Asking about abuse and assessing for family violence--part of nurses' caring role: nurses in key areas now routinely ask patients about family violence. But just how effective is this new assessment requirement?
Last year, police recorded 63,000 incidents involving family violence. (1) A recent University of Auckland study indicates that one in four New Zealand women have been victims of child sexual abuse before the age of 15, (2) while an estimated one in three women are victims of abuse, whether physical, verbal or emotional. On average, 14 women, six men and ten children die every year because of family violence. (3) These bleak statistics and an acknowledgement of the long-term, negative health effects of this abuse were the impetus behind the Ministry of Health (MoH) launching its Family Violence Project in 2001. Four pilot sites at Counties Manukau, Auckland, Hawke's Bay and Lakes District Health Boards (DHB) led the way. At Hawke's Bay DHB's emergency department (ED), nurses have been questioning patients about their risk of family violence since 2002. In 2001, a child protection programme was established following the death of a child from abuse. In 2002, the DHB established a family violence intervention programme (FVIP), implementing routine questioning of patients for partner abuse. The two integrated programmes were developed in collaboration with a number of community organisations including the Police, Child, Youth and Family Service, Women's Refuge and the domestic violence intervention and education programme DOVE. A "systems approach" was developed which included management support, policies, training, resources, audit and evaluation. In 2004, the model was adopted nationally, with Hawke's Bay DHB ED nurse Miranda Ritchie appointed national coordinator. Earlier this year, her role was expanded to national FVIP manager for DHBs, a role that involves site visits and twice-yearly meetings with FV co-ordinators.
"A lot of women were presenting to the ED with injuries caused by assault," said ED clinical nurse specialist Sharon Payne. "Nurses were busy fixing these injuries but they were not doing anything to stop the problems occurring in the first place. Some of us would attempt to refer people on to community agencies for assistance but most of us did not have the knowledge and skills to do this most effectively.
"When Miranda proposed we start routine questioning of women over 16, nurses responded in a variety of ways. Some thought the idea was good; others resented being given extra tasks in an ED that was already very busy. However, after we had done the day's training, most of us embraced the proposal with enthusiasm."
Finding the time and the privacy to do this questioning is always a challenge, Payne said. Questioning about family violence is often done during routine assessment or discharge planning, when a patient is asked about their support networks or any fears they may have about their own safety on their return home. Payne believes asking such questions is all part of a nurse's role to care for patients and ensure their safety. The important thing, she says, is to frame the questions to suit the patient and his or her situation. Similar techniques are used when questioning older people about their social situations.
"I have not met anyone yet who has objected to being asked about their personal safety. In fact, most people are pleased to be asked, particularly older Maori women who recognise there are families out there who have rear problems around domestic violence. We suggest people have a safety plan and strategies in place to protect themselves against further incidences of violence. Not all women who present to the ED get asked these questions, especially when we are very busy. But, ideally, these questions should be part of a nurse's regular assessment of patients, particularly of a social assessment. Now that nurses have more knowledge and skills in this area, they feet more empowered and able to make a difference."
During training sessions, Payne often tells the story of an acquaintance of hers who told her recently she had been beaten by her partner for many years. Some years previously she had presented to the ED with a broken arm but did not disclose that the injury was the result of an assault. If she had been asked about partner abuse then, she would have answered honestly. She finally left the abusive relationship but said she had stayed longer than she should have.
"When I tell this story, nurses feel encouraged to ask the questions, so people get the help they need when they need it, though not all will choose to follow through at that particular time. People arriving in the ED will offer all sorts of explanations for their injuries, but they don't always make sense. Nurses have a gut feeling about what has happened and will talk to people about these things as best they can, bearing in mind their role is to protect people's health and safety."
Routine questioning about family violence is now an accepted part of the work of many health professionals in all DHBs, with a particular focus on nurses working in maternity, paediatric wards, special care baby units, acute assessment areas, EDs and mental health units. Refresher training is also herd regularly, along with attendance at supervision groups.
As new nurses arrive at Hawke's Bay DHB ED, they are expected to attend a FVIP training day within the first eight weeks of their employment. This is part of their orientation package. During the training, the nurses will take part in scenarios, giving them a chance to practise asking the questions. Payne will sometimes invite a new nurse to come with her when she is doing a FV assessment, thus enabling the nurse to see the model at work.
At the Bay of Plenty DHB, a VIP co-ordinator role has been operating since February 2005. This followed months of negotiation with a number of community agencies and senior DHB managers. Memoranda of understandings, based on MoH guidelines, were drawn up with these agencies. However, the groundwork for the coordinating position had begun three years earlier when a steering group was established to review the DHB's child protection policy. Nurses asked that a partner abuse policy be included, as the two issues are often linked. Although the DHB was unsuccessful in becoming part of the MoH's pilot FVI co-ordinating programme in 2004, a full-time co-ordinating position was established, with two nurses working half time in the partner and child abuse roles. Public health nurse educator Nicola Chadwick is the partner abuse co-ordinator. The MoH is now funding FV co-ordinators in all DHBs.
