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Domestic abuse: what healthcare professionals need to know

The RCN is updating its online resources on domestic abuse and violence and will publish a new guide for healthcare professionals next year. Carmel Bagness and Helen Donovan, who are leading the RCN’s online resources on domestic abuse, explain how to identify and support victims of abuse.   
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The RCN is updating its online resources on domestic abuse and violence and will publish a new guide for healthcare professionals next year. Carmel Bagness and Helen Donovan, who are leading the project, explain how to identify and support victims of abuse

Despite increased recognition of domestic abuse in recent years, it often remains hidden. While some healthcare professionals are aware of abuse and have a good understanding of the difficulties in addressing the needs of those affected, this is not always the case.

All healthcare professionals need to understand the issues and have up-to-date knowledge in order to recognise and implement appropriate care and safeguarding measures for anyone who may have been abused or is at risk of abuse.

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The RCN is updating its online resources on domestic abuse and violence and will publish a new guide for healthcare professionals next year. Carmel Bagness and Helen Donovan, who are leading the project, explain how to identify and support victims of abuse


Domestic abuse is defined as 'any incident or pattern of incidents of controlling, coercive,
threatening behaviour, violence or abuse'. Picture: iStock

Despite increased recognition of domestic abuse in recent years, it often remains hidden. While some healthcare professionals are aware of abuse and have a good understanding of the difficulties in addressing the needs of those affected, this is not always the case.

All healthcare professionals need to understand the issues and have up-to-date knowledge in order to recognise and implement appropriate care and safeguarding measures for anyone who may have been abused or is at risk of abuse.

The  government’s definition of domestic violence and abuse, published this year by the Home Office, is: ‘Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality.’

Unrecognised problem

Coercive behaviours are usually subtle and long term and damage health, confidence and wellbeing. They can go unrecognised as abuse by professionals, society and by victims themselves.

Domestic abuse is under-reported and under-recognised, sometimes because of preconceived ideas about who it affects, and sometimes because nurses and others are unsure about what they can do for a victim or suspected victim. 

This is particularly an issue when it is discovered outside of the context of the care being offered, for example, as a result of a visit to the GP or immunisation services, fertility or maternity services or the dentist for unrelated matters.  Issues raised in these appointments can alert professionals to potential problems and the need for further questions. 

Physical and mental symptoms 

Victims may present with symptoms related to musculoskeletal disorders and chronic pain, genito-urinary disorders and respiratory illness. Typical injuries include contusions, abrasions, lacerations, burns, fractures and dislocations, bruises, lost teeth, internal injuries, gynaecological problems and miscarriages.

However, symptoms may not be physical or visible and consequently much more challenging to identify.

Victims may present with psychological and psychiatric problems, such as depression, anxiety, despair and post-traumatic stress disorder. Indicators include self-medication with drugs and alcohol, stress, self-harm and suicide attempts.

Sensitively and safely

Asking a patient or client if they feel safe at home is a good start, but this should be undertaken sensitively and in a safe environment. This often means taking steps to speak to the victim on their own and not in the presence a ‘carer’ or relative who may appear overly protective of them.

It is important to consider how to support the victim to remove themselves from the violent situation, as well as the consequences of this not happening immediately.

Initiating these questions can be difficult for some healthcare professionals, as it may feel intrusive and the person’s reaction is unpredictable. 

Who are the victims?

Domestic abuse can happen to anyone. It is not specific to a gender, race, sexual orientation or age. It crosses social and economic boundaries, can begin at any stage in a relationship and can affect teenagers and people in lesbian, gay, bisexual and transgender relationships.

Current evidence suggests that victims are mainly women assaulted by men, but men are also victims, though the true scale of this is difficult to establish due to under-reporting and stigma. 

About one in four women and one in six men experience domestic abuse in their lifetime, according to the charity Living Without Abuse.

Some cultures are more secretive about the existence of domestic abuse, and sometimes violence is an accepted element of living in a relationship with someone.

