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Maternity nurses’ experiences of caring for pregnant women involved in abusive relationships Basso, Melanie Christine 1994

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MATERNITY NURSES’ EXPERIENCES OF CARINGFOR PREGNANT WOMEN INVOLVED IN ABUSIVE RELATIONSHIPSByMELANIE CHRISTINE BASSOB.S.N., The University of British Columbia, 1986A THESIS SUBMITTED IN PARTIAL FULFILMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIES(School of Nursing)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAOctober, 1 994© Melanie Christine Basso, 1 994In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. it is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)Departaent of_____________The University of British ColumbiaVancouver, CanadaDate ( r±1 ñ I 94DE-6 (2/88)ABSTRACTThe purpose of this study was to examine maternity nurses’ experiences ofcaring for pregnant women involved in abusive relationships. A conceptualframework composed of the relevant concepts of maternity nursing care anddomestic violence was used. The research methodology of phenomenology waschosen as it allows for the development of a special understanding of thephenomenon in question by talking to participants who have firsthand experience.Data were collected using semi-structured, audiotaped interviews that encouragedthe participants to describe the phenomenon in their own words. The studysample consisted of eleven maternity nurses employed in an acute care maternitynursing hospital who were interviewed once from one to three times.Data were simultaneously collected and analyzed over a period of severalmonths. After transcription of the interviews was completed, data was examinedfor common themes according to Colaizzi’s (1978) structure for qualitative dataanalysis.Maternity nurses’ experience was presented in three central, related themes.The first theme, gaining understanding of patients in abusive relationships wascomprised of the sub-themes: (a) discovering the abuse, (b) reacting to discoveryof abuse, and (c) developing relationships. It was found that many of the patients’abusive relationships were discovered through nurses’ use of intuition. As a result,nurses experienced feelings of uncertainty which were reflected in the developmentof nurse-patient relationships and subsequent nursing care.The second theme, facing the realities: the health care context, emergedfrom the health care environment in which the nurses provided care. This themeIIIwas composed of the following sub-themes: (a) identifying the gaps, (b) workingwith others, and (c) providing nursing care. The nurses often felt frustrated at theperceived lack of support for their abused patients, and the lack of support for thenurses’ emotions.The third theme, struggling within the realities: the subjective context,describes the participants’ personal experiences of caring for abused pregnantwomen. Many of the nurses based their own understanding of abuse of their pastpersonal experiences. This theme was comprised of the following sub-themes; (a)nurses’ conceptualization of abuse, (b) feeling fear, and (c) connecting with thepatients.This study has several implications for nursing. In clinical nursing practice,all nurses need to become comfortable with caring for abused women. The goalfor maternity nurses must be for all childbearing women to be assessed for thepresence of abuse. In order to achieve these changes to clinical practice, nursingadministrators must support all front-line nurses to provide effective health care toabused patients. This support should be offered through interactive dialogue andthe provision of counselling services for those nurses experiencing personaldifficulties. Furthermore, nurse educators must strive to educate present andfuture nurses on the issues of domestic violence. Finally, the need for furtherresearch involves examining groups of nurses from other clinical areas in order todetermine the transferability of this present study’s findings, and to explore thesimilarities and differences of nurses’ experiences.ivTABLE OF CONTENTSPageAbstract iiTable of Contents ivAcknowledgements viiChapter One Introduction 1Background to the Problem 1Statement of the Problem 3Purpose of the Study 3Relevance 4Conceptual Framework 4Maternity Nursing Care 4Domestic Violence Against Women 5Maternity Nursing and Domestic Violence 6Definition of Terms 7Assumptions 8Limitations 8Summary 9Chapter Two Literature Review 1 0Domestic Violence 10Historical Perspective 1 0Prevalence of Abused Patients in Health Care System 11Domestic Violence: Contributing Factors 14Personal factors 14Social factors 1 5Domestic Violence and Pregnancy 1 7Prevalence of Abuse in Pregnancy 1 7Characteristics of Abused Women 20Domestic Violence and the Nursing Profession 22Nurse-Patient Relationships 22Nurses’ Attitudes 23Maternity Nursing 24Maternity Nursing and Domestic Violence 26Summary 27Chapter Three Methodology 28The Phenomenological Perspective 28Methodological Criteria 29Sampling 29Reliability and Validity 29Selection of Participants 31Criteria for Selection 31Selection Procedure 31VEthical Considerations 32Interview Process 33Analysis of Data 34Summary 36Chapter Four Analysis of Data 37Descriptions of Participants 38Gaining Understanding of Patients in Abusive Relationships 39Discovering the Abuse 40Nursing Reports 40Nurses’ Assessments 41Using Intuition 43Reacting to Discovery of Abuse: Uncertainty 46Developing Relationships 50Being Non-Judgemental 51Reacting to Patients 51Reacting to Partners 53Building Trust 54Gentle Probing 56Sharing 59Facing the Realities: The Health Care Context 60Identifying the Gaps 60Institutional Constraints 61Lack of In-service Education 64Working with Others 65Talking about Experiences 66Collaborating with Colleagues 68Relationships with Peers 68Relationships with Social Workers 69Relationships with Physicians 70Providing Nursing Care 74Special Attention to Maternity Care 75Abuse Care 76Holistic Care 78Struggling within the Realities: The Subjective Context 81Nurses’ Conceptualization of Abuse 81Feeling Fear 82Connecting with the Patients 85Personalizing 86Relating to Patients 87Empathizing 90Summary 92Chapter Five Discussion of Findings 95Nurses’ Needs for Personal Relationships with Others 95Personal Relationships with Patients 96Personal Relationships with Colleagues 98viRelationships with Physicians 100Nurses’ Subjective Responses to Caring for Abused Women 102Summary 105Chapter Six Implications, Conclusions, and Summary 106Implications 106Implications for Clinical Practice 1 06Implications for Nursing Education 1 08Implications for Nursing Administration 1 09Implications for Nursing Research 111Conclusions 11 2Summary of Thesis 11 4References 11 8Appendices A: Information Letter 130B: Consent Form 131C: Semi-Structured Interview Questions 1 32D: Advertising Poster 1 33VIIACKNOWLEDGEMENTSThis document would not have been possible without the time andcommitment of the eleven nurse participants. I would like to thank each one ofthem for having the courage to share openly and honestly about their personal andprofessional experiences with abuse.I would like to thank my Thesis Committee for their scholarly expertise inguiding me through this academic gauntlet. I would like to acknowledge JanetEricksen and Carolyn Iker for their much appreciated and timely feedback. Mythesis Chairperson, Angela Henderson deserves special recognition for thecountless hours she spent in revision of this document. I’m sure that none of usanticipated the longevity of our committee relationship at the outset of this project.Thanks again for seeing me through to the end.A special mention goes to Langara Research Council who provided financialsupport for the completion of this project.I would especially like to thank my many “editors” who patiently andpainstakingly reviewed and revised this thesis. I would like to acknowledge Dr.Heather Clarke, Wanda Pierson, and Kelly Negrin. My deepest gratitude isexpressed to you for your exceptional abilities to shorten my sentences when theycarried on for too many lines. I am humbled by your unwavering dedication to thisproject. Thank you for all of your support.My heartfelt thanks is extended to my family for providing me with muchneeded emotional support. Thanks to my mother for listening as I struggled withtrying to balance too many activities. Thanks to Dad and Karen for always beingjust a phone call away when I needed to talk.I would like to dedicate this thesis to my wonderful husband Seamus and ourson Daniel. Having these two men in my life gave me the strength and motivationto complete this project. Thank you for believing in me till the end. I love youboth very much.Finally, I would like to thank Roxanne for being my friend, and always beingthere for me.1CHAPTER ONE: IntroductionBackground to the ProblemDomestic violence results in physical and psychological health problems forapproximately one million women in Canada and as many as six million womenannually in the United States (Henderson, 1992; McLeod, 1987). As theprofession of nursing is predominated by women, it can be extrapolated from thesestatistics that many nurses have been battered in abusive relationships.Consequently, health problems resulting from domestic violence require batteredwomen to use the health care system frequently for episodic care in emergencydepartments and health care clinics (Rounsaville & Weissman, 1978). Batteredwomen are found in every area of the health care system (Moss & Taylor, 1991).Campbell and Humphreys (1 984) identified that the nurse is “especially likely toencounter abused women in the emergency room, in prenatal and maternal caresettings, in community health, in primary care settings, in occupational health, andin the mental health field” (pg. 247). Because of this contact, nurses are wellpositioned to play an important role in identification, intervention and prevention ofdomestic violence (Moss & Taylor, 1991).The identification of abuse poses problems from both the nurses and thepatients’ perspectives. First, many nurses have difficulty addressing the issue ofdomestic violence with suspected victims (Henderson, 1992). Nurses feelunprepared to delve into issues surrounding domestic violence because addressingthe cause of the injury can feel like “trespassing in another’s territory” (Randall,1991, pg. 1177). Attitudes of nurses towards domestic violence have not beenwell researched; however, general social attitudes reflect the belief that abuse is a2‘private affair’ (Walker, 1984). Identification of abused women remains a complexand persistent challenge for nurses.The second problem associated with identification of abused patients bynurses is that abused women often do not acknowledge the true cause of theirinjuries (Hadley, 1992). Bohn (1990) contends that women often make up storiesto explain their injuries. This contention is supported by the fact that abusers oftenaccompany their partners when treatment is sought to prevent them from revealingthe truth. Given these two problems, it is little wonder that abuse is poorlyidentified and addressed by nurses.Awareness of pregnancy as a high risk period for abuse has only recentlybeen addressed by researchers (Helton, McFarlane & Anderson, 1 987; Henderson,1992; Stewart & Cecutti, 1993). Findings of studies of battered women indicatethat violence often begins or escalates during pregnancy (Bullock & McFarlane,1989; Campbell & Humphreys, 1984; Helton, 1986; Helton, McFarlane, &Anderson, 1 987; Helton & Snodgrass, 1 987; McFarlane, 1 992; Stewart & Cecutti,1993; Walker, 1984). Prevalence estimates of abuse in pregnancy have beenidentified as high as fifty percent (50%) of women who are already involved inabusive relationships (Bohn, 1990). It has been further estimated that seventeenpercent (17%) of pregnant women in the general population are involved in abusiverelationships (McFarlane, Parker, Soeken, & Bullock, 1992). Given the highprevalence of abuse in pregnancy and the fact that maternity nurses care forpregnant women, it is likely that maternity nurses care for abused pregnantwomen. The extent to which maternity nursing care practices are affected bycaring for abused pregnant women is not well documented in the literature. As no3research was found on the feelings and experiences of maternity nurses who havecared for abused women, the following research project was undertaken to expandthe knowledge base of maternity nurses’ experiences of caring for abused pregnantwomen.Statement of the ProblemGiven the documented prevalence of abuse during pregnancy, it is expectedthat maternity nurses come in contact with women who are experiencing violence.There was insufficient nursing research found which examines the experiences ofmaternity nurses who deliver care to women experiencing abusive or violentsituations. Nurses are still hesitant to intervene in the care of the abuse itselfdespite being the providers of front-line care to these types of patients. A betterunderstanding of how nurses experience caring for abused women is needed toidentify issues and barriers to the provision of appropriate nursing care for abusedwomen.Purpose of the StudyThe purpose of this research study is to describe maternity nurses’experiences of caring for pregnant women involved in abusive relationships. Theresearch question is: “What was the maternity nurses’ experiences of caring forpregnant women involved in abusive relationships?”The objective of this study is to identify common themes from theseexperiences through in-depth exploration of nurses’ experiences as care givers ofwomen who have been abused during pregnancy.4RelevanceIt is intended that the examination of the experiences of maternity nurseswill contribute to further development of nurses’ roles in the care of abusedwomen. Awareness of maternity nurses’ experiences could promote a betterunderstanding of potential barriers to effective care. Furthermore, knowledge ofnurses’ experiences could be used in the development of necessary institutionalhealth care guidelines and appropriate educational in-service opportunities fornurses.ConceDtual FrameworkTwo concepts have been identified in the literature as central to aconsideration of nurses’ experiences with this patient population. The two centralconcepts are maternity nursing care and domestic violence against women.Maternity Nursing CareMaternity nursing is defined as the delivery of professional and quality healthcare while recognizing, focusing on, and adapting to the physical and psychologicalneeds of the childbearing family (Reeder, Martin & Koniak, 1992). Clinicalapplication of this specialized knowledge includes care of the entire childbearingunit - the mother, the father or support person, and the infant (Phillips, 1980).Therefore, maternity nurses assist all family members, not just the new mother andbaby, in adjusting to their new roles.Maternity nurses provide care to childbearing women and their families thatfocuses on health rather than illness (Neeson & May, 1986). The pregnancy periodis viewed as a “normative crisis” that concerns all members of the family (Reederet al., 1992). The philosophy of family centred care evolved in response to5consumer demands for patient oriented care, instead of medically oriented care(Post, 1981). Family centred care is based on the philosophical belief that womendo not experience childbirth in isolation. Friedman (1992) defines the family asconsisting of two or more people who are emotionally involved and live, or havelived, together. Melson’s (1980) definition states family is “anything two or moreindividuals say it is” (p. 3). The birth of a baby represents the birth of a newfamily. Given today’s many variations in family structure, Friedman (1992)contends that maternity nurses care for pregnant women within the family context,whatever context that may represent.Maternity nurses’ work includes prenatal teaching, antepartum care, labourcare during the birth process, and early postpartum follow-up care and teaching.The positive focus of the birth event and usually healthy patients sets maternitynursing apart from many other areas of nursing where the focus of care lies ondisease and illness. This results in satisfaction for its’ practitioners and longevityof work life. Practitioners develop expertise in the field of maternity nursing as anoutcome of education, interest in their work, and longevity of work experience.Domestic Violence Against WomenDomestic violence is a widespread and long-standing social problem. Thescope of domestic violence against women was not well understood in Canadauntil McLeod’s (1 980) survey which revealed estimates that, conservatively,indicated that one in ten women living with a male partner is abused each year.More recent statistics indicate an increase in the frequency of abuse to one in eightCanadian women (McLeod, 1987; Task Force on Family Violence, 1992).However, this apparent escalation in frequency may be reflective of an increase in6reporting, not an increase in actual numbers of abused women. Under-reporting ofthe incidence of domestic abuse frustrates research attempts to determine accuratescope of the problem.Despite startling statistics of the incidence of domestic violence againstwomen, many victims remain undetected (Randall, 1991). Women experiencingdomestic violence are often unable to admit they are in abusive situations. Socialisolation, fear for personal safety, and feelings of low self-esteem are factors inwomen’s reluctance to identify themselves as abused (Campbell & Humphreys,1993; Henderson, 1986; Stewart & Cecutti, 1993; Walker, 1984). Economicdependence on male partners is another factor women consider whencontemplating changing their abusive situation (Sampselle, 1991). Many batteredwomen perceive they have few options, and the addition of a pregnancy seems todecrease their perceived options even further (Campbell, 1992).Maternity Nursing and Domestic ViolenceMaternity nurses are being forced to examine their nursing practice as thedisturbing frequency of prevalence of abuse during pregnancy becomes evident(Bohn, 1990). Domestic violence against women challenges maternity nurses tocare for childbearing women who are involved in abusive relationships (Bewley &Gibbs, 1991). Nurses are becoming increasingly aware of health problems arisingas a result of violence during pregnancy (Moss & Taylor, 1991). An increasedincidence of miscarriage, stillbirths, and premature labours and deliveries followingabusive behaviour by their partners has been observed (Bullock & McFarlane,1989). Nurses report seeing injuries resulting from blows to the abdomen, vaginalarea, breasts, and from sexual assault (Helton, 1986). Other abuse injuries7identified by nurses include pneumothorax, stab wounds, concussions, fractures,and dental injuries (Stewart & Cecutti, 1993). Research has documented anincreased incidence of low birth weight babies born to women who are abusedduring pregnancy (Bullock & McFarlane, 1 989; Newberger, Barker, & Leiberman,1992). A significant consideration for nurses is that spousal abuse is oftenassociated with child abuse; therefore, the safety of the child after birth must beconsidered (Dickstein, 1988). The risk associated with maternal injuries andpotential fetal danger indicate that domestic violence against women, especiallyduring pregnancy, is a critical issue for maternity nurses.The concurrent analysis of the concepts of maternity nursing and domesticviolence against women provides a framework for understanding maternity nursesexperiences of caring for abused pregnant women.Definition of Terms1) For the purposes of the study, ‘domestic violence’, ‘wife abuse’ and‘battered or abused’ will be used interchangeably. The definition for these termshas been adopted from McLeod (1987).“Wife battering is the loss of dignity, control, and safety as wellas the feeling of powerlessness and entrapment experienced bywomen who are the direct victims of ongoing or repeated physical,psychological, economic, sexual and/or verbal violence or who aresubjected to persistent threats or the witnessing of such violenceagainst their children, other relatives, friends, pets and/or cherishedpossessions, by their boyfriends, husbands, live-in lovers, exhusbands or ex-lovers, whether male or female” (pg. 16).8This definition acknowledges the significance of psychological(emotional) abuse. Emotional abuse is viewed as being as detrimental, orpossibly more so, than physical abuse.2) ‘Abusive relationship’ is defined as any intimate, heterosexualrelationship where the perpetrator of abuse is male.3) ‘Pregnancy’ is defined as a uterine conception of gestational agebetween 20 weeks to 40 weeks. Women who are under 20 weeksgestation have not reached the age of viability and are often not cared for bymaternity nurses when complications of pregnancy arise.4) ‘Caring for’ is defined as any situation in which a maternity nursegives direct patient care in a hospital maternal-child care setting.5) ‘Maternity nurse’ is defined as any registered nurse who is currentlyworking in an acute care tertiary maternal-child care setting.AssumDtionsThe researcher has made the following assumptions in this study:1) Domestic violence occurs during pregnancy.2) Maternity nurses encounter abused women in their nursingpractice.3) Maternity nurses will speak candidly about their experiences ofcaring for abused women and their families.4) By virtue of being women, a number of nurses are themselvesabused, or have been involved in abusive relationships.LimitationsThe researcher has identified the following limitations of this study:91) This study was based upon experiences of eleven individual maternitynurses who have cared for abused women. Their realities were unique,personal, and related to their own personal experiences. This, therefore,limits the transferability of the research findings.2) Findings of this research study are limited to nurses who work inurban, tertiary hospital settings where maternity care is offered. Thisresearcher recognizes that the experiences of maternity nurses in ruralsettings could be very different due to availability of health care resources.SummaryThe background to the problem that led to the study has beenintroduced in this chapter. The research problem has been defined, as wellas the purpose of the study, and the research question. A description of theconceptual framework that guides the study was provided which illustratesthe general contextual fabric of the literature on maternity nursing care, anddomestic violence against women. Definitions for terms were presented,and assumptions and limitations outlined.In the next chapter, the researcher examines the literature related tothe problem and the purpose of the study. Literature is presented from boththe theoretical and research perspectives in order to fully delineate theexisting state of knowledge about maternity nurses and the nursing care ofabused pregnant women.10CHAPTER TWO: Literature ReviewThe following examination of the literature consists of both theoretical andresearch perspectives pertaining to the major concepts of domestic violence,domestic violence and the nursing profession, maternity nursing care, andmaternity nursing care and domestic violence against women.Domestic ViolenceDespite the fact that domestic violence has been recognized in the literatureas a health care problem for women, health care providers seem to be generallyunaware of the issues surrounding violent relationships (Sampselle, Petersen,Murtland, & Oakley, 1992). This review of the literature examines the currentstate of information available concerning domestic violence. Domestic violence isexplored from a historical perspective, and the literature is reviewed for theprevalence of abuse of women in the health care system and for factorscontributing to the perpetuation of domestic violence in today’s society.Historical PersDectiveDomestic violence is a phenomenon that has long been a characteristic offamily life (Gelles & Strauss, 1988). From a historical perspective, violence hasbeen entrenched in social institutions for centuries. Dobash and Dobash (1979)addressed the sanctioning of woman abuse by identifying that, historically, abusivebehaviour has existed for centuries as an “acceptable and desirable part ofpatriarchal family system within a patriarchal society” (pg. 31). Given the intrinsicnature of beliefs about the abuse of women, it is not surprising that attempts tochange societal attitudes about abuse are difficult.11The long-standing problem of domestic violence has become betterunderstood through identification of the scope of the problem. McLeod’s (1 987)statistics indicated that abuse within families occurs with alarming frequency, withas many as one in eight women involved in intimate relationships abused by herpartner. The pervasiveness of domestic violence would lead one to conclude thatsocial actions addressing family crimes were abundant. However, Greany (1984)found that community and professional endeavours to oppose violence were limitedbecause of a reluctance to get involved in family matters. Therefore, violentincidents that were reported were dismissed by the police and the judiciary as justdomestic problems (Greany, 1984). Women in abusive relationships were given noassistance or recognition of the devastating effects of their abuse from theinstitutions from which they sought assistance.Prevalence of Abused Patients in the Health Care SystemIt is only recently that