HEALTH POLICY
Dating violence: Promoting awareness and mitigating risk through nursing innovations Terry L. Ames, MSN, FNP-BC (Nurse Practitioner)1 , Lori A. Glenn, DNP, CNM (Associate Professor of Nursing)2,3 , & Leslie E. Simons, MSN, APRN-BC (Nurse Practitioner)4 1
Taylor Clinic, Taylor, Michigan Hurley Medical Center, Flint, Michigan 3 University of Detroit Mercy, Detroit, Michigan 4 Pain Management Center of Lansing, Lansing, Michigan 2
Keywords College students; domestic violence; education; advanced practice nurse (APN). Correspondence Leslie E. Simons, MSN, APRN-BC, Pain Management Center of Lansing, MI 48912. Tel: 517-285-3095; Fax: 517-484-7377; E-mail: [email protected] Received: January 2012; accepted: July 2012 doi: 10.1002/2327-6924.12095 Disclosure The authors received no financial support for the research, authorship, and/or publication of this article. The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Abstract Purpose: The TeLL Dating Violence Project was created by three advanced practice nurses to mitigate the risk of dating violence on a college campus through establishment of an innovative program of education and policy change. Data sources: Literature regarding dating and domestic violence and the subsequent health effects as it pertains to college-aged students was reviewed. Government agency documentation pertaining to the legal requirements to protect students was included. Several college documents were compared for education and awareness programs, safety and prevention measures, and reporting and follow-up procedures. Key stakeholders on campus were accessed to determine unmet student needs. Conclusions: Dating violence is a common occurrence among college students. Women are more likely to be affected and at greatest risk for experiencing nonfatal intimate partner violence and nonconsensual sexual experiences. Dating violence significantly impacts the short- and long-term health of victims and has significant financial effects as well. Implications for practice: Nurses are in a unique position to identify and refer clients who may have experienced dating violence. By partnering with campus health centers, student organizations, and public safety the risk of dating violence can be mitigated. An innovative program developed by a team of advanced practice nurses that involves policy change, awareness, and education is outlined.
The TeLL team The TeLL team was created in response to concerns from multiple departments across the campus of a private university regarding underreporting of dating violence events. “TeLL” was the name chosen to brand the team, making it recognizable across campus. The letters represent “Truth embraces Love without Lies,” incorporated in the phrase “Don’t be afraid to TeLL the truth about dating violence.” Composed of three advanced practice nurses, the team recognized the potential impact to the health of students resulting from campus dating violence. The primary goal was to improve awareness of the phenomena of dating violence on campus. Beginning steps were taken to implement a campus-wide program designed
to increase awareness, enhance safety, and increase reporting through education of students, staff, and faculty. The TeLL team also worked with key stakeholders, making recommendations for safety and policy enhancements that are to be reflected in the student handbook and orientation experiences.
Dating violence Dating violence is a common occurrence on college campuses, affecting an estimated 21% of students (National Institute of Justice, 2005). It encompasses physical, sexual, or psychological/emotional violence within a dating relationship (Centers for Disease Control [CDC], 2011). A review of evidence reveals that the majority
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of significant issues relate to sexual assault. College age women are at greatest risk for experiencing nonfatal intimate partner violence as well as nonconsensual sexual experiences (Catalano, 2007). Statistics demonstrate nearly 20% of women will be victims of completed or attempted rape while in college. Of these, 16% disclose this event to a friend or family member, 13% will report the event to law enforcement. For those who were incapacitated by alcohol or drugs at the time, the rate goes down to 2% (Krebs, Lindquist, Warner, Fisher, & Martin, 2007). Current data from the Bureau of Justice Statistics show that while arrest rates for sexual assault have remained stable, twice as many women reported a sexual assault by an intimate partner in 2010 as compared to 1994 (Catalano, 2012). Research and statistics in the literature focus on the female victims of sexual assault and dating violence (Coxell & King, 1996). According to the 2011 report from the National Center for Victims of Crime (NCVC), gang rape, multiple sexual acts, and weapon use are more common among male victims, and injuries are often more serious than those that occur with female victims. Lack of tracking of sexual crimes against men, as well as lack of research about the effects of male rape may reflect society’s attitudes toward male rape as being unacceptable to discuss. Sexual assault is considered the United States’ most underreported violent crime (National Institute of Justice, 2005). There are personal, societal, and system barriers that contribute to underreporting. Personal barriers include shame, guilt, and embarrassment, not wanting friends and family to know, concerns about confidentiality, fear of not being believed, and fear of retribution from the perpetrator (Padden, 2008). Societal barriers are tied to social norms that are implicit and explicit, tolerance of violence, and sexual desensitization in mass media (Burnett, 2011). System barriers on campus are related to policies of reporting that are unclear or difficult to access, and concerns about the reputation of the university. Coxell and King (1996) report that for men, additional societal barriers that may prevent reporting sexual crimes perpetrated against them are related to negative cultural views toward homosexuality. These views may cause heterosexual males to underreport sexual assault by other males in order to avoid being labeled homosexual. Law enforcement may be unsympathetic if the victim is homosexual. For men sexually assaulted by women, victims may fail to report because of shame or the concern they will not be believed by law enforcement.
