Assessment and Screening in the Healthcare Setting

Barriers to IPV assessment

Staff education

It would be ideal for all health care providers and counselors be trained to assess for intimate partner violence, including physicians and all nursing personnel, EMTs, and public health and mental health professionals. Many victims of Intimate Partner Violence (IPV) are seen in the emergency departments, clinics, and doctors’ offices. It is necessary to have healthcare providers educated about the dynamics of domestic abuse and be authorized to record information in the medical record. Responses to victims of abuse are most effective when coordinated in a multidisciplinary manner and in collaboration with domestic violence advocates.

In adult health care settings, universal and regular face-to-face assessment of women and men by trained health providers markedly increases the identification of victims of violence, as well as those who are at risk. Information gained by the interviews can assist in the treatment of the victim. Battered women have reported that the most important part of their communication with the health care provider is being listened to about abuse (Miller, 2015).

Not only is assessment of victims of IPV important it is also mandated by hospital accreditors and some state health departments. The Joint Commission requires hospitals to have policies for the identification, evaluation, management, and referral of victims of IPV (Burnett, 2018).

• The hospital must safeguard information and potential evidence that may be used in future actions as part of the legal process.
• Hospitals must have policies and procedures that define responsibility for collecting these materials.
  
• Hospital policy must define activities and specify who is responsible for their implementation.
  

Patient barriers to IPV assessment

Because most victims of domestic/intimate partner violence and their children are seen in health care settings, health care professionals can play an important role in identifying and preventing abuse. Todahl and Walters (2011) report only 9%-40% of clinicians screen for IPV. The following are reported by Sprague, et al (2012) as barriers to screening:

• personal discomfort with the topic
  
• inadequate resource
  
• lack of time, training, or privacy to screen
  
• perceptions that IPV screening is not the clinician's role
  
• fear of offending patients
  
• not knowing how to respond to a woman disclosing IPV
  

Another barrier to identifying abused women and men, is the victim’s tendencies to claim an unintentional fall or other type of injury caused the bruises and/or fractures inflicted by an abuser. According to Crandall, et al. (2004) women who suffered blunt intentional trauma exhibited different injury patterns than those hospitalized for accidental injuries. The following table describes the rate at which injuries on different parts of the body occur by accident or by abuse.

Real versus fabricated causes of injuries

The following are several additional documented reasons victims of domestic violence are reluctant to report abuse.

• Fear of the assailant and future attacks
• Belief the situation will improve particularly if the abuser is remorseful and apologetic after attacks
• Lack of sufficient finances to live alone especially if children are involved
• Belief they are guilty of a behavior that causes the abuse
• Embarrassment (Patrick, 2018)

Calton, et al. (2015) in their study found three major barriers to help-seeking exist for LGBTQ IPV survivors: a limited understanding of the problem of LGBTQ IPV by those in the healthcare professions, stigma associated with being an LGBT person, and general inequities in the US. managing.
The problem of domestic/intimate partner violence within communities is increased in the presence of poverty and poverty-related problems, especially when there are weak sanctions against domestic violence. In some communities, distrust of the police is pervasive, and people are often more afraid of dealing with the police than the perpetrator. Therefore, people may need to be assured of confidentiality when they are choosing whether to call the police or not.

Approaches to IPV screening

• Miller, et al. (2015) suggest the following systems approach when implementing IPV screening and counseling.
• Staff and clinician training in effective, client centered IPV assessment that connects patients to support and services regardless of disclosure
• Enhancement of EHRs to prompt appropriate clinical care for IPV and facilitate capturing more detailed and standardized IPV data
• Integrating IPV care into quality and meaningful use measures.

The authors also recommend research studies in different health settings and populations, development of evidenced based quality measures and outcomes and valid and reliable screening and counseling approaches.

State requirements

States differ about requirements for the type of questionnaire. For example, Florida and California have specific forms healthcare institutions are required to use. They are posted in this section. Other states like Idaho, give institutions a choice about which questionnaire to use. Still other states, like Kentucky, have no specific requirements other than saying a tool to assess for domestic violence be in place and used. The Kentucky legal system suggests the use of the Danger Assessment tool (http://www.dangerassessment.org/) as well as the Lethality Assessment Tool (https://www.nccpsafety.org/assets/files/library/Domestic_Violence_Lethality_Screen.pdf).

KentuckyOne Health in Louisville, KY found asking the patients if they were safe at home and if anyone was hurting them in their Emergency Department was not sufficient in identifying the number of patients who were being abused. They changed their system to ask the following four direct questions in a private setting away from possible abusers:

• Have you been injured, hit, kicked, punched in the past year, and, if so, by whom?
• Do you feel unsafe in your current relationship?
• Is there a partner from a previous relationship who is making you feel unsafe now?
• Are you here today for injuries related to intimate partner violence?

On the computerized medical record, there is a prompt for clinicians with dialogue to introduce the questions and inform patients that all patients are asked questions about domestic violence. There are also prompts about what to say if the patient does indicate abuse is occurring. https://www.chausa.org/publications/catholic-health-world/archives/issues/august-1-2016/kentuckyone-health-aims-to-identify-safeguard-victims-of-intimate-partner-violence

A general initial routine IPV screening script that is included in the medical record can aide in having all women being screened for IPV. Here are some recommendations by Laughon, et al. (2008) about what should be included in that initial screening:

• A normalizing statement that says this is a questionnaire that is asked of all patients
  
• An explanation about mandatory reporting processes in your specific state
  
• A general question about safety – Do you feel safe with your domestic partner?
  
• A statement about the fact that all couples argue once in a while

Specific questions of abuse such as these should follow the normalizing statements. Does the patient’s partner do any of the following:

• Physical - hit, slapped, kicked, choked, or otherwise physically hurt or stalk
  
• Sexual – Is he or she forced to have intercourse or engage in other sexual activities
  
• Emotional – Are they called names like stupid, a loser, ridiculing, or other character assassinations
  
• Economic – Do they have access to funds? Have any funds or property been taken away from them?
  
• Psychological - Are they coerced or threatened in any way? Does their partner control and monitor where they are and who they talk with?

References

Burnett, L. B. (2018). Domestic violence Treatment & Management. Medscape. https://emedicine.medscape.com/article/805546-treatment#d10.

Calton, J.M., Cattaneo, L.B. & Gebhard, K.T. (2016). Barriers to Help Seeking for Lesbian, Gay, Bisexual, Transgender, and Queer Survivors of Intimate Partner Violence. Trauma Violence Abuse. 17(5), 585-600.

Crandall, M. L., Nathens, A. B. & Rivara, F. P. (2004). Injury Patterns among Female Trauma Patients: Recognizing Intentional Injury The Journal of Trauma: Injury, Infection, and Critical Care, 57(1), 42-45.

Laughon, K., Renker, P., Glass, N. & Parker, B. (2008). Revision of the abuse assessment screen to address nonlethal strangulation. J Obstet Gynecol Neonatal Nurs. 37(4), 502–507.

Miller, E., McCaw, B., Humphreys, B. L. & Mitchell, C. (2015). Integrating Intimate Partner Violence Assessment and Intervention into Healthcare in the United States: A Systems Approach. J Womens Health (Larchmt). 24(1), 92–99.

Sprague, S., Madden, K., Simunovic, N., et al. (2012). Barriers to screening for intimate partner violence. Women Health. 52(6), 587–605.

Todahl, J. & Walters, E. (2011). Universal screening for intimate partner violence: a systematic review. J Marital Fam Ther. 37(3), 355–369.

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