Running head: IMPACT OF DOMESTIC VIOLENCE SCREENING 1

Impact of Domestic Violence Screening by Emergency Room Nurses

on Reduced Readmission Rates

Jaclyn M. Lynch

Margaret A. Lavery

Colleen M. Davidson

Dana C. Rucereto

Andrea K. Pasierb

James Madison University

IMPACT OF DOMESTIC VIOLENCE SCREENING 2

Abstract

This paper analyses the current literature regarding the use of domestic violence

screening tools by emergency room nurses, and how proper use affects readmission of battered

patients. The emergency department provides a unique opportunity to screen for domestic

violence due to the wide range of patients it serves each day. A meta-analysis of ten literature

sources was used to assess the current research investigating the issue. Readmission rates were

considered for determining the effectiveness of intimate partner violence with the idea that, if a

woman is readmitted into the hospital for similar injuries pertaining to intimate partner violence,

the initial screening was not adequate. This could be due to incompetence by the nurse or

hospital educational gaps. Throughout the literature, it is evident that more research is needed to

make any conclusions based on the effectiveness of routine screening for intimate partner

violence in the emergency room. Although a variety of research strategies exist that have the

potential to yield significant findings, such as educational sessions with pre and posttests, certain

barriers prevent the results from being applicable to the entire population. Small sample sizes

and the exclusion of certain cultures in experimentation leaves gaps in the reliability of the

findings. There is also a large stress on the need for a uniform screening tool for domestic

violence in the emergency department. Finding the best choice for a screening tool and

minimizing healthcare professional and patient barriers is of utmost importance. Once a

universal screening tool is established, the controversy over domestic violence protocol can be

mitigated. Thus, the identification of victims will be clearly evident and appropriate treatment

can be carried out.

Impact of Domestic Violence Screening by Emergency Room Nurses

IMPACT OF DOMESTIC VIOLENCE SCREENING 3

on Reduced Readmission Rates

Domestic violence is defined as a pattern of behaviors used by one partner to maintain

power and control over another partner in an intimate relationship. This behavior includes the

use of physical and sexual violence, intimidation and threats, emotional abuse, and economic

deprivation (Ahmad et al., 2017). Overtime, repeated exposure to one or a combination of these

can lead to severe issues in physical, mental, and emotional health. In the United States, one in

three women will experience domestic violence by their partner, and thus it is crucial for

healthcare workers to recognize and address this issues properly. (Choo & Houry, 2015). The

emergency department provides a ideal opportunity for healthcare workers to screen for domestic

violence due to large quantity of patients seen. The purpose of this literature review will explore

the effectiveness of domestic violence screening performed by emergency department nurses to

help lower the incidence of readmission.

Synthesis of Literature

Similarities in Literature

The emergency room provides a unique opportunity to identify instances of domestic

violence for a number of reasons, and this was a consistent finding across all studies. According

to a study completed by the Pennsylvania State Nurses Association, 37% of injured women in

the emergency department were the result of a current or former partner, illustrating the mass

number of domestic violence victims the emergency department treats (Biresch, 2011).

Additionally, in a systematic review of intimate partner violence intervention research, other

aspects of the emergency department were identified that create an optimal opportunity to

identify domestic violence including the use of the emergency department as medical care for

those who are not seen by regular providers. This systematic review also confirmed that the
IMPACT OF DOMESTIC VIOLENCE SCREENING 4

emergency department treats the largest percentage of abused patients when compared to other

medical settings, coinciding with a literature review completed by the Pennsylvania State Nurses

magazine (Choo et al., 2015).

