The problem knows no Boundaries

1. The problem knows no Boundaries 95% of all cases of reported domestic violence and sexual assault involve men abusing women …… but ………. Abuse can also include: • Women against men • Gay couples • Remember: issue of POWER & CONTROL

2. Societal Problem • Economics – increased use of healthcare system. • Increased incidence of child maltreatment in homes with IPV; • Furthers the cycle of violence; increased incidence of criminal behavior.

3. Reporting Requirements (general abuse mandate) Registered nurses are mandated to report known or observed instances of abuse to the appropriate authorities • Professional capacity/within scope of employment • Failure to report is considered “unprofessional conduct” [by BRN] and can lead to disciplinary action against license • Failure to comply is a misdemeanor, punishable by up to 6 months in jail, a fine of $1000 or both

4. Reporting Laws (1) General Abuse: CPC 11160 • Provider of medical services for a physical condition that they know or reasonably suspect is the result of assaultive or abusive conduct • Includes “adults, children, & others, (including spouses)” • Report the incident to local law enforcement immediately or as soon as practically possible • Prepare & send a written report tolocal law enforcementlwithin2 working days

5. Reporting Laws (obj. 1) Child Abuse-[CPC 11166] • Knowledge • Observation • Reasonable suspicion …that a child is the victim of child abuse • Report to CPS immediately or as soon as practically possible by phone • Prepare & send a written report to CPS within 36 hours of receiving the information about the incident

6. The Face of the Victim •  stress in household • Abused as a child • Married at a young age •  self esteem • Helplessness or perceived helplessness • Financial dependence • Pregnancy a dangerous time

7. Characteristics of the Abuser • Abused or witnessed abuse as a child • Abuse of ETOH or drugs • Controlling behaviors • Pathologic jealousy • Verbal abuse  physical abuse over time

8. The Abuser • Use of isolation, intimidation, threats • Extreme jealousy or possessiveness • Controls access to $$$ & transportation • Low tolerance for frustration • Poor impulse control • Little insight into own behavior • Blames victim for the behavior

9. Cycle of ViolenceWalker, Lenore (1979), The Battered woman. • Tension building •  hostile behaviors •  use of alcohol, drugs • Victim tries to stay out of the way; placates • Battering Incident • Abuser explodes into violence • Hit • Burn • Beat • Rape • Victim is powerless • Victim endures until incident runs its course, usually 2-24 hours • Self-esteem 

10. Cycle of Violence Honeymoon Phase • Abuser remorseful • Abuser makes promises • Victim wants to believe

11. Physical Evidence • Symmetrical bruises on upper arms, wrists, neck • Nail marks or swatch of hair missing from head • Black eyes, fx mandible, • Lacerations around eyes & lips • Subdural hematomas • Rib fx • Bruises on breasts & genitalia • No single sign • Subtle signs • Injuries that do not match the stated mechanism • History of frequent admissions/ visits to health care provider

12. High Index of Suspicion • Abused watches partner for approval before answering • Abused edges to side of bed when abuser comes near • Abused heart rate increases when abuser comes near • Abusers refuse to allow a male nurse to care for partner • Abusers refuse to allow partner alone with caregivers • Abusers refuse to leave the room

13. Further Assessment • Nurse must be alone with the patient when questions are asked • Asking when abuser is in the room may trigger a battering incident!! • Open the subject as a routine • FUND* recommendations: • All females > age 14, regardless of sx of violence. • *Family Violence Prevention Fund

14. CDC “RADAR” screening guideline • R-routinely screen every patient • A-ask directly, kindly, w/o judgment • D-document findings • A-assess patient's safety • R-review options and provide referrals

15. Assessment Tools PVS – Partner Violence Screen • Have you ever been hit, kicked, punched or otherwise hurt by someone in the past year? • Do you feel safe in your current relationship? • Does a partner from a previous relationship make you feel unsafe now? • Benefits of Screening:

16. Safety-Promoting Behaviors • Hide money, house key, car key • Code w/family or friends • Remove weapons • SSN • Birth certificates • Bank account numbers • Hidden bag w/extra clothing • Rent/utility receipts • McFarlane, J. et al (2004), “Increasing the Safety-Promoting Behaviors of Abused Women”, AJN, 104(3) 40-50.

17. Child Maltreatment Child abuse is defined in the California State Penal Code to include: • intentional physical injury to a child less than 18 years of age, inflicted by another • sexual abuse • neglect • permitting to be or willfully endangering the person or health of a child • unjustifiable physical pain or mental suffering • unlawful corporal punishment • abuse or neglect in out-of-home care

18. Children who grow up with violence: • learn that violence is an acceptable way to relieve stress, get what they want, and interact with the world and the people they love. • They then incorporate these attitudes and values into their relationships as they grow up. (Childabuse.stanford.edu)

19. Childabuse.stanford.edu

20. Parental Characteristics (obj.2) • Childhood punishment was seen as unfair and severe • Relationship with parents was negative • Has difficulty controlling aggressive impulses • Free expression of violence is consistent • Socially isolated • Fewer support systems • Teenaged mothers • Low self esteem

21. Child Characteristics (obj. 2) “fit” between child’s temperament and parent’s ability to deal with that behavioral style • Illegitimate • Unwanted • Brain damaged • Physically disabled • Hyperactive • Reminder • Prematurity • Difficult labor & delivery • Multiple births

22. Environmental Characteristics • Chronic stress • Divorce • Poverty • Poor housing • Frequent relocation • Alcoholism • Drug addiction • All social strata • Poverty predisposes but …. • Concealed crises in wealthy families

23. Clinical Tipoffs • Serious injury – no hx of trauma • History inconsistent with severity of injury • Delay in seeking care for significant injury • History that changes during eval • Recurrent injuries w/poor explanation

24. Talking with children • Private place • Do not promise not to tell • Required by law • Do not express shock or criticize family • Use their vocabulary • Avoid leading statements that can distort their report • Reassure them that they have done the right thing by telling • Abuse is not their fault • Determine immediate need for safety • Prepare child about next steps

25. Denial of Child Abuse • The abuser, noninvolved parent, and child may deny the abuse • Each may deny • The event • Awareness of the event • The impact of the event • Responsibility for the event