Sally is distracted, jumpy and has been making careless errors. Last Friday she called in sick for the fifth time in three weeks. When asked about these performance issues, Sally nervously discloses that there are problems at home, but swears that they won't affect work again. As she fights back tears, it's obvious that she is both uncomfortable discussing the issue and also fearful that she'll lose her job. As you look at her, you find yourself wondering if her heavier than usual makeup is covering a bruise on her cheek?

Later, when you see her anxiously looking at a person sitting in a parked car across the street, you realize that these 'problems at home' have just entered your workplace. What now? You're worried about this dedicated employee, but you've got patients and a shift to supervise.

Domestic violence is an abuse of power and control that may include: physical abuse, emotional abuse, intimidation, threats, financial control, social isolation, or sexual abuse.

While victims and their children bear the heaviest personal costs, the effects of intimate partner violence are seen throughout our community.

Take a deep breath, and think long and hard about these things:

• In our workplaces, lost productivity and earnings due to intimate partner violence account for almost $1.8 billion each year. Children exposed to violence in the home, may have difficulty in school, in their social relationships and with physical or emotional health.
• Battered women account for 22-35% of women seeking care for any reason from emergency departments. Health care costs attributed to intimate partner violence exceed $4.1 billion each year for direct medical and mental health services, much of which is paid for by employer health plans.
• Domestic violence seriously impacts homelessness and poverty rates; 50% of all homeless women and children are on the streets because of violence in the home.
• The most appalling cost of domestic violence is that so many members of our community live each day in fear and desperation - fear that they will be intimidated, threatened or attacked within their own home by a person who claims to love them.

Communication is Key

As IPV increases in our society, health professionals need to prepare to best meet the needs of these individuals. Hospitals should have policies that encourage nurses to consider abuse with the patients they serve. These policies need to ensure private, confidential interviewing of all patients and standardize the follow-up for any identified cases. There needs to be routine prompts in an assessment and history that clarify whether the person is in a violent situation.

Although battered women seek medical care frequently, as few as one in 20 are accurately identified by the practitioners to whom they turn for help. As many as 50% of victims murdered by a spouse or lover were seen in a hospital emergency department, but not screened for domestic violence, before they were killed. Research shows this is largely due to lack of knowledge and training, and that battered women expect healthcare providers to initiate discussions about abuse. However, IPV is rarely detected or disclosed without inquiry by the clinician in routine and repeat screenings.

Nurses should understand more specifically the context of IPV and know the community resources available to survivors of this violence. Last, professionals need to recognize the physical, psychological, and emotional support they can give to these individuals. The acronym RADAR, developed by the Massachusetts Medical Society, succinctly represents the thought processes that need to occur with all domestic violence cases:

R: Routine screening.
A: Ask direct questions.
D: Document findings.
A: Assess patient (and children) safety.
R: Review patient options and provide referrals.

The ultimate aim for hospitals is to empower nurses to provide compassionate care for survivors and establish emotional climates conducive to IPV disclosure and subsequent care.

Clients need to know that it is appropriate to disclose IPV in health care settings. The lack of effective communication on safety assessment, referrals, and follow-up for IPV can also present a problem.

"I used to go without medical treatment... I'd wait until it wasn't a choice anymore. And I'd wind up having to go to the emergency room." or "Somebody would find out something was happening in my house, like a social worker, a doctor, a nurse or whatever, I would stop going there and go somewhere else."

And the lack of an emotional connection with the clinician can be another issue to address. Describing an ED visit, one woman commented: "He checked me, he didn't ask any questions, nothing, and they took x-rays and pulled out of there... Maybe I was hoping... that they would talk to me? I mean, they checked me out... but I didn't feel like... emotionally? Like maybe talk, some kind of comfort?"

Benefits of Disclosure: Making Changes, Improving Self-Esteem, Building Relationships

With improved awareness and appropriate intervention, attention is directed to how healthcare professionals can best respond to breaking the cycle. We need to inquire routinely about domestic/family violence, provide sensitive and nonjudgmental support, address patient safety, document the abuse, provide information about resources and options, and offer referrals.

