The question “Are you in a relationship in which you’re being abused?” is not always easy to ask or to answer. Statistics from the Centers for Disease Control and Prevention (CDC) (2003) indicate that 36% of the women who were treated in the emergency department for violent injuries were injured by an intimate partner. However, victims of domestic violence are often reluctant to disclose abuse. Instituting a policy in which all emergency department patients are screened for domestic violence increases the likelihood of identifying abuse in the at-risk patient population.
This article describes how a large urban emergency department implemented universal screening for domestic violence and developed a violence intervention program, but was forced to discontinue the program due to budget constraints. We review the steps that were taken in response to the elimination of the violence intervention program and the process of planning a continuing education program for registered nurses in the emergency department. Literature supporting universal screening in the emergency department and the existence of factors that may present barriers to screening for domestic violence are also explored.
For the purposes of this article, the following definitions are used. Domestic violence is a “pattern of assaultive or intimidative behaviors, including physical and psychological, that adults or adolescents use against their intimate partners” (Ganley, 1998, p. 16). A domestic partner is a current or former spouse, boyfriend, or girlfriend with whom the individual has had an intimate relationship. A registered nurse is a professional, licensed nurse. An emergency department is a specialized area of the hospital that provides care and treatment to patients of all ages and conditions who present to the department for care. The CDC (2004) prefers the term intimate partner violence to domestic partner violence. Domestic violence and intimate partner violence are used synonymously in this article.
Domestic Violence Awareness
Scope of the Problem
Domestic violence has been recognized as a national health problem that results in not only physical abuse, but also psychological and economic abuse. Domestic violence includes forced sexual activity, thus increasing the risk of unplanned pregnancy and sexually transmitted diseases, such as the human immunodeficiency virus (Warshaw & Ganley, 1998). It wasn’t until the 1970s that the health community and the public increased their focus on domestic violence (Humphreys & Campbell, 2003).
Many professional nursing organizations, including the American Association of Colleges of Nursing, the American Nurses Association, and the Emergency Nurses Association, have published position statements in support of curriculum development, training, and continuing education in domestic violence for nurses (Cohn, Salmon, & Stobo, 2002). Despite the existence of domestic violence curricula, a survey of healthcare professionals indicated that only approximately 30% recalled receiving education related to domestic violence (Cohn et al., 2002). The Joint Commission on the Accreditation of Healthcare Organizations (1995) requires hospital standards related to establishing policies, procedures, and education about abuse screening (particularly within emergency departments).
Using the MEDLINE, CINAHL, Biomedical Reference Collection, and Nursing and Allied Health Collection databases, a search of literature written about this topic between 1995 and 2003 was conducted. Key terms used in the literature search included domestic violence, intimate partner abuse, domestic violence screening, spousal abuse, and emergency department.
Incidence of Domestic Violence
A hallmark study conducted by Goldberg and Tomlanovich (1984) determined that one in four women seeking care for any reason in the emergency department have been victims of domestic violence. Abbott, Johnson, Koziol-McLaine, and Lowenstein (1995) determined that 77% of women who had been seen in the emergency department for non-trauma complaints had been victims of domestic violence, but found that only 13% of these patients were screened for domestic violence. Larkin, Hyman, Mathias, D’Amico, and MacLeod (1999) found that one in five patients who went to the emergency department reported exposure to domestic violence.
The Bureau of Justice estimated that women account for approximately 85% of those abused (Rand & Strom, 1997). In 1998, there were five times more women than men victimized by a domestic partner (Rennison & Welchans, 2000). Gerard (2000) found that approximately 35% of emergency department patients were victims of domestic violence, and 95% of those were women. An urban study found that more than 50% of those who reported being victims of domestic violence were also involved as perpetrators (Lipsky, Caetano, Field, & Bazargan, 2004). In addition to physical and psychological trauma from abuse, statistics indicate that domestic partners committed 11% of all homicides (Rennison & Welchans, 2000).
