[1]search | [2]site index | [3]faq | [4]about us | [5]what's new [6]Minnesota Center Against Violence and Abuse Family Violence Nursing Curriculum Marlene Jezierski, BAN, RN Violence Prevention Educator Partners for Violence PRevention, Allina Hospitals and Clinics <[7] marjezier@aol.com > Maura Lynch, BA Coordinator Community Violence Prevention Institute, Metropolitan State University <[8]Maura.lynch@metrostate.edu> Margaret Dexheimer Pharris, PhD, RN, MPH, FAAN Associate Professor College of St Catherine <[9]mdpharris@stkate.edu> Judi Sateren MS, RN Associate Professor Minnesota Associate Intercollegiate Nursing Consortium <[10]jsateren@stolaf.edu> Copyright 2004 Jane Q. Public Published: January, 2004 _________________________________________________________________ [11]Acknowledgements [12]Position Statement [13]How to Use this Curriculum [14]Competencies [15]Scope of the Problem [16]Statistics [17]Relationship of family violence to societal violence [18]Definitions [19]Violence [20]Domestic/intimate partner/family violence [21]Elder abuse [22]Vulnerable adult abuse [23]Categories of abuse [24]Sample Teaching Strategies: Definitions [25]Dynamics [26]Cultural/societal attitudes, beliefs, myths [27]Power and control [28]Limitations of the Cycle of Abuse Theory [29]Understanding the process of change [30]Considerations for various populations [31]Correlates [32]Sample Teaching Strategies: Dynamics [33]Health Care Implications: "It's Not Just a Social Problem" [34]Health care role [35]The effect of family violence on health [36]Selected empirical evidence of health care implications [37]Sample Teaching Strategies: Health Care Implications [38]Integrating into Routine Assessment [39]Barriers to discussing family violence [40]Process of screening [41]Sample Teaching Strategies: Integrating into Routine Assessment [42]Interventions [43]Responses to suspected child abuse [44]Responses to adolescent and adult victims of intimate partner violence. [45]Potential responses to suspected abuse of elders/vulnerable adults/those with disabilities [46]Sample Teaching Strategies: Interventions [47]Legal and Ethical Issues [48]Standards of Care [49]Mandatory reporting requirements in Minnesota [50]Exceptions to mandatory reporting [51]Sample Teaching Strategies: Legal and Ethical Issues [52]Prevention [53]Levels of Prevention [54]Prevention strategies consistent with the MDH Public Health Nursing Section public health nursing intervention wheel [55]Sample Teaching Strategies: Prevention [56]Appendices [57]Appendix A: History of Child Protection [58]Appendix B: Family Violence: Myths and Misconceptions [59]Appendix C: Myths about Batterers [60]Appendix D: The ABC's of Men Who Batter [61]Appendix E: Men Who Sexually Abuse Children [62]Appendix F: Power and Control Wheel [63]Appendix G: Challenges to Change [64]Appendix H: Thoughts on the "Cycle Theory of Violence" and the Dynamics of Domestic Abuse [65]Appendix I: Domestic Violence Theories [66]Appendix J: Speaking to Health Care Providers: Notes to Survivors [67]Appendix K: Gloria's Story [68]Appendix L: Quiz: Have You Ever?..... [69]Appendix M: Family Violence Awareness Exercise [70]Appendix N: Systems Review [71]Appendix O: Victims of Violence: Health Care Provider Needs Assessment and Intervention [72]Appendix P: Barriers to Abuse Assessment and Intervention [73]Appendix Q: Family Violence Screening and Response Tool [74]Appendix R: Small Group Case Scenario Discussions [75]Appendix S: Culturally Sensitive Responses to Victims of Intimate partner Violence [76]Appendix T: Safety Plan---Alexandra House, Blaine, MN (used with permission) [77]Appendix U: The Role of a Domestic Violence Advocate [78]Appendix V: Elder Domestic Abuse, Vulnerable Adult Abuse, and Caregiver Stress [79]Caregiver Stress [80]Elder Domestic Abuse [81]Vulnerable Adult Abuse [82]Appendix W:Elder Intimate Partner Violence Chutes and Ladders (Chutes and Ladders Exercise (2000 WCADV/National Clearinghouse on Abuse in Later Life, NCALL: 608.255.0539 ( revised by M. D. Pharris)) [83]References Acknowledgements The authors would like to thank Marion Kershner, MS, RN, PHN; David McCollum, M.D.; and Cindy Pins, MS, RN for their editorial contributions. Position Statement Nurses are in a unique position to make a significant impact on the problem of family violence. Caring is the essence of nursing and sets the stage for a partnership, which fosters the autonomy and strengths of individuals, families, and communities, supporting them toward health. It has been established that the most important determinant of people being able to discuss the abuse experience is a supportive, nonjudging attitude ( [84]McCauley, York, Jenckes, & Ford, 1998 ). Despite the increased emphasis on the importance of including interpersonal violence content in nursing curricula, many nursing programs in Minnesota lack the necessary integration of violence content across the lifespan. In addition to the American Association of Colleges of Nursing ( [85]1999 ) and the American Nurses Association ( [86]1991 ), several nurse scholars have directly identified this need and how to address it ( [87]Blair & Wallace, 2002 ; [88]Gayan, 2003 ; [89]Woodtli & Breslin, 2002 ). The content of this curriculum grew out of the 1999 AACN competencies. While working as members of the Practice Guidelines Committee of the Minnesota Healthcare Coalition (1996-2001), we informally surveyed Minnesota nursing faculty about their inclusion of family violence education in their curricula. This document was developed in response to those findings to provide Minnesota nursing faculty essential curricular information to develop student competence in preventing, assessing, and responding to family violence across the lifespan. Our names as authors are placed in a circle at the beginning of this document to illustrate the collaborative nature of the process of synthesizing the literature on family violence into a meaningful curriculum outline. We met for hours and sometimes days at a time over a two-year period and all information in this document was collaboratively written in an iterative process. While nurses must be able to respond skillfully to victims of all types of violence, responding to victims of family violence requires sensitivity rooted in understanding how it differs from other types of violence. Distinguishing features of family violence include the * parties' intimate knowledge of one another; * perpetrator's ongoing access to the victim; * secret nature of the problem, generally happening out of public view; * perpetrator's ability to avoid being caught; and * perpetrator's ability to influence consequences if caught. While this document does not address assaults by strangers, many of the skills taught in working with victims of family violence are transferable to working with victims of stranger violence. Key points to consider when utilizing this material include: * A significant percent of students and faculty will have or are experiencing personal violence and have been deeply affected by the experiences. Faculty members who have experienced family violence will benefit from self-awareness and self-care when teaching this content. Recognizing that there are survivors in the classroom sets the stage for an open, supportive, nonjudgmental, and sensitive learning environment. Making affirming statements and providing resource information benefits survivors in the classroom. * The material builds on, but does not include, content on family systems and working with families with limited adaptive ranges and boundary issues. * When working with patients with a history of family violence, nurses must respect the validity of the patient's point of view rather than imposing their own view of what is best for the patient. The role of the nurse is to be a source of support and resources. Patients make informed decisions when provided with objective and relevant information. However, when children and vulnerable adults are being victimized, nurses have a legal and ethical obligation to intervene. * Nurses can effectively establish trusting relationships with their patients if they understand the basic dynamics of abusive relationships. This includes understanding the process of change from victim to survivor. The term victim legitimately refers to anyone who has experienced family violence, however some take offense at the term victim and prefer to be called survivor because it recognizes their accomplishment in overcoming the violence. * Perpetrators of violence may also have been victims of violence. Nurses provide care to victims and perpetrators alike and need to know helpful nursing responses to all patients. * Legal references are current at the time of writing. Since law is an expression of public will, it changes and evolves over time. Most recent legislative changes can be accessed on the Internet at [90]http://www.leg.state.mn.us/leg/statutes.htm How to Use this Curriculum Although some nursing curricula have a specific course on family violence, most nursing programs in Minnesota place the content into a number of courses. The standard to strive for is weaving it in a purposeful way throughout the curricula. In considering where and how to integrate family violence content, Gayan ( [91]2003 ) suggests that, "placement of content reflects faculty's value of the content and sends a message to students about relevancy" (p. 48). Some ways to integrate family violence include * incorporating signs and symptoms of abuse into physical and psychosocial assessment classes and labs; * teaching dynamics of violent relationships and helpful nursing responses in mental health courses; * emphasizing ways of phrasing family violence assessment questions when teaching communication skills; * using role-plays in clinical conferences to teach screening skills; * including screening questions for abuse in health history interviews students conduct with peers; * having students complete independent study assignments on-line (see Section III: Dynamics: teaching strategies); and * including the health effects of abuse when discussing physical and psychological disorders. Examples might include + the prevalence of irritable bowel syndrome in patients who have a history of physical and/or sexual abuse; + the risk of being abused during pregnancy; and + the high rate of depression, suicide, eating disorders in patients who have a history of family violence. Competencies Family Violence Screening and Intervention Competencies for Registered Nurses The following competencies were extracted from the Position Statement on Violence as a Public Health Problem, Competencies Necessary for Nurses to Provide High-Quality Care to Victims of Domestic Violence, Appendix C, American Association of Colleges of Nursing ( [92]1999, pp. 12-13 ). The AACN competencies were revised with AACN permission to reflect best practices in the state of Minnesota. Changes are indicated in bold. 1. Competencies related to acknowledging the scope of the problem. 1. Recognize the prevalence of family violence in all its forms. 2. Recognize risk factors for both victimization and perpetration of family violence. 3. Recognize the potential significant physical and mental health effects of both ongoing and prior family violence. 4. Recognize the effects of violence across the life span, including the long-term effects for children who are either victims or witnesses of family violence. 5. Recognize one's own attitudes about family violence, including the possibility of one's own friends' or family members' victimization and the need to address ongoing issues arising from such experiences. 2. Competencies related to explaining the dynamics of abusive relationships 1. Demonstrate understanding of the concepts of power and control in relationships. 2. Demonstrate understanding of the cycle theory of violence and its misapplications. 3. Demonstrate understanding of common myths and facts related to abusers and survivors. 4. Demonstrate understanding of the process of change. 3. Competencies related to identification and documentation of abuse and its health effects. 1. Recognize the necessity and value of universal screening of all patients---male and female, all ages, all conditions. 2. Articulate developmentally appropriate questions to be used in screening in various settings. 3. If physical violence has occurred, recently or in the past, assess particularly for nonconsensual sexual contact, mental health status, old undiagnosed injuries, risk of suicide and/or homicide through interviews, review of medical records, and physical examination. 4. Assess for current and/or past threats and acts of family violence, particularly child abuse and neglect; intimate partner violence; elder/vulnerable adult abuse, neglect, and financial or material exploitation. 5. Thoroughly document all findings related to abuse, neglect and exploitation. 4. Competencies related to interventions to reduce vulnerability and increase safety, especially of women, children and elders. 1. Know local, state, and national domestic violence referral resources, including shelters and safe houses. 2. Communicate non-judgmentally and compassionately. 3. Conduct safety planning. 4. Refer to community advocacy programs, social worker, shelter and legal counsel as appropriate. 5. Know the role of community advocates. 5. Competencies related to ethical, legal and cultural issues of reporting and treatment. 1. Know state and national legal mandates regarding family violence, including mandatory reporting responsibilities and limitations. 2. Know appropriate methods for collection and documentation of data so that both the patient and the provider are protected. 3. Know the ethical principles that apply to patient confidentiality. 4. Recognize that ethical dilemmas often arise from cultural differences. 5. Recognize that cultural factors are important in influencing the occurrence and patterns of and responses to violence in individuals, families, and communities. 6. Provide culturally competent assessment and intervention while maintaining human rights. 7. Understand the ethical implications of public policy which fails to protect people who are immigrants, particularly those who are undocumented. 6. Competencies related to prevention activities. 1. Increase public awareness of family violence. 2. Promote activities to address prevention with populations at risk (e.g. child witnesses, pregnant women, vulnerable adults, and dependent-frail elderly). 3. Empower individuals and families to prevent and/or reduce violence and to promote family health. 