Violence

Domestic/Family Violence in Nursing

Overview of Domestic Violence

  • Domestic violence encompasses a range of forms and situations that require critical assessment and intervention.

  • Key message: Recognize it, report it, and prevent it.

Assessing for Abuse & Violence

  • Recognize signs: Every patient should be assessed for potential abuse, focusing on various forms of violence:   - Intimate partner violence (IPV)   - Child abuse   - Elder abuse   - Human trafficking

  • Standards & Policies: Follow facility and state policies, which include:   - Assessing potential abuse   - Documenting evidence   - Referring to proper authorities

  • Reporting:   - Only suspicion is necessary for reporting; proof is not required.

  • Human Trafficking:   - Recognized as a major public health issue without standardized screening tools or mandated protocols.

Intimate Partner Violence (IPV)

  • Definition: IPV involves current and former partners, including teens.

  • Forms of IPV:   - Physical: Results in injury or harm.   - Sexual: Encompasses non-consensual acts.   - Stalking: Characterized by repeated unwanted attention.   - Psychological: Includes emotional abuse and control tactics.

  • Teen Dating Violence: A significant concern that falls under IPV.

Health Effects of Violence

Immediate Effects

  • Injuries (various types including cuts and fractures)

  • Traumatic brain injuries

  • Pain and headaches

  • Acute trauma experiences

Long-Term Physical Effects

  • For Children:   - Improper brain development   - Cerebral palsy   - Delayed language and motor skills

  • For Adults:   - Chronic pain and headaches   - Increased risk for chronic diseases:     - Obesity     - Cardiovascular diseases     - Endocrine disorders     - Cancer     - Hypertension

  • Negative Pregnancy Outcomes:   - Includes preterm birth, low birth weight, perinatal death, etc.

  • Reproductive Health Issues:   - Forced sex can lead to chronic pelvic pain, unintended pregnancy, STIs, and UTIs.

Mental Health Effects

  • Increase in depression and anxiety disorders

  • Post-traumatic stress disorder (PTSD)

  • Elevated risk of suicidality

  • Higher chances of substance abuse issues

Social & Behavioral Consequences

  • For Children:   - Higher likelihood of juvenile arrest   - Increased risk of teen pregnancy   - Adult criminal behavior prevalence

  • For Adults:   - Long-term social and emotional dysfunction   - Job loss and financial instability   - Social isolation and neglect of responsibilities

Genetics, Environment, & IPV

  • Population Risk Differences:   - IPV is prevalent across all populations but notably higher among ethnic and racial minorities.   - Disparities linked to systemic factors and socioeconomic inequities.

  • Barriers to Care:   - Societal stressors (e.g., poverty, discrimination)   - Legal concerns (e.g., fear of deportation for immigrants)   - Cultural factors like traditional gender roles and stigma around reporting abuse.

  • Culturally Sensitive Approaches:   - Access to bilingual/bicultural providers and translators is essential.   - Education regarding legal rights and protections under the Violence Against Women Act (VAWA).   - Involvement of religious beliefs and leaders where suitable.   - Importance of community outreach and family involvement.

  • Nurse’s Responsibility: Understand individual experiences while respecting cultural beliefs.

Sexual & Gender Minority (SGM) Considerations

  • Higher Risk for Violence:   - SGM youth face higher rates of adverse childhood events leading to greater IPV risk, especially among multiple marginalized group affiliations.   - Human Trafficking Risk:     - SGM youth make up 3–5% of the population but ~40% of unhoused/runaway youth.     - Unhoused SGM youth are 7 times more likely to experience sexual violence.

  • Barriers to Seeking Help:   - Fear of mistreatment and stigma based on sexual orientation or gender identity.

IPV Screening

  • Use open-ended questions and always interview patients alone.

  • Look for signs of inconsistencies between injuries and explanations provided by the patient.

  • Monitor for patterns through repeated visits, and document all findings carefully:   - History of injuries or hospitalizations.   - Delayed care-seeking patterns.   - Cumulative trauma increases risk for severe physical and mental health effects.

