Critique article analysis -- Lived experience

P A T I E N T P E R S P E C T I V E S

The lived experience of women victims of intimate partner violence

Alice Yuen Loke, Mei Lan Emma Wan and Mark Hayter

Aims and objectives. This study aims to gain a better understanding of the lived experience of female victims of intimate partner

violence.

Background. Intimate partner violence (IPV) is a complex and prevalent social problem associated with significant impairment

in the physical and psychological health of victims.

Design. Exploratory, qualitative design.

Methods. Face-to-face interviews were conducted among nine IPV female victims who presented themselves at an emergency

department of a regional hospital. Data were subject to thematic analysis.

Results. Victims are often ashamed to disclose their situation and reluctant to seek help, afraid of being ridiculed or ignored.

Violent experiences also lead to low self-esteem, depression, and suicidal ideas. They are ambivalent about staying in an abusive

relationship and endure violent incidents in silence until they cannot tolerate any more and seek help at an emergency

department. They have negative experiences in help-seeking: other family members and health professionals coloured by

cultural restraints generally ignore their complaints and need for help.

Conclusions. Provided a preliminary understanding of the experience of Chinese women in Hong Kong. In support of these

women’s help-seeking behaviours, continuing education programmes are needed to better prepare health professionals for

caring for these women.

Relevance to clinical practice. Health professionals should be astute in identifying IPV victims with whom they come into

contact at work. They should assess the immediate physical and emotional needs of these women, be empathetic, show

acceptance, extend a helping hand and assess home safety before discharge.

Key words: Chinese women, intimate partner violence, lived experience

Accepted for publication: 26 February 2012

Introduction

Intimate partner violence (IPV) is a serious social health

concern worldwide (WHO 2002). Reports from various

studies indicate a high prevalence of IPV in all societies.

Although Hong Kong is a westernised society, no matter how

productive or independent women in Hong Kong are, they

are no exception to this prevalence. A review of studies

conducted in different parts of China reported the average

lifetime and annual prevalence of male on female IPV as

19Æ7% and 16Æ8%, respectively, for any type of violence (Tang & Lai 2008). Another study, which surveyed a total of

1132 women in Hong Kong, concluded that marital dissat-

isfaction and age difference within a couple are predictors of

IPV (Tang 1999).Although prevalence and causal factors

have been reported quantitatively, there has been no in-depth

Authors: Alice Yuen Loke, RN, PhD, Professor, School of Nursing,

The Hong Kong Polytechnic University, Kowloon; Mei Lan Emma

Wan RN, MSc, Registered Nurse, Accident & Emergency

Department, Alice Ho Miu Ling Nethersole Hospital, Hong Kong,

Hong Kong; Mark Hayter PhD, RN, Cert Ed, FRSA, Professor,

Faculty of Health and Social Care, University of Hull, Hull, UK

Correspondence: Alice Yuen Loke, Professor, School of Nursing,

Division Head, Division of Family and Community Health, The

Hong Kong Polytechnic University, Hong Kong. Telephone:

852 2766 6386.

E-mail: [email protected]

! 2012 Blackwell Publishing Ltd 2336 Journal of Clinical Nursing, 21, 2336–2346, doi: 10.1111/j.1365-2702.2012.04159.x

qualitative work into women’s experiences of IPV in Hong

Kong and how they relate to the international empirical

evidence on this important health and social issue. This study

is designed to address this gap in the literature.

Background

Chinese culture and intimate partner violence

In traditional Chinese families, the husband has the final

authority on family issues. The social norms provide/dictate

that a ‘good woman’ should obey her husband and perform the

roles of a virtuous wife and mother well. Although the

patriarchal social structure in China may have diminished

somewhat, Chinese women (25–40%) still believe that a good

wife obeys her husband and is obliged to fulfil her husband’s

requests even if she does not feel like it (Hollander 2005).

Fear of losing face and the traditional notion of keeping

things within the family have also made it difficult for the

Chinese families to break the silence regarding the violence in

their homes (Xu et al. 2001). As many as 70% of Chinese

women agreed that family problems should not be discussed

with outsiders (Hollander 2005). Chinese women should

never point out their husbands’ inadequacies or mistakes in

public, a likely cause of IPV victims’ hesitation to disclose

their family problems (Tai 1994). Women endure humiliation

and conceal their experience for fear of being reprimanded by

their husbands.

