1. Roush, Karen MSN, RN, FNP-BC


Too many victims of domestic violence still go unnoticed.


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I'm in the ED, brought here by ambulance after passing out in my bathroom, dehydrated after hours of diarrhea and vomiting. It's crowded: patients parked in stretchers and wheelchairs around the nurses' station, family members hovering. The ambulance crew pulls my stretcher up to the counter and gives report to a nurse seated on the other side. She glances over at me-huge hematoma across my forehead, fat and lacerated lip, ecchymotic nose-and calls out loudly, "Any living will or domestic violence issues?"


In fact, I know what it's like to go to an ED after being battered, how humiliated and weak you feel. Twenty years ago, after many years of abuse, I left my first husband; a few months later he broke into my apartment and attacked me, putting my head through a wall. At the ED that night, I looked much as I do now. The staff reacted with disapproval and embarrassment, offering me no follow-up guidance or resources. After all these years and despite educational initiatives and increased public awareness, the approach is no better: a clinician's suspicion warrants only an offhand question tossed across a crowded ED.

Figure. Karen Roush... - Click to enlarge in new windowFigure. Karen Roush

In the years since I left my ex-husband, the Joint Commission has mandated that hospital EDs have policies for addressing domestic violence, facilities have instituted educational programs and universal screening procedures, and nursing and medical schools have added domestic violence to their curricula. Yet studies regularly find that the majority of people who seek health care for any reason aren't asked about domestic violence, and clinicians say they're uncomfortable talking to patients about abuse and treating its victims.


Although the U.S. Preventive Services Task Force found insufficient evidence to recommend universal screening for domestic violence, most medical and nursing organizations advocate it. The July 2000 report on the findings of the National Violence Against Women Survey stated that about 1.5 million women suffer intimate partner violence annually; 25% of surveyed women and 8% of surveyed men reported experiencing it within their lifetimes. Many get health care for problems unrelated to abuse; when the abuse goes unrecognized, an opportunity to intervene is lost. In qualitative studies, abused women regularly report a willingness to disclose abuse when asked, if they believe the clinician to be caring, nonjudgmental, and able to protect and help them.


It's not enough for health care facilities to add a check box to the admission form and call that "screening." They must provide the resources-time, privacy, and clinician education. More important, they must hold clinicians accountable. Efforts aimed at identifying victims of abuse need not be futile; well-designed intervention programs have been shown to work.


I want to tell the admitting nurse how harmful her indifference is, how it prevents women from seeking care they need, how it alienates and silences them. Even when a woman doesn't respond to the first offer of help, she will have heard that abuse is wrong, that she is valued. It might be the first time she has heard this.


For a week I run into neighbors and acquaintances and watch them try not to look at my black eye and swollen nose. No one asks what happened. I feel their embarrassment for me. Nursing colleagues and other health care professionals react no differently; at times their discomfort is palpable. All too often this is what an abused woman goes through: first the pain and fear of the attacks, then indifference or condescension from the people she turns to, and always the stigma attached to domestic violence. This has to change. We cannot allow another 20 years to pass before those who endure such violence are treated with the justice and compassion they deserve.


For information and materials, visit the National Health Resource Center on Domestic Violence: