Module 7-Abuse and Violence

Rape and Sexual Assault, pg. 196

Perpetration of act of sexual intercourse with person against his or her will and without consent Victim may be overcome by force, fear of force, drugs, intoxicants Crime of violence and humiliation of victim expressed through sexual means Also considered rape if victim cannot exercise rational judgment Only slight penetration necessary Committed by strangers (~28% of rapes), acquaintances, married people, people of same sex Date rape (acquaintance rape) Highly underreported crime Most commonly occurs in victim's neighborhood, often inside or near home Most rapes are premeditated. Male rape is significantly underacknowledged and underreported.

Aggression

Physical attack or injury to another person or destruction of property. Meant to harm or punish another person or force into compliance

Managing the environment

Planned activities Scheduling one-to-one interactions Offer opportunity for problem-solving or conflict resolution Consider safety of other patients (and Yourself!)

Related Disorders:

Possible causes or contributors to Anger Paranoid delusions Auditory hallucinations Dementia, delirium, head injuries Intoxication with alcohol or other drugs Antisocial, borderline personality disorders Depression Intermittent explosive disorder (IED) Acting out

Neurobiologic theories

Possible role of neurotransmitters: decreased serotonin; increased dopamine and norepinephrine Structural damage to limbic system Damage to frontal or temporal lobes

Intimate Partner Violence

Psychological abuse (emotional abuse) can be overt or subtle. Physical abuse: shoving, pushing, battering, choking Sexual: assaults during sexual relations, rape Rates higher among women Increased rates during pregnancy Domestic violence occurs in same-sex relationships with same statistical frequency. o Victims have fewer protections.

Intimate Partner Violence, pg. 188 - Mistreatment or misuse of one person by another in context of emotionally intimate relationship

Psychological abuse (emotional abuse) can be overt or subtle. Physical abuse: shoving, pushing, battering, choking Sexual: assaults during sexual relations, rape Rates higher among women Increased rates during pregnancy Domestic violence occurs in same-sex relationships with same statistical frequency. o Victims have fewer protections. Clinical picture Abuse often perpetrated by husband against wife Abuser's view of wife as belonging to him; strong feelings of inadequacy, low self-esteem; poor problem-solving and social skills Increasing violence, abuse with any signs of independence Dependency trait most commonly found in abused women who stay with their husbands

Health Care Legal Responsibility for Reporting - All 50 states have marital rape statutes

RNs Legally mandated to report suspected or actual abuse to appropriate agencies: State or county child welfare agency Law enforcement agency Juvenile court County health department MUST BE REPORTED immediately, within 24 or 48 hours. (Depends on agency requirements) Every abused patient is a crime victim Assault with a weapon is reportable in most states

Management of aggressive behavior: postcrisis phase

Remove patient from restraint or seclusion as soon as criteria met Calmly discuss behavior (no lecturing or chastising) Give client feedback for regaining control Reintegrate client as soon as he or she is able to participate

Perpetrator Characteristics

Rooted in childhood; lacked good role model History of witnessed or experiencing family violence, neglect, or abusive parents History of prior abusive behavior Lack of self - regard, dissatisfaction with life, inability to assume adult roles Unable to problem-solve or poor problem-solving skills Men believes in male supremacy - Acting out physically makes them feel in control Extreme jealousy, possessive Lack of parenting skills - perceives child is bad Feelings of worthlessness, poor impulse control

Management of aggressive behavior: recovery phase

Talk about situation or trigger Help client relax or sleep Help client explore alternatives to aggressive behavior Assess and document any injuries Debrief staff Encourage other clients to talk about feelings - Do not discuss aggressive client with other clients

Child Abuse - Treatment and intervention

Therapy may be required for significant period. Child's safety and well-being is a priority. Psychiatric evaluation Approach depends on the age of a child. Social services involvement Family therapy/requirements for parents