Need for better understanding of IPV

Recognising women who are vulnerable to victimization is

essential for health professionals. However, when health

professionals hold the cultural belief that family affairs are a

private matter, this may affect their approach towards

women who suffer from intimate partner violence. Even if

women seek health care, most people, including nurses, still

believe that IPV is a private family matter in which other

people should not intervene (Chung et al. 1996). A study

conducted among accident and emergency nurses in Hong

Kong revealed that although 57% of nurses agreed that they

had a duty to intervene, all of them also believed in the

Chinese saying that ‘even a good judge cannot adjudicate

family disputes’ (Chung et al. 1996). A study among emer-

gency room physicians also revealed that nearly half (48%)

agreed with this Chinese saying, with 24% being neutral

(Wong et al. 1997). As many as 61% of these nurses

indicated that they would not directly ask a woman who

was suffering from domestic injuries whether the injuries

were inflicted by the woman’s male intimate partner. While

these nurses can play a crucial role in screening and caring for

victims of IPV, their attitude may interfere with their

willingness to fulfil this responsibility.

While most studies have been conducted in Western

countries, there is a dearth of studies that explore the lived

experiences of women in intimate violent relationships in

Hong Kong. A list of 312 publications on intimate violence

from 1983–2005 was compiled by Coughlan (2006). The

articles focused on populations around the world, including

Cambodian, Vietnamese, Korean, Filipino, South African,

Hispanic, Arab, Jordanian and many more. Only 12 of the

studies were conducted among Chinese women, five of them

among Chinese immigrants in western countries. These

studies mainly identified the prevalence and risk factors of

IPV; only one was a qualitative study focused on the

experiences of victims.

A review of literature was also conducted on IPV in China

(Tang & Lai 2008). Based on the results, among the 19

studies published from 1987–2006, only six were conducted

among Hong Kong Chinese. All of the studies were quanti-

tative and adopted the Conflict Tactics Scale (Straus 1979,

Straus et al. 1996) and the Abuse Assessment Screen (McFar-

lane et al. 1992) to identify the demographics of the female

victims and their family relationship factors. Another study

examined the relationship between domestic violence and

postnatal depression among Chinese women in Hong Kong

(Leung et al. 2002).

As most of these studies focused on identifying the

demographic and family predictive factors of IPV, a quali-

tative study is needed to explore the lived experience of

female IPV victims. This understanding of IPV female

victims’ lived experience of domestic violence will fill the

health professionals’ knowledge gaps of these victims’ strug-

gle and needs. Sharing their experience with the health

professionals can eliminate the stigma attached. The recog-

nition of the lived experiences and help-seeking process of

IPV female victims can also provide healthcare providers with

information to improve their screening approach and services

and to develop effective strategies to meet the needs of IPV

victims.

Methods

Study design and aim

This is a descriptive qualitative study focusing on individual

interpretations of lived experiences, aiming to gain a better

understanding of the lived experiences of women suffering

from intimate partner violence. The objectives of this study

are to explore (1) women’s experience and feelings in violent

Patient perspectives Chinese women victims of intimate partner violence

! 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 2336–2346 2337

relationships, (2) their decision to disclose or stay in the

abusive relationship and (3) their help-seeking experience and

needs.

Purposive convenience sampling was used to recruit women

who were admitted in the Accident and Emergency Depart-

ment (AED) of a regional hospital in Hong Kong from August

2006 to January 2007, reporting physical assault by their

intimate partners. This setting was selected because it was the

intention of this study to recruit women who had not left the

situation. The inclusion criteria were as follows: Hong Kong

Chinese women over the age of 18 and living with the assailant

and who agreed to take part in this study. Those who

demonstrated signs of cognitive impairment or mental illness

and those who were in police custody were not recruited.

Data collection

After receiving treatment and before discharge from the AED,

eligible women were informed of the purpose of the study

and invited to take part. All were ensured of confidentiality

and that their participation in this study would not be

revealed to their partner. Interviews were conducted in a

private room with a comfortable atmosphere in the AED to

ensure privacy and provide a sense of security to enable them

to describe their experiences. The face-to-face interviews

lasted from 40–90 minutes and were recorded on an MP3

recorder.

