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

Definitions

          Domestic violence or intimate partner violence is a pattern of coercive behavior used to establish and maintain power and control over an intimate partner, ex-partner or family member.  Domestic violence includes abusive emotional, psychological, physical, or sexual behaviors committed against individuals regardless of gender or sexual orientation (New York State Coalition Against Domestic Violence, 2011).

Intimate partners are defined as current or former spouses, boyfriends, or girlfriends (Truman & Rand, 2010).

 According to the Centers for Disease Prevention and Control (CDC), 2017, intimate partner violence (IPV) includes four types of behavior:   

Physical violence is when a person hurts or tries to hurt a partner by hitting, kicking, or other type of physical force.

Sexual violence is forcing a partner to take part in a sex act when the partner does not consent.

Threats of physical or sexual violence include the use of words, gestures, weapons, or other means to communicate the intent to cause harm.

Emotional abuse is threatening a partner or his or her possessions or loved ones, or harming a partner’s sense of self-worth. Examples are stalking, name-calling, intimidation, or not letting a partner see friends and family.

Position

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

•  Domestic violence is unacceptable (New York State Coalition against Domestic Violence, 2011).
•  Evidence shows the effects of abuse/violence have a profound impact on an individual’s health, and that abused victims will seek services from nurses for health concerns related to this abuse/violence.
•  Domestic violence is a complex issue.  Very often, a victim will not share this aspect of their relationship with non-professionals, or if they do, are often not believed and therefore think they are unable to get the help and support they need.
•  Significantly, many victims of abuse do not want the relationship to end; but they do however want nurses to help then make the violence stop.
•  Healthcare Employers and Registered professional nurses have a duty to identify and minimize risks associated with domestic violence in daily practice, regardless of the practice setting.
•  Registered professional nurses have the responsibility to advocate for and attend continuing educational offerings that includes screening, assessment, documentation and intervening in suspected cases of intimate partner violence.
•  Healthcare employers must have policies and procedures in place to protect employees from domestic violence in the workplace. 

Background

Intimate Partner Violence/Domestic Violence

Domestic violence, also known as intimate partner violence, exists across all demographic, socioeconomic and cultural groups and remains a serious problem in the United States (CDC, 2017). Statistics reveal that intimate partner violence occurs at least five times more often in females than in males and females are more often to be victimized by someone they know (Rand & Truman, 2010).  Although legislation exists at both federal and state levels, the New York State Coalition against Domestic Violence (2011) notes intimate partner violence continues to occur in all relationships, including in same sex relationships, in teenage relationships and remains the leading cause of violence against women. 

At the federal level, the Violence against Women and Department of Justice Reauthorization Act of 2005 was intended to remedy existing laws by appropriating financial support for services, education and intervention at the community level.  The Act was promulgated to help improve protection services for crime victims, improve enforcement proceedings in cases where there are firearm offenses, and improve enforcement proceedings against perpetrators of domestic violence who engage in interstate travel (United States Department of Justice, 2011). New York State (NYS) law includes requirements for hospitals with maternity and newborn services to provide information concerning family violence to parents of newborns prior to discharge (N.Y. Public Health Law § 2803-p). Regulations include requirements for hospitals to provide for screening, referral, reporting, and management of suspected and confirmed cases of domestic violence (N.Y. Title 10- Health); as well as Social Service requirements for providing support and services to individuals affected by domestic violence. Additional information regarding NYS law and regulations can be found at http://www.health.state.ny.us/regulations/

Nurses, regardless of their work setting, are most likely to encounter victims of suspected abuse, which in many cases they are required by law to report. Victims of domestic violence may fail to seek care out of fear; cultural differences; financial dependence on the abuser; feelings of failure or promises from the abuser to change (Griffin & Koss, 2002).  Other barriers to reporting include (DVRCV, 2017):

• Fear for safety of children or other family member(s);
• Denial or disbelief;
• Emotional attachment to, or love for partner;
• Commitment to relationship;
• Hope the behavior would change;
• Shame and embarrassment;
• Staying for the sake of the children;
• Depression and stress;
• Isolation;
• Lack of faith in other people's ability to help;
• Fear their batterers will kill them if they leave;
• Fear the violence will increase, based on their past experiences;
• Fear their partners are not able to survive alone or may commit suicide;
• Fear the abuser may harm pets;
• Fear they will lose their children; and
• Belief in the value of self-reliance and independence. 

