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Seen but not heard: Battered women’s perceptions

of the ED experience
Author: Marylou Yam, PhD, RN, CS, Oradell, NJ

Introduction need to examine and reshape the delivery of care

to abused women in the emergency department.
A plethora of studies describe helping professionals’
(J Emerg Nurs 2000;26:464-70)
responses to and actions directed toward battered
women in the emergency department. However, re-
search that yields data regarding the clients’ percep-
tions about their actual experiences in the ED set-
D omestic violence is a worldwide health problem
that affects the lives of millions of women each
year. Statistics indicate that a woman is physically
ting is sorely needed. The aim of this study was to
abused every 9 seconds in the United States and that
describe battered women’s perceptions of their ED
experience. 42% of women who are murdered are killed by their
male partners.1 Battering or violence is the single
major cause of injury to women.2 Abuse is associated
A qualitative design, namely a phenomenologic ap-
with long-range health problems including perma-
proach, was used for this inquiry to enable the
women to express themselves in their own voices. nent disabilities resulting from physical injury, sexu-
Informants were recruited from shelters for battered ally transmitted diseases, HIV, and perinatal compli-
women. Women who had sought help for abuse- cations.3 Women who have been subjected to abuse
related injuries at a hospital emergency department may experience psychological problems such as de-
within the past 12 months were asked to participate. pression, suicide, anxiety, posttraumatic stress disor-
Methods used to collect data were in-depth, individ- der, and alcohol and drug abuse.3 A large number of
ual, audiotaped interviews and demographic data abused women present themselves to the health care
sheets. Data analysis was conducted using Colaizzi’s establishment for help. A review of previous studies
(1978) procedural steps. led researchers to estimate that 31% to 54% of women
Results who visit the emergency department report a history
Several categories emerged as being descriptive of of intimate partner violence.4
the women’s perceptions of their ED experience. Although a great many of these women seek help
Themes identified included the women’s feelings in the emergency department, data indicate that only
during the visit, such as fear of their partner, concern
abut 3%5 to less than 10%2 of all battered women are
for children, and loneliness; the women’s belief that
identified by health care professionals. Although the
the ED staff do not understand abuse; satisfaction
with treatment of physical injuries but dissatisfac- nature of the help provided in the emergency depart-
tion with how the issue of abuse is managed; the dif- ment is short term, it is crucial to uncovering hidden
ficulty of disclosing the abuse because of fear, em- violence, reducing the effects of physical and psycho-
barrassment, and a lack of resources; and a request logical trauma, interrupting the cycle of violence, and
that health care professionals display compassion, saving a woman from a potentially life-threatening
provide referrals, and offer options. situation.6
Discussion A plethora of studies from the professional helper’s
The women’s narratives explicate their feelings dur- perspective or through medical record review docu-
ing the ED visit and sensitize nurses to their experi- ment the health care management of abused women
ence. The reports of dissatisfaction with the care in the emergency department.4,7-10 Evidence has
they received in the emergency department add to shown that, in many instances, health professionals fail
the validity of findings from previous studies that to identify abuse,4,8 neglect to implement protocols,7,9
have documented similar results and point to the derogate victims, and/or are unsympathetic.7,11
Fewer studies examine the ED visit from the bat-
Marylou Yam is Chairperson, Department of Nursing, Saint Peter’s tered women’s perspective. In l982, Drake11 conduct-
College, Englewood Cliffs, NJ.
Funded by a research award from the New Jersey State Nurses ed a descriptive inquiry in which 12 battered women
Association. were interviewed.11 The study revealed that none of
For reprints, write: Marylou Yam, PhD, RN, CS, 550 Winne Ave, the women expressed positive feelings about the
Oradell, NJ 07649.
Copyright © 2000 by the Emergency Nurses Association. health care they received. The women relayed in-
0099-1767/2000 $12.00 + 0 18/1/110432 stances of impersonal care, lack of support, and dis-
doi:10.1067/men.2000.110432 interest in their problems. In another study, the

