PEDIATRIC UPDATE
IDENTIFYING MATERNAL INTIMATE PARTNER VIOLENCE IN THE EMERGENCY DEPARTMENT Author: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, Boston, MA Section Editors: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, and Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, AFN-BC, SANE-A, EMT-P
Earn Up to 7.5 CE Hours. See page 458. nalyzing how to screen mothers in potential intimate partner violence (IPV) situations is critically important to the health of mother and child. Research has identified that screening for IPV by emergency nurses is not consistently being performed although regulatory agencies and organizations provide training. 1,2 IPV can be defined as physical, sexual, or psychological harm to a current or former partner or spouse. Sexual intimacy is not required, and IPV can occur among same-sex or heterosexual couples. IPV is a grave public health crisis affecting millions of people. It is unknown why nurses are not screening for IPV, which is also known as domestic abuse. This gap in IPV research on pediatric nurses screening for IPV started my research question regarding pediatric emergency nurses’ self-efficacy, knowledge, and skill in screening for maternal IPV. 3,4 As an experienced emergency nurse, I follow the IPV screening recommendations. The dilemma regarding IPV screening in the pediatric setting is that the mother is not actually the patient. The specific situation that heightened my awareness surrounding this delicate subject occurred when I was the evening triage nurse in the emergency department during a cold winter snowstorm and a woman arrived carrying her 3-month-old infant. An across-the-room assessment showed a healthy infant who was sleeping comfortably and was in no acute distress. The mother looked distraught, stating that the infant was not feeling well. Physical assessment findings and vital signs were normal. What could be causing this disproportionate maternal reaction? On inquiry, it was determined that this was not her first child, which could be a cause for this
A
Patricia A. Normandin, Member, Massachusetts ENA Beacon Chapter, is Emergency Staff RN, Tufts Medical Center, Boston, MA. For correspondence, write: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN; E-mail: [email protected]. J Emerg Nurs 2015;41:444-6. Available online 10 July 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.05.011
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maternal distress. After other causes of maternal distress are ruled out, medical professionals should consider the possibility of an unsafe home situation. Domestic violence (IPV) is a difficult subject to approach and should be discussed at the appropriate time. Screening mothers during pediatric visits could be an ideal moment to intervene in a potentially dangerous family situation. It is well known that women are often reluctant to divulge incidents of IPV and may avoid medical professionals on their own behalf. These particularly vulnerable women may only come into contact with pediatric nurses, who may be able to make a positive difference in a child’s home situation. A factor that should not be overlooked is the link between the increased likelihood of child abuse in homes in which IPV is present. 5 Bandura’s self-efficacy concept may help ED administrators and educators understand why nurses do or do not perform maternal IPV screening: Self-efficacy can be defined as the belief in one’s own capabilities to organize and accomplish the actions to produce a desired goal. 6 My goal in addressing this gap in IPV screening research is to improve the emergency pediatric nurse’s ability to identify, screen, and intervene in potentially unsafe living conditions. Self-efficacy is different from self-esteem. Judging one’s own personal capabilities is perceived self-efficacy in contrast to self-esteem, which is judging self-worth. Perceived self-efficacy plays a role in identifying IPV but is not the only determinant of whether IPV screening takes place. Administrative support for increasing education using both nonverbal and verbal case scenario communication strategies can increase a nurse’s self-efficacy in approaching a personal question such as IPV in a patient’s life. Nursing education strategies that discuss emergency nurses’ personal experiences with IPV, including their feelings regarding other persons they know in IPV situations, can help open the discussion surrounding each nurse’s barriers to screening. ED administrators need to ensure that interdisciplinary team members such as social service staff are available, along with a list of IPV referral resources in the area. Having resources available provides a positive influence to increase the emergency nurse’s self-efficacy in IPV screening and referral. 3,4,6
VOLUME 41 • ISSUE 5
September 2015
Normandin/PEDIATRIC UPDATE
