Violence and Abuse

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Violence and Abuse
JCAHO Mandatory
Annual Competency
Chesapeake Medical Staffing

Content
Domestic Violence
Vulnerable Adult Abuse & Neglect
Child Abuse
Violence in the Workplace

Domestic Violence
Domestic violence is the use of physical abuse,
verbal or emotional abuse, sexual abuse, or
economic abuse (e.g. withholding money, lying
about assets) to exert power or control over
someone or to prevent someone from making a
free choice. Three-fourths of domestic violence
victims are women. Domestic violence is a major
public health problem in the United States and
around the world—even more prevalent than rape
or assault by strangers or acquaintances.

Prevalence
The CDC reports that domestic violence affects
more than 32 million Americans annually, causing
more than 2 million injuries and approximately
1300 deaths (CDC, 2005). Domestic violence
strikes all ages, cultural/ethnic/religious groups,
and social classes. Rape, incest, and dating
violence are all forms of domestic violence.

National Domestic
Violence Hotline
“We have to be very careful when citing
statistical reports that we don’t create the
perception that anyone actually has a handle on
the rate of domestic violence in America. The
truth is, domestic violence is rampant and
diverse, and it’s still something no one wants to
talk about.”
Sheryl Cates, Executive Director
National Domestic Violence Hotline

Categories of Sexual
Violence
Sexual violence can be categorized as:
• Use of physical force to compel a person to engage in
a sexual act against his or her will, even if the act is
not completed.
• Attempted or completed sex act involving a person
who is unable to understand the nature or condition of
the act, to decline participation, or to communicate
unwillingness to engage in the sexual act because of
illness, disability, or the influence of alcohol or other
drugs, or because of intimidation or pressure.
• Abusive sexual contact.

Threats
Threats of physical or sexual violence
may include the use of “words, gestures,
or weapons to communicate the intent to
cause death, disability, injury, or physical
harm.”

Psychological/Emotional
Violence
• Psychological/emotional violence “involves
trauma to the victim caused by acts, threats of
acts, or coercive tactics.”
• Psychological/emotional abuse can include, but
is not limited to, humiliation; controlling what
the victim can and cannot do; withholding
information; deliberately embarrassing the
victim; isolating the victim from family and
friends; and denying access to money or other
basic resources.

Intimate Partner Violence
• Intimate partner violence (IPV) is one of the
most common and least reported crimes
according to the National Violence Against
Women Survey (National Institute of
Justice, 2000).
• Risk of becoming a victim of IPV is highest
among American Indian and Alaskan Native
women and men, African American women,
Hispanic women, young women, and those
below the poverty line.

Stalking
Stalking generally refers to repeated
behavior, such as following someone,
that evokes a high level of fear in the
victim. Stalking is considered by
some states as a type of intimate
partner violence.

Shame and Fear
The shame and fear surrounding domestic
violence silences many victims. Research shows
that at least 4 out of 10 incidents of domestic
violence are not reported to the police (Durose et
al., 2005). Many abused women do not report IPV
(Intimate Partner Violence) to their physicians or
to anyone else.

Risk Factors for
Domestic Violence
• Poverty
• Family/Caregiver Stress
• Pregnancy
• Disability/Impairment

Screening
and Assessment
Every healthcare facility serving women, children, and
older adults needs to screen for potential domestic
violence. This screening need not be lengthy. The
screening can be part of the intake interview or
included as part of the written history. The nurse
admitting a patient to an inpatient unit, ER, L&D or
primary care visit is responsible for completing the
violence screening. A “yes” response is an automatic
referral to a social worker or social services.

Signs and Symptoms
Related to IPV(Intimate Partner Violence)
During the appointment, be aware of lack of eye contact
and/or a husband or boyfriend who is reluctant to leave the
woman alone with the healthcare provider. Suicide attempts
may be directly related to IPV (Intimate Partner Violence).
In addition, make note of:
• delay in seeking care after physical injury
• missed appointments
• vague or inconsistent explanation of injuries
• nonspecific somatic complaint
• depression and social isolation
• substance abuse
• use of alcohol or drugs

Documenting Suspected
Domestic Violence
Accurate, thorough documentation of the patient's
injuries is essential in cases of suspected abuse
because it can serve as objective, third-party
evidence useful in legal proceedings. For example,
medical records can help victims to obtain a
restraining order, or to qualify for public housing,
welfare, health and life insurance, and
immigration relief.

