Intimate partner violence A guide for primary care providers
Photo by Valentin Casarsa / iStock©
By Clarissa Agee Shavers, DNSc, WHNP-BC, TRECOS Fellow
Abstract: Women, men, children, and adolescents who self-disclose exposures to or at risk for exposures to intimate partner violence or domestic violence may exhibit moderate-to-severe psycho-social-emotional, mental, and physical healthcare problems. Healthcare providers have a unique opportunity to assist this population in the primary care office.
ntimate Partner Violence (IPV), which may be interchangeably termed Domestic Violence (DV), is a significantly-reported global healthcare problem for women, men, children, and adolescents.1 Likewise, men and women are equally at risk for exposures to IPV or DV.1,2 Similarly, the literature has shown that exposure to IPV or DV may have a deleterious impact on the lives of women, men, children, and adolescents, including being victims of rape, physical violence, and stalking.1-5 Furthermore, costs associated with exposure(s) to IPV or DV include millions of dollars as well as psycho-socialemotional trauma.6-10 Any patient (male or female), including older adults, adults, children, and adolescents, may present to primary care offices with a possible or potential diagnosis of IPV or
I
Keywords: adolescents, children, domestic violence, intimate partner violence, men, women
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Intimate partner violence: A guide for primary care providers
DV.11-14 Nurse practitioners (NPs) need to be knowledgeable about patients who self-report and may or may not be at risk for exposure to IPV or DV 7; therefore, all patients should be considered at risk for exposures to IPV or DV15,16. Screening and assessing for IPV or DV should be performed by direct questioning on a routine basis for every patient in the primary care office.16-18 Notably and equally, all forms or types of IPV or DV are preventable with appropriate intervention by individuals, families, communities, and society in general.18 NPs can play a significant role in early detection of IPV or DV by screening and assessing—on a routine basis—all patients for actual, potential, or exposures to IPV or DV.1922 Similarly, NPs should be cognizant of the actual or potential risk of exposures to violence and threat of injury for themselves or others as a result of screening, assessing, and possibly treating for self-report of actual or potential exposures to IPV or DV among patients. NPs should be educated regarding all facets involved with IPV or DV screening, assessing, and possibly treating any patient who self-reports actual or potential exposures to IPV or DV in the primary care office. The purpose of this manuscript is twofold. The first is to provide the reader with an overview of the literature pertaining to the impact of actual or potential exposures to IPV or DV among all patient populations in a global healthcare burden or concern perspective. The second is to briefly
stalking, victimization, and mental health problems) as well.26 Similarly, exposures to IPV or DV worldwide result in thousands of deaths and millions of injuries, including actual or fear of death experiences among women, men, children, and adolescents.26 Exposures to IPV or DV may have a profound effect on the individual’s psycho-social-emotional, mental, and overall physical health and well-being, including quality of life (QOL).26 Studies have revealed that female victims of violence had a significantly higher occurrence or incidence of long-term or chronic healthcare problems, such as frequent headaches, chronic pain, difficulty sleeping, asthma, irritable bowel syndrome (IBS), and HIV.26 Likewise, among male victims, researchers have shown similar long-term or chronic healthcare problems’ findings, including decreased physical and mental health.26 Children and adolescents who have histories of exposures to IPV or DV have been noted to exhibit various psycho-social-emotional, mental, and physical healthcare problems that extend into adulthood.27,28 The estimated costs according to the Centers for Disease Control (CDC) associated with the exposure to IPV or DV, including physical assault and stalking, exceed $5.8 billion annually and nearly $4.1 billion dollars of which are for direct medical and mental healthcare services.29 Furthermore, one of the largest components of IPV-related costs include loss of productivity, healthcare, or medical costs.29,30 The literature has shown that up to 25% of women in the United States have been the victims of IPV Children and adolescents exposed to IPV or DV,31 which has resulted, on a naor DV are significantly at risk for anxiety, tional level, in thousands of deaths and depression, and posttraumatic stress disorder. injuries among women, men, children, and adolescents.31-33 Children and adolescents exposed to IPV or DV are sigpresent the topic areas of screening, assessment, clinical nificantly at risk for morbidities and mortalities such as diagnosing, and recommended therapeutic treatment regianxiety, depression, and posttraumatic stress disorder mens for identification of exposures to IPV or DV among (PTSD).33-35 Similarly, in regards to male victims, the Napatients in the primary care office. tional Intimate Partner and Sexual Violence Survey conducted in 2010 revealed almost 53% of male victims ex■ Background and definition of problem perienced some form of IPV for the first time before IPV or DV has been deemed a serious global public health25 years of age, and more than one in four reported male care problem that occurs in every country, geographical rape victims were first raped when they were 10 years old region, educational and developmental level, socioecoor younger.26 nomic, ethnic-cultural, and religious group.23,24 In addiPhysical injury, mental health problems, and complication, IPV or DV have been denoted to be more prevalent tions of pregnancy are some of the reported healthcare among women than men.25 However, findings from the consequences that may result from violence inflicted on women by their male partners or former partners.36-38 As empirical literature have demonstrated that exposures to IPV or DV have been significantly noted among the male for men or male victims of IPV, recent findings from population, including children and adolescents with grave a respective cohort study revealed that of 507 medical reconsequences (for example, severe physical violence, cords of a stratified random sample of 10% (N = 507) male
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Intimate partner violence: A guide for primary care providers
IPV or DV.56 In fact, a recent study conducted by investigaparticipants who were seeking care for PTSD, that for the 120 (24%) medical records that showed documentation of tors in an effort to update the U.S. Preventive Services Task screening for IPV perpetration, 73 (61%) of the medical Force Recommendation found that screening instruments records demonstrated positive results for IPV perpetration accurately identify women experiencing IPV, and screening among the male participants.39 Investigators from this noted study revealed that the male participants with docuNPs should understand that a violence risk mented diagnoses of PTSD, acknowlassessment will take time and allocate an edgement of IPV perpetration, and appropriate timeframe to ensure effectiveness. reported higher rates of relationship conflict accessed the healthcare system twice as often as those without such documentation.39 In addition, researchers have identified women for IPV can provide benefits that vary by population.57 In particular, the study concluded that screening that special-needs youth with chronic medical or developmental disabilities are at risk for medical diagnoses of asymptomatic women for IPV or DV accurately identifies anxiety and depression if they’re bullied by other young women experiencing IPV, may reduce IPV, and improves people.40 Similarly, literature has shown that children and health outcomes depending on the population screened and outcome measured.57 The Patient Protection and Afadolescents who are physically or sexually abused or who go through other trauma-inducing experiences can defordable Care Act Public Law 111-148 supports the screenvelop mental health disorders and related problems.41-43 ing and counseling for IPV and DV among women on an annual basis.58 Similarly, the ICD-10 codes support the Furthermore, reports in the literature have identified that exposures to IPV or DV and the coexistence of reported efforts of HCPs in identification of actual and suspected child abuse may occur in approximately 50% of cases inindividuals of DV or IPV.59 However, nonscreening or a lack volving children as well as the