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Population Health for Nurses

28.5 Family Violence

Population Health for Nurses28.5 Family Violence

Learning Outcomes

By the end of this section, you should be able to:

  • 28.5.1 Distinguish between development and situational crises.
  • 28.5.2 Describe the cycle of violence observed in intimate partner abuse.
  • 28.5.3 Differentiate between neglect and abuse.
  • 28.5.4 Identify strategies to identify abuse against children, pregnant and postpartum clients, and older adults to improve outcomes and safety.
  • 28.5.5 Explain the nurse’s role in abuse and neglect prevention.

A crisis occurs when two or more issues coincide (Early Childhood Learning and Knowledge Center, 2022). Families may go through different types of crises, and the magnitude of a crisis depends on the family’s ability to function and the environment of the crisis. A stressful situation becomes a crisis when a family lacks resources or support and/or necessary coping skills. A crisis may be developmental or situational. A developmental crisis results from predictable change and is due to the normal growth and development changes that occur within a family, such as adolescence. Situational crises are typically events that are out of a person’s control, such as a natural disaster or a family death. Crises can promote growth; they can leave a family even stronger and more resilient. Alternatively, crises can negatively affect families and create a crisis reaction. How families deal with these crises is directly connected to their access to social networks and their cultural backgrounds (Bray, 2022). It is pertinent that community nurses assess the family’s access to these support networks because they can be key players in connecting families with various resources during a crisis.

Cycle of Violence: Intimate Partner Violence

Intimate partner violence (IPV) is abuse that is caused by someone who is or has been romantically involved with the victim to some degree. The abuser could be a current or former spouse and/or a dating partner (CDC, 2022b). The abuse can be a one-time occurrence or occur multiple times over years. IPV can include any of the following types of violence (CDC, 2022b):

  • Physical/contact violence: using a physical form of violence that includes hitting, kicking, or any other type of physical force
  • Sexual violence: forcing or attempting to force a partner into a sex act, touching, or a nonphysical sexual event (e.g., sexting) without the other’s consent
  • Stalking: a pattern of unwanted attention that causes fear
  • Psychological aggression: use of verbal and nonverbal communication with the intent to harm

IPV is common, affecting millions of people in the United States every year (CDC, 2022b). According to the data from the CDC’s National Intimate Partner and Sexual Violence Survey (NISVS), about 41 percent of women and 26 percent of men have experienced physical/contact, sexual violence, and/or any form of IPV (CDC, 2022b). Furthermore, this data shows 61 million women and 53 million men have experienced psychological aggression as a form of IPV in their lifetime. In a small number of cases, IPV can lead to homicide (Messing, 2019).

Pregnant clients are at an increased risk for IPV during pregnancy and the postpartum period (Hasselle et al., 2020). Negative health consequences of IPV during pregnancy can lead to fetal health problems, labor and delivery complications, and negative long-term developmental outcomes for the child. The American College of Obstetricians and Gynecologists (ACOG) recommends that all women be assessed for IPV during prenatal visits (Huecker et al., 2023). Domestic violence is more common in pregnant women than gestational diabetes and preeclampsia.

IPV typically follows a predictable cycle (Figure 28.7) that involves tension building, a violent incident, and a honeymoon phase (World Bank Group Family Network, 2023). During the first phase, the victim is usually in denial and believes they have more control over the incident than they do, while the abuser recognizes their behavior is wrong and fears the victim will leave. The second phase involves violence and can be dangerous for others who try to interfere, although it is important for the victim to have a safe place to retreat to. The victim is most likely to seek help in the third phase; however, many victims do not recognize that the third phase is temporary, and the cycle will repeat.

The three phases of the cycle of intimate partner violence are shown as three parts of a circle, where each phase leads to the next. During the tension building phase, the abuser becomes irritable or stressed, and the victim tries to appease the partner. During the incident occurs phase, the abuser becomes enraged and batters the victim. During the honeymoon phase, the abuser promises to change and acts lovingly towards the victim.
Figure 28.7 The cycle of intimate partner violence has three phases. (See World Bank Group Family Network, 2023; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

IPV is recurrent at the individual level and can continue across generations. Individuals who have experienced IPV in their childhood or teen years are more likely to continue to experience it in adulthood (CDC, 2022b). Children in families where IPV is prevalent are more likely to experience it themselves or become perpetrators in the future. The consequences of IPV are profound. These include depression, post-traumatic stress disorder (PTSD), heart problems, musculoskeletal problems, reproductive disorders, many of which are chronic conditions, and in some cases death by homicide as one in five homicide victims are killed by an intimate partner (CDC, 2022b). The financial cost of IPV to society is estimated at $3.6 trillion (CDC, 2022b). This includes medical services, lost work time, criminal justice costs, and other costs. The CDC (2022b) provides resources and tools to stop or prevent IPV (Table 28.4). Nurses can use and teach these strategies to clients.