464 Volume 26, Number 5


perceptions of battered women and battered women male partner. She could be married or unmarried but
advocates were surveyed.12 Findings revealed that had to be involved in an intimate, cohabiting, hetero-
abused women treated in the emergency department sexual relationship. Purposive sampling was used.
reported feelings of humiliation and blame and be- Women who had sought help for abuse-related injuries
lieved that their abuse was minimized, referrals were at a hospital emergency department at least one time
insufficient, and they were not identified as battered in the previous 12 months were asked to participate.
Specific issues related to battered women’s en- Data collection
counters in the health care setting have also been ex- Women’s perceptions were elicited using semistruc-
amined. Researchers investigated reasons that influ- tured interviews with probing questions. The inter-
ence the identification and management of abused views were audiotaped. All of the interviews were
women in the health care setting.13 Findings revealed conducted at the shelters, in private, at a time conve-
that reasons for nondisclosure included threats of vio- nient for the women. Each woman signed a consent
lence from the abuser, embarrassment, adherence to prior to the interview. Interviews lasted from 60 to 90
gender roles, concerns about police involvement, and minutes. Each woman was interviewed by the same
mistrust in the health care provider.13 Data also researcher, and the following request was made: “Tell
showed that battered women requested that health me about your experience in the emergency depart-
care professionals ask about domestic violence, en- ment.” Other probing questions asked of each partic-
gage in a supportive relationship, and refer them to ipant included the following: “What did the nurse
resources in the community.13 say? Do? What did the doctor say? Do?”
Given the small number of studies exploring the In addition, the researcher collected demograph-
ED visit from the battered women’s perspective, more ic data related to age, race, type(s) of injury, number
data are needed to understand their experience. The of visits to the emergency department, number of
purpose of this study was to describe battered years in the relationship, and types of help sought.
women’s perceptions of the ED experience using a In a phenomenologic investigation, data are
qualitative approach, namely phenomenology. gathered until data saturation is achieved. Data satu-
ration occurs when no new themes or essences
Method emerge from the participants and the data are being
Design repeated.16 In this inquiry, themes became repetitive
The aim of phenomenology is to describe the lived ex- after 5 informants were interviewed.
perience.14 According to Bruyn,15 “Phenomenology
serves as the rationale behind efforts to understand Data analysis
individuals by entering into their field of perception in Interviews were listened to initially by the researcher.
order to see life as these individuals see it.” In other Analysis was begun with the first interview and was
words, individuals’ perceptions as they experience ongoing throughout data collection and presenta-
them are investigated. In this study, the research tions. Data were analyzed using Colaizzi’s method of
question was the following: What are the perceptions phenomenologic analysis.17 Narratives were read and
of the ED experience from the battered woman’s per- reread to get a sense of the data. Significant state-
spective? ments—that is, sentences or phrases that directly ad-
dress the phenomena being explored, namely, the ED
Informants experience—were extracted from the descriptions,
The women were recruited from battered women’s meanings of each significant statement were spelled
shelters in the New Jersey-New York area. After ob- out, and clusters of themes were organized into cate-
taining institutional review board approval, the shel- gories from the formulated meanings.
ters were sent a cover letter, proposal, and letter re- To enhance credibility, audiotapes were tran-
questing their participation in the study. A request to scribed verbatim onto a computer and transcripts
participate was sent to a total of 8 shelters. One shel- were compared with the audiotapes for accuracy.
ter refused to participate, stating they had “no women One measure of theoretic validity relies on whether
who would be candidates.” Only two shelters allowed there is agreement among researchers concerned
the researcher to speak to the women directly to re- with the study as to the terms used to depict the phe-
quest their participation. At the other shelters, the nomenon.18 In this study, to validate the researcher’s
staff recruited the women. For this study, a battered interpretations, significant statements, formulated
woman was defined as a woman who had been sub- meanings, categories, and themes were discussed
jected to the use of physical force (battering) by her with and reviewed by a consultant with expertise in