presence of other adversiof prevention efforts may contribute to thousands of womties.44 en, men, children, and adolescents going undetected for illnesses, injuries, morbidities, or comorbidities as a result IPV or DV has been defined as or referred to as any of violence.60-63 behavior within an intimate relationship that causes physical, psychological, sexual harm, or trauma to those involved In order to promote the healing and restoration of in the relationship.45 Similarly, IPV or DV may include victims or survivors of IPV or DV, it is of utmost necessity for early identification of victims and survivors by HCPs physical violence, sexual violence, dating violence, interperin the primary care office.64,65 Also, HCPs must screen adults sonal violence, emotional abuse, verbal abuse, threats of 45,46 physical or sexual violence, stalking, and bullying. and youth on a routine basis for exposures to technologybased or online bullying, harassment, and unsolicited sexual encounters. These forms of interpersonal violence ■ Screening are psycho-social-emotional and physically distressing for Many professional accrediting bodies require policies and adult/youth victims and may place them at risk for suicide procedures for identifying, treating, and referring IPV or ideation, suicide, and depression.66-68 HCPs in the primary DV victims in ambulatory settings, including primary care offices.47-49 Numerous professional organizations for healthcare office need to be in the forefront in screening all patients for self-reports of actual or possible exposures to IPV care providers (HCPs) have published consensus and other or DV in an effort to prevent the actual, potential, or posprofessional guidelines that encourage screening for early sible adverse outcomes commonly noted in the current identification of IPV or DV.50,51 Many professional and literature.69,70 healthcare organizations also encourage early identification of IPV or DV by screening in an effort to promote positive, healthy outcomes for patients.50-52 In addition, it has been ■ Assessment noted in the literature that HCPs often do not screen for the NPs in the primary care office have a unique opportunity presence and identification of IPV or DV among victims to assess, perform risk assessments, identify, and assist who seek medical care for a number of reasons, including victims, survivors, bystanders, perpetrators, or potential insufficient evidence to support IPV or DV screening in perpetrators exposed to IPV or DV.70,71 However, in order 53-55 healthcare settings. to effectively assess for actual, potential, or possible exposures to IPV or DV, NPs should be knowledgeable of comThe literature states that HCPs may play a key role in monly associated risk factors related to actual, potential, the early identification of and initial or early response to www.tnpj.com
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Intimate partner violence: A guide for primary care providers
Assessing for exposures to IPV or DV among adults, children, and adolescents Women • Investigate for signs/symptoms of various forms of abuse, including emotional, sexual, verbal or threats of abuse, and physical abuse, including during pregnancy and each trimester. • Question use of substances, such as alcohol, tobacco, and street or illegal drugs. • Conduct a thorough health history, including hospitalizations, injuries, surgeries, and methods of contraception.
Men • Ask questions regarding the usage of physical violence between both partners when angry. • Question if he has ever been hit, bullied, or hurt by someone (male or female) physically, emotionally, or verbally. • Ask at which age he became sexually active and if he has ever been touched in a manner that made him uncomfortable. • Identify if he has ever been a victim of rape. • Conduct a comprehensive health history, including injuries, use of substances (such as tobacco products, alcohol, street or illegal drugs), hospitalizations, and occupation or work history.
Children • Assess for signs/symptoms of emotional distress (sadness, anger, fear, hopelessness), somatic complaints (headaches, stomach aches), and emotional abuse or neglect/reports of exposures to IPV or DV at home. • Observe for signs and symptoms of physical violence, including bullying and sexual trauma.
Adolescents • Reports of exposures to IPV or DV at home. • Ascertain for risk of or actual complaints of exposures to physical, emotional, verbal, and sexual violence or abuse at home, school, or in the community. • Screen for dating violence, bullying, and absenteeism from school or home. • Question use of substances, including tobacco, alcohol, street or illegal drugs, and use of contraception(s). Notation: This is an inconclusive list (developed by the author) and reflects recommendations for early assessment or identification in clinical practice. In addition, older adults, adults, children, and adolescents should be routinely screened for depression or emotional distress, suicide ideology/ suicide attempts, deliberate self-harm or harm to others, and should immediately be referred to the MSW or Crisis Counseling if screening results are positive for harm to self or others.
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and possible exposure(s) to IPV or DV.72-75 (See Assessing for exposures to IPV or DV among adults, children, and adolescents.) Such commonly associated risk or evidencebased risk factors include past or present traumatic or violent experiences, including bullying76-78; mental health diagnoses (for example, bipolar disorder, depression79); notably prevalent, subsequent comorbidities of asthma, IBS, diabetes, hypertension; and difficulty sleeping and chronic pain.80 NPs should understand that a violence risk assessment will take time and allocate an appropriate timeframe to ensure effectiveness.81 Similarly, the issue of safety including matters pertaining to confidentiality and the Health Insurance Portability and Accountability Act should always be considered as an important part of the assessment and screening process by the NP when considering assessing, screening, and possibly treating for exposures to IPV or DV.82 The documented, evidence-based policy/procedure or safety plan may include readily available access to the judicial system (if indicated) and an immediate patient referral system for or to the Medical Social Worker (MSW) in the practice office or community for timeliness, appropriate case management, and continuity of care.38 The patient should be provided with a current and updated list of communitybased resources (for example, local shelters or emergency crisis centers that will accommodate women, children, and adolescents or men, children, and adolescents) for support and assistance.83,84 (See IPV or DV screening clinical strategies and recommendations for HCPs in primary care.) In essence, the NP should have a legally documented, evidence-based policy/procedure or safety plan readily available in their facility prior to screening, assessing, and possibly treating for IPV or DV due to the potential or actual safety risks/issues, including risks for injuries and death for all involved.83,84 Additionally, the NP should be cognizant of the relevant state and local policies and laws for reporting to various authorities suspected or actual cases of victimization. Lastly, the patient should be rescheduled for a follow-up visit within 1 to 2 weeks to ensure efficacy and effectiveness of the proposed IPV or DV treatment plan.83,84 ■ Clinical diagnosing Clinical diagnosing may be difficult for the NP assessing or screening for exposures to IPV or DV among women, men, and children due to the private and sensitive nature of IPV or DV85,86 and child developmental issues, especially among young children.87,88 In the same way, assessing and screening for exposure(s) to IPV or DV may be difficult for adolescents as a result of issues relating to growth and development, including internalizing and externalizing www.tnpj.com
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Intimate partner violence: A guide for primary care providers
IPV or DV screening clinical strategies and recommendations for HCPs in primary care Identifying exposures to DV or IPV Identification of exposures to DV or IPV among all patient populations with use of evidence-based screening instruments available from various Domestic Violence or Intimate Partner Violence organizations and agencies including The Domestic Violence Survivor Assessment Tool and The Delphi Instrument for Hospital-based Domestic Violence Programs supported by the Agency for Healthcare Research and Quality (www.ahrq.gov) and the IPV Screening and Counseling Toolkit available from Futures without Violence (www.futureswithoutviolence.org).
