Community Health Nursing Capstone Paper - Sample of Academic Writing

Domestic Violence Prevention

Laura Heim

University of South Florida College of Nursing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domestic Violence Prevention

The location where the community interventions will take place is in the third largest county in Florida, Hillsborough County, north of the downtown Tampa area, where in 2010, 7,110,529 individuals called this county in south Florida home (Florida Department of Health, 2012).  The major employers in Hillsborough are the School District of Hillsborough County with 25,473 employees, MacDill Airforce Base with 12,000 employees, Hillsborough County Government with 10,600 employees, and a notable employer in the fourth spot is the University of South Florida with 9,000 employees (Suncoast Jobs, 2011).  There are numerous health care systems in Florida and Floridahealthfinder.gov is a convenient site where individuals can put in their demographic information to find a provider that fits their needs (2012).              Socioeconomic factors, for the year 2010, in Hillsborough and the state of Florida show that at 14.2%, the level of poverty is higher in Hillsborough County, Florida, than at the Florida state level of 13.8% (Florida Department of Health, 2012).  The difference may look small, but each number, no matter how miniscule, represents a person living, possibly, without the basic necessities.  The number of individuals over the age of 25 with a high school diploma in Hillsborough County is 85.8% compared with the 85.3% for the state of Florida, so as the discrepancy is small, it still shows that the County is above average for the state (Florida Department of Health, 2012).  Also, the population of citizens over the age of five years old who do not speak English well in Hillsborough County is at 10.2%, which is lower than the state of Florida’s total of 11.8% (Florida Department of Health, 2012).                                         Healthy People 2020                                                                                                             Healthy People 2020 is a government health effort which is powered by the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives, the Federal Interagency Workgroup, and Lead Federal Agencies. Authored in part by Dr. Howard Koh, it details a ten-year plan to cover ground in treating diseases after surveying populations to see which individuals are most at risk for certain conditions while providing access to treat those ailments with over 600 objectives and 1200 measures (U.S. Department of Health and Human Services, 2012).  Healthy People 2020, through the U.S. Department of Health and Human Services (2012), was developed with measurable goals in mind to track data to identify and eliminate health problems and disparities among people of different groups while having communities combine their efforts to produce the best results for their citizens.  The health indicators assess what obstacles health care organizations must overcome to treat certain diseases that are highlighted within their communities.  The health indicator groups contain data and statistics which support their cause for concern.                                                                        The 12 leading health indicators include the following:

·        Access to Health Services

·        Clinical Preventive Services

·        Environmental Quality

·        Injury and Violence

·        Maternal, Infant, and Child Health

·        Mental Health

·        Nutrition, Physical Activity, and Obesity

·        Oral Health

·        Reproductive and Sexual Health

·        Social Determinants

·        Substance Abuse

·        Tobacco                                                                                                                                  The above leading health indicators are included in the U.S. Department of Health and Human Services (2012) website.                                                                                                 The Healthy People 2020 U.S. Department of Health and Human Services (2012) health indicators include these national measures: access to Health Services, as only 25% of people do not have a primary care provider, while 20% do not have health insurance.  There are also Clinical Preventive Services, since routine screening and preventive injections are often covered by insurance, but many people do not take advantage of them; Environmental Quality, because 127 million people live in U.S. communities whose air standards are in the unhealthy range; Injury and Violence, due to the fact that 29 million people suffer injuries severe enough each year to send them to the emergency room (U.S. Department of Health and Human Services, 2012).  Maternal, Infant, and Child Health are included, where 31% of the 80% of women who give birth in their lifetimes suffer complications; Mental Health, since 25% of all adults in 2004 and 20% of all children in 2010 suffered with a disorder; Nutrition, Physical Activity, and Obesity, as over 81% of adults and children do not get the recommended amount of daily physical activity (U.S. Department of Health and Human Services, 2012). Oral Health and some other factors are included in the U.S. Department of Health and Human Services (2012) report, because untreated gum disease is related to heart disease, strokes, and diabetes; Reproductive and Sexual Health, where 19 million people are diagnosed with a new sexually transmitted disease (STD) case each year. There are also Social Determinants, as people’s physical environment can affect them positively or negatively; Substance Abuse (SA), with the 600 billion dollar toll on the population annually from SA complications and ramifications, and Tobacco, since as of three years ago over 46 million Americans smoked (U. S. Department of Health and Human Services, 2012).

The Department of Health and Human Services (2012) suggests applying these factors to a population with the collaboration of Federal agencies, including but not limited to the U.S. Department of Health and Human Services (HHS), through combining information from the Affordable Care Act along with points from the Secretary (and Assistant Secretary) to make sure all efforts could be combined as fluidly as possible.                                                                        Data Collection and Interpretation                                                                                                          Strengths in the County of Hillsborough were numerous as evidenced by research through the Florida Charts Florida Department of Health (2012) website; narrowing them down based on major health concerns and public interest data from 2010 revealed positive results in three major areas.  The first showed that new Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome (HIV/AIDS) cases in Hillsborough were 21.8 per 100,000 residents compared to the state of Florida’s 22.3 (Florida Department of Health, 2012). The second item listed includes smoking-related cancer deaths during the years 2004-2006 on a rolling basis as 69.0 per 100,000 residents died from it (smoking) Hillsborough as compared to 87.2 for the state (Florida Department of Health, 2012). The final positive health area supported group care facilities in the county: unsatisfactory inspections of group care facilities for 2008-2010 were 2.0% for Hillsborough while the number went up to 7.5% for the state (Florida Department of Health, 2012). Dealing with these three areas is vital as reported by Healthy People 2020, through the U.S. Department of Health and Human Services (2012), which details leading health indicators.  Leading health indicators show how to deal with ways in which HIV/AIDS can affect reproductive health (even sexual health in children affected with/by it) and reports that smoking is the most preventable form of ailments and mortality with 203 billion dollars going into healthcare to treat people with smoking-related afflictions (U.S. Department of Health and Human Services, 2012).  Finally, mental health awareness and correct treatment of those with it can reduce disability and death within its population (U.S. Department of Health and Human Services, 2012). It is important that Hillsborough County continues to watch state statistics of sexually-transmitted diseases (STD’s), smoking, and mental health issues are problems that can be addressed on a person-to-person level so that individual accountability is held in high regard and respected.                                                                                                Areas Requiring Improvement                                                                                                  The three areas that need improvement in the County of Hillsborough were found on the Florida Charts Florida Department of Health (2012) website where information included the statistics that 20.9% of women without a high school education in this County gave birth which is higher than the state of Florida’s 18.5%; motor vehicle accidents (MVA’s) in Hillsborough were 126.9 per 100,000 people, a great increase above the state’s total of 106.5; and domestic violence rates per 100,000 residents were at 608 for the state and 621.6 for the County for 2008-2010.  Leading health indicators, through the Healthy People 2020 U.S. Department of Health and Human Services website (2012), show that a lack of education leads to a lack of resources both in and out of the health care and insurance spectrum.  There are 22 million people in the U.S. suffering with a substance abuse (SA) issue, and violence (and unintentional) injuries are the top 15 forms of death for Americans of all ages (U.S. Department of Health and Human Services, 2012).  All of these issues need assistance from well-supported agencies that can deal with the large scope of problems these issues present to individuals.                                     The health indicator that will be chosen for this paper as a priority health issue is “Injury and Violence”, as the domestic violence rates for the County of Hillsborough were mentioned to be higher than the state of Florida’s rates (U.S. Department of Health and Human Services, 2012).  Over 51,000 deaths a year in the U.S., according to U.S. Department of Health and Human Services Healthy People 2020 rates (2012) are caused by violent acts.  These violent acts can be a result of domestic violence which includes partner violence and violence against seniors, family members, roommates, children and animals (Drauker, 2002).  The direct victim may not be the only one with physical and emotional damage done, as a ramification of violence is the trickling-down effect of damage where witnesses can suffer temporary and/or chronic life-long problems related to the abuse (U.S. Department of Health and Human Services Healthy People 2020, 2012).                                                                                                                              Determinants of Health Model                                                                                                         The Determinants of Health Model according to the U.S. Department of Health and Human Services Healthy People 2020 (2012) includes the “interrelationships between the range of personal, social, economic, and environmental factors that influence health status” (p. 1). The nurse’s use of interventions for policy making could result in a positive change with an outcome that benefits the general population or specific individuals.  Social factors that influence interventions come from familiarization of a population’s milieu (U.S. Department of Health and Human Services, 2012).  Healthy People 2020 through the U.S. Department of Health and Human Services (2012) shows how personal and social factors work in-tandem to influence a person’s condition, while the economic environment can certainly have an impact as well, perhaps more negative than positive, especially in today’s world.  