Bringing attention to domestic abuse
GETT Y IMAGES
A series of nurse-led initiatives in Nottingham are training staff to identify victims and refer them on to support services. Lynne Pearce reports
22 may 28 :: vol 28 no 39 :: 2014
NURSING STANDARD
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SUMMARY
With the police receiving an emergency call relating to domestic abuse every 30 seconds, it is no wonder that a recent official report, commissioned by the home secretary, described the prevalence and nature of this crime as ‘shocking’. In Nottinghamshire, domestic abuse accounts for 11 per cent of calls to the police for assistance, equivalent to 10 per cent of all recorded crime across the county. And 39 per cent of calls come from repeat victims. But this is not just an issue for the police – as well as treating the injuries and illness that result from abuse, nurses are increasingly involved in identifying victims and directing them to support. ‘We have a really good response to domestic abuse in Nottingham,’ says Selecia Kench, a domestic abuse liaison nurse at Nottingham University Hospitals NHS Trust. Based in the emergency department, she was appointed in 2009 to the then new post. ‘It is important that I am based in A&E,’ says Ms Kench. ‘People affected by domestic abuse are coming through our doors and [could be] discharged home without being referred anywhere else. We need to be able to pick them up here. The other advantage is that staff can just pop in and talk to me about a patient if they need to and I can give on-the-spot advice. If it is a complex case, I can spend time with that patient too.’ She believes her nursing skills are vital to the role. ‘Initially, the patient is coming in with
Nursing skills are vital to the roles of those working with victims of domestic abuse in Nottinghamshire. Specialist nurses at Nottingham University Hospitals NHS Trust are involved in referring patients on to further support services and training hospital staff to identify and respond to signs of abuse. Author Lynne Pearce is a freelance journalist
an injury or a health issue, so they expect to see a nurse and have that problem dealt with,’ says Ms Kench. ‘The opening is talking about their health. As nurses, we have developed our communication skills and we understand, for example, that there can be other things happening when someone has taken an overdose.’ Ms Kench qualified in 1995 and started working as
BEFORE, WE WERE SEEING PEOPLE WITH INJURIES OR MENTAL HEALTH ISSUES BUT WE WERE NOT RESPONDING a staff nurse in the emergency department 13 years ago, when her interest in domestic abuse and safeguarding began. ‘We were seeing people with injuries or mental health issues, but we were not responding to what they were telling us – we just did not have things in place then,’ she says. In her first year in post, she dealt with more than 200 patient referrals. Last year, that figure had more than doubled to 434. ‘And figures for the first three months of this year are already higher than for the same period last year,’ says Ms Kench. ‘It is hard to say whether domestic abuse is increasing, but I think awareness of it across the board has grown hugely. It is not so hidden now.’
Nearly 5,000,000 women – or 30 per cent of the adult female population – have experienced some form of domestic abuse since age 16, according to the latest figures from the Crime Survey for England and Wales, published in February
NURSING STANDARD
Posters with helpline information are displayed around the emergency department. ‘We have created an environment in which patients can see a poster and think “I could get some help here”,’ says Ms Kench. An important part of her role has been providing training to all 300 emergency department staff – from the receptionists to the consultants – in recognising and responding to domestic abuse. Sometimes, this involved challenging entrenched negative attitudes. ‘A change had to happen with some members of staff,’ she says. ‘They did not realise just how many people were affected by domestic abuse, the levels of violence that they can be subjected to and the impact on others, especially children.’
Now Ms Kench is beginning to look at a second round of training that will involve clinical inquiry – in other words, asking the question, rather than waiting for a patient to disclose what has been happening to them. ‘Staff feel much more comfortable about asking now,’ says Ms Kench. ‘When I first started training, I wanted to find out what their barriers were. They felt they could not ask a patient if they did not know how to respond to them, but that has altered now.’ Another significant obstacle was time. ‘A&E is really busy and we are all under pressure. I understand that,’ says Ms Kench. ‘Staff want to be trained by someone who knows what it
77
Women were killed by their partners or ex-partners in 2012/13. Source: Office of National Statistics
may 28 :: vol 28 no 39 :: 2014 23
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New guidance
For Professor McGarry, the most pressing need is education and training. ‘We must make sure that practitioners on the ground can support and manage survivors of abuse. They need to be able to signpost people and have referral pathways in place.’ She believes that new guidance on domestic violence and abuse, produced by the National Institute for Health and Care Excellence (NICE) in February, provides the linchpin for good practice, especially
ALAMY
is like to do their job. I am also aware that domestic abuse is not the only thing on their agenda. But all staff must be able to respond because I am not always here to help.’ While emergency departments undoubtedly play a pivotal role in helping to identify those who are experiencing domestic abuse, every nurse needs to be vigilant, argues Julie McGarry, associate professor and academic lead for safeguarding in the school of health sciences at the University of Nottingham. ‘While many survivors come through the emergency department because their injuries are severe or they might not have a primary care practitioner, it is also the case that they can crop up in many other areas where healthcare professionals traditionally have not considered asking these questions,’ she says. ‘It is about being alert and remembering that it is not always the most obvious presentation. For example, the patient may have irritable bowel syndrome or anxiety.’