Domestic Violence Affecting Pregnant Women and Children
A cross-cultural study of African American, Hispanic, and white women found a risk for domestic violence during pregnancy. When screened for domestic violence by their obstetrician, one in six pregnant women reported abuse (McFarlane, Parker, & Soeken, 1996). There was a delay in prenatal care and increased risk for low birth weight of infants for those women who reported abuse (McFarlane et al., 1996). Maternal weight gain was also less for these women, most significantly for white women, thus placing the health of the fetus at further risk (McFarlane et al., 1996). Abused pregnant women are at an increased risk of miscarriage, premature labor, and fetal injury (Warshaw & Ganley, 1998).
Women who have been screened for domestic violence in the pediatric setting have reported domestic violence 40% of the time (Erickson, Teresa, & Siegal, 2001). Children in families with frequent domestic violence (many of whom are also abused) suffer from sleep and psychological disorders and can have problems at school (Hill & Siegel, 2001). Clearly, domestic violence has detrimental effects on the entire family unit. Early identification of individuals who are victims of domestic violence may assist in preventing further psychological and physical injury.
Barriers to Screening for Domestic Violence
One of the most common barriers to screening for domestic violence is nurses’ lack of education and instruction on how to ask domestic violence screening questions (Cohn et al., 2002; Heinzer & Krimm, 2002). Other barriers to screening identified by emergency department nurses included lack of privacy and time limitations (Ellis, 1999). In a study of perinatal nurses, Moore, Zaccaro, and Parsons (1998) determined that 31% had a personal or family history of domestic violence. Another barrier identified by obstetricians in screening for domestic violence was the inability to fix the problem once identified (Parsons, Zaccaro, Wells, & Stovall, 1995). The lack of adequate referral resources was identified as a common barrier for other healthcare professionals (Hill & Siegel, 2001).
Universal Screening for Domestic Violence
Unlike most other departments at a hospital, the emergency department treats people of all ages, socioeconomic backgrounds, and ethnicities for an unending variety of illnesses and injuries. An emergency department visit may be the domestic violence survivor’s only contact with healthcare providers who can intervene and end the cycle of abuse.
Symptoms of domestic violence may not be as obvious as a bruise or another type of physical injury. Medical complaints may be related to stress and present as dizziness, shortness of breath, and palpitations (Koss, 1993). The U.S. Preventive Task Force released clinical guidelines for family and intimate partner violence that include recommendations for screening (U.S. Preventive Services Task Force, 2004). Universal screening of all patients seen in emergency departments is recommended because the chief complaints of the patient, demographic data, or physical indicators cannot be used to determine those who are victims of domestic violence (Muelleman, Lenaghan, & Pakieser, 1998).
Ideally, those being abused should be identified through universal screening before there is obvious physical evidence of violence. A study by Datner et al. (2002) found that 35% of patients in the emergency department positively responded to domestic violence screening questions, but only 4% were documented in the medical records.
Ellis (1999) performed a chart review of approximately 300 emergency department medical records from a large urban medical center and found that only 8.8% of the charts had evidence that domestic violence screening was performed. This result conflicted with a questionnaire survey done by Ellis in the same emergency department in which 45% of the registered nurses reported that they routinely screened their patients for domestic violence.
In their single-site study, Krimm and Heinzer (2002) reported that patients in the emergency department were not consistently screened for domestic violence and that documentation of screening was not always evident. These studies indicate that many patients are not being screened for domestic violence in emergency departments. With this failure to identify victims, recurrent abuse and future health problems loom for those being abused (Glass, Dearwater, & Campbell, 2001).
Intervention for Domestic Violence
A study by Krasnoff and Moscati (2002) conducted in a large urban hospital demonstrated the effectiveness of emergency department domestic violence intervention. Women identified as domestic violence victims were provided case management. After follow-up, more than half of the women who received intervention perceived themselves as no longer at risk for domestic violence. Other studies have indicated that identification rates and intervention increased after healthcare provider education (Humphreys & Campbell, 2003). With the cost of treatment for victims of domestic violence estimated to be approximately $1.8 billion in the United States, this healthcare problem should not be overlooked (Warshaw & Ganley, 1998).
A Pilot Project for Universal Screening and Intervention for Domestic Violence
The authors became interested in the topic of domestic violence screening during a routine review of emergency department nursing documentation, at which time it was noted that nurses did not indicate they had administered domestic violence screening. A pilot project was developed to determine the educational needs of emergency department registered nurses. This project focused on how certain barriers may affect the ability of registered nurses in the emergency department to ask screening questions. The Analyzing Performance Problems model created by Mager and Pipe (1997) was used to determine possible reasons for the lack of screening for abuse by emergency department staff.
