Chapter 25: Family and Community Violence
Family and Community Violence
Violence from one person toward another is a social act involving a serious abuse of power. Usually, a relatively stronger person controls or injures another, typically the least powerful person accessible to the perpetrator. This includes acts of violence that a partner commits against the other partner, adult abuse by a non-spouse or non-partner, a parent against a child, or a child against a parent.
Cycle of violence
Spouse or partner violence usually follows a predictable cycle
Tension-building phase
The perpetrator has minor episodes of anger and can be verbally abusive and responsible for some minor physical violence (pushing, shoving).
As tension continues to grow, both partners try to reduce it.
The perpetrator may turn to substances and the victim dismisses the significance of the violence.
The vulnerable person is tense during this stage and tends to accept the blame for what is happening.
Acute battering phase
The tension becomes too much to bear, and serious abuse takes place.
The victim may provoke the perpetrator to reduce the unbearable tension.
The vulnerable person can try to cover up the injury or try to get help.
This stage is the most violent and shortest.
Honeymoon phase
The situation is defused for a while after the violent episode.
The perpetrator becomes loving, promises to change, and is sorry for the behavior.
The vulnerable person wants to believe this and hopes for a change.
Eventually, the cycle begins again.
Periods of escalation and deescalation
Usually continue with shorter and shorter periods of time between the two without intervention.
Emotions for the perpetrator and vulnerable person (fear or anger), increase in intensity.
Repeated episodes of violence lead to feelings of powerlessness.
Types of violence
A nurse must prepare to deal with various types of violence and the mental health consequences.
Violence can be directed toward a family member, stranger, or acquaintance. Or, it can come from a human-made mass-casualty incident (a terrorist attack).
Natural disasters (hurricanes and earthquakes), can cause mental health effects comparable to those caused by human-made violence.
Violence against a person who has a mental illness is more likely to occur when factors(poverty, transient lifestyle, or a substance use disorder) are present.
A person who has a mental illness is no more likely to harm strangers than anyone else.
The factor most likely to predict violence between strangers is a history of violence and criminal activity.
Assessment
A forensic nurse has advanced training in the collection of evidence for suspected or actual cases of sexual assault or other forms of physical abuse.
Conduct a nursing history.
Provide privacy when conducting interviews about family abuse.
Be direct, honest, and professional.
Use language the client understands.
Be understanding and attentive.
Use therapeutic techniques that demonstrate understanding.
Use open-ended questions to elicit descriptive responses.
Inform the client if a referral must be made to child or adult protective services. And, be sure to explain the process.
Risk Factors
Cultural differences can influence whether the nursing assessment data is valid, how the client responds to interventions, and the appropriateness of nursing interactions with the client. QPCC
A female partner is the vulnerable person in the majority of family violence, but the male partner can also be a vulnerable person.
Vulnerable persons are at the greatest risk for violence when they try to leave the relationship.
Pregnancy tends to increase the likelihood of violence by a spouse or partner. The reason for this is unclear, but might be related to the added responsibility or the time that will be required to care for the infant.
Older adults or other adults who are vulnerable within the home can suffer abuse because they are in poor health, exhibit disruptive behavior, or are dependent on a caregiver. The potential for violence against an older adult is highest in families where violence has already occurred. G
Family groups
Violence is most common within family groups, and most is aimed at family and friends rather than strangers.
Family violence occurs across all economic and educational backgrounds and racial and ethnic groups.
Family violence can occur against children, spouses or partners, or vulnerable adult family members.
Risk factors for abuse toward a child
The child is under 4 years of age.
The perpetrator perceives the child as being different (the child is the result of an unwanted pregnancy, is physically disabled, or has some other trait that makes them particularly vulnerable).
A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching?
a
“Children older than 5 are at greater risk for abuse”
b
“Substance use disorder does not increase the risk for violence.”
c
“Entering an intimate relationship increases the risk for violence.”
d
“Pregnancy increases the risk for violence from a spouse or partner.”
Types of Violence
Physical violence occurs when physical pain or harm is involved (shaken baby syndrome, strangling, striking or kicking, pushing).
Sexual violence occurs when sexual contact takes place without consent, whether the vulnerable person is able to give consent or not.
Emotional violence includes behavior that minimizes an individual’s feelings of self-worth or humiliates, threatens, or intimidates a family member.
Neglect, which includes the failure to provide the following.
