I say this patient is being abused...

rn/writer, RN · Jun 3, 2007

The idea that this woman has to take the first step is incorrect and unrealistic. Often, the targets of abuse are in no position to take any steps. They are either physically incapable of making contact with authorities, or they are terrified of what the abuser would do to them if they made an attempt and it was found out. In many cases, they have been so intimidated, indoctrinated, and beaten down (psychologically, if not with fists) that they are convinced no one would believe them anyway. That is why many states have mandatory reporting laws when abuse is suspected.

These laws spell out which professions are required to make their concerns known. If you are in such a state and you are considered, by virtue of your license, a mandatory reporter, you must make a report. The law trumps your employer's involvement. They can't not allow you to do something the state demands.

Mandatory reporting laws are designed to motivate those with a voice to speak. Practitioners and educators who are in a position to see evidence that something abnormal is taking place are the first line of defense for the defenseless and they serve as the eyes and ears of law enforcement and social service personnel who have the power to step in and take action.

One of the biggest concerns people have, whether they are madatory reporters or not, is that they aren't sure abuse is taking place. The law doesn't require certainty. It requires only suspicion or concern. Few of us are equipped to do the kind of investigating and evaluating that is needed to make a correct determination of abuse. When so much of our lives is necessarily based on fact and evidence, it can feel wrong to make a report based on only a hunch or some other fleeting sign. This situation is a good example. Without seeing bruises or hearing an account from the patient's own mouth, it's easy to discount your "gut." But when a patient is not allowed to speak for herself, you have to wonder what else is going on. What does that partner want kept quiet?

One reason that abuse reporting laws have become mandatory in many states is because the-powers-that-be understand the hesitation we grapple with. Rather than place any "burden of proof" on us, they wisely decided to take the onus off our shoulders and make our only responsibility the reporting of our suspicions. The burden to pin down the particulars then becomes theirs.

The people who need these laws the most are the ones who have the least recourse on their own. They have been bullied into submission and many have had their survival behaviors disabled. Without someone speaking on their behalf, the abuse will continue.

One of the responsiblities of my job is to ask my patients (postpartum mothers) if they feel safe in their own homes, if anyone is threatening them, or if they have any concerns for their own well-being. If the father of the baby (or anyone else, for that matter) would not let a patient speak, would not leave the room when asked, or seemed in any other way to be trying to control her answers, I would immediately alert the charge nurse and call social services. No debate.

For selfish reasons alone, you have cause to report. If it ever comes out that you had suspicions and did nothing, you could be held accountable.

But most of us are more motivated by our concerns for our patients. The thought that someone is being harmed is hard to live with.

If you report and are wrong, worst case is that some feathers will be ruffled. But what if abuse is occurring and you keep silent?

ERRNTraveler, RN · Jun 3, 2007

Nurses & medical professionals are required to report suspected abuse of children, the elderly, and mentally incapacitated, but adults of sound mind are required to seek help on their own. Legally, if she chooses to stay in the relationship, there is nothing you or any government agency can do about it. Even if he were arrested for actually beating her, no one can stop her from not pressing charges or taking him back. All you can do is ask her husband to leave the room, and provide her with information about resources should she choose to leave him (shelters, counseling services, etc). Also, be careful what you put in the chart. While I agree that this woman is probably in an abusive relationship, you cannot chart "hunches" or what you perceive to be going on. You can only chart facts of what actually happened, like putting what he said in quotes, etc.