The client and delivery-oriented roles of a community health nurse can involve the Determinants of Health Model to assess, plan, and especially intervene for a population whose needs are not being met by the current system of healthcare, if one even exists (Clark 2003).  In the case of domestic violence, the community health nurse would have to be conscientious about her approach within the family system before change; talk could be initiated due to the sensitive nature, and potentially intense environment, that surrounds familial issues.                                                                                               There are multiple factors that contribute to domestic violence and Dr. Drauker (2002) details how environmental factors are not necessarily taken into consideration when treating victims of abuse, especially women, so after 25 years of interventions, domestic violence is still at “epidemic” proportions (she mentions that screenings for those at-risk would be a step in the right direction).  Griffin and Koss (2002) describe how lifestyle can contribute to “partner violence”, because some victims feel entrapped and dependent on their abuser, as this submission shows how partner violence contributes more harm to woman than do rapes, car accidents, and muggings altogether over the years.  Erez (2012) details the fact that although the health system has been affected for years by the aftermath of domestic violence, only in the 1970s was this violence identified as a crime.  Partners may have been abused for centuries, but for the last 40 years the victims now have a voice, through the justice system, to shine a light on their plight.  There is also the biology aspect that goes along with violence, as recognizing women that are pregnant, who have gone through abuse, feel the responsibility of not only caring for themselves but rethinking their milieu as they now have another individual to watch over and hopefully protect (McCosker, Barnard, & Gerber 2004).                                                Population Diagnosis                                                                                                                   Adult female population members at risk for domestic (partner) violence as evidenced by statistics showing violence directed at women in Hillsborough County, Florida where a) 622 women, out of 100,000, were abused between 2008-2010 and b) 12.4% of women in the county had unwanted advances with 10.3% for state of Florida (Florida Department of Health, 2012).                                                              Intervention Wheel                                                                                                                                The Intervention Wheel, developed in 1998 in Minnesota for public health practitioners, is an idea captured in a circular model/graph which, according to Keller, Strohschein, Schaffer, and Lia-Hoagberg (2004), shows three levels (community, systems, family) of environments for people and seventeen interventions that go hand-in-hand with these levels to produce a system of change.  The goals of the wheel are to show what the best practices are for situations and ways to apply these practices to real-world situations that are found in various populations in the community (Keller, et al. 2004).  Rippke, Briske, Keller, Strohschein, and Simonetti (2001) are health care workers who have collaborated on the wheel where it is divided into different colored slices, in which each slice defines the scope of practice and skills that the nurse will put to use while handling her/his specific situation.  It can be applied to the Population Diagnosis area where interventions and even preventative measures can be found by using the Wheel to carry out patient support and activism, as it is, after all, the goal of a community health nurse to be a patient advocate while promoting autonomy among population members who are ready for it.                                                                                    Levels of Prevention Model                                                                                                                      The Levels of Prevention Model is one that, described by Clark (2003), entails three levels with primary, secondary, and tertiary. These three levels are defined with primary associated with promoting health, secondary with treating problems before the turn into major issues, and tertiary by keeping problems from exacerbating (Rippke, et al. 2001).  Primary prevention, according to Clark (2003) “assesses whether or not health was promoted and specific problems were prevented” (p. 265).  The Priority Health Issue of domestic violence could have participants (victims) involved with primary prevention, because the prevention of further physical and emotional damage could be a key goal for the nurse treating people in chronic abuse situations.  The secondary level of prevention entails educating the client and having them identify signs and symptoms of their disease (Clark, 2003).  Regarding violence in a household, it would be wise of the client(s) to put secondary prevention in place through recognition of triggers before a violent outburst could occur from the perpetrator. The Community Health Nursing text explains that tertiary prevention focuses on an individual’s ability to cope and adapt after changes are made to positively impact health (Clark, 2003, p. 65).  The priority health issue fits well with tertiary prevention as patients that can face or get away from their abusers must cope with their new surroundings while gaining confidence in their new-found power.   Victims of domestic violence may not be able to recognize healthy from unhealthy behaviors, so it is the responsibility of the community health nurse to take the time to teach them boundary-setting before starting change-thinking.                                                                                             