"Shanti"'s
* attendance to A&E was one of the moments I realised I needed to
learn more about the cultural and social factors which add to the
complexity of domestic violence, and eventually resulted in this WCMT
travel fellowship.
(*
ALL names and details have been changed to protect confidentiality)
“Shanti"
attended the A&E department with police late one night. I was
nurse in charge of majors, and as the police entered I felt a pang of
frustration. The department was hectic as usual, phones ringing, the
bustle of doctors and nurses and the stress of patients crackling in
the air. The arrival of police officers is never associated with
anything good. I didn't even notice Shanti at first, the police
officers were tall and imposing and I deferred to them, wondering why
they had come to the department. As they started to tell her story in
controlled voices, I noticed her. One of the police officers held her
gently but firmly by the elbow. Birdlike, her eyes flitted around the
department, seemingly debating fight or flight. She was shrouded in a
faded sari, the hood of which cast lunar shadows on her face. She did
not make eye contact with the police or the nurses.
The
police told me Shanti had been effectively kept prisoner since being
brought from Bangladesh following her marriage four years previously.
She had been taken out of school at age 16 even though she had wanted
to continue her education, she was married in Bangladesh and brought
over to the UK to live with her UK born Bangladeshi husband (her
second cousin) at age 18. Now age 22, she had not seen her family for
four years. She had no family or friends in London. Her husband had
been violent and abusive from early on in their marriage. He didn't
like her to leave the house, he treated her as if she was only useful
for housework and cooking and often forced her into sex against her
will. Having finished school at a young age, she spoke little English
and her situation was becoming increasingly desperate. She had
suffered two miscarriages previously due to physical violence from
her husband whilst pregnant, and she believed she was pregnant again,
yet she had no idea of the gestation as had received no ante-natal
care. Shanti was terrified that harm would come to her baby and had
managed to make a phone call to her uncle in Bangladesh who had
alerted the police. Shanti had been brought from the house and her
husband had been taken into police custody.
The
story shocked me. How could a woman be living in such terror just a
couple of miles from our hospital for four years?
But
then I started to think... what if Shanti had attended our department
during the previous four years? With an injury, or with a
miscarriage. Would she have been questioned about domestic violence?
As
health professionals in the emergency department we have a unique
opportunity, in that we see people who might otherwise not have
access to any other health services. People like Shanti, where abuse
is happening 'behind the walls', and yet, whom occasionally have need
of emergency medical care.
Working
with a colleague, we carried out an audit to assess staff knowledge
and resources for domestic violence. We found that language and
cultural barriers were a main hindrance in assessment for domestic
abuse. Nurses felt they did not always have time to use interpreters,
and professional interpreters were not always available. Two nurses
felt concerned about being culturally insensitive, in particular, if
asking the husband or family to wait outside the cubicle. The
majority of nurses wanted specific training on domestic abuse, which
focused on how to detect it in the emergency department. None of the
nurses highlighted pregnancy as a risk factor for domestic abuse. On
further discussion, there was confusion among many of the nurses
about 'honour' based violence and forced marriage.
This
is consistent with the research and policy in this area. It suggests
that people experiencing abuse will frequently attend health services
and yet health care professionals often fail to ask about,
or recognize domestic abuse (1).
Domestic Violence London (1) cites a
1997 study in which only 6% of women attending A&E were
questioned about violence, and yet approx 35% had experienced
violence. When abuse is disclosed the patient may not be
supported adequately (2). Furthermore, and
even more worrying, are the suggestions that domestic abuse, “honour”
based violence and forced marriage may be overlooked because health
professionals do not wish to seem 'culturally insensitive' or they
don't want to highlight their lack of understanding of certain
religious or cultural practices (3).
It was clear to me that something needed to be done to improve services in our department for victims of domestic abuse, and that health professionals require specific training on domestic abuse and how to identify it (in the emergency department), and that this training should include how to deal with the issues of “honour” based violence and forced marriage.
Since
"Shanti's" attendance, we have made many changes to improve
care for victims of domestic violence in our department, including
the appointment of an independent domestic violence advisor who
follows up referrals and carries out training in the Emergency
Department. There is a much clearer referral pathway and we have
increased the resources available e.g. leaflets, posters and lip
balms with helpline number. However, there is a suggestion that the
incidence of "honour"-based violence is increasing (4).
Yet, although the need for specialist services for BME women is
increasing, many are being closed down due to lack of funding (4).
A 'Women's Aid' report (5) suggests
that 47% of these services have had their funding cut. Some women are
being advised to sleep in A&E departments or even night buses due
to lack of space in refuges (6).
As
well as lobbying to ensure that provision of specialist services and
refuges is preserved (you can start by signing 'womens aid' petition
here:
https://you.38degrees.org.uk/petitions/sos-save-refuges-save-lives),
I feel it is necessary for those of us who work with people who may
have experienced violence, to find innovative and creative ways to
ensure that these patients continue to receive advice, support and a
high standard of quality of care.
I
found that I wanted to know more about the issues of 'honour'-based
violence and forced marriage and hear from survivors themselves why
these abuses occur and how we can prevent them. I want to be able to
train staff in emergency departments London-wide to
understand and recognize this type of abuse, and better support
those who report it.
- NHS (2014) Domestic Violence London: A resource for health professionals. NHS Barking and Dagenham. [Online] http://www.domesticviolencelondon.nhs.uk/ [Accessed 19/11/14]
- HM Gov (2009) Domestic violence, forced marriage and “honour” based violence. The Stationary Office. Crown Copyright.[Online]www.womensaid.org.uk/core/core_picker/download.asp?id=1779 [Accessed 19/11/14]
- Kazimirski A, Keogh P, Kumari V, Smith R, Gowland S, Purdon S, Khanum N (2009) Forced marriage: Prevalence and service response. National centre for social research.[Online]https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/222192/DCSF-RR128.pdf [Accessed 19/11/14]
- Williams (2011) 'Honour' crimes against women in UK rising rapidly, figures show. The Guardian. Saturday 3rd December 2011. [Online] http://www.theguardian.com/uk/2011/dec/03/honour-crimes-uk-rising [Accessed 19/11/14]
- Taylor K (2013) A growing crisis of unmet need: what the figures alone don't show you. Women's Aid: Bristol. [Online] www.womensaid.org.uk/core/core_picker/download.asp?id=4245 [Accessed 20/11/14]
- Fawcett (2014) The triple jeopardy: the impact of service cuts on women. [Online] http://www.fawcettsociety.org.uk/2013/02/services/ [Accessed 20/11/14]
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