Domestic abuse is essentially a pattern of behaviour rather than a one-off incident, and tends to increase in frequency and severity over time.

What distinguishes domestic violence from other forms of abuse is that the victim and the perpetrator are known to each other, it takes place largely in private and there is often a lack of objective evidence that abuse has taken place. The abuser may have a great deal of intimate knowledge about their victim and hurt them in subtle ways that may not be understood by others.

Physical attacks may be targeted at areas of the body that are unlikely to be seen by others. Domestic violence is also less likely than other forms of violence to be reported to the police.

It should also be noted that this problem relates to healthcare staff as individuals, just as it does other members of society, both as victims and perpetrators of abuse.

Increased risk 

The challenges for victims from black and minority ethnic communities may be more extreme. In some cases this is due to language issues and a lack of local knowledge or friends and relatives to call on for support.

The National Society for the Prevention of Cruelty to Children says that children living in households where there is domestic abuse are at risk of emotional detachment and physical abuse. Children in this position may fear that they are the cause of the abuse, and may become disruptive or aggressive.

Reassure victims

Be mindful that abuse in the home could be a factor in the behaviour exhibited by any patient in any core setting.

Once the healthcare professional asks the question, they need to be confident that there is a system of support available to the victim, and that the person will not be in greater danger following disclosure. Safeguarding processes need to reflect the fear and anxiety victims have for themselves and other family members.

It is important to reassure victims that they are not to blame and do not have to put up with feeling unsafe or being abused or humiliated at home. 

Local services need to provide support and display an understanding of the consequences for individuals who are frightened or unsure that they have done the right thing in exposing their abuse. 

Having an up-to-date understanding of the issues related to domestic violence is important. All healthcare professionals need to know how to ask questions, and have confidence that there are systems in place to support identified victims, even if these systems cross traditional service boundaries.


The RCN is updating its online resources on domestic abuse, which will be published towards the end of 2016. A guide for healthcare practitioners on how to approach this sensitive subject with patients and clients will be launched in 2017.

What is domestic abuse?

Abuse can encompass, but is not limited to:
  • Psychological – using demeaning language, being rude, aggressive, undermining confidence
  • Physical – hitting, kicking, injuring with an implement
  • Sexual assault and rape
  • Financial deprivation and economic dispossession
  • Emotional – blackmail, mental torture, threats to disown or kill the person or their children or relatives.
Forms of domestic abuse include:
  • Physical violence, causing injury
  • Forced marriage or dowry abuse
  • Honour-based violence
  • Female genital mutilation
  • Sexual violence, including rape
  • Stalking and harassment
  • Deprivation victims of basic needs
  • Enforcing rules and activities that humiliate, degrade or dehumanise the victim
  • Forcing the victim to take part in criminal activity, such as shoplifting or neglect or abuse of children, to encourage self-blame and prevent disclosure to authorities.
Actions for nurses and midwives:
  • Find out more about domestic abuse
  • Ask patients who may be at risk questions such as ‘Do you feel safe at home?’
  • Know what to do, if there are signs of abuse
  • Know where to refer a potential victim to
  • Work with multi-professional organisations and groups.
The charity Living Without Abuse suggests that domestic abuse:
  • Leads to, on average, two women being murdered each week and 30 men being murdered each year 
  • Accounts for 16% of all violent crime, but is still the least likely to be reported to the police
  • Is repeated more than any other crime (on average a victim will experience 35 assaults before they call the police)
  • Is the most quoted reason for becoming homeless
  • Includes forced marriages. In 2010, the Forced Marriage Unit responded to 1,735 reports of possible forced marriages
  • Can lead to suicide. Estimates show each year 400 people take their own lives after attending hospital for domestic abuse injuries in the previous 6 months. Of these, 200 attend hospital on the day they take their own life.

 


Carmel Bagness is RCN professional lead midwifery and women’s health. Helen Donovan is RCN professional lead for public health nursing

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