What characteristics would lead a provider to suspect domestic violence, child abuse, or elder abuse is taking place within a family

Barriers to Effective Screening for Domestic Violence by Registered

Nurses in the Emergency Department

Triage nurses in the emergency department are in a unique position to screen for domestic violence. This study, using Orlando's theory with a focus on two of her five rhajor concepts, identifies barriers that prevent effective screening for domestic violence. A quantitative survey was distributed to 101 registered nurses employed in a large emergency department. Results identified three major barriers and a relationship between age and inservice attendance on domestic violence. Education on abuse and resources should be essential in nursing school curricu- la. Policy development and review should be part of an annual, mandatory inservice for all emergency nurses. Key words: abuse, battering, family violence, partner abuse

June Mary Ellis, MS, RN, CCRN Staff Nurse, Emergency Care Center Harrington Memorial Hospital Southbridge, Massachusetts Forensic Nurse Consultant

T HE ISSUE of violence, or more specif-ically domestic violence, is a health threat that spans all socioeconomic classes, professions, cultures, religions, ages, and gender. Because there are no specific demo- graphic indicators, identification of victims of domestic violence can be difficult. Men as well as women can be victims of domestic violence. However, research has shown that 95-98 percent of victims are women.'-^ Do- mestic violence screening of all women in the emergency department, regardless of their presenting complaint, is one way to effec- tively identify victims of violence. Emergen- cy department registered nurses (RNs), particularly triage nurses, are an obvious choice as screeners, yet there are data to indicate that screening is not being done. This study will therefore explore barriers that prevent effective screening for domestic vi-

The author would like to thank her parents especially for their endless support. She also would like to thank her husband Bob and children Christopher and Jessica Rose for their patience and love. The author thanks Dr. Barbara Madden for her

, expertise and guidance.

Crit Care Nurs Q 1999;22(1):27-41 ©1999 Aspen Publishers, Ine.

27

28 CRITICAL CARE NURSING QUARTERLY/MAY 1999

olence in women by RNs in the emergency department.

PREVALENCE OF DOMESTIC VIOLENCE

Domestic violence is thought to have exist- ed for thousands of years and is not just a health threat of present times. Paleopatholo- gists discovered that in one female group there was an incidence of 30 to 50 percent fractures, compared with the male incidence that was found to be 9 to 20 percent. These fractures were noted to be primarily skull fractures that historians believed were a re- sult of violence rather than some other etiol- ogy.̂ Throughout hundreds of years, domestic violence of woman was accepted; even the Bible has mention of abuse towards women. The women's movement in the 1960s brought to the forefront elements of abuse of women and children. The Journal of Marriage and the Eamily published the first article in a professional journal related to domestic vio- lence in 1971. This article was titled "Vio- lence in Divorce Prone Eamilies.'"* Violence was first introduced as a health issue for this country in 1977 when physicians identified the leading causes of premature adult deaths in the United States as homicides and sui- cides. In 1983, the Centers for Disease Con- trol and Prevention (CDC) began to study and analyze violence from an epidemiologi- cal standpoint.' These studies, which still are being conducted, have provided much infor- mation regarding the causes of violence and violent behaviors. Based on these studies, in 1990 ,the United States Public Health Ser- vice declared violence reduction as one of its goals as the country enters into the year 2000. In addition, the media in the 1990s brought domestic violence to the forefront. Several

well-known celebrities received national at- tention because of their involvement in do- mestic violence incidents, some with fatal results.

Millions of Americans suffer emotional and physical scarring from nonfatal violence, and approximately 25,000 individuals die annually as a result of intentional homicide.^ In additional, 2.2 million individuals are in- jured by violent assaults. In the United States, an act of domestic violence occurs every 7 - 15 seconds.^* Women most often are abused physically and sexually by spouses, signifi- cant others, or individuals known to them.''" It is estimated that 20 to 50 percent of all female patients presenting into the emergen- cy department are battered women.^ In 1994, there were approximately 1.4 million people seen in the emergency department due to intentional violence and about one quarter were intentional injuries from violence by an intimate. These statistics emphasize the need for domestic violence screening of all wom- en particularly in the emergency department setting. The triage assessment always should be based on ruling out abuse regardless of the presenting complaint."

