护士在识别和应对暴力侵害妇女行为方面的作用

1 BACKGROUND

Violence against women (VAW) is the threat of or actual harm by physical, sexual or psychological abuse. Male violence, the most prevalent and dangerous form, is the leading contributor towards death, disease and disability amongst women aged 18–44 globally (Ellsberg et al., 2008). This type of abuse is extremely common; a recent survey of over 22,000 UK women found that as many as 99.7% report having been repeatedly subjected to rape, harassment and physical violence over the course of their lifetime (Taylor & Shrive, 2021), far higher than previously thought. The Femicide Census, which tracks the murders of women by male perpetrators, also consistently reports over 100 deaths per year; rougly one woman every 3 days (Ingala Smith, 2018). Violence against women is a clear and serious public health concern with significant implications for the health, well-being and mortality of women around the world. However, violence should not be an inescapable aspect of women's lives; it can be prevented.

Victims, also commonly referred to as survivors, are likely to require care and treatment from healthcare services (Hooker et al., 2020). Despite this, the nursing response to this issue has been inadequate to date. Nurses and other healthcare professionals can play a vital role in recognising and responding to violence against women and its common expressions; domestic abuse and sexual violence (Bradbury-Jones, 2015).

How this issue is framed is central to how it is perceived or understood and reflects wider social issues in the UK and around the world. Violence against women is a common term and used throughout this discussion to highlight the health and well-being needs of women. However, this tends to obscure the source of the violence: men. When considering these issues, it is therefore important to remember that they do not occur in a vacuum and instead take place against a backdrop of misogyny, male dominance and women's subsequent inequality. Moreover, the ongoing failure to adequately address this issue within nursing and health care is intrinsically linked to medical paternalism and the dominance of medicine over the healthcare hierarchy.

2 WOMEN’S PROBLEMS

In the not-too-distant past, efforts to address violence against women within health care have been described by medical colleagues as ‘ill-considered professional interference’ and that it is ‘doubtful’ women would benefit from support (Fitzpatrick, 2001). This reluctance echoes broader social attitudes that have historically regarded domestic abuse as a private matter and has contributed to the hidden nature of abuse, stigma and ongoing normalisation of male violence.

Within the constructs of a patriarchal society, where male violence is intrinsically linked to male dominance, women remain subjugated, and their experiences hidden. Typically, women's problems are regarded as being a personal problem for women to fix. This obscures the perpetrator of violence and places the blame and responsibility upon victims to keep themselves safe, rather than addressing the source of the problem.

However, whilst perpetrators are solely responsible for violence and abuse, literature on perpetrator recidivism is severely lacking. A community approach to this issue has been shown to be the most effective prevention and intervention strategy (Hague and Bridge, 2008) and forms the rationale for the ongoing implementation of multi-agency risk assessment conferences (MARAC) across local authorities. Nurses, as the largest healthcare professional group, must therefore form an active component of this response, identifying and responding to risk, co-ordinating care and safeguarding women.

3 DEVELOPING KNOWLEDGE

Women who have experienced male violence repeatedly express the importance of supportive, empathic staff and psychologically safe environments (Bradbury-Jones, 2015). In order to achieve this, staff must be knowledgeable and competent in recognising and responding to signs of abuse and disclosures.

Whilst individual nurses may choose to develop their knowledge and understanding in this area, a small number of nurses scattered across services, boards and trusts are not able to lead care on a large scale nor are they able effect the kind of change necessary. A systemic approach is therefore needed that prioritises learning and development and ensures sustainability.

Investing in training and staff development is vital to ensuring staff knowledge and competence. However, training deficits are consistently noted in research. Nurses frequently report lacking the knowledge, confidence, and training to recognise and respond effectively to domestic abuse and sexual violence (Alshammari et al., 2018). As a result, nurses avoid asking about abuse since they are unsure how to ask sensitively and how to respond to a disclosure.

The ongoing lack of development in this area is, no doubt, due to the lack of importance placed upon women's lives, health and well-being. Training is not prioritised in undergraduate curricula or CPD, and specialist nursing staff, capable of delivering such training, are vanishingly rare. But this is nothing new, health care, an historically paternalistic institution, has presided over women's health inequalities for hundreds of years.

4 PATERNALISM AND GENDER ROLES

Within healthcare systems, patriarchy and male dominance find expression in medical paternalism. The traditional dominance of medicine, which once excluded women entirely, remains present to some extent within modern health care. Medical staff, afforded the highest degree of autonomy within healthcare systems, continue to lead in research, policy development and service design and delivery the majority of the time. As such, doctors, nurses and patients exist within an operational hierarchy with medicine dominating from above. This dynamic is inherently gendered, with medical staff acting in the masculine role as dominant protectors and patients as passive, feminine and dependent recipients. Within this system abused women are doubly subordinate, to both their abusive partners and to healthcare staff, and very often must relinquish their autonomy in order to receive the care and treatment of health professionals.