Teach safe and healthy
relationships
  • Social-emotional learning programs for youth
  • Healthy relationship programs for couples
Engage influential adults and peers
  • Men and boys as allies in prevention
  • Bystander empowerment and education
  • Family-based programs
Disrupt the developmental pathways toward partner violence
  • Early childhood home visitation
  • Preschool enrichment with family engagement
  • Parenting skill and family relationship programs
  • Treatment for at-risk children, youth, and families
Create protective environments
  • Improve school climate and safety
  • Improve organizational polices and workplace climate
  • Modify the physical and social environments of neighborhoods
Strengthen economic supports for families
  • Strengthen household financial security
  • Strengthen work-family supports
Support survivors to increase safety and lessen harms
  • Victim-centered services
  • Housing programs
  • First responder and civil legal protections
  • Patient-centered approaches
  • Treatment and support for survivors of IPV, including teen dating violence
Table 28.4 CDC Strategies for Addressing and Preventing IPV (See CDC, 2022b.)

CDC: IPV Statistics and Prevention Strategies

This video describes the prevalence of IPV and offers prevention strategies.

Watch the video, and then respond to the following questions.

  1. Why is it important for community nurses to be aware of the statistics of IPV?
  2. What are some prevention strategies for IPV?

Community nurses are in a key position to assess families for IPV. These nurses have clinical knowledge or practitioner expertise they can apply to risk assessment. Nurses can choose from among 11 evidence-based risk assessment instruments when assessing families for IPV risk (Messing, 2019). These risk assessment tools are also used in other specialties, such as social services, and in criminal justice settings. When administering one of these tools, the nurse should make sure the client is alone and able to speak freely. If the assessment reveals the client is at risk, the nurse should be prepared to counsel the client on the available resources and next steps.

Neglect Versus Abuse

According to the CDC, one in seven children experience some form of child abuse or neglect. Children who live in poverty are five times more likely to experience neglect and abuse than children who do not (CDC, 2022a).

Neglect is the failure to meet the basic physical and emotional needs of children and vulnerable adults. Basic needs may include housing, food, clothing, education, access to medical care, and emotional validation (CDC, 2022a). Abuse can be classified as physical, sexual, or emotional. Physical abuse is the use of physical force to cause physical injury (CDC, 2022a). For example, hitting, kicking, shaking, and burning are forms of physical abuse. Sexual abuse includes pressuring or forcing an individual to engage in sexual acts. This includes fondling, penetration, and/or exposing the individual to other sexual activities (CDC, 2022a). Emotional abuse is a behavior that harms the individual’s self-worth or emotional well-being (CDC, 2022a). This may include name calling, shaming, rejecting, withholding love, manipulation, guilt tripping, and gas-lighting (undermining another person’s perception of reality). While neglect and abuse occur frequently in the treatment of children, they can also occur with vulnerable adults. The federal government defines “vulnerable adult” as an individual age 18 or older who is unable to meet their own needs without assistance. This may be related to incapacity, mental illness, physical illness or disability, cognitive disability, advanced age, chronic use of drugs, chronic intoxication, and confinement (U.S. Department of Justice, n.d.). Though nurses may be wary of wrongfully accusing someone of child abuse or neglect, most states require nurses to report suspected cases. Nurses can play an important role in preventing abuse and neglect of children and vulnerable adults in their communities. Table 28.5 depicts prevention strategies.

Strengthen economic supports to families
  • Strengthen household financial security
  • Family-friendly work policies
Change social norms to support parents and positive parenting
  • Public engagement and enhancement campaigns
  • Legislative approaches to reduce corporal punishment
Provide quality care and education early in life
  • Preschool enrichment with family engagement
  • Improved quality of child care through licensing and accreditation
Enhance parenting skills to promote healthy child development
  • Early childhood home visitation
  • Parenting skill and family relationship programs
Intervene to lessen harms and prevent future risk
  • Enhanced primary care
  • Behavioral parent training programs
  • Treatment to lessen harms of abuse and neglect exposure
  • Treatment to prevent problem behavior and later involvement in violence
Table 28.5 CDC’s Strategies to Prevent Child Abuse and Neglect (See CDC, 2022a.)

