护士在识别和应对暴力侵害妇女道德上方面的作用

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 hing 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 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（备注）

对女童的性侵犯 (VAW) 是身躯、性或认知毒打的威胁或实际伤害。女性性侵犯是最多数和最危险的形式，是导致全球 18-44 岁女性致死、营养不良和残疾的主要原因（Ellsberg 等，2008）。这种类型的滥用尤为多数；最近对大约 22,000 名英国女性进行的一项调查断定，上百 99.7% 的女性分析报告称，她们一生里多次遭受、逆和身躯性侵犯（Taylor & Shrive，2021 年），远高于此前的意味著。女性案发后谋杀女童的杀戮女性人口统计也长时间分析报告每年大约 100 人致死；至少每 3 天就有一个女人（Ingala Smith，2018）。性侵犯妨碍女童不道德是一个明确而严重的公共卫生缺陷，对世界各地女童的有益、扶助和致死率产生实质性阻碍。然而，性侵犯不应成为女童生活里不可避免的一个上都；这是可以公共卫生的。

罪犯，举例来说也称为凯恩，很可能所需公共服务于服务于部门的诊疗和治疗（Hooker 等人，2020 年）。尽管如此，在此之前，诊疗人员对这个缺陷的化学反应还不够充分。牙医和其他公共服务于专业知识人员可以在标记和应付性侵犯妨碍女童不道德及其相似合理化上都充分发挥关键性主导者作用；父母毒打和性性侵犯（Bradbury-Jones，2015 年）。

这个缺陷的开放性是如何看待或思考它的内部，它凸显了英国和世界各地更是广泛的观念缺陷。对女童的性侵犯是一个相似专有名词，在整个讨论里常用以合理化女童的有益和扶助需求。然而，这一般而言掩盖了性侵犯的举例来说：女性。因此，在权衡这些缺陷时，关键性的是要记住，它们不是在真空里频发的，而是在厌女症、女性主导者和女性随后不平等的背景下频发的。此外，在诊疗和公共服务于层面一直最终充分克服这个缺陷，这与照护家长作风和照护在公共服务于等级里的上风显现出内在的连系。

在不久的现在，克服公共服务于里针对女性的性侵犯不道德的共同努力被自然科学同事描述为“权衡不周的专业知识干预”，并且“怀疑”女性是否都会从默许里受益（Fitzpatrick，2001 年）。这种不感到高兴与更是广泛的观念态度相呼应，这些态度正因如此将父母毒打视之为私事，并导致毒打、污名和女性性侵犯长时间正常化的隐藏性质。

在所谓观念的结构里，女性性侵犯与女性统治显现出内在的连系，女性仍然被征服，她们的经历被隐藏起来。举例来说，女性的缺陷被认为是女性所需克服的个人身份缺陷。这掩盖了性侵犯的案发后，并将义务和义务归罪于了罪犯以确保自己的必需，而不是克服缺陷的根源。

然而，虽然案发后应付性侵犯和毒打负全部义务，但严重不够关于案发后的史料。克服这个缺陷的社区分析方法已被验证是最有效的公共卫生和干预解决方案（哥本哈根和布里奇，2008 年），并构成了衔接偏远地区当局长时间实施多部门风险评估都会议 (MARAC) 的基本原理。因此，牙医作为最主要的公共服务于专业知识社会群体，才会成为这一应付措施的共同努力区别于，标记和应付风险、协调诊疗和前提措施女性。

经历过女性性侵犯的女性反复合理化了默许、善解人意的管理层和认知必需环境的关键性性（Bradbury-Jones，2015）。为实现这一目标，管理层才会专业知识知识广博且有潜能标记和应付滥用和披露的迹象。

虽然个别牙医可能都会选择拓展他们在该层面的专业知识知识和思考，但分散在服务于、董事局和信托里的少数牙医无法大规模为首诊疗，也无法进行前提的变革。因此，所需一种更是进一步分析方法，前提权衡深造和拓展并确保可长时间性。