The following is a table from the U.S. Department of Statistics (1998), identifying the most common complaints of patients treated in hospital emergency departments resulting from violence by an intimate. The table clearly shows that most victims are between the ages of 20-45 and approximate- ly half of all persons treated for injuries were treated for injuries of the head or face (51.1%). The majority of abusers (73.6%) used no type of weapon. The most common documented victim injury was bruising (48.6%).

The Joint Commission on the Accredita- tion of Healthcare Organizations (the Joint Commission) requires that emergency de-

Barriers to Effective Screening for Domestic Violence 29

Table 1. Summary of patients treated in the emergency department due to consequences of intimate violence (n = 243,000)

Victim's age 13-19 20-29 30-45 46 or older

Diagnosis of injury Bruise Cut/stab/intemal injury Muscular/skeletal Concussion/head injury Rape/sexual assault Gunshot wound All other

Part of body injured . Head/face

Upper trunk Lower trunk Hands/arms Feet/legs Other

Percent

9.7% 42.2% 41.6%

6.5%

48.6% 24.1% 16.9% 0.9% 2.2% 1.0% 6.4%

51.1% 9.6% 4.8%

18.1% 4.5% 2.1%

Source: U.S. Department of Statistics (1998).

partments have a plan for the education of their employees on domestic violence issues as well as having policies and procedures in place regarding not only domestic violence but also other forms of violence and abuse. These standards also require emergency de- partments to provide some form of documen- tation that they screen and assess for abuse as a standard of practice."'^ However, the re- quirements of the Joint Commission are not implemented consistently and uniformly. Women often have serious physical injuries as a result of domestic violence. Twenty to 30 percent of women seen in the emergency department are victims of domestic violence, yet less than 1 in 25 are identified."

BARRIERS TO DOMESTIC VIOLENCE IDENTIFICATION

A research study''' surveyed 74 battered women and 49 battered women's advocates during an eight-month period. This study reviewed battered women's experiences in the emergency department. The results dem- onstrated that half of the battered women reported having experienced negative treat- ment in the emergency department. Some of the feelings they reported were humiliation, a sense of being blamed for their abuse, having their problem minimized, and most importantly, they felt they were not identi- fied as abused. One woman in the study stated the following:

"No one asked me anything about being battered. It would have been nice if the nurse had not bought my flimsy story, had asked a few questions...talked to me about options, but this never happened. For them not to probe.. .left me feeling that hospital person- nel were cold and uncaring about battered w o m e n . " " * (P-2̂ 3)

Another women reported: "No one in- formed me that there were people and places that could help me. It might have helped me to become victorious more quickly if I had known."'""P^"^ A question in the study asked the battered women to write comments about their experience in the emergency depart- ment. Of the 16 women who answered this question, only two (12.5%) noted a positive and informative experience in the emergency department. Five women (31.3%) reported a positive but not informative experience.

A study was conducted that looked at the prevalence of intimate partner abuse in wom- en treated at community hospital emergency departments. This study was conducted at 11 community hospitals in two states. The de-

30 CRITICAL CARE NURSING QUARTERLY/MAY 1999

sign was an anonymous survey that was distributed to 4,641 women. A total of 3,455 surveys were completed. Of those, 12.6 per- cent of the respondents reported having been in a physically abusive relationship within the past year and 4.6 percent reported having been forced sexually in the last year. There was a reported 36.9 percent who stated they had been abused emotionally or physically by an intimate partner in their lifetime. It was noted further that less then half of the women in this study who reported going to the emer- gency department specifically because of their abuse injuries were identified as abuse victims by the emergency department staff. '̂ This study reveals that women use the emer- gency department as one of their primary sources of health care. Further, the study reports that as previously described, very few are ever identified as such by emergency department staff.