Data were collected through semistructured interviews

with an interview guide developed for the purpose of this

study. A nurse specialist and a physician with over 10 years

of experience in caring for IPV victims in the AED were asked

to consider the relevancy of the interview questions. A pilot

interview was also conducted to test the interview guide for

clarity, coverage and representativeness. Probing questions

were used to encourage open communication.

All interviews were conducted in Cantonese (the dialect

commonly used in Hong Kong). Verbatim transcripts were

transcribed from audiotapes into written Chinese within two

weeks of the interviews.

Data analysis

Once the interviews had been transcribed verbatim, paper

copies were produced for analysis. The transcriptions of

interviews were analysed by the researcher and the nurse

educator independently, both of whom were fluent in both

Chinese and English languages.

The thematic approach to qualitative data analysis

described by Joffe and Yardley (2004) was used to derive

key themes from the data. Initially, line by line coding was

undertaken, as well as reading and rereading transcripts to

become familiar with the data. Coding at this stage was

linked to specific aspects of the women’s accounts and simply

reflected the specific emotion or issue described in that section

of the data. As this coding proceeded, notes were taken and

attempts were made to link them into larger and more

substantive codes or ‘subthemes’. During this process, the

data were explored for links, similarities and differences to

check the robustness of the emerging segments of data. The

two sets of analysed themes were compared and discussed

until a consensus was reached, and the themes were

combined, summarised and classified according to categories.

A final stage of analysis saw the larger codes amalgamated

into more encompassing and significant themes that provided

a picture of the key elements of the participants’ experiences.

These final themes represent the core elements of these

women’s experiences of IPV translated into English. The

statements given by women who shared the same sentiment

and meanings in the interviews were merged under the same

themes and presented in English.

Ethical considerations

Ethical considerations were a major concern because of the

complex and sensitive nature of IPV. Ethical approval was

obtained from the university and hospital ethical committees

prior to the commencement of the study. Interviews were

only commenced after each eligible woman had received a

clear explanation of the purposes of this study and consented

to the study. To protect their identity, the women were not

required to sign a consent form. Participants were informed

that they could withdraw from the study at any point during

the interview and assured that their identity would be

concealed. All the data collected were kept confidential.

A danger to women IPV victims exists when they either

return to their partners or attempt to escape from the abusive

relationship. After the interview, the researcher provided the

women with information on social workers’ availability, and

alternatives such as making arrangements to stay in a

nongovernment organization’s shelter for domestic violence

victims, if desired.

Results

Face-to-face semistructured interviews were conducted with

nine female victims. Six of the women were aged from 39 to

50 and three from 19 to 27; they were 1–14 years younger

than their husbands and had been married for 1–33 years.

Seven had secondary school education, one had primary

school, and another had completed university. Three of the

AY Loke et al.

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women were housewives and six were employed, with an

average monthly income of HK$6700 (US$880). Two of the

husbands were unemployed and five had jobs with an average

monthly income of HK$12,700 (US$1,500), representing

families from the lower social class in Hong Kong.

The women reported that the violent incidents were

provoked by arguments regarding family finances or extra-

marital affairs. All interviewees reported different degrees of

physical abuse, including punching, slapping, shoving,

smothering and having objects thrown at them. Three women

reported psychological abuse, including hostility and intim-

idation, and one reported being sexually abused.

Identified themes of IPV women victims’ lived experience

Four themes were derived from the thematic analysis process:

(A) feelings of shame, low self-esteem, depression and

suicidal ideas; (B) violent experiences leading to despair,

helplessness and insecurity; (C) ambivalence about staying in

an abusive relationship and enduring intimate partner

violence and (D) experiences of help-seeking and needs.

Feelings of shame, low self-esteem, depression and

suicidal ideas

The abused women were ashamed of the domestic violence.

The feeling of shame leads to low-self-esteem, depression and

suicide attempts. They considered family violence to be a

private matter and were ashamed to reveal their situation.

