Millennium Developmental Goal 3 (MDG 3) aims at enhancing gender equity and empowerment of women. Emergency nurses who often encounter women injured by their intimate partners are at risk of developing vicarious traumatisation, which may influence their ability to empower women to move beyond the oppression of intimate partner violence.
This article aims to, (1) describe emergency nurses’ ways of coping with the exposure to survivors of intimate partner violence, and (2) recommend a way towards effective coping that will enhance emergency nurses’ abilities to empower women to move beyond the oppression of intimate partner violence to contribute to the achievement of MDG 3.
The study was conducted in emergency units of two public hospitals in an urban setting in South Africa.
A qualitative design and descriptive phenomenological method was used. Emergency nurses working in the setting were purposively sampled and interviewed. The data were analysed by searching for the essence and meaning attached to the exposure of emergency nurses to survivors of intimate partner violence.
Emergency nurses’ coping responses were either aimed at avoiding or dealing with their exposure to survivors of intimate partner violence. Coping aimed at dealing with the exposure included seeking support, emotion regulation and accommodative coping.
Emergency nurses employ either effective or ineffective ways of coping. Less effective ways of coping may increase their risk of vicarious and secondary traumatisation, which in turn may influence their ability to empower women to move beyond the oppression of intimate partner violence.
Emergency nurses are often in contact with survivors of intimate partner violence (IPV).
Towards achieving Millennium Development Goal 3 (MDG 3) of promoting gender equality and empowering women, one of the key working areas identified was the response to gender-based violence inflicted by a partner.
Frequent exposure to survivors of IPV may put nurses at risk of developing secondary traumatic stress.
A real-life event appraised by an individual as a demand threatening to exceed his or her available resources may result in stress. ‘Coping’ reflects a person’s cognitive and behavioural attempts to alter the problems caused by a stressful event and regulate the stressful, and sometimes intense, emotional responses. Coping with a successful outcome will produce positive emotions whilst a less favourable outcome will lead to negative emotions.
A stressful event emergency nurses often need to cope with is the exposure to caring for survivors of IPV. American studies reported a 17%
Exposure to stressful and traumatic incidents such as IPV may lead to cognitive, behavioural and affective changes in the way emergency nurses relate to others and themselves.
Health care professionals’ ways of coping play a role in the prevention and development of vicarious and secondary traumatisation.
Emergency nurses are expected to identify and respond to survivors of IPV in an attempt to address MDG 3.
The aim of this article is to describe emergency nurses’ ways of coping with the experience of caring for survivors of IPV and to discuss recommendations based on emergency nurses’ experiences.
The research followed a qualitative design and a descriptive phenomenological approach. Guided by the phenomenological philosophy that knowing is grounded in the life-world as the inter-subjective context of human experience,
The study was conducted in emergency units of two public hospitals in an urban setting in South Africa. Formal statistics are not kept, but informal discussions revealed that nurses working in emergency units in South Africa are often required to provide care to female survivors of IPV.
The study population was emergency nurses working for at least one year in the emergency units of two public hospitals in an urban area in South Africa. Considering that male and female nurses’ ways of coping with the exposure to IPV perpetrated against women may differ, the researcher decided to select only female participants. Emergency nurses were informed about the study. The researcher purposively selected emergency nurses willing to participate until data saturation occurred and no new themes emerged.
Data were collected through unstructured interviews conducted in a private room in the hospital. Broad open-ended questions were asked; for example,
Descriptive phenomenological data analysis was pursued to explore the meaning of participants’ responses.
Approval to conduct the study was obtained from the Ethics Committee of the Faculty of Health Sciences, University of Pretoria (ref: 125/2010) and the hospital management. In line with ethical research principles, informed consent was obtained and participants were informed of their right to withdraw at any time without any consequences.
Rigor of the findings was ensured through bracketing, reflexivity and eidetic reduction. The researcher, a psychiatric nurse, bracketed her prior knowledge and assumptions regarding the coping models used to assist clients who have been exposed to trauma. She analysed and reflected on her self-awareness during the research process and recorded these as reflective notes.
In essence participants’ ways of coping were either aimed at escaping or dealing with their exposure to survivors of IPV. Ways to escape the emotions related to care for a survivor of IPV included avoidance, whilst attempts to deal with the experience included seeking support, regulation of emotions and accommodation. Participants used suppression of emotions in an attempt to regulate their emotions. Being unable to change or control IVP as an inevitable phenomenon in an emergency unit, participants used accommodative ways of coping, namely distraction, spirituality, acceptance and meaning making.
A way of coping was to try to avoid exposure to survivors of IPV:
‘I hear the patient explaining the situation that occurred to the sister … it makes me stay away from that unit until that patient leaves.’ (Participant 3, female, 27)
Avoidance also occurred on an emotional level when a participant attempted not to experience any emotions:
‘… in order to work with this person or to help this person I distance myself … I think that’s in order not to experience anger …’ (Participant 7, female, 26).
