Intimate Partner / Family Violence

Online Course #910 or #510 - 3 Contact Hours

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

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

You may print this course or save it to your hard drive if desired. You can return later to take your Independent Analysis and submit it for fast processing. Once you have submitted your Independent Analysis, you will see your results immediately. Your certificate will be mailed First Class after we receive your completed Independent Analysis Evaluation.
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Purpose and Goals

Instructional Objectives:

Introduction

Every 15 Seconds...

Approximately four million women are believed to be battered each year — one every 15 seconds — by their partners. 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, one in six 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 routinely inquire about domestic/family violence, provide sensitive and nonjudgmental support, address patient safety, document the abuse, provide information about resources and options, and offer referrals.
Acts of domestic abuse can be especially violent and often result in the deaths of the victims or innocent bystanders. In addition to possible fatalities, family violence costs the nation from $5-$10 billion annually in medical expenses, police and court costs, shelters and foster care, sick leave, absenteeism, and non-productivity.
As a result of the foregoing situations and demands, healthcare professionals must be better prepared with education in all aspects of domestic/family violence and its various scenarios. You urgently need to know the signs to be alert for and exactly what to do when you see them. Only by learning as much as you can about batterers and battering relationships can you provide the most assistance to battered individuals.
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.

The Three-Phase Theory of Family Violence

In a classic study psychologist Lenore Walker, Ed.D., ABPP, completed extensive research on more than 1,000 battered women, as well as a smaller group of abused men. She found a pattern and labeled it the "Three Phase Theory" of family violence. It involves the Tension Building Phase, the Acute Battering Incident Phase and the Loving Reconciliation Phase.
1. Tension-Building Phase: Tension is a normal factor in everyone’s life and indeed, in all relationships. However, for a variety of reasons, some people react to tensions violently. Once violence occurs within a relationship, it compounds the normal tensions.
During the tension-building phase of a violent relationship, the woman will sense her partner’s increasing tension. She may or may not know what is wrong. The man often is edgy, lashes out in anger and challenges her, tells her she is stupid, incompetent and unconcerned about his welfare. In a violent relationship, the woman generally lets the batterer know she accepts his blame of her. She tries hard not to make any "mistakes" that may upset him. She takes the responsibility for making him feel better and thus begins to set herself up to feel guilt when he eventually explodes in spite of her best efforts to calm and please him.
During the increasing tension, the woman is rarely angry even at the most unreasonable demands or blame. Rather, she internalizes her appropriate anger at the man’s unfairness, and instead feels depression, anxiety, and a sense of helplessness. She may suffer physical symptoms related to her emotional distress, such as headaches, upset stomach, difficulty sleeping, weakness and fatigue. These problems increase the woman’s sense of worthlessness and loss of control and make her more vulnerable to the man’s criticisms.
The woman may often deny her fear in an attempt to minimize the seriousness of the threat, believing she can control the situation. Even if she acknowledges her fear and danger, she often may not seek help. She usually feels ashamed of her failure to please her partner and believes, often correctly, that if other people know about the violence they will blame her for it.
As the tension in the relationship increases, seemingly minor episodes of violence, such as pinching, tripping, slapping, or shoving occur. The batterer knows his behavior is inappropriate, and he fears the woman will leave him. The fear of rejection and loss only serve to increase his rage at the woman and his intense need to control her.
2. Acute Battering Incident Phase: The tension-building phase ends in an explosion of violence. The incident that sets off the man’s violence is often trivial or unknown, leaving the woman desperately confused and feeling very helpless. The woman may or may not fight back. She often attempts to escape the violence, or calls for help. If she cannot escape the beatings, she may make herself feel as if the beatings are happening in a dream. She may not be aware how badly she is hurt.
Following the battering, the woman is in a state of physical and psychological shock. She may be passive and withdrawn, or incoherent. She may not appreciate the seriousness of her injuries and may resist getting treatment. The man may discount the episode, and he usually underestimates the woman’s injuries. He may refuse to summon medical help even when her injuries are obviously life-threatening.
3. Loving Reconciliation Phase: Loving reconciliation may begin within a period of a few hours to several days following the acute battering incident. Both the man and the woman have a profound sense of relief the incident "is over." While the woman may be initially angry with the man, he begins an intense campaign to "win her back." Just as his tension and violence were overdone, his apologies, gifts and gestures of love may also be excessive. He showers her with love and praise that helps to repair her shattered self-esteem. It is nearly impossible for her to leave him during this phase as he is meeting her desperate need to see herself as a competent and lovable woman.
It is during this phase that the woman’s feelings of power and her romantic ideals are nurtured. She believes that this gentle, loving person is her "real" man. She believes if only she can find the key, she can control him and prevent further violent episodes. No matter how often it has happened, somehow this episode seems different and she really believes it will never happen again. During the loving reconciliation, a strong bond develops between the couple, isolating both of them from reality and from anyone who might try to intervene in their destructive relationship. Anyone who has attempted to support the woman and urged her out of the violent relationship may now be seen as "the enemy" trying to separate the loving couple.
Loving reconciliation is a period of intense pleasure and reassurance for the couple. It convinces them there is nothing wrong with their relationship and discourages them from seeking assistance from other people or agencies. It is also isolating and provides them a time of being alone. When the violence recurs, the woman finds she has fewer and fewer places to turn for support.
Loving reconciliation also becomes a kind of reward for the violence. Psychologists have found that any behavior followed by a positive reward will occur more frequently. The more often the periods of uncomfortable tension that end in a violent explosion are followed by loving closeness, the less likely the couple will seek alternatives for handling tension and stress. To end the episodes of violence, this cycle must be broken and new alternatives for handling their tension must be developed by the couples who are caught up in the battering relationship.

