Domestic violence and abuse (DVA) has rapidly become a global public health concern. In the UK, nurses and other health professionals are required to recognise and intervene in all cases where someone may be at risk of DVA.
It is recognised that DVA affects the victim, any children and perpetrators in a multitude of ways. Often these effects will limit physical and emotional wellbeing, with lifelong consequences. Understanding DVA will help nurses and other health professionals to respond and contribute to improving the lives of those affected. This article explores the epidemiology of DVA, focusing on the signs that should prompt concern and how nurses and other health professionals can support these individuals and their families.
Background
The current definition of DVA includes any incident of threatening behaviour, violence, abuse or control that occurs between two adults or young people over the age of 16 years, who are or have been in an intimate relationship or are family members, regardless of sex or sexuality (National Institute for Health and Care Excellence (NICE), 2016). DVA may be physical, psychological, sexual, financial or emotional.
DVA is a contemporary issue within today's society, often occurring in the privacy of personal relationships. However, the effects of DVA are a major public concern (Asato, 2017). DVA is recognised as a global public health issue that impacts on the health and wellbeing of children, families and communities (World Health Organization (WHO), 2017).
DVA is often discussed as a gendered issue, where women are the victims and perpetrators are men. It is important to be aware that an estimated one in six men and one in four women in England and Wales will be affected by DVA (Department of Health (DH), 2017). This article will refer to women in order to reflect the prevalence indicated within the statistics; however, the same care and consideration should be executed when working with every victim and perpetrator regardless of their sex, and the same principles for recognition, management and support should be applied in all cases.
The presence of DVA in any relationship presents significant safeguarding concerns for adults and any children or young people within the home. Research suggests that the psychosocial impact on children and young people who have been exposed to DVA can be severe, leading to increased risks of mental health difficulties, physical health difficulties, reduced educational attainment, increasing vulnerability and risk of involvement in criminal activity. It also impacts on their ability to develop their own future relationships (Callaghan et al, 2018).
Nurses and other health professionals working in all areas are often the first point of contact for victims and children who are affected by DVA, with evidence suggesting that victims of DVA have increased contact with health professionals (Fanslow et al, 1998; Alshammari et al, 2018; Identification and Referral to Improve Safety (IRIS), 2020). All health and social care professionals need to know the signs of DVA and how to manage disclosures and concerns, alongside being able to refer these families for support to protect them from further harm (Royal College of Nursing (RCN), 2019).
The context of DVA
In England and Wales alone, the Office for National Statistics (ONS) (2019) reported that more than 1.6 million women and 786 000 men experienced some form of DVA in the home. The number of reported cases increased by 24% between 2018 and 2019 (ONS, 2019). The ONS (2020) reported that 274 women were killed by a current or ex-partner in a 2-year time frame between 2017 and 2019.
Risk factors
It is well established that certain life events may increase the likelihood of DVA occurring (DH, 2013, NICE, 2014; Women's Aid, 2019). Pregnancy is a time when DVA is recorded as most prevalent, with murder and manslaughter being reported as the leading cause of injury-induced death for pregnant women (Burch et al, 2004). Midwives have an important role to play in making routine enquiries and have a professional responsibility to ask all women about DVA at their initial contact (RCN, 2020). Health visitors will also ask women about any historical and current DVA in order to formulate plans that will support women in providing a safe home environment (Public Health England, 2018).
Where professional discourse prompts certain professionals to address DVA at initial contacts, it is essential that this is readdressed throughout professional involvement and responsibility is shared across all health professionals. In a recent review of the literature on the barriers preventing health professionals screening women for domestic abuse, several factors were identified, such as lack of training or education and lack of confidence, particularly in relation to positive disclosure (Kirk and Bezzant, 2020). This highlights the need for DVA education and training alongside safeguarding training to remain prominent in undergraduate programmes and continuing professional development, to ensure that health professionals develop their knowledge and confidence in managing such cases (Alshammari et al, 2018). Professionals working with adults also need to consider the impact on children in the home as an equal priority alongside the needs of the victim (DH, 2010).
