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, who is typically the least
powerful person accessible to the abuser. This
includes acts of violence that a partner commits
against the other partner, a parent against a
child, or a child against a parent.
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, such as a
Natural disasters, such as 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 such as poverty,
transient lifestyle, or a substance use disorder are present.
A person who has a mental illness is no more likely
to harm others than anyone else. A history of mental
illness does not necessarily predispose an individual
The factor most likely to predict violence between
strangers is a past history of violence and
Cultural differences can influence whether data is valid, how
the client responds to interventions, and the appropriateness
of nursing interactions with the client.
A female partner is the vulnerable person in the
majority of family violence, but a male partner can also
be a vulnerable person.
Vulnerable people are at the greatest risk for violence
when they try to leave the relationship.
Pregnancy tends to increase the likelihood of violence
toward the intimate partner. The reason for this is unclear.
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 in which violence has
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
in the U.S. It’s often termed “maltreatment.”
Family violence or maltreatment can occur against
children, intimate partners, or vulnerable adult
Within a family, a cycle of violence can occur between
Tension‑building phase: The abuser has minor
episodes of anger and can be verbally abusive and
responsible for some minor physical 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
vulnerable person can try to cover up the injury or try
to get help.
Honeymoon phase: The situation is defused for a
while after the violent episode. The abuser 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
Periods of escalation and de-escalation usually
continue with shorter and shorter periods of time
between the two. Emotions for the abuser and
vulnerable person (fear, anger) increase in intensity.
Repeated episodes of violence lead to feelings
Risk Factors for Abuse Toward a Child
The child is under 3 years of age.
A 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
him particularly vulnerable).
Types of Violence
PHYSICAL VIOLENCE occurs when physical pain or harm is
directed toward the following:
An infant or child, as is the case with shaken baby
syndrome (caused by violent shaking of young infants)
An intimate partner, such as striking or strangling
A vulnerable adult in the home, such as pushing an
older adult parent and causing her to fall
SEXUAL VIOLENCE occurs when sexual contact takes place
without consent, whether the vulnerable person is able or
unable to give that consent.
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
Physiological care (food, water, shelter, clothing)
Emotional care, such as interacting with a child, or
stimulation necessary for a child to develop normally
Education, such as enrolling a young child in school
Necessary health or dental care
Failure to provide for the needs of a vulnerable person
when adequate funds are available (most commonly
seen in the elderly)
Unpaid bills, resulting in disconnection of heat
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
Isolation from family and friends
Possible use of threats and intimidation to control the
Usually an extreme disciplinarian who believes in
Poor impulse control
Perceives the child as bad
Poor coping skills
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 Collection Data
Shaken baby syndrome: Shaking can cause intracranial
hemorrhage. Monitor 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
Preschoolers to Adolescents
Check for unusual bruising (on abdomen, back,
buttocks). Bruising is common on arms and legs in
these age groups.
Determine 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
Monitor 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
Check for fractures with unusual features, such as
forearm spiral fractures, which could be a result of
twisting the extremity forcefully. The presence of
multiple fractures is suspicious.
Check for human bite marks.
Monitor for head injuries: level of consciousness, equal
and reactive pupils, and nausea or vomiting.
Older and Other Vulnerable Adults
Check for any bruises, lacerations, abrasions, or fractures
in which the physical appearance does not match the
history or mechanism of injury.
All states have mandatory reporting laws that require
nurses to report suspected abuse. There are civil and
criminal penalties for not reporting suspicions of abuse.
Nursing interventions for child or vulnerable adult
abuse must include the following.
Ensuring a safe environment
Mandatory reporting of suspected or actual cases of
child or vulnerable adult abuse
Complete and accurate documentation of subjective
and objective data obtained
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
Be direct, honest, and professional.
Use language the client understands.
Be understanding and attentive.
Use therapeutic techniques that
Use open‑ended questions to elicit
Inform the client if a referral must be made to child
or adult protective services, and be sure to explain
Provide basic care to treat injuries.
Make appropriate referrals.
Instruct clients regarding normal growth
Inform clients about self‑care and empowerment skills.
Instruct clients about ways to manage stress.
Care After Discharge
Help clients develop a safety plan, identify behaviors
and situations that might trigger violence, and provide
information regarding safe places to live.
Encourage participation in support groups.
Use case management to coordinate community,
medical, criminal justice, and social services.
Use crisis intervention techniques to help resolve
family or community situations where violence has
Nursing interventions for community‑wide or mass
casualty incidents (school shooting, gang violence)
Provide psychological first aid.
Make sure clients are physically and psychologically
safe from harm.
Reduce stress‑related manifestations, such as using
techniques to alleviate a panic attack.
Provide interventions to restore rest and sleep, and
provide links to social supports and information about
Depending on their level of expertise and training,
mental health nurses can provide data collection,
consultation, therapeutic communication and support,
triage, and psychological and physical care.
Critical Incident Stress Debriefing
This is a 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.
Debriefing can take place in group meetings with a
facilitator who promotes a safe environment where
there can be expression of thoughts and feelings.
The facilitator will acknowledge reactions, provide
anticipatory guidance for manifestations that can
still occur, teach stress management techniques, and
The group can choose to meet on an ongoing basis or
disband after resolution of the crisis.
Halter, M. J. (2014). Varcarolis’ foundations of psychiatric mental health
nursing: A clinical approach (7th ed.). St. Louis, MO: Saunders.
Townsend, M. C. (2017). Essentials of psychiatric mental health nursing:
Concepts of care in evidence-based practice (7th ed.). Philadelphia: F. A. Davis
Mental Health Nursing REVIEW MODULE EDITION 2017 Assessment Technologies Institute, LLC. All rights reserved