Apr 7, 2011
by Linda Bullock, PhD, RN, FAAN; Phyllis Sharps, PhD, RN, FAAN and the DOVE Research Teams
Linda F.C. Bullock, PhD, RN, FAAN
University of Virginia
School of Nursing
Claude Moore Educational Bldg
Charlottesville, VA 22908-0826
Phone:Â (434) 982-1966
Phyllis W. Sharps, PhD, RN, CNE, FAAN
Dept. of Community Public Health Nursing
Johns Hopkins University
School of Nursing
525 North Wolfe Street – Room 432
Baltimore, MD 21205
Phone: (410) 614-5312
Dr. Bair-Merritt’s article in this e-journal issue, Home Visiting Programs’ Response to Intimate Partner Violence: What We Know and Why It Matters for the Health of Our Children,â€ makes it clear that children exposed to intimate partner violence (IPV) in the home are impacted negatively by the violence. She points out that the impact of this exposure may be minimized if there is a relationship between a supportive caregiver and the child. Historically, one of the main outcomes of home visitation programs has been to strengthen a caregiver’s supportive parenting role through education and role modeling. Addressing issues of partner violence in the home, however, has not traditionally been a part of home visiting services. In a recent NIH/NINR-funded study, Domestic Violence Enhanced Visitation Intervention (DOVE) [R01 NR009093; Dr. Phyllis Sharps, Principal Investigator, Johns Hopkins University, School of Nursing], an empowerment intervention (DOVE) that home visitors can use to reduce the impact of IPV is being tested in rural Missouri and urban Baltimore. The lessons learned from this study provide rich data for other home visiting programs.
My research team (Bullock, Co-Principal Investigator) has been working with home visitors in several different home visitation programs throughout a large area of Missouri. The home visiting programs that are field testing the DOVE intervention include two Missouri Department of Health and Senior Services prenatal home visiting programs: the Nurse Family PartnershipÂ® program (Building Blocks) and the Missouri Community-Based Home Visiting program (MOCBHV). The Lutheran Family and Children Services home visiting program also participated in the field testing. Nearly a hundred home visitors of varying backgrounds and licensures have worked with the research team in implementing and testing the DOVE intervention in 24 of the 115 counties in Missouri.
Over the course of the first eighteen months of the grant, many formal and informal training sessions for the home visitors were conducted by the researchers. Even with repeated trainings, we were faced with a huge recruitment problem for the study. Eighteen months into the study, there were few referrals because the home visitors claimed they were not finding any women in their caseloads that were positive for current abuse or abuse in the past year. It appeared as if IPV had disappeared in Missouri. The research team and the State Health Department decided to hold another required intensive training in the state’s capitol city for all home visitors, but this time we would also address the barriers to assessing for IPV that could be occurring. This training used different strategies from those in previous training sessions. First, a male expert in the area of IPV was brought in as a key speaker to address the issue of problems with the male partner being in the home at the time of the visit thus preventing the home visitors from screening. Second, role playing was employed so that every home visitor had an opportunity to assess or be assessed while role playing as a woman who was experiencing abuse. Each home visitor also had the opportunity to observe an assessment and make comments to the assessor and the person being assessed about how they viewed the role play as an outsider looking in on an interview.
As a final step, participants were divided into focus groups of six to eight home visitors to determine what they thought were barriers and facilitators for implementing IPV assessments and interventions within their case loads (Eddy et al, 2008). We learned that one of the main barriers to addressing IPV in the home was a lack of knowledge on how to address IPV in this situation. This fueled stress and fear in the home visitors. The stress came from a feeling of inadequacy and fear of making a fool of themselves when they talked to the women about the violence. Home visitors also discussed feeling stressed in trying to control their own personal feelings when addressing the issue. There were also fears regarding safety; not only for the women but also for themselves. The most important facilitator identified by home visitors was a feeling of having a good rapport with the woman and knowing that the woman trusted her. Being able to talk about these barriers and facilitators seemed to make a difference because after this training, referrals to the DOVE study increased in Missouri.
Through five years of experience in Missouri, many lessons have been learned about how to effectively implement assessments and interventions for IPV during home visits. The home visitors have learned from our expertise in the area, but we have also learned from them. We believe that sharing these lessons can be valuable to others. Critical factors to be considered when implementing protocols within home visiting programs are listed below with excerpts from the focus groups conducted with home visitors.
Lessons Learned and Quotations from the Home Visitor Focus Groups
1. Training is best done in conjunction with local resources such as local women’s shelters, law enforcement agencies, and legal services. The home visitors we have worked with expressed the need to understand the laws in their area and what services are available. As one home visitor said:
So that would have been a good educational piece to know what happens when mom and baby go into shelter what will happen next? Am I going to lose my food stamps, am I still going to get “ will I lose everything because I go to shelter and then I won’t have anything? I am just stuck there and I don’t have any answers for those questions.”
