Domestic Violence: Essential Concepts
Online Course #9014 or #2014 - 1 Contact Hour


Author: Shelda L. Shank, RN, BSN, PHN
©2008 National Center of Continuing Education, Inc.


This course meets Legislative and State Board requirements for mandatory violence education in Florida.

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Purpose and Goals

The goal of the enclosed course is to provide basic instruction on domestic violence, including identification, screening, and referral of persons with a history of being, or at risk of becoming, victims or perpetrators of domestic violence.

Instructional Objectives

Upon completion of this course, the learner will be able to:

1. Estimate the number of women who are likely to be victims of domestic -violence.
2. Provide information concerning characteristics of victims and perpetrators of domestic violence.
3. Enumerate some important screening procedures the nurse can use to determine if a patient has a history of being victimized by domestic-violence.
4. List screening procedures the nurse can use to determine if a patient may be a perpetrator of domestic violence
5. Identify important advocacy and support organizations available to the domestic violence victim/perpetrator.

Introduction

    Domestic violence is increasingly recognized as a serious and widespread public health crisis affecting individuals of all ethnic and socioeconomic backgrounds. Domestic violence, also now referred to as intimate partner violence (IPV), has been defined as a pattern of coercive control consisting of physical, psychological and/or sexual assaults against current or former intimate partners. Batterers also commonly use economic abuse, isolation, and intimidation to exert power over their partners. The heart of the problem is always an imbalance of power. The abuser learns that coercion “works,” that it’s effective in controlling the relationship and in reinforcing the power imbalance.

    This course often refers to the battering of women, since 85% of serious domestic assault victims are women, according to the U.S. Department of Justice, Bureau of Justice Statistics. -However, it can also occur by women against men, and between same sex -partners.

Every 15 Seconds...

    As many as 5.3 million women  are believed to be battered each year by their partners – one every 15 seconds. It is so common that it is now the leading cause of injury to American women, accounting for more hospital emergency room visits than auto accidents, muggings, and rapes combined.

    One in four women will be subjected to IPV at some point in life, 324,000 during pregnancy. Domestic violence accounts for more than 30% of female homicide cases. A surprising gallery of famous women reportedly touched by domestic abuse includes: Tina Turner, Daryl Hannah, Roseanne, Madonna, and the late Nicole Brown Simpson.

    Nurses and other healthcare providers are strongly encouraged to recognize, treat, and prevent this “silent epidemic” that rages throughout our society. We are in a unique position to address this public health problem. The prevalence of -domestic -violence among patients in ambulatory care -settings has been estimated to be between 25% and 35%. Yet domestic violence remains extensively under--detected.

    Although battered women seek medical care frequently, as few as one in 20 are accurately identified by the practitioners to whom they turn for help. As many as 50% of victims murdered by a spouse or lover were seen in a hospital emergency department, but not screened for domestic violence, before they were killed. Research shows this is largely due to lack of knowledge and training, and that battered women expect healthcare providers to initiate discussions about abuse.

    With improved awareness and appropriate nursing intervention, attention is directed to how healthcare professionals can best respond to breaking the cycle. We need to inquire routinely about domestic/family violence, -provide sensitive and nonjudgmental support, address patient safety, document the abuse, provide information about resources and options, and offer -referrals.

    With the recent heightened awareness of acts of violence, many state boards of nursing require courses on domestic violence. This requirement is designed to curb the problem of violence by providing information that will help you identify the perpetrators of violence and assist you and others to avoid it.

Causes of Violence Between Partners

    For many years, domestic violence was largely viewed as simply a “family problem.” In numerous instances the police, courts and hospitals, as well as most social service organizations, were hesitant to intervene. However, as a result of growing concern with violence in general, persons from these agencies and other community groups have become more keenly interested in the causes of violence within the home. They are now making an effort to offer meaningful assistance to victims.

Violence between partners may be triggered by numerous factors.

