Chapter 27 Violence

Cathi A. Pourciau
Elaine C. Vallette

Objectives
Upon completion of this chapter, the reader will be able to do the following:
 1.Describe the concepts of interpersonal and community violence.
 2.Identify factors that influence violence.
 3.Identify populations at risk for violence and the role of public health in dealing with the
epidemic of violence.
 4.Describe the role of the nurse in primary, secondary, and tertiary prevention of violence.

Key Terms
abusive head trauma
bullying
child maltreatment
date rape drugs
dating violence
elder abuse
emotional abuse
hate crimes
human trafficking
intentional injuries
interpersonal violence
intimate partner violence
neglect
physical abuse
prison violence
sexual abuse
stalking
terrorism
violence
workplace violence
youth-related violence
Violence is a national public health problem that affects all ages from the young to the
elderly. Violent deaths, however, only tell part of the problem. Although many survive, they
and their families and friends often have permanent emotional and physical scars. Violence
occurs around the world on a daily basis, as evidenced by the nightly newscast and stories
on the Internet. For example:
 April 1999: In Columbine High School, Littleton, Colorado, 13 killed by two teenagers who
then committed suicide.
 September 11, 2001: 2974 people from 90 different countries killed when 19 terrorists
hijacked four planes and intentionally crashed two of them into the World Trade Center’s
twin towers, the third into the Pentagon, and the fourth in an empty field in Pennsylvania.
 October 2006: 5 Amish schoolgirls killed and 6 others wounded in Nickel Mine,
Pennsylvania, by a truck driver who then committed suicide.
 April 2007: 32 killed, 15 wounded at Virginia Tech University in Blacksburg, Virginia, by a
student who then committed suicide—the deadliest school shooting in U.S. history.
 November 2009: 13 killed, 42 injured at a military base in Fort Hood, Texas, by a U.S. Army
psychiatrist.
 January 2011: 6 killed, including a 9-year-old girl, and 12 injured, including Congresswoman
Gabrielle Giffords, at a political meeting in Tucson, Arizona.
 July 2012: 12 killed, 58 injured during a midnight showing of the movie Batman: The Dark
Knight in Aurora, Colorado.
 August 2012: 6 killed at a Sikh Temple in Oak Creek, Wisconsin.
 November 2012: 2 children stabbed and killed by a nanny in New York.
 December 2012: 20 students and 7 adults killed, 2 wounded, at Sandy Hook Elementary
School in Newtown, Connecticut—the second deadliest school shooting in U.S. history.
 April 2013: 3 killed and an estimated 264 injured when 2 men set two pressure-cooker
bombs at the finish line of the Boston Marathon.
 September 2013:12 killed and 3 injured in a Navy Yard complex in Washington, DC, by a
man who was then shot by police.
Although the preceding list shows well-publicized acts of extreme violence, violence occurs
every day in communities across the country. The woman who is beaten and killed by her
husband, the cousins who are kidnapped and murdered by a neighbor, the infant who is
shaken to death by his mother, the young woman who is gang raped, the children who are
sexually abused (such as those by former Penn State Assistant Football Coach Jerry
Sandusky), and the coworkers who are killed by a disgruntled former employee are all
examples of the violence that occurs every day.
The purpose of this chapter is to explore the influence of violence from a public health
perspective as it relates to individuals and communities. It includes discussions of the
effects of violence in terms of homicides and suicides; the direct influence of violence on
individuals and communities; public health interventions to reduce violence; the roles and
responsibilities of the community health nurse in dealing with those experiencing violence;
and measures to increase awareness of violence in the workplace. An in-depth look at the
causes, effects, interventions, and measures to increase awareness of violence is presented.

Overview of Violence
The World Health Organization (WHO) defines violence as “the intentional use of physical force
or power, threatened or actual against oneself, another person, or against a group or community,
which either results in or has a high likelihood of resulting in injury, death, psychological harm,
maldevelopment, or deprivation” (WHO, 2013). In public health, injuries from violence are
referred to as intentional injuries. Violence threatens the health and well-being of people of all
ages across the globe. Worldwide, 1.6 million people lose their lives annually as a result of
violence, and it is one of the leading causes of death among people aged 15 to 44 years (Centers
for Disease Control and Prevention [CDC], 2011). In 2009, in the United States, more than
16,000 people were victims of homicide and more than 37,000 people committed suicide. Many
 more people survive acts of violence and are left with emotional and/or physical scars (CDC,
2012b).
The reasons for the high rate of violence in society are complex. Universally recognized factors
that contribute to violence include the following:
 1.Poverty, unemployment, economic dependency
 2.Substance abuse
 3.Dysfunctional family and/or social environment and lack of emotional support
 4.Mental illness
 5.Media influence
 6.Access to firearms
 7.Political and/or religious ideology
 8.Intolerance and ignorance

History of Violence
Violence is a global problem. From prehistoric times humans have dealt violently with other
humans. In the Bible, Cain killed his brother Abel out of jealousy and anger. Throughout history,
sporting events often resulted in death for the audience’s pleasure, such as the gladiator events in
Rome. Infanticide, or the killing of unwanted newborn children, has been practiced throughout
history. For example, if a female, a twin, sickly, or deformed child was left to die of exposure.
Children, especially firstborn children, were often sacrificed for religious reasons. Infanticide
was not condemned until early in the fifth century; however, this did not protect children in
many societies. Children were considered to be the property of the father, who could do
whatever he wanted with them (Campbell and Humphreys, 1993).
Throughout the ages, corporal punishment has been used as a means of controlling children.
Biblical reference to corporal punishment has often been used as justification for some types of
child abuse. To some parents, “spare the rod and spoil the child” (Proverbs 13:24) implies an
imperative to abusively discipline an errant child. The idea of “beating some sense into him” was
considered necessary to ensure that a lesson was learned. In 1874, the first legal protection
against child abuse in the United States was created when the Society for the Prevention of
Cruelty to Animals intervened to protect an 8-year-old girl. As a result of the notoriety associated
with this case, the New York Society for the Prevention of Cruelty to Children was organized
later that year (Campbell and Humphreys, 1993).
Even nursery rhymes that adults read to small children seem to condone violence against them.
Consider the following Mother Goose nursery rhyme:
There was an old woman who lived in a shoe,
She had so many children she didn’t know what to do,
She gave them some broth without any bread,
And whipped them all soundly and sent them to bed.
(Mother Goose Nursery Rhymes, 2000, pp. 195-196)
Wife beating was legal in the United States until 1824. Wives were seen as their husbands’
chattel and could be beaten for such offenses as “nagging too much.” In fact, the common phrase
“rule of thumb” was derived from English law that allowed a man to beat his wife with a cane no
wider than his thumb. Biblical interpretation of “wives be subject to your husband” (Ephesians
5:22) still provides some men with a faulty rationalization for wife beating. Some cultures and
religions still allow, and even support, abuse of wives.
The silence that long surrounded domestic violence is derived from a historical perspective of
women as their husbands’ property. The problem of assault against women was not explored in
America until the Civil Rights Movement of the 1960s. In fact, marital rape was not considered
an offense in the United States until 1980. In the last three decades, additional cultural issues
have surfaced regarding domestic abuse that includes female circumcision and genital mutilation,
abuse between gay partners, and the realization that men are also victims of domestic violence.
Elder abuse is also a continuing problem. The problem is of greater magnitude now because
people are living longer, resulting in increased numbers of dependent and vulnerable adults.
Elder abuse frequently goes undetected because of a lack of awareness on the part of health care
professionals and society. The exact prevalence of elder abuse is unknown because reporting is
still not mandatory in all states.

