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Domestic Violence Education for Florida Nurses

Online Continuing Education Course

Course Description

MANDATORY NURSING CEU FOR FLORIDA: RN/LPN/CNS/ARNP. CNE course covers care for victims of domestic violence, health effects on adult and child victims, legal remedies for protection, lethality and risk issues, available community resources and victim services, and reporting requirements in Florida.

Course Price: $20.00

Contact Hours: 2

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This course fulfills the Florida requirement for 2 hours of continuing education on domestic violence. We report to CE Broker within 24 hours for Florida license holders.

Domestic Violence Education for Florida Nurses

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this continuing education course, you will have increased your understanding of the impact of domestic violence and the role of the Florida nurse in identifying and responding to patients presenting with known or suspected domestic violence signs and symptoms. Specific learning objectives include:

  • Define “domestic violence” according to Florida law.
  • Describe who is affected by domestic violence.
  • Identify risk and lethality factors associated with domestic violence.
  • Discuss the types and dynamics of domestic violence.
  • Recognize the signs and symptoms of domestic violence.
  • State Florida’s reporting requirements.
  • Identify assistance available to protect victims of domestic violence.

INTRODUCTION


In Seminole County, Florida, Henry Brown, 30, the estranged husband of Chericia Brown, hid in the trunk of her car until she emerged from a restaurant. He stabbed her and tried to hide her in the bushes, but two medical professionals who were in the building saw what happened and attempted to assist Chericia. Henry then ran over Chericia and the two other persons with his vehicle, killing Chericia and injuring the other two. He drove away and picked up their children, ages 4 and 1, from a babysitter. Police pursued him on the interstate highway and, after disabling his vehicle with stopsticks, found the bodies of Brown and the two children inside, dead from gunshot wounds. This tragedy occurred in spite of previous 911 calls for help by Chericia months earlier and an investigation by authorities that determined that Henry Brown was not a danger (Parry, 2016).

This is but one example of recent domestic violence in the United States, where 1 in 3 women and 1 in 4 men are victims of domestic violence (NCADV, 2016). Viewed as a national public health problem, domestic violence is a crime in all 50 states.

The term domestic violence refers to physical, verbal, psychological, sexual, or economic abuse (e.g., withholding money, lying about assets) used to exert power or control over someone or to prevent someone from making a free choice. According to the U.S. Department of Justice (2010), “This includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound someone.” Rape, incest, and dating violence are all considered to be forms of domestic violence.

In Florida law, domestic violence is defined as any assault, aggravated assault, battery or aggravated battery, sexual assault or battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member by another family or household member.

Florida defines family or household member as current or former spouses, persons related by blood or marriage, persons who currently reside together or resided together in the past as if a family, parents of a child in common regardless of whether married or not. With the exception of those who have a child in common, the family or household members must currently reside or have in the past resided together in the same single dwelling unit (Florida Legislature, 2017).

DOMESTIC VIOLENCE TERMINOLOGY

Various other terms are used to refer to domestic violence:

  • Intimate partner violence (IPV) is a more specific term often used when referring to harm to a current or former partner or spouse.
  • Domestic abuse is a term that highlights the nonphysical components of an abusive situation; these include psychological or emotional abuse, threatening, and stalking, as well as neglect or financial exploitation, particularly of older adult family members.
  • Family violence is a term also used to described abusive domestic situations because children in the family may be affected, either as witnesses of violence and/or as victims themselves.

WHO IS AFFECTED BY DOMESTIC VIOLENCE?

Domestic violence may occur in the lives of persons of all ages, cultural/ethnic/religious groups, genders, and social classes. Intimate partner violence is one of the most common but least reported crimes, so it is impossible to know the actual incidence and prevalence. Feelings of shame, fear, and hopelessness often prevent victims from seeking protection and support. Many abused women do not report domestic violence to their healthcare provider or to anyone else. However, the statistics available confirm that the problem is pervasive and alarming.

Domestic violence is an ongoing and critical problem in Florida. According to recent statistics:

  • 107,666 domestic violence offenses were reported, leading to 66,276 arrests.
  • 184 domestically related murders were reported, with 108 perpetrators arrested.
    (Florida Department of Law Enforcement, 2016)

The economic impact of intimate partner or domestic violence that accompanies the personal and emotional impact is clear. This economic impact affects the victim, the employer, and the community. Research indicates that victims of domestic violence in the United States lose 8 million work days, or the equivalent of more than 32,000 full-time jobs, annually. Individuals may develop strained relationships with employers due to poor job performance, tardiness, and absenteeism (CDC, 2015).

In Florida’s Orange County alone, the economic impact was found to be staggering. Domestic violence in 2013–2014 cost employers $164.5 million in absenteeism, medical expenses, and mental health costs (Harbor House, 2015).

Domestic Violence among Women

Victims of domestic violence are usually women and children. Perpetrators of domestic violence are generally, though not always, men. According to the Centers for Disease Control and Prevention (CDC), more than 12 million women and men are victims of intimate partner violence over the course of a year. Many victims do not report IPV to police, friends, health professionals, or family, so these statistics underestimate the problem (CDC, 2012).

Teens and Dating Violence

Teen dating violence is another form of domestic violence that is disturbingly common among high school students and can result in serious long-term and short-term effects. The nature of dating violence can be physical, emotional, or sexual. Dating violence can also include stalking and can take place in person or electronically.

As with adult victims of IPV, many teens do not report their victimization, but according to a 2013 survey, approximately 10% of high school students reported being physically victimized by a boyfriend or girlfriend and another 10% reported sexual victimization from an intimate partner (Kann et al., 2014).

A CDC survey discovered a relationship between adult victims of sexual or intimate partner violence and early exposure to some form of violence between the ages of 11 and 17. This relationship was identified in 23% of females and 14% of males who ever experienced rape, physical violence, or stalking as adults (CDC, 2016b).

