Week 11

I N TI MATE PARTN E R VI OL E N C E
A BU SE
T RAU MA- IN FORM ED C ARE
 Learning Outcomes
1. Discuss IPV & approach to care
2. Discuss abuse & neglect (child, elder)
3. Identify components of the assessment & documentation
4. Discuss mandatory reporting
5. Discuss trauma Informed Care Describe situations for mandatory reporting of abuse (child, elderly, nurses)
6. Discuss HCP approach - perspective, physical examination and documentation
7. Assess for the risk for homicide when working with suspected IPV cases
8. Define the terms of Crisis, Trauma, Violence and Trauma informed Care and Approach
9. Discuss examples of relationship between Violence and Trauma
10. Identify & discuss types and phases of crisis
11. Identify key principles of a trauma informed approach
Intimate
Partner
Violence
 Intimate Partner Violence (IPV)
 Spousal violence and violence committed by current or former
dating partners
 Spousal abuse: physical/sexual violence, psychological violence,
or financial abuse within current/former marital or common-law
relationships, including same-sex spousal relationships
 May include physical/sexual assault, verbal abuse, imprisonment,
humiliation, stalking, denial of access to financial resources,
shelter, or services
 Gender is a key risk factor – women greater risk IPV/ sexual
violence
Copyright © 2019 Elsevier, Inc.
 Three types of IPV-
1. partner terrorism- coercive control -one partner tries to control
the other-results in the most severe health consequences- is most
commonly perpetrated by men
2. resistant violence -a person who is a victim of intimate terrorism
responds with violence
3. situational couple violence- couple conflicts turn to aggression &
becomes violent.-most common IPV
 Health Care Providers’ Responses to
Intimate Partner Violence (IPV)(HHI)
 inconclusive evidence: whether routine screening is effective
greater detection: not necessarily lead to meaningful responses
women report negative experiences with health care providers (HCPs)- focus
on physical consequences, rather than effects and context of IPV
(Jarvis, 2019)

IPV INTERPERSONAL VIOLENCE

Copyright © 2019 Elsevier, Inc.

 Assessing for IPV- Pointers for Health Care
Providers
◦ assume that most patients have a history of abuse of some form
◦ assume some may be currently experiencing abuse
◦ provide care appropriate for those with histories of abuse, whether or
not abuse has been disclosed
◦ routinely inquire about home/work life effects on health

Copyright © 2019 Elsevier, Inc.

 Self-reflection-HCP perspective

 What do I know about IPV?

 What are its causes?
 What are my own experiences?
 How do my beliefs influence the care I give?

What groups do you think are most vulnerable? Could be gender/

cultural/age/ demographic/

Jarvis, 2019
Responding Safely to Intimate Partner
Violence
 may not identify their experiences as abuse
 may be ashamed or anticipate judgement
 privacy may not be available
 may fear responses from HCPs: increase their risks, increase danger - increase the risk
that children will be apprehended.
 Do not stereotype: HCPs ask about IPV with people racialized or living in poverty-
perpetuating stereotypes
Despite the wide-ranging and severe health problems associated with IPV
and the fact that women who are experiencing IPV access health care more
than women who are not abused, primary care providers continue to miss
opportunities for offering support.74 Furthermore, while research shows the
prevalence and interconnections between various health problems and IPV,
victims of violence often must prioritize presenting one health issue to HCPs
and face service delivery silos and institutionalized barriers.43 Some
challenges to providing safe, effective responses to IPV include:
 Effects of Violence on Health

Direct effects: physical injury (bruises, fractures) Mental health problems:

clinical depression
acute and chronic symptoms of
Chronic health problems: anxiety
serious sleep disturbances
Chronic pain
post-traumatic stress disorder (PTSD)
Neurological
Gastrointestinal substance use and dependence

Gynecological thoughts of suicide

 Assessing Collaboratively
Following person’s lead

Listen for cues of abuse

Self-observation- your biases & assumptions

Recognize patterns- physical (injury, chronic pain) & health (sleep, substance abuse)

Develop knowledge- help them understand patterns and danger

Focus on strengths Jarvis, 2019

Copyright © 2019 Elsevier, Inc.

