Physicians described how intervention demanded a certain amount of flexibility of roles, with nurses and physicians playing off each other in tag-team fashion, as necessary. One physician said:
Sometimes when I finish with an exam, I’ll tell the nurse that I suspect something, so when the nurse is giving the discharge instructions, she’ll also re-approach certain kinds of issues and give the woman another opportunity to talk about [the abuse], once she has gotten dressed and composed herself. The door is closed. It’s one-on-one.
Some physicians described how their prenatal team takes advantage of a “window of opportunity” and has helped women get out of their situations and into counseling:
We have a prenatal team that really works together … our nurse, our social worker, our nutritionist, the receptionist, everybody.… It’s a real intense time. But I think once they get out of pregnancy, we really lose that ability to make a change in their lives. It’s a real window of opportunity.
Prioritize Domestic Violence. Even the committed physicians in our study expressed conflict about taking the time to intervene once they had identified abuse. Some physicians advocated dropping the medical procedure (even if that means the loss of reimbursement) to spend the rest of the patient’s time dealing with the abuse. Physicians also described prioritizing domestic violence by conducting continuing education courses and meetings for everyone in the department about rape, domestic violence, and child and elder abuse. One participant reported:
We try to create a culture of caring about domestic violence so that nurses who think they’ve recognized someone as being a nondeclared victim won’t be told, “I’m too busy” by a physician. And so when physicians say, “I think that might be a domestic violence victim, could you go talk to her?” the nurse will see that as a priority. And if anybody asks her, “How come you haven’t got that IV started?” she or he could say, “Because I was in talking to this person trying to determine whether they were a domestic violence victim.”
Small Victories Offer Positive Feedback
These physicians reported receiving little direct feedback about the effectiveness of their interventions with battered women. Yet, they also reported a range of rewards for intervening, from seeing a patient really change her life to glimpsing shifts in the way a woman thinks about herself and the relationship. One physician said:
And the rewarding piece for me comes when at some point she looks up and notices, and you can see this change of realizing that she’s cared about and then what that must mean to her, that she’s worth something. And then later on [there are] those little steps that you can see people make when they feel like they’re worth something. That’s the most ongoing and rewarding thing.
Discussion
The themes described by the purposive sample of physicians in our study offer insight into the process of intervention with victims of domestic violence and help delineate practicable examples of how to apply interventions ( Table 3 ). The behaviors described are supported by quantitative and qualitative data from battered women.33,37
These physicians described the foundation of intervention with victims as giving victims the message that they do not deserve abuse and that they are worth caring about. Battered women themselves report that validation is an important message. In a recent survey,37 battered women rated validating statements and compassion from physicians as among the most desirable interventions, equal to safety planning and offering referrals. In another study,33 survivors of domestic violence described how validation from a health care professional had not only provided relief and comfort, but also “started the wheels turning” toward realizing the seriousness of the situation. These women reported that validation helped them, regardless of whether they had disclosed the abuse or the health care professional had identified it.
Women who are being controlled through abuse by an intimate partner live with debilitating feelings of denial, shame, and humiliation that are sometimes reinforced in health care encounters and keep victims from seeking and receiving optimal care.33,38-41 The physicians in our study recognized these barriers and made efforts to help women break through their denial and plant seeds for change. They also made efforts—and learned through trial and error—to listen and be nonjudgmental. Both of these behaviors were rated as highly desirable by battered women.37 Physician statements made within the context of a trusting relationship can serve to remind women of the seriousness of their situation. Physician behaviors that convey respect through tone of voice and body language could lessen a victim’s shame and help her make small changes over time to improve her situation and her health.