Phrases to Avoid
Health professionals should avoid any phrases
such as “patient claims” or “patient alleges” that
cast doubt on the patient's reliability. Also avoid
legal terms such as “alleged perpetrator” or
“assailant.” Do not use conclusive terms such as
“assault and battery” or “domestic violence” in
documenting a case; let the factual information in
the record speak for itself.

ABCDES Framework
A Assure the woman she is not alone. Isolation enforced by her abusive
partner prevents her understanding that others are in a similar situation
and that health care providers can help.
B Express the belief that violence against the woman is unacceptable in
any situation and that it is not her fault.
C Ensure confidentiality. She may fear (justifiably) that the abuser will
retaliate.
D Document the case thoroughly (see above).
E Educate the woman about the cycle of violence (Box 2), the likelihood
of repeated violence, and her options for ending the abuse.
S Safety. Help the woman formulate a plan of action for either leaving or
remaining in the relationship, which some women do for a variety of
reasons. Provide information about available resources such as hotline
and shelter numbers. Suggest that a quick getaway bag packed with
personal items be hidden or left with a neighbor.

Patient and Family
Interventions
Begin intervention by believing any woman
who admits being abused. She has shown
trust and courage to disclose the facts.
Skillful, nonjudgmental interviewing can
help build trust and establish a therapeutic
relationship. Patient safety, support and
education are professional responsibilities of
health care providers.

Healthcare Setting
"As the single most important and most accessed
institution in the lives of women, the healthcare
setting can provide a unique opportunity to
intervene, making it one of the newest and most
critical areas of the domestic
violence movement
today" (Family Violence
Prevention Fund, 2001).

Healthcare Implications
Domestic violence has an enormous impact on the
healthcare system. Homicide, injury, mental illness,
substance abuse, and the legacy of violence from
generation to generation may all be related to domestic
violence. Women are the most frequent consumers of
healthcare services and the most common victims of
domestic violence. This puts healthcare providers in the
best
position to identify victims of domestic violence and make
appropriate referrals to protect them against further harm.

Vulnerable Adult
Abuse or Neglect

Vulnerable Abuse
Abuse of the vulnerable elder has reached
epidemic proportions in the United States.
Elderly people may be more vulnerable to
abuse than others because of social
isolation and mental impairment.

Vulnerable Adult Abuse
ABUSE: the sustaining of physical injury
by a vulnerable adult as a result of cruel or
inhumane treatment or as a result of a
malicious act by any person.

Signs of Physical Abuse
• Multiple injuries
• Injuries that normally would not occur together
• Bruises, welts or abrasions
• The use of physical restraints, such as tying
• Burns that could come from cigarettes or
immersion to water that is too hot
• A caregiver's refusal to allow visitors to see the
person alone
• Lab findings indicating over-medication

Vulnerable Adult Neglect
NEGLECT: the willful deprivation of
adequate food, clothing, medical
treatment, or rehabilitation therapy,
shelter, or supervision from a vulnerable
adult.

Signs of Physical Neglect
• Dehydration
• Malnourishment without a cause related to
illness
• Failure to provide physical aids such as glasses,
hearing aids, or false teeth
• Pressure ulcers
• Lack of compliance with medical care
instructions

Signs of
Psychological Abuse
• Statements about a caretaker that indicate fear
• Threats or insults by caretaker
• Caretaker talks of person as a burden
• Person is withdrawn; gives short answers to questions,
averts gaze
• Person is not given opportunity to talk to others alone
• Caregiver leaves person alone for long periods of time
• Caregiver ignores person; gives "silent treatment"
• Person shows signs of infantile behavior; antisocial
behavior

Self Neglect
SELF-NEGLECT: the inability of a
vulnerable adult to provide for his/her
physical or mental health and well-being.

Exploitation
EXPLOITATION: any action which
involves the misuse of a vulnerable adult's
funds, property, or person.

Signs of Financial
Neglect or Exploitation
• Someone has the person's mail sent to their own address
• person is confused about his or her income and resources
• possessions and quality of life seems substandard given the
resources the person has
• frequent or large gifts to a caregiver
• frequent checks written to caregiver
• unusual activity in bank accounts
• personal belongings missing
• person signs as surety or co-signer on loans
• someone lives with the person and refuses to leave
• numerous unpaid bills despite adequate income
• other persons added to bank accounts

Maryland Adult
Protective Services
This program serves persons aged 18 or over who lack
the physical or mental capacity to provide for their
daily needs. The purpose of the program is to prevent
or remedy the abuse, neglect, self-neglect, or
exploitation of adults who are unable to protect their
own interests and are at risk of immediate harm to
their own person or to others. The program provides
professional services to protect the health, safety, and
welfare of endangered, vulnerable adults.

