Don't make these mistakes when assessing for violence

Always ask follow-up questions

Do you know how to increase the likelihood that a patient will tell you about abuse? During 293 audiotaped interactions with ED staff assessing for intimate partner violence (IPV), 77 patients disclosed experience with IPV.1 Here are some of the communication pitfalls that researchers found:

Failing to probe further.

Direct straightforward questions about behaviors, such as "Did this injury happen due to a fight with your partner?" prompted patients to disclose abuse, says Karin V. Rhodes, MD, MS, the study's lead author and director of the Division of Health Policy Research in the University of Pennsylvania's Department of Emergency Medicine. Rhodes is a former emergency nurse.

Almost three times as many patients disclosed abuse when ED nurses followed up on nonmedical "clues," such as the patient's mention of stress, and asked even one more question. "Mentioning 'stress' is a common and acceptable way of bringing up a psychosocial issue. Ask what sort of stress she is under and whether there is conflict in her relationship," advises Rhodes.

To increase the chances that a woman will disclose abuse, pause and look directly at her and ask: "Are you in a relationship where you have been hit or threatened?" says Rhodes. Then make sure you add at least one additional question, such as "Have you ever been?" or "Any abusive ex-partners in the picture?" she advises.

Failing to act when a patient discloses abuse.

Less than one-quarter of the women in the study who revealed abuse were referred to legal or counseling services, and providers generally failed to document domestic violence in the medical record. These lapses occurred even though providers were aware they were being taped, and despite annual domestic violence education programs.

"When you do identify someone, let them know you're very glad they told you," says Rhodes. "And then, call your ED social worker or put the patient on the phone to a 24-hour domestic violence hotline. Even if a woman does not need shelter, she may benefit from legal services and group support."

Asking about abuse in the presence of the woman's partner.

"Always interview the patient alone," says Suzanne Murphy, BSN, RN, SANE, an ED nurse at the Hospital of the University of Pennsylvania in Philadelphia. "Every nurse has their own personal style, but I usually act like it is commonplace and ask visitors to step outside for a moment."

If an individual persists in speaking for the patient or hovers nearby, this is a sign that IPV may be occurring, says Murphy. In this case, if you insist on talking to the patient alone, it places the patient at risk, says Murphy. "The abuser will ask what we talked about when he has her alone. If I am unable to speak with the patient alone by asking visitors to leave, I will wait until the time is right," she says. "The visitor may go the restroom or get something to eat."

Another good method is to follow the patient to a diagnostic test such as X-ray or CT, where hospital policy states the visitor can't go, says Murphy. "Helping the patient to the bathroom is another way," she says.

However, triage is the easiest time to do this, says Murphy. "The rooms are small and you can block the visitor from entering in the beginning by saying, 'Just have a seat in the main waiting room, we'll just be a minute.'"

Post resource cards about IPV in the bathroom stalls to ensure that every patient has access to information, recommends Murphy. "This way, every patient gets 'asked' about IPV and can take the information if they feel safe to do so," says Murphy.

At the Hospital of the University of Pennsylvania's ED, a SAFE (sexual assault forensic examiner) Team consists of ED nurses given specialized training to work with victims of abuse, neglect, and violence, says Murphy.

"The first opportunity to ask about potential abuse is at the access point to the emergency department: triage," says Murphy. "The goal is to ask every patient about IPV and have a documented answer in their chart."

Murphy usually says, "Because violence is so prevalent in our lives, I routinely ask all of my patients if they are or recently have been physically or emotionally harmed by someone they love."

When a patient is identified as being in an abusive relationship, the SAFE Team is contacted along with social workers, says Murphy. "Together, we utilize our specialized knowledge and expertise to provide appropriate care and resources," she says. "ED nurses should never feel you have to solve the problem. Our role is to provide resources that empower the patient."

Sources/Resource

For more information on assessment of intimate partner violence, contact:

  • Suzanne Murphy, BSN, RN, SANE, Emergency Department, Hospital of the University of Pennsylvania, Philadelphia. E-mail: Suzanne.Murphy@uphs.upenn.edu.
  • Karin V. Rhodes, MD MS, Director, Division of Health Care Policy Research, Department of Emergency Medicine, University of Pennsylvania, Philadelphia. Phone: (215) 421-1036. E-mail: kvr@sp2.upenn.edu.