Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
HealthStream Regulatory Script Identifying and Assessing Victims of Domestic Abuse Release Date: August 2011 HLC non-CE Version: 604 HLC CE Version: 2 Lesson 1: Lesson 2: Lesson 3: Lesson 4: Lesson 5: Introduction Dynamics of Abuse Identifying Victims Assessment and Referral Reporting Requirements Lesson 1: Introduction 1001 Introduction Welcome to the introductory lesson on identifying and assessing victims of domestic abuse. As your partner, HealthStream strives to provide its customers with excellence in regulatory learning solutions. As new guidelines are continually issued by regulatory agencies, we work to update courses, as needed, in a timely manner. Since responsibility for complying with new guidelines remains with your organization, HealthStream encourages you to routinely check all relevant regulatory agencies directly for the latest updates for clinical/organizational guidelines. If you have concerns about any aspect of the safety or quality of patient care in your organization, be aware that you may report these concerns directly to The Joint Commission. Point 1 of 4 2 1002 Course Rationale This course will discuss domestic abuse, and will provide you with the information you need to: • Identify victims • Assess victims • Refer victims to other resources • Report victims of this form of abuse By doing so, you can: • Maintain compliance with The Joint Commission standards. • Improve public health • Improve your facility’s quality of patient care Specific information for Florida providers to meet state board requirements is also included. Point 2 of 4 1003 Course Goals After completing this course, you should be able to: • List the effects of domestic abuse on the victim and children as it relates to the provision of care. • Cite the methods for assessing victims of domestic abuse in a clinical setting. • Recognize the importance of assessing and reporting domestic abuse as a healthcare provider. NO IMAGE Point 3 of 4 1004 Course Outline This introductory lesson provided the course rationale and goals. Lesson 2 will present background information on domestic abuse. Lesson 3 will discuss identification of victims of domestic abuse. Lesson 4 will present information on assessment and referral. Lesson 5 will discuss domestic abuse reporting. Lesson 6 will help you prepare to care for domestic abuse patients. Point 4 of 4 Lesson 2: Dynamics of Abuse 2001 Introduction Welcome to the lesson on the dynamics of domestic abuse. This lesson will discuss common traits of abusers and victims, the importance of control in an abusive relationship, and the effects of domestic violence. Point 1 of 35 2002 Statistics Domestic abuse occurs between two people in a close, intimate relationship. It is a public health concern in the United States. Each year: • 4.8 million women experience intimate partner related physical assault or rape. • 2.9 million men experience intimate partner related physical assault. • Over 1,500 women (75%) and men (25%) die as a result of domestic violence. In Florida alone, there were 114,759 reported domestic violence offenses and 86 murders in 2009. Understanding abusive relationships will help you to: • See domestic abuse as a public health threat • Identify and care for victims of abuse References 1, 2 Point 2 of 35 2003 Domestic Abuse: Definitions (1) The title of this course includes the term domestic abuse. However, you should be aware that domestic abuse also may be called: • Domestic violence (DV) • Intimate partner violence (IPV) • Partner abuse Regardless of the name, the cycle of power and control that mounts into an assault is the same. Each of these terms describes actual or threatened physical, psychological, emotional, or stalking abuse by a spouse or intimate partner. Reference 3 Point 3 of 35 2004 Domestic Abuse: Definitions (2) Legal definitions of domestic abuse usually focus on threatened or actual physical or sexual violence. States differ in what they consider domestic abuse. For example: • Florida statute 741.30 definition of domestic abuse/violence includes: • Assault or aggravated assault • Battery or aggravated battery • Sexual assault • Sexual battery • Stalking or aggravated stalking • Kidnapping or false imprisonment • Any criminal offense resulting in physical injury or death of one family or household member by another who is or was residing in the same single-dwelling unit Reference 4 Point 4 of 35 2005 Domestic Abuse: Victims In domestic abuse: • The victim is an adult or adolescent. • A woman is the victim in up to 85% of cases. • The abuser is a person who is, was, or wishes to be in an intimate relationship with the victim. Victims can be: • Women in relationships with men • Men in relationships with women • Men or women in same-sex relationships • Adolescents in dating relationships Domestic abuse does not discriminate! References 5, 6 Point 5 of 35 2006 Domestic Abuse: Risk Factors There are a number of general factors that increase the risk of domestic abuse including: • Individual characteristics • Relationship factors • Community factors • Societal factors Remember, not all people identified as “at risk” will engage in abusive or violent behavior. Click on each contributing factor for examples. Reference 7 CLICK TO REVEAL Individual characteristics • Low self-esteem • Low income or unemployment • Low academic achievement • Heavy drug or alcohol use • Antisocial personality traits • Desire for control • Seeing or experiencing violence as a child • Belief in strict gender roles Relationship factors • Marital problems or instability • Dominance and control by one partner • Unhealthy family associations • Economic stress Community factors • Poverty • Lack of social interactions • Weak community sanctions Societal factors • Belief in strict gender roles Point 6 of 35 2007 Domestic abuse: Risk Factors A World Health Organization study across 10 different societies identified specific factors that increased the risk of domestic abuse: o Alcohol abuse o Younger age o Cohabitation o Having outside sexual partners o Attitudes that were supportive of wife beating o Experiencing childhood abuse o Growing up with domestic violence NO IMAGE The same study identified factors that were protective of domestic abuse: o Formal marriage o High socioeconomic status o Secondary education Reference 8 Point 7 of 35 2008 Domestic Abuse: Risk Factors Risk factors have also been identified for violence in male batterers and include: • Depression • Antisocial personality disorder • Youth • Low income • Low educational level • Unemployment • Intermittent employment Family histories of batterers often reveal that the perpetrator [glossary] was a victim of abuse himself or was a witness to violence. They also have: • A history of violence in other relationships • A tendency to not be assertive in direct and positive ways • Feelings of intense inadequacy • Feelings of jealousy and mistrust of partners Often alcohol or other drugs are used to increase a sense of power or worth. Reference 9 Point 8 of 35 2009 Dynamics of Abuse The dynamics of domestic abuse are specific: • The behavior of the abuser is: o Violent o Coercive [glossary] o Controlling o Different in public and private • The goal is to control the victim. In addition, abusers often: • Project blame to the victim • Claim to be victims • Claim loss of control and anger problems • Minimize or deny that they are abusive References 5, 9 Dynamics of Power and Control in Domestic Abuse Common Characteristics of the Common Characteristics of the Abuser Victim Controls access to needed items Fearful of the abuser Outwardly jealous of the victim’s friends, family, coworkers Not allowed access to social support Does not respect the victim’s point of view Rarely exercises or experiences independence Claims authority, knowledge, and/or power through status symbols Minimizes or makes excuses for abusive behavior Accepts a dependant and or submissive role May have offensive injuries [glossary] (i.e., scratches or bite marks) May have serious injuries and stress-related health problems May have defensive injuries (i.e., bruises, cuts) Is willing to accept blame for the abuse Point 9 of 35 2010 Dynamics of Abuse The abuse is often triggered by a major life event, such as marriage, pregnancy, or birth. It may also be triggered by recognition or award given to the victim. The initial response is usually a feeling of shock and revulsion, followed by a commitment that the event will remain isolated. Remorse and reconciliation always occur. The perpetrator will often feel sorry and shower the victim with gifts and attention. The victim often feels guilty for having provoked an attack and feels sorry for the perpetrator’s pain. Reconciliation is followed by a period of increasing tension, building to another violent episode, and a continuing cycle develops. Reference 9 Point 10 of 35 2011 Forms of Abuse Abuse may be: • Physical • Emotional and psychological • Sexual Let’s take a closer look at each type of abuse. Reference 