 Follow the lead of the patient: convey trustworthiness and a willingness to listen, allow the
patient to take the lead in disclosing (or not), and draw on the patient's knowledge to assess the
levels of danger and options.
• Listen for cues that might suggest abuse.
• Self-observe: pay attention to how your assumptions and biases shape your interactions and
how you are reacting.
• Recognize patterns: attend to patterns of physical symptoms (e.g., injuries, chronic pain) and
health problems (e.g., substance use, sleep problems).
• Develop knowledge collaboratively: for example, help individuals recognize connections
between health problems and abuse, and help them evaluate levels of danger.
• Name and support capacity: focus on strengths and capacities; for example, you might say, “It
sounds as though you have been through a lot—you are doing a great job of …”
 Assessing for Risk of Homicide
In Canada, spousal homicide of women 3-4 times higher than men
Indigenous rate 6xs higher than Non-Indigenous

Danger assessment tool:

◦ Determines level of danger
◦ More yes answers more danger
◦ Develop a safety plan
◦ Ongoing support or referral
◦ https://www.dangerassessment.org/DATools.aspx

If the adult person does not want domestic violence or police involved you
cannot call them. Instead you can offer information or pamphlets to them.
If you are not sure call the domestic violence team and seek their input.
Copyright © 2019 Elsevier, Inc.
Case study
IPV
 Child Abuse/
Maltreatment
in j u r y d oe s match t h e stor y, l et C A S

Does a nurse report suspected child abuse?

Nurse has legal ac on to report it
 Child Maltreatment
 Child and Family Services Act, 1990, requires all health care professionals to
report suspected child abuse to the Children’s Aid Society
evaluate any physical injury within the context of a child's age and
developmental stage
Is the injury in line with the child's developmental level
 Child Maltreatment
Types of Child Abuse
Physical
Sexual
Neglect (more common)
Emotional (more common)

Most often occurs in the home by someone known to child

Not always a parent

Not sure if this is intentional

 Child Abuse and Neglect
Child abuse and IPV often overlap.
Types of abuse
◦ Physical
◦ Sexual
◦ Neglect Department of Justice Canada defines child abuse as follows: the
◦ Emotional violence, mistreatment or neglect that a child or adolescent may
experience while in the care of someone they either trust or depend
on, such as a parent, sibling, other relative, caregiver or guardian.
Abuse may take place anywhere and most commonly occurs within
the child's home and by someone known to the child.

Copyright © 2019 Elsevier, Inc.

 Child Abuse: Physical Abuse

Pushing or shoving Holding someone down for

Hitting, slapping, or kicking someone else to assault

Strangling or choking Locking someone in a room or tying

them down
Pinching or punching
Killing someone
Stabbing or cutting
Shooting
Throwing objects at someone
 Child Abuse: Sexual Abuse

Makes sexual comments to a child,

Watches or films a child for sexual
purposes
Sexual contact between an adult
and a child < 16 is a crime
Sexual contact with a child
between 16-18 without consent
Sexual contact that exploits a child
< 18
< 18 cannot give consent to sexual
activity that exploits them

2 year gap
 Child Abuse
NEGLECT- NOT:
Providing proper food or warm clothing
Providing safe and warm place to live
Ensuring child washes regularly
Providing enough health care or
medicine
Meeting child's emotional needs
Preventing physical harm
Supervising child
Not always intentional,
EMOTIONAL ABUSE
Putting a child down or humiliating a
child
Criticizing a child
Constantly yelling at a child
Threatening to harm a child or others
Keeping a child from seeing their
family/friends
Threatening to move a child out of the
home
 Consideration for HCPs- Child Maltreatment
Points to remember
 Can occur to any child- regardless of the ethnicity or income
 no ethnic group is at “greater risk” of perpetrating child maltreatment
 investigations four times higher among Indigenous children
Parents/Home child maltreatment puts children at risk for
experiencing depression and PTSD,

 Parents may not be the perpetrators participating in harmful activities, having

difficulties in relationships, and having negative
beliefs and attitudes toward others
 Removal of children from home is stressful for children
 Evaluate parenting-focus often on mother even if not the perpetrator
 HCP must provide good care even to perpetrator
 Your role is not to rescue the child at the expense of relationships Jarvis, 2019
Copyright © 2019 Elsevier, Inc.
Elder Abuse & Neglect
 Elder Abuse & Neglect
Physical abuse or neglect
◦ failure to provide basic services,
◦ psychological abuse or neglect (failure to provide stimulation)
◦ financial abuse or neglect

Inflicted by any persons in a situation of power or trust

In homes or institutions
Older women at higher risk than older men

Copyright © 2019 Elsevier, Inc.

