Values and Beliefs of the population
The definition of battered women according to Walker, as cited in Grant (1995), describes battered women syndrome as a group of psychological symptoms occurring in a recognizable pattern, in women who report physical, sexual, and or psychological abuse by their partner. The results of this abuse are often manifested as post traumatic stress disorder. Most victims of abuse are able to identify their first encounter of violence with their partner, but they describe the escalating occurrences as a blur, one event blending into the next. Many of the women voiced their concerns for their partners needs and describe their efforts to subdue the violence (Grant, 1995). Some of the beliefs of this population include:
1) The violence and abuse is somehow their fault.
2) They have done something to deserve the abuse.
3) There is something they can do to stop the abuse.
4) An intact family is better for the children.
5) Abuse is normal in a relationship (because of previous family learning).
6) If they ask for help, the violence may increase.
7) Help resources are temporary, and they will have no place to turn when services are discontinued.
8) A mistrust for the medical community to supply beneficial and empathetic services.
A possible explanation of the value and belief system of the battered woman is the profile addressed by Linda Poirier (1997). This profile includes social isolation, feeling trapped in the marriage or relationship, low self-esteem, having witnessed abuse as a child, depression and/or suicidal feelings, financial dependence on spouse, abuse of drugs and alcohol, a trusting nature, and a non-aggressive and traditional attitude. These values and beliefs lead to their patterns of seeking health care. Health care professionals must be aware of the need for an increase in screening for domestic abuse. Studies estimate one-fifth to one-third of women are abused during their lifetime (Thurston, Cory, & Scott, 1998). Policies need to be developed concerning uniform screening of all women to ensure their safety (Langford, 1996).
Reliance on Local, Regional, and Federal Funding
It is estimated that domestic violence leads to 28,700 emergency room visits per year, 39,000 physician office visits, $44 million in total annual medical costs, and 175,000 lost days of work (Poirier, 1997). Funding for services is provided through state and federal appropriations, as well as private donations. Our state office is funded through the U.S. Department of Health and Human Services, Violence Against Women Act and the Victims of Crime Act (OCADVSA, n. d.). The Oklahoma Department of Mental Health and Substance Abuse Services (OKDMHSAS) controls funding. The services provided to battered women include safe shelter, crisis hotlines, emergency transportation, legal advocacy, sexual assault advocacy, child advocacy, counseling, educational training, transitional living, and a variety of outreach, prevention, and educational activities (OCADVSA, n. d.).
One of the medical services provided to victims of domestic violence includes coverage of emergency services. In the case of sexual assault, the Oklahoma Sexual Assault Exam Fund can cover most, if not all, of the cost for a physical exam. If this fund is unable to cover the cost completely, the victim may file a claim with the Victim s Compensation Board. One stipulation of these funds is that the victim must file a police report in order for expenses to be covered (OKADVSA, 1993). Another fund that helps with medical expenses is the Oklahoma Crime Victims Compensation Program. This program covers out of pocket expenses for victims or the families of victims. This can cover medical and dental care, prescriptions, counseling and rehabilitation, work loss or loss of financial support, caregiver work loss, homicide crime scene clean-up, and funeral and burial expenses (District Attorneys Council, n. d.). Requirements for eligibility include reporting the crime within 72 hours, filing claim for compensation within one year, full cooperation with investigation and prosecution, compensation cannot benefit the offender, and claimant cannot have contributed to the injury. The total amount of compensation cannot exceed $20,000 (District Attorneys Council, n. d.).
Another service provided for the victims is legal assistance. This is a new program provided through a grant from the Department of Justice. It provides an attorney for protective hearings or other civil cases that assist women in breaking the cycle of domestic violence. Legal Services of Eastern Oklahoma has volunteered to provide services through this grant (OKCADVSA, 1999).
Patterns of Resource Allocation
Funding for domestic violence programs in Oklahoma are channeled through the Oklahoma Department of Mental Health and Substance Abuse Services (OKDMHSAS). The OKDMHSAS is responsible for the nearly 30 statewide resource centers annual budgets. Funding is distributed yearly based on the previous years spending and services provided (Campbell-Fife, 2000). The annual operating budget for the entire state for fiscal year 2000 was $4,502,936.00. This money is divided based on a base pay contract agreed upon individually by each center and the state. Monies allocated above the total of the contracts is divided based on the following formula: 75% based on population served by the center and 25% based on the area (in square miles) covered by the center (Campbell-Fife, personal communication, Feb 1, 2000). The total number of victims served in the fiscal year 1998 was 16,995, while the centers totaled 383,611 volunteer service hours. Each center that provides services has the right to determine their own resource priorities (Campbell-Fife, personal communication, Feb 1, 2000).
