Position Statement

Domestic Violence

The intent of this position statement is to acknowledge domestic violence as a major public health issue and declare nurses’ ethical duty to the victims and community in addressing this concern.

Position

It is the position of the New York State Nurses Association that:

Domestic violence is unacceptable.
Domestic violence is a complex issue requiring a balance between protecting the victim’s right to choice, confidentiality and personal safety, with that of promotion of assistance for the perpetrator and all others affected by the acts of violence.
Nurses have an ethical duty to identify and minimize risks associated with domestic violence in daily practice, regardless of the practice setting.

Background

Violence confronts us daily through the media. Less visible are the acts of domestic violence. It is believed an act of domestic violence happens every 15 seconds in the United States (Massington, 2004, p.1). For the purposes of this position, domestic violence is defined as “physical, sexual, or emotional/ psychological violence directed towards men, women, children, or elders, occurring in current or past familial or intimate relationships whether the individuals are cohabitating or not and including violence directed toward dating partners” (JOPN, 2000, p.63). The perpetrator uses acts of violence to intimidate, threaten, entrap and/or control the victim. Victims often choose to remain in the abusive relationship, fearful of retribution if reporting this crime, and the cycle of domestic violence continues.

Domestic violence is pervasive, crossing all age, gender, socioeconomic, ethnic, racial and religious groups. Here are some of the facts:

95% of reported cases of domestic violence are perpetrated against women ( Fulton , 2000, p.27). Domestic violence is the leading cause of injuries in women, greater than muggings, stranger rape and car accidents combined (Massington, 2004, p.1).
40% of women assaulted report that the physical abuse began during pregnancy (Scales, 2004, p.12) and for those who experienced violence previously, it has been observed that domestic violence escalated during pregnancy. Abused women often do not receive prenatal care until as late as the third trimester and experience a higher rate of complications such as vaginal bleeding, placenta separation, low birth weight, and miscarriage ( Fulton , 2000, p.28).
One in six newborns discharged from the hospital go home with a mother who suffered abuse during the pregnancy ( Fulton , 2000, p.27).
Child maltreatment affects nearly 3 million children annually and results in the death of more than three children every day (JOPN, 2000, p.64).
Mistreatment of elders is estimated to afflict between 700,000 and 1.1 million individuals annually (JOPN, 2000, p.64).
Approximately 50% of homeless women and children are on the run from domestic violence ( Fulton , 2000 pg. 27).
Of those women whose manner of death is homicide, 40 – 50% died at the hands of an intimate partner; 60% of those homicides occurred when the women left or attempted to leave the abusive relationship ( Fulton , 2000, p.27).
With approximately 50% of homes in the US having a gun, the risk of homicide, particularly against a family member, triples (Valente, 2000, p.29).
Although firearms-related injuries in the US have declined since 1993, they remained the leading cause of injury mortality in 2000, the most recent year for which complete data is available at the time of this report (MMWR, 2003, p.11).
A firearm is used in two-thirds of all intimate partner homicides committed by spouses or ex-spouses. Each year, more than 1,200 women are killed by their husbands or boyfriends and more than 700 of these deaths involve guns (HELP Network News 2004, p.4).
Domestic violence occurs in same gender relationships.
Men are also victims of intimate partner violence.

Domestic violence contributes to a number of long-term consequences, physical and emotional/psychological. Innumerable chronic physical conditions along with mental health problems such as depression, anxiety, post traumatic stress disorder, alcohol and drug abuse, and suicide may result. There is evidence that one tactic women and men use to survive domestic violence is to use the healthcare system (Bohn, 1996). Healthcare providers frequently are the first and only professionals to whom victims turn for help.

The effects of domestic violence also have a financial impact. In 1994, $44 million, 40,000 physician visits and 100,000 hospitalization days were attributed to domestic violence ( Fulton , 2000, p.27). More recent calculations indicated that the average cost of health care in an emergency room visit for a battered person is $1,633 or $857.3 million per year (Scales, 2004, p.12). Yet, despite these alarming figures the full impact of domestic violence has yet to be realized since much remains underreported. Rodriguez, Bauer, McLoughlin & Grumbach (1999) report that less than 15% of women who are abused report being asked about abuse by healthcare professionals. (Massington, 2004, p.1) And it is believed that fewer men report incidents of domestic violence.

It is important that healthcare professionals take into account when screening and treating a victim that domestic violence tends to increase over time and that the most dangerous time for a woman is often when she tries to leave. It is predicted that domestic violence could be reduced by as much as 75% if identification and intervention were offered routinely in medical settings (McFarlane, 1998). As early as 1992, the American Medical Association (AMA) recommended that physicians screen for partner violence at all portals of entry to the healthcare system. Since then, the American College of Obstetricians and Gynecologists, the US Surgeon General and Centers for Disease Control have forwarded recommendations that all women be routinely screened for physical abuse and offered counseling, education, advocacy, and appropriate referrals. The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) requires the development of partner violence protocols (Griffin, 2002, p.4) and the Healthy People 2010 health objectives seek the reduction of physical assault by a current or former intimate partner by 20% and continue to call for surveillance and prevention of violent behavior as a priority issue for the nations.