Another study describes attitudes and prac- tices of perinatal nurses with women who had experienced domestic violence. A total of 275 nurses in perinatal practice participat- ed in this descriptive study. The nurses were from three areas, public health (87), hospital (71), and private offices (117). Incredibly, hospital nurses were the least likely to iden- tify abuse as a problem and also the least likely to have received education related to abuse. These nurses also noted a fear of offending women if they asked about abuse; however, they did report an intention to begin screening for abuse. Despite these research efforts, to date, no research study has been published that identifies potential barriers to the care and assessment of abused women.'^

A qualitative research study, published in 1992, explored primary care physicians' ex- periences with victims of domestic violence. This study used an ethnographic design to

determine which barriers existed among pri- mary care physicians in an urban health main- tenance organization (HMO). A total of 38 physicians were interviewed for the study. The physicians were reported as saying that screening for domestic violence to them was like "opening a can of worms" or "opening Pandora's box." The researchers found that barriers to screening for domestic violence by the physicians included: the subject was too close for comfort, a fear of offending the women, a sense of powerlessness, feeling a loss of control, and time constraints.'^

Women often present to the emergency department with a myriad of complaints re- sulting from domestic violence. The com- plaints can range from headaches, inability to sleep, depression, anxiety, suicidal thoughts to abdominal/pelvic pain and chest pain.'^ Unfortunately, the lack of identification of possible victims of abuse remains costly. It is calculated that the estimated 57,500 women who are victims of intimate violence incur well over $61 million dollars in medical expenses annually. This medical expense figure represents 40 percent of all expenses caused by incidents of intimate violence against women.^ Unidentified domestic vio- lence victims continue to be susceptible to increased health issues that frequently result in repeated emergency department visits and ultimately increased hospital costs.

BARRIERS TO EFFECTIVE SCREENING BY RNS IN THE EMERGENCY DEPARTMENT

The intent of this study is to identify the most common barriers to assessing for do- mestic violence as perceived by RNs work- ing in an emergency department. Prior to

Barriers to Effective Screening for Domestic Violence 31

initiating the study, a retrospective chart re- view was done at a Level I trauma center that treats approximately 200 patients daily in the emergency department. This chart review was performed to determine if screening was being done and if there was a need for a study of barriers to screening. The chart days were picked randomly, but included weekdays and weekends. A total of 296 charts were re- viewed. Criteria previously established by the hospital for abuse screening purposes by its nurses were used as the basis for determin- ing whether the patient should have been screened for domestic violence. The follow- ing criteria were used: trauma history; injury to abdomen, breasts, head, neck, torso, or genitals; multiple injuries; story that is in- consistent with injuries; delay in seeking treatment; injuries to pregnant women; psy- chiatric, alcohol, or drug issues; chronicpain; over-protective partner; and sexual assault. These criteria are consistent with indicators found in the literature."* The nursing triage record has a designated area to check off yes or no as to whether the individual had been asked about domestic violence in his or her life. After reviewing the 296 charts, it was found that 102 charts (35%) contained docu- mentation of a presenting complaint that was related to the screening criteria. Of those 102 charts, nine charts (8.8%) actually had docu- mentation of screening for domestic vio- lence. This retrospective chart review documented an overwhelming need for fur- ther study into what barriers prevent emer- gency department nurses from screening all women for domestic violence.

DEFINITION OF TERMS

For the purpose ofthis study, the following definitions will be applied.

• Domestic violence: A pattern of coer- cive behavior in an intimate relation- ship, past or present, whereby the be- havior of another person is controlled through humiliation, intimidation, fear, and intentional physical, emotional, so- cial, financial, or sexual injury

• Emergency department nurse: A nurse licensed to practice and employed in an emergency department

• Emergency department: A specialized area in the hospital designed to provide care to patients with any type of emer- gency

• Barrier: An obstacle or deterrent that hinders and prevents detection of abuse from domestic violence

• Intimate: A relationship that involves current and former spouses orboyfdends

METHODOLOGY

Conceptual framework

This study was conceptualized using Or- lando's model. Ida Jean (Orlando) Pelletier developed a nursing process based on the interactions between the patient and the nurse. Orlando believes that nursing is a unique and independent discipline because its main con- cern is an individual' s need for help, whether real or potential, in an immediate situation. Orlando identifies nursing's function as, "pro- viding direct assistance to individuals in whatever setting they are found for the pur- pose of avoiding, relieving, diminishing, or curing the individual's sense of helpless- nggg "20(p.i2) Orlando further states, "It is im- portant for the nurse to concern herself with the patient's distress because the treatment and prevention of disease proceed best when conditions extraneous to the disease itself