domestic violence has become a focus for inquiry andresearch. In search of a better understanding of the enormity of the problem ofdomestic violence, many researchers attempted to document the frequency withwhich domestic violence victims access the health care system (Appleton, 1 980;Brendtro & Bowker, 1 989; Flitcraft, 1 977; McFarlane, Parker, Soeken, & Bullock,1992; Moss & Taylor, 1991; Rounsaville & Weissman, 1978). One such study wasconducted by Flitcraft (1977) who completed a one month review of medicalcharts of all women who sought emergency room treatment. These findingsindicated that approximately twenty percent (20%) of the women were positive orsuggestive of battering. Appleton (1980) confirmed these findings in a study inwhich questionnaires were administered to women who entered the emergency12departments of general hospitals. Findings of this anonymous survey reported thattwenty-two (22%) to thirty-five (35%) percent of women indicate they had beenstruck at some time by their intimate partners. Conclusions drawn from these earlystudies indicated that large numbers of victims of domestic violence did seektreatment from health care professionals for injuries of abuse. Secondly, it can alsobe concluded that health care professionals have frequent contact with victims ofdomestic violence.Many of the early prevalence studies used small samples in single clinicalsettings. Rounsaville and Weissman’s (1978) original study of prevalence ofwomen seeking medical care for injuries of abuse used only thirty-seven (37)participants over the period of one (1) month. The findings of this study werebased only on women who admitted their abuse. It was likely that many morewomen did not reveal the true origin of their injuries. When drawing conclusionsfrom prevalence studies, health care professionals must acknowledge thelimitations of findings of studies using small sample size.Drake’s (1 982) study of emergency department visits of battered womenwas also a small (n = 1 2) retrospective study. The sample population consisted ofprimarily African-American and European-American women. Despite the smallsample size, Drake’s study identified clear evidence that many health careprofessionals lacked the ability to provide sensitive care to abused women. Thefact that many health care professionals are reluctant to acknowledge the presenceof woman abuse in their practice is a fundamental difficulty identified whenexamining the obstacles to addressing domestic violence. This difficulty issupported by much of the literature on domestic violence which indicates that13health care professionals do not address issues of abuse when it is suspected(Delgaty, 1 985; Greany, 1 984; Henderson, 1 992; Moss & Taylor, 1 991; Randall,1991).Despite the testimony of well-documented statistics on domestic violence,many incidents of abuse elude detection by health professionals (Campbell &Fishwick, 1993; Landsberg, 1986). Victims of violence most commonly seektreatment for their injuries from medical facilities (Hadley, 1992). Many batteredwomen who come into contact with health care professionals do not reveal theetiology of their injuries when questioned and may even deny the existence ofabuse (Brendtro & Bowker, 1989; Walker, 1984; Campbell, 1993). This reluctanceto disclose abuse may be perceived by health care professionals as ambivalenceand tolerance of abuse and can result in “victim-blaming” (McLeod, 1 987).Hartman (1987) identified that most battered women welcome the opportunity fordisclosure of the abusive situation when asked the appropriate questions and givena supportive environment. Understanding the victim’s fear for herself, her children,if any, and her relationship is essential if health care professionals are to treatabused women effectively. Without appropriate intervention, these women havetheir physical injuries treated and return home, only to return at a later date withsimilar, or more severe, injuries. Bullock, Sandella and McFarlane (1989) furtheridentify that incidents of abuse do not occur in isolation and often escalate inseverity and frequency. One suggestion found in the literature which would beginto address these problems is to educate health care professionals on factorscontributing to abusive situations (Sampselle, 1991).14Domestic Violence: Contributing FactorsMany factors have been identified in the literature as contributing to theexistence of domestic violence. These factors occur from both personal andsocietal origins (Brendtro & Bowker, 1989; Sampselle, 1991). Personal factorsinclude family of origin and individual personality characteristics. Social factorsinclude those factors that are known to sustain violence against women such associetal devaluation of women, male-female power inequality, and the male beliefin women as property.Personal FactorsIntergenerational transmission of violent behaviour has been identified as oneof the most important factors in the perpetuation of domestic violence. TheOntario Medical Association (1991) identified a high incidence of wife abuse and/orchild abuse in families of origin of both batterers and battered women. Theunderlying premise is that, for both men and women, violence becomes abehaviour acquired in the family of origin. Brendtro & Bowker (1989) supportedthis premise by hypothesizing that men learn to batter and women are conditionedto expect violence because of early life experiences. The hypothesis that allindividuals with such childhood histories would develop similarly violent behaviourpatterns as adults was unsupported by their research study of abused women.These researchers found that a high percentage (48%) of male batterers witnessedwife abuse between their fathers and mothers. Of these men, sixty-one percent(61 %) admitted to their wives that they had been battered themselves. However,childhood experiences of abuse were not found to predispose women to abusiverelationships. Twenty-four percent (24%) of the women in their survey disclosed15experience with childhood abuse. Gage’s (1991) study used the findings ofBrendtro & Bowker to corroborate her assertions that women exposed to childhoodabuse are not predisposed to engage in violent relationships later in life. Althoughthe issues of childhood effects of violence on later life for both men and womenhave been well documented in the literature, the findings remain contradictory andinconclusive. Therefore, the presence of violence in the family of origin must beassessed on an individual basis, as it seems it is more likely to influence malepartners than female partners.Issues of needs for control are addressed in the literature. Delgaty (1984)and McLeod (1987) identified that abusers controlled their partners’ socialinteractions and restricted opportunities for independence. Abusive men may beexcessively dependent on their partners and feel threatened by outside interests ofthese women (Ontario Medical Association, 1991). Agudelo (1992) stated thatabuse can only be perpetuated if one partner remains in a non-dominant position.For abusive men, violence becomes a means of controlling their partners.Domestic violence occurs within a social context. Clearly, the social contextof family life is an important factor when determining the presence of domesticviolence. However, focusing only on individual circumstances in the lives ofbattered families ignores the larger social context in which domestic violenceexists.Social FactorsDomestic violence against women has been found in families from all ethnic,economic, religious and educational backgrounds (Torres, 1991; Walker, 1984).The hidden nature of domestic violence permitted it’s existence and perpetuates16the problem. Goldberg and Tomlanovich (1984) identify that one in five peoplethought that practices of domestic violence were acceptable. Attitudes such asthese contribute to society’s tolerance of domestic violence.Sampselle (1991) identified three key social factors that contribute tosustaining violence against women. These factors include societal devaluation ofwomen, male-female power inequality, and the male perception of women asproperty.Social devaluation of women was identified as a contributing factor to apatriarchal viewpoint towards violence. This traditional view fosters negative maleattitudes and serves to maintain womens’ lower status in the hierarchy of society.Power inequality has contributed to the abuse of women because of maledomination in job markets leading to decreased earning power for women. Thisfactor is of particular significance for abused women who, with sole child-rearingresponsibility, leave relationships and are faced with returning to a job marketwhere earning power is often less than their estranged spouses. Lowered standardof living for lone parents and children are common examples of power inequality.Historically, women have been viewed as the property of their fathers and thentheir husbands. Viewing women as property enabled male partners to “maintainauthority” over their spouses and therefore contributed to the sustenance ofdomestic violence (Sampselle, 1991).The final contributing factor that this researcher explored in the literaturewas that of the pregnant state. For some women, pregnancy alone may be acontributing factor to violence. When combined with a relationship containing one17or more social and/or personal contributing factors to violence, a high-risk situationfor abuse may be established.Domestic Violence and PregnancyResearch studies on domestic violence and pregnancy have focused uponthe prevalence of abuse during pregnancy and on determining characteristics ofabused women. King and Ryan (1989) identified that in order to ensure anaccurate prevalence rate of abuse, nurses must assess all women for the presenceof abuse. Both the determination of accurate prevalence rates of abuse inpregnancy and the recognition of characteristics of abused women assist healthcare professionals to better understand the scope and the context of the issues ofviolence in pregnancy.Prevalence of Abuse in PregnancyTo better understand the scope of domestic violence in pregnancy, researchhas focused upon determining prevalence rates. Early studies of battered womenin transition houses and shelters reported thirty-five to one hundred percent (35-100%) of women in abusive relationships had continued to be abused duringpregnancy (Drake, 1982; Gelles & Strauss, 1988; Walker, 1984). A studyconducted by Fagen, Stewart, and Hansen (1983) identified that abuse duringpregnancy was more likely to occur if there was an existing family history ofviolent behaviour. These findings suggested the primary indicator of abuse duringpregnancy is presence of abuse prior to pregnancy. Later studies corroboratedthese findings. Helton, McFarlane and Anderson (1987) studied two hundred andninety (290) women from both public and private clinics. Findings of their studyindicated eight percent (8%) of the women interviewed reported battering during18their current pregnancy. Of these, eighty-seven point five percent (87.5%) ofthese women had been abused prior to the pregnancy. These women had notbeen identified as being in abusive relationships prior to the study. An alarmingfinding of the Helton et al. study was that twenty-nine percent (29%) of thewomen abused during pregnancy reported an increase in violence during thepregnancy. Bullock and McFarlane (1989) supported this finding by postulatingthat domestic violence within the context of an intimate relationship will continueits cyclical repetitive pattern during pregnancy and possibly worsen. Conclusionsdrawn from these studies are that the existence of abuse in a relationship prior topregnancy increases the risk for abuse during pregnancy.A secondary analysis of survey data from nine hundred and forty (940)pregnant women examined the prevalence of abuse among women by their choiceof care giver - nurse-midwife or physician. Sampselle et al. (1992) found thattwelve point two percent (12.2%) of women choosing midwifery care had previousexperience with abuse, whereas only eight point five percent (8.5%) of womenseeking physician care had a history of abuse. Many of the abused women in thestudy identified that the female gender of the care giver was an important factor intheir choice of prenatal care provider. This finding was supported by Holz (1994)who found that most women survivors of abuse sought medical care from femalepractitioners. As midwives are traditionally female, this may explain the higherpercentage of abused women choosing midwifery care (Bewley & Gibbs, 1991).The Sampselle et al. survey concluded there was an overall nine point sevenpercent (9.7%) rate of women with previous history of abuse, with zero point ninepercent (0.9%) of these women currently in abusive relationships. The findings of19this study are comparable with those of Hillard (1985) who identified a ten pointnine percent (10.9%) prevalence rate of pregnant women with previous experiencewith abuse. However, the prevalence is lower than the findings of Helton,McFarlane and Anderson (1 987) who found that fifteen percent (1 5%) of theirstudy sample of pregnant women identified previous experience with abuse. Thedisparity in findings may reflect the methodological differences in data collection.The participants in the Helton et al. study were asked about their abuse in face toface interviews, as opposed to pen and paper questionnaire. This suggests thatthe numbers of abused women identified may be greater when women areapproached by a sensitive care giver.To determine prevalence rates of abuse in the healthy, pregnant population,McFarlane et al. (1992) completed a cross-cultural cohort study of prevalence andseverity of abuse during pregnancy. Their sample included one thousand twohundred (1200) women of African-American, Hispanic-American and Caucasian-American cultures; four hundred (400) participants from each cultural group.Findings revealed a seventeen (17%) overall frequency of abuse during pregnancy,which is a disturbing prevalence. A significant finding of this study was thatabused women were twice as likely to begin prenatal care in the later trimesters oftheir pregnancies than non-abused women. These findings may indicate thatcontrolling behaviours of abusers result in abused women being denied access tohealth care. Prenatal care provides opportunities for women to discuss concerns,and abusers may attempt to prevent opportunities for discussion due to thepossibility of revealing the abusive situations. The indication for health careprofessionals who come in contact with pregnant women is that all women,20particularly those who seek prenatal care in the later stages of pregnancy, must beassessed for the presence of abuse.Caution must be exercised when drawing conclusions about prevalence ratesfor abuse during pregnancy. Research into accurate rates of abuse has beenconducted with healthy, pregnant women and known abused women; women whoare socially impoverished and well-educated women; women of differing culturesand Caucasian women (Helton, McFarlane & Anderson, 1 987; Bullock &McFarlane, 1989; and McFarlane, Parker, Soeken, & Bullock, 1992). Given thisarray of multi-faceted social factors, it has been difficult to compile accurate andgeneralizable prevalence rates of abuse during pregnancy. Campbell and Fishwick(1993) identified that the challenge for nurses as professionals remains to be alertto the possibility of abuse. By taking active roles in identifying individuals in theirpractice setting, nurses can determine the unique prevalence of abuse in thepopulations of patients in their care.Characteristics of Abused WomenNursing literature has increased the understanding of the nature of domesticviolence by describing those who are abused. It is believed that by knowingcommon characteristics of abused women, nurses can better understand thenecessary assessment techniques and intervention strategies.Bullock, McFarlane, Bateman, and Miller (1989) identified characteristics ofbattered women which included behavioral indicators such as fear of partner andlack of eye contact with health professionals. Physical injuries that did notcorrespond to the story of origin were identified by lyer (1980) as possiblyindicative of abuse. Hillard (1985) found a markedly increased prevalence of21emotional problems in abused pregnant women as compared with those who werenot abused, ie: forty-three percent (43%) in the battered group versus five percent(5%) in the non-battered group. These findings were supported by Bewley andGibbs (1991) who found that abused women exhibited an increase in signs ofstress and clinical depression. Furthermore, Greene (1991) asserts that womenwho have been sexually assaulted are more likely to experience nervousbreakdowns, more likely to attempt suicide, and more likely to commit suicide orexperience death by homicide than women in the general population.Dobash and Dobash (1 979) described the assault experiences of onehundred and nine (109) battered women where offenses included shoving, beingslapped, punched, pushed, kicked, urinated on, bitten, choked, burnt, suffocated,stabbed and shot. Physical injuries described were cuts, multiple bruises,disfigurement, broken teeth and bones, and internal injuries. The Ontario MedicalAssociation (1 991) described that repeated episodes of violence resulted inbattered women possessing lowered self-esteem, feelings of guilt, and acceptanceof responsibility for the violence. The discovery of any of these characteristicsshould alert nurses to the possibility of abuse.These behaviourial characteristics were found to be similar to those ofabused pregnant women (Bohn, 1990). Physical features of abuse in pregnancyincluded blows to the abdomen, breasts and genitals (Helton & Snodgrass, 1 987;McFarlane, 1989). Because attacks on these areas could result in miscarriage,placental abruption, premature labour and stillbirth, women who present with anyof these complications of pregnancy should be assessed for the possibility of abuse(Bohn, 1990; Kent, 1989).22The use of documented characteristics of abused women is helpful forfamiliarizing health care professionals with key characteristics that are commonamong abused women. A relevant view point was offered by Ajzen and Fishbein(1980) who suggested that professionals need to assess individual strengths andabilities rather than just focussing on patient problems. This viewpoint clearlystresses the importance of assessment of patients as individuals. In order toidentify abused women consistently, health care professionals need to assesswomen individually using knowledge of the common characteristics of abuse.Domestic Violence and the Nursing ProfessionResearchers have attempted to articulate and clarify nursing’s role whencaring for abused women. Moss and Taylor (1991) declare that nurses play acritical role in the identification, assessment, and intervention of abused women ina variety of settings. The maternity ward has been identified as a prime setting inwhich to assess for the presence of abuse. McFarlane (1992) contends thatassessment for presence of battering in pregnant patients, and initiation ofeducation, advocacy, referral, and counselling are all important roles that maternitynurses play with abused women. Nurses’ unique position as front-line providers ofcare means they have both contact with abused patients and opportunity to beeffective patient advocates (Campbell & Fishwick, 1993).Nurse-Patient RelationshipsNurse-patient relationships are an important component of the identificationof the domestic violence experience. In the literature, nursing roles in the care ofabused women have shifted from passive listening to more active intervention, asillustrated by King and Ryan (1989) who clearly outlined nurses’ roles in caring for23abused patients. According to these authors, active nursing intervention includesactive listening, facilitating the formulation of strategies for the future, andassisting women to establish feelings of self-control and power. Acknowledgementor actual identification of abuse is considered as a form of early interventionbecause violence is revealed before it escalates further. Essential features ofeffective nurse-patient interactions should include providing a non-threateningenvironment, encouraging a sharing of experiences and feelings, and maintainingan individual approach to problem-solving. King and Ryan caution against thedangers of supportive nurses taking over the role of controller for abused women.These authors conclude by saying that the success of nurse-patient interactionsmay be evaluated by outcomes that occur in terms of what the women want to do,and not what nurses feel they should do.Nurses’ AttitudesNurse-patient relationships with abused women have been further exploredthrough examination of nurses’ attitudes towards abuse. Gage (1991) identifiedthat an examination of nurses’ own experiences and attitudes regarding abuse wascrucial to performing unbiased assessments. Sampselle (1991) concurred thatnurses should examine personal attitudes towards the issues of abuse. Theimportance of awareness of nurses’ own beliefs about abuse is stressed in theliterature as a critical first step to developing effective nurse-patient relationshipswith those experiencing domestic violence.Studies of nurses’ attitudes towards the abuse of women have appeared inthe literature. Rose and Saunders (1986) reported that nurses were less likely thanphysicians to believe that wife-beating was justified, and that victims were24responsible for the abuse. They concluded that female practitioners, both nursesand physicians, were more likely to detect abuse and be more empathic whenproviding care. These findings were supported by Bokunewicz and Copel (1992)who found that emergency nurses who received an educational presentation onabuse demonstrated an enhanced awareness of how to identify battered women.These nurses perceived they had a better understanding of the dynamics of abusiverelationships. Moss and Taylor (1991) viewed health care professionals’ adverseattitudes as impediments to effective health care for abused women. Thereadiness of abused women to disclose their abuse may be dependent upon thereceptivity of health care professionals. Therefore, opportunities for abusedwomen to receive help should be offered and not lost due to the insensitivities ofhealth care professionals (Helton et al., 1987).Nurses must be sensitive to women as they encourage disclosure of abuse.Henderson (1 992) confirmed that some nurses may be uncomfortable when facedwith discussing issues of abuse with patients, and suggested that such nursesshould refer these patients to another care giver rather than disregard the patients’needs. Brendtro and Bowker (1989) and Campbell and Fishwick (1993) bothoffered support for this action by identifying that the more closely nurses workwith battered women, the greater the probability that women will admit theirabuse sometime during the treatment process.Maternity NursingTo understand the link between abuse during pregnancy and maternitynursing care, it is helpful to consider the changes in maternity nursing care in thepast two decades. Advances in technology and diversity in family structure are25two challenges which necessitated a change in maternity nurses’ work. Prior tothe early 1 960’s, maternal and newborn care was provided primarily by nurses andmidwives (Reeder, Martin & Koniak, 1992). Changes to legislation governingchildbirth bestowed the responsibility of perinatal care entirely on the medicalprofession. Childbearing couples were shifted from the home into the hospitalsetting for childbirth. The birth process became “medicalized” rather than“naturalized”. During the 1970’s and 1980’s, childbirth intervention throughtechnology became the focus of medical research activities (Cohen & Estner,1983). Maternity nurses were challenged to keep abreast of the advancingtechnology by concentrating on the more technical skills of invasive caring such asfetal monitoring (Andreoli & Musser, 1986). Nurses responded to the technicalshifts which focused their care away from the patient by developing the philosophyof family-centred care. In this way, nurses reinstated their focus of care onto thepatient at the bedside (Meierhoffer, 1992).Many maternity nurses espouse the philosophy of family-centred care(Reeder et al., 1992). Family centred care converts the focus of care from the“individual as client” model of many acute care settings to an “individual within afamily context” model (Minister of National Health and Welfare, 1988). In this way,all members of childbearing families are cared for in the context of the family, inwhatever form that family context exists (Friedman, 1992).The frequency with which maternity nurses care for families experiencingviolence is well documented by recent nursing research. In addition to frequency,studies appear which clarify maternity nurses roles when caring for childbearingfamilies experiencing internal family adversity (Helton, 1986; Helton et al., 1987;26McFarlane et al., 1992). However, a paucity of research studies exist whichassess maternity nurses’ responses to caring for childbearing families experiencingabuse. It is hoped that the completion of this study will add to maternity nurses’knowledge base of caring for abused families from the perspective of those whohave had the experience.Maternity Nursing and Domestic ViolenceThe nursing role in the care of abusive families has received much researchattention. Many