havior, use of illicit substances, unintended pregnancies, posttraumatic stress disorder, depression, suicidal ideation, and eating disorders (Silverman, Raj, Mucci, & Hathaway, 2001). In 2003, the CDC review of the Youth Behavior Inventory Survey found that dating violence is linked to poor academic performance and risk behaviors such as sexual intercourse, attempted suicide, cigarette use, episodic heavy drinking, and physical fighting. Sexual assault is also linked to physical health problems including headaches, fatigue, sleeping disorders, sexual dysfunction, and sexually transmitted diseases, along with psychological issues including depression, anxiety, stress, and suicidal ideation (Vladutiu, Martin, & Macy, 2011). Males report many of the same health issues as women, in addition to confusion about sexual orientation, problems with erection or ejaculation, inability to form close and trusting relationships, and homophobia (Coxell & King, 1996). The annual economic impact for domestic violence is estimated at $8.3 billion, including $460 million for rape (Burnett, 2011). The cost to the healthcare system for treatment of a single sexual assault is $87,000. This includes health care, mental health care, police, social/victim care, loss of productivity, property loss, and loss of quality of life (National Institute of Justice, 2011). Additional costs to the university may include legal action taken by families of students, or fines starting at $27,500 per violation if the requirements of laws to protect students as outlined in the Clery Act are not met (United States Department of Education, 2011). By making campus officials aware of this financial impact, resources can be allocated to implement programs that work toward mitigating the risk of dating violence incidents. Nurses are recognized for their unique work as sexual assault nurse examiners (SANEs). They provide victims with comprehensive care and psychological support, accurate forensic evidence collection, and effective testimony during prosecution (Campbell, Patterson, & Lichty, 2005). In addition, these nurses identify and refer clients who have experienced sexual violence and unresolved sexual trauma (Padden, 2008). Advanced practice nurses are often providers of primary care in campus health centers. Nurses as leaders in health care are also in a unique position to educate and support college students. By partnering with campus health centers, student life, student organizations, and public safety, nurses can promote awareness and prevention measures related to campus dating violence and sexual assault.
Healthcare implications
Policies and laws
The health impact of sexual assault is nearly immeasurable. Significant health issues include risky sexual be-
Historically, domestic violence, sexual assaults, and stalking incidents were ignored by society and treated as
144
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private family matters. The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, as part of the Higher Education Act of 1965, is a federal law that requires colleges and universities to disclose certain timely and annual information about campus crime and security policies (United States Department of Education, Office of Postsecondary Education, 2011). Howard and Connie Clery championed the Clery Act after their daughter Jeanne was raped and murdered in her dorm room at Lehigh University in 1986. One feature of the act is that postsecondary education institutions participating in federal student aid programs can be fined and lose financial aid dollars if found in violation (United States Department of Education, 2011). In 1984, the Family Violence Prevention and Services Act was passed to help prevent domestic violence and provide shelter and related assistance for victims (United States Government Accountability Office, 2007). In response to concerns about domestic violence, sexual assault, and stalking incidents, the Violence Against Women Act (VAWA) was signed into law in 1994. VAWA has improved federal, state, and local responses to sexual assault through changes in public attitudes, policy, and law. Examples include grant funding to educate and prevent domestic violence on campus, clarification that forensic evidence in rape exams is paid for by law enforcement, prohibition of charging fees for filing criminal charges, assistance with serving orders of protection, and mandatory restitution for victims of sex crimes (Roe, 2004). According to the United States Department of Justice (2005), women are more likely to tell a friend about an incident of sexual assault. Students with increased awareness about dating violence are more likely to recognize the event as a reportable crime. If students are also aware of the current process of reporting with confidentiality and respect, they may perceive fewer barriers to reporting. On the campus where the TeLL Program took place, the reporting process begins once a victim contacts public safety about an assault or incident. If a sexual or physical assault has occurred, emergency personnel transport the victim to a local hospital for medical care. After the victim is cleared medically, she/he is transported to a domestic violence shelter for a forensic examination by a SANE. During this visit, the victim receives comprehensive, sensitive care with access to police reporting, legal counsel, and personal counseling.