* * * * Five-Phase Aggression Cycle pg. 180 * * * *

Triggering An event or circumstances in the environment initiates the client's response, which is often anger or hostility. Restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, anger Escalation The client's responses represent escalating behaviors that indicate movement toward a loss of control. Pale or flushed face, yelling, swearing, agitation, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly Crisis During an emotional and physical crisis, the client loses control. Loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting, scratching, shrieking, screaming, inability to communicate clearly Recovery The client regains physical and emotional control. Lowering of voice; decreased muscle tension; clearer, more rational communication; physical relaxation Postcrisis The client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents. Remorse; apologies; crying; quiet, withdrawn behavior

IPV (Intimate Partner Violence) Assessment

Victims do not commonly seek direct help for abuse. (Some may be seeking treatment for other conditions). o Ask all clients if they feel safe o Ask questions about safety (see Box 12.2) Treatment and interventions Laws related to domestic violence, arrest Restraining order/protection order Recognition of stalking Shelters Individual psychotherapy/counseling, group therapy, support and self-help groups Treatment for PTSD

Cycle of Abuse and Violence

Violent episode → honeymoon period → tension-building phase → violent episode Tension building phase Abuser - Edgy, has minor explosion, may become verbally abusive, minor hitting, slapping and other incidents begin Victim - Feels tension and afraid, "Walking on eggshells", Feels helpless, becomes compliant and accepts blame Acute battering phase Abuser - Batters victim (physical or sexual abuse, hostile behaviors) Victim - Tension becomes unbearable. The victim may provoke the incident to get it over with. May try to cover up injuries

Older Adults

Vulnerable due to poor mental and physical health

Predisposing Factors for Victim

Women o Pregnancy o Wife becoming more independent o Attempt to leave the relationship o Low self-esteem, and feeling of hopelessness, powerlessness, guilt, and shame Children o Children most often abused are younger than 3-years-old o Congenital abnormalities or chronic disease, premature or prolonged illness o Unwanted pregnancy o Interferes with emotional boundaries between parents and child Older Adults - Vulnerable due to poor mental and physical health

Do

o Be direct, honest, and professional o Use language the patient understands (culture, level of education) o Ask for clarification if needed o Be attentive o Inform if going to make a report. o Assess for safety and help reduce danger (at discharge)

Children

o Children most often abused are younger than 3-years-old o Congenital abnormalities or chronic disease, premature or prolonged illness o Unwanted pregnancy o Interferes with emotional boundaries between parents and child

Do Not

o Do not accuse or demand o Do not display, horror, anger, shock, or disapproval or the perpetrator or situation o Do not allow the person to feel at fault or in trouble o Do not probe or press for answers o Do not conduct the interview with a group of interviewers o Do not remove clothing (Should be done by trained forensic RN following strict Rape Protocols and evidence collection procedures).

Women

o Pregnancy o Wife becoming more independent o Attempt to leave the relationship o Low self-esteem, and feeling of hopelessness, powerlessness, guilt, and shame

Management of aggressive behavior: crisis phase

o Take charge of situation for safety o Restraint Only staff with training should participate in restraint. Four to six trained staff members are needed. Inform client that behavior is out of control and staff is taking measures for safety.

Managing aggressive behavior: escalation phase

o Take control o Provide directions in a firm, calm voice o Direct client to time-out in quiet room or area o Communicate that aggressive behavior is not acceptable o Offer medication if refused in triggering phase o Show of force

Psychopharmacological Treatments

to treat underlying/comorbid psychiatric diagnosis Lithium: bipolar disorder, conduct disorders, intellectual disability Carbamazepine or valproate: dementia, psychosis, personality disorders Atypical antipsychotics: dementia, brain injury, intellectual disability, personality disorders Benzodiazepines: dementia Haloperidol and lorazepam: decrease agitation or aggression and psychotic symptoms

Hostility

verbal aggression Expressed through verbal abuse, lack of cooperation, violation of rules or norms, threatening behavior May be expressed when a person feels threatened or powerless

NURSING INTERVENTIONS for managing aggression

- Nurse - patient relationship (trust and rapport) - Use calm reassuring approach Limit access to frustrating situation - Encourage patient to seek out staff to help with difficult situations Use of seclusion or restraint - Use of de-escalation techniques - Teach coping skills - Offer PRN medications

