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Domestic Violence & Health in North Carolina: Planning and Implementing Response Programs in Healthcare Settings

Prepared by

Corrine Munoz-Plaza, MPH Jan Capps, MPH The Beacon Program Prepared for

The Governor’s Crime Commission The Beacon Program The North Carolina Department of Effective Practices Project Crime Control and Public Safety University of North Carolina Hospitals CB# 7600 - 101 Manning Drive Chapel Hill, NC 27514 January 2001

Grant #: 180-1-98-4VA-W-020 Grant #: 180-2-99-4VA-W-020

Domestic Violence & Health in North Carolina: Planning and Implementing Response Programs in Healthcare Settings

Prepared by

Corrine Munoz-Plaza, MPH Jan Capps, MPH The Beacon Program

Prepared for

The Governor’s Crime Commission The North Carolina Department of Crime Control and Public Safety

University of North Carolina Hospitals The Beacon Program Effective Practices Project Campus Box 7600, 101 Manning Drive Chapel Hill, NC 27514 Phone (919) 966-9314 Fax (919) 966-9315 http://www.med.unc.edu/wrkunits/3ctrpgm/beacon/

January 2001

Ordering Information

This manual may be ordered from The Beacon Program by writing to Campus Box #7600, University of North Carolina Hospitals, Chapel Hill, NC 27514 or by calling (919) 966-9314. The charge is $3.00, which covers postage and handling. Please make payment by check or money order to “The Beacon Program.”

Acknowledgements

This project was generously supported by Federal Formula Grant # 180-1-98-4VA-W-020 and l80-2-99-4VA-W-020, awarded by the Bureau of Justice Assistance, U.S. Department of Justice through the North Carolina Department of Crime Control and Public Safety/Governor’s Crime Commission. Points of view or opinions contained within this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.

We want to also thank the North Carolina healthcare organizations that participated in the Effective Practices for Healthcare Response to Domestic Violence Project. We greatly appreciate the cooperation, hard work and dedication displayed by all five sites to the issue of domestic violence and the efforts made to plan and develop their own healthcare-based domestic violence response programs. Those sites include: Lenoir Memorial Hospital, Lenoir County; Cleveland Regional Medical Center, Cleveland County; New Hanover Regional Medical Center, New Hanover County; Rural Health Group, Northampton County; and Robeson Health Care, Robeson County.

Finally, we greatly appreciate the guidance, feedback, and assistance provided by the Effective Practices Project’s Statewide Multidisciplinary Team members, which include: Jill Silverman, MD, Diana Solkoff, MPH, Diana Wells, MPH, MSW, RN, Peggy Goodman, MD, Amy Holloway, MSW, Thomas Williams, Janice Kraft, Paige Hall Smith, Ph.D, and Anna Waller, Sc.D. Each member of the team offered invaluable experience and expertise in the areas of domestic violence, data collection and evaluation, and the planning, development and implementation of healthcare-based domestic violence response programs.

Table of Contents

Introduction...... 1 About This Manual...... 3 Definition of Terms...... 5 Chapter I: Domestic Violence & Health...... 6 Definition of Domestic Violence...... 6 Learning to Recognize Domestic Violence...... 7 Impact of Domestic Violence on Health Status...... 8 Health-related Indicators of Domestic Violence...... 8 Healthcare Domestic Violence Statistics...... 9 Role of the Healthcare Provider in Addressing Domestic Violence...... 10

Chapter II: Planning an Institutional Response...... 12 Gain Administrative Support...... 12 Form a Multidisciplinary Planning Team...... 13 Conduct Needs Assessment...... 14 Patient Assessment...... 15 Clinician Assessment...... 16 Healthcare Organization Assessment...... 17 Community Resources Assessment...... 18 Summary of Findings from North Carolina Healthcare Organizations...... 18 Intervention model...... 24 Example Program Models...... 27

Chapter III: Developing Program Components...... 28

Program Components...... 28 Domestic Violence Multidisciplinary Planning Team...... 29 Domestic Violence Policies & Protocols...... 30 Clinical Intervention Services...... 34 Identification...... 37 Assessment...... 42 Intervention...... 45 Documentation of abuse...... 49 Discharge planning...... 52 Follow-up with patients...... 53 Staff Training and Education...... 54 Patient Education...... 56 Community Linkages...... 56 Determining Program Success...... 58

Chapter IV: Program Implementation...... 59 ......

Developing a Budget and Acquiring Resources...... 59 Institutionalizing Routine Screening...... 60 Administering Provider Training...... 61 Marketing the Program...... 61 Determining Program Success...... 62

References...... 66 Appendices...... 68 Appendix A - Effective Practices for Healthcare Response...... 68 Appendix B - Domestic Violence Resources...... 73 Appendix C.1 - Patient Survey...... 84 Appendix C.2 - Clinician Survey...... 86 Appendix C.3 - Healthcare Organization Assessment...... 93 Appendix C.4 - Community Resources Assessment...... 99 Appendix D - Patient Data: Background & Identifying Information...... 101 Appendix E - Legal Issues for Healthcare Providers...... 102 Appendix F - Consent to Photograph...... 108 Appendix G - Danger Assessment...... 109 Appendix H - Safety Plan I...... 111 Appendix I - Safety Plan II...... 113 Appendix J - Body Map...... 120

Addendum (separate documents) Identification, Documentation and Reporting of Child Maltreatment

Identification, Documentation and Reporting of Child Exposure to Domestic Violence

Elder Abuse and Neglect

Introduction

Approximately 4 million women experience domestic violence at the hands of an intimate partner each year (Sassetti, 1993). Because batterers tend to isolate their female partners from family, friends, and services, a visit to the doctor’s office, health clinic or emergency department may be one of the few times a woman comes into contact with professionals in a confidential setting. Early intervention is critical, because violence is almost always repeated, often escalates in severity over time and can ultimately lead to a number of acute and chronic health problems for victims.

In 1992, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) recognized the important role healthcare organizations play in assisting domestic violence victims. In fact, JCAHO now requires accredited healthcare organizations to establish domestic violence policies and protocols in emergency and ambulatory care departments. The American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association also recognize the responsibility healthcare professionals have in addressing domestic violence and have issued their own guidelines for identification and treatment. Such policies and guidelines underscore the importance of identification, treatment and referral of domestic violence victims in healthcare settings.1 Such guidelines can provide a solid foundation to build upon when planning, developing and implementing domestic violence response programs in healthcare settings. By establishing clear policies and protocols for domestic violence screening, assessment, intervention, referral and follow-up, healthcare organizations can accomplish three main goals. These goals are:

1 According to statistics from the United States Department of Justice (1994), approximately 95% of the victims of domestic violence are women and the vast majority of perpetrators are men. Therefore, for the purposes of this manual, victims will generally be referred to as female and perpetrators as male. However, it is important to remember that men in heterosexual relationships can also be victims of domestic violence, as can both men and women involved in same-sex relationships.

1  increasing the rates at which clinicians and staff identify battered women  improving the care provided to patients experiencing domestic violence  coordinating services with local domestic violence agencies and streamlining referral services to appropriate community resources

2 About This Manual

The Beacon Program at the University of North Carolina Hospitals is a hospital-based domestic violence intervention program. Established in 1996, the goal of the Beacon Program is to provide health assessment, counseling, case-management, and community referral for battered women seen in the inpatient and outpatient clinics of University of North Carolina Hospitals. The objectives of the program are to provide services via patient advocacy, counseling, educational services, medical care, and case-management to victims of domestic violence, as well as training to staff and faculty in the assessment, diagnosis, treatment, care and referral of abuse victims. In addition, Beacon Program staff network with community agencies that serve victims of violence to develop coordinated services and referrals. In 1998, the Beacon Program was funded by the North Carolina Governor’s Crime Commission to develop the Effective Practices for Healthcare Response to Domestic Violence project (EPHRDV). The goal of the project was to provide technical assistance to five healthcare organizations throughout North Carolina in the planning and development of each site’s own domestic violence response program. The organizations in North Carolina that agreed to participate in EPHRDV include: Lenoir Memorial Hospital, Lenoir County; Cleveland Regional Medical Center, Cleveland County; New Hanover Regional Medical Center, New Hanover County; Rural Health Group, Northampton County; and Robeson Healthcare, Robeson County. Technical assistance was provided to each site on forming a multidisciplinary planning team, conducting a needs assessment, holding a planning workshop for site administrators, clinicians and local community agencies, implementation of program components, and evaluation of the program after one year. For a more detailed description of the technical assistance provided to each site, refer to Appendix A. Informed by working with each of these five healthcare organizations, this manual is provided as a resource for healthcare organizations and community agencies interested in developing a comprehensive response to domestic violence in a healthcare setting. Whether the organization is a large hospital, regional medical center, or a rural community health center, this

3 manual provides information pertinent to the planning, development and evaluation of programs focusing on intimate partner violence. This manual can both provide technical assistance to administrators, management personnel and other stakeholders in a number of organizational settings (e.g., urban/rural, inpatient/outpatient) and serve as a resource for a wide array of clinicians and healthcare providers. Chapter 1 of this manual defines domestic violence and discusses the relationship between domestic violence and health. Chapter 2 provides suggestions for planning a healthcare-based domestic violence response program, including gaining administrative support for the program, forming a multidisciplinary domestic violence planning team, conducting a needs assessment, and selecting a program intervention model. Chapter 3 discusses the development of program components for a healthcare-based domestic violence response program. Program components that are discussed in this chapter include the role of a domestic violence team, policies and protocols, clinical intervention services, training, patient education, networking with community-based agencies and data collection. Chapter 4 presents strategies for implementing a healthcare-based domestic violence response program. In addition, many model materials are offered throughout the manual and in the Appendices. CEO’s, administrators, department managers and community members interested in developing a comprehensive domestic violence program within a healthcare setting may want to use this manual from beginning to end to guide them in this process. However, other healthcare professionals may find certain sections more appropriate to their needs. Whether you or your organization choose to use the manual in its entirety or prefer to reference specific sections, it is the authors’ hope that the information provided will assist you in improving health services to victims of domestic violence.

