Healthcare Professionals and Domestic Violence Research Paper

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This research paper focuses on the health professional’s role in identifying and responding to domestic violence. The physician, nurse, dentist, physical therapist, or other health professional may be the first person to whom abuse is disclosed. As a result, the acute and chronic effects of domestic violence are healthcare issues that nearly every health professional encounters in the course of routine practice. Providers are expected to know the basics of recognition and intervention related to screening and identification, early intervention, and crisis care for those affected by domestic violence. Therefore, all health professionals are expected to routinely screen, diagnose, assess, intervene, and ultimately help prevent domestic violence.

Outline

I. Health Effects of Abuse

II. Guiding Principles of Care

A. Victim Safety

B. Victim Autonomy

C. Perpetrator Accountability

D. Advocacy for Social Change

III. Barriers to Inquiry and Disclosure in the Healthcare Setting

A. Clinician Barriers to Routine Inquiry

B. Patient Barriers to Disclosure

IV. Current Screening Recommendations

V. Inquiry and Identification in the Healthcare Setting

A. Beginning the Conversation

B. Inquiry in the Healthcare Setting

C. Physical Examination

D. Observation of Partner Behavior

VI. Time Management in the Clinical Setting

VII. Intervention

A. Specific Interventions

B. Providing Information and Validation

VIII. Safety Planning

IX. RADAR: A Practical Framework for Identification and Response

X. Office Staff Training and Security

XI. Conclusion

I. Health Effects of Abuse

Domestic violence causes substantial short- and long-term morbidity and mortality. Acute injuries, long-term sequelae of prior injuries, and chronic illnesses are common manifestations of abuse. Although survivors can sustain life-threatening physical injuries, they may also suffer less obvious effects that are just as debilitating. In addition to physical trauma, survivors present with other medical problems, including chronic pain syndromes, somatization disorders, post-traumatic stress disorder, anxiety, depression, suicidality, and alcoholism and other forms of substance abuse.

According to a 2000 U.S. Bureau of Justice Statistics report, current or former intimate partners murdered 33 percent of all female homicide victims. The true figure is probably higher, as the victim–offender relationship was not discernible in an additional 31 percent of homicides. In contrast, only 4 percent of male homicide victims were killed by an intimate. Recent research has also shown that the leading cause of pregnancy-associated death is homicide, a substantial component of which is intimate partner homicide.

II. Guiding Principles of Care

Healthcare providers should observe four guiding principles of care, originally promulgated by the Family Violence Prevention Fund when addressing domestic violence: victim safety, victim autonomy, perpetrator accountability, and advocacy for social change.

A. Victim Safety

Every aspect of clinical care, including inquiry, assessment, documentation, safety planning, communication, intervention, and follow-up, must be conducted with utmost concern for the safety of the survivor and her/his dependent children. The provider should consider whether what she/he is asking, doing, and/or recommending is going to help the patient become safer or at least not place her/ him at risk for further harm.

B. Victim Autonomy

Abused individuals have had their freedom to make informed, independent choices about their (and their children’s) lives restricted by the batterer’s controlling and intimidating behavior. Facilitating the patient’s ability to make her/his own choices is key to restoring a sense of purpose and well-being for survivors, and can facilitate a patient’s readiness to take proactive steps to seek safety.

C. Perpetrator Accountability

It is important to reframe the violence as occurring because of the perpetrator’s behavior and actions, not the survivor’s. It thus follows that the problem of violence in the relationship, and the need to take definitive steps to end the violence, is the perpetrator’s responsibility. This guiding principle assumes the importance of victim safety but rejects victim-blaming and other excuses offered by the offender as ‘‘explanations’’ for the violence.

D. Advocacy for Social Change

Health professionals acting alone cannot meet all the needs of survivors of abuse. As healthcare professionals and systems grapple with the complex issues involved in responding to domestic violence, the need to collaborate with others in healthcare, law enforcement, the faith community, and society at large becomes apparent. Health professionals can be important catalysts for change so that domestic violence can be more effectively identified and ultimately prevented.

