In this literature review I will investigate what contributing factors prevent women from seeking help when faced with issues of domestic violence in New Zealand. I have refined my search question using Whitehead’s (2013) PECOT model of research to find specific information which I will critically discuss throughout the literature review. I also state why I chose this topic and the implications it has within the New Zealand context. Evidence gained from the literature has lead me to identify recommendations, which include important factors that aim to increase the rate of women speaking out about domestic violence and reduce the rate of domestic violence within New Zealand.
Domestic violence is defined as an act of violence against a person based on their gender, this can be physical, sexual or emotional abuse and is more often involving femal victims and male abusers (The World Health Organisation, 2016). The rates of domestic violence in New Zealand communities have risen over the last 25 years and emerging research has found it to be a significant health issue in our country (The World Health Organisation, 2016). In 2014 60% of all female homicides in New Zealand were committed by a family member (New Zealand Family Violence Clearinghouse, 2016). On average 525,000 people are harmed each year with 80% of these going unreported to authorities (New Zealand Herald, 2016). In 2015 there were 110,114 family violence cases reported to police up 8% from the previous year (New Zealand Family Violence Clearinghouse, 2016).
A number of organisations in recent years have collaborated in order to combat this issue, but there has been little change in women seeking help. Community nurses are vital for the detection of domestic violence and establishing therapeutic and safe relationships for women to speak out about the issue. As nurses, it is our role to engage and communicate as we are the catalyst for change in public health (Castledine, 2002), we are trained to use evidence based practice and we can help to design and implement specific interventions to target the issues of domestic violence within New Zealand communities.
There is an alarming rate of nursing and medical staff who report being uneducated about how to address matters of domestic violence with their clients or patients (Biresch, 2011). If women are twice as likely to disclose matters of domestic violence and abuse if asked by their health professionals (Hegarty and Taft 2001), then why are we not asking the questions? New Zealand has the highest rate of family violence in the developed world (New Zealand Herald, 2016), I question what more can nurses do to notice patterns of domestic violence and support the victims to speak out and seek help before it’s to late?
My clinical issue has arisen because throughout my training I have heard only one preceptor ask a patient if there was any issues of violence in their home. For this patient there was. Over the time she was in hospital she was able to open up to us more about her home life and my preceptor was able to offer her support and explain options for help and services available after leaving the hospital. As it turned out there was a lot of stressors in her marriage and through my preceptor both the patient and her husband were able to recognise their problems. They were both willing and accepting of seeking help. This patient has always stuck in my mind, for many reasons but mainly because she and her husband wanted the help and they wanted to be a non-violent and loving family they just didn’t know how. They had never been approached or asked about domestic violence before. If we as nurses don’t ask the questions about violence at home how can we help? This question lead me to the following research and helped to define my literature review.
In 2000 violence against women was identified as a major public health and human rights issue (Joachim, 2000). Often in cases of domestic violence the women stay with their abusive partners and do not seek help, there are many reasons why women find it so difficult to leave. A fear of change is reportedly one of the main reasons (New Zealand Womens' Refuge, 2016), if the women has been subjected to many years of abuse or grew up in an abusive household they are more likely to feel comfortable in these situations. If they were to leave their relationships they would be alone and for many women this is reportedly more scary than the abuse itself, these women often find the idea of solitude intimidating and therefore stay with their abusers (New Zealand Womens' Refuge, 2016). These victims often do not know how to love themselves therefore leaving an abusive relationships often does not seem appealing. Walker (2009) suggests that some abused women suffer from Stockholm Syndrome preventing them from leaving. Stockholm Syndrome, also known as Survival Identification Syndrome, is a reaction to a frightening situation where the victim forms emotional bonds to the abuser (Encyclopaedia Britannica, 2016). Walker (2009) explains that low self esteem causes victims of abusers to stay in the relationships and not seek help.
Information Related to the Question
Females seeing community health nurses in New Zealand
While men and women can both be vicitims of domestic violence research shows that 95-98% are female victims (Campbell & Humphreys, 1984). This is why I would like to focus my review on female victms of domestic violence.
Women exposed to domestic violence and nurses feelings towards screening for violence
I will focus on articles that discuss the experience of victims of domestic violence in New Zealand. As well as articles discussing nursing interventions on this issue
Women in New Zealand exposed to domestic violence
As I wish to investigate why women are not comfortable speaking out against domestic violence and what nurses can do to improve this, I will focus on articles that express the concerns and barriers to victims asking for help and speaking out and then discuss current and future interventions
To determine barriers that prevent victims seeking help about domestic violence and how nurses can better assist these victims
The aim of this review is to develop further understanding of the behaviors of female victims of domestic violence and to use these findings effectively to discuss interventions for nurses
I have not included time as a factor because each woman's journey will be different
Using the PECOT model of research (Whitehead, 2013) I have narrowed down my search question on New Zealand’s current domestic violence issue. Given there is a much higher rate of domestic violence committed against women, I want to understand the barriers preventing women from speaking out and seeking help. In turn I hope to identify ways in which nurses can work to assist these women in getting help. The literature review will be based on the question; ‘What can New Zealand Nurses do to assist victims of domestic violence coming forward and seeking help’.
