Violence as a Public Health Problem

Position Statement: Because of the prevalence of physical and psychological violence in our society, nurses frequently care for the victims, the perpetrators, and the witnesses of physical and psychological violence. In addition, nurses also may be at risk for experiencing violence in the workplace. As members of the largest group of health care providers, nurses should be aware of assessment methods and nursing interventions that will interrupt and prevent the cycle of violence.

In particular, the American Association of Colleges of Nursing (AACN) recognizes domestic violence as a special form of violence with a high incidence and prevalence requiring health care interventions. AACN recommends that faculty in educational institutions preparing nurses in baccalaureate and higher-degree programs ensure that the curricula contain opportunities for all students to gain factual information and clinical experience regarding domestic violence. At a minimum, this content should include:

  • acknowledgment of the scope of the problem;
  • assessment skills to identify and document abuse and its health effects;
  • interventions to reduce vulnerability and increase safety, especially of women, children, and elders;
  • competence in recognizing how cultural factors influence the patterns of and responses to domestic violence in
  • individuals, families, and communities;
  • legal and ethical issues in treating and reporting; and
  • activities to prevent domestic violence.

Such content, which should focus on domestic violence across the lifespan and across settings, may be integrated or threaded throughout the curriculum or contained in a single course.

In addition, nurse researchers should work with scholars in other disciplines to identify the factors associated with violent behavior, as well as interventions effective in primary, secondary, and tertiary prevention.

Domestic violence : For purposes of this position statement, domestic violence is defined as physical, sexual, or emotional/psychological violence directed toward men, women, children, or elders occurring in current or past familial or intimate relationships whether the individuals are cohabiting or not and including violence directed toward dating partners.

Physical violence is the intentional use of physical force with the potential for causing death, injury, or harm. Physical violence includes, but is not limited to scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, poking, hair pulling, slapping, punching, hitting, burning, and use of restraints or one's body, size, or strength against another person. Physical violence includes use of a weapon (gun, knife, or other object) against a person (CDC Committee on Violence Definitions, 1997).

Sexual violence is divided into three categories: The use of physical force to compel a person to engage in a sexual act against his or her will, whether or not the act is completed; an attempted or completed sex act involving a person who is unable to understand the nature or condition of the act, decline participation, or to communicate unwillingness to engage in the sexual act due to age, illness, disability, influence of alcohol or other drugs, intimidation or pressure; and/or abusive sexual contact (CDC Committee on Violence Definitions, 1997).

Psychological violence is abuse, often verbal, which is intended to control another individual through degradation, humiliation, and fear. This abuse may include threats of harm, physical and social isolation, intimidation and harassment, false accusations and blaming, ignoring or ridiculing needs, name-calling and constant criticism and insults (Brygger, M., Matricciani, R., Tulonen, J., & Campbell, J., 1995).

Violence is a public health issue as perilous as any microbial disease. It has been recognized by the World Health Organization as a public health priority worldwide. The reduction of violence is targeted as one of the major goals of the U. S. national health plan in Healthy People 2000. Domestic violence alone affects a significant proportion of the U.S. population either as direct victims or as witnesses of abuse directed toward spouses or intimate partners, children, and elders. Child maltreatment affects nearly three million children annually and results in the death of more than three children every day (McCurdy & Daro, 1994). Between two and four million women are physically battered each year by partners or former partners (Public Health Service, 1991). The mistreatment of elders is estimated to afflict between 700,000 and 1.1 million individuals annually (ANA, 1998). As much as 35% of the U.S. adult population reports having witnessed a man beating his wife or girlfriend (CDC Office of Women's Health, 1998).

In addition to immediate physical, emotional and/or psychological injury, the sequelae of such abuse is often serious and life-long. Long-term effects may include permanent disabilities resulting from physical damage, sexually transmitted diseases including HIV, and complications of pregnancy and birth including low birth weight babies. Mental health effects such as depression, anxiety, post traumatic stress disorder, alcohol and drug abuse, and suicide also have been documented as sequelae to domestic violence.