Evidence Based Interventions                                                                                                  The levels of prevention may have one or more recipients who benefit from the same preventions, so there can be some overlap within patient groups.  Varcarolis, Carson, and Shoemaker (2006) describe how an individual, such as the victim, can be taught to meet his/her own needs and develop problem-solving skills when ready to learn them.  The community, or family unit in this case, would benefit from health teaching, where the client’s needs are recognized as important to the unit while the members are taught coping skills with emphasis on positive mental and physical health practices (Varcarolis, et al. 2006).  The system-wide health care structure is an intervention recipient who has the duty to protect its citizens, and when all are in accordance with its guidelines, then real change can be achieved.  It is vital that community members take responsibility for their residents and actions are taken when violations occur.                                                                                                                                                       The community health nurse is involved with many stakeholders in the intervention process as is evidenced by the fact that she/he has to create, promote, and evaluate the effectiveness of the intervention. The nurse may watch “changes in the client’s medical status (either positive or negative), social circumstances, and quality of care provided; observing for changes in functional ability or mobility; and identifying evolving educational needs” (Clark, 2003, p. 264)  The community members and health care providers have a stake in the intervention process, especially with the introduction of an infant/child into a high risk situation, as these people have to make sure that the home environment is “safe…with committed parents and caregivers, who can, with assistance, access local, state, and federal resources (which) is basic for success” (Forsythe, Maher, Kirchick, & Bieda, 2007, p. 69).  This leads the conversation to public officials and legislators whose duty it is to protect its citizens from harm, where there need to be, according to Erez (2002) “criminal codes specifically listing the behavior as a crime (rather than merely addressing it within the general law of assault)…(since) it (abuse) 85% coming from a man to a woman, is not a ‘normal’ part of marriage or intimate relationships (where)…law enforcement (must) trend in the movement to address domestic violence through the criminal justice system” (Manuscript No. 3). Stakeholders have the duty to perform an action for intervention and prevention of unhealthy behavior(s).  Funding sources, for the stakeholders, should be aware of the need for discrete counseling centers and provisions for safe houses where women, and certain family members, learn that they have the power to be independent strong women, since many women under the control of men will develop serious debilitating conditions over their lifetimes if they continue to stay with their abusers (Ellsburg, Heise, 2004).                                                                 Community/Population Based Interventions                                                                      Primary Level                                                                                                                                    The primary level recipient, in the spectrum of community health nursing, is the community itself, especially if the community is one where abuse situations may arise among its members.  Again, the goal at the primary level is to prevent a situation from occurring, in this case, domestic violence.  The Minnesota Department of Health shows through the Intervention Wheel that within the community system the goals of collaboration, consultation, health teaching, and delegated functions will help with prevention (Rippke, et al. 2001). Surveillance must be done within the context of the culture in which the abuse is presented as well (Drauker, 2002).   The nurse cannot make assumptions that a community is at-risk for physical and emotional abuse, but she/he, as mentioned, has a duty to keep her/his population safe from harm.   Primary Level with Nursing Interventions                                                                                                Nurses may want to note that violence begins at home and it is their goal to stop violence before it starts within a household (Chinn, 2008). A nursing intervention includes stopping violence before it starts because the learning process of showing others compassion starts in childhood. An example of this intervention-need occurred when a 68 year old female bus monitor was taunted and harassed (to tears) by boys, children, from her New York community (Karimi, 2012).  That incident could make people wonder what skills these children were not taught in the home.  The nurse’s job then could be to teach people coping techniques to deal with anger and other emotions while promoting positive healthy behaviors.  She/he may also want to investigate the reasons surrounding victim submission to her/his offender. The stakeholders, families and local government officials, will probably appreciate an approach that does not solely focus on recognizing risk factors, but one that praises the community members for achievements and positive aspects of the community.   Individuals would benefit from being praised for their efforts to care for one another and the media could contribute by bringing balance to their news reports with reflective pieces on thoughtful individuals and acts of kindness in the community. Secondary Level                                                                                                                                                                                                                                                  The goal at the secondary level is to keep problems, while at their infancy, from exacerbating into large problems as the community health nurse has societal obligations in and out of the workplace (Clark, 2003).  The recipient could be the families that are experiencing some type of abuse.  