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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing: Mental Health and Community Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

Nursing: Mental Health and Community Concepts [Internet].

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Chapter 15 Trauma, Abuse, and Violence

15.1. introduction, learning objectives.

• Delineate adverse childhood experiences
• Incorporate trauma-informed care
• Assess clients for signs of abuse or neglect and intervene appropriately
• Promote safety for victims of abuse, neglect, or intimate partner violence
• Describe strategies to remain safe if workplace violence occurs

The health care system is composed of people who have experienced trauma, both those providing and those receiving care. Supporters of a trauma-informed approach recognize the prevalence of trauma survivors within health care settings and are aware that the service setting can also be a source of re-traumatization. As stated in the article “Trauma-Informed Nursing Practice,” understanding how trauma has affected patients’ lives and their interactions within the health care system is fundamental to responding to patients’ needs and promotes better physical and mental health outcomes. [ 1 ]

Nurses provide care for clients who are experiencing or have experienced neglect, abuse, and intimate partner violence. In many settings, nurses may experience workplace violence while caring for clients who are agitated or combative. This chapter will discuss adverse childhood experiences and trauma-informed care, abuse and neglect of children and vulnerable adults, intimate partner violence, and workplace violence. Be aware that the content in this chapter may trigger powerful emotions, especially for survivors of similar traumatic experiences. Self-awareness and self-care practices should guide your engagement with this chapter.

Read the article “ Trauma-Informed Nursing Practice ” in the  Online Journal of Issues in Nursing  published by the American Nurses Association.

15.2. adverse childhood experiences.

In the late 1990s, a large research study evaluated the impact of adverse childhood experiences on adult health and health behaviors in over 17,000 participants. This research is referred to as the Adverse Childhood Experiences Study. Adverse childhood experiences (ACE)  include neglect, abuse, witnessing violence, or experiencing substance abuse, mental illness, divorce, or imprisonment of a family member. The findings showed that the more negative events a child experienced, the higher the likelihood they had behavior problems and participated in adolescent risky behaviors, including substance abuse and unprotected sexual activity resulting in pregnancy. In addition, the findings showed that adults also struggled with substance abuse and had a higher likelihood of suffering with chronic illness, including alcoholism, chronic pulmonary disease, depression, liver disease, and many more. [ 1 ] Additionally, adults with the highest level of ACEs had a 20-year lower life expectancy than those without high levels of ACEs. [ 2 ] See Figure 15.1 [ 3 ] for an infographic of ACEs.

Figure 15.1

Adverse Childhood Events (ACEs)

View the following YouTube video [ 4 ] on adverse childhood experiences (ACEs), resilience, and trauma-informed care:  How childhood trauma affects health across a lifetime | Nadine Burke Harris .

Although many people who experience individual trauma continue to live their lives without lasting negative effects, others experience traumatic stress reactions causing lasting difficulties. Various biopsychosocial and cultural factors influence an individual’s immediate response and long-term reactions to trauma. For most individuals, regardless of the severity of the trauma, the effects of trauma are met with resilience, defined as the ability to rise above circumstances or meet challenges with fortitude. Resilience includes the process of using available resources to negotiate hardship and/or the consequences of adverse events. [ 5 ]

The Centers for Disease Control and Prevention (CDC) created a resource titled  Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence . This resource contains these six strategies:

• Strengthen economic supports to families
• Promote social norms that protect against violence and adversity
• Ensure a strong start for children
• Teach skills
• Connect youth to caring adults and activities
• Intervene to lessen immediate and long-term harms

Read additional information about the CDC’s prevention strategies in  Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence PDF .

View the following cdc youtube video on adverse childhood experiences and protective factors [ 6 ]: we can prevent aces ., risk factors, protective factors, and prevention strategies.

By bringing attention to the powerful impact that negative childhood experiences have on future health and functioning, the ACE study demonstrates the importance of designing early intervention programs that target abuse, neglect, and violence. [ 7 ] Nurses can help prevent ACEs by educating parents, communities, and policymakers about how to help families provide safe and stable environments for children.

Risk Factors

Risk factors are conditions that increase the likelihood of experiencing ACEs. There are individual, family, and community risk factors for ACEs.

Individual and Family Risk Factors

Individual and family risk factors include the following [ 8 ]:

• Families experiencing caregiving challenges related to children with special needs (for example, disabilities, mental health issues, and chronic physical illnesses)
• Children and adolescents who don’t feel close to their parents/caregivers and feel as though they can’t talk to them about their feelings
• Youth who start dating or engaging in sexual activity at an early age
• Children and youth with few or no friends or with friends who engage in aggressive or delinquent behavior
• Families with caregivers who have a limited understanding of children’s needs or development
• Families with caregivers who were abused or neglected as children
• Families with young caregivers or single parents
• Families with low income
• Families with adults who have low levels of education
• Families experiencing high levels of stress from parenting or economic issues
• Families that have inconsistent discipline, use corporal punishment, and/or have low levels of parental supervision
• Families who are isolated from and not connected to other people (e.g., extended family, friends, neighbors)
• Families with high conflict and negative communication styles
• Families with attitudes accepting of or justifying violence or aggression

Community Risk Factors

Community risk factors include communities with these attributes [ 9 ]:

• High rates of violence and crime
• Limited educational and economic opportunities
• High rates of poverty, unemployment rates, and food insecurity
• Easy access to drugs and alcohol
• Low community involvement among residents
• Few community activities for youth
• Unstable housing where residents move frequently

Protective Factors

Protective factors are conditions that protect people and decrease the possibility of experiencing ACEs.

Individual and Family Protective Factors

Individual and family protective factors against ACEs include the following [ 10 ]:

• Families where caregivers can meet basic needs of food, shelter, and health services for children
• Families that create a consistent family life where children feel safe, stable, and supported in nurturing relationships
• Children who have positive friendships and peer networks
• Children who experience academic success
• Children who have caring adults outside the family who serve as mentors/role models
• Families where caregivers have a college degree or higher education
• Families where caregivers have steady employment
• Families with strong social support networks and positive relationships with the people around them
• Families where caregivers engage in parental monitoring, supervision, and consistent enforcement of rules
• Families where caregivers/adults work through conflicts peacefully
• Families where caregivers help children work through problems
• Families that engage in fun, positive activities together
• Families that encourage the importance of school for children

Community Protective Factors

Communities can intervene to lessen the harms from ACEs and prevent future risks. Community protective factors include communities that demonstrate these qualities [ 11 ],[ 12 ]:

• Families have access to education and support regarding positive parenting
• Families have access to economic and financial help
• Families have access to medical care and mental health services
• Individuals and families have access to safe, stable housing
• Families have access to nurturing and safe child care
• Families have access to high-quality preschool programs
• Families have access to safe, engaging after-school programs and activities
• Adults have work opportunities with family-friendly policies
• There are strong partnerships among the community and business, health care, government, and other sectors
• Residents feel connected to each other and are involved in the community
• Violence is not tolerated or accepted in the community
• Positive parenting strategies are social norms in the community

Many factors contribute to ACEs, including personal traits and experiences, parents, the family environment, and the community itself. ACEs can have lasting negative effects on health and well-being, but these harms can be preventable. To prevent ACEs and protect children from neglect, abuse, and violence, nurses are involved in addressing these risk factors and protective factors with prevention strategies. [ 13 ]

Appropriately addressing traumatic experiences and promoting resilience are important parts of effective mental health care and integral for the healing and recovery process. [ 14 ]

15.3. TRAUMA-INFORMED CARE

Trauma has no age, gender, socioeconomic status, race, ethnicity, or sexual orientation boundaries.  Individual trauma  results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and can have lasting adverse effects on their functioning and mental, physical, social, emotional, or spiritual well-being. Adverse childhood experiences are examples of individual traumas. [ 1 ]

It is natural to feel afraid during and after a traumatic situation. The “fight, flight or freeze” reaction caused by the physiological stress response is intended to protect a person from harm. The sympathetic nervous system (SNS) automatically and unconsciously triggers this physiological stress response whenever there is a perception of threat. [ 2 ]

• Review the physiology of the sympathetic nervous system and the parasympathetic nervous system in the “ Psychotropic Medications ” chapter.
• Review activation of the stress response in the “ Stress, Coping, and Crisis Intervention ” chapter.