Universal screening for domestic violence in all patients older than 12 years who are seen in the emergency department was implemented in 1989 at our facility. This policy coincided with the development of a facility-wide violence intervention service for those experiencing violence or abuse. Healthcare providers were required to assess all patients for domestic violence. In the emergency department, registered nurses generally spend more time with the patient than the physician does, providing nurses the best opportunity to screen for domestic violence. When the policy was implemented, the emergency department nursing staff received a training demonstration about how to screen patients for domestic violence. New staff members received domestic violence education and training during their orientation period in the emergency department.
Violence Intervention Program
California law Penal Code Section 11160 requires healthcare providers to report domestic violence to the police (California Health Care Association, 2000). Studies have shown that identification rates for domestic violence have increased with more widespread screening by healthcare professionals (Garcia-Moreno, 2002; Thompson et al., 2000).
In 1989, a violence intervention program was developed at our facility. Through the program, a registered nurse was on-call 24 hours a day and was responsible for responding to calls from the emergency department within 45 minutes. The emergency department registered nurse only had to have a suspicion of abuse to call the violence intervention program nurse, whose role was to assist patients who were identified as possible victims of violence.
The accurate identification of individuals who are subjected to abuse and their quick referral to intervention programs could result in decreased injury, illness, and death, despite the fact that a busy emergency department is not a friendly environment in which to perform the delicate line of questioning about domestic violence. Unfortunately, in 2003, important programs, including the violence intervention program, were eliminated at the hospital due to county and state budget shortfalls. The emergency department staff took on the roles of screening for and reporting abuse, which were previously the responsibilities of the violence intervention program nursing staff.
Conceptual Framework of the Pilot Project
To determine the educational needs of emergency department nurses following the discontinuation of the violence intervention program, a pilot project was developed. This project was based on Mager and Pipe’s model (1997), Analyzing Performance Problems, which describes a process for identifying and solving problems in human performance to establish the need for further domestic violence training in the emergency department.
This model indicates that one must first recognize that there is a performance problem and then follow a series of 12 steps to determine how to solve the problem. Once the problem is identified, the next step in the process is to determine whether the performance discrepancy is important. If the discrepancy involves a skill deficiency, other questions that must be asked are (1) Could this skill be performed in the past?, (2) Is this skill used often?, and (3) Do the subjects have the capacity to perform the skill? (Mager & Pipe, 1997). If there is not a skill discrepancy, it must be determined whether performance is punishing, whether non-performance is rewarding, whether performance matters, or whether there are obstacles to performance. The model was applied to our study to determine the possible reasons the registered nursing staff in the emergency department rarely screened patients for domestic violence.
In answering the question of whether the performance of screening for domestic violence matters, the literature indicated that screening for domestic violence is important in the prevention of continued risk of abuse and injury. Analysis of the project responses determined the importance of domestic violence to the emergency department registered nurses who answered the questionnaire. The entire emergency department registered nursing staff had previously received basic training in how to screen for domestic violence, indicating that a skill level did exist at one time. Although the Analyzing Performance Problems model was not intended specifically for use in nursing, it was a useful tool in determining what obstacles may exist for this emergency department nursing population in screening for domestic violence.
The purposes of this project were to determine the beliefs and attitudes of emergency department registered nurses when universally screening patients for domestic violence and to assess the continuing education needs of emergency department staff. The authors were attempting to answer the question “What are the factors or perceived attitudes of emergency department registered nurses that may pose as barriers when screening patients for domestic violence?” The results of this project could be used to develop an educational program in domestic violence.
A large urban public hospital emergency department at a level one trauma center with an approximate daily census of more than 160 patients was the setting for this study. Approximately 60 full-time or part-time emergency department registered nurses, who were responsible for screening patients for domestic violence, were employed in the emergency department of the facility.