It is the aim of nurses to screen clients for abuse upon admittance to a health care facility and not judge a patient population as it is the nurse’s duty to not do wrong by the patient, nonmaleficience, and know when/how to report abuse as it is the legal duty of the nurse to do so for those who are living in vulnerable, at-risk situations (Kent & Crusse, 2010).  Women, the victims in this case, must recognize the term “domestic violence” and identify if they are victims of such behavior as different cultures have various terms and conditions defining abuse (McCosker, Barnard, & Garber, 2003).  A nurse then must have enough awareness and composure to handle unique situations that arise.  The community health nurse will want to promote health through screenings of partner violence, especially when the suspected abuser is not around since reporting is difficult when the perpetrator has a looming presence (Hastings, 2008).  If the perpetrator is around during screenings then the victim may continue to stay hiding in the shadows, but when the victim does express concerns, it is vital that the nurse praise her for her honesty and willingness to get help.  Communication techniques include open-ended questions directed toward the victim and knowing the right questions to ask which comes from experience and practice (Varcarolis, et al. 2006).  The nurse may also want to consider his/her own biases when providing treatment as to provide the most appropriate care for the clients and family members who have the greatest stake in the treatment.                                                                                                                     Tertiary Level                                                                                                                                   The nurse will take a sensitive and strong approach when providing tertiary level of care to patients as there are physical and emotional barriers that are present at this point of treatment.  The patients will be the direct victims of abuse whether they are the women themselves and their children and dependents that have witnessed the violence.  Traumatic events, such as violence directed toward women in the household, require, according to Valente (2010), comprehensive evaluations and follow-up care because the victims could have consequences of the abuse such as Post-Traumatic Stress Disorder symptoms.  After the woman is able to recognize that her situation is unhealthy than she may want to make serious life choices such as removing herself from the harmful living conditions as to prevent negative future events.  She would also benefit from counseling and her partner, or ex-partner as the case could be, if not prosecuted would benefit from corrective behavior through mandated classes that promote safe behaviors.  Baker (2007) also takes a Christian-based approach to healing for victims where God is at the center of an eight-step healing process.                                                                                                           The idea of education for the immediate clients (and direct family members) is a good one as it would help them to see that violence is not an acceptable means of communication. Palm cards, small informative papers, can be tucked away for use by the victims in the immediate or future home setting (they can also encourage patient compliance with resource/counseling/safe-haven numbers).  Women, who have been abused, may benefit from counseling current victims as helping others is good for the healing process.  Abuse victims might think that they have no power, but after they recognize that they have the strength to change their lives they become the stakeholders in breaking the cycle of abuse for others in their old situations.                                                                                                                                                                                                                        Conclusion                                                                                            The health policy proposal that could positively impact Hillsborough County’s domestic violence issue is a secondary level intervention to heavily promote domestic violence screenings and report findings with educational counseling measures in health care settings.  There needs to be an awareness brought to health care settings to screen women for domestic violence (American Academy of Orthopedic Surgeons, 2012).  A screening model/tool used in Hillsborough County, Florida could have a positive impact on other counties in the state and the nation, especially since a recent study at an emergency department showed that 119 women out of 595 seen in a two-week period were screened for violence before screening was closely evaluated (Hoke, 2008).  Women in abuse situations have unmet health needs because they may be at a loss for what to do about the violence directed towards them, but carefully executed, informative screenings enable these women to find available services to meet their needs (Drauker, 2002).                                                                                                                                 Carina Storrs (2012) details how studies have shown that pregnant mothers (and others) have benefitted from therapeutic measures targeting abuse, with U.S. Preventive Services Task Force support, and her article goes on to explain that screening is in fact an intervention according to health education specialist, Fern Gilkerson, because it shows victims that other people care.  Gamble (2001) discusses health policies in implementing routine domestic violence screenings while emphasizing the point that patients and providers alike would have reservations quelled if screenings were made direct and to-the-point.  After the health policy is put into place, the domestic violence victim rate could initially rise because of the documented cases coming to light, but that rate would drop after victims become able to access the help that they need to prevent further abuse.

