barriers to screening for dv

8/13/2019 Barriers to Screening for DV

1/1037Domestic Violence Screening Barriers Yonaka et al.

Barriers to Screening for Domestic Violence inthe Emergency DepartmentLisa Yonaka, RN, MSN, Marian K. Yoder, EdD, RN, Janet B. Darrow, RN, MS,

and John P. Sherck, MD

The question Are you in a relationship in which yourebeing abused? is not always easy to ask or to answer.Statistics from the Centers for Disease Control and Preven-tion (CDC) (2003) indicate that 36% of the women whowere treated in the emergency department for violent inju-ries were injured by an intimate partner. However, victimsof domestic violence are often reluctant to disclose abuse.Instituting a policy in which all emergency department pa-tients are screened for domestic violence increases the likeli-hood of identifying abuse in the at-risk patient population.

This article describes how a large urban emergency de-partment implemented universal screening for domesticviolence and developed a violence intervention program,but was forced to discontinue the program due to budgetconstraints. We review the steps that were taken in responseto the elimination of the violence intervention program andthe process of planning a continuing education program forregistered nurses in the emergency department. Literaturesupporting universal screening in the emergency depart-ment and the existence of factors that may present barriersto screening for domestic violence are also explored.

For the purposes of this article, the following defi-nitions are used. Domestic violence is a pattern of as-saultive or intimidative behaviors, including physicaland psychological, that adults or adolescents use againsttheir intimate partners (Ganley, 1998, p. 16). A domes-tic partneris a current or former spouse, boyfriend, orgirlfriend with whom the individual has had an intimaterelationship. A registered nurseis a professional, licensednurse. An emergency departmentis a specialized area ofthe hospital that provides care and treatment to patientsof all ages and conditions who present to the depart-ment for care. The CDC (2004) prefers the term intimatepartner violence to domestic partner violence. Domesticviolence and intimate partner violence are used synony-mously in this article.

DOMESTIC VIOLENCE AWARENESSScope of the Problem

Domestic violence has been recognized as a nationalhealth problem that results in not only physical abuse,but also psychological and economic abuse. Domesticviolence includes forced sexual activity, thus increasingthe risk of unplanned pregnancy and sexually transmit-ted diseases, such as the human immunodeficiency virus(Warshaw & Ganley, 1998). It wasnt until the 1970s thatthe health community and the public increased their focuson domestic violence (Humphreys & Campbell, 2003).

Professional StandardsMany professional nursing organizations, including the

American Association of Colleges of Nursing, the Ameri-can Nurses Association, and the Emergency Nurses As-sociation, have published position statements in support

The identification of victims of domestic violence is impor-

tant to prevent further abuse and injury. The purposes of this

pilot project were to identify potential barriers emergency de-

partment registered nurses encounter in screening patients

for domestic violence and to assess nurses educational

backgrounds for continuing education and training needs.

The most significant potential barriers to screening identi-

fied were a lack of education and instruction on how to ask

questions about abuse, language barriers between nurses

and patients, a personal or family history of abuse, and time

issues. These findings may benefit other researchers who

are trying to determine the continuing education needs of

emergency department staffs.

abstract

Ms. Yonaka is Trauma Program Director, Dr. Yoder is Professor,and Ms. Darrow is Faculty and Lecturer, San Jose State University, SanJose, California. Dr. Sherck is Trauma Medical Director, Santa ClaraValley Medical Center, San Jose, California.

Address correspondence to Lisa Yonaka, RN, MSN, , 751 South Bas-com Avenue, San Jose, CA 95128.


2/1038 The Journal of Continuing Education in Nursing January/February 2007 Vol 38, No

of curriculum development, training, and continuing edu-cation in domestic violence for nurses (Cohn, Salmon, &Stobo, 2002). Despite the existence of domestic violencecurricula, a survey of healthcare professionals indicated

that only approximately 30% recalled receiving educationrelated to domestic violence (Cohn et al., 2002). The JointCommission on the Accreditation of Healthcare Organiza-tions (1995) requires hospital standards related to establish-ing policies, procedures, and education about abuse screen-ing (particularly within emergency departments).