Elder abuse/neglect: Physical examination

Complete head-to-toe examination

Remember-multiple factors can contribute to bruises in older adults:
◦ Medications and abnormal blood values
◦ Underlying hematological disorders
◦ Accidental bruising (on extremities)

Health evaluation known or suspected elder abuse/neglect include baseline laboratory

Copyright © 2019 Elsevier, Inc.

 When Abuse is Disclosed (IPV, Child,
Elderly)
 Assess level of risk- safety plan
 Identify personal strengths/supports
 Identify goals collaboration with patient
& other HCPs

Copyright © 2019 Elsevier, Inc.

Jarvis, 2019
History & Documentation
Prior abuse
History of traumatic injuries
Mental health examination
Detailed, objective, unbiased notes:
◦ statements specify perpetrator and threat
◦ verbatim used by the patient attributed to perpetrator

Use of injury maps

Photographic documentation eg "Bruising ecchymosis on forearm"

Copyright © 2019 Elsevier, Inc.

 Photographic Documentation
CHARACTERISTICS

•Patterned, punch-like abrasion to the mid-forehead

from an assailant wearing a ring with a stone.
•Sutured laceration to the left eyebrow.
•Sutured partial-avulsion injury to the nose.
•Punch-like contusion to the left eye involving the
sclera.
•Manual strangulation-related abrasion to the neck.

Copyright © 2019 Elsevier, Inc.

 Reportable Abuse

College of
Government Canada
Nurses of
of Ontario Criminal Code
Ontario (CNO)
 Sexual Assault

Canadian Criminal Code- sexual assault and sexual touching as

crimes.

4 levels of sexual assault:

1.Forced sexual activity without physical injury

2.Sexual assault with a weapon or verbal threats
3.Sexual assault causing bodily harm
4.Aggravated sexual assault
 Reporting requirements- College of Nurses of
Ontario (CNO)

 Client abuse-misuse of power-betrayal of trust, respect or

intimacy (in the therapeutic relationship) defined as:
 Neglect (e.g., failing to provide the necessities of life)
 Physical: (e.g., striking a client or causing discomfort)
 verbal/emotional: (e.g., shouting at or insulting a client)
 Financial: (e.g., soliciting gifts from a client)
 Sexual: (e.g., inappropriately touching a client)
 As a RN you must report (to CNO) a nurse:

 who poses a serious risk of harm to patients

 who is suspected of sexually abusing a patient
 who is incompetent: significant and repeated lack of knowledge,
skill or judgment-unfit to practice-or practice should be restricted
 who is incapacitated by physical/mental condition that restricts
their ability to practice
 Suspected Child Abuse

 Required by law to report suspected cases of child abuse or

neglect
 If you have reasonable grounds to suspect -must report it to a
children's aid society (CAS)

 http://www.children.gov.on.ca/htdocs/English/childrensaid/reportin
gabuse/index.aspx
 Reporting Elder Abuse

 Mandatory when an older adult resides in a Long-Term Care

Home/Retirement Home and elder abuse is suspected or has
occurred.
 Older adults with developmental disabilities: protected with mandatory
reporting legislation.
 Agencies providing services and supports mandated to report alleged/
suspected/witnessed abuse to the police

 http://www.eapon.ca/what-is-elder-abuse/legislation-reporting/
 http://www.eapon.ca/what-is-elder-abuse/legislation-reporting/
Trauma Informed Care

Crisis:

Copyright © 2014 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 36

 Trauma Informed Care

 practices that promote a culture of safety, empowerment, and healing

 medical office or hospital can be a terrifying experience for someone who has experienced
trauma, particularly for childhood sexual abuse survivors
Harvard, EDU, Mar 25, 2019
Trauma and Violence-Informed Care
◦ assume most patients will have a history of abuse of some form
◦ assume some may be currently experiencing abuse
◦ provide care that is appropriate for those with histories of abuse, whether or
not abuse has been disclosed
◦ routinely inquire about home/work life effects on health

Copyright © 2019 Elsevier, Inc.