Checklist for identifying those at risk Based on 24 questions, the DASH checklist helps front line practitioners to identify high-risk cases where victims face the possibility of murder or serious harm. Questions include: Are you very frightened? What are you afraid of? Is it further injury or violence? Do you feel isolated from family or friends? Does (name of abuser) constantly text, call, contact, follow, stalk or harass you? Is there conflict over child contact? Are you pregnant or have you had a baby in the past 18 months? Is the abuse happening more often? Is it getting worse? Does (name of abuser) try to control everything you do and/or are they excessively jealous? Has (name of abuser) ever threatened to kill you or someone else and you believed them? Has (the abuser) hurt anyone else (for example, family members or someone from a previous relationship)? Are there any financial issues? Are you dependent on (name of abuser) for money or have they recently lost their job? Has (name of abuser) had problems in the past year with drugs (prescription or other), alcohol or mental health? Do you know if (name of abuser) has ever been in trouble with the police or has a criminal history? (tinyurl.com/c8ndrp3)
the recommendations on different levels of training. ‘This is going to be significant and everyone needs to be thinking about it.’ Currently, the professor is evaluating a new role of domestic abuse specialist nurse at Nottingham University Hospitals NHS Trust, which is being carried out by Maggie Westbury on a two-year contract that began last May. Funded through the trust’s charity, Ms Westbury works with all patients who have been affected by domestic abuse, apart from those who have been identified by Ms Kench or other staff in the emergency department. She has referred 80 patients to specialist agencies for help over the past ten months. ‘Sometimes a patient is too poorly to talk when they have come into the emergency department, but then something happens afterwards that alerts staff,’ says Ms Westbury. How a patient behaves when their partner visits can reveal cause for concern, she adds. In common with her colleagues in the emergency department, she uses the domestic abuse, stalking, harassment and honour-based violence (DASH) risk identification checklist (see box left). This has been developed by the charity Co-ordinated Action Against Domestic Abuse (CAADA). While a majority of patients willingly take part in the risk assessment, around a quarter are reluctant. ‘I am open and honest with patients from the beginning,’ says Ms Westbury. ‘I say that I cannot promise
£15.7 billion One in six men will experience domestic abuse in their lifetime, says the ManKind Initiative 24 may 28 :: vol 28 no 39 :: 2014
A report published by Lancaster University in 2009 estimates that domestic abuse costs society £15.7 billion a year, although some organisations such as Women’s Aid suggest a figure as high as £23 billion
NURSING STANDARD
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confidentiality and that we may have to refer to other agencies, particularly if children are involved. If the patient is still talking to me after that then I know it is probably going to be okay.’ Referral to a local multi-agency risk assessment conference (MARAC) is usually triggered if the patient has 14 or more ‘ticks’ on their checklist. MARACs bring together various agencies to share information and draw up a safety plan to support the victim and his or her children.