4. Recognize the need to establish programs to support victims, their family members, and the abuser. Scope of the Problem Statistics Since it is essential that nurses understand the magnitude of family violence, statistics are a necessary part of the curriculum. However, it should be emphasized to students that the numbers themselves are not as important as the overall impact of violence on individual and family systems. Underreporting, as well as variations in definitions of violence and abuse account for the differences in statistical data often found in the literature. In addition, care must be taken when interpreting racial and ethnic differences in reported rates of violence. The ANA ( [93]1998 ), in its Culturally Competent Assessment for Family Violence , clearly points out that differences in rates of violence between racial groups tend to disappear when income is controlled. Reliable family violence sources: Bureau of Justice Statistics: [94]http://www.ojp.usdoj.gov/bjs/ Elder Abuse Prevention and Treatment Resources: [95]http://www.aoa.gov/eldfam/Elder_Rights/Elder_Abuse/Elder_Abuse.asp Family Violence Prevention Fund: [96]http://www.endabuse.org Minnesota Center Against Violence and Abuse: [97]http://www.mincava.umn.edu National Center for Injury Prevention and Control: [98]http://www.cdc.gov/ncipc/wisqars/ National Clearinghouse on Child Abuse and Prevention (DHHS): [99]http://nccanch.acf.hhs.gov/ Office of Juvenile Justice and Delinquency Prevention: [100]http://www.ojjdp.ncjrs.org/ Obtain local statistics through your community health department, advocacy programs, law enforcement agencies, and state department of health and center for crime victim services. Health care cost Intimate partner violence (IPV) is an enormous health problem, with annual excess health care costs of billions of dollars annually in the U.S ( [101]NCIPC, 2003 ). There is an increased relative risk of both overall and diagnosis-specific hospitalizations among abused women. Intimate partner violence has a significant impact on women's health and use of health care ( [102]Kernic, 2000 ). Among female Medica enrollees within the Allina Health Care System alone, it is estimated that over $6 million excess dollars are spent annually to provide health care services to female victims of IPV ( [103]Bohn, 2001 ). Wisner, Gilmer, Saltzman and Zink ( [104]1999 ) found female victims of IPV to incur health care costs approximately 92% greater than a random sample of female patients. Contrary to the findings of other studies, use of emergency room services was not a driving factor in the higher cost. Heterosexual A wide range of studies conducted in the past 20+ years have found that 89-100% of reported cases of physical IPV involve women abused by men. While it is known that abuse occurs in gay, lesbian, bisexual, and transgender relationships, and there are men who are abused by female partners, the vast majority of abuse victims who report IPV are women abused by men. Health care professionals should realize that IPV is perpetrated primarily by men whether against male or female partners and the vast majority of IPV victims are women ( [105]Tjaden & Thoennes, 1998 ). Some statistics documenting the incidence include: * In a survey of 8,000 men and 8,000 women, 25% of women and 8% of men reported rape and/or physical assault by an intimate partner in their lifetime. Ninety-three percent of women and 86% of men who were raped and/or physically assaulted since the age of 18 were assaulted by a male ( [106]Tjaden & Thoennes, 1998 ). * In large prospective emergency department (ED) studies, 37% to 54% of women seen in the ED have been abused by an intimate partner at some point in their lives. ( [107]Abbott, Johnson, Koziol-McLain, & Lowenstein, 1998 ; [108]Dearwater, Cohen, & Campbell, 1998 ). Lesbian, Gay, Bisexual, and Transgender (LGBT) Limited research has been conducted on the rate of LGBT domestic violence. Early research suggested that LGBT domestic violence was more prevalent than violence in heterosexual relationships. However, the National Violence Against Women Survey found that women living with female intimate partners experience less intimate partner violence than women living with male intimate partners and men living with male intimate partners experience more intimate partner violence than do men who live with female intimate partners ( [109]Tjaden and Thoennes, 2000 ). Greenwood, Reif, Huang, Pollack, Canchola, and Catania ( [110]2002 ) studied the prevalence of battering victimization among 2,881 men who have sex with men. They found that 39% of the men, who were from four major urban areas, reported experiencing at least one type of intimate partner battering during the previous five years. The strongest demographic correlate of overall violence was being 40 years of age or younger. The strongest demographic correlates for physical and psychological/symbolic violence were education and HIV serostatus. Race, ethnicity, income, sexual orientation, and city of residence were not correlated with violence. Child and Teen a. Child abuse Child abuse is a serious public health problem due to children's vulnerability and the potential adverse long-term health outcomes. In a survey of more than 15,000 adults conducted by Vincent Felitti, Robert Anda, Dale Nordenberg and colleagues, 10.8% of adult patients acknowledge child physical abuse, 22% said they experienced sexual abuse in childhood, 12.5% indicated childhood exposure to domestic violence, and approximately 33% reported being emotionally abused ( [111]Groves, 2001 ). Young children are at the greatest risk for physical abuse. Forty-one percent of children killed by parents or caretakers are under 1 year of age and only 10% of child fatalities are over 4 years of age. Younger children are not only more physically vulnerable and less able to seek help, but they are also more likely to be suspected as victims and diagnosed as abused when injured, resulting in increased reporting rates ( [112]Gelles, 1997 ). Girls aged 10 to 12 are the most likely victims of sexual abuse by adults. Adolescents are underreported as victims of physical and sexual abuse. Not only are they less likely to be diagnosed and receive help, but they also are often considered delinquent, troublemakers, and contributors to their victimization ( [113]Gelles, 1997 ). These cases represent the following distribution of maltreatment types* ( [114]NCCAN, 2001 ): Neglect 77.4% Physical abuse 24.8% Sexual Abuse 7.3% Medical Neglect 4.5% Psychological Maltreatment 1.0% some cases involved more than one type of abuse/neglect It is important to remember that these are only the rates of substantiated (reported, investigated, and adjudicated by law) cases. Physical and sexual abuse are difficult to substantiate because children are not brought in for medical care until signs of the abuse have disappeared. Furthermore, in cases where physical markers are present, it is often difficult to prove who is responsible. b. Teen dating violence Recent studies have pointed to intimate partner violence as a significant health issue for adolescents. It is associated with increased risk of substance use, unhealthy weight control behaviors, sexual risk behaviors, pregnancy, and suicidality. Approximately 1 in 5 female high school students report being physically and/or sexually abused by a dating partner ( [115]Molidor, Tolman, & Kober, 2000 ; [116]National Center for Injury Prevention and Control, 2001 ; [117]Silverman, Raj, Mucci, & Hathaway, 2001 ). A study done by Ackard and Neumark-Steiner ( [118]2001 ) reports results from the 1998 Minnesota Student Survey on dating violence. They found that one in ten girls and one in 20 boys report being raped or physically abused on dates and approximately six percent of Minnesota boys and girls report some type of date-related violence by the ninth grade. Youth who have been victimized by dating partners are more likely than their non-victimized peers to report having experienced emotional problems including suicidal thoughts, poor emotional well-being, low self esteem, and eating disorders. Elder: domestic abuse, vulnerable adult abuse, and caregiver stress These three categorizations or terms are often used interchangeably, but generally speaking refer to different situations. Studies have found that a significant portion of elder abuse is spousal abuse continuing into older age ( [119]Brandl & Raymond, 1996 ). Elders can also be victimized by adult children, or other caregivers ( [120]Brandl & Raymond, 1997 ). The National Center for Injury Prevention and Control ( [121]2003 ) reports the following breakdown of elder maltreatment substantiated by adult protection agencies. Table1.Percent of Substantiated Cases of Elder Abuse in US Neglect 49% Emotional/psychological abuse 35% Financial/material exploitation 30% Physical abuse 26% Abandonment 4% Sexual abuse 0.3% Other 1.4% Table2.Relationship of Perpetrators to Victims in Elder Abuse (Percent of substantiated cases in the US) Neglect Psych. Phys. Finan. Aban. Child 43% 54% 49% 60% 80% Spouse 30% 13% 23% 5% 6% Grandchild 9% 9% 6% 9% 7% Other relative 4% 12% 5% 10% 0% Friend/neighbor 1% 10% 10% 9% 0% Sibling 9% 2% 5% 1% 0% In-home service provider 4% 1% 0% 2% 7% Relationship of family violence to societal violence The "---isms" It is important to understand the dynamics of abuse in relationships in the societal context of what are known as the "---isms:" racism, classism, homophobia and heterosexism, ageism, and ableism. The "---isms" are personal or institutional forms of discrimination committed by members of the dominant, often majority, culture against individuals or groups from whom they are different, based on characteristics over which neither has any control, such as skin color or physical ability. There can be multiple intersections between the experience of family violence and the experience of the "---isms." Examples include * isolation (the victim of family violence being denied a social network is akin to the heterosexism of a gay person being forced to remain closeted by family pressures); * economic abuse (the victim being put on 'allowance' is akin to the sexism of a woman earning 76 cents on the dollar compared to $1 for the same work by a male counterpart); and * threats and intimidation (the victim being yelled at and cornered is akin to the racism of racial profiling or the classism of a caseworker who threatens to terminate benefits of someone on public assistance). The barriers abuse victims face are confounded by experiences of racism for people of color, homophobia and heterosexism for lesbian, gay, bi-sexual and transgendered (LGBT) people, and so on. This is why ongoing development of cultural competency skills is so critical to effective nursing practice. Evolution of health care response The role of health care professionals in the area of primary, secondary, and tertiary prevention of family violence has slowly evolved as societal awareness has increased. Laws mandating the reporting of child abuse emerged in the 1960's (see appendix A, History of Child Protection). The first battered women's shelters were founded in the 1970s. In the late 1980s and early 1990s most states enacted elder abuse laws ( [122]Haywood & Scott, 1999 ). In Minnesota, health care professionals are mandated to report all cases of suspected abuse of vulnerable adults. With the genesis of the community responses to domestic violence, partnerships evolved between health care organizations and domestic abuse advocacy services. While research clearly documents the major impact of family violence on health, many clinics, hospitals, and other health care sites across the country still resist universal screening. In fact, despite health care professionals in the US being in an optimal position to intervene, most states, including Minnesota, receive a failing grade in terms of training, screening, protocols, reporting, insurance, and legislation and public policy ( [123]Family Violence Prevention Fund, 2001 ). There is much more that policy makers can and should do to improve the health care response. For example, something as simple as a best of practice standard has yet to be agreed upon. Nursing can and should take leadership in crafting those policies. International trends The occurrence of family violence is strongly influenced by cultural forces. Rates of family violence vary from country to country. It is difficult to make accurate country to country comparisons of the incidence of family violence because methods of data collection are not held constant. Generally speaking, cultures that value the care of children and elders, have strong social welfare policies, protect the rights of women, and have strong social sanctions against violent behavior have lower rates of family violence. The United Nations Children's Fund ( [124]UNICEF, 2000 ) reported that even with "spotty" statistics, one-fifth to one half of the female population in a given country has been abused by a family member or intimate partner, or dangerously neglected in childhood. Violence against women and girls continues to be a global epidemic that kills, tortures, and maims-physically, psychologically, sexually and economically. Sports More questions than answers exist in the area of sports and violence. However, violence experts frequently express concern about the behavior of athletes in general, and the lack of positive role modeling that exists in sports. Violent behavior by professional and amateur athletes, including assault, rape and domestic violence has been well documented ( [125]Benedict, 1997 ; [126]Benedict & Yaeger, 1999 ). There are at least two areas of concern for nurses. The first is the experience of violence for youth involved in sports (i.e. win at all costs, intimidation and humiliation surrounding their performance, etc.). Nurses should take the opportunity to educate and intervene with children and teens involved in sports. Education could include principles of respect, good sportsmanship, and conflict management. Perhaps the most important task for nurses is to help parents encourage positive attitudes towards competition and physical activity, recognize signs of anxiety and aggressive behavior, and promote realistic expectations for their child's performance ( [127]Hellstedt, 1988 ). The second area of concern for nurses is the dynamic of college and professional contact sports athletes who commit violent acts and the failure of society to hold them accountable. Women victimized by professional athletes are highly pressured to keep silent. Workplace a. Domestic violence in the workplace Domestic violence knows no boundaries. With the increasing number of working women, there is a correspondent increase in the incidence of domestic violence in the workplace. In a study of 118 battered women, Stanley ( [128]1992 ) found that 69.5% were employed at the time of the abuse. Of that number, 96% stated they experienced problems at work due to their abusive situations. 