The SNS activates many organs during the stress response, resulting in symptoms like increased heart rate, increased blood pressure, rapid breathing, and tense muscles. Cumulative adverse childhood experiences can maintain this threat response in people’s brains, which, over time, can “rewire” their level of physiological reactivity to stress and affect emotional regulation like depression, anxiety, and substance abuse. Trauma survivors are also susceptible to chronic physical and mental illnesses and suicide. [ 3 ] There also tends to be a decrease in positive social behaviors (such as collaboration and kindness) in individuals experiencing a chronic stress response because it requires their full cognitive capacity to respond by “fighting, fleeing, or freezing.”

Arousal and reactivity symptoms include the following [ 4 ]:

• Being easily startled
• Feeling tense or “on edge”
• Having difficulty sleeping
• Having angry outbursts

These symptoms can make the person feel stressed and angry and can make it hard to do daily tasks, such as sleeping, eating, or concentrating. [ 5 ]

Individuals who have a history of trauma may become triggered by engagement with the health care system. They may experience arousal and reactivity symptoms. As a result of the stimulation of the “fight, flight, or freeze” stress response, the parts of the brain involved in memory, planning, decision-making, and regulation are not engaged. This can impact the patient’s involvement with health care services and affect their ability to adhere to treatment plans. [ 6 ] Nurses must understand this potential impact of previous trauma and incorporate patient-centered, trauma-informed care.

Trauma-informed care is an approach that uses a lens of trauma to understand the range of cognitive, emotional, physical, and behavioral symptoms seen when individuals enter health care systems.  Trauma-informed care (TIC)  is a strengths-based framework that acknowledges the prevalence and impact of traumatic events in clinical practice, placing an emphasis on instilling in patients a sense of safety, control, and autonomy over their life and health care decisions. The basic goals of TIC are to avoid re-traumatization; emphasize survivor strengths and resilience; aid empowerment, healing, and recovery; and promote the development of survivorship skills. [ 7 ]

Two influential studies set the stage for the development of TIC [ 8 ]:

• The Adverse Childhood Experiences Study was an extensive study involving more than 17,000 individuals from the United States. It analyzed the long-term effects of childhood and adolescent traumatic experiences on adult health risks, mental health, health care costs, and life expectancy. [ 9 ]
• The Women, Co-Occurring Disorders, and Violence Study was a study focused on the role of interpersonal and other traumatic stressors among women. The researchers examined the interrelatedness of trauma, violence, and co-occurring substance use and mental health disorders and the incorporation of trauma-informed services. [ 10 ]

The Substance Abuse and Mental Health Services Administration (SAMHSA) has defined six core principles of TIC. See Figure 15.2 [ 11 ] for an infographic related to these principles [ 12 ]:

Figure 15.2

Core Principles of Trauma-Informed Care

• Safety:  Throughout the organization, patients and staff feel physically and psychologically safe.
• Trustworthiness and Transparency:  Decisions are made with transparency and with the goal of building and maintaining trust.
• Peer Support:  Individuals with shared experiences are integrated into the organization and viewed as integral to service delivery.
• Collaboration and Mutuality:  Power differences between staff and clients and among organizational staff are leveled to support shared decision-making.
• Empowerment Voice and Choice:  Patient and staff strengths are recognized, built on, and validated, including a belief in resilience and the ability to heal from trauma.
• Cultural, Historical, and Gender Issues:  Biases and stereotypes (e.g., based on race, ethnicity, sexual orientation, age, geography) and historical trauma are recognized and addressed.

View the following YouTube video on ACEs and trauma-informed care [ 13 ]:  What is Trauma-Informed Care?

Trauma-informed nursing practice.

Nurses can incorporate trauma-informed care by routinely implementing the following practices with all clients [ 14 ]:

• Introduce Yourself and Your Role in Every Patient Interaction:  Patients may recognize you, but they may not remember your role. This may lead to confusion and misunderstanding. When a patient understands who you are and your role in their care, they feel empowered to be actively engaged in their own care. They also feel less threatened because they know your name and why you are interacting with them. When one party is nameless, there can be an automatic power differential in the interaction.
• Use Open and Nonthreatening Body Positioning:  Be aware of your body position when working with patients. Open body language conveys trust and a sense of value. Trauma survivors often feel powerless and trapped. Health care situations can trigger past experiences of lack of control or an inability to escape. Using nonthreatening body positioning helps prevent the threat detection areas of the patient’s brain from taking over and helps patients stay regulated. A trauma-informed approach to body position includes attempting to have your body on the same level as the patient, often sitting at or below the patient. It could also include raising a hospital bed in order for the nurse and the patient to be on the same level, reducing the likelihood of creating a perceived power differential through positioning. Additionally, it is important to think about where you and the patient are positioned in the room in relation to the door or exit. Both nurse and patient should have access to the exit so that neither feels trapped.
• Provide Anticipatory Guidance:  Verbalize what the patient can expect during a visit or procedure or what paperwork will cover. Knowing what to expect can reassure patients even if it is something that may cause discomfort. Past trauma is often associated with unexpected and unpredictable events. Knowing what to expect reduces the opportunity for surprises and activation of the SNS symptoms. It also helps patients feel more empowered in the care planning process.
• Ask Before Touching:  For many trauma survivors, inappropriate or unpleasant touch was part of a traumatic experience. Touch, even when appropriate and necessary for providing care, can trigger a “fight, flight, or freeze” response and bring up difficult feelings or memories. This may lead to the individual experiencing increased anxiety and activation of the stress response, resulting in disruptive behaviors and possible dissociation. Dissociation is a break in how a person’s mind handles information, causing disconnection from their thoughts, feelings, memories, and surroundings. Nurses are often required to touch patients, and sometimes this touch occurs in sensitive areas. Any touch can be interpreted as unwanted or threatening, so it is important to ask all clients permission to touch them. Asking permission before you touch patients gives them a choice and empowers them to have control over their body and physical space. Be alert to nonverbal signs such as eye tearing, flinching, shrinking away, or other body language indicating the person is feeling uncomfortable. If the client exhibits signs of discomfort when being touched, additional nursing interventions can be implemented such as a mindfulness or grounding practice.
• Protect Patient Privacy:  Family members and other members of the medical team may be present when you care for a patient. Patients may not feel empowered or safe in asking others to step out. It is crucial that nurses do not put the responsibility on the patient to ask others to leave. It is the nurse’s role to ask the patient (in private) whom they would like to be present during care and ask others to leave the room.
• Provide Clear and Consistent Messaging About Services and Roles:  Trust is built when patients experience care providers who are forthright and honest. Dependability, reliability, and consistency are important when working with trauma survivors because previous trauma was often unexpected or unpredictable. Providing consistency from the nursing team regarding expectations and/or hospital rules can help patients feel secure and decrease opportunities for unmet expectations that might lead to triggering disruptive behavior.
• Use Plain Language and Teach Back:  Avoid medical jargon and use clear, simple language. When patients are feeling triggered (i.e., their “fight, flight, or freeze” system is engaged), information processing and learning parts of the brain do not function optimally, and it is hard to remember new information. When providing education, information, or instructions, break information into small chunks and check for understanding. Offer to write important details down so they can accurately recall the information at a later time. Use clear language and “teach back” methods that empower patients with knowledge and understanding about their care.
• Practice Universal Precaution:  Universal precaution means providing TIC to all patients regardless of a trauma history. Although ACE screening may be part of routine care, it can also have potential negative effects on patients. Unless a trauma-focused intervention is needed to amend the impact of trauma, many TIC experts propose universal precaution rather than direct screening.