nursing research studies were found by this researcher to supportthe exploration of the phenomenon of maternity nursing and domestic violence.Nurses have established a pioneering role in research on domestic violence(Bullock et al., 1989; Campbell & Humphreys, 1984; Helton & Snodgrass, 1987;Henderson, 1986; McFarlane, 1992). Positive correlations between domesticviolence and pregnancy have appeared frequently in nursing literature (Bohn, 1 990;Bullock and McFarlane, 1 989; Helton, 1 986; Hillard, 1 985; Kent, 1 989; Parker &McFarlane, 1991). Nurses have investigated the complexities of abusiverelationships and their influences on the health of both the mother and fetus.Fagen et al. (1983) found that the prevalence and severity of abuse increasedduring the pregnancy period, often with tragic results to the unborn fetus. Newtonand Hunt’s (1984) study of psychosocial stress in pregnancy and low birth weightdemonstrated a significant relationship between life events, low birth weight andprematurity. Bullock and McFarlane’s (1989) study of pregnancy outcomesreported that battered women are two to four times more likely to give birth to lowbirth weight infants. Other health risks for both mother and fetus include anincreased rate of miscarriage and stillbirth and physical injuries such as blows to27the abdomen and genital areas (Bullock & McFarlane, 1989). These researchersidentify the nurse’s unique opportunity for assessment of battering duringpregnancy. “Pregnancy provides an optimum time to inform all women about thepotential for battering and assess the safety status of each client” (Campbell, 1 992pg. 208). Maternity nurses are in prime positions to establish therapeuticrelationships with pregnant women. The hospitalization period provides abusedpatients and maternity nurses with this opportunity.SummaryIn this chapter, the researcher has presented a literature review which hasillustrated the challenge that domestic violence poses for the nursing professionand the abused patient. Theoretical and research literature were explored toidentify trends in nursing knowledge and to illustrate gaps in nursing discourse.One such gap is the exploration of maternity nurses’ experiences of caring forpregnant women involved in abusive relationships. A better understanding of thisphenomenon will enhance nurses’ abilities for assessment and intervention withabused women. A qualitative research approach will encourage participants todiscuss their experiences from their own perspective and their own experiences.In the next chapter, the researcher describes the phenomenological approachto qualitative research and explains the design of the study.28CHAPTER THREE: MethodologyIn this chapter, the researcher presents an overview of the keyunderpinnings of the phenomenological research perspective. A discussion of thesampling process, the criteria for selection and ethical considerations are included.The interview process is described and procedures for analysis of data are outlined.The Phenomenological PersDectiveThe purpose of qualitative research is to develop a special understanding ofa particular phenomenon, event, or interaction (Locke, Spirudoso, & Silverman,1987). This special understanding comes from talking to participants who havefirsthand experience with the phenomenon in question. Since the early 1 980’s,nurses have utilized the research method of phenomenology (Anderson, 1989).Phenornenology focuses on the study of the meaning ascribed by the person withinthe context of the situation. It is an attempt to achieve a sense of theinterpretation that an individual gives to that situation (Ornery, 1983). The intentof the method is to describe the human experience as it is lived (Oiler, 1983). Thefocus on the meaning of experience in phenomenology is a focus on humaninvolvement in the world (Munhall & Boyd, 1993). People’s perceptions arepresented not as they are thought, but as they are lived. Perceptions ofparticipants become the ‘truth’ the researcher seeks.Absence of empirical data on topics of interest encourages researchers toemploy a phenomenological approach. The phenomenological approach isparticularly suited to this study of nurses’ experiences as it permits openexploration of the phenomenon of interest. Nursing-based research is needed togenerate knowledge that may ultimately stimulate effective interventions for29nurses. Qualitative research can provide such knowledge (Kirby & McKenna,1989). Phenomenology is a relevant methodology for the examination of thisphenomenon as it allows for the collection of rich, contextual data from nurses’personal experiences. Phenomenology is the research method selected for thisstudy as there seems to be an absence of published nursing research describingmaternity nurses’ experiences of caring for abused pregnant women. This studyseeks to add to the nursing knowledge base of this phenomenon.Methodological CriteriaSamDlingThe approach to sample selection in phenomenology is known as theoreticalsampling. This method is used by researchers to deliberately select all informantsaccording to the theoretical needs of the research (Morse, 1 987). The researchercontinues to add new informants to the sample until no new ideas emerge from theinterview data. Therefore, there is no predetermined sample size. Studyparticipants continue to be added until saturation of data is reached. Munhall andOiler (1 986) identified that saturation is reached when major themes or patterns ofdata are determined and no new information is added.Reliability and ValiditySandelowski (1986) suggests that reliability and validity in qualitativeresearch are attained by examining the data in terms of the following criteria:1. Truth value refers to determining if the findings are faithful descriptions oflived experience. True understanding of lived experience is attained throughexploration of the contextual reality of the participants and encouragesdevelopment of shared meaning between the interviewer and participants (Merriam,301988). Sandelowski (1993) described truth value as member validation and statesthat this type of validation is ongoing throughout the life of a qualitative researchproject. For this reason, significant statements and themes were validated with theparticipants in this study;2. Applicability in terms of fittingness of the data refers to examininginterview findings to ensure that the participants perceptions are accuratelyreflected. Colaizzi’s (1978) procedure for data analysis was used to ensure thatthe criterion of fittingness is met. Inclusion of verbatim comments extracted fromthe transcripts also allows the reader to gain understanding of the participants’experience and ascertain the fittingness of the data;3. Consistency in terms of auditability ensures that another can clearlyfollow the decision trail of the researcher. Members of the Thesis Committeereviewed the decision trail to ensure clarity. Research participants were involved invalidating themes as necessary;4. Neutrality in terms of freedom from bias was met by bracketing personalideas and opinions. Valle and King (1 978) stated that bracketing is an attempt tosuspend one’s preconceptions and presuppositions. Bracketing is practised inorder to adhere to the rigors required of qualitative research and to attempt torepresent phenomenological descriptions based on the perspectives given throughthe experiences of the participants (Munhall & Boyd, 1993). Bracketing wasaccomplished by encouraging the participant to guide the interview and by theresearcher refraining from any judgements about the content of the participant’sdiscussion.31Selection of ParticiDantsCriteria for SelectionThe sample for study was selected according to the following criteria:1. All participants were maternity nurses employed on antenatal,postpartum, or labour/delivery units of a tertiary acute care maternity hospital.2. Nurses communicated in English.3. Nurses agreed to participate in one to three taped interviews with thisresearcher and were willing to discuss their experiences.4. The nurses cared for patients whom they knew, or suspected, wereinvolved in abusive relationships. Knowledge (or suspicions) of the abuse musthave been present at the time the patient was under care.Selection ProcedureApproval was obtained from the University of British Columbia BehavioralSciences Screening Committee and from the Research Approval Committee of theacute care facility where the research was conducted. After these approvals wereobtained, recruitment of participants began. Potential participants were informedof the research study by posters placed in prominent areas of nursing stations ofthe acute care maternity hospital (Appendix D). Telephone contact numbers of thisresearcher and members of the Thesis committee were identified on the posters.Potential participants contacted this researcher on their own initiative, andmeetings were arranged for explanation of the purpose of the study and discussionof eligibility criteria. Once eligibility was established, information letters weredistributed (Appendix A), consent forms were signed (Appendix B), and all rights of32the participants were explained. At this point, appointments were made for theinterviews themselves.Ethical ConsiderationsThe study participants’ rights were protected in the following manner:1. Written approval was obtained from the University of British Columbia Officeof Research Studies.2. Written consent was obtained from the Research Approval Committee of theacute care facility where the research was conducted.3. Written and informed consents were obtained from participants. Consentincluded permission to audio-tape the interviews (Appendix B).4. Participants were given written information which summarized the nature ofthe study, the focus of the data collection, and how confidentiality of the datawould be protected (Appendix A).5. Participants were informed that participation in the study was voluntary.Participants were informed that withdrawal from the study was possible at anypoint without consequence to employment status.6. Participants were asked to refrain from identifying any patient, health careprovider, or other nurses by name. The participants were informed that theiridentifies were protected through the use of numerical codes. The coding systemwas shared only with the Thesis committee members.7. Audio-tapes and transcribed interviews were kept in the possession of theresearcher. Transcripts, or portions of, were shared only with members of theThesis committee. All audio-tapes were completely erased upon completion of thethesis.33Interview ProcessEleven maternity nurses participated in this study. Each of these nurses wereinterviewed initially in discussions lasting from thirty (30) minutes to ninety (90)minutes. Open-ended semi-structured interview questions were used to guidediscussion about nurses’ perceptions of caring for abused pregnant women(Appendix C).During initial interviews, nurses described patient situations of womeninvolved in abusive relationships. Many clinical examples of nurses’ experiencewith abused women were given. It was found that many of the first interviewsconcentrated on nurses’ anecdotes of patients’ situations, and little data wasreceived about the meanings that these situations held for the nurses. Data aboutpatients’ experiences in abusive relationships was obtained. Nurses alluded to theirown personal experiences with abuse, and/or how they related to situations thattheir patients had experienced. Significant statements were assembled from firstinterviews in preparation for clarification in second interviews. Second interviewsallowed for further exploration of issues raised in first interviews.Eight (8) nurses were interviewed for a second time. During secondinterviews, nurses embellished their experiences of the patient care situationsdescribed in first interviews. Data about nurses’ personal experience with pastabusive relationships was obtained. Due to the in-depth nature of the data, secondinterviews lasted from sixty (60) minutes to one hundred twenty (120) minutes. Itwas found by this researcher that during these interviews, periods of silenceoccurred. No attempt was made to fill in the34pauses. It was noted that often following these periods of reflection, particularlysignificant statements were made.Third interviews, or validation interviews, were completed with two (2) keyparticipants. These interviews were conducted to validate prevalent themesidentified in descriptions of nurses’ experiences of caring for abused patients. Itwas found that during these interviews, nurses were helpful in clarifying theirperceptions of the experience and provided guidance in elucidating the appropriaterepresentative themes. Validation interviews lasted from forty (40) minutes tosixty (60) minutes.Contact was lost with two of the participants after second interviewsbecause of relocation to distant areas. Two of the participants were pregnantduring the first interviews. One of these participants continued in the interviewprocess after her baby was born; the other declined to participate further.Polit and Hungler (1989) identified that the research environment can exert apowerful influence on a participants’ emotions and behaviour. For this reason, allinterviews were carried out in the participants’ homes to ensure a natural andcomfortable setting. All interviews were taped and then transcribed verbatim bythe researcher to ensure confidentiality of the subject material. Transcripts werestudied, and a process of qualitative analysis was undertaken.Analysis of DataData was analyzed according to Colaizzi’s (1978) criteria. The followingsteps were taken:1. The spoken, written and visualised descriptive data were considered in order todevelop an overall feeling and to make sense out of the data;352. The data were examined and coded to identify and capture significantstatements;3. Meanings of the statements were formulated;4. The formulated meanings were clustered into themes;5. The clusters of themes were referred back to the original data in order tovalidate them with any discrepancies noted;6. An exhaustive description of the results was developed;7. Meanings of the description were validated by returning (when possible) to theparticipants and asking them if the findings reflect their experience;8. New data that emerged from the validation interviews was integrated into thecompleted research product.The researcher returned to the participants throughout the data analysisprocess for clarification of themes and/or statements. Themes were examined forrelationships. The meanings of the participants’ experiences began to form apattern. This pattern formed the results of the study.Verbatim quotations of participants’ statements were included in the analysisto exemplify the researcher’s decision trail. This strategy served to ensurefaithfulness to the data.An essential aspect of analysis of data in a qualitative study is sharingreflections about the content of the data with others to clarify one’s thinking.Reflections of the central themes were shared with Thesis committee members.This process facilitated naming and refinement of themes. These themes werethen validated for consistency and accuracy with study participants, as research36results were dependent upon shared meaning between researcher and participant(Merriam, 1988).SummaryThe qualitative research method of phenomenology was chosen for thisstudy as it is appropriate for determining the essence of the phenomenon asexperienced by these nurses. The experiences of maternity nurses caring forabused pregnant women was the phenomenon under question.In this chapter, the researcher has reviewed the study’s design. Theinterview process was explained, and criteria for qualitative analysis of the datawas conveyed. In the next chapter, the researcher will describe the findings of thestudy.37CHAPTER FOUR: Analysis of DataIn this chapter, the findings which resulted from the data analysis of nurses’verbal descriptions of their experiences caring for abused pregnant women arepresented.Prior to presenting the results of the data analysis, a brief description of theparticipants in the study is provided. The description includes the nurses’ ages,gender, and numbers of years experience in nursing, as well as their current area ofemployment and level of nursing education.The results of the data analysis are presented in relation to three central,related themes which emerged from analysis of the interviews. These themescapture the essence of the nurses’ experiences of caring for abused pregnantwomen. The first theme, gaining understanding of patients in abusive situations, iscomprised of the sub-themes of: (a) discovering the abuse, (b) reacting todiscovery of abuse: uncertainty, and (c) developing relationships. Abusivesituations were primarily discovered intuitively as the nurses recognized subtlepatient “trigger” behaviours. Subsequently, nurses experienced feelings ofuncertainty which greatly influenced the development of nurse-patientrelationships.The second theme, facing the realities: the health care context, emergedfrom the health care environment in which the nurses provided care to abusedwomen. This second theme is composed of the sub-themes of: (a) identifying thegaps, (b) working with others, and (C) providing nursing care. Gaps in resourcesidentified were within the hospital environment. The gaps in resources wereidentified as institutional constraints and a lack of in-service education for dealing38with issues of abuse. These gaps were a source of frustration for the nurses asthey provided care to abused women. Nurses found support from collaboratingwith other health care professionals when making or validating patient caredecisions. The responses of other health care professionals were found to be botha source of support for the nurses and a source of difficulty. In the provision ofcare to abused patients, the nurses identified the need to give special attention totheir maternity care as well as to provide nursing care which addressed the abuse.The third theme, struggling within the realities: the subjective context,describes the participants’ personal experiences of caring for abused pregnantwomen. For many of the nurses, the discovery of abuse and subsequent care ofabused women resulted in strong feelings and emotional responses. Many of theparticipants based their own understanding of abuse on their past personalexperiences with abusive relationships. It was discovered that previousexperiences with abuse, or lack of experience, clearly influenced nurses’therapeutic relationships with their abused patients. The principle feelings andresponses of the nurses were comprised of: (a) nurses’ conceptualization of abuse;(b) feeling fear; and (c) connecting with the patients, which resulted from thenurses’ personal understanding of abuse.Descriotion of ParticiDantsIn this study, interviews were conducted with eleven maternity nurses. Allparticipants were female - no male nurses volunteered. The average age ofparticipants was thirty years; the range was from twenty-five years to forty-fiveyears. All participants were Caucasian.39All volunteers were experienced in the field of maternity nursing.Participants had between two and twelve years of work experience in this area.The average span of work employment was five years. All nurses were employedat one acute, tertiary care maternity hospital. Three of the nurses worked on anAntepartum floor, four were from Labour and Delivery, and four worked onPostpartum units. Education levels of the nurses varied. Five nurses weregraduates of diploma programs, six nurses had obtained their Baccalaureatedegrees, with one nurse in the process of completing her Master’s Degree inNursing. One nurse held a Midwifery Certificate.The marital status of the nurses varied. Two of the nurses lived in common-law relationships, five were single and uninvolved in intimate relationships, threewere married, and one was divorced.Several of the nurses interviewed had direct personal experience withabusive relationships in their past histories, although none admitted to beingcurrently involved in an abusive situation. This and other relevant personal datafrom the nurses’ past histories will be discussed within the text.Gaining Understanding of Patients in Abusive RelationshiDsThe participants in the study described a process through which they gaineda better understanding of the individual patients whom they identified as being inabusive situations. The researcher did not prescribe a definition of an abusiverelationship for the nurses. The participants, therefore, could define abusiverelationships according to their own understanding. Knowing the patients asindividuals was important to the nurses as they provided appropriate nursing care.During initial interactions with the patients, the abusive relationships were40discovered through the use of nurses’ feelings of intuition. For many of the nurses,recognizing some of the trigger behaviours of their patients such as lack of eyecontact and unusual interaction between that patients and their partners, was thekey to discovering the abuse.Discovering the AbuseThree possible scenarios unfolded in which nurses described their discoveryof their patients’ abuse. Abuse was discovered by some of the nurses as theyreceived their daily shift report on their assigned patients. Secondly, some of thesituations were discovered by the nurses themselves after the presence of subtletriggers encouraged detailed assessments as they took over the care of thepatients. The third scenario of discovering a patients’ abuse occurred as thepatient was admitted to the health care situation. Detailed assessments occurredeither at the beginning of the nurses’ shift or during admission of a new patientinto the nurses’ care. During their assessments, nurses described their intuitiveawareness that “something wasn’t right”, and that they used their intuition in thediscovery of their patient’s abusive situations. Each participant described aminimum of two to three patient situations that they felt were abusive. Given thenumber of patient situations discussed, it is estimated that two or more discoveryscenarios occurred for each nurse.Nursing ReDortsThe first discovery scenario occurred as maternity nurses received a detailedreport from their nursing colleagues at the commencement of their shift. Duringthis time, for some of the nurses, information was shared verbally about patients’abusive situations. The nurses acknowledged that the awareness of their patient’s41abuse coloured their impressions of the couple before they met them. Nurses’feelings of being “guarded” and having a “prejudiced attitude” influenced theformation of their initial reactions. One nurse described that she formed herprejudiced attitude because of her previous personal experience with abusive men,and this influenced her initial behaviour with the couples.It was documented on the chart that she was abused a week prior to cominginto labour, so at 39 weeks gestation she was abused by her husband. Iguess the man had beat her up quite badly and thrown her down a flight ofstairs. So I kind of went in there with a prejudiced attitude against thecouple I was going to be meeting.I had received a report from the night nurse and she identified that they hada few problems with the couple, mostly the husband. He seemed fine when Iwalked in, but I was guarded already because of what I had heard in thereport.When discovery of abuse resulted from receiving reports, the nurses identified thatthey had some warning of the nursing care situation that they were facing. For themost part, the abuse situations were discovered without warning.Nurses’ AssessmentsThe second scenario of discovering patients’ abusive situations occurred asnurses assumed the care of their maternity patients and completed their ownassessments. In these situations, knowledge of the patients’ abuse was not knownwhen care was initiated. One nurse described her discovering her patient’s abusein the following way:42There were no real factors that alerted us to the fact that she was a victimof violence, we had no social history or anything on this person. This wassomething that I picked Up on after working with [the couple] for a fewdays.The third scenario describing the discovery of patients’ abuse also resultedfrom nurses’ assessments. Discovery of abuse occurred when maternity patientswere newly admitted to the health care situation. Nurses described that discoveryof abuse in this situation also occurred without warning. Discovery occurred as aresult of a thorough nursing assessment that was completed by the nurseassuming primary care of that patient for the duration of that nurses’ shift.It came out very suddenly, that she was just at that bursting point andsomeone had shown some kind of interest in her life and from that point on,[her story of abuse] just came flowing out.When I was first talking to her and she saw that I was concerned for her,her little defense collapsed and I put my arms around her and let her tell herstory.As described in the narratives, the discovery of abuse was often an unexpectedresult of the nurses’ assessments of their maternity patients. Feeling unpreparedfor the discovery of abuse was a common response of the nurses.I’m not sure that I really was prepared for the flood of emotions that pouredout after my simple question. It came as a surprise to me that she openedup such intimate things so easily to a complete stranger.43It