37% of women personally affected by domestic violence report that the abuse has had an impact on their work performance in the form of tardiness, missed work, a lost job or missed career promotions. ( [129]EDK Associates, 1997 ) Intimate partner violence crosses the boundary of home and work in numerous ways. There are two issues to consider in this category. The first issue surrounds the effect intimate partner violence has on the workplace of the victim/survivor. Absenteeism, security concerns related to abusive partners, productivity, and the emotional impact on co-workers can affect workplaces. The second issue involves perpetrators in the workplace. Perpetrators often use the resources of their place of employment to harass their partner (phone calls, emails, etc.). Furthermore, perpetrators may exhibit the same abusive behavior at work as at home, targeting customers, coworkers, and others. The total health care costs of family violence are estimated in the hundreds of millions each year, much of which is paid for by the employer ( [130]Pennsylvania Blue Shield Institute, 1992 ). In a survey commissioned by Liz Claiborne, Inc., Roper Starch Worldwide ( [131]2000 ) found that corporate leaders have grown more aware of domestic violence as an issue that affects their employees and have become less likely to dismiss the issue's bottom-line impact on business, according to a survey conducted for Liz Claiborne Inc, nine in ten senior executives (91%) believe that domestic violence affects both the private lives and the working lives of their employees (this is up from 44% in a similar study conducted in 1994 by the same company). Yet only 12 percent of corporate leaders surveyed say that corporations should play a major role in addressing the issue-the same percentage as when this question was first posed in 1994. Roper Starch Worldwide (2000) also point out that corporate leaders now rank domestic violence on par with terrorism (68%) as a major issue that affects society. But today, they are also significantly more likely to say that they are aware of employees in their company who have been affected by domestic violence (56% in 2002; 40% in 1994). And, while half thought that domestic violence had a negligible impact on the bottom line in 1994, this percentage has dropped significantly to just one-third (33%) saying so today. b. Abusive work environments In addition to the problems presented when domestic violence spills over into the workplace, employers are beginning to address abuse issues within the workplace itself. Often referred to as 'bullying' or 'incivility,' what these behaviors are actually describing is abuse. Healthcare workplaces are known for harsh, abusive behavior within and between the allied professionals in those environments, particularly physicians and nurses. The Joint Commission on Accreditation of Healthcare Organizations has begun to examine this long-silent issue, and guidelines on "Diagnosing and Treating Workplace Abuse and Neglect in Health Care Organizations" are being written for publication by the American Medical Association. Leadership from the nursing profession will provide needed perspective on the nature of the problem and how to respond to it. Bullying There is a growing body of research pointing to the prevalence of childhood experiences of bullying. Children who are experiencing maltreatment at home are at increased risk for both victimization and perpetration of bullying ( [132]Shields & Cicchetti, 2001 ). Childhood bullying may be an indicator of more extensive family violence and recognize the opportunity for screening and intervention. Of over 15,000 children surveyed, 10.6% reported bullying others "sometimes" and 8.8% admitted to bullying others once a week or more, with children who bully showing significantly poorer psychosocial adjustment, such as loneliness, difficulty making friends, fighting, smoking, and using alcohol ( [133]Nansel, Overpeck, Pilla, Ruan, Simons-Morton, & Scheidt, 2001 ). Media The correlation between exposure to media violence and aggressive behavior has been the subject of numerous studies ( [134]Huesmann, Moise-Titus, Podolski, & Eron, 2003 ). According to the American Academy of Pediatrics ( [135]1995 ) the vast majority of studies conclude that there is a causal relationship between exposure to media violence and real-life violence. For children exposed to violent behavior in their homes, the effect of media violence is more profound. Sample Teaching Strategies: Scope of the Problem Timed reminder During the segment on statistics, consider using timed sounds to illustrate the frequency of the incidence of abuse, loss of life, or a similar statistic. Use a taped recording of a hand slapping loudly every 15 seconds to signify how often a woman is assaulted by an intimate partner in the U.S. (FBI, 1995 ). Play it as you cover the statistics section. Participant Cards As students come into the classroom, give them an index card with a statistic about family violence. Begin discussion of each of the various topics that the statistics address by having the student with the corresponding statistic read it out loud. Videos * Tough Guise: Violence, Media, and the Crisis in Masculinity (82 minutes). 1999. Media Education Foundation. 1-800-897-0089, [136]http://www.mediaed.org * Don't Laugh at Me School Anti-Bullying Program. Available from [137]http://www.dontlaughatme.org Web sites * Center for Cross Cultural Health: [138]http://www.crosshealth.com * National Clearinghouse on Child Abuse and Neglect Information: [139]http://nccanch.acf.hhs.gov/ * Minnesota Coalition for Battered Women: [140]http://www.MCBW.org * Silent Witness Project: [141]http://www.silentwitness.net * Speaking Out Against Global Violence: [142]http://www.feminist.com/violence/spot/ * UNICEF: The State of the World's Children, 2001: [143]http://www.unicef.org/sowc01 * Abuse-free workplace resources: [144]http://www.mincava.umn.edu/workviol.asp#A101410100 Assessment and evaluation resources on the health of work and home environments as it relates to violence and providing direction to employers in seeing their role in addressing this issue: Respond2, Inc. 1809 Lincoln Ave. St. Paul, MN 55105. 651.699.6565 Deborah Anderson, President Definitions Various definitions exist of the types of violence that occurs among intimates. Violence Violence is the threatened or actual use of force against a person or a group that either results in or is likely to result in injury, death, emotional damage or coerced behavior ( [145]Governor's Task Force on Violence as a Public Health Problem, 1996 ). Domestic/intimate partner/family violence There is little consensus on how to define these terms and what to call the various forms of abuse and violence among intimates ( [146]Tjaden & Thoennes, 2000 ). We have found the following to be a good general working definition: "A systematic pattern of repeated psycho-social/emotional abuse, coercive control, progressive social isolation, intimidation and violence, injury or sexual assault. The intention of this behavior is to punish, abuse, and ultimately control the thoughts, beliefs and actions of the victim" ( Minnesota Coalition for Battered Women ). Elder abuse An elder can be a victim of family violence without meeting the legal criteria for being a vulnerable adult in the state of Minnesota. A significant portion of what is typically identified as 'elder abuse' is actually abuse by a partner in long-term, intimate relationships. Elders may also be victims of abuse by adult children or others living in their home. In long-term abusive relationships, physical violence/threats as a tactic of control may diminish with old age, but other controlling behaviors often replace them in order to maintain the same control. Other types of violence and neglect of older persons exist but are not domestic violence. Domestic violence is not * self-neglect, * stranger abuse (muggings, scams), * abuse by paid caregivers (institutional elder abuse), * caregiver stress (e.g. overburdened adult children), or * abuse by a partner whose abusive behavior is caused by a medical or mental health condition or reaction to medication. Vulnerable adult abuse Minnesota statute defines vulnerable adult abuse as physical, sexual, or emotional abuse; neglect, or financial/material exploitation of a person who is at least 18 years of age and is dependent on others for care. Health care professionals are mandated by Minnesota statute to report abuse of vulnerable adults by people responsible for their care and acts of violence resulting from a failure to protect vulnerable adults. Categories of abuse 1. Physical: actual or threatened infliction of physical harm which is intentional. Physical violence can include a range of threatened or actual behaviors from slapping and hitting to using a gun. 2. Sexual: any actual or threatened unwanted or coercive sexual contact and/or penetration. Sexual abuse also includes sexual contact with a minor child or vulnerable adult by someone responsible for their care (or, in the case of minors, by someone in a position of authority or in a significant relationship with them). Routine care provided in accordance with standards of practice for health care professionals, and commonly accepted care by parents, guardians, etc. is not sexual contact. 3. Emotional/psychological: the use of coercion, threats, put-downs, insults, and other verbal or nonverbal measures which control another person and results in the loss of self esteem as well as victims believing they deserve the abuse. 4. Neglect: a failure to protect or a failure to fulfill any part of a person's obligations or duties to a vulnerable adult or a child. Neglect also includes abandonment of a child or vulnerable adult on the part of the person who is legally responsible for that person. 5. Financial and material exploitation of vulnerable adults: the illegal or improper use of a vulnerable adult's funds, property, or assets. Examples include but are not limited to: cashing checks without authorization/ permission; forging a signature; misusing or stealing money or possessions; coercing or deceiving a vulnerable person into signing any document (e.g., contracts or will); and the improper use of conservatorship, guardianship, or power of attorney. Sample Teaching Strategies: Definitions Definition word scramble: Take your definition and divide it into relevant phrases. Put each phrase on a separate large post-it note or flip chart sheet. Scramble them up. Add words and phrases that don't belong in the definition on other post it notes. This is much like a magnetic poetry game. This could be done by teams with a prize awarded to the winning team. Definition development: Tell the students you will give them a standard definition for the types of family violence, but you'd like them to create their own. Have students work together to create the most inclusive, yet concise definition possible. Have each group present their definition and see how it compares to the commonly accepted definition. Websites * Minnesota Coalition for Battered Women: [147]www.mcbw.org Phone: 651-646-6177 * Minnesota Statutes are available at: [148]www.leg.state.mn.us/leg/statutes.htm Dynamics The ability to provide supportive care is dependent upon understanding the factors influencing individuals in abusive relationships. Cultural/societal attitudes, beliefs, myths Survivor myths and facts See Appendix B: Family violence: Myths and misconceptions There is a great deal of misinformation and many false assumptions about individuals in abusive situations. Health care professionals who understand the error of these myths are better equipped to provide care, support, and resources to individuals who indicate they are experiencing abuse. Myth Fact 1. Family violence occurs only in the lower socioeconomic class Although poor families are likely to experience interpersonal violence, it occurs at all income levels. Poor families may be identified more often because they often have more contact with social service agencies. 2. Alcohol and drugs are the cause of family violence There is an association between drinking/drug use and family violence, but it is not the root cause. Abusive individuals are abusive whether they are sober or intoxicated ( [149]Kantor & Strauss, 1990 ). 3. Family violence is rare Research consistently shows that women and children are more likely to be assaulted in their homes than on the streets of the most violent American cities ( [150]Bachman & Satzman, 1996 ). Abuser myths and facts See Appendix C: Myths About Batterers, Appendix D: The ABCs of Men Who Batter, and Appendix E: Men who Sexually Abuse Children. Many believe that only 'sick', 'evil' people are abusive. On the contrary, abusers usually lead 'normal' lives in most respects except they believe they are entitled to use violence and abuse to control the lives of their partners and families. Abusers come from every walk of life, every culture, and every socioeconomic level. They do not recognize their behavior as being violence. Often, these unacceptable behaviors are not challenged by society ( [151]Bennett & Williams, 1999 ). The primary treatment objective for abusers is for the abuser to take responsibility for the abusive behavior and to be held accountable through a variety of measures such as legal consequences and reeducation programs. According to the Standards for Batterers Treatment Programs-Philosophy Statement issued by the Domestic Abuse Project in Minneapolis, effective batterer reeducation includes * violence can never be condoned under any circumstances; * abusive behavior is the sole responsibility of the batterer; * provision for the safety of victims/survivors and their children should be utmost in any decision or policy; * violence as a choice is a learned behavior response and can be unlearned in an educational/therapeutic group setting; * the primary goal of treatment programs for batterers is to end the violent, abusive, and controlling behaviors; and * domestic violence and alcohol abuse are often intertwined, however a causal relationship has not been established. They must be treated as separate issues and perpetrators must address the chemical abuse issue before beginning a domestic abuse program. Power and control Domestic violence is much more than simply physical violence. Emotional and psychological abuse is present in all family violence situations. Many survivors of emotional abuse describe it as being more difficult to name, access support for, and ultimately overcome than physical abuse. There are various Power and Control Wheels that describe the dynamics of family violence (see Appendix F: Power and Control Wheels). The behaviors, which form the spokes within the wheel depend on and reinforce each other. Sexual and physical violence, forming the outer rim, reinforce the entire system of control. Physical and sexual violence are not always present in abusive relationships; however, emotional abuse is always present. The wheels illustrate the interdependent and systematic nature of violence in relationships. Economic abuse prevents victims/survivors from gaining financial freedom, which could help them escape the violence. Isolation destroys the support system of relatives and friends who might