Domestic violence includes all physical, sexual and verbal assaults which negatively effect a persons physical person, mental state or sense of safety and trust, this is regardless of age, gender or ethnicity (Campbell, 1995). In 2015 an estimated 20,379 people in America called the domestic violence helpline per day, seeking advice, escape situations or assist someone else (National Network to End Domestic Violence, 2015). New Zealand Womens Refuge (2016) reports 39% of women experience domestic violence, however, one of the biggest difficulties in cases of domestic violence is that very few cases are reported and fewer still result in prosecution of the offender (Griffith, 2014). When asked, New Zeland woman report feelings of shame, fear of blame, denial and fear of reaction by others, as being reasons why they did not disclose abuse. Other barriers of note include consequences for their children, their lack of readiness to leave their abusers and fears of clinicians telling other family members (Davis, 2007). A study conducted by Hegarty and Taft (2001) found that by asking about domestic violence women were twice as likely to disclose, compared with those who are not asked. The women reported feeling safer disclosing to health professionals that were supportive, non-judgemental and had knowelegde of support programs in their communities.
Biresch (2011) reminds us that although the bio-medical model of healthcare focuses on fixing problems patients have, it is important to understand that only the victim can can fix the issue of domestic violence by speaking out and identifying the problem. although there is help available for the victims of domestic violence the first step is for them to speak out and ask for help.
In order to completely understand the barriers preventing victims of domestic violence from speaking out, we need to understand obstacles preventing health professionals accurately identifying these victims. Gomes (2013) suggests that health professionals are under prepared when facing issues of domestic violence, suggesting they feel powerless to ask the difficult questions or to promote change. Professionals world wide recognise this as a reality, nurses report feelings of discomfort, lack of awareness, embarrassment and beliefs that questioning patients about domestic violence constitutes an invasion of privacy (Natan & Rais, 2010). Nursing staff play a vital role in the screening of domestic violence as they are often the first professionals to become aware of domestic abuse within the family (Griffith, 2014). A lack of nursing competence and ability to screen patients has been identified as an area of concern preventing detection of domestic violence by many nurses (Hinderliter, Doughty, Delaney, Pitula, & Campbell, 2003). The need for further training in situations of domestic violence issues is supported by the American Nurses Association who agree there is a lack of education and clinical preperation around domestic violence (Griffith, 2014).
Another barrier of note to screening patients for domestic violence is the nurses own experiences of the issue. If one in every four females in New Zealand is affected by family violence (Ministry of Health, 2016), as a predominantly female workforce it is likely that a significant group of nursing staff are themselves victims of abuse (Davis, 2007).
Implementation for Practice
Early identification and intervention reduces the ongoing risk of harm to families facing domestic violence (Griffith, 2014). Nurses are well placed to identify and offer services to victims of domestic violence; therefore they need to be more assertive in their questioning around violence in the home (O'Connor & Bichan, 2013). Nurses should also be aware of legal provisions that protect and provide help to victims of domestic violence so that they may offer services and up to date advice to victims (Griffith, 2014). The Ministry of Health (2015) in New Zealand believes ethical principals should be considered when working with families in domestic violence situations. Working within the prinicipal of beneficence ensures that health professionals have a responsibility to diagnose and treat the issue of abuse not only addressing the physical symptoms. Failure to address any causes of physical symptoms of abuse is likely to lead to further abuse and therefore further injury suffered by that patient (Ministry of Health, 2015). Griffith (2014) agrees, suggesting that nurses who implement screening for domestic violence into their practise increase the opportunities to provide education and early intervention to both the vicitm of abuse and the abusers themselves. Screening for domestic violence is a fundemental skill which nursing staff need to better attain themselves with. A study conducted in 1998 asked women about good and bad experiences when discussing domestic violence with a nurse. The study of 21 women found that the attitude displayed by the nurse was the main contributor factor to the women deciding whether to disclose abuse or not (McCauley, Yurk & Jenckes, 1998). It is therefore of paramount importance that nursing staff address these sensitive issues as openly as possible to ensure our patients feel safe when talking about their experiences. Davis (2007) suggests that nurses in New Zealand should familiarise themselves with community resources available to women including information on places such as the Womens’ Refuge, which gives women safe accomodation and support. Griffith (2014) also reminds us of the need to explain confidentiality to our patients so that they understand we are obliged to keep their personal lives personal. The establishment of therapeutic relationships between patient and healthcare professional will also assist aiding the patients ability to disclose matters of domestic violence (O'Connor & Bichan, 2013).
