Nurses assessing family violence--some hidden dangers: nurses need to tread carefully when questioning women about their experience of family violence, under the Government's expanded violence intervention programme. There are hidden dangers in this policy approach.

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New Zealand's shocking Level of child abuse and family violence, including mistreatment of older people, is a sad indictment on our society. Family violence is endemic, appears to be increasing and there are no simple answers. Public and political anxiety is very influential in determining a range of policy and practice responses. This is illustrated in the recent extension of the family violence intervention programme. (1,2) This encourages health professionals, with appropriate training, to routinely screen all female health service users aged 16 years and older by simply asking direct questions about safety and abuse.

Family violence is multi-faceted

While supporting initiatives to reduce family violence, we want to acknowledge the multifaceted complexity of family violence within social, cultural, economic and political contexts. (3) One of our key concerns with responses to yet another case of appalling child abuse is the continued ambulance at the bottom of the cliff approach. This approach tends to address organisational needs to manage incidents, without necessarily addressing the actual needs of those being mistreated. It is crucial we Look beyond the rhetoric and the expert-led, problem-focused approach (4) to delve into the multiple dimensions affecting families today. If we really are serious about addressing the violence endemic in our society, we all have a responsibility, not just nurses, social workers and other health professionals. Ironically, the Ministry of Health's ecological model of family violence (1) acknowledges the need for multiple Levels of intervention, but the intervention strategies target "at risk" individuals and largely ignore the macro-level social and environmental factors associated with family violence. (5)

The policy of only assessing women is highly gendered. This, once again, places increasing responsibility on women, who are often the recipients of violence, to ensure theirs and others' safety. It moves the responsibility away from men. It also moves the onus of reporting onto women, increasing the potential for women to be blamed for failing to protect, if they choose not to disclose abuse. Lessons can be Learned from social work, particularly in respect to the gendered nature of assessment work. (6) Risk assessments, along with other form filling and patient notes, can actually serve bureaucratic requirements. Thus, the requirement to complete such assessments may be seen as just another function and when this happens, families can find themselves less involved in assessments. (7) We are not opposed to the assessment of family and child violence per se. However closer working relationships between nurses, social workers and other health professionals alongside families would achieve realistic family and child violence assessments to inform a range of practice initiatives. There are hidden dangers associated with nurses assessing family and child violence in isolation.

First, the data recorded about violence and abuse provides assessments of family life, devoid of the day-to-day contexts in which the family, child and older people live. Will poverty and related stress be part of any family violence assessment? Case notes and recorded histories of violence can set up a predetermined response by "experts", if families and older people present in the future. Recorded assessments can contain unsubstantiated allegations of violence, likely to be regarded as indicative of "higher risk", and possibly one in need of statutory social work or legal action. The latter particularly so, if an older person is involved. Case records are extremely influential for statutory child protection workers, social workers and professionals working in the health sector, as they determine potential courses of action. The politics of risk operates here, as there are many competing pressures on nursing and social work staff to assess family violence risks. Moreover, risk assessments can provide legitimacy to particular responses by State agencies, such as the removal of a child from a family. (7)

Increasing pressure on nurses

This policy initiative also places increasing pressures on nurses to ensure that they, on behalf of the State, are recording any indicators or accusations of abuse and violence. This may compromise nurses' engagement and relationships with families, so crucial to address family violence. Some women, mainly from lower socio-economic and minority groups, find nursing surveillance intrusive and judgmental. (8) The sole focus on women as disclosers of information could pressure them to make particular decisions about their day-to-day family life. It is questionable whether the State is in a position to provide safer options for those women who do disclose, when we know community-based agencies are already struggling to cope with the current workload. Since Plunket nurses started routine screening for family violence they have achieved a 300 percent increase in the number of people identified as at risk and referred for help. (9) This is a great achievement but such dramatic rises in referrals need to be matched with similarly dramatic rises in resources for the agencies these people are referred to.

'Certainty and objective measurements'

Politicians and policy makers are influenced by a particular way of thinking, where certainty and objective measurements dominate. Risk from this perspective can be located, measured objectively and thus resolved. In contrast, social workers are encouraged to work from a constructionist perspective, where risk is regarded in contextual terms, that is, as sets of actions or events that occur within a socio-political context and events. As such, family violence cannot be usefully considered without attention to this. Nevertheless, our wider society is more attracted to the former, positivist understanding, as this is seen as more definite, certain and thus a safer option.

There are risks for nurses and social workers, as well as families, in this latest policy development. Nurses face greater demands--demands to "get it right", to locate abuse and to protect vulnerable children, families and older citizens. This demand, already experienced by social workers, has produced a more risk-averse practice culture, fuelled in part by societal demands to locate, with certainty, child abuse, family violence, and elder abuse and neglect.