Having representatives from the shelter and law enforcement agencies present at IPV trainings can help answer questions like the one above. Along with wanting to know what happens when a woman decides to seek refuge, other questions the home visitors had included laws for mandated reporting of IPV, child abuse laws, and legal resources that were available and how to refer to those services. It has been our experience that the home visitors not only appreciate being able to ask their questions and receive answers from the experts, but they find it valuable to be introduced to local contacts that they can call on in the future as other questions arise.
2. Role playing in training sessions helps to increase the comfort level and the likelihood of home visitors asking the questions and intervening.
The other thing was practicing the questions and hearing how other people are saying their questions and stuff, because I know personally I am like I am getting all into someone’s business and are they going to tell me the truth or not? Even if I ask these questions or did I just put up another wall or am I still going to have the same ¦ there are certain things you can ask as a home visitor that you wonder if you are putting up a wall and then the next time you come there is that little stand back like what is she going to ask me or do I want to continue to have that strong relationship with a strong foundation. So that scares me, but listening to how others are saying it and constantly saying it and then at the end the one woman was saying if I offended you in any way, I am really sorry. Tell me how it felt when I asked you those questions so you can become a better communicator with the subject.
Another home visitor echoed a similar feeling:
I have never had any training on DV so I had never learned about screening. I had never learned about any of that. Even just doing the role playing scenario upstairs really helped me because I had never been forced to ask those questions before and use that. And it was good to try it out on someone that was not going through it instead of having been placed in it and having to do it.
Although usually met with resistance from training participants, it is well worth pushing the issue of role playing during the training and having facilitators present that can help guide this exercise. It has been our experience that for many home visitors, this is the first time they have ever asked the questions out loud. Practicing in a training session not only improves their skills in assessing and intervening, it provides an opportunity to go beyond the first time to ask step.
3. Before the information being presented can be fully utilized by home visitors, the training needs to address their attitudes and beliefs about violence and their own personal experiences with violence.
I think that concept of stirring the pot and that you are going to make it worse just reminded me that I need to look at the whole box or picture and that the outcome is that they learn and they are safe. If it means that he is mad at me and won’t let me come back but she has the numbers that she needs then I need to get over it cause it is not about me, it’s about her and her baby.
Another home visitor clearly struggled with addressing the issue of violence. When confronted, she found her own experiences with the issue were getting in the way of helping other women:
My stress comes into the point of being able to control my feelings. I worked for a family for 1 Â½ to 2 years and didn’t even know that he was abusive and out of the blue one evening she shared her abusive experiences and because of the bond that I shared with her and my sister’s abusive relationship, I wept and I felt bad about that because we are trained not to cry with the family because the concern is that you are going to make her sad. Which in one sense it did make her feel bad but I guess in a good sense it shows her that I am very sympathetic and that I feel her pain in some sense. I am also concerned that as I continue to work with mom if I will be able to handle the emotional part of it.
Other home visitors were more positive in how they were able to handle the issue:
I want to address the idea of frustration and I think that anyone that is going to do this job at some point you have to draw that line of what you can accomplish and then leave it up to them to some point whether it is smoking, abuse or sleeping with their baby or all of those things. You can only give them so much information and then it is up to them. This is the same type of situation. You can’t make them get out of that relationship, but you can give them support and be there for them and that when they are ready you are there for them and will help them.
We all bring our own personal history to any task, but a valuable first step is to acknowledge that history and move beyond that point. Without this crucial step, it is difficult to effectively deal with others experiencing similar problems.
4. The training needs to specifically address communication styles when talking to women about violence.
Over many years of working with vulnerable women, we have come to appreciate their acute abilities to pick up on what we call the phony factor. As one home visitor put it, Making it real, and being real with them, this is what I have heard and this is what I have seen. Home visitors need to understand that they must be totally non-judgmental when talking to women about violence “particularly when addressing the reproductive coercion that may accompany physical and emotional violence. Some home visitors in our training understood their role is to provide information and resources and the woman’s role is to decide what is best for her family. As expressed by this home visitor:
Being careful not to put your personal judgments out there “ making sure you are not prejudging them. What if she does say yes “ what are you going to say? How am I going to make it look like it’s okay, it’s alright and I am glad that you are sharing this with me instead of ‘Girl, how could you’
5. The training should also address concerns the home visitors may have such as whether a requirement to report to authorities such as child protection services will ruin the trust they are trying to build.
We have to consider, do we hotline the situation if we see abuse? It is a little more intrusive with hotline calls and mandating reporting. I think that we think on that end “safety. The duty to warn and safety and I think that is always a concern for us. So, now we have built this relationship with her and if she discloses to us and we hotline her, will that tear down that relationship with her and if she discloses to me that the children in the home might be at risk, that if they pick up the kids, they would have to be in foster care. That is just some of the things that might be going through our heads.