10 Point 11 of 35 2012 Forms of Abuse: Physical Physical abuse or violence involves the use of physical force. The pattern of abuse: • Occurs repeatedly • Increases in frequency and severity over time Examples of physical abuse include: • Pushing or shoving • Slapping, punching, or kicking • Choking • Assault with a weapon • Holding, tying down, or restraining • Leaving the victim in a dangerous place • Refusing to provide assistance when the victim is sick or injured Reference 10 Point 12 of 35 2013 Forms of Abuse: Physical While many of the injuries a victim sustains are minor (scratches, bruises, welts), serious disability or death are possible. In the United States in 2005, intimate partners murdered: • 1181 women • 329 men In 2005, intimate partner violence was a causative factor in 51.9% of female homicides and 8.8% of male homicides. The risk of murder is 75% greater when a victim of domestic abuse leaves the relationship compared with those who stay. It is important to handle situations of domestic violence well in order to manage this risk. References 9, 11 Point 13 of 35 2014 Physical Abuse in Adolescents Dating violence includes physical, sexual, or psychological/emotional violence within a dating relationship. Dating violence is a serious problem among adolescents: • Between 2% and 9% of male and between 4% and 20% of female adolescents report physical or sexual abuse associated with dating. • Serious dating violence, such as rape, occurs in 2.7% of girls and 0.6% of boys, equaling approximately 400,000 adolescents. References 12, 13 Point 14 of 35 2015 Forms of Abuse: Emotional and Psychological Emotional and psychological abuse helps the abuser control the victim through fear and degradation. [glossary] The abuser may: • Threaten or intimidate the victim • Isolate the victim physically or socially • Ignore, dismiss, or ridicule the victim’s needs • Deprive the victim of needed items • Degrade and humiliate the victim • Criticize, insult, or belittle the victim • Make false accusations • Lie and break promises to the victim Reference 10 Point 15 of 35 2016 Forms of Abuse: Sexual Sexual abuse is very difficult for victims to discuss. Examples include being forced to: • Have sexual contact without giving permission • Have unprotected sex • Forced to perform undesired sex acts Victims may also be: • Physically harmed during sexual activity • Assaulted with objects or weapons intravaginally, orally, or anally Reference 10 Point 16 of 35 2017 Sexual Abuse Statistics In a recent survey of 9,684 adults, forced sex was experienced by: • 10.6% of women at some time in their life • 2.1% of men at some time in their life Approximately 10% of all assault-related injury visits by females to an emergency department (ED) are for sexual assault. However, up to 66% of women injured during a rape do not seek medical treatment. Reference 14 Point 17 of 35 2018 Consequences of Domestic Abuse Domestic abuse may affect the victim’s: • Medical health • Health during pregnancy • Management of chronic illness • Participation in preventive health measures • Mental health • Children Let’s take a closer look at each of these categories. References 5, 15 Point 18 of 35 2019 Consequences: Medical Health Victims of domestic abuse can develop chronic stress-related and other medical illnesses. These illnesses may include: • Arthritis • Chronic neck or back pain • Migraine and other types of headache • STDs [glossary] (including HIV/AIDS) • Chronic pelvic pain • Peptic ulcers • Chronic irritable bowel syndrome • Frequent indigestion, diarrhea, or constipation • Temporomandibular joint syndrome [glossary] Up to 50% of women presenting to the emergency department are suffering from domestic abuse. Patients who present with frequent medical complaints should be considered as possible victims of domestic abuse. References 6, 10 Point 19 of 35 2020 Consequences: Health in Pregnancy Pregnancy is a time of increased risk for domestic violence. It has been estimated that 6%of all pregnant women in the United States are abused by intimate partners. However, one study of patients attending a prenatal care clinic reported active violence occurred in 19% to 23% of patients. Up to 45% of pregnant women have experienced domestic abuse sometime in their life Abused women experience pregnancy complications including: • Low weight gain • Anemia • Infection • First and second trimester bleeding • Placental abruption [glossary] • Depression • Suicide attempts • Substance abuse Of women seeking abortion, 22% report domestic abuse within the past 12 months. Additionally, the pregnancy rate among rape victims is 5%, resulting in 32,000 unwanted rape-related pregnancies per year. References 3, 6 Point 20 of 35 2021 Consequences: Management of Chronic Illness The abuser often: • Limits the victim’s access to medical care • Interferes with the victim’s compliance with medical care As a result, victims often poorly manage chronic illnesses such as: • Asthma • HIV/AIDS • Seizures • Diabetes • Gastrointestinal disorders • Hypertension Reference 15 Point 21 of 35 2022 Consequences: Participation in Preventive Health Measures Victims of domestic abuse are less likely to have preventive health screenings and visits including: • Yearly physicals • Mammograms • Pap smears • Prenatal care Reference 16 Point 22 of 35 2023 Consequences: Mental Health Victims of domestic abuse are at increased risk for: • Drug and alcohol use/abuse • Eating disorders • Depression • Posttraumatic stress disorder • Anxiety • Sleeping disorders • Suicide Of women presenting to an ED, those with a history of domestic abuse or who are experiencing current domestic abuse are 3 times as likely to attempt suicide compared with women without an abuse history. A study of 3429 women in an HMO [glossary] found that women with an abuse history were 4 times more likely to suffer severe depressive symptoms compared to those without a history of domestic abuse. Reference 17 Point 23 of 35 2024 Consequences: Adolescents Adolescents who are victims of dating violence are more likely to: • Binge drink • Use drugs • Smoke cigarettes • Engage in fighting • Engage in sexual activity • Be involved in abusive relationships in the future • Be infected with a sexually transmitted disease • Become pregnant • Have a shortened time between pregnancies Many adolescents do not perceive the consequences of dating violence. References 9, 10, 13 Point 24 of 35 2025 Consequences: Adolescents (2) Mental health consequences of dating violence include: • Depression • Posttraumatic stress disorder • Low self-esteem and poor body image • Suicidal thoughts and attempts Identified risk factors for adolescent dating violence include: • Older age • Female gender • Experiencing other potentially traumatic events • Experiencing recent life stressors References 9, 10, 13 Point 25 of 35 2026 Consequences: Children Children are affected by domestic violence. Domestic abuse during pregnancy may result in low birth weight infants, and is associated with increased risk for premature delivery and perinatal death. Young children exposed to domestic abuse have been shown to develop poor sleep habits, irritability, and poor weight gain. Children who are exposed to domestic abuse may develop: • Posttraumatic stress disorder • Physical health problems • Behavioral health problems: o Depression o Anxiety o Violence toward peers References 6, 10, 17 Point 26 of 35 2027 Exposure to Domestic Violence Children exposed to domestic abuse are at greater risk for: • Suicide • Substance abuse • Running away from home • Prostitution • Sexual assault • Promiscuous behavior • School dropout These problems may continue into adulthood. References 6, 10 Point 27 of 35 2028 Exposure to Domestic Violence NO IMAGE Domestic abuse is an important risk factor for child abuse. Violence against a mother is associated with a 50% likelihood that children in the home are being abused. Of families reported to child protective services, between 26% and 73% are affected by domestic abuse. Child maltreatment has been found in 30% to 60% of families, and in some studies 100%, in which a woman is a victim of domestic abuse. The impact of children witnessing domestic abuse is serious enough that several states have expanded their definition of child abuse to include witnessing violence between parents. References 6, 10, 17 Point 28 of 35 2029 Domestic Abuse: Barriers to diagnosis Several barriers prevent recognition of domestic abuse by health professionals. These include the belief that: • Victims are poor, inner city women and children • Domestic violence is rare in families that appear “normal” • Domestic violence is a private matter • Victims are in some way responsible for the abuse • The professional cannot really provide any useful intervention References 3, 6 Point 29 of 35 2030 Domestic Abuse: Barriers to diagnosis Barriers to diagnosis also exist in the victims of abuse: • Fear of retaliation from the abuser • Fear of police involvement • Cultural or language barriers preventing