PANDORA’S BOX REVISITED:
TEACHING PRIMARY CARE PROVIDERS
TO ASSESS FOR DOMESTIC VIOLENCE

By
Lisa Kozar Bohen, RN, BSN, CEN

Submitted in Partial Fulfillment of the Requirements
For the Master of Science in Nursing Degree

Edinboro University of Pennsylvania

Approved by:

Jjmith Schilling, CRNP, PhD.
(Committee Chairperson

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William Xpoan, PhD.
Associate Provost, Academic Affairs
Director, Liberal Studies
Gannon University
Committee Member

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Priwry Care Provi
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Table of Contents
Contents

Page

Abstract

i

Chapter I - Introduction

1

Background of the Problem

1

Barriers to Treatment

2

Finding a Solution

3

Statement of the Problem

4

Theoretical Framework

5

Statement of Purpose

7

Assumptions

7

Limitations

8

Definition of Terms

9

Summary

10

Chapter II - Review of Literature

11

Defining Violence

11

An Historical Challenge

11

Statistics

13

The Violent Relationship

14

Injury Patterns Consistent with Abuse
The Primary Care Provider

Learning to Assess

Contents

Page

Documentation and Mandatoiy Reporting

20

Treatment and Referral

21

Summary

21

Chapter III - Methodology

23

Time Frame

23

Target Audience

24

Writing a Script

24

Production Facilities

24

Equipment

25

Filming Sequence

25

Evaluation and Editing

26

Distribution

27

Summary

27

References

28

Appendix A: Script

31

Appendix B: Evaluation Form

52

I

Abstract
Pandora s Box Revisited: Teaching Primary Care Providers to Assess for

Domestic Violence
Every 7 seconds in the United States, a woman is beaten by her male partner
(Hinterliter, Pitula, & Delaney, 1994). Domestic violence is the primary cause of
injury to women in the United States and injures more women yearly than motor

vehicle accidents, muggings, and rapes combined (Gagan, Badger, & Baker, 1999).
The costs to health care are staggering in terms of both lives and dollars;

approximately $44 million is required yearly to treat the effects of abuse (Gagan et
al., 1999).

Primary health care providers cite many barriers to the effective assessment
and treatment of domestic violence victims (Sugg, Thompson, Thompson, Mauiro, &

Rivera, 1999). The predominant theme among providers is a lack of confidence in

identification and management skills related to domestic violence (Sugg et al., 1999).
This lack of confidence can be correlated with a paucity of domestic violence
education within the medical curriculum. Medical schools in the United States

average only 2 required hours of domestic violence training and less than 50% of
family medicine residency programs require any type of education related to victims
of abuse (Rodriguez, Bauer, McLoughlin, & Grumbach, 1999). Other barriers

include (a) lack of time, (b) personal history of abuse, (c) denial, and (d) a sense of

powerlessness to change the victim’s situation (Gremilion & Kanof, 1996).

ii

In order to provide domestic violence education to primary care providers, a
teaching video was developed. The goal of the video was to create an educational

tool with a nonthreatening format, that providers could view to improve assessment

and management skills related to domestic violence. The video was developed using
the theoretical framework of Health Promotion by Nola Pender (Pender, 1996). The

video provides an overview of the problem of domestic violence, information on
assessment, and several vignettes in which providers can view role-plays involving

domestic violence victims. A copy of this video is available at the Baron-Fomess
Library at the Edinboro University of Pennsylvania.

In summary, domestic violence remains a significant cause of morbidity in the
adult population (Gremillion & Kanof, 1996). Primary care providers may not assess

patients for domestic violence related to a myriad of barriers. In order to eradicate
domestic violence from the scope of American health care, all providers need to have

primary indoctrination as well as continuing education in domestic abuse.

1

Chapter 1
Introduction

This chapter provides a discussion about domestic violence. It includes
working definitions of domestic violence and abuse as well as current statistics

regarding the prevalence and epidemic of domestic violence in the United States.
This chapter also provides a basic understanding of why health care providers do not
provide domestic violence assessment for their patients on a regular basis, thus

contributing to the continuing morbidity of violence. The Health Promotion Model,
as presented by Nola Pender (1996), provides the conceptual framework for this
scholarly project. The problem statement, purpose of the project, assumptions, and
pertinent definitions are provided.

Background of the Problem
Every 7 seconds in the United States, a woman is beaten by her male partner
(Hinterliter, Pitula, & Delaney, 1994). Domestic violence is the primary cause of
injury to women in the United States and injures more women yearly than motor

vehicle accidents, muggings, and rapes combined (Gagan, Badger, & Baker, 1999).

Of all women seeking treatment in emergency departments, 22% to 40% are victims
of abuse (Gagan et al., 1999).

When victims of domestic violence seek help or escape from abusive
situations, they often choose to seek out physicians and nurses with the perception
that they will be the most helpful (Gremillion & Kanof, 1996). Unfortunately, this
may be an erroneous perception. Currently, only 7% to 25% of domestic violence

cases are identified by primary care providers and only 2% to 7% of patients seen in

2

ambulatory care settings are assessed for verbal or physical abuse (Sugg,

Thompson, Thompson, Maiuro, & Rivera, 1999).

Barriers to Treatment. Primary care providers cite many barriers to the
effective assessment and treatment of domestic violence victims. Overwhelmingly,
providers list a lack of confidence in identification and management skills related to

domestic violence (Sugg, Thompson, Thompson, Maiuro, & Rivera, 1999). This
lack of confidence has been related to educational deficits in the care of an abused

patient. Rodriguez, Bauer, McLoughlin, & Grumbach (1999) found that medical
schools in the United States only required an average of 2 hours of domestic
violence training and less than 50% of family medicine residency programs required

any type of education related to victims of abuse. A recent survey of California

physicians demonstrated that only 22% had domestic violence education within the
5 years prior to the survey (Rodriguez et al., 1999).
Another barrier includes a lack of time as evidenced in a 1992 study by Sugg

and Inui. Physicians were interviewed regarding their experiences with domestic
violence victims. Many physicians interviewed made reference to the issue of

domestic violence as “opening Pandora’s box.” They believed that by assessing
victims for domestic violence they might find situations that they could not

effectively manage within the 15 minute time frame of the office visit. This is
expressed in the following:

I think that some physicians and I do the same thing, if you are very busy

and have lots of patients waiting, you just don’t ask a question that you

3

know is going to open a Pandora’s box. Even if it crosses your mind, you
don’t ask. (Sugg & Inui, 1992, p. 3158)

Other barriers cited by health care providers included fear of offending

patients with assessment questions (Sugg, Thompson, Thompson, Mauiro, &
Rivera, 1999). However, a study of primary care patients showed that 85% did not
believe that assessment for violence was invasive or offensive (Sugg et al., 1999).

Providers also may have difficulty coming to terms with the presence of abuse

within their practices. A study reported in 1999 revealed that 50% of clinicians, and
70% of nurses and other health care workers, believed that domestic violence was
either rare or very rare. Only 12 % of clinicians and 1% of nurses and other health

care workers believed that it was common (Sugg et al, 1999).
Personal factors also played a part in the reluctance of primary care

providers to assess patients for domestic violence (Gremilion & Kanof, 1996).

These factors can include (a) sex bias, (b) a personal history of abuse, (c) idealized

concepts of family life, and (d) a sense of powerlessness to change the victim’s
situation.

Finding a solution. Primary care workers routinely screen patients for a

variety of conditions (Titus, 1999). Assessment data bases include questions about
smoking, alcohol intake, and cholesterol levels. These questions are asked in order

to reduce the morbidity and mortality of chronic, preventable diseases such as

cancer and heart disease. Clearly then, in order to reduce the morbidity and
mortality of domestic violence, patients must be routinely screened for domestic

4

violence at all visits in all health care facilities (Titus, 1996). According to King

(1996):
If one third of all women had breast cancer, certainly I would be asking all
women about their of risk or current knowledge of breast cancer. Knowing

that abuse happens, questions about it should be among the foremost
questions we ask (p. 1864).