1. Stress situations such as job loss, financial problems, pregnancy, or role changes within the family.
2. Frustrations associated with underachieving or not achieving goals.
3. Alcohol and/or other substance abuse.
4. Abuse-prone attitudes and beliefs: "Show the woman who's boss," or "I wouldn't hit her if she didn't deserve it."
5. Childhood experiences of abuse and/or parental violence.
6. Mental, physical, or emotional disorders.

The Abuser: Often Called the Offender

    Just what kind of man is the person who abuses women? Research reveals that batterers come from every walk of life. They are as varied as the circumstances in which they live. Batterers are usually men who were physically or psychologically abused in their homes when they were children. Often they grew up in homes where episodes of violence were common, and their father either beat or completely dominated their mother.

    Batterers are also manipulative and often will exhibit a dual personality that is convincingly charming one minute and violent or aggressive the next. The batterer’s victim will never know which behavior he will exhibit the next moment, hour, day or week. To protect herself she must be constantly on the alert to ensure he is kept calm.

    The majority of battering men will refuse to admit they have a problem. This is true in the sense that what they are seeking is control of the woman, and they want their control to be absolute and complete. Often because of his larger size, the batterer is in little danger of physical harm from his victim. Frequently if the battered woman attempts to protect herself by fighting him, he will become more enraged and the battering more intense. The batterer will not usually volunteer himself for help and treatment until after the woman has left him and the battering environment and sought help on her own. When the victim is unwilling or unable to leave and seek help, the batterer really has no incentive to change his behavior.

     The abuser will often refuse to take responsibility for his destructive behavior. He may use excuses such as, “I was drunk,” “I didn’t know what I was doing,” or “It just happened.” He may, in fact, believe his abuse and violence are justified; in any case, the assaults will continue to occur.

Victims of Domestic Violence

All individuals with evidence of trauma need to be questioned directly about the potential for domestic abuse using a structured, nonjudgmental, confidential interview conducted in privacy and safety. Current recommendations include routine screening of all female patients over age 14.

Recognizing the Battered Woman

    If you suspect that someone is the victim of domestic/family violence, what are some of the signs to confirm your suspicions? You should be especially suspicious if the woman is frequently absent from work or social activities. If she reappears wearing long sleeves in warm weather, sunglasses indoors, scarves around her throat, or in extremely heavy makeup, this should raise questions in your mind.

    If the woman is often absent from work or otherwise is homebound as a result of a high incidence of sickness, surgeries or other ailments, you should suspect she is a victim of battering. Suspect abuse if she is unable to hide blackened eyes, broken limbs or bruises; and when asked about them, says she was in an accident or experienced a fall, is really clumsy or some other excuse. If she seems to be excessively private, avoids old friends, or if her personality suddenly changes drastically, it is not unreasonable for you to suspect she is a battered woman.

    Whenever you suspect battering and the woman victim either will not or cannot admit she is in danger, keep in mind she is suffering from a learned helplessness. Often, her state of mind is such that she believes she must rely totally on the batterer to survive. She is also worried about her health and well- being because she is aware of the fact he might harm her if she attempts to leave. If children are involved, she will also be concerned about their welfare. This is your opportunity to share some kindness with her and respect whatever she decides to do.

Points to Remember

1. Recognize that she has been traumatized.
2. Do not minimize her feelings.
3. Tell her that the violence is not her fault.
4. If there are weapons and drugs / alcohol involved, let her know the combination can be lethal.
5. Encourage her to talk to someone she trusts about the violence.
6. Assess for woman abuse on child abuse calls.

Children - The Silent Victims of Domestic Violence

    Children who witness domestic violence are themselves victims of abuse. Unless directly abused, they are often overlooked and do not receive adequate services. The children of battered women must contend with the same myths and untruths about battering which confront their mothers. They must also deal with adult prejudice which tells them, “It’s not so bad...don’t worry. Everything will be all right.” Meanwhile, everything they feel and have experienced is bad.