Interpersonal Violence
Homicide and Suicide
In the United States, homicide claimed the lives of 12,765 individuals in 2012. Sixty-nine
percent of the deaths were firearm-related. Young people, particularly black and Hispanic males,
are at higher risk than the general population. Further more, in 2012, blacks were more likely to
commit homicide than whites and were more likely to be victims of homicide than whites. Of
those murdered for whom race was established: 50.6% were black, 46% were white, and 3.4%
were of other races; 78% were male and 22% were female. More than 50% of the victims were
killed by someone they knew (Federal Bureau of Investigations [FBI], 2012).
Homicide is the third leading cause of death among all races and both sexes in the age-groups 1
to 4 years and 20 to 29 years; is the fourth leading cause of death in the 5 to 14 year age-group;
and ranks fifth in the 30 to 34 year age-group. Black females are more likely to be victims than
white females, but among all females, homicide ranks in the top ten causes of death in those aged
1 to 44 years (CDC, 2012a). Notably, 37% of female murder victims are killed by an intimate
partner (FBI, 2013).
Homicide is the leading cause of death for black males aged 15 to 34 years, and the second
leading cause for black males aged 1 to 4 and 10 to 14 years; homicide is the third leading cause
of death in white males aged 15 to 29 years (CDC, 2012a).
Often ignored or overlooked, suicide is listed as the tenth leading cause of death for all
Americans in all age-groups in 2010. More people die of suicide than of homicide in the United
States; suicide took the lives of 38,364 people in 2010, an average of 105 people per day. This
form of death affects virtually all ages. For people aged 15 to 24 years, suicide is the third
leading cause of death, and for people aged 25 to 34 years, it is the second leading cause. It ranks
fourth among persons aged 35 to 54 and eighth in those aged 55 to 64. Males commit suicide
four times more often than females. In Native Americans and Alaska Natives, suicide is the
second leading cause of death in those aged 15 to 34 years. Of suicides in men in 2010, 56%
were committed with a firearm (CDC, National Center for Injury Prevention and Control
[NCIPC] 2012b).
In women, the leading method of suicide was poisoning, followed by the use of firearms (CDC
NCIPC, 2012b). Women with a history of sexual assault are more likely to attempt or commit
suicide than other women. Studies show that women who attempt suicide are more likely to have
 been physically abused by intimate partners and are more likely to have posttraumatic stress
disorder (PTSD).
Risk factors for suicide include:
 1.Psychiatric disorders such as major depression, bipolar disorder, and/or schizophrenia
 2.Substance abuse
 3.Posttraumatic stress disorder
 4.Bulimia or anorexia nervosa
 5.Past history of attempted suicide
 6.Genetic disposition to suicide
 7.Age, (e.g., elderly and Caucasian males have high rates)
Refer to Chapter 24: Populations Affected by Mental Illness, for further discussion on suicide.

Intimate Partner Violence

Intimate partner violence (IPV), formerly known as domestic violence, is a pattern of coercive
behaviors perpetrated by someone who is or was in an intimate relationship with the victim, such
as a spouse, ex-spouse, boyfriend or girlfriend, ex-boyfriend or ex-girlfriend, or date. These
behaviors may include battering resulting in physical injury, psychological abuse, and sexual
assault that contributes to progressive social isolation and intimidation of the victim. Abuse is
typically repetitive and often escalates in frequency and severity.

RESEARCH HIGHLIGHTS: Physical Dating Violence from

Middle to High School
A study led by a professor at the University of Georgia examined the association of physical
dating violence with relationship quality and acceptability of aggression. The study showed “that
the kids who were involved in dating violence are consistently involved in dating violence and
this violence starts early.” The study began while the sample of students were in 6th grade and
followed them through the 12th grade. Close to a third of study participants report abusive
relationships, and this cycle increases over time. “Bad dating experiences particularly those
related to physical violence, are associated with a plethora of negative experiences such as
anxiety, depressed moods, suicidal thoughts, alcohol and drug abuse, lower educational
achievement and poor relationships with parents,” the researchers observed.
Data from Orpinas P, Hsieh HL, Song X, et al: Trajectories of physical dating violence from
middle to high school; association with relationship quality and acceptability of aggression, J
Youth Adolesc 42(4):551-565, 2012.
More than 12 million incidents of IPV occur each year. In 2007, 2340 people died as a result of
IPV, 70% of whom were female (CDC NCIPC, 2012d). Violence may also be directed by
women against women in lesbian relationships, by men against men in homosexual relationships,
and by women against men.
IPV crosses all ethnic, racial, socioeconomic, and educational lines. About 30% of women and
1% of men report experiencing physical forms of IPV at some point in their lives. The following
are risk factors for victims of IPV (CDC NCIPC, 2012d):
 •Low self-esteem
 •Poverty
 •Risky sexual behavior
 •Eating disorders and/or depression
 •Substance abuse
 •Trust and relationship issues
Victims of IPV frequently suffer in silence and accept abuse as a transgenerational pattern of
normal behavior. When children witness abuse between parents, they learn that violence is a
means of control.
Each year in the United States, more than 207,000 people are victims of sexual assault. In 66%
of reported rapes, the women knew the perpetrators (Rape, Abuse, & Incest National Network,
2009). Women may report that they were subjected to forced intercourse when they were ill or
had recently given birth. They also report forced anal intercourse and other violent sexual
acts. Box 27-1 includes considerations for working with victims of intimate partner violence.
Pregnancy does not protect women from the danger of abuse. Indeed, pregnancy may increase
stress within the family and provoke the first instances of battering. It is estimated that one in six
pregnant women have been abused by a partner (March of Dimes, 2008).
Societal awareness of IPV during pregnancy is a relatively recent phenomenon; the mention of
abuse during pregnancy began to appear in the literature in the 1980s. The image of a woman
being battered during pregnancy shatters the idealized image of pregnancy as a time of nurturing
and protection. All pregnant women should be routinely screened for abuse. Common signs of
IPV in pregnancy are delay in seeking prenatal care, unexplained bruising or damage to breasts
or abdomen, use of harmful substances (cigarettes, alcohol, drugs), recurring psychosomatic
illnesses, and lack of participation in prenatal education. Violence during pregnancy can result in
hemorrhage, spontaneous abortion, stillbirths, preterm deliveries, and fetal fractures.
Dating violence, which has become a national concern, refers to abusive, controlling, or
aggressive behavior in an intimate relationship that can take the form of emotional, verbal,
physical, or sexual abuse. It happens in straight and gay relationships. Research indicates that 9%
of high school students have been victims of physical dating violence and that it occurs more
frequently among black students than Hispanics or whites (CDC, 2006). Furthermore, almost
22% of women and 15% of men report some form of partner violence between ages 11 and 17
years (CDC NCIPC, 2012e).