4 Definition of Terms

Healthcare provider includes: Nurses Physicians Social Workers Medical Students Mental Health Practitioners Emergency Medical Services Technicians Physical Therapists Occupational Therapists Other Clinical or Non-Clinical Staff Allied Health Professionals Family Nurse Practitioners Physician Assistants

Community Agencies include: Community DV Shelters/Programs Police Departments Sheriff’s Departments Department of Social Services Community Mental Health Programs Batterers Treatment Programs Victim Assistance Programs Teen Violence Projects Other Domestic Violence Agencies

Intimate partners can be: Married or Common Law Partners Legally Separated Partners Legally Divorced Partners Current or Former Boyfriends Current or Former Girlfriends Current or Former Same-Sex Partners Current or Former Dating Partners

5

Chapter I

Domestic Violence & Health

Domestic Violence and Health

Definition of Domestic Violence Domestic violence is defined as chronic abuse by one current or former intimate partner against the other for the purpose of control, domination, and/or coercion. Domestic violence can include acts of physical, emotional and sexual abuse. Domestic violence episodes are not simply random acts of violence or incidents of mere loss of temper; rather, such episodes are part of a complex, continuing pattern of behavior of which violence is only one component. The Centers for Disease Control and Prevention use the term intimate partner violence to refer to domestic violence. Under this definition, intimate partners can include current or former spouses, as well as boyfriends or girlfriends of both heterosexual and same-sex relationships.

Common Domestic Violence Terms

 domestic abuse  spouse abuse  dating violence  courtship violence  battering  marital rape  date rape

6 Learning to Recognize Domestic Violence…

Male Privilege Denial & Blaming

Treating a partner like a servant Making light of abuse

Making all the big decisions Saying the abuse did not happen

Acting like “master of the castle” Saying your partner caused the violence

Defining men’s and women’s roles Humiliating your partner

Verbal & Emotional Abuse Using Isolation

Putting your partner down Controlling your partner’s behavior

Making your partner feel bad about themselves Limiting partner’s outside involvement

Calling your partner names Using jealousy to justify actions

Making your partner feel crazy

Using Children Using Economic Control

Using the children to make your partner feel guilty Preventing your partner from working

Using the children to relay messages Making your partner ask you for money

Using visitation to harass your partner Giving your partner a strict “allowance”

Threatening to take the children away Denying access to family income

Using Male Intimidation

Using threatening gestures to scare your partner

Smashing or throwing things

Destroying your partners property

Abusing pets

Threatening to use a weapon or displaying one

7 Impact of Domestic Violence on Health Status Physical health consequences of domestic violence can include injury and death, gastrointestinal problems, chronic pain, sleeping and eating disorders, HIV/STDs, miscarriage, and unwanted pregnancies. Psychological consequences can include depression, suicidal thoughts and attempts, lowered self-esteem, post-traumatic stress disorder, and alcohol and other drug abuse.

Possible health-related indicators of abuse include…

Delay in seeking medical care Difficulty sleeping

Mental health issues Eating disorders

Addictive behavior STD’s

Self mutilation Fear

Suicide attempts or ideation Gastrointestinal problems

Headaches Crying jags

Partner speaks for patient Partner “shadows” patient

Delay in obtaining prenatal care Multiple injuries

Bi-lateral frontal bruising Bite marks

8 Healthcare Domestic Violence Statistics

General Statistics

. The AMA (Flitcraft, et al., 1992) states that between one-fifth and one-third of all women seen in healthcare settings have a history of domestic violence.

. According to a U.S. Department of Justice study, 37% of women who sought treatment at hospital emergency rooms for violence-related injuries in 1994 were injured by a former or current partner (Rand, 1997).

Pregnancy

. Surveys of pregnant women in North Carolina public health clinics found that 3- 14% of the women surveyed had been physically abused during pregnancy and 26- 30% had ever been physically abused (Martin et al, 1996; Moore, 1996; Helm-Quest, 1994; and Covington, Wright, and Piner, 1995).

Healthcare Costs

. It has been estimated that domestic violence results in $44 million in direct medical costs each year (Price & Robinson 1994).

9 Role of the Healthcare Provider in Addressing Domestic Violence Providers and advocates can potentially reach and assist large numbers of women experiencing intimate partner violence through the development of effective response programs within various healthcare settings. Unfortunately, women may have already faced “In a prior abusive situation I was resistance and barriers in obtaining help from family, in, I was kicked and cracked two ribs in that situation. And the doctor friends, and other service providers. Recognizing these asked me how it happened and I barriers can help providers understand why women may told him I fell down a flight of stairs.” -- Battered woman be hesitant to talk about abuse. “A lot of times when I went to my Through patient advocacy, healthcare providers doctor, he was just too busy. He had so many people waiting, he just can empower patients by: didn’t have time to ask, “How did you get this bruise?” or “Why is your jaw swollen?”  Helping them build self-respect -- Battered woman  Minimizing their feelings of humiliation (Bauer and Rodriguez, 1995) and self blame

 Underscoring that violence is not acceptable  Improving patient care  Preventing the prescription of harmful therapies

Although healthcare providers have the potential to play an important role in supporting women with an abuse history, overall response to victims of domestic violence has been poor. Few healthcare providers identify the role domestic violence can play in their patients’ lives.

In fact… Recent research on the screening practices of clinicians in California found that approximately 10% of primary care physicians routinely screen new patients for domestic abuse and only 9% routinely ask patients about abuse during regular check-up visits or follow-up care.

(Rodriguez et al., 1999)

10 Examination of training programs for healthcare providers also reveals that few have incorporated information on domestic violence. Sugg and Inui (1992) observed that 61% of practicing physicians did not receive violence education, either during medical school, residency, or continuing education. One study asked a national sample of 1,000 women about where they had received help for domestic violence. Although medical personnel were utilized rather frequently, they were viewed by these women as less effective than any other group, including social workers, clergy, police, lawyers, and domestic violence advocates (Bowker & Maurer, 1987).

JCAHO Standards In order to address the issue of domestic violence within healthcare organizations, the Joint Commission for the Accreditation of Healthcare Organizations issued standards (1992) related to the identification, treatment and referral of victims of domestic violence. For more information on JCAHO standards, visit their web site at www.jcaho.org or call (630) 792-5000.

JCAHO Standards on Domestic Violence

Patient assessment standards include: Standard PE.1.8 – Possible victims of abuse are identified using criteria developed by the healthcare organization.

Standard PE.8 – Patients who are possible victims of alleged or suspected abuse or neglect have special needs relative to the assessment process (related to the organizations’ responsibility for collecting, retaining and safeguarding evidentiary material for potential future legal proceedings).

Human Resources Management standards include: Standard HR.3 – Organization leaders ensure the competence of all staff members is routinely assessed, maintained, demonstrated and improved.

Standard HR.3.1 – The organization encourages and supports self-development and learning for all staff.

11 Chapter II

Planning an Institutional Response

Planning an Institutional Response

This section discusses the steps necessary to plan a healthcare organization’s response to domestic violence. These steps include gaining administrative support, forming a domestic violence team, conducting a needs assessment and selecting an intervention model on which to base program services.

Gain Administrative Support In order for an organization to develop an effective response to domestic violence, high- level administrators need to support the organization’s new role. The administration must recognize that healthcare organizations have a responsibility to respond to both patients and employees who are in violent relationships. Any attempt to create a domestic violence program in a healthcare organization without the full support of the administration will adversely affect the program’s ability to provide quality services and curtail the life of the program. Gain “buy- in” for the program by meeting with key administrators, including the:

 President or CEO

 Director of Patient Services “Buy-In” Meeting Agenda  Director of Women’s and . Rationale for Healthcare Response Children’s Services . Accreditation Standards and Guidelines . Domestic Violence Program Components  Clinic Managers . Implementing a Response Program

View a meeting with top administrators as an opportunity to convince them of the importance of developing a comprehensive response to domestic violence. Present appropriate statistics that highlight the health consequences and costs of domestic violence, while outlining standards on domestic violence from organizations such as the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and guidelines from the American Medical

12 Association (AMA). In addition, providing examples of other healthcare-based domestic violence programs throughout the nation will help administrators to better understand potential program components and the process for implementing such components in a healthcare setting.