Patterns of Insurance Coverage
The battered women population is a very diverse group. Members of this population range from those living in poverty to those who are members of our highest economic class. For the members of the higher economic status accessibility to insurance coverage and health care is not a major factor due to their abundance of financial resources. Resources are not as readily available for those in the middle and lower classes. For those who have insurance, counseling services may not be covered. For those of the lower class who cannot afford insurance coverage, many are not aware of the services available to them. Consequently, they may delay seeking medical care and counseling due to their lack of resources (Rodriguez, Quiroga, & Bauer, 1996). Another barrier in insurance coverage relates to the doctor s reluctance to report abuse. Insurance companies may deny coverage to victims of domestic violence by calling it a preexisting or high-risk condition. Physicians may be reluctant to compromise a vulnerable patient s health care coverage (Gremillon & Kanof, 1996, p.772). A disadvantage of insurance coverage is HMO s require patients to see their primary care provider. This may cause victims to be reluctant to seek health care to prevent discovery of the abuse (Plitsas, 1996). Once the victim is identified by health care providers counseling services are available. Counseling services are provided on a needs basis through the YMCA. These services are available to anyone in need of assistance, regardless of their insurance coverage. The YMCA bills insurance companies for allowable services and the remainder of the cost is funded through grants and legislation (Pierce, personal communication, Feb 8, 2000).
Expectations of the Public for Care
Victims of domestic violence view healthcare providers as an ineffective source of help. Once identified, battered women were, treated insensitively and had their abuse minimized or ignored and (healthcare providers) subtly blamed women for their abuse. (Langford, 1996, p. 39). Due to this treatment, the subject of abuse has become an area of silence between victims and healthcare providers. Some contributors to the silence may be the patient s inability or unwillingness to seek medical help, the patient s withholding of information from the health care provider, and the health care provider s failure to ask the patient about battering. (Rodrigues, Quiroga & Bauer, 1996, p. 155). Other areas of concern for victims are police who are hesitant to get involved, prosecutors who minimize charges, and judges who are effected by the myths and stereotypes of abuse. (Family Violence Prevention Fund, n. d.; Flitcraft, Hadley, Hendricks-Mathews, McLeer & Warshaw, 1992).
Abuse victims desire for these officials to address the issue of abuse and be an advocate for them. Members of this population are entitled to: respect of their confidentiality, our belief and validation of their experiences, our acknowledgement of the injustice, our respect of their autonomy, our help in planning for their future safety, and promoting access to community services (Domestic Violence Project, Inc., n. d.). Cultural issues are also of concern related to language and value barriers (Family Violence Prevention Fund, n. d.).
Diagnostic Statements about the Population
Nursing Diagnoses
1. Actual or potential risk for impaired individual coping among women related to disruption of emotional bonds secondary to abuse, dysfunctional relationships, unsatisfactory support system, and inadequate knowledge of psychological and community resources as manifested by verbalization of the inability to cope or ask for help, difficulty with life stressors, and ineffective coping strategies (Carpenito, 1996).
2. Actual or potential risk for powerlessness (physical and psychological) among battered women related to feelings of loss of control and lifestyle restrictions secondary to abusive relationships (verbal, physical, and sexual) and fear of harm and violence as manifested by expressions of dissatisfaction over the inability to control the situation, depression, inability to leave the abusive relationship, bruises and contusions with varying states of healing, victim of rape assault, and unsatisfactory dependency needs upon the abuser (Carpenito, 1996).
3. Increased risk of a self esteem disturbance among women related to feelings of failure secondary to dysfunctional relationships, history of abusive relationships, and feelings of helplessness secondary to repeated episodes of abuse as manifested by self-negating verbalizations of I deserve to be treated like this and/or I am a terrible person , expressions of shame or guilt in regards to abusive partner or self, possible denial of problems obvious to others, ineffective use of defense mechanisms, and poor body presentation (posture, eye contact, movements) (Carpenito, 1996).
Goals
1. The community will initiate programs within the schools that focus on the exploration of gender roles and expectations, personal safety, legal statutes, and teen dating violence.
2. The community will acknowledge the prevalence and possibility of abuse and will provide resources to women at risk, in terms of community resources, safe shelters, and legal assistance to ensure safety for all involved parties, which is the highest priority.
Primary Interventions
1. The nurse will help initiate and spread awareness of abuse in order to promote healthy and positive lifestyles for victims of abuse (Stanhope & Lancaster, 1996).
2. The nurse will become a resource person and address the knowledge gaps to improve services for victims and perpetrators (Stanhope & Lancaster, 1996).
