Universal screening turns up cases that would have been missed

Relying on indicators, one ED missed 80% of patients later identified as having been victims of domestic violence

Nurses should be on the lookout for the not-so-obvious indicators of domestic violence in all women, says Susan Hohenhaus, RN, an emergency nurse at the University of North Carolina Hospital in Chapel Hill, NC. "Typically, an injury that is inconsistent with the patient history will raise a red flag, but repetitive domestic abuse can also cause chronic pain, depression, or GI problems," she stresses.

At University of North Carolina Hospital's ED, the majority of clinicians were opposed to universal screening. "Everyone felt it would bog the system down, and there were also concerns about violating the privacy of patients," recalls Anna Waller, ScD, research assistant professor for the department of emergency medicine.

Nurses set out to determine whether their facility's screening method for domestic violence was effective. First, the triage nurse screened all female patients using a list of indicators. (See list, above.) "Rather than asking direct questions about abuse, we looked for indicators, not just physical ones, but also emotional problems or alcohol abuse," she says.

The examining nurse then screened all women for domestic violence using direct questions. Both nurses collected information so the number of victims identified could be compared. "A partner piece of paper went with the patient to the examining nurse, and she asked every patient about domestic violence, without knowing whether indicators were present," says Waller.

Results clearly showed that screening with indicators was inadequate. "By relying strictly on indicators, we missed about 80% of the women we identified when we used direct questioning," says Waller. "Relying on indicators isn't enough-every patient needs to be questioned."

When women were asked abuse assessment questions in private, 13% reported some level of current abuse. "We didn't even ask about previous relationships, we only asked if they were currently in a relationship where they felt unsafe," explains Waller.

The policy has since been implemented and has helped to detect victims who don't present with obvious injuries. "What gets people on board with universal screening is when they come across someone who had a totally reasonable explanation for their injuries, who turns out to be a victim of domestic violence," says Waller. "That's when they realize it is important to ask everybody."

Every woman needs to be screened, because victims aren't always obvious. "If you don't ask everyone, that one person will slip through the cracks because you didn't ask her, since she has an attentive husband, is beautifully dressed, and a pillar of the community," notes Hohenhaus.

Other indicators may not come directly from the victim. "If the patient's family comes with her, and the children are fearful of caregivers, that is a sign there may be abuse in the home," says Hohenhaus. "Children may also speak directly about abuse. One child came to us and said, 'My mom told you that she fell down the stairs, but my dad hit her.'"

Nurses need to get used to raising this sensitive subject. "It's an uncomfortable thing to talk about, but experience helps," says Mary Anne Nolan, RN, CEN, clinical coordinator at Columbia Deering Hospital in Miami, FL, which uses a laminated card to assist nurses in screening adult female patients. (See Domestic Violence Guide, page 102.) "Also, the more patients you ask, the more you come to understand how much domestic violence is out there, which motivates you to ask everyone."

Approaches should vary based on the situation. (See chart on conducting routine screening, page 99.) If the same woman comes in several times for a migraine headache and domestic violence is suspected, a less direct approach may be appropriate. "You can take a softer approach by saying something like, 'Sometimes when I see women who have this problem, something is not quite right at home,'" says Hohenhaus.

Some women may take offense, but the public is getting used to being asked about domestic violence. "It's very similar to child abuse, in that people used to be offended, but now everyone knows if you bring in a child with an unexplained broken arm, someone will look at you strangely and ask questions," says Hohenhaus.