Form a Multidisciplinary Planning Team

The healthcare organization should form a team to develop an appropriate response to domestic violence. A multi-disciplinary, multi-departmental team can draw on the experience and views of different people to best identify what issues need to be addressed and gauge the viability of alternative solutions. A critical function of the team is to coordinate with community agencies that have expertise in the area of domestic Key Personnel for Team violence and provide services to women currently Within the organization: experiencing violence or with a history of abuse. For this reason, the team should include . CEO or President . Public affairs representatives representatives from the local domestic violence . Quality management directors program or other appropriate agencies in the . Medical directors community. . Clinic managers . Nursing managers Designating a leader who can take . Social workers . Key security personnel responsibility for the team and coordinate the . Interpreter services organization’s efforts is extremely important. Strong . Human resources . Employee wellness leadership can help ensure the team’s effectiveness coordinators within the organization. While a “champion” for a Outside the organization: domestic violence program cannot develop and . Local DV agency personnel implement a domestic violence program alone, it is . Local law enforcement preferable that a lead person is identified who is . Mental health workers . Social service staff directly responsible for program coordination and . Private practice physicians . Local school officials delivery of victim services. . Local prosecutor’s office Given the importance of identifying someone to take the lead on developing and maintaining a domestic violence response program, every effort to obtain funding for at least one paid staff person is critical. While not absolutely necessary to establishing an effective program, funding will provide a greater likelihood that the

13 program will survive over time. How much funding is needed will depend on the number of staff required to perform program duties, the size of the organization, estimated patient load, and the scope of services and training.

Conduct Needs Assessment In order to ensure that programs developed to address the issue of domestic violence are as effective as possible, the healthcare organization should seriously consider first conducting a needs assessment. By doing so, the organization and community partners can assess any current response to domestic violence and determine the specific training needs of providers. In addition, a needs assessment can provide insight into the attitudes and perceptions of the patient population, as well as the types of services they expect clinicians to provide relative to domestic violence.

Definition of Needs Assessment “A systematic set of procedures undertaken for the purpose of setting priorities and making decisions about program or organizational improvement and allocation of resources.” (Witkin & Altschuld, 1995)

Many healthcare organizations may already feel that they know what they need without conducting a formal assessment. However, when conducted properly, a needs assessment can provide valuable information which can inform the development and implementation of a domestic violence program.

14 Reasons for conducting a needs assessment include:

 Providing a picture of the current response to domestic violence  Determining gaps in existing services  Assessing how best to allocate available resources  Determining the availability of community resources  Starting a dialogue with agencies serving abused women

There are four main areas to explore in conducting an assessment of an organization’s response to domestic violence:

. Patients . Clinicians . The healthcare organization . Local community resources

Patient Assessment Since the patients of the healthcare organization are to be the direct beneficiaries of the organization’s activities, their needs should be addressed and their input should be included. Questions that should guide this part of the assessment are:

How willing are patients to discuss domestic violence with their healthcare provider?

What barriers may impede patients from discussing domestic violence with their healthcare provider?

Have patients ever been asked about domestic violence by a healthcare provider?

What knowledge do patients have about services in their community that assist persons who experience domestic violence?

15 Patient Survey Guidelines

 Since it is impossible to survey all female patients your organization serves, you will need to choose a sample. In order for the data from the sample to be generalized to all patients, the sample will need to be large (at least 100 patients total) and randomly selected.

 Someone other than the women’s healthcare provider should give them the survey to complete (e.g. a clerk or receptionist or the domestic violence program coordinator). Assure those women surveyed that their responses are anonymous. If a woman does not read, do not have someone read the questions to her. Because the questions are of a sensitive nature, she may feel compelled to give the responses she thinks the surveyor wants to hear.

Clinician Assessment

Staff’s needs should also be assessed to identify training needs as well as to serve as a baseline for evaluation. It is ideal to survey all staff who have direct contact with patients including physicians, nurses, social workers, patient advocates, allied health, and clerical staff. These are the groups that should ultimately receive training as well. Questions that should guide this part of the assessment include:

16 What are providers’ current practices with regards to asking patients about their abuse history?

What are the barriers that impede clinicians from talking about domestic violence with their patients?

What do providers expect will happen as an outcome of talking with their patients about domestic violence?

What are clinicians’ responsibilities in identifying, assessing and providing appropriate referrals to patients whom experience domestic abuse?

17 Clinician Survey Guidelines

 The survey should include questions on clinician’s knowledge, attitudes, and behaviors. Questions should be related to identifying and assisting battered women in healthcare settings.

 Recognize that the response rate for clinician surveys is typically quite low. In order to try to improve the response rate, remember these key points:

 Make sure the survey does not take the average clinician more than 5-10 minutes to complete.

 Request ten minutes out of staff meetings to administer the survey. It is harder for people to ignore a survey if someone is there to proctor the administration of it. In addition, the surveys can be collected immediately.

Healthcare Organization Assessment

Assess the healthcare agency to determine gaps in services and areas of need. The two questions that should guide this part of the assessment are:

How does the healthcare agency currently serve domestic violence patients?

What does the healthcare agency need to improve services to women experiencing domestic violence?

This section of the assessment should help the agency think through what it will take to develop and implement the components of a comprehensive healthcare agency response to domestic violence. Generally, the Director of Women’s and Children’s Services or a high level administrator within the organization will have access to the information needed to complete a healthcare organization assessment.

18 Community Resources Assessment

Assess the community to determine gaps in service and areas of need. The questions that should guide this part of the assessment are:

What services does the community have in place to serve women who are abused?

What can the community do to serve abused women better?

How can the healthcare organization and community agencies work together to better serve abused women?

Conducting an assessment of community resources can serve as a vehicle for gaining support from the community for serving abused women. The domestic violence program should be able to provide most of this information, but other community organizations will need to be contacted as well. Sample surveys and assessment tools that were developed specifically for healthcare settings by the Beacon Program’s Effective Practices for Healthcare Response to Domestic Violence Project are provided in Appendices C.1-C.4. These tools were piloted by five healthcare sites throughout North Carolina, including: Lenoir Memorial Hospital, Lenoir County; New Hanover Regional Medical Center, New Hanover County; Cleveland Regional Medical Center, Cleveland County; Rural Health Group, Northampton County; and Robeson Healthcare Corporation, Robeson County. A summary of the information obtained from the patient and clinician surveys from four of the five sites follows (analysis of the data from the final site was not complete at printing).

Summary of Findings from North Carolina Healthcare Organizations Unfortunately, conducting a needs assessment is often time consuming and labor intensive. Realistically, many organizations may not have the adequate time, resources, or staff available to effectively develop or revise survey and assessment tools or collect and analyze data. While obtaining data specific to the organization during the planning stages is ideal, it is certainly possible to develop a successful program without obtaining local data.

19 Because the authors recognize that many healthcare organizations will have to forego conducting a needs assessment, pertinent findings from the needs assessments conducted under the Effective Practices for Healthcare Response to Domestic Violence project follow. While data certainly varies across all sites and is not necessarily representative of all healthcare organizations in North Carolina, significant similarities across the data do exist. In addition, some of these similar findings are also supported in the larger body of literature focusing on domestic violence in healthcare settings. Therefore, in the event a healthcare organization is not able to conduct a site-specific needs assessment, reviewing the following summary of findings from four of the five healthcare organizations in North Carolina may help inform the planning and development of a domestic violence response program.

Effective Practices Patient Survey Summary The patient survey results from all sites are generally similar. Patients answered a series of questions that addressed the following: (1) their awareness of domestic violence services in their community; (2) the role of the healthcare provider in providing domestic violence services; (3) whether or not they had ever been asked about domestic violence by a healthcare provider; and (4) identifiable barriers to talking to a provider about domestic violence. The following is a general summary of results from the patient surveys across four of five sites:

Awareness of Domestic Violence Services in Community

 35-54% of the patients surveyed did not know that their community had a special agency that provides services to domestic violence victims.

Barriers to Talking with Providers about Domestic Violence

 A significant number of patients at each site cited each of the following as barriers to talking about domestic violence in a healthcare setting:

a) afraid my partner would find out (32-68%) b) afraid other people would find out (35-50%) c) too ashamed (44-64%) d) think their healthcare provider would blame them (9-12%) e) think their healthcare provider would not believe them (15-25%)

20 f) think their healthcare provider would not care (15-41%) g) talking about it wouldn’t do any good (22-54%) h) think it is too personal to talk about (27-46%) i) fear that staff at the healthcare organization gossip (23-30%)

Role of Provider in Addressing Domestic Violence

 84-91% of patients surveyed believed providers should ask about domestic violence and 61- 73% said they would feel comfortable talking to a provider about domestic violence.

 Patients surveyed overwhelmingly believed that healthcare providers should provide the following services to women experiencing domestic violence:

a) treat injuries (93-98%) b) educate about domestic violence (96-98%) c) provide information about resources (96-97%) d) assist in finding shelter (92-96%) e) help contact police (90-92%)

Note: While it was not possible to analyze racial differences among patients across all sites, compelling racial differences were noted at a couple of the sites. For instance, black women tended to have higher barriers than white women, particularly barriers that are related to providers (i.e., I think my healthcare provider would blame me, etc.). It is important for healthcare organizations to recognize that racial differences may exist and that such differences may have implications for screening, intervention services, provider training and patient education.

These findings have implications for healthcare organizations across North Carolina. The results suggest that female patients surveyed in a variety of healthcare organizations located throughout North Carolina believe that healthcare providers should routinely ask patients about abuse and provide a wide range of services to identified patients. In short, patients expect their healthcare organizations to comprehensively address domestic violence. These findings can be used by healthcare organizations to gain “buy-in” and support for domestic violence response programs among administrators, clinicians and other staff. In addition, identified barriers to women discussing domestic violence with a provider can be addressed through patient education and staff training. Furthermore, healthcare organizations need to take into account cultural differences in developing education materials and training providers. Finally, findings about the types of services women expect can help healthcare

21 organizations further identify training topics for providers and the types of victim services that need to be provided as part of any response program.