Developing a safety plan for victims Development of a Safety Plan for Victims of IPV or DV in the practice setting. The Safety Plan should include a list of shelters for distribution for women, men, children, and adolescents, instructions on how to safely leave a dangerous situation and precautions. In addition, the victim or victims of IPV or DV should be provided with information on how to obtain confidential help from the legal and court systems. Include in public facilities such as restrooms, exam rooms, and waiting rooms posters regarding IPV or DV, local phone numbers, and websites for assistance with IPV or DV.
Providing resources Provide a list of toll-free phone numbers to the victim or victims such as the National Domestic Violence Hotline: 1-800-799-SAFE (1-800-799-7233) and their Local Domestic Violence Hotline as part of information provided to all patients.
Referring victims Referrals for victims of IPV or DV to evidence-based counseling or mental health interventions/programs (for example, Crisis Support, Cognitive Behavioral Therapy, Individual or Group Counseling) that assist in promoting the psycho-social-emotional and mental health well-being of victimized or traumatized patients should be initiated by HCPs in an appropriate and timely manner.
Collaborating with community and healthcare colleagues Collaboration with local community-based interventions or coordinated services and programs for victims of IPV or DV including MSWs and counselors, law enforcement, hospitals, court systems, and other treatment facilities.
Documenting safety plans Documented Safety Plans and Protocols for patients and staff in the healthcare facility for distribution and posting in the facility including common areas such as public restrooms and patient exam rooms or waiting rooms. Objective and thorough documentation of clinical visits and exam findings in the patients medical records.
Participating in IPV or DV education Participate in ongoing formal and informal IPV or DV training or education sponsored by various healthcare educational or professional organizations including the National Resource Center on Domestic Violence (www. nrcdv.org or www.vawnet.org), Domestic Violence Resource Network at www.acf.hhs.gov/programs/fysb/ fv-centers, and Medscape, LLC Continuing Medical Education activities at http://www.medscape.org.
Providing education Educate the patient regarding the cycle or patterns of an abusive and dangerous relationship and when to seek help. Sources: • Agency for Health Care Research and Quality. 2013. Rockville, MD. http://www.ahrq.gov/contact/index.html. • Futures Without Violence. 2013. http://wwwfutureswithoutviolence.org. • Office of Disease Prevention and Health Promotion U. S. Department of Health and Human Services. 2013. 2013 Toll-Free Numbers for Health Information. National Health Information Center, Office of Disease Prevention and Health Promotion, U. S. Department of Health and Human Services, Washington, DC. • National Resource Center on Domestic Violence. 2013. http://www.nrcdv.org/contact-us/. • National Online Resource Center on Violence Against Women. 2013. http://www.vawnet.org/contact/. • Family Violence Prevention & Services Resource Centers. Domestic Violence Resource Network (DVRN). 2013. http://www.acf.hhs.gov/programs/fysb/fv-centers. • Medscape, LLC. 2013. http://www.medscape.org/public/about.
behavior problems, sexuality, sexual risk-taking behaviors, prevalence of adolescent dating violence, and bullying.89-91 NPs may ask direct questions using age and developmentally appropriate language when communicating with children and adolescents in efforts to open up the lines of communication and promote an atmosphere of trust to www.tnpj.com
assist with clinical diagnosing.92 In a similar manner, the NP may further open up lines of communication for women, men, children, and adolescents by establishing and maintaining a trusting, caring, empathetic, nonjudgmental, and safe environment, which may assist with establishing a clinical diagnosis of IPV or DV.92-94 The Nurse Practitioner • December 2013 43
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Intimate partner violence: A guide for primary care providers
Ensuring a quiet and conducive environment will aid in facilitating an open, honest, and confidential communication exchange between the patient and NP.95 The NP may also want to assure that the patient is alone while screening for exposures to IPV or DV. Likewise, the NP should inform the patient prior to disclosure that the information shared will be held to the highest level of confidentiality. Nevertheless, the NP should apprise the patient that there is a possibility that the information may be shared with the legal system if there is any indication that a child, youth, or older adult may be at risk for harm or injury, according to the state mandatory reporting of abuse or neglect. In the same manner, the NP should continue to try to identify patients, including couples at special risk for relationship violence in an effort to possibly circumvent potential violence or possible negative outcomes.96-100 This may include screening and assessing for dating or relationship violence among high-risk groups, including children, adolescents, and young adult couples in an effort to lower the risk of relationship conflict and violence.47-49 Also, asking the following simple questions may aid in identifying whether or not a patient is at risk for IPV or DV: Do you feel afraid? Do you feel like someone is trying to harm or threaten you? Is someone hurting you? Has someone touched you in a way that made you feel afraid or uncomfortable? ■ Reducing IPV and DV IPV or DV has been deemed to be a serious and ever-growing global healthcare concern.23,24 NPs can play a key role in reducing the burden and global impact of exposures to IPV or DV among women, men, children, and adolescents in our society by incorporating–on a routine basis–screening for or identification of actual, potential, or possible exposures to IPV or DV in the primary care office.70,71 Thus, the conduction of a thorough assessment, including a comprehensive history and physical exam by NPs, may contribute to the current recommended early identification and preventive efforts as well as health promotion and disease prevention. Providing therapeutic treatment regimens for IPV or DV patients at the appropriate timeframes may alleviate the tremendous cost burden associated with IPV or DV.5-10 Finally, with the utilization of routine screening, assessment, and possibly treating of IPV or DV among women, men, children, and adolescents by NPs in the primary care office may assist in improving the lives and QOL for this population.18,23,25 ■ HCPs to promote well-being HCPs can and should be involved in all endeavors to promote the overall health and well-being of all women, men, 44 The Nurse Practitioner • Vol. 38, No. 12
children, and adolescents who self-disclose or are at risk for exposures to IPV or DV in society. By screening, assessing, and possibly treating for exposures to IPV or DV, the HCP may further contribute to the global efforts of minimizing or ameliorating the potential negative healthcare consequences that may occur as a result of such exposures.1 HCPs may contribute to the ongoing trend of incorporating evidence-based and inquiry-based science, theory, and practice in the primary care office as a result of screening or identification, assessment, and possible treatment of actual, potential, or possible exposures to IPV or DV on a routine basis for all patients.