Causes of Violence Between Partners

Violence between partners may be triggered by numerous factors. Some of these triggering factors are listed below.

1. Stress situations such as job loss, financial problems, pregnancy or role changes.
2. Frustrations: Underachieving or not achieving goals.
3. Alcohol and/or other substance abuses.
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 or physical disorders.

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.

Warning Signs of Violence

• was abused as a child; in early family life, the mother may have been abused by the father.
• loses their temper more often than is appropriate; often expresses anger in violent ways such as hitting a wall or furniture.
• has already revealed violent attitudes or actions toward others.
• drinks too much or abuses other drugs.
• is unusually possessive; needs to constantly know where the significant other is, who they are with, and what they are doing.
• may have very strict traditional ideas about the roles of men and women.
• may be easygoing, gentle and loving most of the time, but there are sporadic incidents of violence.
• promises never to hit or abuse again, but eventually is violent again.

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. Often, adverse conditions and circumstances are blamed for men who become what has been referred to as "short-term batterers." Many times after men have experienced business failures or periods of prolonged unemployment, or have been unable to achieve important goals, they often will batter the weakest, most defenseless person in their life: usually their wife, girlfriend or a significant other. The "long-term batterers" are those who always beat their wife or others who are close to them. These men often have a long history of criminal activities.
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. Some of them will say they feel pain, grief and psychological discomfort after the victim leaves them. The truth of this should be seriously questioned because batterers are manipulative and may not show their true emotions. Some will act lovingly and say they are sorry for the violent acts and make what seem, at the time, to be sincere promises in an effort to encourage the victim to return. Some will become even more violent and aggressive in an intensified effort to force her back; others will simply give up and move on to batter other women.
There is no single profile of domestic abusers, other than they are usually male. Like the victim, the abuser may come from any background. To outsiders he may appear to be a good provider; a warm, loving father; and a law-abiding citizen. Nevertheless, he frequently has a low self-esteem, strong jealousy, and extreme possessiveness. He may be under the influence of alcohol or drugs at the time of the assault. 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 recur.

Recommended Treatment for the Batterer

When counseling the batterer, you should stress that stopping the violence is the main focus of therapy. The violent partner must accept the responsibility for his actions and learn how to control the anger and violence. If the violence is treated as a learned behavior, it will open the possibility for a therapeutic change.
If both the man and wife or partner are involved, they can be helped by being taught how to resolve conflict by practicing more effective communication and problem solving. They must learn more acceptable ways of getting along and the man must understand that the partner’s complaints should be a legitimate concern for him. Also, he must learn that using violence to control the situation is not acceptable and will not be tolerated. Stress, alcohol use, and jealously are other issues that should be addressed.
Treatment may take the form of individual, group, or conjoint therapy. You should recommend conjoint treatment (husband and wife or partner together) only when the acts of violence are infrequent and not severe. Other factors that must be present are: the wife must not be in immediate or serious danger; both partners want to stay together; and the perpetrator will admit he has a problem and will commit himself to avoiding violence in the future. You may prefer conjoint therapy to other methods because it offers several advantages.
With conjoint therapy, you are able to get a more accurate picture of the situation and provide the partners with the same information and advice. Also it will allow you to learn about and help them change the behavior patterns that lead to violence and educate the victim of danger signs so she can protect herself.
Conjoint therapy also has drawbacks. The victim’s safety may be jeopardized if she accurately reports her partner’s behavior and he then retaliates. When they are both present, it is often hard for them to speak candidly about whether they want to stay together. If you involve the victim in treatment it may suggest to her that she is partly responsible for the violence of her partner.
Often conjoint treatment is not possible because the victim is in danger and afraid to participate, or because her partner will not admit his problem. If this is the case, you should refer the abuser to a program for batterers. This will usually involve group therapy with interventions aimed at eliminating the violence. You should refer the victim to a battered women’s support group where she can have access to resources and support to make her own decisions concerning the future of the relationship. After they have completed these sessions, you may suggest conjoint treatment, but you must be confident that the abuser has accepted responsibility and the victim has made an independent decision to remain with him.