disclosure or making disclosure more difficult • Shame to admit to such loss of control in one’s life, especially in successful business women • Poor self-esteem causing the victim to feel like the abuse is his or her fault • Fear of loss of financial support • Lack of trust in caregivers • Long periods of time between abuse episodes may contribute to the patient’s denial of a problem It is important to be aware of these potential barriers to diagnosis in order to avoid them if possible. References 3, 6 Point 30 of 35 2031 Review Select the answer that best fits the question. MULTIPLE CHOICE INTERACTION Which of the following is most likely to be a victim of domestic abuse? a. A woman in an intimate relationship with a man b. A man in an intimate relationship with a woman c. A man in an intimate relationship with another man d. A woman in an intimate relationship with another woman Correct answer: A Feedback for correct: Correct. Anyone in an intimate relationship can be a victim of domestic abuse. Most victims are women in relationships with men. Feedback for Incorrect: Incorrect. Anyone in an intimate relationship can be a victim of domestic abuse. Most victims are women in relationships with men. Point 31 of 35 2032 Review Drag and drop the appropriate word from each pair to fill in the blanks in the following sentences: 1. Domestic abuse is ________ in intimate relationships. (common/uncommon). 2. Domestic violence tends to recur in an abusive relationship, becoming ______ frequent and _________severe over time. (more/less, more/less). 3. Domestic abuse can contribute to _______ medical illness in the victim. (stress-related/phantom). 4. Domestic abuse ______ harm children who only witness it. (can/cannot) Point 32 of 35 2033 Review At the beginning of the lesson, we discussed common characteristics of an abuser and his/her victim? Can you remember what these were? Type your response in the box below and click Submit to compare your answer to ours. The abuser commonly: • Controls access to needed items • Is outwardly jealous of the victim’s friends, family, coworkers • Does not respect the victim’s point of view • Claims authority, knowledge, and/or power through status symbols • Minimizes or makes excuses for abusive behavior • May have offensive injuries The victim: • Is often fearful of the abuser • Is not allowed access to social support • Rarely exercises or experiences independence • Accepts a dependant and/or submissive role • Is willing to accept blame for the abuse • May have serious injuries and stress-related health problems • May have defensive injuries (i.e., bruises, cuts) Point 33 of 35 2034 Review The WHO conducted a study across 10 different societies and identified characteristics that when present increased the likelihood of domestic abuse occurring. Can you recall some of these factors? Type your response in the box below and click Submit to compare your answer to ours. Common characteristics across several societies that were associated with domestic abuse were: • Alcohol abuse • Younger age • Cohabitation • Having outside sexual partners • Attitudes that were supportive of wife beating • Experiencing childhood abuse • Growing up with domestic violence Point 34 of 35 2035 Summary You have completed the lesson on the dynamics and consequences of domestic abuse. NO IMAGE Remember: • Domestic abuse occurs between intimate partners. Most victims are women. • Domestic abuse occurs in all communities, socioeconomic classes, and ethnic groups. • The abuser engages in assaultive and coercive behaviors. The goal is to control the victim. • Domestic abuse may be physical, emotional, and/or sexual. • Domestic abuse tends to escalate over time. • Domestic abuse may affect the victim’s physical health, mental health, and children. • Beliefs of both health professionals and patients can stand in the way of discovering and diagnosing domestic abuse. Point 35 of 35 Lesson 3: Identifying Victims of Domestic Abuse. 3001 Introduction Welcome to the lesson on identifying victims of domestic abuse. This lesson will present the benefits of routine screening, the appropriate timing of the initial assessment, and the appropriate questions to ask. Additionally, signs and symptoms of domestic abuse will be reviewed and the appropriate response to a denial of abuse discussed when concern of abuse still exists. Point 1 of 24 3002 Introduction: The Joint Commission Standard PC.01.02.09 The Joint Commission has a standard for victims of abuse. Standard PC.01.02.09 states: “The hospital assesses the patient who may be a victim of possible abuse and neglect.” In the rationale for this standard, the Joint Commission discusses the important role providers play in protecting victims of abuse. Reference 18 Point 2 of 24 3003 The Joint Commission Standard PC.01.02.09 Standard PC.01.02.09 requires hospitals to: • Have written criteria for identifying possible victims of abuse • Educate their staff about how to recognize abuse • Identify possible victims o At admission o On an ongoing basis • Make referrals for appropriate assessment and care • Report cases to appropriate agencies This is because victims may be unable or reluctant to talk about the abuse. Reference 18 Standard PC.01.02.09: EP1: The hospital has written criteria to identify patients who may be victims of domestic abuse. EP2: The hospital maintains a list of agencies that can provide assessment and care EP3: The hospital educates staff how to recognize signs of possible abuse as well as their role in follow-up. EP4: The hospital uses criteria to identify possible victims: • At admission • On an ongoing basis EP5: The hospital either assesses the patient with possible abuse or refers to an appropriate agency Point 3 of 24 3004 Identifying Victims Front-line healthcare workers should screen patients for domestic abuse routinely as part of usual patient care. As part of a standard health history, patients should be asked direct questions regarding abuse by intimate partners. Questioning should occur in a nonjudgmental, relaxed, and open manner in a private place. No friends, relatives, or caregivers should be present, except young children under 3 if necessary. An interpreter should be provided if needed and the interpreter should not be a family member, friend or known to the patient. Patients should be questioned in their native tongue. These questions should be asked even if there are no obvious signs of abuse. References 5, 10 Point 4 of 24 3005 Identifying Victims Routine questioning, as opposed to questioning only when an event has occurred, provides more opportunities to identify domestic abuse. NO IMAGE One of the most important factors for patients who have suffered domestic abuse is being listened to about the abuse. Even if no disclosure results from the questioning, it still communicates support and caring to the patient. Reference 5 Point 5 of 24 3006 Routine Inquiry: All Patients or Females Only? Routine inquiry for domestic abuse can include: • All adolescent and adult patients • Female adolescents and adults only Since men are usually the batterers, routinely assessing men may not be appropriate. • It is recommended to assess men only if precautions have been taken to protect potential victims. • Before assessing all patients for domestic abuse, providers should understand the dynamics of perpetrators and victims. Consult your supervisor or facility guidelines for facility-specific policies on the screening of patients. Reference 5 Point 6 of 24 3007 Routine Inquiry: Benefits Healthcare providers can identify and prevent domestic abuse. Although not proven, routine inquiry is believed to result in: • More detection of domestic abuse • Reduced illness or death that may result from the violence • Opportunities to educate patients regarding the increased risk of child abuse and the effects of childhood exposure to domestic abuse Routinely asking about domestic abuse enables you to: • Identify victims • Help victims and their children • Provide support to victims • Educate victims • Validate domestic abuse as a healthcare issue Reference 5 Point 7 of 24 3008 Routine Inquiry: When and Where The Joint Commission expects hospitals to identify victims of abuse: • At entry into the hospital system • On an ongoing basis Because domestic abuse affects so many aspects of a victim’s life, almost any encounter with the healthcare system may be an opportunity to assess for domestic abuse. Consult your supervisor regarding assessment policies at your facility. References 5, 18 Point 8 of 24 3009 Routine Inquiry: When NOT to Screen Do NOT inquire about domestic abuse if: • It cannot be done in private. • It may be unsafe for you or the patient. • An interpreter is not available, if needed. If routine inquiry is not performed: • Make a note in the patient’s chart • Make a follow-up appointment Reference 5 Point 9 of 24 3010 Routine Inquiry: Questions and Strategies When asking about domestic abuse, start by saying: Because domestic violence is so common today, I ask all patients about it. Or