Definitions:
C ri si s
Hand image is from Crisis Care Canada
Trauma
Vi ol ence
Trauma i nformed care a n d a p proach
 Crisis
 state of emotional distress
 subjective crisis state defined by client/family/ members of the community
 arising from situational, developmental, biological, psychological, sociocultural, and/or spiritual
factors.
 temporary inability to cope by usual resources/coping mechanisms
 Unless stressors alleviated and/or the coping mechanisms are bolstered- disorganization result
RNAO, 2017
 Trauma
 experience overwhelms capacity to cope occur at any age
 may include child abuse, neglect, violence and war interfere with sense of
safety, self, and self-efficacy
 interfere with ability to regulate emotions and navigate relationships
 out of control, frightening experience that has disconnected us from sense of
resourcefulness, safety, coping, or love
 multiple traumatic events, repeated experiences of abuse, prolonged abuse-
overwhelming- may have a significant impact on living
(Crisis Care Canada 2012)
 Violence
 intentional use of physical force or power, threatened or actual
 against oneself, another person, or against a group or community
 results in or has a high likelihood of resulting in injury, death, psychological harm,
maldevelopment, or deprivation
Health Canada (2018)
Relationship of Violence and Trauma
Different forms of violence can have interrelated traumatic effects
 Examples:
 Child maltreatment: increase person's vulnerability to interpersonal
violence in adulthood
 Children's exposure: to intimate partner violence (IPV)- negative health &
social outcomes similar to those from direct forms of abuse
 Exposure to systemic violence (such as racism): increase vulnerability to
other forms of violence
 Health Canada, 2018
systemic violence- can result in historical and intergenerational trauma- War- Refugee
encampment
generations that are safe and healthy environments bare the trauma from previous generations-
Nazi Germany/inhumane treatment of Jewish citizens- Aushwitz has carried forth to
generations.
Self-directed violence- exposure to interpersonal forms of violence –multiple traumas
experienced- person inflicts violence on themselves (self mutilation or “cutting”, substance
abuse, violent relationships, suicide.
 Developmental
Situational
Disaster or

Types of Crisis: adventitious crisis

RNAO, 2017
 Developmental/Maturation Crisis
 may occur during developmental stage physical, cognitive, instinctual, sexual changes
create internal conflict- may trigger a crisis
 response to crisis can result in psychological growth or regression
 Examples: major life events such as leaving home during late adolescence, marriage, birth
of a child, retirement, and death of a parent
(RNAO 2017; Jakubec, 2014)

Moved to Windsor from Toronto, unable to cope

 Situational
 crisis in response to events that are external and unanticipated
 examples- loss or change of a job, death of a loved one, financial troubles, exacerbation of a
chronic condition, or the experience of sudden illness
 examples- major life events such as leaving home during late adolescence, marriage, birth of a
child, retirement, and death of a parent
(RNAO, 2017)

Go to work, get fired,

hospitalized, worried about their bank account (suddenly lost their jobs ..)
 Disaster/Adventitious Crisis
 unexpected, unplanned, or random crisis results from events that are not part of everyday
life - natural disasters or violent crime
 may threaten survival
 experiencing or witnessing such events can also overwhelm a person’s ability to cope
 have the potential to challenge a person’s basic assumptions and world views
 increase vulnerability
 can cause long-lasting psychological harm (e.g. post-traumatic stress disorder (PTSD))
 can cause -anxiety disorders, substance use and mood disorders, and medical problems (such
as arthritis, headaches, and chronic pain
(RNAO, 2017)
Phases of Crisis Phase 4-
overwhelming
anxiety=
Phase 2- Phase 3-trial cognitive
impairment,
problem and error emotional
Phase 1- solving resolutions instability and
Problem= ineffective= ineffective= behavioural
anxiety severe disturbances
increased
anxiety anxiety/panic
RNAO, 2017

Phase 1: A problem arises that threatens the person’s self-concept, contributing to increased
anxiety levels. The anxiety stimulates the use of the person’s usual problem-solving techniques.
Phase 2: If the usual problem-solving techniques are ineffective, anxiety continues to rise,
producing feelings of extreme discomfort. The person makes trial-and-error attempts in an effort
to restore balance.
Phase 3: If the trial-and-error attempts fail, the anxiety escalates to severe or panic levels. The
person adopts automatic relief behaviours (such as compromising needs or redefining the
situation to reach an acceptable solution).
Phase 4: When measures are ineffective and do not reduce anxiety, the person transitions into a
state of overwhelming anxiety, which can lead to cognitive impairment, emotional instability, and
behavioural disturbances that signal the person is in crisis.
P1: exam coming up
P2: crisis solve?: if not, increase anxiety, (time management)(b/w work and school)
P3: try stuff (try to call in sick…)
P4: overwhelm, (emotional instability)
 Signs and Symptoms of Crisis
Unique to each person.
Examples of signs and symptoms of Crisis
Inability to meet basic needs
Decreased use of social support
Inadequate problem-solving
Inability to attend to information
Isolation
Denial
Exaggerated startle response
 List some signs and symptoms of a crisis
Hypervigilance Self-hatred
Panic attacks Feels strange
Perceived lack of control
Feeling numb
Weeping
Confusion
Grief/Sadness
Incoherence
Irritability
Depression Being on guard or jumpy
Physical symptoms (shaking,
headaches, fatigue, loss of appetite,
and aches and pains)
 Trauma Informed
Approaches
Guiding Framework-
Recommendations 1.1 to 4.4
1. Key Principles
2. Guiding Values