Those who harm their dating partners are more likely to be depressed and more aggressive than their peers. Other characteristics of abusive dating partners include:

  • Trauma symptoms (irritability, anxiety, anger, difficulty concentrating, or insomnia)
  • Exposure to harsh parenting
  • Exposure to inconsistent discipline
  • Lack of parental supervision and warmth
  • Belief that using dating violence is acceptable
  • Alcohol use
  • Behavioral problems in other areas
  • Having a friend involved with dating violence
    (CDC, 2016b)

Consequences of teen dating violence may include:

  • Depression and anxiety
  • Tobacco, alcohol, and drug use
  • Antisocial behaviors
  • Thoughts about suicide
  • Continued victimization in college
    (CDC, 2016b)
DATING VIOLENCE AND FLORIDA LAW

Florida legislation defines dating violence as “violence between individuals who have or have had a continuing and significant relationship of a romantic or intimate nature.” The existence of such a relationship is determined based on the consideration of the following factors:

  • A dating relationship must have existed within the past 6 months.
  • The nature of the relationship must have been characterized by the expectation of affection or sexual involvement between the parties.
  • The frequency and type of interaction between the persons involved in the relationship must have included that the persons have been involved over time and on a continuous basis during the course of a relationship.

The term does not include violence in a casual acquaintanceship or violence between individuals who only engaged in ordinary fraternization in a business or social context. It clarifies that those who are in a dating relationship are not required to have resided together to be eligible for an injunction for protection against violence.

Source: Online Sunshine, 2017a.

Domestic Violence among Older Adults

Florida statutes define older adults as ages 60 and over and include disabled adults ages 18 to 60 within the same statute that protects elders. Abuse is defined as any intentional act, threat, or act of omission that leads to impairment of the vulnerable person’s physical, mental, or emotional well-being by a relative, caregiver, or member of the household (Online Sunshine, 2017b).

Knowledge of elder abuse is thought to be about 20 years behind the fields of domestic violence and child abuse, and there is an urgent need for research on the topic (NCEA, 2016). Abuse of older adults may be missed by professionals who work with these patients because of a lack of training in detecting abuse. Abuse may go unreported by the victims themselves because they may be unable to physically or cognitively seek help, they do not want to get the abuser in trouble, or they fear retaliation.

Various studies on elder abuse present different findings, but the most common type of elder abuse is financial, followed by neglect, physical, and sexual abuse.

The most common physical findings of physical abuse among older or disabled adults include physical injuries that are common to victims of violence or neglect, and increased susceptibility to new illnesses (NCEA, 2016).

Domestic Violence among Minority Racial and Ethnic Groups

Domestic violence is a crime without cultural boundaries. It affects people from all walks of life regardless of race, religion, or economic class.

Some cultures believe that the family is the only appropriate forum for dealing with domestic violence, and outside interference is not encouraged or accepted. Other ethnicities may even resist acknowledging that domestic violence exists as a problem. It can be challenging to assist victims who do not understand that help is available. Language barriers and lack of knowledge of legal rights or resources can also be an obstacle to seeking help. Similarly, some victims may not trust the police, fear deportation, feel shame or guilt, or have a history of child victimization. It is essential for health professionals to consider cultural differences when working with immigrant and diverse communities in order to provide appropriate and sensitive services (NIJC, 2013).

The predominant minority racial/ethnic communities in Florida are Hispanic (26%), African Americans and Afro-Caribbeans (16%), with very small percentages of Native Americans, Asians, and other groups (U.S. Census Bureau, 2015).

U VISA and T VISA

The U visa is a nonimmigrant visa that was created in 2000 with the passage of the Victims of Trafficking and Violence Protection Act (including the Battered Immigrant Women’s Protection Act). It is a unique visa for victims of crimes who have suffered substantial mental or physical abuse and are willing to assist law enforcement in the investigation or prosecution of the criminal case. It was developed with the intent to strengthen the ability of law enforcement to investigate and prosecute certain types of cases.

Victims who are granted a U visa are given temporary legal status and work eligibility in the United States for up to four years. This program helps law enforcement agencies assist many victims of crimes who would otherwise not be served.

The T visa is a similar plan in which qualifying victims of trafficking, along with approved family members, may reside in the U.S. for approximately four years if they comply with criminal justice system requests.

Sources: U.S. DHS, 2016, 2014.

Intimate Partner Violence and Lesbian, Gay, Bisexual, Transgender, Queer/Questioning and Intersex Persons

An estimated 3.5% of persons who live in Florida identify as lesbian, gay, bisexual, or transgender (Gates & Newport, 2013). The national Violence Against Women Survey summarizes the second year of data collection from the National Intimate Partner and Sexual Violence Survey (Breiding et al., 2011), in which 21.5% of men and 35.4% of women who live with a same-sex partner reported intimate-partner physical violence in their lifetimes.

Persons who identify as lesbian, gay, bisexual, transgender, queer/questioning, or intersex (LGBTQI) do not often access services or report to the police. There are many reasons they do not seek help, such as:

  • An LGBTQI victim may fear that the abuser will reveal his or her sexual orientation or biological gender to family, friends, or coworkers.
  • Abusers may threaten to reveal an infected person’s positive HIV status to others or to transmit HIV to the victim if he or she is HIV negative.
  • These individuals fear institutional discrimination and homophobic or transphobic care providers.
  • A transgender person may not have undergone sexual re-assignment surgery and may avoid a physical exam by a clinician that might include observation of his or her genitals.

Law enforcement authorities may not recognize same sex individuals as intimate partners and may have a difficult time determining the primary abuser or that the assaultive behavior is actually a domestic crime. Access to services is severely limited by lack of shelters that serve male victims. Sensitivity to the needs of this group is paramount to effecting social change and helping victims receive needed assistance (Sanctuary for Families, 2014; NCAVP, 2012).