Despite a focus on patient centred care, nursing can often be guilty of participation within these structurally oppressive and misogynistic practices where the patient remains subordinate. The nurse's role is typically one of concern and advocacy; however, even this should be acknowledged as taking place from a position of superiority, control and dominance.

A cursory glance of online patient feedback site Care Opinion reveals many poor experiences for women who disclose abuse to healthcare staff, including nurses of both sexes. This feedback often reflects a lack of staff knowledge and sensitivity, whilst patients navigate retraumatising practices and procedures. Despite being a majority female workforce and being more likely to have experienced male violence than their non-nursing peers (Cavell Nursing Trust, 2016), experience alone is not sufficient to guide high standards of nursing care or eradicate the possibility of internalised misogyny within the profession.

However, nurses, as the largest patient facing workforce and who frequently lead on the development of models of care, should be well placed to not only identify and respond to violence against women; they are also well placed to lead strategic development in this area. This is not without its challenges since nurses, too, are subordinate to the dominant medical hierarchy. This unique position of being both the dominator and the dominated presents a tension that is not possible to resolve entirely without addressing the structural oppression of women within health care, at every level.

Healthcare leaders, managers and educators must therefore prioritise education, development and training on the issue of violence against women in order to improve knowledge, standards of care and ultimately women's health and well-being outcomes. However, they must also recognise and challenge the structural barriers, misogyny and oppression that has prevented or restricted development for women as patients and practitioners thus far. The influence of nurse leadership has profound implications for patient outcomes (Francis, 2013), and this is particularly true for the role of health care in addressing violence against women. Whilst the gendered nature of this issue is recognised, nursing leaders, organisations, unions and institutions have a role in challenging the status quo with clear implications for patient care.

5 CONCLUSION

Male violence is a significant public health concern affecting a high percentage of women. Nurses and other healthcare professionals have a responsibility to recognise and respond to the signs of domestic abuse and sexual violence in order to address ongoing health inequalities, safeguard women and ultimately save lives.

Ending violence against women cannot be achieved by individual nurses, however, and ultimately requires systemic change and investment in training, development and research. If nurses are to address the significant risks facing women, then nurse educators, leaders and managers must prioritise and invest in the development of knowledge and care to ensure that registrants are confident and competent to address this issue.

Importantly, they must also recognise and challenge the oppressive and structurally patriarchal systems that present barriers to advancing practice and understanding in this area. Ultimately, it is women who will continue to suffer the burden of inaction.

ACKNOWLEDGMENT

Both authors contributed equally to this editorial.

CONFLICT OF INTEREST

The authors declare that they have no Conflict of interest.

全文翻译（仅供参考）

1 背景

对妇女的暴力 (VAW) 是身体、性或心理虐待的威胁或实际伤害。男性暴力是最普遍和最危险的形式，是导致全球 18-44 岁女性死亡、疾病和残疾的主要原因（Ellsberg 等，2008）。这种类型的滥用极为普遍；最近对超过 22,000 名英国女性进行的一项调查发现，多达 99.7% 的女性报告称，她们一生中多次遭受强奸、骚扰和身体暴力（Taylor & Shrive，2021 年），远高于此前的预期。追踪男性肇事者谋杀妇女的杀戮女性人口普查也持续报告每年超过 100 人死亡；大约每 3 天就有一个女人（Ingala Smith，2018）。暴力侵害妇女行为是一个明确而严重的公共卫生问题，对世界各地妇女的健康、福祉和死亡率产生重大影响。然而，暴力不应成为妇女生活中不可避免的一个方面；这是可以预防的。

受害者，通常也称为幸存者，很可能需要医疗保健服务机构的护理和治疗（Hooker 等人，2020 年）。尽管如此，迄今为止，护理人员对这个问题的反应还不够充分。护士和其他医疗保健专业人员可以在识别和应对暴力侵害妇女行为及其常见表达方面发挥重要作用；家庭虐待和性暴力（Bradbury-Jones，2015 年）。

这个问题的框架是如何看待或理解它的核心，它反映了英国和世界各地更广泛的社会问题。对妇女的暴力是一个常见术语，在整个讨论中使用以强调妇女的健康和福祉需求。然而，这往往掩盖了暴力的来源：男性。因此，在考虑这些问题时，重要的是要记住，它们不是在真空中发生的，而是在厌女症、男性主导和女性随后不平等的背景下发生的。此外，在护理和医疗保健领域一直未能充分解决这个问题，这与医疗家长作风和医疗在医疗保健等级中的主导地位有着内在的联系。

2 女性问题

在不久的过去，解决医疗保健中针对女性的暴力行为的努力被医学同事描述为“考虑不周的专业干预”，并且“怀疑”女性是否会从支持中受益（Fitzpatrick，2001 年）。这种不情愿与更广泛的社会态度相呼应，这些态度历来将家庭虐待视为私事，并导致虐待、污名和男性暴力持续正常化的隐藏性质。

在男权社会的结构中，男性暴力与男性统治有着内在的联系，女性仍然被征服，她们的经历被隐藏起来。通常，女性的问题被认为是女性需要解决的个人问题。这掩盖了暴力的肇事者，并将责任和责任推给了受害者以确保自己的安全，而不是解决问题的根源。