BOX 27-1 CONSIDERATIONS FOR WORKING WITH VICTIMS

OF VIOLENCE
 1. Working with victims of intimate partner violence (IPV):
o • Establish rapport and trust.
o • Deal with issues of confidentiality honestly.
o • Provide current information regarding shelters and sources of support.
o • Recognize and accept that clients may “choose” to stay in an abusive relationship.
 2. Working with victims of child abuse:
o • Protect the well-being of the child; this is the primary obligation of health care
providers.
o • Report child abuse; it is a legal and ethical obligation in all states.
o • Establish rapport and trust; this may take time.
o • Remain objective when dealing with suspected family members.
 3. Working with victims of elder abuse:
 o • Establish rapport and trust; this may take time.
o • Report elder abuse; it is an ethical obligation for health care providers and a legal
obligation in most states.
o • Remember that competent adults have the right to make decisions about their own
care, even if it means staying in an abusive situation.
o • Support efforts to create respite programs and support groups for caregivers.
 4. Advocating for the rights of vulnerable populations, which is the responsibility of all
health care professionals:
o • Support research on effective interventions for violence prevention and reduction.
o • Lobby for a decrease in media violence.
o • Support community efforts to increase resources for victims of violence.
o • Lobby for effective regulation of firearms and cyberstalking.
Dating violence can involve the use of date rape drugs, such as gamma-hydroxybutyrate
(GHB), flunitrazepam (Rohypnol), and ketamine, to reduce inhibitions and promote anesthesia or
amnesia in the victim. GHB is odorless and colorless and can easily be made at home.
Instructions are available in libraries and on the Internet, possibly explaining the drug’s rapid rise
in popularity. Although illegal in the United States, it has become available in many nightclubs,
where it is sold in clear liquid form. GHB has been touted as an aphrodisiac and an anesthetic. It
is actually a depressant that slows down the respiratory system and has been responsible for
numerous overdoses and multiple deaths. When mixed with alcohol, it can be deadly.
Flunitrazepam, which is classified as a benzodiazepine, has been compared to methaqualone
(Quaalude), the “love drug” of the 1960s and 1970s. Like GHB, flunitrazepam is not legal in the
United States, but many reports have been received of its use at fraternity parties, college
gatherings, and in bars. Two other drugs in the benzodiazepine family, alprazolam (Xanax) and
clonazepam (Klonipin), are also used as date rape drugs. The ability to provide a quick, cheap
high with long-lasting effects may explain their popularity. When they are combined with
alcohol, serious side effects, including death, have been reported.
Ketamine (ketamine hydrochloride) is an anesthetic used primarily in veterinary practice. It
causes a lost sense of time and problems with memory. Another drug that is becoming more
common as a date rape drug is carisoprodol (Soma), a prescription muscle relaxant and central
nervous system depressant.
Studies have also linked alcohol, “a hallmark of college campus social life,” with dating
violence. Substance abuse is often implicated in sexual assaults on college campuses. Alcohol
contributes to sexual assault because it impairs the ability to think clearly, lowers inhibitions, and
impairs the ability to evaluate an unsafe situation.
Stalking is a pattern of repeated and unwanted attention, contact, harassment, or any type of
conduct directed at a person that instills fear. Types of stalking include messaging through the
Internet or cell phone (cyberstalking), damaging the victim’s property, following the victim,
obtaining personal information about the victim, and making direct or indirect threats to the
victim’s family or friends. In one 12-month period, approximately 3.4 million people reported
being stalked (U.S. Department of Justice, Office on Violence Against Women [USDOJ
OFAV], 2009). Owing to the severity of the problem, in 2004, the National Center for Victims
of crime proclaimed January as National Stalking Awareness Month (National Center for
Victims of Crime, 2014).
Bullying is defined “as a repeated oppression, psychological or physical, of a less powerful
person by a more powerful person or group of persons” (van der Zande, n.d.). Types of
bullying include cyberbullying, physical threats or violence, verbal bullying, and workplace
bullying. Bullying can occur in any setting, real world or online, and at any age. See Box 27-2.
IPV is about control, not anger. The objective of abuse is to exert power and control over the
victim. Victims may have been exposed to violence as children. In these cases, the learned
response is often one of helplessness that implies passivity and acceptance of abuse. Box 27-
3 presents commonly held myths associated with IPV.
The Domestic Abuse Intervention Project (2011) in Duluth, Minnesota, has developed a wheel
of violence that depicts the types of power and control that are used by perpetrators. Figure 27-
1 depicts the Power And Control Wheel, “a helpful tool in understanding the overall pattern of
abusive and violent behaviors that are used by a batterer to establish and maintain control over
his partner. Very often, one or more violent incidents are accompanied by an array of these other
types of abuse.” This organization has also developed other wheels that focus on domestic abuse
programs that include equality, abuse of children, and nurturing children. Their newest model
focuses on using children after spousal separation to maintain power and control.
Victims of abuse often experience chronic fatigue and tension, disturbed sleeping and eating
patterns, and vague gastrointestinal and genitourinary complaints. Misdiagnosis often occurs
because of the obscurity of the symptoms and/or the failure to adequately assess the patient.
Victims tend to stay in an abusive relationship on the basis of cultural,

BOX 27-2 BULLYING

Bullying includes repeated harmful acts and a real or perceived imbalance of power. Often
underreported, bullying creates a climate of fear. Bullying can be physical, verbal, or
psychological/relationalbullying or cyberbullying.
 •Physical bullying involves assault, intimidation, and/or destruction of property
 •Verbal bullying includes threats and name-calling
 •Psychological/relational bullying can include all of the above and is distinguished by the
power imbalance between the victim and the bully
 •Cyberbullying consists of targeting the victim online
Modified from U.S. Department of Justice, Office of Justice Programs: OJP Factsheet, 2011.
Available from <http://www.ojp.usdoj.gov/newsroom/factsheets/ojpfs_bullying.html>.

BOX 27-3 COMMON MYTHS ASSOCIATED WITH INTIMATE

PARTNER VIOLENCE
 • It occurs only in poor, uneducated, minority households.
 • It is a private family matter (vs. a societal problem).
 • It only occurs in heterosexual relationships.
 • Victims deserve the abuse.
 • Victims can change the abusers’ behavior.
 • Abusers will stop the abuse on their own without professional intervention.
religious, and economic factors. According to a study by Campbell and Humphreys (1993), the
people more likely to leave abusive relationship s are those who have resources and power (e.g.,
a job, credit cards, and status outside the family), no children, and no personal history of abuse
(of themselves or their mothers). The most dangerous time for victims is when they leave or
attempt to leave the relationship. The victim is much more likely to be killed at this time than at
any other time in the relationship.

Child Maltreatment
Most child maltreatment occurs within the family. Children are abused more often by parents
than by other relatives or caregivers. Maltreatment is more commonly seen in families living in
poverty, in families in disorganization, or with parents who are younger and are substance
abusers. Risk factors for child maltreatment include but are not limited to special needs children
(children with disabilities, mental retardation, or chronic illness), children less than 4 years of
age, family history of violence, substance abuse, poverty, and social isolation (CDC NCIPC,
2012c). The four types of child maltreatment are:
 •Neglect
 •Physical abuse
 •Emotional abuse
 •Sexual abuse
In some families all children are equal targets, whereas in other families a particular child may
be selected as the designated recipient of abuse. The child may be singled out by a particular
physical characteristic that evokes
negative

FIGURE 27-1 Power and Control Wheel.

(Developed by the Domestic Abuse Intervention Project, 206 West Fourth Street, Duluth,
MN 55806. Used with permission.)
emotions in the abusive parent. Although statistical reporting of child abuse is mandatory
throughout the country, reported numbers are probably an underestimation. Children are not
likely to report the abuse because they fear reprisal.
According to the (CDC NCIPC, 2012a), in 2010, there were more than 695,000 confirmed cases
of child maltreatment in the United States. Girls were more likely to be victims than boys, and
infant’s less than 1 year old accounted for 21.7% of nonfatal maltreatment cases, followed by
12.9% of children who were 1 year old. More than 1500 children died in the United States of
abuse and neglect in 2010. Of child maltreatment cases in 2008, 80% of deaths occurred in
children younger than 4 years, whereas 10% of deaths occurred in children between the ages of 4
and 7 (CDC NCIPC, 2010a).
Neglect is the failure of the responsible person to provide basic needs such as shelter, food,
clothing, education, and access to medical care. Seventy-one percent of all child maltreatment
cases are classified as neglect (CDC NCIPC, 2010a). Failure to provide a nurturing environment
for a child to thrive, learn, and develop and to provide for the health needs of a child can also be
construed as neglect. Examples of emotional neglect include failure to cuddle and/or physically
stimulate a newborn, failure to give positive feedback, failure to pay attention to the overall
emotional needs of a child, and failure to show affection.
Physical abuse is an intentional injury inflicted on a child by another person and accounts for
16% of child maltreatment cases (CDC NCIPC, 2010a). Parents who abuse often have
unreasonable expectations of their children and may misinterpret children’s behavior as threats to
their parental self-esteem and need to control. Physical abuse includes beating, burning, biting,
and bruising. The type of physical injury varies only with the adult’s imagination. Patterned
injuries may give some clue as to how the child was injured. A child who touches a light cord or
light plug might be beaten with it, producing a looped or linear pattern. A child who plays with
matches or the stove might have his or her hand placed in the flame. A crying child or a child
who talks back might have hot pepper sauce poured into his or her mouth or might be suffocated
with a pillow.
Abusive head trauma/inflicted traumatic head injury, also known as shaken baby syndrome, is
a leading cause of death from abuse in the United States. Most victims are between 3 and 8
months of age. In this form of abuse, violent shaking of the infant causes trauma at the junction
of the brainstem