While the literature unanimously confirmed the emergency department as an appropriate

opportunity for screening, multiple studies confirmed several barriers to performing the

screening. First, a single screening tool has not been determined as the most appropriate. Much

of the literature reviewed mentioned a separate screening tool, which lead to unstandardized

results and inconsistent data. Additionally, even at hospitals with pre-existing protocol, many

nurses are unaware of it. They instead rely on personal judgements to dictate who receives

screening. This defeats the all encompassing nature of screening before symptoms are overtly

obvious, particularly among groups who are not typically associated with domestic violence,

such as Caucasian and people of a wealthier socioeconomic status (Robinson, 2010). In addition

to lack of knowledge, nurses throughout the various studies expressed their lack of comfort in

asking emotionally charged questions pertaining to domestic violence (Roark, 2010). A lack of

comfortability leads to lack of competence, which affects the willingness to disclose such

personal information (Ahmad et al., 2017).

Controversies in Literature

While the studies consistently support a need for screening in the emergency department,

inconsistencies presented in the difference of survey and documentation tools used. In a study

completed in 2010, nurses were to complete a pre and post-test after training and implementing

domestic violence screening tools asserted that the training was adequate in identifying cases of

domestic violence (Boursnell & Prosser, 2010), while a study in the Journal of Family Violence
IMPACT OF DOMESTIC VIOLENCE SCREENING 5

identified a need for consistent documentation to make the screening effective (Ritchie, Nelson,

Wills, & Jones, 2013).

There is a clear emphasis on a need for a universal screening tool of domestic violence

victims within the emergency department setting. This requires a thorough review of all available

evidence on domestic violence and intimate partner violence so that the strengths and limitations

can be clearly identified. Once the research is consolidated healthcare professionals will have the

means to overcome the barriers they face within screening (Ahmad et al., 2017). Despite the

barriers many healthcare professionals face, “many patients view screening as helpful and one

large, multicenter study reported that 80% to 89% of female ED patients think physicians should

ask about abuse (Houry et al., 2008).”

Limitations in Literature

Domestic violence research is considered a challenge due to multiple factors, but

particularly due to the emotionally inherent nature of the issue. Manifestations of abuse and the

consequences that follow are displayed differently from patient to patient. Therefore, to

generalize the problem and its characteristics is impossible. Similarly, domestic violence data

can lose its integrity because of the lack of quantitative methods. Nurses may omit the truth to

ensure they will not paint themselves in a negative light. They may state the professional answer,

rather than the truth of their behavior regarding current screening issues (Robinson, 2010).

Another limitation that exists within the literature is associated with sample size.

Although there is nothing precise about the number of participants when designing studies, a

small number may require careful interpretation because they do not normally yield reliable

estimates that can convey nationwide trends. This phenomena is evident within a study by Roark

conducted in 2010, that only investigated a sample size of 100, in which, 90% were female
IMPACT OF DOMESTIC VIOLENCE SCREENING 6

(Roark, 2010). Similarly, a qualitative study conducted by Soglin (2009) solely focuses on

English speaking women (Soglin et al., 2009). These small sample sizes, and the exclusion of

minority sub-populations, create a discrepancy in the reliability of data as the findings cannot be

applied to the larger United States population.

Recommendations

The topic of domestic violence is a very personal and emotional topic to discuss with a

patient, which is why the screenings have not yet achieved a routine level. Houry et al. (2008)

suggests a solution to this problem by administering a written or computer-based questionnaire.

This can be beneficial in multiple ways; it allows the patient to be open and honest, it is a low

cost and effective way to identify at-risk victims, and takes away some stressors from the

healthcare professional that would be performing the assessment (Houry et al., 2008).

Additionally, finding in-depth hard data, beyond simple qualitative studies, was limited. These

qualitative studies took the form of a one time interview or a quick set of questionnaires. Results

from interventions are never immediate, and thus leads to skewed data if the collection period

occurs prior to patients implementing personal changes (Choo et al., 2015). Therefore it is

recommended to continue a study over a long period of time, such as five years, to ensure

accurate information is gathered.