Such familiarity can also occur in the ED setting, as in one case where the abused woman accepted advice from a nurse who had treated her a few weeks earlier for IPV-related injuries. When the participant returned to the ED with more injuries, the nurse recognized her:

"And I started crying, and she said, 'Two weeks ago you were here, now you're back here again today and it's for the same thing. Your face isn't all bruised up like it was two weeks ago, but you're hurtin'. What's goin' on?' I broke down and told her...She was like, 'Well, you don't need to be in a relationship like that." The woman acted on referrals and left her abusive partner as a result of this encounter.

Patient-Clinician Encounters

Instead of an immediate end to the abuse, these patient-clinician encounters resulted in a shift in the participant's self-esteem, perception of the violent relationship, or awareness of alternatives, eventually empowering her to seek help for the abuse on her own. For example, clinicians' assurances that relationship violence was unacceptable resonated. One woman reported her primary care doctor's sympathetic insistence that the batterer's behavior was wrong set the stage for her to take action: "She was like, 'No...no one who loves you will put their hands on you.' You know, it's not right. 'That's not real love.'...After [he broke] the wrist, I said, 'No more."

Advocacy: Empowering the Victim

"Empowerment advocacy believes that battering is not something that happens to a woman because of her characteristics, her family background, her psychological "profile," her family of origin, dysfunction, or her unconscious search for a certain type of a man. Battering can happen to anyone who has the misfortune to become involved with a person who wants power and control enough to be violent to get it." – Barbara Hart, Seeking Justice: Legal Advocacy Principles and Practice.

The primary goal of intervention is empowerment. By sharing your observations, by agreeing that what's happening is wrong, just by listening in a warm and accepting way, you give the victim strength and determination. Many victims are relieved at the opportunity to tell the truth instead of constantly covering up. You may learn that you're the first person to confirm that her feelings of hurt and anger, the desire for support and change, are normal. Perhaps most important, you will have supported the patient's independence and autonomy as a decision-maker and helped her to recognize her strengths and resources as a survivor.

In summary, battering is a pattern of behavior used to establish power and control over another person with whom an intimate relationship is or has been shared through fear and intimidation, often including the threat or use of violence. Battering happens when one person believes that they are entitled to control another. Intimate partner violence may include intimate partner relationships, live-in partners, and dating relationships, but also familial, elder, and child abuse may be present in a violent home.

Rural and urban women of all religious, ethnic, socio-economic, and educational backgrounds, and of varying ages, physical abilities, and lifestyles can be affected by violence. u

–Domestic Violence is Not Just a Private Issue-It Impacts All of Us–

Resources

National Center on Child Abuse:
1-800-4 A-Child

National Domestic Violence Hotline:
1-800-799-SAFE (Emergency 24 Hour)

National Center of Elder Abuse
www.elderabusecenter.org

References and Suggested Readings

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Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G., Walters, M.L., Merrick, M.T., Chen, J., & Stevens, M.R. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

Brackley MH, Williams GB, Wei CC "Substance abuse interface with intimate partner violence: what treatment programs need to know." Nurs Clin North Am, Dec 2010, 45(4) p581-9, vi

Brykczynski KA, Crane P, Medina CK, et al. "Intimate partner violence: advanced practice nurses clinical stories of success and challenge." J Am Acad Nurse Pract, Mar 2011, 23(3) p143-52

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D'Avolio DA, "System issues: challenges to intimate partner violence screening and intervention." Clin Nurs Res, Feb 2011, 20(1) p64-80

Department of Justice Bureau of Statistics Intimate partner violence [Online] Accessed 2012 July 02, available at http://bjs.ojp.usdoj.gov/

Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S., Ross, J., Hawkins, J., et al. (2010). Youth Risk Behavior Surveillance- United States 2009. Morbidity and Mortality Weekly Report , 1-148.

Fraser C, Family issues associated with military deployment, family violence, and military sexual trauma. Nurs Clin North Am, Dec 2011, 46(4) p445-55, vi

Hawley DA, Hawley Barker AC, Survivors of intimate partner violence: implications for nursing care. Crit Care Nurs Clin North Am, Mar 2012, 24(1) p27-39

Humphreys J, Epel ES, Cooper BA, et al., Telomere shortening in formerly abused and never abused women., Biol Res Nurs, Apr 2012, 14(2) p115-23

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