consider saying: Many times people complaining of _______have worse symptoms or more trouble recovering from______if they have been exposed to traumatic events. Have you ever been hurt emotionally, physically, or sexually in the past or recently? Then, if the response is “yes” to having experienced violence, ask direct questions in a nonjudgmental manner: Has your intimate partner ever hit you? Does your intimate partner ever force you to participate in sex? Did someone cause these bruises? Was it your partner? Reference 5 Point 10 of 24 3011 Routine Inquiry: Questions and Strategies Inquiry regarding adolescent dating violence should include: • Asking adolescents if they are in a dating relationship • Asking if they ever feel threatened in the relationship • Asking if they know of peers who are experiencing dating violence Websites that offer additional information on adolescent dating violence include: • http://www.chooserespect.org (CDC National Center for Injury Prevention and Control) • http://www.breakthecycle.org • http://www.thesafespace.org References 5, 12, 13 Point 11 of 24 3012 Routine Inquiry: Cultural Competence Providers need to remember that culture will influence how the patient experiences abuse and the healthcare system. Issues that must be considered include: • Language barriers • Differing terms to describe abuse • Cultural acceptance of abuse • Resource limitations • Ease of communication with providers • View of the healthcare system • Providers personal assumptions The questions used and the approach taken should be adapted in order to be culturally relevant to the patient. Listen to the patient. Words that are used by the patient may be incorporated into the questioning. Examples include: • Coastal Inuit people use the term “acting funny” to describe domestic abuse • In some Latin communities the term “disrespects you” refers to domestic abuse Reference 5 Point 12 of 24 3013 Cultural Competence You should ask questions in a culturally sensitive way. Examples include: In the patient’s own language: Does your boyfriend respect you? Being specific to the patient’s culture: Abuse is widespread and can happen even in lesbian relationships. Does your partner ever try to hurt you? Being indirect may work best for some patients: If a friend was being hurt or threatened by a partner do you know where they could get help? Reference 5 Point 13 of 24 3014 Disclosure Many victims will not disclose abuse because they: • Are embarrassed or ashamed • Fear retaliation • Are accompanied by a spouse or partner • Have experienced insensitive, judgmental attitudes in healthcare personnel • May not see their experiences as being abusive Clinicians should continue to be watchful for the signs of domestic abuse. References 5, 17 Point 14 of 24 3015 Indicators (1) Signs of domestic abuse can include: • Missed medical appointments • Not following medical advice • Discomfort when questioned • Presence of a partner who: • Controls the interview • Appears overly anxious or concerned • Will not leave the patient alone with you • Unusually high number of healthcare visits • Repeated visits with vague complaints • Health problems often related to abuse • Repeat vaginal or urinary tract infections References 5, 9 Point 15 of 24 3016 Indicators (2) Additional signs of domestic abuse include: • Unexplained injuries • Inconsistent or unlikely explanations for injuries • Delaying medical treatment for an injury • Injuries to the head, neck, chest, breasts, abdomen, or genitals • Bilateral or multiple injuries • Multiple injuries in different stages of healing • Injury to the breasts or abdomen during pregnancy The persistent emotional badgering and physical or sexual abuse creates great shame and feelings of worthlessness and incompetence. When a woman has experienced this, she may present as markedly passive and dependent, especially if the perpetrator is with her. References 5, 9 Point 16 of 24 3017 Indicators (3) In adolescents, signs that dating violence may be occurring include: • Physical signs of injury • Poor self-esteem • Problems at school • Changes in mood or personality References 5, 12 Point 17 of 24 3018 Responding to Indicators If the patient denies abuse: • Respect his or her right not to disclose • Inform the patient of your support • Offer the patient information on domestic abuse resources • Reassess the patient (schedule a follow up appointment) Reference 5 Point 18 of 24 3019 Inquiry: Perpetrators This lesson has focused on identifying patients who are victims of domestic abuse. However, in some cases, you may suspect that a patient is a perpetrator of domestic abuse. In general, identifying perpetrators is difficult. Perpetrators rarely disclose. However, they may discuss questionable behavior (see table). Questions that focus on anger management may be the most productive when discussing with men. Perpetrators of domestic abuse may discuss: • Anger • Temper issues • Stress • Arguments • Fighting • Heavy drinking If you suspect domestic abuse, ask indirect questions: • “What happens when you fight?” • “Has your partner ever been injured during an argument or fight?” • “Have you ever been injured during an argument or fight?” If the patient reveals domestic abuse: • Express concern for the perpetrator and his/her victim • Refer the patient to available resources for further evaluation or treatment References 5, 7 Point 19 of 24 3020 Inquiry and Assessment Resources The Centers for Disease Control and Prevention (CDC) has compiled a number of instruments that can be used to assess victims and perpetrators of domestic violence including: • A compilation of domestic abuse assessment instruments for use in healthcare • Measuring intimate partner violence victimization and perpetration: A compendium of assessment tools In addition, the following guideline from the Family Violence Prevention Campaign will be useful: • The National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings References 5, 19 Point 20 of 24 3021 Review Select the answer that best fits the question. MULTIPLE CHOICE INTERACTION Which patient should be screened for domestic abuse victimization during an annual exam? a. A 42-year-old Latina woman b. A 37-year-old African-American woman c. A 17-year-old Caucasian adolescent d. All of these e. None of these Correct answer: D Correct Feedback: Correct. Race and age do not determine screening. All adult and adolescents should be screened. Incorrect Feedback: Incorrect. The correct answer is D. All of these. Race and age do not determine screening. All adult and adolescents should be screened. Point 21 of 24 3022 Review Select the answer that best fits the question. MULTIPLE CHOICE INTERACTION Your patient is a 32-year-old woman with fractured ribs. She says she tripped over a toy and fell down the stairs. You suspect domestic violence. Which of the following questions should you ask? a. I think your husband fractured your ribs. What did you do to make him that angry and violent? b. I wonder if you really fractured your ribs in an accidental fall. Did someone hit or kick you? c. I know your husband was lying! How could you let him do that to you? How could you let him lie about it? d. Did you leave your children at home with your husband? I would never leave my children with such a monster. Correct answer: B Feedback for A: Incorrect. Do not suggest that the victim is to blame. You need to support and validate the victim. The best answer is B. Feedback for B: Correct. It is important to not judge the patient. You need to support and validate the victim. Do not suggest that she is to blame. Feedback for C: Incorrect. It is important to not judge the patient. Do not suggest that the victim is to blame. You need to support and validate the victim. The best answer is B. Feedback for D: Incorrect. It is important to not judge the patient. You need to support and validate the victim. The best answer is B. Point 22 of 24 3023 Review Knowing the indicators of abuse is important to being able to recognize that domestic abuse may be occurring. Can you recall some of these indicators? Type your response in the box below and click Submit to compare your answer to ours. Possible signs of domestic abuse include: • • • • • • • • • • • • • • • Missed medical appointments Not following medical advice Discomfort when questioned Presence of a partner who: • Controls the interview • Appears overly anxious or concerned • Will not leave the patient alone with you Unusually high number of healthcare visits Repeated visits with vague complaints Health problems often related to abuse Repeat vaginal or urinary tract infections Unexplained injuries Inconsistent or unlikely explanations for injuries Delaying medical treatment for an injury Injuries to the head, neck, chest, breasts, abdomen, or genitals Bilateral or multiple injuries Multiple injuries in different stages of healing Injury to the breasts or abdomen during pregnancy 23 of 24 3024 Summary You have completed the lesson on identifying victims of domestic abuse. NO IMAGE Remember: • Asking about domestic abuse should be part of routine clinical practice and should be ongoing. Check with your supervisor or consult facility guidelines for facility-specific policies. • Routine inquiry increases the opportunity to identify and help victims. It also validates domestic abuse as a healthcare issue. • Domestic abuse inquiry should include direct questions about abuse. Ask questions in a culturally sensitive way. • The CDC has compiled a number of screening tools that you may find useful. • Healthcare staff must be alert for signs and symptoms of domestic abuse. • If a patient denies domestic abuse, respect the right not to disclose. Communicate your support and availability. Point 24 of 24 Lesson 4: Assessment and Referral 4001 Introduction Welcome to the lesson on assessment and referral for victims of domestic abuse. This lesson will include the components of an assessment for domestic abuse, the formation of a safety plan, appropriate referrals, and proper evidence collection and documentation. Point 1 of 25 4002 Assessment Only trained healthcare staff should assess victims of domestic abuse. The goals are to: • Create a supportive environment • Collect information about related health problems • Assess the immediate and long-term health and safety needs • Develop and implement a safety plan Reference 5 Point 2 of 25 4003 Assessment Components Assess patients in crisis immediately. Other patients may be accessed during follow-up appointments. Immediate assessment should include: • Validation • Information • Assessment of immediate safety Additional assessments should include: • Health issues • Social, cultural, and personal issues • Pattern and history of abuse • Questions about the abuser • Patient’s suicide and homicide risk Let’s take a closer look at each component. Reference 5 Point 3 of 25 4004 Assessment Components: Validation Provide validation by: • Listening and not judging • Expressing concern for the patient’s safety • Emphasizing that the patient is not to blame for the abuse For example: • I believe you. • I am concerned about your well-being and safety. • No one deserves to be treated this way. It is not your fault. • You are not alone and help is available. References 5, 17 Point 4 of 25 4005 Assessment Components: Information Provide the patient with basic information on domestic abuse: • Frequency • Cycle of abuse • Consequences • Effects on children For example: • Domestic abuse is common in all kinds of relationships. • It tends to become more frequent and severe. The cycle of abuse includes tension building, abuse, and a honeymoon period. • Domestic abuse can affect your health. • It can be dangerous to children in your home. References 5, 17 Point 5 of 25 4006 Assessment Components: Immediate Safety Ask questions to determine if the patient: • Is in immediate danger • Has a safe place to go • Has children who may be in danger Also determine: • If the violence has increased • If the abuser has weapons • If the abuser has held the patient against his or her will • If the abuser has stalked the patient Based on the answers to these questions: • Refer the patient to local resources for safety (e.g., the police, emergency shelters, etc.) • Help the patient plan for safety Reference 5 Point 6 of 25 4007 Planning for Safety Safety forms help victims learn and remember how to protect themselves and their children from domestic violence. Forms are often divided into sections, such as: • • • • Safety during a violent incident Safety when preparing to leave an abuser Safety at home Safety with a protection order Click on each item to learn more. Reference 5 CLICK TO REVEAL Safety during a violent incident This section asks the victim to complete statements such as: • If I have to leave home during a violent incident, I will go _______. • I can keep my car keys ready in/at ______, to be prepared to leave quickly. Safety when preparing to leave an abuser This section asks the victim to complete statements such as: • I will keep copies of important documents, keys, clothes, and money in/at _______. • I will open a savings account within ________ days/weeks/months, to increase my independence. Safety at home This section reminds the victim of how to stay safe at home. For example: • Change the locks • Replace wooden doors with steel doors Safety with a protection order This section reminds the victim how to use a protection order. For example: • Always carry a certified copy of the order, and keep a photocopy • Give a copy of the order to local police departments Point 7 of 25 4008 Assessment Components: Abuse-Related Health Issues Address any health issues related to the abuse. Remember, abuse causes physical and mental health problems. Click here for a brief review of these problems. [link to pop-up] [Pop-up] Abused patients may suffer from: • Arthritis • Chronic neck or back pain • Migraine and other types of headache • STDs (including HIV/AIDS) • Chronic pelvic pain • Peptic ulcers • Chronic irritable bowel syndrome • Frequent indigestion, diarrhea, or constipation • Complications in pregnancy • Poor management of chronic illness • Substance abuse • Depression • Posttraumatic stress disorder • Anxiety • Suicidal ideation and attempts • Eating disorders References 5, 15 Point 8 of 25 4009 Assessment Components: Abuse-Related Social, Cultural, and Personal Issues Determine: • If the patient was a victim of child abuse • If the patient has social supports in place • If the patient is pursuing separation, divorce, or emergency shelter • How the patient’s community views abuse, marriage, and divorce • How the patient responds to community expectations • How the abuse has affected the patient’s children • How the abuse has affected the patient’s life, work, school, and other relationships Reference 5 Point 9 of 25 4010 Assessment Components: Pattern and History of Abuse Ask the patient: • When the abuse started • If the abuse has ever led to hospitalization • What happened during the most serious event • If the abuse has been sexual • If the abuser controls the victim’s access to needed items and support • If the abuser has ever hurt other family members, children, or family pets Reference 5 Point 10 of 25 4011 Assessment Components: Characteristics of the Abuser Ask questions to find out if the abuser: • Uses illegal drugs or alcohol • Is more violent when using drugs/alcohol • Has mental health problems • Takes medication • Has a criminal record Reference 5 Point 11 of 25 4012 Assessment Components: Homicide/Suicide Risk Determine the patient’s suicide and homicide risk. Ask questions such as: • Do you think about killing yourself? Do you have a plan? • Have you ever thought about killing your abuser? Do you have a plan? References 5, 7 Point 12 of 25 4013 Domestic Abuse: Referral Hospitals may refer victims to other hospitals or agencies for assessment. The Joint Commission requires facilities to have a list of available resources. These resources may include: • Emergency shelter/housing • Transportation • Organizations able to provide for other basic needs (e.g., food, clothing) • Counseling or support groups for victims and their children • Childcare/welfare assistance • Legal assistance • Substance abuse treatment • Police • The legal system Important note: Victims of domestic abuse should NOT be referred to couples counseling. This may increase the risk of serious harm to the victim. References 5, 18 Point 13 of 25 4014 Documentation and Collection of Evidence Careful documentation is critical for future legal actions. In some cases, the medical record provides the only evidence of abuse. You should avoid judgmental statements. For example: • “Patient states…” should be used instead of “Patient alleges…” • “Patient declines …” should be used instead of “Patient refuses…” References 5, 6 Point 14 of 25 4015 Documentation: Written Record The following should be documented: • Statements made by the victim, including any taped interviews • Appearance and behavior of the victim • Name of the abuser and his or her relationship to the victim • Date, time, location, and description of the abusive event(s) • Any objects or weapons used during the abusive event(s) • Names and descriptions of any witnesses • Detailed description of injuries (see image on the right) • Results of laboratory or other diagnostic procedures Reference 5 Point 15 of 25 4016 Documentation: Photographs Photographs can provide valuable corroborating [glossary] evidence. When taking photographs of injuries: • Photograph prior to medical treatment, if possible • Use color film and a color standard • Photograph bite marks in black-and-white and in color • Hold up a coin, ruler, or other object to show the size of the injury • Include the victim’s face in at least one picture • Take at least two pictures of every major injury • Carefully label all photographs Reference 5 Point 16 of 25 4017 Collection of Evidence: Rape Kit In the case of sexual assault, each state has legally mandated procedures for collecting evidence to: • Establish the time and place