Mitigating the risk of sexual assault Each university is required by law to protect students from assaults, document crime statistics, and provide counseling and treatment for the victim. The main
resource for reporting an assault is campus public safety, and prompt reporting is essential to keep the university community safe (United States Department of Education, 2011). Some universities have comprehensive programs, paid for in part with grants from Office on Violence Against Women (2012). These include mandatory education, campus awareness programs, counseling, medical services provided by forensic nurses, promise or pledge statements from public safety, on-campus safe house, and ongoing follow-up (Central Michigan University, 2011; Lehigh University, 2011; Michigan State University, 2011). However, many other universities and colleges do not offer comprehensive education and awareness programs or specific promise or pledge statements. They will provide educational programs detailing techniques to avoid sexual assault and dating violence, but these are upon request and not part of a formal orientation or awareness program (Madonna University, 2011; University of Detroit Mercy, 2011). Counselors on the campus where the intervention took place revealed that many assaults are unreported and that most victims do not seek assistance until a year or more after becoming symptomatic psychologically. Not only does this prevent the pursuit of criminal prosecution, it makes counseling more challenging.
Recommendations for nursing The purpose of this project was to utilize an innovative approach of empowering students to mitigate the risk of becoming a victim of dating violence. A group of advanced practice nurses conducted meetings with representatives from Public Safety, Dean of Students, Counseling Center, Student Health Center, and the local referring emergency department to discuss the policies and procedures that are specific to dating violence and sexual assault. The outcome of these meetings was a unified goal of addressing issues of knowledge, awareness, and safety issues surrounding campus dating violence. As a result, a campus-wide program focusing on education, safety, and reporting was created.
Campus initiatives Education and awareness The education and awareness initiative began with a candlelight vigil held in conjunction with a universitywide presentation on domestic violence. For this event, the TeLL team created and distributed both a brochure and business card with information about dating violence, how to prevent it, and the process of reporting it. The brochures and cards are available in the public safety 145
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office and distributed in key student areas on campus including common areas and restrooms. A campus-wide presentation entitled “Healthy Dating Relationships” was presented in February 2012 by the TeLL team and a panel of key personnel from partner departments. Representatives came from Public Safety, Campus Health Center, Dean of Students, and the Counseling Center to discuss their department’s role in prevention of and response to dating violence. Eighteen students, as well as several faculty and staff attended the presentation. Again the informational brochures and cards were provided to attendees. A survey was conducted to determine the impact of the presentation and nine were returned. Respondents agreed that as a result of the program, they were able to identify the characteristics of a healthy dating relationship, define dating violence, describe the role alcohol plays in dating violence incidents, and identify the health impact of dating violence on college students. They indicated that if they or a friend became a victim of dating violence, they would report the incident to Public Safety and seek health care with examination of injuries along with support from the Counseling Center. Additionally, if they witnessed a friend or acquaintance at risk of becoming a victim of dating violence, they would report the incident to public safety and assist them in avoiding the incident. All but one respondent would recommend continuing campus presentations on dating violence. The drama department presents skits every fall to incoming freshman and new students and is currently creating a program dramatizing dating violence and its effect on students, to debut 2012 fall semester. The TeLL team will also participate in orientation in the 2012 fall semester, presenting “Healthy Dating” to new students and their parents. As part of the faculty and staff development, the TeLL team will conduct an in-service to key stakeholders detailing the impact, reporting, and prevention of campus dating violence during the 2012–2013 academic year. The candlelight vigil will again take place in October 2012, with community health nursing students and representatives of student organizations assisting in planning and presenting the event.
Reporting Focusing on the transparency and awareness of policies and processes for reporting dating violence will improve the acceptability of student reporting. After review of the current materials provided to students, the TeLL team made recommendations for the Student Handbook section on sexual assault. This included using language that was student centered, supportive, and easy to navigate along with making it more accessible in a separate 146
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document such as a brochure or card. It also expanded the information on sexual assault to include dating violence. These recommendations are being incorporated into the 2012–2013 Student Handbook. In process is the creation of an icon on the public safety website that will enable concerned students, faculty, and staff quick and easy access to reporting information without downloading the lengthy online Student Handbook.
Safety An increased awareness of the process for reporting an incident may not just increase the likelihood of reporting, but also act as a deterrent for potential offenders, improving safety on campus. The public safety website contains excellent information on crime prevention, and periodically safety reminders are sent to students by email. Recommendations by the TeLL team included measures to enhance safety information, highlighting public safety contact information and availability of campus escorts. This initiative could be accomplished in several ways including provision of an easily visible sticker to be placed on the back of the hanging parking tag, highly visible reflective signs at key areas on campus, and campuswide e-mail reminders. These recommendations are under review by key departments.
