Plunket faces up to family violence: because of its impact on the health of children, the Plunket Society has developed a specific policy to help staff screen for family violence.

THE PUBLIC focus on the effects of family violence in New Zealand has increased in recent years. Family violence significantly affects the health of women and children. (1) It was appropriate the issue gained national attention and became the theme of International Nurses Day in 2001.

The negative impact family violence has on children's development, and the relationship between violence and child abuse, has prompted the Plunket Society to develop a family violence policy. (2) The intent of this policy is to advocate for children's health and safety, through routine screening of women about issues relating to family violence.

In 1998, the Family Violence Guidelines for health sector providers were published. (1) This document contained standards that could be used by providers in developing policies and practices aimed at reducing the incidence and effects of family violence. These guidelines made several significant statements. Firstly, they made family violence a priority health issue, defining it as physical, sexual and/or psychological in nature. This reiterates the definition contained in the Domestic Violence Act of 1995. Psychological abuse included damage to property, threats, intimidation and "causing or allowing the child to witness the physical, sexual or psychological abuse of another person". (1)

While traditionally family violence may have been associated with physical abuse, the guidelines challenged agencies to look beyond the visible signs of violence and recognise the long-term health effects of other forms of abuse.

Secondly, the definition of family used in the guidelines meant family violence could be perpetrated by a wide variety of people. The term "family" applied to anyone related by biology (whether living in the same location or not), or living together in an economic capacity in the same household. These parameters meant previous relationships with partners, cohabitating flatmates and boarders were included in the broadened definition of family violence.

The release of Te Rito: New Zealand Family Violence Prevention Strategy, (3) further reinforced the significance of family violence as a major social issue, and indicated that community agencies were expected to collaborate to address this problem. This document outlines the need for intersectoral action to influence resource prioritisation and to enable family violence to be seen as a key political issue. Ministerial, regional and local level responsibilities are outlined as part of 18 action areas where improvements need to be made.

The adverse effects on children of family violence (also known as domestic violence) are well documented. (4,5) Children living in violence are three times more likely to have behavioural difficulties, and six to eight times more likely to access health care than their counterparts who do not live in an environment of family violence. (6) An exaggerated startle response is often present in babies, with increased physical child health problems (such as bedwetting and asthma) manifesting due to high stress levels. (7) Children living in violent situations may also experience lower self-esteem, lower social competence, increased anxiety, increased aggressiveness and bullying, compulsive traumatic play, and other antisocial behaviour. (6,8)

Unborn children are also at risk. New Zealand research found that six percent of men arrested for domestic violence had pregnant partners. (9) Added to this, the increased physical, gynaecological, mental health issues and suicide attempts experienced by the victims of family violence (10,11) means the cost to New Zealand in health dollars is large. In 1994 the costs of violence towards women and children (including the cost of police callouts) was estimated at $2.74 billion per annum. (12,13)

As primary health care providers, Plunket staff are in the privileged position of working with families in their homes and communities. This setting allows holistic, client-centred partnerships to develop, using a socio-ecological approach that enables health and social issues to be addressed in the client's environment. With access to around 87 percent of the babies born in New Zealand each year, Plunket staff were in a position to be able to influence a change in attitude about violence towards women and children. (14)

As the emphasis on reducing family violence in New Zealand gained momentum, it became evident a separate Plunket policy about family violence, (complementing the Plunket child protection policy (15,16)), was required to guide clinical practice, as abuse relating to children is one element of a larger context of family violence. One nurse ethicist discusses the "duty of care" health professionals are ethically obliged to carry out, but warns that without a specific policy, which outlines strategies to assist nurses to identify family violence, there is a risk that nurses may exercise "moral blindness" due to their inexperience, discomfort or personal experiences with family violence. (17)

Issues pertaining to maintaining professional boundaries, assessment of child risk, safety, and staff support systems needed to be made more explicit for staff, through the development of a specific policy relating to the dynamics of family violence.

Development of policy; Plunket's clinical services group developed a policy framework and wide consultation was undertaken. Individual and group discussions were held with staff to identify the range of family violence issues in practice. This feedback provided data, to guide the content of the draft policy. Information was collected about practice scenarios, safety fears, and perceived barriers to implementing routine family violence screening. Staff were asked to submit comments on the framework and content of the draft policy. Three rounds of staff consultation and policy submissions culminated in a reviewed draft of the family violence policy.

A decision was made to pilot the draft policy in four areas--Waitakere, Waikato, Hawke's Bay and the West Coast. Staff in these areas would pilot the routine screening of women for family violence over six-months. The pilot areas were diverse demographically, with a mix of urban, semirural, and rurally remote areas, a range of ethnicities (including Maori, immigrants, and Pacific peoples), and differences in socio-economic status. Each pilot area also had differing numbers of anti-violence services available. This was particularly relevant to the pilot project, as one of the barriers to implementation identified was lack of referral agencies in some areas.

Implementation in pilot areas: As part of introducing the policy to the pilot areas, referral networks were identified and developed. For routine screening to be implemented successfully, Plunket staff needed to have current knowledge about the community agencies that could support the women and their children. Organisations such as Women's Refuge, the Department of Child, Youth and Family, the police, and counselling agencies, were invited to area meetings to discuss their roles, the services provided by their agencies and how women could be referred for support and advice.

