TERMINOLOGY AND KEY CONCEPTS

Both women and men can experience family violence but statistics and research overwhelmingly show that most incidents of family violence are perpetrated by men against women and children (National Council to Reduce Violence against Women and their Children, 2009). The following key definitions are adapted from the National Council to Reduce Violence against Women and their Children.

FAMILY VIOLENCE DEFINED

‘Family violence’ refers to violence against a person perpetrated by a family member, who may be an intimate partner, parent, sibling or an adolescent. This includes the violence of an adolescent or adult child towards their parent. Family violence is also sometimes referred to as domestic violence although this term is predominantly used to describe the abuse of a person, most often a woman, by her male intimate partner; it can also be violence perpetrated within intimate same-sex relationships. The term ‘family violence’ is preferred over ‘domestic violence’ to capture how violence may be perpetrated by a range of people in intimate, family and other relationships of mutual obligation; and how the effects reverberate throughout the entire family (Keel, 2004).

Family violence is an ongoing pattern of behaviour aimed at controlling another person, for example by using behaviour which is violent and threatening. In most cases, the violent behaviour is part of a range of tactics to exercise power and control over women and children (Department for Planning and Community Development, 2007). There is a range of behaviours associated with family violence (see Table 5.1).

TABLE 5.1 Behaviours associated with family violence

Source: Flinders Institute for Housing, Urban and Regional Research: Women, Domestic and Family Violence and Homelessness: A Synthesis Report, Report prepared for the Office for Women, Department of Families, Housing, Community Services and Indigenous Affairs, 2008.

INTIMATE PARTNER VIOLENCE DEFINED

Intimate partner violence is defined as any behaviour within an intimate relationship that causes physical, psychological or sexual harm. This includes:

The lifetime prevalence of violent acts within intimate relationships is comparable for women and men, but repeated coercive, sexual or severe physical violence is perpetrated largely against women by men (Tjaden and Thoennes, 2000). Intimate partner violence also occurs in same-sex relationships but much of the research to date has focused on heterosexual relationships.

CHILD ABUSE AND NEGLECT DEFINED

‘Child abuse and neglect occurs when a person having the care of a child inflicts, or allows to be inflicted, on the child a physical injury or deprivation which may create a substantial risk of death, disfigurement or the impairment of either physical health and development or emotional health and development. Child abuse or neglect also occurs when a person having care of a child creates, or allows to be created, a substantial risk of injury other than by accidental means; this includes sexual abuse and exploitation of a child’ (Angus, Wilkinson and Zabar, 1994:28). For categories of child abuse see Table 5.2. All states and territories in Australia have legislation to protect children from abuse and neglect and it is mandatory for nurses to report suspected child abuse to the appropriate authorities. However, legislative definitions of abuse or what constitutes abuse or maltreatment differ from state to state. Nurses are advised to familiarise themselves with the legislation in their state (Forrester and Griffiths, 2010). It is not currently mandatory to report child abuse in New Zealand, but best practice staff who suspect child abuse report it to appropriate authorities such as the police or a child, youth or family service (Ministry of Health New Zealand, 2008).

TABLE 5.2 Categories of child abuse

Source: Taylor P, Moore P, Pezzullo L et al: The cost of child abuse in Australia, Melbourne, 2008, Australian Childhood Foundation and Child Abuse Prevention Research Australia.

ELDER ABUSE AND NEGLECT DEFINED

Prevalence of elder abuse has been reported at 5–6% (Cooper, Selwood and Livingston, 2008), yet it remains largely invisible. The most common type of elder abuse is financial abuse, and women are twice as likely to be abused as men (McFerran, 2009). The term financial abuse is used when the family member (or carer) deprives the older person of sufficient financial resources to fulfil their basic needs (Federation of Community Legal Centres, Victoria, 2011). Elder abuse is a serious and complex problem that affects many vulnerable older people and may occur in different settings including the privacy of the person’s home, residential care or hospital. Abuse of older people is defined as any single or repeated act, or lack of appropriate action, which causes harm or distress to an older person that occurs within a relationship where there is an implication of trust (e.g. by family, carers and friends) (Australian Capital Territory, 2006; Glasgow and Fanslow, 2006; WHO/INPEA, 2002). This definition includes elder neglect. Elder neglect may be intentional (active neglect) or unintentional (passive neglect) caused by a carer’s own condition or inadequate knowledge (Glasgow and Fanslow, 2006). Neglect occurs when another person fails to meet the physical and emotional needs of an older person (Glasgow and Fanslow, 2006). Similarly to other forms of abuse, elder abuse is a universal problem not limited to any one gender, religious, cultural, ethnic or social economic group (Glasgow and Fanslow, 2006). Abuse can include physical, psychological/emotional, sexual, financial/material and social abuse and/or neglect (see Table 5.3). Another area of abuse that has also been identified is the abuse of power of attorney. This type of abuse occurs when a person given enduring power of attorney fails to operate in the best interests of an older person (Glasgow and Fanslow, 2006; Age Concern New Zealand, 2004).