For Better or For Worse

One of the most frequently asked questions concerning domestic violence where the woman is being battered is, "Why does she stay?" Her friends and family simply cannot understand why she doesn’t just pack her belongings and walk away from the situation. They wonder why she does not end the relationship, ask for help, or at least act to change her situation. When considering this question and searching for an answer, researchers have concluded that there are many reasons why women and men who are in a violent relationship elect to remain.
Some of the reasons why women remain in a battering relationship can be ignorance, love, fear, pride, embarrassment, loyalty, financial dependence, low self-esteem, or a combination of any or all. Many women who are victims of domestic violence have children, and are financially dependent on the abuser because they have neither money nor job skills. Another possibility is that at the moment she is unable to extract herself from the situation because she has been, in a sense, brainwashed. The image of herself has, at that particular point, been virtually destroyed. She has been told that she is worthless, incapable, and incompetent.
Her personality has been carefully and conscientiously destroyed by her offending partner. Her will has been paralyzed and her perceptions of reality are seriously skewed. Even if she could summon the courage to escape, she still may have no idea where to turn or where to find help. She cannot live in the street. She often does not have a job and probably does not have any money.
Worse, her friends and family may be reluctant or unable to offer her shelter because they may fear reprisals from her violent partner or they simply may be unwilling to get involved in her private affairs. They may even have sheltered her when she left her battering partner on previous occasions only to see her return to him. Friends and family simply do not acknowledge just how bad her situation is or just how hopeless she feels. They must begin to acknowledge it and face the fact that progressive torture is happening: here in America, in the twenty-first century, and to a woman they know, because she needs all the help she can get.
Another root of domestic violence you should consider is that abuse is often handed down from one generation to the next. Men who witness violence as a child are more likely to become an abusive adult, and women far more likely to be involved in an abusive relationship. The fact is that many victims have experienced family violence during their childhood, and so they consider it to be a normal part of their lives. It is often a result of this belief that some men or women fail to realize that physical assault of a spouse is indeed a crime.
Some victims of domestic violence are too ashamed or too embarrassed to admit to anyone they are being beaten or that they made the wrong choice of a life partner. Personal, cultural, and religious beliefs will also play a strong role in the victim’s decision to remain in the relationship or marriage. Many women will stay in a violent situation simply because they believe the offending partner when he makes seemingly sincere promises to change. For the man who is experiencing domestic violence from a woman, his shame and embarrassment are greatly intensified as a result of the typical social role patterns and expectations demanded of males.
Most significantly, the woman involved in a violent situation often will stay because she fears the consequences if she leaves her partner. The breaking point is different for every woman who decides to remove herself from the battering environment. The decision may be made after the first or even the fiftieth assault, but the day will finally arrive when the victim decides she is unable to tolerate the physical and/or emotional abuse any longer.
There is another important factor relating to why the woman stays in a battering relationship. We must remember Maslow’s theory that belonging satisfies one of the basic human needs. People of all cultures readily form social relationships. They do so even when there is little similarity between them and also there is no material benefit. Once a relationship has been established, the resistance to ending it is very strong. People often maintain even destructive relationships, such as those with an abusive partner, rather than breaking the bond.
There are battered women’s hotlines and shelters available where the domestic violence victim can find powerful and supportive advocates. In some instances shelters do not exist and many times if they are available, their resources are extremely strained. These shelters should not be expected to do the job alone. Understanding the dynamics of the violent family can be the beginning of the process of developing more effective intervention by all agencies/professions. Experience has shown that the only way to break the deadly cycle of domestic violence is through effective, early intervention.

Recognizing the Battered Woman

If you suspect that a friend or relative is the victim of domestic/family violence, what are some of the signs to confirm your suspicions? You should be especially suspicious if your friend or family member 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.