As introduced in Health Promotion and Maintenance Across the Lifespan, elder abuse and neglect are defined as the intentional act or failure to act that causes harm or risk of harm in the adult who is age 60 or greater (CDC, 2021b). Some vulnerable adults are also at risk for abuse and neglect because of mental conditions or disabilities. Common types of abuse include physical, sexual, or emotional abuse or neglect. The abuser is typically someone the older adult knows and trusts, such as a family member, friend, or caregiver. Abuse may occur in the older adult’s home or in an institutional setting, such as a long-term care facility or nursing home. An estimated one in ten U.S. adults experience some form of abuse or neglect (CDC, 2021b). According to the WHO, global rates of elder abuse in professional settings are high, with two out of three staff indicating they have committed some form of elder abuse (WHO, 2022). Risk factors for abuse and neglect in residential settings include staff burnout, lack of qualified staff, and stressful working conditions (CDC, 2020). The box below lists abuse prevention strategies.

CDC Elder Abuse Prevention Strategies

  • Listen to older adults and their caregivers to understand their challenges and provide support.
  • Report abuse or suspected abuse to local adult protective services, long-term care ombudsman, or the police.
  • Educate oneself and others about how to recognize and report elder abuse.
  • Learn how the signs of elder abuse differ from the normal aging process.
  • Check in on older adults who may have few friends and family members.
  • Provide overburdened caregivers with support such as help from friends, family, or local relief care groups; adult day care programs; counseling; or outlets intended to promote emotional well-being.
  • Encourage and assist people (either caregivers or older adults) having problems with drug or alcohol abuse in getting help.

(See CDC, 2021b.)

Identifying Abuse

Because abuse may be difficult to identify, a thorough history of present illness is necessary to make a correct diagnosis (Gonzalez et al., 2022). The community nurse must be able to identify different types of abuse and how they manifest in different age groups.

Identifying Abuse in Children

When working with children, the caregiver is the primary spokesperson. Getting a full history of events from the caregiver is one of the first screening steps. For example, when explaining the cause of a child’s injury, the parent or caregiver should be able to easily give the history of the events. If the parent or caregiver stops to think or keeps changing the story, this should raise the suspicion of abuse and should be thoroughly investigated. Depending on the age and developmental status of the child, they may or may not be able to tell the nurse what happened. Some children are nonverbal, and others may be too frightened to say anything. In addition to the history of the present illness, a thorough medical history is needed. The nurse should assess for risk factors for abuse as well as medical conditions that can mimic signs of abuse, such as clotting or bleeding disorders, that would increase the chances of a child having explained bruising. Other relevant diagnoses include diseases that affect bone integrity, vitamin D deficiency, and genetic disorders that may increase the child’s risk of fractures.

During the history, the nurse should observe the family’s behavior. Does the child seem fearful? Do they avoid either parent or caregiver? How do the parent(s) or caregiver(s) act with the child? The nurse must thoroughly assess any injury. Signs and symptoms of possible physical abuse in children include the following:

  • A nonambulatory infant with any injury
  • Injury in a nonverbal child
  • Injury inconsistent with child’s physical abilities and a statement of harm from a verbal child
  • Mechanism of injury not plausible or multiple injuries, particularly at varying ages
  • Bruises on the torso, ear, or neck in a child younger than 4 years of age
  • Burns to genitalia
  • Stocking or glove distributions or patterns
  • Caregiver being unconcerned about the injury
  • An unexplained delay in seeking care or inconsistencies or discrepancies in the histories provided

The most common sign of physical abuse, bruising, is easy to miss since ambulatory children are prone to falling. Burns are also a common form of abuse and should be thoroughly assessed. Head, skeletal, and abdominal trauma must always be thoroughly assessed for abuse as these are common causes of mortality in children (Gonzalez et al., 2022). Nurses have a legal and moral obligation to identify and report child abuse. Most often, child abuse is first seen in the ER, and nurses are usually the first ones to notice it.

Identifying abuse among infants and toddlers can be challenging because they are nonverbal. The nurse must perform a thorough physical assessment and carefully question the parent or caregiver. The main difference when assessing for possible abuse in a school-age child or adolescent is that they are verbal and can tell you what happened during the event. Signs and symptoms, which may be the same, include unexplained bruising, burn marks, and/or nonspecific symptoms such as abdominal pain, anxiety, and generalized pain.

Evidence of abuse among adolescents and particularly teenagers can appear in a variety of ways. Clients in this age group who are victims of abuse are likely to develop eating disorders, dress younger/older than their age, struggle academically in school, experience depression, abuse substances, or run away (Stanford Medicine, 2023). When screening this age group for potential abuse, it is important to ensure the client understands that the nurse is required to report certain findings of abuse and may not be able to keep everything confidential.