HEALTH EFFECTS OF DOMESTIC VIOLENCE

Domestic violence has an enormous impact on the health of those who are affected as well as on the healthcare system. Injuries sustained during episodes of violence are only part of the damage to victims’ health.

Physical and psychological abuse are related to other adverse effects, including complaints such as headaches, back pain, pelvic pain, gastrointestinal disorders, gynecological disorders, obstetrical problems, sexually transmitted infections, central nervous system disorders, and heart or circulatory conditions. Intimate partner violence is also linked to mental health problems, including depression, anxiety, antisocial behavior, low self-esteem, inability to trust men, fear of intimacy, posttraumatic stress disorder, substance abuse, suicide, and risky sexual activity (Dillon et al., 2013).

Children who are subjected to domestic violence develop problems such as attachment disorder, depression, anxiety, and oppositional defiance disorder. A violent environment will have the greatest adverse effects on the brains of the youngest children, even infants. This is because the developing brain of a child is highly sensitive, and the chronic state of fear and stress that these children experience prevents the brain from developing normally. Instead, the brain is influenced adversely by abnormal patterns of neurological activities and brain chemicals (Child Welfare Information Gateway, 2015).

RISK FACTORS AND LETHALITY

Common Risk Factors

The National Institutes of Health published a systematic review of risk factors for intimate partner violence (Capaldi et al., 2012). They include:

  • Low self-esteem
  • Age range in adolescence and young adulthood
  • Unemployment and low income
  • Minority group membership
  • High levels of acculturation stress
  • Financial and work-related stress
  • Lack of parental support and/or monitoring in adolescents
  • Adolescent involvement with aggressive peers
  • Social isolation
  • Conduct problems
  • Depression and irritability
  • Substance use
  • Separation
  • Low relationship satisfaction
  • Childhood victimization
  • Exposure to interparental violence
  • Alcohol use
POVERTY

Although domestic violence is found in all walks of life, those who live in poverty face additional challenges. The CDC (2016c) lists poverty as a risk factor for intimate partner violence. Poverty damages health and well-being in countless ways; exposure to domestic violence is just one. When IPV and persistent poverty intersect, they limit coping options. Both poverty and IPV lead to stress, feelings of powerlessness, and social isolation, which combine to produce posttraumatic stress disorder, depression, and other emotional difficulties.

Such women face risks from the batterer and risks resulting from their poverty.

  • Risks from the batterer include physical injury; threats and loss of security, housing, and income; and potential loss of their children.
  • Risks from poverty include food insecurity, lack of access to health insurance and healthcare, possibly racism, unsafe neighborhoods, and poor schools for their children.

The double jeopardy of poverty and IPV challenges abused women and the healthcare and social service professionals responsible for protecting them. Intervening to stop the violence is only the first step. Issues of income, housing, and healthcare—both mental and physical—must also be addressed. For instance, research shows that domestic violence is a primary cause of homelessness for women and families. A study in Massachusetts showed that 63% of homeless women were survivors of IPV (National Alliance to End Homelessness, 2014).

FAMILY/CAREGIVER STRESS

Families stressed by illness, unemployment, alcohol, and/or drug use are more likely to experience violence. This is particularly true with elder abuse, especially if the older person is frail or mentally impaired, the caregiver is poorly prepared for the task, or needed resources are unavailable. Adult children who abuse their parents frequently suffer from mental and emotional disorders, alcoholism, drug addiction, and/or financial problems that make them dependent on the parents for support. These families respond to tension or conflict with violence because they have not learned any other way to respond.

PREGNANCY

IPV often begins or escalates during pregnancy, making pregnancy an especially dangerous time for women in abusive relationships. Any type of abuse during pregnancy increases the risk of health problems for the woman and the unborn child because a pregnant woman is particularly vulnerable both physically and emotionally.

Trauma from physical abuse can cause a woman both acute injury and increase her risk for an obstetrical emergency, preterm birth, complications during labor, or miscarriage later in the pregnancy (NDVH, 2013). Battering can also lead to posttraumatic stress disorder and the continuation of unhealthy habits as smoking and drug or alcohol use. Abused women are also at high risk for postpartum depression.

Miscarriage, low birth-weight, or other injury may occur in the developing fetus, and a study by Lannert and colleagues (2014) suggests that a fetus whose mother experiences violence can be affected by her elevated cortisol levels. Cortisol is a neurotoxin, and babies who have a high cortisol exposure in utero may develop nightmares, intolerance to noise and bright lights, and emotional problems later in life. In other words, a baby whose mother is a victim of domestic violence can suffer consequences of the abuse even before being born.

DISABILITY/IMPAIRMENT

According to research, women with a disability are more likely to experience IPV than those without a disability (CDC, 2012). Having a disability limits a woman’s options for escaping or resolving the abuse (Nosek et al., 2001). Unemployment further disadvantages women with disabilities, decreasing their chances of being able to break the cycle of violence (Smith & Strauser, 2008).

Risk of Lethality

Without any sort of intervention, abuse tends to escalate. While not all abusers kill and there are no perfect predictors of time and place, research has revealed some patterns of escalation in domestic violence. The time of separation—when an abuse victim leaves the abuser and just afterward—presents the greatest threat to the abuser’s ability to maintain power and control.