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Intimate partner violence: A guide for primary care providers
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35. Miller E, Decker MR, Raj A, Reed E, Marable D, Silverman JG. Intimate partner violence and health care-seeking patterns among female users of urban adolescent clinics. Maternal and Child Health Journal. 2009;14(6): 910-917. 36. Barnes JE, Noll JG, Putnam FW, Trickett PK. Sexual and physical revictimization among victims of severe childhood sexual abuse. Child Abuse Negl. 2009;33(7):412-420. [PubMed]. http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2723796/. 37. Devries KM, Mak JY, Bacchus LJ, et al. Intimate partner violence and incident depressive symptoms and suicide attempts: A systematic review of longitudinal studies. PLOS Medicine. 2013;10(5):e1001439. http//www. plosmedicine.org/article/info%Adoi%2F10.1371%2Fjournal.pmed.1001439. 38. American College of Obstetricians and Gynecologists. Intimate partner violence. Committee Opinion No. 518. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;119:412-7. 39. Gerlock AA, Grimesey JL, Pisciotta AK, Harel O. Documentation of screening for perpetration of Intimate Partner Violence in male veterans with PTSD. AJN. 2011. 111(11):26-32.
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55. Beynon CE, Gutmanis IA, Tutty LM, Wathen CN, MacMillan HL. Why physicians and nurses ask (or don’t) about partner violence. BMC Public Health. 2012;12(473). 56. Chamberlain L, Levenson R. Reproductive health and partner violence guidelines: An integrated response to intimate partner violence and reproductive coercion. San Francisco, CA: Family Violence Prevention Fund; 2010. 57. Nelson HD, Bougatsos C, Blazina I. Screening women for intimate partner violence: A systematic review to update the U.S. Preventive Services Task Force Recommendation. Ann Intern. Med. 2012;156(11):796-W-282. 58. Department of Health and Human Services. Group health plans and health insurance issuers relating to coverage of preventive services under the Patient Protection and Affordable Care Act. Fed Reg. 2011;76(149):46621-46626. 59. McKenzie K, Fingerhut L, Walker S, Harrison A, Harrison JE. Classifying external causes of injury: History, current approaches, and future directions. Epidemiol Rev. 2012;34(1):4-16. 60. Mikton C. Preventing intimate partner and sexual violence against women: taking action and generating evidence. WHO Department of Violence and Injury Prevention and Disability. 2010;16(5):359-60. 61. National Coalition Against Domestic Violence (NCADV). Male victims of violence. http://www.ncadv.org/files/MaleVictims.pdf.
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Intimate partner violence: A guide for primary care providers
62. Hamby S, Finkelhor D, Turner H, Ormrod R. Children’s exposure to intimate partner violence and other family violence. Juvenile Justice Bulletin. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention; 2011. 63. Mulford C, Giordano PC. Teen dating violence: A closer look at adolescent romantic relationships. NIJ Journal. NCJ 224089. 2008;261:34-40. http:// www.nij.gov/journals/261/teen-dating-violence.htm. 64. Chibber KS, Krishnan S. Confronting intimate partner violence, a global health care priority. Mt Sinai J Med. 2011; 78(3):449-457. http://www.ncbi. nlm.nih.gov/pmc/articles/PMC3100675/pdf/nihms279958.pdf. 65. Feder G, Ramsay J, Dunne D, et al. How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria. Health Technology Assessment. 2009;13(16):1-216. http:// www.hta.ac.uk/full/mono/mon1316.pdf. 66. Schnurr MP, Mahatmya D, Basche RA. The role of dominance, cyber aggression perpetration, and gender on emerging adults’ perpetration of intimate partner violence. Psychol Viol. 2013; 3(1): 70-83.
83. Dichter ME, Gelles RJ. Women’s perceptions of safety and risk following police intervention for intimate partner violence. Violence Against Women. 2012. 18(1):44-63. 84. Durborow N. How to create a healthcare-based domestic violence/sexual assault program. San Francisco, CA: Futures Without Violence National Health Resource Center on Domestic Violence; 2013. http://www. futureswithoutviolence.org/userfiles/File/HealthCare/How%20to%20 Create%20a%20Healthcare-based%20DVSA%20-Program.pdf. 85. Alaggia R. An ecological analysis of child sexual abuse disclosure: consideration for child and adolescent mental health. J Can Acad Child Adolesc Psychiatry. 2010;19(1):32-39. 86. Magnussen L, Shoultz J, Richardson K, et al. Responding to the needs of culturally diverse women who experience intimate partner violence. Hawaii Medical Journal. 2011;70(1):9-15. 87. Roberts AL, McLaughlin KA, Conron KJ, Koenen KC. Adulthood stressors, history of childhood adversity, and risk of perpetration of intimate partner violence. Am J Prev Med. 2011;40(2):128-138. 88. Capaldi DM, Langhinrichsen-Rohling J. Informing intimate partner violence prevention efforts: Dyadic, developmental, and contextual considerations. Prev Sci. 2012;13(4):323-328.
67. Stein ND, Mennemeier KA. Addressing the gendered dimensions of harassment and bullying: What domestic and sexual violence advocates need to know. Harrisburg, PA: The National Resource Center on Domestic Violence & The National Sexual Violence Resource Center; 2011. http://www.vanet.org/ Assoc_Files_VAWnet/CIB_HarassmentBullying.pdf.
89. Terzian MA, Andrews KM, Moore KA. Preventing multiple risky behaviors among adolescents: Seven strategies. Washington, DC: Child Trends. 2011;112:2011-24.
68. Marganski A. Virtual relationship violence and perspectives on punishment: Do gender or nationality matter? Future Internet. 2013;5: 301-316.
90. Camacho K, Ehrensaft MK, Cohen P. Exposure to intimate partner violence, peer relations, and risk for internalizing behaviors: A prospective longitudinal study. J Interpers Violence. 2012;27(1):125-141.