Read a continuing education article titled “ Trauma-Informed Nursing Practice ” in the  American Journal of Nursing . [ 15 ]

The resilient zone and self-regulation skills.

Individuals who have experienced repetitive or cumulative trauma may develop a dysregulated rhythm of their sympathetic nervous system (SNS) and parasympathetic nervous system (PNS), leaving them reactive and stuck in a state of hyperarousal, hypoarousal, or oscillating between the two extremes as their nervous system attempts to find balance. Simply put, the SNS “activates” the stress response, and the PNS “calms” the stress response. When out of balance, individuals may exhibit behaviors such as substance use disorders, self-harming, violence, poor school and work performance, bullying, and social disengagement. [ 16 ] Nurses can teach clients self-regulation skills by paying attention to their “fight, flight, or freeze” symptoms and learning how to balance their SNS and PNS systems.

Self-regulation skills teach clients how to return to a healthy balance of SNS and PNS stimulation called the resilient zone. See Figure 15.3 [ 17 ] for an illustration of the resilient zone when the SNS and PNS are in balance. When in the resilient zone, the hormones released by the SNS during the “fight, flight, or freeze” stress response do not block conscious information processing by the brain. This balance promotes better capacity for flexibility and adaptability, prosocial behavior, improved problem-solving, and strategic thinking. [ 18 ]

Figure 15.3

The Resilient Zone

Teaching self-regulation skills enables the individual to pay attention to symptoms of the stress response and use techniques to purposefully stimulate the PNS. They focus on quality of breath, heart rate, and muscle tension and then use relaxation breathing, progressive muscle relaxation, meditation, or other methods to stimulate the PNS. These skills can be used prior to and during challenging events, as well as practiced over time to build deeper nervous system balance. [ 19 ]

Read more about stress management, self-regulation skills, and grounding techniques in the “ Stress, Coping, and Crisis Intervention ” chapter.

Post-traumatic stress disorder (PTSD) is diagnosed in individuals who have been exposed to a traumatic event with chronic stress symptoms lasting more than one month that are so severe they interfere with relationships, school, or work. PTSD has been placed in a new diagnostic category in the  DSM-5  called “Trauma and Stressor-related Disorders.” Read more about PTSD in the “ Anxiety Disorders ” chapter.

15.4. ABUSE AND NEGLECT

Child neglect and abuse.

All 50 states and the District of Columbia have child abuse and neglect reporting laws that mandate certain professionals and institutions refer suspected maltreatment to a Child Protective Services (CPS) agency. Each state has its own definitions of child abuse and neglect that are based on standards set by federal law. Federal legislation defines child abuse and neglect as, “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.” [ 1 ] In 2019 there were 656,000 victims of child abuse and neglect, with a victim rate calculated as 9 victims per 1,000 children across the United States. In addition, 74.9 percent of victims were neglected, 17.5 percent were physically abused, and 9.3 percent were sexually abused. Child fatalities are the most tragic consequence of maltreatment. In 2019 it was estimated that 1,840 children died from abuse and neglect in the United States. The youngest children are the most vulnerable to maltreatment, with 45.4 percent of child fatalities younger than 1 year old. A perpetrator is the person who is responsible for the abuse or neglect of a child. Furthermore, 77.5% of perpetrators are a parent of the victim. [ 2 ]

An organization called A Safe Haven for Newborns is dedicated to preventing infant abuse and abandonment through education, prevention, and direct assistance (see Figure 15.4 [ 3 ]).

Figure 15.4

A Safe Haven For Newborns. Used under Fair Use.

Signs of Neglect and Abuse

Neglect  is a situation in which a parent or caretaker fails, refuses, or is unable, for reasons other than poverty, to provide the necessary care, food, clothing, or medical or dental care, which seriously endangers the physical, mental, or emotional health of the child. Signs of child neglect include the following [ 4 ]:

• Exhibits poor hygiene or body odor
• Is inappropriately dressed for weather
• Demonstrates needed medical or dental care
• Is left alone unsupervised for long periods of time
• Appears malnourished
• Is constantly hungry or begs for or steals food
• Demonstrates exhibits extreme willingness to please
• Is frequently absent from school
• Arrives early and stays late at school, play areas, or other people’s home

Physical Abuse

Physical abuse  is defined as injury inflicted on a child by other than accidental means. Physical injury includes, but is not limited to, lacerations, fractured bones, burns, internal injuries, severe or frequent bruising, or great bodily harm. Signs of physical abuse in children are as follows [ 5 ]:

• Bruises and/or welts on face, neck, chest, back, or soft muscle areas less prone to bruising by natural play or accidents (e.g., abdomen, breasts, under arm, inner thigh)
• Injuries in the shape of object (e.g., belt or cord)
• Unexplained burns on palms, soles of feet, or back; a line of demarcation from submerging in hot liquids (e.g., ankles, buttocks, wrists); burns in the shape of object (e.g., fork, cigarette)
• Fractures that do not fit the story of how an injury occurred
• Delay in seeking medical help
• Extremes in behavior (e.g., very aggressive or withdrawn and shy)
• Afraid to go home
• Frightened of parents
• Fearful of other adults
• Failure to thrive

However, some injuries are not visible to observation, such as shaken baby syndrome, a serious brain injury resulting from forcefully shaking an infant or toddler.

Sexual Abuse

Sexual abuse  is defined as sexual intercourse or sexual touching of a child; sexual exploitation; human trafficking of a child; forced viewing of sexual activity; or permitting, allowing, or encouraging a child to engage in prostitution. Here are signs of sexual abuse in children [ 6 ]:

• Pain, swelling, or itching in genital area
• Bruises, bleeding, discharge in genital area
• Difficulty walking or sitting, frequent urination, or pain
• Stained or bloody underclothing
• Sexually transmitted diseases
• Refusal to take part in gym or other exercises
• Poor peer relationships
• Unusual interest in sex for age
• Drastic change in school achievement
• Runaway or delinquent behavior
• Regressive to behaviors expected for a younger child

Read additional information about human trafficking in the “ Vulnerable Populations ” chapter.

Emotional abuse.

Emotional abuse  is defined as harm to a child’s psychological or intellectual functioning, which is exhibited by severe anxiety, depression, withdrawal, or aggression. Emotional damage may be demonstrated by substantial and observable changes in behavior, emotional response, or learning that are incompatible with the child’s age or stage of development. Signs of emotional abuse in children include the following [ 7 ]:

• Low self-esteem
• Self-denigration
• Severe depression
• Unusual level of aggression
• Severe anxiety
• Extreme withdrawal
• Failure to learn

Child Protective Services

Child Protective Services (CPS) agencies provide services to children and their families, both in their homes and in foster care. Services are provided to prevent future instances of child maltreatment and remedy conditions that brought the children and their family to the attention of the agency. [ 8 ]

Elder Neglect and Abuse and Adults at Risk

Elder abuse is a common problem in the United States. Abuse, including neglect and exploitation, is experienced by about 1 in 10 people aged 60 and older who live at home. From 2002 to 2016, more than 643,000 older adults were treated in the emergency department for nonfatal assaults, and over 19,000 homicides occurred. This information is considered an underestimate of the problem because it is limited to those individuals treated in emergency departments and doesn’t include those who do not seek treatment. Victims must decide whether to tell someone they are being hurt or continue being abused by someone they depend upon or care for deeply. [ 9 ]

Elder abuse is defined as an intentional act or failure to act that causes or creates a risk of harm to an older adult. An older adult is defined as someone age 60 or older. [ 10 ] Adults at risk are also considered vulnerable adults at risk for abuse.  Adults at risk  are defined as adults who have a physical or mental condition that impairs their ability to care for their own needs. [ 11 ] Older adults and adults at risk are potentially susceptible for abuse, neglect, or financial exploitation by caregivers or a person they trust. [ 12 ] A  caregiver  is a person who has taken responsibility for all or part of an individual’s care.

