What to do when you suspect domestic abuse
The nurses’ training aid that offers you practical strategies for the best outcomes
The nurses’ training aid that offers you practical strategies for the best outcomes
- Nurses have a professional duty to take reasonable steps to protect patients
- Why taking a holistic approach will achieve the safest outcomes for the individual
- Practical advice: what nurses need to know about building patients' trust
Domestic violence and abuse affects around two million people in the UK each year, two thirds of them women.
Only around 600,000 of these cases – ranging from physical violence to more subtle psychological abuse or controlling and coercive behaviour – were recorded as crimes by the police and fewer than half of these resulted in arrest, according to the Office for National Statistics.
Nurses are 3 times more likely …
to experience domestic abuse than the general population
Source: Cavell Nurses' Trust
Many cases will never come to the notice of the police or other authorities. But often the individual who is subject to the abuse will be in touch with the NHS, perhaps through a routine appointment with their GP or hospital, or through an emergency department attendance.
Timely intervention is key to protecting individuals
The actions of healthcare staff at this moment of interaction can be crucial in protecting the person, and other members of the family, and enabling them to access help from a variety of agencies.
But recognising the signs of abuse and then broaching such a sensitive subject is something many healthcare professionals find difficult. Those who have been in practice for some time may have received little training in it, while students and newly qualified staff may find the lectures on domestic abuse they had are of limited practical use in preparing them for what can be distressing conversations.
Enter Parveen Ali, a senior lecturer at the University of Sheffield's school of nursing and midwifery. Dr Ali has a particular interest in intimate partner violence and has developed a board game to be used in training sessions on domestic abuse – both in a university course and for health and social care professionals already practising.
The game uses question cards to help players build knowledge about domestic abuse and its indicators. Persona cards and scenario cards introduce players to fictional individuals and circumstances, and allow them to apply some of the knowledge they have gained during the game to identify and assist the individuals.
Ideally, the game has two to 12 players and takes around 45 minutes to an hour to complete. The teams aim to bring their playing pieces to a ‘safety zone’ by providing correct answers to questions and exploring scenarios.
Game is a stimulus to discussion and learning about domestic abuse
The game gives information about who is at risk, types of abuse and their indicators and impact, what health and social care professionals can do and how they need to record information. It also prompts players to discuss their responses and develop a deeper understanding of what it is like to be subjected to domestic abuse – and why people are often reluctant to speak out.
If a board game sounds an odd way to tackle such a serious subject, Dr Ali is adamant that games have been shown to enhance learning without trivialising the issue. ‘We know that people’s attention span is usually about 20 minutes. Beyond that you lose interest and your attention diverts,’ she says. ‘Games are normally very good at helping people to retain information for longer.’
The game, developed with funding from the University of Sheffield and the Burdett Trust for Nursing, aims to generate discussion about domestic abuse and how victims react, she says. ‘It might be “why does someone not leave?” or “what would you do in a particular situation?”.’
‘The scenarios were realistic and could be related to practice to aid discussion’
Rebecca Slack, postgraduate nursing student, University of Sheffield
Dr Ali also believes that by separating players into groups, the game encourages people to 'think more carefully' about the issues. 'It helps to explore something that is really very sensitive. You can provide information on a large scale in a lecture theatre but to have discussions and to explore different aspects works better in small groups.’
The game was developed with Focus Games, which specialises in health-related games. Its format may be developed to produce versions concentrating on child abuse and elder abuse.
A practical learning tool
Pilot projects with students at Sheffield convinced Dr Ali it was effective. ‘I was very pleased – they played it for about an hour and a quarter and then I just had to stop them,’ she says.
Rebecca Slack, a postgraduate nursing student at Sheffield, played the game as part of her training. She says it has made her more aware of what to look out for, and how she ought to react as a nurse. ‘The scenarios were realistic and could be related to practice to aid discussion,’ she adds.
It has been welcomed by the survivor-led group Apna Haq, which is based in Rotherham and supports women and girls from black and ethnic minority backgrounds. Umma Rubab, one of the women it supports, said: ‘Professionals need to understand that domestic violence is wider than apparent physical abuse that they may see.
‘Mental and verbal abuse cannot be seen but needs to be identified, and if professionals do not have a holistic understanding of the issue, they may miss the signs and never identify that domestic violence and abuse is even taking place.’