Financial impact The financial impact is considered to illustrate the need to pursue resources and grant funding to implement programs that work toward decreasing the risk of dating violence incidents. Support for victims of sexual assault does not require additional funding through the campus, as no cost care is provided through the Rape Prevention Service Dollars or STOP funding (Campbell et al., 2005). This includes the cost of emergency department care, forensic exams, and medication to prevent sexually transmitted infections and unintended pregnancy, as well as counseling. It is important that this information is shared with students, as awareness of the free services may be limited, and fear of the cost of care could prevent reporting of incidents. The potential financial impact to a private, mediumsized university similar to the one where the TeLL program took place relates to student withdrawal as a result of trauma or poor academic performance. Based on national statistics that 20% of women are victims of sexual assault on campus, a medium-sized coeducational college of 5000 undergraduate students could potentially have 625 cases. If only 30 (less than 5%) of those students leave, there is a potential for significant loss of tuition from otherwise capable students. The university also risks
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additional financial losses through fines and discontinuation of federal aid if laws are not followed, as well as potential lawsuits from families. The initial costs of the TeLL program were less than $500, and included the candlelight vigil, campus-wide presentation, updates to existing resources, and education materials for students. A more comprehensive education, reporting, and safety initiative would cost about 29% of the tuition cost of just one student for one semester at this institution, which is significantly less than the potential cost of incidents that occur and go unreported.
Conclusion The health care and financial burden of dating violence is significant when compared to that of initiatives designed to decrease the risk. Nursing plays a vital role in mitigating the risk of dating violence and its longterm health effects. Innovative approaches in partnership with key stakeholders enhance awareness of students and academic staff along with healthcare providers. The TeLL team plans to continue these initiatives, engaging more involvement across campus, working with key departments to improve awareness of dating violence and reporting procedures, and making recommendations to improve safety and policies. Grant funding opportunities through the campus programs within the Office on Violence Against Women (2012) are being pursued to fund initiatives. The survey data will continue to be collected with subsequent presentations, and as the number of participants grows, the impact on attitudes will continue to be measured. Additionally, a critical appraisal of the annual safety report will provide information as to the number of reported incidents. It is anticipated that these numbers will increase and fill the gap of unreported incidents if educational programs and materials successfully increase awareness. If the program is effective, sustaining it long term may lead to decreased violent events, healthier students, reduced financial burden, and a safer campus community.
References Burnett, L. B., (2011). Domestic violence. Medscape, 1–7. Retrieved from http://emedicine.medscape.com/article/805546-overview Campbell, R., Patterson, D., & Lichty, L. F. (2005). The effectiveness of sexual assault nurse examiner (SANE) programs: A review of psychological, medical, legal, and community outcomes. Trauma Violence Abuse, 6, 313–329. doi: 10.1177/1524838005280328 Catalano, S. (2012). Intimate partner violence: Attributes of victimization, 1993-2011. United States Department of Justice Bureau of Justice
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Statistics. Retrieved from http://www.bjs.gov/content/pub/pdf/ipvav9311. pdf Catalano, S. (2007). Intimate partner violence in the United States. United States Department of Justice, Bureau of Justice Statistics. Retrieved from http://www.ojp.usdoj.gov/bjs/intimate/ipv.htm Centers for Disease Control (CDC). (2011). Intimate partner violence: Risk and protective factors. Injury Center: Violence prevention. Retrieved from http://www.dc.gov/ViolencePrevention/intimatepartnerviolence/ riskprotectivefactors.html Central Michigan University. (2011). Campus safety. Retrieved from http://www.cmich.edu/Police/Campus Safety.htm Coxell, A. W., & King M. B. (1996). Male victims of sexual assault and rape. Sexual and Marital Therapy, 11(3), 297–308. Krebs, C. P., Lindquist, C. H., Warner, T. D., Fisher, B. S., & Martin, S. L. (2007). The campus sexual assault (CSA) study. National Institute of Justice. Retrieved from https://www.ncjrs.gov/pdffiles1/nij/grants/221153.pdf Lehigh University. (2011). Playing it safe: Annual security report and safety escort map. Retrieved from http://www.lehigh.edu/∼inlpd/PDFs/Playing It Safe 2011 WEB.pdf Madonna University. (2011). Campus safety. Retrieved from http://www.madonna.edu/pdf/univres/CampusSafetyHQP.pdf Michigan State University. (2011). Annual security and fire safety report. Retrieved from http://police.msu.edu/cleryandfiresafetyreport.asp National Institute of Justice. (2005). Sexual assault on campus: What colleges are doing about it. Retrieved from https://www.ncjrs.gov/pdffiles1/nij/ 205521.pdf National Institute of Justice. (2011). Casework cost of sexual