Statement of the Problem

Domestic violence remains a significant cause of morbidity in the adult
population (Gagan, Badger, & Baker, 1999). It is estimated that 2 to 4 million
incidents of domestic violence occur each year in the United States. Victims of
domestic violence often feel powerless to end the cycle of abuse (Gremillion &

Kanof, 1996). They often perceive their primary care providers as a vital link to
safety. Victims may feel unable to list abuse as a chief complaint but may present

with a variety of somatic and stress-related illnesses (Rodriguez, Bauer,

McLaughlin, & Grumbach, 1999).
Primary care providers often do not assess adult patients for incidences of
domestic violence during routine health care visits (Rodriguez, Bauer, McLaughlin,
& Grumbach, 1999). Providers may feel inadequately trained to assess patients for

a variety of reasons including lack of education, lack of confidence in assessment,

and personal discomfort with domestic violence issues (Rodriguez et al., 1999).
Because patients receive either inadequate or no assessment, many adult women and

men continue to be at risk for injury or death from abusive intimate partners
(Stapleton, 1997).

5

Theoretical Framework
The Health Promotion Theory of Nursing (Pender, 1996) provides an

interactive process by which prevention and health promotion become the
gatekeepers to wellness in the adult population. Using Pender’s theory, behaviors
are modified to provide optimal health and wellness. When unhealthy behaviors are

not identified, they proceed to illness behaviors and the focus of prevention and
wellness is lost.
Pender (1996) sees wellness and health promotion as stemming from three
distinct categories. These categories include (a) individual characteristics and

experiences, (b) behavior-specific cognitions and affect, and (c) behavioral
outcome. The behaviors in these categories can lead to or away from health

promotion dependent upon the individual’s current access to health promotion and
care.

Individual characteristics and experiences are based on both prior related
behaviors and personal factors. These personal factors are biological, psychological

and sociocultural (Pender, 1996). As applied to primary care providers, the barriers
to assessment of domestic violence victims can be based on both prior related

behaviors and personal factors. Frustrating past experiences with assessment,
personal experience with domestic violence, lack of sufficient education related to
assessment, and denial can all be categorized within these realms.

An individual’s prior related behaviors and personal factors then lead to
behavior-specific cognitions and affect. Prior related behaviors will lead to four
possible activities including (a) perceived benefits of action, (b) perceived barriers

6

to action, (c) perceived self-efficacy, and (d) activity-related affect (Pender, 1996).

Thus, a lack of knowledge related to the magnitude of domestic violence in a given
practice as well as any past aborted or disastrous attempts at domestic violence

assessment by a primary care provider may lead to perceptions of inadequacy and
failure and thwart any further attempts by the provider.
Personal factors will also be affected by the interpersonal influences of

family and peers. These influences provide norms, support, and models of behavior
(Pender, 1996). Personal factors may also be affected by situational influences to

provide the individual with options, demand characteristics, and aesthetics of any
given situation. Within the realm of domestic violence assessment, a past personal
experience with violence, denial, or a personal bias related to domestic violence

victims may be formed related to the perceived norms and attitudes as created by
both interpersonal and situational influences (Pender, 1996).
Both prior related behaviors and personal factors can lead to health
promoting behaviors either directly or through behavior-specific cognitions and
affect (Pender, 1996). The health promoting behavior is dependent upon the

immediate competing demands and preferences of the individual. Issues such as
time, education, professional support, and the ability to provide appropriate

resources to a domestic violence victim, may all be factors which can effect the

primary care provider and that can be included within these behavioral outcomes.
The Health Promotion Model ideally embraces the dilemma of domestic

violence with an interactive structure based upon individual characteristics and

experiences, behavior-specific cognitions and affect, and behavioral outcomes

7

(Pender, 1996). The education of primary care providers, including nurse
practitioners, to recognize and treat domestic violence can assist providers to
embrace their commitment to a specific plan of action leading to the health
promoting behavior of domestic violence eradication.

Statement of Purpose
The purpose of this scholarly project was to produce an educational

videotape program that will teach primary care providers to reduce or eliminate the
barriers to domestic violence assessment in their patient populations. This video

presents an overview of the morbidity and mortality of domestic violence. It
provides statistical and theoretical information regarding domestic violence. It

teaches primary care providers assessment skills in order to identify those patients
who may be at risk, or who are already involved in a violent relationship. This tool

teaches providers appropriate intervention skills and resources in order to empower
victimized patients with safety plans for themselves and their families.

Assumptions
For the purpose of this study, the following assumptions were made:

1. Primary care providers desire the personal safety of their patients.
2. Patients in violent relationships desire safety for themselves and their

families.

3. Patients in violent relationships will reveal abuse to
primary care providers in an environment they perceived as safe.

8

4. Primary care providers may lack the skills and knowledge to assess

their patients for domestic violence.
5. Primary care providers are motivated to learn assessment skills and to

remove assessment barriers in order to assist their patients.
6. The educational and clinical backgrounds of nurse practitioners

make them ideal candidates to provide primary, secondary, and tertiaiy care to
patients involved in violent relationships.
Limitations
The limitations of this project are identified as follows:

1. The magnitude of the topic of domestic violence is difficult to contain

within a videotape format conducive to the attention span of the average learner.
2. Because of the confidentiality protecting the victim of domestic abuse,

actors were used in filming the videotape. This may have resulted in a diminished

emotional affect.
3. The videotape was filmed at the offices of a primary care provider, so

filming could only take place in the evenings and weekends resulting in a serious

time constraint.
4. The physical size and lay-out of the medical offices made camera

position and lighting difficult.
5. Budgetary constrains prevented the use of film clips which may have

enhanced the final product.

9

Definition of Terms

The following terms are defined as they apply to this project:
1. Partner violence is the threat or infliction of harm between past or

present intimate partners, without regard to the legal or domiciliary status of the
violent relationship (Flitcraft, 1995).
2. Violence is the use of physical force resulting in injury or abuse (Mish,
1993).

3. Domestic violence is the assault, threat, or intimidation of an intimate

partner (Abbott, Johnson, Kozial-McClane, & Lowenstein, 1995).
4. Mandatory reporting consists of laws that mandate reporting of

suspected domestic violence by health care providers (Glass & Campbell, 1998).
5. Abuse is physical, sexual, emotional or verbal (Parsons,
Zaccaro, Wells, Stovall, & Thomas, 1995).

6. Emotional abuse consists of one partner using psychological or
emotional factors in order to manipulate or intimidate another partner (Gagan,

Badger, & Baker, 1999).
7. Battering Syndrome is a condition in which victims of assault

experience a general increase in somatic symptoms and emotional problems
(McCauley et al., 1995).
8. Intimate partner violence is any physical, emotional, or sexual abuse to
an individual by a current or past intimate partner (Rodriguez, Bauer, McLoughlin,

& Grumbach, 1999).

9. Pandora’s box is “the box sent by the gods to Pandora, which she was

10

forbidden to open and which loosed a swarm of evils upon mankind when she
opened it out of curiosity” (Mish, 1993).

Summary

Domestic violence is a significant cause of morbidity and mortality in the
United States (Gagan, Badger, & Baker, 1999). Despite victims’ perception of

health care providers as vital sources of relief, physicians and nurses often do not

assess patients for domestic violence in emergency department, primary care, or

clinic settings (Gremilion & Kanof, 1996). The issue of domestic violence and its
sequelae has been likened by some health care providers as opening a Pandora’s box

for which they are ill prepared (Suggs & Innui, 1992). There are currently a myriad
of barriers preventing primary care providers from adequately assessing and treating
victims of domestic violence (Sugg, Thompson, Thompson, Mauiro, & Rivera,
1999). These barriers stem from both perceived and real inadequacies in the

education of primary care providers related to violence.
In order to eradicate domestic violence from the scope of American health

care, all providers need to be educated in domestic abuse. As indicated and
supported by the Health Promotion Model (Pender, 1996), education will help to

eliminate the barriers to domestic violence assessment. The purpose of this project
is to provide a videotape that can provide primary care providers with education and

guidance related to domestic violence to assist them in making accurate and

compassionate assessments of all patients.

