Do you selectively screen for victims of domestic violence?
Screen women with certain injuries . . . you will miss victims’
When a woman came to a Kansas City ED with a chief complaint of sore throat, no one thought to screen her for domestic violence. Several months later, she was killed by her male partner in a domestic violence-related homicide.
The false belief that most victims of domestic violence come to the ED with "suspicious" injuries is an incorrect and dangerous assumption, warns Robert L. Muelleman, MD, FACEP, medical director for emergency services at Nebraska Health Systems and professor of emergency medicine at the University of Nebraska Medical Center, both based in Omaha. Muelleman notes that a growing body of research supports universal screening in the ED.
In fact, victims of domestic violence most often come to the ED not for injuries, but for stress-related complaints such as headaches or anxiety, and routine problems such as bronchitis, notes Muelleman. "If you only screen women with certain types of injuries, you will miss domestic violence victims."
One study followed women who came to the ED without domestic violence injuries and found that 20% later returned with domestic violence injuries, he says.1
"If the goal of screening for domestic violence is to catch it early to prevent it from getting worse, then you need to screen women without injuries," Muelleman urges.
Another study focused on women who were killed by their male partners.2 "We found that half of these women were in the ED prior to the murder," says Muelleman, one of the study’s researchers. "When we looked closely at the charts, we saw that none had been screened for domestic violence."
Most of those ED visits were not related to injuries, he notes. More than 1 million women seek medical attention with injuries and stress-related problems stemming from domestic violence, says Muelleman.3 "So it makes as much sense to screen for domestic violence as for cervical cancer or diabetes," he says.
Ask all patients about abuse
Routinely screen for violence regardless of presenting complaint, urges Alice Kramer, MS, RN, CEN, clinical nurse specialist for emergency services at St. Luke’s Medical Center in Milwaukee.
The ED visit is an excellent time to assess risk, says Kramer. "Families come to the ED feeling very anxious and vulnerable. If we can offer a safe and respectful place to talk about domestic violence, it is an invaluable opportunity," she notes.
Research shows that 12% to 35% of ED patients are victims of domestic violence.4,5 But despite the compelling statistics and research, few EDs perform universal screening, says Kramer. "ED nurses should be asking psychosocial questions routinely," she says. "We absolutely need to consider the social context of people’s lives."
When a pregnant woman came to the ED several times with migraine headaches, an astute ED nurse asked specifically about domestic violence. "She adamantly denied physical abuse," says Kramer. However, the woman admitted that her boyfriend abused her verbally, she recalls. "She realized that his behavior was controlling and abusive and were affecting her own health and well-being, as well as the baby’s."
The woman accepted some printed information and arranged for follow-up calls at home, Kramer reports. "She felt less isolated having been given this education and respectful dialogue," she says. "She now knows the signs of increasing risk, and knows of options that are hers to use if she decides to."
Domestic violence screening in all EDs was one of the goals of Healthy People 2000, the national prevention initiative coordinated by the U.S. Department of Health and Human Services.6 "However, less than 30% of EDs are compliant with this request," reports says Deborah Trautman, MS, RN, director of nursing for emergency medicine at the Johns Hopkins Hospital in Baltimore.7
EDs fail to screen
Even when EDs have screening protocols in place, patients aren’t always screened, Trautman emphasizes. To be successful, a domestic violence screening program has to sustain its momentum with updated protocols, education of patients and ED staff, and inclusion of screening questions on the nursing assessment form, she says. (See forms on Screening for Domestic Violence: Emergency Department/Urgent Care, Implementation of Domestic Violence Protocols, and Domestic Violence Guide, inserted in this issue.)
Here are ways to facilitate screening in your ED:
• Solicit and share positive feedback.
Positive feedback can encourage nurses to continue screening, says Muelleman. "If you ever find out that by screening a woman in the ED, you really improved her life, you will always screen," he says. Develop relationships with staff members at community programs and shelters and ask them to pass along any positive comments from patients about ED interventions, he suggests.
• Offer interventions through volunteer advocates.
As research director of Truman Medical Center in Kansas City, MO, Muelleman implemented a specific intervention, instead of requiring nurses to screen all patients. "Volunteer advocates were on call in the ED and would come down if a woman wanted to meet with them," he explains. "We found that the identification rate went up significantly."