然而，虽然肇事者应对暴力和虐待负全部责任，但严重缺乏关于肇事者累犯的文献。解决这个问题的社区方法已被证明是最有效的预防和干预策略（海牙和布里奇，2008 年），并构成了跨地方当局持续实施多机构风险评估会议 (MARAC) 的基本原理。因此，护士作为最大的医疗保健专业群体，必须成为这一应对措施的积极组成部分，识别和应对风险、协调护理和保护女性。

3 发展知识

经历过男性暴力的女性反复表达了支持、善解人意的员工和心理安全环境的重要性（Bradbury-Jones，2015）。为实现这一目标，员工必须知识渊博且有能力识别和应对滥用和披露的迹象。

虽然个别护士可能会选择发展他们在该领域的知识和理解，但分散在服务、董事会和信托中的少数护士无法大规模领导护理，也无法进行必要的变革。因此，需要一种系统性方法，优先考虑学习和发展并确保可持续性。

投资于培训和员工发展对于确保员工的知识和能力至关重要。然而，在研究中一直注意到培训缺陷。护士经常报告缺乏认识和有效应对家庭虐待和性暴力的知识、信心和培训（Alshammari 等人，2018 年）。因此，护士避免询问虐待，因为他们不确定如何敏感地询问以及如何回应披露。

毫无疑问，该领域持续缺乏发展的原因是缺乏对妇女生活、健康和福祉的重视。本科课程或 CPD 并未优先考虑培训，并且能够提供此类培训的专业护理人员极为罕见。但这并不是什么新鲜事，医疗保健是一个历史上家长式的机构，数百年来一直在主导着女性的健康不平等。

4 家长式和性别角色

在医疗保健系统中，父权制和男性主导权在医疗家长作风中得到体现。曾经完全排斥女性的传统医学主导地位在现代医疗保健中仍然存在。医务人员在医疗保健系统中享有最高程度的自主权，他们在大多数情况下继续领导研究、政策制定以及服务设计和交付。因此，医生、护士和患者存在于一个操作层次结构中，医学自上而下占主导地位。这种动态本质上是性别化的，医务人员作为主要保护者扮演男性角色，而患者则是被动、女性和依赖的接受者。在这个系统中，受虐待的妇女对施虐的伴侣和医护人员都具有双重从属地位，

尽管专注于以患者为中心的护理，但护理人员往往会因参与这些结构性压迫和厌恶女性的做法而感到内疚，而患者仍然处于从属地位。护士的角色通常是关注和倡导的角色之一；然而，即便如此，也应该承认这是在优越、控制和支配地位上发生的。

粗略浏览一下在线患者反馈网站 Care Opinion，就会发现向医护人员（包括男女护士）披露虐待行为的女性有许多糟糕的经历。这种反馈通常反映了员工缺乏知识和敏感性，而患者则在应对再创伤实践和程序。尽管女性劳动力占多数，并且比非护理同龄人更有可能遭受男性暴力（Cavell Nursing Trust，2016 年），但仅凭经验不足以指导高标准的护理或消除内化厌女症的可能性。职业。

然而，护士作为最大的患者面对的劳动力并且经常领导护理模式的发展，不仅应该能够识别和应对针对妇女的暴力行为；他们也有能力领导该领域的战略发展。这并非没有挑战，因为护士也从属于占主导地位的医疗等级。这种既是支配者又是被支配者的独特地位呈现出一种紧张局势，如果不解决各级医疗保健中对妇女的结构性压迫，就不可能完全解决这种紧张局势。

因此，医疗保健领导者、管理者和教育工作者必须优先考虑关于暴力侵害妇女问题的教育、发展和培训，以提高知识、护理标准并最终提高妇女的健康和福祉。然而，他们还必须认识到并挑战迄今为止阻碍或限制女性作为患者和从业者发展的结构性障碍、厌女症和压迫。护士领导力的影响对患者的预后有着深远的影响（Francis，2013)，尤其是医疗保健在解决暴力侵害妇女行为方面的作用。虽然该问题的性别性质已得到认可，但护理领导者、组织、工会和机构在挑战现状方面发挥着作用，对患者护理有明确的影响。

5 结论

男性暴力是一个重要的公共卫生问题，影响到很高比例的女性。护士和其他医疗保健专业人员有责任识别和应对家庭虐待和性暴力的迹象，以解决持续的健康不平等问题，保护妇女并最终挽救生命。

然而，终止对妇女的暴力行为无法由个别护士实现，最终需要系统性变革以及对培训、发展和研究的投资。如果护士要解决女性面临的重大风险，那么护士教育者、领导者和管理人员必须优先考虑并投资于知识和护理的发展，以确保注册者有信心并有能力解决这个问题。

重要的是，他们还必须承认并挑战压迫性和结构上的父权制度，这些制度对推进该领域的实践和理解构成了障碍。最终，女性将继续承受不作为的负担。

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