October 2000 465


the phenomenologic method, and they were deter- gonna do, this is all going through my mind. I’m wor-
mined to be consistent with the data. Thus, theoreti- ried about him. While I was waiting...somebody could
cal validity was established. have been talking with me, they just left me waiting.
You’re gonna sit and you’re gonna wait, till they
Results get rid of their priorities first.
The 5 participants ranged in age from 22 to 36 years. At this point you are thinking—what did he do to
Two of the women were white, 2 women were African me and oh my God, here I am with all these people
American, and one woman was biracial (white and who are going to know what happened to me.
Hispanic). None of the women were married; rather, They were nice, but they wanted me to press
all of them had been living with their male partners. charges, and I was too afraid to do that.
The number of years that the women were in the abu- In addition, women who had children were con-
sive relationship ranged from 4 to 11 years. Collec- cerned about their well-being. For example, one
tively, the total number of visits to the emergency de- woman stated:
partment was approximately 13. The number of visits You are nervous and you are not thinking straight.
to the emergency department per person ranged from They have to understand I have kids at home, that I
2 to 4 visits. One woman was hospitalized and re- had to let my children know I wasn’t dead. So I didn’t
quired surgery for abuse-related injuries. Injuries in- let them admit me.
cluded concussions, eye injuries, a fractured humerus,
and a complication of abuse during pregnancy (pla- Beliefs about how staff perceive women who have been
centa previa). All of the women had use of shelter ser- abused and the problem of abuse
vices, and 4 of the women had used hot line numbers Themes expressed by respondents included the
for domestic violence. following:
Following analysis of significant statements and • Blaming the woman
theme clusters, 5 categories were identified: • Pity
1. Feelings experienced during the ED visit: a mul- • Misunderstanding abuse
titude of emotional states All of the women shared their beliefs about how
2. Beliefs about how staff members perceive women they believed staff perceived them and the issue of
who have been abused and the problem of abuse abuse. This category included themes of blame, pity,
3. Perceptions of the nurse and physician and of the and abuse not being understood. The women be-
care received lieved that health care professionals did not really un-
4. Concerns about disclosure: Should I tell? derstand the essence of their abusive existence.
5. Suggestions for caregivers Three of the women believed that the doctors and
nurses had a matter-of-fact attitude toward battered
Feelings experienced during the ED visit: a multitude of women and that health care professionals did not
emotional states consider their situation to be serious. For example:
Themes expressed by respondents included the They just say oh, okay she’s hurt, another woman
following: beat up by her man, treat her, send her home, you
• Anger know, that’s how they treat you.
• Concern for children They kept trying to get me to press charges, kept
• Inability to think clearly telling me I shouldn’t be going through this. They just
• Loneliness can’t understand why you don’t do that. They don’t
• Embarrassment know, they’ve never experienced it.
• Frustration (Regarding abuse) They have no idea. The people
• Fear of partner at the hospital don’t know. They are coming from their
Women described multiple and varied emotional houses with white picket fences and do not know
states, which at times were experienced simultane- what I dealt with at home.
ously. Feelings of fearfulness and embarrassment Other women articulated instances in which they
were common to all the women. In addition, some of believed that staff blamed and pitied them.
the women expressed anger and frustration regarding They don’t treat you as though you’ve been hurt,
the long waiting period in the emergency depart- not because it’s your fault, but because someone de-
ment. Three of the women described feeling lonely liberately did this to you, and that they have a prob-
while waiting to be seen. lem and that you need to get away from them.
I felt frustrated and kind of scared because I got I feel like a lot of the hospital staff feel, like why
this man locked up and what is he thinking, what’s he would you stay? It’s your fault, you know?