is important to note that each of the nurses described at least one scenario inwhich they used their intuition to discover their patients’ abuse.Usina IntuitionNurses described their use of intuition as the precursor to discovering someof their patients’ abusive relationships. During the initial phase of the nurse-patientrelationship, nurses’ index of suspicions about the presence of abuse was arousedby their feelings of intuition. Intuition was defined in terms of “gut feelings” orhaving a “sixth sense” about the presence of abuse. One nurse described herfeelings of intuition:I think it initially starts off as an intuitive thing, just little feelers go out. I justhave this gut instinct that these women are in a really bad relationship.In all cases, nurses observed subtle patient behaviours that they felt wereindicative of abuse. Nurses consistently described these behaviours as “triggers”or “cues”. Triggers were described as lack of eye contact, patients who appearedwithdrawn or demonstrated feelings of low self-esteem, patients who were isolatedfrom family and friends, or patients who flinched when sudden movements weremade. One participant described her patients’ subtle behaviours as triggers.I can think of three women where I just walked into the room, and theydidn’t make eye contact, or if they did, they would talk initially and keeptheir eyes down and they would look up very quickly, and just the tone oftheir voice, the way they would answer questions, the way they would bewhen the partner would be in the room, which was much different thanwhen they were by themselves, just more sort of subtle things like that werethe triggers for me.44Some participants described the dynamics of the couples’ relationships, such asunusual interactions between patients and their partners, as triggers. Thesetriggers were characterized as “poor” relationship dynamics where the partner wasin control, and when patients were “different” when the partners were not present.The couples’ unusual interactions with each other was described by one nurse inthe following way:It was both my gut feeling and observing the client with her partner and littlethings she did that were triggers. She didn’t look directly at him, but shewould say “I don’t want you to be mad at me”. It was her needingconstant approval for her talking that sort of tipped something in my mind, Ithit me that there was something wrong with that. To me, if someone won’tmake eye contact then you wonder why it is that they are doing that.The nurses identified that using their feelings of intuition was an integral part ofdiscovering their patients’ abuse. The presence of triggers precipitated feelings ofintuition which, in turn, encouraged the nurses to explore their patients’ personalrelationships and home situations more carefully. The identified triggers wereimportant clues to presence of abusive relationships. Two participants summarizedthe triggers that initiated their feelings of intuition in the following way:Sometimes when people would come in, you would get a feeling of.. .1 don’tknow just how to describe it, like a gut feeling. I would feel it right down inmy stomach that there was something wrong between the couple. There isa friction between them and it would trigger some kind of a feeling about itand you can see the relationship between these people is on edge.45I guess it was the vibes you pick up from the client, things they will andwon’t tell you, the way they will or won’t look at you when you are talkingabout a certain topic. . . .so I guess the gut feeling comes for the clientherself, and from watching the interaction between her and her partner.One nurse stood out in her approach to the discovery of her patients’ abusivesituations and based her assessments of patients’ abuse solely on her use ofintuition. She described how she would orchestrate her actions in order to confirmher patient’s abuse.Sometimes I would have to actually take the patient with me into the circ(circumcision) room and lock the door because that was the only way I couldget the patient alone. Then I would ask her about the abuse and just let hertalk.This nurse’s recognition of triggers in the patient’s behaviours was based on heruse of intuition and her personal understanding of patients’ needs in abusivesituations. This nurse identified that she had had many clinical experiences withabused women and felt comfortable in using direct confrontation with the patientswhom she suspected were being abused. She stated:I got to the point where I would know when I walked into the room thatthere was some problem with the couples’ relationships, and usually it wasbecause of abuse. I was almost never wrong.This nurse provided many anecdotes of her unique understanding of abusethroughout the interviews. These unique perspectives are included within the moresimilar experiences of the rest of the participants. For most of the nurses, thediscovery of their patients’ abusive situations resulted in strong feelings and46emotions. Uncertainty was one of the strong feelings which emerged asparticipants discussed their reactions to discovering the abusive relationships oftheir patients.Reacting to Discovery of Abuse: UncertaintyIt was discovered that strong feelings of uncertainty influenced thedevelopment of nurse-patient relationships. These feelings of uncertainty emergedin relation to discovering the patients’ abuse and the resulting nursing caredecisions, as indicated in the following narratives:I think there is a lot of uncertainty out there, you are not sure if yourintuition [about the abuse] is correct, and you don’t know if you are doingthe right thing. You don’t know what the consequences are and that isreally a concern, especially if you are not sure that what you are doing isgoing to help the patient.I felt really uncomfortable talking to her about this because it was stuff that Ireally didn’t know very much about. Uncomfortable is a blanket word. Iguess I felt uncomfortable about the fact that I couldn’t do anything aboutthe situation that she was in. I guess I felt useless and I couldn’t doanything about it, I really wanted to but I didn’t know how to start.Intermingled with descriptions of discovering the abusive situations were thesenurses’ feelings of uncertainty and feeling “uncomfortable”. Uncertainty wasrelated to nurses’ feelings of wanting to support their patients in the best wayspossible, but feeling somewhat unprepared as to how best to care for their abusedpatients. One nurse described her feelings:47I felt very alone and uncertain about how best to proceed with this lady.As a result of feelings of uncertainty, some nurses identified that they did notconfirm the presence of abuse, or intervene with abused patients. The followingexcerpts, which exemplify nurses’ feelings of uncertainty, were extracted fromnarratives in which nurses described their nursing care. These excerpts chroniclethe nurses’ lack of confirmation or intervention with abused patients to whom theyprovided maternity nursing care..it was hard on me I wasn’t sure how I felt about [the abuse].I never talked about the abuse. I was afraid she would break down, and Iknew she didn’t want that.I didn’t raise the issue about abuse. I wasn’t ready to touch on that topicyet.I felt completely at sea because I didn’t know how to approach caring forsomeone who was abused.These excerpts are descriptions of nurses’ feelings as they discussed the discoveryof their patients’ abuse. The significance of these feelings lies in the implicationsfor patient care, particularly for abused patients. These excerpts indicate thatthese nurses did not address the abuse with their patients, although they knewabout it, or suspected it. One nurse summarized her feelings about not addressingthe abuse:48So in a sense, you feel like you gypped the patient off, but in a sense,you’ve got to realize that you did all that you could based on what you had.It is important to note that not all the participants addressed the abuse with theirpatients but steadfastly believed that the abusive relationships existed. Many ofthe nurses chose to discuss their initial experiences with discovery of maternitypatients in abusive situations which they described as being new and unfamiliar inthe nurses’ repertoire of nursing experiences. Although these nurses hadsubsequent experiences with caring for abused women, feelings of uncertaintypersisted. Feelings of uncertainty resulted from being unsure of how to proceed inthe care of abused women. The nurses identified that they felt that expectationsof them as health care professionals were different in the care of abused womenthan with non-abused patients. One nurse recalled feeling her abused patient caresituation was “complex”.I realized that this couple weren’t just your “average Joe” obstetricalpatients. I could see that they had stresses in their relationship that wentbeyond having a baby, and that the situation was more complex.She went on to describe her feelings in relation to this couple.I had a strong feeling that she was probably being abused, but I wasn’t sureshe wanted me to bring up the subject.Taking cues from the patients sometimes added to nurses’ feelings of uncertainty.The narrative indicated that, for this nurse, she felt that the couple needed “morecare” in their complex situation that likely involved abuse. This nurse felt unsurethat the couple was ready, or if they even wanted any intervention that wouldaddress the abuse.49Nurses’ feelings of uncertainty had an impact on the ways in which theydeveloped their nurse-patient relationships, and their subsequent provision ofpatient care. As the context of feeling uncertain was further explored, theparticipants clarified that they felt it was important that the patients not know oftheir personal feelings.It’s the not knowing what you can do about the [abuse], and feeling like youcan’t do anything except listen. But I really didn’t want her to know howuncomfortable I felt, because it was important that she had a chance to tellher story.For the participants, personal feelings of uncertainty were shared with nursingpeers, health care colleagues, and significant others, but not the patientsthemselves. Not sharing their personal feelings with the patients set the nursesinto conflict because of the sensitive nature of the information that the patientswere sharing with them.I think the hardest thing was making the patient know that I valued what shehad shared with me, although it made me feel threatened because I felt like Ihad to do something with it, and I couldn’t let her know how I really felt.Undercurrent feelings of uncertainty and feeling “threatened” were present formany of the nurses. These feelings formed the context in which interpersonalrelationships between patients and nurses were based. These feelings led to onenurse’s description of the conflict she experienced.It’s that whole inner conflict. You so desperately want to help someonebecause that is why you went into nursing. You want to help make them all50better but you can’t. Yes, it is like an ache, an inner conflict and innerturmoil.Another nurse described that her undercurrent feelings were related to herperceptions of the boundaries of her nursing role.I think about what this poor woman had been through and what she had togo home to, and it made me feel angry. You struggle to care for peoplewithin the boundaries of nursing, and sometimes you want to go further, butyou know that you can’t.For some of the nurses, discovering patients’ abuse elicited feelings ofuncertainty as they realized the unique needs of these individual patients. Moreand more, maternity nurses are faced with patients who are experiencing this typeof psychological distress. The nurses’ perceptions of their abilities to interveneeffectively with abused patients resulted in their feelings of prejudice,unpreparedness, and uncertainty. While acknowledging these feelings, the nursesfostered their nurse-patient relationships carefully.Develorinci RelationshipsRegardless of a patient’s culture, language, circumstance or illness, nursesestablish relationships with their patients that are, by their nature, responsive topatients’ needs. Nurses in this study discussed the importance of carefullydeveloping relationships between themselves and their maternity patients followingthe discovery of their abuse. Understanding the process of how these nursesdeveloped their relationships with their abused patients is extremely importantbecause coping with patients’ pain and psychological distress is inherent inprofessional nursing practice. Although it is acknowledged that maternity nurses51develop unique relationships with their patients who are not abused, the nurses inthis study identified that discovery of their patient’s abuse led them to payparticular attention to fostering these relationships by being non-judgemental,building trust to develop a rapport, gently probing into the patients’ background,and sharing like personal experiences.Beinc Non-JudgementalThe nurses clearly articulated their convictions that the patients deserved toreceive non-judgemental care. Some of the nurses found that their prejudicedattitudes towards the abusing couple made it difficult to be non-judgemental. Inorder to differentiate their feelings, the nurses chose to build relationships withtheir patients separately from their partners. These reactions were described.Reacting to øatients.The nurses felt strongly that providing non-judgemental nursing care to theirabused patients was the basis for developing relationships with these patients. Itseemed important to many of the nurses that their own attitudes and feelings,identified as they discovered the patients’ abusive situations, were not to becommunicated to either the patients or their partners. These nurses believed thatby appearing non-judgemental about their patients’ situations, they could foster therelationships with their patients and gain a better understanding of the abuse fromthe patients’ perceptions. This better understanding also fostered nurses’knowledge of their patients as individuals. When asked about how providingnon-judgemental care was unique to the care of abused patients, one nurseanswered that providing non-judgmental care meant that the patient received hersupport and not her opinion.52I can honestly say that [the patient] felt that I was trying to work for her andI was not trying to be judgemental. With her, it was really important to methat she feel supported especially after I knew what had happened to her.She trusted that I was not going to give her my opinion about what sheshould do.This narrative illustrates that this nurse’s support for her patient was based on herbelief that nursing care should be non-judgemental. Providing non-judgementalcare was characterized by one nurse as part of her nursing role.Whether [their relationship] is right or wrong, that is not my place to bedeciding that. So when [abused women] come to the hospital, that is myrole to support them, and to listen to them, and to respect what they aresaying whether I like it or not.This nurse talked at length about her need to give non-judgemental care to abusedwomen. She reiterated her beliefs in the following narrative:I just see myself in a supportive role no matter what [the patients] do, but Idon’t give my opinion any more. I share my concern more than I used to.The above narratives illustrate that these nurses felt the need to provide nonjudgemental care to patients in abusive situations despite the presence of their ownattitudes and feelings about abuse. All nurses, including those who addressed theabuse with their patients and those who did not, concurred with the belief that thepatients deserved to be treated in a non-judgemental way. However, reactions topartners known to be abusive posed difficulty for the nurses in their attempts to benon-judgemental.53Reacting to Dartners.Nurses identified that prejudiced attitudes against the partners negativelyinfluenced their relationships with these men. They described how they tried beingnon-judgemental in their reactions to the patients’ partners. Contrary to theirpersonal feelings, many of the nurses went out of their way to include the partnersin the developing relationships with the patients.I really tried to be non-judgemental and I tried to include him, but it wasreally hard for me to like him because of the way he presented himself.For this nurse, her attempts to be non-judgemental with her patients’ partnerprevented her from articulating her true feelings about his presence in the nursingcare situation. She identified that her motivation for being non-judgemental was tobest support her patient and not cause undue tension and strain in the developingrelationship. When asked to explain why it was important that she avoid unduetension with her patient, she answered:She was the kind of patient you wanted to walk up to and give a hug andsay its going to be alright. But the best thing I could do was offerunconditional, non-judgemental care and try to include her jerk of a husbandbecause she wanted him there.The focus of this nurse’s concern was her developing relationship with the patient.Her commitment to providing non-judgemental care outweighed her negativefeelings for her patient’s partner. Another nurse was convinced that her patient’sright to non-judgemental care outweighed her right to be judgemental of herpatient’s partner.54I was trying my best to be non-judgemental. Perhaps that is why I tried sohard to get him involved. I was really concerned about her, and she neededmy help in so many other ways. So I didn’t want to rock the boat with herand she had already been through enough.As is illustrated by the narratives, the participant’s motivation for being nonjudgemental when developing relationships and providing care to abused patientsand their partners was based on their perceptions of the patients’ needs for thistype of support. Nurses further developed their nurse-patient relationships byfostering trust and rapport with the patients and respecting their patients’ personalboundaries.Building TrustMany of the participants perceived that timing was important in thedevelopment of nurse-patient relationships. The nurses felt they wanted to build atrust with the patients prior to intervening in the sensitive areas of the abuse. Thedeveloping nurse-patient relationships were based on nurses’ “sense” of thepatients’ needs for trust.If I sensed [the abuse] then I would really work hard on developing at least alittle bit of trust with this woman so at least she would feel a little bitcomfortable. And if there was something that would come up, then wehave a bit of a base.Developing trusting relationships with abused patients was recognized by theparticipants as important for establishing the patients’ priorities for care. Thefollowing narrative illustrates one nurse’s efforts to build trust with her patient inorder to demonstrate her commitment to establishing a therapeutic relationship.55Although I never actually told her, I wanted to create an openness with herto let her know that if she ever wanted to talk, that I was there. I reallywanted to show her that it was a non-judgemental thing, that if she chose toopen up to me that it was okay.Nurses worked on developing trust by getting to know their patients, thus gaininga better understanding of the patients as individuals in difficult situations. Buildingtrust within their relationships assisted the nurses to decrease their feelings ofuncertainty because they were able to base nursing care decisions on individualizedpatients’ needs. The nurses were also better able to help the patients byencouraging them to talk about their situations. Nurses identified they respectedthe patients’ personal boundaries, as illustrated by the following narratives..on one hand, I wanted to respect the wall she had put up, but on the otherhand, I felt there was a lot underlying it. I thought she might have neededsomeone to talk to and I wanted to be there for her.I find the most important thing is respecting the woman’s boundaries andhelping her to feel that she is in control and is making decisions when she isready.Developing therapeutic relationships with abused women was strongly associatedwith building trust and rapport with the patients, as indicated in this narrative:[Abuse] is such an intimate problem that you need to build up trustingrelationships in order for the [patients] to open up to you, and for them toreally believe that you care, and are there willing to help.56Respecting the patients’ boundaries was a key factor in developing therapeuticrelationships and cultivating a sense of trust with the patients. In the abovenarratives, the nurses described how they built trust by respecting their patients’personal boundaries with the intention of helping them to provide the best care andsupport to their abused patients.Gentle ProbingIn furthering their relationships with abused women, nurses explained howthey also used gentle probing to ask questions about the patients’ relationshipswith their partners. Questions asked about the abusive situations often focused onpatients’ backgrounds and past histories. Nurses identified that probing into thepatient’s past helped them to gain a better understanding of the patient’s abusivesituation.With someone who hasn’t got an identified problem, I probably wouldn’t betrying to find out who is her extended family and what kind of life she ledand what kind of childhood she had, but those things were interesting to mebecause I wanted to see what kind of history she came from and what kindof history he comes from too. It helps me to sort out in my own mind howthese things happen.Gentle probing and questioning the patients about their backgrounds often resultedin the nurses receiving further disclosures about patients’ abuse. One nurseobserved that many of her abused patients broke down and talked about the abuseafter being asked open ended questions about their home situations.I said “you look like you are afraid to go home, what is it going to be like foryou when you go home?”, and she started to cry. Then she opened up and57said she was afraid to go home and she didn’t know what she was going todo.In addition to asking probing questions, nurses used active listening when patientsresponded to their questions. The following narrative illustrates this:I saw listening to her as part of my role as her nurse because I spent lots oftime with her and probably had a lot better chance of finding out informationin general by letting her talk about her family and friends. She also told meabout the physical environment that she was going home to so I got a goodperspective on her home life.Receiving abuse disclosures and further explorations of abusive situations wasdifficult for many of the nurses. Although nurses expected to receive answers totheir probing questions, some responded to their patients’ disclosures with feelingsof distress. One participant summarized her response in the following way:I knew when I asked her the questions that there was more going on, but Ireally did go through a whole gamut of emotions with them after she told meall about [the abuse]. I had to think about it, and sort out it out in my headhow I really felt.Further knowledge about patients’ abusive situations was acquired by askingprobing questions as the nurses developed the trusting relationships with theirpatients. As a result, nurses’ understanding of the patients in abusive situationsincreased. For some of these nurses, the developing relationships with theirabused patients resulted in the nurses’ sharing their own experiences of abuse.58SharingMany of the nurses acknowledged personal experiences with abuse in theirown pasts. The developing relationships between nurses and patients werestrongly influenced by the presence of nurses’ past experiences with abuse.Although the influences of past experiences are explored more fully later in thistext, the sharing of abuse experiences with patients clearly affected the developingrelationships. One participant described her experiences of sharing her own abusewith her patients.After what I’ve been through, I can support them in a much more effectiveway and I don’t need to share a lot. The less I share and the way that I sayit is just as effective than if I go into this big story about my own abuse. Ifeel I can help them. I enjoy taking care of these women.Another nurse with personal experience of abuse offered this narrative aboutsharing her experiences with her patients.Yes, I have been abused, and yes, I let this person do this to me, but if youare sharing instead of talking at someone, if you are sharing experiences,and you really do understand what they are saying, you can be empathicbecause you’ve been there and you can really understand.Sharing experiences with patients was one way in which some of the nursesdeveloped relationships their patients. One nurse shared her own experience offeeling the emotional and psychological pain that comes with being abused. Shestated:59I find it easy to identify with these women and the different stages that theyare in. I think that going through a lot of emotional pain yourself, you canidentify and see that in other people.By sharing experiences with their patients, the nurses felt they “received somecredibility” in the eyes of their patients when asking probing questions about thepatients’ abuse. The nurses identified that sharing of experiences led to greatertrust in the nurse-patient