Risk factors for domestic violence femicide or homicide include:

  • Previous nonfatal strangulation (7 times higher)
  • Separation from the abuser
  • Pregnancy (3 times higher)
  • Perpetrator substance or alcohol abuse (problem drinking is associated with twofold increase of completed or attempted femicide)
  • Access to firearms
  • Use of firearms during previous incidents of domestic violence
  • Perpetrator unemployment
    (Riviello, 2014)
SAFETY PLANS

A safety plan is something that an abuse victim can begin working on at any time. In a safety plan, the individual develops personalized and practical steps, both physical and psychological, to take while in the relationship, when planning to leave, and after leaving. Details on the elements of a safety plan, along with forms that a victim can use to create a plan, are available online. Nurses and other healthcare professionals should keep such forms and/or information available with other resources for domestic abuse victims.

Healthcare professionals can also use the following questions to evaluate immediate safety issues:

  • Where is the abuser now?
  • Does the abuser know where the client is now?
  • Has the abuser threatened to use weapons?
  • Are weapons available to the abuser?
  • Is the abuser intoxicated?
  • Does the abuser have a criminal record?
  • Are there children? Are they safe now?
  • Are they being abused?
  • Is the abuser verbally threatening the client?
  • Is the abuser frightening relatives and friends?

(See “Resources” at the end of this course.)

HOMICIDE-SUICIDE

Incidents in which a family member kills a domestic partner or other family members and then kills himself are fortunately rare. The point of separation is a vulnerable period, and risk factors for homicide-suicide have been identified as:

  • Prior domestic violence
  • Access to a gun
  • Threats with a weapon
  • Stepchild in the home
  • Estrangement
  • Unemployment
  • Poverty
  • White, non-Hispanic male
  • Possessively jealous
  • Substance abuse
  • Family stressors
    (Auchter, 2010)
ACCESS TO GUNS

Studies have demonstrated that the risk of homicide to a victim of domestic violence is five times higher when the abuser has access to a gun (Campbell, 2003) and that incidents of homicide are reduced when persons under a restraining order are prohibited from purchasing a firearm (Sorenson, 2006). Federal law prohibits individuals who have been convicted of domestic violence misdemeanors or are subject to domestic violence protective orders from possessing guns or ammunition.

Florida does not specifically require the surrender of firearms at the scene of a domestic violence incident, per statutes 790.07, 790.08, and persons convicted of domestic violence misdemeanors can purchase firearms. Statutes 790.233 and 741.31(4)(b)(1) do prohibit the purchase or possession of a firearm by any person who has been issued a protective order related to domestic violence, stalking, or cyberstalking (Law Center to Prevent Gun Violence, 2016).

WHAT DO THE DYNAMICS OF DOMESTIC VIOLENCE LOOK LIKE?

Although intimate partner violence can be manifested in a variety of manners and severity, the CDC recommends using a consistent definition in order to monitor trends over time (CDC, 2016a). There are four main types of intimate partner violence:

  • Physical violence
  • Sexual violence
  • Psychological aggression
  • Stalking
    (Breiding et al., 2015)

Research indicates that intimate partner violence occurs in a three-phase cycle (Walker, 2017):

  • A period of increasing tension, leading to verbal and physical abuse
  • Acute battering incident
  • A “honeymoon” period of calm and remorse in which the abuser is kind and loving and begs for forgiveness

When stress and conflict begin to build, the cruel cycle begins again. Over time, the first two phases grow longer and the honeymoon phase diminishes.

Physical Violence

Physical violence can be defined as “the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes but is not limited to scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, slapping, punching, burning, use of a weapon, and use of restraints or one’s body, size, or strength against another person.” Physical violence can also include coercing another person to perform those acts (Breiding et al., 2015).

Sexual Violence

There are five categories of sexual violence as identified by the CDC. These include:

  • Rape or penetration of the victim. The definition includes attempted rape and penetration that is drug-facilitated or forced.
  • Forcing the victim to penetrate another person. This act includes alcohol- or drug-facilitated incidents.
  • Unwanted penetration of the victim by the use of nonphysical methods such as verbal pressure or abuse of authority.
  • Unwanted sexual contact in which the perpetrator touches the victim or forces the victim to touch the perpetrator either directly or through the clothing without the victim’s consent. The areas of the body involved in the definition include genitalia, buttocks, anus, groin, inner thigh, and breast.
  • Unwanted noncontact sexual experiences, such as exposure to pornography, sexual harassment, filming or photography, and threats of sexual violence.
    (Breiding et al., 2015)
RAPE UNDER FLORIDA LAW

F.S. 794.011 currently includes rape under the offense of sexual battery. The statutes no longer give a separate legal definition for rape. The statute states that the perpetrator must have engaged in oral, vaginal, or anal penetration of the victim with a sexual organ or another object or union by the perpetrator’s sexual organ with the victim’s mouth, vagina, or anus. If the rape victim is under the age of 12, lack of consent is presumed, and if over the age of 12, it must be shown the victim did not consent voluntarily. Under Florida laws, there needs to be shown a lack of consent but not a lack of resistance or protest. In 2015, the statute of limitation doubled from four to eight years that sexual battery cases could be prosecuted.

Psychological Aggression

Psychological aggression is defined by the CDC as “the use of verbal and nonverbal communication with the intent to harm another person mentally or emotionally, and/or to exert control over another person” (Breiding et al., 2015). This form of abuse may include name-calling, humiliation, and control over finances, transportation, and access to family and friends.

It may also include reproductive coercion, such as deliberately exposing a partner to sexually transmitted infections (STIs); attempting to impregnate a partner against her will (by damaging condoms or throwing away her birth control pills, also called birth control sabotage); threats or acts of violence if the partner does not comply with the perpetrator’s wishes concerning the decision to terminate or continue a pregnancy; as well as threats or acts of violence if the partner refuses to have sex.

Psychological aggressors may exploit vulnerabilities of the victim, such as immigration status or disabilities, or present false information to the victim with the intent of causing victims to doubt their memories or perceptions.