They were also ashamed to go out, for their partners’ violence

often resulted in bruises and swelling on their face and neck

that could readily be seen by others. They said:

I am ashamed to talk about the violence in my family; I don’t want to

wash my ‘dirty linen’ in public or share it with others. (01, 02, 03, 06,

07, 08, 09)

After my husband beats me, there are obvious bruises on my face. So

I stay at home all the time to avoid having to explain the cause of

these injuries to others. (07, 08)

Abused women have low self-esteem, feeling that they are not

worthy of respect and do not deserve love in the relationship.

The abused women kept thinking about their husband’s

insulting comments about their inadequacy as a wife. They

often blamed themselves and tried to change. They said:

After he reprimands me, I wonder if I am as useless as he said. I often

blame myself, asking myself if I have not done enough as a wife.

Perhaps I have done something wrong, and not paid enough attention

to my husband? (01,03)

I must not be worth loving, the way he is treating me. He said he

would make me happy when we got married. Now he makes me feel

not worthy of being loved. (01, 02, 03, 04, 06, 09)

Most abused women reported symptoms of depression,

including insomnia, fluctuating emotions and loss of appetite,

and having lost satisfaction in life. These women expressed

that they could not see the beauty of living and that life had

no purpose and had suicidal thoughts because they found life

meaningless. They said:

I keep thinking about our relationship, so that I have to rely on

sleeping pills to sleep. I can also hardly eat. (01, 04,06)

When I am alone, I often think about our relationship and could just

cry… (05)

Nothing really interests me in life. I don’t see anything good about

life. I am like a walking corpse without a spirit. (01, 02)

I think I have lost the will to live. I have attempted suicide many

times, but was saved. I saw how sad my children were, so I dare not

attempt suicide again. (01, 04)

When a suicide attempt did not end her suffering, one woman

wanted to hurt her husband so that she could escape from the

situation by being in jail. She said:

I once attempted to leap from a building to end my life, but I could

not. I then thought about hurting him and how being sent to jail

might be an escape. (06)

The above theme which emerged from the interviews revealed

that intimate partner violence (IPV) is associated with

significant psychological distress in victims, causing shame,

low self-esteem, depression and suicidal ideas.

Violent experiences leading to despair, helplessness and

insecurity

The abused women were despairing, helpless and insecure

about living with a violent husband.

They were in despair because of their husbands’ lack of

remorse and the repeated violence against them. They felt

helpless because they were living with their husbands under

the same roof and nobody else could protect them. They

said:

Initially, he apologized for his act and promised not to hurt me again.

But his violence has grown over the years and is repeated without

regret. (03, 05)

I can’t figure out any solution. It is hard for anyone to intervene. He

doesn’t think he is wrong, and can’t control himself when he gets

mad. (04, 05, 07, 09)

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I could not find anyone who could help. I told my relatives, but they

can’t help as they don’t live with me. Even the police cannot watch

him all the time. (03, 04, 07)

The women were afraid of arguing with their irritated

husbands, or they would end up being beaten. One woman

felt extremely unsafe and was kept awake by her fear. The

women remarked:

I am afraid all the time that I may irritate him. When he loses his

temper, he beats me. I am frightened all the time and dare not offend

him. (02, 04, 05, 09)

My husband pulls me out of bed when I am sleeping. I feel unsafe and

am afraid that one day I will be murdered. I often wake up and am

unable to fall back to sleep. (01)

Interviews also revealed that the experiences of intimate

partner violence (IPV) lead to despair helplessness, and

insecurity of these victims.

Ambivalence about staying in an abusive relationship and

enduring Intimate Partner Violence

Eight of the nine abused women interviewed had tried to

leave the abusive situation at some point. They were

ambivalent about staying in the abusive relationship. How-

ever, many of the abused women would do anything to keep

the family together. They believed a divorced woman and

children from a broken family would be socially stigmatised.