Because of the prevalence of physical and psychological violence in our society, nurses frequently care for the victims, the perpetrators, and the witnesses of physical and psychological violence. In addition, nurses may also be at risk for experiencing violence in the workplace. As members of the largest group of health care providers, nurses should be aware of assessment methods and nursing interventions that will interrupt and prevent the cycle of violence.

In recognition of the magnitude of the health problems related to violence, a number of nursing organizations have issued position statements concerning the various aspects of violence. These organizations to date include the American Nurses' Association (1991); the National Black Nurses' Association, Inc. (1994); the American College of Nurse-Midwives (1995); the Association of Emergency Room Nurses (1996); and the National Nursing Summit on Violence against Women (1997).

In view of the pervasive nature of violence as a major health problem, the American Association of Colleges of Nursing (AACN) hereby recognizes the position statements of these nursing organizations. In particular, the AACN recognizes domestic violence as a special form of violence with a high incidence and prevalence requiring health care interventions. Therefore, the AACN recommends that the faculty in educational institutions preparing nurses in baccalaureate and higher degree programs ensure that the curricula contain opportunities for all students to gain factual information and clinical experience regarding domestic violence. This information and practice should include, at a minimum, the following:

  1. acknowledgment of the scope of the problem;
  2. assessment skills related to the identification and documentation of abuse and its health effects;
  3. interventions to reduce vulnerability and increase safety especially of women, children, and elders;
  4. cultural competence in dealing with violence as a health care problem;
  5. legal and ethical issues in treating and reporting; and
  6. activities to prevent domestic violence.

A detailed list of recommended competencies is included in Appendix A. In addition, AACN recommends that:

  1. Faculty in schools of nursing should acknowledge their own assumptions about domestic violence and stay current in their knowledge of the concomitant health problems.
  2. Content relative to domestic violence across the lifespan and across settings should be included in all baccalaureate and higher degree programs in nursing. Such content may be integrated or threaded throughout the curriculum or contained in a single course.
  3. If content is integrated or threaded throughout the curriculum it is recommended that the faculty adopt a curriculum plan that specifies the location of violence related content along with a plan for periodically tracking the implementation of this plan. For curriculum suggestions see Appendices.
  4. Students should have opportunities to practice in clinical settings where they have experiences related to screening, assessing and/or caring for victims of violence.
  5. High quality materials related to domestic violence should be available for professional continuing education in formats compatible with non-traditional learners at times and places convenient to the practicing professional.
  6. Nurse researchers should work with scholars in other disciplines to identify the factors associated with violent behavior; as well as interventions effective in primary, secondary, and tertiary prevention.

Suggestions for integrating content on domestic violence in baccalaureate and master's degree nursing programs are included in Appendices B and C.

Mecca Cranley, PhD (Task Force Chair)
Dean, School of Nursing
State University of New York / Buffalo

Eileen Breslin, PhD
Dean, School of Nursing
University of Massachusetts-Amherst

Cynthia Capers, PhD
Dean, College of Nursing
University of Akron

Jackie Campbell, PhD (consultant)
Professor, School of Nursing
Johns Hopkins University

Janet Quillian, DrPH (consultant)
Associate Professor, School of Nursing
Seattle University

Joan Stanley, PhD (staff liaison)
Director, Education Policy
American Association of Colleges of Nursing
jstanley@aacnnursing.org

American College of Nurse-Midwives. (1997). Position statement: Violence against women. Washington, DC: Author 

American Nurses Association. (1998). Culturally competent assessment for family violence. Washington, DC: American Nurses Publishing. 

American Nurses Association. (1991). Position statement: Physical violence against women. Washington, DC: Author. 

Brygger, M., Matricciani, R., Tulonen, J., & Campbell, J. (Eds.). (1995). A guide for nurses: Responding to domestic violence. Maryland Physicians' Campaign Against Family Violence. Baltimore, MD: Medical and Chiurgical Faculty of Maryland. 

Campbell, J.C. (1986). Nursing assessment for risk of homicide with battered women. Advances in Nursing Science, 8 (4), 36-51. 

Centers for Disease Control and Prevention. (1997). Committee on Violence Definitions. Atlanta: Author. 

Centers for Disease Control and Prevention, Office of Women's Health. (1998). Violence and injury. Atlanta: Author. 