Reporting Adult Abuse
or Neglect
Under Section 14-309 of the Family Law Article, Annotated
Code of Maryland, any health practitioner, police officer,
or human service worker who has reason to believe that a
Vulnerable adult is in danger is required to report that
fact to the local department of social services. The law
states "any person who in good faith makes or participates
in making a report under this subtitle or participates in an
investigation or a judicial proceeding resulting from a report
under this subtitle is immune from any civil liability that
would otherwise result."

Toll Free Hot Line
to Report Adult Abuse
TOLL FREE ABUSE HOTLINE
1-800-91-PREVENT (1-800-917-7383)
OR YOUR LOCAL DEPARTMENT OF
SOCIAL SERVICES.

Child Abuse

Recognition
Child abuse is both shocking and commonplace. Child
abusers inflict physical, sexual, and emotional trauma
on defenseless children every day. The scars can be
deep and long-lasting. Unfortunately, the more subtle
forms of child abuse such as neglect and emotional
abuse can be even more traumatizing than violent
physical abuse. The first step in helping abused or
neglected children is learning to recognize the signs of
child abuse and neglect.

Difficult to Recognize
It's not always easy to recognize when a child has been
abused. Children who have been mistreated are often afraid
to tell anyone because they think they will be blamed or
that no one will believe them. Parents also tend to overlook
symptoms because they don't want to face the truth. This is
a serious mistake. A child who has been abused needs
special support and treatment as early as possible. The
longer he continues to be abused or is left to deal with the
situation on his own, the less likely he is to make a full
recovery.

CAPTA (Child Abuse Prevention & Treatment Act)
Child abuse and neglect are defined by both Federal and
State law. The Child Abuse Prevention and Treatment Act
(CAPTA) is the Federal legislation that provides minimum
standards for the definition of child abuse and neglect that
States must incorporate in their statutory definitions. Under
CAPTA, child abuse and neglect means, at a minimum, any
recent act or failure to act on the part of a parent or
caretaker, which results in death, serious physical or
emotional harm, sexual abuse, or exploitation, or an act or
failure to act which presents an imminent risk of serious
harm.

Definition of Child Abuse
Child abuse consists of any act, or failure
to act, that endangers a child's physical
or emotional health and development.
Someone is abusive if he or she fails to
nurture the child, physically injures the
child, or relates sexually to the child.

Types of Child Abuse
The four major types of child abuse are:
• physical abuse
• sexual abuse
• emotional abuse
• neglect

Physical Indicators
of Child Abuse
• Any injury (bruise, burn, fracture, abdominal or
head injury) that cannot be explained
• Multiple injuries (in various stages of healing)
• Unexplained injuries (especially located in parts
of the body not usually affected by normal
childhood activity (i.e. eyes, mouth, neck,
cheeks, lower back, genital area, buttocks,
abdomen)

Signs of Sexual Abuse
• Fearful behavior (nightmares, depression,
unusual fears, attempts to run away)
• Abdominal pain, bedwetting, urinary tract
infection, genital pain or bleeding, sexually
transmitted disease
• Extreme sexual behavior that seems
inappropriate for the child's age

Signs of Emotional Abuse
• Sudden change in self-confidence
• Headaches or stomachaches with no
medical cause
• Abnormal fears, increased nightmares
• Attempts to run away

Signs of
Emotional Neglect
• Failure to gain weight (especially in infants)
• Desperately affectionate behavior
• Voracious appetite and stealing of food

Long-Term Consequences
of Abuse and Neglect
In most cases, children who are abused or
neglected suffer greater emotional than physical
damage. A child who is severely mistreated may
become depressed or develop suicidal, withdrawn
or violent behavior. As the child gets older,
he/she may use drugs or alcohol, try to run away,
refuse discipline or abuse others. As an adult,
he/she may develop marital and sexual
difficulties, depression or suicidal behavior.

Reporting Suspected
Child Abuse or Neglect
CODE OF MARYLAND REGULATIONS, Section
07.02.07 requires reporting child abuse or neglect
in the following manner:
An individual shall immediately report suspected child
abuse or neglect to the local department of social services,
or report the suspected incident to a local law enforcement
agency. Reports of abuse shall be made to the local
departments of social services or the appropriate law
enforcement agency. Reports of neglect shall be made to
local departments of social services.