relationships.Few of the nurses felt comfortable sharing past experiences of abuse withtheir patients. Only one nurse described that she regularly shared her experiencesof her own abuse with her patients because she found it a useful strategy forbuilding trust and establishing relationships with her patients. Although not allnurses had experiences with abuse to share with their patients, the common themeidentified by the nurses was their commitment to carefully developing relationshipswith their abused patients. Many nurse-patient relationships were developed underthe stress of nurses’ feelings of uncertainty. Nevertheless, nurses’ struggled toprotect their patients from their uncertainty by being non-judgemental as theirrelationships evolved. Being non-judgemental with the patients’ partners was foundto be more difficult for the nurses, although they confessed that the desired resultsof their efforts were focused on establishing trust with their abused patients.Building trust and rapport was achieved by attempting to respect the patients’personal boundaries and spending time with the patients. Gentle probing questionswere also used as a strategy for developing relationships with patients. Thequestions were intended by the nurses to assist them in gaining understanding ofthe patients and the extent of their abusive situations. For some of the nurses,60asking about the patients’ abuse led them to share their own abuse experiences.Sharing experiences resulted in stronger, interpersonal relationships with theirpatients. For the nurses without personal experience with abuse, relationshipswere developed through the other strategies described in the narratives.The participants outlined their process of gaining understanding of theirpatients in abusive relationships through discovering their abuse and developing therelationships. An understanding of the patients obviously influenced the provisionof nursing care. The nurses also discussed the difficulties of nursing abusedwomen from within the context of the health care system.Facing the Realities: The Health Care ContextThe experiences of the maternity nurses in this study were greatly influencedby the external constraints of the health care system. The health care resourcesavailable to assist the nurses as they cared for their abused patients were thecause of much discussion. Three main themes depict the realities of providing carewithin the existing health care as system described by the participants: identifyingthe gaps, working with others, and providing nursing care.Identifying the GaDsAs the participants provided nursing care to their abused patients, theyattempted to access additional health care resources to assist them in their care.Many nurses identified the existence of institutional constraints as well as gaps ineducational resources. These gaps hampered nurses’ attempts to providecomprehensive care to their abused patients. The nurses felt frustration as a resultof inadequate supportive resources to assist them in helping the abused women.61Institutional ConstraintsAs the participants identified the gaps in available resources, they describedthe limited support to address abuse they felt from the institution. All nurses wereemployed in the same institution. One nurse described her frustration at not havingaccess to what she identified as “necessary” infrastructure.As far as the hospital doing anything specific, I think it doesn’t exist. Weare out there on our own, and I find it really frustrating when we identifysomething like abuse and there isn’t any resources that we can access thatwill help to tell us what to do. It is a big problem and [the hospital] needs toprovide us with some necessary resources to help these women.As illustrated in the narrative, this nurse’s frustration with the lack of resourceswas evident. Frustration with the lack of resources was a consistent lament of thenurses. One nurse commented:I really felt that I was on my own with this woman. It was really frustratingknowing that she needed help, and that there wasn’t much that I could offerher in the way of support from the hospital.Many participants felt that it was the hospital’s responsibility for providingthe institutional support to assist them in providing better care for these women indifficulty. None of the nurses felt that they had a role in ensuring that thesesupportive resources be implemented, nor did they see that they could raiseawareness of the need for these type of services. This theme of wanting supportwas illustrated as nurses expressed their desires for written guidelines or policies tosupport them in their nursing roles. One participant discussed the need forinstitutional support for nurses to fulfil their roles more effectively.62There is nowhere in the Policy and Procedure Manual for us to look up under“abused patient” to help us, or to guide us , and tell us what to do when wefind out about these patients.Clinical guidelines were desired by nurses to provide direction as they discoveredtheir patients’ abuse. Again the nurses did not discuss that they could participatein the development of guidelines. Because no mention of helping to write theguidelines was made, it is unclear to the researcher if the nurses wanted, or werewilling to take part in guideline development, if given the opportunity. However,the nurses clearly felt that their roles in caring for abused patients would be madeeasier by direction from written guidelines.I’ve never been one to promote paper pushing but I definitely think thatwhen you are dealing with something like abuse, having written guidelineswould help us to pick up more of these ladies, and give us some ideas aboutwhat we can do.Nurses expressed their ideas about other desired resources such as informationpackets for patients, or resources packages for nurses.I’ve been pushing for a long time for Community Awareness Resourcespackage for postpartum nurses. We need to know what resources are outthere and we need to know that we can access them, as opposed to relyingon the Community Health nurse.I think we need information packets, something right on the ward, or on ourinformation board. If there is something on abuse written there, the patientswill know that they can at least talk about it, or pick up a pamphlet for later.63Another nurse discussed her ideas about the need for information packets to assistnurses in the care of abused patients. She saw that the need for current, availableinformation was a strong indicator of the lack of institutional support for nursescaring for patients with abusive situations.How do they expect us to try to help these ladies when we don’t even havea pamphlet that we can hand them. Even if there was just a phone numberfor them to call, it would be better than what we have now, which isnothing. The hospital really needs to get its act together about this issuebecause its the nurses that are doing all the work, and we need help.Institutional constraints were a reality faced by the nurses in the provision of careto abused women. However, the health care context of the hospital itself wasidentified as generally supportive in other areas such as staffing ratios and patientcare autonomy. When asked to describe her views of working as a nurse in thisacute care institution, one nurse articulated:I think in general we have a lot of latitude when we care for our patients. Idon’t feel that there is someone breathing down my neck, and we are ableto develop really strong relationships with our patients because we havegood patient ratios. I think it helps us to pick up on the psychosocial stuffbecause we aren’t run off our feet.Institutional support comprised an important component of the health care context.The nurses felt there was some support from the institution, but there was alsogaps in the resources for abuse care. Nurses identification of these gaps ininstitutional support led to discussions of gaps in other resources. As participants64discussed desired resources, the lack of in-service education for nurses wasidentified.Lack of In-service EducationNurses’ desire for in-service education or training in the area of domesticviolence was identified. Most of the participants identified their frustration atfeeling inadequately prepared to deal with the issues of abuse in their patientsbecause of lack of education. One nurse articulated her wish to have in-serviceson the issues of abuse.We have in-services on death and dying so I think it would be good to havesomeone come in to talk about abuse, even the signs and symptoms ofabuse to look for. It would be nice to be able to pick [the abuse] upconsistently.The nurses believed it was the responsibility of their institution to provide in-serviceeducation. Surprisingly, none of the participants discussed the possibility ofattending continuing education programs on domestic violence of their own accord.The nurses externalized the responsibility for formal education on the issues ofabuse and there was no evidence that they felt any need to be proactive in meetingtheir own learning needs. In most situations, they identified feeling unprepared todeal with their abused patients because they lacked education. One nurseexpressed her thoughts:I know I would definitely like to learn a lot more about [abuse]. I feelinadequate and I’ve tried to help them, but I think I could learn a lot moreabout abuse and the signs that you are to look for. I feel like I get to a65certain level and then I don’t know where to go from there and I want tolearn more about how to do that.Wanting education on the issues of domestic violence stemmed from the identifiedgaps in resources available to the nurses. As with the development of clinicalguidelines, the nurses did not assume any personal responsibility for educating andpreparing themselves for dealing with abused patients. The nurses felt that it wasthe responsibility of the hospital to provide the education necessary to facilitateeffective assessments of abused patients. There was no evidence of nurses’convictions about life-long learning.A second gap identified by the nurses was their desire for clinical guidelinesor policies of care for abused women. These gaps in resources created some ofthe difficulties nurses experienced when providing care to abused women withinthe health care context. In spite of these gaps, there were some supportiveresources available within the health care context. The nurses used the resourcesavailable to them to provide patient care to abused women. They discussed thathaving supportive resources had a positive impact on their nursing care of abusedwomen.Working with OthersSupportive resources described by nurses primarily included their nursingpeers and health care colleagues. Nurses found that the support of colleagues washelpful when providing nursing care to abused patients and coping with theirresulting feelings. Utilizing the support of significant others at home was identifiedby some nurses as helpful for coping with their feelings after caring for an abusedwoman. The consistent theme identified by the participants when working with66others in the health care environment was the strategy of talking about theirexperiences.TalkinQ About ExDeriencesThe participants discussed the importance of talking about their nurse-patientrelationships that involved abusive situations. Talking about experiences occurredeither as the nurses were still involved with the patients or after the relationshipswere terminated. One nurse talked extensively of the benefits that she perceivedfrom being able to talk with her peers about her nursing care of abused women.This nurse identified that discussing her feelings helped her to prepare for dealingwith other abused women.So what makes the difference for me was to be able to talk about [theabuse] with my friends at work and identify my feelings around the issuesthat came up. This helps me so that next time I find myself in a situationwhere I am caring for an abused woman, I will feel better prepared for it.Other participants identified that talking to nursing peers was a source of supportand wisdom for their patient care efforts. The benefits of sharing knowledge aboutpeers’ experiences with abused women were identified. Two participants offeredtheir views of the importance of talking about experiences:• . .and [your peers] can help you think things through because they havedealt with similar situations. You need support because you may changeyour ideas, and maybe you can help [the patient], but you don’t act on itbecause you aren’t sure.67Even though you talk to your work mates, you are still making the decisionby yourself; the decision of whether or not you are going to investigate yourgut feelings, and talk to your patient about these things. Even if you are,you should go to your work mates and say “this is what I’ve found and thisis what I’m going to do” and they say “have you thought about this”, andhelp you to think about what you are going to say. I find that really helpful.Some of the participants found that timely support for talking about theirexperiences with patients in abusive situations was not always available when theyneeded it. Some of the nurses found that not talking about their feelings while atwork meant they went home with their feelings unrecognized.Its nice to debrief and bounce things off one another to keep your headabove water. But I think it would be nice if your co-workers would say “thatwas a difficult case, you did a good job”. But sometimes you just end upgoing home before anyone says anything because you’ve all had a hard day.Talking about demanding nursing care experiences occurred at home for some ofthe participants. Nurses discussed how they utilized the support of their significantothers to cope with their feelings experienced in the care of abused women. Onenurse identified that she felt lucky to have someone at home with whom she couldtalk over her experiences.I am very lucky that I have some one at home who I can talk to about mywork. There are many girls that live alone, and I know they find it hard togo home to an empty house after some of the situations that we’ve had todeal with.68The value associated with talking about experiences was reiterated by many of theparticipants. Nursing peers and significant others were a strong support forpersonal feelings. Nurses also identified the value of colleagues’ input whenmaking nursing decisions about the care of abused women.Collaborating with ColleaguesAnother theme which involved nurses’ working with others wascollaborating with colleagues. The nurses described both the benefits anddifficulties of collaborating with their health care colleagues as they carried outtheir nursing duties with abused patients. In this context, health care colleaguesincluded nursing peers, social workers and physicians.RelationshiDs with Deers.The participants described that working with nursing peers helped them tocope with their nurse-patient relationships, and that peers were supportive of theirown needs for guidance.I say, if you decided to do something to help your [abused patient], there issupport out there. You have to make the effort to say “I think that weshould do this” and your colleagues will make the effort at that point, butyou need to direct your support into what you need. All of us can relate todealing with difficult patients or an uncomfortable situation.Collaborating with peers in the nursing care of abused patients took on varyingforms for the participants. One nurse described how she would coordinate hernursing care with other staff members so that she could spend time with herabused patient.69I ask my co-workers to help with my patient load so that I can spend timewith this woman and give her my attention.While nurses talked with their peers in order to debrief about their personalfeelings, they also collaborated to achieve support for their decision-making inregards to patient care. One nurse expressed that the input of other members ofthe health care team was supportive of her nursing care of the patient.It really helps when there are others around to share in the care of an abusedpatient, then it isn’t so trying on one person. It is up to us to pick up on acertain amount of these women’s care, and then someone else helps fromthere, so its not you doing all the problems on your own.Another nurse described collaborating with peers as sharing information with thosewho were directly involved in the patient’s care.I would share my concerns with other people who were relieving me forbreaks and the charge nurse. Also if I was the one to give report to thepostpartum floor, definitely I would tell them about what I had observed.RelationshiDs with social workers.In addition to sharing information with nursing peers, the participantsidentified the supportive resources of the social workers. Referrals to socialworkers were the most common referrals made by the nurses. Given the sensitivenature of the reason for referral, the nurses generally consulted with the patients,and discussed their reasons for referring the patients to the social worker.I ask the patient if she feels comfortable if I share the information anddiscuss it with the social worker and I would say something like “this is70really important information about you and your baby, and I really want youto feel supported and have some people helping you to make decisions.”Collaborating with social workers was generally viewed as supportive of meetingthe patients’ needs. Nurses identified feeling confident about the support for thepatients when they referred to the social workers. The nurses felt good about theirintervention of referring the patients due to their confidence in their social workcolleagues.Well we do have some excellent people that we can refer to. I think thatsocial workers are quite excellent with that and I think they are experts inthe field of dysfunctional situations.As well as support from peers and social workers, nurses discussed support forabused patients from physicians.RelationshiDs with ihysicians.Many of the nurses felt they had developed a good rapport with thephysicians, both with the general practitioners and the obstetricians that have theirpractice in the acute care maternity hospital. Good working relationships withphysicians was an important factor in attaining support for the nurses’ clinicaldecisions.I usually find that the better I know the doctor, the easier it is for me to gethis or her support for my suggestions about patient care. From theirperspective, too, they feel better when they know, and can trust yourjudgement as a nurse.As the nurses described their attempts to access the support of the patients’physicians, either for confirmation of the presence of abuse or for assistance with71referral of the patients to other health care resources, they recounted their surpriseat situations where physicians were reluctant to include themselves in patient careplanning.I finally got a hold of the physician so I could tell him of my suspicions of thepatients’ abuse. I was really surprised when he just accepted the situation,and asked me what I was going to do about it. He seemed happy to letsomeone else intervene, and told me to go ahead with what I thought wasbest for this woman.Physicians’ reluctance to get involved when consulted about suspicions of theirpatients’ abuse was a consistent finding. Even the physicians that the nurses feltwere “patient advocates” seemed unwilling to get involved. Again, the nursesreiterated their convictions that the success of the nurse-physician interactionsdepended upon their having developed good working relationships.In my experience, I find that the doctors who come to [the hospital] a lot aremore willing to listen to the nurses when they ask for Doctors’ orders. Ithink it is because they know the nurses better.. .especially when it comes to[dealing with] something like abuse.It was speculated by some of the participants that lack of knowledge on the part ofthe physicians was the problem. This participant described her experience withone of the physicians whom she considered to be a strong patient advocate.My experience with this physician is that he is always there for his patients.I was really surprised when I found he wasn’t willing to get involved withany of the abuse stuff. I don’t think that most physicians know what to do,so they don’t want to get involved.72Even when the patients were in the hospital setting, the nurses found that thephysicians were reluctant to get involved.It was never picked up on or acted on in the hospital because the doctorswere in and out the room constantly and nobody addressed that. It was likenobody wanted to get involved.Physicians not wanting to get involved in the care of abused women hadimplications for the nurses providing care to these patients. Nurses identified theirneed for knowledge of resources that could be accessed without referral fromphysicians. One nurse identified a resource that she had learned about through herwork in the community.I just happened to learn of a place called WestCoast Perinatal where, as astaff nurse anywhere, you can phone this group and say “listen, this is whatI’ve got, can you follow up on it?”, and there is no health care professional.What I mean is that you don’t need a Doctor to do that. We need to knowabout more places like that.Although the participants were frustrated with the physicians lack of support, theysaw this as outside of their control. They felt they needed to be able to intervenewith these women by working with other available resources and providing optionsoutside the realm of physician referral. The gaps in physicians’ knowledge, andtheir own willingness to get involved in the care of abused women, wereacknowledged as beyond the scope of nurses’ practice.We have to be accountable and responsible for our own nursing care, and ifthe physicians are not willing to get involved, then we can’t be the ones to73educate them. We can only do our little bit while we have the patients onthe ward, but it would be better if we could all work together.Collaborating with health care colleagues was summarized by one participantas she acknowledged difficulties experienced by nurses who were involved withcare of patients in abusive situation. She referred to the needs for multidisciplinary services given the complex nature of the supports required.We have to be able to help the nurses while they are dealing with peoplewho are known to have a dysfunctional relationship. We need to realize thatthey are going to be exhausted, they are going to need to reach outphysically to these people, they are going to need to do extradocumentation, because there is always the legal aspect on this, and theyare going to have to call in other support services that we have, and thatincludes social work, the physician and even the police.The legal aspects of care were not generally discussed by the participants,although the possibility of police involvement was considered by some. The needto approach abused patients’ care from a multi-disciplinary perspective wasimplied, although these exact words were not stated by the nurses. Overall, thenurses viewed supportive collaboration as strongly shared between their nursingpeers and the social workers. The physicians were not included in the list ofsupportive resources, and this was acknowledged as a source of difficulty for thenurses. The nurses expressed their beliefs that good working relationships thatwere based on mutual respect for clinical judgement were essential for obtainingtheir requests for Doctors’ orders.74The participants in this study provided nursing care to abused women withinthe health care context of an acute, tertiary care maternity hospital. This hospitallacked the necessary resources needed by nurses to deliver comprehensive nursingcare to abused women. The existence of gaps in institutional and educationalresources was frustrating for the participants. Support was obtained for bothclinical decisions and personal feelings from significant others, nursing peers, andhealth care colleagues such as social workers.Nurses provided care within the context of the health care system. Thenursing care and the necessary adaptations to care for abused women arediscussed from within the health care context.Providing Nursing CareOne of the central ways in which nurses enact their professional roles isthrough the provision of nursing care to their patients. As in every nursing caresetting, including the maternity setting, the situational demands often necessitatethat nurses respond to patients promptly and with knowledge and skill based onclinical experience. As discussed in the literature review, maternity nurses providecare based primarily on frequent observations and assessments of patients’physical and psychological adaptations to their maternity care situations, whetherin the labour and delivery, antepartum, or post-partum units. Unique or unusualpatient situations require that nurses adapt their “usual” repertoire of carebehaviours to meet the needs of individual patients. As nurses’ knowledge of theclinical abuse situations described for this study became clearer, they applied thisunderstanding in the provision of appropriate nursing care.75The nurses recognized that their patients required maternity nursing care aswell as nursing care which addressed the abuse. The nurses had to adapt theirmaternity nursing care in order to meet the special needs of their abused maternitypatients. Adaptations to nursing care were described as