Establishing a therapeutic relationship provides nurses the opportunity to assess for and intervene in domestic violence (Bradbury-Jones, 2016). Research reveals, however that education regarding screening and intervention for registered professional nurses remains a significant barrier to assessing for abuse (Bradbury-Jones, 2016; Stinson & Robinson, 2006).

 The New York State Department of Health has established a Sexual Assault Forensic Examiner (SAFE) – Designated Hospital Program to provide specialized care to sexual assault patients.  This program requires that the hospital:

•  Establish an organized program/service specifically to carry out and oversee the provision of sexual assault services, including the development and implementation of policies and procedures, detailing staffing requirements, initiating and conducting community outreach programs, participating in an organized data collection system, and routinely following-up with patients/law enforcement officials and crime laboratory personnel regarding evidence collection activities.
•   Designate a program coordinator to exercise administrative and clinical oversight for the program.
•   Ensure the program includes a cohort of specially trained individuals.
•   Establish/participate in an interdisciplinary task force that includes local Rape Crisis Programs, other service agencies, and law enforcement representatives/local prosecutors.
•   Develop services that meet community needs and ensure that quality victim services are available.
•   Provide Sexual Assault Forensic Examiners on-site or an on-call system that makes an examiner available to the patient within 60 minutes of arriving at the hospital, except under exigent circumstances.
•   Maintain a designated and appropriately equipped, private room in or near the hospital’s emergency department to meet the specialized needs of sexual assault patients. (Including access to shower and be handicapped accessible).
•   Coordinate outreach activities in the community and with other hospitals to share best practices, provide training opportunities and promote the availability of the program, to the extent feasible.
•   Participate in regional and statewide quality assurance initiatives designed to measure program effectiveness and reporting requirements. 

          SANE Nurses:  Sexual Assault Nurse Examiners (SANE) are registered nurses who have completed specialized education and clinical preparation in the medical forensic care of the patient who has experienced sexual assault or abuse.  Nurses who have obtained SANE training and meet the clinical practice requirements have the opportunity to take a board certification examination through the International Association of Forensic Nurses.   SANE nurses are an integral part of the SAFE program.

Pregnant women and children

          Kothari, Cerulli, Marcus, and Rhodes (2009) found pregnant women are more likely to experience violence; abused women are more likely to become pregnant and a women’s prenatal status will influence their decision in seeking help from criminal justice and emergency services.

In 2008, the Family Violence Prevention Fund noted that 15.5 million children are exposed to at least one occurrence of intimate partner violence within their home; and that children of mothers who experience prenatal physical domestic violence are at an increased risk of exhibiting aggressive, anxious, depressed or hyperactive behavior. Studies reviewed by Meltzer, Doos, Vostanis, Ford, and Goodman (2009) noted increased internalized and externalized problems in children who witnessed episodes of ongoing violence in their homes. Graham-Bermann and Perkins (2010) supported these findings in their research and found behavioral issues such as social, thought and attention problems increased with more exposure to violence. 

Additional research demonstrates that children exposed to violence are likely to experience post-traumatic stress disorder; are at a greater risk of having allergies, asthma, gastrointestinal problems, headaches and flu; and developing serious health problems as adults (Family Violence Prevention Fund, 2008). The impact of intimate partner violence on children as direct recipients has been addressed in NYS education law which requires certain individuals, including nurses, to provide documentation of having completed coursework regarding the identification and reporting of child abuse and maltreatment (N.Y. Education Law § 6507) .

