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Contemporary Theories of Nursing Practice- Domestic Abuse (Comparison of Health Services in UK and India)
Domestic abuse is an issue that exists globally which not only causes physical distress but is also concerned with an associated mental anguish (Matczak et al., 2011). Additionally, this domestic abuse has economic repercussions too Allard,(2013) suggests that people who have experienced domestic abuse most often visit the emergency department (ED) after the first episode. but are unrecognised as signs of abuse (Farchi et al., 2013). In spite of the frequency of the victims visit to the ED, the cases of abuse are still largely unrecognised. This scenario is quite alarming, and statistics associated with the prevalence have been reported at 1.2 million women and 700,000 men between the ages of 16-60 years have experienced abuse (Guy et al., 2014). Furthermore, the 8.5% of the women and 4.5% men have experienced abuse in the last year alone. Totally, 28.3% of the women and 14% of the men have been victims of domestic abuse since the age of 16 (Office for National Statistics, 2015; Guy et al., 2014; Oram et al., 2013). Of this 6.8 % of the women and 3% of the men have reported various types of partner abuse involving extreme force as well (Guy et al., 2014). As per the reports by Department of Health (DOH) and The National Institute of health and Care Excellence (NICE), it has been stated that both the elderly as well as the children are also subject to such type of abuse; 52% of the children and more than 250,000 elders experience maltreatment as well as abuse (Washington State Department of Health, 2013).
India too is no exception as the statistics of domestic abuse here too are just as alarming. The reports by the National Crime Records Bureau have depicted that women experience both partner abuse as well as physical abuse (40% and 36%); wherein partner abuse can include physical and mental as inflicted by only the partner and physical abuse by any member of the family such as father, brother and so on. Even though, domestic abuse is considered as an offence as per “Protection of Women from Domestic Violence Act” (PWDVA)., 55% of them still face abuse. However, in India, this is considered “normal” due to several cultural factors as opposed to the UK or other western countries. Here it can be stated that the crime rate against women remains at 1 in 85,312. The PWDVA also states that in recent times, men too have started coming forward to seek help for domestic abuse (Gupta, 2014). In view of this, another researcher Oram et al. (2013) also states that the prevalence of domestic abuse amongst men have been on the rise. These statistics hence project that domestic abuse does not affect only women but affect men too.
The reports derived from various studies/ governmental updates put much emphasis on the reality that is domestic abuse. It is imperative to state here that much of the responsibility of nurses who work in the ED is to identify these victims of domestic abuse (Cho et al., 2015). This is reiterated by Robinson (2010) who states that the ED nurses form the first line of contact for the intervention and treatment of the victims of abuse abuse, wherein, they can use an assessment tool such as the HITS (hurts, insults, threatens and screams) scale for determing the same. Along the same lines, (McGarry et al., 2014) too stresses that it is the responsibility of the ED nurses to refer such cases of abuse to the police or Non-Governmental Organisations (NGO).
Here, domestic abuse may be defined as an incident that is associated with threatening behaviour, inflicted abuse or violence which can be physical, psychological, emotional, sexual and financial (Local Government Association, 2015). Most commonly, the abuse may be inflicted by present or former intimate partners, or other family members of any gender or sexuality (Washington State Department of Health, 2013). On the other hand, the World Health Organisation (WHO) defines domestic abuse specfic to Intimate Partner Violence (IPV) (Garcia-Moreno et al., 2012) as behaviour that causes physical or psychological harm within the confines of an intimate relationship. Another definition of the Royal college of Nursing (RCN) is similar to the one provided by the department of Health but which also encloses factors such as intimacy, emotional relations and familial connections. Further to this, a report released by the adult social services in the UK state that while there exists a large gender differnce in terms of domestic violence women are more likely to experience abuse than men. It has also been stated that men who report such violence are usually doing so as a retaliation to the complaints against them. But even so, it was depicted that women rarely came forward on their own and needed coaxing and consolation to do so (Local Government Association, 2015).
As for IPV in India, research (Sohani et al., 2013) shows that India is a nation that is rapidly developing especially in terms of the population. The current population has been placed at 1.2 billion with an estimated sex ratio of 940 females for every 1000 males. IPV in India is quite predominant due to the socio-cultural predominance on the longevity of partnerships and also due to the largely patriarchal societal norms. Krishnan et al .(2012) in his study, has reported that the domestic abuse faced by women in India are mostly perpetrated by their own family members. This finding is also consistent with the global scenario on the same. For a low socio-economic country such as India, the prevalence is rather high. Haddad et al. (2011) in their report state that more than 1.6 million deaths occur worldwide as a result of domestic abuse. They suggest that over 90% of these deaths occur in low to middle socioeconomic countries against women. Allard (2013), however, further states that domestic abuse can affect any gender, irrespective of the socio-economic background.