Conclusion

The lack of respect for human dignity and human rights is a core problem related to domestic violence. Healthcare professionals are often the only individuals with whom victims share their experiences and at the ethical core of all healthcare professions is the principle of nonmaleficence. This principle asserts the professional’s obligation not to inflict harm on others and is always applicable, even when the domestic violence is not considered a violation of the law, such as psychological or financial abuse. Additional clarity as to nurses’ ethical duty to victims of domestic violence is evident in the American Nurses Association (ANA) Code of Ethics for Nurses. In working with victims of domestic violence, no matter how difficult or unseemly, the American Nurses Association (ANA) Code of Ethics for Nurses states the nurse respects “the inherent worth, dignity, and human rights of every individual” (2002 , p.7) and the nurse “promotes, advocates for, and strives to protect the health, safety, and rights of the patient” (2002 , p.12). The ANA Code also calls for nurses to collaborate with public and health professionals to promote the health needs of people, wherever they may be.

Recommendations

The New York State Nurses Association recommends that nurses:

Reaffirm their professional and ethical obligation to become knowledgeable regarding the nature and dynamics of domestic violence.
Promote an environment that preserves the patient’s/victim’s right to privacy and protects the patient’s/victim’s right to make autonomous decisions.
Develop cultural competence for more effective screening, care and counseling of individuals affected by domestic violence.
Become educated in the skills necessary for effective detection, prevention and intervention of domestic violence.
Support opportunities through education, research, and policy changes to advance societal efforts to break the destructive cycle of domestic violence.
Promote universal screening for domestic violence as a routine part of taking a history by all healthcare providers.
Support inclusion of related content in undergraduate nursing curricula.
Encourage expansion in use of sexual assault nurse examiners (SANE) and other forensic nurse examiners.

Other NYSNA position statements addressing violence include:

Sexual Harassment in the Workplace
Workplace Violence
Gun Violence
Elder Abuse, Neglect and Maltreatment

Approved by the NYSNA Board of Directors on November 2, 1998.
Reviewed and revised by the Expanded Council on Nursing Practice on April 1, 2005.
Approved by the Board of Directors on April 8, 2005.

References

American Association of Colleges of Nursing. (2000). Position statement. Violence as a public health problem. Journal of Professional Nursing, 16(1), 63-69.

American Nurses Association. (2002). Code of ethics for nurses. Washington , DC : Author.

Bohn, D. (1996). Sequela of abuse: Health effects of childhood sexual abuse, domestic battering and rape. Journal of Nurse Midwifery, 41, 442-456.

Centers for Disease Control and Prevention. (2003). First reports evaluating the effectiveness of strategies for preventing violence: Early childhood visitation and firearms laws. Findings from the task force on community preventive services. Morbidity and Mortality Weekly Report, 52(No. RR-14), 11.

Domestic violence and guns. (2004, Summer). Help Network News, 4.

Fulton, D. R. (2000). Recognition and documentation of domestic violence in the clinical setting. Critical Care Nursing Quarterly, 23(2), 26-34.

Griffin, M. P., & Koss, M. P. (2002). Clinical screening and intervention in cases of partner violence. Online Journal of Issues in Nursing. Retreived September 1, 2004 , from http://www.nursingworld.org/ojin/topic17/tpc17_2.htm

Massington, M. C. (2003). Domestic violence and communication: Interviewing the abused patient. The University of Arizona College of Nursing . Retrieved September24, 2004, from http://wwwjuns.nursing.arizona.edu/articles/Fall%202003/masington.htm

McFarlane, J., Soeken, K., Campbell, J. et al. (1998). Severity of abuse to pregnant women and associated gun access of the perpetrator. Public Health Nursing, 15, 201- 206.

Rodriguez, M.A, Bauer, H.M., McLoughlin, E., & Grumbach, K. (1999). Screening and Intervention for Intimate Partner Abuse. Journal of the American Medical Association, 282, 468-474.

Scales, B. A. (2004). Domestic violence awareness in the perianesthesia setting. Journal of Perianesthesia Nursing, 19(1), 11-17.

Valente, S. M. (2000). Evaluating and managing intimate partner violence. The Nurse Practitioner, 25(5), 18-35.

For more information on nursing practice, contact NYSNA's Education, Practice and Research Program at 518.782.9400, ext. 282 or by e-mail.