11

Chapter Two
Review of Literature

This chapter provides a review of literature related to domestic violence. It

encompasses studies and anecdotal articles from 1989 to the present. It is noted that
the literature concerning the issue of domestic violence is vast. Therefore, attempt
has been made to provide a concise overview. The issues covered include the

history of violence, statistical information, definitions related to the violent
relationship, injury patterns consistent with abuse, and assessment techniques. An
overview of documentation, mandatoiy reporting, and guidelines for treatment and
referral are also included.

Defining Violence
By strictest dictionary definition, violence can be defined as (a) exertion of
any physical force so as to injure or abuse, (b) injury by or as if by distortion,
infringement or profanation, and (3) intense, turbulent and often destructive action

or force (Mish, 1993). When violence is used by one human against another, it is a
claim of power and control (Toffler, 1990). Violence is identified as one of the

three fundamental sources of all human power, the other two being money and
knowledge. Toffler (1990) described violence as the lowest form of power because

it can only be used to punish.
An Historical Challenge

When assessing patients for domestic violence or hearing stories about

women who are being abused, the most frustrating question asked is often, “Why

12

does she stay?”(Hoff, 1992). A close examination of the history of violence against
women can provide some answers to that question.
Violence has historical roots in several areas including economic, social,
cultural, social-psychological, and political/legal (Hoff, 1992). Women have
historically been economically disadvantaged related to their male partners.
Women began the 19 century as the property of the men with whom they lived,
either fathers or husbands. They ended the 20th century still economically

disadvantaged, making only 72 cents to every dollar earned by men. Women and
children continue to comprise the largest block of indigent Americans, especially if

they are women and children of color. When divorcing or leaving a male partner, a

woman’s standard of living will tend to decrease by 73%. A man’s standard of
living after divorce will tend to increase by 42%. Thus a woman may not be
financially empowered to leave an abusive situation (Hoff, 1992).
Social and cultural standing also play an important role in the continued
victimization of women (Hoff, 1992). Many women feel unable to leave an abusive

situation as the loss of a relationship may mean a loss of social standing within the

community or circle of peers. Women may also have been raised in families where
they are socialized to be the “gentle sex.” They are encouraged to assume the

majority of responsibility for child-rearing and family development. These social
bonds may be impossible to break even in the face of a violent relationship.
There are also political and legal obstacles for women to overcome in

abusive relationships (Hoff, 1992). Traditionally, spousal violence has been treated

by the law as a private matter between husband and wife, related to the wife’s status

13

as the property of her husband. Indeed, the common expression “rule of thumb”

evolved from the judicial custom of permitting a man to beat his wife as long as the
stick was no thicker than the man’s thumb. By assessing the historical context of
violence, it can become clear why society is making inadequate headway in the

eradication of domestic violence.
Statistics

A woman is beaten by a male partner every 7 seconds in the United States
(Hinterliter, Pitula, & Delaney, 1994). Partner violence is the leading cause of
injuiy to women in the United States with 3 to 4 million women abused each year
by an intimate partner. The primary cause of serious injury to women between the

ages of 15 and 44 is domestic violence (Sisley, Jacobs, Poole, Campbell, &
Esposito, 1999). Approximately 17% of nonfatal, violence-related injuries were

inflicted by someone with whom the victim had an intimate relationship (Stapleton,
1997). Yearly, women experience over 572,000 violent victimizations committed

by an intimate partner (Stapleton, 1997). One in five American women can expect
to be involved in a violent relationship at some time in their lives, generally between

the ages of 18 and 24 (Flitcraft, 1995). One in six women is assaulted during
pregnancy. At every age in the lifespan, women are more likely to be assaulted by

an intimate partner than by a stranger (Flitcraft, 1995).
Domestic violence is also a burden on financial resources (Poirier, 1997).

The yearly cost of treating domestic violence victims is estimated at $44 million

dollars. There are 28,700 emergency room visits and 39,000 physician office visits
yearly related to domestic violence (Poirier, 1997).

Women who are victims of

14

violence access the health care system at a cost that is 92% higher than women who

have not been abused (Wisner, Gilmer, Saltzman, & Zink, 1999).
In a study of managed care enrollees, victims of domestic abuse spent $1775
more each year than those women not abused (Wisner et al., 1999). This study
analyzed the computerized cost data for 126 women who had been identified as

domestic violence victims and who were enrolled in a managed health care plan in

Minnesota. The cost data were compared against a random sample of 1007

generally enrolled female patients of the same managed care plan who had used
health care services in that same year. A history of domestic abuse is thought to be
so clearly associated with higher morbidity and mortality that some insurance

companies have attempted to define it as a “pre-existing condition” and denied

health care benefits on that basis (Sisley, Jacobs, Poole, Campbell, & Esposito,
1999).

The Violent Relationship

Clearly, not all relationships become violent. However, there are few
consistent positive predictors for domestic violence and any relationship can

become violent at any time (Hinterliter, Pitula, & Delaney, 1994).
The most common theory of violence is the Cycle of Violence (Walker,

1979). This theory describes the violent relationship as having three distinct phases:
(a) The Tension Building Phase, (b) The Violent Explosion, and (c) The

Honeymoon Phase.

According to Walker (1979), the Tension Building Phase is a phase of less
severe violence as the batterer becomes progressively more cruel. The victim will

15

attempt to placate the batterer and will withdraw and suppress her own anger in

order to avoid conflict. This suppression can build tension and cause the victim to
have feelings of low self-esteem and guilt.

The second phase in the cycle is the Violent Explosion (Walker, 1979).

Within this phase, the batterer inflicts severe or fatal injury to the victim. This

results in a regaining of power and control over the victim. The victim, in turn,
experiences a learned helplessness consisting of powerlessness and loss of control.
The victim is incapable of stopping this phase or lessening the abuse.
Finally, according to Walker (1979), the relationship evolves into the
Honeymoon Phase. During this phase, the batterer is calm and even penitent about
the abuse. The batterer may promise never to abuse the victim again and may be

loving and generous. However, tension in the relationship will rebuild and the cycle
will continue unbroken.

Injury Patterns Consistent with Abuse
The patterns of injury and illness in domestic violence are diverse (Sisley,

Jacobs, Poole, Campbell, & Esposito, 1999). The physical injuries sustained during
abuse may range from minor cuts and scrapes to lethal gunshot wounds (Sisley et

al., 1999). Battered women are more likely to be injured in the head, face, neck,

throat, chest and abdomen, whereas nonbattered injured women are more likely to
be injured in the spine and lower extremities (Muelleman, Lenaghan, & Pakieser,

1996). A ruptured tympanic membrane has a positive predictive value of 100% for
physical abuse (Muelleman et al., 1996). Other physical signs that a person may

have been physically abused include (a) injuries on unusual parts of the body, on

16

several different surfaces or in central areas such as the face, neck, throat, chest,
abdomen or genitals, (b) fractures that require significant force or that rarely occur

by accident, such as spiral fractures, (c) multiple injuries at various stages of
healing, (d) patterns left by whatever object was used to inflict injury such as belts,

teeth, ropes or utensils, and (e) injuries to a pregnant woman (Chez, 1994).

