Victim Services in Hospitals

• Hospitals and emergency clinics provide 45.7 percent of all medical care received by victims of violent crime. (Bureau of Justice Statistics, 2001).
• 51.9 % of women report being physically assaulted in their lifetime. (Tjaden, 1998).
• 31.5 % of women who reported being raped since the age of 18 sustained some type of personal injury. More than a third (35.6%) of those reporting physical injury received medical care. 81.9 percent of all medical care received by rape victims occur in hospitals. (Tjaden, 1998).
• Personal crime is estimated to cost 18 billion annually in medical and mental health care expenditures. When factoring for lost earnings and expenditures on victim assistance programs, the annual cost of victimization is estimated at 105 billion dollars. (Miller, 1996).
• Annually from 1992-1996, more than 150,000 medical professionals were victims of either simple or aggravated assault. When considering all surveyed professions, 20.4 percent of all incidents of workplace violence involved an armed offender. Within the medical profession, 7.2 percent of victimizations involved an armed offender. (Warchol, 1998).
• During the years of 1983-1999 there were 104 abductions of newborns and infants (birth through six months) by non-family members from hospitals; 57 were taken from a mother’s room (55%); 15 from a nursery (14%); 16 from pediatrics (15%); and 16 from elsewhere on the hospital premises (15%). (Rabun, 2000).

Overview

Hospitals spend millions of dollars each year treating victims of crime — including victims of physical abuse, assault, homicide, rape, aggravated assault and domestic violence. At an average county hospital, treatment of gunshot wounds can exceed 100 million dollars annually (Ordog,1995). Hospitals are essential settings for providing victim assistance and services. Over seventy percent (70%) of reported victims of aggravated assault, robbery, and forcible rape (Federal Bureau of Investigations, 1995) seek medical treatment in hospital emergency departments (Bureau of Justice Statistics, 1997).

However, many hospitals find themselves too severely understaffed or undertrained to effectively deal with the physical, emotional and medical needs of patient/victims. Due to the tremendous costs associated with caring for crime victims, and because hospitals often are the first to provide services to victims, they must be prepared to comprehensively and effectively address the multiple and unique needs of such victims.

Services for Patients

Hospitals across the country are implementing victim service programs to ensure that their staff are adequately prepared to respond to the immediate crisis needs, and some longer-term needs, of crime victims appearing in their emergency rooms for medical care. Establishing effective hospital-based programs requires a number of important considerations and components, including:

• Developing appropriate protocol to identify various forms of abuse and establishing standard procedures for medical examinations of such patient/victims;
• Training for all medical and social services staff to help them recognize the signs of abuse;
• Training in such areas as crime victim sensitivity, death notification, grief counseling, and crime victim compensation;
• Providing private space in hospitals for crime victims and family members;
• Providing for emergency room crisis counseling to crime victims and their families;
• Developing interdisciplinary approaches (with law enforcement, prosecutor’s offices, social services agencies and victim advocacy organizations) to handle victims of assault;
• Protecting the confidentiality of patient/ victims;
• Providing follow-up assistance and support for victims of family violence;
• Offering counseling for patient/victims concerned about pregnancy, sexually transmitted diseases, HIV/AIDS, etc.; and
• Developing direct liaisons with all local victim assistance and social service agencies that provide assistance and services for primary and secondary crime victims.

In an article in the Journal of Psychosocial Nursing (1994), Dr. Ann Burgess (University of Pennsylvania School of Nursing), Dr. Allen Burgess (Northeastern University), and Dr. John Douglas (retired Unit Chief, Investigative Support Unit, National Center for the Analysis of Violent Crime, FBI Academy) developed six essential steps for effective hospital patient care of survivors of violence.

Crisis Response

Victims and victimizers of violence are admitted into acute care settings, such as hospital emergency departments or trauma centers. The majority of cases will be gunshot or knife wounds, and require acute trauma care. Hospitalization will be required for moderate to severe injuries.

Injury Assessment

Although many hospitals have their own assessment protocols, special protocols need to be developed which include specific questions to screen for violence and identify both victims and victimizers when they present themselves to emergency rooms for medical treatment.