TABLE 27-1 PHYSICAL AND BEHAVIORAL INDICATORS OF

CHILD ABUSE AND NEGLECT
PHYSICAL INDICATORS BEHAVIORAL INDICATORS
Physical Abuse
Unexplained bruises and welts in various stages of healing Wary of adult contact
that may form patterns Apprehensive when other children cry
Unexplained burns by cigars or cigarettes or immersion Constantly on alert
burns (e.g., socklike, glovelike, or on buttocks or genitalia) Exhibiting extremes of behavior; aggressive or pa
Burns in the shapes of objects and withdrawn, or overly friendly to strangers
Rope burns Frightened of parents
Unexplained lacerations or abrasions Afraid to go home
Unexplained fractures in various stages of healing; multiple
or spiral fractures
Unexplained injuries to mouth, lips, gums, eyes, or external
genitalia
Physical and Emotional Neglect
 PHYSICAL INDICATORS BEHAVIORAL INDICATORS
Hunger Begging or stealing food
Poor hygiene Alone at inappropriate times or for prolonged peri
Poor or inappropriate dress Delinquent behavior
Lack of supervision for prolonged periods Stealing
Lack of medical or dental care Arriving early to and departing late from school
Constant fatigue, listlessness, or falling asleep in class Lack of affection
Sexual Abuse
Difficulty in walking or sitting Exhibiting negative self-esteem
Torn, stained, or bloody underwear Exhibiting inability to trust and function in intima
Genital pain or itching relationships
Bruises in or bleeding from the external genitalia, vaginal, Exhibiting cognitive and motor dysfunctions
or anal area Exhibiting deficits in personal and social skills
Sexually transmitted disease Exhibiting bizarre, sophisticated, or unusual sexua
Drug and alcohol abuse behavior or knowledge
Developmental delays Delinquent or a runaway behavior
Exhibiting suicide ideation
Reporting sexual assault
Emotional Abuse
Failure to thrive Exhibiting behavior extremes from passivity to
Lag in physical development aggression
Speech disorders Exhibiting habit and conduct disorders (e.g., antis
Developmental delays behavior and destructiveness)
Exhibiting neurotic traits
Attempting suicide
and spinal cord that can result in death. Serious and permanent brain damage may occur, with
results such as cerebral palsy, severe retardation, blindness, hearing loss, and developmental
delays. In 65% to 90% of abusive head trauma cases, the father or the mother’s boyfriend is the
perpetrator (KidsHealth, 2011).
Emotional abuse accounts for approximately 7% of all child abuse cases and is the behavior that
may damage a child’s self-worth or emotional well-being (CDC NCIPC, 2010a). The child may
demonstrate a substantial impairment in behavior, such as being overly compliant or passive,
being very aggressive, or being inappropriately adult or infantile. Emotionally abused children
frequently do not progress at a normal rate of physical, intellectual, or emotional development.
They also have an increased risk of suicide. Emotional abuse usually occurs in the home,
unwitnessed by others. Emotional abuse might include name calling—such as “you’re stupid,”
“you’re a slut,” “you’re bad,” or “you’re evil”—shaming, withholding love, rejection, or
threatening behavior. Impairment in behavior may also occur in children who are not abused;
therefore, identification of emotional abuse is difficult.
Sexual abuse involves engaging a child in sexual acts. Incest is defined as sexual relations
between persons considered too closely related to marry. Approximately 9% of child abuse cases
are sexual abuse (CDC NCIPC, 2010a). The incidence of sexual exploitation of children by
Internet pedophiles has increased in recent years. Most research has focused on girls as victims
of sexual abuse, but boys are also targets. The victim may refrain from reporting abuse because
he is ashamed or because cultural values expect males to be assertive and capable of self-
defense.
Low self-esteem, psychiatric disorders, chronic health problems, depression, suicidal ideation,
substance abuse, eating disorders, obesity, sexual maladjustment, delayed developmental
processes, and high-risk sexual behaviors may result from child maltreatment (CDC NCIPC,
2011). The child may delay reporting the abuse for months or years, because it may take that
long for him or her to feel safe. Table 27-1 describes physical and behavioral indicators of child
abuse and neglect.
All states mandate that health care providers and teachers report suspected child abuse.
Reporting child abuse may be one of the hardest things a nurse will ever have to do, but may be
one of the most rewarding when an abused child is removed from a harmful situation.

Elder Abuse
Elder abuse lags far behind child abuse and IPV as a social and health care issue because
society fails to recognize the cruelty many older adults experience. Failure to recognize abuse is
likely attributable to the perception of elders as an “invisible” segment of the population. The
exact number of abused elders is unknown because of underreporting and no uniform reporting
system. Estimates indicate that 2% to 10% of the older adult population suffer some form of
abuse. Reasons for underreporting include shame on the part of the victim, social and physical
isolation from resources, and the failure of health care providers to routinely assess for abuse and
neglect during points of contact. The most likely victims are those in poor physical or mental
health, those dependent on others for physical or financial support, and those confused,
depressed, or who are socially isolated (National Center on Elder Abuse [NCEA], 2005).
According to the NCEA (2011), types of abuse and neglect of older adults are as follows:
 •Physical abuse (purposeful infliction of physical pain or injury or unnecessary physical or
drug-induced restraints)
 •Psychological-emotional abuse (verbal assault, threats, provoking fear, or isolation)
 •Sexual abuse (unwanted sexual contact or taking pornographic pictures)
 •Neglect (withholding of personal care, food, or medications, intimidation, humiliation,
abandonment)
 •Financial exploitation (theft or misuse of money or property)
 •Health care fraud and abuse (charging for services not delivered, or Medicaid fraud)
Elder abuse tends to escalate in incidence and severity. When an older adult cannot care for
himself or herself because of the physical or mental infirmities of age, what happens to that
person may depend on whether relatives can provide care, or whether the person has financial
resources to obtain care in his or her own home, a retirement home, or a residential care facility.
Caregivers are often adult children or other relatives. The generation of individuals currently in
their 40s, 50s, and 60s is often called the “sandwich generation” because they are caring for their
children at the same time they are providing care for their aging parents. As parents age, the role
reversal is often painful and demanding for both the elder and the caregiver.
Care of an aging parent requires sacrifice and commitment. As parents age, they may become
more physically and cognitively impaired, increasing the likelihood of abuse. Elders who were
themselves abusers are more likely to be abused by their caregivers. Older adults may undergo
changes in personality that make it difficult for their adult children to care for them. They may
need to be lifted, which may be difficult for someone with limited strength. They may need
assistance walking, toileting, or eating that requires time the caregiver may not have. There is
also an intimacy in caring for a parent that the caregiver may not be comfortable with.
All of these factors cause stress, which can be associated with abuse—especially in families in
which violence is a response to stress. The needs of the older adult may exceed the family’s
ability to meet them.
In many ways, helpless older adults are in the same vulnerable position as children, because they
are dependent on others for care. The population of the United States is aging, and by 2020, the
number of adults older than 85 years is expected to account for 19% of the population (USDHHS
Administration on Aging, 2012). Recognition of physical and behavioral indicators helps the
professional become aware of possible abusive situations. None is conclusive in itself; however,
each alerts the professional to the need for careful and complete assessment. Even though nurses
are required to report instances of elder abuse, they may be reluctant to do so because assessment
is not always conclusive. However, if there is a question of possible abuse, it must be reported to
the appropriate authorities for further investigation. The State of New York took the lead in
passing legislation with its “Granny’s Law,” which stiffened the penalties for assaults on
elders. Table 27-2 lists the indicators of possible abuse of older adults.