32 CRITICAL CARE NURSING QUARTERLY/MAY 1999

and its management do not cause the patient additional suffering."^' 'P^^-^ '̂

Orlando^' *P '̂ describes her model as re- volving around five major interrelated con- cepts:

1. the function of professional nursing 2. the presenting behavior of the patient 3. the immediate reaction or internal re-

sponse of the nurse 4. the nursing process discipline 5. improvement Orlando perceives the function of profes-

sional nursing as finding out and meeting the patient's immediate needs for help. The pre- senting behavior of the patient is any observ- able verbal or nonverbal behavior. The professional nurses' reactions include their individual perceptions, thoughts, and feel- ings. The nursing process discipline includes the nurse communicating with the patient the nurse's reaction and then asking for valida- tion from the patient. Resolving the present- ing behavior or coming to a workable solution constitutes improvement.

In applying Orlando's model to the prob- lem of domestic violence screening, the tri- age nurse should identify the immediate needs of a battered person by assessing his or her verbal and non-verbal cues. Some victims of domestic abuse will admit readily that they were abused but some will not. Direct ques- tioning by the nurse may provide for deter- mining the patient's immediate need for help. It is the patient's immediate behavior in the triage area that will determine the nurse's response, according to Orlando's model. Regardless, the triage nurse, while observing the behavior of the patient, will sense a need and then will proceed to share his or her reaction or perception with the patient. Or- lando offers, "The nurse does not assume that any aspect of her reaction to the patient is

correct, helpful, or appropriate until she checks the validity of it in exploration with the patient." '̂<P'̂ > Such a conceptual stance compels the nurse to screen for domestic violence by asking the patient about abuse in his or her life. Asking the question assists the patient in talking about abuse that he or she may not have discussed had the question not been asked. The nursing process begins after the patient validation process has occurred. "Any observation shared and explored with the patient is immediately helpful in ascer- taining and meeting the need or finding out that there is no need at the time."^' <p35-36) Training received by RNs concerning identi- fication of domestic violence can have a positive effect on breaking the barriers to identification and may be required to assist the patient's immediate needs and validate the nurse's own immediate reaction. Accord- ing to Orlando, improvement occurs when the nurse and patient mutually agree on a plan that the patient finds acceptable. For a victim of domestic violence, this simply may be a number for a referral or it could be as exten- sive as the patient moving to a shelter. The key to improvement is the mutually agreed upon plan between the nurse and patient.

Barriers may exist that prevent effective screening in the emergency department for victims of domestic violence. The physical surroundings of the work environment, a lack of privacy, or not being able to get the patient alone could prevent screening. A lack of peer, administrative, or management sup- port could be another possible barrier. Others may feel that screening for domestic vio- lence will not change the situation of the patient because he or she always will go back to the same abusive situation. Some nurses may have issues of violence in their own lives and screening for abuse makes them feel too

Barriers to Effective Screening for Domestic Violence 33

uncomfortable because it is too personal an issue. In many cases, it is easier to distance one's self from the problem than to deal with it directly. Emergency department nursing remains a very challenging, fast-paced envi- ronment in which the immediate presenting problem may take precedence over screening a patient for domestic violence. Further, emergency department nurses who recog- nize and work with victims of abuse may find themselves so frustrated that this defeatism may be sensed and picked up by the victims. This sense of frustration could cause victims to feel at a loss to disclose their abuse. There may be a lack of education on the part of the emergency nurses on how to screen for do- mestic violence, what cues to look for, and what questions to ask. A lack of knowledge concerning options such as referral services, legal options, or shelter information may hinder the screening process. This study was conducted to identify potential barriers to screening for domestic violence in an effort to identify victims of abuse and improve the care received.

Research design

The research design is a quantitative sur- vey approved by the appropriate human sub- jects review boards. The survey sought to identify barriers that may exist that prevent RNs from screening for domestic violence while working in an emergency department. The questionnaire format encourages truth- fulness because anonymity is maintained. This method also is economical and easier to tabulate and score. The entire questionnaire would take approximately five minutes to complete. Several questionnaire items were adapted from a tool provided by A.L. O'Connor (personal communication. May,

1998) and Moore et al.,'^ whose study looked specifically at attitudes and practices as bar- riers to screening for domestic violence in a large sample population of perinatal nurses.