of the assault • Establish the identity of the rapist These procedures are organized into a protocol called a “rape kit.” A forensic exam for a sexual assault victim is free. The victim is not required to report the assault or rape. Victims can also have evidence collected but remain anonymous. The "Jane Doe Rape Kit" uses a number instead of a name for identification. This way the evidence is there if the victim decides to report later. References 5, 6 Point 17 of 25 4018 Collection of Evidence: Proper Behavior Rape victims can be traumatized again by the procedures used to gather information and evidence. NO IMAGE It is important that the environment be safe, nonjudgmental, and sensitive. The examination should occur as soon after the assault as possible, after first being assessed for serious injury. Social services or a specialized rape intervention team should be present. The history should be completed before the victim is asked to disrobe. Be sure to document birth control use, medications, recent vaginal infections, and the time of any previous consensual intercourse. References 5, 6 Point 18 of 25 4019 Rape Kit Protocol (1) Most rape kit protocols require: • The patient to disrobe on a clean paper sheet • The patient bag each item of clothing in a separate paper bag • The patient to place the sheet in a separate paper bag • A gown to be given to the patient and have the patient lie on the exam table • Collect blood samples • An oral examination for injuries, and collect saliva. • Collection of fingernail scrapings • Documentation of all physical injuries • Determination of the location of semen with a Wood’s light [glossary] References 5, 6 Point 19 of 25 4020 Rape Kit Protocol (2) • • Perform a genital exam: • Collect samples of pubic, head, and body hair • Collect pubic hair combings • Inspect external genitalia for injury and particulate evidence • Collect vaginal and anal swabbings Ask the patient to give a urine specimen Important: All elements of this protocol may not apply in your state. Check with your supervisor or experienced legal counsel. Additionally: • • • Blood and appropriate cultures are obtained to screen for sexually-transmitted diseases. HIV testing is repeated in 6 months. Pregnancy test should be performed and the patient offered emergency contraception. References 5, 6 Point 20 of 25 4021 Forensic Evidence Corroborating forensic evidence also may be collected in cases of non-sexual domestic abuse. This evidence may include: • Torn, stained, or bloody clothing • Fingernail scrapings • Hair • Fibers • Soil • Debris • Other foreign materials • Blood • Saliva Collect, store, and transfer evidence of domestic abuse with strict adherence to chain-of-evidence protocols[glossary]. Reference 6 Point 21 of 25 4022 Referral The Elements of Performance (EP) 2 of the Joint Commission Standard PC.01.02.09 requires the hospital to maintain a list of agencies that can provide or arrange for assessment and/or care. These community resources can provide: • Legal aid • Shelter • Victim counseling • Batterer counseling • Child protection services The American Recovery and Reinvestment Act of 2009 included $175 million for the STOP (ServicesTraining- Officers- Prosecutors) Violence Against Women Formula Grant Program. This program provides grant funding to enhance state, local, and tribal law enforcement efforts to combat domestic violence. The United States Department of Justice provides a list of state domestic violence coalitions and national organizations on its website. Click here to go to the DOJ website. Take note of the available resources in your state. Please link “Click here” to http://www.ovw.usdoj.gov/statedomestic.htm References 18, 20 Point 22 of 25 4023 Review You are reviewing a safety brochure with a victim of domestic abuse. She is having trouble completing some of the statements. She asks you to suggest two or three possibilities for each of the blanks. Type your thoughts in the spaces below. Click Submit to compare your suggestions to ours. 1. If I have to leave home during a violent incident, I will go to ______. 2. I can keep my car keys ready _________, to be prepared to leave quickly. 3. I can teach my children to _________ during a violent incident. Here are our suggestions: 1. If I have to leave home during a violent incident, I will go to ______. -A neighbor’s house -A friend’s house -A relative’s house 2. I can keep my car keys ready _________, to be prepared to leave quickly. -On a hook by the front door -In my purse in the front closet -Under a rock by the garage 3. I can teach my children to _________ during a violent incident. -Call the police -Leave the house Point 23 of 25 4024 Review Select the answer that best fits the question. TRUE / FALSE INTERACTION Rape kits are the same in all states. a. True b. False Correct answer: B Incorrect Feedback: State and local protocols for collecting evidence of sexual assault vary. Familiarize yourself with local requirements. Correct Feedback: Correct! State and local protocols for collecting evidence of sexual assault vary. Familiarize yourself with local requirements. Point 24 of 25 4025 Summary You have completed the lesson on assessing and referring victims of domestic abuse. NO IMAGE Remember: • The goals of a domestic abuse assessment are to create a supportive environment, to collect pertinent information, and to determine the patient’s immediate and long-term health and safety needs. • Be prepared to refer victims of domestic abuse to other local resources. • Careful documentation is critical for future legal actions. • Familiarize yourself with local rape kit requirements. • Evidence can be collected even if the victim does not want to file a report. Point 25 of 25 Lesson 5: Reporting Requirements 5001 Introduction Welcome to the lesson on state-mandated reporting requirements for suspected cases of domestic abuse. In this lesson you will learn of the importance of knowing the reporting requirements in your state and how mandatory reporting laws may affect the interaction with patients. Point 1 of 7 5002 The Joint Commission Standard For Abuse Standard PC.01.02.09 specifies that all identified cases of abuse must be reported internally, and to outside agencies as mandated by hospital policy and applicable law. Reference 18 Point 2 of 7 5003 Reporting Requirements Healthcare providers in 47 states are required to report certain cases of domestic abuse. Reporting is based on the types of injuries involved. For example: In Florida, healthcare providers are required to report gunshot or life threatening wounds or injuries indicating an act of violence. The types of injuries that may be reportable are given in the table to the right. For adolescents, abuse by their guardians and all forms of sexual abuse must be reported. Learn the mandatory reporting requirements in your state. References 5, 21 Point 3 of 7 5004 Reporting Requirements: Significance If your state requires you to report domestic abuse: • Inform your patients of this limit on confidentiality before beginning any domestic abuse inquiry or assessment • Inform identified victims of your obligation to report abuse Some states require that children who have been exposed to domestic abuse be reported to protective services, even if the children are not direct victims of the abuse. In other states, simple exposure to domestic abuse is not reportable, allowing the provider more discretion. In these cases, consideration can be given to whether the child experienced any direct injury, the potential for danger in the situation, and the ability of the mother to provide safety Reference 5 Point4 of 7 5005 Reporting Requirements What types of injuries resulting from domestic abuse do you believe should be reported? Type your response in the box and click Submit to compare your answer to ours. Did your list include any of these injuries? • Any injury • Injury resulting from criminal activity • Injury resulting from general violence • Injury inflicted intentionally • Injury inflected by gun or firearm • Injury inflected by knife or other sharp object • Burn injury • Injury likely to cause death Point 5 of 7 5006 Review Select the answer that best fits the question. MULTIPLE CHOICE INTERACTION Most states require healthcare providers to report certain cases of domestic abuse. Reporting depends on the: a. Age of the victim b. Types of injuries involved c. Mental-health history of the abuser d. Presence of witnesses to the abuse Correct answer: B Feedback for B: Correct. Reporting is based on the types of injuries involved. Feedback for Incorrect: Incorrect. Reporting is based on the types of injuries involved. Point 6 of 7 5007 Summary You have completed the lesson on reporting requirements. NO IMAGE Remember: • Most states require healthcare providers to report certain cases of domestic abuse. Reporting depends on the types of injuries involved. • Learn the reporting requirements in your state. • Inform patients of your obligation to report, if any. Point 7 of 7 Lesson 6: Preparing to Care for Domestic