SharonH, RN · Jun 3, 2007

The idea that this woman has to take the first step is incorrect and unrealistic. Often, the targets of abuse are in no position to take any steps. They are either physically incapable of making contact with authorities, or they are terrified of what the abuser would do to them if they made an attempt and it was found out. In many cases, they have been so intimidated, indoctrinated, and beaten down (psychologically, if not with fists) that they are convinced no one would believe them anyway. That is why many states have mandatory reporting laws when abuse is suspected.
These laws spell out which professions are required to make their concerns known. If you are in such a state and you are considered, by virtue of your license, a mandatory reporter, you must make a report. The law trumps your employer's involvement. They can't not allow you to do something the state demands.
Mandatory reporting laws are designed to motivate those with a voice to speak. Practitioners and educators who are in a position to see evidence that something abnormal is taking place are the first line of defense for the defenseless and they serve as the eyes and ears of law enforcement and social service personnel who have the power to step in and take action.
One of the biggest concerns people have, whether they are madatory reporters or not, is that they aren't sure abuse is taking place. The law doesn't require certainty. It requires only suspicion or concern. Few of us are equipped to do the kind of investigating and evaluating that is needed to make a correct determination of abuse. When so much of our lives is necessarily based on fact and evidence, it can feel wrong to make a report based on only a hunch or some other fleeting sign. This situation is a good example. Without seeing bruises or hearing an account from the patient's own mouth, it's easy to discount your "gut." But when a patient is not allowed to speak for herself, you have to wonder what else is going on. What does that partner want kept quiet?
One reason that abuse reporting laws have become mandatory in many states is because the-powers-that-be understand the hesitation we grapple with. Rather than place any "burden of proof" on us, they wisely decided to take the onus off our shoulders and make our only responsibility the reporting of our suspicions. The burden to pin down the particulars then becomes theirs.
The people who need these laws the most are the ones who have the least recourse on their own. They have been bullied into submission and many have had their survival behaviors disabled. Without someone speaking on their behalf, the abuse will continue.
One of the responsiblities of my job is to ask my patients (postpartum mothers) if they feel safe in their own homes, if anyone is threatening them, or if they have any concerns for their own well-being. If the father of the baby (or anyone else, for that matter) would not let a patient speak, would not leave the room when asked, or seemed in any other way to be trying to control her answers, I would immediately alert the charge nurse and call social services. No debate.
For selfish reasons alone, you have cause to report. If it ever comes out that you had suspicions and did nothing, you could be held accountable.
But most of us are more motivated by our concerns for our patients. The thought that someone is being harmed is hard to live with.
If you report and are wrong, worst case is that some feathers will be ruffled. But what if abuse is occurring and you keep silent?

Miranda, my understanding of mandatory reporting laws(which do not exist in every state by the way) is that you are required to report injuries due to suspected abuse. That is not the case here. Without injuries and without a statement from the woman what is she going to report specifically? There is another side to her liability and if she starts trouble merely because "a look", that can open a whole 'nother kettle of worms. Some of the others have made good suggestions by invoking patient privacy and having the husband step out of the room next time at which time she can ask the patient directly if she is in fear for her safety. But until the patient answers affirmatively or has injuries suggesting as much, there is nothing else she can do.

CRNI-ICU20 · Jun 3, 2007

This is classic domestic abuse behaviour. Look at what is normal: a husband who comes in with a wife....and when a question is directly posed to the wife, the NORMAL husband waits for the wife to express her concerns etc. WITHOUT INTERRUPTION OR PUT DOWNS OR REPRIMANDS. In this situation, it was NOT NORMAL. Sometimes abuse is so subtle, and because we live in a society where we have desensitized and sanitized it to the point where many of us are confused as to whether or not it really is abuse or not! The victim really was telling you to help her. Often these situations call for a moment where he's not able to control her every move, word, or thought. You can provide that for her by doing just what the above people suggested, and that is, to isolate her from him during examination, citing that due to privacy laws, that she must be allowed to speak with her health care providers alone. Many abusers will ignite at this "new" loss of control, and may attempt to cause harm, right then and there; or may stomp out, taking her with him. Anytime an abuser loses his/or her grip on control of the victim, there will be reaction. Some will back down, if enough solidarity is shown, but the others here also made reference to the fact that many abusers will wait to take their frustration and anger out on the victim when they return home.

Women who are caught in this cycle of violence and abuse will often "protect" their abuser, much like Stockholm Syndrome victims, because they fear that if they don't they will suffer even more hell fire and damnation.

So, if you report a suspicion, or report a hunch, it will often backfire, unless there is actual physical evidence of the abuse, ie burn marks, scars, different stages of bruises (this is one of the best ways to show abuse over time) or multiple broken bones in different stages of healing....in women it's usually ribs and facial bones. Without the supportive evidence, you are likely to be incredulous, and that could be problematic, if in this litigious society, the accused decides to sue.....one must be VERY careful.....