The questionnaire asked five demographic questions related to gender, age, number of years in nursing, number of years in emer- gency department nursing, and educational preparation. Participants also were asked if they ever had attended an inservice on do- mestic violence. There also were two ques- tions related to screening for domestic violence. Five questions concerned how well prepared the respondents felt they were to perform the following: (1) ask routine ques- tions, (2) provide support, (3) inform women about legal options, (4) identify warning signs of abuse and, (5) make appropriate referrals. Responses to preparedness questions ranged from prepared, somewhat prepared, or not prepared. Additional questions explored how prepared the nurse was to discuss options available if the woman discloses abuse. A total of 14 barriers were listed randomly for the respondents to identify which barrier(s) applied to the individual in his or her nursing practice. An "other" category was provided for study participants to cite barriers not already listed. The questionnaire also asked the nurse to describe what would be most helpful in furthering the development of their domestic violence screening skills. Finally, three optional questions at the end of the questionnaire asked about personal experi- ences with domestic violence in either their own lives or the lives of family or friends.

Sample

The questionnaire was administered to 101 RNs currently employed at a large, urban Level I trauma center that treats approxi-

34 CRITICAL CARE NURSING QUARTERLY/MAY 1999

mately 90,000 patients annually. A Level I trauma center has the ability to treat all ages and types of patients from infants to the elderly. This specific hospital setting was chosen because of the high volume and the diversity of patients seen annually.

Data collection

The questionnaires were distributed to the sample population by placing them in a sealed envelope addressed to the individual emer- gency department nurse. The mailboxes were located in the emergency department. Ac- companying the questionnaire was a cover letter stating the purpose of the study, re- sources available if an individual needed assistance, and where to place the completed questionnaire. Informed consent is assumed by the voluntary completion of the question- naire.

The respondents were asked to complete and return the questionnaire to a return box located in a central area in the emergency department. The box was designed to mini- mize tampering and reviewing of any com- pleted questionnaires. The charge nurses on each shift periodically would remind their staff that the questionnaires were in their mailboxes to complete if they chose to. Com- pleted questionnaires were removed from the return box every 48 hours.

Data quality

The questionnaire was reviewed for com- pleteness and accuracy by an expert faculty member who is the chairperson of a graduate forensic nursing program. The questionnaire also was distributed to 19 RNs in a rural community hospital for review of content validity and clarity.

The limitations of this study include its relatively small sample size. A total of 101 questionnaires were distributed to RNs in the emergency department. Another limitation remains the fact that this study was conduct- ed at only one hospital emergency depart- rnent.

Data analysis

Data from the questionnaires were ana- lyzed using The Statistical Program for the Social Sciences (SPSS) 7.5 version. This analysis was designed to reveal the percent- age of respondents who have attended an inservice on domestic violence. It was also designed to determine the percentage of emer- gency department nurses who feel all women should be screened and, of these nurses, what percentage routinely screen for domestic vi- olence.

The most common barriers and those seen as most influential in blocking screening—as well as the percentage of respondents who identified domestic violence in their lives— are presented in a simple frequency table.

Chi-square tests were used to determine relationships between demographic vari- ables—specifically age, years in nursing, years in emergency department nursing with level of education—and the responses on questions regarding attendance at inservices, screening for domestic violence, and wheth- er the respondents feel women should be screened.

RESULTS

Outof 101 possibleparticipants, 40(39.6%) completed the survey. As Table 2 illustrates, the majority of the respondents were female

Barriers to Effective Screening for Domestic Violence 35

Table 2. Relationship of demographic variables to selected questions (n = 40)

Age 20-29 (n = 5) 30-39 (n = 14) 40-49 (n = 18) 50-59 (n = 3)

Years in Nursing 1-9 (n= 13) 10-19 (n = 24) 20-29 (n = 3)

Years in Emergency Nursing 1-9 (n = 28) 10-19 (n= 12)

Level of Education Diploma (n = 7) Associate (n = 1!) Bachelor (n= 16) Master (n = 6)

Attended inservice on domestic violence

2 12 18 3

10 23 2

23 12

6 10 13 6

Do you screen for domestic violence?