be able to provide information, support and resources. Threats instill fear. The interweaving of these dynamics builds barriers that prevent escape from an abusive relationship (see Appendix G: Challenges to Change: Issues Keeping Family Violence Survivors from Seeking Help). Wheels have also been developed to illustrate how to achieve relational health (see Appendix F: Power and Control Wheels). In addition to the wheels appended in this document, wheels from a Native American perspective, for nurturing children, and Spanish language wheels can be accessed from the Minnesota Program Development, Inc. website on the Duluth Model at [152]www.duluth-model.org Limitations of the Cycle of Abuse Theory When studying current theories, thoughtful consideration should be given to the perspective of those experiencing battering (see Appendix H: Thoughts on the Cycle Theory of Violence and the Dynamics of Domestic Abuse and Appendix I: Theories on Domestic Violence) for in depth analysis of current thinking on the cycle theory. Although most nursing texts present the Cycle of Abuse Theory ( [153]Walker, 1979 ) there are serious limitations to this theoretical framework. The cycle is described in three phases: tension building, acute battering incident (explosion), and honeymoon. While individuals in abusive relationships may relate to some or all of the elements of this cycle, many survivors experience only parts. Ellen Pence ( [154]1987 ) points out that, the process of education must constantly compare theory to the real experiences of women so that we do not operate from false assumptions. Such assumptions lead us to actions that do not result in changing the system. Perhaps there is no better example of this than the cycle of violence theory and the many theories that have in the past few years dominated the work with batterers, resulting in hundreds of men's groups forming around the country which focus on teaching men who beat women into submission to reduce their stress level, to cope with anger differently, to express feelings differently rather than working with batterers on issues of power and dominance. These theories focus on the psychology of battering rather than on the political and social context of battering, and they analyze battering piecemeal (p. 22). Understanding the process of change It is very important that nurses recognize that their role is not to prescribe, decide, or judge what a patient should do, but rather to partner with the patient to provide information and resources for informed decisions. In perhaps no other health care situation is respect for patient self-determination as critical. When working with people in abusive relationships, there is a temptation to jump to a "you've got to get out!" approach. This judgmental stance robs patients of the right to their own choices and creates a barrier between the nurse and patient that may never be overcome. Key elements of nursing partnership include the following caring nursing actions: * talking with the victim/survivor in private; * accepting patient choices in a nonjudgmental manner; * expressing concern for safety; * making supportive statements (e.g. "you don't deserve this," "I'm sorry this happened to you," etc.); and * offering assistance when the person is ready. Actions which could be harmful include * telling people what to do; * blaming the victim; * violating confidentiality; and * talking to the abuser about the abuse. Considerations for various populations Immigrant, refugee, undocumented For immigrants experiencing family violence, nurses need to consider the cultural and familial context in which the violence occurred and how it is viewed by the victim. This underscores the imperative to engage the services of a professional interpreter when the nurse does not fluently speak the patient's language. Family, friends, and members of the extended community should not be used to assist in these cases. If a professional interpreter is not available on site, a phone interpreter should be utilized. Community pressures and language barriers can keep women trapped and isolated in violent relationships. Fear of immigration sanctions compound this isolation and entrapment. It is important for nurses to consider the ramifications of actions taken to end the abuse, particularly when involving the legal system. In cases where the patient does not have full legal status in the U.S., contact with local law enforcement and the legal system is advised (without revealing the patient's identity) to ascertain whether the patient would be re-victimized by being reported to immigration. Victims/survivors should be fully informed of the possible outcomes of various actions they might take to deal with the abusive situation. If a person without legal documentation reports a domestic assault to the police and is later deported to where she had been tortured as a political prisoner, reporting the domestic abuse was more dangerous than not reporting ( [155]Jang, Marin, & Pendleton, 1997 ). Many immigrants feel as though they must choose between freeing themselves from the abuse and maintaining connection to their family and cultural community (see Appendix F: Immigrant and Refugee Power and Control). Teens Adolescence is a time when independence, autonomy, sexual identity, and intimacy are mastered-all of which can be disrupted by an abusive relationship. Teens, whose major social goal is to "fit in," are often very reluctant to reveal abuse when it occurs. Some may not even know that they are being abused. Denial is often the only coping mechanism in their repertoire. While they attempt to suppress the cognitive recollection of the abuse, it becomes manifested in their actions. At least 10% will attempt suicide after the abuse ( [156]Pharris & Nafstad, 2002 ). A nurse who develops rapport with the teen and specifically asks about victimization will be able to guide the teen toward healing. A more effective way of dealing with teen violence is to prevent it. Nurses must look for opportunities to teach teens to differentiate between respectful and violent behavior. Several good resources exist for teaching teens about sexual abuse, healthy dating relationships, and teen dating violence ( Center for the Prevention of Sexual and Domestic Violence, 2000 ; [157]Levy, 1998 ; [158]Levy & Giggans, 1995 ;Quiet Storm Project, 2001 ). Rural Populations One study of 136 women seen in two rural medical clinics found 20-28% of the women had experienced recent intimate partner abuse ( [159]Johnson & Elliot, 1997 ). Another study of 1693 Minnesota women showed the prevalence of physical, sexual and emotional abuse in rural women to parallel that of their urban counterparts ( [160]Kershner, Long & Anderson, 1999 ). Rural victims of violence have some unique challenges, including: * lack of access to public transportation and/or phone service; * lack of anonymity and confidentiality; * unavailability or ineffectiveness of legal and social services; * more hunting weapons in the home; and * fewer resources, such as jobs, child care, etc. ( [161]Kershner & Anderson, 2002 , [162]Kershner, Long, & Anderson, 1999 ). Communities of Color Family violence has been referred to as an "equal opportunity" problem because it happens to people in all demographic categories. Unfortunately, current research on the prevalence, health consequences, and responses to family violence in communities of color in particular has been limited, at best. For example, Torres, Campbell, Campbell, et al. ( [163]2000 ) point out that "few studies have specifically examined the relative prevalence of abuse during pregnancy in different ethnic groups" (p. 304). Campbell, Sharp, Campbell, and Lopez ( [164]2002 ) further note that "the theories currently used in domestic violence practice and research generally are one-dimensional in nature and applied uniformly across cultural groups...overall, the applicability of these theories...remains uncertain" (p. 5). Nurses need to understand the diversity within and between racial/ethnic groups, that family violence happens in a larger cultural context, and the nature of institutional racism experienced daily by people of color. Nurses' responses to patients of color are informed by their own understanding and experiences of racism. The inclination of patients of color to disclose abuse is influenced by their perception of the race and the cultural sensitivity of the individuals and institutions caring for them. They are also influenced by the relevance and accessibility of the resources offered them. Nurses demonstrate cultural competence through * an awareness of their own biases, prejudices, and knowledge; * an awareness of the extent to which racism is experienced by the people they serve; * a recognition of professional power, in order to avoid imposing one's own values on the patient; * knowledge concerning patients and their cultures; and * openness to listening to and respecting new ideas and different perspectives ( [165]Fazio & Ruiz-Contrereas, 1998 ). Regardless of the racial/ethnic background of nurses and patients, the nursing profession and healthcare organizations must prioritize implementation of cultural competency education relevant to the communities in which they operate. This is best accomplished through partnership with community organizations. People with disabilities People with disabilities have more frequent contacts with health care professionals. It is important not to make any assumptions about people with disabilities and the nature of their relationships with others. The greater the degree of dependence on others, the greater the likelihood of abuse and exploitation people with disabilities experience ( [166]Pharris, 1999 ). In 1995-96 Berkeley Policy Associates conducted a survey of women with disabilities which found that women with disabilities were more likely to experience abuse by health care professionals and personal assistants, family members, intimate partners, or friends ( [167]Curry & Navarro, 2002 ). Children and elders with disabilities are also more likely to be abused by people responsible for their care. Factors to consider regarding the abuse of people with disabilities include: * Leaving abusive relationships may be more difficult because of the presence of a disability. Curry and Navarro ( [168]2002 ) make this point by drawing on the words of a survivor who states, "You finally say, 'Okay, this is it. I'm going to do whatever I can to change this marriage. And by the way, can you bring my scooter to me so I can leave you?'" * The traumatic stress of the abuse often compounds the sense of vulnerability that some people with disabilities feel. Coming to terms with this can be intense and further disabling. * People who have just gained some independence may be at risk for losing their newly gained independence and self-confidence. * Prosecuting a legal case may depend on proving the extent of the disability, in which case the person may become further stigmatized by the system in the process. Lesbian, gay, bisexual, transgender (LGBT) Abuse thrives in silence and isolation. Due to the compulsory secrecy many LGBT people experience about their sexual orientation and relationships, LGBT domestic violence is often referred to as 'the closet within the closet.' "Straight" is the assumed sexual orientation of "a battered woman" in the traditional health care model. LGBT patients fall outside the care model historically designed for non-battered members of the white, heterosexual population. Regardless of sexual orientation, many battering victims commonly face barriers of ignorance and prejudice in receiving supportive, appropriate care and services in medical settings. Battered LGBT patients often face barriers that can literally mean the difference between life and death. There are many similarities in the dynamics of the abuse of power and control of LGBT and heterosexual relationships. It is important to understand, however, that LGBT domestic violence happens in a cultural context characterized by factors such as: * homophobia and heterosexism; * ignorance about LGBT people; * understanding that LGBT women can be perpetrators and LGBT men can be victims; * limited self-reporting ; and * limited-to-non-existent services for LGBT people. Nurses can eliminate bias by not assuming the sexual orientation of patients and by using gender neutral language in relationship to the patient's partner. In accordance with the Code of Ethics for Nurses ( [169]ANA, 2001 ), nurses must provide equally sensitive care to each patient. Correlates The impact on children who witness family violence. In families where there is intimate partner violence, children are at high risk for being abused. There is a significant correlation between intimate partner abuse and abuse of children. Children's responses to witnessing adult domestic violence vary considerably depending on the child's age, gender, level of violence in the home, degree of the child's exposure, whether or not they are abused, and the presence of other risk and protective factors. Some children have such resilience that they are able to cope with the chaos of a violent home in constructive ways. While children are affected by violence in their lives, not all experience long-term negative consequences. Studies of children who witness domestic abuse have shown that the experience can have long-lasting emotional, behavioral, cognitive, spiritual, and physical effects. Children in violent homes may experience harmful circumstances * observing a parent being abused, which some have suggested may be as harmful as being abused themselves; * being abused themselves. It is often assumed the abuse in these circumstances is perpetrated by the abuser of the parent, however, sometimes the victimized parent is the one who abuses the child; and * being neglected Kolbo ( [170]1996 ) points out that children from violent homes exhibit more aggressive and delinquent behavior, and more withdrawn, anxious behaviors compared to children from non-violent homes. They also perform significantly below their peers in academics, school sports and social activities. Studies have shown that children exposed to domestic violence have a significantly higher rate of psychiatric problems than other children. Exposure to violence in the home has been found to be one of the most significant predictors of an adolescent's later use of violence in the community ( [171]Singer, Mille, Guo, Slovak & Frierson, 1998 ). Childhood exposure to domestic violence is the major predictor for being a perpetrator or victim of domestic violence in adulthood. Behaviors vary in different age groups: * less than 1 year: crying, failure to thrive, exaggerated startle response, frozen posture, stillness, sad and withdrawn facial expression, and lack of interest in exploration. * Toddlers and preschoolers: aggression to adults and peers, defiant, noncompliant, night terrors, temper tantrums, intense