Ms Litten is still a rarity. Working as a health visitor for five years in inner city Nottingham re-ignited an interest in domestic abuse that began during her training, when she undertook a placement in a refuge. ‘It seemed to me that domestic abuse was a factor in almost every case I dealt with as a health visitor,’ says Ms Litten. ‘I became particularly interested in the long-term effects on children.’ Formerly a nursery nurse, her expert knowledge of children’s
DOMESTIC ABUSE ONLINE NOW
FREE RESOURCES http://rcnpublishing.com/r/domestic-violence
PRACTITIONERS NEED TO BE ABLE TO SIGNPOST PEOPLE AND HAVE REFERRAL PATHWAYS IN PLACE More than 270 MARACs are currently operating across the UK, managing in excess of 64,000 cases each year. They usually include representatives from the police, education, housing, mental health, drug and alcohol services, specialist domestic abuse services and probation. Nottinghamshire has three MARACs, with domestic abuse nurse specialist Hester Litten acting as health representative on one of them. ‘Here, they have been running since 2007. We meet fortnightly to look at cases involving the 20 most high-risk victims, the perpetrators and their families,’ explains Ms Litten, who works for Nottingham CityCare Partnership, which runs a variety of community services across the city. Appointed to her role in 2008 as one of the first clinical nurse specialists in domestic abuse,
35
NURSING STANDARD
health is particularly useful during MARAC discussions, she believes. ‘I understand how a normal child develops. That means I can better explain to others the impact that domestic abuse may have on a child,’ she says. ‘This includes how it could affect their brain development,
Resources National Domestic Violence Helpline – 0808 2000 247 – for assistance with refuge accommodation advice. ‘Honour’ Helpline – 0800 599 9247 – for advice on forced marriage and ‘honour-based’ violence. Sexual Assault Referrals Centres – www.rapecrisis.org.uk/Referralcentres2.php. Broken Rainbow – 08452 604460 – www.brokenrainbow.org.uk for advice for lesbians, gay, bisexual and trans people. NICE Report: Domestic Violence and Abuse – How Services can Respond Effectively (PH50) (guidance.nice.org.uk/PH50). Women’s Aid – national charity supporting a network of 9,300 specialist services – www.womensaid.org.uk
Domestic abuse has more repeat victims than any other crime, with an average of 35 assaults before the victim calls the police, says the charity Refuge
their growth and their mental health. For example, a child might be labelled as being autistic, but the true diagnosis is domestic abuse.’ Training is also a large part of her role. Of CityCare’s 1,500 employees, those who are non-clinical receive at least two hours’ training as part of their induction, while clinical staff receive a day’s training. Health visitors have an extra half day on top of this, specifically exploring the effect of domestic abuse on children. The full day’s training begins with a session on understanding domestic abuse. ‘This addresses the fact that it is not just physical – it looks at the intricacies of coercive control,’ explains Ms Litten. Other topics include how to recognise the signs of abuse and what to do if you suspect it is happening. Information about the other agencies that provide support is provided. She adds: ‘We deal with the old chestnuts, such as “why don’t they just leave?” and those who say “well I just wouldn’t stand for it”. By the end of the day, everyone understands it is nowhere near as simple as that’ NS
In an NSPCC report published in 2011, one in four young people aged between 10 and 24 reported that they experienced domestic violence and abuse during their childhood may 28 :: vol 28 no 39 :: 2014 25
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GETT Y IMAGES
A series of nurse-led initiatives in Nottingham are training staff to identify victims and refer them on to support services. Lynne Pearce reports
22 may 28 :: vol 28 no 39 :: 2014
NURSING STANDARD
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 14, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
SUMMARY
With the police receiving an emergency call relating to domestic abuse every 30 seconds, it is no wonder that a recent official report, commissioned by the home secretary, described the prevalence and nature of this crime as ‘shocking’. In Nottinghamshire, domestic abuse accounts for 11 per cent of calls to the police for assistance, equivalent to 10 per cent of all recorded crime across the county. And 39 per cent of calls come from repeat victims. But this is not just an issue for the police – as well as treating the injuries and illness that result from abuse, nurses are increasingly involved in identifying victims and directing them to support. ‘We have a really good response to domestic abuse in Nottingham,’ says Selecia Kench, a domestic abuse liaison nurse at Nottingham University Hospitals NHS Trust. Based in the emergency department, she was appointed in 2009 to the then new post. ‘It is important that I am based in A&E,’ says Ms Kench. ‘People affected by domestic abuse are coming through our doors and [could be] discharged home without being referred anywhere else. We need to be able to pick them up here. The other advantage is that staff can just pop in and talk to me about a patient if they need to and I can give on-the-spot advice. If it is a complex case, I can spend time with that patient too.’ She believes her nursing skills are vital to the role. ‘Initially, the patient is coming in with
Nursing skills are vital to the roles of those working with victims of domestic abuse in Nottinghamshire. Specialist nurses at Nottingham University Hospitals NHS Trust are involved in referring patients on to further support services and training hospital staff to identify and respond to signs of abuse. Author Lynne Pearce is a freelance journalist
an injury or a health issue, so they expect to see a nurse and have that problem dealt with,’ says Ms Kench. ‘The opening is talking about their health. As nurses, we have developed our communication skills and we understand, for example, that there can be other things happening when someone has taken an overdose.’ Ms Kench qualified in 1995 and started working as
BEFORE, WE WERE SEEING PEOPLE WITH INJURIES OR MENTAL HEALTH ISSUES BUT WE WERE NOT RESPONDING a staff nurse in the emergency department 13 years ago, when her interest in domestic abuse and safeguarding began. ‘We were seeing people with injuries or mental health issues, but we were not responding to what they were telling us – we just did not have things in place then,’ she says. In her first year in post, she dealt with more than 200 patient referrals. Last year, that figure had more than doubled to 434. ‘And figures for the first three months of this year are already higher than for the same period last year,’ says Ms Kench. ‘It is hard to say whether domestic abuse is increasing, but I think awareness of it across the board has grown hugely. It is not so hidden now.’