Children — The Silent Victims of Domestic Violence

Who will speak for them?
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.

Caught In The Crossfire!
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.

• Yearly, 3.3 million children in the US, between 3-17 years of age, are at risk of exposure to parental violence.
• In general 70% of men who abuse their female partners also abuse their children.
• More than 50% of child abductions result from domestic violence.
• Abusive partners use children as pawns in custody fights to coerce their partners to reconcile with them. Often, these coercive incidents occur during court ordered visitation.
• Children’s lives are frequently disrupted by moves to escape domestic violence. They lose considerable school time; flee home without books, money, or changes of clothing; and live in the family car when shelters are unavailable.
• Among children who witness abuse, 40% suffer anxiety, 48% suffer depression, 53% act out with their parents, 60% act out with siblings.

It is important to educate multidisciplinary professionals in attending to the ethical principles of beneficence, autonomy, and justice in dealing with these children. Children who witness violence at home must receive top priority in the allocation of scarce resources. Diagnostic screening and assessment efforts must incorporate standard questions about family violence into mental health and school counseling interviews. Sensitive intervention and referral, linking victims and witnesses with intervention specialists, will do much to limit the sequelae often seen with family violence. Nurses must advocate for and support primary prevention programs in elementary and secondary school systems. If we look at nothing else except the number of children entering shelters because of domestic violence, then it seems imperative that we recognize who these children are, what they have survived, and what it is they need from us.

Violence and the Older Adult

The U.S. population has an increasing number of older adults. One health problem often unrecognized in this aging population is elder abuse. Statistics uncover a frightening picture of elder abuse in this country. The National Aging Resource Center on Elder Abuse estimates the incidence of abuse in domestic settings (not institutions) at approximately 2 million cases per year. However, because this is still very hidden, it is difficult to determine the exact scope of the problem. Researchers estimate that only 1 out of 14 incidents of elder abuse actually comes to the attention of law enforcement or human service agencies.
Elderly people can be victims of neglect or physical violence; verbal, sexual or psychological abuse; or financial exploitation. The problem may worsen as the population of elderly Americans multiplies. By the year 2020 people over age 65 will number about 52 million, almost one-sixth of the total population. Those aged 85 years or older are the fastest growing group.
This abuse seems to be related to the inability of one party to meet the care demands required by the elderly, by him- or herself, or by the situation. It also seems to be related to an inhibiting dependency between the parties, a negative execution of power over the weaker, and a history of violence. More than two-thirds of older abuse perpetrators are family members of the victim, typically serving in a caregiving role. Victims often have no outside support, and may live with intergenerational family violence. At greatest risk are the frail and/or isolated. We must recognize the seriousness of the problem and take steps to prevent it.

Reporting Elder Abuse
Reporting suspected elder abuse is simple. Call your local Long-Term Care Ombudsman or local law enforcement to report abuse in a long-term care facility, such as a nursing home or board and care home. Abuse occurring anywhere other than a long-term care facility should be reported to the county Adult Protective Services agency (APS). But, if you suspect abuse that seems to be life-threatening, don’t hesitate. Call the police or sheriff’s department. They will notify any other agency that may need to be involved.

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-
• ife 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

Initial Assessment

• 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

Examination

• Have patient undress and put on exam gown so that all areas of the body can be visualized
• Check pattern of injuries
• Document the actions and demeanor of patient and partner. Use direct quotes of their comments to you. Be as objective as possible.
• Document physical assessment findings in detail; any evidence of injury from potential battery should be recorded on a body map and described in a quantitative manner
• Record visual evidence of abuse via Polaroid or video recording, and make sure your documentation is consistent with the pictures. If photography is used, include full body views (anterior/posterior). Separate photos for each injury site using a 90 degree angle and include an object for scale or size (ruler, coin, etc.). Written consent of the victim may be needed.
• Conduct mental status examination
• Use open-ended, nonjudgmental questions; never imply blame or ask why
• Recognize potential evidence; collect, preserve and maintain chain of custody

If your client answers NO, or will not discuss the topic:

There are many reasons a person will deny abuse. Be aware of some of the clinical findings that may indicate abuse. It is reasonable to suspect abuse if some of the following clinical findings are present:
Recurrent trauma history; injury to the head, neck, torso, breasts, abdomen or genitals; bilateral or multiple injuries; unexplained injuries or injuries that are inconsistent with the explanation given; delay between the occurrence of the injury and seeking medical treatment; behavioral cues such as depression, suicide ideation, anxiety and/or sleep disorder, panic attacks, symptoms of Post Traumatic Stress Disorder, alcohol/substance abuse problems; chronic pain symptoms of which no etiology is present; and a partner that seems overly protective, controlling or will not leave the woman’s side.