    Many parents minimize or deny the presence of children while the mothers are being assaulted. However, interviews with children of battered women reveal they have seen and heard, and can give detailed accounts of violent behavior that their mother or father never realized they had witnessed. Events can be witnessed in many ways, not just by sight. Children may hear their mother’s screams and crying; the abuser’s threats; sounds of fists hitting flesh, glass breaking, and wood splintering; cursing and degrading language. Children also witness the consequences of the abuse after it has occurred – their mother’s bruises and torn clothes, holes in walls, broken furniture, their mother’s tears. They sense the tension in the house, and in their mother.

    Many fathers inadvertently injure their children while throwing furniture or other household objects when abusing their -partners. The youngest -children sustain the most serious injuries, such as concussions, or broken shoulders and ribs. These children also suffer poor health, low self-esteem, poor impulse control, sleeping difficulties, and feelings of powerlessness. They are at high risk for alcohol and drug use, sexual acting out, running away from home, isolation, loneliness, fear and suicide.

Victims of Domestic Violence

    All individuals with evidence of trauma need to be questioned directly about the potential for domestic abuse using a structured, nonjudgmental, confidential interview conducted in privacy and safety. Current recommendations include routine screening of all female patients over age 14.

Recognizing Signs & Symptoms

    In addition to the obvious signs listed below, be alert to the presentation of stress-related complaints such as headaches, or stress-enhanced conditions such as chronic upper respiratory problems or bronchitis.

Physical Abuse: Trauma/pattern of injury inconsistent with event history; delay in -presentation.

Emotional or Sexual Abuse: Adults frequently present with complaints associated with long-term stress and chronic anxiety. Children or adolescents may present with behavioral problems. The elderly may present as withdrawn or fearful of authority.

Neglect: Lack of attention to person or environment.

Patterned Injuries: Central injuries to the face, head, neck, breasts, abdomen, and genitals are prevalent in contrast to accidental injuries affecting the periphery or extremities. A pattern of multiple non-life threatening injuries at varying stages of healing is highly suspicious. In children and the elderly, spiral fractures may be indicative of abuse.

Pregnancy: Escalation of domestic violence is seen in pregnant women with up to 35% of obstetric patients suffering some type of physical assault.

    Screen for batterers, too. The batterer may be our patient in some circumstances, and treating contributing factors can help stop abuse. A batterer may suffer from depression, chemical dependency, or post-traumatic stress disorder, for example. Past head injuries have also been associated with pathological jealousy and violence. Empathy, rather than a confrontational approach, may make the batterer more amenable to treatment.

Prevention and Intervention Strategies

• Recognize potential victims; take your time to establish rapport, and ask direct questions about domestic battering. Simple and specific is best.

• Implement your agency’s DV protocol if domestic violence is suspected

• Triage for immediacy of need for -treatment

• If injuries do not require immediate trauma or surgical care, take history from patient alone in private room

• If injuries require immediate trauma or surgical care, call security, local police, or both if partner seems disruptive or dangerous

• Contact victim’s advocacy representative and offer services to client as available

What Should You Do if Clinical Signs are Evident?

    If any of the clinical signs are evident, and there are negative responses to the screening questions, it is appropriate to ask additional questions to prompt information such as:

•   Sometimes when I see an injury like yours, it is because someone hit them. Did that happen to you?

• I don’t know if this is a problem for you, but many women I see are dealing with an abusive relationship, so I’ve started asking about domestic violence routinely.

Help for Victims of Domestic Violence

            The violence your patient is experiencing will not simply go away no matter how often she wishes or prays it will. Neither will it simply get better. Once it has started, it will recur more often and each time it will get progressively worse. It does not matter how much she loves her partner. She must know that she is in danger of losing her life and needs to take steps to assure her own safety.

Information Sources

National Domestic Hotline:
1-800-799-SAFE (Emergency 24 Hour)

National Center on Elder Abuse:
1-202-682-2470

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