The following are types of elder abuse [ 13 ]:

• Physical abuse:  Physical abuse refers to illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force and includes acts such as hitting, kicking, pushing, slapping, and burning. See Figure 15.5 [ 14 ] for an infographic describing physical signs of elder abuse.
• Sexual abuse:  Sexual abuse refers to forced or unwanted sexual interaction of any kind. This may include unwanted sexual contact or penetration or non-contact acts such as sexual harassment.
• Emotional abuse:  Emotional abuse refers to verbal or nonverbal behaviors that inflict anguish, mental pain, fear, or distress, such as humiliation or disrespect, verbal and nonverbal threats, harassment, and geographic or interpersonal isolation.
• Neglect:  Neglect is the failure to meet the person’s basic needs, including food, water, shelter, clothing, hygiene, and essential medical care.
• Financial abuse:  Financial abuse is the illegal, unauthorized, or improper use of money, benefits, belongings, property, or assets for the benefit of someone other than the individual.
• Treatment without consent:  Treatment without consent refers to the administration of medication or the performance of psychosurgery, electroconvulsive therapy, or experimental research on an individual who has not provided informed consent.
• Unreasonable confinement or restraint: Unreasonable confinement or restraint refers to the intentional and unnecessary confinement of an individual in a locked room, involuntary separation from their living area, use of physical restraints, or the provision of unnecessary or excessive medication. (This does not include the use of these methods or devices if they conform with state and federal standards governing restraint or seclusion.)

Figure 15.5

Physical Signs of Elder Abuse. Used under Fair Use.

Adult Protective Services

Adult Protective Services are available to provide aid to elder adults and adults at risk who have been abused, neglected, or exploited. Adult Protective Services are services provided to an individual with a developmental disability, degenerative brain disorder, serious mental illness, or other incapacity to keep them safe from abuse, neglect, or financial exploitation; prevent them from experiencing deterioration; or stop them from inflicting harm on themself or another person.

Protective services may include outreach, counseling, and referral for services; coordination of services for individuals; and tracking and follow-up. See Figure 15.6 [ 15 ] for an illustration related to reporting concerns about vulnerable adults.

Figure 15.6

Reporting Concerns About Vulnerable Adults. Used under Fair Use.

Find resources in your area for reporting elder abuse at the  National Adult Protective Services Association website .

Read more about protective services in your state. here are links to wisconsin’s  adult protective services ., find elder care resources in your community at  eldercare locator, mandatory reporting.

Mandated reporters  are required by law to report suspected abuse and neglect they see in the course of their professional duties. Nurses and other professionals are referred to as mandated reporters because they are required by state law to report suspected neglect or abuse of children, adults at risk, and the elderly. Nurses should be aware of the county or state agencies to whom they should report suspected abuse. For example, in Wisconsin, suspected neglect or abuse is reported to the Child Protective Services (CPS) or law enforcement. Persons required to report and who intentionally fail to report suspected child abuse or neglect may be fined up to $1,000 or imprisoned for up to six months or both. [ 16 ] See Figure 15.7 [ 17 ] for an image related to reporting suspected abuse and neglect.

Figure 15.7

Report Suspected Child Abuse. Used under Fair Use.

What to Report

Mandatory reporters who suspect neglect or abuse should contact their county social/human services department, sheriff, or local police department immediately. When making a report, explain what happened or is happening to the child or vulnerable adult. Describe the nature of the abuse or neglect and be as specific as possible. Be prepared to give the name, DOB, address, and telephone number of the victim, as well as the name of their parent or caregiver. Include information on any known or reported Native American ancestry. If you do not know all of this information, report what you do know and explain all you know about the situation and family dynamics. [ 18 ]

When a report is filed, the receiving department will make a safety screening determination based on state statutes. If the report meets the criteria for alleged maltreatment, a social worker from the county department of social/human services will proceed with an investigation of the reported maltreatment and work with the parents to assess the situation to determine if any support or assistance is needed to protect the child or vulnerable adult and help the family. [ 19 ]

Find resources in your area for reporting suspected child abuse at  ChildHelp National Child Abuse Hotline .

Read more about protective services in your state. access wisconsin’s information at  child protective services ., 15.5. intimate partner violence.

Intimate partner violence (IPV), sexual assault, and rape are crimes with long-lasting effects on victims and are a great cost to society. These crimes happen to both women and men and are often associated with substance use. A recent national survey found that 22 percent of women and 14 percent of men reported experiencing severe physical violence from an intimate partner in their lifetimes. [ 1 ] IPV is a significant public health issue that has many individual and societal costs. About 35% of female IPV survivors and more than 11% of male IPV survivors experience some form of physical injury related to IPV, and some deaths occur. About 1 in 5 homicide victims are killed by an intimate partner, and over half of female homicide victims in the US are killed by a current or former male intimate partner. [ 2 ] See Figure 15.8 [ 3 ] for a CDC infographic related to IPV.

Figure 15.8

Intimate Partner Violence Statistics

Intimate partner violence (IPV)  is abuse or aggression that occurs in a romantic relationship. “Intimate partner” refers to both current and former spouses and dating partners. IPV can vary in how often it happens and how severe it is. It can range from one episode of violence that could have lasting impact to chronic and severe episodes over multiple years. IPV can include any of the following types of behaviors [ 4 ]:

• Physical violence:  When a person hurts or tries to hurt a partner by hitting, kicking, or using another type of physical force
• Sexual violence:  Forcing or attempting to force a partner to take part in a sex act, sexual touching, or a nonphysical sexual event (e.g., sexting) when the partner does not or cannot consent
• Stalking:  A pattern of repeated, unwanted attention and contact by a partner that causes fear or concern for one’s own safety or the safety of someone close to the victim
• Psychological aggression:  The use of verbal and/or nonverbal communication with the intent to harm another partner mentally or emotionally and/or to exert control over another partner

View the following CDC YouTube video on intimate partner violence [ 5 ]:  What is Intimate Partner Violence?

Teen dating violence.

When IPV occurs during adolescence, it is referred to as  teen dating violence (TDV) . TDV affects millions of U.S. teens each year. Youth from marginalized groups, such as the LGBTQ+ population are at greatest risk of experiencing sexual and physical dating violence. [ 6 ] The use of alcohol and drugs is also a risk factor for non-consensual sexual contact among undergraduate and graduate students. [ 7 ] See Figure 15.9 [ 8 ] for an infographic used to teach about healthy relationships.

Figure 15.9

Healthy Versus Unhealthy and Abusive Relationships. Used under Fair Use.

Warning Signs of Intimate Partner Violence

These observations should heighten a nurse’s suspicion of IPV [ 9 ]:

• Inconsistent explanation of injuries.
• Delay in seeking treatment for injuries.
• Frequent emergency department or urgent care visits. (Abusers typically do not want their victims to form an ongoing care relationship with one clinician. They may feel the victim will be less likely to find an ally in an emergency department where care may be more fragmented.)
• Missed appointments. The patient may not keep appointments because the abuser will not allow medical attention.
• Late initiation of prenatal care during pregnancy.
• Repeated abortions. Unplanned pregnancy may result from sexual assault and/or not being allowed to use birth control by the abuser.
• Medication nonadherence. Victims may not take medicines because the abuser has taken them away or not allowed the partner to fill prescriptions.
• Inappropriate affect. Victims may appear jumpy, fearful, or cry readily. They may avoid eye contact and seem evasive or hostile. Additionally, flat affect or dissociation may suggest post-traumatic stress disorder.
• Overly attentive or verbally abusive partner. The clinician should be suspicious if the partner answers questions for the patient. If the partner refuses to leave the examination room, the nurse should find a way to get the partner to leave before questioning the patient.
• Apparent social isolation.
• Reluctance to undress or have a genital, rectal, or oral examination or difficulty undergoing these or other examinations.