Knowing there was a specific intervention available encouraged nurses to screen, says Muelleman. "The main argument against screening is, If they say yes, what will we do other than hand her a piece of paper with phone numbers?’"
By bringing volunteers to the ED to work those details out, nurses began screening more, says Muelleman. "In the ED, we don’t have time to troubleshoot. The advocates helped with obtaining orders of protection and giving referrals for counseling," he says.
After the program was implemented, the number of women identified as domestic violence victims who went to shelters increased from 11% to 28%, and the number of women screened who sought counseling rose from 1% to 15%, he reports.
The intervention had no effect on the number of women seeking orders of protection, he notes. "We worked with the town judges and arranged to fax information to them in the middle of the night if necessary, so the judge could fax back the order if indicated," he says.
The ED also set up a legal clinic to address orders of protection, child custody, and housing issues related to domestic violence.
Nurses will feel frustrated
• Address personal issues with domestic violence.
Nurses often express frustration with women who return to violent relationships, notes Muelleman.
"The reality is that most women will go back to their abuser, so you’ve got to deal with that," he says. "If you are cynical about that, the woman will perceive that."
Nurses should be informed about the "natural history" of domestic violence, Muelleman recommends. "The fact is that most women are not prepared for the action stage of change, and that the nurse should not measure his or her success by whether the patient takes action," he says.
If the patient moves from the denial stage to an awareness of the problem (contemplation stage), the nurse should count that move as a success even if the patient goes back to the relationship, says Muelleman. "To get frustrated at the patient who goes back to her abuser makes as much sense as getting mad at a diabetic who has high blood sugar or a hypertensive patient having high blood pressure," he notes.
Repeat inservices about domestic violence annually, he recommends. "It’s also effective to have a survivor at the inservice to discuss her perception of the health care system at the time she was still being abused," Muelleman adds. "The local shelters can help locate someone willing to discuss this."
• Include screening in protocols.
Protocols can help standardize screening, says Kramer. The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, requires EDs to have a protocol in place, she says. The Joint Commission also requires that all staff are educated and able to assess for domestic violence, Kramer notes. (See Domestic Violence Working Tool for Health Care Providers, Domestic Violence Screening/Documentation Form, and Minimal Elements of a Domestic Violence Protocol inserted in this issue.)
Use your own words’
• Use a script to start with.
You might find it easier to begin screening using a script in the beginning, Kramer suggests. "Often, nurses think it has to be perfect, or are afraid that they will say something wrong, that there is a complicated, complex language you need to use," she explains. "But the key is to use your own words, and speak with respect and compassion."
The specific words you use are less important than the way you ask the questions, emphasizes Muelleman. "It’s not what you ask, it’s how you ask it," he says. "If you ask about domestic violence with the same empathy as you ask about the patient’s last tetanus shot, you are not likely to get an honest response."
When screening patients, nurses in the ED should ask the following two questions, suggests Kramer:
1. Have you ever been hit or hurt by, or threatened or afraid of someone close to you?
2. Have you ever experienced physical, emotional, or sexual violence? If so, would you like to talk with someone? (See list of suggested screening questions, inserted in this issue.)
• Start by asking certain patients.
If you’re not comfortable asking every patient about abuse, start by screening high-risk patients, suggests Kramer. Ask pregnant women and women with injuries, she says.
It’s also helpful to start with patients you have a rapport with, says Kramer. "That may mean patients of the same ethnicity and age group, or whomever you are comfortable with," she says. "To be comfortable asking all patients, you have to be doing it and actually practicing the words."
• Don’t get discouraged if it doesn’t come naturally.
Asking patients about the sensitive issue of domestic violence is an acquired skill, Kramer says. "It’s like any other nursing skill — you have to do it to learn it," she explains. "You have to begin to ask the questions."
1. Muelleman RL, Liewer JD. How often do women in emergency departments without intimate violence injuries return with such injuries? Acad Emerg Med 1998; 5:982-985.
2. Wadman MC, Muelleman RL. Domestic violence homicides: ED use before victimization. Am J Emerg Med 1999; 17:689-691.
3. The National Committee for Injury Prevention and Control. Injury Prevention: Meeting the Challenge. New York City: Oxford University Press; 1989.