The authors recruited 33 emergency department registered nurses for the project by displaying signs in the emergency department. Staff members were assured that their responses would remain anonymous and confidential. Furthermore, staff was informed that if the results were published, no direct reference to individuals in the emergency department would be made. Findings from the study are non-experimental and cannot be generalized due to the limitations of the study, which include the use of a modified tool, a single-site convenience sample, and a small sample size.
An anonymous questionnaire containing three components was used as a screening tool. The instrument was developed for use with obstetrical and gynecological registered nurses and tested for reliability and validity by colleagues of Dr. Mary Lou Moore of Wake Forrest University, Winston-Salem, North Carolina. Written permission was obtained to modify the questionnaire for use in the emergency department.
The first component of the tool consisted of 18 statements used to determine the nurses’ beliefs and attitudes about screening for domestic violence. These statements were rated on a Likert-type scale from 1 to 5 (where 1 is equivalent to strong disagreement, 2 to disagreement, 3 to uncertain, 4 to agreement, and 5 to strong agreement with the statement). The second component consisted of demographic information collected about the emergency department registered nurses. The third component consisted of two questions with a yes or no answer regarding the selection of patients and the routine for screening them. An additional question was added to the original statements asking if any problems were encountered related to language barriers (Table 1).
Screening for Domestic Violence Questionnaire
Pilot testing for the reliability of the questionnaire was accomplished through a review done by emergency department nursing colleagues, including a master’s-prepared forensic nurse educator. The questionnaire was then distributed to all emergency department registered nurses during staff meetings. A total of 33 questionnaires were completed.
Although non-experimental, the data were analyzed using nonparametric methods of analysis. Table 2 provides the complete demographic data of participants. Of the 33 registered nurses who completed the questionnaire, 88% were women and 12% were men. Seventy-two percent of participants were between 40 and 59 years old, 21% were younger than 40 years, and 6% were 60 years or older. By ethnicity, 49% of participants were white, 21% were Filipino, 12% were Hispanic, 9% were Asian non-Filipino, and 6% identified themselves as belonging to other ethnic groups. Fifty-seven percent of participants had a baccalaureate degree, 6% had an associate degree, and 6% had completed a diploma program in nursing. Thirty-nine percent of participants had more than 21 years of nursing experience, 24% had at least 16 years of experience, 20% had 6 to 15 years of experience, and 15% had less than 6 years of experience.
Demographics of Respondents (N = 33)
Eighty-seven percent of the participants expressed an interest in receiving training about how to ask questions about abuse. The highest-ranking potential barrier to domestic violence screening identified in the questionnaire was the existence of language barriers, which make it difficult to talk about abuse with patients. Additional barriers included a personal or family history of abuse and a lack of training in how to deal with abuse. Twenty-nine percent of respondents reported that time issues affected their ability to screen for abuse. Conflicting results were obtained regarding questions about routine screening. Fifty-one percent of the registered nurses indicated that they routinely screened all patients for abuse, but 74% also responded to a separate question that they only screened selected patients. This finding may indicate that registered nurses routinely screen selected patients with more obvious signs of abuse but universally screen patients only some of the time.
Further study is needed to determine the significance of the discrepancy in these findings. Our finding may indicate that when there is an obvious cue of abuse, such as a bruise or visible injury, the registered nurse is more likely to selectively screen these patients. Self-reported results indicated that emergency department registered nurses believed abuse is a problem in the emergency department population, the victims do not bring the abuse on themselves, it is appropriate to inquire about abuse, physical contact is not expected in families, abuse is not just a lower socioeconomic group phenomenon, abuse is a medical problem, and abuse is an important issue to verify (Table 3).
Registered Nurses’ Disagreement with Questionnaire Statements (N = 33)
Demographics of the participants indicated an educated, older, and ethnically diverse population of emergency department nurses. More than half of the registered nurses in the study were educated at the baccalaureate level (Table 2). This may increase screening possibilities because most baccalaureate programs now include curricula about family violence (Cohn et al., 2002). It is also noteworthy that the majority of the registered nurses had been practicing for more than 16 years and therefore may not have been exposed to family violence education in nursing school. Overall, the data indicated that emergency department registered nurses recognize that abuse is a problem in the emergency department population and are concerned about domestic violence. This is consistent with the premise that nurses recognize a concern for this population as a part of their nursing practice.