References

Ackley, B., & Ladwig, G. (2011). Nursing diagnosis handbook. (9 ed.). St Louis, Missouri:            Elsevier.                                                                                                                   American Academy of Orthopedic Surgeons (AAOS). (2012). Family violence state statuses.          Retrieved from http://www.aaos.org/about/abuse

Baker, J. (2007). Life's healing choices - freedom from your hurts, hang ups, and habits. New     York, NY: Howard.

Chinn, P. L. (2008). Violence, injury, and human safety. ANS. 31, (2). Retrieved from http://www.nursingcenter.com

Clark, M. (2003). Community health nursing. (4 ed.). Upper Saddle River, NJ: Pearson Prentice           Hall.   

Drauker, C. B. (2002). Domestic violence: The challenge for nursing. E-journal of issues            in         nursing, 7(1), 23. Retrieved from            http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/

Ellsberg, M., & Heise, L. (2004). Domestic violence: A global health priority. In Center for            American Progress Article. Retrieved from            http://www.americanprogress.org/issues/2004/10/b224093.html

Erez, E. (2002). Domestic violence and the criminal justice system: An overview. E-journal            of issues in nursing, 7(1), (Manuscript No. 3). Retrieved from            http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/

Florida Department of Health. (2012). Florida charts, community health assessment resource          tool set. Retrieved from http://www.floridacharts.com/charts/chart.aspx

Forsythe, P. L., Maher, R., Kirchick, C., & Bieda, A. (2007). Safe discharge for infants with            high-risk home environments. E-Journal of Advances in Neonatal Care, 7(2), 69-75.            Retrieved from http://www.nursingcenter/com/prodev/ce_article.asp?tid=712210 Gamble, E. (2001). Emergency department screening for domestic violence. Popular            Government Publication. Retrieved from               http://www.sog.unc.edu/pubs/electronicversions/pg/pgspr01/article5.pdf               Hastings, D. P. (2008). Investigating intimate partner violence. OR Nurse E-Journal. 2(1), 56.         Retrieved from www.ORNurseJournal.com                                                                               Hoke, N. (2008). Trauma library in review: Barriers to screening for domestic violence in the       emergency department. Journal of Trauma Nursing, 15(2), 79. Retrieved from            http://www.nursingcenter.com/Inc/JournalArticle?ArticleID_ID=809831                                                             Karimi, F. (2012) Middle schoolers bully bus monitor, 68, with stream of profanity, jeers. CNN.   Retrieved from http://www.cnn.com/2012/06/21/us/new-york-bullied-bus            monitor/index.html                                                                                                                                      Keller, L. O., Strohschein, S., Schaffer, M. A., & Lia-Hoagberg, B. (2004). Population-based   public  health  interventions: Innovations in practice, teaching, and management. part ii. Public Health Nursing, pmid:            15363027                                                                                         Kent, V. P., & Crusse, E. P. (2010). Targeting abuse. Nursing made incredibly easy!, 8(4), 22 28.       Retrieved from            http://www.nursingcenter.com/prodev/cearticleprint/asp?CE_ID=1027745                                      Mc Cosker, H., Barnard, A., & Gerber, R. (2003). Phenomenographic study of women's          experiences of domestic violence during the childbearing years. E-Journal of            issues  in nursing, 9(1). Retrieved from            http://www.nursingworld/org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/Rippke, M., Briske, L., Keller, L. O., Strohschein, S., & Simonetti, J. (2001). Public health            interventions,  applications for public health nursing practice. Minnesota department of                     health division of community health services public health nursing pdf. Retrieved from            http://www.health.state.mn.us/divs/cfh/ophp/resources/docs/phinterventions_manual2001Storrs, C. (2012). Screening women for domestic violence could help prevent abuse. Health Day.            Retrieved from http://www.healthfinder.gov/news/newsstory.aspx?Docid=664533                     U.S. Department of Health and Human Services, Office of Disease Prevention and Health      Promotion. (2012). Healthy People 2020. Retrieved from            http://www.healthypeople.gov/2020/default.aspx                                                                Valente, S. M. (2010). Evaluating and managing adult PTSD in primary care. E-Journal of The      Nurse  Practitioner.  Retrieved from www.tnpj.com                                                                Varcarolis, E. M., Carson, V. B., & Shoemaker, N. C. (2006). Foundations of psychiatric mental health  nursing - a clinical approach. (5 ed.). St Louis, Missouri: Elsevier.