Nontraumatic injury may also be indicative of abuse (Campbell, Anderson,

Fulmer, Girouard, McElmurry, & Raff, 1993). Recent research reflects pain as the
most common physical complaint of abused women in the health care system
(Campbell et al., 1993). Victims of long-standing abuse may present with a

“battering syndrome” in which physical abuse is followed by an increase in general
medical symptomatology combined with emotional illness (Gremillion & Kanoff,
1996). Victims may have subtle and somatic complaints ranging from chest pain to
fatigue, headache, gastrointestinal upset, insomnia, back pain, and depression

(Gagan, Badger, & Baker, 1999). They may also have histories of irritable bowel
syndrome, arthritis, and pelvic inflammatory disease related to years of physical

assault (Campbell et al., 1993). Behavioral clues to abuse may include (a) repeated

visits to health care facilities, (b) complaints of pain without obvious tissue injury,
(c) suicidal attempt or ideation, and (d) considerable delay between onset of injury
and presentation to a health care facility for treatment (Gagan et al., 1999).
The Primary Care Provider

Primary care providers are still often unwilling and/or unable to assess and
treat the victims of violence. In a recent study, approximately one in 35 female

emergency department patients was cormctl, identified as being a victim of

17

domestic violence where a chart review of patient histoiy and complaints showed

that one in four patients were battered women (Sisley et al., 1999). Another study

conducted m an outpatient family practice clinic showed that 22.7% of the female
patients reported being assaulted by an intimate partner during the year prior to the
sample. Less than 2% of these women had ever been asked about domestic violence

by their primaiy care provider.
The failure to diagnose and document domestic violence can perpetuate the

cycle of violence and increase morbidity and mortality (Sisley, Jacobs, Poole,
Campbell, & Esposito, 1999). In a study examining frequency and type of

emergency department visits of domestic violence-related homicide victims, 44%
had presented to an emergency department in the year prior to death. Of these

victims, 93% had an injury-related complaint. Health care providers had

documented only one intervention for domestic violence in that 93% (Sisley et al.,
1999).

There are several identified barriers to consistent assessment for domestic

violence by primary care providers (Sisley, Jacobs, Poole, Campbell, & Esposito,

1999). These barriers include lack of training, lack of confidence in assessment, and

a real or perceived lack of resources when an abuse victim is identified. Only 23%
of California emergency departments provided continuing education related to
domestic violence for their staff.
A mail-in survey of California obstetrical and gynecological medical
residents in 1999 showed that 75% were unable to recognize clinical scenarios

related to domestic violence on a questionnaire (Sisley et al., 1999). A lack of

18

clinical protocols related to domestic violence and the mandated brevity of office
visits may also play a large part in assessment deficits (Eisenstat & Bancroft, 1999).

Most health care workers across the spectrum do not receive formal training
in assessing domestic violence (Sisley, Jacobs, Poole, Campbell, & Esposito, 1999).

This lack of training leads to a knowledge deficit related to domestic abuse as well

as perpetuation of the myths of abuse. These myths include (a) the belief that
domestic violence is rare, (b) that only certain social classes or racial groups are

victims of domestic violence, and (c) that patients would be offended by domestic
violence assessment (Sisley et al., 1999).

Primary care providers may also feel inadequate in their abilities to assess
for domestic violence and helpless to assist victims related to knowledge deficits

regarding available resources (Sisley, Jacobs, Poole, Campbell, & Esposito, 1999).
Because of these knowledge deficits, primary care providers may also have
unrealistic expectations regarding the ability of a woman to leave an abusive

situation. This can lead to frustration and impatience and destroy fragile bonds of

trust between the victim and the provider.
Learning to Assess
The self-reporting of domestic violence in the primary care setting is

approximately 8% (Sisley et al., 1999). With assessment this figure rises to 29%

(Sisley et al., 1999). It is, therefore, clearly imperative that all women be screened
at all visits in all health care facilities with the goal of early intervention and

prevention (Eisenstat & Bancroft, 1999).

19

There are many opportunities to screen women for domestic abuse in the

primary care setting (Family Violence Prevention Fund, 2000). These can include
(a) while taking a routine health history, (b) during a routine health assessment, (c)

during an initial visit for a new health complaint, (d) during a visit with a new
patient, (e) after a patient has started a new intimate relationship, and (f) during a

periodic, comprehensive health check-up.
When screening for abuse is performed in a sensitive and nonjudgmental

manner, victims of abuse are not offended by the assessment (Sisley, Jacobs, Poole,
Campbell, & Esposito, 1999). In fact, a lack of assessment may be perceived by
victim as a lack of concern and may increase feelings of entrapment and
helplessness. Victims of domestic violence need to know that the provider

recognizes that there is a problem, that the violence is unacceptable, and that the

provider is willing to act as an advocate for the victim.
There are several assessment tools available to assist primary care providers
in the identification of domestic violence. The mnemonic RADAR may be a useful

assessment tool and includes (a) Remember to ask about violence and victimization
in the course of the routine patient encounter, (b) Ask directly, (c) Document
findings in the medical record, (d) Assess safety, and (e) Review options and refer

as appropriate (Alpert, 1995).
The Partner Violence Screen (PVS) consists of three questions: (a) Have you

been kicked, bit, punched or otherwise hurt by someone within the past year? If so
by whom? (b) Do you feel safe in your current relationship? (c) Is there a partner
from a previous relationship who is makmg you feel unsafe now? (Sisley, Jacobs,

20

Poole. Campbell & Esposito, 1999). Thl, screen has been shown to be 65% to 70%
successful in assessing domestic violence victims and takes an avernge time of 20
seconds to administer (Sisley et al., 1999).
Documentation and Mandatory Reporting

The documentation of domestic violence is both necessary and controversial
(Eisenstat, 1999). Obviously, clear documentation is necessary in order to assist the

victim with future legal proceedings. The documentation of injuries should include
location, depth, direction, character, and appearance of all wounds (Eisenstat, 1999).

This documentation should be completed in clear, objective, medical terminology.

Controversy exists in documentation of domestic violence injuries related to
confidentiality and safety of the victim (Glass & Campbell, 1998). Information
which might be gleaned by the batterer may lead to retaliation (Eisenstat, 1999).

Several states have passed legislation mandating the reporting of violence on
a variety of levels (Glass & Campbell, 1998). Proponents of mandatory reporting
list the objectives to include (a) the enhancement of safety of the abused woman,

(b) data collection regarding incidence and prevalence of domestic violence, (c)

documentation, and (d) to enhance the ability to respond effectively to a victim of
domestic violence, (Glass & Campbell, 1998). Opponents of mandatory reporting
believe that unless informed consent is obtained from all victims, the mandatory

reporting system may actually revictimize the abused woman and even further

imperil her safety (Glass & Campbell, 1998).

21

Treatment and Referral
The treatment of the domestic violence victim includes interventions on

primary, secondary, and tertiary levels (Gagan, Badger, & Baker, 1999). Primary

prevention in domestic violence is aimed at avoiding dangerous levels of violence
through health promotion activities. This can include helping the victim to create a

safety plan when danger is imminent. The safety plan includes access to documents

that validate identification and eligibility for assistance, access to transportation,
extra sets of keys, emergency money, emergency phone numbers, a safe place to go

for the night, and a packed suitcase containing whatever the victim and any children
may need during an emergency stay (Chez, 1994).

Secondary prevention involves the early detection and treatment of violence

and it’s sequelae in order to prevent permanent complications and loss of function

(Gagan, Badger, & Baker, 1999). Direct assessment for abuse, resource referrals,
and clear medical documentation are considered to be secondary prevention

measures (Gagan, et al., 1999). Tertiary prevention includes those activities that
take place when violence has already occurred such as counseling, injury treatment,

and physical rehabilitation (Gagan, et al., 1999).

Summary
Domestic violence is well documented os a significant cause of morbidity

and mortality. Violence has roots in the economic, social, cultural, s

psychological, and politicaHegal arenas (Hoff, 1992). Despite the prevalence of

domestic violence, victims can be difficult to assess related to the lack of predrchve
factors for a violent relationship (Hinterliter. Pitula, & Delaney. 1994). The diverse

22

patterns of complaint and injury may also hinder accurate assessment and diagnosis

of abuse (Sisley, Jacobs, Poole, Campbell, & Esposito, 1999). In addition, primary

care providers may have significant barriers to assessment including lack of
education and confidence, lack of time, and personal factors (Sisley et al., 1999).
Primary care providers need thorough and continuing education to recognize and

assess for domestic violence in their patient populations and provide primary,

secondary and tertiary care.

23

Chapter Three
Methodology

The purpose of this scholarly project was to produce a teaching and training

film for primary care providers. Domestic violence has been shown to be a
significant source of morbidity and mortality in the United States (Stapleton, 1997).
Victims of domestic abuse have shown confidence in health care providers as links

to safety, yet many providers do not assess their patients for domestic abuse on a

routine basis (Gremilion & Kanof, 1996).