For this reason, it's best to give her opportunity to speak with you AND A WITNESS, alone.....document everything....

In the mean time, learn to ask the right questions:

The Domestic Violence websites all have great suggestions....but here are some that may help you when interviewing a potential victim of abuse:

1) scenario#1: "I noticed some bruising around your eye, tell me how that happened...."

2) scenario #2: "you seem very depressed and sad, are you having any major stressors in your life right now that I can offer some help with?"

3) "do you sleep well?"

4) "are you working steadily?"

5)"do you have a work number where I might be able to call you?"

6)"you are complaining of many aches and pains all over your body.....how long has this been going on, and have you seen any other medical people about this?"

7) "when was the last time you did something really nice for yourself?"

In and of themselves, these seem like pretty innocuous questions, but to a keen listener and observer, and to someone who is being abused, these questions will often open a floodgate that has been ready to burst open given the right person at the right time in the right place.

Many domestic violence patients want to speak out on behalf of themselves and their children, but are so beaten down and fear driven, they no longer have a sense of direction or a vehicle for getting to that point. YOU are the compass and vehicle for many of them. The American Academy of Family Physicians is a great resource for treating and assisting abuse victims.

Here's their website:

http://www.aafp.org/online/en/home/policy/policies/v/violencepositionpaper.html

http://www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=198

The second website is very helpful as a tool to screen whether or not a person is being abused. Many doctor's routinely place this questionaire in the packet that a new patient fills out as part of their medical history. It is estimated that one in four women are abused, and nearly 30% are killed by their intimate partner in this country a year! From a health care prospective, this is HUGE! I hope this has helped you, and good for you for having such keen insight into this patient's situation....I hope you can help her.

While it is partly true that unless she speaks out for herself, it is unlikely help will come, it is more true that all she needs is a compass, in the form of a caring professional, to point her in the direction she needs to go....given the tools, and support, many women will take the out....some won't....but some will....

blessings, crni

kTIE · Jun 4, 2007

You need to report this to your social worker on the floor. She will take it out of your hands and if she feels necessary to report this to A.P.S. Your supervisor will not be able to follow this up as well as the social worker or case manager on your floor who can spend the time investigating and they also have to document their findings. Better for you legally.

justme1972 · Jun 4, 2007

One of the local hospitals here has a policy that unless the patient is a minor or of dimenished mental capacity, the initial assessment is done with the patient and healthcare professional, and that's it.

Sometimes it's the only time abused women are alone and can talk to someone and come forward that something is seriously wrong.

KellieNurse06 · Jun 4, 2007

Absolutely you can report it......and anonymously.

We literally just had an abuse inservice last week at the home care agency I work for.

The social worker will come out unannounced, and pay a visit. If the woman says no, and she probably will........they will know if she is just afraid by exactly what you have described her behavior as doing......and the social worker will again make an unannounced visit..just to "see how you're doing" ......they don't just dissappear after the supposed abused person refuses help.........it doesn't go that way. I would definetly report this......maybe she was afraid to say anything with him there....but you can always call her up if you have to for any reason.....say for an upcoming appointment.......and ask so she can just give a yes or no answer..........maybe it will work,maybe not. Once that social worker comes out....that makes the victim feel better & gives them power because "someone knows" something is going on......... we had a 2 hr inservice that was really informative & lots of info......Good Luck

NurseCherlove · Jun 4, 2007

I am worried about this woman! Unfortunately, after reading the previous posts here, I'm afraid I agree that there isn't much from a legal perspective that you can do (as it does not sound like you witnessed any overt signs of abuse and she didn't have the chance to tell you).

Even if there were no noticeable bruises or even if it's "just" emotional abuse, abuse is rarely a stagnate phenomenon...it pretty much always escalates. This info. needs to be communicated to this woman and the related dangers.

Sounds like you work in an MD office. Surely there must be some "reason" that she needs a follow up phone call or maybe even a random "patient satisfaction survey", whatever. But if it were me, I would try to call her and relay my concerns to her. If he is there, you'll have to sum it all up in 30-60 seconds, relaying the fact that abuse escalates, help is available to her (have the name of the organization handy), and to tell him X was the reason for your call when she hangs up (to tell her that her labs were ok, etc.). Obviously, don't say all of this if you suspect he has picked up another phone to listen in. Maybe you could get lucky and he won't even be there!

