Violence, in particular domestic or intimate partner violence (IPV), is a relatively newly recognized issue for the medical field and healthcare professionals. It wasn’t until 1985 that U.S. Surgeon General C. Everett Koop presented interpersonal violence as a public health issue, separate from an issue of criminal justice or community welfare. [1] Since then, professional medical organizations, healthcare systems, and regulatory bodies have made recommendations and policies about how to best identify and treat issues related to intimate partner violence in a healthcare setting. Hospitals serve as pivotal places for screening and intervention, as people present to hospitals for many reasons. The most severe presentation of IPV in a hospital could be a physical injury that leads someone to seek treatment in the Emergency Department or be transported to a Trauma Center. Recognizing the prevalence of abuse among pregnant and perinatal women, the American College of Obstetrics and Gynecologists was one of the first professional organizations to educate its members on domestic violence.[2] Pregnancy, labor and delivery, and postnatal care provide many opportunities for a person to interface with medical providers in inpatient and outpatient settings, build trust, and potentially disclose concerns for abuse that may not include physical violence.
Over the past 40 years, the healthcare field, and hospitals specifically, have evolved their understanding of IPV as a healthcare issue and how to address it. IPV accounts for a large number of injuries, a physical health concern that could lead people to seek emergency medical care. According to the CDC, 35% of female survivors of IPV and 11% of male survivors of IPV experience a physical injury related to abuse.[3] While physical injury is only one type of abusive behavior a victim may experience, it is usually one of the more obvious, providing healthcare workers an opportunity to screen and help. Since 2004, The Joint Commission on Accreditation of Healthcare Organizations has had standards in place to guide hospitals on how to address domestic abuse through policies on screening and education for staff. [4] In 2010, Governor O’Malley signed the Maryland Domestic Violence Health Care Screening and Response Initiative to increase the number of specialized domestic violence programs available, specifically in hospital settings, and provide support through technical assistance.[5] Additionally, the American College of Emergency Physicians, the U.S. Preventative Services Taskforce, and the Institute of Medicine all require or encourage some level of education for providers and screening of patients.[6] Screening for and intervening in IPV is an important area of prevention as IPV can lead to death; one in five homicide victims are killed by an intimate partner and more than 50% of female homicide victims are killed by a current or former partner.[7]
In determining the best way for hospitals to play a part in reducing homicides due to intimate partner violence through screening for risk factors for domestic violence, much research has been done into the efficacy of different screening tools that can be used with targeted or generalized populations. Choo and Houry (2014) described screening as “looking for a condition before it is overly symptomatic,” and therefore, “recommend screening every patient whenever possible”. Some of the validated tools for doing this effectively in a hospital include the HITS, the Universal Violence Prevention Screening Protocol, and the Partner Violence Screen.[8] The hospital setting contributes to the patient’s privacy, and universal screening helps to normalize discussion of IPV in order to reassure the patient that the information and response will be handled with sensitivity and confidentiality. Intervention into issues related to IPV has been shown to correlate with improved health outcomes for women, making it an important part of a person’s overall health and wellbeing to receive help, if desired, for intimate partner violence. [9]
Of course, there are many reasons that a healthcare provider, especially in a bustling and high-volume area of the hospital, may be hesitant to ask about IPV despite it being required by the Joint Commission. Healthcare providers have a mounting number of tasks and screenings to complete in order to deliver quality healthcare and many standards and metrics to which they are held accountable. Introducing additional screenings to the patient-provider encounter might seem logistically impossible. Additionally, while many providers are willing to screen and are motivated to help, they are unaware of how to respond to a positive screening, and lack knowledge of the available resources for referral, either in the hospital or the community. A study published in the Journal of Trauma Nursing in 2013 found that the most common reason that nurses don’t screen for IPV is due to a lack of training.[10] Higher screening to referral rates occur when the intervention program is located in the hospital setting with the medical providers, and it has been shown that the co-location of resources makes healthcare providers better able to improve safety for patients.[11] McCloskey, et. al. (2006) found that “healthcare providers may make positive contributions to women’s access to intimate partner violence services. Intimate partner violence interventions relate to women’s reduced exposure to violence and better health.”[12]
In order to comply with the IPV screening requirement in hospitals, and to contribute to improved outcomes for patients, it is recommended that hospital healthcare providers familiarize themselves with the screening used in their hospital and use it universally. Hospital healthcare providers should also learn what resources exist in the hospital, possibly in the form of a Hospital-Based Intimate Partner Violence Program, and how to refer patients to the program. In an informal survey conducted of eight hospital-based programs in Maryland, responses show that 2,669 victims of IPV received screening and intervention. Of these victims, 36% were in the hospital for reasons other than assault, which means the abuse could have gone undetected if not for the implementation of universal screening for IPV. Of those individuals served, 85% of them learned of new resources through their contact with the hospital-based IPV program.[13] If there is not a hospital-based program, providers should reach out to their local Domestic Violence Resource Center to learn about referral options.