BACKGROUND

Using the MEDLINE, CINAHL, Biomedical Refer-ence Collection, and Nursing and Allied Health Collec-tion databases, a search of literature written about thistopic between 1995 and 2003 was conducted. Key termsused in the literature search included domestic violence,intimate partner abuse, domestic violence screening,spousal abuse, and emergency department.

Incidence of Domestic Violence

A hallmark study conducted by Goldberg and Tomla-novich (1984) determined that one in four women seekingcare for any reason in the emergency department have beenvictims of domestic violence. Abbott, Johnson, Koziol-McLaine, and Lowenstein (1995) determined that 77% ofwomen who had been seen in the emergency departmentfor non-trauma complaints had been victims of domesticviolence, but found that only 13% of these patients were

screened for domestic violence. Larkin, Hyman, Mathias,DAmico, and MacLeod (1999) found that one in five pa-tients who went to the emergency department reportedexposure to domestic violence.

The Bureau of Justice estimated that women accountfor approximately 85% of those abused (Rand & Strom,1997). In 1998, there were five times more women than menvictimized by a domestic partner (Rennison & Welchans,2000). Gerard (2000) found that approximately 35% ofemergency department patients were victims of domesticviolence, and 95% of those were women. An urban studyfound that more than 50% of those who reported being

victims of domestic violence were also involved as perpe-trators (Lipsky, Caetano, Field, & Bazargan, 2004). In ad-dition to physical and psychological trauma from abuse,statistics indicate that domestic partners committed 11%of all homicides (Rennison & Welchans, 2000).

Domestic Violence Affecting Pregnant Women andChildren

A cross-cultural study of African American, Hispan-ic, and white women found a risk for domestic violenceduring pregnancy. When screened for domestic violence

by their obstetrician, one in six pregnant women repored abuse (McFarlane, Parker, & Soeken, 1996). Therwas a delay in prenatal care and increased risk for lowbirth weight of infants for those women who reporte

abuse (McFarlane et al., 1996). Maternal weight gain waalso less for these women, most significantly for whitwomen, thus placing the health of the fetus at furtherisk (McFarlane et al., 1996). Abused pregnant womeare at an increased risk of miscarriage, premature laboand fetal injury (Warshaw & Ganley, 1998).

Women who have been screened for domestic violence in the pediatric setting have reported domestiviolence 40% of the time (Erickson, Teresa, & Siega2001). Children in families with frequent domestic violence (many of whom are also abused) suffer from sleeand psychological disorders and can have problems aschool (Hill & Siegel, 2001). Clearly, domestic violenchas detrimental effects on the entire family unit. Earlidentification of individuals who are victims of domestviolence may assist in preventing further psychologicand physical injury.

Barriers to Screening for Domestic Violence

One of the most common barriers to screening for domestic violence is nurses lack of education and instruction on how to ask domestic violence screening question(Cohn et al., 2002; Heinzer & Krimm, 2002). Other barrers to screening identified by emergency department nurseincluded lack of privacy and time limitations (Ellis, 1999

In a study of perinatal nurses, Moore, Zaccaro, and Parsons (1998) determined that 31% had a personal or family history of domestic violence. Another barrier identifieby obstetricians in screening for domestic violence was thinability to fix the problem once identified (Parsons, Zaccaro, Wells, & Stovall, 1995). The lack of adequate referral resources was identified as a common barrier for othehealthcare professionals (Hill & Siegel, 2001).

Universal Screening for Domestic Violence

Unlike most other departments at a hospital, themergency department treats people of all ages, socio

economic backgrounds, and ethnicities for an unendinvariety of illnesses and injuries. An emergency deparment visit may be the domestic violence survivors onlcontact with healthcare providers who can intervene anend the cycle of abuse.

Symptoms of domestic violence may not be as obvious as a bruise or another type of physical injury. Medcal complaints may be related to stress and present adizziness, shortness of breath, and palpitations (Kos1993). The U.S. Preventive Task Force released clinicaguidelines for family and intimate partner violence tha



include recommendations for screening (U.S. PreventiveServices Task Force, 2004). Universal screening of all pa-tients seen in emergency departments is recommendedbecause the chief complaints of the patient, demographic

data, or physical indicators cannot be used to determinethose who are victims of domestic violence (Muelleman,Lenaghan, & Pakieser, 1998).