special attention tomaternity care, abuse care, and holistic care.SDecial Attention to Maternity CareNursing an abused maternity patient required that the nurses adapt theirmaternity care while acknowledging the unique needs of the abused women. Thisspecialized care was described as maternity care which focused on supporting thepatients’ self-esteem and need for self-confidence.I spent a tremendous amount of time, mostly helping her with breast-feedingand trying to raise her self-esteem, and trying to encourage her and tellingher that she could do this by herself.I tried to reinforce the baby behaviours with her, and the bonding with herbaby because these women don’t have much confidence, and that is onething for us to do is to foster that self-confidence.Also included in specialized maternity care was the provision of comfort care. Onenurse clearly described the changes to her nursing care as she tried to meet theneeds of her abused patient.So I tried to do little things for her. I know we aren’t supposed to do this,but I ran a bit of a bubble bath for her to make her bottom feel better. I alsoput a flannel sheet on her bed so it was more comfortable and made sure hercurtains were open so she didn’t feel isolated in her dark room.76Making the patient physically comfortable was addressed by some of theparticipants as part of the special attention they provided in the care of abusedwomen. These nurses felt that the abused women had had enough unhappinessand discomfort in their lives. By providing care that made the patients physicallycomfortable, the nurses felt they were “doing something” to help the patients.The nurses indicated that they overcompensated in their attempts to provide extraattention to these women. Although the nurses provided this comfort care toabused patients, they also acknowledged this was not unique to the care of thispatient population.Don’t get me wrong, I do try my best to make all my patients as comfortableas I can, but I just felt that I wanted to try to do something extra for thiswoman because she seemed to be hurting in so many different ways.Their emphasis on the importance of providing specialized maternity care toabused women was based on nurses’ perceptions of the patients’ needs. Theseneeds included supporting the patients’ self-esteem, building confidence in theirabilities to provide baby care, and physical comfort care. The role of maternitynurses is to provide specific, individual care to non-abused women. However, asdescribed in the narratives, the participants differentiated the nursing care theyprovided as trying to specifically meet the needs of their abused patients.Abuse CareAbuse care was described by the nurses as interventions that directlyaddressed the patients’ abusive relationships. Abuse care included providing thewomen with resource options and crisis information, active listening about the77abusive relationships, and assessing the safety of both abused women and theirbabies. One nurse described her intervention which included an explicit safety plan:I’ve been really specific and told women that said they honestly couldn’tleave that this is what they need to do. “You need an extra set of keys, youshould keep them outside the house, you should have some money in yourcar or with a friend that you trust, you should have a bag packedsomewhere either at a friends’ house or in your car”. You do all of thesethings with these women because you have to be realistic, and you know[the abuse] is going to happen again.This participant was really clear in her approach to intervention with abusedwomen. Most of the participants were not as able to provide their patients withsuch explicit instructions as the safety plan. Most of the participants who providedabuse care chose to focus their interventions on active listening and providingwomen with initial exploration of resource options.If a woman was openly discussing the abuse, then I saw my role as sittingdown and listening to her and identifying her main concerns, and the thingsthat were important to her at that point. Then I might try to get her to saywhat she thinks she would like to do next.I found myself wanting to play a role in addressing the abuse with herbecause it was me who had started developing the rapport. I wanted her toknow that she wasn’t alone, and that if she wanted to find out some of heroptions, and get some resources, that I was going to be there to help her.78Abuse care included addressing nurses’ concern for the newborn babies andany other children at home that would be affected by the abusive relationship. Onenurse focused her abuse care on assessing for the safety of a baby that was goinghome to the abusive situation.I felt worried about the baby and asked if she had thought about his safety.She said she knew he would never hit him, but I knew as soon as she leftthat I was going to phone Community Health to get an early follow-up.Another participant indicated her concern for the baby in an abusive situation.I worried about the baby, like I was protective of the baby, but I knew that Icouldn’t just take this child from him; it was his daughter.Abuse care included referral to other health care professionals such as communityhealth nurses, physicians, and social workers. Providing care within the healthcare system was found to be a major theme contributing to the nurses’ experiencesof caring for abused women. Referral to health care professionals was addressedwithin that context.Nursing care was rendered by both the special attention to care provided toabused women, and through directly related abuse care. The differentiation ofthese two focuses for nursing care led some of the nurses to consider the need fora holistic type of care.Holistic CareThe participants discussed the need to integrate maternity care with abusecare when nursing abused women. In order to address the complex needs of thesepatients, nurses addressed the integration in terms of providing total care, orholistic care. Nurses saw that caring for abused patients provided opportunities to79meet patients’ total needs on both physical and psychological levels. Oneparticipant contributed a particularly poignant narrative illustrating this:It is very rewarding when you have helped somebody fully. You have takencare of their physical needs and their emotional needs, and you go homefeeling like “I helped someone today”.Another participant described a similar interpretation of the need to address abusedpatients’ needs from a holistic perspective:We need to learn a lot more about abuse and about abusive relationships,and about difficult pasts. All of these things totally affect who we are aspeople and who our patients are as people. Until we learn to care for peoplefrom a holistic perspective, we will always separate their uterus from theirminds. We are not meeting our patients’ needs when we do that.The need to address patient care from a holistic perspective was expressed by thisparticipant as nurses’ responsibility.Nursing has to take responsibility for helping women to deal with their issuesbecause we have so much interaction with these women. We have to workthrough our whole feelings about “what do I do with this information” and “Ican’t deal with this”. We have to recognize women from a holisticperspective and provide responsive care to help them meet their needs andnot our own.One nurse articulated her ambition that the provision of holistic care happen on acomprehensive level, particularly when caring for abused women.I see that we aren’t those humanistic, holistic people that touch and feel andsense and smell. So I see that if we got back to that type of care, I’m sure80that we would be better able to appreciate [abused women’s] psychologicalneeds as well as their physical needs.The need for total, or holistic, care for abused women was addressed by many ofthe nurses in recognition of the complex needs of this patient population. Thedesire to provide holistic care was seen as the best way to address both thephysical and psychological needs of abused women. The nurses also believed thatchanges to the health care context would need to occur so that supports would bein place to provide the necessary follow up treatment for these abusive families.For the participants, a major part of their nursing care was spent meeting, orattempting to meet, the special needs of their maternity patients involved inabusive relationships. Addressing the abuse directly and fostering their patients’self-esteem through baby care were two ways nurses provided nursing care.Nurses in this study recognized the need to integrate maternity care and abuse carein order to holistically meet the physical and emotional needs of abused patients.For the nurses, understanding their patients in abusive relationships wascoupled with the reality of providing nursing care within the health care system.All of the participants provided care within the same health care context as allnurses were employed at the same acute care institution. The realities of providingcare within the health care system were explored with the participants.As nurses explored the circumstances from which nursing care wasdelivered, another major theme emerged. Nurses provided nursing care from theirown subjective contexts, which was derived from their own personal feelings andresponses to caring for abused pregnant women.81Struggling Within the Realities: The Subjective ContextThe participants in the study held certain beliefs which influenced the waysin which they saw and interpreted the world around them. This included theirpersonal beliefs about abuse and abusive relationships. Due to the variations innurses’ beliefs about abuse, the ways in which maternity nursing care for abusedwomen was carried out varied.Throughout the narratives, nurses interjected their personal feelings andemotions within their nursing care descriptions of abused women. As thosefeelings and emotions were examined, there emerged a subjective context fromwhich nursing care was delivered. The subjective context varied amongparticipants because it was based on personal or individual understanding of abuseand abusive relationships. These varied subjective contexts encompassed thenurses’ innermost, personal values and reflections upon which they provided theirnursing care.Nurses’ Conceotualization of AbuseEach of the participants had a different conceptualization of abuse whichbecame evident as they each discussed their personal experiences. Of the elevenparticipants, seven identified personal experiences with abuse. These experiencesincluded physical abuse in the family of origin; date rape as a teenager; spousalabuse, including during pregnancy; sexual abuse as a child; child witness of wifeabuse carried out by the participant’s father; and emotional abuse by a significantother. Two of the eleven nurses described their experiences with abuse of a closefriend in a physically abusive relationship and that their personal lives were82influenced by the violence. The remaining two of the eleven nurses described alack of awareness of personal experience with abuse.The nurses drew on their past experiences with abuse within the context ofdelivering care to abused patients. Throughout the data, nurses recountedsituations where they provided care to their abused patients and outwardly seemedto take these care experiences in their stride. However, the true personalexperiences of the participants surfaced during the individual descriptions ofnursing care. Nurses’ personal feelings resulted in difficulties when caring forabused patients. These difficulties resulted in personal struggles for the nurses.The subjective context revealed a new dimension of the nurses’ experiencesof caring for abused women. The subjective contexts were based on two principalpersonal emotional reactions experienced in response to the nursing care of abusedwomen. These two reactions included feeling fear and connecting with thepatients.Feeling FearIn conjunction with feelings of uncertainty, nurses experienced feeling fearwhen engaged in the nursing care of abused women. Fear was a multi-facetedfeeling comprised of fear of making a mistake about the presence of abuse and fearof upsetting the patients. These feelings were clearly described by two of theparticipants in the following narratives:I guess being the one to open up the can of worms is what our biggest fearis. You also fear upsetting them or asking the wrong thing or asking toomuch that they are not ready to divulge yet.83I guess the fear is that the patient will get really upset and then we will haveto deal with that.For one of the nurses, the fear of making a mistake about her patients’ abuse wassuch that she identified a need to withdraw from the patient care situation whileshe dealt with her feelings.Once you feel you are on guard yourself, because you feel you made amistake or if you have done something that made you feel uncomfortable,you tend to withdraw. I felt that need a couple of times as I was involved in[the patients’ abuse] situation.Fear of making a mistake about the presence of abuse was explored with theparticipants. The nurses reiterated that discovering a patients’ abusive situationwas usually an unexpected result of completing a comprehensive assessment of amaternity patient. The nurses also contended that it was the presence of triggers,and their own feelings of intuition that precipitated the discovery of abuse. Whendiscussing their personal feelings about actually conducting the assessment whenabuse was suspected, the nurses clearly identified that the fear of making amistake was potentially a reflection on their nursing skills. One nurse described herfear of making a mistake in this way:I saw that as, if I made a mistake, it would be a reflection back on me, so Iguess it was my feelings that held me back because I didn’t want to make amistake. That is an insult to her if it wasn’t true.Feelings of fear, for some of the nurses, were related to upsetting the patients byaddressing the abuse, and being uncertain about the interventions available oncethe abuse was discovered.84If you have assessed it wrong, [the patients] may wonder what you aretrying to tell them. It is really frightening for most women because, even ifyou are right, any kind of change can be frightening. So I think it is a hardthing to do, and I would be really afraid of making a mistake.One nurse identified that her fear of making a mistake was enough to prevent herfrom completing the assessment that would have confirmed her suspicions ofabuse. The following narrative illustrates her decision not to intervene due to herown fear and uncertainty about her nursing skills.I suppose I could have said to her “I’ve noticed that there is a bit of tensionbetween you and your partner, how is that relationship?”. I guess I couldhave but I was scared of opening up Pandora’s box and then I couldn’t doanything about it anyway. So what right did I have to ruin her life?This nurse’s perception of “ruining her patient’s life” was indicative of her feelingsof fear of making a mistake. These feelings had a direct impact upon her ability toprovide nursing care which related to the abuse.Nurses also described that their feelings of fear were related to facing theirown feelings about abuse. When asked to identify the most difficult aspect ofcaring for abused patients, one nurse responded that caring for abused patientswas difficult because of her fear of facing her own feelings about abuse. Twonurses, who identified that they lacked clinical experience in the care of abusedpatients, confirmed this fear of facing their feelings. One of these nursesarticulated her feelings:I think the fear is delving into your own feelings. I think it is easier to readabout it than it is to talk about [abuse]. Of course it is easy enough to just85forget about the abuse. You can always say there is nothing that you cando.Another nurse offered this narrative in relation to fear of facing her own feelingsabout abuse:I think what I was really afraid of was facing my own feelings about some ofthese horrible things and it is just easier to pass them over and make themappear so that they were not as bad.Feelings of fear, as identified, were expressed as multi-faceted emotions by manyof the nurses. Fear was experienced in relation to making a mistake aboutdiscovering the presence of patients’ abuse and fear of upsetting the patients bydiscussing the abuse.It is important to consider nurses’ feelings of fear from the context of bothdeveloping relationships with abused patients and providing nursing care. Feelingsof fear represented many of the underlying feelings and responses of the nurses’experiences of caring for abused maternity patients. Feelings of fear, as withfeelings of uncertainty, decreased as maternity nurses got to know their individualpatients and worked through facing their own feelings. It was mentioned thatnurses focused their learning needs for in-service education on characteristics ofabused women. Fear of making a mistake seemed to be a lingering fear as nursesdid not feel confident in their abilities to consistently recognize abused women.Despite the nurses’ underlying feelings of fear as they developed theirpatient relationships, they identified feeling strongly connected to their abusedpatients even if the abuse was never addressed. Many of the participants who did86address their patients’ abuse also experienced a feeling of connectedness with theirpatients.Connecting with the PatientsOne component of the nurses’ subjective experiences resulted from theintimate nature of the relationships with abused patients. Discussions with theresearcher about these relationships led to nurses’ discussions of their pastpersonal experiences. Many of the nurses identified past personal experience withabuse in their own lives.PersonalizingFor some of the nurses, connecting with their patients occurred from apersonal level in which they felt the actions of the patients were a reflection ofthemselves. Nurses identified that they felt very involved in the patients’situations, therefore they found it difficult to separate their personal feelings.Her going home really upset me because I felt that she was basically blowingher chances to ever be able to take the baby home. I felt very disappointedwhen she left with her partner and was not going to the rehab centre whichis something I felt that she would have done if she was committed tokeeping her baby. I guess I felt like I’d failed a bit even though I knew Icouldn’t do very much.As is illustrated by the above narrative, this nurse personalized her patients’ actionsby feeling that somehow she had the ability to control her patients’ decisions. Partof the reasons for personalizing her patients actions, for this nurse, was related toher past experience with abuse. She indicated that her personal reactions to herpatient care situation were motivated by her desire to help abused women get out87of their abusive relationships. Her disappointment at not being able to help thispatient resulted in her identified feelings of failure.For one of the nurses, personalizing her patients’ situation resulted in hertaking a block of time to put the situation in perspective. This nurse discussed herrelationship with the patient at length, which she indicated was reflective of herstrong connection to the patient.I can remember what [the situation] did to me, and it bothered me for daysafterwards. I remember driving home and rehashing the whole thing in myhead, and for days, I thought about this. I think it helped me to deal with herand my own feelings too.Another nurse, who had no personal experience with abuse, personalized herpatients’ reactions by describing her own experience in a difficult relationship:At first I couldn’t understand it. But then after having gone through adivorce myself, I know it is not the same situation, but then I slowly beganto realize, from a security perspective, you can’t leave. She had a house, aroof over her head, and food on the table, and someone who sort of caredfor her. I knew exactly what she was feeling.Personalizing patients’ reactions by identifying with their psychological painoccurred for many of the nurses. The participants asserted that these feelingsoften resulted from relating to the patients.Relatinci to PatientsMany nurses identified that they related to the situations of abuse that thepatients described. The patient situations may have induced memories,sometimes painful ones, of past personal experiences. One nurse identified that88she had been abused during pregnancy. Her response to her patient was based onrelating emotionally to the similarity of the situation.My husband was the same when I was in labour too. I knew emotionallywhat this woman was going through, wanting to have the contact and thisman was not being there for her.One nurse poignantly described her feelings:You ache. You can relate to her and you feel.. .l’ve never been in thatsituation that she has been in, and I never asked her about it, and I can’timagine being there and feeling like she did, but you have an ache of . . . notsympathy, but empathy.This narrative illustrates the depth of the personal, intimate reactions of the nurseswho cared for abused women.Many of the nurses expressed that relating to their patients from a personalperspective posed difficulties for them. Desire to help the patients was based noton conventional clinical knowledge, but on personal experience.I knew I was starting to heal when I could see that she was still in real deep.I wanted her to be more aware of how dependant she was on an abusiveperson and that she didn’t have to be like that, and I was angry she couldn’tsee what kind of a situation she was in. I think that was where myfrustration was.One nurse described how her past personal experience with abuse helped her torelate to her patients.I was in a situation very similar too, so I could relate to her and I really feltfor this lady. I was involved in an abusive situation for ten years, and I am89just recently out of it, and am still very aware of the pain and the hurt that Iwent through.This nurse went on to describe how her husband “only hit her once”, and that shewas “not allowed to talk in the relationship”. For this nurse, the experience ofcaring for her abused patient brought back strong memories of her own personalexperiences with abuse. It was not surprising that she related to her patientssituation.Having personal experience with abuse was not the only criteria for relatingto patients. Nurses without experience with abuse also related to their patients.The presence of patients’ psychological pain was recognized by all the participants.It was not surprising that nurses without personal experience with abuse alsoconnected with their patients, and one of the main reasons was the presence ofpsychological pain. One of the nurses who did not have experience with abusedescribed that relating to her abused patients was based on her own desires tohelp the patient who was experiencing psychological pain.I related to this women because she was hurting and needed help. I don’tknow why I related to her, but I was interested in the Native culture and Ifelt quite comfortable taking to her. I felt that I could help her.Relating to patients occurred on many levels for the participants and for manyreasons. The nurses felt strongly that relating to the patient from a personal levelresulted in feeling closely connected to their abused patients. These strongfeelings were the catalyst for many of the nurse’s decisions about their provision ofnursing care. One nurse contended that due to her nursing care, her patients feltcomfortable enough to disclose their abuse to her. Their disclosures of abuse led90to this nurses’ feelings of being happy to look after them. These feelings aredescribed in the following narrative:.1 was happy that I was the one to be looking after her, and not someoneelse. Had it been someone brusque and efficient, and looking after thephysical needs, that perhaps neither one of those women would have feltthat they could have spoken up and said anything [about their abuse].This nurse also discussed her perception that her patients were glad that it was herlooking after them, instead of someone else. This theme was identified by many ofthe nurses as empathizing with their patients’ feelings.EmDathizinciFor some of the nurses, providing nursing care to abused women resulted intheir empathizing with some of their patients’ feelings. For example, one nursediscussed a patient situation which was similar to her own experience ofinvolvement in an abusive relationship as an adult. She identified that she basedher nursing interventions on the type of care she would have appreciated when shewas involved in this abusive relationship. An excerpt from the narrative illustratesthis:R (Researcher): It seems you spent a lot of time developing the relationshipbetween you and the patient.P (Participant): Yes, I did.R: Why was it so important for you to do that?P: Because nobody ever did it for me, and I know how hard it is to trustanybody, or to let anyone in, it is a scary thing to do.91This nurse’s understanding of abusive relationships was based on her personalexperience. Often, nurses identified that their personal understanding of patients’feelings influenced decisions they made about nursing care because they wanted tobe caring and supportive of the patients. Another one of the nurse’s empathizedwith her patient’s feelings. Her empathy was based on her