Community Violence
The United States is one of the most violent countries in the industrialized world. Every day we
hear about some community, region, or state that has been affected by violent crime. Community
violence may not affect everyone directly, but it affects all indirectly. In contrast
to interpersonal violence, which affects only one or two individuals, community violence
usually occurs suddenly and without warning and can potentially destroy entire segments of the
population. Community violence includes workplace violence, youth violence, gang-related
violence, hate crimes, and terrorism.

Workplace Violence
Workplace violence is a serious safety and health issue. Violence in the workplace includes
physical assaults such as rape and homicide, muggings, verbal and written threats and bullying.
In 2011, there were 458 workplace homicides out of a total of 4609 fatal work injuries in the
United States (U.S. Bureau of Labor Statistics, 2012). Workplace violence tends to be more
common in some service-oriented work environments, including health care. Such violence is
widely believed to be underreported, perhaps in part because of belief that it is an expected part
of certain jobs. In the health care field, frequent areas for the occurrence of violence include
emergency departments, psychiatric units, geriatric units, and waiting rooms. Nurses and nursing
assistants who work directly with patients are often at risk. Nurses who work in public health

TABLE 27-2 INDICATORS OF POSSIBLE ELDER ABUSE OR

NEGLECT
Abuse
Physical Indicators
Bruises, black eyes, welts, lacerations, and rope marks
Bone and skull fractures
Open wounds, cuts, punctures, untreated injuries in
various stages of healing
Sprains, dislocations, and internal injuries/bleeding
Signs of being subjected to punishment and signs of
being restrained
Laboratory findings of medication overdose or
underutilization of prescribed drugs
Report of being hit, slapped, kicked, or mistreated
The caregiver’s refusal to allow visitors to see an elder
alone
Unexplained sexually transmitted disease
Elders sudden change in behavior
Elder’s report of sexual assault
Neglect
Physical Indicators
Dehydration, malnutrition, untreated bedsores, and poor
personal hygiene
Unattended or untreated health problems
Hazardous or unsafe living conditions/arrangements (e.g.,
improper wiring, no heat, or no running water)
Unsanitary and unclean living conditions (e.g., dirt, fleas,
lice, soiled bedding, fecal/urine smell, inadequate
clothing)
Elder’s report of being mistreated or neglected
Abandonment (desertion of an elder at a hospital, nursing
facility, or other similar or public places or institutions)
Emotional/Behavioral Indicators
Being emotionally upset or agitated
Being extremely withdrawn and noncommunicative
nonresponsive
Unusual behavior usually attributed to dementia (e.g
sucking, biting, rocking)
Sudden change in behavior
Elder’s report of being verbally or emotionally
mistreated
Financial Indicators (Material Exploitation)
Sudden changes in bank account or banking practic
(e.g., unexplained withdrawal of large sums of mon
inclusion of additional names on an elder’s bank
signature card)
Unauthorized withdrawal of the elder’s funds using
elder’s automatic teller machine card
Abrupt changes in a will or other financial documen
(e.g., power of attorney)
Unexplained disappearance of funds or valuables
Bills unpaid despite the availability of adequate
financial resources
Elder’s signature being forged for financial transact
or for the titles of his/her possessions
Sudden appearance of previously uninvolved relativ
interested in the elder’s affairs and possessions
Unexplained sudden transfer of assets to a family
member or someone outside the family
The provision of services that are not necessary
Report of financial exploitation
 Modified from Administration on Aging/National Center on Elder Abuse: Signs and symptoms of elder abuse, 2
Available from <http://www.ncea.aoa.gov/Main_Site/FAQ/Basics/Types_Of_Abuse.aspx>.
roles are not immune to violence because their work may bring them in direct contact with
individuals prone to violent behavior. Identification of risk factors may offer some protection to
the worker whether in the hospital or home or public health setting. Examples of risk factors
include:
 •Increasing numbers of acute and chronically mentally ill patients
 •Working alone
 •Availability of drugs at the worksite
 •Low staffing levels
 •Poorly lit parking areas and corridors
 •Long waits for service
 •Inadequate security
 •Increasing numbers of substance abusers
 •Access to firearms
Violence also negatively impacts the workplace, resulting in low morale, increased job stress and
turnover, reduced trust of management and/or coworkers, and hostile work environments.

Youth-Related Violence
Violence is taking a toll on American youth. In 2010, juveniles (less than 18 years of age)
accounted for 13.7% of all violent criminal arrests. Racial disparities are evident in youth-related
violence, because blacks are more likely to be victims than either whites or Hispanics. Most of
the increased homicide rates among American youth are attributable to death caused by firearms
(CDC NCIPC, 2012f). Table 27-3 lists risk factors for youth-related violence.
Youth-related violence is more concentrated in minority communities and inner cities, putting a
disproportionate burden on these communities. Violence is a complicated and multilayered
problem. Adolescents and children increasingly use violence to settle disputes. Children are often
not taught peaceful ways of resolving differences and learn by what they observe at home, on
television, and in movies. Consequently, schools have become a common site for violence.
See Chapter 29 for more information on violence in schools.

TABLE 27-3 RISK FACTORS FOR YOUTH-RELATED

VIOLENCE
Individual Risk Factors Involvement with drugs, alcohol or tobacco
Antisocial beliefs and attitudes
Low IQ
History of violent victimization
History of early aggressive behavior
Attention deficits, hyperactivity or learning disorders
Poor behavioral control
Deficits in social, cognitive or information-processing abilities
Exposure to violence and conflict in the family
 High emotional distress
History of treatment of emotional problems
Community Risk Factors Diminished economic opportunities
High concentration of poor residents
High level of family disruption
Low levels of community participation
Socially disorganized neighborhoods
High level of transiency
Family Risk Factors Poor family functioning
Low emotional attachment to parents or caregivers
Low parental education and income
Parental substance abuse or criminality
Poor monitoring and supervision of children
Harsh, lax, or inconsistent disciplinary practices
Authoritarian child-rearing attitudes
Peer/Social Risk Factors Association with delinquent peers
Involvement in gangs
Social rejection by peers
Lack of involvement in conventional activities
Poor academic performance
Low commitment to school and school failure
Data from Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Divis
of Violence Prevention: Youth violence: Risk and protective factors, 2013. Available from
<http://www.cdc.gov/ViolencePrevention/youthviolence/riskprotectivefactors.html>.

Gangs
Gangs are increasingly responsible for crimes and violence throughout the United States. In
2009, the National Gang Threat Assessment reported that 94.3% of gang-related homicides
involved the use of firearms. In 2011, there were an estimated 1.4 million youth gang members
in the United States and the American Commonwealth (USDOJ, Bureau of Alcohol, Firearms,
and Explosives [ATF], 2012).
Reasons that young people give for joining gangs include the belief that gangs will protect them,
peer pressure, the need for respect, and a sense of belonging. Gangs exist in all 50 states, and it is
estimated that gangs are responsible for approximately 48% of all crime, up to 90% in some
areas. These crimes include illegal alien smuggling, armed robbery, assault, auto theft, drug and
weapon trafficking, identity theft, and murder (USDOJ, Bureau of Alcohol, Firearms, and
Explosives [ATF], 2012).