1 4

11 2

4 13 1

12 6

1 4 9 4

Should all women be screened for domestic

violence?

2 7

10 2

5 13 3

15 6

4 4 8 5

(92.5%). Ages ranged from 24-59, with a mean of 39 years. The total years in nursing ranged from 1-9 (32.5%), 10-19 (60%), 20- 29 (5%), and 30-39 (2.5%). The respondents reported the following educational back- grounds: high school diplomas (17.5), asso- ciates degrees (27.5%), bachelors degrees (40%), and master's degrees (15%).

It is interesting that 35 (87.5%) of the respondents had attended some type of inser- vice on domestic violence, yet only 21 (52.5%) felt that nurses should screen all women for domestic violence. Eighteen (45 %) responded that they do routinely screen their patients for domestic violence, which conflicts with the previously cited chart re- view done in the same agency that noted only 8.8 percent of charts indicated screening was performed.

No statistically significant correlation or relationships between years in nursing, years

in the emergency department, or level of education could be established using chi- square analysis due to the small cell sizes and limited sample size. A statistically signifi- cant relationship was observed between age and attendance at inservices, X^ (n = 40) = 13.35, E < . 0 1 .

The three highest self-ranked barriers were: (1) a lack of privacy for screening in the health care setting, (2) not enough time to ask about domestic violence, and (3) not know- ing how to ask about domestic violence. Table 3 highlights the frequency distribution and percentages of the 15 barriers. In the "other" section, three respondents wrote that they had no barriers and three others checked this off but did not write a comment. Respon- dents were not limited to identifying only one barrier that existed for them, they could check as many as they felt applied. The directions asked for the respondents to circle the one

36 CRITICAL CARE NURSING QUARTERLY/MAY 1999

Table 3. Identified barriers (n = 40)

Barriers

There is a lack of privacy for screening in my healthcare setting. I don't have enough time to ask about domestic violence. I don't know how to ask about domestic violence. I don't know how to get the woman alone to ask the questions. I feel uncomfortable asking. Other I am afraid of offending the patient. I don't know what to do if the answer is "yes." I don't know enough about the issue of domestic violence. I can't fix the problem anyway. I feel the woman will end up staying with the abuser anyway. I don't feel I have support from my colleagues. I don't feel I have support from nursing management. I don't feel it is really my job to screen. 1 don't feel the screening box is conveniently located.

Frequency

24 10 8 7 6 6 5 5 4 4 4 3 3 2 2

Percent

60.0% 25.0% 20.0% 17.5% 15.0% 15.0% 12.5% 12.5% 10.0% 10.0% 10.0% 7.5% 7.5% 5.0% 5.0%

barrier that had the biggest impact on them, but only 45 percent circled the one barrier.

Five questions were asked to determine how well prepared a nurse was to intervene with victims of domestic violence (see Table 4). For the most part, two thirds of nurses felt prepared to ask routine questions about do- mestic violence, provide support, and make appropriate referrals. The most profound knowledge deficits that seemed to exist con- cerned legal options and identification of warning signs of abuse.

All respondents answered the optional ques- tions at the end of the questionnaire as de- scribed in Table 5. It is disturbing to note that 57.5 percent of the respondents had a person- al experience with domestic violence. Even more disturbing is the physical nature ofthis violence, with 35 percent reporting having been hit, kicked, or punched while only 25 percent ofthis group identified this as abuse. Only 2.5 percent reported being abused cur- rently.

In answer to the question "What would be most helpful to you personally to further develop your skills in screening and provid- ing comprehensive care to possible victims of domestic violence?," 42.5 percent of the respondents requested more inservices on domestic violence and available interven- tions, 10 percent stated lack of privacy was an issue, and 7.5 percent noted lack of time in their nursing care was a problem. Five per- cent asserted that they had no problems with their domestic violence skills, while 35 per- cent did not answer the question.