An important finding from this pilot study was the nurses’ wishes to know how to specifically ask patients about domestic violence. Although emergency department nurses exhibit expert critical-thinking skills in triage and the treatment of emergency department patients, these findings suggest a desire for more task-oriented techniques for screening for abuse. In a busy emergency department, it is not surprising that time limitations affect screening for domestic violence because more urgent patient issues demand immediate attention from the nurses.
The desire of registered nurses to learn more about how to ask questions when screening for domestic violence provided a wonderful opportunity to educate nurses who already had the mind-set to learn. There is also an opportunity for further study to develop evidence-based standards for training and frequency of continuing education for effective domestic violence screening. Cohn et al. (2002) provided a useful source for a synthesis of information on the education and training of healthcare personnel in family violence.
Our finding that nurses often have personal or family histories of violence is consistent with previous studies, although the implications of personal violence and its effect on screening for domestic violence are unknown (Moore et al., 1998). An additional barrier that has been identified includes the challenge of screening patients who speak a foreign language despite access to translators at the facility in which the research was conducted.
The Analyzing Performance Problems model (Mager & Pipe, 1997) indicates that training needs must first be met to improve performance. This model could be used to gain a better level of understanding of the needs for education and training in other emergency departments.
As a result of this project, an additional hour-long continuing education presentation on domestic violence and screening was provided to the emergency department nurses at this facility. The content for the class was developed from the results of the questionnaire and included specific terminology that could be used to “ask the question” (Table 4). Ideally, it would be optimal to provide more time for this training, possibly to include a role-playing session and other techniques to facilitate questioning patients about domestic violence, but due to hospital staffing and budgetary constraints, educators must be creative and provide condensed in-service education in shorter time frames. A follow-up questionnaire will be used to determine whether there has been increased compliance with screening and to determine the effectiveness of the educational program and need for further training.
Outline of Domestic Violence Recognition and Reporting Training
Implications for Practice
Similar surveys could be performed in other emergency departments to determine the need for further education and training. Perhaps the barrier of lack of time may be eased somewhat with the emergency department registered nurse staffing ratio requirements that were signed into California law in 2003, as Assembly Bill 394, and implemented in 2004. This new law requires a minimum and specific nurse-to-patient staffing ratio for acute care facilities (California Nurses Association, 2003). The new emergency department staffing ratios are 1 registered nurse to 4 patients, which contrasts with the current ratio of between 1:5 and 1:8. Future study could determine whether a change in staffing ratios increases the amount of time the registered nurse has available to screen for abuse and thus potentially increase the identification of those who are being abused.
Another difficult task is that of addressing the aspect of diversity and providing trained translators to assist in the screening of emergency department patients for domestic violence. Translators provide expert language skills, but their training and knowledge in family violence issues may vary or be nonexistent. An opportunity exists to investigate the effectiveness and accuracy of translations in this situation.
Further investigation may also determine that, despite the registered nurses’ use of critical-thinking skills in the emergency department, the desire may exist for more task-oriented questioning techniques when screening for domestic violence. Staff developers and educators in the hospital setting may have the opportunity to use multiple media forums, such as computerized information tools, to train registered nurses in how to ask questions about abuse.
The effect of domestic violence on families and the healthcare system warrants continued investigation into evidence-based curriculum, education, and training methods for emergency department registered nurses and healthcare professionals. Domestic violence training must take into account the possible barriers of beliefs or attitudes, language barriers, the limited amount of time spent with patients, and the possible effects of previous experiences with personal violence. This study provides initial information that others can build on to investigate these issues in future research and information that can be integrated into a domestic violence training curriculum.