I know many will view my above advice as going beyond professional boundaries, but I am just saying what I would do, since legally I think the OP's hands are tied.

Jo Dirt · Jun 4, 2007

After talking with your supervisor, you could try reporting to Adult Protective Services.
Unfortunately, I think you are very probably right about the patient.

Regarding APS:

The last thing you want to do is get anyone involved with Adult Protective Services.

Yes, they advertise under the guise of being there to protect adults, but

APS does not function to "protect" adults, they will come if called but their main focus is old and disabled people and their main agenda deals with ensuring the government will not lose access to the elderly person's finances and assets should they need to go into a long term care facility.

I have dealt with harrassment from APS in dealing with my father-in-law first hand.

They will come out on a complaint (in his instance, he is demented and extremely paranoid and believes people are out to harm him). So someone not familiar with his mental condition heard about his and requested an investigation from APS. The social worker misrepresented herself and lied from the first time she came out there, and when my husband confronted her about this later she did not deny it at all...in fact, they feel justified in doing ANYTHING they feel they need to so they can gain access into the old person's finances and assets. It is really sickening, she would come out and sweet talk my father-in-law and put suggestions in his mind and he basically melted in her hands. She wrote on her notes he gave her the okay to access his bank accounts, finances, assets, etc. But she didn't just access his bank accounts, she went through mine and my husband's bank accounts, which was CRIMINAL (but you are dealing with the government, after all) That was the ULTIMATE goal of APS, and as she said, their main goal is to make sure he "qualifies" for Medicaid when he exhausts his assets and finances if he should go to the nursing home. It had NOTHING to do with protecting him, they want to ensure if at all possible old people will be as little a burden as possible on the government (as explained by the Deficit Reduction Act of 2005).

An elder law attorney can verify this for anyone who thinks they really create government agencies for the benefit of "protecting" anyone. It's really Government Protection Services.

Adult Protection Services will not help this woman. That is not their interest. So don't even contribute to the hardships this woman is dealing with by even calling them.

The only one who can help this woman is herself, and if she is too scared nothing anyone else can do will help her. Unfortunately, you can't protect people from themselves.

DutchgirlRN, ASN, RN · Jun 4, 2007

The idea that this woman has to take the first step is incorrect and unrealistic. Often, the targets of abuse are in no position to take any steps. They are either physically incapable of making contact with authorities, or they are terrified of what the abuser would do to them if they made an attempt and it was found out. In many cases, they have been so intimidated, indoctrinated, and beaten down (psychologically, if not with fists) that they are convinced no one would believe them anyway. That is why many states have mandatory reporting laws when abuse is suspected.

Thank You, that's exactly how I feel about it. I want to ask my supervisor if it's okay if I call her doctor to discuss this issue. I believe that her diagnosis is a direct result of a certain kind of injury. Sad so really sad. I could tell she was scared to death of him.

Jo Dirt · Jun 4, 2007

Thank You, that's exactly how I feel about it. I want to ask my supervisor if it's okay if I call her doctor to discuss this issue. I believe that her diagnosis is a direct result of a certain kind of injury. Sad so really sad. I could tell she was scared to death of him.

But what do you feel you can really do for this woman?

That is why it is called the cycle of abuse. You can report it, someone can investigate, but that is about all that can be done. I've seen a lot of abuse and it is disturbing and keeps you up at night but unless she is declared mentally incompetent and the government takes guardianship of her there is nothing anyone can do, as much as people don't want to accept this reality.

The police can come and take her away, but do you think this means she will not go back? It isn't even likely that she will consider not going back. Abuse makes me fighting mad but when you think about it we are really helpless to do anything.

DutchgirlRN, ASN, RN · Jun 4, 2007

But what do you feel you can really do for this woman? Abuse makes me fighting mad but when you think about it we are really helpless to do anything.

I am not helpless to do anything. By reporting it I have done my duty "so to speak", if the patient or the law let it go then it's beyond my control.