Some PREDICTORS of potential violence

-Hyperactivity -Increasing anxiety and tension Verbal abuse Recent acts of violence Stone silence Isolation that is new Alcohol and drug intoxication Possession of a weapon Loud Diagnosis (paranoid, ODD, delusions etc.) History of limited coping skill Setting limits by the RN puts the nurse at risk

Five-Phase Aggression Cycle

-Triggering -Escalation -Crisis -Recovery -Postcrisis

A 10-year-old boy tearfully confides to the school nurse that his uncle has been sexually abusing him for the past 6 months. Which statement by the nurse is BEST? 1. "Your secret is safe with me. I won't tell anyone until you're ready." 2. "How could your parents not see that this was happening to you?" 3. "It takes a lot of courage to share this information." 4. "Would you like me to call the police to report this?"

1. By telling, child is hoping that the nurse will help; nurse needs to use vertical chain of command and report suspected abuse 2. Criticizing the family or expressing shock is non-therapeutic; may frighten child or make him feel guilty. 3. CORRECT: Important to reassure the child that he has done the right thing by telling an adult; establish a trusting relationship, use empathy, warmth, compassion, active support 4. Nurse has a duty to report. Nurse should not ask the child if it is "OK" for the nurse to call the police.

An angry client tells the nurse that another client is "a jerk and will be sorry for disrespecting me." Which response, if made by the nurse, is BEST? 1. "You sound angry. Please sit down and tell me what happened." 2. "The staff will keep that client away from you at all times." 3. "You're both adults. You need to work out these differences yourselves." 4. "The staff will have to observe the situation for a while to see who is responsible."

1. CORRECT: Acknowledges the anger and gives client time to describe the situation and his/her feelings; allows client to vent and can diffuse some of the emotion; assault cycle includes triggering phase, escalation, crisis phase, recovery, post-crisis depression

Despite repeated interventions in the psychiatric unit, a new client's behavior escalates to verbal abuse. The new client begins to physically threaten other clients in the recreation room. Which action by the nurse is BEST?

1. Call the client's family to the hospital. 2. Explore the cause of the client's anger with the other clients. 3. Put the client in a quiet room. 4. Inform the other clients that they must leave the recreation room.

Rape Trauma Nursing interventions

1. Provide support and stay with the patient. (Do not leave the patient alone at any time. May need to assess for self-harm potential and suicide ideation). 2. Explain legal process available and obtain informed consent to collect data that can be used as legal evidence such as photos and pelvic exam results. The rape survivor has the right to refuse either medical exam/treatment and/or legal exam to collect evidence. 3. Implement crisis intervention counseling (involve hospital social worker if available). 4. Determine physical condition of patient (bruising, cuts, etc.) and provide treatment for injuries. DO NOT remove clothing without following evidence-collection protocols. DO NOT allow the patient to eat or drink anything until they have been assessed (may need to do oral swabs for semen). 5. Documentation is important for the victim - Document patient statements verbatim. Chart findings as observed (measurement and depth of wounds; vaginal, rectal, oral exudate; presence of foreign body, etc.) but do not make suppositions, i.e., "appears to be a burn mark made by a cigarette." Instead chart, "3 mm diameter, circular burn marks." 6. Encourage patient to talk about the incident and express emotions, but do not press for information and DO NOT ask "Why" questions. Provide empathetic, objective, and nonjudgmental care. Use therapeutic techniques of reflection, open-ended questions and active listening. Let the patient know that sexual assault is not their fault. 7. Follow hospital protocol for rape trauma (contact a trained nurse examiner/forensic nurse to do physical assessment and obtain evidence). If Forensics RN is not available, contact hospital supervisor; to determine facility policies; use "Rape Kit" and Rape Protocols to collect evidence. Write excellent notes to remind yourself of all the details in the event you are called upon to testify in court. 8. Assess available support system and offer to call a support person for the patient. Identify community support and refer to rape advocacy programs. 9. Ensure prophylactic medication for prevention of sexually transmitted infections and medication to prevent pregnancy have been offered. 10. Provide patient-teaching so the rape-survivor will know what to expect in both the ACUTE PHASE and LONG-TERM PHASE of Rape-Trauma Syndrome.