Prison Violence
The United States has one of the world’s highest incarceration rate, 2.9% of adults (1 in 34
adults) being under some form of correctional supervision. Inmates are both victims and
perpetrators of violence. With more than 1.5 million prisoners in federal and state prisons or
local jails, prison violence includes allegations of physical abuse as well as reports of rape by
both corrections officers and inmates (USDOJ, Bureau of Justice Statistics, 2012). The public
and the judicial system have expressed little sympathy for this population for a variety of
reasons, including indifference, disbelief, and denial. Little research exists to reflect the long-
term effects on these victims or on society when they are released. See Chapter 31for more
information on forensic and correctional nursing.

Human Trafficking
Human trafficking is a global problem and public health issue. It may involve prostitution,
sexual exploitation, forced labor, slavery, and removal of organs. Threats, coercion, abduction,
fraud, and abuse of power are all methods used by human traffickers. An estimated 2.4 million
people across the globe are victims of human trafficking at any given time, and 80% of them are
being used as sexual slaves (HumanTrafficking.org, 2012). The United Nations Office on
Drugs and Crime (2013) is actively helping states and countries legislate against and prevent
trafficking.

Hate Crimes
Hate crimes are crimes in which the offender is motivated by factors such as an individual’s
race, sexual orientation, religious beliefs, ethnic background, or national origin. Hate crimes may
include murder, sexual or physical assault, harassment, attacks on homes or on places of
worship, or vandalism. Because hate crimes attack an individual’s identity, the emotional effects
are compounded. In 2009, 6604 hate crimes were reported in the United States even though it is
estimated that only 44% of hate crimes are reported. The most commonly reported hate crimes
are motivated by race, followed by religion and sexual orientation (USDOJ, Office of Justice
Programs, 2011).

Terrorism
Terrorism has been present throughout history. The U.S. Department of Defense
(2014) defines terrorism as “the unlawful use of violence or threat of violence to instill fear and
coerce governments or societies. Terrorism is often motivated by religious, political, or other
ideological beliefs and committed in the pursuit of goals that are usually political.” All terrorist
acts include at least three key elements—violence, fear, and intimidation. Nurses need to be
prepared for terrorism in whatever form it takes, from an explosion at a local refinery to an act
that affects an entire region or country, such as biological, chemical, or nuclear incidents. Mental
and physical health issues remain a nursing concern for the victims, responders, and the
community long after the act has occurred. See Chapter 28 for a more detailed discussion of
terrorism.

Factors Influencing Violence

Controversy surrounds the factors that influence violence in today’s society. Three of them are
easy access to firearms, the impact of media, and mental illness. Firearms are readily available,
and even children are carrying guns to school. The influence of media is pervasive in our society,
especially among adolescents and young adults.

Firearms
Approximately 270 million privately owned firearms exist in the United States, and more than 1
million new handguns are sold in the United States annually. The United States ranks number
one in privately owned guns among 179 countries, and statistics indicate that firearms are the
weapon of choice in homicides in the United States. Of the nearly 13,000 murders in this country
in 2010, 67.5% were committed with firearms (FBI, 2013).
Concern about firearms arises when it has been shown that guns kept in the home for self-
protection are more likely to kill a family member or a friend than an attacker. Furthermore, the
presence of a gun in the home triples the risk of homicide in the home and increases the risks of
suicide three to five times and of accidental deaths by four (Edelman, 2013). The cost of gun
violence is staggering. Direct cost of violence related to firearms in the United States is in
millions of dollars annually. Indirect costs, including loss of productivity, mental health
treatment, rehabilitation, and legal and judicial costs, adds even more. Heated discussions
regarding firearms occur daily between opponents and proponents of gun control. Even the
underlying meaning of the second amendment of the Constitution, “the right to bear arms,” is
argued.

Media
Media violence is prevalent and is accessible to all age-groups. It includes exposure to, and
participation in, violent video games, music and music videos that depict rape or violence, and
virtual violence that allows subscribers to harm or kill victims. Television and movies often
depict people being tortured or killed in such graphic detail that may make it hard for children
and adults to distinguish between reality and fantasy. Media violence has become more
pronounced and graphic in nature. The public health community believes that repeated exposure
to media violence leads to emotional desensitization to real-life violence.

Mental Illness
Mental illness is considered by many to be a major factor in violence. Studies, however, are
inconclusive in their findings that all violence is committed by mentally unstable persons.
Prosecutors and defense attorneys argue the case of whether someone is evil or mentally unstable
when these cases go to court.
Following the violence in Newtown, Connecticut, there has been an increased push for
legislation to fund public health strategies that identify and treat mental illness across the
country. This is especially important since the budget crisis in the United States has forced many
states to eliminate or reduce the availability of mental health services. See Chapter 24 for a
more in-depth discussion of mental illness.
Violence from a Public Health Perspective
Dealing with violence has traditionally been the U.S. criminal justice system’s responsibility.
However, because violence is also a public health epidemic, efforts are being made to prevent
and manage it using public health strategies and community approaches such as church groups,
community groups, and local, state, and federal governments. Violence, as discussed previously,
has a tremendous influence on morbidity and mortality rates and health care resources. The
public health system is challenged to go beyond its traditional programs to include prevention
and management of violence. As is true with most public health problems, many interrelated
factors must be addressed.

Healthy People 2020 and Violence

Violence was one of the areas addressed by Healthy People 2000 and again in Healthy People
2010 and Healthy People 2020. Several objectives regarding violence and abuse prevention have
been established. The Healthy People 2020 table lists a few of these (HealthyPeople.gov, 2012).
These objectives are intended to target causes of violence and abuse, improve national data
collection and analysis, provide input for legislative funding, facilitate research efforts, and
concentrate public health efforts on models that demonstrate effectiveness.

HEALTHY PEOPLE 2020: Objectives Related to Injury

and Violence Prevention
 IVP–29: Reduce homicides.
 IVP–30: Reduce firearm-related deaths.
 IVP–31: Reduce nonfatal firearm-related injuries.
 IVP–32: Reduce nonfatal physical assault injuries.
 IVP–33: Reduce physical assaults.
 IVP–34: Reduce physical fighting among adolescents.
 IVP–35: Reduce bullying among adolescents.
 IVP–36: Reduce weapon carrying by adolescents on school property.
 IVP–37: Reduce child maltreatment deaths.
 IVP-38: Reduce nonfatal child maltreatment.
 IVP-41: Reduce nonfatal intentional self-harm injuries.
 IVP-42: Reduce children’s exposure to violence.
 IVP-43: Increase the number of states and the District of Columbia that link data on violent
deaths from death certificates, law enforcement, and coroner and medical examiner reports
to inform prevention efforts at the state and local levels.
From HealthyPeople.gov: Healthy People 2020: Topics & objectives: Injury and violence
prevention, 2012. Available from
<http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=24>.
Many of the Healthy People 2020 objectives are difficult to achieve because of complex barriers.
These barriers include lack of comparable data sources and standardized definitions as well as
inadequate resources to establish consistent tracking systems and fund prevention programs.

Prevention of Violence
The nurse who cares for people experiencing violence must be a skilled clinician who is
knowledgeable about both the problem and available community resources. Box 27-4

BOX 27-4 SAFETY ISSUES FOR THE COMMUNITY HEALTH

NURSE
Plan Ahead
 • Know the area you are visiting.
 • Schedule the visit ahead of time, and get the correct address, directions, and information
about who will be in the home.
 • Tell the office where you will be, and check in regularly.
 • Carry a cell phone, possibly a pager, and a small amount of money.
 • Dress for function and mobility, and wear a name tag. Avoid any provocative clothing.
 • Ensure that the vehicle you drive is in good repair, has a full gas tank, and has emergency
equipment. Always carry two sets of car keys.