They also had conflicting feelings about the effects of

domestic violence and parental separation on children. They

said:

I want my children to live happily in a family, so I can’t divorce my

husband. Both I and my children from a broken family would be

‘looked down on’ by others. (01, 03, 04, 07)

I don’t want my children to witness all this. I am afraid that he will

hurt the children. But divorce is detrimental to children, they are

innocent. (01, 02, 03, 05, 09)

The women tried to endure the pain or to withdraw from

arguments to prevent attacks. Financial insecurity was the

crucial reason why these IPV victims stayed in their abusive

relationships. They did not see any way out because of

financial self-insufficiency. They said:

If he beats me or throws things at me, I let him. I clean up the mess

afterwards. I only try to stop him if it is serious or if I can barely

endure the pain. (01, 02, 04, 08)

I am ambivalent. If I stay with him, the violence will continue. If I

leave, I’ll confront financial and housing problems. I am trapped in

this abusive relationship and can’t leave as I don’t know which

situation is worse. (09)

Women tend to withdraw or keep silent while enduring

IPV. Violence was seen by the abused women as an

aberrant event beyond the control of their husbands. The

women reported being beaten on a situational basis; they

believed that when the stressor was removed, their

husbands would stop. They described this in the following

statement:

I sometimes leave for a few hours after he beats me. Then I pretend

that nothing has happened and go back home. (01, 05, 08, 09)

He’s fine if he doesn’t lose his temper, but he just turns into another

person once he gets mad or drunk. He is out of control and goes

crazy, and he will beat me. (05, 07, 08)

Three women said their husbands had taken good care of the

family and the children, apart from the violent incidents.

They said:

I can’t leave my husband because he has provided for the family and

deserves the family and our kids, even though he beats me sometimes.

(03, 06, 08)

The above theme and quotes revealed that although these

victims were psychologically distressed by the intimate

violence, they had ambivalent and conflicting feelings about

staying in an abusive relationship. These women choose to

stay with the family for the sake of family completeness

and for the children, allowing themselves to remain

trapped in abusive relationships enduring intimate partner

violence.

Experiences of seeking help and needs

The women were more likely to keep their silence and endure

the pain of violence when the violence was less severe to

avoid confrontation. They knew they will require a shelter

and financial support to meet immediate needs but were

reluctant to seek help because they did not know what

services were available in the community for them. They also

expressed their fear that seeking help would make the violent

incidents even worse and felt that they will be in danger if

they returned home after seeking help.

Now that other people know about this, I’m afraid it will affect our

relationship. Since I reported him to the police, I cannot face him. I

am now in trouble. (03, 04, 05)

If I run away from home or get a divorce, I don’t know how I will

cope with living. I do not know if there are any organizations that can

help, and I need information. (06, 09)

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I want to find a place to live. I cannot even afford to rent a small

room. If I had a place to live, many of the problems I am facing could

be solved. (01, 06)

I just need money to maintain my children and myself. (02, 04,

05)

The women would only break the silence when they were

escalating in violence and perceived increased threat or threat

of death.

In the past, he hit me with his fists so I tolerated it. But this time he

used a hard object. I realized that the children and I were in danger,

so I called the police. (01, 04)

However, the abused women reported mostly their negative

help-seeking experiences. These women complained that

their friends or relatives were not able to be empathetic to

their situation and suffering and complained that most people

could only offer unrealistic solutions and not practical help.

They said:

I told my family that my husband had beaten me, but they blamed

and scolded me for having a conflict/arguing with him face-to-face.

(02)

Some people advise me not to argue with my husband. But I don’t

know how to avoid irritating him; I don’t even know what I do

sometimes that irritates him. (07)

I told one of my relatives about my circumstances, and she just keeps

giving me advice without being truly concerned about my feelings.

She just told me to move out. (01,05,09)

Three abused women also reported that they had negative

experiences when seeking help from police and doctors. Two

complained that the police belittled their feelings and

recommended that they compromise and reconcile with their

partners. The abused women said that doctors merely provide

treatment for injuries and are not concerned about their

feelings; after all, they cannot help solve their domestic

problems.

I called the police for help, but they only told us to stop quarreling. I

begged them to help, but all they said was, ‘Just forgive him, all men

are like him; being a woman, you should know’. The police were,

like, forming an alliance with him. (01,07)

When the policeman came, he just told us that money is not a

problem, and that we could apply for social assistance. Since

then, he is no longer afraid of the police.

