Nursing Continuing Education

Domestic Violence

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This is Your Course on 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, 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 terrorist attack. 
  • 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 to violence. 
  • The factor most likely to predict violence between strangers is a past history of violence and criminal activity.

Data Collection

Risk Factors

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 already occurred.

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 in the U.S. It’s often termed “maltreatment.” 
  • Family violence or maltreatment can occur against children, intimate partners, or vulnerable adult family members. 
  • Within a family, a cycle of violence can occur between intimate partners. 
    • 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 begins again. 
    • 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 of powerlessness. 
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 the partner 
  • 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 the following:

  • 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
ECONOMIC MALTREATMENT
  • 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 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 
  • Isolation from family and friends

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 child 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 Collection Data

Infants

  • 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 is suspicious.

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 other object. 
  • 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 lit cigarettes. 
  • 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.

Patient-Centered Care

Nursing Care

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 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. 
  • Provide basic care to treat injuries. 
  • Make appropriate referrals. 
  • Instruct clients regarding normal growth and development. 
  • 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 been devastating.

Interventions

Nursing interventions for community‑wide or mass casualty incidents (school shooting, gang violence)

Early Intervention

  • 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 critical resources. 
  • 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 provide referrals. 
  • The group can choose to meet on an ongoing basis or disband after resolution of the crisis.

References

  1. Halter, M. J. (2014). Varcarolis’ foundations of psychiatric mental health nursing: A clinical approach (7th ed.). St. Louis, MO: Saunders. 
  2. Townsend, M. C. (2017). Essentials of psychiatric mental health nursing: Concepts of care in evidence-based practice (7th ed.). Philadelphia: F. A. Davis 
  3. Mental Health Nursing REVIEW MODULE EDITION 2017 Assessment Technologies Institute, LLC. All rights reserved

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