Failures to screen all mothers for IPV are missed opportunities by emergency nurses to identify families in unsafe situations. Studies have shown that 3 of 4 persons experiencing IPV treated in emergency departments were not identified as persons experiencing IPV because they had medical complaints and not injuries linked to IPV. 1 Research has linked child abuse and child injury to children of women living in IPV situations. 5,7 Increasing emergency nurses’ self-efficacy in screening for IPV may identify more mothers in crisis or unsafe circumstances and thus provide appropriate referral and, ultimately, safe living situations for families. 1,3–5,7 Some barriers to IPV screening by health care providers were found to be lack of education, along with difficulty knowing how and when to inquire. Other barriers include fear of offending the patient, lack of privacy, lack of time, lack of satisfactory referral resources, language barriers, and the nurse’s own personal or family history of violence. Women living in IPV situations have described several reasons for not revealing unsafe situations, including fear of the legal system, fear of losing their children, fear of harsh judgment by health care providers, and possible retaliation by abuser. 1–4 Lack of IPV identification in the emergency department can contribute to ED overcrowding. Women with a history of IPV seek care at emergency departments with vague complaints for themselves and their children at a higher percentage than women not involved in IPV situations. If mothers in IPV situations are not identified, they will continue to bring their children to the emergency department, potentially undergoing unnecessary tests. It is imperative that organizations identify strategies to increase emergency nurses’ self-efficacy, knowledge, and skills in screening for IPV. Emergency nurses must maintain vigilance in identifying IPV situations to ensure appropriate referral and patient safety. Mothers living in IPV situations have been identified as a risk factor for child abuse, overuse of emergency services, and having feelings of unmet needs, which highlights the need for IPV screening. 5,7 It is vital that all emergency nurses, including those whose patient is the child, be helped to increase their self-efficacy in IPV identification. This is critical for the mother and child who may be in an unsafe situation, which triggered the ED visit. Strategies to increase emergency nurses’ identification of persons experiencing IPV are multifaceted. Research has shown that some emergency nurses have identified lack of self-efficacy in addressing IPV as a reason for not screening. 3,4 IPV training needs to address strategies to
September 2015
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increase self-efficacy in screening, including nurses’ personal experiences, and eliminate barriers for each individual organization. It is critical that IPV curricula provide appropriate safety plan training and referral if a positive IPV screening is revealed. The National Domestic Violence Hotline, 1-800-787-SAFE (1-800-787-7233), should be prominently available. Other helpful Internet resources can be found at http://www.cdc.gov/ violenceprevention/pub/ipv_factsheet.html, http://www. ncadv.org, http://endabuse.org, and the Family Violence Prevention Fund. 1,3,4,7 Nurses should be encouraged to screen everyone for IPV in private; to communicate in a caring manner; and if the child is the patient, to treat the child first. Nurses should consider the child’s age when questioning the mother. Screening of the mother should be done alone if the child is 3 years old or older to prevent the child from repeating the conversation to the potential family perpetrator, causing an unsafe situation. Many IPV screening tools exist, but no single screening tool that has well-established psychometric properties has been found. 8 Emergency nurse administrators and educators need to recognize the impact of self-efficacy on whether the emergency nurse feels capable of organizing and executing the course of action required to screen all patients for IPV. Emergency nurse educators need to provide tools in their IPV curriculum to increase emergency nurses’ self-efficacy, knowledge, and skills in screening for IPV. Unidentified persons experiencing IPV will continue high utilization of emergency services without appropriate referral to supportive services for such persons. Not screening for IPV and not referring persons experiencing IPV to services add to ED overcrowding and unnecessary testing. Emergency nursing administrators can increase emergency nurses’ self-efficacy by ensuring more education about IPV screening is provided and listing available resources in the area, including social service support. These efforts may increase compliance among staff regarding IPV screening and referral, ultimately resulting in better patient care.
REFERENCES 1. Rhodes KV, Kothari CL, Dichter M, Cerulli C, Wiley J, Marcus S. Intimate partner violence identification and response: time for a change in strategy. J Gen Intern Med. 2011;26(8):894-899. 2. Campbell JC. ED nurses still not screening. ED Nurs. 2007;128-129. 3. Normandin PA. Pediatric Emergency Nurses’ Self-Efficacy, Knowledge, and Skills in Screening for Maternal IPV [dissertation], Weston, MA: Regis College; 2010.
WWW.JENONLINE.ORG
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4. Hollingsworth E, Ford-Gilboe M. Registered nurses’ self-efficacy for assessing and responding to woman abuse in emergency department settings. Can J Nurs Res. 2006;38(4):54-77.
8. Rabin RF, Jennings JM, Campbell JC, Bair-Merritt MH. Intimate partner violence screening tools. Am J Prev Med. 2009;36(5):439-445.
5. Bair-Merritt MH. Intimate partner violence. Pediatr Rev. 2010;31(4):145-150.
Submissions to this column are encouraged and may be sent to Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN [email protected] or Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, AFN-BC, SANE-A, EMT-P [email protected]
6. Bandura A. Self-Efficacy, New York, NY: W.H. Freeman and Company; 1997. 7. Casanueva C, Foshee VA, Barth RP. Intimate partner violence as a risk factor for children’s use of the emergency room and injuries. Child Youth Serv Rev. 2004;27:1223-1242.