Participants’ attempts to deal with their experiences included
Participants who used support-seeking verbalised that ‘it feels better’ to talk to colleagues as talking provides a way of ventilating feelings:
‘I can come here and say to Sister X: “You know what Sister X? We have got this patient. This is what happened to this patient; this is so sad.”’ (Participant 1, female, 32)
Emergency nurses also talked to the spiritual counsellors who provide support to patients and hospital staff on a voluntary basis:
‘… he is here for us … you just go there and talk to them … It’s good for us … the spiritual counsellors … and then after that I’m back to normal.’ (Participant 8, female, 46)
Participants attempted emotion regulation as a way of coping. They sometimes cried when they were emotionally touched by a case:
‘I will go to the bathroom, I cry then I come back and feel a little bit relieved afterwards.’ (Participant 3, female, 27)
Crying was not so much seen as a way of coping but rather as something happening when one is not able to control one’s emotions:
‘… there are experiences that you get to the extent where you cannot hold yourself – you will end up crying …’ (Participant 1, female, 32)
Crying was not something participants wanted others to see: ‘You will just like wipe your tears … and say:
‘… people must not see that I am crying.’; ‘… going somewhere to hide yourself from people not seeing you are hurt’; ‘… but isn’t it you won’t let others see; you just cry internally?’ (Participant 4, female, 50)
Participants felt as if they had no choice but to suppress their emotions as a way of coping:
‘I became angry, but I didn’t show it to the family…’; ‘… you know you have to take your feelings aside …’ and ‘… keep it inside of me; you just let it go.’ (Participant 3, female, 27)
The suppressed emotions stay unresolved:
‘… what will you do about it? You do nothing about it…’ and can escalate into strong feelings: ‘What will you do? You will just hate …’ (Participant 4, female, 50).
Suppressing emotions have far-reaching consequences:
‘… so keeping it to myself it will cause me a lot of harm; for me and my family and those who know me, my friends …’ (Participant 8, female, 46).
Participants felt a sense of duty to suppress their personal emotions and provide help. They mentioned that the nurse was expected to always be in control:
‘This is what I have to do, that’s it …’; ‘… you have to pull yourself together … regain your strength to do your work.’ (Participant 4, female, 50)
‘I didn’t show (my feelings) to the family and relatives because I must comfort the patient. I must not be emotional in front of the patient. I must give hope to the patient, be supportive, though it was hurting to me. But I tried to be strong for the sake of the patient …’ (Participant 3, female, 27)
‘I have to carry on even though it is difficult for me … it’s my responsibility … I should provide help first for there’s no way that I cannot help a patient because of my emotions … I must just help out no matter how bad it can be …’ (Participant 4, female, 50).
‘… we have to deal with it (IPV) whether we like it or not, and we have to get some positive results from that …’ (Participant 4, female, 50).
Participants used different ways to adapt to or accommodate the inevitable exposure to survivors of IPV in the emergency unit, namely, distraction, spirituality, acceptance and meaning making.
Distraction: Some participants sought distraction in the form of time-out after being emotionally upset by a specific case, for example:
‘… you just want to cool down a little bit … just need a little time …’; ‘… just go to the kitchen and grab something …’; ‘… listen to the music – whatever you can do to just relieve yourself’, and ‘… usually what I do I go outside. There are porters, so I just sit with them and they always make a noise, and I listen to whatever they are saying, and talk to them and come back to my work.’ (Participant 1, female, 32)
Small talk with co-workers also provided distraction:
‘… we are chatting about something different; they (the images of the injured survivor) can’t come back …’ (Participant 1, female, 32).
At home, participants’ family members provided distraction, for example:
‘… when I am playing with my daughters I am trying to forget what happened…’ (Participant 8, female, 46).
Spirituality: Participants used internal spiritual resources to help them cope:
‘… the first thing that I do before I can go to the patient, I am just taking a two minutes break to ask God for strength, and for power and suddenly … I have started to stand for that woman … and I think God also sees that my child is in trouble, let me give her the strength to do what she is suppose to do …’ (Participant 8, female, 46).
This participant found spiritual meaning in providing care to survivors of IPV:
‘… for us to be here is because of the purpose from God. He knows that there will be some other people outside who need our help so He will give us the strength almost every day so that we can help those people because they are not able to help themselves.’ (Participant 8, female, 46)
Acceptance: Although acceptance was described as a difficult process, some participants managed to come to terms with their experiences. For one participant, the death of a woman exposed to IPV was a particularly difficult situation to cope with; the description indicates how spirituality helped her to accept the inevitable:
‘… at the end I just told myself let me accept what has happened … but it’s difficult to accept it … I just told myself I have got a family I have to look after. I have got a job and I have patients that want my help … what is left is just to pray to God to let it not happen again. Sometimes it’s very hard to accept – you are in denial about what happened – but in the end you have to accept. It’s done, she’s gone; she’s gone and she can’t come back. I can’t walk around with it forever.’ (Participant 8, female, 46)
Meaning making: Participants aimed to answer three questions as they struggled to make meaning of IPV, namely:
‘Who is that person who can do these horrible things?’; ‘Why is the person still in this relationship?’ and ‘Why is it happening to us women, what went wrong?’ (Participant 2, female, 29)
A question that bothered participants concerned the reasons for a person hurting his intimate partner:
‘How can another person cause this pain … what drove them to inflict this pain on this other person?’ (Participant 2, female, 29)
Participants reflected on the contradictory behaviour perpetrators of IPV often display:
‘At the same time they tell the world that they love this other person and then this is definitely not the way to show that they love this person. Mm … It’s just so contradicting …’ (Participant 7, female, 26).