Physical care, such as feeding
Emotional care (interacting with a child, stimulation necessary for a child to develop normally)
Education, such as enrolling a young child in school
Necessary health or dental care
Economic Abuse
Failure to provide for the needs of a vulnerable person when adequate funds are available
Unpaid bills, resulting in disconnection of gas, water, or electricity
Vulnerable person characteristics
Demonstration of low self-esteem and feelings of helplessness, hopelessness, powerlessness, guilt, and shame
Attempts to protect the perpetrator and accept responsibility for the abuse
Possible denial of the severity of the situation and feelings of anger and terror
Perpetrator characteristics
Possible use of threats and intimidation to control the vulnerable person
Usually an extreme disciplinarian who believes in physical punishment
Poor impulse control
Perceives the victim as bad
Violent outbursts
Poor coping skills
Low self-esteem
Feelings of worthlessness
Possible history of substance use disorder
Difficulty assuming typical adult roles
Likely to have experienced family violence as a child
Age-Specific Assessments
Infants
Shaken baby syndrome: Shaking can cause intracranial hemorrhage. Assess for respiratory distress, bulging fontanels, and an increase in head circumference. Retinal hemorrhage can be present.
Any bruising on an infant before age 6 months is suspicious.
Preschoolers to adolescents
Assess for unusual bruising (on the abdomen, back, or buttocks). Bruising on arms and legs in these age groups is an expected finding from playing and other physical activities.
Assess the mechanism of injury, which might not be congruent with the physical appearance of the injury. Numerous bruises at different stages of healing can indicate ongoing beatings. Be suspicious of bruises or welts that resemble the shape of a belt buckle or other object.
Assess for burns. Burns covering “glove” or “stocking” areas of the hands or feet can indicate forced immersion into boiling water. Small, round burns can be from lit cigarettes.
Assess for fractures with unusual features (forearm spiral fractures) which could be a result of twisting the extremity forcefully. The presence of multiple fractures is suspicious.
Assess for human bite marks.
Assess for head injuries: altered level of consciousness, unequal or nonreactive pupils, and nausea or vomiting.
Older and other vulnerable adults G
Assess for any bruises, lacerations, abrasions, or fractures in which the physical appearance does not match the history or mechanism of injury.
A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome?
Select all that apply.
a
Sunken fontanels
b
Respiratory distress
c
Retinal hemorrhage
d
Altered level of consciousness
e
Increase in head circumference
A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse?
Select all that apply.
a
Abrasions on knees
b
Round burn marks on forearms
c
Mismatched clothing
d
Abdominal rebound tenderness
e
Areas of ecchymosis on torso
A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following?
a
Refusing to pay bills for a dependent, even when funds are available, is neglect.
b
Intentionally causing someone to fall is an example of physical violence.
c
Striking a sexual partner is an example of sexual violence.
d
Failure to provide a stimulating environment for normal development is emotional abuse.
Patient-Centered Care
Nursing Care
All states have mandatory reporting laws that require nurses to report suspected child or vulnerable adult abuse; there are civil and criminal penalties for not reporting suspicions of abuse.
Document subjective and objective data obtained during assessment.
Provide basic care to treat injuries.
Make appropriate referrals.
Help client develop a safety plan, identify behaviors and situations that might trigger violence, and provide information regarding safe places to live. QS
Use crisis intervention techniques to help resolve family or community situations where violence has been devastating.
Interventions for community-wide or mass casualty incidents (a school shooting or gang violence)
Early intervention
Make sure clients are physically and psychologically safe from harm.
Provide psychological first aid.
Reduce stress-related manifestations by using techniques to alleviate a panic attack.
Provide interventions to restore rest and sleep, and connect the client to social supports and information about critical resources.
Depending on their level of expertise and training, mental health nurses can provide assessment, consultation, therapeutic communication and support, triage, and psychological and physical care.
Critical incident stress debriefing
This is a tertiary crisis intervention strategy that assists individuals who have experienced a traumatic event, usually involving violence (staff experiencing client violence, school children and personnel experiencing the violent death of a student, rescue workers after an earthquake) in a safe environment.
This type of debriefing involves distinct phases: introducing the purpose of the group, discussing facts about the incident, discussing first thoughts about the incident, describing personal reactions, listing altered behaviors or physical changes since the incident, providing teaching on stress management and anticipatory guidance, and providing closure to the session by affirming the participants or providing referrals as needed.