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VOLUME 41 • ISSUE 5
September 2015
IDENTIFYING MATERNAL INTIMATE PARTNER VIOLENCE IN THE EMERGENCY DEPARTMENT Author: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, Boston, MA Section Editors: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN, and Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, AFN-BC, SANE-A, EMT-P
Earn Up to 7.5 CE Hours. See page 458. nalyzing how to screen mothers in potential intimate partner violence (IPV) situations is critically important to the health of mother and child. Research has identified that screening for IPV by emergency nurses is not consistently being performed although regulatory agencies and organizations provide training. 1,2 IPV can be defined as physical, sexual, or psychological harm to a current or former partner or spouse. Sexual intimacy is not required, and IPV can occur among same-sex or heterosexual couples. IPV is a grave public health crisis affecting millions of people. It is unknown why nurses are not screening for IPV, which is also known as domestic abuse. This gap in IPV research on pediatric nurses screening for IPV started my research question regarding pediatric emergency nurses’ self-efficacy, knowledge, and skill in screening for maternal IPV. 3,4 As an experienced emergency nurse, I follow the IPV screening recommendations. The dilemma regarding IPV screening in the pediatric setting is that the mother is not actually the patient. The specific situation that heightened my awareness surrounding this delicate subject occurred when I was the evening triage nurse in the emergency department during a cold winter snowstorm and a woman arrived carrying her 3-month-old infant. An across-the-room assessment showed a healthy infant who was sleeping comfortably and was in no acute distress. The mother looked distraught, stating that the infant was not feeling well. Physical assessment findings and vital signs were normal. What could be causing this disproportionate maternal reaction? On inquiry, it was determined that this was not her first child, which could be a cause for this
A
Patricia A. Normandin, Member, Massachusetts ENA Beacon Chapter, is Emergency Staff RN, Tufts Medical Center, Boston, MA. For correspondence, write: Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN; E-mail: [email protected]. J Emerg Nurs 2015;41:444-6. Available online 10 July 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.05.011
444
JOURNAL OF EMERGENCY NURSING
maternal distress. After other causes of maternal distress are ruled out, medical professionals should consider the possibility of an unsafe home situation. Domestic violence (IPV) is a difficult subject to approach and should be discussed at the appropriate time. Screening mothers during pediatric visits could be an ideal moment to intervene in a potentially dangerous family situation. It is well known that women are often reluctant to divulge incidents of IPV and may avoid medical professionals on their own behalf. These particularly vulnerable women may only come into contact with pediatric nurses, who may be able to make a positive difference in a child’s home situation. A factor that should not be overlooked is the link between the increased likelihood of child abuse in homes in which IPV is present. 5 Bandura’s self-efficacy concept may help ED administrators and educators understand why nurses do or do not perform maternal IPV screening: Self-efficacy can be defined as the belief in one’s own capabilities to organize and accomplish the actions to produce a desired goal. 6 My goal in addressing this gap in IPV screening research is to improve the emergency pediatric nurse’s ability to identify, screen, and intervene in potentially unsafe living conditions. Self-efficacy is different from self-esteem. Judging one’s own personal capabilities is perceived self-efficacy in contrast to self-esteem, which is judging self-worth. Perceived self-efficacy plays a role in identifying IPV but is not the only determinant of whether IPV screening takes place. Administrative support for increasing education using both nonverbal and verbal case scenario communication strategies can increase a nurse’s self-efficacy in approaching a personal question such as IPV in a patient’s life. Nursing education strategies that discuss emergency nurses’ personal experiences with IPV, including their feelings regarding other persons they know in IPV situations, can help open the discussion surrounding each nurse’s barriers to screening. ED administrators need to ensure that interdisciplinary team members such as social service staff are available, along with a list of IPV referral resources in the area. Having resources available provides a positive influence to increase the emergency nurse’s self-efficacy in IPV screening and referral. 3,4,6
VOLUME 41 • ISSUE 5
September 2015
Normandin/PEDIATRIC UPDATE