Effective Practices Clinician Survey Summary

Unlike the patient survey piloted by the Effective Practices for Healthcare Response to Domestic Violence project, the clinician survey is a rather lengthy assessment tool (provided with permission for use or adaptation in Appendix C.2). While it certainly never hurts to gather as much data as possible, administering a survey of this length may prove difficult in many healthcare settings given clinicians’ tight schedules. If there is any concern that the response rate will be low with the longer survey, consider administering a shorter version. The important thing is to develop a survey that asks clinicians about a number of key issues related to patients experiencing domestic violence or with a history of abuse, including: (1) clinician’s attitudes, perceptions and knowledge; (2) obstacles to identifying and treating abused patients; (3) the degree to which they feel prepared to identify and treat abused patients; (4) what they expect will happen if they address violence in their patients’ lives; (5) how frequently they ask patients about abuse and what methods they use to “screen”; and (6) their “usual practice” intervention methods after identifying a patient with an abuse history. The following is a general summary of results from the clinician surveys across four of five sites:

Clinician Responsibilities

 32-75% of providers across the sites agree that clinicians should ask all women patients about abuse as part of a routine physical exam or history taking.

Perception of Preparation

 The following figures represent the degree to which providers believe they are well prepared to:

a) screen women for abuse (13-41%) b) counsel abused women (5-19%)

c) document injuries (19-41%) d) assist with a safety plan (9-23%)

22 Screening

 The following figures represent those clinicians reporting that they use the following screening behavior “always/often” in their practice:

a) 35-48% screen based on Injuries b) 19-36% screen based on Symptoms (not injury) c) 15-33% screen All women once (1 st visit) d) 3-12% screen All women more than once

 The following figures represent those clinicians reporting that they use the following screening methods “always/often” when they screen for abuse:

a) 39-48% use “Red Flags”/psychic distress method b) 42-56% use how are things at home method c) 15-44% ask patients if they are safe at home d) 21-53% ask specific and direct questions about violence

Usual Practice

 Assessment

a) 47-80% of those reporting document as usual practice b) 29-65% assess for risk of suicide as usual practice c) 29-56% assess for risk of homicide as usual practice d) 26-54% assist patient in developing a safety plan

 Referral

a) 46-89% refer to local domestic violence program as usual practice b) 34-68% refer to law enforcement as usual practice c) 33-62% refer to psychiatry/mental health as usual practice d) 30-72% refer to pastoral care as usual practice e) 24-50% refer to couples counseling as usual practice f) 20-50% refer to substance abuse treatment as usual practice

 Counseling/Education

a) 49-84% tell the patient about community resources as usual practice b) 46-72% provide some counseling as usual practice c) 37-78% discuss the relationship b/n abuse & health as usual practice

23 d) 33-61% encourage the patient to leave the abusive relationship e) 23-55% provide educational materials as usual practice f) 11-33% talk to the abuser about his violence

Perceived Outcomes

 The following figures represent the expected health-related outcomes reported by providers:

a) 96-98% improve patients’ health b) 93-96% document abuse c) 96-100% let them know somebody cares d) 77-86% decrease use of health services (including emergency visits) e) 89-99% help the patient remain safe

 The following figures represent the expected domestic violence-related outcomes reported by providers:

a) 69-81% help her leave her partner b) 79-87% decrease the violence c) 98-100% locate community resources

Impact of Intervening on Clinicians

 How does intervening with battered women make clinicians feel?

- Most feel more frustrated

- However, most are more likely to continue to ask their patients about DV

- And, most are more inclined to believe that DV is a problem clinicians need to address

These findings have implications for healthcare organizations across North Carolina. While a sizeable proportion of reporting clinicians at each site understand the importance of routinely asking women about abuse, many do not feel that it is important for clinicians to routinely ask women about abuse. Clearly, organizations that are developing and instituting a domestic violence response program that promotes universal or routine screening need to address attitudinal barriers (albeit through training or other methods of consciousness raising efforts) among clinicians with regards to questioning patients about current or past abuse. Second, a majority of the clinicians surveyed reported that they did not believe they were well prepared to

24 provide a number of key skills and that they lacked knowledge pertinent to domestic violence issues. In addition, reporting providers have some unrealistic outcome expectations. By gaining an improved understanding of the cycle of violence and dynamics of abusive relationships, providers can come to realize that addressing the violence in patients’ lives requires a very different approach than the majority of other health factors they regularly encounter. Every domestic violence situation is different and intervening is a slow process. Providers have little control over the violence because they are not intervening with the violent partner. Therefore, it is not realistic to assume that by talking with a patient about the situation, they can decrease the violence. In addition, leaving an abusive partner is a process that can often take many months or even years; in fact, victims of domestic violence may never leave their abusive partner. Providers who expect that patients will simply leave the abusive relationship will likely become frustrated and may even build resentment against their patient. The important message is that asking about abuse with a patient is itself an intervention. By addressing violence in patients’ lives, healthcare providers send a message that violence is not acceptable and open the door to critical counseling, resources, and services. In short, proper training can ensure that clinicians have both the knowledge and skills to intervene in a sensitive, appropriate and effective manner, while also helping providers to maintain realistic outcome expectations when dealing with domestic violence patients.

Intervention Model Domestic violence response programs in healthcare settings can be organized in a number of ways. Therefore, before developing program components, the healthcare organization should decide upon an appropriate intervention model for identifying and assisting abused women.

25 Factors that will influence the selection of an intervention model include:

 organization size  type of clinical setting  clinician availability  time constraints  funding options  availability of community resources

26 Across the country, existing programs vary in terms of staff, structure, resources, and services offered. On page 27, several example program models are shown. While these models are viable options for healthcare organizations, there are a number of other models that can be used to create successful response programs. For a comprehensive description of existing programs throughout the country, refer to the guide by the Family Violence Prevention Fund, entitled, “Best Practices: Innovative Domestic Violence Programs in Health Care Settings.” Model A is likely to be used in a healthcare organization with limited resources to put toward a domestic violence response program. Under the model, primary providers are trained in the identification, assessment, intervention, documentation and referral of domestic violence patients. While providers are trained in each of these areas, the emphasis within this program model is realistically placed on identification, documentation and referral. Given the time constraints of primary providers, it is not realistic to assume they can provide a high level of assessment, intervention, and counseling services to identified patients in the healthcare setting. Therefore, providers will need to refer their identified patients to the local domestic violence agency for more detailed assessment and counseling. Certainly, it is ideal that all healthcare organizations develop a coordinated community response and network with local domestic violence agencies. However, in order for a primary provider model to be successful, it will require a strong working relationship between the healthcare organization and local service agencies, since the bulk of the intervention will occur after a referral is made outside the healthcare organization. Model B can also be successfully utilized in healthcare organizations with limited staff and financial resources. Under the program, existing staff (i.e., social workers, nurse clinicians) are designated and trained to provide in-depth assessment, intervention, documentation and referral services as part of their regular clinical duties. The role of the primary provider will fall primarily on identification, at which time they will triage the patient to those staff designated to provide comprehensive services within the organization. Model C is an on-site domestic violence advocacy program. This program model requires a designated staff person to be on-call and to respond to referrals from primary providers throughout the healthcare organization. The advocate provides comprehensive assessment, intervention, documentation, and referral services. A program based on this model will require sufficient financial resources to fund specialized program staff and services. While a program of this kind is more costly

27 and resource dependent, there are several advantages to such a model. First, while all models require some level of training for primary providers, there will tend to be a wide variation in the skills, knowledge and willingness among providers to offer comprehensive services. Therefore, having an on-site advocate will take the pressure off of providers to provide time-consuming services and help them feel more secure about “what to do” when they identify a patient. Hopefully, being able to rely on the advocate will result in primary providers asking patients more often and consistently about abuse (providers will still need adequate training in how to ask patients appropriately about their abuse history). In addition, because the on-site advocate actually intervenes with the patient, this can help streamline and standardize those services (rather than relying on a large number of primary providers who may each have individual methods for providing services).

28 Example Program Models

Model A – Primary Providers Healthcare providers are trained to ask their patients about domestic violence, assess their safety and needs, document the abuse, and provide referrals and follow-up as part of routine care for patients. To provide this level of care, healthcare providers are trained in communication and counseling skills and knowledge of a range of issues specific to domestic violence. Providers can refer their patients to local domestic violence programs to provide follow-up counseling and support groups for battered women and their children.

Model B – Existing Staff A sufficient number of designated hospital or practice staff (e.g., patient advocates, case managers, social workers, nurse clinicians) are specifically trained to provide crisis intervention, safety assessment and planning, counseling, referral and follow- up as part of their clinical duties. The primary providers refer identified patients to members of the response team.

Model C – Domestic Violence Advocacy Program Healthcare providers inquire about abuse and refer battered women to an on-site domestic violence advocacy program for further assessment and intervention (the Beacon Program uses this model). While the primary provider can offer initial assessment, documentation and referral, a domestic violence advocate can provide more extensive services as needed. If an advocate is not available 24-hours, providing access to initial crisis intervention and advocacy over the telephone is another alternative.

29 Chapter III

Developing Program Components

Developing Program Components

This section discusses the steps necessary to develop a healthcare-based domestic violence response program. A comprehensive healthcare based domestic violence program aims to improve the health and well being of abused women, not only within the healthcare organization, but in the community it serves as well. Questions that can guide the development of program components include:

What services currently exist for patients who experience abuse and are these services effective?