4. Ernst AA, Nick TG, Weiss SJ, et al. Domestic violence in an inner-city ED. Ann Emerg Med 1997; 30:190-197.
5. McLeer S, Ansar RA. A study of battered women presenting in an emergency department. Am J Public Health 1989; 79:65-66.
6. Department of Health and Human Services. Healthy People 2000: National Promotion of Disease Prevention Objectives. Washington, DC; 1990.
7. Centers for Disease Control and Prevention. Emergency department response to domestic violence. Morbidity & Mortality Weekly Report 1993, 42:617-620.
The Health Resource Center on Domestic Violence, a project of the Family Violence Prevention Fund, provides support to develop a comprehensive health care response to domestic violence. Comprehensive information packets for emergency medicine, multidisciplinary protocols, and research studies on domestic violence are available, including a guide, Best Practices: Innovative Domestic Violence Programs in Health Care Settings ($5 per copy plus $5 shipping and handling charge), and a laminated reference card on domestic violence (five for $5, plus $5 shipping and handling). A handbook, Working with Battered Immigrant Women, is available in English and Spanish at a cost of $8 plus $5 shipping and handling. The center’s National Domestic Violence Hotline, (800) 799-SAFE, is available for 24-hour multilingual crisis intervention and referral services. For more information, contact:
• Family Violence Prevention Fund, 383 Rhode Island St., Suite 304, San Francisco, CA 94103-5133. Telephone: (888) RX-ABUSE or (415) 252-8900. Fax: (415) 252-8991. E-mail: ordering@fvpf. org. Web site: www.fvpf.org.
The Nursing Network on Violence Against Women International provides nurse with research and resources pertaining to domestic violence. For more information, contact:
• Kathi Mills, PMB 165, 1801 H St., B5, Modesto, CA 95354. Telephone: (888) 909-9993. Web site: www.nnvawi.org. E-mail: email@example.com.
The American Medical Association offers Diagnostic and Treatment Guidelines on Domestic Violence, and Domestic Violence: A Directory of Protocols for Health Care Providers. Single copies are $5 each, including shipping and handling. To obtain a copy, contact:
• Cynthia Colvin, American Medical Association, Department of Mental Health, 515 State St., Chicago, IL 60610. Telephone: (312) 464-4541. Fax: (312) 464-5842. E-mail: cynthia_colvin @ama-assn.org. Web site: www.ama-assn.org.
A National Directory of Domestic Violence Programs: A Guide to Community Shelter, Safe Homes, and Service Programs is available for $50 plus $7 shipping and handling charge. For more information, contact:
• National Coalition Against Domestic Violence, P.O. Box 18749, Denver, CO 80218. Telephone: (303) 839-1852, ext. 101. Fax: (303) 831-9251. E-mail: firstname.lastname@example.org. Web site: www.ncadv.org.
A 1998 position statement, Domestic Violence, Child Maltreatment, and Human Neglect, is available from the Emergency Nurses Association. Copies can be downloaded from the Web site (www.ena.org), or single copies can be ordered at no charge. To obtain a copy, contact:
• Emergency Nurses Association, 915 Lee St., Des Plaines, IL 60016-6569. Telephone: (800) 900-9659 or (847) 460-4000. Fax: (847) 460-4001.
The City Rubber Stamp Co. offers a rubber stamp to provide a notation about domestic violence screening on a patient’s chart. The stamp documents that screening took place and records the results in a check-off box format. A hand stamp costs $7.50, and a plastic self-ink stamp costs $8.95. There is a $2.50 shipping and handling charge. For an order form, contact:
• City Rubber Stamp Co., 557 Howard St., San Francisco, CA 94105. Telephone: (415) 957-5811. E-mail: citystamp@mindspring. com.
The National Conference on Health Care and Domestic Violence will be held Oct. 13-14, 2000, in San Francisco. Conference information and on-line registration are available at www.fvpf.org/health/ conference.html, or contact:
• National Conference on Health Care and Domestic Violence, National Health Resource Center on Domestic Violence, Family Violence Prevention Fund, 383 Rhode Island St., Suite 304, San Francisco, CA 94103-5133. Telephone: (888) RX-ABUSE or (415) 252-8900. Fax: (415) 252-8991. E-mail: email@example.com. Web site: www.fvpf.org.