Ideally, those being abused should be identified throughuniversal screening before there is obvious physical evi-dence of violence. A study by Datner et al. (2002) foundthat 35% of patients in the emergency department positive-ly responded to domestic violence screening questions, butonly 4% were documented in the medical records.

Ellis (1999) performed a chart review of approximately300 emergency department medical records from a largeurban medical center and found that only 8.8% of thecharts had evidence that domestic violence screening wasperformed. This result conflicted with a questionnairesurvey done by Ellis in the same emergency departmentin which 45% of the registered nurses reported that theyroutinely screened their patients for domestic violence.

In their single-site study, Krimm and Heinzer (2002)reported that patients in the emergency department werenot consistently screened for domestic violence and thatdocumentation of screening was not always evident.These studies indicate that many patients are not beingscreened for domestic violence in emergency depart-ments. With this failure to identify victims, recurrentabuse and future health problems loom for those being

abused (Glass, Dearwater, & Campbell, 2001).

Intervention for Domestic Violence

A study by Krasnoff and Moscati (2002) conducted ina large urban hospital demonstrated the effectiveness ofemergency department domestic violence intervention.Women identified as domestic violence victims were pro-vided case management. After follow-up, more than half ofthe women who received intervention perceived themselvesas no longer at risk for domestic violence. Other studieshave indicated that identification rates and intervention in-creased after healthcare provider education (Humphreys &

Campbell, 2003). With the cost of treatment for victims ofdomestic violence estimated to be approximately $1.8 bil-lion in the United States, this healthcare problem shouldnot be overlooked (Warshaw & Ganley, 1998).

A PILOT PROJECT FOR UNIVERSAL SCREENING

AND INTERVENTION FOR DOMESTIC VIOLENCE

The authors became interested in the topic of domesticviolence screening during a routine review of emergencydepartment nursing documentation, at which time it wasnoted that nurses did not indicate they had administered

domestic violence screening. A pilot project was devel-oped to determine the educational needs of emergencydepartment registered nurses. This project focused onhow certain barriers may affect the ability of registered

nurses in the emergency department to ask screeningquestions. The Analyzing Performance Problems modelcreated by Mager and Pipe (1997) was used to determinepossible reasons for the lack of screening for abuse byemergency department staff.

Universal Screening

Universal screening for domestic violence in all patientsolder than 12 years who are seen in the emergency depart-ment was implemented in 1989 at our facility. This policycoincided with the development of a facility-wide violenceintervention service for those experiencing violence orabuse. Healthcare providers were required to assess all pa-tients for domestic violence. In the emergency department,registered nurses generally spend more time with the pa-tient than the physician does, providing nurses the best op-portunity to screen for domestic violence. When the policywas implemented, the emergency department nursing staffreceived a training demonstration about how to screen pa-tients for domestic violence. New staff members receiveddomestic violence education and training during their ori-entation period in the emergency department.

Violence Intervention Program

California law Penal Code Section 11160 requires

healthcare providers to report domestic violence tothe police (California Health Care Association, 2000).Studies have shown that identification rates for do-mestic violence have increased with more widespreadscreening by healthcare professionals (Garcia-Moreno,2002; Thompson et al., 2000).

In 1989, a violence intervention program was developedat our facility. Through the program, a registered nurse wason-call 24 hours a day and was responsible for respondingto calls from the emergency department within 45 minutes.The emergency department registered nurse only had tohave a suspicion of abuse to call the violence intervention

program nurse, whose role was to assist patients who wereidentified as possible victims of violence.

The accurate identification of individuals who aresubjected to abuse and their quick referral to interven-tion programs could result in decreased injury, illness,and death, despite the fact that a busy emergency depart-ment is not a friendly environment in which to performthe delicate line of questioning about domestic violence.Unfortunately, in 2003, important programs, includingthe violence intervention program, were eliminated atthe hospital due to county and state budget shortfalls.