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.

Victims of Crime

You must recognize that every battered woman is the victim of a crime. Battered women are also frequently sexually assaulted and raped by the batterer. According to Harvard Medical School research, counting acts by both partners, 8.7 million American couples (nearly one out of six) experience violence each year, and 3.4 million experience severe violence.
Research states that the most serious danger is physical injury or death. In fact, up to 25 percent of all homicides in the United States are committed by a husband or wife. All states have legislated criminal sexual assault statutes and approximately 49 states have marital rape laws.
According to studies completed at outpatient clinics, violence by husbands occurs in more than 50 percent of couples seeking marital therapy but it is often overlooked by therapists. One of the reasons is that wives spontaneously responded on the written forms that aggression was a major problem in their marriages. When a victim of domestic violence is present for treatment, there are certain responses and assurances she really needs. Consistent with information concerning domestic violence is the fact that survivors need reassurance from you. Some examples of reassurance include:

1. She is not a crazy person.
2. She is not alone; there is help available.
3. Domestic violence is a crime and she is a victim.
4. No one deserves to be beaten.
5. Her accounts of abuse are believed.
6. There is hope that the cycle of violence can be broken.
7. There are specific places and organizations where she can go for help.

Nurses and other caregivers often ask if there is a typical profile of the violence victim. Insofar as a "typical" profile of a domestic violence victim, there has never been one established. However, it is a fact that the victims of domestic violence are usually women. Old, young, white, black, married, single, professional, unemployed, rich, poor, all are potential domestic violence victims.
Children are also victims in a battering environment even if they are not physically abused themselves. When children witness violence between their parents, they may learn violence as a way of life and later become involved in abusive relationships themselves.

Help for Victims of Domestic Violence

The violence your patients are experiencing will not simply go away no matter how often they wish or pray 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 they love their partner. They must know they are in danger of losing their life and need to take steps to assure their own safety.
If they want protection, the first step must be taken by them. There are many people and places she can call, so she must gather her courage and make a call for help. She can call a friend, family, or the police. She can also call her church, a physician, or a counselor. There are also women’s centers, shelters and family crisis centers. They are always open and she will be able to reach them by phone. Family crisis centers have hotlines and are open 24 hours a day, every day. If she is unable to find the family crisis center, call the police, sheriff, district attorney, public library, or Salvation Army. The Salvation Army has kind and caring people who will help without regard to color, religion or ethnic background. They will put her in touch with people who offer exactly the assistance needed. She must not stop until help is obtained. Her very life depends on it.

What to Do if You Become A Victim of Domestic Violence

Below are some practical steps that you can teach victims or suspected victims of abuse.
If your abuser has left the house but you think he may return, you should either leave or call a friend to come and stay with you. However, if your abuser is still in the house and you think he may batter you again, you should call the police or leave as soon as possible. It will take a lot of courage to leave the house but it may save you from a future filled with repeated acts of violence. You may want to tell the police you would like to be taken to a women’s shelter or some other safe place, or you may prefer to ask them to tell you the location of a shelter, so you can go there on your own.
If you believe you are in danger, leave your home and if there are children, take them with you. Even if you must leave in the middle of the night, it is better than possibly subjecting yourself to more beatings.
If you are unable to leave, ask someone you trust to stay with you. Develop an "exit plan" in advance for you and your children. Know exactly where you could go, even in the middle of the night — and how to get there. Pack an "overnight bag" in case you have to leave in a hurry. Include toilet articles, medications, an extra set of keys, clothing, and a special toy for each child.
When you decide to leave, whether for a short time or permanently, be sure to also take the following items: drivers license or some acceptable type of identification card, money, checkbooks, credit cards, address book, Green card(s) for immigration verification, your and children’s birth certificates, title to your car, lease, rental agreement, house deed, bankbooks, insurance papers, pictures, medical records for the whole family, social security cards, welfare identifications, school records, work permits, passport, divorce papers, jewelry and other valued items.
It will be a good idea to gather these in one place as you are thinking about leaving so you can obtain them if you need to leave in a hurry. Remember, you can legally take anything that belongs to you alone and anything that belongs to you and your husband together. You can withdraw money you have in a joint bank account with your husband or partner. You may not take anything that belongs only to your husband or partner. You may not destroy property that belongs to both of you or only to your husband or partner.
If you do not take everything you need when you leave, you have the right to ask the police to escort you back to your house later to pick up the items. The police can only allow you to take items that obviously belong to you or your children, such as clothing. If you can, it may be more convenient for you to wait until your partner goes to work or leaves the home for some other reason and then go into the house and get what you need. If you go back and your husband or partner won’t let you in, the police cannot force him to let you in without a court order.
Once you move, if you are concerned your attacker may try to find you, be careful to whom you (or your children) give your new address and phone number. You should consider renting a post office box or using the address and phone number of a friend.
Be aware that addresses are a part of restraining orders and police records. If you go to court, you should consider using only your post office box or perhaps using your lawyer’s address as your own. This can be extremely important if your partner has threatened your life or you believe he will attempt to find and abuse you later.
If you are a nurse or other caregiver and you are experiencing a battering relationship, there is help available to you. There are numerous shelters available to women who are being battered or otherwise abused. In spite of what you may have been told, these shelters and family crisis centers do not act to break families up. Rather, they work to save lives and often provide counseling services to the batterer or have the information to direct them where they can receive help and assistance.