assault. Retrieved from http://www.nij.gov/tpoics/forensics/events/dnamtgttrans5/ clarke2/tsld019.htm Office on Violence Against Women. (2012). Grants to reduce sexual assault, domestic violence, dating violence, and stalking on campus program. United States Department of Justice. Retrieved from http://www.ovw.usdoj.gov/docs/ campus-solicitation.pdf Padden, M. L. (2008). Sexual violence and the silent reaction rape: Implications for Nurses. Nursing for Women’s Health, 12(2), 106–113. doi:10.1111/j.1751-486X.2008.00296.x. Roe, K. J., (2004). The violence against women act and its impact on sexual violence public policy: Looking back and looking forward. National Alliance to End Sexual Violence, 1–10. Retrieved from http://www.vawnet.org/ Assoc Files VAWnet/VAWA-SVPubPol.pdf Silverman, J. G., Raj, A., Mucci, L. A., & Hathaway, J. E. (2001). Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, and suicidality. Journal of the American Medical Association, 286(5), 572–579. doi: 10.1001/jama.286.5.572 United States Department of Education. (2011). The Clery Act. Higher Education Center. Retrieved from http://www.higheredcenter.org/mandates/ clery-act United States Department of Education, Office of Postsecondary Education. (2011). The handbook for campus safety and security reporting, Washington, DC, 2011. Retrieved from http://www.ed.gov/admins/lead/safety/campus.html United States Government Accountability Office. (2007). Services provided to victims of domestic violence, sexual assault, dating violence, and stalking. Retrieved from http://www.gao.gov/products/GAO-07–846R University of Detroit Mercy. (2011). Student handbook. Retrieved from http://www.udmercy.edu/slo/office/handbook/UDM SP 2010 2011.pdf University of Michigan. (2011). Annual security report and fire safety report. Retrieved from http://www.umich.edu/∼safety/pdf/annual report 2011.pdf Vladutiu, C. J., Martin, S. J., & May, R. J. (2011). College- or university-based sexual assault programs: A review of program outcomes, characteristics, and recommendations. Trauma Violence & Abuse, 12(61), 78–86. doi: 10.1177/1524838010390708
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Dating violence: Promoting awareness and mitigating risk through nursing innovations Terry L. Ames, MSN, FNP-BC (Nurse Practitioner)1 , Lori A. Glenn, DNP, CNM (Associate Professor of Nursing)2,3 , & Leslie E. Simons, MSN, APRN-BC (Nurse Practitioner)4 1
Taylor Clinic, Taylor, Michigan Hurley Medical Center, Flint, Michigan 3 University of Detroit Mercy, Detroit, Michigan 4 Pain Management Center of Lansing, Lansing, Michigan 2
Keywords College students; domestic violence; education; advanced practice nurse (APN). Correspondence Leslie E. Simons, MSN, APRN-BC, Pain Management Center of Lansing, MI 48912. Tel: 517-285-3095; Fax: 517-484-7377; E-mail: [email protected] Received: January 2012; accepted: July 2012 doi: 10.1002/2327-6924.12095 Disclosure The authors received no financial support for the research, authorship, and/or publication of this article. The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Abstract Purpose: The TeLL Dating Violence Project was created by three advanced practice nurses to mitigate the risk of dating violence on a college campus through establishment of an innovative program of education and policy change. Data sources: Literature regarding dating and domestic violence and the subsequent health effects as it pertains to college-aged students was reviewed. Government agency documentation pertaining to the legal requirements to protect students was included. Several college documents were compared for education and awareness programs, safety and prevention measures, and reporting and follow-up procedures. Key stakeholders on campus were accessed to determine unmet student needs. Conclusions: Dating violence is a common occurrence among college students. Women are more likely to be affected and at greatest risk for experiencing nonfatal intimate partner violence and nonconsensual sexual experiences. Dating violence significantly impacts the short- and long-term health of victims and has significant financial effects as well. Implications for practice: Nurses are in a unique position to identify and refer clients who may have experienced dating violence. By partnering with campus health centers, student organizations, and public safety the risk of dating violence can be mitigated. An innovative program developed by a team of advanced practice nurses that involves policy change, awareness, and education is outlined.
The TeLL team The TeLL team was created in response to concerns from multiple departments across the campus of a private university regarding underreporting of dating violence events. “TeLL” was the name chosen to brand the team, making it recognizable across campus. The letters represent “Truth embraces Love without Lies,” incorporated in the phrase “Don’t be afraid to TeLL the truth about dating violence.” Composed of three advanced practice nurses, the team recognized the potential impact to the health of students resulting from campus dating violence. The primary goal was to improve awareness of the phenomena of dating violence on campus. Beginning steps were taken to implement a campus-wide program designed
to increase awareness, enhance safety, and increase reporting through education of students, staff, and faculty. The TeLL team also worked with key stakeholders, making recommendations for safety and policy enhancements that are to be reflected in the student handbook and orientation experiences.