III. Barriers to Inquiry and Disclosure in the Healthcare Setting

Survivors present frequently in the healthcare setting, coming in contact with clinicians who are in a position to identify abuse and respond effectively. The vast majority of patients (victims and nonvictims alike) expect healthcare providers to know about domestic violence, and welcome being asked about it during the healthcare encounter. However, despite the substantial prevalence of abuse seen in the healthcare setting, most providers still do not routinely inquire about domestic violence unless clear indicators of trauma are present. Recognizing and addressing the barriers faced by clinicians and patients can increase clinicians’ ability to detect domestic violence and to respond effectively.

A. Clinician Barriers to Routine Inquiry

Routine confidential inquiry about domestic violence is often omitted from the healthcare encounter, despite well-publicized recommendations and, in some cases, mandates in the guidelines and standards of professional associations and recognized experts. Many providers feel they have insufficient time to fully evaluate, support, and plan for safety with patients who have disclosed abuse. Some believe it is not their job to ‘‘pry’’ into patients’ ‘‘private’’ lives, or may be hesitant to ‘‘open Pandora’s box’’ and initiate a foray into time-consuming issues that they feel reluctant or poorly equipped to address. Far too many providers have had little or no education or training about domestic violence and lack both the knowledge and the skills needed to incorporate routine inquiry or even basic awareness into their practice patterns. Nearly 50 percent of the physicians in Sugg’s landmark 1992 study expressed feelings of powerlessness and inadequacy when trying to help abused patients. Many providers feel ill-equipped to respond to a disclosure of abuse, in part because they are unaware of community-based referral resources. Time constraints, discomfort with the topic, beliefs about the acceptability of certain behaviors, and possible personal exposure as a victim, witness, or even perpetrator are additional barriers to inquiry and response in the healthcare setting. Finally, some find it difficult to deal with patients who cannot acknowledge their own abuse and leave the abuser, use alcohol or other drugs, or have psychological sequelae. Such challenges interfere not only with inquiry, evaluation, assessment, and safety planning, but also with clinicians’ ability to establish trust and convey empathy.

B. Patient Barriers to Disclosure

Even after sustaining injuries, survivors of domestic violence rarely disclose without being asked in a sensitive and patient manner. Patients cite fear of retaliation, distrust of the healthcare system, fear of being reported to the police, fear of losing children, and fear of deportation. Long-term abuse is associated with shame, guilt, and low self-esteem, all of which impede the patient’s ability to seek help from healthcare providers. Financial dependence on the abuser often makes leaving impossible and therefore renders disclosure futile. Patients from ethnic minorities may accept violence as a cultural norm and may not discuss it with their provider. Language differences may impede frank discussions of abuse, especially if the abuser acts as interpreter. Finally, language and cultural differences between patient and provider are barriers to both disclosure and identification.

IV. Current Screening Recommendations

The American Medical Association recommends routine screening for domestic violence by all healthcare providers. This recommendation has been endorsed by other professional organizations, including the American College of Emergency Physicians and the American College of Obstetricians and Gynecologists. The Joint Commission on the Accreditation of Healthcare Organizations requires that hospitals institute protocols for domestic violence screening and referral. Research has yet to systematically investigate the impact of screening on long-term health outcomes. Efforts to elucidate this impact have been hampered by concerns over the inability to identify and follow survivors without jeopardizing safety. Given the low risk associated with screening (compared with other screening tests), the prevalence of domestic violence in healthcare settings, and the short- and long-term effects of abuse on victims’ health, these recommendations are generally felt to be appropriate even in the absence of outcomes research.

V. Inquiry and Identification in the Healthcare Setting

A. Beginning the Conversation

Although survivors access medical services more frequently than do nonabused individuals, most do not volunteer a history of abuse even to their primary care physicians. Survivors are more likely to disclose their history in the healthcare setting if the provider is perceived to be knowledgeable, nonjudgmental, respectful, and supportive. Patients voice clear preferences for providers to take the initiative to inquire, as a matter of standard practice, about domestic violence during the course of routine healthcare. The gender of the provider or clinician is not an important factor in the willingness of most patients to disclose abuse. Indirect interventions such as placing educational posters or brochures in the waiting room, examination rooms, and lavatories also communicate concern and interest to patients, increasing their comfort in revealing abuse.

