– a story of domestic violence and how to approach it in a clinical setting
Working in a surgical ICU means you see a great deal of injuries in patients everyday. Most – accidents, some – medical required surgery, others – violence. Despite the measures put in place to combat violent crime, SAPS crime statistics as well as the Victims of Crime Survey 2014/15 results indicate that levels of violent crime are rising. This is particularly alarming as it contributes towards an increasing climate of fear among people and is further exacerbated by the fact that certain forms of violence typically take place in intimate, domestic settings (Statistics South Africa, 2015). To me, violence is the worst kind of hurt to see in patients as it is not coincidental or by chance that the patient is in hospital, it was the sole purpose of someone else that has the patient lying there in critical care. Moreover, when that purpose stems from someone that is closest to them, someone who was meant to protect them, is when it is at its most shocking – domestic violence (DV). During ward rounds one morning, a new patient was introduced. She was intubated (via an endotracheal tube) and ventilated and had multiple surgeries following an attack. She lay there with frightened eyes, unable to speak and unable to move. This woman had been stabbed 37 times by her partner.
37 times. Just let that sink in.
My initial response was that of shock, then anger, then sincere empathy. The problem herein was the fact that I did not know how to respond to this information or if I should even respond at all. We had a physiotherapy session everyday for six days and not once did I bring it up. Was that the right thing to do? What I did focus on was trying to give her a sense of independence, a sliver of her power back. This stems from knowing what it is like to be disempowered by a close male figure in one’s life and attempting to build her up from experiencing that as well. I reassured her every session that all her progress comes from her, ‘Well done, you worked so hard! Look where you are now’, ‘I’m proud of you‘, ‘You‘re doing so well’. This seemed to put a sparkle in her eyes every now and then. However, how could I have approached it better?
The Department of Health has recognised the role of health care professionals to identify and provide interventions for patients who have experienced DV (Olive, 2007). There is a clear body of evidence which indicates that a substantial number of people who have experienced DV and abuse attend the emergency department (ED). However, many individuals do not receive effective identification or support. The findings in a study highlight that staff highly valued the role of the nurse as one which offered support both professionally and personally. To me, the role of a nurse in providing support can be strongly related to that of a Physiotherapist as both professions involve spending longer periods of time with the patient when they are at their most vulnerable.
The problem lies with the fact that the ED/ICU/general ward is ideally suited to identify at risk individuals but is not institutionally organised in a way that prioritises the social concerns of their patients (McGarry & Nairn, 2015). A study aimed at examining interventions and practices carried out by the ED professionals found there is a need for more effective change of information and cooperation with different heath care providers concerning how to act with women and their family members in DV situations. Practitioners face challenges from ambiguity in practice guidelines and the lack of research to support interventions (Olive, 2007). It has also been established that health care professionals do not know enough about the legislation concerning DV and their professional duty (Leppakoski & Paavilainen, 2013). Various studies have shown that health care professionals attribute their reluctance to or discomfort with inquiring about DV to factors such as lack of time, behaviours attributed to women living with abuse (e.g., denial), lack of training and effective interventions, the complexities of providing whole family care and partner presence (Leppakoski, Flinck, & Paavilainen, 2014).
A study investigated how to survey women presenting to the ED to determine from them how best to identify and discuss issues of DV. The study concluded that the ED is an appropriate setting to discuss DV issues and a significant percentage of women will disclose DV only if asked directly about it. Many victims of DV feel very comfortable discussing DV with ED health care professionals (Hayden, Barton, & Hayden, 1997). Simple direct questioning in a supportive environment is effective in facilitating disclosure and hence detecting cases of abuse. Women will have negative perceptions of emergency care if their abuse is minimalised or not identified as women want their needs and the needs of their children to be explored and addressed (Olive, 2007). Healthcare is one of the few avenues women living with DV have to receive emotional and physical support. Healthcare that ignores psychosocial issues further damages women’s sense of self. Women require timely information and empathetic support from healthcare professionals to assist them in understanding and labelling their experiences as DV. This enhances women’s ability to feel deserving of, and ideally achieve, a life without violence (Reisenhofer & Seibold, 2013).
Ultimately, asking about domestic violence is undesirable but contrary to popular belief – patient’s generally find being asked about abuse acceptable (Leppakoski, Flinck, & Paavilainen, 2014). Step one in my progress for the future is; approach the situation! I avoided the situation all together and this was wrong. Step two is how to approach it. Olive (2007) suggests three focal areas to address; (1) Providing physical, psychological and emotional support; (2) Enhancing safety of the patient and their family; (3) Promoting self-efficacy (Olive, 2007). Providing physical, psychological and emotional support during Physiotherapy sessions seems viable. Enhancing the safety of the patient and their family might need consent from the patient for me to refer her to a social worker and get the police involved. It will also be helpful for me to, in the future, enquire if the health-care facility (specifically the ICU ward I was working in at the time) has any specific protocols for these situations. Promoting self-efficacy is something that I had already touched on in my physiotherapy management with this patient and can continue doing if I find myself in this situation again.
Domestic violence is so prevalent in South Africa and knowing if and how to approach the situation is of important value for me as a student physiotherapist as holistically, this is part of my profession to help the patient heal.
Hayden, S. R., Barton, E. D., & Hayden, M. (1997). Domestic violence in the emergency department: How do women prefer to disclose and discuss the issues? The Journal of Emergency Medicine, 15(4), 447 – 451.
Leppakoski, T., & Paavilainen, E. (2013). Interventions for women exposed to acute intimate partner violence: emergency professionals’ perspective. Journal of Critical Nursing, 22(15), 2273-2285.
Leppakoski, T., Flinck, A., & Paavilainen, E. (2014). Assessing and Enhancing Health Care Providers’ Response to Domestic Violence. Nursing Research and Practice.
McGarry, J., & Nairn, S. (2015). An exploration of the perceptions of emergency department nursing staff towards the role of a domestic abuse nurse specialist: a qualitative study. Interantional Emergency Nursing, 23(2), 65 – 70.
Olive, P. (2007). Care for emergency department patients who have experienced domestic violence: a review of the evidence base. Journal of Clinical Nursing, 1736-1748.
Reisenhofer, S., & Seibold, C. (2013). Emergency healthcare experiences of women living with intimate partner violence. Journal of Critical Nursing, 22(15), 2253 – 2263.
Statistics South Africa. (2015). Exploration of selected contact crimes in South Africa: In-depth analysis of Victims of Crime Survey data. Crime Statistics Series, 3.