The Aftermath of Violence

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Violence Across the Lifespan: Implications for Critical Care

The Aftermath of Violence Mary Dahlgren Gunnels, RN, MS, CHES, CEN

V iolence, with its aftermath of injury and death, affects all Americans. The consequences of violence extend through the continuum of care, from the prehospital arena to re-entry into the community. The impact of violence on patients and their families, on caregivers, and on society as a whole is extremely difficult to measure. Critical care nurses routinely encounter victims of intentional injury. This article highlights the devastating effect of violent injury and discusses its lingering consequences. Interventional opportunities that can directly impact the aftermath of violence are also presented. CASE STUDIES Case History One J. is a 17-year-old boy

who came into the emergency department following a gunshot to the left thigh. Initial reports stated that the boy was playing with a gun that accidentally discharged in the garage at home. Subsequent information, however, reveals that the injury was the result of gang retaliation. J. recently left a school-based gang, who demonstrated

From the Oregon Health Sciences University, Portland, Oregon

their disapproval by shooting him with a 38-caliber handgun. J.'s parents are Hispanic and Asian American, well educated, and financially secure. J's gunshot wound resulted in a left proximal femur fracture that was repaired surgically, although there were retained bullet fragments in the leg and pelvis. He progressed well postoperatively and was discharged home after a 10-day hospital stay. He was non-weight bearing on his right lower extremity and progressed slowly with physical therapy. He refused to work with the occupational therapist most of the time and spoke to the social worker only once. He withheld all information from his parents, who believed that he and a friend were just playing with a loaded gun in their garage. K. is a 30-year-old man assaulted with a baseball bat. This man has a complex psychosocial history, which includes a long history of petty crime and intravenous drug abuse. He is unemployed. The circumstances of the assault were unknown, and the patient was unconscious on arrival to the hospital. The victim experienced a closed-head injury, a subdural hematoma, and a right temporal bone fracture as a result of the assault. These injuries required emergent

Case History Two

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repair with a return to the operating room for a cranioplasty 2 weeks later. He progressed slowly with physical, occupational, and speech therapy. At the end of the third week of hospitalization, he was discharged to a skilled nursing facility. He was ambulatory only with moderate assistance. His rehabilitation was complicated by a skull wound infection, which required readmission to the hospital. Case History Three L. is a 69-year-old woman who stabbed herself in the chest with a steak knife. She was found unconscious at home and was transported to the trauma center. L. had a history of diabetes mellitus, hypothyroidism, depression, and previous suicide attempts. She has a husband and daughter, and her family's financial resources are limited. L. required a thoracotomy, open cardiac massage, and internal defibrillation in the emergency department. She survived the surgical repair of her right atrium and right ventricle lacerations. She progressed quickly and was transferred to the inpatient psychiatric unit 2 weeks after the incident. She was discharged to home with her husband nearly 4 weeks after her suicide attempt, with referrals for outpatient community rehabilitation. This atypical example of attempted suicide by an elderly female represents a growing problem in the geriatric population. Suicide in the elderly has risen during the past decade, with approximately 19<'!0 of the 284,262 completed suicides occurring among people older than 65 years of age. 23 These three case scenarios feature violent mechanisms of injury in patients ranging in age from 17 to 69 years. These patients are of varied socioeconomic and cultural backgrounds; they live in urban and rural settings. The physical and psychological effect of violence prevails in each patient, and the outcomes extend far beyond the acute phase of hospitalization. Each victim's injuries are dramatic in nature and clearly the result of violent acts. The implications for the victim, family, friends, and

the public at large are profound. Critical care nurses caring for these patients need to consider the short- and long-term effects of violence that affects these patients and their families. In addition, the caregivers must be aware of the impact these patients have on them professionally as well as personally.