B. Inquiry in the Healthcare Setting

All adolescent and adult patients should be screened for current and past abuse in the course of routine care. Patients should be interviewed in private, without the partner, children, or other relatives present. The most dramatic yet relatively uncommon presentation of domestic violence in the clinical setting is that of an acute injury sustained from a recent assault. More commonly, survivors present with chronic, nonspecific ‘‘red-flag’’ medical complaints (e.g., back pain, headaches, nonspecific abdominal pain) or common medical or behavioral conditions (e.g., vaginal discharge, sprains and strains, anxiety, depression, panic, social phobia, alcoholism).

It is easiest to begin a conversation about domestic violence if posters, literature, or other practice-wide messages are visible. If this is not yet the case, it is still quite easy to broach the subject to individual patients, the vast majority of whom welcome such an overture. Clinicians can frame questioning about domestic violence by referring to posters or literature displayed in the office, if available, or by simply stating: ‘‘As you may know, abuse by a partner—a spouse, date, or even an ex-partner—is unfortunately very common in our society, including in my own practice. Because of this, I am now asking every patient if she/he is safe at home and in her/his relationships.’’

Once an appropriate framing statement is made, accompanied by respectful yet actively engaged body language and eye contact appropriate to the patient’s culture, any one (or more) of the following simple, direct questions can be posed:

• ‘‘At any time [or, ‘‘in the past year’’ or ‘‘currently’’] have you been hit, slapped, punched, strangled, threatened, made to feel afraid, or hurt in any way by a current or former partner/ husband/date?’’
• ‘‘Every couple has conflicts. What happens when you and your partner disagree?’’
• ‘‘Do conflicts ever make you fearful or turn into physical fights?’’
• ‘‘I see patients who are being hurt or threatened by someone they love. Is this happening to you?’’
• ‘‘Do you ever feel afraid of your partner?’’
• ‘‘Do you feel safe in your home and around your spouse or intimate partner?’’

Domestic violence is indeed prevalent throughout the world, but by no means directly affects a majority of patients. Statistically speaking, therefore, the answer to an initial screening question is likely to be no. Even so, most patients are grateful to have been asked, as routine inquiry about domestic violence indicates a level of caring and compassion that many seek and appreciate from their healthcare providers. There are cases, however, in which a patient may be in an abusive relationship, yet is not ready to disclose to anyone, including physicians. Such individuals may offer a half-answer to a screening question, such as, ‘‘My husband loves me,’’ or simply turn away and say nothing. Should this be the case, the clinician can gently follow up with an additional question, such as: ‘‘When I speak with someone with a situation/sadness/ problem such as yours, it is sometimes because someone has hurt or mistreated her/him. Has someone been hurting you?’’

When injuries are in suspicious locations or if the explanation does not correlate with the injury, probing gently for further details can uncover ongoing domestic violence. Even a simple question such as, ‘‘Can you tell me who hurt you?’’ can be an effective and sensitive way to ask about abuse.

C. Physical Examination

Typical injuries are located on the upper arms, chest, abdomen, thighs, head, neck, and mouth. Black eyes, contusions, and evidence of attempted strangulation are commonly seen. Multiple injuries in varied stages of healing or those that cannot be explained adequately or consistently typify chronic, recurrent trauma due to domestic violence. Any injury suspected to be a result of sexual assault should be cause to suspect ongoing domestic violence. In addition to acute injuries, patients can have multiple medical complaints without significant physical findings.

D. Observation of Partner Behavior

In addition to clues from the history or physical examination, certain partner behaviors should also raise suspicion for domestic violence. The partner may come into the examination room, exhibit overly attentive or controlling behavior, answer questions directed to the patient, or insist on being present throughout the encounter. If getting a domestic violence history is crucial, the partner should be asked to leave, or can be distracted by asking him/her to fill out forms or answer questions ‘‘privately,’’ thus leading him/her to believe that he/she is being treated as an ‘‘expert,’’ while the patient is being asked about abuse privately by another member of the healthcare team. It is best to create and enforce an office policy that permits partners and other family to come into the examining room only after the examination is completed. Such an ‘‘office protocol’’ serves to prevent and avoid the awkward situation of having to ask a partner to leave the examining room.