There are several barriers cited by providers as being incremental in their
lack of assessment. Many providers have noted a lack of confidence in assessment

skills (Sugg et al., 1999). This lack of confidence can be related to the paucity of

primary and continuing education required by medical and nursing schools related
to domestic violence (Rodriguez, Bauer, McLoughlin, & Grumbach, 1999).

In response to this lack of confidence, this educational video tool seeks to
provide a basic overview of domestic violence as well as assessment techniques for
use by the primary care provider. The video is aimed at health care professionals,
primary care providers, and ancillary nursing staff.

Time Frame
The project was prepared in several steps. The first step was to assess the

target audience and decide what information to include in the tape. An arbitrary

time frame of 20 minutes was selected as no data were available related to attention

24

spans most conducive to learning. This time was felt to be adequate for presenting a
complete overview of material without becoming overwhelming. The target time
frame also respected the primary care provider’s time limitations and is only 5

minutes longer than a standard office visit. The format of a videotape presentation
was also felt to be more user-friendly and could provide professional continuing

education at the office or at home as needed.

Target Audience
The target audience for this videotape included any and all health care

professionals who might have an opportunity to interview patients on a regular
basis. Examples of interview opportunities include initial health histories, routine
check-ups, prenatal care, and acute care visits.
Writing a Script
Based on the review of literature, topics for the script were determined and
the script was written (Appendix A). After careful study and review of the current

literature, the script was broken down into the following: (a) an overview with
statistics, (b) discussion of assessment barriers, (c) examples of injury patterns, (d)

tools for assessment, (e) resources for referral, and (f) a summary.

Production Facilities
In order to produce the videotape, filming facilities and equipment were
needed. WSEE, a television station in fine, Pennsylvania, was consulted and

graciously agreed to provide equipment and production time free of charge. A
medical facdity was needed for filming pmposes and the offices of Heaithy Families

Primary Care. Erie, PA were offered In order to proleet cunent patient

25

confidentiality, all filming would be

during

primary care facility. Because of the sensitive nature of this topic, actors were

chosen to portray medical personnel and victims of domestic violence.
Production began once the script was completed and the facilities procured.

Two 8 hour days were scheduled for shooting. These days were on the weekend
after office hours during April, 2001.

Equipment
The equipment needed to produce the videotape included cameras, lights,

microphones, and editing equipment. The camera used was a JVC KYI 9 3-CCD.
The lighting kit was a Kliegl Brothers portable light kit. The video tape recorder
was a JVC % inch portable videocassette recorder, VO-8800. The videotape used
was Quantegy % inch videotape. The microphones were Lectronics CR187 wireless

microphone system. It was edited on an Apple Power Macintosh, 9600/300 using
the Spherous software editing system. Music utilized in the videotape was selected

from the Valentino Music Library. The final product was presented on Fuji Yz inch

videotape.
Filming Sequence

The videotape begins with a dramatic vignette showing a physician taking a
history and physical of a female patient. An on-camera host then introduces the
program and provides an overview of domestic violence. The statistical segment is

presented using onscreen graphics to enhance the information and keep the viewer’s

attention. Onscreen graphics were also used to explain the common barriers to
assessment. Music was used prior to the introduction and interspersed to segue

26

between topics. Different types of lighting were used throughout the videotape in
order to differentiate between narration, clinical presentation, and vignette.
Throughout the videotape, information is accented and reinforced with the

use of dramatic vignettes. The vignettes were created by volunteers, none of whom
are professional actors. A basic script was provided, but improvisation was

permitted as long as the basic sentiment of the piece was maintained. This gave
these segments a more natural tone. Comments by the host were interspersed
between each vignette to provide segue between topics.

Each segment was shot several times at different angles. This method

permitted a greater variety of options from which to edit the final product and
offered a greater opportunity to present a detailed and interesting videotape.

Evaluation and Editing
Upon completion, the videotape is 26 minutes long. Although this is six
minutes longer than originally anticipated, upon discussion with the producer and

director, it was unclear what areas could be removed without losing the integrity of
the message.

The completed tape was then shown to a focus group consisting of nurse

practitioner students. This group was given an evaluation form to complete at the
end of the tape (Appendix B). The response from this focus group w
overwhelmingly favorable, and no changes were made to the tape based on this
focus group.

27

Distribution

This videotape is available, free of charge, to educate health care providers
and students. A copy of this tape has been donated to the Nurse Practitioner
program of Edinboro University of Pennsylvania and will be available through the

Baron-Fomess Library.
Summary
The goal of this videotape is to promote interest and improve assessment

capabilities of primary care providers related to domestic violence. With the help of

this videotape, the personal safety of primary care patients can be increased and the

morbidity and mortality of domestic violence decreased.

References

Abbott, J., Johnson, R., Koziol-McLain, J,. & Lowenstein, S. (1995). Domestic
violence against women. JAMA, 273, 1763-1767.

Alpert, E. J. (1995). Violence in intimate relationships and the practicing
internist: New “disease” or new agenda? Annals of Internal Medicine, 123, 774-781.

Campbell, J. C., Anderson, E., Fulmer, T. L., Girouard, S., McElmurry, B., &

Raff, B. (1993). Violence as a nursing priority: Policy implications. Nursing Outlook,

41, 83-92.

Chez, N. (1994). Helping the victim of domestic violence. American Journal of

Nursing, 33-37.
Eisenstat, S. A., & Bancroft, L. (1999). Primary care: Domestic violence. New

England Journal of Medicine, 341, 886-892.
Flitcraft, A. (1995). From public health to personal health: Violence against
women across the lifespan. Annals of Internal Medicine, 123, 800-802.
Gagan, M. J., Badger, T. A., & Baker, M. (1999). Nurse practitioner

interventions for domestic violence. Clinical Excellence for Nurse Practitioners^, 273278.

Glass, N„ & Campbell, J. C. (1998). Mandatory reporting of intimate partner
violence by health professionals: A policy review. Nursing Outlook, 46,279-283.

Gremillion, D. H. & Kanof, E. P. (1996). Overcoming barriers to physician
involvement in identifying and referring victims of domestic violence. Annals of
Emergency Medicine, 27, 769-773.

Hinterliter, D, Pitula, C., & Delaney, K. (1998). Partner violence. American

Journal of Nurse Practitioners, 32-40.
Hoff, L. A. (1992). Battered women: Understanding, identification, and

assessment. Journal of the American Academy of Nurse Practitioners, 4, 148-155
McCauley, J., Kern, D. E., & Kolodner, K. (1995). The battering syndrome:
Prevalence and clinical characteristics of domestic violence in primary care internal
medicine practices. Annals of Internal Medicine, 123,737-746.

Mish, F. (Ed.)(1993). Merriam Webster’s Collegiate Dictionary (10th ed.).
Springfield, MA: Merriam-Webster, Inc.

Muelleman, R. A., Lenaghan, P. A., & Pakieser, R. A. (1996). Battered women:
Injury locations and types. Annals of Emergency Medicine, 28,486-492.
Parsons, L, Zaccaro, D., Wells, B., & Stovall, T. (1995). Methods of and attitudes
toward screening obstetrics and gynecology patients for domestic violence. American
Journal of Obstetrics and Gynecology, 173, 381-386.
Pender, N. J., (1996). Health promotion in nursing practice (3rd ed.). Stanford,
CT: Appleton & Lange.

Poirier, L. (1997). The importance of screening for domestic violence in all
women. The Nurse Practitioner, 22,105-122.
Rodriguez, M., Bauer, H., McLoughlin, E., & Grumbach, K. (1999). Screening

and intervention for intimate partner abuse: Practices and attitudes of primary care
physicians. JAMA, 282, 468-474.

Sadovsky, R. (1997). Patterns of injury type and location in battered women.
American Family Physician, 55, 1379-1380.

Sisley, A., Jacobs, L. M., Poole, G., Campbell, S., & Esposito, T. (1999).