Intervention and Treatment

Interventions will vary according to the nature of the injury, its impact on the patient, whether the patient is the victim or victimizer, other health issues of the patient, and the patient’s motivation and resources to deal with the abuse or violent incident. Rehabilitation nursing will be required for those with long-term injuries, such as spinal cord or head injuries.

A safety plan must be developed with the patient/victim for the hospital, the home and at work. Exploration of where and how the patient feels safe and what resources are required to strengthen safety are critically important. The patient needs to know what they can do to increase their safety and what resources and assistance are available for them from the hospital and from the community.

Recording and Reporting

Nurses must carefully document each patient’s history and assessment of injury. Health care records are official documents and may be used in legal proceedings — as well as within the health care system to follow a patient. State laws require the re-porting of certain crimes (e.g., shootings, stalkings and child abuse).

Directing Outpatient Referrals

Referrals are of two types: additional nursing services and community resources. Nursing services include advanced practice nurses, such as nurse practitioners, primary care nurses, clinical specialists in psychiatric mental health nursing, rehabilitation nurse specialists, community health nurses, and visiting nurses. Nurses must also know what community services and resources are available for crime victims. Advocacy services, when available, are vital for rape and domestic violence victims. It is important to encourage the input of the patient/victim in deciding what kinds of referrals are made.

Follow-Up Care

Violence often is a pattern of coercive behaviors. Subsequent abuse and injury must be checked at each health care contact with the patient/victim. The follow-up should be done by each nurse practitioner seeing the patient/victim. These follow-up inquiries can be brief and to the point.

Services for Staff

Violence has now expanded into the hospital-setting. In a 1998 survey by the Emergency Nurses Association (E.N.A.), emergency department managers reported a twenty-nine percent (29%) increase in workplace violence (E.N.A., 1999). Over thirty percent (30%) of recently surveyed nurses report being victims of workplace violence within the past year. Nurses indicated the need for additional policies to increase personal safety (as cited in Carroll,1998).

Within the medical profession, nurses are more likely to be victims of workplace violence than any other staff worker (Warchol, 1998). A study of emergency room (ER) nurses in two hospitals reveal that eighty two percent (82%) of nurses report having been assaulted during their career. Within the past year, fifty six percent (56%) of ER nurses reported being assaulted. Surprisingly, the majority of ER nurses (73%) view being assaulted as "goes with the job" (Erickson, 2000).

Therefore, in addition to improving and increasing victim services for patients in the hospital-setting, hospital-based programs should also include victim assistance activities and services to address their own staff and volunteer needs. These activities and services are geared toward:

• Providing debriefings following any critical incidents within the hospital-setting, as well as providing peer support groups and referrals to community-based assistance programs;
• Developing policies to allow staff to have time off from work to deal with mental health issues, problems in the criminal justice system, and practical concerns as the result of victimization;
• Providing crisis intervention, counseling and advocacy;
• Ensuring confidentiality and privacy;
• Developing or providing educational materials to help individuals understand victimization and victims' rights;
• Implementing preventive safety strategies and security plans to ensure the safety of patients and staff;
• Establishing special procedures to ensure maximum protection for emergency room workers who often deal with offenders and their victims treated in the hospital-setting;
• Training for all hospital personnel on how to defuse a violent patient or visitor, as well as how to handle violent acts when they do occur; and
• Developing contingency plans for disasters and critical incidents.

Conclusion

Hospitals, both private and government-funded, must be prepared to deal with victims of violent crime who become their patients, as well as their own staff and volunteers who may become crime victims while on the job within the hospital-setting or in their life outside the workplace. All of the medical community must become involved in reducing the traumatic effects of crime victimization in whatever ways possible — especially since they are often the first responders to victims of violent crime.

References

Bureau of Justices Statistics. (1997). "Violence-Related Injuries Treated in Hospital Emergency Departments." Washington, D.C.: U.S. Department of Justice.

Bureau of Justice Statistics. (January 2001). Criminal Victimization in the United States, 1999: Statistical Tables. Table #76. Washington, D.C: U.S. Department of Justice.

Carroll, Victoria; Morin, Karen H. (September/October 1998). "Workplace violence affects one-third of nurses." American Nurse.

Emergency Nurses Association. (1999). The 1998 survey on prevalence of violence in U.S. emergency departments. Des Moines, IL.

Erickson, Lisa; Williams-Evans, S. Alicia. (2000). "Attitudes of emergency nurses regarding patient assaults." Journal of Emergency Nursing. 26:3.