Advocacy: Empowering the Victim

"Empowerment advocacy believes that battering is not something that happens to a woman because of her characteristics, her family background, her psychological "profile," her family of origin, dysfunction, or her unconscious search for a certain type of a man. Battering can happen to anyone who has the misfortune to become involved with a person who wants power and control enough to be violent to get it." — Barbara Hart, Seeking Justice: Legal Advocacy Principles and Practice.

The primary goal of intervention is empowerment. By sharing your observations, by agreeing that what’s happening is wrong, just by listening in a warm and accepting way, you give the victim strength and determination. Many victims are relieved at the opportunity to tell the truth instead of constantly covering up. You may learn that you’re the first person to confirm that her feelings of hurt and anger, the desire for support and change, are normal. Perhaps most important, you will have supported the patient’s independence and autonomy as a decision-maker and helped her to recognize her strengths and resources as a survivor.
One gesture in helping her carry out her decision is to give her the address and telephone number of the nearest family crisis center. Additionally, if you should find evidence of severe or frequent marital violence, immediately evaluate the danger, especially the danger of homicide. Try to find out if guns or other weapons are available to either partner. Investigate the possibility of alcohol or drugs and establish if they are used by the couple. Also consider the involvement of third parties, especially if they are children.
Healthcare professionals have been challenged to design effective anti-violence strategies as a part of health care reform. Nurses who have knowledge about violence can make a significant contribution to this challenge.

Thoughts and Decisions

Despite the fact that crime in general is leveling off or decreasing in the U.S., incidents of domestic violence continue to increase. The problem remains immense, and while much of societal violence lies outside the healthcare profession, there remains a major role, if not a responsibility, for all nurses and healthcare providers to prevent our young from learning violence as acceptable behavior and to intervene where violence is causing physical and emotional injuries to our patients. The fruits of our commitment will come when we, as nurses, treating patients one at a time, make a difference by breaking the cycle of violence that engulfs people’s lives.

National Help and Information Sources for You and Your Client:

National Center on Child Abuse: 1-800-4 A-Child

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

National Center on Elder Abuse: 202-682-2470

After we receive your completed test, we will send a detailed packet of helpful information concerning domestic violence and the profile of the abuser. Also included are the long-term effects on the victims, and nationwide resources to obtain help for children, adults and the elderly who have been abused.
We hope this course has helped provide you with a better understanding of the causes of abuse, how to recognize a person who has been abused, and the hope that it can be prevented with your intervention. You, as a healthcare professional, are in the best position to provide assistance for the victims who otherwise may not, or cannot, or are too afraid to, seek the help they need to stop the abuse.

Battering — Violence — Power — Control — Denial — Anger — Coercion — Threats — Intimidation — Emotional Abuse —Manipulation — Isolation — Blaming — Harassment — Addictions — Aggression — Anxiety — Fear — Grief — Guilt — Trivializing — Ignoring...

Battering is always a choice

1.

• If you are pregnant, has this happened during your pregnancy? How many times?
• Has physical violence increased in severity over the past year? Has a weapon been used, or use of a weapon threatened?

• local police or sheriff's department
• child protective services
• adult protective services

• Domestic violence hotline
• Crisis shelter and services
• Legal aid
• Medical and mental health services

YES I am ready to take the Independent Analysis Quiz!