I don’t think physicians can help me; they only give me pain-killers

and a physical check-up. They never ask me about the incidents or

show caring. (05, 07, 08)

While there were abused woman who complained that social

workers did not offer realistic solutions or help, another had

a different experience and was appreciative of the support

from a social worker. This is what she said:

The social workers just told me to escape from violent scenes. This is

impossible, for he can grab me. Another told me to get a divorce. This

means they can’t help. (02)

I told a social worker that I have suicidal ideation. She understood

that my emotion state was not stable, so she phoned me many times,

enlightened me and taught me what to do. (07)

For some women, this interview provided an opportunity to

ventilate, and they appreciated the concern shown by the

interview nurse in the emergency department.

I would be suffering if I continued to hide this from others. Now I feel

some relief. Of course, it is not appropriate to share my feelings with

everyone. I really appreciate those who know how to comfort me,

analyze my situation, and give me some advice. (03, 05, 08, 09)

The above suggests that victims do not receive the necessary

services until they are in danger. However, they had used the

interview as an opportunity to ask for help and information

and indicated their needs to the interviewer. They hoped that

nurses at the emergency department would provide them

with relevant information and expressed their appreciation to

those who listened and provided practical suggestions.

Discussion

This study aimed to explore the lived experience of women

who reported physical assault by their intimate partners at

the Accident and Emergency Department (AED) of a

regional hospital. Though the women in this study were

recruited in the AED, it is important to emphasise that

intimate partner violence is widespread in patient popula-

tions across different medical specialties. A study that

compared intimate partner violence among women in

hospital waiting rooms across medical specialties showed

that women in addiction recovery programmes reported the

highest rates of IPV, followed by those in emergency

departments and in obstetrics and gynaecology departments

(McCloskey et al. 2005). A large number of studies have

focused on the relationship between intimate partner abuse

and adverse pregnancy outcomes (Janssen et al. 2003) and

postnatal depression (Leung et al. 2002). Women who suffer

from intimate partner violence can present themselves in

different medical settings, including during pregnancy, thus

these women are not to be neglected.

Patient perspectives Chinese women victims of intimate partner violence

! 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 2336–2346 2341

Psychological distress and decision to stay

The results of this study unveiled the feelings and lived

experiences of women suffering from IPV. The abused

women’s feelings of despair and helplessness were gradually

reinforced by the repeated violence of their husbands, their

self-insufficiency and their experiences of disclosure. They felt

helpless because they had no control over the violence

committed towards them. This feeling of helpless leads to low

self-esteem, depression and suicide attempts.

A previous study in the West suggested that the IPV cyclic

pattern usually went from tension rising to an abusive

episode, and then to a honeymoon period (Walker 1979,

Domesticviolence.org 2009). This honeymoon period

explained why victims repeatedly forgave their husbands, in

that the abusers usually apologised profusely, promising

never to do it again, professing love, crying and bringing the

victims flowers. However, this was not the case of women in

this study. This may be due to the cultural belief that Chinese

men do not necessarily view marital violence as a violation of

women’s rights, seldom apologise and do not show remorse.

Victimised wives with damaged self-esteem may not neces-

sarily feel that they have a right to complain (Yick &

Agbayani-Siewert 1997).

Chinese women choose to stay with the family for the

sake of their children and therefore allow themselves to

remain trapped in abusive relationships. The victims of IPV

in this study had endured the violence for years and

struggled to remain in their relationships. They had con-

flicting feelings and worried about the effect on children of

either parental separation or witnessing violence. They chose

to stay in the relationship to provide their children with ‘a

family’. It was the Chinese women’s belief that they should

obey and be good wives to their husbands and good mothers

to their children. A study among Mexican women also

found that women chose to stay in abusive families because

they worried about the psychological effects on their

children or chose to leave only when they thought the

abuser might become violent towards the children (Acevedo

2000).

Whether women can successfully leave their abusive

relationships depends on their ability to support themselves

financially after leaving (Lutenbacher et al. 2003). Even those

who had paid jobs were worried about their financial

situation and chose to stay. The reasons were that women

lived in the context of shared lives and the associated

resources. Leaving meant changing what they were used to

and could be perceived as threatening. It is a limitation of this

study that most women were from the lower social classes,

making it difficult for them to leave their homes.

Help-seeking behaviours and attitudes from professionals

Although women in this study expressed shame at disclosing

their experience, nearly all of them had told someone (family

members, policemen or social workers) before. They were

embarrassed to start the conversation about their violent

experiences because many were being ridiculed or prejudiced.