Emergency Nurses Association. (1996). Position Statement: Domestic violence. Chicago, IL: Author. 

McCurdy & Daro (1994). Current trends in child abuse reporting and fatalities: The results of the 1993 annual fifty-state survey. Chicago: National Committee to Prevent Child Abuse. 

McFarlane, J. & Parker, B. (1994). Abuse during pregnancy: A protocol for prevention and intervention. White Plains, NY: March of Dimes training manual. 

National Black Nurses' Association. (1994). Position statement on the reduction of violence in African American communities. Washington, DC: National Black Nurses' Association, Inc. 

U. S. Public Health Service. (1991). Healthy People 2000: National health promotion and disease prevention objectives. Washington, DC: U.S. Department of Health and Human Services, Public Health Service, DHHS publication no. (PHS) 91-50212. 

U. S. Public Health Service, Office on Women's Health. (1997). National Nursing Summit on Violence Against Women, October 20, 1997. Washington, DC: U. S. Public Health Service, Department of Health and Human Services. 

World Health Organization. (1997). Violence against women. Women's health and development programme. Geneva: World Health Organization. 

Additional Suggested Reading 

Adams, D. (Ed.). (1995). Health issues for women of color. Thousand Oaks: Sage. 

Berkowitz, C., et al. (1993). American Medical Association treatment and guidelines on child sexual abuse. Archives of Internal Medicine 1, 19-27. 

Bohn, D. (1998). Clinical interventions with Native American battered women. In C.M. Renzetti & J.L. Edleson (Series Ed.) & J.C. Campbell (Vol. Ed.), Empowering survivors of abuse: Health care for battered women and their children (pp. 241-258). Thousand Oaks: Sage. 

Burge, K.S. (1997). Violence against women. Primary Care 24 (1), 67-81. 

Burgess, A., & Fawcett, J. (1996). The comprehensive sexual assault assessment tool. The Nurse Practitioner, 21(4): 66, 71- 86, April 1996. 

Burgess, A., & Hartman, C. (1992). Nursing interventions with children and adolescents experiencing sexually aggressive responses. In P. West, et al., Psychiatric and mental health nursing with children and adolescents (pp. 361-376). Gaithersburg, MD: Aspen Publishers. 

Campbell, D.W. & Gary, F.A. (1998). Providing effective interventions for African American battered women: Afrocentric perspectives. In C.M. Renzetti, & J.L. Edleson (Series Ed.) & J. C. Campbell (Vol. Ed.), Empowering survivors of abuse: Health care for battered women and their children.(pp. 229-240). Thousand Oaks: Sage. 

Campbell, J.C. (1998). Abuse during pregnancy: Progress, policy, and potential. American Journal of Public Health, 88 (2), 185-187. 

Campbell, J.C. (1995). Adult response to violence. Violence: A plague in our land. Washington, DC: American Academy of Nursing. 

Campbell, J.C. (Ed.). (1998). Empowering survivors of abuse: Health care for battered women and their children. Newbury Park: Sage. 

Campbell, J.C. (Guest editor). (1993). Special issue on domestic violence. AAWHONN's Clinical Issues in Perinatal and Women's Health Nursing. Centers for Disease Control and Prevention. (1997). Committee on Violence Definitions. Atlanta: Author. 

Campbell, J.C. (1992). Ways of teaching, learning, and knowing about violence against women. Nursing & Health Care, 13, (9), 464-470. 

Campbell, J.C. & Campbell, D.W. (1996). Cultural competence in the care of abused women. Journal of Nurse-Midwifery, 41, (6), 457-462. 

Campbell, J.C., Harris, M. J., & Lee, R. K. (1995). Violence Research: An Overview. Scholarly Inquiry for Nursing Practice: An International Journal, 9(2), 105-126. 

Campbell, J.C., & Humphreys, J. (1993). Nursing care of survivors of family violence. St. Louis: Mosby. 

Campbell, J.C., & Lewandowski, L. (1997). Mental and physical health effects of intimate partner violence on women and children. Psychiatric Clinics of North America, 20 (2), 353-374. 