separation anxiety, hyper-vigilance, multiple fears, emotional withdrawal. Toddlers become reckless and accident-prone. * School children and adolescents: all the same behaviors as younger children as well as early and excessive experimentation with sexuality and illegal substances, problems with authority figures, school failure, and criminal behavior ( [172]Lieberman, 2000 ). Child protective service and health care professionals often interpret children witnessing of domestic violence as a failure to protect on the part of the mother who is being battered. It is critical to remember, however, that this line of reasoning does not recognize that the perpetrator is responsible for creating the dangerous environment in the first place, and must be held accountable for stopping the violence. Generally speaking, the children are safe when the mother is safe. Abuse of animals Abusers use the threat or actual killing of animals as a way to establish or maintain control of their victim(s). Maiming or killing a pet is more than an act of aggression against the animal. Animal abuse is a likely indicator of abuse of family members. In the case of children who beat, torture, or mutilate animals, such behavior suggests serious psychopathology ( [173]Robin, 1999 ). Substance abuse Abusers who use drugs and alcohol are more likely to inflict injury on family members ( [174]Grisso, Schwarz, Hirschinger, Sammel, Brensinger, et al, 1999 ). However, while substance abuse may be a contributing factor, no evidence has been found to support a causal relationship between substance abuse and family violence. Not all batterers abuse substance and not all those who use substances batter. Abusers often use alcohol as an excuse for their violence and as a way to avoid responsibility for their behavior. Substance abuse treatment will not stop the violent behavior. Shared characteristics of alcoholism and family violence are denial, minimization, isolation, and intergenerational patterns. Coping through substance abuse is a common response to family violence. Some women who have been battered also have substance abuse problems; however, this is not the reason they are being battered. Women who abuse substances have experienced more violence as children and experience significantly more abuse as adults compared to the general population ( [175]Miller, Downs, & Gondoli, 1989 ; [176]Miller & Downs, 1993 ). Mental health A review of the literature does not reveal a causal relationship between serious and persistent mental illness and the perpetration of abuse and violence. However, research indicates that intimate partner violence and child abuse increase the risk for mental health problems, particularly post traumatic stress disorder and depression, in those who have been abused ( [177]Golding, 1999 ). "Co-dependency" Explaining family violence in an addiction framework is problematic because battering is neither an addiction nor a symptom of addiction; they are separate problems requiring separate solutions. Their relationship is sometimes contributory, but not causal. Equating them is dangerous for the victim and does not hold the perpetrator accountable. Furthermore, "co-dependency", an extension of addiction theory, is refuted by the following: * society still sanctions violence in intimate relationships, * the batterer is responsible for causing the power imbalance in the relationship by violating the standards for healthy, respectful relationships, * a change in the "co-dependent's" behavior will not stop the coercive control and violence; * "enabling" and "co-dependence" are simply euphemisms for survival tactics; and * the victim needs more than the perpetrator's sobriety alone to be safe. Caregiver stress Caregiver stress is commonly used to explain why a person is abused by a family member on whom they are dependent for care. Three problems with naming this dynamic caregiver stress include: * it absolves the abusive party of responsibility for their abusive behavior; * it suggests that if the victim were not dependent on the caregiver, there would be no stress or abuse, thus blaming the victim for the situation; and * it prevents appropriate interventions from taking place (e.g. making a mandatory report to protective services, safety planning, offering information about power and control, and resource options) ( [178]Practice Guidelines Education and Training Committee, 1998 ). Sample Teaching Strategies: Dynamics Interactive case scenarios: MINCAVA, Global Prevention ( [179]www.globalvp.umn.edu/ ). This is an independent and interactive learning case scenario involving various aspects of community responses to a family violence situation. Students have an opportunity to answer questions about the scenario and refer to linked online articles for further information. Survivor story: Hearing from someone who has experienced abuse is powerful and contributes significantly to the learning experience. A guide for preparing survivors to share their story is available (see Appendix J: Speaking to Health Care Professionals: Notes to Survivors). In the absence of having an individual who is comfortable sharing their story and willing to answer questions, various videos are available. Discussion could include identifying elements of power and control as well as barriers to change. Slide show of images drawn by children who have witnessed domestic violence. The Domestic Abuse Project of Minneapolis has put together a slide show of children's art and commentaries. This work is available and may be downloaded from the Internet at: www.mincava.umn. Interactive power and control discussion * Introduce the concept of the power and control wheel. * Define and/or give an example of one of the quadrants (e.g. the economic abuse section). * Ask the group to give examples of economic abuse (e.g. "can you think of examples of economic abuse in a power and control situation?"). * Continue group discussion on other quadrants of the wheel. Understanding dynamics * Gloria's story : A brief and very effective interactive skit to involve students in understanding the difficulties survivors face (Appendix K). * Quiz: Have you ever... : A series of questions designed to increase student awareness of abuse dynamics (Appendix L). * Family Violence Awareness Exercise : Reflective questions to help students explore their attitudes towards victims and perpetrators of abuse (Appendix M). Videos * All Ways Welcome (1990). Active Living Alliance for Canadians with a Disability. Ontario Ministry of Citizenship, Culture, and Recreation (1-800-771-0663). * Broken Vows: Religious Perspectives on Domestic Violence (1994). Seattle, WA: Center for the Prevention of Sexual and Domestic Violence. * Elder Abuse: Five Case Stories. Terra Nova films. This film follows the real-life experience over time of five elders who are victims/survivors of family violence. Available from [180]www.terranova.com * Domestic Violence Hurts Us All: Improving Accessibility for Domestic Abuse Victims among the Deaf and Hard of Hearing Community. This 25 minute film reviews dynamics of domestic abuse, myths and facts about people who are deaf or hard of hearing, and provides a tour of a battered women's shelter for women who are deaf or hard of hearing. Available from the Community Action Council, 15025 Glazier Ave., Suite 100, Apple Valley, MN 55124 and the B. Robert Lewis House (612-452-7466, TTY: 612-405-9455, FAX: 612-452-8027). * Just to Have a Peaceful Life. Pat's story: this is the true story of a life-long abusive relationship and the challenges that people face. This film powerfully illustrates the dynamics of leaving an abusive relationship for people in their 70s-80s. Available from [181]www.terranova.com * Love---All That and More (2001). A set of three videos: What Do You Want (22 minutes), Let's Talk About Sex (19 minutes), and Putting it All Together (23 minutes). Center for the Prevention of Sexual and Domestic Violence, Seattle WA. Phone: 206-634-1903, fax: 206-634-0115, website: [182]www.cpsdv.org * My Girlfriend Did It. Real-life stories of lesbian battering. Available from Casa de Esperanza 651-646-5553. * The Quiet Storm Project (2001). This video, produced by a coalition of domestic abuse service programs in Minnesota, could be used by faculty and students to teach teens in the community or on the college campus about the dynamics of teen dating violence. It tells the story of a young woman who becomes involved in a relationship in which control and violence unfold. There is also a segment of victims and perpetrators of teen dating violence discussing the dynamics of the abuse. Available through [183]www.thequietstormproject.com * Reflections from the Heart of a Child. 1996. This video deals with the relationship between substance abuse and child development. The father in this video drinks and abuses the mother. Students experience the family dynamics through the eyes of the children in this family. Available from Hazelden Foundation. * When Help is There. This film has five multicultural scenarios of real-life elders who are survivors of family violence and how they were helped in their journey out of the violent situation. Available from Terra Nova films [184]www.terranova.com * Elder Issues: Nutrition, Falls, and Abuse. (2002). ConceptMedia 1-800-233-7078 or [185]www.conceptmedia.com * The Vulnerable Young Child: Child Maltreatment, Part I: Neglect and Sexual Abuse and Part II: Psychological and Physical Abuse (2000). Available from Concept Media. Additional Resources * Animal Rights Coalition. 612-822-6161 * The Humane Society of the United States. 1-888-213-0956. * Physicians for a Violence Free Society (2003). Abuse assessment response course: Systems approach to partner violence across the life span. San Francisco: Author. This curriculum is available on a CD. It is a comprehensive, well-organized multimedia educational tool with power points, videos, participant handouts, and instructor guides. * MS Foundation for Women ( [186]www.ms.foundation.org ) has published Safety and Justice for All, a report that examines the role that the state's criminal justice system can play in preventing violence against women, particularly poor women, immigrant women, and women of color. * Minnesota Advocates for Human Rights is scheduled to release a report in Spring of 2004 entitled, "State and Community Responses to Domestic Violence Against Immigrant and Refugee Women in the Twin Cities." Minnesota Advocates for Human Rights, 650 Third Ave. South, Suite 550, Minneapolis, MN 55402-1940, 612-341-3302, [187]hrights@mnadvocates.org , [188]www.mnadvocates.org Websites * Center for Cross Cultural Health: [189]www.crosshealth.com * Center for Research on Women with Disabilities (CROWD): [190]www.bcm.tmc.edu/crowd/ * End Abuse (a newsletter of the Family Violence Prevention Fund): [191]www.endabuse.org * Institute on Domestic Violence in the African American Community: [192]www.dvinstitute.org * Minnesota Center Against Violence and Abuse; [193]www.mincava.umn.edu * Women's Rural Advocacy Programs: [194]http://www.letswrap.com/dvinfo Health Care Implications: "It's Not Just a Social Problem" Health care role Ethical considerations Family violence violates human rights, has a major impact on health and causes great suffering. Physical and sexual abuse is illegal; emotional abuse is unethical and robs people of their basic rights to dignity and individuality. Nursing practice is driven by a unique set of ethical principles focused on patient advocacy and empowerment. The 2001 American Nurses Association Code of Ethics for Nurses includes statements that say nurses should * practice with compassion and respect for the inherent dignity, worth and uniqueness of every individual; * promote, advocate for and strive to protect the health, safety and rights of the patient; and * safeguard the patient and the public when health care and safety are affected by incompetent, unethical or illegal practice of any person ( [195]ANA, 2001 ) Ethical principles that apply to family violence include: * patient well being; * patient self-determination; * fairness; * non-malfeasance ( non-infliction of harm ); * beneficence ( production of benefit ) * fidelity ( including confidentiality and non- deception ); and * reparation ( restitution or compensation for wrong ). Standards for hospital accreditation (JCAHO, 2002) Objective criteria must be in place and staff must be trained in the use of these criteria to identify and assess possible victims of * abuse and neglect; * physical assault; * rape or other sexual molestation; * domestic abuse; and * abuse or neglect of elders and children. Staff must be able to make appropriate referrals for victims of abuse and neglect. A current list of private and public community resources for such victims must be available to staff. Quality improvement Adherence to abuse screening and intervention standards ( [196]JCAHO, 2002 ) should be measured on an ongoing basis. It is not possible to know if the job is being done well without measurement. Nurses should be cognizant of screening compliance, skill levels, perceptions of patients and their families, and effectiveness of screening and intervention. Studies have shown that implementation of abuse screening, while initially successful, often deteriorates to baseline. It is theorized that ongoing education and evaluation helps to prevent this kind of deterioration. Measurement indicators include, but are not limited to: * percentage of patients screened; * number of referrals made; * patient perceptions of the screening experience; and * patient perceptions of referrals (were their needs met?). Advanced measurement involves research on the value of screening and intervention and what patients do and do not find helpful. Risk management Consideration must be given to issues of privacy and confidentiality. Particular concerns are * potential for liability of health care professionals who do not screen or provide information to people who are at risk (see [197]American Health Lawyers Association, 2000 ); and * safety of the patient who is being abused (e.g. taking measures to protect the patient from the abuser in the health care setting, maintaining strict confidentiality so as not to disclose information that would place the patient at greater harm, and planning for safety upon disposition). The effect of family violence on health Physical, sexual, and/or emotional abuse can impact any system of the body. Because the effects can be manifested in many ways, nurses must be well aware of the wide range of potential health effects, which can include anything from headaches, to chronic pain, irritable bowel syndrome, fibromyalgia, depression, and other disease entities that are difficult to treat. Appendix N (Systems Review) includes a review of the physiological, psychosocial, and behavioral effects of abuse on the neurological, orofacial, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, and integumentary systems. Selected empirical evidence of health care implications 1. Chronic pain Fifty-three percent of patients presenting with pain and 65% of women examined for chronic headaches report a history of sexual or physical victimization ( [198]Koss, & Heslet, 1992 ). Fifty-three percent of the 150 women who presented to one hospital-based chronic pain center showed a history of physical and/or sexual abuse. A majority sought medical attention repeatedly ( [199]Haber, 1985 ). 