The setting in which questioning occurs is important. The nurse must ensure that the patient feels safe and comfortable. Individuals are more likely to disclose their experiences of IPV when the nurse uses the following strategies [ 10 ]:

• Provide privacy. Other people present in the room should be asked to leave for the interview and examination. Resistance of a partner to leave is a warning sign.
• Appear concerned with good eye contact.
• Be nonjudgmental and compassionate.
• Use open-ended questioning and ask only a few questions.
• Ask about “being hurt” or “treated badly” and avoid phrases like “domestic violence,” “victim,” “abused,” or “battered.”
• Assure confidentiality unless mandatory reporting is required or someone is in grave danger (i.e., duty to warn).
• Do not pressure to disclose, leave the relationship, or press charges.
• Encourage shared decision-making and respect for the patient’s decisions.

The physical examination can provide warning signs that abuse may be occurring. The presence and location of injuries are important. Any injury without a good explanation, particularly involving the head and neck, teeth, or genital area, should raise suspicion. Typically, victims of domestic violence present with injuries on the central part of the body such as the breasts, abdomen, and genitals. Wounds on the head and neck, particularly neck bruising, may be caused by attempted strangulation. Wounds on the forearms often occur when a victim is in a defensive position. Bruises of different ages may be present due to repeated abuse. There may be other evidence of sexual assault, including sexually transmitted infections or unintended pregnancy. [ 11 ]

People experiencing abuse may deny the abuse for several reasons. They may not feel safe in disclosing information, especially if questions are not asked in a private environment or there is a fear of information not being kept confidential. They may not be emotionally ready to admit the reality of the situation, they may blame themselves, or they may feel like a failure if they admit to being abused. They may fear rejection, feel ashamed, believe that the abuse will not happen again, fear reprisal by the abuser, believe that they have no alternatives, or lack knowledge of resources that could help them. There may be language or cultural barriers between nurses and patients that interfere with communication or discomfort with using an interpreter to discuss sensitive issues. [ 12 ]

Patients for whom IPV is suspected but is not acknowledged should be asked again at subsequent visits. Research indicates patients are more likely to disclose information after they have been asked about IPV repeatedly in the health care setting and it is “normalized,” meaning it happens frequently to many people. [ 13 ]

SAFE Survey

The Joint Commission recommends that hospitals use criteria to identify possible victims of abuse and neglect upon hospital entry and on an ongoing basis, educate staff about how to recognize signs of abuse, assist with referrals of possible victims, and report abuse in accordance with law and regulation.

Several IPV screening tools have been studied for use in emergency departments and clinics. SAFE is an example of a short survey tool that stands for the following assessments [ 14 ],[ 15 ]:

• S: Stress/Safety:  Do you feel safe in your relationship?
• A: Afraid/Abused:  Have you ever been in a relationship where you were threatened, hurt, or afraid?
• F: Friends/Family:  Are your friends or family aware you have been hurt?
• E: Emergency Plan:  Do you have a safe place to go and the resources you need in an emergency?

Read the following PDF for additional information about Minnesota Department of Health’s IPV screening tools: Family Home Visiting Intimate Partner Violence Screening & Referrals Toolkit

Interventions and safety plans.

Survivors of IPC are often afraid to leave their abusive partners because of the threats that have been made against them or their loved ones. The biggest threats for victims are strangulation (ten times more likely to be killed), the presence of a firearm (five times more likely), or if the abusive person is suicidal. It is not uncommon for an abusive person to threaten to kill themselves if they feel as if they’re losing control over their partner, and they pose a serious risk to their victim if they have attempted suicide in the past, talk about a specific plan, or have access to a gun. Domestic violence is the single biggest indicator of murder-suicides in the United States, and this has escalated to include survivors’ friends and family. [ 16 ]

Safety is a top priority when IPV is identified. Before the patient leaves the office, referrals to local resources should be made with a personalized safety plan in place. The most dangerous time in a relationship occurs when the abused person decides to leave. Nearly 77 percent of domestic violence-related homicides occur upon separation, and there is a 75 percent increase of violence upon separation for at least two years. [ 17 ] As the abuser realizes they are losing power and control over their partner, they often escalate tactics to increase fear in the individual leaving the relationship in an effort to make the individual stay. A  safety plan  is a set of actions that can help lower the risk of being hurt by an abusive partner. It includes specific information and resources that will increase one’s safety at school, home, and other places visited regularly. View an infographic related to a safety plan in Figure 15.10 . [ 18 ]

Figure 15.10

Safety Plan

Resources for Survivors of IPV

Guide clients experiencing IPV to create a personalized online safety plan at the National Domestic Violence Hotline’s  Create a Safety Plan  web page.

If you need help or know someone who is experiencing IPV, visit the  National Domestic Violence Hotline  or call 1-800-799-7233. Online resources for developing a customized safety plan are available.

Read about teen dating and healthy relationships at the  Love is Respect website .

Preventing IPV

There are many negative health outcomes associated with IPV, including chronic conditions affecting the heart, digestive, reproductive, musculoskeletal, and nervous systems. Survivors may experience mental health problems such as depression and post-traumatic stress disorder (PTSD) and are at higher risk for engaging in behaviors such as smoking, binge drinking, and risky sexual behaviors. [ 19 ]

Nurses and communities can promote healthy, respectful, and non-violent relationships to help reduce the occurrence of IPV. [ 20 ] See Figure 15.11 [ 21 ] for an infographic related to IPV prevention strategies from the CDC.

Figure 15.11

Preventing Intimate Partner Violence

15.6. WORKPLACE VIOLENCE

Workplace violence  consists of physically and psychologically damaging actions that occur in the workplace or while on duty. Examples of workplace violence include direct physical assaults (with or without weapons), written or verbal threats, physical or verbal harassment, and homicide. [ 1 ]

Violence committed by patients or family members toward health care staff can occur in many health care settings, so nurses must be prepared to cope effectively with agitated patients to reduce the risk of serious injury to the patient, themselves, staff, and other clients. Up to 50 percent of health care professionals are victims of violence at some point during their careers. There is a wide range of risk factors for patient violence, including the environment, a patient’s social and medical history, interpersonal relationships, genetics, neurochemistry and endocrine function, and substance abuse. In the emergency department (ED), substance intoxication or withdrawal is the most common diagnosis in combative patients. Known psychiatric illness is also a risk factor for violent behavior, with schizophrenia, personality disorders, mania, and psychotic depression most often associated with violence. Psychosis, delirium, and dementia can also lead to violent behavior. [ 2 ]

Some states are introducing legislation to increase the penalties for people who commit violence against nurses, making battery to a nurse a felony instead of a misdemeanor. A recent law passed in Wisconsin in 2022 makes it a felony to threaten a health care worker. [ 3 ] See Figure 15.12 [ 4 ] for an illustration related to stopping workplace violence for nurses in Wisconsin.

Figure 15.12

Stop Workplace Violence. Used under Fair Use.