Violence in America. A public health crisis — domestic violence. Journal of Trauma, 46,
1105-1112.

Stapleton, S. (1997). Treating domestic violence. American Medical News
(Online).
Available: www.ama-assn.org/sci-pubs/amnews/pic... /pick0915.htm.

Sugg, N. K., & Inui, T. (1992). Primary care physicians’ response to domestic
violence: Opening Pandora’s box. JAMA, 267, 3157-3160.

Sugg, N., Thompson, R., Thompson, C., Maiuro, R., & Rivara, F. (1999).

Domestic violence and primary care attitudes, practices and beliefs. Archives of Family

Medicine, 8, 301-306.
Titus, K. (1996). When physicians ask, women tell about domestic abuse and
violence. JAMA, 275, 1863-1865.

Toffler, A. (1990). Powershift. New York: Bantam Books, Inc.
Walker, L. (1979) The Battered Woman, New York: Harper & Row.

Wisner, C. L., Gilmer, T. P., Saltzman, L. E., & Zink, T. M. (1999). Intimate
partner violence against women: Do victims cost health plans more? The Journal of

Family Practice, 48,439-443.

Appendix A
Script

Ask Now, Ask Always

Learning to Assess for Domestic Violence in Primary Care Patients
Scene opens in physician office. Patient is seated on an examining table and
the physician is seated beside her with a chart in hand.

Physician:

Mrs. Smith, how are you feeling today?

Mrs. Smith:

Um...Fine, I guess.

Physician:

So, you’re here today for a routine physical and a PAP smear. We

haven’t seen you for awhile. Any changes in your health since last year? Any new
medicines?

Mrs. Smith:

Not really... I’m just really, really tired all the time.

Physician:

Well, full-time job, full-time Mom. It’s really no surprise that

women are always tired these days. But we’ll take a look at everything. Do you
still smoke?
Mrs. Smith:

No, I quit about six months ago.

Physician:

That’s great! Do you use alcohol?

Mrs. Smith:

Once in awhile, maybe a couple of glasses of wine a week.

Physician:

And how is your diet? Are you eating balanced meals and exercising

at least three times per week?

Mrs. Smith:

I try to, but sometimes I just can’t find the time.

Physician:

Well, it will make you feel better. I can’t stress enough how

important that exercise is.

Mrs. Smith:

O.K.

Physician:

Any changes in your family history?

Mrs. Smith:

No.

Physician:

Do you do your own breast exams?

Mrs. Smith:

Yes.

Physician:

Great. Well, everything looks pretty good. Let’s take a quick look at

you and we’ll get you out of here.

(Knock on door)
Physician:

Yes?

Secretary:

I’m sorry to bother you, Dr. Carson, but I have the Emergency Room

on the phone. They need to speak with you right away.
Physician:

O.K., I’ll be right out. (Performs quick examination of patient).

Well, everything looks great. I’m going to order some routine bloodwork to check

for anemia and make sure your thyroid is o.k. I’ll call you with those results and let
you know if we need to do anything else. In the meantime, if you need anything,

please call. See you later.
Mrs. Smith:

Good-bye

(Fade to black and come up on Host, seated at desk)

Host: Routine exam? Perhaps. However, in taking an updated health history for
Mrs. Smith, the provider left out one key question. A question that could prevent a

tragedy or even save a life. This patient was not assessed for the presence of
domestic violence in her life.

Hello, I’m Lisa Zompa, and this program is called, Ask Now, Ask Always, Learning
to Assess for Domestic Violence in Primary Care Patients. This tape is intended for

all health care professionals who work in primary care as well as any allied health

workers. The purpose of this tape is to teach all providers and health care workers
to assess for and ask the essential questions, which may alert you to the presence of
domestic violence in your patients.

(Music and title graphics)
A primary care office is a busy place. Patients stream in and out all day and the
average time per patient is approximately 15 minutes. Within that time, primary

care providers need to find out a great deal of information about their patients. So
where does Domestic Violence fit in? What is Domestic Violence? Do you have
patients in your practice that are being abused?

Let’s first take a short quiz to assess your basic knowledge of Domestic Violence.

(Slide of Question #1)
Question #1: Which of the following is true about violence in the United States?

a)

Women are six times more likely to be attacked and physically

harmed by people with whom they have had an intimate relationship.
b)

Women and men are more likely to be robbed or assaulted at night
by people they do not know.

c)

Women can usually talk an attacker out of physically assaulting them

and so are not usu;tally physically injured during an attack.

d)

The majority of women who are physically assaulted are attacked in
a strange place.

If you answered ‘a’ you selected the correct answer. Let’s look at the question.

According to U.S. Department of Justice Statistics, women are attacked

approximately six times more often by people with whom they’ve had an intimate

relationship. Women can be assaulted at home, in the workplace, on campus or
during or after a dating experience.
Domestic violence remains a significant cause of morbidity in the adult population.
Every 7 seconds, in the United States, a woman is beaten by her male partner.

Domestic violence is the primary cause of injury to women in the United States and

injures more women each year than motor vehicle accidents, muggings and rapes
combined. Each year, women are victims of more than 4.5 million violent crimes.

Of all women seeking treatment in emergency departments, 22 to 40% are victims
of abuse. Approximately 17% of nonfatal, violence-related injuries have been
inflicted by someone with whom the victim had an intimate relationship. More than

half of the homeless women and children in the United States are homeless because
of a violent situation in the home.

Now let’s look at Question #2:
(Slide for Question #2)
The best definition of Domestic Violence is:
a)

b)
c)

d)

Any physical injury that requires medical attention.

Married women or men who are punched or slapped by their spouses.

A shouting match that has to be broken up by the police.

Emotional, physical, psychological, financial or sexual abuse that
one partner uses to control another.

If you answered ‘d’ you selected the correct answer. How are you doing on the quiz

so far? Now lets review the definitions of domestic violence.
There are many faces and facets to domestic violence. It can include threats, both
physical and emotional. It can include name-calling, the withholding of money or
other necessary resources. Please keep in mind for our purposes, that approximately

95% of domestic violence occurs against women by their past or present male
partners, however, consider that in a small number of cases, men are abused by their
female partners. Domestic violence can also be seen in homosexual relationships

and even in teenage dating relationships. So, no segment of the patient population is

exempt from the possibility of Domestic Violence.

One long-standing myth about domestic violence is that it doesn’t happen to “nice
girls” and “respectable women”. Many primary care providers find it difficult to
believe that they would have any abuse victims in their patient population. This

couldn’t be further from the truth. Any woman is at risk for abuse regardless of
race, culture, occupation, income level or geographic region.
There are also few positive predictors for assessing domestic violence, However,

according to the American Medical Association, risk factors may include.
•

Women who are single, separated or divorced.

•

Women between the ages of 17 and 28. Approximately 1 in 5 American

women can expect to be involved in a violent relationship at some time
in their lives, generally between the ages of 18 and 24.

•

Women who abuse drugs or alcohol.

Women who are pregnant. Approximately, 1 in 6 pregnant women are

assaulted during pregnancy. According to the Journal of the American

Medical Association, abuse during pregnancy can lead to miscarriages
and low birth-weight babies.
Another myth related to domestic violence is that the injuries inflicted rarely require

hospitalization or even medical treatment. However, of all women seeking
treatment in emergency departments, 22 to 40% are victims of abuse, and many are

repeat visitors.
(Insert Testimony #1)
Woman A:

I went to the Emergency Room for chest pain. They did a lot of

tests, but they didn’t find anything. I was exhausted and depressed. When the nurse

came to discharge me, she kept looking at me funny... she finally asked me... ”Is
everything all right at home?” I was scared, but a little relieved; nobody had ever
asked me that before. “How did you know?” I asked her. I wanted to tell her
everything but I didn’t have time. He was coming to pick me up. The nurse asked
me if I was safe. I told her my sons would take care of me and I left. I didn t leave

him for two years, but it was always in my mind that I could go back there and find
that nurse if I needed to.

Host: Now let’s do question #3

Which of the following is a sign of domestic abuse?
a)

b)
c)

A woman who has to call her partner for a ride home from work.