What services are still needed for patients who have a history of intimate partner abuse?

What methods can the organization use to improve the identification, assessment, and intervention with patients experiencing domestic violence?

How can the healthcare organization raise awareness among providers and community members about domestic violence and resources for patients experiencing domestic violence?

Program Components Once the intervention model for a Domestic Violence Program Components program is decided upon, the organization 1. Domestic violence team can begin developing the various program 2. Domestic violence policies & protocols components. How the healthcare 3. Clinical intervention services organization develops each of these 4. Staff training 5. Patient education components will depend on the needs and 6. Community linkages resources of the organization and the 7. Determining program success community it serves. 1. Domestic Violence Multidisciplinary Planning Team

28 The first and most essential component of the organization’s program is a domestic violence team or task force. Rather than functioning as a step in the process, the domestic violence team should be an ongoing source of support, consultation and guidance for any healthcare based domestic violence program. Once the team has developed the response program, they can meet regularly to address issues as they arise. During the planning phase, the team will likely need to meet often (i.e., once a month or so) and as a single body in order to set consistent goals and objectives for the program. Assuming the team is large enough, it may function best if the team then forms into smaller committees to address various issues. For instance, it may be necessary early on to form a committee to create or modify existing policies and protocols within the organization in order to appropriately address domestic violence. Another committee could address staff and clinician training. However the team decides to structure itself, it is critical that each committee designates a leader and develops a clear action plan for achieving stated goals and objectives. In the event that committees are created, it is also important that the team meet as a single body on a regular, if less frequent, basis. This will help ensure appropriate communication between all team members and committees and maintain a shared vision for the program.

Multidisciplinary Team Checklist

 Select key personnel to play a role in the multidisciplinary team and foster their commitment.

 Convene the team to set goals and objectives for program planning and development.

 Create appropriate committees to address various aspects of the program (for example, policies and protocols, staff and clinician training, victim services, etc.).

 Designate a leader or leaders for the overall team, as well as each committee.

 Meet regularly. During the initial planning and start-up phase of the program, the team may need to meet as often as once a month. Once the program is up and running, the team may meet quarterly or as needed.

29 2. Domestic Violence Policies and Protocols While a domestic violence policy can define domestic violence prevention as a priority for a healthcare organization, a domestic violence protocol can outline the steps providers can take to identify and assist women in their care. The distinction in definitions of policies and protocols is less important than assuring that the healthcare organization has a written commitment to addressing domestic violence and that clinicians have access to guidelines outlining specific procedures of care for domestic violence patients. To get started developing domestic violence policies and protocols, find out how your organization defines “policy” vs. “protocol”. Also, determine the process your organization uses to develop, approve, and distribute them.

Policy vs. Protocol Policy Protocol general statement outlining set of procedures providing how an organization plans to instructions on how to respond address a particular issue to a specific situation

Example Policy on Screening:

Research has indicated that women are particularly at high risk for domestic abuse. While some of these women may present with acute injuries, others may present with conditions that do not immediately suggest abuse, but are in fact related. Therefore, in order to address this issue, we promote routine screening of all women for domestic violence.

Example Protocol on Screening:

1. Nursing role: Triage and injury screening for women a. Consider abuse indicators b. Screen all women in private, confidential setting c. Screen for abuse in all women using these questions: Do you feel your partner controls you too much? Does your partner threaten to harm you in any way? In the last year, have you been hit, pushed, shoved, kicked, slapped or choked by a partner?

Note: These are examples of selected items that might be included in a policy or protocol on domestic violence and do not represent complete policies or protocols.

30 Domestic Violence Policies Policy is a means to formalize and standardize the healthcare response to domestic violence. Setting policy to support a response to domestic violence within the healthcare organization is a very important step in the process.

Healthcare organizations should develop policies that:

 State that domestic violence is an important health issue  Require staff to appropriately respond to domestic violence victims  Stipulate that all domestic violence protocols are accessible to staff  Require staff to attend training  Assure patient confidentiality  Assure patient and staff safety

In addition to impacting patients, domestic violence also affects the lives of many healthcare employees. Policies and protocols that address employee experiences with domestic abuse are also important. The Family Violence Prevention Fund (FVPF) has developed a model domestic violence policy for the workplace and a packet with sample policies, posters, and activities to help employers develop their response to domestic violence. For information on how to contact FVPF, refer to the website section of the Domestic Violence Resources in Appendix B.

Domestic Violence Policy Guidelines

A general domestic violence policy should include:  the definition of domestic violence used by the organization.  the health agency’s mission and objectives regarding domestic violence.  why the healthcare organization has the responsibility to address the issue.  the healthcare organization’s plan for addressing domestic violence issues -- screening, confidentiality, documentation, reporting requirements, etc.

31 Domestic Violence Protocols Domestic violence protocols stipulate the expected standard of care for patients who are currently in an abusive relationship or have had a history of abuse. Protocols provide step-by- step instructions for providers and staff on how to address specific situations when treating domestic violence patients. Collaborate with the local domestic violence program in developing the protocol, as they will be able to help in developing appropriate screening tools and intervention guidelines. In addition, the Family Violence Prevention Fund (FVPF) has information and resources on developing domestic violence policies and protocols in healthcare settings. For information on how to contact FVPF, refer to the website section of the Domestic Violence Resources in Appendix B.

Domestic Violence Protocol Guidelines

Department specific protocols should include:  The purpose and rationale of the protocol. A brief statement as to how the protocol can be used and by whom, as well as to why this specific protocol has been developed for the particular setting.

 Defined roles for various staff including physicians, nurses, social workers, security, and patient check-in staff.

 Procedures and tools for routine screening. For example, in healthcare settings that promote routine screening, protocols will state that all women should be screened, when they will be screened, and where they should be screened.

 Procedures and tools for assessment. Lethality assessment tools should assess risk for further abuse and assess needs that the victim may have. If a significant proportion of clients do not speak English, translate the tools into the appropriate language(s). Tools for safety planning should also be made available.

 Procedures and tools for documentation. Documentation tools should accommodate your system of charting. Consider whether the documentation of domestic violence will be part of the medical record that is accessible to all the organization’s providers or will be kept separately. For more detailed information on documenting domestic violence cases, refer to pages 49-51.

 Procedures and tools for referral. Include tools for providing information on community resources, including a list of resources for shelter, counseling, childcare, legal services, social services, etc. Have handy resource cards or packets of resource materials that the provider can reference easily and subsequently provide to patients.

32 Clinical Protocol Checklist

 Definition of Domestic Violence

 Rationale for Screening  Does the organization promote routine/universal screening?

 Screening  When will patients be screened? (at every visit, at first visit, annually)  Where will they be screened? (private place)  What will clients be screened for? (physical abuse, sexual abuse, emotional abuse)  What tool will be used for screening? Will it screen for current or past abuse? Or both?  Who will do the screening? (nurse, social worker, may vary by clinic or service)  What provisions will be made for women who do not speak English?

 Assessment  Who will do the assessment of risk and needs? (Same person who does the screening or other person?)  What tool will be used for assessment of risk?  What tool will be used for assessment of needs?

 Referrals  How will you provide information on community resources? (pamphlets, resource cards)  Will staff do a safety plan with the women? If so, which safety plan? Or, will staff refer the women to the domestic violence program to do the safety plan?

 Documentation*  Will domestic violence be incorporated into the medical record or separately documented?  How will response to domestic violence questions be coded? Who will code?  Will the body map be used?  Is a camera available to photograph injuries?  Is there a consent form to photograph injuries?  Will a documentation checklist be used?  What is the “chain of evidence” for photos and other evidence?

 Follow-up  Will staff schedule additional appointments to discuss the battering?  Will staff in one clinic follow up with women identified in other settings?

 Protocol Logistics  How will new staff be trained on the protocol?  Is the protocol mandatory?  If so, how will it be enforced or monitored?  How will the protocol be incorporated into other screening and intake forms?

*For more comprehensive documentation guidelines, refer to pages 49-51.

33 3. Clinical Intervention Services Clinical intervention services provided to patients currently experiencing domestic violence or with a past history of abuse should include a comprehensive assessment (outlined in more detail on pages 42-44). Providers also need to be aware of community resources for domestic violence and how to access these resources. Having knowledge of 24-hour crisis services (often provided by the local domestic violence agency) is critical in the event that on-site assistance is not available during evening and weekend hours. In addition to referrals, victims may need help in navigating the various helping systems available to them. Case management is an effective means to coordinate services and referrals. Although available services vary widely across communities, Maternity Care Coordinators, Child Service Coordinators and Social Workers are examples of groups that may be able to play this case management role.