personalunderstanding of her patient’s situation.I felt frustration because nothing I did or said could convey that I wasn’tgoing to hurt this woman because she was terrified of everybody, even herphysician whom she said she liked very much. I felt her distrust, her fear,and her anger. She was especially angry that we had to do these[obstetrical procedures] things to her.During further discussion, this nurse clarified that her perception of her patient’sfeelings were a reflection of her own fears around abuse. She related to thispatient because the patient’s pregnancy had resulted from marital rape. This nursedisclosed that her own rape occurred while she had been pregnant. She identifiedthat her patient’s feelings were similar to ones she herself had experienced duringher abusive incident and that her own experience provided her with insight.I was glad I was aware of the situation because having been raped myself asa teenager, I know the importance of not feeling dirty, and sometimes peopledon’t physically touch you after.By empathizing with her patient’s feelings, this nurse based her nursing decisionson her perceptions of the care her patient needed. The subjective context for thisnurse strongly influenced her nursing care of this abused woman because of theintense level of connection this nurse felt with the patient.92For the nurses in this study, connecting with patients occurred for manyreasons. Past personal experience, sometimes related to abuse, prompted many ofthe nurses’ feelings of connectedness with their patients. For the nurses withpersonal abuse experience, this resulted from their powerful feelings of relating totheir patients. Relating to patients occurred for all nurses, both for those withexperience of abuse and for those who did not. The nurses also described howthey personalized their patients’ actions as reflections of their care. This resulted,for some of the nurses, in their feelings of failure when the patients acted contraryto the nurses’ wishes. Finally, the nurses described how they empathized with theirpatients’ feelings. Empathy with the patients’ feelings resulted in nurses usingtheir own perceptions to determine patient care priorities. Connecting with thepatient occurred within the nurses’ subjective contexts of providing patient care.As illustrated by the narratives, the subjective contexts varied for the nurses anddepended upon their personal experiences.SummaryIn this chapter, the researcher has presented an analysis of the dataextracted from interviews completed for this study. Verbatim examples ofparticipant’s comments illustrated the identified themes.Participants of the study were described. Then, maternity nurses’experiences were summarized from the three central, related themes of gainingunderstanding of patients in abusive relationships, facing the realities: the healthcare context, and struggling within the realities: the subjective context. Thesethemes represent maternity nurses’ experiences of caring for pregnant womeninvolved in abusive relationships.93In summary, the participants described the threefold process they used togain understanding of their patients in abusive relationships. The first element ofthis process was comprised of discovering the patients’ abuse through nursingreports, nurses’ assessments and nurses’ use of intuition. The second elementconsisted of reacting to the discovery of abuse with uncertainty. The third elementincluded developing the relationships by being non-judgemental, building trustwithin the relationship, gently probing for information about a patients’ backgroundand sharing personal experiences with abuse.The second theme, facing the realities: the health care context, describedthe external constraints of delivering nursing care within a hospital environment.Gaps in institutional resources were identified by the nurses. Feelings of frustrationwere experienced as the nurses attempted to deliver comprehensive care to theirabused patients. Nurses felt that the institution should be largely responsible forproviding the supports necessary to provide adequate care. Supports were desiredin the form of written policies and/or clinical guidelines, and in-service educationwhich would better prepare nurses to identify abused women. Nurses describedproviding appropriate nursing care that was delivered in recognition of the specialneeds of abused women, through abuse care and through recognition of the needfor nurses to provide care in a holistic manner.Supportive resources from within the health care context were identified inthe form of nursing peers and social workers. These health care colleaguesprovided assistance in decision-making about patient care, and the nurses’ resultingfeelings. Physicians were identified as generally reluctant to get involved in the94care of abused women, and this was identified as a source of frustration that wasnot within the nurses’ control.The third major theme was struggling within the realities: the subjectivecontext. This theme was the derivation of nurses’ personal conceptualizations ofabuse resulting from both their personal experiences and their experiences withabused women. Feelings of fear were the basis of the primary personal emotionsexperienced in response to caring for abused women. These emotions stronglyinfluenced the nurses’ personal outlook as they provided their patient care, andresulted in the nurses’ strong feelings of connectedness with their abused patients.Nurses’ descriptions of past experience with abuse were woven intodiscussions of their patients’ care situations. Nurses explained how the intimatenature of the care experiences often resulted in them connecting with theirpatients. Connecting with the patients occurred through personalizing thereactions of their patients, relating to their patients on a personal level, and byempathizing with the feelings of their patients.To better understand the findings of the study, the literature must again beexplored. In the next chapter, both theoretical and research based literature isexamined to elucidate the major themes found in this analysis of data.95CHAPTER FIVE: Discussion of FindingsMajor findings related to maternity nurses’ experiences of caring for abusedpregnant patients are discussed in this chapter. Although many key conclusionsemerged from the data, three notable findings are addressed using both theoreticaland research-based nursing literature: (a) nurses’ needs for personal relationshipswith others; (b) relationships with physicians; and (c) nurses’ subjective responsesto caring for abused women.The first finding addresses the significance of nurses’ needs for personalrelationships with both their patients and their health care colleagues. Nurses’needs to mollify their feelings of uncertainty were instrumental in establishingpersonal relationships which in turn helped the nurses to effectively care for abusedwomen. The second finding examines nurses’ relationships with physicians in thecontext of the physicians’ reluctance to become involved in the care of abusedpatients. The third finding presents the individual nurses’ subjective responses toabuse and abusive relationships and the impact of these responses on patient care.Nurses’ Needs for Personal RelationshiDs with OthersParticipants in this study reflected positively on the personal relationshipsthat developed with both their patients and their nursing colleagues. According tothe participants, these relationships were pivotal in the overall nursing careexperiences because they influenced both patient care decision-making and the feltpersonal support received by the nurses when caring for abused patients.96Personal RelationshiDs with PatientsAll of the nurses in the study expressed a strong need to establish personalrelationships with their abused patients. This expressed need was important forthree reasons.First, nurses described their relationships with abused patients as personalbecause of the intimate nature of the conversations held between the women andthemselves. The nurses felt these conversations were private and personal, andthe nurses felt “special” that the patients shared about their abusive situations.The nurses generally lacked confidence in their abilities to assess the needs ofabused women, so by “getting to know” their patients on a more personal level,they were able to best determine the unique needs of the individual patients.According to the nurses, getting to know their patients helped them to pacify theirfeelings of uncertainty and gave them more confidence to provide care and tointeract effectively with abused women. By establishing personal bonds, thenurses felt more certain of their abilities to deliver appropriate, competent nursingcare, and more strongly about their need to advocate for the patients.Second, as the intimate nature of the relationships developed between thenurses and their patients, the nurses identified that they felt protective of thesepatients. They felt even more strongly that they had to be the proponents forrelevant and appropriate nursing care decisions. Getting to know the patients bybuilding trust and gentle probing strengthened the nurses’ confidence to provideappropriate nursing care decisions. The nurses found that by including the patientsin nursing care planning, they were better able to meet the patients’ needs and thismade their experience more positive.97Third, by establishing personal relationships with their patients, the nursesdescribed feelings of being “connected”. These connections occurred at varyinglevels because of nurses’ differing conceptualizations about abuse resulting fromtheir own personal experience with abusive relationships. For some of the nurses,memories of their own past experiences with abuse were stimulated by theirpatients’ abusive situations. As a result of the intimate nature of the personalrelationships, some of the nurses shared their own past personal experiences ofabuse with their patients. The nurses who did not have abuse in their backgroundsshared personal anecdotes about themselves. As a result of these feelings of beingconnected, the nurses generally felt good about having made a difference in theirpatients’ care.A review of relevant literature reveals that the finding related to nurses’strong needs to develop patient relationships is not unique to this study. Severalstudies support the findings that developing interpersonal relationships withpatients was critical to providing appropriate nursing care (Jenks, 1 993; Ramos,1992; Tanner, Benner, Chesla & Gordon, 1993). Jenks contended that nursesplaced such importance on development of the relationships with their patients thatthey felt insecure and uncertain about their abilities to make appropriate clinicaldecisions when the interpersonal relationships did not exist. Ramos characterizedthe development of the nurse-patient relationships as being central to professionalnursing practice. The centrality of interpersonal bonds was explored throughdescriptions of critical situations in which nurses experienced a sense ofconnection with their patients. Perceptions of close relationships were commonlyexperienced by the nurses in Ramos’ sample. Factors which influenced the amount98of emotional attachment experienced by the nurses included the amount of timespent with the patients, the patient’s level of illness acuity, and the amount of“biological, psychological and social data” (pg. 504) collected on individualpatients. Both Jenks’ and Ramos’ findings are congruent with the reactions ofnurse participants in this present study.The work of Tanner et al. (1 993) identified that nurses in their studydescribed “knowing the patient” as knowing both the patient’s pattern ofresponses as well as knowing the patient as a person. The researchers furtherargued that not understanding the patients’ complete clinical situation decreasednurses’ overall effectiveness and diminished their abilities for being strong patientadvocates. Tanner et al. concluded by identifying that knowing the patientrequired an involved, rather than detached understanding of the patient’s situationand that this knowledge enabled nurses to make skilled clinical judgements. Theseconclusions are congruent with the findings of this present study and offer insightinto nurses’ needs for personal relationships with their patients.Personal RelationshiDs with ColleaguesNurses in this study also described a strong need to establish personalrelationships with their nursing colleagues. In general, these relationships werefound to be supportive for two reasons.First, good working relationships between and among staff memberspositively influenced the outcomes of many of the described nurse-patientsituations. In many cases, colleagues shared information and “stories” aboutexperiences with patients in abusive situations. These “stories” includeddiscussions of successful and unsuccessful nursing interventions. Having personal99relationships among colleagues encouraged the nurses to “bounce ideas off oneanother”, which was seen as helpful for obtaining support or validation for patientinterventions. The nurses saw their peers as supportive of assisting them whenmaking clinical decisions about their abused patients.Secondly, having personal relationships with colleagues was supportive ofthe nurses’ private feelings which resulted from their interactions with abusedwomen. Personal relationships were characterized as occurring with colleagueswho went beyond “professional” fraternity, and encouraged the divulgence of thenurses’ personal feelings. Many of the nurses described feeling fear anduncertainty when delivering nursing care to abused patients, and nurse colleaguesprovided an emotional outlet for these feelings. Having “friends at work” withwhom the nurses could talk about their experiences was generally seen as key tohelping the nurses put their experiences into perspective. Personal relationshipswith nursing colleagues allowed these nurses to share their feelings, both positiveand negative, with others who may have had similar experiences, and contributedto the nurses’ satisfaction with their experiences of caring for abused women.The responses of these participants are elucidated by the findings in theliterature. Tanner et al. (1993) identify that personal relationships among nursingcolleagues provide nurses with allies when the need for colleague support arises.In this present study, such relationships encouraged the nurses to collaborate withtheir colleagues in providing the best possible care to abused women. Furthersupport for this finding was offered by Jenks (1993) who identified that personalrelationships with fellow staff nurses facilitate nurses’ clinical decision-making. Inthis present study, valuable observations, experiences and opportunities for nurses100to share and discuss patient care decisions result from strong personal relationshipsamong staff nurses. The nurses perceived that being able to share experiences andpersonal feelings with their nursing peers was worthwhile.Personal relationships with nursing colleagues was identified as a key featurein the experience of caring for abused women. The literature clearly recognizes thepositive influence of colleague relationships on clinical decision-making. In general,the nurses found their nursing colleagues to be supportive for both clinical decision-making and personal feelings.RelationshiDs with PhysiciansNurses’ relationships with physicians during the care of abused patients is asecond noteworthy finding of this study. The distinct features of the nurse-physician relationships are described.As the nurses discovered that their patients were involved in abusiverelationships, they sought the input of the patients’ physicians for confirmation oftheir suspicions about abuse and for guidance in the planning of care. The nursesexpressed their surprise when the physicians, even the physicians who wereconsidered “patient advocates”, were reluctant to engage in collaborative planningfor the abuse care of their patients. Because physicians were hesitant in taking anactive part in patient care planning, the nurses drew on the information learnedfrom their personal relationships with the patients to suggest what they felt to beappropriate strategies. Because the nurses generally had established good workingrelationships with physicians, they obtained support easily for their suggestions.Good working relationships were defined as resulting from mutual trust and respectfor clinical judgement. The Registered Nurses Association of British Columbia101(1989) corroborated this finding and took it one step further. They studied nurse-physician relationships and found that when nurses and physicians knew eachother socially, fewer power struggles in the work place resulted. In this study,power struggles between nurses and physicians were not the issue. The nursesexplained that they truly felt that the physicians had abdicated the responsibility forclinical decision-making to them. Without the cooperation of the physicians, thenurses felt they were put in the awkward position of accepting responsibility forpatient care planning when they did not feel confident.Other pertinent literature on nurse-physician relationships was supportive ofthese findings. Jenks (1993) found that although nurses desired a collaborativerelationship with their physician colleagues, often they approached the physicianswith requests for permission for their own clinical decisions rather than to requestthe physicians’ collaboration in decision-making. In this study, the nurses werequite directive in their requests for supportive interventions for their abusedpatients. Jenks’ findings help to explain that many nurses adamantly advocate forsuitable interventions for their patients without collaborating with physicians. Theunique situation in this study is that the nurses did not feel confident in their rolesin the care of abused women, and generally felt disappointed in the lack ofguidance from the physicians. Several of the participants identified that thephysicians seemed “happy to let someone else intervene”.A contrary viewpoint was offered by Henry (1993) who described the natureof nurse-physician relationships as collaborative. The nurses in this studyperceived that the physicians made little effort to collaborate in patient careplanning for abused women. It was noted by the nurses that, although it was102common practice for the physicians to be collaborative, in situations dealing withabuse, the physicians seemed to be ill at ease when consulted about thesepatients. As an aside, several of the nurses insinuated that physicians’ unease wasthe result of a weak knowledge base in the area of domestic violence. Withrespect to the collaborative nature of nurse-physician relationships, the literaturewas found to be incongruent with the narratives of the nurses in this study.Nurses’ Subjective Resronses to Caring For Abused WomenIn this study, while gaining an understanding of the patients in abusiverelationships, the nurses experienced subjective responses to both the patients andtheir situations. Two of these key responses are discussed.Nurses in this study experienced fear as they provided nursing care toabused women. However, it was found that the nurses’ fears were as individualand subjective as the participants themselves. Some of the nurses felt fear inrelation to being wrong or making a mistake about a patients’ abusive situation.They were afraid of upsetting the patients or even losing their trust as a result oftheir possible misinterpretation of cues and behaviours. Nurses may even havedenied the existence of the problem rather than jeopardizing the delicate beginningsof a personal relationship. Denial of the situation may also have resulted fromthese nurses attempts to control their feelings of fear. Tilden and Shepard (1989)acknowledge that denial may function as a protective measure for nurses who feelvulnerable or overwhelmed.Other nurses described that their fears were related to fears of facing theirown feelings about abuse. These nurses identified that, although they were awarethat abusive relationships did occur during pregnancy, they were not prepared for103their first clinical encounters with abused patients. Whitley (1 992) defined fear asbeing caused by an identifiable source, and included such reactions such asapprehension, dread, and tension. This definition does not concur with thesubjective descriptions of fear by the nurses in this present study. These nurses’feelings of fear were related to the fear of the unknown, whether it was thereactions of their abused patients or facing their own feelings. Many nurses hadnot yet confronted their own feelings regarding abuse and generally found theexperience of caring for abused women difficult for this reason. Feelings of“helplessness and frustration” were often described, and the nurses coped withthese feelings by developing interpersonal relationships with their patients andtrying to meet their physical and/or psychological needs as best they could. Thenurses identified that their fears were primarily based on their perceived lack ofeducation on the issues of domestic violence and administrative support forappropriate intervention with abused women.The most notable point about the subjective responses of fear was its’ effecton patient care. Although the nurses felt hesitant when addressing issues ofabuse, they took their cues from their patients and continued to probe gently inorder to build a base of trust. In situations where the nurses did not address theabuse, they felt that they “gypped the patient” by not meeting all of her needs.Some of the nurses found that their feelings of fear interfered with their abilities toproperly assess the situation. Fear of “opening a can of worms”, or “openingPandora’s box” were common concerns expressed. Henderson (1 992) assertedthat nurses must learn they don’t have to have all the answers before they ask thequestions.104This reaction of the nurses was not unique to this study. Henderson andEricksen (1994) identify that nurses may be afraid to intervene because they fearthat they may do “damage” to a woman if they counsel incorrectly. Some nursesin this study were hesitant to perform complete assessments based on their fear ofmaking a mistake about the abuse. Tilden and Shepard (1 989) recognize thatnurses may be hesitant to intervene because they feel that domestic violence isoutside of the health care domain. Gage (1991) identifies that not all primaryhealth care providers feel they are in a position to provide intervention to abusedwomen.The second key subjective response of the nurses in this study involved theeffect of nurses’ past experiences with abuse on patient care. For the participantsin this study, the nursing care experience was highly individualistic and involved acontinual process of examining personal feelings and reactions to the patients’abusive situations. Based on the subjective nature of their personalconceptualizations of abuse, the nurses experienced some personal difficultieswhile providing nursing care. Feelings such as personalizing patient actions andpersonally relating to the abused patients were two examples of the nurses’reactions. Fenton (1988) supported these findings by saying that nurses may be“deeply affected” by the experience of caring for patients facing difficult situations,and consequently may have difficulty coming to terms with such situations.The principal problem for many of the nurses in this study was that theyfound it emotionally distressing to care for abused patients. Little help for relief oftheir distress was found in the nursing literature. The literature containsinformation on “how to” care for abused women, but does not provide direction on105how to reconcile one’s own personal distress. More recognition in the professionalliterature of these difficulties is needed in order to begin to assist nurses toovercome them.SummaryThis chapter has explored three key findings of this study of maternitynurses’ experiences of caring for abused pregnant women in the context of currentliterature. A variety of sources were reviewed from research and theoreticalfoundations.In the next chapter, the researcher presents implications for the profession ofnursing, as well as conclusions and a summary of the study.106CHAPTER SIX: Implications, Conclusions and SummaryImolicationsThe findings of this study have implications for clinical practice, nursingeducation, nursing administration, and nursing research.lmDlications for Clinical PracticeA variety of implications for clinical practice have emerged from the findingsof this study. The suggestions noted in this section are not new for nursingpractitioners but support the urgent need for nurses to address the difficult issuessurrounding domestic violence.The first major implication for clinical practice is that nurses need to becomecomfortable with assessing and interviewing abused women. A lofty, butattainable goal for nurses is for all women in maternity settings to be assessed forthe presence of abuse. Nurses working in maternity settings are uniquelypositioned to address issues of violent relationships as they are the front-linecaregivers (Moss & Taylor, 1991). As evidenced by the narratives, abused womenexist in maternity nurses’ caseloads. Therefore, nurses must become proactive istheir search for knowledge on how to best address the needs of abused women.Knowledge of appropriate interventions such as listening, assessing for patientsafety, and