Dating violence Dating violence is a common occurrence on college campuses, affecting an estimated 21% of students (National Institute of Justice, 2005). It encompasses physical, sexual, or psychological/emotional violence within a dating relationship (Centers for Disease Control [CDC], 2011). A review of evidence reveals that the majority
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of significant issues relate to sexual assault. College age women are at greatest risk for experiencing nonfatal intimate partner violence as well as nonconsensual sexual experiences (Catalano, 2007). Statistics demonstrate nearly 20% of women will be victims of completed or attempted rape while in college. Of these, 16% disclose this event to a friend or family member, 13% will report the event to law enforcement. For those who were incapacitated by alcohol or drugs at the time, the rate goes down to 2% (Krebs, Lindquist, Warner, Fisher, & Martin, 2007). Current data from the Bureau of Justice Statistics show that while arrest rates for sexual assault have remained stable, twice as many women reported a sexual assault by an intimate partner in 2010 as compared to 1994 (Catalano, 2012). Research and statistics in the literature focus on the female victims of sexual assault and dating violence (Coxell & King, 1996). According to the 2011 report from the National Center for Victims of Crime (NCVC), gang rape, multiple sexual acts, and weapon use are more common among male victims, and injuries are often more serious than those that occur with female victims. Lack of tracking of sexual crimes against men, as well as lack of research about the effects of male rape may reflect society’s attitudes toward male rape as being unacceptable to discuss. Sexual assault is considered the United States’ most underreported violent crime (National Institute of Justice, 2005). There are personal, societal, and system barriers that contribute to underreporting. Personal barriers include shame, guilt, and embarrassment, not wanting friends and family to know, concerns about confidentiality, fear of not being believed, and fear of retribution from the perpetrator (Padden, 2008). Societal barriers are tied to social norms that are implicit and explicit, tolerance of violence, and sexual desensitization in mass media (Burnett, 2011). System barriers on campus are related to policies of reporting that are unclear or difficult to access, and concerns about the reputation of the university. Coxell and King (1996) report that for men, additional societal barriers that may prevent reporting sexual crimes perpetrated against them are related to negative cultural views toward homosexuality. These views may cause heterosexual males to underreport sexual assault by other males in order to avoid being labeled homosexual. Law enforcement may be unsympathetic if the victim is homosexual. For men sexually assaulted by women, victims may fail to report because of shame or the concern they will not be believed by law enforcement.
havior, use of illicit substances, unintended pregnancies, posttraumatic stress disorder, depression, suicidal ideation, and eating disorders (Silverman, Raj, Mucci, & Hathaway, 2001). In 2003, the CDC review of the Youth Behavior Inventory Survey found that dating violence is linked to poor academic performance and risk behaviors such as sexual intercourse, attempted suicide, cigarette use, episodic heavy drinking, and physical fighting. Sexual assault is also linked to physical health problems including headaches, fatigue, sleeping disorders, sexual dysfunction, and sexually transmitted diseases, along with psychological issues including depression, anxiety, stress, and suicidal ideation (Vladutiu, Martin, & Macy, 2011). Males report many of the same health issues as women, in addition to confusion about sexual orientation, problems with erection or ejaculation, inability to form close and trusting relationships, and homophobia (Coxell & King, 1996). The annual economic impact for domestic violence is estimated at $8.3 billion, including $460 million for rape (Burnett, 2011). The cost to the healthcare system for treatment of a single sexual assault is $87,000. This includes health care, mental health care, police, social/victim care, loss of productivity, property loss, and loss of quality of life (National Institute of Justice, 2011). Additional costs to the university may include legal action taken by families of students, or fines starting at $27,500 per violation if the requirements of laws to protect students as outlined in the Clery Act are not met (United States Department of Education, 2011). By making campus officials aware of this financial impact, resources can be allocated to implement programs that work toward mitigating the risk of dating violence incidents. Nurses are recognized for their unique work as sexual assault nurse examiners (SANEs). They provide victims with comprehensive care and psychological support, accurate forensic evidence collection, and effective testimony during prosecution (Campbell, Patterson, & Lichty, 2005). In addition, these nurses identify and refer clients who have experienced sexual violence and unresolved sexual trauma (Padden, 2008). Advanced practice nurses are often providers of primary care in campus health centers. Nurses as leaders in health care are also in a unique position to educate and support college students. By partnering with campus health centers, student life, student organizations, and public safety, nurses can promote awareness and prevention measures related to campus dating violence and sexual assault.