Providing Sensitive Clinical Intervention Services Numerous challenges exist to identifying and assisting abused women in healthcare settings. A victim may be reluctant to identify herself for several reasons. She may:

 Not recognize the behavior or relationship as abusive  Be ashamed or embarrassed  Fear she will be blamed for the abuse  Blame herself for the abuse  Fear for the safety of herself and her children  Feel that she has no control over what happens in her life  Believe that her injuries are not severe enough to mention  Associate negative repercussions with disclosing abuse in the past  Want to protect her partner because of emotional or financial dependence  Fear that her children will be taken away from her  Be afraid of police or social services involvement  Hope that the batterer will change (as he often promises to do)  Fear a loss of her medical insurance (if abuse is discovered) The psychological trauma women experience as a result of abuse may prevent them from

34 seeking medical attention. Some women may even cling more steadfastly to their abusive partner and distrust outside assistance. In order to isolate and maintain control over their partner, a batterer may restrict his partner’s use of health services or insist on accompanying her to appointments. Providers can help women feel more comfortable discussing abuse in their lives by making a few simple changes. For instance, displaying posters and information on domestic violence in waiting areas and examining rooms sends the message that it is appropriate Same-Sex Domestic Violence to discuss domestic violence. Screening women for domestic violence in private, away Women who are involved in same-sex relationships may experience additional barriers to from their partners, family, and friends, keeps disclosing their experiences with domestic violence. Life experiences and fear of their responses confidential and may help homophobic reaction to their relationship may result in lesbian women refusing to disclose them feel less inhibited. information or acknowledge that the perpetrator is Actively listening to women and another woman. Healthcare providers need to question their own assumptions regarding conveying empathy for their situation is heterosexual norms and ask questions that are “gender-neutral” (i.e., substitute partner for critical to providing quality care. An abuse husband/boyfriend). In instances where a woman discloses her sexual orientation, it is critical that victim may have previously sought help from the provider appears non-judgmental. Such a reaction will let the patient know that she is safe to ill-trained or insensitive providers, law discuss the true nature of her relationship and may enforcement officers, family members, or facilitate disclosure of any abuse. clergy. Alternatively, she may never have Note: Remember that gay men can also be victims of violence in their intimate relationships. discussed her abuse with anyone. A provider may be the first person to whom she has revealed the abuse or the first person to take her disclosure seriously. Often, well-meaning family members, friends, and healthcare providers will say things like:

“Why don’t you just leave?” “I would never let that happen to me!” “What did you do to make him angry?”

35 Those words can have devastating effects on victims. This kind of reaction implies the victim is inferior or weak for staying in the relationship, that she knowingly and willingly tolerates the abuse, and that you blame her for the abuser’s violent actions. Alternatively, supportive comments that encourage women to disclose more information include statements such as: Remember, an advocate is

“I’m sorry this has happened.” … a supportive person who understands the dynamics of “You’ve really been through a lot.” abusive relationships and “You are not to blame.” believes in a patient’s right to live without fear of abuse and assault. Advocates offer support, options, safety Healthcare providers who are accustomed planning and connect people to community resources. to prescribing a “cure” to a problem are often frustrated by their inability to heal abused women and by patients’ seemingly “non-compliance” with prescribed treatment. Healthcare providers can set realistic goals and avoid gauging success by whether or not the patient leaves the abusive relationship. The primary goal of the intervention is to provide the patient with the information, support, and tools she needs to make her own decisions about her future. Empowerment advocacy is based on the fundamental belief that victims of domestic Self Determination violence have the right to control their own lives. …is your patient’s inherent In their process of victimization, control has been right to make personal decisions based on their own taken away from them. Providers can help give needs, feelings, beliefs and women that control back by respecting their knowledge about their situation. decisions.

36 Clinical Intervention Steps In order to transition from planning a healthcare-based domestic violence program to developing program components, providers will need to understand the critical steps involved in providing clinical intervention services for domestic violence. The steps for clinical intervention are:

Step 1: Increasing the identification of patients who are experiencing abuse

Step 2: Conducting a violence assessment with identified patients

Step 3: Providing intervention services Step 4: Documenting abuse incidents and history in the medical record Step 5: Discharge planning Step 6: Following-up with patients

Clinical Intervention Step 1: Identification

The first step in clinical intervention is identification. Below are some guidelines for screening women for domestic violence. The Family Violence Prevention Fund (FVPF) offers additional screening guidelines (for contact information, refer to the website section of the Domestic Violence Resources in Appendix B).

Ask all Women about Abuse Consider All Types of Abuse Both the American Medical Association (AMA) and the American Many healthcare providers tend to focus on physical abuse when College of Obstetricians and Gynecologists addressing domestic violence. However, in clinics or offices, patients (ACOG) recommend that domestic violence often present without traumatic injury. Even in Emergency Departments, and its impact on health justify routine women without injuries come seeking questioning of all women patients in help for health problems associated with acute domestic violence. In emergency, surgical, primary care, pediatric, addition to physical violence, sexual, emotional, and psychological abuse is prenatal, and mental health settings. Since

37 there are male victims of domestic violence (however, studies show that women make up approximately 95% of all victims) in heterosexual and same-sex relationships, JCAHO recommends that healthcare organizations screen all patients for abuse. While healthcare organizations may choose to screen all patients, screening men for domestic violence raises several unique issues that are not fully addressed by this manual. First, there is still debate on the appropriate clinical response to male victims of domestic violence and, once identified, there may be few local resources available to assist them. In addition, it is feasible that by screening male victims, providers may identify batterers who present themselves as victims of domestic violence. Healthcare organizations that screen all patients should develop clear policies and protocols for identifying, assessing, and intervening with male victims. Because domestic violence can cause a wide array of symptoms, lists of indicator conditions may prove to be too broad. In a University of North Carolina Hospital Emergency Department study, female patients were screened for domestic violence at triage if they presented with a least one symptom from a list of “indicators.” An evaluation of this identification method found that the sensitivity was only 50%; in other words, this method missed as many women as it identified (Waller et al., 1996). Since neither demographic nor health factors can accurately predict who is a victim, all women should be asked about domestic violence. With regard to identification of domestic violence victims, remember the following key points:

 Ask all women  Talk to women about abuse in a confidential setting  Develop a comfortable repertoire of abuse-related questions

 Use gender-neutral questions that do not assume heterosexuality

 Frame your questions so that they are direct and non-judgmental

 Document that the patient was asked about domestic violence

38 Asking all women conveys the message that domestic violence is an important health concern and can happen to any woman. Even if a woman is not ready to disclose the abuse when asked about her experiences by a healthcare provider, bringing up the subject provides a rare opportunity to raise awareness about the issue and suggest available resources. Ultimately, asking women about domestic violence can serve as a form of secondary prevention. There are three crucial messages to convey to women who are currently experiencing domestic violence or who have a history of abuse. These are:

“You don't deserve to be abused.”

“There are many women in your situation.”

“There are sources of help available to you.”

When a woman engages in self-blame with such comments as “I always talk too much and make him mad,” tell her that nothing she says can justify someone else battering her. If she minimizes her injuries, point out the seriousness of her injuries. In addition, do not seek to verify the patient’s statement of abuse through conversations with her companion, whether a spouse, a partner, or some third person. Such disclosures violate confidentiality and may lead to retaliation by the batterer against the patient or against medical staff. Providers can use several of the suggested questions on the following page verbatim or modify them for their own use when talking with patients.

Ask about Abuse in Person

One large study compared rates of domestic violence found by using a written intake form with a questionnaire in a reproductive health clinic versus having a nurse ask directly about abuse (McFarlane et al., 1992). The study found four times as many women reported they had been abused when asked by a nurse, as opposed to a written questionnaire (29.3% vs. 7.3%, respectively). If it is not possible to question a woman about abuse in private, postpone any discussion until a later date when a one-on-one conversation is possible.

39 Ask Directly about Abuse

Patients often respond openly to direct questions about domestic violence. A study of female patients showed that many abused women readily responded to questions about abuse and were relieved that someone had directly asked them how they had been hurt. Furthermore, the majority of non-abused women did not appear to mind being asked questions about domestic violence (McLeer and Anwar, 1989).

Suggested Abuse Questions for Providers

Of the numerous questions below, providers can find two or three questions that they feel comfortable asking patients. Providers can open up the conversation by stating something like:

“Our staff is concerned about our patients’ safety and health, so we are asking all our patients these questions.”

Physical abuse

 “Does your partner threaten to harm you in any way?”

 “Do you feel your partner controls (or tries to control) you too much?”

 “In the last year, have you been hit, pushed, shoved, punched or kicked by a partner?”

 “Has your partner or ex-partner ever threatened to hurt you or someone close to you?”

 “Many patients tell me that someone close to them has hurt them. Is this true for you?”

 “Do you have guns in your home? Has your partner ever threatened to use them?”

 “It looks like someone hurt you. Tell me about it.”

Sexual abuse

 “Has anyone ever forced you to do something sexually that made you uncomfortable?”

 “Does your partner ever force you to have sex or perform sexual acts against your will?”

 “Has your partner ever forced you to have sex when you didn't want to? Does your partner ever force you to engage in sex that makes you feel uncomfortable?”

Emotional/psychological abuse

 “Do you feel equal to your partner?”