Based on your reading about workplace hostility, which of the following are acceptable responses when interpreting JCAHO standards in regard to maintaining a culture of safety in the workplace: (Select all that Apply)

A. "I have been taking care of Mrs. Ross every shift for a week. Someone else will have to take care of her." B. "I feel upset when you yell at me like that." C. "Don't page me again, I am very busy." D. "I would like to request a different assignment today." E. "Everyone is fed up with you always showing up late for work."

Clinical picture

Abuse often perpetrated by husband against wife Abuser's view of wife as belonging to him; strong feelings of inadequacy, low self-esteem; poor problem-solving and social skills Increasing violence, abuse with any signs of independence Dependency trait most commonly found in abused women who stay with their husbands

Clinical Picture of Abuse and Violence

Abuse: wrongful use and maltreatment of another Perpetrator typically someone the person knows Victims across life span: spouses, partners, children, elderly parents Types of injuries Physical -Psychological -Sexual -Emotional -Neglect -Economic -

Acute battering phase

Abuser - Batters victim (physical or sexual abuse, hostile behaviors) Victim - Tension becomes unbearable. The victim may provoke the incident to get it over with. May try to cover up injuries

Tension building phase

Abuser - Edgy, has minor explosion, may become verbally abusive, minor hitting, slapping and other incidents begin Victim - Feels tension and afraid, "Walking on eggshells", Feels helpless, becomes compliant and accepts blame

"Honeymoon phase"

Abuser - Loving behavior, gives gifts and doing something special for the victim. Contrite, sorry, makes promises to change Victim - Trusting, hoping for change, wants to believe change will occur

Rape Trauma Syndrome - variation of PTSD (2 phases)

Acute phase Long - Term Reorganization Phase

Nursing Assessment of Sexual Assault

All patients should be assessed for abuse Complaints may be vague and include pain, insomnia, hyperventilation or gynecological problems. Assessment must be completed with victim alone. Interview with a calm, tactful, understanding, and relaxed attitude. When interviewing sit near the patent (keep in mind potential gender issues) Focus on the Nurse - Patient relationship

Managing aggressive behavior: triggering phase

Approach in a nonthreatening, calm manner Convey empathy Encourage verbal expression of angry feelings Use clear, simple, short statements Allow client time for self-expression Suggest client go to a quieter area Offer PRN medications if ordered Suggest physical activity, such as walking

Rape and Sexual Assault

Assessmento Physical examination to preserve evidence o Description of what happened o Rape kits, rape protocols Treatment and intervention o Immediate support o Education (see Box 12.6) o Give control back to victim o Prophylactic treatment for STIs, pregnancy o Counseling o Supportive therapy

The Nursing Process: Assessment

Be aware of factors influencing aggression in psychiatric environment/unit milieu Individual clients History of violent or aggressive behavior in the past How client handles anger Beliefs about anger Assess behavior to determine phase of aggression cycle (see Table 11.1, next page)

Acute phase

Begins immediately after assault, lasts for 2-3 weeks Usually seen in ED by an RN more at this stage The person may appear self-contained/calm however they are dealing with shock, emotional numbness, and disbelief Cognitive functioning may be impaired The person may be crying, hysterical, restless or even smiling Physically may be sore with bruises on breast, throat or back, vaginal trauma may have occurred. May be embarrassed and feel shame, guilt or anger May have the inability to discuss the event

True or false? It is considered unprofessional to assume a client with a history of violent or aggressive behavior is more likely to exhibit similar behavior in the future

FALSE - A history of violent or aggressive behavior is one of the best predictors of future aggression.

Psychosocial theories

Failure to develop impulse control Inconsistent responses to children's behaviors Interpersonal rejection

Characteristics of Violent Families

Family violence: spouse battering; neglect and physical, emotional, or sexual abuse of children; elder abuse; marital rape Common characteristics Social isolation Abuse of power and control Alcohol and other drug abuse Intergenerational transmission process

Dynamics of rape

Generally accepted that rape is not sexual crime Exertion of power, control, infliction of pain or punishment. Feminist theory: women historically objects for aggression. Primary motivation of victim is to stay alive. Severe physical and psychological trauma Treatment has improved, but many still believe a woman provokes rape with behavior. Common myths (see Box 12.5)

Hostility and Aggression

Hostility = verbal aggression Expressed through verbal abuse, lack of cooperation, violation of rules or norms, threatening behavior May be expressed when a person feels threatened or powerless Aggression = Physical attack or injury to another person or destruction of property. Meant to harm or punish another person or force into compliance Sudden, unexpected. Identifiable stages in the Aggression cycle (See Cycle of Aggression section).