入股于培训和管理层拓展对于确保管理层的专业知识知识和潜能至关关键性。然而，在研究里一直说明了培训缺陷。牙医经常分析报告不够重新认识和有效应付父母毒打和性性侵犯的专业知识知识、决心和培训（Alshammari 等人，2018 年）。因此，牙医避免转告毒打，因为他们不明确如何敏感地转告以及如何回应披露。

显然，该层面长时间不够拓展的原因是不够对女童生活、有益和扶助的重视。本科课程或 CPD 并未前提权衡培训，并且才会提供此类培训的专业知识诊疗人员尤为罕见。但这并不是什么新鲜事，公共服务于是一个历史上家长式的部门，数百年来一直在主导者着女性的有益不平等。

在公共服务于种系统里，个人主义制和女性主导者权在照护家长作风里得到体现。曾在几乎压抑女性的传统自然科学上风在现代公共服务于里仍然存在。志愿者在公共服务于种系统里享有最高者程度的独立性，他们在大多数情况下继续为首研究、政策制定以及服务于设计和交付。因此，医生、牙医和病患存在于一个操作系统内里，自然科学左至右占去上风。这种动态直觉上是性别化的，志愿者作为主要前提措施者扮演女性角色，而病患则是某种程度、女性和依赖的接受者。在这个种系统里，受毒打的女童对施虐的伴侣和病人都兼具双重归属于威信，

尽管专注于以病患为里心的诊疗，但诊疗人员一般而言都会因参与这些功能性剥削和厌恶女性的不合时宜而深感内疚，而病患仍然处于归属于威信。牙医的角色举例来说是关注和宣扬的角一；然而，即便如此，也应该承认这是在优越、控制和支配威信上频发的。

粗略浏览一下在线病患反馈网页 Care Opinion，就都会断定向病人（除此以外男女牙医）披露毒打不道德的女性有许多糟糕的经历。这种反馈举例来说凸显了管理层不够专业知识知识和敏感性，而病患则在应付再创伤实践和程序。尽管女性劳工占去多数，并且比非诊疗同龄人更是确实遭受女性性侵犯（Cell Nursing Trust，2016 年），但仅凭经验所能指导高标准的诊疗或消除密切相关厌女症的可能性。职业。

然而，牙医作为最主要的病患面临的劳工并且经常为首诊疗模式的拓展，不仅应该才会标记和应付针对女童的性侵犯不道德；他们也有潜能为首该层面的战略拓展。这并非没有再一，因为牙医也归属于于占去上风的照护等级。这种既是支配者又是被支配者的独特威信描绘出一种紧张局势，如果不克服各级公共服务于里对女童的功能性剥削，就不可能几乎克服这种紧张局势。

因此，公共服务于为首者、管理者和教育工作者才会前提权衡关于性侵犯妨碍女童缺陷的教育、拓展和培训，以减少专业知识知识、诊疗标准并之后减少女童的有益和扶助。然而，他们还才会重新意识到并再一在此之前阻挠或限制女性作为病患和从业者拓展的功能性障碍、厌女症和剥削。牙医为首力的阻碍对病患的预后显现出不可磨灭的阻碍（Francis，2013)，尤为是公共服务于在克服性侵犯妨碍女童不道德上都的主导者作用。虽然该缺陷的性别性质已得到认可，但诊疗为首者、一个组织、工都会和部门在再一现状上都充分发挥着主导者作用，对病患诊疗有明确的阻碍。

女性性侵犯是一个关键性的公共卫生缺陷，阻碍到较低数目的女性。牙医和其他公共服务于专业知识人员有义务标记和应付父母毒打和性性侵犯的迹象，以克服长时间的有益不平等缺陷，前提措施女童并之后危在旦夕生命。

然而，终止对女童的性侵犯不道德无法由个别牙医实现，之后所需更是进一步变革以及对培训、拓展和研究的入股。如果牙医要克服女性面临的实质性风险，那么牙医的学生、为首者和工作人员才会前提权衡并入股于专业知识知识和诊疗的拓展，以确保注册者有决心并有潜能克服这个缺陷。

关键性的是，他们还才会承认并再一剥削性和结构上的个人主义税制，这些税制对挺进该层面的实践和思考构成了障碍。之后，女性将继续承受不作为的负担。