40 Ask Women about Domestic Violence Routinely

Women who initially do not disclose their abuse may later choose to discuss it. A woman may not admit domestic violence the first time she is asked because she may be embarrassed, may not trust the provider, or may be afraid of the abuser. Also, since abuse may Remember…. begin at any time, a woman who has not been …a certain percentage of women abused at one visit may begin experiencing will remain unidentified, even in healthcare settings that abuse by the time of her next visit. Finally, institutionalize routine screening. clinicians should consider screening women Therefore, make resources available to women in a manner that with increased frequency during pregnancy. affords privacy. One method of Several healthcare organizations have ensuring anonymity is to make brochures or posters available in already developed screening tools to identify waiting rooms, lobbies or restrooms. abused women (some of these tools also include assessment questions). Healthcare providers can modify pre-existing tools to meet their needs or develop their own screening instrument. Using tools that have already been developed may be simpler and more effective than developing a tool. The Beacon Program has developed a 3” x 5” DV Screening Questions question card for providers to reference when Our staff is concerned about our patients’ talking to patients about abuse (right). In safety and health, so we are asking all our patients these three questions: addition, the Family Violence Prevention Fund Do you feel your partner controls (or tries (FVPF) has published clinical guidelines on to control) you too much? Does your partner threaten to harm you in routine screening, which include general screening any way? policy and guidelines for the following settings: In the last year, have you been hit, pushed, shoved, punched or kicked by a primary care, emergency departments and urgent partner? care, obstetrics/gynecology and family planning, If Patient Answers yes, Call: inpatient and mental health. For information on 1-888-378-0551 how to contact FVPF to obtain these guidelines, PLEASE DOCUMENT PATIENT RESPONSE IN refer to the website section of the directory of DESIGNATED AREA OF RECORD Domestic Violence Resources in Appendix B.

41 Clinical Intervention Step 2: Assessment

Once an abused patient has been identified, it is critical to assess her immediate safety and risk for future violence, her coping mechanisms, health status, and referral needs. Assessment should provide the foundation for Areas to Assess whichever services are planned. Encourage the woman to discuss  Safety & lethality her situation in detail, including exactly what has been occurring,  Coping mechanisms  Health status its frequency, and her emotional feelings and reactions. Listening  Referral needs to the woman's experiences may be difficult, but having her describe her situation is an essential step in helping her recognize the serious and dangerous nature of her relationship.

Assess Immediate Safety Make sure that the battering victim is safe in the clinic setting by assessing the potential risk of immediate serious injury or homicide by the batterer. The following checklist of questions are those suggested by the Family Violence Prevention Fund in order to assess the victim’s immediate safety (Warshaw et al., 1995).

Imminent Danger Checklist

 Is the victim’s partner here now or likely to return?  What would she like you to do if her partner tries to get her to leave the setting?  Does she want you to call security or the police?  Does she want to leave with her partner or keep hidden and then find a shelter?  Does she need to call someone to pick up her children?  Does she have a protective order?  Does she need to be home by a certain time in order to avoid further abuse?

42 43 Once the potential for immediate danger has been assessed, it is also important to assess a patient’s general safety and risk for homicide and suicide. While they are not predictive of whether or not a patient will become a victim, the following factors have been associated with severe abuse and partner homicide:

 Access to weapons  Threats of violence  Substance abuse  Use of violence in other situations  Controlling behavior

The Danger Assessment (Campbell, 1986) instrument provided in Appendix G is a widely accepted assessment tool and can be used to consider a patient’s potential for becoming a victim of homicide. The questions on this form are based on research identifying which factors are associated with partner homicide and may be used to assist the woman in objectively evaluating her safety within a relationship. It is important that any discussion with a patient about the risk for homicide is done in an extremely sensitive manner. While it is absolutely critical that patients who are experiencing violence in an intimate relationship understand the potential for extreme danger, the provider does not want to unduly frighten patients or use fear tactics to convince patients to take actions they may not otherwise pursue – such as leaving their partner. This can be a very difficult balance to maintain as a provider. Ultimately, it is important to talk calmly and objectively to patients about the violence and let them make decisions based on their supreme knowledge of the situation.

44 Assess Coping Mechanisms Ask victims about how they cope with the abuse. Assess whether the patient is using alcohol or drugs to deal with the physical and/or psychosocial pain resulting from involvement in a violent relationship. Alcohol and other drugs can reduce women's abilities to make rational decisions, particularly during episodes when her partner is violent. Alcohol and drugs can also be used for suicide attempts, so make sure to assess a patient’s risk for self-harm. Many people think about suicide; however, the situation becomes urgent if a woman has formulated a plan to commit or attempt suicide. People with a suicide plan typically will act on it in the near future. If the patient threatens to kill herself or her partner, call for an emergency psychiatric evaluation.

Assess Health Status Assess the woman’s health status. This is a good time to explain the relationship between domestic violence and health to your patient. The clinician should address the medical needs of the patient with special attention made to the contribution of domestic violence to physical complaints. Evaluation and documentation of physical injuries is certainly important and is discussed further on pages 49-51. In addition, patients who are in abusive relationships need to be questioned about depression, suicidal ideation, and substance abuse, as they are at particularly high risk for these conditions. Diagnostic evaluation for sexually transmitted diseases should be considered, as the prevalence of these infections is relatively high in this population. It is important for the clinician to explore the possible relationship between other physical symptoms such as headaches, abdominal pain, and musculoskeletal pain, all of which may be caused or exacerbated by the abuse at home.

45 Clinical Intervention Step 3: Intervention

Recognize the Stage of Her Relationship

Recognize that different women are at different stages in their relationships and some women may not be ready to disclose the abuse. Providers may become frustrated when a woman returns to her batterer or does not follow the treatment plan developed. A woman faces many obstacles to leaving her batterer that many people find hard to understand. On the surface, her decisions may appear to be non-productive or even destructive. However, providers need to be aware that many women may never leave their abusive partner. Given this fact, providers can focus on assisting women in developing a safety plan, so that she can maximize her safety within the relationship and have ready access to resources.

Potential Relationship Stages

Cannot admit that there is a problem Admits abuse, but not ready to leave Women in this stage may not be ready to A woman in this stage most likely needs to hear develop a plan to leave the batterer. She that she does not deserve the abuse and that may need a clear, broad definition of what there are sources of help. constitutes abuse.

In the process of leaving Recently left an abusive relationship

A woman in this stage will need support for A woman in this stage may need continued her decisions and may need referrals for support, either through support groups or long-term assistance such as education, counseling. Recognize that the situation can childcare, and housing. Developing a safety remain very unsafe, even after a woman has plan is extremely critical, since any attempt separated from an abusive partner. to leave the relationship may be extremely dangerous for her and her children.

If a woman says that she cannot leave her batterer or chooses not to leave the relationship, tell

46 her:

“I am afraid for your safety.” “I am afraid for the safety of your children.” “The violence is likely to get worse.” “I am here for you when you are ready to leave.”

Develop a Safety Plan

A woman may face the greatest danger when she attempts to leave the batterer. Regardless of whether the victim plans to stay or leave, she will need assistance in developing a safety plan so that she will be able to escape in the event of a subsequent abusive incident. Two sample safety plans are provided in Appendix H and Appendix I. The first is a checklist. The second is a more thorough, but lengthy document. If a woman does not feel comfortable taking a safety plan document home with her because it may be difficult to hide from the batterer, provide her enough time to complete it and then file it in her medical record. Review the safety plan at a subsequent visit to determine if the woman’s situation has changed and provide her an opportunity to update the plan.

Refer to Appropriate Services

A woman with an abusive partner can take steps to protect herself and her children. Providers can help empower women by working with them to plan strategies for meeting crisis and long-term needs and focusing on the needs and the barriers that they identify (Hoff, 1993). Resources exist in nearly every community that can assist women and help them cope with all aspects of the abuse.

47 An abused woman may need specific information and practical help in a number of key areas. The types of referrals that may be appropriate include:

 Emergency housing  Transitional housing  Food  Cash  Clothing  Healthcare services  Substance abuse counseling  Financial counseling  Job training and career opportunities  Childcare  Legal assistance  Social services  Peer counseling/support groups  Professional mental health services

48 Types of Referrals Survivors May Need

Child Care For survivors of domestic violence with children, childcare is a critical resource. The Counseling/Support local domestic violence agency can provide The local domestic violence agency may information on childcare resources. offer support groups for battered women. In addition, they can provide referrals to other counseling programs or private therapists.

Legal Aid Women in abusive relationships may need free or affordable legal help with obtaining domestic Financial Assistance violence protection orders (DVPO’s) or Financial Assistance assistance with child custody issues, divorce Counseling in this area can be proceedings, etc. Contact the local domestic extremely important for women, as violence agency or court advocate for financial dependence on the batterer information. is often an element of abusive relationships. Information on eligibility criteria for financial assistance, such as government assistance, Supplemental Security Income (SSI), Supplemental Security Disability Income (SSDI), Victim’s Substance Abuse Treatment Compensation Fund and Medicaid, may be obtained from the Department Women may need referrals to substance of Social Services (DSS) or the local abuse treatment. The local domestic violence domestic violence agency. organization should be able to provide appropriate referrals.

Education/Job Training In order to become financially independent, some women may Housing want to further their education or job training. Contact the local Housing referrals may include emergency shelter community college, Employment through the local domestic violence agency. Security Commission (ESC) or Information on temporary or long-term housing domestic violence agency for options, which may be available through the Housing information on available programs. Authority or Department of Social Services, may also be beneficial.

49 Clinical Intervention Step 4: Documentation of Abuse

Documentation can occur through the use of notes, photographs, and body maps. Thorough and accurate documentation of the healthcare provider's findings is essential when assisting a patient with domestic violence issues. Unfortunately, many women have failed in their attempts to obtain legal action against their abuser, to gain custody of their children, or to prove a case of self-defense, because they had no tangible documentation of the abuse. In addition to providing key evidence, detailed and accurate documentation can supply the information necessary for assuring continuity of care by future providers who may be responsible for a patient’s case. Guidelines for documenting domestic violence cases follow. For a sample consent to photograph and a sample body map refer to Appendix F and Appendix J, respectively. The following are guidelines for documenting both subjective and objective information in a patient’s medical record:

. Document the woman’s response to the screening and assessment tools and keep copies of these tools in the woman's medical record. Ask the woman about the cause and circumstances of any injury, recording her statement verbatim. If she states that the injuries resulted from battering, follow up with questions about: (1) the instrument, weapon, or body part used to injure her; (2) any past incidents of abuse, neglect or exploitation; (3) the batterer’s name and her relation to the batterer; and (4) other relevant social history. Record in her medical record her explanation for injuries by writing, “Patient states...” For example, the medical record could state, “Patients states that her boyfriend, John Doe, punched her in the jaw at 6:00 p.m. yesterday.”