Elder Abuse

          Domestic violence impacts the elder population on multiple levels from family caretakers to outside entities, with abusive scenarios including physical and psychological abuse, neglect and financial exploitation. In a literature review, Lachs and Pillemer (2004) examined risk factors, screening, and intervention strategies and concluded that a multidisciplinary approach is successful in the accurate identification, confirmation and management of abused elders.

By utilizing a representative sample of individuals aged 60 and older across NYS, the Elder Abuse Prevalence Study (2011) confirmed that the incidence of elder abuse was nearly 24 times greater than the number of cases referred to intervention agencies. Psychological abuse was cited as most common, followed by financial, physical and sexual abuse self-reported by the participants as compared to documented cases. The study confirms that collection of data regarding elder abuse, with an emphasis on cross-systems collaboration, will serve in identification and management of elder abuse victims; increase focus on prevention and intervention; and promotion of public and professional awareness campaigns to direct resources to elders who face mistreatment by trusted caregivers (New York State Elder Abuse Summit, 2011). Registered professional nurses are in a position where identification of abuse in the home is crucial for prevention, early intervention and management. If the caretaker is recognized as the abuser, the nurse, using education and interpersonal skills, can provide support to both the abuser and abused. Referrals to other team members will ensure response and identification of resources available to integrate into the plan of care (Lachs & Pillemer, 2004).

Current Federal and State laws that impact elder abuse include the Elder Justice Act which provides monies for coordinating and developing leadership at the national level and grants for research and intervention strategies in long term care as well as adult protective services (Loewy, 2010). In NYS, a 2009 amendment was made to the power of attorney statute to increase the responsibilities of the agent to ensure safety of the elder’s finances (Loewy, 2010). Penal law was amended in 2008 making it a felony to defraud more than one person, when two individuals identified in that group are elderly as defined in the law (Loewy, 2010).  For more information on Elder abuse please see NYSNAs Elder Abuse, Neglect and Maltreatment Position statement at http://www.nysna.org/practice/positions/position3_10.htm

Registered Professional Nurses and Other Healthcare Employees

          Registered professional nurses and other healthcare facility employees may themselves be at risk of violence if their partner or a partner of a co-worker comes into the workplace to commit an act of domestic violence.  Registered professional nurses who conduct home visits may also be at risk when entering a home where there is a danger of domestic violence.  According to the National Institute of Occupational Safety and Health (NIOSH), women in healthcare, production, and office/administration have the highest proportion of homicides related to intimate partner violence (Tiesman, et al, 2012)

Effects of Domestic Violence

          Intimate partner violence can affect the health and well-being of the victims in many ways. Physical and emotional injuries can contribute to lifelong illness, personal and social difficulties. IPV has also been linked to harmful health behaviors such as smoking, alcohol and/or drug abuse and engaging in risky sexual behaviors (CDC, 2009). Although not all individuals who experience a traumatic event develop the symptoms of post-traumatic stress disorder (PTSD). The potential for exposure during one’s lifetime exposure to a traumatic event is estimated at 40 to 90% for the general population, while prevalence for developing PTSD is estimated at 7-12% (Astur et al., 2006). Research indicates that women who experience intimate partner violence are more likely to develop PTSD, which is associated with impaired immune function, obesity, increased risk of diabetes, increased severity of premenstrual syndrome symptoms; depression, suicide, and increased likelihood of re-abuse (Scott-Tilley, Tilton, & Sandel, 2009).

Screening

          Registered professional nurses are ethically and legally bound to routinely screen and assess individuals in many settings; and to ensure the appropriate intervention and referrals are identified to help decrease potential harm (Emergency Nurses Association, 2006). Griffin and Koss (2002) suggest that women be screened in private without other family members present, and asked simple questions directed at whether they have been hurt, threatened, demeaned or frightened by their partner at any time.  These techniques are helpful in reducing some barriers to self-reporting the abuse. Healthcare professionals must take into account when screening and treating, that domestic violence tends to increase over time and that the most dangerous time for a woman is often when she tries to leave (Griffin & Koss, 2002).