Researchers report that psychological/emotional (nonphysical) violence may be more difficult to endure and have more lasting effects than physical violence, particularly in middle-aged and older women. This kind of abuse appears to be more effective in controlling the victim’s behavior than physical violence because it erodes self-esteem and increases uncertainty, hopelessness, and fear (Seff et al., 2008).

The “invisibility” of nonphysical abuse serves as a barrier to reporting the abuse. Victims may fear that law enforcement officers will not recognize psychological or emotional violence as a crime (Seff et al., 2008).

Stalking

The U.S. Department of Justice (2016) identifies several types of unwanted “stalking” behaviors that would cause a reasonable person to experience fear. Examples of behaviors that are experienced by stalking victims include.

  • Receiving unwanted phone calls
  • Receiving unsolicited or unwanted letters or e-mails
  • Being followed or spied on
  • Having the stalker show up at places without a legitimate reason
  • Having the stalker wait at places for the victim
  • Receiving unwanted items, presents, or flowers
  • Having information or rumors about the victim posted on the Internet, in a public place, or by word of mouth

Although these acts individually may not be criminal, collectively and repetitively they may cause a victim to fear for his or her safety or the safety of a family member. Women are disproportionately victimized by stalking, with a prevalence of 1 in 6 women experiencing stalking in their lifetime compared to 1 in 19 men (Breiding et al., 2011).

EFFECTS OF STALKING

Victims of stalking suffer from both short-term and long-term effects and are more likely than their nonvictim counterparts to experience:

  • Posttraumatic stress disorder (PTSD)
  • Asthma
  • Diabetes
  • Headache
  • Chronic pain
  • Difficulty sleeping
  • Limited activity
  • Poor physical health
  • Poor mental health
    (Black et al., 2011)

Stalking often precedes murder or attempted murder of women by their intimate partners (femicide). Researchers reported that 76% of women murdered by their former partners had been stalked by their partners in the year prior to their murder. Most women were stalked after the relationship had ended. More than half of femicide victims had reported the stalking to police before they were killed by their stalkers (McFarlane et al., 1999).

DIGITAL ABUSE / CYBERSTALKING

Half of people ages 14 to 24 reported experiencing digitally abusive behavior, and females were more likely to have been targeted than males. Nearly 1 in 4 young people currently in a dating relationship report that their dating partner checks up with them many times each day either online or by cell phone to see where they are, whom they are with, and what they are doing. Others report that their dating partners attempt to manipulate and control them by checking the text messages on their phone without permission, demanding their passwords, or demanding that they “unfriend” former dating partners on social networks.

Although there is no universally accepted definition of cyberstalking, the term is used here to refer to the use of the Internet, email, or other electronic communications devices to stalk another person. Cyberstalking has become an all-too-common means of harassment, particularly by spurned intimate partners. Even though cyberstalking does not involve physical contact with the perpetrator, it can constitute emotional and psychological abuse.

The Stalking Resource Center recommends that victims of cyberstalking:

  • Trust your instincts.
  • Call the police if there is immediate danger and explain why certain actions cause fear.
  • Keep a record of each contact and save all emails, text messages, photos, and other communications.
  • Connect with a local advocate to discuss options and a safety plan.
  • Call the National Domestic Violence Hotline.
    (NRCVC, 2014)
STALKING UNDER FLORIDA LAW

Stalking is defined in Florida as willfully, maliciously, and repeatedly following, harassing, or cyberstalking another person. Stalking involves a pattern of unwanted behavior with malicious intent that causes substantial emotional distress to a specific person with no legitimate reason. Unwanted behavior can consist of many things such as actual following of a person or continuously calling, texting, emailing, leaving notes or sending letters, and leaving or sending objects or gifts.

Under F.S. 784.048, stalking is a first-degree misdemeanor charge. Aggravated stalking is a third-degree felony charge if the:

  • Offender stalks a minor under the age of sixteen (16)
  • Offender makes a credible threat of bodily injury or death
  • Victim has an injunction for protection or other court-ordered prohibition of conduct by the offender

UNDERSTANDING PERPETRATORS AND VICTIMS

People outside of abusive relationships often wonder both why a perpetrator abuses and why a victim of abuse remains in such a relationship.

Why Perpetrators Abuse

Typically, abusers want power and control, and all their various behaviors are intended to achieve that end.

Although an abuser’s behavior may also arise from or be exacerbated by a mental illness, that is not usually the case; however, abusive behaviors may be complicated by substance abuse problems. Health professionals should be alert to any signs of these complicating factors when assessing high-risk individuals.

Why Victims Stay

There are many reasons why victims stay in abusive relationships, and in any given relationship there may be numerous factors that form an interrelated web. These reasons fall into three broad categories: situational factors, emotional factors, and personal beliefs. It is important for healthcare professionals to understand the many reasons why victims remain in these relationships in order to provide appropriate treatment, assistance, and referrals.