The emergency department staff took on the roles ofscreening for and reporting abuse, which were previ-ously the responsibilities of the violence interventionprogram nursing staff.

Conceptual Framework of the Pilot Project

To determine the educational needs of emergencydepartment nurses following the discontinuation ofthe violence intervention program, a pilot projectwas developed. This project was based on Mager andPipes model (1997), Analyzing Performance Prob-lems, which describes a process for identifying andsolving problems in human performance to establishthe need for further domestic violence training in theemergency department.

This model indicates that one must first recognizethat there is a performance problem and then follow aseries of 12 steps to determine how to solve the prob-lem. Once the problem is identified, the next step inthe process is to determine whether the performancediscrepancy is important. If the discrepancy involves askill deficiency, other questions that must be asked are(1) Could this skill be performed in the past?, (2) Is thisskill used often?, and (3) Do the subjects have the capac-ity to perform the skill? (Mager & Pipe, 1997). If thereis not a skill discrepancy, it must be determined whetherperformance is punishing, whether non-performance isrewarding, whether performance matters, or whetherthere are obstacles to performance. The model was ap-

plied to our study to determine the possible reasons theregistered nursing staff in the emergency departmentrarely screened patients for domestic violence.

In answering the question of whether the performanceof screening for domestic violence matters, the literatureindicated that screening for domestic violence is impor-tant in the prevention of continued risk of abuse and in-jury. Analysis of the project responses determined theimportance of domestic violence to the emergency de-partment registered nurses who answered the question-naire. The entire emergency department registered nurs-ing staff had previously received basic training in how to

screen for domestic violence, indicating that a skill leveldid exist at one time. Although the Analyzing Perfor-mance Problems model was not intended specifically foruse in nursing, it was a useful tool in determining whatobstacles may exist for this emergency department nurs-ing population in screening for domestic violence.

Purposes

The purposes of this project were to determine thebeliefs and attitudes of emergency department registerednurses when universally screening patients for domestic

violence and to assess the continuing education needs oemergency department staff. The authors were attemptinto answer the question What are the factors or perceiveattitudes of emergency department registered nurses th

may pose as barriers when screening patients for domestviolence? The results of this project could be used to develop an educational program in domestic violence.

METHODSSetting

A large urban public hospital emergency departmenat a level one trauma center with an approximate dailcensus of more than 160 patients was the setting for thstudy. Approximately 60 full-time or part-time emergency department registered nurses, who were responsible for screening patients for domestic violence, weremployed in the emergency department of the facility.

Sample

The authors recruited 33 emergency department registered nurses for the project by displaying signs in themergency department. Staff members were assured thatheir responses would remain anonymous and confidential. Furthermore, staff was informed that if the resulwere published, no direct reference to individuals in themergency department would be made. Findings fromthe study are non-experimental and cannot be generaized due to the limitations of the study, which includthe use of a modified tool, a single-site convenience sam

ple, and a small sample size.

Instrument

An anonymous questionnaire containing three components was used as a screening tool. The instrumenwas developed for use with obstetrical and gynecologicregistered nurses and tested for reliability and validitby colleagues of Dr. Mary Lou Moore of Wake ForreUniversity, Winston-Salem, North Carolina. Writtepermission was obtained to modify the questionnaire fouse in the emergency department.

The first component of the tool consisted of 18 state

ments used to determine the nurses beliefs and attitudeabout screening for domestic violence. These statemenwere rated on a Likert-type scale from 1 to 5 (where 1 equivalent to strong disagreement, 2 to disagreement, to uncertain, 4 to agreement, and 5 to strong agreemenwith the statement). The second component consisted odemographic information collected about the emergencdepartment registered nurses. The third component consisted of two questions with a yesor noanswer regarding the selection of patients and the routine for screeninthem. An additional question was added to the origina



statements asking if any problems were encountered re-lated to language barriers (Table 1).

