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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.
Assessment
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.
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