SITUATIONAL FACTORS
  • Economic dependence and inability to support herself and her children
  • Fear of greater physical danger to herself and her children if they try to leave
  • Fear of being hunted down and suffering a worse beating than before
  • Fear of being killed if she leaves, often based on real threats by her partner
  • Fear of emotional damage to the children
  • Fear of losing custody of the children, often based on her partner’s remarks
  • Lack of alternative housing; nowhere else to go
  • Lack of job skills or the inability to get a job
  • Social isolation resulting in lack of support from family and friends
  • Social isolation resulting in lack of information about her alternatives
  • Lack of understanding from family, friends, police, ministers, etc.
  • Negative responses from community, police, courts, social workers, etc.
  • Fear of involvement in the court process, sometimes due to bad prior experiences
  • Fear of the unknown (“Better the devil you know than the devil you don’t.”)
  • Fear and ambivalence over making formidable life changes
  • “Acceptable violence,” in which the violence escalates slowly over time and numbs the victim so that she is unable to recognize a pattern of abuse
  • Fear of losing ties to the community, including the children leaving their school, leaving behind friends and neighbors, losing contact with her “old life”
  • Ties to her home and belongings
  • Family pressure (“Mom always told you it wouldn’t work out,” or “You made your bed, now sleep in it.”)
  • Fear of her abuser doing something to “get” her (reporting her to welfare, calling her workplace, etc.)
  • Inability to access resources due to language barriers, disability, homophobia, etc.
  • Lack of time needed to plan and prepare to leave
EMOTIONAL FACTORS
  • Insecurity about being alone or on her own; fear she cannot cope with home and children by herself
  • Loyalty (“He’s sick; if he had a broken leg or cancer, I would stay. This is no different.”)
  • Pity, feeling sorry for him
  • Wanting to help (“If I stay, I can help him get better.”)
  • Fear that he will commit suicide if she leaves, often based on her partner’s remarks
  • Denial (“It’s really not that bad. Other people have it worse.”)
  • Love, particularly when the abuser is quite loving and lovable when he is not being abusive
  • Love, especially when remembering what he used to be like
  • Guilt, believing that their problems are all her fault, often with the agreement of her partner
  • Shame and humiliation in front of the community (“I don’t want anyone else to know.”)
  • Unfounded optimism that the abuser will change
  • Unfounded optimism that things will get better, despite all evidence to the contrary
  • Learned helplessness, as a result of trying every possible method to change things without success, thereby coming to expect failure (also seen with prisoners of war, hostages, those in extreme poverty, etc.)
  • False hope (“He’s starting to do things I’ve been asking for,” such as counseling, anger management, etc.)
  • Feeling responsible, as though she only needs to meet some set of vague expectations in order to earn the abuser’s approval
  • Insecurity over her potential independence and lack of emotional support
  • Guilt about the failure of the marriage/relationship
  • Demolished self-esteem (“Just like he says, I’m too fat, stupid, ugly, etc., to leave.”)
  • Simple exhaustion, feeling too tired and worn out from the abuse to leave
PERSONAL BELIEFS
  • Parenting: that the children need two parents (“A crazy father is better than none at all.”)
  • Religious and family: pressure to keep the family together no matter what
  • Duty (“I swore to stay married till death do us part.”)
  • Responsibility: it is up to her to work things out and save the relationship
  • Belief in the dream of growing up and living happily ever after
  • Identity: being raised to feel that all women need a partner—even an abusive one—in order to be complete or accepted by society
  • Violence: thinking all partners relate this way (often among women who experienced a violent childhood)
  • Other religious and cultural beliefs
    (WRAP, 2007)

ASSESSMENT

Assessing for Signs and Symptoms

Even though many healthcare professionals are alert to signs of potential child abuse, too few screen for domestic violence among adults. Every healthcare facility that serves women, children, and older adults should screen for potential domestic violence. This screening need not be lengthy. The screening can be part of the intake interview or included as part of the written history. Patients should have the opportunity to respond to the questions in a confidential setting outside the presence of the patient’s family, caregiver, or the person who brings the patient to the appointment.

Healthcare professionals should be alert for signs and symptoms that may be related to domestic violence:

  • Delay in seeking care or missed appointments
  • Vague or inconsistent explanations of injuries or nonspecific somatic complaints
  • Depression, chronic pain, and social isolation
  • Substance abuse and use of alcohol or drugs
  • Signs of abuse in pregnant clients (because abuse often escalates during pregnancy)
  • Lack of eye contact and/or an intimate partner who is reluctant to leave the woman alone with the healthcare professional
  • Patient who is fearful, anxious, withdrawn, angry, nonresponsive, or afraid to talk openly
  • Suicide attempts
DANGER ASSESSMENT INSTRUMENT

The Danger Assessment Instrument is an excellent tool and has been used for over 25 years by health professionals, law enforcement, and advocates. The tool consists of 20 questions that the client may respond to with yes/no answers. The various questions are weighted for risk factors associated with intimate partner homicide. Some of the risk factors include past death threats, partner’s employment status, and partner’s access to a gun. Culturally competent versions are now available to evaluate same-sex and immigrant relationships for lethality. The tool is available online for certified professionals to download after they have completed a brief online training and post-test. (See “Resources” at the end of this course.)

Sources: Messing et al., 2013; Campbell et al., 2009.

PHYSICAL EXAMINATION

During the physical examination, the clinician should:

  • Look for injuries on many areas of the body, especially the face, throat, neck, chest, abdomen, and genitals.
  • Note any bruises, burns, or wound patterns that resemble teeth marks, hand prints, belts, or cigarette tips.
  • Note any pain or tenderness from touching.
  • Be alert for puncture wounds, fractures and dislocations, scars on the vulva or rectum, or any unexplained vaginal or anal bleeding, particularly in older adults.
  • Be aware that the patient may wear a glove or sock to conceal a scalded hand or foot.

Following an established procedure for examination will ensure that no critical information is overlooked:

  1. Have the patient change into an exam gown that will allow all areas of the body to be examined.
  2. Check for injuries.
  3. Document physical findings in detail and include measurements, preferably using a report form that is specified for domestic violence exams.
  4. Photograph injuries, including long-distance, mid-range, and close-up perspectives. Photograph each injury with and without a scale.
  5. Conduct a mental status exam.
  6. Use open, nonjudgmental questions regarding the mechanism of injury.
  7. Do not cut clothing or discard any potential evidence. Collect, preserve, and maintain chain of custody. All evidence should be stored in paper bags. Wet evidence should be placed inside of a waterproof container and given to law enforcement for immediate processing.
    (CCFMTC, 2014)
NONPHYSICAL SIGNS

It is important to remember that many victims of domestic violence may show no physical signs of injury at all. Non-fatal strangulation, which can be a strong predictor of future homicide, may leave no marks. Sexual assault may result in no visible trauma. In fact, there may be no physical signs resulting from the top five predictors of lethality: threatening to use a weapon, threatening to kill the victim, constant jealousy, strangulation, and forced sex.

