Threads of Violence_Story Graphics_Header
PatNormandin_authorphoto By Patricia A. Normandin DNP, RN, CEN, CPN, CPEN, FAEN

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Connect with on the Circle
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Threads of violence

Violence occurs across lifespans, ethnic groups, genders, and economic incomes. Perpetrators continue to prey on vulnerable people and think they will get away because it is a complex situation not always easily recognized. But if we empower ourselves with forensic science knowledge, this can be stopped. 

As nurses, we may be a survivor’s only access to care. Each of us can be the eyes, ears, voice, and advocate regarding forensic science during patient care because all nursing settings are untapped opportunities to expose hidden interpersonal violence situations. Perpetrators know how to systematically dominate and control those vulnerable to persuasion. Understanding trauma-informed care principles can guide nurses’ therapeutic communication and response when uncovering hidden violence.

Things are not always what they seem—I’ve learned that all too well.

On an extremely cold, snowy night, I was working the evening shift as a triage nurse in the emergency department. A very distressed and anxious mother ran in with her 3-month-old baby, who she said was very sick. This situation was not unique in my line of work, but when I peeked at her baby, she was sleeping in the mother’s arms, warm, pink, vital signs normal, in no distress. 

I asked her, “Is this your first child?”

“No,” she responded. “This is my third.”

There it was—my red flag. Why would she, an “experienced mother,” leave home in the middle of a cold, snowy night, with her tiny (seemingly healthy) baby?

I decided to bring the baby directly back to a room to see the doctor because the mother was so upset. Because of my forensic emergency nursing experience, I felt this approach would be best, rather than ask about her safety right then and there. I needed to validate her concern first and develop trust between us. 

Unfortunately, even after sharing my concern with the doctor, he did not agree. The baby was discharged without the mother being screened for intimate partner violence. 

I learned a big lesson that night. I couldn’t leave the screening up to anyone but me. In that moment, I decided I would go on a quest for an evidence-based approach to screening mothers of children brought into the emergency department.

So, as a focus of my doctoral research, I developed the “See, Pull, Cut the Threads of Violence” format.


Seeing
violence
It’s important that nurses in all work settings educate themselves on signs of violence, at least specific to their patient population to see risk factors. For example:

  • Nurses who care for neonates: Look at the family from a forensic view if the neonate is born with fetal alcohol syndrome or develops neonatal abstinence syndrome after birth. These may indicate the mother is in an unsafe living environment. Many people who become addicted to alcohol and drugs did not start out of choice but due to coercion, persuasion, or choice to block out their pain (incorporate trauma-informed principles). Consult healthcare provider and social services for plan of care and follow-up.
  • Nurses who care for infants, children, and adolescents: See every visit from a forensic perspective. Be sure to have the child completely undressed to do a head-to-toe skin assessment for symptoms or signs of injuries or scars from abuse. Look in hidden areas such as in between toes and under the hair line. Does the child have bruising in areas that developmentally could not have self-injured? Signs of neglect of the child would include poor hygiene, immunizations not up to date, malnourishment, poor dental health, missing pediatric well-child check-ups, and delay in developmental milestones without medical cause. Adolescents are at high risk to become involved in violent situations due to their developmental stage and inexperience with relationships.

    Notify the healthcare provider (including social services) if you suspect any abuse or neglect to collaboratively plan for child safety. Also, privately assess the mother’s safety for intimate partner violence or human trafficking. Always ask the mother when she is alone. Remember children have ears and the perpetrator may quiz the child when they return home to see what the nurse asked the mother. Developmentally, children 3 years old and older may be able to repeat what was spoken between the nurse and mother. Perpetrators may ask the child questions upon return from the hospital which can make a dangerous and/or deadly situation for the mother. 
  • Nurses who care for antepartum, peripartum, and postpartum women: Analyze each woman from a forensic perspective because this is a high-risk time for intimate partner violence. During the perinatal time, the woman’s responsibilities expand to care of herself (involving frequent doctor visits) and a neonate who is totally dependent on the mother. The birth of a child increases the financial responsibility on the partner, too. Partners may feel neglected, angry, and stressed which can lead to unhealthy, violent episodes in the relationship.

    Past medical history can raise some red flags, too—women in human trafficking situations may report multiple partners and not be allowed to use birth control, leaving abortion as her only option. 
  • Nurses who care for other vulnerable persons: Women, elders, disabled persons, transgender, gender-nonconforming persons, undocumented immigrants, and other vulnerable persons are also at high risk. Utilize a trauma-informed approach to individualize communication. 
  • Nurse educators: I challenge every nurse educator, no matter what setting you teach in, to educate all new nurses and interdisciplinary care providers about forensic science. In order to fulfill our purpose as patient advocates, we have to be able to identify intimate partner violence, human trafficking, child abuse, elder abuse, and persons with disabilities abuse. These patients need to be identified and offered interventions and referral. Beyond that, nurse educators need to ensure that the agency in which they work has policies and procedures in place that address these forensic issues, so nurses can offer interventions and referrals. If they are not in place or clear, I challenge you to collaboratively write them!


Pulling
the threads
Using a trauma-informed care therapeutic communication approach will help pull information from the survivor. This means that we apply empathetic communication because we do not know what psychological or physical trauma the patient has experienced in the past. The patient could have a hidden post-traumatic stress disorder. Be mindful that our communication should be therapeutic and be careful not to retraumatize the patient by our inquiry if the patient does not want to discuss. 

Should they choose to leave the situation, offer resources and services. But if the patient prefers to stay in the situation, it is vital that we support their decision with resources, ensure a safety plan, and phone numbers to call in case of emergency.


Cutting
the threads of violence
Nurses must appropriately report (cut) while abiding by HIPAA and medical-legal reporting laws. But, to make things more complicated, every state has their own medical-legal reporting laws. They vary from state to state regarding nurses as intimate partner violence mandated reporters. (I’ve linked a few websites in the resources section on the left, but I suggest confirming with the Board of Registration of Nursing where you live and work.)

Additionally, investigate what social services are available to patients in unsafe situations in your community. I’ve personally called each agency in my area to ask these questions:

Additionally, investigate what social services are available to patients in unsafe situations in your community. I’ve personally called each agency in my area to ask these questions:

  • What is your target population? 
  • What are your hours?
  • Do you offer housing? If yes, do you offer housing for families or only for adults?
  • Do you address the needs of intimate partner survivors? 
  • Do you have housing or services for human trafficking survivors? 
  • What other specific services do you offer to address substance use disorders, behavioral health conditions, immigration issues, and outstanding legal warrants?

Active participation in the legislative process that protects patients from violence is a method to cut these threads, too. Nurses collaborating with the legal system is empowering for patients to allow advocacy from a medical-legal standpoint.


Our power
Victims of violence may be deeply embedded in unsafe situations without the personal tools to see the red flags of danger, or it could be a family member, friend, or person of perceived authority that is committing these horrific acts. We have the power to stand up and advocate for them.

I’ll never know what happened to that mother and her tiny baby after that night in the ED. I hope she is out there somewhere, removed from her past situation, and safe. What I do know is that since then, I’ve done everything in my power to help others like her. Maybe if we all train ourselves to look for the threads, we can unravel the power of intimate partner violence all together.

 

Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, FAEN, is a member of Sigma’s Pi Epsilon at-Large Chapter and Theta at-Large Chapter. She is an Emergency Department Staff RN and Nurse Scientist at Tufts Medical Center and Floating Hospital for Children. She is Adjunct Faculty at Tufts University School of Medicine in Boston, Massachusetts, USA and at Curry College School of Nursing in Milton, Massachusetts, USA.

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