Major barriers to assessing and intervening in suspected cases of intimate partner violence continue to exist within the healthcare system due mainly to lack of education (Stinson & Robinson, 2006). Griffin and Koss (2002) reflect that assessment for domestic violence is proportionate with educational offerings.  The ANA (2002) advocates for education of registered professional nurses in the assessment, prevention, intervention and referral skills related to domestic violence.

The Joint Commission requires the development of partner violence protocols (Griffin & Koss, 2002, para. 9) and the Healthy People 2020 health objectives (IVP-39 & 40) seek the reduction of physical violence, sexual violence, psychological abuse, and stalking by a current or former intimate partner (Healthy People 2020, electronic document).

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 non-maleficence. This principle asserts the professional’s obligation to ensure harm is not inflicted on others. Additional clarity as to nurses’ ethical duty to victims of domestic violence is evident in the Code of Ethics for Nurses.

In working with victims of domestic violence, no matter how difficult or unseemly, the Code of Ethics for Nurses (2015) states the nurse respects “the inherent worth, dignity, and human rights of every individual” (p. 7)  and the nurse “promotes, advocates for, and strives to protect the health, safety, and rights of the patient” (p. 12). The Code of Ethics for Nurses also calls for nurses to collaborate with public and health professionals to promote the health needs of people, wherever they may be. Any victim of domestic violence or sexual assault requires compassionate care and should be provided information about the cycle of violence and resources available to help victims make decisions that are in their own bests interests.

Recommendations

The New York State Nurses Association recommends that registered professional nurses:

• Reaffirm their professional and ethical obligation to become knowledgeable regarding the nature and dynamics of domestic violence.
• Help 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, to have SANE practitioners in every hospital.
• Have knowledge of the NYS Department of Health (SAFE) New York State Sexual Assault Forensic Examiner Designated Hospital Program that should include having Sexual Assault Nurse Examiners (SANE), in order to make recommendations, advocate for, and help to establish such a program if one does not exist, so that eventually every hospital has a program. 
• Advocate that healthcare facilities incorporate guidelines provided by the NYS Office for the Prevention of Domestic Violence found in Information for Professionals http://www.opdv.ny.gov/professionals/workplace/privatepolicy.html into policy.
• Advocate that healthcare employer policies should include risk controls that include, but are not limited to:

1. Procedures staff can follow to alert security personnel of restraining orders;
2. Access to control measures to limit entry to both the facility and the unit where

 the potential victim works;

1. Policies to transfer an employee, at the employee’s request, to another unit,  

 Shift, and/or location that is unknown to the partner;

1. Escorts from workplace to parking lot or public transportation station;
2. Having other staff persons screen the at-risk employee’s phone calls;
3. Training all staff on procedures related to domestic violence;
4. Home care agencies should develop a risk assessment toll to be used when

 conducting pre-home visit assessments and develop procedures to protect  

 employees from potential violence during home visits.

Approved by the Board of Directors on November 2, 1998; April 8, 2005; June 15, 2011.

Reviewed and revised by the expanded Council on Nursing Practice on April 1, 2005;

The Council on Nursing Practice March 14, 2011.

Reviewed and Revised:  March 16, 2018

Note:  The use of the term “patient” anywhere in this document is intended to be generic and refers to the recipient of nursing care.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretative statements. Silver Springs, MD: Author.

American Nurses Association. (2002). Position statements: Domestic violence. The challenge for nurses. Retrieved from http://ana.nursingworld.org/mods/archive/mod419/cevifull.htm.

Astur, R., St Germain, S., Tolin, K. D., Ford, J., Russell, D., & Stevens, M. (2006). Hippocampus function predicts severity of post traumatic stress disorder. Cyber Psychology Behavior, 9(2), 234–240. doi:10.1089/cpb.2006.9.234

Bradbury-Jones C, Clark M (2016) How to address domestic violence and abuse. Nursing Times; online issue 12, 1-4.

