Download Identifying and Assessing Victims of Domestic Abuse

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
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Accessed April 25, 2011.
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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.