NURS 585 Group Project: Inconsistent Intimate Partner Violence Screening in the Hospital Setting

As a group we noticed different practices in screening for intimate partner violence (IPV) in various hospital settings. Click 'start course' to begin, and follow the prompts to navigate through the dilemma. 

 

By: Taylor Andrews, Alexandria Budgell, Madison Colbran, Jaimie Graham, Kendra Gudjonson, Shannon Herrick & Megan Morgan

Dilemma Introduction

Intimate partner violence (IPV) has been a criminal and public health issue for several decades. It affects the health and wellbeing of men, women, children, and society as a whole.

WHAT IS INTIMATE PARTNER VIOLENCE (IPV)?

Definition

Domestic violence (DV) exists in many different forms, from physical and sexual harm to verbal and economic abuse. 

Intimate partner violence (IPV) is abuse by one partner in an intimate relationship against the other


Statistics

  • IPV is the leading type of DV experienced by women
  • In Canada, rates of IPV are approximately 4x higher among women than among men

Result

The adverse health consequences of IPV lead victims to frequently use health care services. Thus, health care providers are often, sometimes unknowingly, in contact with women affected by IPV.

OUR DILEMMA

The health care system has a key role in addressing IPV against women, however, domestic violence screening continues to be inconsistent in both policy and implementation across healthcare settings.

*The focus our dilemma is specifically IPV between a woman and man, with the woman as the victim

Background

Stats

The World Health Organization (WHO) indicated that one in women globally experience sexual and/or physical violence by a partner in their lifetime

HISTORY

Healthcare providers (HCP) and services are crucial in abused women’s care, but the quality and consistency of HCP's screening for DV has been a focus of concern for decades. 

Evidence

There is insufficient evidence to support the effectiveness of screening as an intervention to reduce domestic violence. However, there is also a lack of evidence indicating that screening for domestic violence is ineffective. Although evidence surrounding effective health care interventions for IPV remain inconclusive, there is a global consensus that health-care systems play a key part in the multi-sectoral response to IPV against women.

Healthcare Role

  • The health care system provides women with a safe environment where victims can confidently disclose abuse
  • Victims of IPV identify health care professionals as someone they trust to disclose abuse and potentially receive supportive care.

The crucial role HCPs and systems can play is not recognized or properly implemented resulting in inconsistencies in care provided for patients experiencing IPV

The Impact

The Impact of IPV

IPV can have numerous short-term and long-term health consequences for survivors including psychosocial, physical, emotional, financial, and sexual issues

The effect of IPV extends beyond the victim’s to include:

  • Victim’s family, employers, and friends
  • Society as a whole due to additional financial strain on the health care system and loss of productivity
  • Governments and other organizations as a considerable amount of Canadian resources are spent towards combating IPV

Participants and Stakeholders

IPV directly and indirectly affects all Canadians- $ 7.4 billion in health costs due to spousal violence

Total Victim Costs ($3,694,739,100)

Total Justice System Costs: Police, court, legal aid, child protection, etc.

$271,964,457

Health Care: emergency department, physician visits, etc.

$8,159,984

Mental Health Issues: medical services, work loss, suicide attempts

$146,868,486

Productivity Losses: lost wages, lost education, lost childcare services, etc. 

$37,125,687

Other Personal Costs: damaged property, divorce or separation, moving, etc.

$ 211,865,378

Intangible Costs: pain and suffering, loss of life 

$3,290,719,155

Third-Party Costs  ($691,012,807)

Funeral Expenses 

$1,023,432

Cost of Other Persons Harmed/Threatened: healthcare, productivity losses

$ 9,047,144

Social Services Operating Costs: shelters, crisis lines, support centers, victim services

$ 353,039,355

Losses to Employers: lost output, tiredness and distraction, administration costs

 $ 52,123,343

Negative Impact on Children Exposed to IPV: medical, missed school days, lost future income, etc.

$ 153,241,598

Other Government Expenditures 

$ 96,270,249


Zhang, T., Hoddenbagh, J., & McDonald, S. (2011). An estimation of the economic impact of spousal violence in Canada, 2009. Justice Canada.