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One nurse hollered at me and said: “Are you the part of the caregiver. The woman explained that
crazy?” “What’s the matter with you?” They can’t do the nurse recorded her answers but did not respond
that. They can’t holler at you. I mean that’s their opin- to her situation:
ion, but it is not good for the person. They (doctors and nurses) just wanted to get me
That feeling sorry for you. That was the most un- out. They ask you questions like a textbook. They
comfortable. People just pity you and I shouldn’t be could act like they really care—even if they don’t, pre-
pitied. That made me feel uncomfortable. They treat tend. They just want to get you out so they can see
you like they feel bad for you. the next person. They act like they are reading a text-
book when they talk to you. They write down the an-
Perceptions of the nurse, physician, and care received swers, but just say ah, um....
Themes described by respondents included the All the women spoke positively about the medical
following: treatment they received for their physical injuries.
• Unconcerned However, with regard to the underlying cause of their
• Controlling injuries, they conveyed that the abuse was not ad-
• Lack of humanness and compassion dressed and that the physicians and nurses only “saw
• Rushed, hurried approach the outside.”
• Physical injuries treated The themes “abuse not addressed: I’m hurting on
• Abuse not addressed: I’m hurting on the inside too the inside too” and “physical injuries treated” are re-
All the informants discussed their perceptions of flected in the following comment:
the nurse, physician, and care received. Themes that As far as medical treatment, they are great, but
emerged included the sense that nurses and physi- as far as knowing how you feel and you are feeling
cians displayed a lack of concern, appeared to lack pretty lousy—they only see the outside—they don’t
humanness in their work, and were not compassion- see the inside.
ate. Some comments that reflect these perceptions In spite of treating the physical problems, the
include the following: issue of abuse is not addressed and the cycle of abuse
She (the nurse) was just there to take my vital remains uninterrupted. In essence, the women are
signs. I don’t think she was really too much con- seen, but not heard. One woman stated,
cerned. She was trying to do her job and get me out You get to the hospital and there is nobody there.
of there so she could see the next patient. The doctors treat you, stitch you, give you your dis-
One woman believed that the staff’s lack of con- charge papers and send you home, which means you
cern and intervention caused her to delay seeking are going home to the same man.
help. She stated: Other examples of these themes are illustrated in
The doctor said nothing to let me know that he the following statements:
was really concerned about the fact that my boyfriend They asked me nothing. I told the nurse and I told
hit me with a bottle and I think, had somebody en- the doctor. Nothing. Nothing was said, and I didn’t go
couraged me back then to leave him, I wouldn’t be to a shelter. I went back home after the hospital, limp-
here now. ing around, and his father called and asked me, “Just
The women perceived staff as not being compas- don’t leave, please don’t leave him.”
sionate and provided numerous accounts of a rushed I told the nurse what happened. I told her my
and hurried approach on the part of caregivers. One son’s father beat me up. He had pushed me on the ce-
participant stated: ment. I sprained my knee. She just wrote down what
They have no compassion whatsoever, none. And was hurting me and my vital signs and that was it.
that’s the field they chose! They chose this field to help She didn’t ask any more questions.
people, so I would expect them to be understanding. The doctor asked: “What happened?” I said, “My
It seems as if they want to get you out. boyfriend hit me with a bottle.” The doctor asked:
One woman saw the nurse as too busy to listen to “What did you do?” The client stated: What did I do?
her plight. She explained that it would have been help- What could I do? He sent me for x-rays, removed the
ful if the nurse took the time to listen and talk with her: glass, and cleaned my eye. The doctor could have
I don’t think the nurse had the time to, let’s put it said, “This is not right. If you want to talk to me I can
that way, to really sit down and say, okay, listen, this sit you down. I can let you know there’s a bit more
is not right, if you want to talk to me, if you need my that I can help you with if you want to get out of this.”
help or whatever. The women described interactions in which staff
In addition to feeling rushed, one woman voiced were controlling and told them instead of asked them
a statement that indicated a lack of humanness on what they wanted to do. For example:

October 2000 467


Suggestions for caregivers

They’ve got to understand that you are with this
guy who is controlling you and telling you all the time Themes reported by respondents included the
what to do and you don’t need to be told what to do— following:
you don’t need one more person telling you what to • Express compassion
do. They don’t treat you independently. • Have an advocate available
• Make me feel safe
Concerns about disclosure—should I tell? • Explore options
Themes described by respondents included the • Listen
following: • Talk with me
• Fear • Interview me privately
• Embarrassment All of the women suggested strategies for inter-
• Lack of resources/support systems ventions. It seemed as though they wanted to protect
• Opening up: Disclosing the abuse other women from having similar experiences. They
All of the women spoke about the difficulty of dis- talked about the need for compassion on the part of
closing the abuse to staff. At times, they wanted to in- staff and for the presence of an advocate for battered
form the physician or nurse how their injuries oc- women in the emergency department. The women all
curred but were afraid or embarrassed to speak out. requested that they be interviewed privately and that
Two of the women explained that their abuser was their options be explored. Many of the suggestions
present during the questioning. Statements that re- centered around the need for staff to take the time to
flect these themes included: question them about their injuries and listen to their
I was too embarrassed to tell. stories of abuse.
I was afraid to tell; my boyfriend was right there. The doctor could have said this is not right. If you
The doctors believed him when he said he was my want to talk to me I can sit you down, I can let you
brother and I couldn’t tell them he was lying. know there’s a bit more I can help you with, if you
It intimidates you and especially with him stand- want to get out of this.
ing right there and him making sure you don’t open Give me a chance; you asked (what happened)—
your mouth. you opened the door. Don’t open the door and shut it.
Two of the women who had been interviewed Ask my boyfriend to leave so I can open up to you.
alone also indicated that fear and a lack of resources Two of the women suggested that a “trained
and support systems inhibited them from disclosing counselor” be available in the emergency department
their dilemma: for battered women.
As much as they kept telling me, I just wouldn’t A trained counselor on call 24 hours a day. If you
say anything. I mean there’s a list of reasons. At that need to go to the emergency room they’re there with
time—you’re scared, you have nowhere else to go. the woman to let the doctors know she was physical-
They were nice but they wanted me to press ly abused. The counselor could tell them (doctors and
charges and I was too afraid to do that. I never told nurses) she may not be comfortable with some of you.
anybody that he hurt me because I thought he would I’m here to be with her.
find out. The advocate would know what to tell staff to say
One woman explained that staff are unaware of or not to say. Like when the nurse was hollering at me.
the “risk” involved in revealing abuse. She stated: She would know what to say and she would know
They (nurses and physicians) can’t understand what to tell the staff to say or not to say. You are al-
why you won’t go out on a limb and say that he did ready feeling bad and she would try to make you feel
this to me. comfortable.
One woman did reveal her abusive situation to a One woman suggested that a follow-up call is
nurse. She relayed the following: needed; because of the way the woman is feeling at
One nurse, I did tell. She really seemed concerned the time of the visit, she often needs a few days to de-
about it so that’s why I told her what really happened. cide what to do. This woman suggested:
Because she didn’t flat out ask me—are you a victim Maybe some way to follow up, like a few days later
of violence? She didn’t ask me like a textbook. She told call me and ask me how I feel and what I want to do.
me that a lot of women came in here and they’re Other comments reflected the women’s request
abused by their husbands. She started telling me sto- to be cared for with compassion and to talk with them
ries about other women and then asked me. I felt more not at them regarding their options:
comfortable talking then. She gave me a whole list of I’ve been through a rough ordeal—treat me like a
places to call and I started calling them from then on. human being.