Healthcare implications
Policies and laws
The health impact of sexual assault is nearly immeasurable. Significant health issues include risky sexual be-
Historically, domestic violence, sexual assaults, and stalking incidents were ignored by society and treated as
144
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T. L. Ames et al.
private family matters. The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, as part of the Higher Education Act of 1965, is a federal law that requires colleges and universities to disclose certain timely and annual information about campus crime and security policies (United States Department of Education, Office of Postsecondary Education, 2011). Howard and Connie Clery championed the Clery Act after their daughter Jeanne was raped and murdered in her dorm room at Lehigh University in 1986. One feature of the act is that postsecondary education institutions participating in federal student aid programs can be fined and lose financial aid dollars if found in violation (United States Department of Education, 2011). In 1984, the Family Violence Prevention and Services Act was passed to help prevent domestic violence and provide shelter and related assistance for victims (United States Government Accountability Office, 2007). In response to concerns about domestic violence, sexual assault, and stalking incidents, the Violence Against Women Act (VAWA) was signed into law in 1994. VAWA has improved federal, state, and local responses to sexual assault through changes in public attitudes, policy, and law. Examples include grant funding to educate and prevent domestic violence on campus, clarification that forensic evidence in rape exams is paid for by law enforcement, prohibition of charging fees for filing criminal charges, assistance with serving orders of protection, and mandatory restitution for victims of sex crimes (Roe, 2004). According to the United States Department of Justice (2005), women are more likely to tell a friend about an incident of sexual assault. Students with increased awareness about dating violence are more likely to recognize the event as a reportable crime. If students are also aware of the current process of reporting with confidentiality and respect, they may perceive fewer barriers to reporting. On the campus where the TeLL Program took place, the reporting process begins once a victim contacts public safety about an assault or incident. If a sexual or physical assault has occurred, emergency personnel transport the victim to a local hospital for medical care. After the victim is cleared medically, she/he is transported to a domestic violence shelter for a forensic examination by a SANE. During this visit, the victim receives comprehensive, sensitive care with access to police reporting, legal counsel, and personal counseling.
Mitigating the risk of sexual assault Each university is required by law to protect students from assaults, document crime statistics, and provide counseling and treatment for the victim. The main
resource for reporting an assault is campus public safety, and prompt reporting is essential to keep the university community safe (United States Department of Education, 2011). Some universities have comprehensive programs, paid for in part with grants from Office on Violence Against Women (2012). These include mandatory education, campus awareness programs, counseling, medical services provided by forensic nurses, promise or pledge statements from public safety, on-campus safe house, and ongoing follow-up (Central Michigan University, 2011; Lehigh University, 2011; Michigan State University, 2011). However, many other universities and colleges do not offer comprehensive education and awareness programs or specific promise or pledge statements. They will provide educational programs detailing techniques to avoid sexual assault and dating violence, but these are upon request and not part of a formal orientation or awareness program (Madonna University, 2011; University of Detroit Mercy, 2011). Counselors on the campus where the intervention took place revealed that many assaults are unreported and that most victims do not seek assistance until a year or more after becoming symptomatic psychologically. Not only does this prevent the pursuit of criminal prosecution, it makes counseling more challenging.
Recommendations for nursing The purpose of this project was to utilize an innovative approach of empowering students to mitigate the risk of becoming a victim of dating violence. A group of advanced practice nurses conducted meetings with representatives from Public Safety, Dean of Students, Counseling Center, Student Health Center, and the local referring emergency department to discuss the policies and procedures that are specific to dating violence and sexual assault. The outcome of these meetings was a unified goal of addressing issues of knowledge, awareness, and safety issues surrounding campus dating violence. As a result, a campus-wide program focusing on education, safety, and reporting was created.
