Johns Hopkins Magazine - April 1994 Issue

Nurses: At the Front Line for Battered Women

By Sue De Pasquale

Battering is the single most common source of injury to women-- more common than car accidents, muggings, and rape by a stranger combined, notes Nursing School professor Jacquelyn Campbell. In fact, she says, at least 20 to 30 percent of all women in this country are involved in a relationship that has been or is currently physically abusive, according to a 1993 survey by the Family Violence Prevention Fund.

Nevertheless, when women bearing abuse-related injuries and illnesses come into emergency rooms, very few are asked how they sustained their injuries. Studies of patient records show that abuse is documented in just 5 percent of all cases, says Campbell, whose recent book Nursing Care of Survivors of Family Violence (co-authored with Janice Humphreys) was named American Journal of Nursing's Book of the Year for 1993.

Campbell believes that nurses are uniquely equipped to intervene. "We're taught from the beginning to look at the whole person," she says. "We're taught to look at the patient's family, his or her environment." Moreover, most nurses are female, and therefore less threatening to the battered patient, says Campbell, who has spent more than a decade working in shelters for abused women.

Battered women coming into emergency trauma units, community health clinics, and prenatal health care clinics don't always show overt signs of being physically abused, Campbell says. That's why it's important for nurses to routinely ask questions relating to family violence: "Have you ever been physically hurt by anyone?" or "How do you and your partner resolve disagreements?" If fighting is mentioned, then the nurse might follow up with, "Does the fighting ever get physical? Does it ever involve pushing or shoving?"

Says Campbell, "The idea is to stay away from words like 'abuse,' or 'battery' or 'rape,' because many women don't think of it that way." Nor do their partners.

It's important for nurses routinely to ask every female patient such questions, Campbell stresses in her book, and in the Family Violence class she's teaching at the School of Nursing this spring. "If 20 to 30 percent of all women are abused, then it certainly makes sense to ask everyone--abuse is much more common than other things we routinely ask about, such as HIV," she says.

Nurses should also look to certain illnesses as tip-offs to abuse: PIDS (pelvic inflammatory disease syndome) can signal episodes of forced sex; irritable bowel syndrome, chronic headaches, and depression are frequently associated with the prolonged stress of battering; and chronic back pain is seen in women who've been repeatedly shoved against cabinets and walls.

Once a nurse ascertains that a woman has indeed been battered, the abuse should be documented in the patient's medical records, which can later be used in court, Campbell says. Next, nurses should take the time to listen to and document the patient's battering history, as well as to provide information about available shelters, support groups, and legal services. Campbell also recommends conducting a homicide "danger assessment" to make sure the woman's life isn't in immediate danger.

Some women may not be ready to leave their situation or make changes, and Campbell counsels her nursing students not to get angry or frustrated by that. "We shouldn't be telling the patient what to do. We should be working with her to find out what she wants to do--whatever she needs help with. Maybe her most pressing concern is about her kids."

While Campbell's book on family violence is already widely used by nursing educators, she would like to see a more systematic approach toward including such training in nursing school curricula nationwide. "Part of the nursing role is to connect with people, and to talk with them about the problems they're having," she says. "For nurses, dealing with female battery is not so outside what we've always done."

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