Consequences of Violent Injury Patient Considerations

The physical consequences of violent injury must be addressed first. The injured patient must be medically stable before a rehabilitation plan can begin. Once the patient is stable, the cognitive and psychosocial factors are evaluated with consideration of the physical factors present. 12• 14 The psychological effects of the violent act are incorporated into the rehabilitation plan by the rehabilitation team members. The referral process for counseling, victims' rights advocacy, psychotherapy, and other psychosocial needs should be considered throughout the rehabilitation process.12• 14 Posttraumatic stress disorder (PTSD) can affect all ages of victims, as well as loved ones or caregivers. PTSD is most commonly associated with criminal victimization and violent injury and can present years after the traumatic incident. 31 All victims of violence should receive evaluation for PTSD either while in the hospital or within several weeks from the date of discharge. PTSD presents with varied symptomalogy, ranging from mild anxiety and depression to severe changes in behavior and sleeping patterns (e.g., nightmares). It is important that a victim, particularly if returning to an environment at risk for violence, have a dedicated caseworker or therapist to facilitate community re-entry. PTSD, if untreated, can lead to polysubstance abuse and violent behaviors. 31 Family Considerations

Acknowledgment of the stress experienced by families of violence victims provides op-

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portunities for intervention by the critical care nurse. Consideration of the immediate effects of violent injuries on a family member or friend should be overlooked. Fear for personal safety and that of the injured victim is a common stressor, particularly if the perpetrator is unknown or at large. Families must also care for the victim's children, property, or pets; deal with law enforcement agencies; complete multiple forms; and contact the victim's employer if the victim was employed. These issues exacerbate the anxiety related to an unexpected, terrifying situation. Most critical care nurses are adept at crisis intervention methods and other techniques that enhance coping. 14 Recognition that family structure may change as a result of violent injury is an important component in the longterm outcomes of patients and farnilies.14 Financial counseling and emergency funding may be required, particularly if the injured patient was the primary earner in the family. Identification of personal stressors for family and friends and counseling to address these stressors may enhance patient outcomes, particularly if the family or friend was a witness to the violent act.24 Caregiver Considerations

Violence can have a tremendous impact on caregivers. Nurses must support their colleagues through stressful situations, and coworkers should recognize when stress affects job perfonnance and personal behaviors. Caution is necessary in the workplace when violently injured patients are treated, particularly if the incidents are related to gang activity or domestic violence. Precautionary measures include separation of multiple or rival victims, limited access to the victim, use of hospital security or police protection, and use of aliases rather than the victim's name. 15• 24 Societal Considerations

Violence affects the daily life of all Americans. A major dilemma is how to control the cycle of violence with increasing access to a seemingly unlimited supply of guns and weapons, as

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well as exposure to violence in the media.7- 9 The development of trauma systems in the United States is described as one reponse to this cycle. According to trauma surgeon Donald Trunkey, 35 American trauma care systems reflect an essential component of a unified reponse to violence.20 Economics, legal issues, and prejudice toward persons with disabilities are key factors that plague injured victims of violence in American society. The traditional approach toward these problems has been one of avoidance or dismissal. The modem public health model to address violence has emerged in the educational and medical communities, particularly in the area of youth violence. 32 The public health model implies that tertiary responses to violent injury and death (e.g., rehabilitation) are insufficient. Injury is considered to be a preventable illness. Primary prevention, such as public education and advocacy, and secondary prevention, such as clinical education, are acceptable responses.24 Private grants and governmental funding currently reflect this public health approach to violence.6• 16• 29 The economic impact of violent injuries is evident in direct and indirect costs. Medical and rehabilitation expenditures, long-term supportive care, and unemployment compensation are some of the direct costs that affect Americans regardless of location or health care delivery system. An estimated 37% of trauma patients are without insurance, placing the burden on the health care system and the state in which the patient was injured. The economic and societal impact of violence is significant, with costs of disabling injury predicted to range from $2 to $20 billion annually.20· 21• 36 For every firearm death, it is generally estimated that three firearm victims are hospitalized. 4• 11 The Centers for Disease Control and Prevention report that firearm deaths may exceed deaths by motor vehicle accidents in the United States during the coming decade. Firearm injuries are underreported and limited infonnation about the morbidity, disability, and cost associated with these injuries may indicate that the problem is worse than realized.