2. Pregnancy Homicide has been found to be the leading cause of pregnancy-associated death ( [200]Horon & Cheng, 2001 ). Pregnancy-associated death is defined as all deaths occurring up to one year after termination of pregnancy ( [201]Frye, 2001 ). In reviewing violent deaths of women between the ages of 15 and 50, in the District of Columbia over a 12-year period, Krulewitch, Pierre-Louis, de Leon-Gomez, Guy, and Green ( [202]2001 ) found homicide to be the most common manner of death for both pregnant and non-pregnant women, with pregnant women experiencing a slightly higher homicide rate. A survey of prevalence rates for abuse during pregnancy reveals a range between 0.9% to 20%, with most studies between 3.9% to 8.3% (Gazmararian, Lazorick, Spitz, Ballard, Saltzman, & Marks, 1996 ). Gazmararian, Lazorick, Spitz, Ballard, Saltzman, and Marks (1996 ) point out that "...there is reason to believe that violence may be a more common problem for pregnant women than preeclampsia, gestational diabetes, and placenta previa, 3 conditions for which pregnant women are routinely screened and evaluated"(p. 1919). Parker, McFarlane, and Soeken ( [203]1994 ) studied 1,203 multiracial women and found that one in five teens and one in six adult women experience abuse during pregnancy. They also found that abuse is related to low birth weight and late entry into prenatal care. 3. Gastrointestinal An association exists between abuse history and gastrointestinal illness. Health care professionals should therefore ask patients with severe or refractory illness about abuse history ( [204]Drossman, Talley, Leserman, Olden, &. Baerreiro, 1995 ). Forty-four percent of patients in a gastro-enterology clinic reported a history of sexual or physical victimization during childhood or adulthood. Symptoms consistent with irritable bowel syndrome were evident in more than 60% of gynecologic referrals for chronic pelvic pain. As in pelvic pain, victimization histories are common in patients with irritable bowel syndrome ( [205]Drossman, Talley, Leserman, Olden, & Baerreiro, 1995 ). 4.Substance abuse Compared to men, women are more likely to use alcohol to self-medicate mood and to cope with trauma, and less likely to use substances as a means of aggression ( [206]Miller, Downs, & Gondoli, 1989 ; [207]Miller & Downs, 1993 ). 5. Mental health Existing research supports the hypothesis that family violence increases the risk for mental health problems. In a review of the literature among women who have been abused, the prevalence of mental health problems was as follows ( [208]Golding, 1999 ): * 48% depression (18 studies); * 18% suicidality (13 studies); * 64% PTSD (11 studies); * 19% alcohol abuse (10 studies); and * 9% drug abuse (4 studies). The long term consequences of childhood abuse and neglect vary depending upon such factors as relationship to the abuser, frequency and duration of abuse, ages of victim and abuser, response by parents/guardians, and adequacy of the social, medical and legal response systems. Emotional, physical, and/or sexual abuse of children may result in a number of psychological consequences, including but not limited to * anxiety; * repetitive nightmares; * feelings of guilt and shame; * psychosomatic symptoms, such as headaches, stomachaches, bedwetting; * depression; * social withdrawal; * decreased self-esteem; and * disturbed sleep. Behavioral problems resulting from abuse and neglect seen in childhood and adolescence include: * developmental delays; * extreme shyness and clinging behavior; * difficulty socializing with peers; * disruptive classroom performance; * poor academic performance; * truancy and running away; * early use of drugs alcohol; * eating disorders; * suicide and suicide attempts; * fear of intimacy; * difficulty trusting others; and * overly sexualized relationships ( [209]Loos and Alexander, 1997 ). Continued exposure to abuse may lead to more serious levels of anxiety, anger, hostility, and guilt. Adolescents and adults with a history of abuse are over represented in the prison population and have more psychiatric diagnoses like post traumatic stress disorder (PTSD) and major depression. ( [210]Silverman, Reinherz, & Gianconia, 1996 ). Untreated sexual abuse and assault during adolescence is associated with increased sexual dysfunction, school failure, poor contraceptive use, PTSD, anxiety, eating disorders/obesity, somatization, insomnia, nightmares, poor self-esteem, depression, prostitution, multiple sex partners, interpersonal problems, sexual relations problems, substance abuse, psychiatric admissions, teen pregnancy, and risky health behaviors ( [211]ACOG, 1998 ). Males who have been abused as children are more likely to respond by externalizing (fighting, swearing, guns, reckless use of cars, etc.), whereas females internalize (depression, suicide attempts, anxiety, withdrawing, etc.) ( [212]Pharris & Nafstad, 2002 ). 6. Fibromyalgia People with fibromyalgia are significantly more likely to report episodes of lifetime sexual abuse than randomly selected matched controls (53% versus 42%). Fibromyalgia patients also report physical abuse either in childhood or as an adult with much greater frequency than control patients ( [213]Boisset-Pioro, Esdaile, & Fitzcharles, 1995 ). 7. Hospital admissions Kernic, Wolf, and Hold ( [214]2000 ) compared 1355 women known to be exposed to intimate partner violence to non-abused women and found an increased risk of hospitalizations among abused women. In a five-year follow-up study comparing 117 battered women to a control group of 117 non-battered women, those battered had a dramatically higher use of 'somatic' hospital care. Categories of admissions included non-traumatic surgical disorders, trauma, gynecological disorders, induced abortion, medical disorders, and suicide attempts ( [215]Bergmen & Brismar, 199l ). Battered Women (n=117) Control Group (n=117) One hospital admission 77% 50% Total # of admissions 420 119 Psychiatric admissions 69 1 Source: Bergmen & Brismar, 199l Sample Teaching Strategies: Health Care Implications Have students assess their clinical setting for adherence to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards as they relate to training, assessment, treatment, and referral for violent victimization. (e.g. is training in place?, do nurses do universal screening?, are referrals readily available?, etc.). Integrating into Routine Assessment Many articles describing the effects of family violence encourage health care professionals to incorporate universal screening into their practice ( [216]Campbell, Cohen, McLoughlin, Dearwater, Nah et al., 2001 , [217]Davis & Harsh, 2001 ). While a best-of-practice model in the area of routine screening has not been universally adopted or standardized, and barriers to screening still exist in many environments, universal screening has been strongly advocated by nurse and physician leaders throughout the country. It is now recommended that all clients, adolescent and older, be screened for family violence as follows ( [218]Family Violence Prevention Fund National Advisory Committee for the National Consensus Guidelines, 2002, p.13 ): * as part of the routine health history (e.g. social history/review of systems); * as part of the standard health assessment (or at every encounter in urgent care); * during every new patient encounter; * during periodic comprehensive health visits (screen for current IPV victimization only); * during a visit for a new chief complaint (screen for current IPV victimization only); and * when signs and symptoms raise concerns or at other times at the provider's discretion. A holistic nursing needs assessment and intervention grid has been developed by Marlene Jezierski, BAN to guide nurses in their work with victims of violence and is available as a reference (see Appendix O: Victims of Violence: Nursing Needs Assessment and Interventions). The manner in which assessment is conduct has been found to be extremely important in facilitating disclosure of abuse. In a study of women in group therapy for domestic violence, McCauley, York, Jenckes, and Ford ( [219]1998 ) found that while 86% of the women had seen their regular health care professionals in the prior year, only 1 in 3 had discussed the abuse during that visit. The most important determinant of whether to disclose the abuse was found to be "a supportive, nonjudgmental clinician attitude" (p. 554). According to a consensus report issued by the Family Violence Prevention Fund in partnership with the American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, Child Witness to Violence Project of Boston Medical Center, and the National Association of Pediatric Nurse Practitioners, all health care professionals seeing children and adolescents in public health, private practice, and managed care settings should incorporate intimate partner violence screening into their routine patient assessment ( [220]Groves, Augustyn, Lee, & Sawires, 2002 ). Barriers to discussing family violence Numerous barriers exist for health care professionals when screening for family violence. These barriers may be due to a variety of factors, including lack of education and comfort, personal biases, personal experiences with abuse, systems barriers, lack of privacy, or adherence to various cultural myths (see Appendix P: Barriers to Abuse Assessment and Intervention). Many health care professionals do not screen because they believe there is no evidence that their intervention would be of any help, especially in the area of intimate partner violence. However, Holt, Kernic, Lumley, Wolf, and Rivara ( [221]2001 ) studied 2,691 adult females and found that women who seek permanent protection through legal no-contact orders experience significantly less subsequent violent victimization, as evidenced by police reports. It is incumbent upon nurses to find ways to overcome barriers to discussing family violence in order to optimize patient care. The health care professional Nursing barriers include: * uncertainty about how to respond to affirmative responses; * fear that the patient will become angry; * belief that it is not the responsibility of the professional to ask questions about family violence; and * time constraints. The Patient Patient barriers include: * reluctance to disclose unless asked directly; * fear of the abuser; * feelings of shame; and * perception of the professional as hurried or not really wanting to hear about the abuse. The system System barriers include: * non-supportive workplace; * lack of specific institutional policies; and * lack of privacy. Process of screening Screening must be done with sensitivity, objectivity, and insight. Without an understanding of the dynamics and issues victims of violence face, nurses cannot provide effective interventions. When nurses possess adequate knowledge and sensitivity, patients are more likely to feel comfortable disclosing abuse. A patient, understanding, and respectful tone of voice and an open body posture create an environment conducive to patient disclosure. In some cases, it may be preferable or necessary to use a written form to screen for family violence (see http://www.pvs.org/npn_sample.html for a screening tool developed by David McCollum, MD). Setting the stage The authors suggest that prior to the preface statement, when time permits, nurses use a funneling technique to ask a few broad, non-threatening questions about how things are going in the family and/or with intimate partners, such as: * "How are things going in your relationship with family members?"...with your partner? at home? * "How do you feel about how differences are solved in your family/relationship?" If there is an indication of potential family violence, more direct follow-up questions are asked. Because some patients may react negatively to the words "abuse" and "violence," naming a range of abusive behaviors and experiences may be more useful. For example: * "Are you experiencing any stress or anger problems in your relationships?" * "All people argue, how do you and your partner handle disagreements?" * "Do your fights ever become physical?" Prior to asking specific abuse screening questions, a preface statement is recommended, such as: * "We at ______ hospital/clinic/agency are concerned about the effect that difficult or harmful relationships have on the health of our patients, so we ask everyone the following confidential questions", or * "We recognize that many people experience events in their lives that affect their physical and mental health, such as difficult or harmful relationships." Stated in this manner, the patient is more likely to view the questions as a reflection of the nurse's concern than as someone being singled out. Principles of effective screening Questions should be phrased in such a way as to invite disclosure and not convey judgment. For example, asking a patient, "you're not being abused, are you?" is both leading and potentially stigmatizing and unlikely to elicit an honest response. Questions should be specific enough so that the patient understands exactly what is being asked. Many authors suggest asking, "are you safe?" yet this question may be interpreted in a number of ways (i.e. are you using safe sexual protection or do you have a burglar proof house). A more appropriate question is "Is anyone important to you hitting you, kicking you, punching you, or hurting you in any other way?" followed by "Is someone important to you yelling at you, threatening you, or otherwise trying to control your life?" ( [222]Feldhaus, Koziol-McLain, Amsbury, Norton, Lowenstein, & Abbott, 1997 ). When someone responds with a vague answer, the nurse needs to follow up with a clarifying question. For example, if a patient responds to a question about being hit, kicked, punched, or otherwise hurt by someone important to them by stating, "well, not really..." The nurse can respond with a clarifying question, such as, "you sound uncertain about that, would you tell me more about what you mean by not really. " See Appendix Q: Family Violence Screening and Response Tool. Special Considerations 1. Elders 1. Older adults often experience other forms of abuse (neglect, financial, medical), therefore it is appropriate to ask one or two different questions such as: + has anyone ever refused to take care of you when you needed help? (e.g. withholding food/water, medications or basic cares such as bathing or toileting? Denied you visits to your doctor?); + have you signed any documents in the last year that you did not understand?; or + If someone is helping you with your finances, are you uncomfortable with their assistance? ( [223]Anoka County Community Health Nursing, 1999 ). 