This home visitor clearly struggles with her responsibilities of being a mandated reporter and her role as a helping person for this family. Training should demonstrate how working in partnership with the woman, letting her know that you will not report her without her full knowledge, not only empowers her but also builds trust and confidence so that she can confide her inner thoughts and feelings. This extends to the woman also knowing that what she shares will be confidential, and is of particular importance in rural areas such as Missouri.
6. A huge barrier for home visitors in addressing violence is the presence of the male abuser in the home.
This was a common concern among all the home visitors we have worked with in Missouri, and one that became less of a problem after we brought in a male expert in the area of IPV. Based on his advice and our experiences, we train home visitors to take the woman’s lead on how to deal with her partner. We also recommend the home visitor have brochures in her/his bag that address fathering and/or child development. If the client’s partner appears during the visit, the home visitor can engage him in his role in helping to ensure the child has the best chance of developing to his/her full potential. It seemed that this may not be something home visitors consider, as seen in the following quote,Maybe that is a good idea to bring in some information pamphlets with me in case I have to shift ¦ and he walks into the room one day unexpectedly. During the training, we also suggested that if the home visitor feels uncomfortable discussing IPV in the home for fear of the male partner, then she could meet the woman at another location for one of the scheduled visits. In response, a home visitor stated, I had never thought about meeting her at the WIC clinic or her primary care “you know that is something we can do because they are in the house and I think that is going to have a big impact on our program.
7. Working with families where abuse is occurring is not a happy experience for anyone, particularly when there is a lack of resources in the community for referral. This is reflected in the following statement by a home visitor:
“so it’s like now what do I do because I can’t leave phone numbers to call. I have no way to get you transportation which happens in —which is the site that I am from. I have girls that don’t have a phone and don’t have transportation. I can’t leave phone numbers. I can’t say here is this transportation. So, what do I do? There is my question, because I am stuck.”
Over the five years of working with the DOVE study, we have come to appreciate that, perhaps, the most important thing for any woman is to have the opportunity to discuss her situation with someone, like a home visitor, who will not judge her and who will let her have control of what she needs to do to keep herself and her children safe. In circumstances like these, we have trained home visitors to offer the use of their own cell phone to work out a safety plan with an advocate at either a local shelter or the National Domestic Violence Hotline (1-800-799-SAFE).
When I first started I had that inner sense of ˜Oh my gosh, I have to do something inside me “ you stay calm on the outside and you do the nursing thing “but on the inside I was going crazy. Then I realized that like anything else it has a cycle and that people are not always ready at the same time and in my situation like other programs, I am in their lives for a long period of time. So, I am noticing with these ladies that the more I see these ladies the more they see you, the more they see you caring by connecting them with something. It helps them open up and empowers them “so I just take it just a little bit at a time.
8. Because work in this area is difficult, we recommend frequent team meetings or regularly scheduled meetings with a supervisor for debriefing.
We have found this important in our own work with women experiencing abuse. One of the home visitors expressed the same sentiment:
I think that my struggle is feeling a little inadequate and not knowing what to say. I can encourage them and tell them that what is happening is not okay. I haven’t had a lot of experience with physical abuse but right now I am dealing with verbal and emotional abuse with two of my clients and just thinking that I don’t know the perfect thing to say, and others said taking it home and being so upset and thinking I don’t know how long you can do this type of work since it affects me so much so a variety of emotions.
With Sec 2951 of the 2010 Healthcare Reform Bill, Maternal, Infant, and Early Childhood Home Visiting Programs, calling for home visitation programs to be strengthened by providing comprehensive services to improve outcomes in at risk families, the lessons from DOVE are invaluable. States will be required to measure improvement in rates of IPV, particularly among those women receiving home visitation services. Although IPV is not something that home visitors have ignored when working with families, it is not a health issue that is routinely assessed or addressed in a standardized procedure during most home visits. Not addressing IPV could be one reason that the outcomes home visitors hope to achieve have not been realized.
In summary, it is vital to assess each woman for current IPV so that resources can be offered to improve the health and safety of clients and their children. For assessments to be accurate and for an intervention to be effective, however, very specific training and support must be available for those providing the services. More than how to assess and intervene; the training must include role playing, specific strategies to address barriers that could prevent talking about the issue in the home environment, and last, but not least, the provider’s personal feelings or experiences that may intrude. The DOVE model provides home visiting programs a ready means of implementing this training and intervention. Failure to deal with the elephant in the room will ultimately cause more harm than good.
Eddy, T., Kilburn, E., Chang, C., Bullock, L., Sharps, P., and the DOVE Research Team. (2008). Facilitators and barriers for implementing home visit interventions to address intimate partner violence: Town and gown partnerships. Nursing Clinics of North America, 43, 419-435.