护士在识别和应对暴力侵害妇女行为之外的作用

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 hing been repeatedly subjected to rape, harassment and physical violence over the course of their lifetime (Taylor Price 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 he 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 he 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 he 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 oid 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 nigate retraumatising practices and procedures. Despite being a majority female workforce and being more likely to he experienced male violence than their non-nursing peers (Cell 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 he 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 he 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 se 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 he no Conflict of interest.

全文翻译（仅供参考）

对男士的使用暴力 (VAW) 是身体、性或焦虑施暴的威胁或实际伤害。成年人使用暴力是最普遍和最危险性的形式，是加剧当今世界 18-44 岁成年人死亡、病症和残疾的主要原因（Ellsberg 等，2008）。这种类型的成瘾极为普遍；最近对至少 22,000 名英国成年人进行的一项调查辨认出，据统计 99.7% 的成年人统计数据称，她们一生中不会多次遭受、扰和身体使用暴力（Taylor Price Shrive，2021 年），远高于此前的预期。成年人嫌疑人谋杀男士的杀戮成年人人口普查也小规模统计数据每年至少 100 人死亡；大约每 3 天就有一个女人（Ingala Smith，2018）。使用暴力漠视男士行为是一个恰当而严重的焦虑卫生情况，对世界各地男士的保健、子孙后代和死亡率产生重大严重影响。然而，使用暴力不其所成为男士穷困中不会不可避免的一个总体；这是可以卫生保健的。

受害者，不一定也称为生存者，很确实只能低收入维修服务私人机构的保健和治疗（Hooker 等人，2020 年）。尽管如此，在世界上，保健人员对这个情况的反其所还毕竟充分。保健人员和其他低收入大学本科人员可以在比对和对策使用暴力漠视男士行为及其常见表达总体展现极为重要起到；父母施暴和性使用暴力（Bradbury-Jones，2015 年）。

这个情况的框架是如何看待或理解它的核心，它说明了了英国和世界各地越来越广泛的弱势群体情况。对男士的使用暴力是一个常见术语，在整个讨论中不会使用以突显男士的保健和子孙后代需求。然而，这常忽视了使用暴力的来源：成年人。因此，在考虑这些情况时，极为重要的是要想到，它们不是在真空中不会再次发生的，而是在厌女症、成年人积极支持和成年人随后不平等权利的背景下再次发生的。此外，在保健和低收入领域仅仅未能充分其所付这个情况，这与照护家长作风和照护在低收入等级中不会的积极支持声望有着内在的连系。

在不久的即使如此，其所付低收入中不会针对成年人的使用暴力行为的期望被外科同事所述为“考虑不周的大学本科干预”，并且“怀疑”成年人是否不会从支持中不会得益于（Fitzpatrick，2001 年）。这种不情愿与越来越广泛的弱势群体态度相呼其所，这些态度历来将父母施暴视为私底下，并加剧施暴、污名和成年人使用暴力小规模正常本土化的隐藏连续性。

在男权弱势群体的结构中不会，成年人使用暴力与成年人支配有着内在的连系，成年人仅仅被消灭，她们的境遇被隐藏起来。不一定，成年人的情况被认为是成年人只能其所付的个人情况。这忽视了使用暴力的嫌疑人，并将法律责任和法律责任推给了受害者以保障自己的安全，而不是其所付情况的开端。

然而，虽然嫌疑人对策使用暴力和施暴负全部法律责任，但严重依赖关于嫌疑人的古文献。其所付这个情况的社区步骤已被证明是最有效的卫生保健和干预策略（海牙和布里奇，2008 年），并构成了跨地方当地政府小规模实施多私人机构后果评估不会议 (MARAC) 的基础理论。因此，保健人员作为远至少的低收入大学本科群体，不必成为这一对策措施的积极组成部分，比对和对策后果、协调保健和保护成年人。

境遇过成年人使用暴力的成年人反复表达了支持、善解人意的员工和焦虑安全环境的极为重要性（Bradbury-Jones，2015）。为实现这一目标，员工不必基本知识渊博且有能力比对和对策成瘾和披露的似乎。

虽然个别保健人员确实不会选择拓展他们在该领域的基本知识和理解，但分散在维修服务、董事不会和信托中不会的少数保健人员没有大规模执行者保健，也没有进行适当的转变。因此，只能一种系统对性步骤，必需考虑研习和拓展并保障小规模性。