3. The nurse will initiate home visitations services for adolescent mothers, early adult age women, and women with family incomes below ten thousand dollars per year (Stanhope & Lancaster, 1996).
Rationale
The nurse will need to strengthen battered women and family members so that they can cope more effectively with various life stressors and demands. The nurse will need to help reduce the destructive elements in the community that support and encourage the use of human violence (Stanhope & Lancaster, 1996).
Teenage mothers, young adult women (19-29), and women with family incomes of less then ten thousand dollars per year, carry the highest risk for actual or potential abuse (CDC web page, 1999).
Secondary Interventions
1. The nurse will help to direct women and their abusers towards discussing their problems and seeking alternatives for dealing with the tension that led to the abusive situation (CDC web page, 1999).
2. The nurse will be able to recognize abuse, ask suspected victims about possible abuse, and refer battered women to temporary or permanent safe locations (Stanhope & Lancaster, 1996).
3. The nurse must radiate caring, acceptance, understanding, compassion, and a non-judgmental and non-authoritative attitude in regards to the abuser and the battered woman. The behavior, not the person, must be condemned (Stanhope & Lancaster, 1996, p.746).
Rationale
Nursing interventions are directed towards the early diagnosis of abuse and prompt treatment. The nurse needs to be perceptive to the cues of possible abuse and intervene early to prevent further physical or psychological damage (Stanhope & Lancaster, 1996).
Tertiary Interventions
1. The nurse will care for the battered women and their families experiencing abuse by developing an open and honest relationship with all family members, establishing safety as the number one priority and ensuring measures to promote a safe environment (Stanhope & Lancaster, 1996).
2. The nurse will need to recognize and capitalize on the violent family s strengths, as well as to assess and deal with its problems (Stanhope & Lancaster, 1996, p.747).
3. The nurse needs to give the victim reassurance that their feelings and responses are normal, they are not alone in their dilemma, and they do not deserve to be abused (Stanhope & Lancaster, 1996).
4. The nurse needs to be a resource person and offer continual support for positive individual and family decisions that ensure the safety of the victim (Stanhope & Lancaster, 1996).
Rationale
Nursing interventions need to be geared towards rehabilitation for the abused victim and their families. Ensuring safety is a crucial aspect of this level of intervention. Psychological recovery is an important factor and the nurse needs to teach and to explore with the victims and families, how to deal with their problems in nonviolent ways in order to decrease the incidence of abuse (Stanhope & Lancaster, 1996).
Strengths
Battered women are instinctive in regards to potential abuse or oncoming violence. They are capable of understanding the non-verbal cues and they are very resilient. Battered women are usually devoted to their husbands and children and fear leaving their families. They are determined to stay in the relationship because deep down they love their partners and do not want to be apart from them (CDC web page, 1999).
Weaknesses
Battered women tend to be more passive than their male counterparts and they have a weaker stature. Battered women tend to have low self-esteem and they become stereotyped to society norms that tolerate violence. Female victims of abuse are more likely then men to need medical attention, take time off work, spend more days in bed, and suffer from more stress and depression. Battered women are more likely to have shame and humiliation in regards to abuse and they are more likely to fear that the revelation of the abuse will further jeopardize their safety (CDC web page, 1999).
Interdisciplinary Planning
Responding to domestic violence should involve an, interrelationship between the health, legal, and social sectors so, women are not continually referred to various agencies (Getting help: Support web page, 1999, p. 1). Support is a main component involved in an interdisciplinary care teams plan of care.
Crisis intervention is the first thing that takes place. This involves the following: crisis hot lines, shelters, medical services, transportation networks, and laws that allow victims or perpetrators to be removed from the home (Getting help: Support web page, 1999, p. 1). Emotional support is another critical intervention, which includes self-help groups, assertiveness training, self-esteem, and confidence building sessions, and parenting skill courses. Finally, legal assistance may also be needed for custody of children, property matters, financial support, or restraining orders. Many different people and services come together to form an interdisciplinary team to provide safety, emotional, physical, and psychological treatment for battered women.
References
Attala, J. M., McSweeney, M., Mueller A., Bragg, B., & Hubertz, E. (1999). An Analysis of Nurses Communications in a Shelter Setting. Journal of Community Health Nursing, 16 (1), 29 40.
Battered Women in America. Retrieved 1/31/00 from the World Wide Web: http://cua6.csuohio.edu// sanda/pres/biele94/sId004.htm.
Brown, T., Finney, J., Jestis, T., Johnson, R., McCorkel, D., Roach, C., Schlinke, L., Smith, S., Snook, E., & Warning, W. (1998). Population Assessment: Battered Women. University of Central Oklahoma. Department of Nursing.