69. Mitchell TL. Trauma-informed care emerging as proven treatment for children, adults with behavioral, mental health problems. National Center for Youth Law, 2013;31(3):3p.
91. Kann L, Olsen EO, McManus T, et al. Sexual identity, sex of sexual contacts, and health-risk behaviors among students in grades 9-12-Youth Risk Behavior Surveillance, selected sites, United States, 2001-2009. MMWR Morb Mortal Wkly Rep. 2011;60(7):1-133.
70. Centers for Disease Control and Prevention. Sexual Violence, stalking, and Intimate Partner Violence widespread in the US: CDC Online Newsroom-Press Release. http://www.cdc.gov/media/releases/2011/p1214_sexual_violence.html. 71. Jaeger JR, Spielman D, Cronholm PF, Applebaum S, Holmes WC. Screening male primary care patients for intimate partner violence perpetration. J Gen Intern Med. 2008;23(8):1152-1156. 72. Young MED, Deardorf J, Ozer E, Lahiff M. Sexual abuse in childhood and adolescence and risk of early pregnancy among women ages 18-22. J Adolesc Health. 2011;49(3):278-293.
92. Edelson JL, Nguyen HT, Kimball E. Honor our voices: A guide for practice when responding to children exposed to domestic violence. Minneapolis, MN: Minnesota Center Against Violence and Abuse (MINCAVA); 2011. http:// www.honorourvoices.org/docs/GuideforPractice.pdf. 93. Usta J, Antoun J, Ambuel B, Khawaja M. Involving the health care system in domestic violence: What women want. Ann Fam Med. 2012;10(3):213-220. 94. Kersey-Matusiak, G. Culturally competent care: Are we there yet? Nurs Management. 2012;43(4)34-39.
73. Webster CD, Bloom H, Augimeri L. Violence risk assessment in everyday psychiatric practice: Twelve principles help guide clinicians. Psychiatric Times. 2009;26(12).
95. Liebschutz J, Battaglia T, Finley E, Averbuch T. Disclosing intimate partner violence to health care clinicians—what a difference the setting makes: A qualitative study. BMC Public Health. 2008;8:229.
74. Lee AMR, Galynker I. Violence in bipolar disorder: What role does childhood trauma play? Psychiatric Times. 2010;27(11).
96. Lacoursiere T, Fontenot HB. The impact of running away on teen girls’ sexual health. Nurs for Women’s Health. 2012;16(5): 411-417.
75. Cuevas CA, Finkelhor D, Omrod R, Turner H. Psychiatric diagnosis as a risk marker for victimization in a national sample of children. J Interpers Violence. 2009;24(4):636-652.
97. Hanby S, Finkelhor D, Turner H. Teen dating violence: Co-Occurrence with other victimizations in the National Survey of Children’s Exposure to Violence (NAtSCEV). Psychology of Violence. 2012;2(2):111-124.
76. Holt S, Buckley H, Whelan S. The impact of exposure to domestic violence on children and young people: A review of the literature. Child Abuse & Neglect. 2008;32(8):797-810.
98. Vernberg EM, Nelson TD, Fonagy P, Twemlow SW. Victimization, aggression, and visits to the school nurse for somatic complaints, illnesses, and physical injuries. Pediatrics. 2011;127(5):842.
77. Garcia LS, Coker AL, Williams CM, et al. Lessons learned in implementing a psychosocial screener in a high risk obstetrics clinic. Family Violence Prevention & Health Practice. http://www.futureswithoutviolence.org/health/ejournal/ 2012/02/lessons-learned-in-imple.
99. Kerr DCR, Capaldi DM. Young men’s intimate partner violence and relationship functioning: Long-term outcomes associated with suicide attempt and aggression in adolescence. Psychol Med. 2011;41(4):759-69.
78. Wolfe D, Crooks CC, Chiodo D, Jaffe P. Child maltreatment, bullying, gender-based harassment, and adolescent dating violence: Making the connections. Psychol Women Quart. 2009; 33(1):21-24. 79. Trevillion K, Oram S, Feder G, Howard LM. Experiences of domestic violence and mental disorders: A systematic review and meta-analysis. PLoS ONE. 2012;7(12):e51740. 80. Women’s Health, Maternal and Child Health, Maryland Department of Health and Mental Hygiene. Intimate partner violence (IPV): A guide for health care providers. Baltimore, MD; 2012. http://www.phpa.dhmh. maryland.gov/mch/Documents/IPV%20Guide%20for%20providers_ May.2013.pdf. 81. Sundborg EM, Saleh-Stattin N, Wandell P, Tornkvist L. Nurse’s preparedness to care for women exposed to intimate partner violence: A quantitative study in primary health care. BMC Nursing. 2012;11:1-11. 82. McKenzie K, Fingerhut L, Walker S, Harrison A, Harrison JE. Classifying external causes of injury: History, current approaches, and future directions. Epidemiol Rev. 34(1):4-16.
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100. Berger A, Wildsmith E, Manlove J, Steward-Streng N. Relationship violence among young adult couples. Child Trends Research Brief. 2012;1-8: 2012-14.
Dr. Clarissa Agee Shavers, DNSc is the Principal Investigator and Program Director of The Safer Tomorrows: Injury Prevention and Violence Reduction Project© of the United States of America, Canada, and West Indies Caribbean Trinidad and Tobago, Detroit, M.I.
The author has disclosed that she has no financial relationships related to this article.
DOI-10.1097/01.NPR.0000437577.21766.37
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Photo by Valentin Casarsa / iStock©
By Clarissa Agee Shavers, DNSc, WHNP-BC, TRECOS Fellow
Abstract: Women, men, children, and adolescents who self-disclose exposures to or at risk for exposures to intimate partner violence or domestic violence may exhibit moderate-to-severe psycho-social-emotional, mental, and physical healthcare problems. Healthcare providers have a unique opportunity to assist this population in the primary care office.