referring patients to appropriate resources is well within the realm ofnursing practice and is essential to providing effective nursing care. Nurses mustrecognize that they possess the necessary skills to provide care to abused women.A second implication for nursing practice is supported by Wilkinson (1989)who suggests that nurses should seek appropriate help when coping with theeffects of emotional distress in order to maintain their effectiveness as caregivers.107All nurses who are uncomfortable dealing with abuse have a professional obligationto provide competent care to patients (Canadian Nurses Association, 1991). Manynurses in this study identified that they valued the opportunity to debrief and sharepersonal and common experiences with their nursing colleagues. Nurses canenhance this opportunity with regular and ad hoc scheduling of debriefing sessions.Such contact among colleagues can facilitate the sharing of advice and experienceswhich may offset feelings of isolation and uncertainty. Open sharing of informationbased on lived experiences needs to be recognized as a valuable component of thelearning process.Further implications for nursing practice were identified in relation toaddressing nurses’ attitudes and knowledge about domestic violence. Nurses mustdevelop an awareness of their own attitudes and beliefs that could influence theirinteractions with abused women (Boychuk, 1994). Further understanding of thedynamics of abusive relationships is needed by all nurses. Finally, increasingknowledge and skills in the area of assessment for abuse must be confronted.These three areas were common challenges experienced by the nurses in thisstudy.A final implication for nursing practice stems from nurses’ identified desiresfor clinical guidelines and in-service education. The Registered Nurses Association(1 993) identifies that professional personal development is expected in order tocomply with professional standards for practice. Nurses must take responsibilityfor calling staff meetings and setting agendas to discuss issues of clinical concern.Sitting on policy committees and requesting in-service education are well within therealm of nursing responsibilities.108lmDlications for Nursing EducationA major implication for nursing education is that nursing schools’ curriculaneed to incorporate courses on domestic violence. Ryan and King (1 993) suggestthat few nurses have received formal education in this area. If nurses are toprovide appropriate care to abused patients, nursing students need to understandhealth problems related to domestic violence. This can only be achieved byaddressing the myths and stereotypes associated with domestic violence (King &Ryan, 1989). Nursing school curricula need to incorporate theoretical contentwhich examines the health care effects of domestic violence in the context of thelarger social picture. Tanner (1993) challenges schools of nursing to provideopportunities for students to become informed, caring professionals who are ableto provide sensitive nursing care to women in abusive relationships. The multifaceted issues surrounding domestic violence must be included in nursing curricula.Tilden and Shepard (1987) argue that the inclusion of domestic violencecontent needs to go one step further. They contend that in order to ensuredomestic violence course content in nursing schools is integrated, licensure examsshould include domestic violence content, and that knowledge about domesticviolence be mandatory for licence renewal and certification.The need for continuing and in-service education programs on domesticviolence is a second major implication for nursing education. Many of the nurses inthis study had received no formal education in the area of domestic violence.Young & McFarlane (1991) identified that “the educational preparation of healthcare providers in the area of abuse during pregnancy was severely lacking”(pg.202). The education of nurses in clinical practice is a challenge for nurse109educators as there are, in Canada, no requirements for nurses to update theirclinical skills by taking further education. Innovative ways to educate nurses ondomestic violence are needed. One suggestion is to offer peer-run in-serviceswhere nurses who have encountered abused women share their experiences.Nurses could be invited to learn from the groundwork of colleagues who have livedthe experience.The implications for nurse educators are many. This study emphasizes theimportance of understanding the issues of domestic violence. However, theeducational needs of caregivers go beyond didactic teaching methods whereparticipants passively receive information about theories of violence and nursingcare approaches for dealing with domestic violence. Educators need to besensitive to the possibilities that students attending these educational programsmay find the content difficult due to past personal experiences. Opportunities forinteractive dialogue on nurses’ personal meaning of this type of information shouldbe encouraged. In addition, information on appropriate resources for studentsshould be made available by the nurse educator.The final implication for nursing education is that, given the number of moraland ethical issues involved in the care of abused women, nurses must learn toresolve ethical problems in an effective way. Nurses in this study struggled withmany difficult issues as they cared for their abused patients. Content in ethicaldecision-making must be integrated into nursing curricula and in-service education.lmrlications for Nursing AdministrationThis study has many implications for nurse administrators. The goal ofnurse administrators is to facilitate the effective provision of patient care to abused110women. To achieve this end, nurse administrators should seek feedback fromnursing staff about the type of supports that would be helpful when caring forabused patients. This type of interaction would afford opportunities for front-linenurses to provide input into appropriate care practices. This could be accomplishedthrough staff meetings and/or solicitation of feedback through verbal or writtencommunication with the nurse administrators.Nurse administrators need to acknowledge that nurses in acute care settingsare presently caring for abused women. Nurse administrators can support nursesin providing excellent care to abused women through the implementation anddissemination of appropriate policies and procedures for assessment andintervention. This would address the concerns for institutional support desired bythe nurses in this study. Guidelines for protocol development of domestic violencetraining programs have been issued by both the federal (Health and WelfareCanada) and provincial (Ministry of Health) health authorities. The CanadianNurses Association (1992) issued the Family Violence: Clinical Guidelines forNurses in recognition of the need to support nurses in their roles of caring forabused women. Therefore, it behooves nurse administrators to provide nurseswith explicit written guidelines that are necessary to maintain high standards ofnursing care.A third implication for nursing administration involves establishingmechanisms for counselling of staff members who identify personal issues whichmay be impacting on their abilities to provide nursing care. This was supported byFenton (1988) who declared that nurse administrators have a responsibility to beaware of, and supportive of, nurses who may be experiencing emotional distress as111a result of participation in a patient care situation which involves abuse. One ofthe ways that support may be offered is through the provision of access tosupportive counselling that is available separate from the work environment.Another implication for nurse administrators is the need to be supportive ofin-service education on domestic violence for staff members. Nurses in thispresent study clearly identified their desires for in-service education. Staffdevelopment and education is a worthwhile priority of nursing administration(Davitz & Davitz, 1980). This implication is supported by the Task Force on FamilyViolence (1 992) which recommended that sufficient high quality training beprovided to all those working with family violence victims.Nurse researchers are at the forefront of the development of nursingknowledge in the area of domestic violence (Campbell & Humphreys, 1993). Thefinal implication for nurse administrators is to provide support for conductingclinical research studies on domestic violence. By sitting on research committeesand keeping abreast of current nursing research projects, nurse administrators canfoster the development of nursing knowledge in domestic violence.lmDlications for Nursing ResearchThis study identified the complex and highly subjective nature of the nursingcare experiences of maternity nurses. It is not known if the experiences of nursesfrom other clinical settings are consistent with the findings of this study.Repeating this study with nurses from other clinical areas, including the communitynurses, would contribute to further understanding of the current status of clinicalknowledge in this area as well as expand the transferability of the findings of thisstudy.112Another suggestion for further study would be to implement institutionalpolicy and procedure guidelines for assessment and intervention with abusedwomen and then evaluate their impact on nurses’ feelings of uncertainty in theirnursing roles. Further exploration is needed to determine the effectiveness ofwritten protocols for patient care.A final suggestion for further study would be to complete aphenomenological study of nurses’ attitudes towards patients with differing culturalbackgrounds. In this study, nurses discussed searching for an understanding ofthe influences of a patients’ culture on violent relationships. Bohn and Parker(1993) argue that the findings of studies which examined racial differences inabuse during pregnancy have been inconsistent. The need for further study of theinfluence of culture on nursing care of abused women is clear. DeMarco, Campbelland Wuest (1993) identify that through careful scholarly analysis and critique, themore difficult and hidden attitudes of ethnocentrism which arise out inunintentional insensitivity and ignorance can begin to be understood.ConclusionsThe first conclusion of the findings is that nurses used intuition in thediscovery of patients’ abuse. Intuition was based upon the nurses’ recognition ofunusual patient behaviours and interactions between the patients and theirpartners. The nurses felt uncertain about relying on their intuition, and thisresulted in hesitance when addressing the abuse. Nurses need to be encouragedto acknowledge their feelings of intuition and follow up on them. Farrington (1993)supported this conclusion by stating that expert judgements and clinical decisionmaking result from nurses’ acknowledgement of their gut feelings that things are113not quite right. One participant summarized this conclusion by saying, “If yoususpect abuse, it is probably there.”The second conclusion is that many of the nurses in this study haveexperience with abuse in their backgrounds. Holz (1994) reported that as many asforty-five percent (45%) of health care providers are survivors of childhood sexualabuse. Many of the nurses drew on their personal experiences and, as a result,weathered personal difficulties when caring for abused women. Adequateresources to assist these nurses to cope with difficult personal feelings arepresently lacking in health care institutions.The third conclusion is that there is a need for institutional policies andprocedures that clearly outline protocols for assessment and intervention withpatients who are experiencing abusive relationships. The perceived lack ofresources from nursing and hospital administrative offices was clear in nurses’descriptions of the health care environment in which they provided nursing care toabused women.The fourth conclusion is that all nurses require formal education on theissues of domestic violence. Theoretical content must be included in basiceducation programs. Practising nurses require in-service education to address theirspecific learning needs. As women experiencing abusive relationships are foundmore frequently in health care institutions, all nurses, including fledgling nurses,must be appropriately educated to effectively assist these patients.The fifth conclusion is that nurses in this study welcomed the opportunitiesto talk about their involvement with abused patients. Despite being a caringprofession, nurses may not actively support one another when difficult situations114arise (Pick & Leiter, 1991) Time spent debriefing with colleagues about theirencounters with abused patients helped the nurses to shape their subjectiveunderstanding of their nursing care experiences. Opportunities for supporting oneanother as nurses become more involved in domestic violence identification,intervention, and prevention efforts must occur frequently.SummaryThis study was undertaken to describe and explore maternity nurses’experiences of caring for pregnant women involved in abusive relationships. Thisstudy addressed the major question: “What are maternity nurses’ experiences ofcaring for pregnant women involved in abusive relationships?”The conceptual framework that directed this study was formed from tworelated concepts. Maternity nursing care and domestic violence in pregnancy werethe two concepts which guided exploration of the relevant bodies of literature.This initial review of literature delineated the present state of the knowledge of theabuse experience of domestic violence in pregnancy and of the social and healthcare context of maternity nursing care.The research method used to conduct this study was phenomenology. Thisqualitative approach seeks to facilitate understanding of the meaning of people’slived experiences. Phenomenology is a useful method of inquiry for developing afoundational knowledge base when little is known about a subject (Taylor, 1993).The perceptions of maternity nurses were explored in relation to caring for abusedpregnant patients.Eleven maternity nurses who had lived the experience of caring for abusedpregnant women participated in the study. All of the participants were employed in115the same acute care maternity hospital. Data were collected through the use ofsemi-structured interviews A total of twenty-one (21) interviews were conductedin the participants’ homes. Each interview lasted between sixty (60) to one-hundred twenty (120) minutes. All interviews were audio-taped for transcriptionpurposes.Analysis of the data occurred by examining transcriptions of the interviews.Common themes were identified from raw data and coded to reflect the generalintent of the statements. Using Colaizzi’s (1978) method of qualitative dataanalysis, the coded data was then explored for possible relationships and validatedwith the study participants. Anecdotal field notes taken during the interviewspreserved the context of subjective data. Identified common themes were furtherexplored in subsequent interviews with eight (8) of the nurses. To ensure truthand faithfulness to the data, synthesis and refinement of the general themes of thenurses’ experience were validated with two (2) of the participants.Nurses’ relationships with others comprised the first of the major findings ofthis study. In particular, nurses first described their needs to develop personalrelationships with their abused patients. These interpersonal relationships served atwofold purpose. The nurses acquired intimate knowledge about the patients andtheir abusive relationships. This insight into the patients’ situation allowed thenurses to advocate for appropriate interventions. Second, the importance ofdeveloping personal relationships with their nursing colleagues was described. Thenurses reiterated that they received both personal and professional support fromtheir colleagues for themselves as they cared for abused women.116The second key finding reflects nurses’ relationships with physicians. Theserelationships comprised an important part of the nurses’ experiences of caring forabused women because the physicians were hesitant to become personallyinvolved in patient care planning. Lent (1992) identified that physicians may beuncomfortable dealing with the situation because they are unaware of availableresources or may feel unprepared to handle the complex problems associated withan abusive relationship. The physicians seemed to rely on the nurses’ judgementsto coordinate the best plan of care for the individual patients involved. Thisreliance on nurses’ judgements was interpreted by the nurses as abdication ofresponsibility on the part of the physicians. The nurses felt disappointed in thereactions of the physicians.Two key subjective responses to caring for abused women comprised thethird noteworthy finding of the study. Feelings of fear constituted the first keyresponse and were related to fear of making a mistake about the presence of abuseand nurses’ fear of facing their own feelings about abuse. These feelings directlyinfluenced the enactment of nursing roles as the nurses felt hesitant to performcomplete assessments on their abused patients. Lack of education and institutionalsupport were two stumbling blocks cited as contributing to nurses’ hesitance.The second key subjective response of the nurses was related to nurses’past personal experiences with abuse. Personal conceptualizations of abuse had astrong impact on the enactment of nursing roles because of personal difficultiesexperienced by the nurses. The discussions of nursing roles found in the literaturewere valuable for direction in “how to” care for abused women. However, it was117noted that further recognition of nurses’ personal difficulties when dealing with thesensitive issues of domestic violence is needed in the literature.In summary, this study has explored the phenomenon of caring for abusedpregnant women from the perspective of those who have lived the experience. Itwas found that the process of understanding and caring for abused women washighly subjective and individualistic based on nurses’ conceptualizations of abuse.It is hoped that the findings of this study contribute to the evolving understandingof the personal nature of nurses’ experiences of caring for abused women.118REFERENCESAgudelo, S.F. (1992). Violence and health: Preliminary elements for thought andaction. International Journal of Health Services,22(2), 365-376.Anderson, J.M. (1989). The phenomenological perspective. In J. Morse (Ed.)Qualitative nursing research: A contemporary dialogue Rockville, Maryland:Aspen Publication.Andreoli, K.G. & Musser, L.A. (1986). 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Journal ofNursing Education,32(8), 339-340Tanner, C., Benner, P., Chesla, C., & Gordon, D. (1993). The phenomenology ofknowing the patient. Image: Journal of Nursing ScholarshiD,,(4), Winter,273-280.Task Force on Family Violence (1992). Is anyone listening? Canadian Cataloguingin Publication Data.Taylor, B. (1993). Phenomenology: One way to understand nursing practice.International Journal of Nursing Studies,.(2), 171-1 79.Tilden, V. & Shepard, P. (1987). Increasing the rate of identification of batteredwomen in an emergency room department: Use of a nursing protocol.Research in Nursing and Health,10(4), 209-25.Tilden, V. & Shepard, P. (1989). Response of the health care delivery system tobattered women. Issues in Mental Health Nursing,1Q(3/4), 309-320.Torres, 5. (1991). A comparison of wife abuse between two cultures: Perceptions,attitudes, nature and extent. Issues in Mental Health Nursing,j.(1), 113-131.Walker, L. (1984). The battered woman syndrome. New York: Springer PublishingCompany.Wilkinson, J. (1989). Moral distress: A labour and delivery nurse’s128experience. Journal of Obsterical, Gynaecological and NeonatalNurses, November/December, 51 3-51 8.Whitley, G. (1992). Concept analysis of fear. Nursing Diagnosis,.(4)155-161Valle, R. and King, M. (1978). Existential-Dhenomenoloaical alternatives forDsvchologv. New York: Oxford University.Young, A. & McFarlane, J. (1991). Preventing abuse during pregnancy: A nationaleducational model for health providers. Journal of Nursing Education,(5),202-206.129APPENDIX130APPENDIX AInformation Letter for Potential ParticipantsMy name is Melanie Basso, and I am a Registered Nurse and a Master’sstudent in the School of Nursing at the University of British Columbia. For myMaster’s Thesis, I am studying the experiences of maternity nurses. In particular, Iam interested in talking to maternity nurses who have cared for patients whomthey knew were involved in an abusive relationship. If you feel that this is asituation that you have encountered, and would be willing to talk about it, pleasecontact myself, either at home or at work. I can tell you more about the study andset up a convenient interview time. All interviews will be conducted in the mostconvenient location for the study participants.As a participant in this study, you will be asked to discuss your experienceswith patient situations that you have been directly involved in where there wassuspected or confirmed abuse of the patient. As a health care professional, I aminterested in what resources you used and in what resources you feel would havebeen helpful. To allow for full recall of the interview, the interviews will beaudiotaped. These tapes will be destroyed when the study is complete.It is expected that one or possibly two interviews will be required. Thelength of the interviews would be about one hour each. Confidentiality will bestrictly maintained; no names will be used in the interview or in the study. Eachstudy participant will be assigned a coded number, and only the researcher willhave access to the identities of these numbers. You would be under no obligationto continue participation once we have begun, and if you decided to withdraw,your nursing employment would not be affected in any way.It is expected that this information will assist maternity nurses to betterunderstand the experience of caring for patients that are abused. A second goalwould be to gain understanding of the effects of domestic violence on the deliveryof maternity nursing care. I hope you feel this study is worthwhile and willconsider becoming a participant.If you have any question, you may contact me at 879-4778 (H) or324-5414 (W), or my Thesis Committee who are:Ms. Angela Henderson: 822-7435 Ms. Janet Ericksen 822-7505SincerelyMelanie Basso RN BSN131APPENDIX BConsent FormMaternity Nurses Experience of Caring for Pregnant WomenExposed to Domestic ViolenceI agree to be a participant in the above named research project.I understand that the project is being conducted by Melanie Basso (879-4778), andis under the supervision of Angela Henderson (822-7435) and Janet Ericksen (822-7505) from the School of Nursing at the University of British Columbia.I have read the information sheet that describes a study investigating theexperiences of maternity nurses who have cared for women involved in abusiverelationships during pregnancy. I understand that my participation would involvetalking about my experience of patient care. I also understand that the interviewswill be conducted in strictest confidence, by Melanie Basso, and that they will lastapproximately one hour. I understand that the interviews will be audiotaped, andthat the tapes will be destroyed upon completion of the study.I understand that my identity will be kept confidential and that will not bepersonally identified in any way during the study. All data will be kept by theprincipal investigator, and will be destroyed when the study is completed.I understand that I may contact Melanie Basso, or Angela Henderson or JanetEricksen at any time if I have questions. I also can receive a summary of theproject if I so request.I understand that I have the right to withdraw from the project at any time and thatsuch withdrawal will in no way jeopardize my nursing employment. I give consentto participate in this study and have been given a copy of the information letter andconsent form for future reference.Participant: Date:132APPENDIX CSEMI-STRUCTURED INTERVIEW QUESTIONS1. Describe your personal experience of caring for a pregnant patientwho had been involved in an abusive relationship?2. What factors alerted you to recognize that your patient was a victimof domestic violence?3. What, if any, interventions were you involved in, or did you observefrom other disciplines?4. Do you feel your nursing care changed or was altered in any way inthe care of this patient and her family?5. What supports/services do you feel would have been helpful to you inyour experience?133APPENDIX DMasters Thesis StudyMaternity NursesExperienceOf Caring ForPregnant Women Involved in anAbusive RelationshipDo you:-Work as a Registered Nurse on an Antepartum, Postpartum,orLabour and Delivery ward;Have You:-Cared for a pregnant woman who you know was involved in anabusive relationship where there was abuse duringpregnancy;Are you:-Willing to talk about your experience;If you:-Are willing to donate one to two hours of your time tonursing research that is addressing this important issue;-Are interested in finding out more details in how you canparticipate in this research project;Please contact:Melanie Basso (MSN Student Investigator)TEL: (H) 879-4778 (W) 324-5414Angela Henderson (Principal Investigator)TEL: (W) 822-7435

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