TABLE 5.3 Definitions of elder abuse

Source: Glasgow K, Fanslow JL: Family violence intervention guidelines: Elder abuse and neglect. Wellington, 2006, Ministry of Health.

HEALTH EFFECTS OF FAMILY VIOLENCE

ASSESSING FOR FAMILY VIOLENCE

In Australia the National Council to Reduce Violence against Women and their Children (2009) advocates a policy of ‘the first door must be the right door’; that is, the first point of contact women have with health professionals should be supportive of disclosure about abuse and have the capacity to respond in an appropriate and timely manner. In many instances it will be nurses who are the first point of contact. Women should be able to expect professional and compassionate care from nurses and that the complexity of their needs regarding abusive situations will be taken into account. Even if a woman chooses not to follow up with referral or take any other action at that first point of contact, if she has received a sensitive and appropriate response it is more likely she will seek assistance at a later stage.

Nurses have an important role in identifying and responding to people who are victims of family violence. Nurses work closely with women, their children and families and they often come into contact with families at a time of crisis when family members may be seeking support and reassurance (Department of Human Services, Victoria, 2001). This places nurses in an ideal position to provide support and facilitate access to appropriate and timely assistance, while respecting their privacy (Australian Nursing Federation, 2006) and right to make their own decisions. Screening for family violence as part of routine assessment and care can assist in the identification of women and children at risk; however, any assessment must be done within a context of effective systems of support, with the capacity to protect family members following disclosure. There is increasing support for routine screening of all women presenting to health services. However, the efficacy of this practice remains contentious, particularly if healthcare providers do not fully appreciate the complexities of family violence and consequences of disclosure for women and their children or their responsibilities as healthcare providers. The majority of both women who have been abused and those who have not say they are in favour of routine screening, believing it would assist women to get help (Gielen, O’campo, Campbell et al, 2000; Glass, Dearwater and Campbell, 2001).

In New Zealand, the Standards Council (2006) proposed a three-step approach to screening and assessment for family violence: screening, risk assessment and safety planning and intervention. The first step is screening, which involves the systematic application of inquiry about women’s personal history with family violence to identify persons at risk and opportunities for intervention. Second, risk assessment is the process of undertaking a more thorough examination of circumstances, family relationships and family member interactions to determine the risk to the individual and other family members. Finally, safety planning is the process for identifying and planning to minimise harm and maximise safety (Standards Council, 2006). Screening should therefore be followed by risk assessment and safety planning if screening is to be effective in preventing harm and breaking the cycle of family violence. Before asking questions about family violence, nurses should be aware of the complexities of family violence, implications of asking questions about family violence and women’s disclosure. While the gender of the nurse does not necessarily affect disclosure, nurses should be sensitive to the possibility that the person may have a preference about the gender of the nurse they would feel comfortable with in disclosing information about abuse. Nurses should also have a good understanding of resources to assist a person experiencing violence and potential referral options and should also ask if the person has a gender preference of the practitioner to whom they are being referred (see Table 5.5 and Box 5.1).

TABLE 5.5 Approaches to assessment and disclosure about abuse

Source: Hegarty K, Taft A, Feder G: Violence between intimate partners: working with the whole family, BMJ 337:a839, 2008.

ASSESSING FOR INTIMATE PARTNER VIOLENCE

The opportunity for screening for intimate partner violence presents itself each time the nurse has an interaction with a patient; however, there are some presentations that may strongly suggest experience of violence (see Table 5.6). Awareness of such signs and symptoms should alert the nurse to the possibility of violence. If intimate partner violence is suspected it is appropriate to undertake an assessment. To facilitate disclosure nurses should consider using a ‘funnelling’ technique, which involves starting with indirect questions such as ‘How are things at home?’ and moving towards more direct questions such as ‘Do you ever feel unsafe at home?’

TABLE 5.6 Potential presentations of intimate partner violence

Source: Zink T, Elder N, Jacobson J et al: Medical management of intimate partner violence considering the stages of change: precontemplation and contemplation. Ann Fam Med, 2:231–239, 2004.