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Indirect costs include loss of productivity, which can be permanent or temporary for the patient and even the family. Traumatic brain injury (TBI) is estimated to affect nearly 100,000 Americans (approximately one third of all patients hospitalized) annually with lifelong disability. 13• 17•33 The clinical effects of TBI range from mild disorientation to low-level cognitive functioning, which can last a lifetime. One study revealed that only 15% of TBI patients were able to return to work and function normally. 13 The economic implications, although difficult to measure, are frightening in scope. Legal issues complicate the life of the patient injured or disabled by violent injury, and affect law enforcement agencies, the judicial system, and the health care providers who work closely with the victim. Local, state, and federal laws can provide solutions for families seeking compensation, justice, and protection. This process, however, can be exceedingly slow and vary widely in enforcement. 6-8· 21 The public health approach toward violence has not overcome American prejudice toward persons disabled by violence. Provision of services, particularly for rehabilitation, has not been a priority during the previous decade when violent crime and injury in America has exploded.5 Awareness of violence and its devastating effects has only recently moved to the forefront of government health care initiatives, resulting in funding for five regional TBI research centers as well as the Centers for Disease Control and Prevention. 5· 13

Intervention Opportunities

Critical care nurses can access a variety of hospital resources for victims of violence. The rehabilitation specialists can be helpful in establishing a rehabilitation plan while the patient is still in the critical care unit. Social workers, physical and occupational therapists, speech language pathologists, clinical nurse specialists, domestic violence counselors, and patient advocates are invaluable team

members who prepare the patient for transition into rehabilitation and eventually the community. 12 The hospital chaplain can provide comfort measures and spiritual support to patients and families.18 Hospital volunteers are also excellent resources for victims, families, and staff. Many volunteers dedicate time because of their personal experiences with injury and violence, and can provide community referral information. The psychiatric and psychosocial counselors offer comprehensive approaches toward the issues that affect injured patients and their loved ones. Many hospitals and communities now have clinics that offer therapeutic services for those afflicted with PTSD. Physician referrals for PTSD evaluation are typically required, and patients without funding can pay for treatment on a sliding scale fee basis. Victims of Violence Youth

Youth violence has gained national attention in recent years, and more opportunities for participation by injured or at-risk youths in educational programs exist. School-based programs offer the injured youth education in violence prevention strategies through mediation and conflict resolution curricula.9 Community-based programs can be identified through law enforcement and health care provider resources (e.g., hospitals, local health departments). If a young person has particular concerns about gang-related activities, information can be obtained through these types of resources, even in smaller cities and rural settings. 19 The younger victim of violence may be more comfortable with peers in the school and community programs. Innovative programs include re-enactment programs and gun courts. Re-enactment programs for young victims and their friends, schoolmates, and families simulate a real-life trauma experience.6 The victim and group travel from the emergency department to the morgue, role playing as persons involved in the care of a trauma patient who dies. Victims generally

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participate in the learning sessions that follow the re-enactment, which makes the experience more meaningful for the participants. These programs also offer opportunities for caregivers interested in injury prevention. The Rhode Island "Gun Court" designates one judge to handle all youth gun violence litigation.6 The judge offers alternative sentences that focus on prevention activities, with emphasis on conflict resolution, education, and speedier trials. Victims can use real-life experiences to promote conflict resolution. Young victims may experience emotional healing and improve confidence by participating in these types of programs.

