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Routine Universal Screening From Policy to Practice

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Title: Routine Universal Screening From Policy to Practice


1
Routine Universal ScreeningFrom Policy to
Practice
  • By Sarah Kaplan, MSW, RSW
  • Coordinator Assault and Sexual Abuse Program
  • Womens Health Champion
  • Cornwall Community Hospital

2
Objectives
  • To understand the importance of routine universal
    screening
  • To obtain evidence for policy development in
    regards to routine universal screening
  • To learn the necessary steps in the
    implementation of routine universal screening

3
Why Should Screening for Intimate Partner
Violence Occur in a Health Care Setting?
  • Health care settings are a common place where
    abused persons will go for help
  • Nurses are often the first member of the
    healthcare team to interface with women
    experiencing abuse
  • Nurses are accessible to the public, enjoy a high
    degree of public trust
  • Nurses interact with people during times of
    stress and illness as during developmental
    transitions such as adolescence, pregnancy and
    parenthood
  • Nurses use a holistic health promotion framework
  • Nurses possess the clinical skills to accurately
    assess abuse of a patient
  • Early recognition is crucial for the health and
    safety of an abuse victim
  • IPV can often be the missing piece to a complete
    diagnosis

4
When It Works A nurses story
  • A woman presented at our emergency with a broken
    arm. When questioned on the cause, she stated she
    fell down. She denied abuse from the screening.
    The nurse felt her injuries were not consistent
    with her story and a little later in the exam
    room gently questioned her again and the truth
    came out. She stated that her husband had broken
    her arm in a violent episode. Because of the
    nurses sensitivity this womans real issue was
    addressed and she was given the choice to have
    additional support.

5
What is Intimate Partner Violence
  • Partner abuse is a behavioural pattern used by
    one person to gain/maintain power and control
    over another. This occurs in all types of
    intimate partner relationships including
    common-law and same sex. It may or may not
    include physical abuse. Abuse can include other
    forms of mistreatment and cruelty such as
    constant threatening, psychological, emotional,
    verbal abuse and sexual assault. Sexual assault
    is defined as any form of sexual activity with
    another person without that persons consent.

6
Prevalence Data
  • 17 - 30 of all women treated in hospital
    emergency departments are victims of domestic
    violence (Waller, Hohenhaus, Shah, Stern)
  • A study which reviewed hospital emergency room
    records found that only 1 in 25 cases of wife
    assault was identified. (Ontario Womens
    Directorate)
  • Worldwide, 10 - 50 of women report having been
    hit or physically assaulted by an intimate
    partner (Taket et al.)
  • 8 of women and 7 of men experienced some type
    of violence - ranging from threats to sexual
    assault - in their intimate relationships during
    the five years covered by the survey. The survey
    also found that the violence experienced by women
    tended to be more severe and more often repeated
    than the violence directed at men. (Statistics
    Canada 1994)

7
Health Consequences of Intimate Partner Violence
  • More physical symptoms
  • More frequent users of health care
  • More likely to suffer chronic pain
  • Increased rates of depression, anxiety, low
    self-esteem and attempted suicide
  • Pregnancy related complications

8
Economic Consequences of Intimate Partner Violence
  • Health-related costs of violence against women in
    Canada exceed 1.5 billion/year (Health Canada)
  • Findings from the US indicate more frequent
    periods of unemployment, lower personal incomes,
    greater job turnover, health problems that affect
    job performance (Lloyd Taluc)

9
What is Routine Universal Screening
  • Routine screening is performed on a regular basis
    regardless of whether or not signs of abuse are
    present FREQUENCY of the screening the WHEN
  • Universal occurs when nurses ask everyone over a
    specific age about abuse CHARACTERISTICS of the
    group being screened the WHO

10
CCH Policy
  • POLICY
  • 1.       Routine universal screening (RUS) will
    be implemented to improve the care provided to
    victims of intimate partner violence by
    recognizing and referring patients to the
    appropriate resources.
  • 2.       RUS will be done by specially trained
    staff who
  • a.   will screen all women and men over the age
    of 12 for partner abuse.
  • b.   will be knowledgeable about the dynamics of
    woman abuse, and its impact on the abused
    woman and her child(ren).
  • c.   Be skilled in responding effectively to
    disclosures of abuse.
  • d. Be knowledgeable about community resources
    for abused women and their children.