468 Volume 26, Number 5


I mean medically, they did things like order med- each reported dissatisfaction with the care received
ication. But they need to have some kind of literature and offered strategies that would be helpful for nurs-
they can hand you so you can read. Rather than es and physicians to use. For example, the women re-
telling you what to do. You are nervous and you are quested that nurses and physicians explore options,
not thinking straight at the time. deal with safety issues, interview them privately, and
They can’t be pushy on what you tell somebody take the time to listen and talk to them. The battered
to do—they did that a lot. “You should do this or women in this inquiry expressed the need for com-
somebody telling you what you should do.” I think passionate care and to be given referrals, which is
they need a different tactic, perhaps like, “We have similar to what was reported in the investigation by
some literature if you would like to read this.” Just do Campbell et al.12 The data are congruent with inter-
it in a different approach. ventions cited in the literature as being effective in
The following comments indicate the need for dealing with battered women.10,19,20
staff to deal with the woman’s fear and safety con- The women reported an unconcerned attitude
cerns first and the importance of informing the women and rushed and hurried approach on the part of health
of the availability of safe places where they can go. care professionals. Even with time constraints, it is
You are upset and you are scared and the more crucial that nurses and physicians provide a quiet
they push and try to get you to do things—I mean you place for the women to be interviewed alone, apolo-
know this person that’s doing this stuff to you and you gize for the long wait, and offer a comment of con-
are not going to do anything because you are scared. cern. Providing appropriate referrals can be done effi-
Let me know there is a place I can go to be safe. caciously. For instance, an information sheet of
community resources could be developed and used
Discussion by all the staff. ED staff members need to know that
Thematic analysis revealed commonalities in the bat- they can obtain information from local crisis centers
tered women’s descriptions that may be similar to and hot lines. If advocates are not available, staff
those of other patients who have sought help in the should have a good understanding of the resources
emergency department. For example, other clients that are available in their hospitals. Also, the patient
may experience similar problems of impersonal care could be given access to a phone and a local hot line.
and feel frustrated with the long waiting period. How- The women in this study indicated that disclos-
ever, because of the circumstances of their injuries, ing the nature of their injuries is difficult. Techniques
these feelings and emotions may be heightened for for questioning battered women are well documented
battered women. Also common to the women in this in the literature. However, the realization that these
study and possibly dissimilar to clients with other women may lack knowledge about resources and feel
health problems are the feelings of fear, shame relat- fearful and embarrassed is requisite to couching
ed to their injuries, and the struggle to decide questions, sharing information, and conveying a pro-
whether to reveal the cause of their physical trauma. fessional demeanor that emulates trust and may en-
Unlike other clients, these women will return to the able the woman to discuss the nature of her physical
emergency department unless a significant change trauma. Because some women, as in this study, may
occurs in their lives. not disclose that they have been abused, it is impor-
The narratives in this inquiry seem to support tant that information be available to all women. A
findings of previous research11,12 in that the women comment such as “Because this happens to many
reported instances of feeling blamed and sometimes women, we have information for everyone who might
believed that the abuse was not taken seriously. find it helpful” may encourage a woman to reach out.
Moreover, consistent with the findings reported by A factor that was identified in the data as facilitating
Rodriguez et al,13 fear was a reason for not disclosing disclosure was when a nurse asked a woman about
the nature of their injuries. However, unlike previous the nature of her injuries in a nondirect manner and
research, the data in this inquiry illuminated the shared stories of other women who had been abused.
range of emotions and feelings that the women may One woman in this inquiry indicated that attempts by
experience during their ED encounters, such as con- staff to tell a woman what to do may not be therapeu-
cern for their children, anger, loneliness, and frustra- tic. Even if the woman chooses not to disclose that
tion. Although the data yielded in this study are rich, she has been abused, if we share the availability of
the sample size is small, and more research is needed options and create a supportive environment, she
to confirm these findings. may disclose the abuse on another occasion.
In this study, the women were all satisfied with In spite of Joint Commission on Accreditation of
the treatment of their physical injuries; however, they Healthcare Organizations guidelines and literature

October 2000 469


describing therapeutic interventions and staff educa- 2. American Nurses Association. Domestic violence: im-
tion, abused women in this sample reported dissatis- pacting the nation’s health care delivery system. Nurs
faction with the care they received in the emergency Trends Issues 1997;2:1-9.
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data, as well as findings from previous research, point sition paper: domestic violence as a public health problem.
Washington: 1999; The Association.
to the need for researchers to examine the work cul-
4. Rodriguez MA, Bauer HM, McLaughlin E, Grumbach K.
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consultation and Dr Claire Manfredi, Associate Professor, nomenological alternative for psychology. New York: Oxford
Villanova University, for her review of this manuscript. University Press; 1978.
18. Maxwell JA. Understanding and validity in qualitative
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