It’s the Law
Health practitioners, educators, human service
workers, and police officers are required to
report, both orally and in writing, any
suspected child abuse or neglect, with oral
report being made immediately and the
written report being made within 48 hours of
the contact which disclosed the suspected abuse
or neglect.

Violence : An
Occupational Hazard
Today more than 5 million U.S. hospital workers from many
occupations perform a wide variety of duties. They are exposed
to many safety and health hazards, including violence. Recent
data indicate that hospital workers are at high risk for
experiencing violence in the workplace. Several studies indicate
that violence often takes place during times of high activity and
interaction with patients, such as at meal times and during
visiting hours and patient transportation. Assaults may occur
when service is denied, when a patient is involuntarily
admitted, or when a health care worker attempts to set limits
on eating, drinking, or tobacco or alcohol use.

What is workplace
violence?
Workplace violence ranges from offensive
or threatening language to homicide. NIOSH
(National Institute for Occupational Safety
and
Health) defines workplace violence as violent
acts (including physical assaults and threats
of assaults) directed toward persons at work
or on duty.

Examples of Violence
• Threats: expressions of intent to cause harm,
including verbal threats, threatening body
language, and written threats.
• Physical assaults: attacks ranging from
slapping and beating to rape, homicide, and the
use of weapons such as firearms, bombs, or
knives.
• Muggings: aggravated assaults, usually
conducted by surprise and with intent to rob.

High Risk Units
Violence may occur anywhere in the
hospital, but it is most frequent in the
following areas:
• Psychiatric units
• Emergency departments
• Waiting rooms
• Geriatric units

Risk Factors
• Working directly with volatile people, especially, if they
are under the influence of drugs or alcohol or have a
history of violence or certain psychotic diagnoses
• Working when understaffed-especially during meal times
and visiting hours
• Transporting patients
• Long waits for service
• Overcrowded, uncomfortable waiting rooms
• Working alone
• Poor environmental design

Risk Factors (cont)
• Inadequate security
• Lack of staff training and policies for preventing and
managing crises with potentially volatile patients
• Drug and alcohol abuse
• Access to firearms
• Unrestricted movement of the public
• Poorly lit corridors, rooms, parking lots, and other areas

Prevention Strategies for
Employers
To prevent violence in hospitals, employers should
develop a safety and health program that includes
management commitment, employee participation,
hazard identification, safety and health training, and
hazard prevention, control, and reporting. Employers
should evaluate this program periodically. Although
risk factors for violence are specific for each hospital
and its work scenarios, employers can follow general
prevention strategies.

Safety Tips for Hospital
Workers
Watch for signals that may be associated
with impending violence:
• verbally expressed anger and frustration
• body language such as threatening gestures
• signs of drug or alcohol use
• presence of a weapon

Maintain Behavior That
Helps Diffuse Anger
• Present a calm, caring attitude.
• Don't match the threats.
• Don't give orders.
• Acknowledge the person's feelings (for example, "I know
you are frustrated").
• Avoid any behavior that may be interpreted as aggressive
(for example, moving rapidly, getting too close, touching,
or speaking loudly).

Be Alert
• Evaluate each situation for potential violence when you
enter a room or begin to relate to a patient or visitor.
• Be vigilant throughout the encounter.
• Don't isolate yourself with a potentially violent person.
• Always keep an open path for exiting-don't let the
potentially violent person stand between you and the
door.

Steps to Defuse An
Escalating Situation
• Remove yourself from the situation.
• Call security for help.
• Report any violent incidents to your management.

Workplace Violence
Prevention
All hospitals should develop a comprehensive violence
prevention program. No universal strategy exists to
prevent violence. The risk factors vary from hospital to
hospital and from unit to unit. All healthcare workers
should be alert and cautious when interacting with
patients and visitors. You should actively participate in
safety training programs and be familiar with the
hospital policies, procedures, and materials on
violence prevention.

Summary: You Must
Report Abuse or Neglect
All health care providers are obligated by Maryland
law to report cases of suspected child abuse or
vulnerable adult abuse or neglect to either the police or
local social service agencies.

Healthcare Workers Can
Make a Difference
Healthy People 2010 named injury and violence
as one of the ten leading health indicators that
will be used to measure the health of the United
States during the first ten years of the twenty-
first century. Health professionals can make a
critical difference in the progress toward ending
this costly, destructive epidemic and halting the
transmission of violence from generation to
generation.

Violence and Abuse

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