ntimate Partner Violence (IPV), which may be interchangeably termed Domestic Violence (DV), is a significantly-reported global healthcare problem for women, men, children, and adolescents.1 Likewise, men and women are equally at risk for exposures to IPV or DV.1,2 Similarly, the literature has shown that exposure to IPV or DV may have a deleterious impact on the lives of women, men, children, and adolescents, including being victims of rape, physical violence, and stalking.1-5 Furthermore, costs associated with exposure(s) to IPV or DV include millions of dollars as well as psycho-socialemotional trauma.6-10 Any patient (male or female), including older adults, adults, children, and adolescents, may present to primary care offices with a possible or potential diagnosis of IPV or
I
Keywords: adolescents, children, domestic violence, intimate partner violence, men, women
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Intimate partner violence: A guide for primary care providers
DV.11-14 Nurse practitioners (NPs) need to be knowledgeable about patients who self-report and may or may not be at risk for exposure to IPV or DV 7; therefore, all patients should be considered at risk for exposures to IPV or DV15,16. Screening and assessing for IPV or DV should be performed by direct questioning on a routine basis for every patient in the primary care office.16-18 Notably and equally, all forms or types of IPV or DV are preventable with appropriate intervention by individuals, families, communities, and society in general.18 NPs can play a significant role in early detection of IPV or DV by screening and assessing—on a routine basis—all patients for actual, potential, or exposures to IPV or DV.1922 Similarly, NPs should be cognizant of the actual or potential risk of exposures to violence and threat of injury for themselves or others as a result of screening, assessing, and possibly treating for self-report of actual or potential exposures to IPV or DV among patients. NPs should be educated regarding all facets involved with IPV or DV screening, assessing, and possibly treating any patient who self-reports actual or potential exposures to IPV or DV in the primary care office. The purpose of this manuscript is twofold. The first is to provide the reader with an overview of the literature pertaining to the impact of actual or potential exposures to IPV or DV among all patient populations in a global healthcare burden or concern perspective. The second is to briefly
stalking, victimization, and mental health problems) as well.26 Similarly, exposures to IPV or DV worldwide result in thousands of deaths and millions of injuries, including actual or fear of death experiences among women, men, children, and adolescents.26 Exposures to IPV or DV may have a profound effect on the individual’s psycho-social-emotional, mental, and overall physical health and well-being, including quality of life (QOL).26 Studies have revealed that female victims of violence had a significantly higher occurrence or incidence of long-term or chronic healthcare problems, such as frequent headaches, chronic pain, difficulty sleeping, asthma, irritable bowel syndrome (IBS), and HIV.26 Likewise, among male victims, researchers have shown similar long-term or chronic healthcare problems’ findings, including decreased physical and mental health.26 Children and adolescents who have histories of exposures to IPV or DV have been noted to exhibit various psycho-social-emotional, mental, and physical healthcare problems that extend into adulthood.27,28 The estimated costs according to the Centers for Disease Control (CDC) associated with the exposure to IPV or DV, including physical assault and stalking, exceed $5.8 billion annually and nearly $4.1 billion dollars of which are for direct medical and mental healthcare services.29 Furthermore, one of the largest components of IPV-related costs include loss of productivity, healthcare, or medical costs.29,30 The literature has shown that up to 25% of women in the United States have been the victims of IPV Children and adolescents exposed to IPV or DV,31 which has resulted, on a naor DV are significantly at risk for anxiety, tional level, in thousands of deaths and depression, and posttraumatic stress disorder. injuries among women, men, children, and adolescents.31-33 Children and adolescents exposed to IPV or DV are sigpresent the topic areas of screening, assessment, clinical nificantly at risk for morbidities and mortalities such as diagnosing, and recommended therapeutic treatment regianxiety, depression, and posttraumatic stress disorder mens for identification of exposures to IPV or DV among (PTSD).33-35 Similarly, in regards to male victims, the Napatients in the primary care office. tional Intimate Partner and Sexual Violence Survey conducted in 2010 revealed almost 53% of male victims ex■ Background and definition of problem perienced some form of IPV for the first time before IPV or DV has been deemed a serious global public health25 years of age, and more than one in four reported male care problem that occurs in every country, geographical rape victims were first raped when they were 10 years old region, educational and developmental level, socioecoor younger.26 nomic, ethnic-cultural, and religious group.23,24 In addiPhysical injury, mental health problems, and complication, IPV or DV have been denoted to be more prevalent tions of pregnancy are some of the reported healthcare among women than men.25 However, findings from the consequences that may result from violence inflicted on women by their male partners or former partners.36-38 As empirical literature have demonstrated that exposures to IPV or DV have been significantly noted among the male for men or male victims of IPV, recent findings from population, including children and adolescents with grave a respective cohort study revealed that of 507 medical reconsequences (for example, severe physical violence, cords of a stratified random sample of 10% (N = 507) male
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Intimate partner violence: A guide for primary care providers
IPV or DV.56 In fact, a recent study conducted by investigaparticipants who were seeking care for PTSD, that for the 120 (24%) medical records that showed documentation of tors in an effort to update the U.S. Preventive Services Task screening for IPV perpetration, 73 (61%) of the medical Force Recommendation found that screening instruments records demonstrated positive results for IPV perpetration accurately identify women experiencing IPV, and screening among the male participants.39 Investigators from this noted study revealed that the male participants with docuNPs should understand that a violence risk mented diagnoses of PTSD, acknowlassessment will take time and allocate an edgement of IPV perpetration, and appropriate timeframe to ensure effectiveness. reported higher rates of relationship conflict accessed the healthcare system twice as often as those without such documentation.39 In addition, researchers have identified women for IPV can provide benefits that vary by population.57 In particular, the study concluded that screening that special-needs youth with chronic medical or developmental disabilities are at risk for medical diagnoses of asymptomatic women for IPV or DV accurately identifies anxiety and depression if they’re bullied by other young women experiencing IPV, may reduce IPV, and improves people.40 Similarly, literature has shown that children and health outcomes depending on the population screened and outcome measured.57 The Patient Protection and Afadolescents who are physically or sexually abused or who go through other trauma-inducing experiences can defordable Care Act Public Law 111-148 supports the screenvelop mental health disorders and related problems.41-43 ing and counseling for IPV and DV among women on an annual basis.58 Similarly, the ICD-10 codes support the Furthermore, reports in the literature have identified that exposures to IPV or DV and the coexistence of reported efforts of HCPs in identification of actual and suspected child abuse may occur in approximately 50% of cases inindividuals of DV or IPV.59 However, nonscreening or a lack volving children as well as the presence of other adversiof prevention efforts may contribute to thousands of womties.44 en, men, children, and adolescents going undetected for illnesses, injuries, morbidities, or comorbidities as a result IPV or DV has been defined as or referred to as