Domestic Violence Reporting for Nurses
Spotting the warning signs
Nurses have a legal and ethical responsibility to report suspected cases of domestic violence. However, abuse can take many ugly forms, some of which are easier to spot than others. In this article, we’ll talk about the warning signs to help you better protect your patients.
Scope of the Problem
According to the Centers for Disease Control and Prevention (CDC), 24 people in the U.S. are victims of physical violence, rape or stalking every minute. That adds up to more than 12 million women and men each year. The most recent National Intimate Partner and Sexual Violence Survey found that:
◗ One in four women and one in seven men have experienced severe intimate partner violence (IPV). An intimate partner is a current or former spouse, boyfriend, girlfriend or partner.
◗ Women are disproportionately affected by sexual violence, IPV and stalking. Women are four times more likely than men to be beaten, six times more likely to be slammed against something and nine times more likely to be hurt by choking or suffocating.
◗ Eighty-one percent of the women who experienced rape, stalking or IPV reported significant short- or long-term effects such as post-traumatic stress disorder (PTSD).
Although some of these numbers have declined since 2000, domestic violence remains the leading cause of injury to women between the ages of 15 and 44 in the U.S. Younger women, particularly women with children under 18, are significantly more likely to become victims of domestic violence. The Bureau of Justice Statistics reports that women aged 18 to 24 and 25 to 34 experience the highest rates of IPV, with single women in homes with children under 18 experiencing it 10 times more frequently than in homes with married adults with children and six times more than single women with no children.
Studies suggest that the rates of IPV among LGBT people are similar or even higher than those among heterosexual people.
Common Warning Signs
Since it’s both our legal duty and our professional responsibility as patient advocates to report possible abuse, it’s important for nurses to know the signs — especially the subtler ones. Common indicators of IPV may include any or all of the following:
◗ Black eyes
◗ Bruises in various stages of healing, particularly on breasts or genitalia
◗ Symmetrical bruises on upper arms, wrist or neck
◗ “Bathing-suit pattern” marks that are covered by clothing
◗ Subdural hematomas
◗ Patches of missing hair
◗ Fractured mandibles
◗ Ruptured tympanic membranes
◗ Lacerations around the eyes and lips
◗ Rib fractures
◗ Unexplained venereal disease or genital infections
◗ Recurrent urinary tract infections
◗ Anal or genital bleeding or injury
◗ Marks consistent with the size of objects such as cigarettes or belts
◗ Signs of neglect, such as malnutrition, poor hygiene or skin ulcers
◗ Use of makeup or other methods to hide indicators
◗ Injuries not consistent with explanation of how they occurred.
Obviously, not all of these indicators are necessarily signs of domestic violence and some IPV victims may not present with any of these signs. Spotting domestic abuse often involves a combination of objective signs and subjective impressions, such as a patient who is strangely evasive about suspicious bruises.
You should make a point of routinely screening all patients using private, low-key questioning that’s incorporated into the rest of your exam. Victims of IPV may become very defensive when confronted about their situations, so don’t show any more emotion when asking these questions than you would about any other health issue. Maintaining a calm, even, nonjudgmental attitude will help to preserve the patient’s dignity and may encourage him or her to open up to you.
The above indicators are common signs of abuse among all victims, but certain populations are especially vulnerable. Next, we’ll take a look at who they are and the special signs for which you should be alert.
Child abuse creates universal heartbreak among our ranks. Abused kids need help, but unless there are clear-cut signs of physical violence (such as fractures, head trauma or soft tissue damage), it can be challenging to distinguish indicators of abuse from normal childhood activity, like falling from a bike.
One of the most common and deadly forms of child abuse is not physical violence, but neglect. According to data from the National Child Abuse and Neglect Data System, neglect was a contributing factor in more than 71 percent of child maltreatment fatalities in 2011.
Possible signs of child maltreatment may include:
◗ Developmental delays
◗ Speech disorders
◗ Failure to thrive
◗ Poor hygiene
◗ Inappropriate seasonal clothing
◗ Lack of supervision
◗ Unattended medical needs
◗ Chronic truancy
◗ History of psychological disorders.
Children and adolescents who are being sexually abused may also exhibit signs like stomach aches and abdominal pain, regressive bedwetting, repeated urinary tract and yeast infections and dramatic fluctuations in weight.
Teasing and bullying are often dismissed as kid stuff, but they can have severe consequences. Not only can “harmless” teasing escalate into greater violence, persistent bullying or emotional abuse can also push young victims to self-harm, like “cutting,” or even suicide. Worse, teenagers may have a hard time convincing adults that the problem is real until it’s too late.
