Domestic violence screening protocols promote early detection, intervention

Identifying victims of abuse helps break the cycle, even if they don't seek help immediately

Estimates indicate that 17-30% of the women who are seen in the ED are there because of illnesses or injuries caused by domestic violence.1-3 Yet many of these women are overlooked even though signs and symptoms are present, says Susan Hohenhaus, RN, an emergency nurse at the University of North Carolina Hospital in Chapel Hill, where a protocol was developed to increase identification, documentation, and referral of domestic violence victims.

ED nurses must increase identification of domestic violence victims through careful screening, urges Anna Waller, ScD, research assistant professor for the department of emergency medicine at the University of North Carolina in Chapel Hill. "The examining nurses are the ones who need to be screening patients," she stresses. "Nurses have more time to build a relationship with the patient, and we must do whatever we can to get victims of abuse the help they need."

Therefore, ED nurses must take a leadership role to develop effective domestic violence protocols, urges Hohenhaus. "Having a protocol to identify and refer victims ensures that domestic violence is always on our minds, so there is less of a chance that screening will be overlooked," she says.

Many nurses are reluctant to raise the issue in the ED because they lack the time and resources to solve the complex problem. "Like most health care providers, I believed that if domestic violence was mentioned, the outcome would have to be a resolution to the problem," says Linda Hutson, RN, an emergency nurse at the University Hospital Medical Center in Cincinnati, OH, which also developed a domestic violence protocol. (See screening portion of protocol on page 99.)

Nurses must learn to recognize the indicators, history, and injuries typically seen with domestic violence, stresses Hutson. "We are responsible for asking questions about violence in a woman's life because of the substantial health risk violence presents," she says. "This problem cannot be solved by the ED staff. But, at a cost of more than $44 million in medical bills per year and over 5400 deaths, this is a significant health care issue that cannot be ignored."

Just asking is an intervention

It's not necessary to resolve the issue in the ED, Waller emphasizes. "It's frustrating when you see the same woman come in three weeks later with another injury, but nurses should realize they don't have to fix it for these people," she says. "It's OK to ask even if they don't do anything, because the asking itself is an intervention."

Screening techniques should vary depending on the situation. If an injury looks suspicious, direct questions are most effective. "Sometimes, the shock value of saying, 'Who did this to you?' is very effective, as opposed to just asking the woman how she got hurt," says Hohenhaus.

Even if a victim denies abuse, just asking the question plants a seed, says Hohenhaus. "Many victims of domestic violence have told us time and again that until a nurse or physician asked them about abuse, they just thought they were different from everybody," she notes. "But being asked made them acknowledge the problem, even if it's months or years later."

Bringing up the subject sends a message that accepting chronic abuse is not acceptable, especially when children are involved. "When I ask victims of domestic violence whether or not their child is being abused, they look at me like I am crazy and say, 'Of course not! I wouldn't let that happen to my child.' Yet they let it happen to themselves," says Mary Anne Nolan, RN, CEN, clinical coordinator at Columbia Deering Hospital in Miami, FL.

Frank discussion can enable the victim to help herself at a later point in time. "Most of them don't want to talk to anyone, but maybe they will next time," says Waller. "Just identifying people is still helping, even though you are not calling the shelter every time."

An on-site advocate automatically comes to the University of North Carolina's ED whenever a domestic violence victim is identified. "We send someone over regardless of whether the patient wants to talk, and they rarely refuse. Whereas, if we asked them if they wanted us to call someone, most would probably say no," says Waller.

Here are some things to consider when screening for domestic violence:

Screen in private. Asking sensitive questions about abuse should only be done in private. "Triage is not the place to be screening for domestic violence," says Waller. If the triage nurse suspects abuse, a note should be made on the patient's chart for the examining nurse to address, she advises.

Be creative about giving information. Since many victims of domestic violence will not acknowledge a need for help, information should be provided discreetly. At Columbia Deering Hospital's ED, cards reading "Need help? Don't die for love" in English and Spanish, with a toll-free 24-hour hotline number, are left in the bathroom. "They disappear very quickly and frequently have to be replenished, probably because they are in a private location," says Nolan.

When asking about abuse, don't couch your words. In cases of severe injury, don't hesitate to be blunt. "We tell women straight out, 'The injuries we see now are very serious. That means the violence is escalating and you could wind up getting killed,'" Hohenhaus says.

On one occasion, a woman who repeatedly came to the ED severely beaten was warned by nurses. "The very last words we said were, `The next time we see you, you're going to be dead,'" says Hohenhaus. "The next morning, the woman was killed by her abuser and brought to the ED." The man was later charged with two misdemeanor counts of assault on another woman but not charged with the woman's murder, she reports.

Involve all ED clinicians. Ideally, patients should be asked about domestic violence more than once. "Our protocol is nursing-based, but we certainly don't want to be the only ones asking," says Hohenhaus. "This is not a one-person task-both nurses and physicians should be asking these questions."

Don't feel like you have to solve the entire problem. If a women acknowledges being abused, the next step may be to provide her with a written safety plan or resources for the future. "The perception is that if the woman says yes, then you have to get her out of the house and into a shelter," says Hohenhaus. "But in the vast majority of cases, that is not what these people want." Sometimes just a recognition that the abuse is happening is significant, she adds.

Develop your own style for asking sensitive questions. Protocols should include guidelines for the type of questions to ask, but nurses should personalize their delivery. "You do need to ask specific, direct questions, but if you recite questions like, 'Have you been hit, kicked or punched by anyone,' like you are checking off a list, it sounds rote," says Hohenhaus.

Don't be afraid to keep asking. It pays to be persistent. When a woman came to the ED with multiple lacerations and bruises on her face and arms, she insisted she had fallen in the driveway. "She spent three hours insisting there was no abuse. But after being asked the question for what seemed like the 100th time, she finally admitted that her husband had done this to her," says Hohenhaus.

The victim declined to press charges but did allow photos to be taken. "We told her that it was her choice, but that if she ever wanted to follow up and report this, the photos would be in her record," says Hohenhaus.

References

    1. McLeer SV, Anwar R. A study of battered women presenting in an emergency department. Am J Public Healt. 1989: 79:65-66.

    2. Rosenburg M, Finley MA: Violence in America: A Public Health Approach. New York. Oxford University Press, 1991.

    3. Randall T: Domestic violence intervention calls for more than treating injuries. JAMA 1990; 264: 939-940