Health and Wellness

Ending the cycle

Nurses nationwide join Oklahoma RNs to end intimate partner violence through House of Delegates action.
For more than a decade, certified nurse-midwife and researcher Anne “Nancy” Woods, PhD, MPH, CNM, has been passionate about addressing the mental and physical health issues of women who’ve endured intimate partner violence (IPV).
Beyond immediate injuries, women can experience a range of health concerns—from depression to chronic pain to GI problems—that can continue throughout their lifespan, particularly if gone untreated, according to Woods, a Maryland Nurses Association member, and other nurse experts in IPV.
Woods recalls how one patient described the lasting health effects of IPV: “It took me years to leave him, but he’s never left me.”
Meanwhile, in Oklahoma, IPV nurse researcher and educator Janet Sullivan Wilson, PhD, RN, has been working on IPV prevention efforts and other strategies to help professionals intervene before violence escalates and leads to a fatality. She recently returned from a meeting of the state domestic violence fatality review board, which includes healthcare, social service, law enforcement, and advocacy representatives.
Wilson and the interdisciplinary team review and analyze every domestic violence fatality to determine what could have been done to prevent a death. Oftentimes it’s a difficult task because the red flags—a history of escalating, frequent abuse, threats, and the act of leaving the abuser—aren’t widely known by professionals or the public.
“The danger signs for intimate partner violence can be assessed,” says Wilson, an Oklahoma Nurses Association (ONA) member. “So we are developing protocols for interventions to keep women safe and help nurses and other professionals respond more effectively.”
The need for nurses to be able to look beneath the surface and understand the subtleties of IPV signs and symptoms is, in part, what led Wilson, along with the ONA president and executive director, to craft a resolution for ANA’s House of Delegates (HOD) summer meeting. More than 98% of the nearly 460 nurse delegates present approved the ONA-introduced measure, which, along with a resolution on human trafficking, builds on the profession’s long-standing work of meeting the needs of vulnerable populations.
What follows is the second of a two-part series on these vital HOD actions with a focus on IPV, which is defined as actual or threatened physical, sexual, psychological, or emotional abuse by a current or former spouse, partner, boyfriend, or girlfriend. Intimate partners can be of the same or opposite sex.
Both Woods and Wilson praised the HOD action, which they hope will lead to an increased national dialogue on IPV and the routine screening of all patients.

Getting started
Wilson knows the dire statistics within Oklahoma and beyond all too well. She states, “In October 2008, the Washington, DC–based Violence Policy Center ranked Oklahoma fourth in the nation in the number of domestic violence–related fatalities occurring each year.”
Nationwide, annual estimates range from 960,000 incidents of violence against a current or former spouse, boyfriend, or girlfriend to 3 million cases involving solely women who are physically abused by their husband or boyfriend, according to the nonprofit organization, the Family Violence Prevention Fund.
Wilson says that she sees nurses as a natural group to take on the issue of IPV because, aside from law enforcement, they are often the “first responders” to domestic violence cases. And, given that nursing is a female-dominated profession, it makes sense that nurses would want to help IPV victims, most of whom are women.
So 4 years ago, Wilson headed to her state nurses association. “She (Wilson) felt nurses needed to not only better identify victims but also be better prepared to communicate effectively with and respond to the needs of victims of IPV,” says ONA Executive Director Jane Nelson, CAE.
At the time, there also were several stories in the local news about domestic violence, according to Nelson. One case involved a spouse who killed his wife after mistakenly thinking she had told a nurse that she was being abused.
Wilson and ONA leaders also believed it was important for nurses to know how to protect themselves if they were targeted by a patient’s abuser. With this in mind, ONA formed a task force in 2005 to study the issue and subsequently created a continuing education article on IPV that ran in its publication, the Oklahoma Nurse, which goes out to every RN and LPN in the state. The article was reprinted in the general media, and ONA has posted IPV-related resources for nurses online. ONA also collaborated with nursing and other organizations to build more momentum within their communities and state.
“We then decided we needed to go a step further, so we submitted the resolution to ANA so it could reach a national platform,” Nelson says.
To make its case, ONA reported that IPV victims are repeatedly seen in emergency departments (EDs) and primary provider offices, where their injuries are treated but the IPV is either not dealt with or missed. Beyond the injuries that have occurred during violent episodes, research reveals that persons experiencing violence have been shown to develop chronic illnesses and long-term disabilities, including arthritis, migraines, and stomach ulcers, as well as mental health and substance abuse problems. Furthermore, children in violent households face an increased risk of physical and psychological abuse, behavioral problems, and eating disorders.
The HOD-approved resolution, which builds on ANA’s  position statement on ending violence against women, specifically calls for ANA to:
•    oppose IPV in all forms
•    increase awareness and education among nurses about its enormous effect on families, children, and communities
•    endorse the use of routine, universal, and culturally sensitive IPV screening tools and protocols among all nursing specialties and in all settings
•    advocate for the use of IPV documentation guidelines that are clinically and legally complete and accurate.