Debriefing can take place in group meetings with a facilitator who promotes a safe environment where there can be expression of thoughts and feelings. QTC
The facilitator will acknowledge reactions, provide anticipatory guidance for manifestations that can still occur, teach stress management techniques, and provide referrals.
The group can choose to meet on an ongoing basis or disband after resolution of the crisis.
Client Education
Understand expected growth and development patterns for children; parenting classes can be helpful.
Develop skills to assist with problem solving (assertiveness training).
Find ways to manage stress in a positive way (meditation or relaxation).
Consider external changes that can help reduce stress (a career change, or moving).
Interprofessional collaboration
Encourage participation in support groups.
Use case management to coordinate community, medical, criminal justice, and social services.
Assist with client relocation, if needed to a safe house, shelter, a family or friend’s home, or foster care.
Discus therapies that could be beneficial (family, individual, or partner therapy, communication courses).
Talk with the caregivers about community agencies that could provide relief, (day-care or sitter programs).
A nurse is caring for an adult client who has injuries resulting from spousal violence. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority?
a
Advise the client about the location of safe houses and shelters.
b
Encourage the client to participate in a support group for survivors of abuse.
c
Implement case management to coordinate community and social services.
d
Educate the client about the use of stress management techniques.
Sexual Assault
Sexual assault is defined as pressured or forced sexual contact, including sexually stimulated talk or actions, inappropriate touching or intercourse, incest, human sex trafficking, female genital mutilation, and rape (forced sexual penetration). Sexual assault can be male to female, female to male, female to female, male to male. Children and vulnerable adults can also be victims of sexual assault. Sexual violence also refers to the denial of emergency contraception or measures to prevent sexually transmitted infections, organized rape during war or conflict, and sexual homicide.
Most survivors of sexual assault suffer long-term, severe emotional trauma. Rape-trauma syndrome, which is similar to posttraumatic stress disorder, can occur after a sexual assault.
Rape
Rape is defined as nonconsensual sexual activity involving any penetration of the vagina or anus with any body part or object, or the oral penetration by a sex organ of someone else. It is a crime of violence, aggression, anger, and power.
Types of rape include stranger, marital, date, and acquaintance. The majority of perpetrators are known to the person who is raped. Acquaintance rape and spousal (or marital) rape specify the relationship between the perpetrator and vulnerable person. Date rape is a form of acquaintance rape in which the parties agreed upon a social engagement.
Alcohol and other substances are often associated with date or acquaintance rape (drug assisted sexual assault). These substances produce a sedative and amnesic effect on the vulnerable person.
Specific substances
Gamma-hydroxybutyrate: Street names include “G” and “liquid ecstasy.”
Flunitrazepam: Street names include “roofies,” “club drug,” and “roachies.”
Ketamine: Street names include “black hole,” “kit kat,” and “special K.”
A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching?
a
“Rape is a crime of passion.”
b
“Acquaintance rape often involves alcohol.”
c
“Young adults are the typical victims of sexual assault.”
d
“The majority of rapists are unknown to the victims.”
Assessment
Risk Factors
There is no “typical” description of a person who is vulnerable to rape. Individuals of all ages are affected by sexual assault.
There is no “typical” sexual assault survivor. Individuals can experience a variety of physical and emotional injuries and effects.
Expected findings
Rape-trauma syndrome
Sustained and maladaptive response to a forced, violent sexual penetration against the individual’s will and consent.
Initial emotional (or impact) reaction
An expressed reaction is overt and consists of emotional outbursts, including crying, laughing, hysteria, anger, and incoherence.
A controlled reaction is ambiguous. The survivor can appear calm and have blunted affect, but can also be confused, have difficulty making decisions, and feel numb.
Following the initial emotional response, clients can experience a variety of emotional reactions, including embarrassment, a desire for revenge, guilt, anger, fear, anxiety, and denial. These reactions can persist and become sustained and maladaptive.
A somatic reaction can occur later in which the client can have a variety of physical manifestations
Muscle tension, headaches, and sleep disturbances
Gastrointestinal manifestations (nausea, anorexia, diarrhea, abdominal pain)
Genitourinary manifestations (vaginal pain or discomfort)
Acute stress disorder
Occurs after a traumatic event (sexual assault) and manifestations are similar to post traumatic stress disorder. In acute stress disorder manifestations appear and persist at least 3 days and can extend to one month. Manifestations lasting longer than one month are then classified as post traumatic stress disorder.