Nearly 5,000,000 women – or 30 per cent of the adult female population – have experienced some form of domestic abuse since age 16, according to the latest figures from the Crime Survey for England and Wales, published in February
NURSING STANDARD
Posters with helpline information are displayed around the emergency department. ‘We have created an environment in which patients can see a poster and think “I could get some help here”,’ says Ms Kench. An important part of her role has been providing training to all 300 emergency department staff – from the receptionists to the consultants – in recognising and responding to domestic abuse. Sometimes, this involved challenging entrenched negative attitudes. ‘A change had to happen with some members of staff,’ she says. ‘They did not realise just how many people were affected by domestic abuse, the levels of violence that they can be subjected to and the impact on others, especially children.’
Now Ms Kench is beginning to look at a second round of training that will involve clinical inquiry – in other words, asking the question, rather than waiting for a patient to disclose what has been happening to them. ‘Staff feel much more comfortable about asking now,’ says Ms Kench. ‘When I first started training, I wanted to find out what their barriers were. They felt they could not ask a patient if they did not know how to respond to them, but that has altered now.’ Another significant obstacle was time. ‘A&E is really busy and we are all under pressure. I understand that,’ says Ms Kench. ‘Staff want to be trained by someone who knows what it
77
Women were killed by their partners or ex-partners in 2012/13. Source: Office of National Statistics
may 28 :: vol 28 no 39 :: 2014 23
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New guidance
For Professor McGarry, the most pressing need is education and training. ‘We must make sure that practitioners on the ground can support and manage survivors of abuse. They need to be able to signpost people and have referral pathways in place.’ She believes that new guidance on domestic violence and abuse, produced by the National Institute for Health and Care Excellence (NICE) in February, provides the linchpin for good practice, especially
ALAMY
is like to do their job. I am also aware that domestic abuse is not the only thing on their agenda. But all staff must be able to respond because I am not always here to help.’ While emergency departments undoubtedly play a pivotal role in helping to identify those who are experiencing domestic abuse, every nurse needs to be vigilant, argues Julie McGarry, associate professor and academic lead for safeguarding in the school of health sciences at the University of Nottingham. ‘While many survivors come through the emergency department because their injuries are severe or they might not have a primary care practitioner, it is also the case that they can crop up in many other areas where healthcare professionals traditionally have not considered asking these questions,’ she says. ‘It is about being alert and remembering that it is not always the most obvious presentation. For example, the patient may have irritable bowel syndrome or anxiety.’
Checklist for identifying those at risk Based on 24 questions, the DASH checklist helps front line practitioners to identify high-risk cases where victims face the possibility of murder or serious harm. Questions include: Are you very frightened? What are you afraid of? Is it further injury or violence? Do you feel isolated from family or friends? Does (name of abuser) constantly text, call, contact, follow, stalk or harass you? Is there conflict over child contact? Are you pregnant or have you had a baby in the past 18 months? Is the abuse happening more often? Is it getting worse? Does (name of abuser) try to control everything you do and/or are they excessively jealous? Has (name of abuser) ever threatened to kill you or someone else and you believed them? Has (the abuser) hurt anyone else (for example, family members or someone from a previous relationship)? Are there any financial issues? Are you dependent on (name of abuser) for money or have they recently lost their job? Has (name of abuser) had problems in the past year with drugs (prescription or other), alcohol or mental health? Do you know if (name of abuser) has ever been in trouble with the police or has a criminal history? (tinyurl.com/c8ndrp3)
the recommendations on different levels of training. ‘This is going to be significant and everyone needs to be thinking about it.’ Currently, the professor is evaluating a new role of domestic abuse specialist nurse at Nottingham University Hospitals NHS Trust, which is being carried out by Maggie Westbury on a two-year contract that began last May. Funded through the trust’s charity, Ms Westbury works with all patients who have been affected by domestic abuse, apart from those who have been identified by Ms Kench or other staff in the emergency department. She has referred 80 patients to specialist agencies for help over the past ten months. ‘Sometimes a patient is too poorly to talk when they have come into the emergency department, but then something happens afterwards that alerts staff,’ says Ms Westbury. How a patient behaves when their partner visits can reveal cause for concern, she adds. In common with her colleagues in the emergency department, she uses the domestic abuse, stalking, harassment and honour-based violence (DASH) risk identification checklist (see box left). This has been developed by the charity Co-ordinated Action Against Domestic Abuse (CAADA). While a majority of patients willingly take part in the risk assessment, around a quarter are reluctant. ‘I am open and honest with patients from the beginning,’ says Ms Westbury. ‘I say that I cannot promise
£15.7 billion One in six men will experience domestic abuse in their lifetime, says the ManKind Initiative 24 may 28 :: vol 28 no 39 :: 2014
A report published by Lancaster University in 2009 estimates that domestic abuse costs society £15.7 billion a year, although some organisations such as Women’s Aid suggest a figure as high as £23 billion
NURSING STANDARD
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 14, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
confidentiality and that we may have to refer to other agencies, particularly if children are involved. If the patient is still talking to me after that then I know it is probably going to be okay.’ Referral to a local multi-agency risk assessment conference (MARAC) is usually triggered if the patient has 14 or more ‘ticks’ on their checklist. MARACs bring together various agencies to share information and draw up a safety plan to support the victim and his or her children.