11
RNAO Best Practice Guidelines
  • Published in 2005
  • Panel of experts nurses, social worker
  • Evidence based
  • Website, click on-line catalogue then best
    practice guidelines

www.rnao.org/bestpractices
12
RNAO Organization and Policy Recommendations
  • Implementation of this BPG requires adequate
    planning, resources, organizational support, as
    well as appropriate facilitation.
  • An assessment of organizational readiness and
    barriers to education.
  • Dedication of a qualified individual to provide
    the support needed for the education and
    implementation process.
  • Opportunities for reflection on personal and
    organizational experience in implementing
    guidelines.

13
RNAO Organization and Policy Recommendations
  • Health care organizations develop policies and
    procedures to support effective practice
  • Health care organizations work with the community
    at a systems level to improve collaboration and
    integration of services between sectors

14
RNAOPractice Recommendations
  • Nurses implement routine universal screening in
    the context of a health history for all females
    12 years of age and older in all health care
    settings
  • Nurses develop skills to foster an environment
    that facilitates disclosure. This necessitates
    that nurses know
  • how to ask the question
  • how to respond to disclosure
  • Nurses develop approaches that are responsive to
    the needs of all women taking into account
    differences based on race, ethnicity, class,
    religious/spiritual beliefs, age, ability, or
    sexual orientation.
  • Nurses know how and what to document
  • Nurses understand their legal obligations when a
    disclosure is made

15
RNAO Education Recommendations
  • Mandatory educational programs in the workplace
    be designed to
  • Increase nurses knowledge skills
  • Foster awareness and sensitivity about woman abuse

16
How to Screen
  • Screening questions are part of routine health
    history.
  • Nurses consider immediate safety of patient.
  • Screening occurs when patients condition is
    stable.
  • Questions are asked directly to patients, while
    maintaining visual contact where privacy can be
    assured.
  • forms are NEVER handed to patients to read and
    fill out.
  • Patients are screened alone, never in the
    presence of their partner, other family members,
    or children over 3.
  • Where language is a barrier, only trained
    cultural interpreters are used, never family
    members.

17
Asking the Question
  • Explain because of the high prevalence of
    violence in our society and the impact on health,
    we are asking questions about abuse
  • Tailor your approach to the individual
  • Inform patients that they will be screened each
    time they come to the hospital
  • Send a clear message that violence is unacceptable

18
Sample Questions
  • It is our duty to be patient advocates and screen
    for abuse. We know that many individuals
    experience problems in relationships that can
    result in health problems. Are you in a
    relationship with someone who threatens to or
    has hurt you in any way?
  • Have you ever been emotionally, physically, or
    sexually abused by your spouse/partner?
  • stay away from terms that denote gender until
    stated by the patient (wife, husband, girlfriend,
    boyfriend)

19
If They Answer Yes
  • Are you safe now
  • Would you like to talk about it
  • When did this happen
  • Have you talked to anyone else about this
  • How are you coping
  • What do you need right now

20
Response to No When You Suspect YES
  • Discuss what you have observed and why you are
    still concerned
  • Im concerned about how you got these injuries.
    Did someone do this to you?
  • We often see injuries/symptoms like yours when a
    patient has been hurt by a spouse/partner. Is
    this happening to you?
  • Offer educational information about the health
    effects and prevalence of abuse
  • Offer resources
  • Document response

21
Responding to a NO
  • Share general information about abuse
  • Document response

22
Documentation
  • Documentation is an integral aspect of safe,
    effective nursing practice (CNO, 2004c) and must
    be comprehensive, legible and accurately reflect
    screening practice (Health Canada, 1999b,c MLHu,
    2000).
  • The record needs to include
  • a safety check.
  • direct quotations of what the person said.
  • direct observations made by the nurse.
  • referrals discussed and made and/or information
    given.

23
Barriers to Screening for the Nurse
  • Fear of a yes answer and then what do I do
  • Fear of offending the patient
  • No time
  • Not a nurses role
  • Believe its the victims fault
  • Lack of awareness regarding intimate partner
    violence
  • Lack of support by employer
  • Personal history of abuse

24
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25
Barriers From the Clients Perspective
  • The children
  • Religious/cultural beliefs
  • Doesnt see situation as abusive
  • Fear of retaliation
  • Fear regarding immigration status
  • Concern for partner - arrested
  • Lack of knowledge of available resources

26
What Are the Steps to Implement RUS
  • Develop a committee of interested individuals
  • Allocate one committee individual to champion
    this project
  • Develop a hospital wide policy
  • Develop a strategic plan for hospital wide
    implementation
  • Develop a screening tool
  • Develop a method of evaluation
  • Develop a mandatory training session
  • Develop a plan to support nurses who begin to
    screen
  • Organizational commitment to Routine Universal
    Screening
  • Involve relevant community partners shelters,
    crisis lines etc.