Federal Bureau of Investigations. Crime in the United States. (1995). Washington, D.C.: U.S. Department of Justice.

Miller, Ted; Cohen, Mark; and Wiersema, Brian. (1996). Victim Cost and Consequences: A New Look. Washington, DC: National Institute of Justice, U.S. Department of Justice.

Ordog, G. J.; Wasserberger, J.; Ackroyd, G.; "Hospital Costs of Firearm Injuries." Journal of Trauma, February 1995. p. 1.

Rabun, John, Jr. (2000). For Hospital Professionals: Guidelines on Prevention of and Response to Infant Abductions. Alexandria, VA: National Center for Missing and Exploited Children.

Tjaden, Patricia; Thoenness, Nancy. (November 1998). Prevalence, Incidence, and Consequences of Violence Against Women: Findings From the National Violence Against Women Survey. Washington, DC: National Institute of Justice, U.S. Department of Justice.

Warchol, Greg. (1998). Workplace Violence, 1992-1996. Washington, D.C.: Bureau of Justice Statistics, U.S. Department of Justice.

Bibliography

Foley, T.S. and M.A. Davies. (1983). Nursing Care of Victims. St Louis, MO: C.V. Mosby.

National Center for Victims of Crime (1997) "Crisis Intervention," Get Help Series, Arlington, VA.

National Center for Victims of Crime (1996) "State Compensation Laws," Get Help Series, Arlington, VA.

National Center for Victims of Crime (1995) "Workplace Violence Employee Information," Get Help Series, Arlington, VA.

National Center for Victims of Crime (1997) "Workplace Violence Employer Information," Get Help Series, Arlington, VA.

Lanza, Marilyn. (1992, June). "Nurses as Patient Assault Victims: An Update, Synthesis, and Recommendations." Archives of Psychiatric Nursing, 6(3): 163-171.

Lipscomb, Jane and Colleen Love. (1992, May). "Violence Toward Health Care Workers: An Emerging Occupational Hazard." American Association of Occupational Health Nurses Journal, 40(5): 219-228.

Shand, C., J. Broadmore and R. Milford. (1989). Manual for the Medical Management of Sexual Abuse, 2nd edition. Auckland, NZ: Doctors for Sexual Abuse Care.

White, K., J. Snyder, R. Bourne and E. Newberger. (1989). Treating Child Abuse and Family Violence in Hospitals: A Program for Training and Services. Lexington, MA: Lexington Books.

For further information, please contact:

American Medical Association
515 N. State Street
Chicago, IL 60610
(312) 464 - 5000

American College of Obstetricians and Gynecologists Resource Center
409 12th Street, SW
Washington, DC 20024
(202) 638 - 5577

American Social Health Association
P.O. Box 13827
Research Triangle Park, NC 27709
(800) 227 - 8922 (CDC Hotline for STD)
(800) 342 - AIDS (CDC Hotline for AIDS)
(919) 361 - 8400

Health Resource Center on Domestic Violence
Family Violence Prevention Fund
1001 Potrero Avenue
Building 1, Suite 200
San Francisco, CA 94110
(800) 313 - 1310

National Crime Victims Research and Treatment Center
Medical University of South Carolina
171 Ashley Avenue
Charleston, SC 29425
(843) 792 - 2945

Surgeon General
U.S. Department of Health and Human Services
Public Health Service
200 Independence Avenue, SW
Room 716-G
Washington, DC 20201
(202) 245 - 6467

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
(202) 245 - 6296

National Institute of Mental Health
U.S. Department of Health and Human Services
Division of Epidemiology and Services Research|
Violence and Traumatic Stress Research Branch
Parklawn Building, Room 10C-24
5600 Fishers Lane
Rockville, MD 20857
(301) 443 - 3728

National Maternal and Child Health Clearinghouse
8201 Greensboro Drive
Suite 600
McLean, VA 22102
(703) 821 - 8955

Nursing Network on Violence Against Women International
14980 SW 103^rd Avenue
Tigard, OR 97224
(503) 494 - 7207

All rights reserved.

Copyright © 2001 by the National Center for Victims of Crime.   This information may be freely distributed, provided that it is distributed free of charge, in its entirety and includes this copyright notice.