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Partner violence is one of the decisive health risks for women worldwide.

For about 10 years, the interventional possibilities of health care to protect the health of victims of violence have also been discussed in Germany. In addition to treating specific health problems, health care can recognise the presence of violence, document findings in a way that can be used in court, reduce long-term consequences and, in cooperation with other supporting institutions, help to clarify the possibilities of protection against further violence. A first guideline for the documentation of findings in cases of violence against women was developed in Germany between 2000 and 2003 by the S.I.G.N.A.L. intervention programme for the surgical emergency department of a Berlin hospital. It was based in particular on the experience of some New York clinics. All documentation systems for partner violence that currently exist in Germany are directly or indirectly influenced by S.I.G.N.A.L..

The interdisciplinary network Violence Prevention in Health Care in Hesse was founded at the end of 1999. The aim of the "Hessian documentation form in cases of domestic violence" developed there was to improve the civil court protection of women affected by partner violence by practising and inpatient doctors.

The aim of the A.U.S.W.E.G. project was to gain insights into the extent to which and under what conditions the Hessian documentation form for domestic violence was accepted, used and achieved its goals in health care.

For this purpose, the implementation strategies of the guideline for action were analysed, the attitudes of physicians to the possibilities of health protection and documentation that can be used in court in cases of domestic violence against women were surveyed, and hypotheses were developed as to whether and under which conditions nurses in Germany could take on essential tasks in the assessment and documentation of the consequences of domestic violence against women. Focus groups, participant observations, expert interviews and standardised written surveys were conducted.

It initially became apparent that, despite the commitment of all those involved, a comprehensive implementation of the Hessian documentation form was not successful. The guidelines for action and the documentation form are well suited for improving documentation that can be used in court, but their structure as well as the distribution and implementation strategies do not yet sufficiently correspond to the logic of health care. The developed materials contain important questions, but not comprehensively the questions of anamnesis, documentation of findings, treatment and secondary prevention that are relevant for guidelines of medical action. Implementation has so far been mainly through public relations and training, neither systematically nor bindingly. The documentation is not gratified. The guidelines for action can only be found to a limited extent via the doctors' expected information search strategies.

Structural problems can be seen as the cause. There is insufficient data on the relevance of the health consequences of domestic violence against women for health care in Germany. Goals, primarily relevant areas of care and care situations are not communicated clearly and unambiguously. Findings on which interventions have proven themselves from the perspective of health care with which degree of scientific evidence are partly not available, partly not sufficiently processed. The organs, structures and processes of health care are included in the development and implementation process, but on a non-binding basis. The framework conditions are not sufficiently clarified.

The guideline for action has been taken note of by doctors rather sporadically. They tend to see themselves as contact persons in cases of domestic violence and, according to their statements, would mostly approach women in cases of suspicion. Lack of time was not formulated as a decisive obstacle. The assistance provided by a guide to action was almost uniformly described as very helpful, without it being known that such a guide existed. In contrast, the willingness to participate in further training was less pronounced.

Doubts can be raised as to whether doctors in Hesse are sufficiently sensitised to develop a suspicion that a patient's health problems or injuries could also be the result of domestic violence if she does not raise the issue herself. A lack of certainty of action in health care could lead to an unspoken agreement between the patient and the doctor not to raise a suspicion with the doctor in the first place.

In principle, nurses could imagine taking on tasks in the context of caring for the consequences of domestic violence or preventing violence as part of their work. This could include questions of screening, support with documentation that can be used in court and, if necessary, preservation of evidence as well as clarification of the need for protection and cooperation with support systems outside the health care system. However, nurses in Germany need an explicit mandate to do this. The explicit mandate must bindingly define the framework of action of the caregivers; the available time and a protected place must be guaranteed. Perceptions, attitudes, attribution processes, insecurities and behavioural strategies of untrained caregivers seem to be similar internationally. Lack of knowledge and psychosocial protection, coupled with social attribution processes, can lead to the perception that domestic violence against women is an issue of marginalised groups and occurs predominantly in relation to alcohol abuse. Training of caregivers can influence this in principle, but then not change it sustainably if it is a one-off training programme. Uncertainties in action can lead to the consolidation of attribution processes that partner violence affects marginalised groups.

Health care has probably not yet sufficiently succeeded in recognising, understanding and accepting its function in the context of partner violence. This probably results in forms of inadequate and incorrect care, not in terms of acute physical injuries, but in the prevention of long-term health consequences.

In the long term, the goal would be not to focus exclusively on 'suspicion', but to discuss general screening according to international models and to introduce a clear algorithm of action laid down in a guideline. Structural framework conditions have to be changed; well-founded, care-related research is necessary. The path to such a change in practice in Hesse could lead via protective outpatient clinics in the six care areas of the hospital requirement plan, which test a change in practice and make their expertise available in a consultative and advisory capacity.