A number of tools to screen for intimate partner abuse are available. The Abuse Assessment Screen (AAS) has been used in many different healthcare settings, has been translated into at least seven languages and has strong support for reliability and validity (Soeken et al, 1998). This tool has since been adapted by Sohal et al (2007) in the ‘HARK questionnaire’ which focuses on four key areas of enquiry—humiliation, being afraid, sexual assault, physical violence (see Table 5.7). Nurses may feel more comfortable introducing questions about violence with comments such as ‘because family violence is so common in our society, we are asking all women the following questions’ or ‘because domestic violence has such serious healthcare consequences, we are asking all women the following questions’. This both alerts the woman that questions about violence are coming and reassures the woman that she is not being singled out for these questions. When asking questions about violence it is important for the nurse to first listen to, then validate, the woman’s experiences. Women may not be ready to take action but listening, validating and showing compassion are acts of care that plant the seeds for change (Gerbert et al, 2000) (see Table 5.8).

TABLE 5.7 Possible questions to ask if you suspect intimate partner violence

Source: Hegarty K, Taft A, Feder G: Violence between intimate partners: working with the whole family, BMJ 337:a839, 2008.

TABLE 5.8 Possible ways to validate disclosure

Source: Hegarty K, Taft A, Feder G: Violence between intimate partners: working with the whole family, BMJ 337:a839, 2008.

If a woman answers yes to any of your questions about violence, you should consider moving to a comprehensive assessment to better understand the woman’s circumstances and to assess her and her children’s safety. Further enquiry should be made about the length of time of the abuse, whether it is still occurring, the severity of the abuse and the impact on the woman and her children. A good way to start is by asking the woman to ‘tell me about this abuse in your relationship’. Even if the woman minimises the level of abuse such as it is ‘only emotional’ or ‘not that bad’ or ‘we just fight a lot’, more may be revealed as you gently assess the situation. This type of assessment is like ‘peeling layers of an onion’, when more is uncovered as the assessment continues. A woman is not ‘in denial’ if she minimises the abuse: this is a normal response that often accompanies the experience of trauma from violence.

It is appropriate for you to show your concern about the degree of violence. Important messages to convey during the assessment are that the abuse is not the woman’s fault; you are concerned about what is happening and there is help available. It is also important to convey that there are several potential health problems associated with family violence for both the woman herself and her children and this is why you are concerned and asking about her experience. This can be the catalyst for women seeking further assistance. In one survey of 265 women who had been abused and who had accepted a referral to a social worker, 59% said it was because the medical provider expressed concern that their presenting health problem was related to intimate partner violence (McCaw et al, 2002).

It is important to also assess and document prior abuse, including prior intimate partner violence, childhood physical and sexual abuse and prior sexual assaults of all kinds (stranger, date, intimate partner). Cumulative trauma has been shown to be associated with more severe mental and physical health problems (McCauley et al, 1997). It is also important to determine the history of traumatic injuries, since these may have an impact on the current health condition. For example, a woman may have experienced prior episodes of head trauma, which may be related to chronic but subtle neurological symptoms and problems. All survivors of violence should be given a mental status examination, with particular attention to the most frequent mental health problems associated with violence: depression, suicidality, PTSD, substance abuse and anxiety. Chapter 21 gives direction for conducting this part of the assessment.

ASSESSING FOR CHILD ABUSE AND NEGLECT

Nurses who suspect child abuse or neglect should involve other members of the healthcare team (medical practitioners, social workers, counsellors) as screening and assessing processes are complex and there are serious implications for the child and their family. There are also requirements to refer the child and family to child welfare and/or legal authorities. The team should gather and document the evidence carefully before proceeding to making a notification to the authorities. If abuse and neglect go unchecked the implications and risks for the child and perhaps other family members are serious.

An important part of evaluating any child for suspected abuse is to determine the child’s age and developmental level. Could the child have suffered the injury that is being reported based on their developmental level? For example, the history that a 3-week-old child rolled off a bed causing injury is not developmentally plausible. Because the nurse may not be able to directly observe the child’s motor and cognitive milestones during the history taking, it is important to ask the caretakers directly. Is your child crawling, pulling to stand or walking? What other developmental issues are currently being faced at home: tantrums, toilet training, etc? The medical history is also an important part of the assessment. Has the child had previous hospitalisations, injuries, or do they suffer from any chronic medical conditions? Does the child take any medication that may cause easy bruising? Does the child have a history of repeated visits to the hospital? Was there a delay in seeking care for anything other than a minor injury?