Context & Events

There is an urgent need to assess and identify appropriate healthcare system level interventions for IPV. Health care systems need to strengthen the ability of HCPs to care for women experiencing IPV.

It is important to identify effective screening methods for IPV because identifying women experiencing IPV is the first step in providing appropriate treatment and care. Match the definition with the correct screening method

Universal Screening

  • standardized routine screening to ALL women that is consistent among all health care institutions
  • screening targeted towards high risk populations (i.g. Pregnant women)
  • all women are asked, but inconsistent methods of inquiry and questioning depending on patient and health care situations
  • screening due to red flags or indications of abuse present

Selective Screening

  • all women are asked, but inconsistent methods of inquiry and questioning depending on patient and health care situations
  • screening targeted towards high risk populations (i.g. Pregnant women)
  • screening due to red flags or indications of abuse present
  • standardized routine screening to ALL women that is consistent among all health care institutions

Routine Enquiry

  • screening targeted towards high risk populations (i.g. Pregnant women)
  • screening due to red flags or indications of abuse present
  • all women are asked, but inconsistent methods of inquiry and questioning depending on patient and health care situations
  • standardized routine screening to ALL women that is consistent among all health care institutions

Case-Finding

  • standardized routine screening to ALL women that is consistent among all health care institutions
  • screening due to red flags or indications of abuse present
  • screening targeted towards high risk populations (i.g. Pregnant women)
  • all women are asked, but inconsistent methods of inquiry and questioning depending on patient and health care situations

Review Screening Types

Universal Screening

standardized routine screening to ALL women that is consistent among all health care institutions

Selective Screening

screening targeted towards high risk populations (i.g. Pregnant women)

Routine Enquiry

All women are asked, but inconsistent methods of inquiry and questioning depending on patient and health care situations

Case Finding

screening due to red flags or indications of abuse present 

Who Became Concerned, and why??

Views

The Joint Commission on the Accreditation of Healthcare Organizations

Feel that there is necessity for HCPs to be educated and prepared to address  IPV issues in healthcare settings

The Canadian Task Force on Preventive Healthcare

Suggests that there is a lack of evidence to support the benefits of IPV screening

Some groups believe screening should only be targeted to high risk populations.

Some believe is it unethical to implement screening for IPV when there is lack of suggesting evidence that screening is beneficial, as it may cause more harm. 

IPV is not a disease, some argue that screening then is inappropriate

Beliefs and Assumptions

Beliefs and Assumptions Influencing the Dilemma

  • Screening or routinely asking all women about IPV in all healthcare settings (Universal screening) will increase identification of women experiencing abuse
  • Screening will lead to appropriate interventions and support for victims
  • Screening will decrease the incidence and prevalence of IPV and the detrimental health consequences
  • Universal screening may lead to potential adverse outcomes that are unknown due to insufficient evidence surrounding IPV screening methods 

Positions Taken

Health Care Providers

  • Some HCPs screen selectively, rather than routinely only screening those individuals with obvious signs of injury or abuse 

  • Healthcare students have reported a lack of preparedness or confidence in working with women with IPV

  • Nurses report concerns about asking appropriate questions and being uncertain about what to do when an individual discloses IPV

  • HCPs often lack the knowledge of relevant support networks or referrals available to IPV victims

SCREENING

Inhibiting Factors

  • Lack of personal comfort and confidence in asking IPV-related questions

  • Lack of training /familiarity with resources

  • Perceived lack of effective interventions

  • Perceived lack of time/opportunity 

  • More pressing acute medical problems

  • Fear of offending the patient

  • Fear of causing retaliation from husband or relatives

  • Lack of personal experience impedes inquiring about IPV



Enabling Factors

  • Perceived high efficacy in handling IPV-related issues
  • Low fears of offending clients
  • Professional preparedness
  • Availability of support networks for IPV victims 

Patients

  • Research suggests female patients in the emergency department preferred self-completed questionnaires rather than face-to-face screening

  • Research has found that female patients expect HCPs to inquire about IPV and found it socially acceptable to screen 

Barriers to disclosing IPV: 