any of violence.60-63 behavior within an intimate relationship that causes physical, psychological, sexual harm, or trauma to those involved In order to promote the healing and restoration of in the relationship.45 Similarly, IPV or DV may include victims or survivors of IPV or DV, it is of utmost necessity for early identification of victims and survivors by HCPs physical violence, sexual violence, dating violence, interperin the primary care office.64,65 Also, HCPs must screen adults sonal violence, emotional abuse, verbal abuse, threats of 45,46 physical or sexual violence, stalking, and bullying. and youth on a routine basis for exposures to technologybased or online bullying, harassment, and unsolicited sexual encounters. These forms of interpersonal violence ■ Screening are psycho-social-emotional and physically distressing for Many professional accrediting bodies require policies and adult/youth victims and may place them at risk for suicide procedures for identifying, treating, and referring IPV or ideation, suicide, and depression.66-68 HCPs in the primary DV victims in ambulatory settings, including primary care offices.47-49 Numerous professional organizations for healthcare office need to be in the forefront in screening all patients for self-reports of actual or possible exposures to IPV care providers (HCPs) have published consensus and other or DV in an effort to prevent the actual, potential, or posprofessional guidelines that encourage screening for early sible adverse outcomes commonly noted in the current identification of IPV or DV.50,51 Many professional and literature.69,70 healthcare organizations also encourage early identification of IPV or DV by screening in an effort to promote positive, healthy outcomes for patients.50-52 In addition, it has been ■ Assessment noted in the literature that HCPs often do not screen for the NPs in the primary care office have a unique opportunity presence and identification of IPV or DV among victims to assess, perform risk assessments, identify, and assist who seek medical care for a number of reasons, including victims, survivors, bystanders, perpetrators, or potential insufficient evidence to support IPV or DV screening in perpetrators exposed to IPV or DV.70,71 However, in order 53-55 healthcare settings. to effectively assess for actual, potential, or possible exposures to IPV or DV, NPs should be knowledgeable of comThe literature states that HCPs may play a key role in monly associated risk factors related to actual, potential, the early identification of and initial or early response to www.tnpj.com
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Intimate partner violence: A guide for primary care providers
Assessing for exposures to IPV or DV among adults, children, and adolescents Women • Investigate for signs/symptoms of various forms of abuse, including emotional, sexual, verbal or threats of abuse, and physical abuse, including during pregnancy and each trimester. • Question use of substances, such as alcohol, tobacco, and street or illegal drugs. • Conduct a thorough health history, including hospitalizations, injuries, surgeries, and methods of contraception.
Men • Ask questions regarding the usage of physical violence between both partners when angry. • Question if he has ever been hit, bullied, or hurt by someone (male or female) physically, emotionally, or verbally. • Ask at which age he became sexually active and if he has ever been touched in a manner that made him uncomfortable. • Identify if he has ever been a victim of rape. • Conduct a comprehensive health history, including injuries, use of substances (such as tobacco products, alcohol, street or illegal drugs), hospitalizations, and occupation or work history.
Children • Assess for signs/symptoms of emotional distress (sadness, anger, fear, hopelessness), somatic complaints (headaches, stomach aches), and emotional abuse or neglect/reports of exposures to IPV or DV at home. • Observe for signs and symptoms of physical violence, including bullying and sexual trauma.
Adolescents • Reports of exposures to IPV or DV at home. • Ascertain for risk of or actual complaints of exposures to physical, emotional, verbal, and sexual violence or abuse at home, school, or in the community. • Screen for dating violence, bullying, and absenteeism from school or home. • Question use of substances, including tobacco, alcohol, street or illegal drugs, and use of contraception(s). Notation: This is an inconclusive list (developed by the author) and reflects recommendations for early assessment or identification in clinical practice. In addition, older adults, adults, children, and adolescents should be routinely screened for depression or emotional distress, suicide ideology/ suicide attempts, deliberate self-harm or harm to others, and should immediately be referred to the MSW or Crisis Counseling if screening results are positive for harm to self or others.
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and possible exposure(s) to IPV or DV.72-75 (See Assessing for exposures to IPV or DV among adults, children, and adolescents.) Such commonly associated risk or evidencebased risk factors include past or present traumatic or violent experiences, including bullying76-78; mental health diagnoses (for example, bipolar disorder, depression79); notably prevalent, subsequent comorbidities of asthma, IBS, diabetes, hypertension; and difficulty sleeping and chronic pain.80 NPs should understand that a violence risk assessment will take time and allocate an appropriate timeframe to ensure effectiveness.81 Similarly, the issue of safety including matters pertaining to confidentiality and the Health Insurance Portability and Accountability Act should always be considered as an important part of the assessment and screening process by the NP when considering assessing, screening, and possibly treating for exposures to IPV or DV.82 The documented, evidence-based policy/procedure or safety plan may include readily available access to the judicial system (if indicated) and an immediate patient referral system for or to the Medical Social Worker (MSW) in the practice office or community for timeliness, appropriate case management, and continuity of care.38 The patient should be provided with a current and updated list of communitybased resources (for example, local shelters or emergency crisis centers that will accommodate women, children, and adolescents or men, children, and adolescents) for support and assistance.83,84 (See IPV or DV screening clinical strategies and recommendations for HCPs in primary care.) In essence, the NP should have a legally documented, evidence-based policy/procedure or safety plan readily available in their facility prior to screening, assessing, and possibly treating for IPV or DV due to the potential or actual safety risks/issues, including risks for injuries and death for all involved.83,84 Additionally, the NP should be cognizant of the relevant state and local policies and laws for reporting to various authorities suspected or actual cases of victimization. Lastly, the patient should be rescheduled for a follow-up visit within 1 to 2 weeks to ensure efficacy and effectiveness of the proposed IPV or DV treatment plan.83,84 ■ Clinical diagnosing Clinical diagnosing may be difficult for the NP assessing or screening for exposures to IPV or DV among women, men, and children due to the private and sensitive nature of IPV or DV85,86 and child developmental issues, especially among young children.87,88 In the same way, assessing and screening for exposure(s) to IPV or DV may be difficult for adolescents as a result of issues relating to growth and development, including internalizing and externalizing www.tnpj.com
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Intimate partner violence: A guide for primary care providers
IPV or DV screening clinical strategies and recommendations for HCPs in primary care Identifying exposures to DV or IPV Identification of exposures to DV or IPV among all patient populations with use of evidence-based screening instruments available from various Domestic Violence or Intimate Partner Violence organizations and agencies including The Domestic Violence Survivor Assessment Tool and The Delphi Instrument for Hospital-based Domestic Violence Programs supported by the Agency for Healthcare Research and Quality (www.ahrq.gov) and the IPV Screening and Counseling Toolkit available from Futures without Violence (www.futureswithoutviolence.org).