They were also disappointed that others were reluctant to

help, creating barriers to their help-seeking.

Women in this study reported that they would not have

sought help if they had not perceived a threat to their safety.

This is consistent with reports that most women tend to put

up with IPV until they perceive danger (Ellsberg et al. 2001).

When the abuse is less severe, women are more likely to

endure the pain of violence, withdrawing from the argument

or scene. When the violence became severe, involving the use

of deadly objects, the women would call for help. This

suggests that victims do not receive the necessary services

until they are in danger.

The women in this study were ridiculed when they told

others of their IPV experience, which was consistent with the

findings of other studies (Flinck et al. 2005). These women

complained that their friends or relatives were not able to

offer practical help. They were also disappointed with the

police officers and social workers, who were prejudiced and

underrated their experience. As a result, these women were

reluctant to seek help, believing that the ‘helping’ profes-

sionals could not offer help. Intimate partner violence is a

taboo subject in the mainstream Chinese culture of Hong

Kong. Health professionals, including doctors and nurses,

who hold the cultural belief that a ‘family affair is a private

matter and that other people should not intervene’ may

affect their compassion, empathy and their approach to IPV

victims and become reluctant providers (Inoue & Armitage

2006).

Although women expressed that they hoped that health

professionals would be able to help, none of them mentioned

their experience in approaching nurses for help related to

their IPV experience. However, the women who took part in

this study considered the interviews as a way to call for help.

This incident, which had resulted in their needing emergency

care, had opened up an opportunity for them to share their

experience with the interviewer, a nurse working on the

accident and emergency department.

Literature on the help-seeking of abused women from

formal support groups often refers to policemen, social

workers, medical personnel, crisis hotline workers, mental

health professionals, clergymen, women’s group advocates

and staff at women’s shelters (Goodman et al. 2003, Liang

et al. 2005). It is unfortunate that the nursing profession, the

AY Loke et al.

! 2012 Blackwell Publishing Ltd 2342 Journal of Clinical Nursing, 21, 2336–2346

largest group of health professionals and comprised of mostly

women, is not included in the list of formal support for

abused women, even though in most circumstances nurses are

the first healthcare professionals to come into contact with

these women.

It has been reported that IPV victims are ashamed at

disclosing their situation but are willing to discuss their

problems if professionals approach them directly with respect

and a guarantee of privacy (Fraser et al. 2002). They also

value direct questions with nonjudgmental understanding

and support (Rodriguez et al. 1996). The acceptance and

appropriate response of nurses can encourage women to seek

help according to their needs.

The insensitivity of others and their reluctance to help

also hindered the abused women’s efforts to make the

decision to leave and seek help from others or to reshape

their lives. It is of concern that the perception of the general

public and the associated social stigma attached to IPV have

contributed to these women’s feelings of helplessness,

influencing their decision to stay in the abusive relationship

and compromising their help-seeking experience. A study

conducted in Thailand also shared this concern (Saito et al.

2009).

Assisting battered women to identify their health needs

The results of this study suggest that abusive relationships

had negative psychological effects on battered women.

However, these women mainly expressed their needs relating

to financial assistance and shelter arrangements to reshape

their lives. This is consistent with other studies (e.g. Shim &

Haight 2006). Women were concerned about the danger

lurking when they returned home. Others were not aware of

the resources available to help them.

These were women who had been injured acutely and

severely enough to seek medical treatment. The degree of

stress and disorientation experienced by these victims under

these circumstances also made it difficult for the interviewed

women to clearly articulate their needs and utilise their

problem-solving skills. Studies have found that IPV decreases

victims’ decision-making and problem-solving skills and

lowers their perceptions of self-efficacy and self-esteem

(Gianakos 1999, Yick et al. 2003).

Professionals should be astute in detecting, assessing and

identifying these women’s needs and should respect their

privacy and provide protective measures. Healthcare profes-

sionals, nurses working across medical specialties and the

police should be aware of the needs of these women and have

understanding of IPV and the importance of helping these

victims.