In Maryland, the Health Care Coalition Against Domestic Violence brings together experts working at the intersection of healthcare and domestic violence to offer support and training on best practices for healthcare providers to respond to abuse, and to promote a proactive and effective response to IPV. The Coalition is led by a steering committee of professionals across Maryland who fulfill the mission to ensure that anyone experiencing IPV has access to proactive, effective, and life-saving assistance from their healthcare providers. Many strategic partnerships of the Coalition include other statewide organizations committed to ending domestic violence in Maryland, such as the Center for a Healthy Maryland, MedChi, and the Maryland Network Against Domestic Violence. In order to serve the clinical and allied professionals represented by these networks, the Coalition offers trainings, seminars, workshops, and printed educational materials to health care providers to increase awareness of the health-related consequences of IPV, offer support on how to identify risk factors and provide details on evidence-based tools for intervention. An extremely popular area of interest is the overlap between domestic violence and other social determinants of health (e.g. HIV) or demographically marginalized groups (e.g. LGBTQ individuals). For more information about the Coalition, its services and resources, or available trainings or educational materials, please visit the website at www.healthanddv.org. [14]
Written by: Erin Walton, LCSW-C, Health Care Coalition Against Domestic Violence Steering Committee Member
September 23rd, 2021
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[1]Flitcraft, A. (1993). Physicians and domestic violence: Challenges for prevention. Health Affairs, 12(4), 154–161. https://doi.org/10.1377/hlthaff.12.4.154
[2] Flitcraft, A. (1993).
[3] Centers for Disease Control and Prevention. (2020, October 9). Preventing intimate partner violence |violence prevention|injury center|cdc. Centers for Disease Control and Prevention. Retrieved September 12, 2021, from https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html.
[4] Women’s Health, Maternal and Child Health Maryland Department of Health and Mental Hygiene. (2013, January). Intimate Partner Violence (IPV) A guide for health care providers. Retrieved from https://health.maryland.gov/phpa/mch/Documents/IPV%20Guide%20for%20providers.January.pdf.
[5] GOVERNOR’S OFFICE OF CRIME PREVENTION, YOUTH, & VICTIM SERVICES. Crime Prevention, Youth, & Victim Services, Maryland Governor’s Office of. (n.d.). Retrieved September 12, 2021, from https://msa.maryland.gov/msa/mdmanual/08conoff/coord/crime/html/08cr.html#domesticinitiative.
[6] Choo, E. K., & Houry, D. E. (2015). Managing intimate partner violence in the emergency department. Annals of emergency medicine, 65(4), 447–451.e1. https://doi.org/10.1016/j.annemergmed.2014.11.004
[7] Centers for Disease Control and Prevention. (2020, October 9). Preventing intimate partner violence |violence prevention|injury center|cdc. Centers for Disease Control and Prevention. Retrieved September 12, 2021, from https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html.
[8] Choo, E. K., & Houry, D. E. (2015). Managing intimate partner violence in the emergency department. Annals of emergency medicine, 65(4), 447–451.e1. https://doi.org/10.1016/j.annemergmed.2014.11.004
[9] McCloskey, L. A., Lichter, E., Williams, C., Gerber, M., Wittenberg, E., & Ganz, M. (2006). Assessing intimate partner violence in health care settings leads to women’s receipt of interventions and improved health. Public health reports (Washington, D.C. : 1974), 121(4), 435–444. https://doi.org/10.1177/003335490612100412
[10] DeBoer, Mican I. BSN, RN, CEN; Kothari, Rashmikant MD; Kothari, Catherine MA; Koestner, Amy L. MSN, RN; Rohs, Thomas Jr MD What Are Barriers to Nurses Screening for Intimate Partner Violence?, Journal of Trauma Nursing: July/September 2013 – Volume 20 – Issue 3 – p 155-160 doi: 10.1097/JTN.0b013e3182a171b1
[11] Halliwell, G., Dheensa, S., Fenu, E., Jones, S. K., Asato, J., Jacob, S., & Feder, G. (2019). Cry for health: A quantitative evaluation of a hospital-based advocacy intervention for domestic violence and abuse. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4621-0
[12] McCloskey, L. A., Lichter, E., Williams, C., Gerber, M., Wittenberg, E., & Ganz, M. (2006). Assessing intimate partner violence in health care settings leads to women’s receipt of interventions and improved health. Public health reports (Washington, D.C. : 1974). Retrieved September 12, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1525344/.
[13] The Maryland Healthcare Coalition Against Domestic Violence. Maryland Health Care Coalition Against Domestic Violence. (n.d.). Retrieved September 12, 2021, from https://healthanddv.org/.
[14] The Maryland Healthcare Coalition Against Domestic Violence. Maryland Health Care Coalition Against Domestic Violence. (n.d.).