Abuse Patients 6001 Introduction Welcome to the lesson on preparing for patient care. This lesson will help you prepare to care for domestic abuse patients, Lesson 6: Preparing for Patient Care • Questions to ask victims • Questions to ask perpetrators • Having the appropriate tools Point 1 of 10 6002 Questions to Ask Victims Asking about domestic abuse in a nonjudgmental manner can be difficult. What questions will you ask to: • Determine if the patient is a victim of domestic abuse? • Obtain additional information if the patient indicates that he or she is a victim? When asking about domestic abuse, start by saying: Because domestic violence is so common today, I ask all patients about it. Or consider saying: Type the questions you would ask in the box provided. Several example questions were covered in this course. Click the Submit button to compare your responses to those given earlier in the course. Many times people complaining of _______have worse symptoms or more trouble recovering from ______if they have been exposed to traumatic events. Have you ever been hurt emotionally, physically, or sexually in the past or recently? Then, if the response is “yes” to having experienced violence, ask direct questions in a nonjudgmental manner: • Has your intimate partner ever hit you? • Does your intimate partner ever force you to participate in sex? • Did someone cause these bruises? Was it your partner? Point 2 of 10 6003 Questions to Ask Perpetrators You suspect a patient is a perpetrator of domestic violence. What questions will you ask this patient? Type the questions you would ask in the box provided. Remember, questions that focus on anger management may be the most appropriate. Examples given in this course include: • “What happens when you fight?” • “Has your partner ever been injured during an argument or fight?” • “Have you ever been injured during an argument or fight?” Click the Submit button to compare your responses to those given earlier in the course. Point 3 of 10 6004 Having the Appropriate Tools As we mentioned, there are a number of instruments that will help you to appropriately care for your patients when domestic abuse may have occurred. NO IMAGE These include: • A compilation of domestic abuse assessment instruments for use in healthcare Please link to http://www.cdc.gov/NCIPC/pubres/ipv_and_sv_screening.htm • Measuring intimate partner violence victimization and perpetration: A compendium of assessment tools Please link to http://www.cdc.gov/ncipc/dvp/Compendium/Measuring_IP V_Victimization_and_Perpetration.htm • The National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings Please link to http://endabuse.org/section/programs/health_care/_conse nsus_guidelines Click on each link to be taken to the specific document or website. Spend some time reviewing each so that you are familiar with the tools and information available to you. Make notes about each tool/website in the form provided on the next screen. Click the print button if you want to print a copy of the information for later reference. Point 4 of 10 6005 Having the Appropriate Tools Tool/Website A compilation of domestic abuse assessment instruments for use in healthcare Website link http://www.cdc.gov/NCIPC/pubres/ipv_and_sv_screening.htm Measuring intimate partner violence victimization and perpetration: A compendium of assessment tools http://www.cdc.gov/ncipc/dvp/Comp endium/Measuring_IPV_Victimizati on_and_Perpetration.htm The National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings Please link to http://endabuse.org/section/progra ms/health_care/_consensus_guideli nes Notes Point 5 of 10 6006 State Specific Information As we mentioned, each state has different requirements for domestic abuse: • Training • Screening • Protocol • Reporting Click on the link provided below to find a link to the Domestic Violence Coalition in your state. Domestic Violence Coalitions Please link to http://www.ovw.usdoj.gov/statedomestic.htm Insert a box for learner to type responses to the questions below. Add a print button at the bottom of the page to allow the learner to print the information they entered into the form. Link to State Domestic Violence Coalition (you can copy and past the link here): Resources available at this site: Information requiring further follow-up: Complete the information asked in the form here. Click the Print button if you want to print a copy of the information for your records. Point 6 of 10 6007 Summary You have completed the lesson on preparing to care for patients and this course. NO IMAGE Point 7 of 10 Course Glossary # Term Definition chain of evidence protocols offensive injuries FBI procedures (including documentation and testimony) that ensure that evidence is not altered or tampered with in any way after being obtained; also referred to as chain of custody protocols injuries sustained when attacking or assaulting another person Federal Bureau of Investigation coercive degradation STD plausible intended to compel or force diminishment or demeaning sexually transmitted disease reasonable corroborate Wood’s light Temporomandibular joint syndrome Placental abruption HMO Perpetrator to add credibility by confirming facts or evidence ultraviolet light used to reveal semen in the assessment of sexual abuse inflammation of the joint which connects the mandible to the skull premature separation of the placenta from the uterus possibly causing death of the fetus health maintenance organization one who commits a crime Pages 8-10 of lesson 6 References: Please add disclaimer from regulatory library 1) CDC. Intimate Partner Violence Fact Sheet. Available at http://www.cdc.gov/ViolencePrevention/pdf/IPV-FactSheet.pdf. Accessed April 24, 2011. 2) Florida Dept of Children and Families. Focus on Domestic Violence, Annual Report 2009-2010. Available at: www.dcf.state.fl.us/programs/domesticviolence/publications/publications.shtml. Accessed May 8, 2011. 3) Gunter J. Intimate partner violence. Obstet Gynecol Clin N Am. 2007;34: 367-388. 4) The Florida Legislature. Online Sunshine. Florida statute 741.28. Available at http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0700-0799/0741/Sections/0741.28.html. Accessed April 25, 2011. 5) The Family Violence Prevention Fund. National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings.. San Francisco, CA. The Family Violence Prevention Fund; 2004. 6) Toohey J. Domestic violence and rape. Med Clin N Am. 2008: 92; 1239-1252. 7) Marx J, Hockberger R, Walls R. Rosen’s Emergency Medicine. 7th edition. St Loius, MO. Mosby; 2009. 8) Abramsky T, Watts C, Garcia-Moreno C. What factors are associated with recent intimate partner violence? findings from the WHO multicountry study on women’s health and domestic violence. BMC Public Health. 2011; 11:109-126. 9) Beck B. Domestic violence. In: Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry. St Louis, MO: Mosby; 2008. 10) Zolotor A, Denham A, Weil A. Intimate partner violence. Prim Care Clin Office Pract. 2009;36: 167-179. 11) CDC. Morbidity and Mortality Weekly Review. April 11, 2008. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5703a1.htm. Accessed April 24, 2011 12) Wolitsky-Taylor K, Ruggiero K, Danielson C. Prevalence and correlates of dating violence in a national sample of adolescents. J Am Acad Child Adolesc Psychiatry. 2008; 47: 755-762. 13) Ackard D, Eisenberg M, Neumark-Sztainer. Long-term impact of adolescent dating violence on the behavioral and psychological health of male and female youth. J Pediatrics. 2007; 151: 476-481. 14) CDC. Sexual Violence Data Sheet. Available at www.cdc.gov/violenceprevention/pdf/SV-DataSheet-a.pdf. Accessed April 24, 2011. 15) Coker A, Smith P, Bethea L, King M, McKeown R. Physical health consequences of physical and psychological intimate partner violence. Arch Fam Med. 200; 9: 451-457. 16) Lentz G. Rape, incest, and domestic violence: discovery, management, counseling. In: Katz: Comprehensive Gynecology. 5th edition. St Louis, MO. Mosby. 2007. 17) Falsetti S. Screening and responding to family and intimate partner violence in the primary care setting. Prim Care Clin Office Pract. 2007; 34: 641-657. 18) The Joint Commission. Provision of care, treatment, and services. In: 2011 Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL The Joint Commission; 2011: PC.01.02.09. 19) Centers for Disease Control and Prevention. A compilation of domestic abuse assessment instruments for use in healthcare. Available at: http://www.cdc.gov/NCIPC/pub-res/ipv_and_sv_screening.htm. Accessed May 31, 2011. 20) United States Department of Justice. FAQs About STOP Violence Against Women Formula Grants under the American Recovery and Reinvestment Act of 2009. Available at http://www.ovw.usdoj.gov/recovery-faq.htm. Accessed April 24, 2011. 