Conclusion

The findings from this study contribute to a better awareness

and understanding of IPV victims and their needs. Help-

seeking behaviours are usually triggered or hindered by

feelings of insecurity, an increase in the severity of IPV and

previous help-seeking experiences. IPV has severe impacts on

the physical and psychological health of victims that warrant

special attention from health professionals. The position

statements of the American Nurses Association (ANA 2008)

and the Emergency Nurses Association (ENA 2006) clearly

declare the prevention, assessment and research on violence

against women as healthcare priorities.

Health professionals may find themselves incapable of

handling these women, who usually present with multiple

social problems (Hamberger et al. 1998). It is not uncommon

for physicians to treat only the physical injuries, belittling the

abusive act, blaming the victim, finding excuses for the

abusive man and failing to make referrals to social workers or

follow-up appointments. Health professionals, particularly

nurses working in accident and emergency departments, who

are often the first to come into close contact with these

women in need of help should learn to overcome this obstacle

and approach suspected victims with assured respect and

sincerity.

Relevance to clinical practice

Early and effective interventions can reduce the negative

consequences of IPV and the likelihood of women tolerating

potentially fatal violence. The results of this study highlight

the deficiency of the healthcare sector in dealing with IPV

victims, and the influence of a cultural perception of IPV.

Helping professionals should play an important role in the

identification and management of victims of IPV. The

emergency department is the healthcare facility most likely

to be the first point of contact for women in abusive

relationships, for treatment of injuries or manifestations of

stress inflicted by IPV (Jackson et al. 2001, ENA 2006).

Alertness to presentations of possible IPV cases and under-

standing of women’s abusive experiences are paramount.

Screening for suspected IPV cases is essential for the early

identification of IPV victims. Asking questions directly about

IPV as a routine part of a patient’s history will help providers

become more familiar and comfortable with these difficult

questions (Lutenbacher et al. 2003).

A screening protocol for identifying and caring for IPV

victims is needed for effective and efficient service in the

protection of these victims. Health professionals should also

assess the physical and psychological health ramifications of

Patient perspectives Chinese women victims of intimate partner violence

! 2012 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 2336–2346 2343

these victims (Xu et al. 2001). There is a lack of culturally

appropriate instruments for assessing IPV against Chinese

women (Xu et al. 2001), and instruments from western

countries are therefore adopted, such as the most commonly

used tools for assessing IPV, the Conflict Tactics Scale (CTS)

and the Abuse Assessment Screen (ASS). Screening tools

adopted from other countries are often inadequate, as

translated phrases may not have the same meaning across

different cultures (Lopez 2001). It is important to incorporate

cultural values to reflect the realities of these women’s

experience and to adapt and develop an appropriate and

culturally sensitive screening tool for the assessment of IPV

(Kasturirangan et al. 2004, Xu et al. 2001).

The traditional Chinese cultural attitude of nurses and

other health care professionals regarding privacy and family

affairs has hampered their ability to recognise the need to

provide services to these IPV victims. Nurses and health

professionals should be empathetic towards these victims and

provide them with the needed respect and care. Educators

should take into consideration these cultural beliefs in their

curriculum to prepare health professionals who are capable

of managing these patients who are victims of intimate

partner violence (Chung et al. 1996).

Many battered women are revictimised when they return

home after seeking professional help. There is a need for

collaboration and communication between health profes-

sionals from the AED, social workers, the police and battered

women’s advocates for continual care. A cohesive community

response to IPV will tackle some of the barriers that women

encounter when seeking help. Interventions for these women

should include essential services such as assessment of home

safety before discharge, follow-up visits, counselling, infor-

mation about community resources and family-oriented

services to prevent revictimization.

Implications

Most nurses have no formal training in working with

domestic violence. An educational programme on IPV is

needed to promote acceptance and appropriate screening for

victims through an understanding of their feelings, appropri-

ate communication skills and effective interventions to

protect these victims.

Future studies should include women from different

settings, identification of high-risk groups, the association

between spouses’ personalities and violence, and male

perceptions of their violent behaviours. Particularly impor-

tant in further study is to explore the attitudes and percep-

tions of healthcare professionals towards intimate partner

violence.

Contributions

Study design: AYL, MLEW; data collection and analysis:

MLEW, AYL, MH and manuscript preparation: MLEW,

AYL, MH.

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