A woman who partner keeps track of where she is at all times.

A teenager whose boyfriend asks her not to see other boys.

d)

A pregnant woman whose husband files for divorce.

If you answered ‘b’ you are going in the right direction. Other signs of domestic
abuse can include:

•

Partners who isolate women from family and friends.

•

Partners who harm pets or destroy personal property.

•

Partners who coerce a woman into having sex or doing sexual acts
against her will.

•

Partners who constantly belittle or criticize a woman, sometimes in front
of her friends or family.

(Insert Testimony #2)
Woman B:

He never hit me. But everything was always wrong. The house

wasn’t clean enough, I worked too many hours, my friends called too much, the kids
were out of control. He told me that I was fat that I was stupid, that I couldn t do
anything right unless he was around. I finally left him, but it took years of

counseling before I stopped believing that he was right.
Host: We only have two more to go... let’s try question #4.
When victims of domestic violence seek help or escape from abusive

situations, they generally choose to seek out:
a)

A clergy person

b)

A family member or friend

c)

A health care professional

d)

A police officer or lawyer.

If you answered ‘c’ you answered correctly.

Most women who are invoked in abusive relationships perceive health cam
workers, in particular, physicians and nurses, as the best resources for relief or

resolution of an abusive situation. Currently, the self-mporting „f domestic violence
in a primary care setting is approximately 8%. With direct assessment, this figure

can rise to 29
%. Unfortunately, however, many medical personnel are still not willing or able to
assess patients for domestic abuse. At the time of this taping, only 7 to 25% of

domestic violence cases are identified by their primary care providers and only 2 to
7% of patients seen in ambulatory care settings are ever assessed for verbal or

physical abuse.

In a recent study, approximately 1 in 35 female emergency department patients was
correctly identified as being a victim of domestic abuse where a chart review of
patient histories and chief complaints showed that 1 in 4 patients were actually

being abused. Another study conducted in an outpatient family practice clinic
showed that 22.7% of the female patients reported being assaulted by an intimate

partner in the year prior to the sample. However, less than 2% of these women had
ever been asked about domestic violence by their primary care provider. Another

study still, examined the frequency and type of emergency department visits of
domestic violence-related homicide victims. Of these victims, 44

had presented

to an emergency department in the year prior to death. Of these victims, 93 /□ had
an injury related complaint. Health care providers had documented only one

intervention for domestic violence in that 93%.
(Insert Testimony #3)

Nurse A:

I work in an Emergency Department and JCAHO requires that we

assess all females 14 and older for domestic violence. But we only do it about 60%
of the time. Most of the time we forget, or we are embarrassed, there never seems

to be a good time to do this. Plus, if they do have a problem with violence, there are
so many forms to fill out and follow-up to do. Sometimes, if we are really busy, I

might just forget on purpose to ask, because I know I don’t have the time to do the
paperwork.
Host: Perhaps you have had similar experiences in your practice. Hopefully, we
can change your outlook by the end of this tape. For now, let’s review the fifth and
final question.

What can you do to help a patient whom you believe is being battered?
A)

Absolutely nothing. The patient has to take charge of the situation
themselves.

B)

Report the abuse immediately to the proper legal authorities and

make yourself available to testify against the abuser as needed.
C)

Assess the patient for domestic violence at all patient visits. If abuse

is determined, provide the patient with a safety plan and as many
resources as possible to get to safety when she is able.

D)

None of the above.

If you answered ‘c’, you have answered correctly.
Being the primary care provider of a patient in a violent relationship will never be

easy. Many women who have been abused have mixed fears and feelings regardtng

their abusive partners. Some are convinced that they actually “deserve the abuse”

while others may still love the partners that abuse them. To understand these

patients better, let’s review the cycle of violence.
The cycle of violence was developed by Walker in 1979 to describe the violent

relationship. Within the cycle are three distinct phases;-

Phase I:

The Tension Building Phase

This is a phase of less severe violence. However, the abuser is becoming

progressively more cruel to the victim. The victim will see the deterioration of the

abuser and will attempt to placate him, to create calm in the relationship. In order to

do this, she may be more withdrawn and may suppress her own feelings in order to
avoid conflict. This only builds more tension and often causes the victim to have
feelings of low self-esteem and guilt.

(Insert Testimonial #4)
Man and woman are at a kitchen table with a fast food bag on it.

Man: Why didn’t you cook something? You don’t have anything better to do all
day. I work hard all day, I think I deserve a little more than stupid burgers when I
get home.

Woman:

Honey, I’m sorry, the kids were begging for burge.:rs and I wasn’t

sure what time you would be home. If you don t want this, I can ma

y

something else right now. I think there might even be leftover spaghetti from last

night. I can heat that up if you want.

Man: Forget it...I don't want stupid burgers, and I sure don't want yOur goddamn
spaghetti. You can't even make spaghetti right, it tastes like goddamn Chef Boy-RDee. If I wanted to open a can, I can do that myself, you are so useless

Woman:

I know, I m sorry. I’ll make you something else. (Starts to remove

the burger bag).
Man: (Shoves bag to floor) I said I don’t want anything. I’ll go down to the bar

where at least I can get a hot meal. At least they care about me. You’re too busy
yapping on the phone all day with your stupid friends, eating cookies and getting

fatter by the second, watching T.V. all day long. I’m out of here... don’t wait up.
Host: The second phase is the violent explosion. During this phase, the abuser can
inflict severe or even fatal injury to the victim. This results in a regaining of power

and control over the victim. The victim, in turn, experiences a learned helplessness
with powerlessness and loss of control. The victim is incapable of stopping this
phase or lessening the abuse. The life of the victim is most in danger during this
stage.

Man: Where the hell were you? You were supposed to be home from work an
hour ago... where the hell have you been? I’ve been sitting here waiting for you to
get home. I called your work, you didn’t know that did you? They said you left 45
minutes ago. It only takes 15 minutes to get home. Where were you? You found

yourself a boyfriend? You slutting around on me? Who is he? Who d want

you...you fat, ugly pig.

Woman:

I wasn’t doing anything. I stopped „ the store

to pick up a

prescription for Tommy. He has an ear infect™ and the doctor calfed somethntg in.
I wanted to get to the drugstore before it closed.

Man: Why the hell didn’t you call? Where is the prescription? You don’t have it,
do you? You’re a goddamn liar.

Woman:

It’s in my purse by the door. Let me get it. I’ll show it to you.

Man: If anybody is going to show anything to anybody, I’ll do the showing. And

I’m going to start by showing you why you better not lie to me again.

Woman:

Stop it, you’re hurting me. I just went to the drugstore. Let me get

my purse... please... I’ll prove it to you.
Man: Shut up. I don’t want to hear anymore of your goddamn lies. I sent the kids
to the neighbors to eat dinner, since their stupid, whoring mother couldn t be home
to fix them anything. And while they’re gone, I’m gonna teach you a little lesson

about coming home on time, nobody lies to me, goddammit.
Host: The final phase in the cycle of violence is the honeymoon phase. During

this phase, the abuser is calm and sorry about the abuse. He apologizes profusely.

He may promise to never abuse the victim again, and may be loving and g
Very often, the victim accepts the apology and forgives the be

Unfortunately, this cycle will repeat again and again as tension in the relationship
builds. The violence will continue and may even continue to escalate in seventy.

Well, how did you do on the quiz? Fell like you have a good ha

in domestic

violence in your practice? Or was some of thismatena! ama! ey«pener? !fyou

been taught or stressed in your training or practlce In ftct_ most pnrM^
providers list a lack of confidence in identification and management skills related to
domestic violence. This lack of confidence has been related to a lack of training in
the care of victims of abuse. Currently, most medical schools in the United States

only require an average of two hours of domestic violence training and less than
50% of family medicine residency programs require any type of education at all
related to victims of abuse. A recent survey of California physicians demonstrated

that only 22% had any domestic violence education within the five years prior to the
survey.