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school, and community-based educational programs to prevent future injury and devastation. Parents are vital players in youth violence prevention programs. One example of a neighborhood-based prevention group is the Peace Officer Corps, which sets the standard by keeping peace in neighborhoods without guns in New York.7 Family and friends of victims can spearhead legislative efforts to promote gun safety and reduce injury by violence. 15• 29 Public awareness campaigns and legislation urging zero-tolerance policies are effective means to provide positive direction after a devastating event. Caregivers

Adult and Elderly Victims

Adults can benefit from participation in support groups for victims of violence, which often aileviate feelings of anger, guilt, and depression.'1 Participation in communitybased prevention programs or legislative task forces that address prevention and victim's rights can provide excellent avenues for victims motivated to make a difference. Suicide prevention programs include counseling other victims personally or via telephone crisis lines. Safe houses and shelters are available in most communities for victims, and offer interventional activities as well as protection. Serving as an expert on a victim's panel can provide a victim of violence a means to contribute to prevention programs. The THINK FIRST! Head and Spinal Cord Injury Prevention program uses victims of all ages to speak to groups and appear in educational videos. if> These victim experts are effective in public appearances at special events or press conferences, and in television public service announcements. Family and Friends

Remarkable responses to violence have been demonstrated by the victim's family and friends. Participation in support groups and the victims' therapies is a contributing factor to rehabilitation. 12• 25• 31• 36 Victim's families and friends often support neighborhood,

Caregivers, particularly critical care nurses, encounter many opportunities to help patients, families, and themselves with issues resulting from violence. Six areas that affect caregivers are (1) recognition and treatment of personal and professional stressors, (2) support of collaborative projects and coalitions, (3) provision of a role model or expert testimony, ( 4) participation in professional organizations, (5) development of public awareness and education programs, and (6) championing legislation. Recognition of stress-related behaviors after providing care for a patient traumatized by violence is important for colleagues and managers. Many health care providers voluntarily participate as members or leaders of hospital debriefing teams and community crisis teams as a method to address the problems of violence and injury. Participating in critical incident stress debriefing sessions offers caregivers who feel powerless about the impact of violence on patients and colleagues opportunities to help others, which, in tum, promotes personal healing and recovery. Examples of collaborative projects and coalitions in which a nurse offers valuable insight are hospital trauma re-enactment programs, multidisciplinary violence, prevention teams, collection of surveillance data, and local or state SAFE KIDS coalitions. 1• 10• 25--V Collaborative sponsorship of special events can generate public and professional interest in

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the issues related to violent injury and disability. The Centers for Disease Control and Prevention's "Violence Prevention Conference" brought criminal justice, education, health care, public health, research, and social work professionals together to seek solutions to the problem of violent injury in America. 16 A critical care nurse can teach community education programs or serve on legislative task forces as a role model and expert who provides care for victims of violence. The public, the media, and legislators value the opinions, testimony, and insight of expert nurses. Nurses can join legislative task forces, either individually or through participation in professional organization and community efforts. Legislation to address victim rights, injury prevention, trauma systems, and issues that link violent injury to the public health approach is one solution. 22• 28• 29• 34 Nurses can invest their time based on their particular area of interest or concern. Participation in professional organizations is an excellent way to influence the practice issues that affect nurses who deal with violence. Nursing organizations, such as the Emergency Nurses Association, American Association of Critical Care Nurses, American Nurses Association, and the Associations of Spinal Cord Injury and Rehabilitation Nurses, support advocacy, public education, research, and legislative projects on behalf of violently injured patients.3• 10• 12 Collaborative organizations include the National Head Injury Foundation, The Children's Safety Network, The HELP Network, and the Center to Control Handgun Violence. 26• Tl, 30 Volunteering to serve in professional and community organizations affords an opportunity to raise public and professional awareness about the challenges that face patients disabled or injured by violence. Interest in an area of victim advocacy can lead to a local grassroots effort to address the issues that impact patients and the community.