Campbell, J.C., & Parker, B. (In press). Clinical nursing research on battered women and their children: A review. In A.S. Hinshaw, J. Shaver, & S. Feetham (Eds.), Handbook of clinical nursing research. Newbury Park: Sage. 

Campbell, J. C., & Parker, B. (1996). Battered women and their children: Review of nursing research and policy implications. In B. McElmurry & R. Parker (Eds.) Annual review of women's health, volume III, 259-284. New York: NLN Press. 

Campbell, J. C., & Parker, B. (1992). Review of nursing research on battered women and their children. In J. J. Fitzpatrick, R. L. Taunton, & A. K. Jacox, Annual review of nursing research, volume 10, 77-94. New York: Springer. 

Clinical Guidelines. (1997). Injury and domestic violence prevention. The Nurse Practitioner, 22 (81), 120-130. 

Dearwater S., Coben, J., Nah, G., Campbell, J., McLoughlin, E., & Glass, N. (1998). Prevalence of domestic violence in women treated at community hospital emergency departments. 

Journal of the American Medical Association. 280, (5), 433-438. 

Feldman, H. (1995). Nursing care in a violent society: Issues and research. New York: Springer. 

Fishwick, N. (1998). Issues in providing care for rural battered women. In C.M. Renzetti & J.L. Edleson (Series Ed.) & J.C. Campbell (Vol. Ed.), Empowering survivors of abuse: Health care for battered women and their children (pp. 280 - 290). Thousand Oaks: Sage. 

Hoff, Lee Ann. (1994). Violence issues: An interdisciplinary curriculum guide for health professionals. Ottawa, Canada: Health Programs and Services Branch. (Copies available from: National Clearinghouse on Family Violence, Family Violence Prevention Division Health Programs and Services Branch, Health Canada Ottawa, ON K1A 1B5) 

Hoff, Lee Ann & Ross, Margaret. (1995). Violence content in nursing curricula: Strategic issues and implementation. Journal of Advanced Nursing, 21, 137-142. 

Juneau, B. (1996). Special issues in critical care gerontology. Critical Care Nursing Quarterly, 19, (2), 71-83. 

Krugman, R.D. (1995). Future directions in preventing child abuse. Child Abuse and Neglect, 19, (3), 273-279. 

Lenburg, C., Lipson, J., Demi, A., Baney, D., Stem, P., & Gage, L. (1995). Promoting cultural competence in and through nursing education. Washington, DC: American Academy of Nursing. 

Moss, V., Campbell, J.C., Halstead, L., & Pitula, C. (1997). The experience of terminating an abusive relationship from an Anglo and African American perspective: A qualitative descriptive study. Issues in Mental Health Nursing. 18, (5). 

National League for Nursing. (1997). Violence in the nursing curriculum nurse educators speak out. Nursing & Health Care Perspectives, 18, (5), 252-259. 

O'Hearn, R.E., & Davis, K. (1997). Women's experience of giving and receiving emotional abuse. Journal of Interpersonal Violence, 12, (3), 375-391. 

Paluzzi, Patricia A., and Quimby, Charlotte Houde. (1998). Domestic violence education. Washington, DC: American College of Nurse-Midwives. 

Pettee, E.J. (1997). Elder abuse: Implications for staff development. Journal of Nursing Staff Development, 13, (1), 7-12. 

Philadelphia Family Violence Working Group. (1996). The RADAR domestic violence training project for health care providers: Overview and evaluation. Philadelphia: Philadelphia Physicians for Social Responsibility. 

Poitier, L. (1997). The importance of screening for domestic violence in all women. The Nurse Practitioner, 22, (5), 105-122. 

Post, S.G., Frutig, R.P., & Bennett, J. (1997). The moral challenge of children at risk: Protective policies and pediatrics. Clinical Pediatrics. 36, 625-634 

Reiniger, A., Robinson, E., & McHugh, M. (1995). Mandated training of professionals: A means for improving reporting of child abuse. Child Abuse & Neglect 19, 63-69. 

Rodriguez, R. (1998). Clinical interventions with battered migrant farm worker women. In C.M. Renzetti & J.L. Edleson (Series Ed.) & J.C. Campbell (Vol. Ed.), Empowering survivors of abuse: Health care for battered women and their children (pp. 271 - 279). Thousand Oaks: Sage. 