2. Nurse researchers have identified tools for elder neglect assessment ( [224]Fulmer, Paveza, Abraham, & Fairchild, 2000 ) and elder abuse and neglect ( [225]Fulmer, 2002 ). A thorough physical exam of older adults should include assessing for not only physical abuse, but also signs of neglect and financial exploitation. Health care professionals should look for changes over time---findings that are new or unusual for the patient. However, in families with abuse and neglect, care is often episodic and sought from different providers. Changing health care provider frequently is also a red flag for possible abuse and/or neglect. 2. Children 1. Every child seen for any reason should have a nonverbal assessment for possible child abuse. A head to toe physical assessment should be done to detect patterned injuries, patterns of injuries, and injuries that are inconsistent with the history given. Psychological abuse is associated with "poor appetite, lying and stealing, encopresis and enuresis, low self-esteem or negative self-concept, emotional instability or emotional maladjustment, reduced emotional responsiveness, inability to become independent, incompetence or underachievement, inability to trust others, depression, prostitution, failure to thrive, withdrawal, suicide, and homicide" ( [226]Meyers, Berline, Briere, Hendrix, Jenny & Reid, 2002, p. 86 ). 2. Interviewing children about abuse is a complex process that requires a highly skilled practitioner. The American Professional Society on the Abuse of Children ( [227]Meyers, Berline, Briere, Hendrix, Jenny & Reid, 2002 ) gives the following guidelines for interviewing children who have been victims of abuse: + ideally, forensic interviewing teams provide for the child to share the story just one time (a child asked repeatedly may think that they did not answer the question correctly the first time); + ask open-ended, nonleading questions. A poor question would be "Where did he touch you?" when the child did not say anyone touched him in the first place, or "He touched you, didn't he?" A good question would be "Did anyone touch you here?" ( [228]Meyers, Berline, Briere, Hendrix, Jenny & Reid, 2002, p. 252 ); + open-ended questions are not a panacea. Typically, young children's response to free recall and open-ended questions provide accurate but overly succinct information rather than error-ridden information; + While not leading, follow up with questions that are intended to obtain more information e.g. "were your clothes on or off" "describe how they got off" "Did this happen one time or more than one time?" etc. + if sexual abuse is suspected, ask about pain, bleeding, dysuria, other physical symptoms; + when physical injuries are present, the question "What caused this mark here?" should be directed to the communicating child and parent for all injuries. The answers to the question should include details about what objects caused the injury or came in contact with the child;. + if injury is highly suggestive of abuse, additional questions must be asked to determine when the injury occurred, where it occurred, who witnessed the injury, the child's developmental abilities related to the injury (e.g. The parent of a two-day-old says "My baby rolled off the bed"); and + children's accuracy declines when asked yes-no questions. Conclusions from research suggest ( [229]Meyers, Berline, Briere, Hendrix, Jenny & Reid, 2002, p. 352 ): o yes-no questions should be avoided altogether with preschoolers; o 5-year-olds are 89% accurate in responding to yes-no questions; and o young children can be expected on average to make more errors in their statements than older children and adults. Screening for intimate partner violence in the pediatric setting The Family Violence Prevention Fund national consensus guidelines for child and adolescent health ( [230]Groves, Augustyn, Lee, & Sawires, 2002, p. 21 ) recommend the following screening guidelines in the public health and clinical pediatric setting: 1. screen female caregivers/parents who accompany their children during new patient visits; at least once per year at well child visits and thereafter, whenever they disclose a new intimate relationship; 2. screen female and male caregivers/parents known to be in same-sex relationships who accompany their children during new patient visits, at least once per year at well-child visits, and thereafter, whenever they disclose a new intimate relationship; 3. ask pregnant teens at first prenatal visit; at least once per trimester; and at the postpartum visit; and 4. also ask whenever signs and symptoms raise concerns. Specifically, screen when the child or adolescent has: + obvious physical signs of physical or sexual abuse; + behavioral or emotional problems, such as increased aggression, increased fear or anxiety, difficulty sleeping or eating, or other signs of emotional distress; or + chronic somatic complaints. Also screen when care-giving adults present with obvious physical injuries or a history of intimate partner violence. Cultural considerations Nurses should be able to conduct a general cultural assessment with members of different ethnic and cultural groups before attempting to understand their experience of family violence. Nursing faculty must repeatedly stress the importance of listening to the patient's unique experience, cultural beliefs, values, and traditions. Cultural knowledge cannot be assumed solely by a person's race or ethnicity. Nurses' cultural competence is as important for best practices in family violence interventions as is any technical skill. Students should be given basic information about culturally competent interventions, which begin with ( [231]Fazio & Ruiz-Contrereas, 1998 ) * an awareness of one's own biases, prejudices, and knowledge; * a recognition of professional power, in order to avoid imposing one's own values on the patient; * knowledge concerning patients and their culture; and * an openness to listening to and respecting new ideas and different perspectives. Use of a family member or someone from the patient's community to interpret during the screening process is inappropriate; only trained objective interpreters should be used. Perpetrators In many settings, particularly in public health, nurses are working with entire families in which power and control are an issue. The Duluth Domestic Abuse Intervention Project (2002 ) has developed an excellent guide for interviewing perpetrators of domestic abuse. Sample Teaching Strategies: Integrating into Routine Assessment Scenarios One of the most effective learning strategies is participation in the skill being learned. Role-playing provides immediate application of principles. Role-play can be made significantly less threatening by using multiple small groups that involve everyone rather than a performance in front of the class by a few people. Our post course evaluations consistently reflect a high value for the role-play experience (See Appendix R: Small Group Case Scenario Discussions, Physicians for a Violence Free Society and Appendix S: Culturally Sensitive Response to Victims of Intimate Partner Violence, created by Marlene Jezierski, BAN, RN for role play exercises). Videos One Voice/Domestic Violence: Identifying Victims and Batterers (1998). Concept Media, Intercollegiate Center for Nursing Education. Additional teaching resources Physicians for a Violence Free Society (2003). Abuse assessment response course: Systems approach to partner violence across the life span. San Francisco: Author. This curriculum is available on CD. It is a comprehensive, well-organized multimedia educational tool with power points, videos, participant handouts, and instructor guides. Interventions Essential elements of a sensitive nursing response include attentive listening, unhurried presence, a manner that expresses interest and conveys openness to any response, an ability and willingness to help, and utilization of community resources. There are three generally agreed upon guiding principles for interventions with family violence: * the safety of victims is of primary importance; * autonomy of adult victims to direct their own lives is respected; and * effective interventions hold perpetrators, not victims, responsible both for the violence and for stopping it. Responses to suspected child abuse Responses to screening When child abuse is suspected, the role of the nurse becomes more complex and emotionally charged, as nurses go through the mandatory reporting process to child protective services and/or the police (see chapter VII for mandatory reporting guidelines). It is difficult to maintain an objective, caring presence when the nurse knows or suspects that parents have abused their children, however, it is important to consider that this is often part of a transgenerational pattern of victimization and abuse. This does not excuse the behavior, but rather puts it into a context that provides for a more caring and helpful response. It is helpful to remind students that they are not the judge, jury, or police, but rather nurses charged with caring for a vulnerable family, prioritizing the safety and well-being of children, and painting an objective picture in case the legal system is involved. The way nurses respond when children disclose physical, sexual, or emotional abuse can open the door for a healthy physical, emotional, and legal response to the abuse. Helpful communication principles for responding to a child who discloses abuse include ( [232]Reilly & Martin, 1995 ): * Find a place to talk where there are no physical barriers between you and the child. * Be on the same eye level as the child. * Don't interrogate or interview the child. * Be tactful. Choose your words carefully, don't be judgmental about the child or the alleged abuser. Listen to the child. Do not project or assume anything. Let the child tell her own story. * Find out what the child wants from you. A child may ask you to promise not to tell anyone. Be honest about what you are able to do for the child.. * Be calm. Reactions of disgust, fear, anger, etc., may confuse or scare a child. Assess the urgency of the situation. Is the child in immediate danger? Safety needs may make a difference in your response. * Confirm the child's feelings. Let him know that it is okay to be scared, confused, sad, or however he is feeling. * Believe the child and be supportive. * Assure the child that you care. Some children will think you may not like them anymore if they tell you what happened. Let her know that you are still her friend and that she is not to blame. * Tell the child it is not his fault. Many children will think that the abuse happened because there is something they did or did not do. Don't over dramatize. * Tell the child you are glad he told. * Tell the child you will try to get her some help. * Let the child know what you will do. This will help build a sense of trust, and he will not be surprised when he finds out that you told someone. * Tell the child you need to tell someone whose job it is to help with these kinds of problems. * Report your suspicions to the appropriate agency. When child abuse is suspected, the legal medical forensic assessment and exam should be done by a multidisciplinary team skilled in responding to child maltreatment. If, when doing an initial assessment it becomes evident that a key piece of evidence to corroborate the parent's story of what happened is present in the home, the police should be notified of its existence ( e.g.a child has a pattern injury and the parents state, "he fell against the safety gate" inform the police so that they can take pictures of the position of the gate prior to the parents' return home). Evidence is more credible from a "hot crime scene" (i.e. one that is undisturbed) than from one that is "cold" (i.e. may have been tampered with). Safety assessment and planning If a nurse believes that it is not safe for the child to return to the home (i.e. the child has been severely abused or neglected, there is imminent danger of death or harm, abuse has occurred and is likely to escalate or recur, and/or there is imminent risk to the child if she/he returns), in addition to involving the police and/or child protective services, the nurse must assure a safe disposition. If a child protection worker is consulted and approves disposition back to the home where the abuse occurred, and the nurse's assessment reveals that the child is at risk for harm, it is incumbent upon the nurse to advocate for alternative placement, which might include an overnight admission into the hospital until a more in depth risk assessment and referral can occur. Documentation a. Description of injuries Nursing documentation of victims of child abuse should include a thorough and precise description of injuries, including type, location, size, color, and shape. Rather than stating "belt marks" or "hand marks on the buttock," describe what you see; do not speculate. Photos of injuries are extremely valuable in legal prosecution of cases. The photos, combined with thorough charting, paint an accurate picture for the defense attorney, prosecutor, judge, and jury. Body maps may also be useful, particularly when there are multiple injuries. b. Description of alleged abuser, when present. Description of the behaviors and comments of the alleged abuser should also be included in the legal evidentiary report. For example, "Father refuses to leave patient's side. Answers questions for patient." When documenting injuries that corroborate or fail to corroborate the history given, the following statement should be included: "This injury is/is not consistent with the history given and the child's developmental stage." Resources and referrals It is the responsibility of the nurse to make referrals to community resources when a child is the victim of abuse or is at risk for being abused. Programs directed toward the prevention and treatment of child abuse fall within the public health model of levels of prevention. Primary prevention activities can be carried out by nurses in a variety of ways including education on effective parenting, stress management, growth and development. Referring families to programs such as Head Start or Minnesota Early Learning Design (MELD) also falls within the primary prevention focus. An example of secondary prevention is home visitation with new parents by public health nurses, a strategy that has been proven in several studies to significantly reduce the rate of documented child abuse cases. Home visiting is deemed to be the most effective strategy for preventing child abuse ( [233]Finkelhor, as cited in Barnett, Miller-Perrin, & Perrin, 1997 ). Finally, tertiary prevention in the form of family support initiatives is directed