Campus initiatives Education and awareness The education and awareness initiative began with a candlelight vigil held in conjunction with a universitywide presentation on domestic violence. For this event, the TeLL team created and distributed both a brochure and business card with information about dating violence, how to prevent it, and the process of reporting it. The brochures and cards are available in the public safety 145
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office and distributed in key student areas on campus including common areas and restrooms. A campus-wide presentation entitled “Healthy Dating Relationships” was presented in February 2012 by the TeLL team and a panel of key personnel from partner departments. Representatives came from Public Safety, Campus Health Center, Dean of Students, and the Counseling Center to discuss their department’s role in prevention of and response to dating violence. Eighteen students, as well as several faculty and staff attended the presentation. Again the informational brochures and cards were provided to attendees. A survey was conducted to determine the impact of the presentation and nine were returned. Respondents agreed that as a result of the program, they were able to identify the characteristics of a healthy dating relationship, define dating violence, describe the role alcohol plays in dating violence incidents, and identify the health impact of dating violence on college students. They indicated that if they or a friend became a victim of dating violence, they would report the incident to Public Safety and seek health care with examination of injuries along with support from the Counseling Center. Additionally, if they witnessed a friend or acquaintance at risk of becoming a victim of dating violence, they would report the incident to public safety and assist them in avoiding the incident. All but one respondent would recommend continuing campus presentations on dating violence. The drama department presents skits every fall to incoming freshman and new students and is currently creating a program dramatizing dating violence and its effect on students, to debut 2012 fall semester. The TeLL team will also participate in orientation in the 2012 fall semester, presenting “Healthy Dating” to new students and their parents. As part of the faculty and staff development, the TeLL team will conduct an in-service to key stakeholders detailing the impact, reporting, and prevention of campus dating violence during the 2012–2013 academic year. The candlelight vigil will again take place in October 2012, with community health nursing students and representatives of student organizations assisting in planning and presenting the event.
Reporting Focusing on the transparency and awareness of policies and processes for reporting dating violence will improve the acceptability of student reporting. After review of the current materials provided to students, the TeLL team made recommendations for the Student Handbook section on sexual assault. This included using language that was student centered, supportive, and easy to navigate along with making it more accessible in a separate 146
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document such as a brochure or card. It also expanded the information on sexual assault to include dating violence. These recommendations are being incorporated into the 2012–2013 Student Handbook. In process is the creation of an icon on the public safety website that will enable concerned students, faculty, and staff quick and easy access to reporting information without downloading the lengthy online Student Handbook.
Safety An increased awareness of the process for reporting an incident may not just increase the likelihood of reporting, but also act as a deterrent for potential offenders, improving safety on campus. The public safety website contains excellent information on crime prevention, and periodically safety reminders are sent to students by email. Recommendations by the TeLL team included measures to enhance safety information, highlighting public safety contact information and availability of campus escorts. This initiative could be accomplished in several ways including provision of an easily visible sticker to be placed on the back of the hanging parking tag, highly visible reflective signs at key areas on campus, and campuswide e-mail reminders. These recommendations are under review by key departments.
Financial impact The financial impact is considered to illustrate the need to pursue resources and grant funding to implement programs that work toward decreasing the risk of dating violence incidents. Support for victims of sexual assault does not require additional funding through the campus, as no cost care is provided through the Rape Prevention Service Dollars or STOP funding (Campbell et al., 2005). This includes the cost of emergency department care, forensic exams, and medication to prevent sexually transmitted infections and unintended pregnancy, as well as counseling. It is important that this information is shared with students, as awareness of the free services may be limited, and fear of the cost of care could prevent reporting of incidents. The potential financial impact to a private, mediumsized university similar to the one where the TeLL program took place relates to student withdrawal as a result of trauma or poor academic performance. Based on national statistics that 20% of women are victims of sexual assault on campus, a medium-sized coeducational college of 5000 undergraduate students could potentially have 625 cases. If only 30 (less than 5%) of those students leave, there is a potential for significant loss of tuition from otherwise capable students. The university also risks
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additional financial losses through fines and discontinuation of federal aid if laws are not followed, as well as potential lawsuits from families. The initial costs of the TeLL program were less than $500, and included the candlelight vigil, campus-wide presentation, updates to existing resources, and education materials for students. A more comprehensive education, reporting, and safety initiative would cost about 29% of the tuition cost of just one student for one semester at this institution, which is significantly less than the potential cost of incidents that occur and go unreported.
Conclusion The health care and financial burden of dating violence is significant when compared to that of initiatives designed to decrease the risk. Nursing plays a vital role in mitigating the risk of dating violence and its longterm health effects. Innovative approaches in partnership with key stakeholders enhance awareness of students and academic staff along with healthcare providers. The TeLL team plans to continue these initiatives, engaging more involvement across campus, working with key departments to improve awareness of dating violence and reporting procedures, and making recommendations to improve safety and policies. Grant funding opportunities through the campus programs within the Office on Violence Against Women (2012) are being pursued to fund initiatives. The survey data will continue to be collected with subsequent presentations, and as the number of participants grows, the impact on attitudes will continue to be measured. Additionally, a critical appraisal of the annual safety report will provide information as to the number of reported incidents. It is anticipated that these numbers will increase and fill the gap of unreported incidents if educational programs and materials successfully increase awareness. If the program is effective, sustaining it long term may lead to decreased violent events, healthier students, reduced financial burden, and a safer campus community.
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