Domestic Violence Screening
by Nurses in the
Primary Care Setting
Karen Hetzel, PhD., PMHCNS-BC
Rhode Island College
Research & Evidence-Based
Practice Symposium
Kappa Tau
12-05-09
Purpose of the Study
To ascertain how nurses in primary care
settings can adopt routine screening of
their female patients for domestic
violence into their practice.
Aim of the Study
1st aim of this study was to identify barriers
perceived by nurses that prevent them from
routine screening of patients. Concurrently,
identifying environmental facilitators as
perceived by nurses in assisting them in
screening for domestic violence occurred.
2nd aim of this study was to deliver a structured
educational program to primary care nurses on
domestic violence and its screening and
intervention.
Research Questions
1. What are the barriers identified in primary care settings by
nurses that prevent them from effectively screening for
domestic violence ?
2. What facilitates effective screening for domestic violence by
nurses in the environment of primary care settings ?
3. What is the impact of a domestic violence educational program
intervention delivered to nurses in primary care settings on
decreasing the barriers identified by the nurses to screening
for domestic violence ?
4. Does a domestic violence educational program intervention
increase the identification and intervention of domestic violence
by nurses in a primary care setting as compared to pre
intervention conditions ?
Method
The method was survey driven using focus
groups and a structured educational program.
The survey was given to ascertain a baseline of
knowledge and awareness that nurses in
primary care settings have about domestic
violence in their practice. The focus groups
explored the needs nurses have, to be able to
effectively screen and intervene routinely in
their daily practice.
Method (cont.)
An established educational program was
modified specifically to educate nurses in the
outpatient setting derived from the survey
and focus group results. The nurses who
attended the program were interviewed by a
research assistant following the program to
evaluate the program’s effect and change in
practice by the nurses related to screening,
intervening and documenting domestic
violence in their female patients.
Survey Participants
n = 22 participants
Sex 100% Female
Race 100% White
Age 26-51+yo
Marital Status 86% Married
Education Level – 55% RNCS/NP/Midwife;
18%LPN;18% AD/Diploma; 9% BS
Years in practice - 50% 15-25+yrs.
Practice Setting ~ 50% Pediatric; 23% Internal
Medicine;18% Ob/Gyn; 9% Family Practice
Survey Results
• 68% of participants had suspected a female
patient(s) to be a victim of domestic violence.
• 36% of participants had a female patient tell them
they were a victim of domestic violence without
being asked about it.
• 55% of participants had the opportunity to ask
female patients about past or present day domestic
violence and screened positive.
• 73% of participants had the opportunity to
intervene with female patients that screened
positive for domestic violence.
Survey Results (cont.)
• 50% of participants had domestic violence content
in their nursing curriculum.
• 32% of participants had attended a CEU
program on domestic violence.
• 73% of participants’ who had domestic violence
content in their nursing curriculum or attended a
domestic violence CEU program, acknowledged it
influenced their practice.
• 45% of participants worked in facilities, presently or
in the past, where screening measures for domestic
violence were in place.
Survey Results (cont.)
In order to screen routinely, the participants identified the
following as essential elements within their practice sites:
Questions to ask and how
When and where to use them
Local resources and referrals
Signs and symptoms of domestic violence
Office protocols for screening
Outcomes for those who get help
Patient rights regarding screening
Teens and domestic violence
Effect on children exposed to domestic violence
Focus Groups
2 Focus Groups were held with 5 nurses &
nurse practitioners to discuss how they could
adopt screening female patients for domestic
violence into their daily practice. Several
questions were posed regarding barriers and
facilitators within their practices.
Focus Group Participants
n = 5 participants
Sex 100% Female
Race 100% White
Age 26-50+ yrs. old
Marital Status 100% Married
Education Level - 80% NP; 20% RN BS
Years in practice - 60% 15 - 25+yrs; 40% 6-10 yrs
Practice Setting - 60% Pediatric; 20% Ob/Gyn ;
20% Internal Medicine
Focus Group Results
In order to screen routinely, the participants identified the
following as essential elements within their practice sites:
Knowledge of the cycle of violence
Awareness of signs & symptoms
Knowledge of the best local resources
Ability to stay nonjudgmental
A prompt to ask ?s in patients’ charts
A team approach within their practices
Palm cards with information in rest rooms
Available social supports for victims
Knowledge of the legal process
Awareness of staff as potential victims
Informational literature in different languages for patient use
The Program
Consisted of (3) one hour lunch sessions on 3
consecutive days at a pediatric practice site with
lunch provided and continuing education credits
given to the nurses and nurse practitioners
Each of the 5 participants was given a packet of
information on the domestic violence intervention
program, which included the needs, suggestions and
concerns from the surveys and focus groups and
some content of the PVS Abuse Assessment
Response Course and the AWOHNN
Universal Screening for Domestic Violence
The Program (cont.)