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Screening for Domestic Violence Questionnaire
|________ Gender:||1: Female||2: Male|
|________ Age:||1: 20 – 29||2: 30 – 39||3: 40 – 49||4: 50 – 59||5: > 60|
|________ Ethnicity:||1: African American||2: Filipino||3: Asian non-Filipino||4: Caucasian||5: Hispanic||6: Other|
|What is your position: ________ RN ________ Physician Assistant ________ Physician|
|If you are an RN or Physician Assistant, please indicate your highest degree earned:|
|________ Diploma||________ Associate Degree||________ Nursing||________ Baccalaureate Nursing||________ Masters Nursing|
|How many years have you been a Registered Nurse, a Physician’s Assistant, or a Physician?|
|___ Less than 2||__ 2 – 3||___ 4 – 5||___ 6 – 10||___ 11 – 15||___ 16 – 20||___ 21 and above|
|Questions about adult patients and abuse:|
|___ Is it part of your ROUTINE to screen ALL patients for abuse? 1: Yes 2: No|
|___ Do you screen SELECTED patients for abuse? 1: Yes 2: No|
|Please indicate the extent to which you agree with the following statements. Please circle the selected number.|
|1 = strongly disagree||2 = disagree||3 = uncertain||4 = agree||5 = strongly agree|
|1||2||3||4||5||Abuse is not a problem in my patient population.|
|1||2||3||4||5||I am not trained to deal with the problem of abuse.|
|1||2||3||4||5||I would like some training in how to ask questions about abuse.|
|1||2||3||4||5||I am concerned about domestic violence and screen all of my patients.|
|1||2||3||4||5||I intend to institute the screening for abuse, but have not done so.|
|1||2||3||4||5||I do not have time to ask about abuse.|
|1||2||3||4||5||I have a history of abuse in myself or in my close family.|
|1||2||3||4||5||It is none of my business. It is a private issue.|
|1||2||3||4||5||I believe I may offend my patients if I ask about abuse.|
|1||2||3||4||5||I screen selected patients, especially those in lower socioeconomic situations.|
|1||2||3||4||5||Some physical contact may be expected in families. I see no reason to interfere.|
|1||2||3||4||5||Even if a patient tells me she is abused, there is no way to verify it is true.|
|1||2||3||4||5||I feel more qualified to deal with concrete physical problems than psychological issues.|
|1||2||3||4||5||Middle and upper class patients are unlikely to be victims of abuse.|
|1||2||3||4||5||Some people bring this on themselves. I cannot hope to change them.|
|1||2||3||4||5||It is not a medical problem.|
|1||2||3||4||5||There are too many other important problems to ask.|
|1||2||3||4||5||Language barriers make it difficult to talk about abuse.|
Demographics of Respondents (N = 33)
| ⩾ 60||2|
| Asian non-Filipino||3|
| Diploma in nursing||2|
| Associate degree – nursing||8|
| Associate degree – other||1|
| Baccalaureate degree – nursing||19|
| Baccalaureate degree – other||2|
| Master’s degree – other||1|
|Years of nursing practice|
| < 2||2|
| ⩾ 21||13|
Registered Nurses’ Disagreement with Questionnaire Statements (N = 33)
|Middle and upper class patients are unlikely to be victims of abuse.||30|
|Abuse is not a problem in my patient population.||30|
|It is not a medical problem.||29|
|Some people bring this on themselves. I cannot hope to change them.||30|
|It is none of my business. It is a private issue.||29|
|Some physical contact may be expected in families. I see no reason to interfere.||28|
|Even if a patient tells me she is abused, there is no way to verify it is true.||29|
|There are too many other important problems to ask about.||26|
|I screen selected patients, especially those in lower socioeconomic situations.||21|
|I believe I may offend my patients if I ask about abuse.||21|
|I have a history of abuse in myself or in my close family.||20|
|I am not trained to deal with the problem of abuse.||19|
|I do no have time to ask about abuse.||21|
|I feel more qualified to deal with concrete physical problems than psychological issues.||14|
|I intend to institute the screening for abuse, but have not done so.||12|
|I am concerned about domestic violence and screen all of my patients.||17|
|Language barriers make it difficult to talk about abuse.||6|
|I would like some training in how to ask questions about abuse.||1|
Outline of Domestic Violence Recognition and Reporting Training
Definition of Domestic Violence and Pattern of Abuse
Relationships of All Types May Include Domestic Violence
Domestic Violence Screening: Asking the Question
Examples on how to approach the subject
Examples of questions for domestic violence screening
Delay in treatment
Vague complaints, depression, anxiety, substance abuse
Injuries of Abuse
Mechanism of injury and patterned injury
Injury inconsistent with history
Various stages of healing
Multiple injury sites
Completing Required Reporting
Domestic Violence Resources