Asking about abuse
Launching the extended Health VIP in August this year, Health Minister Pete Hodgson said: "A health professional simply asking about abuse often marks the turning point for victims. Many had never been asked about violence at home before. Perhaps no one other than a health professional could ask." (4) With an extra $11.2 million allotted to the sector for the FVIP 2007-2010, victims of violence using health services would receive the support they required and staff would be trained appropriately to screen health service users, Hodgson said.
Since the programme began in 2002, over 4500 health professionals have been trained in FV intervention, Plunket has made over 600 referrals for child abuse and, in the past year, 500 GPs and midwives have been trained in FV intervention. However, Hodgson also emphasised that ending family violence was everyone's business. "It cannot become the fodder for politics. This is our society; this is all of our business." (4)
Further progress was made at the Bay of Plenty DHB when the MoH announced in 2006 its "train the trainers" programme. Each DHB had to meet certain criteria to get onto this programme, which saw large numbers of staff trained in FV questioning techniques. The Bay of Plenty DHB now has its own training programme which has been delivered, over the last six months, to hospital and community nurses working in key areas, Maori health workers and social workers. The programme is tailored to fit the profile and capacity of both the community and the DHB, and covers both child protection and partner abuse, as experience in the region shows a strong correlation between the two. "Our DHB also provides cover for staff when they are away at this training or at a refresher course, a further sign of its commitment to the intervention programme," said Chadwick.
Varied response from nurses
Feedback from the nurses has been varied, she says. Part of the reason for this may be the fact that for many, asking questions about abuse may well raise some very personal issues. "Statistics tell us that one in three women are victims of abuse. We need to acknowledge that nurses, who are part of society, may well reflect this statistic. In this country, as in many others, abuse has traditionally been regarded as a taboo or private issue that no one likes to acknowledge or talk about. Most nurses have embraced the programme, but some fear they may offend people if they ask such personal questions. This is something we address in our training and refresher courses.
"Our surveys show that 90-95 percent of women who are asked these questions are not offended. Choosing the right time to assess family violence is, of course, critical. A patient must be clinically stable and in a private area when questioned. I am impressed at how creative nurses are at finding ways to speak to patients privately, eg taking them into a private cubicle to measure their weight or asking the questions when they are taking a patient through to the x-ray department."
With the extra government funding now available for FV co-ordinators, Bay of Plenty DHB intends increasing the number of full-time positions. However, as Chadwick says, each DHB is reliant on community agencies to respond to requests for support when people decide to make an approach.
"Nurses and other health professionals can't tell people what to do. Our intervention is to ask the questions and offer some resources if people want to seek help. We try to empower women to make their own decisions around their personal safety. We can suggest they ring an agency there and then or perhaps tater when they feel the time is right."
Chadwick says non-government agencies are asked to track how and why people are referred or self refer to their services but she believes it is still hard to assess what flow-on effect interventions at the DHB are having on numbers. "Women subjected to personal violence are all at different stages on the journey to seeking help. Consequently, there has not been a flood of referrals since the DHB programmes began, but we do know our interventions are having some effect."
Chadwick is resigning from her co-ordinating role next month. Having helped establish the programme and training package, she is happy to step aside to let others continue the work. She remains utterly committed to the need for DHB health professionals, particularly nurses who have the most contact with patients, to ask art women over 16 whether they are victims of partner abuse. "Victims of abuse come from all cultures and socio-economic groups. By routinely asking all women questions about their safely, we reduce stigma towards particular groups. People can choose to say 'no' to the questions, but we can suggest that abuse is a societal problem and that they may know others who could benefit from receiving the resources. It is up to them whether they pass them on or take a look themselves tater."
Changing societal attitudes
Being a VIP co-ordinator has been very rewarding work, says Chadwick, one that has enabled her to understand the complexities of working in a community setting. She likens it to being involved in other major public health programmes like stopping drink driving or antismoking campaigns. "This initiative is proactive rather than reactive. Nurses and doctors still have high profiles in the community, so it is good for people to see us standing up and saying that family violence is not ok. Like other public health programmes, however, getting the message out and changing society's attitudes may take a generation or more. The challenge is to get the training embedded into staff calendars and to ensure it becomes an accepted part of training and practice."
November 25 is White Ribbon Day, the International Day for the Elimination of Violence against Women. This year, dozens of government and social service agencies are working together to encourage men to challenge each other on attitudes and behaviour that condones or supports violence towards women. See www.whiteribbon.org.nz for further details.
(1) Families Commission. (2007) www.nzfamilies.org.nz/white-ribbon.php. Retrieved 26/10/07.
(2) University of Auckland (2007) New Zealand Violence Against Women Study. Press release 24/10/07.
(3) Clark, H. (2007) Launch of Campaign for Action on Family violence. Speech notes. www.beehive.govt.nz. Retrieved 26/10/07.
(4) Hodgson, P. (2007) Reducing family violence. Speech notes. www.beehive.govt.nz. Retrieved 20/10/07.
By co-editor Anne Manchester
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|Title Annotation:||NEWS FOCUS|
|Publication:||Kai Tiaki: Nursing New Zealand|
|Date:||Nov 1, 2007|
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