Moving the issue
Several years ago, The Joint Commission mandated that hospitals screen for domestic abuse, educate healthcare providers on how to identify and intervene with abuse victims, and provide victims with community referrals.
“In Oklahoma and across the nation, we’ve screened and reported incidents of child and elder abuse, but we’ve not heavily assessed for IPV,” says ONA President Karen Tomajan, MS, RNC, CNAA. In the past few years, The Joint Commission has helped to drive the responsibility of nurses and other professionals to address this issue. But more staff education and the widespread use of standardized tools clearly are needed, according to Tomajan, who says, “Those are two of the crucial pieces addressed in the HOD resolution.”
At the facility where Tomajan works, a work group created to implement The Joint Commission standards on assessing for abuse found that many nurses did indeed feel ill-prepared to identify or intervene with victims, particularly when the abuser accompanies the victim to the hospital. “Nurses need to know how to safely and comfortably initiate questions, use the tools effectively, and recognize patterns of abuse,” Tomajan says.
That comfort level, according to Woods, comes with practice. She believes it’s important for nursing students and practicing nurses to participate in IPV educational programs that use simulation and role modeling. “These programs help nurses get more comfortable asking the questions and intervening, help reduce the societal stigma around IPV, and allow for a more open dialogue on the issue,” says Woods, whose current research focuses on the interconnections among abuse, mental health problems, and pregnancy outcomes.
Woods adds that when nurses are presented with patients who may have been abused, a good approach—one that she learned from a physician colleague—is to acknowledge one’s own shortcomings. “We need to be able to sit down in a private place and be humble enough to say, ‘I may not know the right words to ask’ or ‘I’m not that familiar with your culture, but I’d like for us to work through this together,’” Woods says. “It’s more like treating a patient as a colleague.”
Wilson adds, “When someone does tell you something, you must believe it.” She urges nurses to look at the assessment tools and different protocols that are out there, and to promote their use within their facilities.
Many EDs and obstetric units have implemented abbreviated three-question screening tools. But just asking the questions isn’t enough, according to the nurse experts. “It’s important that nurses screen for current and past abuse—listening for complaints, such as chronic pain, depression, or fatigue,” Woods says. “And even if patients answer ‘No’ to all questions, it’s also vital that nurses are able to tell patients how to access IPV resources in their communities.”
For more information on IPV, go to:
•    ANA-sponsored CE in the June 2007 issue of American Nurse Today
•    Centers for Disease Control and Prevention: www.cdc.gov/injury
•    Family Violence Prevention Fund: www.endabuse.org
•    Johns Hopkins University, School of Nursing/IPV nurse expert Jacquelyn Campbell, PhD, RN, FAAN: www.dangerassessment.org/WebApplication1/.

Susan Trossman is Senior Reporter in ANA’s Communications Department.

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