BARRY WILLIAMS / Special

Kabee Johnston, RN, SANE-A, is education committee chair of Gwinnett Hospital System's Domestic Violence Task Force.

Every nine seconds, a woman is physically abused in the United States. Each day, at least three women die at the hands of their abusers.

Between 20 percent and 30 percent of homicides across the country are related to domestic violence.

At home, the statistics are no better. For example, in Gwinnett County several years ago, the number of homicides related to domestic violence reached into the 70 percent range. Nearly 30 percent of the suicides in the county also were connected to family violence.

Health care providers often are on the front line when it comes to domestic violence, seeing victims when they come to the emergency room for treatment. The records these providers keep may help put an abuser in jail and save a life.

Pat King, RN, an investigator with the Gwinnett County Solicitor's Office, champions the reduction of domestic and family violence. She also is a law enforcement officer, having completed peace officers standards training in Georgia. Working with the justice system, health care professionals and law enforcement, King is familiar with the brutal statistics and the consequences of poor documentation from the first instances of abuse.

"Health care professionals can often help us make a case by thoroughly documenting the information a potential victim shares," she said. "When the information is not thorough, we can lose a case."

She relayed a story about a recent case with chart notes from both a physician and a nurse that read "the patient was hit with a fist."

"Did that fist come out of the blue or was it attached to someone?" King said. "Nurses can really help by probing just a bit more and making sure their notes are complete." In most cases, they do, she said.

Using R-A-D-A-R Gwinnett Hospital System created an active Domestic Violence Task Force several years ago and continually provides training to help staff identify and report abuse.

Denise Proto, RN, MS, CEN, is a nurse educator in emergency services at Gwinnett Medical Center. She helps nurses understand the role they play in helping identify and reduce domestic violence. "Letting women know that they're not alone - that they have resources and that they can be in a safe environment - is important," Proto said.

"However, as caregivers, we also have to understand that the fear a victim feels may prevent her from coming forward. Sometimes it's hard for us as caregivers to understand and not be judgmental," she added.

Kabee Johnston, RN, SANEA, is manager of perinatal operations at Gwinnett Hospital System. In addition to her management duties, she is chair of the education committee of the hospital's Domestic Violence Task Force. The hospital has developed several policies and programs to help identify and deal with suspected victims of domestic violence.

These programs include teaching staff to be aware of victims of possible domestic abuse and family violence using a technique called R-AD- A-R. By using a "decision tree" to ask questions without being too confrontational, the staff sometimes can identify an abuse victim and open the door to a conversation. The first part of R-A-D-A-R is "routinely ask."

"If we routinely ask during the admission process if a patient feels safe, we may be able to get them to open up," Johnston said. "Pregnancy is a particularly high-risk time, and we need to be able to identify a possible victim of abuse to protect her and the baby."

"Someone could come in with irritable-bowel syndrome or as a victim in an automobile crash, and we should still ask the question," Proto said.

"Who's to say that she isn't suffering from abuse that has increased her stress or caused her to crash her car as a last resort to end a violent relationship?"

Proto spoke of one case where a crash victim tried to commit suicide in a one-car wreck because of an untenable abusive situation at home.

"It's important for us to ask everyone who comes in, so that we can become comfortable with the verbiage," she said. "Then it becomes a universal screening tool."

Fear can paralyze
Fear for safety is often the largest stumbling block that keeps women from stepping up and admitting they're in an abusive relationship, according to statistics. Their self-esteem is at its lowest, they've been isolated and made to feel incapable of taking control. Financial issues also may keep abuse victims from making the step to break the cycle.

Debra Nichols, APRN, BC, a psychiatric clinical nurse specialist at Gwinnett Hospital System, said abuse victims may try to treat their injuries at home to avoid being discovered. When they come into the hospital for treatment, however, it may signal that they're ready to reach out for help.

"They may be afraid that they'll be hurt more if they tell someone about the abuse," Nichols said, "so they may hide out at home and stay isolated. We want to let them know that this is a safe environment and that there is help available."

Breaking a cycle
Even with the resources available through health care providers, state agencies and other groups, breaking the cycle of abuse is not simple. "The victim must be ready to make a change," Johnston said. "We have to allow them the chance and information to help themselves ... to break the cycle."

Johnston also works as a sexual assault nurse for Gwinnett County.

"It's so bothersome to me that there's a lot of emotional abuse that destroys a woman's self-esteem," she said. "I'm being proactive for women because of what I've seen."

A byproduct of the Domestic Violence Task Force at Gwinnett Hospital System is the ability to help staff who may experience abuse themselves.

"This gives staff members information and resources without having to come forward [about their own situation]," Johnston said. "Hearing about domestic violence may trigger the thought that what their partner is doing to them is not OK."

The challenges to health care professionals regarding family violence often go against the grain of their training. For example, some may not understand why a victim can't just walk away from her abuser.

"We teach staff to be nonjudgmental, because domestic violence is an emotional and psychological web that needs to be untangled," Proto said. "Domestic violence is not a single incident; it's part of a process.

"What we need to do is find out what has happened without making the patient feel devalued or misunderstood," she said. "Then we need to accurately and completely document injuries and statements."