Chapter 10: Assessing for Violence

Chapter 10: Assessing for Violence

• Violence encompasses intimate partner violence, child abuse, elder abuse, and human trafficking. These represent significant health concerns.

• In the U.S., one in four women and one in ten men experience intimate partner violence. On average, 19,000 calls are made daily to domestic violence hotlines.

• Approximately, one in seven children experiences abuse or neglect, with five children dying daily as a result.

• Elder abuse affects one in ten people aged 60 or older.

• The Joint Commission has set standards requiring all healthcare settings to assess, document, and refer cases of family violence (including intimate partner violence, child abuse, and elder abuse).

Learning Objectives

• Describe how to create a physically and emotionally safe environment for interviewing and assessing clients who have experienced domestic violence.

• Employ domestic violence screening tools to identify victims of violence across the lifespan.

• Teach clients at risk for violence how to create a safety plan.

• Accurately document physical findings using injury maps.

• Analyze client interviews and physical assessments to formulate valid clinical judgments regarding domestic violence or suspected abuse.

Types of Violence

Intimate Partner Violence

• In the U.S., approximately 10 million people are physically abused annually by intimate partners (average of 20 people every minute).

• Intimate partner violence involves any close relationship (boyfriend, girlfriend, spouse, dating partner, or sexual partner) that includes emotional connectedness and physical/sexual contact (current or former).

Intimate Partner Violence (4 main categories)

• Physical violence: force that causes death or disability.

• Sexual violence: without consent.

• Stalking.

• Psychological aggression (emotional abuse): Harm caused through nonverbal or verbal communication.

Child Abuse and Neglect (4 main categories)

• Neglect: Failure to provide a child's basic needs.

• Physical abuse: Non-accidental injury.

• Sexual abuse: Touching, pornography.

• Emotional abuse: Harms a child's development or self-esteem.

• One in six hundred thousand children experience child abuse or neglect annually. Neglect is most common, followed by physical abuse.

• Child Abuse and Prevention Treatment Act defines child abuse/neglect at both federal and state levels. Recent amendments to this act include sex trafficking and human trafficking, and enhance protection for infants.

• Every state defines child abuse/neglect. Some states include parental substance use in the definition.

Elder Abuse and Neglect (5 Main Categories)

• Physical abuse.

• Sexual abuse or abusive sexual contact.

• Psychological or emotional abuse.

• Neglect.

• Financial abuse or exploitation.

• Elder abuse and neglect is often underreported. In approximately 60% of cases, perpetrators are family members (most commonly an adult child or spouse).

• Almost every state has a form of mandatory reporting of elder abuse. A mandated reporter only needs suspicion of abuse or neglect to report it.

Human Trafficking

• 40 million people worldwide are victims.

• Disproportionately affects women and girls (71%), and 25% are children.

• Vulnerable groups are unhoused people, runaway youth, and victims of previous violence.

• Signs include delayed medical care, inconsistent stories, bruising, withdrawal, reluctance to accept help, hostility, self-mutilation, difficulty answering questions, and accompanying individuals who won’t leave.

Abuse, Exploitation, and Neglect in Patients with Intellectual and Developmental Disabilities (IDD)

• Abuse, exploitation, and neglect are common in people with IDD compared to the general population.

• Perpetrators are often known to the victim. Limited communication can make it hard to understand the cause of injuries.

• Abuse can include unexplained changes in physical or mental health; changes in behavior (withdrawal, disruptive behavior); inappropriate attachments and sexualized behavior.

• Neglect can be a recurring pattern of inadequate care (missed appointments, nonengagement, nonadherence.)

• Behaviors indicative of abuse in clients with limited communication include new-onset urinary or fecal incontinence; withdrawal; excessive masturbation; refusal to allow bathing; self-restraint; sexual aggression toward others; verbal or physical aggression; suicidal behaviors, and/or night terrors.

Nursing Assessment of Family Violence

Screening

• USPSTF recommends screening all women of child-bearing age (14-46) for intimate partner violence.

• Early detection is crucial in preventing lasting negative health consequences.

• Interview the victim separately from the potential perpetrator when possible.

• Note any discrepancies in injury explanations, inconsistent stories, and frequent requests for care of injuries.

Intimate Partner Violence

• Normalize the topic of intimate partner violence by asking all patients.

• Understand which screening tools are used in your facility.

• Some hospitals use single questions while others use standardized tools, such as the HITS, E-HITS, HARK, PVS, or WAST.

Elder Abuse and Neglect

• USPSTF does not recommend a specific elder abuse. However, other agencies recommend routine screening.

• The Elder Abuse Suspicion Index is a validated tool applicable in primary care for cognitively intact patients.

Child Abuse and Neglect

• Monitor patients for signs of abuse and neglect.

• Conduct a history away from caregivers if the child is verbal, using open-ended questions and spontaneous statements.

• Use appropriate language and familiar words to communicate with these patients.

• Medical and injury history is important to consider when assessing patients for possible abuse/neglect.

Collecting Subjective Data: Interview Techniques

• Create a safe and confidential environment.

• Establish a trusting rapport.

• Actively listen.

• Use simple, direct questions in a relaxed and calm manner.

• Do not screen patients if there are immediate safety concerns.

• Discuss any legal, mandatory reporting requirements and confidentiality limits before the patient's interview.

• Allow the patient to provide complete answers without interruption.

• Convey a nonjudgmental attitude with empathy and compassion.

Danger Assessment

• Begin by using a calendar to document the frequency and severity of violence throughout the year. Then, evaluate a series of yes/no questions to assess potential risk level.

Assessing a Safety Plan

• Ask the client whether they have a packed bag ready, whether they have told their neighbors/family/friends about the abuse and to contact the police, whether they know where to go if they need to leave, and whether, or not weapons are present in the home.

• Gather important documents, including cash, social security cards, birth certificates, driver's license, utility receipts, bank account numbers, insurance policies, marriage license, jewelry, and important phone numbers, as well as a protection order if applicable.

Documentation

• Detailed, unbiased progress notes.

• Appropriately used injury maps.

• Photographic documentation.

• Verbatim record of threats.

• Exact terms used by the abused patient when describing sexual organs and/or sexually assaultive behavior.

Photographic Documentation

• Digital photos are invaluable for medical records.

• Obtain written consent before taking photos.

• If a patient is unconscious or cognitively impaired, consent is not legally required for taking photographs.

This quiz examines the critical aspects of assessing violence, including intimate partner violence, child abuse, elder abuse, and human trafficking. It emphasizes the importance of creating a safe environment for victims and utilizing effective screening tools in healthcare settings.