Ross, Margaret, Hoff, Lee Ann, & Coutu-Wakulczk, Ginette. (1998). Nursing curricula and violence issues. Journal of Nursing Education, 37, (2), 53-60. 

Salber, Patricia R. & Taliaferro, Ellen. (1995). The physician's guide to domestic violence. How to ask the right questions and recognize abuse...another way to save a life. Volcano, CA: Volcano Press. 

Sengstock, M.C. & Barrett, S.A. (1992). Abuse and neglect of the elderly. In J.Campbell and W.O. Humphreys (Eds), Abuse and neglect of the elderly in family settings (pp. 173-205). St. Louis: Mosby. 

Stanhope, J., & Lancaster, J. (1996). Community Health Nursing. St. Louis: Mosby. (Update in 2000). 

Stuart, G. S., & Sundeen, S.J. (1991). Principles and practice of psychiatric nursing (4th ed.). St. Louis: Mosby. 

Tilden, V. (Guest editor). (1989). Special issue on domestic violence. Issues in Mental Health Nursing. 

Torres, S. (1998). Intervening with battered Hispanic pregnant women. In C.M. Renzetti & J.L. Edleson (Series Ed.) & J.C. Campbell (Vol. Ed.), Empowering survivors of abuse: Health care for battered women and their children (259 -270). Thousand Oaks: Sage. 

Woodti, A., & Breslin, E. (1996). Violence-related content in the nursing curriculum: A national study. Journal of Nursing Education, 35, (8), 367-374. 

Appendix A

 

Competencies Necessary for Nurses to Provide High
Quality Care to Victims of Domestic Violence

Competencies related to acknowledging the scope of the problem.

  1. Recognize prevalence of domestic violence in all its forms.
  2. Recognize risk factors for both victimization and perpetration of domestic violence.
  3. Recognize the significant physical and mental health effects of both ongoing and prior domestic violence.
  4. Recognize the effects of violence across the lifespan, including the long-term effects for children who are either victims or witnesses of domestic violence.
  5. Recognize one's own attitudes about domestic violence, including possibility of own friends' or family members' victimization and the need to address ongoing issues arising from such experiences.

Competencies related to identification and documentation of abuse and its health effects.

  1. Know developmentally appropriate questions to be used in screening in various settings (for example, McFarlane and Parker's (1994) "Abuse Assessment Screen").
  2. If physical violence, assess particularly for forced sex, mental health status, old undiagnosed head injuries, risk of suicide and/or homicide (for example, Campbell's (1986) "Danger Assessment").
  3. Assess for possibility of child abuse in the home and the effects of violence on children.
  4. Assess for possibility of elder abuse in the home.
  5. Document extent of current and prior injuries using body map and photographs if possible.

Competencies related to interventions to reduce vulnerability and increase safety, especially of women, children and elders.

  1. Know local, state, and national domestic violence referral resources, including abuse shelters and safe houses.
  2. Communicate non-judgmentally and compassionately with the victim.
  3. Conduct safety planning with the victim.
  4. Refer to social worker, shelter, and legal counsel as appropriate.

Competencies related to ethical, legal and cultural issues of reporting and treatment.

  1. Know state and national legal mandates regarding domestic violence, including mandatory reporting responsibilities.
  2. Know appropriate methods for collection and documentation of data so that both the patient and the provider are protected.
  3. Know the ethical principles that apply to patient confidentiality for victims.
  4. Recognize that ethical dilemmas often arise from culture differences.
  5. Recognize that cultural factors are important in influencing the occurrence and patterns of and responses to domestic violence in individuals, families, and communities.
  6. Provide culturally competent assessment and intervention while maintaining human rights.

Competencies related to prevention activities.

  1. Increase public awareness of domestic violence.
  2. Promote activities to address prevention with populations at risk (e.g., child witnesses, pregnant women, and dependent-frail elderly).
  3. Promote activities to assist with behavioral changes in battering and battered individuals.
  4. Recognize the need to establish programs to support victims, their family members, and the abuser.
Appendix B

Suggestions for Integrating Content on Domestic Violence

 
Topic 
 
Suggested Cources & Experience:
 Screening & Assessment   Health Assessment; Family; Health Promotion MCH; Community Health; Adult/Geriatric.