Assessment of the combative patient begins with risk assessment and attention to safety measures. Violence typically erupts after a period of mounting tension. In a typical scenario, the patient first becomes angry, then resists authority, and finally becomes confrontational. However, violent behavior may erupt without warning, especially when caused by medical illness or dementia. A nurse may identify verbal and nonverbal cues of agitation and defuse the situation before violence happens. It is helpful to observe the nonverbal communication of a client’s hands as an indicator of tension. Other signs of impending violence include the following [ 5 ]:

• Confrontational behavior
• Angry demeanor
• Loud, aggressive speech
• Tense posturing (e.g., gripping arm rails tightly or clenching fists)
• Frequently changing body position or pacing
• Aggressive acts (e.g., pounding walls, throwing objects, or hitting oneself)

Patients who are agitated but cooperative may be amenable to verbal de-escalation techniques. Actively violent patients and uncooperative, agitated patients, particularly those who exhibit signs of impending violence, require immediate physical restraint per an agency’s policy. Assume that all violent patients are armed until proven otherwise, especially those presenting to an emergency department. [ 6 ]

Read about crisis intervention techniques in the “ Stress, Coping, and Crisis Intervention ” chapter.

Verbal de-escalation techniques.

Verbal de-escalation techniques should be attempted before physical restraints or sedative medications are implemented. During initial interactions with the patient, it will rapidly become clear whether the patient will cooperate or continue to escalate. This interaction also enables the nurse to assess the patient’s mental status. If the patient remains agitated or is incapable of interacting appropriately, then restraints become necessary. [ 7 ]

When attempting to de-escalate an individual, the nurse should adopt an honest and straightforward manner. Friendly gestures can be helpful. Offer a comfortable place to sit or something to eat or drink (but not a hot liquid that could be used as a weapon) to establish trust. Many individuals will decompress at this point because offering food or drink appeals to their most basic human needs and builds trust. [ 8 ]

The nurse should demonstrate a nonconfrontational, attentive, and receptive demeanor without conveying weakness or vulnerability. A calm and soothing tone of voice should be used. Avoid direct eye contact, do not approach the patient from behind or move suddenly, and stand at least two arm’s lengths away. [ 9 ] The nurse should ensure a quick exit route to the door and never allow the individual to come between them and the door. Stethoscope and badge holders should not be worn around the neck to prevent strangulation risks.

In some cases, an agitated patient may be aware of their impulse control problem and may welcome limit-setting behavior by the nurse (e.g., “I can help you with your problem, but I cannot allow you to continue threatening me or the emergency department staff”). It is difficult to predict which patients will respond to this limit-setting approach. Some patients may interpret such statements as confrontational and escalate their behavior. [ 10 ]

A key mistake when interviewing an agitated or potentially violent individual is failing to address violence directly. They should be asked relevant questions, such as, “Do you feel like hurting yourself or someone else?” and “Do you carry a gun?” Stating the obvious (e.g., “You look angry”) may help them to begin sharing their emotions. Speak in a conciliatory manner and offer supportive statements to diffuse the situation, such as, “You obviously have a lot of will power and are good at controlling your emotions.” [ 11 ]

A consensus statement from the American Association for Emergency Psychiatry De-escalation Workgroup describes these ten key elements for verbal de-escalation [ 12 ]:

• Respect personal space:  Maintain a distance of two arm’s lengths and provide space for easy exit for either party.
• Do not be provocative:  Keep your hands relaxed, maintain a open body posture, and do not stare at the patient.
• Establish verbal contact:  The first person to contact the patient should take the lead in communicating.
• Use concise, simple language:  Avoid elaborate and technical terms because they are hard for an impaired person to understand.
• Identify feelings and desires:  “What are you hoping for?”
• Listen closely to what the patient is saying:  After listening, restate what the patient said to improve mutual understanding (e.g., “Tell me if I have this right…”).
• Agree or agree to disagree:  Agree with clear specific truths or agree in general (e.g., “Yes, everyone should be treated respectfully.”)
• Set clear limits:  Inform the patient that violence or abuse cannot be tolerated.
• Offer choices and optimism:  Patients feel empowered if they have some choice in matters.
• Debrief the patient and staff.

The “philosophy of yes” is a de-escalation technique that encourages the nurse to respond affirmatively to an agitated individual. Examples of initial responses using this approach include “Yes, as soon as,” “Okay, but first we need to,” or “I absolutely understand why you want that done, but in my experience, there are better ways of getting what you need.” [ 13 ]

However, some approaches to the combative patient are counterproductive and can lead to escalation. Arguing, condescension, or commanding the patient to calm down can have disastrous consequences. Patients often interpret such approaches as a challenge to “prove themselves.” A threat to call security personnel can also invite aggression. Other potential mistakes include criticizing or interrupting the patient, responding defensively or taking the patient’s comments personally, or not clarifying what the patient wants before responding. [ 14 ]

Never lie to a patient (e.g., stating “I am sure you will be out of here in no time” when this is not the case). After the lie becomes apparent, the patient may take out frustrations violently upon an unsuspecting nurse or colleague. Take all threats seriously. It is especially important not to deny or downplay threatening behavior. If verbal techniques are unsuccessful and escalation occurs, the nurse should excuse themselves and summon help. [ 15 ]

Applying Physical Restraints

Physical restraints may be used when verbal de-escalation techniques are unsuccessful despite a professional approach to the combative patient. Restraints should never be applied for convenience or punishment, and they should be removed as soon as possible, usually after adequate chemical sedation is achieved.

Restraints should be implemented systematically using an institutional protocol. The protocol typically begins after the examiner leaves the room when verbal de-escalation techniques have been unsuccessful, and assistance is summoned. It can be helpful to consider the application of restraints like a procedure, similar to running an advanced cardiac life support code. [ 16 ]

The restraint team should have at least five people, including a team leader. The leader is the only person giving orders and should be the person with the most experience implementing restraints, whether a clinician, nurse, or security officer. Before entering the room, the leader outlines the restraint protocol and warns the team of anticipated dangers (e.g., the presence of objects that may be used as weapons). All team members should remove personal effects (e.g., stethoscopes, pens, jewelry, etc.) the combative patient could use against them. If the patient to be restrained is female, at least one member of the restraint team should be female to diminish potential allegations of sexual assault. [ 17 ]

The restraint team should enter the room in force and display a professional, rather than threatening, attitude. Many violent individuals decompress at this point because the show of force protects their ego (e.g., “I would have fought back, but there were too many against me”). The leader speaks to the patient in a calm and organized manner, explaining why restraints are needed and what the course of events will be (e.g., “You will receive a medical and psychiatric examination, as well as treatment”). The patient is instructed to cooperate and lie down to have restraints applied. Some patients will be relieved at the protection to self and others afforded by restraints when they feel themselves losing control. However, even if the patient suddenly appears less dangerous, physical restraints must be placed after the decision to use them has been made; do not negotiate with the patient at this point. [ 18 ]

If it becomes necessary to use force to control the patient, one team member restrains a preassigned extremity by controlling the major joint (e.g., knee or elbow). This can be accomplished by locking the major joint in extension. The team leader controls the head. If the patient is armed with a makeshift weapon, two mattresses can be used to charge and immobilize or sandwich the patient. Restraints are applied securely to each extremity and tied to the solid frame of the bed (not side rails because later repositioning of side rails also repositions the patient’s extremity). To prevent their lower extremities from flailing independently, it may be best to cross the legs at the ankle and then attach the restraint to the bed frame on the opposite side. [ 19 ]

Leather is the optimal material for restraining a combative patient because it is strong, prevents escape, and is less constricting than typical soft restraints. Gauze should not be used. Soft restraints are helpful in restricting extremity use in a semi-cooperative patient but are less effective in a truly violent patient who continues to struggle. If chest restraints are used, it is vital to ensure adequate chest expansion for ventilation. Never apply pressure to the client’s chest or back while they are immobilized due to asphyxiation risk. After the patient is immobilized, announcing “The crisis is over” can have a calming effect on the restraint team and the patient. [ 20 ]

