When explaining her beloved profession, Tina Bloom cites an analogy that those in public health often use. There’s a river, she says, and health providers like Bloom wait on the banks. People who have fallen in are drowning—and the role of health care providers is to rescue them. They pull the people to shore and give them blankets and food. They do what they can to offer safety. But Bloom wants to help more and help earlier.
“At some point, you start to think about what’s happening upriver,” she says. “Why are all these people ending up in the water? Nursing research allows us to look at those upstream causes and figure out why people end up in the river in the first place.” As an assistant professor in the Sinclair School of Nursing, Bloom’s work focuses on safety planning. She is designing and testing a website for women in abusive relationships that might help them find ways to lessen their danger.
“Women who are in abusive relationships are at high risk for poor health outcomes because of ongoing violence—and the effects that violence has on their physical and mental health. Women aren’t responsible for the violence, but sometimes there are things they can do that can help reduce their exposure,” Bloom notes. For example, when a woman senses violence is coming she should reconsider her location within the house, moving from the kitchen (with its potential weapons) or from a room without exits to rooms that are inherently safer. A woman can also learn to construct a safety plan for her children to keep them out of harm’s way when violence erupts and to recognize the warning signs that may indicate that the level of danger in the relationship is increasing. There are also other strategies she can employ, such as stashing money, important papers, and a bag of clothes in a secret place so that she can leave quickly if necessary. She can also connect with resources and advocates in her community for ongoing support and services.
This is the kind of information health care providers and domestic violence prevention advocates convey every day to women on a one-by-one basis. Taking advantage of technology to extend their influence, Bloom is working on an interactive web-based “safety decision aid” that will provide abused women with individualized advice while reaching more than one client at a time. Her current project involves a partnership with investigators in three other states to test the online decision aid. This initiative expands on a smaller study that she helped develop in Oregon, where ninety abused women (twenty-four of whom were Spanish speakers) pilot-tested the program.
The decision aid allows each abused woman to assess her own level of peril via the Danger Assessment, a validated tool for use in abusive relationships. It also allows her to identify safety measures she’s already taken, and to explore her priorities (feelings for her partner; the need for resources such as income, housing, or health insurance; concerns for her children; and desire for privacy). The interactive routine produces a personalized safety plan based on this information, and provides additional resources. It is available in both English and Spanish.
Bloom explains that limited access to information represents a huge barrier to safety planning. “Here in Missouri, one in three residents are rural, and rural women are especially vulnerable,” she cautions. “They are often very isolated, may lack transportation and other resources, and may live hundreds of miles from the nearest battered women’s shelter.” Because the safety decision aid is Internet-based, Bloom hopes that even women in remote areas of Missouri will someday be able to use it to get help.
“Women don’t have to be computer whizzes to access this instrument,” she explains. With narration to guide them, women of all literacy levels can use the site. Participants will even have individual logins so that they can repeat the test and watch how their answers change over time. The program moves from general to more personal questions. Does the user have children? What other safety measures has she taken? Has she hidden money? Removed a weapon? After the woman completes the Danger Assessment and questionnaires about her mental health and safety, the program allows her to compare the relative importance of various factors in her safety decisions: her relationship and feelings for her partner, the well-being of her children, her concerns for safety, her desire for privacy, and her need for resources.
The program then provides the woman with individualized feedback about her risk factors and level of danger. It also shows her priorities in the order she has ranked them. If she disagrees with the priorities, she is encouraged to go back and switch them around. Finally, the program returns with an action plan that lays out various steps, tips about safety for children, restraining orders and other legal processes, and information to help women find local community resources and help.
While there is abundant anecdotal evidence that safety planning works, Bloom says there is no scientific proof. The current study, therefore, is intended to produce the evidence that safety planning helps to reduce the risk of repeat violence and to improve mental health for abused women in the long term. The whole goal—in terms of the river analogy—is to see whether safety planning can prevent women from falling into the water.
The collaborative study is taking place in four states, with a total of 720 participants, and is funded by the National Institute of Mental Health. Partners include the Johns Hopkins School of Nursing, Oregon Health and Sciences University School of Medicine, and the University of Arizona School of Social Work, and Bloom heads up the Missouri portion. The study will be randomized, with some participants receiving personalized safety planning and others only general information. In order to protect the safety of the women involved, the investigation follows the extensive guidelines established by the Nursing Research Consortium on Violence and Abuse.
Bloom began her nursing career in the traditional way, working in a labor and delivery room in Oregon. Her first research experience consisted of interviewing 500 pregnant women about domestic abuse. “I came to realize that through nursing research you could help potentially a lot of people at the same time,” she explains. So it is that Bloom continues to work her way further upstream, armed with dedication and a website, always pursuing a single goal: to help prevent women from falling into the river.