VI. Time Management in the Clinical Setting

Healthcare professionals, particularly physicians, may be reluctant to engage in inquiry and identification because of concerns about having insufficient time to screen and respond in a careful and patient manner, given the multiple responsibilities and time pressures of daily practice. Judicious time management, however, will allow both for universal screening and for targeted follow-up. The most common scenario is for inquiry to produce a negative report (i.e, no history of abuse), in which case the patient is almost always grateful for having been asked. Most patients who have experienced abuse are not in immediate danger, even if the abuse is ongoing. The clinician can perform a quick danger assessment, validate and support the patient using brief supportive statements, offer emergency hotline numbers and other referral resources, and arrange a separate time to interview the patient in depth about her/his abuse history. It is rare to see a patient who presents in acute danger in the office setting. This unusual situation is nonetheless as urgent as a cardiac, respiratory, or diabetic emergency, and should be treated accordingly. Screening for abuse, therefore, should not add substantially to the clinician’s schedule, and may ultimately save time by allowing for abuse to be addressed in a separate, dedicated visit.

VII. Intervention

When a survivor seeks help following disclosure, the following questions, which deal with immediate safety, should be asked in a private setting:

• ‘‘What happened?’’
• ‘‘Has this happened before? How did it begin?’’
• ‘‘How badly have you been hurt in the past?’’
• ‘‘Have you ever needed to get emergency help or go to a hospital because of an assault?’’
• ‘‘Has your abuser threatened to harm or kill you, him/herself, or anyone else?’’
• ‘‘Have you ever been threatened with a weapon, or has a weapon ever been used on you?’’
• ‘‘Have you ever tried to get an order of protection?’’
• ‘‘Have the children ever seen or heard you being threatened or hurt?’’
• ‘‘Have the children ever been threatened or hurt by your partner?’’
• ‘‘Are your children safe and cared for right now?’’
• ‘‘Do you know where the abuser is right now?’’
• ‘‘Is it safe for you to return home today? Do you need emergency help right now? Do you feel you need to flee for your safety?’’
• ‘‘Do you have a safe place to go?’’
• ‘‘Do you know how you can get help if you are hurt or afraid?’’
• ‘‘Have you been able to talk to anyone else about this?’’

As important as it is to ask the right questions, it is critical to refrain from asking questions in a manner that might frighten or intimidate the patient, increase her/his sense of humiliation and shame about the abuse, or be interpreted as ‘‘blaming the victim.’’ Here are some pitfalls to avoid:

. Most survivors do not identify themselves as ‘‘abuse victims’’ per se because of the perception of shame, helplessness, and worthlessness associated with such a value-laden term. Therefore, avoid using labels such as ‘‘victim’’ or ‘‘battered’’ when speaking with patients. Instead, use resilience-promoting terms like ‘‘survivor’’ whenever possible.

• Do not inquire about abuse in the presence of the partner, friends, roommates, or family members.
• Do not break confidentiality by disclosing information, discussing your concerns, or providing advice to anyone without the survivor’s explicit consent.
• Never ask a patient what she/he did to provoke the abuse, or why she/he has not terminated the relationship.
• Listen attentively, but do not ask a survivor of any type of sexual violence to provide you with more details than she/he feels comfortable offering.

A. Specific Interventions

Following disclosure, the primary roles of the healthcare provider are to communicate concern, provide information, review options and resources, initiate safety planning, provide medical treatment, and arrange for follow-up. The clinician also must evaluate the need to file a mandated report to the appropriate agency for children, elderly, or disabled patients, and in those states in which clinicians are required by law to report domestic violence. Care and/or referral for acute and chronic medical and psychological issues, plus referral for comprehensive primary care should be undertaken as indicated. A discussion of safer sex practices and protection against sexually transmitted infections and pregnancy, especially for patients who have been raped, should occur. Most importantly, the patient should be referred to community experts who provide direct service to survivors. Each clinical practice or healthcare facility should maintain a resource and contact list of local agencies to which patients can be referred. These programs can forge natural partnerships with the healthcare community, working together toward a sustained, coordinated community response to domestic violence. Local resources include police departments; domestic violence service, advocacy, and intervention agencies; batterer intervention programs; social service agencies; services offered by religious communities; local government or county court offices; culturally specific agencies, programs, and community centers; schools and other educational institutions; political and community opinion leaders; and companies that address violence in the workplace.