27
What We Did
  • 2000 2005
  • Creation of committee
  • Research on screening
  • Screening tool created
  • Evaluation methodology created
  • Support plan developed
  • Training developed
  • Screening began 2002
  • Participation on RNAO BPG Panel
  • 2005 present
  • Hospital policy ratified
  • New training developed
  • Strategic plan for hospital wide implementation
    approved by senior admin
  • All RNs will be receive training and will begin
    screening
  • RUS prompt on electronic charting
  • RUS tick box on in-patient chart
  • In-progress self-directed learning package for
    on-going education

28
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29
Data
  • From Jan. 1/07 July 1/07
  • 23,043 persons triaged in ER
  • 2,028 not applicable too young for example
  • 5,088 not screened RN not trained yet for
    example, non-compliant nurse
  • 15,770 marked negative to screening not
    entirely accurate
  • 157 individuals answered yes to screening and
    were provided follow-up services ASAP,
    shelters, referral info
  • 26 per month compared to 10 per month in the last
    year
  • We are improving albeit slowly

30
Where Are We Now
  • Hospital has amalgamated
  • Screening is taking place in the ER
  • Electronic charting screening is a required
    field
  • On Patient Admission Assessment Form
  • As each dept. completes its training we move to
    the next according to a priority list
  • RUS training part of ER nurse orientation
  • Looking at making RUS training part of hospital
    orientation for all new nurses
  • Working on a self-directed learning package

31
What were/are some Challenges
  • Compliance with this new task need strong
    message that this is a hospital policy apparent
    in the data
  • Issues relating to violence are difficult,
    controversial and triggering
  • Ensure you have everything in place before you
    begin - especially a policy
  • Training due to staffing issues - difficult to
    train large groups of staff where shift work is a
    reality
  • Appropriate environment triage not always
    private
  • Hospital amalgamation, construction

32
What Helped Us
  • RNAO Best Practice Guidelines Woman Abuse
    Screening, Identification and Initial Response
    (2004)
  • Task Force on the Health Effects of Woman Abuse
    Final Report by the Middlesex-London Health
    Unit
  • Strong commitment by the Cornwall Community
    Hospital Violence Issues Committee
  • Buy in from Hospital Senior Administration
  • Expertise of the Assault and Sexual Abuse Program
  • Solid support from community partners womens
    shelters, Eastern Ontario Health Unit

33
Kudos
  • Participated in Provincial project on Hospital
    Response to Woman Abuse
  • Part of Expert Panel for Registered Nurses of
    Ontario Best Practice Guidelines on Woman Abuse
    Screening, Identification and Initial Response
  • Interview w/Rita Chelli CBC as one of the first
    hospitals in Ontario to implement universal
    screening
  • Regularly contacted by Hospitals across the
    province to provide support in launching RUS

34
Final Words
  • We assert that routine universal screening, in
    conjunction with comprehensive staff education
    and ongoing agency and managerial support,
    benefits our patients and our community.

35
References
  • Asher, J., Crespo, E.I., Sugg, N.K. (2001).
    Detection and treatment of domestic violence.
    Contemporary OB/GYN, 46, 61-66.
  • Department of Health (2000). Domestic Violence A
    resource manual for health care professionals.
    Retrieved December 19, 2003, from
    http//www.doh.gov.uk/pdfs/domestic.pdf
  • Family Violence Prevention Fund (2004). National
    consensus Guidelines on identifying and
    responding to domestic violence victimization in
    health care settings. Retrieved December 19,
    2003, from http//endabuse.org/programs/display.ph
    p3?DocID206
  • Malecha, A. (2003). Screening for and treating
    intimate partner violence in the workplace. AAOHN
    Journal, 5, 310-316.
  • Middlesex-London Health Unit. (2000). Task force
    on health effects of woman abuse Final report.
    London Middlesex-London Health Unit.
  • Poirier, L. (1997) The Importance of Screening
    for Domestic Violence in All Women. The Nurse
    Practitioner, 22, 105-122.
  • Punukollu, M. (2003) Domestic Violence Screening
    Made Practical. The Journal of Family Practice,
    52 (7), 105-122.
  • Statistics Canada (2004) Family Violence in
    Canada A Statistical Profile ? Minister of
    Industry, Ottawa.
  • Waller, A. E., Hohenhaus, S. M., Shah, P.J.,
    Stern, E. A.(1996). Development and validation of
    an emergency department screening and referral
    protocol for victims of domestic violence. Annals
    of Emergency Medicine, 27, 754-760.

36
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