After restraints have been applied, the patient should be monitored frequently and their position changed regularly to prevent circulatory obstruction, pressure injuries, and paresthesias, as well as to avoid rhabdomyolysis associated with continued combativeness. A standardized form based on agency policy is typically used for documentation. Documentation should include the specific indication for restraints and alternatives attempted. In addition to monitoring, nurses must ensure that basic needs (e.g., hydration, food, toileting) are met for any patient who is physically restrained or chemically sedated. Physical restraints should be removed as soon as possible. [ 21 ]

Chemical Sedation

Chemical sedation may be necessary, with or without physical restraints, in a combative patient who does not respond to verbal de-escalation techniques. The ideal sedative medication for an agitated or violent patient is rapid-acting with minimal side effects. The major classes of medications used to control the violent or agitated patient include benzodiazepines, first-generation (typical) antipsychotics, second-generation (atypical) antipsychotics, and ketamine [ 22 ]:

• For severely violent patients requiring immediate sedation, a rapid-acting first-generation antipsychotic (e.g., haloperidol or droperidol), benzodiazepine (e.g., midazolam), or a combination of both may be prescribed. Second-generation antipsychotics, such as olanzapine, risperidone, and ziprasidone may also be prescribed.
• For patients with agitation from drug intoxication or withdrawal from an unknown cause, benzodiazepines are typically prescribed. Lorazepam and midazolam are used most often. Benzodiazepines may cause respiratory depression and excessive sedation, so close monitoring is essential after administration.
• Ketamine may be prescribed when initial treatments with benzodiazepines or antipsychotics have failed, especially in patients with excited delirium. However, clients receiving ketamine have increased risk for respiratory distress and may require endotracheal intubation and mechanical ventilation.

Post-Restraint Evaluation

After the patient is restrained, the cause of their agitation will be evaluated to determine if it is medical, psychiatric, or substance-use related. Patients over the age of 40 with new psychiatric symptoms are likely to have a medical cause. Elderly patients are at higher risk for delirium due to medical illness (such as a urinary tract infection) or adverse reactions to medications. Patients with a history of drug or alcohol use disorder may exhibit violent behavior as a manifestation of an intoxication or withdrawal syndrome. Violent behavior unrelated to medical illness, drug intoxication, or withdrawal should be followed by psychiatric consultation and evaluation. [ 23 ]

Defense Against Assault

Physical assault may occur despite appropriate precautions and interventions with a violent individual. If assaulted, immediately summon help. Maintain a sideward posture, keeping the arms ready for self-protection. If faced with an oncoming punch or a kick, deflect with an arm or a leg. If choking is attempted, tuck in the chin to protect the airway and carotid arteries. If bitten, do not pull away, but rather push toward the mouth and hold the nares shut to entice the opening of the mouth. [ 24 ] In a similar manner, don’t pull away if your hair is pulled, but instead pull the client’s hand toward your head and push up to bend their wrist backwards and increase the likelihood of them releasing their grip due to pain.

If threatened with a weapon, try to appear calm and comply with the individual’s demands. Adopt a nonthreatening posture and avoid sudden movements. Do not attempt to reach for the weapon. Avoid arguing, despair, or whining. If taken hostage, attempt to establish a human connection with the hostage taker because there is less risk of violence if a relationship has been established. Do not bargain, make promises, or lie because the consequences could be disastrous. Reassure the hostage taker that an authorized person should arrive promptly to hear their complaints or demands. If a weapon is put down, do not reach for it, but rather attempt to verbally resolve the crisis while awaiting arrival of law enforcement. [ 25 ]

Every hospital should have a written plan of action to implement in the case of extreme violence. The plan should include prevention and safety measures, a means for rapid notification of security and police personnel, evacuation plans, medical treatment, and crisis intervention. A novel approach uses a trained violence management team to provide a mechanism for dealing with aggressive patients and to protect the staff. [ 26 ]

Mandatory training for clinical and non-clinical staff must also be incorporated with written plans of action. This multifaceted approach improves nurses’ self-perception and confidence against workplace violence. [ 27 ]

Interpersonal Conflict Among Health Care Team Members

Conflict is inevitable when working on a health care team composed of members with different personalities, roles, and responsibilities. Some conflicts among some team members can escalate to verbal threats or harassment. Common sources of interpersonal conflict in health care settings are passive-aggressiveness, horizontal aggression, defensiveness, peer informer behavior, and victimization behaviors. It is essential for all nurses to develop conflict resolution skills to effectively address these behaviors and maintain a safe work environment.

Read more information about interpersonal conflict and conflict resolution skills in the “ Conflict Resolution ” section of the “Collaboration Within the Interprofessional Team” chapter of Open RN Nursing Management and Professional Concepts.

15.7. spotlight activity.

This Spotlight Activity is based on a real case originally presented in, “Trauma-Informed Care in Nursing Practice” by Dowdell and Speck (2022). Identifying details have been changed or omitted to protect the anonymity of the client. [ 1 ]

Dana is a 34-year-old female who arrived at the Emergency Department with a neck injury she reports “happened this morning when I slipped and fell.” The nurse notes that Dana’s address given is in a different community about 50 miles away from the hospital. Initial physical examination revealed bruise patterns in various stages of healing all over Dana’s body and three linear abrasions over the trapezius muscle on the right side of the neck consistent with attempted strangulation.

While awaiting diagnostic testing results, the nurse established a therapeutic nurse-client relationship and asked Dana a few follow-up questions about the events leading up to the injury and the relationship with the partner. Dana stated, “We fight a lot” and “My partner has a lot of angry outbursts.” Upon the nurse’s use of effective therapeutic communication, Dana shared that the injury resulted from “being choked and beaten,” and the partner had done similar actions on “several previous occasions in front of the children.” Dana then told the nurse, “My partner can’t find out that I am here in this hospital.”

A contrast computed tomography (CT) scan revealed swelling of Dana’s right carotid artery and soft tissue in the neck. Laboratory tests also indicated that Dana had severely elevated blood sugars resulting in diabetic ketoacidosis (DKA).The health care team initiated a medication regimen to safely manage the DKA and also prevent a stroke from the injury.

The nurse noted that, over time, Dana became increasingly agitated in the ED with repetitive neurological assessments, fingersticks for bedside glucose levels, and the noises and high activity level of the ED. Establishing physical and psychological safety for both Dana and staff became a nursing priority during Dana’s time in the ED.

Following trauma-informed care (TIC) guidelines to create a safe environment, the nurse asked Dana, “What do you need to feel safe here right now?” Dana immediately responded, “I can’t have all these people coming at me. It’s too much – too much noise, too many people touching me, it’s just too much.” The nurse moved Dana out of the trauma bay, which was near the ambulance entryway, and into a room where the nurse was able to close the door. The nurse also posted signage on the door asking all staff and visitors to contact the nurse before entering the room. Following agency protocol, the nurse swiftly gained Dana’s consent for anonymity, meaning the client’s name and room number(s) would not be shared with anyone outside of the hospital. Following these nursing actions, Dana’s anxiety and agitation levels dropped noticeably in the ED. When an ICU bed became available, she was transferred there for medical management.

Dana was present during the handoff report from the ED nurse to the ICU nurse to validate information and it also improved Dana’s sense of safety. Following the TIC cue given by the ED nurse, the ICU nurse asked Dana, “What else do you need to feel safe here right now?” Dana requested a private room, if available, to rest, listen to music, and “stay calm.” The ICU nurses implemented a safety plan that included consistent staff and coordinated, clustered care.This plan minimized disturbances, thereby providing dedicated periods for rest between timed blood glucose monitoring and nursing monitoring of Dana’s neurologic state and neck swelling.