HITS Screening Tool for IPV

  • A tool that assesses the frequency of specific partner behaviors with a scoring mechanism:   1. Physically hurt   2. Insulted or talked down to   3. Threatened with harm   4. Screamed or cursed at

  • Case Example:   - Patient example who scores various levels on the HITS tool illustrating the complexity of IPV denial and the need for intervention options, emphasizing the nursing action required for support and care.

Elder Abuse & Neglect

  • Forms of Elder Abuse:   - Physical Abuse: Includes intentional injury, threats, or inappropriate restraint.   - Sexual Abuse: Any non-consensual sexual contact, including scenarios lacking consent capability.   - Psychological/Emotional Abuse: Actions that instill fear, humiliation, or isolation.   - Neglect: Failure to meet basic needs such as hygiene and medical care.   - Financial Abuse/Exploitation: Unauthorized resource use for personal gain.

Elder Abuse Screening

  • Elder Abuse Suspicion Index (EASI) includes a set of questions addressing reliance on others for care, feelings of being controlled, and past experiences of fear or harm in older adults.

  • Key Indicators: Poor eye contact, malnourishment, hygiene issues, and observable physical injuries.

Human Trafficking

  • Vulnerable Populations:   - Include unhoused persons, runaway youth, SGM individuals, and victims of past violence.

  • Health Care Considerations:   - Often present without disclosing their conditions; high risk for physical and mental health issues.

  • Definition: Involuntary engagement in labor or commercial sexual activities, noting that any commercial sex act involving a minor qualifies as trafficking regardless of coercion.

  • Industries affected: Can be found in both legal and illegal sectors.

Signs of Human Trafficking

  • Physical: Unexplained injuries, malnutrition, and untreated medical conditions.

  • Behavioral: Symptoms of fear, anxiety, reluctance to speak, vague histories, etc.

Child Abuse & Neglect

  • Types of Abuse:   - Neglect: Failing to meet essential needs, including prenatal drug exposure.   - Physical Abuse: Non-accidental injuries.   - Sexual Abuse: Includes exploitation and pornography; sex trafficking in certain contexts.   - Emotional Abuse: Influences emotional development adversely.

  • Legal Considerations: Definitions are state-dependent, and providers are mandated to report suspected abuse.

Screening for Child Abuse

  • Observe caregiver-child interaction while looking for trust levels and signs of anxiety.

  • Documentation of caregiver behavior and response to inquire if the child shows signs of withdrawal or anxiety is critical.

Red Flags for Child Abuse

  • Subjective Indicators: Inconsistencies between history and physical findings; delay in seeking medical care; recurrence of injuries.

  • Objective Indicators: Non-mobile infants having unexplained bruising.

Abuse: Documentation Essentials

Objective Assessment of Adults

  • Older Adults: Recognize increased bruising risk due to medications such as anticoagulants.

  • Documentation Steps: Include clear progress notes, injury maps, photos where appropriate, and verbatim quotes from discussions with patients about abuse. Maintain an unbiased tone and avoid speculation on injury causes.

Forensic Documentation

  • Wound Classification:   - Incisions: Cuts from sharp objects; length exceeds depth.   - Lacerations: Irregular shaped wounds resulting from blunt trauma.   - Abrasions: Superficial skin injuries from friction.   - Punctures: Small but deep wounds from sharp objects.   - Contusions (bruises): Result from torn blood vessels.   - Burns: Various forms including thermal, chemical, and electrical.   - Penetrating Wounds: Extend into organs/body cavities, necessitating critical care.   - Skin Ulcers: Develop from chronic conditions.   - Avulsions: Sections of skin or tissue torn away.   - Hematomas: Localized collections of blood outside vessels.   - Fractures: Breaking or cracking of bones.

Case Studies for Ethical and Real-World Applications

  • Situational assessment to determine the best action based on the individual case presented:   - Evaluating the patient’s surroundings for safety   - Developing a plan of action based on suspected abuse scenarios

  • Important nursing intervention decisions related to suspected abuse cases are evident, showing the need for sensitivity and proper action to ensure patient safety and adherence to legal and ethical standards.