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Identifying IPV/DV in healthcare is critical. Many professional organizations recommend routine screening for IPV/DV. Among them are the American Association of Colleges of Nursing, the American Nurses Association, the American Academy of Pediatrics (AAP), American College of Nurse Midwives, and National Association of Pediatric Nurse Practitioners.
Changes in healthcare funding have contributed to broadening screening for DV/IPV. The Affordable Care Act requires many insurance plans to provide coverage for certain recommended preventive health services which will help ensure that women can receive, without cost-sharing, a comprehensive set of recommended preventive health services, including screening and counseling for interpersonal and domestic violence (USDHHS, 2012).
Identifying current or past abusive and traumatic experiences can help prevent further abuse, lessen disability, and lead to improved health status. Because they are often trusted resources in their com-munities, health care providers are in a unique position to connect women who experience interpersonal and domestic violence with support (USDHHS, 2012).
Providers do not need to be experts on interpersonal and domestic violence to conduct screenings. Screening can occur during any visit with a primary care provider or as part of any other health care visit. Just as providers routinely screen patients for diabetes or high blood pressure and refer them to specialists as needed, providers can also screen for interpersonal and domestic violence and provide a referral to local domestic violence programs and services (USDHHS, 2012).
If a woman discloses abuse, the provider can provide brief counseling to: 1) promote the patient’s immediate safety; 2) discuss the possible relationship between current or previous interpersonal and domestic violence and the patient’s health concerns; and 3) link the patient to support services and resources (USDHHS, 2012).
In order to effectively be able to identify and respond to IPV/DV, healthcare providers must have information and training on the subject. They need to be able to feel comfortable asking a patient about IPV/DV and they need to feel as though they have something to offer the patient, once IPV/DV is disclosed.
Training sessions funded by AHRQ improved primary care providers' confidence in asking and treating victims of domestic violence. Providers who participated in the training increased their screening for domestic violence from 3.5 percent prior to the training program to 20.5 percent after training. Upon completion of the training sessions, participants stated they (Kass-Bartlesme, 2004):
- Felt less fear of offending patients by asking about domestic violence.
- Had less fear for their own safety.
- Asked patients more often about possible domestic violence.
- Offered strategies to abusers to seek help.
- Provided strategies so victims could change their situation.
- Had better access to information on managing domestic violence.
- Had methods to ask abusers about domestic violence while minimizing the risk to the victims.
Using a public health model, that has been effective in treating other conditions and illnesses (for example, smoking cessation, drinking and driving campaigns, immunizations, etc.), it is the routine inquiry and assessment that can identify IPV/DV. Making routine inquiry and assessment of IPV/DV a routine part of healthcare history and examination, reinforces the role of healthcare providers in IPV/DV and gives the patient information about where to receive assistance if she chooses. Even if patients choose not to disclose the abuse, they know that the healthcare provider can be approached about the subject in the future.
Assessment
Inquiry for past and present IPV/DV should occur:
- As part of the routine health history (e.g. social history/review of systems);
- As part of the standard health assessment (or at every encounter in urgent care);
- During every new patient encounter;
- During periodic comprehensive health visits (assess for current IPV/DV victimization only);
- During a visit for a new chief complaint (assess for current IPV/DV victimization only);
- At every new intimate relationship (assess for current IPVDV victimization only);
- When signs and symptoms raise concerns or at other times at the provider's discretion.
Assessment for IPV/DV should be:
- Conducted routinely, regardless of the presence or absence of indicators of abuse;
- Conducted verbally as part of a face-to-face health care encounter;
- Included in written or computer based health questionnaires;
- Direct and nonjudgmental using language that is culturally/linguistically appropriate;
- Conducted in private: no friends, relatives (except children under 3) or caregivers should be present;
- Confidential: prior to inquiry, patients should be informed of any reporting requirements or other limits to provider/patient confidentiality;
- Assisted, if needed, by interpreters who have been trained to ask about abuse and who do not know the patient or the patient's partner, caregiver, friends or family socially.
The goals of the assessment are to:
- Create a supportive environment in which the patient can discuss the abuse;
- Enable the provider to gather information about health problems associated with the abuse; and
- Assess the immediate and long-term health and safety needs for the patient in order to develop and implement a response.
The timing of assessment is important:
- Initial assessment should occur immediately after disclosure;
- Repeat and/or expanded assessments should occur during follow-up appointments;
- At least one follow-up appointment (or referral) should be offered after disclosure of current or past abuse with health care provider, social worker or DV advocate.
Case Study
1. Roseanne (continued)
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Today at work, Roseanne is caring for a baby in the
neonatal intensive care whose mother has only come to
the NICU for 2 hours in the past week. Roseanne watches
the mom; she recognizes the bruises on her face, not
quite covered up by makeup. She appears anxious and
is tearful. Roseanne knows just how she feels-but she
cannot bring herself to ask the mom about her experience.
Roseanne decides to talk with her supervisor; she admits
that she suspects IPV/DV in the family of the baby she
is caring for. She then begins to cry and tells her
supervisor that she recognizes the abuse because it
looks so much like her own situation.
Roseanne requests that the supervisor intervene on
behalf of the mom and screen for IPV/DV, because Roseanne
is unable to do so. Roseanne's supervisor offers her
support to Roseanne both for the patient and for Roseanne
herself. She talks with Roseanne about safety planning,
refers her to the Employee Assistance Program at work
and offers emotional support as well. Roseanne recognizes
that she has to make a change, but she isn't sure what
to do.
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There are multiple assessment tools available. In 2007, the CDC released Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Healthcare Settings. This document can be accessed at http://www.cdc.gov/ncipc/pub-res/images/ipvandsvscreening.pdf.