We can expect similar implications for nursing practice, made more salient as the acute shortage of qualified nurses demands more of those in practice. Will nurses be encouraged to challenge narrow approaches to risk assessment? What will happen when they do not know--when nurses are uncertain, as so often happens in complex clinical situations? Will nurses opt for a cautious recording of possible risks? How will nurses manage the high workload demands, while working to develop rapport within a professional relationship, sufficient to encourage individuals to disclose family violence? Paradoxically, risk assessments, aimed at assisting health professionals identify violence, may contribute to more stress in their work.

Health professionals have a professional responsibility to advocate for those living with violence. Our intention here is to raise attention to some of the hidden dangers inherent in this policy initiative. To summarise:

* The need for focused training about risk assessments, their strengths and limitations and the way these differ between nursing and social work is crucial.

* Under the new policy, increasing responsibility falls to women for the care and protection of themselves and children, making it highly gendered. And it sends a message to men that they need not talk about their understandings of family violence or consider their part in its perpetuation. Further, the role of men in maintaining violence is not a focus in this policy, except for the way women are expected to manage life post-disclosure--their lives undoubtedly will be different.

* Important lessons can be learned from the risk-averse nature of child protection workers, particularly the way in which case records showing a history of violence, or unsubstantiated allegations of violence, can lead to State agencies drawing conclusions that children are actually at higher risk than they are in reality. (7) The implications of de-contextualised family violence assessment work are grave indeed, particularly for those most vulnerable. There is a likelihood of unintentional State harm when case records show a history of violence, even when this is unsubstantiated.

Conclusion

That New Zealand has shocking statistics in child fatality and family violence is an appalling indictment on us all. That elder abuse and neglect is largely hidden, private and under reported (10) should concern us all. Policy initiatives aimed at assisting women, children and vulnerable older people reach services that can support and assist them are to be applauded. However, there are hidden dangers in policy initiatives that firstly de-contextualise highly complex notions and secondly, target women with families. Women are expected to both disclose violence or abuse in an unfamiliar, divorced environment, and are then placed in the sole position of decision making about possible options. These include an option not to disclose, with associated potential blaming, if abuse is subsequently revealed.

Social work and nursing have much to offer and learn from each other, particularly as the way each discipline approaches risk assessment work is quite different. Further, working closely together offers nurses, social workers and family members the best possible assessment context; a context that encourages and supports relational practice, rather than one where the pressure to get it "right" can only add to day-today practice pressures.

The aim of the policy is to detect violence and refer women, children and older people to community agencies best placed to support and assist them to make safe decisions. Yet the State has, at times, acted swiftly and without full assessments, supported by the rhetoric of "at risk", to serve organisational and bureaucratic requirements, rather than family needs. While the task of assessing child, family violence and elder abuse and neglect is complex, it is not one we are shying away from. Our hope is that more discussion and consideration will occur to inform family violence policy initiatives, within a socio-environmental framework, to ensure all New Zealanders work together to remove the scourge of family violence.

References

(1) Ministry of Health. (2002) Family violence intervention guidelines: Child and partner abuse. Wellington: Ministry of Health.

(2) Ministry of Health. (2007) Family violence intervention guidelines: Elder abuse and neglect. Wellington: Ministry of Health.

(3) Little, L. & Kantor, G.K. (2002) Using ecological theory to understand intimate partner violence and child maltreatment. Journal of Community Health Nursing; 19: 3, 133-145.

(4) McPhee, D. M. & Bronstein, L. (2002) Constructing meaning: strengthening the policy practice link. Social Work Education; 21: 5, 651-662.

(5) MacDonald, M. A. (2004) From miasma to fractals: The epidemiology revolution and public health nursing. Public Health Nursing; 21: 4, 380-391.

(6) Scourfield, J. (2002) Gender and Child Protection. Palgrave Macmillan Houndmills: New York.

(7) Stanley, T.W. (2005) Making Decisions: Social Work Processes end the Construction of Risk(s) in Child Protection Work, Doctor of Philosophy in Social Work thesis (unpublished), University of Canterbury, Christchurch.

(8) Wilson, H. V. (2003) Paradoxical pursuits in child health nursing practice: Discourse of scientific mothercraft. Critical Public Health; 13: 3, 281-293.

(9) Hodgson, P. (2007) Reducing family violence, http://www.beehive.govt.nz/ViewDocument.aspx?DocumentlD=30215 Retrieved 16/08/07

(10) Fallon, P. (2006) Elder Abuse and/or neglect. Literature review. Wellington: Ministry of Social Development Te Manatu Whakahiato Ora--Centre for Social Research and Evaluation.

Tony Stanley, DipSW, PhD, is a senior lecturer in the School of Community Studies, Christchurch Polytechnic Institute of Technology (CPIT).

Judy Yarwood, RN, MA, DipTching (Tertiary), is a principal lecturer in the School of Nursing, CPIT.

Glynnis Brook, BA, MA (Social Work Hons), is a senior lecturer in the School of Community Studies, CPIT.

Paul Watson, RN, BA (Hons), PhD Cand, is postgraduate programme leader in nursing at CPIT.