Routine Universal Screening From Policy to Practice

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Routine Universal ScreeningFrom Policy to
Practice

• By Sarah Kaplan, MSW, RSW
• Coordinator Assault and Sexual Abuse Program
• Womens Health Champion
• Cornwall Community Hospital

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Objectives

• To understand the importance of routine universal
  screening
• To obtain evidence for policy development in
  regards to routine universal screening
• To learn the necessary steps in the
  implementation of routine universal screening

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Why Should Screening for Intimate Partner
Violence Occur in a Health Care Setting?

• Health care settings are a common place where
  abused persons will go for help
• Nurses are often the first member of the
  healthcare team to interface with women
  experiencing abuse
• Nurses are accessible to the public, enjoy a high
  degree of public trust
• Nurses interact with people during times of
  stress and illness as during developmental
  transitions such as adolescence, pregnancy and
  parenthood
• Nurses use a holistic health promotion framework
• Nurses possess the clinical skills to accurately
  assess abuse of a patient
• Early recognition is crucial for the health and
  safety of an abuse victim
• IPV can often be the missing piece to a complete
  diagnosis

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When It Works A nurses story

• A woman presented at our emergency with a broken
  arm. When questioned on the cause, she stated she
  fell down. She denied abuse from the screening.
  The nurse felt her injuries were not consistent
  with her story and a little later in the exam
  room gently questioned her again and the truth
  came out. She stated that her husband had broken
  her arm in a violent episode. Because of the
  nurses sensitivity this womans real issue was
  addressed and she was given the choice to have
  additional support.

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What is Intimate Partner Violence

• Partner abuse is a behavioural pattern used by
  one person to gain/maintain power and control
  over another. This occurs in all types of
  intimate partner relationships including
  common-law and same sex. It may or may not
  include physical abuse. Abuse can include other
  forms of mistreatment and cruelty such as
  constant threatening, psychological, emotional,
  verbal abuse and sexual assault. Sexual assault
  is defined as any form of sexual activity with
  another person without that persons consent.

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Prevalence Data

• 17 - 30 of all women treated in hospital
  emergency departments are victims of domestic
  violence (Waller, Hohenhaus, Shah, Stern)
• A study which reviewed hospital emergency room
  records found that only 1 in 25 cases of wife
  assault was identified. (Ontario Womens
  Directorate)
• Worldwide, 10 - 50 of women report having been
  hit or physically assaulted by an intimate
  partner (Taket et al.)
• 8 of women and 7 of men experienced some type
  of violence - ranging from threats to sexual
  assault - in their intimate relationships during
  the five years covered by the survey. The survey
  also found that the violence experienced by women
  tended to be more severe and more often repeated
  than the violence directed at men. (Statistics
  Canada 1994)

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Health Consequences of Intimate Partner Violence

• More physical symptoms
• More frequent users of health care
• More likely to suffer chronic pain
• Increased rates of depression, anxiety, low
  self-esteem and attempted suicide
• Pregnancy related complications

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Economic Consequences of Intimate Partner Violence

• Health-related costs of violence against women in
  Canada exceed 1.5 billion/year (Health Canada)
• Findings from the US indicate more frequent
  periods of unemployment, lower personal incomes,
  greater job turnover, health problems that affect
  job performance (Lloyd Taluc)

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What is Routine Universal Screening

• Routine screening is performed on a regular basis
  regardless of whether or not signs of abuse are
  present FREQUENCY of the screening the WHEN
• Universal occurs when nurses ask everyone over a
  specific age about abuse CHARACTERISTICS of the
  group being screened the WHO

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CCH Policy

• POLICY
• 1.       Routine universal screening (RUS) will
  be implemented to improve the care provided to
  victims of intimate partner violence by
  recognizing and referring patients to the
  appropriate resources.
• 2.       RUS will be done by specially trained
  staff who
• a.   will screen all women and men over the age
  of 12 for partner abuse.
• b.   will be knowledgeable about the dynamics of
  woman abuse, and its impact on the abused
  woman and her child(ren).
• c.   Be skilled in responding effectively to
  disclosures of abuse.
• d. Be knowledgeable about community resources
  for abused women and their children.