  • Feelings of shame

  • Fear of embarrassment

  • Fear for the sake of children

  • Fear of husband/partner retaliation


  • Low education level

  • Feudal and traditional families

  • Lack of knowledge on legal rights

Health Care System

  • It is difficult to provide adequate privacy in the hospital setting for screening

  • There is a lack of after-hours social services available to address IPV-related issues

  • Staff shortages lead to a lack of time that staff can actually allot to screening 

  • Research concerning the effectiveness of universal screening is conflicting and therefore difficult to build policies and protocols upon 

Our Position

Regardless of the inconsistencies of the evidence regarding the benefits of universal screening, we still believe it is our due diligence to screen all patients, providing them with the opportunity to confide their concerns in us.

Implications and Influences of the dilemma:

  • Inequities exist among HCPs in their knowledge, confidence, and training related to IPV screening. These inequities ultimately lead to inconsistent screening among staff 

  • Without clear protocols or policies regarding IPV screening, staff have minimal evidence-based recommendations to guide their practice 

  • With a lack of clinical guidance or training, staff are not prepared to respond to those individuals who do disclose IPV

  • The healthcare system has not created a culture supportive of IPV-related care

Strategies

Education and Training

For Nursing Students

  • Studies reveal that students report being taught how to screen but not how to respond when someone discloses 

  • Experiential learning

    • Interactive workshops which allow for role-play to practice responses

    • Allow students to build confidence rather than memorizing a script of how best to respond

    • Prepares students to individualize their responses and adapt to the unique needs of each patient 

For Hospital Staff

  • Ongoing training sessions have been noted to have significant increases in staff comfort with screening 

  • Training has been found to build high provider self-efficacy for screening

  • Training staff teaches providers of the need to screen and offer help

    • can increase providers’ competence with IPV

    • builds awareness of screening procedures and supports

    • help the provider understand the benefits of screening

Repetitive Screening

  • Hospital staff should be encouraged to repetitively inquire about IPV throughout the patient’s hospital stay 

  • In the maternity setting recurrent screening throughout pregnancy increased identification rates 

  • HCPs should screen adolescents as young as 12 years of age for IPV because individuals between the ages of 12 to 16 years can consent to sexual activity

  • Studies have shown that no harm or adverse effects are linked to repetitive screening 
  • The RNAO (2005) recommends that HCPs conduct routine universal screening when obtaining a patient’s health history

  • The RNAO recommends normalizing questions related to IPV, such as “This is a question that we ask each of our patient’s”

Screening Tools

  • Self-administered IPV screening tools especially those delivered by computer result in higher rates of disclosure, referrals, and better overall satisfaction among women.

  • Computer screening can eliminate barriers of face-to-face screening such as: staff shortages, time, facilitator’s subjectivity or patient comfort

Systems Level Changes

IPV experts or advocates

  • Quick access to an IPV advocate increases the likelihood of identification and referral for services

  • Waalen, Goodwin, Spitz, Petersen, and Saltzman (2000) found that having a staff member designated as an IPV-victim advocate resulting in higher rates of identification

    • Hospitals with an advocate had a detection rate of 47% as compared to the control groups with a detection rate of 11%.

Primary prevention:

  • Primary prevention including: poster signage and pamphlets can be given to patients.
  • Example - Southhealth campus RED STICKER INITIATIVE in perinatal nursing: a bathroom only to be used by female patients in triage has IPV signage, recommending that woman place a tiny red sticker on the bottom of their urine cup if they are experiencing domestic violence

Collaboration with local advocacy agencies and IPV experts

  • Establishing relationships with members of other hospital and community groups (e.g. social work) may help with patient referrals.

  • Interprofessional collaboration allows nurses to help patients access the support that they require in a timely fashion. 


Development of unit-based policies and procedures:

  • Policies and procedures provide structure for HCPs thus ensuring that IPV is consistently addressed.


Conclusion

Conclusion

IPV has been a criminal and public health issue for several decades. It affects the health and wellbeing of men, women, children, and society as a whole.

Regardless of the inconsistencies of the evidence regarding the benefits of universal screening, we still believe it is our due diligence to screen all patients, providing them with the opportunity to confide their concerns in us.

References

References

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  • Graphics and images courtesy of colourbox.com