An Oregon Response to Violence Through participation in Ceasefire Oregon, a state event was organized to bring attention

to the problem of injury and death by gun violence. Ceasefire Oregon is a communitybased, multidisciplinary organization that promotes public awareness and education about the issues surrounding injury from gun violence in the state. The 1996 Oregon Silent March was a media event in which 392 pairs of shoes were placed on the steps of a downtown courthouse square to represent the number of Oregonians who died by gun violence in a single year. 3 The Oregon Silent March program featured speakers who discussed the impact of gun violence on their lives during the 30-minute program and press conference. There was a "Die-In" on the steps of the courthouse steps to simulate American deaths and injuries from guns during a 30-minute period. The shoes were then packed and shipped to join the national Silent March in Washington, DC, where 40,000 pairs of shoes were displayed on the Capitol steps to represent annual American gun deaths. Three pairs of actual victims' shoes were displayed in Oregon and Washington, DC. This public awareness event represents an excellent example of participation by patients, family, and caregivers in one common cause: to prevent violent injury and death. The speakers, family members, and caregivers of victims were interviewed on nearly every Oregon television and radio station. A poignant story with a feature photograph appeared in the major newspaper. Event volunteers (nurses, medical students, physicians, community leaders, and victims' friends and families) distributed educational materials. This caregiver and community approach to raising issues about gun violence sparked awareness, discussion, media coverage, and participation by those affected by violent injury and death. The motivation to improve gun safety education resulted, and a community video on safe storage of guns is being developed. A legislative effort to enact a safe storage bill, supported by professional nursing organizations, is now in progress in Oregon.

THE AFTERMATH OF VIOLENCE

CASE STUDY OUTCOMES ]. returned to clinic repeatedly over a 2month period, at which time he was walking with minimal difficulty. He refused to speak to the psychologist who scr:eens victims for PTSD at the trauma clinic. He was quiet and planned to return to the same school in the fall. His parents remain unaware of the truth about the shooting. Opportunities for participation in violence prevention programs and antigang support groups have not yet been realized. K. recovered from the physical injuries; however, his mental functioning is markedly impaired. He lives on the street and

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sleeps in shelters or in the homes of friends or acquaintances. He has been noncompliant with follow-up appointments despite encouragement from a community case worker. He cannot work and has returned to his previous patterns of polysubstance abuse. Community re-entry programs or victims' panel participation are unlikely. L. has made gradual progress. She and her family participated in the outpatient counseling program. The husband and daughter are grateful that she did not die. This patient has the potential to return to an active life, where she could take part in victims' advocacy programs and legislative task forces that address suicide as a public health problem.

SUMMARY Violence, with the injuries produced and lingering consequences, affects patients, families, and caregivers. Each case is tragic; however, the opportunity for intervention and proactive approaches to education, prevention, and legislative action abound. Most caregivers agree that the social causes of violence, such as breakdown of family and lack of education opportunities, must be addressed to implement long-term solutions.32, ' 5 Recommendations for critical care nurses and all caregivers who deal with the impact of violence in their professional and personal lives include Recognize which problems violence imposes on patients, their families and friends, and health care providers. Identify what interventions could as.5ist in dealing with these ismles. Be aware of safety issues associated with victims of violence and take immediate measures to maintain a safe environment. Initiate referrals for rehabilitation services at the earliest opportunity. Broaden knowledge of the resources at the institution where the victim is treated and in the victim's community. Trauma coordinators, social workers patient advocates, and volunteers can often provide guidance. Be involved. Prevention, research, professional and public education, and professional, community and legislative coalitions can provide positive direction. Be tolerant. A disabled or mentally impaired man moving slowly through an express grocery line may be a victim of violence. Families, caregivers, and the public at large are all affected by the patient who has been injured by violence. Caring for a victim of violence presents many opportunities to make a difference as a critical care nurse.

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ACKNOWLEDGMENTS Special thanks to my colleagues Lynn Eastes, Pamela Frankel, Maureen Harrahill, and Patricia Southard for their support and guidance in my professional and public endeavors.

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Address reprint requests to Mary Dahlgren Gunnels, RN, MS, CHES, CEN Oregon Health Sciences University Trauma Program, UHN-&; 3181 SW Sam Jackson Park Road Portland, OR 97201