Some participants reasoned that a family history of violence can contribute to the perpetrator’s behaviour:
‘Sometimes the person was raised in a home where there was constant physical abuse and to them it’s the norm; it’s the way how you deal with anger … to turn to violence for solving a problem.’ (Participant 7, female, 26)
Emergency nurses provide care to seriously injured survivors knowing that:
‘the very same women who are abused in those relationships, they still stay … going to go back to that person …’ (Participant 1, female, 32).
Participants presented rationales for women to stay in relationships where they are exposed to violence:
‘… if I do this (leave) then I lose the man that I love …’ (Participant 9, female, 39)
‘… sometimes I told myself it’s because she’s not working, the reason why she keeps on staying in that relationship …’ (Participant 6, female, 36)
‘… this man was in serious power because of the occupation he was doing and the poor woman had nothing … he was so wild …’ (Participant 4, female, 50)
‘… men they have got this belief – especially in our culture – they will tell you: these things a woman is not supposed to do, and then they take advantage of this thing because they have got powers.’ (Participant 4, female, 50)
‘… she’s afraid to leave that relationship and go back home. At home there’s nobody working and she’ll go home with those kids and it’s going to be a burden on her parents …’ (Participant 6, female, 36)
‘… some of the families, especially we blacks, we have this tendency of not accepting other situations when somebody has failed (divorce) …’ (Participant 5, female, 35)
Gender inequalities forms part of the MDG 3 and participants linked cultural sanctioning and gender inequalities to IPV. Participants reflected on IPV as a social problem:
‘… you realise there’s been lots of people coming through, lots of organisations … but men are still abusive. And you ask yourself: these campaigns have existed for years but men still continue to abuse women in different ways.’ (Participant 2, female, 29)
It can be deduced from the findings that emergency nurses attempt to cope with the exposure to survivors of IPV, either through aiming to escape, or dealing with their experiences so as to fulfil their professional responsibilities.
Researchers propose many ways to conceptualise coping.
Engagement coping, a direct approach toward a stressor or related thoughts and emotions points to better adjustment and lower levels of distress than disengagement coping.
The different ways people use to regulate emotions may have different outcomes.
Accommodation refers to the adjustments a person makes to cope with events that cannot be controlled.
Meaning making attempts to cognitively restructure, make sense of, or find benefit in adverse events.
Trying to find meaning in the senselessness and suffering associated with IPV, participants either changed their global beliefs or the situational meanings they attached to IPV in order to avoid emotional distress. Participants tried to find an explanation behind the behaviour of the perpetrator and the woman who stays in the violent relationship. They ascribed the perpetrator’s violence to a violent upbringing and the women’s reluctance to leave as caring for her children or family. They reappraised their understanding of intimate relationships within the context of culture, socio-economic factors and gender inequalities. Ongoing discrepancies between global and appraised meaning may alter a person’s belief system, a characteristic of vicarious traumatisation.
The dimensions of knowledge development in nursing may provide a way for emergency nurses to challenge their current ways of coping and take corrective action.
Reflection may help to develop health care professionals’ coping skills, protect nurses against burnout and enhance emotional resilience.
Nurses vulnerable to secondary traumatisation may benefit from prevention programmes that facilitate effective, problem-focused coping, emotion regulation, constructive reappraisal
Emergency nurses may play an important role in attaining MDG 3 by identifying and empowering women exposed to IPV. Emergency nurses used a variety of ways to cope with the exposure to survivors of IPV. Engagement coping seems to be more constructive than disengagement coping, for example, seeking help versus avoidance. There seems to be a thin line between emotional suppression, regarded as dysfunctional coping, and manipulation of emotional boundaries to maintain professionalism. Accommodative coping may be functional; for example, acceptance facilitated by spirituality, whilst attempts at meaning making that disrupt global beliefs can give way to vicarious traumatisation. Coping in the study context was individual and ‘silent’ as emergency nurses tend to not discuss their ways of coping. The lack of formal structures to help emergency nurses cope with the exposure to survivors of IPV put nurses at risk for vicarious traumatisation. Impeding nurses’ ability to empower survivors of IPV, vicarious traumatisation may be a potential stumbling block in reaching MDG 3: promoting gender equality and empowering women.
The authors wished to thank the UNEDSA project grant through the Community-Oriented Nursing Education for Women and Child Health Programme: A joint collaborative initiative of the University of Pretoria and the University of Limpopo (Medunsa Campus) for the scholarship and support. The authors thank the research participants for sharing their ways of coping.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
A.v.d.W. was responsible for the research design and method and collected and analysed the data. N.v.W. was the supervisor for the research and E.J.v.R. the co-supervisor.