STRANGULATION

Strangulation is one of the most lethal forms of domestic violence: unconsciousness may occur within 10 seconds and death within four minutes. Strangulation is also one of the best predictors for future homicide of victims of domestic violence. One study showed that “the odds of becoming an attempted homicide increased by about seven-fold for women who had been strangled by their partner” and that the risk of completed homicide increases to 800% (Glass et al., 2008).

Yet strangulation has been overlooked in the medical literature, and many states still do not adequately address this violence in their criminal statutes. As of January 1, 2017, 41 states, including Florida, have passed legislation that categorizes nonfatal strangulation as a felony crime.

Many victims of strangulation do not seek medical attention because “they look fine.” When law enforcement officers respond to emergency calls, they may think the same, because in the majority of cases there are no visible signs.

In some cases, injuries may be apparent. A strangulation victim may struggle violently, which could lead to neck injuries. Efforts to fight back may also lead to injury on the face or hands of the assailant. Victims of strangulation may also experience difficulty breathing, speaking, or swallowing; nausea; vomiting; light headedness; headache; and involuntary urination and/or defecation (TISP, 2014).

(See also “Resources” at the end of this course.)

Documenting Suspected Domestic Violence

Accurate, thorough documentation of the patient’s injuries is essential in cases of suspected abuse and can serve as objective, third-party evidence useful in legal proceedings. For example, medical records can help victims to obtain a restraining order or to qualify for public housing, welfare, health and life insurance, and immigration relief. Documentation includes:

  • The patient’s own words set off in quotation marks or identified by such phrases as “the patient states” or “the patient reports”
  • Any description in which the patient identifies the abuser, such as “my boyfriend kicked me”
  • The time of day when the patient is examined and, if possible, how much elapsed time since the injuries occurred; for example, “patient says that last night her husband punched her”
  • Legible handwriting; poor handwriting on medical records can cause documentation to be deemed inadmissible as evidence

A documentation form for mandated reporters, although not required, is helpful to prompt the clinician to include all of the necessary information. (See “Florida Abuse Hotline” under “Resources” at the end of this course.)

REPORTING REQUIREMENTS IN FLORIDA

Although every person has a responsibility to report suspected abuse, neglect, or abandonment, some occupations are specified in Florida law as required to report to the state hotline. These occupations are considered professionally mandated reporters, and the names of such reporters are entered into the record of the report but held as confidential (Online Sunshine, 2017c). However, informed consent is required in cases of domestic violence (see box below).

Occupations Required to Report Abuse

According to Florida Statute 39.201, mandatory reports of child, elder, or vulnerable adult abuse, abandonment, or neglect must be reported by the following occupations:

  • Assisted living facility staff
  • Adult daycare center staff
  • Adult family care home staff
  • Bank, savings and loan, or credit union officer, trustee, or employee
  • Chiropractor/chiropractic physician
  • Day care center staff
  • Department of Business and Professional Regulation staff conducting inspections of public lodging establishments
  • Emergency medical technician
  • Florida Advocacy Council member
  • Foster care worker
  • Hospital personnel engaged in the admission, examination, care, or treatment of children or vulnerable adults
  • Health professional
  • Institutional worker
  • Judge
  • Law enforcement officer
  • Long-term care ombudsman council member
  • Medical examiner
  • Mental health professional
  • Nurse
  • Nursing home staff
  • Osteopath/osteopathic physician
  • Paramedic
  • Physician
  • Practitioner who relies solely on spiritual means for healing
  • Professional adult care, residential, or institutional staff
  • Professional child care worker
  • Residential care worker
  • School teacher
  • School official or other school personnel
  • Social worker
  • State, county, or municipal criminal justice employee or law enforcement officer
    (FL DCF, 2013)
INFORMED CONSENT AND REPORTING DOMESTIC VIOLENCE

One exception to the mandatory reporting of abuse concerns victims of domestic violence. In Florida, a healthcare provider may not report domestic violence without informed consent from an adult, even if the victim admits to the violence. Reporting suspected domestic violence without informed consent is considered unethical in the state of Florida and may leave the healthcare provider who reported the violence open to civil action.

Florida Statue 790.24, however, does require healthcare professionals who knowingly treat a gunshot wound or life-threatening injury indicating an act of violence to report immediately to the county sheriff’s department, with or without the victim’s consent (Online Sunshine, 2017c).

Content of Reports

The mandated person reporting abuse should be prepared to describe:

  • Victim name(s)
  • Possible responsible person or alleged perpetrator name(s)
  • Complete address and/or directions to the location
  • Telephone numbers, including area code
  • Estimated or actual dates of birth
  • Social Security numbers, if available
  • A brief, concise description of abuse, neglect, abandonment, or exploitation, including physical, mental, or sexual injuries, if any
  • Names of other residents and their relationship to the victim(s), if available
  • A brief description of the victim’s disability or infirmity for vulnerable adults
  • The relationship of the alleged perpetrator to the victim(s)

Where to Report

The victim of domestic violence should be counseled to report the incident to law enforcement and be referred for guidance and support to a local Domestic Violence Advocacy organization. The Florida Domestic Violence Hotline number is 800-500-1119 (TTY 800-621-4202).

Chapters 39 and 415 of the 2013 Florida Statutes (F.S.) state that any person who knows or has reasonable cause to suspect child abuse; neglect or abandonment by a parent, legal custodian, caregiver, or other responsible person; or abuse, neglect, and exploitation of vulnerable adults (including the elderly) who are unable to adequately provide for their own care or protection shall immediately report such knowledge or suspicion to the Florida Abuse Hotline of the Department of Children and Families (see “Resources” at the end of this course).

