28.5 Family Violence

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.

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.

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.

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.

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.

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.