Posttraumatic stress disorder
Can occur beyond 1 month after the attack. Long-term psychological effects of sexual assault include the following.
Reliving the event (flashbacks, recurrent dreams, and other intrusive thoughts about the assault)
Increased activity (visiting friends frequently or moving residence) due to a fear that the assault will reoccur
Hyperarousal and increased emotional responses (easily startled, anxiety, angry outbursts, difficulty falling asleep or concentrating)
Avoidance, fears, and phobias (fear of being alone, fear of sexual encounters, avoiding triggers of the event, memory problems about the trauma, emotional numbness, guilt, and depression)
Difficulties with daily functioning, low self-esteem, depression, sexual dysfunction, and somatic reports (headache or fatigue)
Compound rape reaction
Some survivors of rape can experience additional disorders as a result of the sexual assault.
Mental health disorders (depression or substance use disorder)
Physical disorders (manifestations of a prior physical illness)
Silent rape reaction
The survivor does not report or tell anyone of the sexual assault, including family, friends, or the authorities.
Abrupt changes in relationships with partners
Nightmares
Increased anxiety during interview
Marked changes in sexual behavior
Sudden onset of phobic reactions
No verbalization of the occurrence of sexual assault
Patient-Centered Care
Nursing Care
Perform a self-assessment. It is vital that the nurse who works with the client who has been sexually assaulted be empathetic, objective, and nonjudgmental. If the nurse feels emotional about the assault due to some event or person in their own past, it can be better to allow another nurse to care for the client.
Perform an initial and ongoing assessment of the client’s level of anxiety, coping mechanisms, and available support systems. The nurse should also assess for indications of emotional and/or physical trauma.
Provide a private environment for an examination with a specially trained nurse-advocate, if available. A sexual assault nurse examiner (SANE) is a specially trained nurse who performs such examinations and collects forensic evidence. QTC
Follow national standard protocol for the assessment, which includes client information, examination, documentation of biological and physical findings, collection of evidence, and follow-up as needed to document additional evidence.
Provide for client safety. Let the client know they are safe. QS
Provide nonjudgmental and empathetic care.
Obtain informed consent to collect data that can be used as legal evidence (photos, pelvic exam). The rape survivor has the right to refuse either a medical examination or a legal exam, which provides forensic evidence for the police.
Treat any injuries, and document care given.
Assist the SANE with the physical examination and the collection, documentation, and preservation of forensic evidence. Sexual assault evidence collection kits are used for collecting blood, oral swabs, hair samples, nail swabs, or scrapings, and genital, anal, or penile swabs. Document physical injuries in narrative and pictorial form, using body maps or photographs. Also document subjective data, using the client’s verbatim statements.
Support the client while legal evidence is being collected (samples of hair, skin, semen). Avoid minimizing the client’s level of emotional suffering, as psychological responses can be subtle or not easily identifiable. Refrain from asking “Why” questions. Let the client know that the sexual assault is not their fault.
Assess for suicidal ideation.
Administer prophylactic treatment for sexually transmitted infections as outlined by the Centers for Disease Control and Prevention. This can include prophylactic treatment of syphilis, chlamydia, gonorrhea, HIV, and hepatitis exposure. QS
Evaluate for pregnancy risk and provide for prevention (emergency contraception).
Assess for support systems and call the client’s available personal support system (a partner or parents) if the client gives permission.
Assist the client during the acute phase of rape-trauma syndrome to prepare for thoughts, manifestations, and emotions that can occur during the long-term phase of the syndrome.
Encourage the client to verbalize their story and emotions.
Listen and let the client talk. Use therapeutic techniques of reflection, open-ended questions, and active listening.
Nursing actions
Care After Discharge
Provide phone numbers for 24-hr hotlines for sexual assault survivors.
Promote self-care activities. Give follow-up instructions in writing, because the client might be unable to comprehend or remember verbal instructions.
Initiate referrals for needed resources and support services. Individual psychotherapy and group therapy can be helpful to increase coping skills and prevent long-term disability (depression or suicidal ideation).
Schedule follow-up calls or visits at prescribed intervals after the assault.
Emphasize importance of after care, as sexual assault clients historically have a poor compliance rate with follow-up visits.