DISCUSSION AND RECOMMENDATIONS

It is well documented in the literature that domestic violence is a major health threat to this nation.' Health care providers, especial- ly nurses, are in an ideal position to improve the identification of domestic violence vic- tims through thorough screening. Some re-

Barriers to Effective Screening for Domestic Violence 37

Table 4 Intervention preparation (n = 40)

Interventions repared

75.0% 65.0% 62.5% 55.0% 30.0%

Somewhat prepared

20.0% 32.5% 32.5% 42.5% 55.0%

Not prepared

2.5% 2.5% 5.0% 2.5%

15.0%

Make appropriate referrals for victims of domestic violence. Provide support to a woman who discloses domestic violence. Ask routine questions about domestic violence. Identify warning signs of abuse. Inform a battered woman about their legal options.

search has focused on identifying the charac- teristics of a typical battered patient in an attempt to aid health care workers in their identification of these patients." There is no true characteristic of a battered woman, which is why it is so vitally important that all wom- en be screened for domestic violence. Rou- tine screening is recommended by Sassetti, who states, "Although correctly diagnosing this health care problem (domestic violence) is the exception, screening is nearly non- existent. This entity is at least as common as breast cancer and far more common than thyroid problems, hypertension, and colon cancer, for which primary care physicians routinely screen."'**^"*

The retrospective chart review performed prior to the initiation ofthis study document- ed a significant lack of domestic violence screening of women by RNs in the emergen- cy department. The questionnaire results of this study noted that 45 percent of the respon- dents stated that they do screen routinely for domestic violence, which is not consistent with the findings of the chart review. Perhaps the nurses are screening for domestic vio- lence but not documenting this in the domes- tic violence screening box. In that case, what is not documented is considered not done.

The two most frequently cited barriers were a lack of privacy in the health care setting and

time constraints. Hospital administrators must become involved in the recognition and re- moval of barriers to optimize nursing care. Emergency departments must have private areas conducive to screening for domestic violence. Time constraints also remain an issue that must be addressed. If victims of domestic violence are returning repeatedly to the emergency department for complaints related to abuse, this only increases the work- load of the emergency department. It would be far better to screen initially rather than perpetuate this cyclical pattern. The third most frequently cited barrier is not knowing how to ask about domestic violence. This barrier could be reduced through inservices and role playing. The more a nurse asks about abuse, the more comfortable he or she will become with asking. This barrier also could be decreased by presenting the topic of do- mestic violence and its solutions early in the curriculum of nursing programs. This would allow for more time for the nurse to feel comfortable in asking about abuse.

Nurses themselves should be self directed and seek out information about domestic violence. There are many resources and agen- cies available that could provide information on such issues as referral services, legal op- tions, and warning signs of abuse. Many hospitals and agencies have patient advo-

3 8 CRITICAL CARE NURSING QUARTERLY/MAY 1999

Table 5. Response to optional questions (n = 40)

Have you, a family member, or friend experienced abuse? If yes, who experienced abuse?

myself parent spouse/partner friend other

Has anyone hit, kicked or punched you? Are you currently being hit, kicked or punched?

Frequency

23

10 4 1 3 5

14 1

Percent

57.5%

25.0% 10.0% 2.5% 7.5%

12.5% 35.0% 2.5%

cates on call and available to answer ques- tions or come and speak with the patient or nurse.

A large percentage of respondents (57.5%) have had personal experience with domestic violence. It would be interesting to further explore whether it is an internal or external barrier that prevents these nurses from screen- ing for domestic violence.

CONCLUSION

Nurses must overcome the barriers that exist for them in order to be effective advo- cates for victims of domestic violence. If these victims are not identified, then nurses are not doing their job. An absence of domes- tic violence screening is not found just in the nursing profession; the article by Sugg,'^ which addressed barriers in physicians, had similar themes such as time constraints that were documented also with nurses in this study. The chi-square analysis proved a sta- tistically significant relationship between age and attendance at inservices. This could be because of the large frequency of nurses who are 30 years or older who have had to attend inservices for license renewal and have more

of an opportunity to attend a variety of inser- vices. This documents a need for inservices to be given to the more novice nurse.

Policies and procedures to guide the RN in the identification and care of the domestic violence patient should be readily available. This would comply with the standards set by the Joint Commission to develop a means of identifying, assessing, and referring victims of domestic violence. The American College ofPhysicians (ACP) policy statement in 1986 also recommends hospitals develop proto- cols for the identification and treatment of domestic violence victims. The American College of Emergency Physicians (ACEP) concurs, asserting that domestic violence identification and assessment be a part of a physicians evaluation of a patient.^^ In addi- tion, physicians and nurses must be cogni- zant of the requirements in their state of employment with regard to mandatory re- portable conditions. An example of a model policy for the identification and care of the domestic violence patient is included in Ap- pendix A.

