Domestic abuse: how to spot the signs and support colleagues who may be affected

Nurses in all sectors will come into contact with people experiencing domestic violence and coercive control, but can also be at risk of abuse themselves

• The COVID-19 pandemic has thrown a spotlight on domestic abuse, as people have been forced to spend more time at home
• Research suggests that nurses are up to three times more likely to experience this kind of abuse than the general public
• How to spot the signs of abuse and tips for supporting colleagues who may be reluctant to disclose

In the early stages of the COVID-19 pandemic, reports of domestic violence and abuse soared.

According to the charity Women’s Aid, the pandemic created the ‘perfect storm’, with lockdown leaving some people trapped with their abuser and feeling like ‘sitting ducks’.

Unexpected dip in calls for help from nurses in the first UK lockdown

The Cavell Nurses’ Trust, which gives financial and other support to nurses, midwives and healthcare assistants facing problems, including domestic abuse, was expecting an increase in calls for help. Yet demand actually decreased in the first few weeks of lockdown.

The trust’s 2016 survey suggested that nurses, midwives and healthcare assistants are three times more likely than the general population to experience domestic abuse.

Why calls fell as COVID-19 cases rose isn’t clear, says the charity’s communications manager Paul Steiner.

‘As always, it’s potentially a number of issues, for example, domestic abuse victims not having as much time to themselves during lockdown to consider their situation and make a decision to leave an abusive relationship.

‘Also, many nurses, midwives and healthcare assistants were redeployed. This may have caused upheaval and added stress to those in an abusive relationship, meaning they had less time to think about exiting the situation.

‘Once the charity identified this drop-off, we quickly put awareness activities in place and applications began to increase.’

• RELATED: How nurses can help people at risk of an escalation of domestic violence and abuse in the COVID-19 pandemic

Victims of domestic abuse are overwhelmingly female

Regardless of the pandemic, with a predominantly female workforce, nursing will feel the impact of domestic abuse. Although anyone can be affected, victims of domestic abuse are overwhelmingly female; the World Health Organization estimates that one in three women worldwide will be directly affected at some point in their lives.

Domestic abuse is now discussed more openly in healthcare settings and is included on some preregistration nursing courses.

Although this primarily tends to relate to spotting the signs in patients and offering support, there is also a recognition that nurses themselves may be the subjects of abuse – and talking about it more generally helps to raise awareness of that.

University of Sheffield division of nursing and midwifery senior lecturer Parveen Ali, who has published widely on the topic, says this is positive.

‘It’s not so long ago that we as nurses and midwives didn’t really talk about domestic abuse – we didn’t really see it as a healthcare issue,’ says Dr Ali.

• RELATED: What to do when you suspect domestic abuse

‘Understanding of the issue – and the role that healthcare professionals can play – has increased in the past decade. This is a good thing: when people started talking about it, it helped them reflect on their own experience, and ask themselves if what they had experienced with a previous relationship or current relationship was abuse.

‘At the same time, hospitals and other healthcare organisations started developing policies and referral pathways to make it clearer. Understanding and information is growing day by day.’

Domestic abuse affects all social and professional groups

Dr Ali would like to see more evidence before concluding that nurses are more likely to be victims of domestic abuse by virtue of the fact they are nurses, rather than because it is a predominantly female profession.

‘If you look at domestic abuse around the world, one in three women has experienced some form of it,’ she says.

‘Even if you look at figures from the UK only, the numbers of women being exposed to domestic abuse is quite high, and we’re only talking about the cases we know. There’s obviously a lot of under-reporting because it’s stigmatising, it’s embarrassing and people don’t talk about it.

• RELATED: Nurses at heightened risk of domestic abuse

‘The majority of nurses are women, and abuse happens in all social strata and that explains why nurses would come into that category.

‘It also may be that it may have been a motivating factor for us to join the profession, especially in mental health nursing or for mature nurses who may have joined nursing after being abused or exposed to abuse. But I don’t think there’s enough evidence to make big claims about that.’

Dr Ali stresses that anyone can become involved in an abusive relationship – even people who are senior leaders at work, and those who appear to be confident and in control of their lives. Nurses are no different.