Pilot testing for the reliability of the questionnaire wasaccomplished through a review done by emergency depart-

ment nursing colleagues, including a masters-prepared fo-rensic nurse educator. The questionnaire was then distribut-ed to all emergency department registered nurses during staffmeetings. A total of 33 questionnaires were completed.

TABLE 1

SCREENING FOR DOMESTIC VIOLENCE QUESTIONNAIRE

Background information

____ Gender: 1: Female 2: Male

____ Age: 1: 20 29 2: 30 39 3: 40 49 4: 50 59 5: > 60

____ Ethnicity: 1: African American 2: Filipino 3: Asian non-Filipino 4: Caucasian 5: Hispanic 6: Other

What is your position: _____ RN _____ Physician Assistant ____ Physician

If you are an RN or Physician Assistant, please indicate your highest degree earned:

____ Diploma ____ Associate Degree ____ Nursing ____ Baccalaureate Nursing ____ Masters Nursing

____ Other ____ Other ____ Other

How many years have you been a Registered Nurse, a Physicians Assistant, or a Physician?

____ Less than 2 ____ 2 3 ____ 4 5 ____ 6 10 ____ 11 15 ____ 16 20 ____ 21 and above

Questions about adult patients and abuse:

____ Is it part of your ROUTINEto screen ALLpatients for abuse? 1: Yes 2: No

____ Do you screen SELECTEDpatients for abuse? 1: Yes 2: No

Please indicate the extent to which you agree with the following statements. Please circlethe selected number.

1 = strongly disagree 2 = disagree 3 = uncertain 4 =agree 5 = strongly agree

1 2 3 4 5 Abuse is not a problem in my patient population.

1 2 3 4 5 I am not trained to deal with the problem of abuse.

1 2 3 4 5 I would like some training in how to ask questions about abuse.

1 2 3 4 5 I am concerned about domestic violence and screen all of my patients.

1 2 3 4 5 I intend to institute the screening for abuse, but have not done so.1 2 3 4 5 I do not have time to ask about abuse.

1 2 3 4 5 I have a history of abuse in myself or in my close family.

1 2 3 4 5 It is none of my business. It is a private issue.

1 2 3 4 5 I believe I may offend my patients if I ask about abuse.

1 2 3 4 5 I screen selected patients, especially those in lower socioeconomic situations.

1 2 3 4 5 Some physical contact may be expected in families. I see no reason to interfere.

1 2 3 4 5 Even if a patient tells me she is abused, there is no way to verify it is true.

1 2 3 4 5 I feel more qualified to deal with concrete physical problems than psychologicalissues.

1 2 3 4 5 Middle and upper class patients are unlikely to be victims of abuse.

1 2 3 4 5 Some people bring this on themselves. I cannot hope to change them.

1 2 3 4 5 It is not a medical problem.

1 2 3 4 5 There are too many other important problems to ask.

1 2 3 4 5 Language barriers make it difficult to talk about abuse.



RESULTSDemographics

Although non-experimental, the data were analyzedusing nonparametric methods of analysis. Table 2 pro-vides the complete demographic data of participants. Ofthe 33 registered nurses who completed the question-naire, 88% were women and 12% were men. Seventy-two percent of participants were between 40 and 59 yearsold, 21% were younger than 40 years, and 6% were 60

years or older. By ethnicity, 49% of participants werwhite, 21% were Filipino, 12% were Hispanic,9% werAsian non-Filipino, and 6% identified themselves as belonging to other ethnic groups. Fifty-seven percent o

participants had a baccalaureate degree, 6% had an associate degree, and 6% had completed a diploma programin nursing. Thirty-nine percent of participants had morthan 21 years of nursing experience, 24% had at least 1years of experience, 20% had 6 to 15 years of experiencand 15% had less than 6 years of experience.