Ms Litten is still a rarity. Working as a health visitor for five years in inner city Nottingham re-ignited an interest in domestic abuse that began during her training, when she undertook a placement in a refuge. ‘It seemed to me that domestic abuse was a factor in almost every case I dealt with as a health visitor,’ says Ms Litten. ‘I became particularly interested in the long-term effects on children.’ Formerly a nursery nurse, her expert knowledge of children’s
DOMESTIC ABUSE ONLINE NOW
FREE RESOURCES http://rcnpublishing.com/r/domestic-violence
PRACTITIONERS NEED TO BE ABLE TO SIGNPOST PEOPLE AND HAVE REFERRAL PATHWAYS IN PLACE More than 270 MARACs are currently operating across the UK, managing in excess of 64,000 cases each year. They usually include representatives from the police, education, housing, mental health, drug and alcohol services, specialist domestic abuse services and probation. Nottinghamshire has three MARACs, with domestic abuse nurse specialist Hester Litten acting as health representative on one of them. ‘Here, they have been running since 2007. We meet fortnightly to look at cases involving the 20 most high-risk victims, the perpetrators and their families,’ explains Ms Litten, who works for Nottingham CityCare Partnership, which runs a variety of community services across the city. Appointed to her role in 2008 as one of the first clinical nurse specialists in domestic abuse,
35
NURSING STANDARD
health is particularly useful during MARAC discussions, she believes. ‘I understand how a normal child develops. That means I can better explain to others the impact that domestic abuse may have on a child,’ she says. ‘This includes how it could affect their brain development,
Resources National Domestic Violence Helpline – 0808 2000 247 – for assistance with refuge accommodation advice. ‘Honour’ Helpline – 0800 599 9247 – for advice on forced marriage and ‘honour-based’ violence. Sexual Assault Referrals Centres – www.rapecrisis.org.uk/Referralcentres2.php. Broken Rainbow – 08452 604460 – www.brokenrainbow.org.uk for advice for lesbians, gay, bisexual and trans people. NICE Report: Domestic Violence and Abuse – How Services can Respond Effectively (PH50) (guidance.nice.org.uk/PH50). Women’s Aid – national charity supporting a network of 9,300 specialist services – www.womensaid.org.uk
Domestic abuse has more repeat victims than any other crime, with an average of 35 assaults before the victim calls the police, says the charity Refuge
their growth and their mental health. For example, a child might be labelled as being autistic, but the true diagnosis is domestic abuse.’ Training is also a large part of her role. Of CityCare’s 1,500 employees, those who are non-clinical receive at least two hours’ training as part of their induction, while clinical staff receive a day’s training. Health visitors have an extra half day on top of this, specifically exploring the effect of domestic abuse on children. The full day’s training begins with a session on understanding domestic abuse. ‘This addresses the fact that it is not just physical – it looks at the intricacies of coercive control,’ explains Ms Litten. Other topics include how to recognise the signs of abuse and what to do if you suspect it is happening. Information about the other agencies that provide support is provided. She adds: ‘We deal with the old chestnuts, such as “why don’t they just leave?” and those who say “well I just wouldn’t stand for it”. By the end of the day, everyone understands it is nowhere near as simple as that’ NS
In an NSPCC report published in 2011, one in four young people aged between 10 and 24 reported that they experienced domestic violence and abuse during their childhood may 28 :: vol 28 no 39 :: 2014 25
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