The content was presented in a multi-media format, with a 17paged packet for each participant to follow, presentation of
didactic content, video, role plays and question and answer
periods. At the third session, environmental facilitators were
given to the participants.
The packet content included the following subheadings:
Definition, Prevalence & Dynamics of Domestic Violence
Impact on Health & Children
Common Misconceptions & Presentations
Barriers to Responding
Screening Techniques & Guidelines
Clinical Management with Referrals & Resources
Documentation
Medical-Legal Aspects
Post Intervention Interviews
A research assistant individually
interviewed each participant involved,
one week later at the practice site. The
research assistant utilized the PostIntervention Interview Guide designed
by the researcher . Five open ended & 5
closed ended questions were utilized all related to the intervention program &
domestic violence screening.
Themes from Post Intervention Interviews
Changed practice to include screening of domestic
violence with female patients
More aware of domestic violence because of the
education received in the intervention program
Asking more appropriate questions in regards to
domestic violence
Being more keen in picking up warning signs & hints
that domestic violence is occurring with a patient.
Quotes from Post Intervention Interviews
“It has heightened my awareness”
“I have tuned into how mom’s look, cues that
are given… I’m more comfortable”
“You don’t know unless you ask”
“You leave the door open”
Research Question #1
Barriers Identified to Screening• Time constraints to screen/intervene
• Screening questions not on health forms
• Lack of knowledge of the cycle of violence
• Need for user-friendly domestic violence
materials
• Lack of environmental facilitators
• Unawareness of local resources
• Language differences
Research Question #2
Facilitators identified for Screening• Female providers
• Supportive team approach to patient care
• Openness to learn about
screening/intervening
• Readiness to try to incorporate it into daily
practice
• Recognizing the need for environmental cues
regarding domestic violence in primary care
settings
Research Question #3
Impact of a domestic violence intervention program
• Surprise by the statistics of lifetime prevalence of
domestic violence & how potentially lethal certain
presentations of victims could be.
• Unaware of the increased danger a victim and her
children is/are in when she/they decide to leave
• Unaware when a victim is pregnant, how the incidence
of violence and homicide increases
• More comfortable with the knowledge of domestic
violence and its components & consequently felt better
prepared to screen & intervene with female patients.
Research Question #4
Increase identification & intervention of
domestic violence by nurses in a primary care
setting ~
No participants had been told by a
patient that they were a victim of domestic
violence by the time of the post intervention
interviews. No interventions for domestic
violence victims had occurred.
Recommendations
• Future studies be conducted with nurses and nurse
practitioners in larger primary care settings with
regard to domestic violence screening and
intervention practices.
• Primary care settings screen all female patients for
domestic violence and intervene as indicated.
• Protocols be adopted for domestic violence
screening guidelines in individual primary care
settings.
• All Schools of Nursing incorporate domestic
violence content and development of skills into
curriculums.
Implications for Practice
• If female patients are screened by nursing routinely
for domestic violence in primary care settings, they
may be able to end the cycle of violence and have a
fresh start on life.
• Female patients who have been screened and
provided with interventions by nursing will be safer,
when they are ready to leave their abusive
relationships.
• Screening female patients for domestic violence is
an intervention in and of itself. Nursing can be a
change agent and advocate its benefit and use in
primary care settings.
References
• Association of Women’s Health, Obstetric and Neonatal Nurses
(AWOHNN). (2003). Universal Screening for Domestic Violence, 2nd
edition. CD-ROM.
• Family Violence Prevention Fund (FVPF). Programs.(n.d.).Retrieved
November 15, 2009, from http://www.endabuse.org/section/programs
• Hetzel, K. (2004). Domestic violence screening by nurses in the primary
care setting. (Doctoral dissertation, University of Rhode Island, 2004).
Dissertation Abstracts International.
• McNutt, L., Carlson, B., Rose, I., & Robinson, D. (2002). Partner
violence in the busy primary care environment. American Journal of
Preventive Medicine, 22(2), 84-91.
• Physicians for a Violent-Free Society (PVS). (2002). Abuse
Assessment Response Course. CD-ROM.
Acknowledgements
Massachusetts Nurse’s Foundation
Theta Chapter at-Large
Delta Upsilon Chapter at-Large
Nursing Foundation of RI
Contact Information
Karen Hetzel, PhD., PMHCNS-BC
Associate Professor
Rhode Island College
School of Nursing
600 Mt. Pleasant Ave.
FLS 134
Providence, RI 02908
401-456-9742
khetzel@ric.edu