Statement Responses

Eighty-seven percent of the participants expressed ainterest in receiving training about how to ask questionabout abuse. The highest-ranking potential barrier to domestic violence screening identified in the questionnairwas the existence of language barriers, which make it dificult to talk about abuse with patients. Additional barriers included a personal or family history of abuse andlack of training in how to deal with abuse. Twenty-ninpercent of respondents reported that time issues affectetheir ability to screen for abuse. Conflicting results werobtained regarding questions about routine screeningFifty-one percent of the registered nurses indicated thathey routinely screened all patients for abuse, but 74%also responded to a separate question that they onlscreened selected patients. This finding may indicate tharegistered nurses routinely screen selected patients witmore obvious signs of abuse but universally screen pa

tients only some of the time.Further study is needed to determine the significance o

the discrepancy in these findings. Our finding may indicatthat when there is an obvious cue of abuse, such as a bruisor visible injury, the registered nurse is more likely to selectively screen these patients. Self-reported results indicatethat emergency department registered nurses believed abusis a problem in the emergency department population, thvictims do not bring the abuse on themselves, it is approprate to inquire about abuse, physical contact is not expectein families, abuse is not just a lower socioeconomic grouphenomenon, abuse is a medical problem, and abuse is a

important issue to verify (Table 3).

DISCUSSION

Demographics of the participants indicated an educaed, older, and ethnically diverse population of emergency department nurses. More than half of the registerenurses in the study were educated at the baccalaureatlevel (Table 2). This may increase screening possibilitiebecause most baccalaureate programs now include curricula about family violence (Cohn et al., 2002). It is alsnoteworthy that the majority of the registered nurse

TABLE 2

DEMOGRAPHICS OF RESPONDENTS (N= 33)

Characteristic No.

Gender Female 29

Male 4

Age (y)

2029 4

3039 3

4049 13

5059 11

>60 2

Ethnicity

Filipino 7

Asian non-Filipino 3

Caucasian 16

Hispanic 4

Other 2

Unknown 1

Education

Diploma in nursing 2

Associate degree nursing 8

Associate degree other 1

Baccalaureate degree nursing 19

Baccalaureate degree other 2

Masters degree other 1

Years of nursing practice

< 2 2

23 1

45 2

610 4

1115 3

1620 8

> 21 13



had been practicing for more than 16 years and thereforemay not have been exposed to family violence education

in nursing school. Overall, the data indicated that emer-gency department registered nurses recognize that abuseis a problem in the emergency department populationand are concerned about domestic violence. This is con-sistent with the premise that nurses recognize a concernfor this population as a part of their nursing practice.

An important finding from this pilot study was thenurses wishes to know how to specifically ask patientsabout domestic violence. Although emergency depart-ment nurses exhibit expert critical-thinking skills in tri-age and the treatment of emergency department patients,

these findings suggest a desire for more task-orientedtechniques for screening for abuse. In a busy emergencydepartment, it is not surprising that time limitations affectscreening for domestic violence because more urgent pa-tient issues demand immediate attention from the nurses.

The desire of registered nurses to learn more abouthow to ask questions when screening for domestic vio-lence provided a wonderful opportunity to educate nurs-

es who already had the mind-set to learn. There is also anopportunity for further study to develop evidence-basedstandards for training and frequency of continuing edu-cation for effective domestic violence screening. Cohnet al. (2002) provided a useful source for a synthesis ofinformation on the education and training of healthcarepersonnel in family violence.

Our finding that nurses often have personal or familyhistories of violence is consistent with previous studies,although the implications of personal violence and itseffect on screening for domestic violence are unknown

TABLE 3

REGISTERED NURSES DISAGREEMENT WITH

QUESTIONNAIRE STATEMENTS (N= 33)

Statement No.

Middle and upper class patients are unlikely tobe victims of abuse. 30

Abuse is not a problem in my patient population. 30

It is not a medical problem. 29

Some people bring this on themselves. Icannot hope to change them. 30

It is none of my business. It is a private issue. 29

Some physical contact may be expected infamilies. I see no reason to interfere. 28

Even if a patient tells me she is abused, thereis no way to verify it is true. 29

There are too many other important problemsto ask about. 26

I screen selected patients, especially thosein lower socioeconomic situations. 21

I believe I may offend my patients if I askabout abuse. 21

I have a history of abuse in myself or in myclose family. 20

I am not trained to deal with the problemof abuse. 19

I do no have time to ask about abuse. 21

I feel more qualified to deal with concretephysical problems than psychological issues. 14

