Domestic Violence/Intimate Partner Violence: Applying Best Practice Guidelines

Best Practice Guidelines, Con't.

Introduction

Defining the Problem

Statistics

Identifying Abuse

Consequences of Violence

Risk Factors for IPV/DV

Dynamics of Abuse

Select Populations and IPV/DV

Barriers to the Identification of Violence

Best Practice Guidelines

Reporting IPV/DV

Documentation & Follow-up

Safety Planning

Conclusion

Resources

References

Appendix A

Appendix B

Appendix C

Appendix D

Appendix E

Test

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Case Study 1. Roseanne (continued)

 

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.

 

 

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.

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.

Intervention

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;
    • 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, Kentucky Adult and Child Abuse Reporting Hot Line:(800) 752-6200; Kentucky Spouse Abuse Shelter Hot Line: (800) 544-2022 VINE: The National Victim Notification Network (800) 511-1670.

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 Reporting IPV/DV