21) American Academy of Orthopedic Surgeons. Family Violence State Statutes. Available at http://www.aaos.org/about/abuse/ststatut.asp. Accessed April 24, 2011. ASSESSMENT 1. Choose the true statement about domestic abuse and abusive relationships. a. Women are rarely victims. b. The victim is an adult or adolescent. c. Domestic abuse does not occur in same-sex relationships. d. Power and control are not usually issues in a violent relationship. Correct: B Rationale: In domestic abuse, the victim is an adult or adolescent, in 85% of cases a woman. Victims can be men, women, or adolescents in any type of intimate relationship. The abuse occurs because of the abuser's desire to control the victim. 2. Which factor increases the risk of domestic abuse? a. Marital stability b. Belief in strict gender roles c. Healthy family associations d. High academic achievement Correct: B Rationale: Belief in strict gender roles is a risk factor for domestic abuse. 3. Which of the following is not part of the cycle of violence? a. Remorse b. Tension building c, Violent episode d. Forgiveness Correct: D Rationale: The cycle of violence begins with a violent episode that is followed by remorse, then reconciliation, followed by tension building and a repeated violent episode and so on. 4. Which is the most likely characteristic of the victim in a violent relationship? a. The victim rarely exercises independence. b. The victim feels confident and empowered. c. The victim is outwardly jealous of the abuser's friends. d. The victim does not respect the abuser's point of view. Correct: A Rationale: Victims of domestic abuse rarely exercise independence. 5. Which is the most likely characteristic of the abuser in a violent relationship? a. The abuser is fearful of the victim. b. The abuser takes on a dependant role. c. The abuser accepts responsibility for the abuse. d. The abuser controls the victim's access to needed items. Correct: D Rationale: In an abusive relationship, one aspect of the abuser's control of the victim often includes controlling access to needed items. 6. Which statement is true about the likely effects of domestic abuse? a. Domestic abuse rarely affects the victim's mental health. b. Adolescent victims are at elevated risk for binge drinking. c. Victims have high rates of participation in preventive healthcare. d. Victims tend to have excellent management of chronic illnesses. Correct: B Rationale: Domestic abuse has a wide range of potential physical and mental effects. For example, adolescent victims are at increased risk for many psychological and behavioral problems, such as binge drinking and drug abuse. 7. Which of the following is a likely effect of domestic abuse? a. A pregnant victim has normal weight gain. b. An adolescent victim has high self-esteem. c. The child of a victim is at greater risk for prostitution. d. An adult victim has excellent access to medical care. Correct: C Rationale: Children who witness domestic violence are at risk for a wide range of mental, physical, and behavioral health problems. For example, they are at increased risk for engaging in behaviors such as sexual assault, promiscuity, or prostitution. 8. Which statement is true about the effects of physical abuse in a violent relationship? a. Physical injuries are always minor. b. The victim usually has offensive injuries. c. Physical abuse sometimes ends in death. d. The abuser usually has defensive injuries. Correct: C Rationale: While many injuries are minor, the victim in a violent relationship may be seriously injured or killed. 9. Victims of domestic abuse are at increased risk for posttraumatic stress disorder. a. True b. False Correct: A Rationale: This statement is true. 10. To identify victims of domestic abuse in the healthcare setting, which of the following is a best practice? a. Screen for abuse only in new patients. b. Screen patients for abuse on a routine basis. c. Ask direct questions about abuse only if the patient has obvious injuries. d. Ask questions about possible abuse with the patient's intimate partner present. Correct: B Rationale: Frontline healthcare workers should screen patients for domestic abuse routinely. 11. Which of the following is most likely to be a sign of domestic abuse in a patient? a. The patient follows medical advice. b. The patient has repeat urinary tract infections. c. The patient makes a single healthcare visit with a clear complaint. d. The patient is comfortable answering questions about possible abuse. Correct: B Rationale: Repeat vaginal or urinary tract infections can be a warning sign of domestic abuse. 12. Which type of injury is mostly likely to be a sign of domestic abuse? a. A broken toe b. A single injury c. Bilateral or multiple injuries d. Injuries with a clear explanation Correct: C Rationale: Bilateral or multiple injuries can be a sign of domestic abuse. Multiple injuries in different stages of healing are also suspicious. 13. Which factor MUST be present when screening a patient for domestic abuse? a. Privacy b. Language barriers c. The patient's partner d. Obvious physical injuries Correct: A Rationale: Delay domestic abuse screening if you cannot ensure privacy, safety, and effective communication. 14. When an interpreter is needed, it is best to use someone familiar to the patient such as a friend or family member. a. True b. False Correct: B Rationale: The interpreter should not be someone who is known to or related to the patient. 15. One important aspect of domestic abuse assessment is validation. Which of the following statements would best validate a victim? a. Why don't you just leave your husband? b. I am concerned about your safety and health. c. Why did you get involved with someone who is so unstable? d. You must have done something to make your husband hit you. Correct: B Rationale: It is important to provide validation to a victim of domestic abuse. Provide validation by listening and not judging, expressing concern for the patient's safety, and emphasizing that the patient is not to blame for the abuse. 16. Which of the following is a key component of a domestic abuse assessment? a. Blaming the victim b. Arresting the abuser c. Providing information to the victim d. Providing information to the abuser Correct: C Rationale: Victims should be provided with basic information about domestic abuse, including information about the cycle of abuse, consequences of abuse, and effects on exposed children. 17. Which procedure should be included in the assessment of domestic abuse, if the abuse includes recent sexual assault? a. MRI b. Rape kit c. Mandatory report to the police d. Referral to couples counseling Correct: B Rationale: In the case of sexual assault, each state has a rape kit procedure for collecting evidence. 18. Which of the following should be discussed during a domestic abuse assessment? a. The abuser's point of view b. The abuser's drug and alcohol use c. The victim's contribution to problems in the relationship d. The victim's failure to make healthy relationship choices Correct: B Rationale: The victim should be asked about the abuser, for example, whether the abuser uses illegal drugs or alcohol, and whether he is more violent when using drugs/alcohol. 19. How many states require healthcare providers to report ANY injury resulting from domestic violence? a. 0 b. 6 c. 27 d. 43 Correct: B Rationale: Healthcare providers in most states are required to report certain cases of domestic abuse, based on the types of injuries involved. In six states, providers are required to report ANY injury resulting from domestic violence. 20. What is the Joint Commission's standard on reporting identified cases of domestic abuse to outside agencies? a. All cases must be reported. b. Providers may not report without the patient's consent. c. Providers may use their own discretion in choosing which cases to report. d. All cases must be reported as mandated by hospital policy and applicable law. Correct: D Rationale: Standard PC.01.02.09 specifies that all identified cases of abuse must be reported to outside agencies as mandated by hospital policy and applicable law. 21. Which is a best practice if your state requires you to report domestic abuse? a. Do NOT inform patients of this limit on confidentiality. b. Inform patients of this limit on confidentiality AFTER domestic abuse screening/assessment. c. Inform patients of this limit on confidentiality BEFORE domestic abuse screening/assessment. Correct: C Rationale: If your state requires you to report domestic abuse, be sure to inform patients of this limit on confidentiality BEFORE any domestic abuse screening or assessment. 22. How many states require healthcare providers to report injuries resulting from domestic abuse, if the injury was inflicted by knife or firearm? a. 0 b. 6 c. 27 d. 43 Correct: D Rationale: Healthcare providers in most states are required to report certain cases of domestic abuse, based on the types of injuries involved. In 43 states, providers are required to report injuries inflicted by knife or firearm. 23. When talking to a male who may be a perpetrator of abuse, it is better to ask about emotional issues in order to carry on a productive interview. a. True b. False Correct: B Rationale: Questions that focus on anger management may be the most productive when discussing with men.