Triggers of controlling behaviours that may sometimes lead to domestic abuse can include the victim or perpetrator being affected by depression, loss of employment, moving away from support networks, anxiety, suicidal thoughts, self-harm, excessive alcohol use and drug use (DH, 2017).
Health professionals working with adults and children need to be alert to circumstances that may raise concerns. They should be equipped to demonstrate confidence and professional curiosity in asking about DVA. Professional curiosity has increasingly been identified as an emerging theme through adult and child serious case reviews and failure to employ curiosity by professionals and organisations can potentially increase the risk to those in most need (Thacker et al, 2019). In addition, the health professional needs to know how to manage any disclosures and provide ongoing safe support through appropriate signposting and referrals, with guidance from safeguarding teams and leads within their organisation.
Political frameworks that drive professionals in the safe and effective management of DVA are continually at the forefront of the government agenda (NICE, 2014; Home Office, 2019; 2020). Local authorities and healthcare trusts have their own individualised strategies for service provision and access to local agencies that support victims and families affected by DVA.
Categories and signs of DVA
Many of the signs of DVA are present across more than one category.
Table 1 sets out some of the most common behaviours that may occur in categories of DVA; this is by no means exhaustive and each category includes many more behaviours.
| Physical | Sexual | Emotional | Psychological | Financial | Coercive control |
|---|---|---|---|---|---|
| Shaking | Forced sex | Swearing | Intimidation | Preventing work | Developing reliance |
| Smacking | Sexual insults | Undermining confidence | Insults | Undermining efforts to find work or study | Portraying an exaggerated need for the person |
| Punching | Sexually transmitted disease | Making racists comments | Critical language | Refusing access to money | Monitoring the person's behaviour and movements |
| Kicking | Preventing breastfeeding | Expressing superior knowledge | Denying abuse | Asking for explanation for every penny spent | Causing anxiety |
| Biting | Sexual exploitation | Making the person feel unattractive | Inferior treatment | Making the person beg for money | Causing constant worry about relationship |
| Starving | Ignoring religious prohibitions | Name calling | Threats to harm victim or children | Gambling | Causing the person to feel exhausted |
| Stabbing | Refusing to practice safe sex | Making the person feel stupid | Forced marriage | Not paying bills | Wanting to be present at all times |
| Female genital mutilation | Non-consensual sexual games | Restricting friendships | Shouting | Causing debt | Being critical of victim's family or friends |
Effect of DVA
DVA has a plethora of serious effects that have a negative impact on the health and wellbeing of victims, children and perpetrators. (Keeling and Mason, 2008). The cost to the economy in England and Wales of DVA was estimated to be in excess of £66 billion during 2016-2017 (Oliver et al, 2019). This includes NHS costs for primary and secondary care services that treat physical injury and provide mental health support, as well as the preventive measures that help keep victims and families safe.
Table 2 lists some examples of the signs that may be presented when DVA is evident within a relationship. This is not an exhaustive list and each individual and family must be assessed accordingly; similar signs may appear in both victim and children. It is important for health professionals who may identify DVA to recognise that women are most at risk of serious harm or death when they leave their violent or controlling partners (DH, 2017). Awareness of the signs of DVA and changing behaviours should help build professional competence in addressing and readdressing DVA at multiple safe opportunities.
| Effect on an adult | Effect on a child | Effect on a perpetrator |
|---|---|---|
| Recurrent sexually transmitted disease | Physical injury | Loss of employment |
| Broken bones/physical injury, burns, stab wounds | Tiredness, anxiety, depression | Loss of home |
| Tiredness and fatigue | Burns or stab wounds | Ostracised by community/family |
| Maternal death | Self-harm | Crime |
| Miscarriage | Eating disorders | Suicide |
| Guilt | Truancy/problems at school | Prison |
| Loss of hope/desire | Sexual precocity | Post-traumatic stress disorder |
Assessing risk in DVA
Success in tackling DVA relies on a multi-agency approach. Everyone involved needs to be knowledgeable, to feel confident and to contribute towards helping women and children create safer lives for themselves (DH, 2017).