Screening can also occur through simple verbal questioning. According to the American College of Obstetricians and Gynecologists (ACOG), IPV/DV screening, which they recommend should be conducted on ALL patients, can be conducted by making the following statement and asking these three simple questions (ACOG, 2014):
"Because violence is so common in many women's lives and because there is help available for women being abused, I now ask every patient about domestic violence:
- Within the past year -- or since you have been pregnant -- have you been hit, slapped, kicked or otherwise physically hurt by someone?
- Are you in a relationship with a person who threatens or physically hurts you?
- Has anyone forced you to have sexual activities that made you feel uncomfortable?"
Pregnant women should be screened throughout the pregnancy because some women do not disclose abuse the first time they are asked and abuse may begin later in pregnancy (ACOG, 2014).
Screening should occur (ACOG, 2014):
- At the first prenatal visit
- At least once per trimester, and
- At the postpartum checkup.
ACOG also suggests that screening should occur for women who are not pregnant (ACOG, 2014):
- At routine ob-gyn visits;
- Family planning visits;
- Preconception visits.
If the patient says "no":
- Respect the patient's response;
- Let the patient know that you are available should the situation ever change;
- Assess again at previously recommended intervals;
- If patient says "no" but you believe s/he may be at risk, discuss the specific risk factors and offer information and resources in exam and waiting rooms, or bathrooms.
Interventions will vary based on the severity of the abuse,
the patient's decisions about what s/he wants for assistance
at that time and if the abuse is happening currently. It is
important to let the patient know that you will help regardless
of whether s/he decides to stay in or leave the abusive relationship.
It is also important for the healthcare provider to NOT impose
her or his own values onto the patient. Since the patient
is already suffering from the abuse of control and power,
the healthcare provider should support the patient to make
her/his own decisions and not further exert power over the
patient by making decisions for her/him.
For the patient who discloses current abuse, assessment should
include at a minimum an assessment of immediate safety:
- "Are you in immediate danger?"
- "Is your partner at the health facility now?"
- "Do you want to (or have to) go home with your partner?"
- "Do you have somewhere safe to go?"
- "Have there been threats or direct abuse of the children
(if s/he has children)?"
- "Are you afraid your life may be in danger?"
- "Has the violence gotten worse or is it getting scarier?
Is it happening more often?"
- "Has your partner used weapons, alcohol or drugs?"
- "Has your partner ever held you or your children against
your will?"
- "Does your partner ever watch you closely, follow you
or stalk you?"
- "Has your partner ever threatened to kill you, him/herself
or your children?"
If the patient states that there has been an escalation in
the frequency and/or severity of violence, that weapons have
been used, or that there has been hostage taking, stalking,
homicide or suicide threats, providers should conduct a homicide/suicide
assessment.
Assess the impact of the IPV (past or present) on the patient's
health. There are common health problems associated with current
or past IPV victimization. Disclosure should prompt providers
to consider these healthcare risks and assess:
- How the (current or past) IPV/DV victimization affects
the presenting health issue
- "Does your partner control you access to healthcare or
how you care for yourself?"
- How the (current or past) IPV/DV victimization relates
to other associated health issues
Assessment of the pattern and history of current abuse:
- "How long has the violence been going on?"
- "Have you ever been hospitalized because of the abuse?"
- "Can you tell me about your most serious event?"
- "Has your partner forced you to have sex, hurt you sexually,
or forced you into sexual acts that made you uncomfortable?"
- "Have other family members, children or pets been hurt
by your partner?"
- "Does your partner control your activities, money or
children?"
For all patients who disclose current abuse, providers should:
- Provide validation:
- Listen non-judgmentally;
- "I am concerned for your safety (and the safety of
your children)";
- "You are not alone and help is available";
- "You don't deserve the abuse and it is not your fault";
- "Stopping the abuse is the responsibility of your
partner not you".
- Provide information:
- "Domestic violence is common and happens in all kinds
of relationships";
- "Violence tends to continue and often becomes more
frequent and severe";
- "Abuse can impact your health in many ways";
- "You are not to blame, but exposure to violence in
the home can emotionally and physically hurt your children
or other dependent loved ones"
- Respond to safety issues:
- Offer the patient a brochure about safety planning
and go over it with her/him (see Appendix
D for a sample safety plan);
- Review ideas about keeping information private and
safe from the abuser;
- Offer the patient immediate and private access to
an advocate in person or via phone;
- Offer to have a provider or advocate discuss safety
then or at a later appointment;
- If the patient wants immediate police assistance,
offer to place the call;
- Reinforce the patient's autonomy in making decisions
regarding her/his safety;
- If there is significant risk of suicide, the patient
should be kept safe in the health setting until emergency
psychiatric evaluation can be obtained.
- Make referrals to local resources:
- Describe any advocacy and support systems within
the health care setting
- Refer patient to advocacy and support services within
the community
- Refer patients to organizations that address their
unique needs such as organizations with multiple language
capacities, or those that specialize in working with
specific populations (i.e. teen, elderly, disabled,
deaf or hard of hearing, particular ethnic or cultural
communities or lesbian, gay, transgender or bisexual
clients)
- Offer a choice of available referrals including on-site
advocates, social workers, local IPV/DV resources
or the National DV Hotline (800) 799-SAFE, TTY (800)
787-3224 and local Florida Domestic Violence Hotline
at 1-800-500-1119.
For the patient that discloses past history of IPV/DV victimization:
- "When did the abuse occur?"
- "Do you feel you are still at risk?"
- "Are you in contact with your ex-partner?" "Do you share
children or custody?"
- "How do you think the abuse has affected you emotionally
and physically?"
Continue on to Management of IPV/DV in the Healthcare Setting,
Con't.
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