While in the ICU, the nurses taught Dana evidence-based methods for reducing anxiety, including deep breathing, grounding techniques, and moderating anxiety-provoking stimuli such as social media and electronics. In addition, the nurses noted the vocal and nonverbal cues that indicated Dana was feeling anxious, such as speaking in a raised voice or using rapid hand movements while speaking. Noticing these behaviors allowed nurses to ask follow-up questions such as “Do you feel safe at this moment,” then review anxiety-reducing techniques by asking Dana, “Which technique would you like to use now?” By offering person-centered choices and creating a predictable structure around clustered nursing actions, the nurses promoted a feeling of safety for Dana as well as techniques to self-regulate anxiety.

The health care team identified Dana’s priority health concerns as DKA management and decreasing the risk for a stroke following nonfatal carotid trauma.The nursing team added Dana’s increased risk for subsequent fatal strangulation as a priority concern that must be addressed before discharge. However, when asked by the nurses, “What is important to you to include in your discharge plan,” Dana identified the priorities of finding safe housing and employment with fair pay. Therefore, the nursing team recommended that upon discharge, Dana would transfer directly to community wraparound services for a variety of assistance including transitional housing, job training, day care, medical care, and cognitive behavioral therapy.

Reflective Questions

What actions did the nurses perform with Dana to implement Trauma Informed Care (TIC)?

What other actions do you plan to implement with your patients regarding TIC?

“Dana” could be a male or a female, and Dana’s “partner” could be a male or a female. Do gender differences or sexual orientation affect your attitudes toward Dana’s risks and follow-up care?

How might Dana’s children be affected by Dana’s ongoing abuse?

What if Dana’s partner showed up at the hospital with a gun threatening to kill Dana? How would you respond as a nurse to keep yourself, other patients, and staff safe?

15.8. LEARNING ACTIVITIES

XV. GLOSSARY

Adults who have a physical or mental condition that impairs their ability to care for their own needs.

Traumatic experiences during childhood such as neglect, abuse, or witnessing violence, substance abuse, mental illness, divorce, or imprisonment of a family member.

A person who has taken responsibility for all or part of an individual’s care.

A break in how the mind handles information, causing a person’s disconnection from their thoughts, feelings, memories, and surroundings.

An intentional act or failure to act that causes or creates a risk of harm to an older adult aged 60 or older.

Verbal or nonverbal behaviors that inflict anguish, mental pain, fear, or distress, such as humiliation or disrespect, verbal and nonverbal threats, harassment, and geographic or interpersonal isolation.

The illegal, unauthorized, or improper use of money, benefits, belongings, property, or assets for the benefit of someone other than the individual.

Trauma resulting from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and can have lasting adverse effects on their functioning and mental, physical, social, emotional, or spiritual well-being. Adverse childhood experiences are examples of individual traumas.

Abuse or aggression that occurs in a romantic relationship. IPV can include physical violence, sexual violence, stalking, or psychological aggression.

Nurses and other professionals required by state law to report suspected neglect or abuse of children, adults at risk, and the elderly they see in the course of their professional duties.

When a parent or caregiver fails, refuses, or is unable, for reasons other than poverty, to provide the necessary care, food, clothing, or medical or dental care, which seriously endangers the physical health of a child or vulnerable adult.

Injury inflicted on a child or vulnerable adult by other than accidental means. Physical injury includes, but is not limited to, lacerations, fractured bones, burns, internal injuries, severe or frequent bruising, or great bodily harm.

The ability to rise above circumstances or meet challenges with fortitude. Resilience includes the process of using available resources to negotiate hardship and/or the consequences of adverse events.

A healthy balance of stimulation by the sympathetic nervous system (SNS) and parasympathetic nervous system (PNS).

A set of actions that can help lower the risk of a person being hurt by an abusive partner that includes specific information and resources that increases their safety at school, home, and other places visited regularly.

Sexual intercourse or sexual touching; sexual exploitation; human trafficking; forced viewing of sexual activity; or permitting, allowing, or encouraging prostitution with a child or vulnerable adult.

Intimate partner violence that occurs during adolescence.

A strengths-based framework that acknowledges the prevalence and impact of traumatic events in clinical practice, placing an emphasis on instilling in patients a sense of safety, control, and autonomy over their life and health care decisions. The basic goals of TIC are to avoid retraumatization; emphasize survivor strengths and resilience; aid empowerment, healing, and recovery; and promote the development of survivorship skills.

Physically and psychologically damaging actions that occur in the workplace or while on duty. Examples of workplace violence include direct physical assaults (with or without weapons), written or verbal threats, physical or verbal harassment, and homicide.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing: Mental Health and Community Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 15 Trauma, Abuse, and Violence.
• PDF version of this title (53M)

In this Page

• INTRODUCTION
• ADVERSE CHILDHOOD EXPERIENCES
• TRAUMA-INFORMED CARE
• ABUSE AND NEGLECT
• INTIMATE PARTNER VIOLENCE
• WORKPLACE VIOLENCE
• SPOTLIGHT ACTIVITY
• LEARNING ACTIVITIES

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Caring for women subjected to violence: a WHO curriculum for training health-care providers, revised edition, 2021

WHO is launching a “Revised edition, 2021” for the Caring for women subjected to violence: A WHO training curriculum for health-care providers today. The revised edition includes 4 new modules three of which are for health managers to assess and strengthen health facility readiness and one module, which is for managers and providers to support prevention of violence against women. The earlier content published in 2019 remains unchanged . The 2021 edition is aimed at creating an enabling health systems environment for health workers to provide quality care to women subjected to violence.

Companion guide:   Addressing violence against women in pre-service health training: integrating content from the Caring for women subjected to violence curriculum , 2023

Related tools

• Handouts 28 pages
• Resources for exercises 110 pages
• Slide Deck , 315 pages, PDF, 14 MB (All sessions)

Sessions presentations (pptx)

Orientation and introductions  

Session 1. Understanding violence against women as a public health problem

Session 2. Understanding the survivor’s experience and how providers’ values and beliefs affect the care they give

Session 3. Guiding principles and overview of the health response to violence against women

Session 4. Provider–survivor communication skills

Session 5. When and how to identify intimate partner violence

Session 6. First-line support using LIVES, part 1: Listen, Inquire, Validate

Session 7. Know your setting: identify referral networks and understand the legal and policy context

Session 8. First-line support using (LIV)ES, part 2: Enhancing safety and providing Support

Session 9. Clinical care for survivors of sexual assault/rape, part 1: history-taking and examination

Session 9a. Forensic examination (supplemental)

Session 10. Clinical care for survivors of sexual assault/rape, part 2: treatment and care

Session 11. Documenting intimate partner violence and sexual violence

Session 12. Care for mental health and self-care for providers

Session 13. Addressing family planning and HIV disclosure for women subjected to violence (supplemental)

Session 14. Assessing health facility/service readiness (module for health managers)

Session 15. Strengthening service readiness: improving health workforce capacity  (module for health managers)

Session 16. Strengthening service readiness: improving infrastructure for privacy,  ensuring supplies (module for health managers)

Session 17. Preventing violence against women (supplemental)

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A nurse is giving a presentation about family violence at a local community center. A)True B)False

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The given statement "A nurse is giving a presentation about family violence at a local community center" is A) True because it important to educational activity that healthcare professionals

In this context, the nurse's presentation on family violence at a community center is a common and important educational activity that healthcare professionals engage in to raise awareness about domestic violence, provide support and resources for individuals experiencing violence in their families, and promote prevention strategies.

By addressing topics related to family violence, the nurse can contribute to community education, advocacy, and the overall well-being of individuals and families impacted by violence. Such presentations are valuable in increasing understanding, encouraging open dialogue, and fostering a supportive environment for those affected by family violence.

The answer is A) True.

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