B. Providing Information and Validation

The provider–patient relationship is strengthened when the patient is reassured that she/he is being treated honestly and respectfully in the clinical setting. Clinicians should listen attentively and respectfully, communicating messages that can validate the patient and begin the difficult process of healing and recovery, specifically:

• Disclosure should be acknowledged as an act that is both difficult and courageous.
• Domestic violence is against the law, and survivors have legal rights.
• The abuser—not the victim—is at fault for perpetrating the abuse that has occurred.
• The patient is believed—she/he does not have to provide proof or verification that abuse has occurred.
• She/he is not to blame; no one deserves to be hit, hurt, or abused in any way.
• She/he is not alone; many have endured similar situations and have benefited from help from the healthcare system and from community agencies.
• Her/his safety is of utmost importance.
• She/he will set the pace for action and healing.
• Interactions and disclosures that take place in the healthcare setting are confidential to the extent possible under the law.
• Limitations of clinician/patient confidentiality, particularly in respect to mandated reporter responsibilities, will be disclosed and discussed honestly.
• Follow-up both for the presenting complaint and for comprehensive primary care will be arranged.

VIII. Safety Planning

A safety plan is a detailed, individually developed protocol that a survivor can use to get and stay safe. Although healthcare professionals should know the elements and importance of safety planning, the specific details of each plan should be worked out by the survivor in conjunction with an experienced domestic violence advocate. To develop a safety plan, the survivor’s degree of danger and the specific resources needed to flee suddenly and to maintain violence-free, independent living must be addressed. The plan should include:

• A safe place to go along with an alternative, if possible (friends, family, shelter, or safe house)
• Preparation of necessary items including cash, driver’s license, other identification, car keys, medications, and a change of clothing for survivor and children
• Records to take and/or keep secure, such as birth certificates, visas, passports, Social Security numbers, prescriptions, bank account numbers, credit card records, other financial information, school records, and work history or resume
• Contact information for friends, relatives, spiritual leaders, and healthcare providers
• A copy of the survivor’s order of protection, if one has been issued
• Other items deemed necessary when the safety plan is being developed

Each safety plan is individualized according to the immediate and anticipated safety needs of each patient, the needs of dependent children, identified financial resources and needs, and expected living arrangements. Since abusers often search their victims’ belongings, before giving any written materials to a patient, ask her/him if it is safe to take written materials from the office. Quite often, safety planning and other vital information need to be provided more than once.

Many survivors choose to stay in abusive relationships because they believe it is safer to stay than to leave. Each survivor faces difficult and potentially volatile and dangerous decisions when preparing to leave an abusive relationship. Informed decisions by patients must be respected, regardless of whether the clinician is in agreement with the survivor’s choices. A patient who remains in an abusive relationship should not be labeled as difficult or noncompliant. Choosing not to leave usually reflects the limited resources available to a survivor, or her/his reasonable assessment of available options and safety needs. Deciding to stay may also reflect fear of being ostracized by one’s own family or of having the children lose a parent, or may represent reluctance to risk losing a significant relationship with someone who once seemed to be a loving and caring partner. For reasons of safety, time management, and treatment, the provider should not attempt to speak with or counsel an abuser in an acute or volatile situation. Couples counseling or marriage counseling in such situations is unwise and potentially dangerous and is therefore contraindicated.

The survivor’s role is to decide when it is safe to leave and when the logistical, spiritual, economic, and emotional resources to support this decision are in place. The clinician’s role is to provide the patient with options, support, and information about resources in a manner that is compassionate, concerned, and nonjudgmental. Disclosure of domestic violence may herald an especially dangerous period for both survivor and children. Therefore, once disclosure is made, particular attention must be paid to the safety and well-being of children and others living in a home in which domestic violence is occurring.

IX. RADAR: A Practical Framework for Identification and Response

RADAR—an acronym for Remember to ask, Ask directly, Document findings, Assess safety, and Review options/Refer to appropriate services—is a model five-step approach to identify and treat survivors of abuse. The RADAR model, developed by Elaine Alpert for use by the Massachusetts Medical Society, has been used extensively in clinical settings since 1992 (Alpert 2004). Using RADAR, clinicians can detect domestic violence, treat its effects, and refer patients to appropriate services. The RADAR five-step approach is as follows:

1. Remember to ask. Inquiry cannot take place unless healthcare providers remember to ask. Incorporating inquiry into routine clinical practice is now the recognized and recommended standard of care.