Failures to screen all mothers for IPV are missed opportunities by emergency nurses to identify families in unsafe situations. Studies have shown that 3 of 4 persons experiencing IPV treated in emergency departments were not identified as persons experiencing IPV because they had medical complaints and not injuries linked to IPV. 1 Research has linked child abuse and child injury to children of women living in IPV situations. 5,7 Increasing emergency nurses’ self-efficacy in screening for IPV may identify more mothers in crisis or unsafe circumstances and thus provide appropriate referral and, ultimately, safe living situations for families. 1,3–5,7 Some barriers to IPV screening by health care providers were found to be lack of education, along with difficulty knowing how and when to inquire. Other barriers include fear of offending the patient, lack of privacy, lack of time, lack of satisfactory referral resources, language barriers, and the nurse’s own personal or family history of violence. Women living in IPV situations have described several reasons for not revealing unsafe situations, including fear of the legal system, fear of losing their children, fear of harsh judgment by health care providers, and possible retaliation by abuser. 1–4 Lack of IPV identification in the emergency department can contribute to ED overcrowding. Women with a history of IPV seek care at emergency departments with vague complaints for themselves and their children at a higher percentage than women not involved in IPV situations. If mothers in IPV situations are not identified, they will continue to bring their children to the emergency department, potentially undergoing unnecessary tests. It is imperative that organizations identify strategies to increase emergency nurses’ self-efficacy, knowledge, and skills in screening for IPV. Emergency nurses must maintain vigilance in identifying IPV situations to ensure appropriate referral and patient safety. Mothers living in IPV situations have been identified as a risk factor for child abuse, overuse of emergency services, and having feelings of unmet needs, which highlights the need for IPV screening. 5,7 It is vital that all emergency nurses, including those whose patient is the child, be helped to increase their self-efficacy in IPV identification. This is critical for the mother and child who may be in an unsafe situation, which triggered the ED visit. Strategies to increase emergency nurses’ identification of persons experiencing IPV are multifaceted. Research has shown that some emergency nurses have identified lack of self-efficacy in addressing IPV as a reason for not screening. 3,4 IPV training needs to address strategies to
September 2015
VOLUME 41 • ISSUE 5
increase self-efficacy in screening, including nurses’ personal experiences, and eliminate barriers for each individual organization. It is critical that IPV curricula provide appropriate safety plan training and referral if a positive IPV screening is revealed. The National Domestic Violence Hotline, 1-800-787-SAFE (1-800-787-7233), should be prominently available. Other helpful Internet resources can be found at http://www.cdc.gov/ violenceprevention/pub/ipv_factsheet.html, http://www. ncadv.org, http://endabuse.org, and the Family Violence Prevention Fund. 1,3,4,7 Nurses should be encouraged to screen everyone for IPV in private; to communicate in a caring manner; and if the child is the patient, to treat the child first. Nurses should consider the child’s age when questioning the mother. Screening of the mother should be done alone if the child is 3 years old or older to prevent the child from repeating the conversation to the potential family perpetrator, causing an unsafe situation. Many IPV screening tools exist, but no single screening tool that has well-established psychometric properties has been found. 8 Emergency nurse administrators and educators need to recognize the impact of self-efficacy on whether the emergency nurse feels capable of organizing and executing the course of action required to screen all patients for IPV. Emergency nurse educators need to provide tools in their IPV curriculum to increase emergency nurses’ self-efficacy, knowledge, and skills in screening for IPV. Unidentified persons experiencing IPV will continue high utilization of emergency services without appropriate referral to supportive services for such persons. Not screening for IPV and not referring persons experiencing IPV to services add to ED overcrowding and unnecessary testing. Emergency nursing administrators can increase emergency nurses’ self-efficacy by ensuring more education about IPV screening is provided and listing available resources in the area, including social service support. These efforts may increase compliance among staff regarding IPV screening and referral, ultimately resulting in better patient care.
REFERENCES 1. Rhodes KV, Kothari CL, Dichter M, Cerulli C, Wiley J, Marcus S. Intimate partner violence identification and response: time for a change in strategy. J Gen Intern Med. 2011;26(8):894-899. 2. Campbell JC. ED nurses still not screening. ED Nurs. 2007;128-129. 3. Normandin PA. Pediatric Emergency Nurses’ Self-Efficacy, Knowledge, and Skills in Screening for Maternal IPV [dissertation], Weston, MA: Regis College; 2010.
WWW.JENONLINE.ORG
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PEDIATRIC UPDATE/Normandin
4. Hollingsworth E, Ford-Gilboe M. Registered nurses’ self-efficacy for assessing and responding to woman abuse in emergency department settings. Can J Nurs Res. 2006;38(4):54-77.
8. Rabin RF, Jennings JM, Campbell JC, Bair-Merritt MH. Intimate partner violence screening tools. Am J Prev Med. 2009;36(5):439-445.
5. Bair-Merritt MH. Intimate partner violence. Pediatr Rev. 2010;31(4):145-150.
Submissions to this column are encouraged and may be sent to Patricia A. Normandin, DNP, RN, CEN, CPN, CPEN [email protected] or Joyce Foresman-Capuzzi, MSN, RN, CCNS, CEN, CPN, CTRN, CCRN, CPEN, AFN-BC, SANE-A, EMT-P [email protected]
6. Bandura A. Self-Efficacy, New York, NY: W.H. Freeman and Company; 1997. 7. Casanueva C, Foshee VA, Barth RP. Intimate partner violence as a risk factor for children’s use of the emergency room and injuries. Child Youth Serv Rev. 2004;27:1223-1242.
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