Key issues for nurses to keep in mind
- Nurses have a professional duty under the Nursing and Midwifery Council’s code to ‘take all reasonable steps to protect individuals who are vulnerable or at risk of harm, neglect and abuse’. The National Institute for Health and Care Excellence also has guidelines on quality standards on domestic violence, which say healthcare professionals should respond appropriately to disclosures but emphasise the role of their employer in supporting them with training and referral pathways
- People facing domestic violence don’t only present in the emergency department. Women who have experienced physical abuse make greater use of mental health services, outpatients and primary care than the general population
- Domestic abuse and coercive and controlling behaviour occur across all ethnic, cultural and religious boundaries and men as well as women can be subject to it. Nurses need to be careful not to make assumptions or accept behaviours as ‘just part of the culture’ when they are, in fact, abusive
‘Healthcare professionals are also human beings – things go on in their own relationships’
Parveen Ali, University of Sheffield senior lecturer who developed the board game on domestic abuse
- People experiencing abuse may not always present with the stereotypical manifestations – abuse goes much deeper and further than black eyes and bruising. Studies of intimate partner violence have found victims have higher rates of pain, vaginal discharge, memory loss and dizziness than the general population, together with psychological effects such as post-traumatic stress disorder and eating disorders. Coercive and controlling behaviour became an offence in 2015, but the signs it is occurring may be subtle and difficult to interpret: the individual may not even recognise it themselves
- While a nurse may suspect something is wrong and probe about domestic abuse, the person may not be in a position to disclose what has happened to them. Healthcare professionals often find it difficult to understand why this should be, especially if it happens repeatedly. But it is important to keep offering the opportunity to talk about it and information about sources of help. Disclosure may require trust to be built, access to a private space, and repeated visits
- Even once abuse has been disclosed, the person may not be able to ‘escape’ the environment immediately for a host of reasons, ranging from financial to psychological. Nurses need to keep on offering whatever assistance they can
- The situation changes when children are also at risk. Nurses need to be aware of their duties under their organisation’s child protection policies
- Dealing with domestic abuse can be distressing and traumatic. Nurses may have been victims as well – or know a family member who has been. ‘Healthcare professionals are also human beings. Things go on in their own relationships’ Parveen Ali points out. 'They need to look after themselves – and each other – when dealing with domestic abuse cases'
Changing attitudes bring greater scope for healthcare intervention
Attitudes to domestic abuse among healthcare staff and the wider public have changed over the years. As recognition has increased, so has the impetus for healthcare professionals to play a role in recognising it and ensuring the victim is given access to help. With attitude change has come a focus on safeguarding of children and vulnerable adults.
‘Healthcare professionals don’t always feel very confident and competent when asking questions or don’t know how to respond when someone discloses abuse,’ says Dr Ali.
‘In A&E, for example, their sixth sense may tell them something is wrong but they don’t know how to ask questions or don’t have time to do so.’
Many people will be reluctant to disclose what has happened to them, even if they are repeatedly accessing the NHS. They may be accompanied by the perpetrator or other family members, and nurses may need to create an opportunity for them to be seen alone.
Despite the barriers to disclosure, Dr Ali says nurses are well-placed to create the sort of environment where the individual trusts them and so feel able to reveal what is happening to them. But she emphasises that organisations also need to support their staff by providing private areas for disclosure and ensuring referral pathways are in place and specialist support is available. Increased awareness of the issues is important – but it may only be the first step.
Sources of help for your patients – or for you
If you work for an NHS trust or board, you are likely to have protocols on handling domestic violence and safeguarding that should determine your actions. There will be staff with particular responsibilities in this area who can advise you on what to do next and on areas such as information sharing.
The NHS website has contact information for people seeking help and support for domestic violence. These include:
- National Domestic Violence Helpline for women on 0808 2000247
- Men’s Advice line on 0808 802 0327
- Galop: support for LGBT people experiencing domestic abuse
Many domestic violence victims will need support from their local council or from a local refuge if they are to leave their home. National organisation Refuge may be able to help.
Nurses affected by domestic abuse can also contact the RCN's counselling service by calling 0345 772 6100 for an appointment.
Alison Moore is a health journalist