Nurses often feel unprepared or unaware of written protocol regarding domestic violence

screening. A study conducted in 2010 investigating the role of a nurse in domestic violence

screening found that only 38% of the nurses interviewed knew of the written protocol mandated

by their respective hospital. Although, all three hospitals did have existing policy (Robinson,

2010). This causes the nurses to start relying on their own predetermined judgement on whether

a patient is at a high risk of being victim to domestic abuse. Proper protocol takes stereotyping
IMPACT OF DOMESTIC VIOLENCE SCREENING 7

out of the equation, and therefore it is recommended for each hospital to create and educate staff

on their respective procedures for domestic violence patients.

Conclusion

In completing this literature review, the most vital statistics and assertions centered

around the necessity of screening for domestic violence in the emergency department because of

the sheer number of victims seeking treatment in that specific medical setting. Additionally, in

researching this topic it became clear that many gaps exist in the data, and that despite numerous

organizations identifying domestic violence as a priority topic, there is yet to be one uniform

screening tool. Furthermore, none of the studies identified a measurable way to track what

happens to individuals who screen as positive for potential domestic violence, such as

readmission rates. In fact, there was no information regarding readmission rates at all. Even

though the emergency department has been identified as a key role in early identification, there is

currently no way to track follow up visits with these individuals as they might seek treatment at a

wide variety of primary care providers. Overall, it is clear that many steps need to be taken in

order to create better, more measurable outcomes for victims of these heinous acts.

References

Ahmad, I., Ali, A., Rehman, S., Talpur, A., & Dhingra, K. (2017). Intimate partner

violence screening in emergency department: A rapid review of the literature. Journal of

Clinical Nursing, 26(21-22), 3271-3285. doi:10.1111/jocn.13706

Biresch, J. (2011). Assessing domestic violence in the healthcare setting: Article one in a
IMPACT OF DOMESTIC VIOLENCE SCREENING 8

five-part series on DV. Pennsylvania Nurse, 66(2), 6–10.

Boursnell M., & Prosser S. (2010). Increasing identification of domestic violence in

emergency departments: A collaborative contribution to increasing the quality of practice

of emergency nurses. Contemporary Nurse: A Journal for the Australian Nursing

Profession, 35(1), 35–46. https://doi.org/10.5172/conu.2010.35.1.035

Choo, E., Gottlieb, A., DeLuca, M., Tape, C., Colwell, L., & Zlotnick, C. (2015).

Systematic review of ED-based intimate partner violence intervention research. Western

Journal of Emergency Medicine: Integrating Emergency Care within Health, 16(7),

1037-1042. doi:10.5811/westjem .2015.10.27586

Choo, E., & Houry, D. (2015). Managing intimate partner violence in the emergency

department. Annals of Emergency Medicine, 65(4), 447–451.

https://doi.org/10.1016/j.annemergmed.2014.11.004

Houry, D., Kaslow, N., Kemball, R., McNutt, L., Cerulli, C., Straus, H., … Rhodes, K. (2008).

Does screening in the emergency department hurt or help victims of intimate partner violence?

Annals of Emergency Medicine, 51(4), 433–7.

https://doi.org/10.1016/j.annemergmed.2007.11.019

Ritchie, M., Nelson, K., Wills, R., & Jones, L. (2013). Does training and documentation

improve emergency department assessments of domestic violence victims? Journal of

Family Violence, 28(5), 471–477. https://doi.org/10.1007/s10896-013-9514-0

Roark, S. (2010). Intimate partner violence: Screening and intervention in the health care

setting. Journal of Continuing Education in Nursing, 41(11), 490–495.

https://doi.org/10.3928/00220124-20100601-02
IMPACT OF DOMESTIC VIOLENCE SCREENING 9

Robinson, R. (2010). Myths and stereotypes: How registered nurses screen for intimate

partner violence. JEN: Journal of Emergency Nursing, 36(6), 572–576.

https://doi.org/10.1016/j.jen.2009.09.008

Soglin, L., Bauchat, J., Soglin, D., & Martin G. (2009). Detection of intimate partner

violence in a general medicine practice. Journal of Interpersonal Violence, 24(2), 338–

348. https://doi.org/10.1177/0886260508316481