When this networking bad been completed, Plunket clinical educators and clinical advisers facilitated a family violence workshop for staff in the pilot areas. The content of the workshop included:

[] understanding the cyclic process of family-violence;

[] understanding the health impact of family violence on women and children;

[] differentiating between the myths and the facts that surround family violence;

[] practising asking women screening questions about family violence and responding appropriately when a disclosure is made;

[] developing safety plans with women;

[] critically analysing scenarios relating to family violence and formulating possible responses; and

[] discussing practice issues, such as documentation and suitable use of resources.

Specific attention was also given to support systems available to staff, which included emphasising the usefulness of the society's nationwide professional supervision programme already in place.

Evaluation of the pilot: The four family violence pilots began on November 1, 2001 and were completed on April 30, 2002. An anonymous pre- and post-pilot survey was chosen as the method of evaluation. This enabled an assessment to be made about staff's knowledge level, their ability to begin routine screening and the identification of perceived barriers to undertaking this work. Plunket's ethics committee had passed the survey.

A second research project, which aimed to record the journey of change in practice for Plunket staff, was also undertaken in one of the pilot areas, using focus groups. The data from this research resulted in a list of recommendations to improve the experience of family violence screening for other Plunket staff.

The main concerns reported by Plunket staff were safety issues, perceived client reactions to being asked a question about family violence and the small number of other health professionals involved in antiviolence work. By the end of the pilot, however, family violence screening had become an integral part of practice and the fears about safety or negative client reactions had been overcome.

Over the following 12 months, many other agencies also began working towards the practice of routine screening, raising public awareness that family violence is not acceptable in New Zealand society.

Conclusion: Plunket staff are becoming more knowledgeable about their role in reducing the effects of family violence through the implementation of Plunket's family violence policy. Women receiving Plunket services will now be routinely screened for family violence, as a health promotion intervention. Asking a screening question in a safe environment offers women the opportunity to disclose their situation, so Plunket staff can offer information or refer a woman to an appropriate specialist family violence agency.

For tamariki/children enrolled for well-child services with the Plunket Society, staff have taken a step towards increasing awareness and reducing the incidence of family violence in New Zealand. In a society where violence towards women and children is receiving increasing media attention, it seems timely that Plunket staff continue to develop their roles as advocates for children. While the development and implementation of this policy took longer than initially anticipated, it was important appropriate consultation, research, and staff education was undertaken, as well as ensuring staff support systems were available. The family violence policy will be implemented in all areas within the next six months.

REFERENCES

(1) Ministry of Health. (1998) Family violence guidelines for health sector provider to develop practice protocols. Wellington: Author.

(2) Royal New Zealand Plunket Society, (Inc.) (2003) Family Violence Policy and Protocol. Wellington: Author.

(3) Ministry of Social Development, (2002) Te Rito: New Zealand family violence prevention strategy. Wellington: Author.

(4) Jaffe, P.G., Hurley, D.J., and Wolfe, D. (1990) Children's observations of violence: 1. Critical issues in child development and intervention planning. Canadian Journal of Psychiatry; 5, 466-479.

(5) Ministry of Health. (2002) Family Violence Intervention Guidelines: Child and Partner Abuse. Wellington: author

(6) Campbell, J. (2000) Physical and mental health effects of domestic violence: Health Care systems' response. Lecture notes from DSAC Workshop.

(7) Wills, R (2000) Health effects of domestic violence. Lecture notes from DSAC Workshop.

Chez, R. (1997, Spring). Homing in on abuse: What to ask and how to listen. Contemporary Nurse Practitioner; 20-25.

(8) Everingham, W. (2000) Child protection starts with women protection. Lecture notes prepared for Midland Plunket Core Education workshops (un published).

(9) Maxwell, G., Barthauer, L., and Julian, R. (2000) The role of primary health care providers in identifying and referring victims of family violence. Wellington: Office of the Commissioner for Children.

(10) Auckland Healthcare. (2000) Health consequences of male partner violence: Factsheet 2. Auckland; Health Promotion Unit.

(11) Fanslow, I. (1995) Emergency protocols of care for women abusedhypartners:development, implementationandevaluation. New Zealand: University of Auckland.

(12) New Zealand Health Strategy (2001) DHB Toolkit: Interpersonal Violence (Edition 1). Wellington: Ministry of Health.

(13) Snively, S. (1994). The New Zealand Economic Cost of Family Violence. Wellington: Coopers and Lybrand.

(14) Royal New Zealand Plunket Society (Inc.) (2001 b) Plunket Annual Report 2001. Wellington: Author.

(15) Royal New Zealand Plunket Society, (Inc.) (2001a) Child protection policy. Wellington: Author.

(16) Royal New Zealand Plunket Society (Inc.). (1996) Child protection policy. Dunedin: Author,

(17) Wilson, D. (2000) Care and advocacy: Moral consequences or moral blindness when working with women experiencing partner abuse. Journal of Nursing Law; 7: 2, 43-50.

--Belinda Macfie, RCpN, BN, BSocSci, MMS, is the Midland clinical adviser for the Plunket Society.

--Anne Lensen, RGON, BN, MN, is the Central clinical adviser for the Plunket Society.