Domestic violence has existed since Pale- olithic times and shows no signs of becoming extinct. Nurses cannot ignore this health prob- lem. They must educate themselves to pro-

Barriers to Effective Screening for Domestic Violence 39

vide the best care possible to the victims of domestic violence. Hospitals cannot ignore the need for education as part of the annual mandatory inservices. A major first step in providing this care is for nurses and physi- cians to be able to identify the victims. Col-

laboratively, identification of domestic vio- lence victims can be increased. It is essential that domestic violence screening by RNs on all women patients in the emergency depart- ment be performed if the domestic violence continuum is to be stopped.

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4 0 CRITICAL CARE NURSING QUARTERLY/MAY 1999

Appendix A

Policy and Procedure: Identification and Care of the Domestic Violence Patient

Policy

Physicians and RNs will provide appropriate documentation, assessment, management, and referrals when domestic violence victims are suspected or identified.

Purpose

• To identify patients who present with injuries resulting from domestic violence.

• To provide appropriate assessment and management of domestic violence patients.

• To provide appropriate referral services available to domestic violence patients.

Definitions

Domestic violence: A pattern of coercive behavior in an intimate relationship—past or present—whereby the behavior of another person is controlled through humiliation, intimidation, fear, and/or intentional physical, emotional, social, financial, or sexual injury. This behavior may escalate over time to become more intense, severe, controlled or physical.

Physical abuse: May result in pushing, slapping, kicking, or choking the victim. It may also include assault with a weapon, living in a dangerous area, or refusing assistance when one is sick or injured.

Emotional abuse: May include coercion, threats, destroying trust, name calling, and intimidation.

Social abuse: May include jealousy, isolation from outside relationships or faihily members.

the inability to use the telephone, threatening deportation, and intense possessiveness.

Financial abuse: May include withholding money, denying employment, sabotaging present employment, and denying educational opportunities.

Sexual abuse: May include unwanted sexual acts, hurting the victim during sexual acts, or forcing the victim to have sex or have unprotected sex to protect against pregnancy or sexually transmitted diseases.

Intimate relationships may include any of the following:

• are or were married to one another • are or were residing together in the same

household • are or were related by blood or marriage • have a child in common • are or have been in a dating or engagement

relationship

Procedure

Make every attempt to assess the individual alone in a private and safe area. Do not use family members as interpreters if one is required.

Individuals presenting with the following problems should be carefully screened for domestic violence:

• any injury to a pregnant woman • pregnant women with vague, non-specific

complaints • individuals with an over-protective partner

who will not leave the individual alone with the health care professional

• individuals presenting with vague, non-

Barriers to Effective Screening for Domestic Violence 41

specific complaints such as headaches, migraines, musculoskeletal pains, fatigue, insomnia, chest pain, heart palpitations, hyperventilation, or gastrointestinal disorders

• individuals who present with a central distribution of injuries to the face, head, neck, throat, chest, breasts, abdomen, or genital areas

• multiple injuries in various stages of healing

• injuries inconsistent with the "story" • a delay in seeking treatment from the time

of the injury • repeated visits to the emergency

department with an increase in the severity of their injuries

• individuals with depression, anxiety, drug/ alcohol abuse, or suicidal individuals

Documentation

Document the date, time, place, individual involved, and location of the injury. Use direct quotes from the individual.

Document the abuse and any physical findings.

Document the use of any weapons. A weapon can be any item that is used to injure another individual. It is mandated by law to report the use of any weapon. (Each state will have a different reporting method.)

Document if the individual was burned. In many states, if the bum exceeds 5 percent of the total body surface, then it must be reported.

Whenever possible, use photographs to document injuries. Over time, the injuries will disappear but the photographs will remain a permanent visual documentation. Photographs are integral for the preservation of injuries that can be used at a later date as evidence.

Referrals

• shelters for domestic violence victims • hotlines for domestic violence • police • domestic violence advocates • sexual assault referrals • counseling programs • clergy