Developing a safety plan for victims Development of a Safety Plan for Victims of IPV or DV in the practice setting. The Safety Plan should include a list of shelters for distribution for women, men, children, and adolescents, instructions on how to safely leave a dangerous situation and precautions. In addition, the victim or victims of IPV or DV should be provided with information on how to obtain confidential help from the legal and court systems. Include in public facilities such as restrooms, exam rooms, and waiting rooms posters regarding IPV or DV, local phone numbers, and websites for assistance with IPV or DV.
Providing resources Provide a list of toll-free phone numbers to the victim or victims such as the National Domestic Violence Hotline: 1-800-799-SAFE (1-800-799-7233) and their Local Domestic Violence Hotline as part of information provided to all patients.
Referring victims Referrals for victims of IPV or DV to evidence-based counseling or mental health interventions/programs (for example, Crisis Support, Cognitive Behavioral Therapy, Individual or Group Counseling) that assist in promoting the psycho-social-emotional and mental health well-being of victimized or traumatized patients should be initiated by HCPs in an appropriate and timely manner.
Collaborating with community and healthcare colleagues Collaboration with local community-based interventions or coordinated services and programs for victims of IPV or DV including MSWs and counselors, law enforcement, hospitals, court systems, and other treatment facilities.
Documenting safety plans Documented Safety Plans and Protocols for patients and staff in the healthcare facility for distribution and posting in the facility including common areas such as public restrooms and patient exam rooms or waiting rooms. Objective and thorough documentation of clinical visits and exam findings in the patients medical records.
Participating in IPV or DV education Participate in ongoing formal and informal IPV or DV training or education sponsored by various healthcare educational or professional organizations including the National Resource Center on Domestic Violence (www. nrcdv.org or www.vawnet.org), Domestic Violence Resource Network at www.acf.hhs.gov/programs/fysb/ fv-centers, and Medscape, LLC Continuing Medical Education activities at http://www.medscape.org.
Providing education Educate the patient regarding the cycle or patterns of an abusive and dangerous relationship and when to seek help. Sources: • Agency for Health Care Research and Quality. 2013. Rockville, MD. http://www.ahrq.gov/contact/index.html. • Futures Without Violence. 2013. http://wwwfutureswithoutviolence.org. • Office of Disease Prevention and Health Promotion U. S. Department of Health and Human Services. 2013. 2013 Toll-Free Numbers for Health Information. National Health Information Center, Office of Disease Prevention and Health Promotion, U. S. Department of Health and Human Services, Washington, DC. • National Resource Center on Domestic Violence. 2013. http://www.nrcdv.org/contact-us/. • National Online Resource Center on Violence Against Women. 2013. http://www.vawnet.org/contact/. • Family Violence Prevention & Services Resource Centers. Domestic Violence Resource Network (DVRN). 2013. http://www.acf.hhs.gov/programs/fysb/fv-centers. • Medscape, LLC. 2013. http://www.medscape.org/public/about.
behavior problems, sexuality, sexual risk-taking behaviors, prevalence of adolescent dating violence, and bullying.89-91 NPs may ask direct questions using age and developmentally appropriate language when communicating with children and adolescents in efforts to open up the lines of communication and promote an atmosphere of trust to www.tnpj.com
assist with clinical diagnosing.92 In a similar manner, the NP may further open up lines of communication for women, men, children, and adolescents by establishing and maintaining a trusting, caring, empathetic, nonjudgmental, and safe environment, which may assist with establishing a clinical diagnosis of IPV or DV.92-94 The Nurse Practitioner • December 2013 43
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Intimate partner violence: A guide for primary care providers
Ensuring a quiet and conducive environment will aid in facilitating an open, honest, and confidential communication exchange between the patient and NP.95 The NP may also want to assure that the patient is alone while screening for exposures to IPV or DV. Likewise, the NP should inform the patient prior to disclosure that the information shared will be held to the highest level of confidentiality. Nevertheless, the NP should apprise the patient that there is a possibility that the information may be shared with the legal system if there is any indication that a child, youth, or older adult may be at risk for harm or injury, according to the state mandatory reporting of abuse or neglect. In the same manner, the NP should continue to try to identify patients, including couples at special risk for relationship violence in an effort to possibly circumvent potential violence or possible negative outcomes.96-100 This may include screening and assessing for dating or relationship violence among high-risk groups, including children, adolescents, and young adult couples in an effort to lower the risk of relationship conflict and violence.47-49 Also, asking the following simple questions may aid in identifying whether or not a patient is at risk for IPV or DV: Do you feel afraid? Do you feel like someone is trying to harm or threaten you? Is someone hurting you? Has someone touched you in a way that made you feel afraid or uncomfortable? ■ Reducing IPV and DV IPV or DV has been deemed to be a serious and ever-growing global healthcare concern.23,24 NPs can play a key role in reducing the burden and global impact of exposures to IPV or DV among women, men, children, and adolescents in our society by incorporating–on a routine basis–screening for or identification of actual, potential, or possible exposures to IPV or DV in the primary care office.70,71 Thus, the conduction of a thorough assessment, including a comprehensive history and physical exam by NPs, may contribute to the current recommended early identification and preventive efforts as well as health promotion and disease prevention. Providing therapeutic treatment regimens for IPV or DV patients at the appropriate timeframes may alleviate the tremendous cost burden associated with IPV or DV.5-10 Finally, with the utilization of routine screening, assessment, and possibly treating of IPV or DV among women, men, children, and adolescents by NPs in the primary care office may assist in improving the lives and QOL for this population.18,23,25 ■ HCPs to promote well-being HCPs can and should be involved in all endeavors to promote the overall health and well-being of all women, men, 44 The Nurse Practitioner • Vol. 38, No. 12
children, and adolescents who self-disclose or are at risk for exposures to IPV or DV in society. By screening, assessing, and possibly treating for exposures to IPV or DV, the HCP may further contribute to the global efforts of minimizing or ameliorating the potential negative healthcare consequences that may occur as a result of such exposures.1 HCPs may contribute to the ongoing trend of incorporating evidence-based and inquiry-based science, theory, and practice in the primary care office as a result of screening or identification, assessment, and possible treatment of actual, potential, or possible exposures to IPV or DV on a routine basis for all patients.
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Dr. Clarissa Agee Shavers, DNSc is the Principal Investigator and Program Director of The Safer Tomorrows: Injury Prevention and Violence Reduction Project© of the United States of America, Canada, and West Indies Caribbean Trinidad and Tobago, Detroit, M.I.
The author has disclosed that she has no financial relationships related to this article.
DOI-10.1097/01.NPR.0000437577.21766.37
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