If the child is verbal, a history should be obtained away from the caretakers through open-ended questions or spontaneous statements. It is important to remember that children may have suffered significant trauma yet respond only minimally to open-ended questions (Myers, Berliner, Briere et al, 2002). Keeping the questions short and using age-appropriate language and familiar words can help to enrich the history taking. Children older than 11 years of age can generally be expected to provide a history at the level of most adults (Myers et al, 2002). Consultation with and referral to another member of the team who is experienced with child abuse and interviewing children will ensure a more comprehensive and accurate assessment.

ASSESSING FOR ELDER AND VULNERABLE PERSON ABUSE AND NEGLECT

Screening for possible elder abuse and neglect can be more complicated than assessments for intimate partner violence. Older people can present for healthcare with few or multiple health, physical and cognitive challenges. Screening for intimate partner violence in older people is very similar to screening for intimate partner violence among younger women and similar questions can be used. However, you may modify the introductory statement as follows: ‘Because domestic violence has such serious healthcare consequences, we are asking women of all ages the following questions’.

While some older women have been in abusive relationships for decades, others are experiencing physical and sexual violence for the first time from normally non-abusive partners who themselves are afflicted with behaviour-altering neurological illness (e.g. Alzheimer’s disease, organic brain syndromes). An older woman who has been abused in a long-term abusive relationship may be trying to outlive her abuser, whereas the newly abused older woman may be reluctant to disclose because of embarrassment, shame and fears that her partner will be institutionalised. Older people are also vulnerable to abuse from other family members and caretakers. Assessment of physical abuse and/or neglect in the cognitively impaired person is much more complicated. Physical findings that are inconsistent with the history provided by the patient, family member or caregiver are significant red flags of possible abuse and neglect.

When assessing the older person it is useful to start with indirect questions then move to a more direct inquiry if abuse is suspected. In the case of those who rely on care from others, who are in aged care facilities and those who may be cognitively impaired it is also important to include caregivers in your assessment (Table 5.9). There is no mandatory reporting of elder abuse in either Australia or New Zealand; however, there are policies and systems set up so complaints about elder abuse can be investigated. For example, in Australia under the Aged Care Act 1997 there is a ‘Charter of Residents Rights and Responsibilities’, which states explicitly that people living in aged care homes have the right to be treated with dignity and respect, and to live without exploitation, abuse or neglect. If anyone suspects elder abuse they are able to make a complaint via an aged care complaints investigation scheme.

TABLE 5.9 Possible questions for assessing older people

Source: Standards Council: New Zealand Standard: Screening, risk assessment and intervention for family violence including child abuse and neglect, New Zealand, 2006, Standards Council.

PHYSICAL EXAMINATION

Important components of the physical examination of the known individual who has been abused include a complete head-to-toe visual examination, especially if the person is receiving health services secondary to reported abuse. When the examination reveals physical findings, knowledge of basic medical forensic terminology is essential in all documentation. Table 5.10 lists the most common forensic terms, with definitions. Bruising may be an indication of abuse. A new bruise is usually red and will often develop a purple or purple-blue appearance 12 to 36 hours after blunt-force trauma. The colour of bruises (and ecchymoses) generally progresses from purple-blue to bluish-green to greenish-brown to brownish-yellow before fading away. This process will be the same on all people; however, depending on the colour of a person’s skin, the process may be more or less visible, and more or less able to be photographed. There are multiple factors that can contribute to the older person bruising more readily or more severely than younger people. Medications and abnormal blood values related to medication side effects and underlying haematological disorders can affect ease of bruising or the formation of ecchymoses. Common medications that increase risk for bruising or bleeding complications include, but are not limited to, the following: aspirin, clopidogrel, heparin, ibuprofen, any of the non-steroidal anti-inflammatory drugs, prednisone, valproic acid and warfarin. Bilberry, garlic, ginger and ginkgo are among the more common supplements linked to increased risk of bruising and/or bleeding complications (Doyle, Harold and Johnson, 2001).

TABLE 5.10 Forensic terminology

Adapted from Miller BF, Keane CB, O’Toole M: Miller-Keane encyclopaedia dictionary of medicine, nursing, and allied health, edn 7, Philadelphia, 2005, Saunders; Sheridan DJ: Treating survivors of intimate partner abuse: forensic identi.cation and documentation. In Olshaker JS, Jackson MC, Smock WS, editors: Forensic emergency medicine, Philadelphia, 2001, Lippincott Williams & Wilkins; Taber’s cyclopedic medical dictionary, Philadelphia, 1997, Davis.