At 1st year level one of these courses might be designated to present the didactic content (overview) in relation to domestic violence. For example, the physical assessment course could include information related to identifying suspicious physical injuries and locating them on a body diagram. A course covering principles of communication could deal with how to ask appropriate questions to elicit information about violence in the home.

Clinical experiences could occur in sites that allow students to assess vulnerable individuals across the life span (shelters, elder day care or child day care centers, etc.). Students may observe local task forces on violence, legal systems, and related community activities.

All clinical settings are appropriate for assessment and screening.
     
Intervention & Documentation   Clinical experiences in urgent care sites, emergency rooms, homeless shelters, jails, public health agencies, as well as primary care sites and home care. For example, MCH clinical assignments would include doing routine screening for early cases of domestic violence.
     
Ethical/Legal and Cultural Issues   Courses in sociology, criminal justice, anthropology and bioethics as well as nursing courses that include content on culture and/or professional issues. For example, courses dealing with the care of children, women, or elders should address societal attitudes that may contribute to domestic violence.
     
Prevention Activities   Courses in sociology, community health, and health promotion. For example, students working with childbearing or childrearing families could teach principles and methods of discipline which are non-violent.

Students doing school nursing could help children deal with classroom and playground conflicts using words rather than fists.
 
Appendix C

Suggested leveling for Selected Competencies

Topic 
 
Baccalaureate Level
 
Master's Level
Screening and Assessment   a. Acquire a knowledge base of state and national mandates pertaining to domestic violence

b. Create a climate of effective, nonjudgmental and caring communication

c. Utilize developmentally appropriate questions

d. Develop an awareness of abuse symptomology and associated risk factors

e. Incorporating valid and reliable tools in screening

f. Recognize signs and symptoms of emotional and physical abuse of both genders across the life span

g. Adequately assess clients via interview and appropriate health examination processes

h. Identify and prioritize problems of emotional and physical abuse		    a. Evaluate culturally appropriate screening instruments

b. Utilize community assessment to evaluate client needs for program planning
         
         
Documentation and Intervention   a. Understand and incorporate professional guidelines in obtaining and recording evidence

b. Record specific, concise, and objective information utilizing body maps and photographs as required

c. Document health teaching and anticipatory guidance relative to domestic violence client situations

d. Recognize emergency situations and initiate appropriate plan and/or referral for client

e. Provide care within integrated health care services using national accepted guidelines and standards

f. Provide anticipatory guidance and brief skill counseling

g. Engage in early case finding with appropriate interventions

h. Initiate appropriate referrals

i. Identify local resources for education, caretaking, and support services

j. Consult with other interdisciplinary team members

k. Maintain appropriate clinical follow-up		    a. Engage in data generation, dissemination, and research utilization relevant to violence

b. Apply a theory-based conceptual framework in providing nursing care

c. Participate in legislative and policy making activities relevant to violence

d. Diagnose and manage the client health status over time

e. Provide crisis counseling

f. Develop care guidelines
         
Ethical, Legal, and Cultural Issues   a. Recognize situations presenting ethical dilemmas

b. Know state and national regulations

c. Identify cultural factors that influence domestic violence patterns for various cultural groups

d. Explain culturally normative behaviors and relationship patterns that could be misconstrued as dysfunctional and/or violent

e. Demonstrate culturally sensitive skills for appropriate interventions in situations of domestic violence		   a. Analyze and formulate strategies for solving ethical dilemmas

b. Participate in activities to influence legislation and policy

c. Delineate relevant health care factors that emerge from the interaction of culture and violence

d. Develop skills to differentiate normative behaviors from domestic violence

e. Demonstrate cultural competency for the management of abusive/violent situations exhibited within a selected population of clients
         
Prevention Activities   a. Enhance public awareness of domestic violence

b. Promote activities to address prevention with populations at risk (such as child witnesses, pregnant women, dependent frail elderly)

c. Promote activities to assist with behavioral changes in battering and battered individuals		   a. Implement programs to support victims, abusers, and family members

Published March 1999