Embedding routine enquiry into contemporary nursing practice is essential in striving to reduce the impacts of DVA and ensure women are aware where support is available. Building a rapport with the victim of abuse allows an assessment of current risk both to the victim and any other household members such as children (Schroeder, 2011). Asking women a question regarding DVA, not only provides an opportunity for women to share concerns should they feel safe to do so, it also opens doors for future disclosures (DH, 2017).
Midwife and health visitor practice incorporates essential tools that address DVA at all initial contacts. It is essential to ensure all potential victims are aware of the professionals and agencies that can offer support. Health professionals should be equipped with this knowledge and should reassure the victim that help is available. Once victims feel confident that a health professional can provide safety and support, they are more likely to reach out for professional help.
Professionals should not rely on someone else to ask this question, or wait for disclosures. Professional curiosity should guide safe practice for all healthcare workers (DH, 2017). Asking about DVA is the responsibility of every nurse, with the Nursing and Midwifery Council (NMC) embedding this into safe practice (NMC, 2018:15). Registrants are duty bound to provide care and protect all members of the public at all times with public protection and personal safety a fundamental element across all nursing practice. When asking perceived victims of DVA about personal relationships nurses need to ensure they are equipped with skills to manage the situation without any further risk of harm (NMC, 2018).
It is therefore important that health professionals develop skills in managing conversations with potential victims in order to learn the signs that a person may be experiencing DVA and in this way minimise the risk of further harm (DH, 2010).
Professional practice points include (DH, 2017):
Managing DVA
Following disclosure or evidence of domestic abuse, the nurse or other health professional has a duty to ensure that correct procedures and referrals are completed, to promote the safety of the victim and family unit (DH, 2017), acting in a way that ensures they follow legislation and local guidelines (NICE, 2016; NMC, 2018).
The Domestic Abuse, Stalking and Honour Based Violence (DASH) Risk Identification, Assessment and Management Model is a national risk assessment and management checklist that has been implemented across all areas of the UK since 2009 (DASH, 2009). The risk assessments support practitioners and professionals working with victims of abuse in identifying the severity of risk and the pathways that can be followed to help minimise further harm.
There was widespread agreement from social care, health and the police that a proactive approach to risk was needed to keep victims and their families safe. All professionals in health and social care should be trained and skilled in accessing the DASH tool and implementing its use in practice. The tool itself can be easily downloaded from the DASH web page (www.dashriskchecklist.co.uk). Local healthcare trusts and authorities usually have links on their home intranet pages for easy access.
The tool has a total of 27 questions that are divided into sections. These sections explore the current situation, children and/or dependants, domestic violence history and questions around the perpetrator(s).
The questions included in Box 1 are only one part of the assessment tool. Questions are scored when the answer is ‘yes’ and a total score denotes the severity of risk. This would then help professionals identify safety strategies that should be applied for care of the victim and their family. A higher number of yes responses would identify a high-risk victim.
It is important for health professionals to consider these questions as a tool to assess risk and action can be taken on professional judgement. If the professional is unsure, he or she should seek advice from safeguarding leads or the police. Further details can be documented within the DASH tool to help with assessment and safety planning.
Possible referral agencies
Awareness of support services and agencies that can provide ongoing help to victims and families will allow nurses and other health professionals the ability to ensure a victim's safety and reduce further harm.
Although risk assessments are the standard tool in identification, management must come from continued intervention. Appropriate referral pathways will help ensure this process is implemented and families are given the correct support following disclosure or identified risk of harm. Referrals should consider support from agencies such as:
Summary
Recent statistics report that 2.3 million people experienced DVA in the year ending March 2020 (ONS, 2020). There is need to respond to the year-on-year rise in significant mental distress issues affecting the health and wellbeing of today's and future generations. All nurses and other health and social care professionals should be skilled and knowledgeable to recognise, assess and protect victims and families where DVA could be evident. Minimising risk of harm and death is an issue that is high on the health agenda (Home Office, 2020).
Protecting people from further abuse requires a multi-agency approach. Nurses must ensure they are confident to address DVA; however, they should not work in isolation. Communication with others is vital. Nurses and other health professionals in all settings should be aware of agencies that may be best placed to provide suitable and safe strategies to assist victims and their families.