Violence in the home directly affects the wellbeing of families in New Zealand. In 1996 after the World Health Organisation declared that family violence is a serious public health issue, New Zealand government agencies developed Te Rito: New Zealand Family Violence Prevention Strategy. The strategy includes goals and objectives for family violence prevention, as well as rationale for these actions (Ministry of Social Development, 2002).
He Korowai Oranga and the New Zealand Context
According to the Family Violence and Death Review Committee’s (2014) statistics Māori are 13 times more likely to be the cause of, or them victim to domestic violence issues, than that of the non-Māori population. Therefore, in the New Zealand setting it is important that nurses have an understanding of He Korowai Oranga, the Māori Health Strategy, as it underpins all aspects of practice including dealing with matters of domestic violence (Ministry of Health, 2015). The principals of partnership, participation and protection are essential when supporting Māori and their communities (Davis, 2007). New Zealand offers a range of rehabilliation programs for Māori men using Tikanga, to assist men to be accountable for their actions (McMaster & Wells, 2003). Through the use of Te Reo Māori and te taha wairua New Zealand nurses can help address domestic violence while respecting the mana and tapu of the individuals and their whanau (McMaster & Wells, 2003). Therefore practising in a way which is culturally safe.
Recommendations and Rational
Through analysing the literature on domestic violence within both the New Zealand context as well as globally, I was able establish the following recommendations for nurses to better their practice in cases of domestic violence. Frequently throughout this literature review a common recommendation was for nursing staff to receive further education around the topic of domestic violence. First brought to attention by Hinderliter, Doughty, Delaney, Pitula, & Campbell (2003) in their American based research outlining nurses’ feelings of competency and ability to screen patients for domestic violence. This study found that there was a general lack of education and clinical preparation for screening patients for domestic violence. A recommendation to amend this is in-service training held in the workplace to better nurses’ abilities to answer questions their patients may have, as well as portray a comfortable and non-judgmental approach to discussing domestic violence issues (Hinderliter, Doughty, Delaney, Pitula, & Campbell, 2003). Although this was an American study I believe in-service training focusing on domestic violence as well as any barriers to screening patients for this issue, would be an essential tool for New Zealand nurses. Nurses need to enhance their knowledge to better understand both the victim and the abuser of domestic violence situations (Biresch, 2011). Research shows that an effective way to raise the level of knowledge and attitude toward domestic violence, is a simulation type of approach to give prior experience of screening for and dealing with matters of domestic violence and therefore better facilitate actual screening in a clinical setting (Natan, Ari, Bader, & Hallak, 2011).
Interestingly, though the lack of nurses’ education about domestic violence was identified as a main contributor preventing victims disclosing issues of domestic violence, leading nursing curricula is yet to implement violence related content within nursing schools, despite the recognition of domestic violence as a health concern and the recommendations from nursing organizations’ (Davila, 2006).
A second recommendation was having nurses use a common tool to screen for victims of domestic violence, one universal tool that should be used on all female client interaction throughout the healthcare system. The A.B.C.D.E assessment framework is a helpful way to identify victims of domestic abuse. Developed in 2000 the framework is used to collect and document the necessary information and ensure safety for the client and healthcare professional (Everingham, 2000).
A – Ask and assess for safety.
B – Believe what the woman says and be supportive.
C – Collect resources.
D – Document and intervention.
E – Ensure safety for the client and yourself (Everingham, 2000).
In the New Zealand healthcare system, using a universal tool for screening for victims would assist nurses to better their practice in cases of domestic violence. As nurses have already identified they feel like they are not trained to handle these cases (Natan, Ari, Bader, & Hallak, 2011). By implementing the A.B.C.D.E assessment framework in all areas of healthcare, nurses would have a guide to follow when collecting information for potential victims.
The question ‘what can New Zealand Nurses do to assist victims of domestic violence coming forward and seeking help’ has been answered throughout this literature review. This review has revealed a significant issue of domestic violence within New Zealand culture, the statistics show that over the period of one year 33,209 domestic violence issues were reported to Women’s Refuge in New Zealand (New Zealand Women’s Refuge, 2016). In summary this literature review has found overwhelming evidence portraying the need for better education around the matter of domestic violence, for our health professionals so that they may better assist victims of domestic violence. With proper and careful implementation it is likely that better education of health care professionals could lead to more women coming forward and getting support and in turn reducing the occurrences of domestic violence in New Zealand. Nursing staff should have more readily available assessment frameworks so that they feel confident in screening for domestic violence. This review has also established that it would be beneficial for all areas of healthcare in New Zealand to use a universal screening tool so that all healthcare professionals understand what has been done and what needs to be done for each individual patient. When working within the New Zealand context it is important to understand the Māori healthcare strategy, He Korowai Oranga, which allows us to practise in a way that is safe for healthcare professionals as well as our patients. Furthermore, it is essential to know about community programmes on offer to all patients we encounter who are involved with domestic violence, whether they are the abuser, the victim or children who may be involved.
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