toward stabilizing families once child abuse has occurred. Nurses can provide referrals to crisis intervention and counseling services to assist in breaking the cycle of family violence. Examples of resources are: * emergency telephone numbers, such as the national child abuse hotline (1-800-422-4453); * emergency child care facilities, such as crisis nurseries; * respite programs to give parents some relief from child care; * home visits by public health nurses; * parent education programs; and * family support programs, such as the Family Support Network (1-800-CHILDREN, [234]www.familysupport.org ). Websites related to child abuse: * National Clearinghouse on Child Abuse and Neglect [235]http://nccanch.acf.hhs.gov/ * Child Protection Network [236]http://child-abuse.com * National Committee to Prevent Child Abuse: [237]www.childabuse.org * American Academy of Pediatrics: [238]www.aap.org Cautions for informing parents of mandatory report While the student may find that many clinicians are reluctant to inform parents of their intention to file a mandatory report, it is important to consider the following: * Given the high likelihood that children still remain with their parent(s) when child abuse reports are filed, an important focus of nursing care is developing a trusting relationship through which parenting can be nurtured. The best way to uphold the integrity of the nurse-parent relationship is to inform the parent of the report in a caring, nonjudging, and matter of fact manner. In this process it is helpful to convey to the parent the importance of their role in their child's life. * If there are concerns for the safety of the child or others in response to informing the parent(s) of the child abuse report, or if parental drug or alcohol use might distort their reactions, informing parents of the child abuse report should be done in a manner that assures the safety of all involved. Responses to adolescent and adult victims of intimate partner violence. Working with victims who are in an abusive relationship takes time and patience. For each survivor the journey is different. It is often difficult to understand the decisions patients make, such as deciding to remain in an abusive relationship; and there is a tendency for nurses to assume they know what is best for the patient. However, if the patient senses the nurse does not approve of what she is doing, she will be less likely to discuss her situation with the nurse and she may lose confidence in herself. The nurse must understand the necessity of providing vital information without the patient feeling judged or pressured. Responses to screening Response Type Patient Response Nurse Response Affirmative: Current "Yes, I am in an abusive situation" Supportive, nonjudgemental, caring, assesses patient safety, offers options and resources Affirmative: Current, but patient minimizes abuse "Yes, he hits me, but he promised me he won't do it again" "Typically these behaviors only get worse without intervention. I fear for your safety!" Affirmative: Past "Yes, I was in an abusive situation" or "I am an incest survivor" Explore past experience with resources and present need to speak with someone. Offer resources Affirmative: Exposure "I know someone who is being abused" Offer to answer any questions and provide information/resources. Affirmative: Patient abuse of another "I sometimes hit my child." Provide resources (support groups, crisis nursery, parenting tips, identify stressors). [See child abuse section for nursing responses to suspected child abuse.] Affirmative: Possible abuse by child "I am afraid of my son." Supportive, nonjudgmental, caring, assess patient safety, offer options and resources Negative response, but nonverbal cues indicate possible abuse Change in affect after question asked, seeming sad and fearful. Startles easily. Opportunity to educate and raise awareness about community resources Negative response, no concerns Opportunity for primary prevention through community education. Patient gets angry or defensive "You have no business asking me that question!" Reaffirm purpose of screening. "I'm sorry you feel that way; we ask because abuse impacts people's health and many people are experiencing family violence and want help." The nurse should not feel any guilt for asking. Safety assessment and planning Assessment of the degree of lethality is essential. Research shows that people are at greater risk of homicide when guns are in the home. However, even in the absence of such risk factors, a survivor may still be at serious risk. People have different levels and expressions of fear. The risk of danger may be high, yet some people may not recognize that risk or display a fear response. Nurses should verbally and nonverbally express concern regardless, since survivors are often unable to see the danger they are in. Several danger assessment and safety planning tools exist which can provide students with examples on which to base their practice. One of the most widely known danger assessment tools has been developed by Jacquelyn Campbell, PhD, RN and can be accessed at: [239]http://www.son.jhmi.edu/research/CNR/Homicide/ For a sample safety plan, see Appendix T: Safety Plan (Alexandra House, Blaine, MN). Documentation As in any other medical record documentation, the nurse must be objective and thorough. Even if a survivor is convinced she will never report her abuser, she might change her mind in the future. The thorough, accurate documentation of her injuries and other assessment findings will be available to the court to demonstrate the seriousness of the case over time. It is important for nurses to understand the difference between subjective and objective data for legal evidentiary purposes. For example, describing the survivor as "anxious" could be interpreted in the courtroom as subjective. Subjective data should be presented as direct quotes (e.g. "I'm afraid and feel anxious-I know he's going to kill me (sobbing)"). Good nursing documentation simply describes what is observed, such as "Patient's hands shaking and respirations rapid as she speaks. Patient pacing back and forth from door to window. When a door slammed down the hall, patient turned wide-eyed toward the door and jumped back." The National Institute of Justice has developed guidelines for documentation of domestic violence ( [240]Isaac & Enos, 2001 , [241]www.ojp.usdoj.gov/nij ). a. Description of injuries Nursing documentation of survivors of intimate partner violence should include a thorough and precise description of injuries, including type, location, size, color, and shape. Rather than stating "choke marks" or "finger marks", describe what you see; do not speculate. Photos of injuries are extremely valuable in legal prosecution of cases. The photos, combined with thorough charting, paint an accurate picture for the defense attorney, prosecutor, judge and jury. Body maps may also be useful, particularly when there are multiple injuries. b. Description of abusive partner, when present. Description of the behaviors and comments of the abusive partner should also be included in the medical record. For example, "Partner refuses to leave patient's side. Answers questions for patient." Resources and referrals Nurses should identify the key agencies in the community that serve abuse victims. These include both in-house and community resources (e.g. hospital/clinic social workers, victim service organizations, crisis hot lines, batterer treatment programs, child and adult protective services, etc.). When the patient desires support, arranging an immediate personal contact is always preferable. The national domestic violence hotline number is 1-800-799-SAFE. Abuse victims benefit greatly when nurses partner with domestic abuse advocates. Domestic violence advocates are very knowledgeable and provide numerous supportive services (See appendix U: The Role of a Domestic Violence Advocate). Cautions a. Contraindications for couples counseling* Battered women's advocates have long understood and advocated against the use of couples counseling in cases of domestic violence due to its lack of effectiveness and the danger in which it places the victim. Physicians for a Violence-free Society ( [242]2002 ) points out that "joint counseling is generally inadvisable and should be attempted only when the violence has ended. If joint counseling is undertaken, both partners must give independent, voluntary consent. The counselor should have adequate skills and training to deal with domestic violence without further escalating the violence. Joint counseling should only be considered when * the violence has completely stopped; * the victim and family are no longer fearful; * the batterer has successfully completed a batterer's program; * both parties desire to work on their relationship; or * co-morbid alcohol or substance abuse issues have been addressed" ( [243]PVS, 2002, p. 5 ). *couples counseling is also referred to as marriage counseling, family therapy, conjoint therapy, and joint therapy. b. Cautions when applying behavior change models to the lives of victims of family violence. Several authors ( [244]Brown, 1997 ; [245]Frasier, Glowa, Slatt & Kowlowitz, 2000 ; [246]Kramer, 2001 ) have recently advocated for the use of the transtheoretical model of behavior change ( [247]Prochaska & Velicer, 1997 ) to guide practitioners when working with victims of domestic violence. The transtheoretical model presents behavior change stages: pre-contemplation, contemplation, preparation, action, and maintenance. This model encourages practitioners to assess their patient's readiness to implement changes in their lives and to tailor interventions to be of maximal help. The transtheoretical model was originally conceptualized for people with addictions (smoking, alcohol, drug use, etc.). It therefore needs modification when being applied to victims of family violence, where the abuser has total control and responsibility. For example, Frasier, Slatt, Kowlowitz, and Glowa ( [248]2001 ) caution against using the concept of "relapse," substituting instead "returning." In addition, they argue that the problem behavior does not lie with the victim of family violence, but rather with the abuser. In the nurse response, the message that the abuser is responsible for change must come through loud and clear. Frasier et al. ( [249]2001 ) apply the transtheoretical model to teach health care professionals helpful responses to victims/survivors as they move through the various stages of change. Potential responses to suspected abuse of elders/vulnerable adults/those with disabilities Knowledge of the legal and functional definitions of vulnerability are essential for effective nursing assessment and response to situations where abuse of adults is suspected. (See Appendix V: "'Elder domestic abuse', 'Vulnerable adult abuse' and 'Caregiver stress.'" ) Responses to Screening Patient Status Intervention Patient has mental and physical capacity to protect self & declines referral * Accept patient's decision. * Listen and be respectful. * Discuss the tendency for abuse to become more frequent and severe over time. * Provide emergency contact numbers. Patient has mental and physical capacity to protect self & accepts referral * Discuss the tendency for abuse to become more frequent and severe over time. * Arrange for on-site or telephone advocacy. * Offer written emergency numbers and appropriate referrals. * Develop and review safety plan. Patient cannot adequately care for or protect self due to physical or mental disability * Contact Adult Protection to address guardianship and related matters. * Address immediate safety concerns. Safety assessment and planning Safety assessment and planning is essential regardless of the patient's vulnerability status. Assessment of the degree of lethality is essential. As previously stated, even when the risk of danger is high, some patients may not recognize the risk or display a fear response. Nurses should verbally and nonverbally express concern since patients are often not able to see the danger they are in. The extent to which nurses involve patients in safety planning depends on their capacity to adequately care for and protect themselves. It is incumbent on the nurse to advocate for the patient's safety. Possible options include but are not limited to hospital admission, order for protection, and safe home placement. Documentation As with any other medical record documentation, the nurse must be objective and thorough. It is important for nurses to understand the difference between subjective and objective data for legal evidentiary purposes. For example, describing the survivor as "anxious" could be interpreted in the courtroom as subjective. Subjective data should be presented as direct quotes. Documentation for this population may include statements such as "She won't fill my prescriptions," or "I'm only allowed to go to the bathroom twice a day," or "I only get $5 a week allowance." a. Description of injuries Nursing documentation of family violence should include a thorough and precise description of injuries, including type, location, size, color, and shape. Rather than stating "choke marks" or "finger marks," describe what you see and hear; do not speculate. As already stated, photos of injuries are extremely valuable in legal prosecution of cases. Body maps may also be useful, particularly when there are multiple injuries. When documenting injuries that corroborate or fail to corroborate the history give, the statement, "This injury is/is not consistent with the history given" provides a nursing assessment of the injuries seen. b. Description of alleged abuser, when present Description of the behaviors and comments of the alleged abuser should also be included in the legal evidentiary report. For example, "Daughter refuses to leave patient's side. Answers questions for patient." Resources and referrals Nurses in any location should identify the key agencies in the community that serve vulnerable adults and elders victims of intimate partner violence. These include both in-house and community resources (e.g. public health agency/hospital/clinic social workers, adult protective services, victim service organizations, crisis hot lines, batterer treatment programs, etc.). * Clearinghouse on Abuse and Neglect of the Elderly, National Center on Elder Abuse: [250]www.elderabusecenter.org * Elder Abuse Prevention and Treatment Resources: [251]http://www.aoa.dhhs.gov/eldfam/elder_rights/elder_abuse/elder _abuse.asp * National Committee for the Prevention of Elder Abuse: [252]www.preventelderabuse.org * Elder Abuse Law Center: [253]www.elder-abuse.com * American Society on Aging: [254]http://www.asaging.org/ * National Institute on Aging (the primary NIH organization for research on elder abuse): [255]www.nia.nih.gov Cautions (See Appendix V: "Elder domestic abuse," "Vulnerable adult abuse" and "Caregiver stress"). The terms elder domestic a