Approaching the Home

 • Notice the environment, animals, fences, activity, possible indicators of crime, and places
you could go for assistance if necessary.
 • Walk with confidence, and maintain a professional attitude.
 • Listen for signs of fighting before knocking. If you hear sounds of fighting, leave!
 • Do not enter a home if you suspect an unsafe situation.

In the Home
 • Be aware of who is in the home and what is going on. If angry people are in the home, use
your professional and social skills. Do not expect the client to protect you.
 • Note the exits, and sit between the client and an exit of the home. Be prepared to leave
quickly if the situation changes suddenly.
 • If someone in the home is violent, leave and call 911.

Handling a Tight Situation

 • Do not show fear; control your breathing.
 • Speak calmly and in a soothing manner. Be assertive but not aggressive.
 • Repeat the reason for your visit, and find a reason to leave.

Leaving the Home

 • Take all of your belongings, and keep your car keys in your hand.
 • Watch for cars following you when you leave. Do not stop. If you feel that you are in
danger, go to the nearest police station or well-lighted business and ask for help.
 • Trust your instincts. Never forget your own safety.
Modified from Oregon Public Health Association, Public Health Nursing Section, Seattle–King
County Department of Public Health, and Washington State Public Health Association: Public
health nursing domestic violence protocol [booklet], Seattle, WA, and Salem, OR, 1993,
Authors.
presents tips regarding safety issues for a community health nurse. A considerable body of
knowledge has been developed about trends in violence. Table 27-4 provides the components of
a comprehensive program to reduce violence in individuals and the community.

Primary Prevention
The goal of primary prevention is to stop violence, abuse, or neglect before it occurs. Education
plays a major part in primary prevention and may include life-skills training such as parenting
and family wellness, anger management, and/or conflict resolution. Professionals should increase
their awareness of violence and identification of cases. The nurse can work in or with the
community to educate citizens about the problem of violence, potential causes of violence, and
available community services.
Primary prevention must begin at a community level, helping to change attitudes about abuse
and violence. Primary prevention focuses on stopping the transgenerational aspect of abuse,
starting with young children and continuing throughout the life span. Mentoring and peer
programs can be designed to promote healthy relationships and decrease conflict. For example,
parenting is one of the most difficult jobs that individuals will undertake, yet there is a
widespread myth that parenting “comes naturally.” Classes for parents should focus on physical
care of the infant, including ways to soothe and manage a “fussy” baby, the effect of fatigue on
new parents, the need for support, and the fears and questions of new parents. Nurses in the
hospital have little time to help new parents learn basic newborn care before discharge. Some
hospitals and public health agencies provide follow-up to parents to ensure that they can
adequately care for their newborn. This support is especially given to all persons deemed to be
high risk for infant abuse, including teenage mothers, mothers without support, or women with a
history of spousal abuse.

Secondary Prevention
The goal of secondary prevention is to assess, diagnose, and treat victims and perpetrators of
violence. Consideration of the safety of the potential victim is critical.
Secondary prevention begins with assessment. For example, consistent assessment of women
during health care visits will increase case finding and provide opportunities for early
intervention that is particularly crucial during pregnancy. Women should be interviewed in
private when asked about abuse. Questions should be asked in a matter-of-fact way and the
health care provider should not show shock or dismay at the response. The Nursing Research
Consortium on Violence and Abuse has developed a simple three-question abuse assessment

screening. See Resource Tool 27A for the Abuse Assessment Screen. These three
questions should be asked of all women at each visit, and careful and detailed documentation
should be done.
Victims, once identified, must be offered resources to increase their safety. However, all victims
may not be ready or able to leave the situation, and available options must be explored. Victims
should have knowledge of legal options and how to access them. The nurse must be ready to
intervene when the abuse involves a child or someone who is cognitively impaired. Some states
have developed protocols for nurses who deal with victims of violence. Review of these
protocols can help the nurse become familiar with the questions to ask and suggestions that

should be made to help the victim develop a safety plan. See Resource Tool 27B for a
sample of a safety plan.
Another example of secondary prevention involves screening for abuse in the elderly that should
occur at every health care visit. Elder abuse remains underreported across the United States;
therefore routine screening can facilitate early intervention. Nurses can help raise professional
and community consciousness of elder abuse by participating in political activities to create or
strengthen mandatory reporting laws and funding of support groups.

TABLE 27-4 EXAMPLES OF PREVENTION STRATEGIES TO

REDUCE VIOLENCE FOR INDIVIDUALS AND COMMUNITIES
INDIVIDUALS COMMUNITY
Primary Prevention—Goal: Promotion of Optimal Parenting and Family Wellness
Life-skill training in schools, Community education concerning violence
churches, and communities Reduction of media violence
Education of children, Development of community support services such as crisis lines, respite care
adolescents and adults on families with dependent members, shelters for battered women and their chil
methods of conflict resolution and development and vigorous enforcement of anti-stalking measures, includ
Parenting classes in hospitals, cyberstalking
schools, and other community Handgun safety education
agencies
Mental health services for all
age-groups
Training for professionals in
early detection of violence
Secondary Prevention—Goal: Diagnosis of and Service for Families in Stress
 INDIVIDUALS COMMUNITY
Nursing assessment for evidence Education of all health professionals in assessment of violence and possible
of violence in all health care protocols for dealing with victims
settings List of hospital emergency departments and trauma centers with 24-hour
A safety plan for victims response Reporting of different types of abuse
Knowledge of legal options Coordination with medical authorities, Coordination with voluntary and soci
Shelter referral for victims service agencies for provision of services
Social services for individuals or Death review teams to review deaths from injury, especially in infants and
families children
Referral to self-help groups in Public authority involvement by police, district attorneys, and courts
the community Epidemiological tracking and evaluation of violence
Referral to appropriate
community agencies
Tertiary Prevention—Goal: Reeducation and Rehabilitation of Violent Families
Empowerment strategies for Foster homes, shelters, and care for dependents
battered women Public authority involvement
Professional counseling services Follow-up care for known cases of abuse, neglect, or violence
for individuals
Parenting reeducation (i.e.,
formal training in child-rearing)
Counseling services for
individuals and families
Self-help groups
The nurse should work with family members or caregivers who provide care for the elderly to
promote healthier relationships. Helping the caregiver deal with stress by finding respite care, a
home health aide, or counseling may help. Documentation is crucial in meeting medical-legal
requirements. The nurse should record observations accurately and refrain from opinions and
interpretations, because this documentation may be used in court proceedings.
The problem of violence cannot be managed by nurses alone, but rather in combination with
other professionals, including physicians, child and adult protective services providers, social
workers, clergy, and police. This interdisciplinary approach leads to optimal outcomes. Public
health surveillance is important in obtaining accurate numbers of intentional injuries for
individuals. Death review teams can analyze records to determine whether an injury was
intentional or unintentional.

Tertiary Prevention
Tertiary prevention is aimed at rehabilitation of individuals, families, groups, or communities
and includes both victims and perpetrators of violence. Rehabilitation may take months or even
years, depending on the situation. For example, the September 11, 2001, attack on the United
States disrupted thousands of lives and changed the country’s sense of security. This attack
affected everyone in the country, not just those in the immediate vicinity. After all these years,
the effects continue. The nurse must be able to work in conjunction with a variety of mental
health professionals and social service agencies to provide coordinated care. The nurse may have
also been a victim and may be experiencing many of the same problems as those he or she is
trying to help with. Self-care and recognition of the nurse’s own limitations or needs are critical.