CASE

Donna, an office nurse in a busy OB/GYN practice in Florida, noted multiple bruises in various stages of healing on her patient Brandy’s legs during a routine prenatal visit. Donna asked Brandy about the bruises, and Brandy admitted they were the result of her husband kicking her. Following Florida protocol, Donna counseled Brandy to report the incident to law enforcement, especially because of the possibility of harm to her unborn baby. However, Brandy did not want to do so and expressed fear of what would happen if Donna reported the abuse herself.

Donna told her that she could not report domestic violence without Brandy’s consent, but that she was required to recommend she contact law enforcement and refer her for guidance and support to the local Domestic Violence Advocacy organization. Donna gave Brandy the Florida Domestic Violence Hotline number and encouraged her to call.

DOMESTIC VIOLENCE AND DEMENTIA

In Florida the legal system has struggled with domestic violence and dementia issues. These issues are becoming more common with the increasing number of older adults and those with dementia. These persons are increasingly becoming involved with law enforcement, causing police, prosecutors, judges, psychiatric workers, and other caregivers to struggle in finding a balance between humane treatment of this vulnerable but sometimes aggressive segment of the population and the need to protect the public.

Healthcare workers may report spousal abuse to Adult Protective Services when a patient with dementia exhibits violent behavior, but if the violence is dementia-related and the client is receiving dementia care services, there may be nothing more that the APS worker can do. It may be prudent to attempt to have guns and other obvious weapons removed from the home or to notify the police.

Involving the police may result in more elders with dementias becoming incarcerated. Some people in the dementia care field are concerned that inappropriate actions (such as incarceration of a confused elder) may result from the interactions between law enforcement and Adult Protective Services. Cognitive decline is usually gradual, making it difficult to determine at which point people are no longer culpable for their actions. A response that is both fair and humane will require cooperation between law enforcement and Adult Protective Services.

Source: Nerenberg, 2006.

COMMUNITY RESOURCES

Obtaining an Injunction

A protective order or injunction for protection is a document that is signed by a judge and informs the abuser to stop the abuse or face serious legal consequences. A protective order can be issued to both male and female victims of domestic violence.

There are two types of civil protective orders in Florida:

  • Temporary (ex parte) injunctions designed to provide immediate protection
  • Final injunction, which may set a period of time or may not have an expiration date

Aside from an injunction for protection against domestic violence, there are three other types of injunctions available in Florida:

  • Injunction against repeat violence (which includes stalking)
  • Injunction against dating violence
  • Injunction against sexual violence

In Florida, injunctions for protection are issued under the civil law system. When a victim asks the court for protection from the abuser, the victim is not asking the court to arrest that person for committing a crime. But if the abuser violates the civil court order of protection, he may then be sent to jail. In a civil case, the victim has the right to drop the case.

The criminal law system handles all cases that involve crimes such as assault, harassment, theft, etc. A criminal complaint involves the abuser being charged with a crime. In a criminal case, the district attorney is the one who can decide to drop the case and the victim does not have any control over whether or not the case continues. In 2015, SB 342 (no contact orders) became law. The law allows no contact orders to be enforced as part of a pre-trial release of the defendant (Florida Senate, 2017).

Domestic Violence Services in Florida

The Domestic Violence Program works closely with the Florida Coalition Against Domestic Violence to regulate, certify, and monitor approximately 40 domestic violence centers across the state of Florida. These domestic violence centers provide crisis intervention and support services to adult victims of domestic violence and their children free of charge, 24 hours a day, 7 days a week.

The Florida Coalition Against Domestic Violence’s Economic Justice Initiative is meant to assist those working with domestic violence survivors to provide economic empowerment programs. These programs provide education in financial literacy, access to local resources, expanding access to banking services, and building financial stability. In addition, FCADV provides assistance to identify potential solutions to long-term housing needs (FCADV, 2014). It is reported that there are emergency shelters for those survivors in immediate danger, but there are no affordable housing options available that provide long-term housing (Wick & Douglass, 2014).

Most communities also have Child Protective Services and Adult Protective Services agencies to which known or suspected cases of abuse should be reported.

Florida law has established batterer’s intervention programs for perpetrators of domestic violence. The court usually imposes attendance at a batterer’s intervention program as a condition of probation.

CONCLUSION

Domestic violence in any form deprives those who are affected of their basic human rights. Children, who are the future of our society, are witnesses of this abuse and suffer irreparable damage from the exposure. Healthcare professionals can make a critical difference in ending this costly, destructive epidemic and interrupt the transmission of violence from generation to generation. By being alert to the possibility of domestic abuse in patients of every age, race, cultural, and socioeconomic group, nurses can identify, protect, and assist victims in resolving their situations.

To accomplish this goal, healthcare professionals must be present for their patients, learn to ask the right questions, and speak for those who are too afraid to ask for help. Nurses must put forth a coordinated effort with advocacy groups, community resources, and law enforcement in order to be effective change agents.

RESOURCES

Danger Assessment Instrument

Domestic Abuse Intervention Project Power and Control Wheel

Florida Abuse Hotline (Department of Children and Families)
800-96-ABUSE (800-962-2873)
800-453-5145 (TDD)
800-914-0004 (Fax)

Florida Coalition Against Domestic Violence

Florida Domestic Violence Hotline
800-500-1119
800-621-4202 (TDD)

Florida Elder Helpline
800-963-5337
800-955-8770 (TDD)

National Domestic Violence Hotline
800-799-SAFE (800-799-7233)
800-787-3224 (TTY)

National Network to End Domestic Violence

Nursing Network on Violence Against Women International

Rape, Abuse, and Incest National Network
800-656-HOPE (4673)

What is a safety plan?

REFERENCES

NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course.

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