Even if you have been educated during your training, you still may have found
roadblocks to the successful assessment of domestic violence. Many primary care
providers feel that lack of time is a major stumbling block to assessment and, in
fact, several primary care providers have made reference to the issue of domestic

violence as the opening of Pandora’s Box. In other words, a positive assessment for

domestic violence opened a situation they could not effectively handle within the

15-minute time frame of an office visit.
(Insert Testimony #5)

Physician:

My office technically books me with a patient every 15 minu

sometimes, double and triple books me on busy days. Sometimes

a

depressed patient, the kind where you walk into the room and the patient
tears. You just want to sit down and cry too, because you know that you are going

to be behind at least an hour to an hour and a half after that. People don t want to
wait 15 minutes before they start complaining. If they think they ha

long, they won’t come back. I don’t even want to think about abuse. Whatdoldo
with this woman? I don’t have any medicine or treatment that is going to help.
Isn’t that what social services is for? Wouldn’t she be better offjust going to the

hospital?

Host: Time isn’t the only problem for primary care providers. Some providers
don’t assess because they don’t want to offend their patients by bringing up an

awkward subject. However, a study of primary care patients showed that 85% did

not believe that assessment for violence was invasive or offensive. Some patients
believed that the practice was more progressive and caring when they chose to

assess for personal safety.

Some providers may have a difficult time coming to terms with the idea of abuse in
their practice. We would all like to believe that our practices are exempt from

something like abuse, and indeed, approximately 50% of clinicians interviewed in

1999 believed that domestic violence in their practices was rare or very rare. 70%

of nurses and health care workers also believed that abuse was rare or veiy rare.
Unfortunately, they could not be more wrong. There are 28,700 emergency room

visits and 39,000 physician office visits yearly related to domestic violence. The
yearly cost of domestic violence to the health care system is $44 million dollars
Women who are victims of violence access the health care system at a cost that is

92% higher than women who have not been abused.
In a recent study of managed care enrollees, victims of domestic abuse spe
more on health care each year than women who are not abused. A history of
domestic abuse is thought to be so clearly associated with a higher morbidity

mortality that some insurance companies attempted to define domestic violence as a

“pre-existing condition” and deny health care benefits on that basis.
•asis. Clearly then,
your practice contains some victims of domestic violence.

In order to raise the comfort level of primary providers in providing assessment and
care for victims of abuse, we need to examine some of the factors surrounding the

issue of abuse. One of the hardest questions that we ask ourselves may be, “Why
does she stay?” It may seem easy, and even an issue of common sense. If a woman

is being abused in a relationship, she should leave the relationship. Unfortunately,
there are economic, social, psychological, cultural and even political factors that
may influence the ability of a woman to leave an abusive relationship. Let’s

examine some of those issues.

Throughout history, women have been at an economic disadvantage compared to

their male partners. Women and children continue to comprise the largest block of
indigent Americans, particularly, if they are women and children of color.

Typically, when a woman divorces or separates from a male partner, her standard of
living will tend to decrease by 73%. A man’s standard of living will tend to

increase by 42%. A woman may not have the financial resources to support herself
and her children if she leaves a relationship. An abusive partner may also attempt to
control a victim by limiting her access to money and may attempt to us

pressure to force her to return to the relationship.
(Insert Testimony #6)
Woman:

He never ever hit me

or theldds. but the whole mueltalwewere

married, I never had any money. He had everything.

He held the checkbook and all

the credit cards. A lot of the cards were in my name, but I never saw them. He

gave me money every week to buy groceries, but he would check all the receipts. I

had to ask him for everything, clothes for the kids, shoes, everything. The most I
ever had in my purse at any one time was a $S bill that my mother gave me for my
birthday. When I finally told my mother what was going on, she lent me the money
to get out. If I hadn’t talked to her, I would still be there.

Host: There are also political and legal obstacles for many women to overcome
within an abusive relationship. The legal system may actually even work against a

woman trying to find relief from an abusive situation. If a woman seeks to obtain a

Protection from abuse court order, she may find the following problems:
•

The abusive partner may increase his violent behavior when served with

the court order.
•

A protection from abuse order may not include the children of the
relationship.

•

The abusive partner may lose a job because of the protective order. Tin

may cut down on child support or other vital financial resource

•

A woman may lose her job if she misses work to go to court to obtain a

.

protection order.
A woman may not be able to afford her rent if an abusive partner is
forced to leave as a result of a protective order.

What are the red flags for domestic violence? Unfortunately, few P11?
™ positively predictive for diagnosing a violent relattonship. Phystea! Mings tn

d„es.ic violence can range from „„ cuts md
During a physical exam, patients need to be examined for

•

Injuries on unusual parts of the body

•

Injuries on several different areas of the body

•

Injuries occurring in central areas of the body such as the face, neck,
throat, chest, abdomen or genitals.
Fractures that require significant force or fractures which rarely occur by

•

accident such as spiral fractures.
•

Multiple injuries in various stages of healing.

•

Injuries which have the patterns of whatever objects were used to inflict
injury such as belts, teeth, ropes or utensils.

•

Any injury to a pregnant woman.

Please keep in mind that nontraumatic injury may also be indicative of abuse. Pain

is the most common physical complaint of abused women. Victims
standing abuse may present with a “battering syndrome”. A victim presenting with

battering syndrome may have an increase in general, somatic complaints
accompanied by emotional illness. Complaints may include chest pa in,

headaches, gastrointestinal upset, insomnia, back pain and depression.

have been abused for many years may also present with histones
syndrome, arthritis and pelvic inflammatory diseas
Please keep in mind the following behavioral clu
•

Complaints of pain without obvious tissue injwy

•

Repeated visits to health care facilities

•

Suicidal attempts or ideations

.

Considerable delay between the onset of injury

presentiti<„,

a

health care facility for treatment.
Despite wanting the best personal safety for all the patients in your practice, how

can you be sure to accurately assess each patient for domestic violence? Keep in

mind the simple pneumonic RADAR:

R Remember to always ask about violence and personal safety
•

Ask directly and ask when the woman is alone

•

D - Document your findings using clear medical terminology in the
medical record.

•

A - Always assess for safety

•

R - Review options and refer each patient as is appropriate

How can you assess? Most importantly, find the words which feel comfortable to
you. The partner violence screen consists of three questions and takes

approximately 20 seconds to administer. Ask:

•

Have you been kicked, bit, punched or otherwise hurt by someone within

the past year?
♦

Do you feel safe in your curreniit relationship?

•

Is there a partner from a previous relationship who is making y

unsafe now?
^y variation or form of the partner violence screen with whic Y
comfortable will achieve the desired affect. Keep in mind, howe

victims will feel comfortable admitting violence the first time they are screened. It
may take up to seven screenings before a victim may be willing to open up and ask

for help. Be patient.

When should you assess a patient?
Always! Especially during:

•

Routine health histories

•

Routine physicals

•

Any acute care visits

•

After a patient has begun a new relationship

•

During all prenatal visits

What should you do if a patient admits to abuse?
Assess the patient’s immediate personal safety. Is she in danger now?
If no immediate plan is in place in your practice to assist abused women, use the

following telephone numbers:
1-800-SAFE - This number is accessible from all 50 states and can provide

crisis intervention, counseling and referrals to battered women s shelters and
services. Translators are available as needed.

Safenet — This local number can provide onsite help at your practice to
assess women and find appropriate counseling and shelter.

Thank you for watching, “Ask Now. Ask ^ways ” ™
provided important information for your practice and the personal safety

patients.

Appendix B
Focus Group Evaluation Form
1)

What is the title of this presentation?

2)

Did you find the length of this presentation to be:
Too long

3)

Just Right

Were the dramatic scenes helpful in presenting the information?
Yes

4)

Too Short

No

Somewhat

Did you learn anything new about Domestic Violence during this
presentation?
Yes

5)

No

Was the amount of information presented during the presentation:

Too Much

Too Little

Just Enough

6)

What are the strengths of this presentation?

7)

What are the weaknesses of this presentation?

8)

Would this tape be valuable as continuing education for your coworkers.
Yes

No

Unsure