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RNAO Best Practice Guidelines

• Published in 2005
• Panel of experts nurses, social worker
• Evidence based
• Website, click on-line catalogue then best
  practice guidelines

www.rnao.org/bestpractices
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RNAO Organization and Policy Recommendations

• Implementation of this BPG requires adequate
  planning, resources, organizational support, as
  well as appropriate facilitation.
• An assessment of organizational readiness and
  barriers to education.
• Dedication of a qualified individual to provide
  the support needed for the education and
  implementation process.
• Opportunities for reflection on personal and
  organizational experience in implementing
  guidelines.

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RNAO Organization and Policy Recommendations

• Health care organizations develop policies and
  procedures to support effective practice
• Health care organizations work with the community
  at a systems level to improve collaboration and
  integration of services between sectors

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RNAOPractice Recommendations

• Nurses implement routine universal screening in
  the context of a health history for all females
  12 years of age and older in all health care
  settings
• Nurses develop skills to foster an environment
  that facilitates disclosure. This necessitates
  that nurses know
• how to ask the question
• how to respond to disclosure
• Nurses develop approaches that are responsive to
  the needs of all women taking into account
  differences based on race, ethnicity, class,
  religious/spiritual beliefs, age, ability, or
  sexual orientation.
• Nurses know how and what to document
• Nurses understand their legal obligations when a
  disclosure is made

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RNAO Education Recommendations

• Mandatory educational programs in the workplace
  be designed to
• Increase nurses knowledge skills
• Foster awareness and sensitivity about woman abuse

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How to Screen

• Screening questions are part of routine health
  history.
• Nurses consider immediate safety of patient.
• Screening occurs when patients condition is
  stable.
• Questions are asked directly to patients, while
  maintaining visual contact where privacy can be
  assured.
• forms are NEVER handed to patients to read and
  fill out.
• Patients are screened alone, never in the
  presence of their partner, other family members,
  or children over 3.
• Where language is a barrier, only trained
  cultural interpreters are used, never family
  members.

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Asking the Question

• Explain because of the high prevalence of
  violence in our society and the impact on health,
  we are asking questions about abuse
• Tailor your approach to the individual
• Inform patients that they will be screened each
  time they come to the hospital
• Send a clear message that violence is unacceptable

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Sample Questions

• It is our duty to be patient advocates and screen
  for abuse. We know that many individuals
  experience problems in relationships that can
  result in health problems. Are you in a
  relationship with someone who threatens to or
  has hurt you in any way?
• Have you ever been emotionally, physically, or
  sexually abused by your spouse/partner?
• stay away from terms that denote gender until
  stated by the patient (wife, husband, girlfriend,
  boyfriend)

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If They Answer Yes

• Are you safe now
• Would you like to talk about it
• When did this happen
• Have you talked to anyone else about this
• How are you coping
• What do you need right now

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Response to No When You Suspect YES

• Discuss what you have observed and why you are
  still concerned
• Im concerned about how you got these injuries.
  Did someone do this to you?
• We often see injuries/symptoms like yours when a
  patient has been hurt by a spouse/partner. Is
  this happening to you?
• Offer educational information about the health
  effects and prevalence of abuse
• Offer resources
• Document response

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Responding to a NO

• Share general information about abuse
• Document response

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Documentation

• Documentation is an integral aspect of safe,
  effective nursing practice (CNO, 2004c) and must
  be comprehensive, legible and accurately reflect
  screening practice (Health Canada, 1999b,c MLHu,
  2000).
• The record needs to include
• a safety check.
• direct quotations of what the person said.
• direct observations made by the nurse.
• referrals discussed and made and/or information
  given.

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Barriers to Screening for the Nurse

• Fear of a yes answer and then what do I do
• Fear of offending the patient
• No time
• Not a nurses role
• Believe its the victims fault
• Lack of awareness regarding intimate partner
  violence
• Lack of support by employer
• Personal history of abuse

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Barriers From the Clients Perspective

• The children
• Religious/cultural beliefs
• Doesnt see situation as abusive
• Fear of retaliation
• Fear regarding immigration status
• Concern for partner - arrested
• Lack of knowledge of available resources

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What Are the Steps to Implement RUS

• Develop a committee of interested individuals
• Allocate one committee individual to champion
  this project
• Develop a hospital wide policy
• Develop a strategic plan for hospital wide
  implementation
• Develop a screening tool
• Develop a method of evaluation
• Develop a mandatory training session
• Develop a plan to support nurses who begin to
  screen
• Organizational commitment to Routine Universal
  Screening
• Involve relevant community partners shelters,
  crisis lines etc.