(RNAO, December 2017)

 Practice Recommendations for
Trauma Induced Care
Safety
Cultural, Trustworthin
ess and
Historical, and
Gender Issues transparency
Key Principles

Empowerment, Peer support

Voice, and Choice

Collaboration and
Mutuality

RNAO, 2017
 key principles of a trauma-informed
approach

Safety
Organizational: staff & people they serve feel physically and psychologically safe- physical setting is safe

interpersonal interactions promote a sense of safety Understanding safety concerns a high priority.

RNAO, 2017
 Key Principles Of A Trauma-informed Approach

Trustworthiness & transparency

Organizational: operations and decisions- transparency

goal of building & maintaining trust with persons/family members, among staff, others
involved in organization

RNAO, 2017
Key Principles Of A Trauma-informed Approach

Peer support

• peer support/mutual self-help-: key for establishing safety &

hope, building trust, enhancing collaboration, & using their
stories/lived experience to promote recovering and healing
• “peers”- individuals with lived experiences of trauma –
• “trauma survivors”

RNAO, 2017
Key Principles Of A Trauma-informed Approach

Collaboration and Mutuality

• importance placed on partnering & leveling of power between staff & persons, and
organizational staff (clerical, housekeeping personnel, professional staff, administrators)
• healing happens in relationships and sharing of power and decision-making
• organization recognizes everyone has a role to play

RNAO, 2017
 Guiding Values
1. Avoiding Harm 7. The whole person
2. Intervening in person-centered ways 8. The person as a credible source
3. Shared responsibility 9. Recovery, resilience, and natural supports
4. Trauma informed 10. Prevention
5. Establishing feelings of personal safety 11. Services are provided in the least
restrictive manner
6. Strength based
12. Right are respected

(RNAO, December 2017)

1. Avoiding harms- Interprofessional team members work towards establishing physical and
psychological safety for the person experiencing crisis, their family, and their nurse and/or
health-care provider. The individual in crisis will be treated with respect at all times.
2. Intervening in person-centered ways. Interprofessional team members seek to understand
the person and their circumstances, goals, and self-identified needs and preferences for
support, and how these can be incorporated in the crisis response and used to provide
interventions that best meet their needs.
3. Shared responsibility. Interprofessional team members collaborate with persons
experiencing crisis to help them regain control over their life. They also work with persons
experiencing crisis to engage them as active participants in their care.
4. Trauma-informed. Interprofessional team members recognize and understand the impact of
trauma histories on the lives of people experiencing crisis.
5. Establishing feelings of personal safety. Interprofessional team members work with persons
experiencing crisis to establish personal safety, a sense of security, and an understanding of
what may increase feelings of vulnerability. The provider takes the time to understand the
needs of the person experiencing crisis and works to address them.
 Case study:
 Sue: 20yrs, South Asian descent
 Comes to ED with onset of preterm labours , 7 months pregnance
 Fell, Bruises on her jaw, and her right lower arm
 Is she at risk for intimate partner violence:
• Do not need to know the statistics
• Abuse during pregnancy is a significant health issues, with serious consequences
What approach should be in responding to potential interpersonal violence?

• what is danger assessment? Is an instrument for women for more accurately see for
themselves how frequent and severe the violence has become over the past year.
Health care providers can also determine their risk of homicide
 If abuse is discovered, what should you do?
 You should convey the abuse is not the pt’s fault
 Convey help is possible
 Documentation must included detailed, nonbiased progress notes, the use
of injury maps, photographic documentation in health records
 Include verbatim statements in documentation, especially statement that
identify the reported perpetrator and severe threats of harm made by the
reported perpetrator
 Follow established policies and procedures to assess, documenta and
make referrals for intimate partner violence

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