Summary
Violence is a major public health issue in the United States and affects individuals across the life
cycle. Morbidity and mortality statistics indicate that violence is epidemic in many communities.
Whether it occurs at home, in the neighborhood, or at school, violence affects countless numbers
of individuals. The influence of media, easy access to and proliferation of firearms, and mental
illness in the United States are considered contributing factors to violence. The cycle of violence
will persist if not broken. The abuser is also a victim, and the ultimate victim is society, which
must care and pay for the results of violent acts.
Violence is a public health epidemic, and national objectives for reducing it have been identified.
The core public health functions of needs assessment and surveillance, policy development, and
assurance are useful methods of combating this epidemic. The literature describes interventions
that focus on the three levels of prevention. The need for continued research in violence should
be a funding priority at the local, state, and national levels. The reality of violence has been
validated. Everyone is affected.

CASE STUDY APPLICATION OF THE NURSING PROCESS

Karen, 36 years old, comes to the neighborhood clinic where you are the nurse. She is obviously
distraught and is holding her head down when she enters the exam room. As you are getting her
vital signs, she lifts her head and you notice multiple bruises on her face, around her left eye, and
on her left cheek and the right side of her neck. She sees you looking at her and she begins to
cry. You ask her what happened and she tells you that her boyfriend hit her two nights ago. As
you question her further, you find out that she is divorced, has custody of her two children, a boy
age 8 and a daughter age 3, and is unemployed. Her ex-husband lives three states away, about an
8-hour drive. She has been with the current boyfriend about 6 months and they have been living
together about 3 months. He hit her repeatedly the night before last after he came home upset
about a problem at work. The attack ended as abruptly as it started. He apologized repeatedly,
hugged her, and left the house. Her children were in bed and did not witness the abuse. She took
the children to a friend’s house and then went to an after-hours clinic for treatment. While she
was at the after-hours clinic, the police were notified, and she pressed charges against her
boyfriend. He was arrested later that night and she subsequently filed a restraining order against
him.
After further discussion, she tells you that this is not the first time he has hit her; that it has
happened twice before, always after something has upset him. She then states that she knows he
loves her and that he would not deliberately hurt her—that she must have done something to
make him angry. She feels that he does really love her and she regrets having him arrested and
filing the restraining order. She felt as if she had no choice once the clinic personnel and the
police urged her to do something. He is now in the county jail and she is considering going to the
police station and dropping the charges. She does admit, however, that she is afraid about how
angry he is going to be once he gets out.
You tell her about the cycle of domestic violence and how it repeats itself. You give her
information about local shelters and explain that abusers usually do not stop their cycle of
violence on their own, but only after counseling and support. You also tell her that she may be in
danger of serious harm and even death if she stays with him. You recommend that she leave
where she is living, take her children with her, and talk with an attorney before doing anything
about the legal situation.
One month later, Karen again appears in your clinic. She tells you that she did leave home and
take her two children to her ex-husband’s house. She also states that the boyfriend is still in
county jail, that she did not drop the restraining order, and that she has moved in with her
boyfriend’s mother. She visits him every Sunday afternoon and talks to him once a week on the
phone. His mother refuses to speak with him.

Assessment
The following are the summary assessment points:
 •The boyfriend has a history of intimate partner violence (IPV)—duration unknown.
 •Karen is a stay-at-home mom, with two children under the age of 9 years, who currently
live with their father in another state.
 •Karen does not have close family in the area.
 •Karen does not believe that she is in danger.
 •Karen believes she lacks employable skills.
 •The boyfriend’s abuse is aggravated by problems at work.

Diagnoses
 • Potential for severe injury or death related to abuse
 • High risk for emotional trauma from dysfunctional family dynamics
 • High risk for loss of children

Planning
Short-Term Goals
 • Boyfriend will be referred for anger management classes once released.
 • Strategies will be identified to help Karen regain her children.
 • A safe setting will be identified for Karen and the children.

Long-Term Goals
 • Karen will be free of IPV.
 • Karen will enter individual counseling.
 • Boyfriend will enter counseling.

Intervention
Individual
Karen was assessed for injuries, and none was found to be life threatening. She was given a
referral for counseling at the local counseling center where a community health nurse works. She
was also given locations and numbers for local shelters. She did leave the charges against her
boyfriend standing and decided not to drop the restraining order.
Karen agreed to enter counseling and continues to live with her boyfriend’s mother until other
arrangements can be made. She decided to leave her children at her ex-husband’s house until she
feels more secure about her situation. Karen has spoken with the community health nurse at the
local counseling center. The nurse’s goals are centered on Karen’s ongoing physical and
emotional well-being.
During these visits the nurse was able to engage Karen in conversation regarding her future and
that of her children. Karen indicated that this most recent episode of violence had frightened her
and caused her to question the wisdom of her decision to stay with her boyfriend. Her boyfriend
was found guilty of domestic abuse and was released after 2 months with a probation period of 2
years and mandatory anger management classes. She and her ex-husband are discussing child
care arrangements and the possibility of her moving closer to him where she should be able to
find work.

Community
The community health nurse arranged to speak at the monthly breakfast meeting of community
pastors where she presented an informational program on IPV. Within 3 weeks she received
speaking invitations from four of the nine churches represented at the meeting. The first of the
programs will take place in the next month. In two of the churches, “mother’s day out” (a partial
day of babysitting) services are available to church members, and after an appeal from the
community health nurse, one of the churches has expressed a willingness to open its program to
non–church members.

Evaluation
Individual and Community
You and the community health nurses jointly focused on safety as a priority of care for Karen.
The visit to the after-hours clinic and the medical personnel’s call to the police started the chain
of events. Karen’s injuries created an opportunity for the community health nurse to maintain
contact and provide psychosocial support. During visits the nurse was able to speak openly with
Karen and offer options to enhance her coping skills. One of the local pastors has encouraged
Karen to focus on both her children and her own future.
Karen came back into the clinic where you are working and seems healthier. She states that she
is going to move to the same area where her ex-husband is living and will be reconciled with her
children. Karen also says that her ex-husband agreed to help her find employment in the area.
Her boyfriend continues to fulfill the requirements of his probation, and he acknowledges that
this will be an ongoing recovery process.
Levels of Prevention
Primary
Goal: Promote safety and prevent violence.
 •Encourage contact with friends in the neighborhood and at church.
 •Provide services of the community health nurse.
 •Provide community education programs about anger management.
 •Provide community education programs about IPV.

Secondary
Goal: Assess for signs of IPV.
 •Facilitate health care for treatment of injuries.
 •Provide both physical and psychosocial support.
 •Provide referral for anger management.
 •Provide individual and family counseling.
 •Provide a 24-hour abuse hotline number.

Tertiary
Goal: Promote development of healthy family dynamics.
 •Encourage continued use of community resources.
 •Encourage community involvement with other young families.
 •Provide community education programs on the cycle of violence.

Learning Activities
 1. Investigate professional responsibilities relative to reporting abuse, neglect, or violence in
your state. Share findings with classmates.
 2. Using the telephone directory or computer search engine, find three public or private
agencies in the community that provide help for victims of violence. Make a list of the
telephone numbers and post copies of it in public areas.
 3. Call a child abuse center in the community and ask what services they provide.
 4. Call a battered women’s shelter and determine the procedure for securing shelter
placement for a battered victim and her children.
 5. Visit a respite center for the elderly and observe the clients and the activities that are
provided. Observe behaviors that would contribute to stress in the caregiver.
 6. Find out what support groups exist in the community for older adult caregivers.
 7. Read your local newspaper for 1 month and clip articles that deal with violence and gun
control. Determine how many individuals were killed or injured during that period. How
many of the deaths and injuries were gun related?
 8. Look up the laws that relate to reporting of child and elder abuse in your area.