投资者于招聘和员工拓展对于保障员工的基本知识和能力至关极为重要。然而，在研究课题中不会仅仅似乎招聘不足之处。保健人员常统计数据依赖认识和有效对策父母施暴和性使用暴力的基本知识、信心和招聘（Alshammari 等人，2018 年）。因此，保健人员避免转告施暴，因为他们不确定如何敏感地转告以及如何回其所披露。

毫无疑问，该领域小规模依赖拓展的原因是依赖对男士穷困、保健和子孙后代的重视。本科课程或 CPD 并未必需考虑招聘，并且都能提供此类招聘的大学本科保健人员极为罕见。但这并不是什么新鲜事，低收入是一个历史上家长式的私人机构，数百年来仅仅在积极支持着成年人的保健不平等权利。

在低收入系统对中不会，父权制和成年人积极支持权在照护家长作风中不会赢取说明了。在此之前完全排斥成年人的传统外科积极支持声望在当今低收入中不会仅仅存在。医护在低收入系统对中不会行使最高总体的自主权，他们在大多数但不会继续执行者研究课题、政策制订以及维修服务设计和交付给。因此，医生、保健人员和患儿存在于一个操作方法数据模型中不会，外科自上而下九成积极支持声望。这种动态本质上是异性恋本土化的，医护作为主要保护人扮演成年人主角，而患儿则是被动、成年人和依赖的并不只能。在这个系统对中不会，受施暴的男士对施虐的婚姻和病患都具有双重从属声望，

尽管专注于以患儿为中不会心的保健，但保健人员常不会因参与这些整体反抗和厌恶成年人的处理方式而感到内疚，而患儿仅仅处于从属声望。保健人员的主角不一定是关注和倡导的角一；然而，即便如此，也其所该声称这是在优越、操控和控制声望上再次发生的。

粗略浏览一下因特网患儿一个系统对网站 Care Opinion，就不会辨认出向病患（仅限于**保健人员）披露施暴行为的成年人有许多糟糕的境遇。这种一个系统对不一定说明了了员工依赖基本知识和敏感性，而患儿则在对策再创伤有系统对和程序。尽管成年人劳动者亦然，并且比非保健出类拔萃越来越有确实遭受成年人使用暴力（Cell Nursing Trust，2016 年），但仅凭经验足以指导高质量的保健或抑止内本土化厌女症的确实性。正职。

然而，保健人员作为远至少的患儿随之而来的劳动者并且常执行者保健Mode的拓展，不仅其所该都能比对和对策针对男士的使用暴力行为；他们也有能力执行者该领域的战略拓展。这并非没有随之而来，因为保健人员也从仅指九成积极支持声望的照护等级。这种既是控制者又是被控制者的独特声望呈现出一种紧张局势，如果不其所付各级低收入中不会对男士的整体反抗，就不确实完全其所付这种紧张局势。

因此，低收入执行者者、管理者和初等教育工作者不必必需考虑关于使用暴力漠视男士情况的初等教育、拓展和招聘，以降低基本知识、保健标准化并再次降低男士的保健和子孙后代。然而，他们还不必认识到并随之而来在世界上阻碍或限制成年人作为患儿和从业者拓展的整体障碍、厌女症和反抗。保健人员执行者力的严重影响对患儿的预后有着深远的严重影响（Francis，2013)，尤其是低收入在其所付使用暴力漠视男士行为总体的起到。虽然该情况的异性恋连续性已赢取认可，但保健执行者者、组织、劳工和私人机构在随之而来境况总体展现着起到，对患儿保健有恰当的严重影响。

成年人使用暴力是一个极为重要的焦虑卫生情况，严重影响到极好比例的成年人。保健人员和其他低收入大学本科人员有法律责任比对和对策父母施暴和性使用暴力的似乎，以其所付小规模的保健不平等权利情况，保护男士并再次挽救心灵。

然而，终止对男士的使用暴力行为没有由个别保健人员实现，再次只能系统对性转变以及对招聘、拓展和研究课题的投资者。如果保健人员要其所付成年人面临的重大后果，那么保健人员初等教育者、执行者者和管理人员不必必需考虑并投资者于基本知识和保健的拓展，以保障注册者有信心并有能力其所付这个情况。

极为重要的是，他们还不必声称并随之而来反抗性和结构上的父权体制，这些体制对后退该领域的有系统对和理解构成了障碍。再次，成年人将继续承受不作为的负担。