DOCUMENTATION

Documentation of intimate partner violence, child and elder abuse must include detailed, nonbiased progress notes, the use of injury maps and photographic documentation in the health record. Examples of photographic documentation are included in this chapter (Figs 5.1 to 5.4^*).

Figure 5.1 Patterned, fingernail-like scratch abrasions to the left lateral neck from a manual strangulation mechanism of injury.

Figure 5.2

Figure 5.3 Multiple, patterned-punch-like contusions to the right upper arm.

Figure 5.4 Multiple, patterned, ‘hidden’ punch-like contusions to the upper abdomen and lower anterior chest.

Written documentation of histories of intimate partner violence and elder abuse needs to be verbatim, in the words of the person, but within reason. It is clinically unrealistic to document verbatim every statement made by an abused person. However, it is critical to document exceptionally poignant statements made by the victim that identify the reported perpetrator and severe threats of harm made by the reported perpetrator. Other aspects of the abuse history, including reports of past abusive incidents, can be paraphrased with the use of partial direct quotations.

When quoting or paraphrasing the history, do not sanitise the words reportedly heard by the victim. Verbatim documentation of the reported perpetrator’s threats interlaced with curses and expletives can be extremely useful in future legal proceedings. Also, be careful to use the exact terms a person who has been abused uses to describe sexual organs or sexually assaultive behaviours.

Photographic documentation in the medical record can be invaluable. Prior written consent to take photographs should be obtained from competent adults. Most health facilities have standardised consent to photograph forms. If the person is unconscious or cognitively impaired, the taking of photographs without consent is generally viewed as ethically sound since it is a noninvasive, painless intervention that has high potential to help a suspected abuse victim. When documenting the history and physical findings of child abuse and neglect, use the words the child has given to describe how their injury occurred. Remember that the possibility arises that the abuser may be accompanying the child. If the child is nonverbal, use statements from caregivers. It is important to know your employer/institutional protocol for obtaining a history in cases of suspected child abuse. Some protocols may delay a full interview until it can be done by an expert in child abuse.

Newer, patterned, looped, cord-like contusions to the right upper posterior shoulder and left lower posterior shoulder; patterned, looped, cord-like scar to the right mid-lateral back; scabbed, cord-like abrasions to the mid-back; patterned, kick/stomp heel-like contusion to the left mid-back; and patterned foot/kick/stomp-like heel and sole bruise imprint to the upper left posterior shoulder.

CULTURAL AND SOCIAL CONSIDERATIONS

Family violence crosses all cultures, religions and socioeconomic circumstances. There may be different interpretations of what constitutes abuse in different cultures (Glasgow and Fanslow, 2006). For example, the right of parents to discipline their children using physical force such as slapping or hitting; rights of passage rituals that result in physical injury. Also definitions of abuse may include disrespect, dishonour, lack of esteem for elders or ignoring the needs of elders (Glasgow and Fanslow, 2006). Further, some health treatments such as ‘cupping’ used in Chinese medicine, which involves applying pressure to cups placed on the skin, can leave bruising from the rim of the cups that might be misinterpreted when examined by the untrained eye. Therefore it is important for nurse to take into account the individual and family’s cultural context and religious beliefs when assessing and responding to family violence.

Not all persons of the same gender, family or culture will share the same attitudes, values or beliefs (Royal Australian College of General Practitioners, 2008). From this perspective it is the patient who is the expert in their own culture, gender roles and understanding of what constitutes abuse and violence, the level of disclosure and whether they are ready to seek help. The needs of persons of culturally and linguistically diverse backgrounds will also differ for a range of reasons including cultural and religious beliefs, level of education, language skills and fluency, family relationships, length of time since migration, prescribed gender roles, social networks, economic circumstance, lack of understanding of Australian laws and beliefs and attitudes towards family violence. Differences across cultures may affect disclosure because of fear and distrust of authority including government officials, fear of breaching religious beliefs, not understanding their rights under Australian law, fear of bringing shame and dishonour to the family, lack of family support, fear of being ostracised from community and family and dependence on a spouse for residency (Department of Health, Western Australia, 2007).

It is important to seek advice from other professionals with expertise and understanding of different cultural and religious beliefs and, if possible, to include them in the interview. An interpreter should also be considered if an individual’s first language is other than English. However, it is also important to be aware of the potential sensitivities associated with disclosure in the presence of a person from the same cultural or religious background. While beliefs and interpretations about violence may differ across cultures this is not an excuse for violence. Being equipped with knowledge of different cultural and religious beliefs will assist the nurse to approach a family violence assessment in a culturally appropriate and sensitive way.