I intend to institute the screening for abuse,but have not done so. 12

I am concerned about domestic violence andscreen all of my patients. 17

Language barriers make it difficult to talkabout abuse. 6

I would like some training in how to askquestions about abuse. 1

TABLE 4

OUTLINE OF DOMESTIC VIOLENCE

RECOGNITION AND REPORTING TRAINING

I. Definition of Domestic Violence and Pattern of Abuse

II. Relationships of All Types May Include DomesticViolence

III. Myths/Misconceptions

IV. Domestic Violence Screening: Asking the Question

a. Examples on how to approach the subject

b. Examples of questions for domestic violencescreening

V. Mandated Reporting

VI. Patient Presentations

a. Behavior

b. Verbal clues

c. Delay in treatment

d. Vague complaints, depression, anxiety,substance abuse

VII. Injuries of Abuse

a. Mechanism of injury and patterned injury

b. Injury inconsistent with history

c. Various stages of healing

d. Multiple injury sites

VIII. Medical Documentation

IX. Completing Required Reporting

X. Domestic Violence Resources



(Moore et al., 1998). An additional barrier that has beenidentified includes the challenge of screening patientswho speak a foreign language despite access to transla-tors at the facility in which the research was conducted.

The Analyzing Performance Problems model (Mager& Pipe, 1997) indicates that training needs must first bemet to improve performance. This model could be usedto gain a better level of understanding of the needs foreducation and training in other emergency departments.

As a result of this project, an additional hour-longcontinuing education presentation on domestic violenceand screening was provided to the emergency depart-ment nurses at this facility. The content for the class wasdeveloped from the results of the questionnaire and in-cluded specific terminology that could be used to askthe question (Table 4). Ideally, it would be optimal toprovide more time for this training, possibly to includea role-playing session and other techniques to facilitatequestioning patients about domestic violence, but dueto hospital staffing and budgetary constraints, educa-tors must be creative and provide condensed in-service

education in shorter time frames. A follow-up question-naire will be used to determine whether there has beenincreased compliance with screening and to determinethe effectiveness of the educational program and needfor further training.

IMPLICATIONS FOR PRACTICE

Similar surveys could be performed in other emergen-cy departments to determine the need for further educa-tion and training. Perhaps the barrier of lack of time maybe eased somewhat with the emergency department reg-

istered nurse staffing ratio requirements that were signeinto California law in 2003, as Assembly Bill 394, animplemented in 2004. This new law requires a minimumand specific nurse-to-patient staffing ratio for acute car

facilities (California Nurses Association, 2003). The newemergency department staffing ratios are 1 registerenurse to 4 patients, which contrasts with the current ratio of between 1:5 and 1:8. Future study could determinwhether a change in staffing ratios increases the amounof time the registered nurse has available to screen foabuse and thus potentially increase the identification othose who are being abused.

Another difficult task is that of addressing the aspecof diversity and providing trained translators to assisin the screening of emergency department patients fodomestic violence. Translators provide expert languagskills, but their training and knowledge in family violence issues may vary or be nonexistent. An opportunity exists to investigate the effectiveness and accuracof translations in this situation.

Further investigation may also determine that, despitthe registered nurses use of critical-thinking skills in themergency department, the desire may exist for more taskoriented questioning techniques when screening for dometic violence. Staff developers and educators in the hospitsetting may have the opportunity to use multiple medforums, such as computerized information tools, to trairegistered nurses in how to ask questions about abuse.

The effect of domestic violence on families and th

healthcare system warrants continued investigation intevidence-based curriculum, education, and training methods for emergency department registered nurses anhealthcare professionals. Domestic violence training mutake into account the possible barriers of beliefs or attitudes, language barriers, the limited amount of time spenwith patients, and the possible effects of previous experences with personal violence. This study provides initiinformation that others can build on to investigate thesissues in future research and information that can be integrated into a domestic violence training curriculum.

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key points

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CE QUIZ ANSWERS

1. A 2. A 3. C 4. A

5. D 6. B 7. D 8. C9. B 10. D


10/10

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