While bullying should always be taken seriously, it’s of particular concern in the context of dating and relationships. In a nationwide CDC survey about dating abuse, 9.4 percent of high school students reported that they had been intentionally hit, slapped or physically hurt in the 12 months prior to the survey.
If a teen admits to being in a relationship with someone who shows signs of dominance, jealously and frequent bursts of anger or controlling behavior, your red flag should be flying at full mast.
Pregnancy is often the time when domestic violence begins. The CDC reports that IPV affects as many as 324,000 pregnant women each year, which makes prenatal visits an essential time for nurses to screen for abuse. Things to watch out for among the OB population include prenatal care that starts late in pregnancy, poor nutrition, pre-term labor and low birth weight infants.
While pregnant women and women with infant children are often the victims of IPV, don’t overlook the possibility of pregnant or new mothers abusing or neglecting their own children. Hormonal changes during and after pregnancy are certainly normal, but watch out for extremes of pregnancy-related or postpartum sadness, depression or anxiety, particularly if those extremes coincide with any of the indicators for child abuse or neglect.
Elder abuse is also common and often missed. In addition to the physical frailty that can make seniors vulnerable, dementia and other forms of cognitive impairment may limit a senior’s ability to report abuse. Furthermore, many seniors are dependent on their caregivers — even if those caregivers are abusive — and fear that complaining will make a bad situation even worse.
Such fears contribute to sad statistics: 72 percent of seniors who report to the ER for treatment of abuse symptoms won’t admit that abuse is occurring. That is particularly true of sexual abuse, which is the most underreported form of abuse suffered by individuals over 60.
Signs to watch for in senior patients include indicators of neglect or not having the basic necessities of life. Pay particular attention if patients express fears about feeling unsafe where they live. Also keep an eye on the behavior of caregivers. A caregiver who is uncooperative with healthcare providers and/or treats the senior poorly may indicate a bad situation.
Reporting Requirements in California
According to the California Board of Registered Nursing, nurses “must report known or observed instances of abuse to the appropriate authorities.” Your responsibility isn’t limited to your own patients, either. The BRN says the requirement “applies to those situations that occur in the RN’s professional capacity or within the scope of employment.” The board takes that responsibility very seriously and if you fail to report abuse, you could be subject to disciplinary action.
Although there are national guidelines regarding domestic violence and advocacy, each state’s reporting requirements are different. Futures Without Violence (www.futureswithoutviolence.org), a national advocacy group, has provided a reference guide entitled, “California’s Domestic Violence and Mandatory Reporting Law: Requirements for Health Care Practitioners,” which includes an overview of reporting guidelines and answers to frequently asked questions.
Like the rest of us, you’re a nurse because you want to advocate for your patients and make a difference. By picking up on the warning signs of domestic violence, you’ll be doing exactly that — and maybe saving a life while you’re at it.
California Domestic Violence Facts
◗ About 40 percent of California women experience intimate partner violence (IPV) in their lifetimes.
◗ Women aged 18–24 are at the highest risk.
◗ California women experience higher rates of IPV during pregnancy.
◗ Of the California women experiencing IPV, 75 percent have children under 18 at home.
◗ The California Student Survey reports that 5.2 percent of California 9th graders and 8.2 percent of 11th graders have experienced IPV.
◗ Rates of IPV among LGBT partners are estimated to be greater than or equal to the rates experienced among heterosexual partners.
Source: California Partnership to End Domestic Violence
California Domestic Violence Facts
CDC Injury and Prevention Control - Intimate Partner Violence – www.cdc.gov/violenceprevention/intimatepartnerviolence
Download “Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings”
Health Cares About IPV - Intimate Partner Violence Screening and Counseling Toolkit – www.healthcaresaboutipv.org
National Center on Domestic and Sexual Violence – www.ncdsv.org
Los Angeles LGBT Center – www.lalgbtcenter.org
The National Domestic Violence Hotline – www.thehotline.org
Elder Abuse, Attorney General of California – www.oag.ca.gov/bmfea/elder
Download “A Citizen’s Guide to Preventing & Reporting Elder Abuse”
Sue Montgomery, RN, BSN, CHPN, is a critical care and hospice nurse who writes on healthcare issues. She is a member of the Hospice and Palliative Nurses Association and American Medical Writers Association.
This article is from workingnurse.com.