‘Once someone is in an abusive relationship, it’s hard to get out of it,’ she says. ‘It’s hard to accept it, or even realise that you are in an abusive relationship. When you think of the long shifts that nurses work, the pressures on them and all the juggling they have to do, it can be easy for them to blame themselves.’

Coercive control: subtle and difficult to detect

This is even more the case when it comes to coercive control, which has only been recognised relatively recently, she adds.

‘Domestic abuse isn’t only the physical hitting, or sexual or psychological abuse; it’s also about coercive control. What we see is that the majority of abusive relationships are coercively controlling. Sometimes in coercive controlling relationships there may not be any physical abuse at all, which means it’s even more difficult to acknowledge it.’

Perpetrators are often charming and manipulative, says Dr Ali, which makes it even harder for women to trust their own feelings.

‘You get women who have been exposed to coercive control and even their own family members, siblings, parents would say, “Oh, he’s so charming, he takes care of you so well”, because that’s how the person presents to them. So then you feel even more unsure about whether what they are doing is abuse.

‘When someone is saying to you to wear this or wear that, or eat this or eat that, or don’t go here or there, are they being caring or is it abuse? It is difficult.’

• RELATED: The board game that helps you identify domestic violence and abuse

What to do if you spot the signs of domestic abuse

Dr Ali has developed a FutureLearn course on supporting victims of domestic abuse, aimed at health and social care staff, which has been accessed by 12,000 people worldwide. It makes it clear that spotting the signs of domestic abuse is only the first step – you then have to know what to do about it when you suspect it.

‘You can support people by being present, telling them that you are there to support them, that you believe them. They might not open up to you the first time, but by having a non-judgemental attitude and providing them with opportunities to talk or giving subtle cues about the sorts of services that are available, you are helping them to process things.

‘It’s a drip, drip, drip approach and eventually it might help them to make the decision to get out of their situation.’

Workplace policies that can help keep staff safe

In advice to NHS organisations on supporting staff who might be experiencing domestic abuse, NHS Employers points out they have a legal obligation to assess any risk and support the health, safety and wellness of employees.

There are positive examples, such as Milton Keynes University Hospital NHS Foundation Trust, which recently published its domestic abuse policy. Steps include offering staff up to six weeks’ paid leave if they need to leave home urgently due to domestic abuse, and salary advances if required.

‘It affects every part of people’s lives… it often affects the way they function at work, so it might mean that they find themselves in a disciplinary procedure because of poor performance, sickness and absence, through no fault of their own’

Debby Edwards, domestic abuse support project lead, University Hospitals Birmingham NHS Foundation Trust

In 2019, University Hospitals Birmingham (UHB) NHS Foundation Trust set up a service to support staff. The trust is working with Birmingham and Solihull Women’s Aid and other agencies to provide a safe space where staff can seek assistance.

Project lead Debby Edwards, who is also lead nurse for medicines management, says that while responding to domestic abuse can be complex, a non-judgemental approach that assures staff they are believed is key.

‘We’re trying to develop a safe culture that says that if you are experiencing domestic abuse, we will support you,’ she says. ‘We know it massively affects every part of people’s lives, including their health, family and friends.

‘Because of this, it often affects the way they function at work, so it might mean that they find themselves in a disciplinary procedure because of poor performance, sickness and absence, when it’s through no fault of their own.’

Ms Edwards works closely with the trust’s human resources and chaplaincy teams and other staff to support members of staff, and is also involved in raising awareness.

They are exploring ways of supporting people financially and possibly, post-pandemic, by offering hospital accommodation to those who need to leave a domestic abuse situation.

‘What we’re doing at UHB is innovative,’ says Ms Edwards. ‘But domestic abuse affects everybody; it will touch each and every one of us, whether that’s personally or through our family or friends or neighbours.

‘We know it’s common and we know that nursing is a predominantly female profession, so we know it’s going to be common among nurses. And from our perspective, we need to care for our nurses so that they can care for patients.’

• RELATED: The provision of emergency healthcare for women who experience intimate partner violence: part 1. An integrative review

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Jennifer Trueland is a health journalist