Assessment indicators

Infant - Shaken baby syndrome - assess for respiratory distress, bulging fontanels and retinal hemorrhages. Child / Adolescent o Assess for unusual bruising on abdomen, back or buttocks - Bruising on hands and arms are common o Assess for mechanics of injury Bruises in different stages of healing Be suspicious of bruises that are in shape of belt buckle or other objects including hand; finger bruise marks; circumferential bruises around arms, legs (shaking or squeezing child). o Assess for burns - burns covering glove or stocking areas can indicate submersion in hot water. Round burns can indicate cigarette burns o Assess for fractures with unusual features. Spiral fractures o Assess for human bite marks o Assess for head injuries - LOC, equal and reactive pupils and nausea and vomiting

Child Abuse

Intentional injury of a child 1. Physical abuse or injuries 2. Neglect or failure to prevent harm 3. Failure to provide adequate physical or emotional care or supervision 4. Abandonment 5. Sexual assault or intrusion 6. Overt torture or maiming Clinical picture of parents Minimal parenting knowledge and skills Emotionally immature, needy, incapable of meeting own needs Frequently view children as property Cycle of family violence: adults raising children in same way they were raised Adults who were victims of abuse frequently abuse their own children. Detection and accurate identification are the first steps (see Box 12.3). Nurses have a DUTY TO REPORT suspected child abuse - Nurse does not have to decide for certainty if abuse occurred.

Long - Term Reorganization Phase

Intrusive thoughts - Flashbacks, dreams with violent content, insomnia Increased activity - Includes moving, changing telephone numbers, frequent visits to old friends due to fear that the assailant will return Increased emotional lability o Intense anxiety, mood swings, crying spells, and depression o Fears and phobias develop as a defensive reaction Fear of outdoor or indoor depending on where the rape occurred Fear of being alone Fear of crowds Fear of sexual encounters and activities

Elder Abuse

Maltreatment of older adults o Physical, sexual, psychological abuse o Neglect of self-neglect o Financial exploitation o Denial of adequate medical treatment Estimated 10% of population over age 65 abused by caregivers. 60% to 65% of victims are women. People who abuse elders almost always in caretaker role or elders depend on them in some way. Most cases when one older spouse is taking care of another Bullying between residents in senior living facilities Elders often reluctant to report abuse o Want to protect family members o Fear losing support Clinical picture: variable depending on the type of abuse Assessment (possible indicators, see Box 12.4) Assess for any bruises, laceration, abrasion, or fractures that do not match description of injury Treatment and intervention o Caregiver stress relief o Additional resources o Possible removal of elder or caregiver

Interventions: 5-Phases Aggression Cycle - Most effective and least restrictive when implemented early in the aggression cycle:

Managing the environment Managing aggressive behavior: triggering phase Managing aggressive behavior: escalation phase Management of aggressive behavior: crisis phase Management of aggressive behavior: recovery phase Management of aggressive behavior: postcrisis phase

Etiology of Hostility and Aggression

Neurobiologic theories Possible role of neurotransmitters: decreased serotonin; increased dopamine and norepinephrine Structural damage to limbic system Damage to frontal or temporal lobes Psychosocial theories Failure to develop impulse control Inconsistent responses to children's behaviors Interpersonal rejection

Anger

Normal human emotion Results when a person is frustrated, hurt, or afraid Handled appropriately, a positive force for resolving conflicts, solving problems, making decisions Body physically energized for self-defense ("fight-or-flight" response) Inappropriate expression or suppression: negative force Physical or emotional problems Interference with relationships

Workplace Violence

Overt actions: verbal outbursts, physical threats Passive activities: refusing to perform assigned tasks, uncooperative attitude Occurrence of disruptive and intimidating behaviors In 2016, the JCAHO added workplace bullying (lateral violence).