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What We Did

• 2000 2005
• Creation of committee
• Research on screening
• Screening tool created
• Evaluation methodology created
• Support plan developed
• Training developed
• Screening began 2002
• Participation on RNAO BPG Panel

• 2005 present
• Hospital policy ratified
• New training developed
• Strategic plan for hospital wide implementation
  approved by senior admin
• All RNs will be receive training and will begin
  screening
• RUS prompt on electronic charting
• RUS tick box on in-patient chart
• In-progress self-directed learning package for
  on-going education

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Data

• From Jan. 1/07 July 1/07
• 23,043 persons triaged in ER
• 2,028 not applicable too young for example
• 5,088 not screened RN not trained yet for
  example, non-compliant nurse
• 15,770 marked negative to screening not
  entirely accurate
• 157 individuals answered yes to screening and
  were provided follow-up services ASAP,
  shelters, referral info
• 26 per month compared to 10 per month in the last
  year
• We are improving albeit slowly

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Where Are We Now

• Hospital has amalgamated
• Screening is taking place in the ER
• Electronic charting screening is a required
  field
• On Patient Admission Assessment Form
• As each dept. completes its training we move to
  the next according to a priority list
• RUS training part of ER nurse orientation
• Looking at making RUS training part of hospital
  orientation for all new nurses
• Working on a self-directed learning package

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What were/are some Challenges

• Compliance with this new task need strong
  message that this is a hospital policy apparent
  in the data
• Issues relating to violence are difficult,
  controversial and triggering
• Ensure you have everything in place before you
  begin - especially a policy
• Training due to staffing issues - difficult to
  train large groups of staff where shift work is a
  reality
• Appropriate environment triage not always
  private
• Hospital amalgamation, construction

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What Helped Us

• RNAO Best Practice Guidelines Woman Abuse
  Screening, Identification and Initial Response
  (2004)
• Task Force on the Health Effects of Woman Abuse
  Final Report by the Middlesex-London Health
  Unit
• Strong commitment by the Cornwall Community
  Hospital Violence Issues Committee
• Buy in from Hospital Senior Administration
• Expertise of the Assault and Sexual Abuse Program
• Solid support from community partners womens
  shelters, Eastern Ontario Health Unit

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Kudos

• Participated in Provincial project on Hospital
  Response to Woman Abuse
• Part of Expert Panel for Registered Nurses of
  Ontario Best Practice Guidelines on Woman Abuse
  Screening, Identification and Initial Response
• Interview w/Rita Chelli CBC as one of the first
  hospitals in Ontario to implement universal
  screening
• Regularly contacted by Hospitals across the
  province to provide support in launching RUS

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Final Words

• We assert that routine universal screening, in
  conjunction with comprehensive staff education
  and ongoing agency and managerial support,
  benefits our patients and our community.

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References

• Asher, J., Crespo, E.I., Sugg, N.K. (2001).
  Detection and treatment of domestic violence.
  Contemporary OB/GYN, 46, 61-66.
• Department of Health (2000). Domestic Violence A
  resource manual for health care professionals.
  Retrieved December 19, 2003, from
  http//www.doh.gov.uk/pdfs/domestic.pdf
• Family Violence Prevention Fund (2004). National
  consensus Guidelines on identifying and
  responding to domestic violence victimization in
  health care settings. Retrieved December 19,
  2003, from http//endabuse.org/programs/display.ph
  p3?DocID206
• Malecha, A. (2003). Screening for and treating
  intimate partner violence in the workplace. AAOHN
  Journal, 5, 310-316.
• Middlesex-London Health Unit. (2000). Task force
  on health effects of woman abuse Final report.
  London Middlesex-London Health Unit.
• Poirier, L. (1997) The Importance of Screening
  for Domestic Violence in All Women. The Nurse
  Practitioner, 22, 105-122.
• Punukollu, M. (2003) Domestic Violence Screening
  Made Practical. The Journal of Family Practice,
  52 (7), 105-122.
• Statistics Canada (2004) Family Violence in
  Canada A Statistical Profile ? Minister of
  Industry, Ottawa.
• Waller, A. E., Hohenhaus, S. M., Shah, P.J.,
  Stern, E. A.(1996). Development and validation of
  an emergency department screening and referral
  protocol for victims of domestic violence. Annals
  of Emergency Medicine, 27, 754-760.

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Thank You