Domestic Violence/Intimate Partner Violence:
Applying Best Practice Guidelines

Best Practice Guidelines for Domestic Violence/Intimate Partner Violence

Introduction

Defining the Problem

Statistics

Identifying Abuse

Consequence of Violence

Risk Factors for Victimization and Preparation

Dynamics of Abuse

Select Populations and IPV/DV

Barriers to Identifcation of Intimate Partner Violence/Domestic Violence

Best Practice Guidelines for Intimate Partner Violence/Domestic Violence

Safety Planning

Conclusion

Resources

References

Test

Exit to Menu

With the current focus on evidence-based practice, the Agency for Healthcare Research and Quality (AHRQ) reported that the U.S. Preventive Services Task Force (USPSTF) did not find enough evidence to recommend for or against routine screening for IPV/DV among the general population. However, the USPSTF reinforced the necessity for healthcare providers to be able to identify the signs and symptoms of IPV/DV, document the evidence, provide treatment for victims, and refer victims to counseling and social agencies that can provide assistance (Kass-Bartlesme, 2004).

Identifying IPV/DV in healthcare is critical. Many professional organizations recommend routine screening for IPV/DV. Among them are (Horner, 2005): 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.

A focus on outcomes in healthcare has helped to fuel the work of identifying best practice guidelines or evidence-based practice. Through the work of a panel of content experts, research review and literature review have helped to shape these guidelines. This process has yielded best practice guidelines for a number of different illnesses and conditions (see Resource section of this course for more information on these guidelines).

The federal government's National Guideline Clearinghouse, identifies guidelines for intervention in IPV/DV. They list The Family Violence Prevention Fund's 2004 publication of National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings. The full reference appears in the Reference section of this course; the full guidelines can be retrieved from the Family Violence Prevention website at http://endabuse.org/programs/display.php3?DocID=206. These guidelines will be referred to as the Guidelines during this course.

These Guidelines offer a variety of healthcare professionals, working in a variety of healthcare settings, the ability to address IPV/DV. Responses to intimate partner victims are most efficient and effective when coordinated in a multi-disciplinary manner and in collaboration with IPV/DV advocates so that no single provider is responsible for the entire intervention.

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.

The Guidelines recommend that all adolescent and adult patients are routinely assessed for IPV/DV. These women want help. Some studies have shown that approximately 70 to 81 percent of survivors of abuse want their health care professionals to ask them about domestic abuse during their appointments (USDHHS, 2008). Patients should be asked about current and lifetime exposure to IPV/DV victimization. Direct questions about physical, emotional and sexual abuse should be asked. Due to the long term consequences of IPV/DV on health, the Guidelines recommend integrating assessment for current and lifetime exposure into routine care. They acknowledge that in some settings lifetime exposure assessment may be limited due to time constraints, such as emergency departments or urgent care facilities.

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.

In 2007, the CDC released a compendium of assessment tools for use in identifying IPV/DV in the healthcare settings. A variety of instruments are available in the compendium, which can be accessed at http://www.cdc.gov/NCIPC/pub-res/ipv_and_sv_screening.htm.

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, 2006).

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:

1. Within the past year -- or since you have been pregnant -- have you been hit, slapped, kicked or otherwise physically hurt by someone?
2. Are you in a relationship with a person who threatens or physically hurts you?
3. 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, 2006).

Screening should occur (ACOG, 2006):

• 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, 2006):

• 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 Best Practice Guidelines for Domestic Violence/Intimate Partner Violence, Con't.