Hence, it can be suggested here that the nurses screening in the ED must be aware enough to ask questions to the victims so as to ascertain whether they were subjected to domestic abuse. This is especially because victims may not typically volunteer information on the details of their abuse. However, the barriers to asking such questions are that the women may exhibit hostility when the suggestion of abuse is made, mostly due to fear. It thus becomes imperative for the nurses to be able to ask the right questions, which includes those from the HITS scale such as over the past 12 months how often have you been hurt, insulted, threatened and screamed. The recommendations by National Institute for Health and Care Excellence (2014) aligns to the same by suggesting that all the staff in all services are to be trained so that the indicators for domestic abuse can be recognised. Conversely, there is also evidence that nurses face certain barriers when it comes to the assessment of the patients for domestic violence. These barriers can be attributed to lack of or inadequate knowledge pertaining to the issue of abuse, constraints with time and also the process of familiarising with the patient (Allard, 2013). In this case, McGarry et al. (2014) has reinforced the need for specialist nurses training in the ED so that nurses are trained completely for both identifications as well as intervention for the cases of domestic abuse. For the year of 2009, Nottingham University Hospital (NHS Trust) has initiated a role for a specialist nurse to be of help to the victims of domestic abuse. In comparison, it can be said that such a specific role in India is yet to be developed which bears the implication that the awareness and reporting of domestic violence is to be enhanced.
In spite of numerous efficient implements, the motivation is that proficient training is a must for all ED staffs to make use of them. Besides training, nurses should have better consciousness to diagnose the signs and symptoms of misuse. It was evidenced by Gibbons (2011), which depicts that nurses must at once evaluate sufferers reporting to ED as they might have severe wounds that can even be fatal. Therefore, the skill to diagnose the signs, symptoms and consequences is compulsory apart from simple documentation of physical wounds and sufferers psychological condition. The (HSE) Health and Safety Executive 2007 proposed numerous signs of domestic abuse that nurses ought to be focused on. The signs are X-rays displaying fractures which might be old or new, specifically in forearm and those in phases of healing; Wounds on parts of the body; bruising and marks on shoulder back and neck; “red flag” pointers of high-risk offensive circumstance like choking and throttling wounds; patients who do not care for their wounds, reveal extreme dread, fear and uneasiness, who give incorrect and imperfect clarifications on wounds; the continuous company of intent other half’s or associate buddies; repeated presentation to crisis departments; intervals midst of injuries and visits (Gibbons, 2011).
However, in the UK several agencies such as Non- Governmental Organizations (NGO), general practitioners, mental health services and Emergency departments (McGarry et al., 2014) are offering services to domestically abused victims. ED provides medical advice to female victims of minimum 5 years’ tolerance in tangling into high-risk abusive relationships, according to Coordinated Action against Domestic Abuse (Coartinated Action Against Domestic Abuse, 2012). The longer tenure of abusive acceptance levels proliferates the risks involved in getting treated because the victims are ought to get hurt or killed during escape attempts. After encountering various domestic abuses, the nurses in ED have a crucial handling domestically abused victims. Allard (2013) signifies that the indispensable duty of an ED nurse is to provide medical assistance and advice to the suffered victims. According to McGarry et al. (2014), there are two types of victims associated with the abuse. The former victims are exposed directly to domestic abuse whereas the latter is pertained to reasons such as self-harm and others. The victims are in direct contact with the nurses in ED. The first point of contact for victims in ED are their nurses because they recognise and provide solutions for their needs at all nodes. The New Jersey State Nurses Association differs from this opinion and states the fact that the service providers of medical assistance always accuse the victims of their sufferings. Also, it states that the nurses do not have any concern for the victims and the treatment offered to the victims do not match their requirement. With respect to their struggles involved by the victims, the common drawbacks in treating the victims of domestic abuse (Rhodes et al., 2007) are assessing the victims in front of an unknown person, lacking to identify the levels of abuse disclosed, lack of offering safety, lack of finding their risk levels, failure in offering adequate services required. Soanes (2006) advice the ED nurses to prioritise the victim’s requirements and create a platform to reveal their abuse experiences in a private environment to overcome the above-mentioned problems.
The nurses point of view differs from the typecasts of the victims as discussed by Robinson (2010). The assessment of the victims is done by nurses are subjective to each other. Victims belonging to a lower economic class are more prone to abuses and are affected majorly. There arises a fear of inappropriate behaviour to the nurses towards the victims since that may be a reason for victim’s short stay in ED. Nurses identified the fact that gender plays a vital role in disclosing the sufferings. American nurses believed that victims would not listen and practice the instructions and guidance offered to them (Robinson, 2010). Also, the Intimate Partner Violence(IPV) victims are supposed to not be trustworthy, and women of that category tend to be more aggressive during assessments Matczak et al. (2011) provides the fact that Indian women feel at ease to share their abusive history without any gender disparity in order to get viable solutions to their sufferings. This is indicative that in the UK women tend not to be very open about their abuse whereas in India, women open upto females nurses quite easily. The main reason for this is that even though domestic abuse is considered to be illegal, there are no formal policies in place that places emphasis on reporting the event in India (Matczak et al., 2011).
In conclusion, curbing or increasing the reporting and recognising victims of domestic abuse requires an integrated approach. This is both in the cases of UK as well as India. Victims generally report to the ED due to either a dire need for treatment, anonymity or both. Therefore, the integration must occur at the governance level, health care sector level, and finally in nurse training too. The implementation of specialist nurses as a role to handle this domestic abuse can prove to be beneficial. Further, more innovative ideas, novel approaches may also be considered. This can be in the form of stringent policies or decisions made by governing authorities as well. The healthcare structure can be modified to include a framework of support to these victims. Therefore, a respite is most certainly an important requirement in the cases of domestic violence and abuse which is a very underrated global issue.
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