Identifying Abuse in Pregnant or Postpartum Clients

Signs and symptoms of abuse in pregnant clients or postpartum clients may include injuries to the body, breasts, genitals, rectum, and buttocks (Huecker et al., 2023). Defensive injuries may be present on the forearms and hands. Additionally, these clients may exhibit nonspecific signs and symptoms, such as headaches, palpitations, chest pain, painful intercourse, chronic pain, and chronic fatigue. Psychological signs and symptoms may include anxiety and depression (Huecker et al., 2023). These clients may wear clothing to cover up the abuse and may make up reasons for their injuries. Since most clients who are pregnant receive prenatal care, community nurses can use this time to identify at-risk populations and prevent abuse by providing resources to these families.

How to Spot Intimate Partner Violence in a Medical Setting

This video from the Maryland Health Care Coalition Against Domestic Violence describes how health care providers can identify IPV.

Watch the video, and then respond to the following questions.

  1. What are cues nurses should look for to identify IPV?
  2. During what types of interactions in health care settings are nurses likely to observe signs of IPV?
  3. If a nurse suspects IPV, what should the nurse do to address the situation?

Identifying Abuse in Older Adults

Identifying abuse in older adults can be difficult due to the declining cognitive and mental status of this population. Certain mental health disorders such as dementia, Alzheimer’s disease, and traumatic brain injuries make effective communication difficult and these clients poor historians. This makes it difficult for the nurse to establish a sequence of events leading up to the injury. Behavioral manifestations of abuse in older adults may include agitation, inappropriate behavior, and losing bowel and/or bladder control (Lin, 2020). Minor signs or symptoms of abuse in older adults may include cuts, scratches, bruises, and welts. More serious signs or symptoms may include head injuries, broken bones, constant physical pain, soreness, and fatigue (CDC, 2021b). Table 28.6 provides some tools for assessing abuse or IVP in vulnerable populations.

Abuse of Children
Abuse of Older Adults and Vulnerable Populations
Intimate Partner Violence Risk Assessment Tools
Table 28.6 Assessment Tools for Abuse or IVP in Adults, Children, and Vulnerable or Older Adults

Abuse and Neglect Prevention

As discussed in Foundations of Public/Community Health, levels of prevention include primary, secondary, and tertiary. Nurses can implement strategies at all levels to help families in crisis and prevent abuse and neglect. However, nurses must carefully select feasible interventions that maintain client privacy and autonomy.

  • Primary prevention strategy: strengthening household resources. Community nurses can strengthen household resources by connecting them to community resources such as SNAP benefits, health insurance, and affordable housing and educating them on healthy relationships, coping skills, and communication skills.
  • Secondary prevention strategy: screening families at risk for crisis events. This includes utilizing resources/screening tools listed in Table 28.6.
  • Tertiary prevention strategy: preventing further risk or damage after an event. For example, if a woman and her children have experienced or are experiencing abuse, providing them with a safe shelter or housing.

Case Reflection

Working with Client Families Who Are At Risk of Abuse or Neglect

Read the scenario, and then respond to the questions that follow.

Linda is a home health nurse who visits clients who have recently had babies. Linda partners with her local community services board to provide these families with resources; she also conducts risk assessments, such as screenings for postpartum depression and IPV.

Linda visits Elena in the suburban home Elena shares with her husband outside a major city. Elena recently delivered her first child. Elena is on maternity leave and has good benefits from her job as a marketing consultant for a major firm. She states that she is happy and feels good following the birth of her child.

Linda and Elena discuss the baby’s feeding schedule, weight, and sleep. Linda asks about Elena’s health—her sleep patterns, eating habits, and weight loss postpartum—and screens her for postpartum depression.

As they talk, Linda notices that Elena is wearing a long-sleeve sweater despite the room’s warm temperature. She also notices bruises on Elena’s face covered with makeup. Linda asks Elena if she is being hit, kicked, or slapped. She asks Elena if she feels safe in her home and if she is concerned for the baby’s safety. Elena looks at her hands and says she is safe. She explains that the bruise on her face came from running into the door at night when getting up to feed the baby. Linda examines the baby thoroughly for any evidence of trauma or failure to thrive.

Linda shares with Elena that it is okay to ask for help and gives her IPV resources (hotline numbers) Elena can use if needed. Linda asks Elena if she can visit again in a couple of weeks. Elena agrees, and they schedule the next visit.

  1. In this scenario, what subjective and objective cues are concerning for abuse?
  2. What risk factors for IPV does this client have?
  3. What steps should Linda take to ensure clients are in a safe environment?
  4. Why is it important for Linda to follow up with another visit?
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