Centers for Disease Control and Prevention. (2017). Understanding intimate partner violence. [Fact Sheet]. Retrieved from https://www.cdc.gov/ViolencePrevention/intimatepartnerviolence/index.html.

DVRVC. (2017). Barriers to disclosure. Retrieved from http://www.dvrcv.org.au/help-advice/older-people/barriers-disclosure.

Emergency Nurses Association. (2006). Intimate partner and family violence, maltreatment, and neglect. [Position Statement]. Retrieved from http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Violence__Intimate_Partner_and_Family_-_ENA_PS.pdf

Family Violence Prevention Fund. (2008). Facts on children and domestic violence. Retrieved from http://www.endabuse.org/userfiles/file/Children_and_Families/Children.pdf

Graham-Bermann, S. A., & Perkins, S. (2010). Effects of early exposure and lifetime exposure to intimate partner violence (IPV) on child adjustment. Violence and Victims, 25(4), 427-439. doi:10.1891/0886-6708.25.4.427

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

Healthy People 2020 Proposed Objectives. (2010). Injury and violence prevention. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=24

Kothari, C. A., Cerulli, C., Marcus, S., & Rhodes, K. V. (2009). Prenatal status and help seeking for intimate partner violence. Journal of Women’s Health, 18 (10). doi:10.1089=jwh.2008.1310

Lachs, M. S., & Pillemer, K. (2004). Elder abuse. Lancet, 364, 1263-72.

Loewy, E. (2010). Progress in prosecuting financial abuse of older New Yorkers. Capital Commons Quarterly, 4(3), 10-12. Retrieved from http://www.albanyguardiansociety.org/pdf/CCQ_09172010.pdf

Meltzer, H., Doos, L., Vostanis, P., Ford, T., & Goodman, R. (2009). The mental health of children who witness domestic violence. Child & Family Social Work, 14, 491-501. doi:10.1111/j.1365-2206.2009.00633.x

New York State Department of Health. (2018). Sexual Assault Forensic Examiner (SAFE) Program.  www.health.ny.gov/professionals/safe/

N.Y. Education Law § 6507 (2011).

N.Y. Public Health Law § 2803-p (2011).

New York State Coalition Against Domestic Violence. (2011). Principles for practice. Retrieved from http://nyscadv.org/principles.htm

New York State Elder Abuse Summit. (2010 March). Under the Radar: New York State Elder Abuse Prevalence Study. Symposium held at Samaritan Hospital, Troy, NY.

New York State Office for the Prevention of Domestic Violence (2018).  Information for Professionals, NYS Domestic Violence and the Workplace Model Policy for Private Business. http://www.opdv.ny.gov/professionals/workplace/privatepolicy.html

Scott-Tilley, D., Tilton, A., & Sandel, M. (2009). Biologic correlates to the development of post-traumatic stress disorder in female victims of intimate partner violence: Implications for practice. Perspectives in Psychiatric Care, January 2010, 46(1), 26-36.

State of New York, Official Compilation of Codes, Rules and Regulation. Title 10 – Health, § 405.9 (15e).

Stinson, C. K., & Robinson, R. (2006). Intimate partner violence: Continuing education for registered nurses. The Journal of Continuing Education in Nursing, 37(2), 58-62.

Tiesman, H. M., Gurka, K. K., Konda, S., & Harlan, A. (2012). Workplace Homicides among US women: The role of intimate partner violence.  Annals of Epidemiology. 22(4) 277–284.

Truman, J., & Rand, M. (2010). Criminal victimization, 2009, (NCJ 231327) U.S. Department of Justice, Bureau of Justice Statistics. (2010). National crime victimization survey criminal victimization.Retrieved from http://bjs.ojp.usdoj.gov/content/pub/pdf/cv09.pdf

United States Department of Justice. (2011). The facts about violence against women. Retrieved from http://www.ovw.usdoj.gov/docs/vawa.pdf

**This position statement is made in honor of Marie Jo Faye, RN. She was an active NYSNA member and worked at Montefiore Medical Center.