2. Ask directly. Identifying abuse can be accomplished either through routine screening during the clinical encounter or by direct inquiry if domestic violence is suspected. In either case, principles of respectful patient interviewing should be employed. Clinicians should use engaged body language, sit at the same level as the patient, make eye contact and allow the patient adequate time to respond to questions, listening carefully to the patient’s responses and noting the patient’s affect. The use of engaged body language and other nonverbal cues will underscore the clinician’s interest in the patient’s wellbeing and will facilitate disclosure of traumatic or otherwise difficult experiences. Physicians and other healthcare providers can also facilitate a safe atmosphere by training office staff to be sensitive to trauma issues and by placing patient education materials and helpful telephone numbers in waiting rooms, examination rooms, and restrooms.

3. Document findings. Careful documentation of abuse-related injuries and illnesses is an essential component of the healthcare response. Documentation can be useful in court proceedings, for risk management, and to justify services provided. Documentation should be clear and accurate, using written descriptions, freehand sketches, preprinted body diagrams, and/or photographs (including patient consent for photodocumentation). Written accounts should be clear and nonjudgmental, using direct quotations when applicable. Photographs, which can be taken in digital format, should be signed or initialed and dated by the healthcare provider with a notation that the photo image is both accurate and unaltered. At least one photograph should include the patient’s face; the injury being documented; a ruler, coin, or other size guide; and a written notation of the date, in a single image.

4. Assess safety. Following disclosure, healthcare professionals can play an invaluable role in assessing danger, initiating safety planning, and making referrals to communitybased services. Important determinants in assessing risk are the survivor’s level of fear, and her/his own appraisal of immediate and future safety needs. Additional indicators of escalating risk include increase in frequency/ severity of abuse, threats of homicide or suicide by the partner, presence or availability of a firearm or other weapons, and new or increasingly violent behavior by the perpetrator outside the relationship. Disclosure may herald a particularly dangerous period for both survivor and children. Therefore, once disclosure is made, particular attention must be paid to the safety and well-being of children and others living in a home in which domestic violence is occurring.

5. Review options/Refer as appropriate. Caring for domestic violence survivors is a team effort. While inquiry, immediate follow-up, and safety assessment in the clinical setting remain within the purview of the healthcare provider, follow-up often requires involvement of community-based domestic violence ‘‘specialists.’’ Such specialists include shelter and legal advocates, court-based victim-witness advocates, social workers and other mental health clinicians, and community providers. Community-based programs provide hotlines, safety planning, emergency shelter, support groups, and legal assistance resources. Arranging to see the patient in follow-up is critical, as it conveys critical support and caring for the patient’s welfare. Follow-up also can be both educational and reinforcing for the clinician.

X. Office Staff Training and Security

Office personnel can facilitate screening, referral, and patient assessment and provide crucial support when time constraints hinder clinicians. Office staff also can provide ongoing patient contact and follow-up, keeping in mind the safety and confidentiality needs of each patient.

All office staff should receive training about domestic violence. Training the entire ‘‘team’’ allows for sharing responsibilities, mutual support, and a lessening of the workload and emotional responsibilities for each individual. Each office should develop screening and intervention protocols that adhere to guiding principles of care, taking into account the security, logistical, time, and emotional needs of office staff. The office team can thus work smoothly and seamlessly for screening, response, and follow-up.

A suspected batterer should never be spoken to about any abuse-related behavior that he/she has not disclosed independently. Discussion of any survivor-originating information with the batterer violates the confidential relationship between clinician/ office and patient/survivor, puts staff at risk, and increases the chance that the batterer will retaliate by injuring or killing the victim. Within the constraints of mandated reporter responsibilities, strict confidentiality must be maintained with respect to medical records and conversations concerning survivors. Suspicious behavior by a batterer in the office or vicinity can be reported to security staff or police more effectively when office personnel have been appropriately trained.

XI. Conclusion

The healthcare visit provides an ideal opportunity for inquiry about domestic violence. Routine inquiry fosters the ability of patients to develop confidence in making informed choices that promote safety. There is no simple and easy solution for the complex problem of domestic violence; however, early diagnosis and efficient and compassionate intervention can ameliorate the serious effects of physical, sexual, and psychological abuse for current, as well as future, generations.

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