 Use neutral language to describe the patient’s statements about the cause of injures. Rely on phrases such as “the patient reports…” or “according to the patient…”, while avoiding phrases such as “the patient claims…,” “the patient alleges…,” or “the patient contends…” This type of language sounds judgmental and implies that the provider does not believe what the patient has reported.

 Use language that is active, not passive. For example, the statement “Ms. Smith reports that her boyfriend, John Doe, punched her in the left eye with his fist” is much better than “Patient was punched in the left eye with a fist.” Passive language tends to minimize the violence that the patient has actually experienced.

50  Record a brief statement from the patient regarding the history of violence. For example, “This is the fourth incident of physical violence by her boyfriend, John Doe. Prior episodes have involved slapping and pushing. Abuse is becoming more severe.” Avoid recording long descriptions and quotes by the woman, which deviate from the actual abuse (e.g., “He gets jealous when I spend time with my friends”).

 Record current and past injuries that are identified during the physical exam. Remember that X-rays or CT scans showing old injuries can support a history of abuse. A thorough description of the injury should include the length, width, depth, shape, color, and location of the wounds. These characteristics assist in determining the age and type of wound and the probable cause of the injury.

 Note the exact location of each injury in relation to fixed body landmarks. Anyone reading the description should be able to easily locate a particular injury in relation to other injuries and to the body as a whole.

 Look for specific patterns of injury. Trauma distributed over the head and neck, the front of the torso, and areas that later can be concealed by clothing should raise concern. Unintentional injuries are less likely to be patterned. The recognizable imprint of an object in a wound also raises the likelihood that the injury was inflicted.

Photographs If possible, photograph any injuries. While written documentation can be challenged in court, photographic documentation is difficult to dismiss and can often compensate for the inadequacies of written descriptions and the observer’s memory. Even if the woman does not want to take legal action at the present time, photographs will be invaluable if she decides to take action at a later date. The following are general guidelines for photographing injuries:

 Photograph a woman’s injuries only after obtaining her informed, signed consent. A sample of a consent form is provided in Appendix F. All procedures should be explained clearly so that the woman can understand what is being done.

 Photographs should accurately reveal the extent of all injuries. Ideally, at least two photographs are necessary. The first photograph should show the injury and the patient’s face for purposes of identification, while the second photograph should be closer and show more details of the injury. Include a scale, such as a ruler, to demonstrate the size of an injury.

 Label each photograph. Clearly mark the back of each photo with: (1) the name of both the patient and the examiner; (2) the patient’s medical record number; and (3) the date of the photograph. A sealed copy should be kept in the medical record.  Keep in mind that instant photography is preferable to standard film. Instant cameras

51 have no negatives to develop that can be lost or damaged. In addition, a photograph can be provided to the patient on the day of treatment and can help ensure patient confidentiality. Polaroid offers special cameras and a training program for photographing domestic violence injuries (contact information for Polaroid in Appendix B).

Body map A body map (Appendix J) can be used as an alternative method for documenting injuries that may not show up well on photographs. Simply identify all injuries, new and old, on the body map. In addition, a body map can supplement any photographs by enabling police officers, the prosecutor, and jurors to relate the photographic depiction to injuries discussed in the written medical record.

Documentation Guidelines

The goals of documentation include:  Providing a legal record by documenting the abuse clearly and accurately.  Demonstrating objective findings and outcomes.  Maintaining confidentiality of patient medical records.

Important items to include in any documentation of an abuse-related injury:  Note the patient’s account of the incident.  State objective findings.  Provide a detailed description of the injury, any treatment provided, and  necessary follow-up (physical therapy, X-rays, medication, etc.).

 Use photos and body maps, whenever possible.  Include results of laboratory tests or medical exams.  Document information given to the patient and any referrals made with patient’s consent.

 Note any interactions with the alleged perpetrator.

Even if there is no injury, note the following in the medical record:  Any suspicions and the reasons for those suspicions.  A statement that the provider questioned the patient about violence.  A record of the patients denial or agreement with questioning.

52 Clinical Intervention Step 5: Discharge Planning

Before a woman in a violent relationship is released from the healthcare organization, there are several ways providers can help her improve her and her children’s safety and wellness. While the woman is still at the hospital or clinic, first help her consider whether it is safe for her to return home. If not, help her contact a family member, friend, or a local shelter for emergency housing. If she does decide to return home, assist her in developing a safety plan so she can be better prepared to protect herself and her children in the likely event of another violent episode. The safety plan can be general or customized to her situation if she has special needs or circumstances (see Appendix H and Appendix I for sample safety plans). In addition, provide the patient referrals for shelter, support groups, childcare, and other domestic violence services that are appropriate to her situation. Also, explain to her that she has legal options and provide her with any necessary legal referrals. Finally, make sure she knows how to care for any injuries and take any medicines that may have been prescribed. Remember that a patient who discloses abuse to a provider may feel very uncertain and uncomfortable doing so, especially if this is the first time she has talked about the violence. With this in mind, always reassure a patient upon discharge that it is safe for her to return at any time to discuss the abuse or other needs she may have and that everything she has disclosed during her present appointment is strictly confidential.

Discharge Guidelines

 Consider the following:

 Is there a safe place for her and her children to go when they leave?  Does she know how to treat or address injuries and other health issues? What about prescribed medications? Any follow-up appointments?  Does she understand her legal options and have appropriate numbers?  Does she have a safety plan in place in case of future violence?

 Provide written material that will be safe for her to take home. Many batterers go through their partners’ personal items (purses, etc.) Make sure she knows what is written on any material and use codes to refer to domestic violence.

 Trust her judgement, as she is the expert on her own situation.

53 Clinical Intervention Step 6: Follow-up with Patients

Follow-up is an important, yet often neglected, step in domestic violence clinical intervention. Discussing the abuse with a woman repeatedly lets her know that the abuse is being treated seriously and informs the healthcare provider about the woman's changing needs. Questions to ask during follow-up may include:

“Has the battering continued or escalated?”

“Have you made any decisions about how you want to address abuse in your relationship?”

“If you have contacted any community agencies, have they proven helpful?”

“Do you need additional referrals?”

“Does your safety plan need to be revised?”

Follow-up Guidelines

Offer to schedule future visits with her, giving her additional opportunities to talk.

Make a note in her medical record that she should be screened for abuse at her subsequent visits. This is particularly critical if she is not willing to schedule a future appointment at that time.

54 4. Staff Training and Education

If possible, all staff should receive training and education about domestic violence and related policies and procedures specific to their particular healthcare setting and role. Training should occur upon being hired and then at appropriate regular intervals thereafter, as well as when job duties are changed or expanded. Generally, training on an annual basis is recommended. The breadth and depth of training should be informed by the expected clinical responsibilities and anticipated work setting for each employee and healthcare provider. Training content for each group of staff is discussed below.

Clinical staff Regardless of the intervention model, clinicians should be trained on how to do a basic intervention with domestic violence patients.

Training should help providers achieve three goals: Clinical Staff Physicians  Acquire a core body of knowledge on domestic Nurses violence Family Nurse Practitioners Physician Assistants  Master the specific clinical skills for identification Paramedics and intervention Lab Technicians PT’s & OT’s Pharmacists Dentists Social Workers Psychologists

55  Gain awareness of local community organizations and domestic violence resources

Regular training will reinforce the importance of screening, assessment, intervention, and advocacy on behalf of victims of abuse, and provide educational opportunities for those who have not been previously trained. Opportunities for training in domestic violence exist during in- service training, regularly scheduled meetings such as grand rounds, specially arranged symposia, or professional meetings. The Beacon Program training may be obtained by contacting Diana Solkoff, Program Coordinator, at (919) 966-9314.

Other staff Ancillary staff with direct patient Other Staff contact should also receive training CEO’s Administrators appropriate to their role in the healthcare Clinic Managers Supervisors Security Risk Managers setting. The context of training should be Social Workers Employee Assistance Occupational Health Human Resources appropriate to the specific professional or vocational responsibilities of the individual.Clinician Training Training management Topic Area Checklist* personnelCore knowledge can be very effective in raising institutional consciousness about domestic violence and gainingDefinitions the supportand prevalence of those of whodomestic wield violence influence in policy and decision-making.  Tactics of abuse (e.g., physical, sexual, emotional/psychological, and economic)  Special populations (e.g., pregnant, substance abusers, etc.)  Health-related effects of domestic violence on victims and their children  Healthcare providers’ role in addressing domestic violence and patient barriers  Legal rights of victims and the legal responsibilities of healthcare providers  Personal safety for victims and for healthcare workers

Clinical Skills  Framing and asking domestic violence screening questions  Recognizing signs and symptoms of distress in victims of abuse  Assessing the patient’s situation by obtaining a history of abuse, determining the patient’s immediate risk of danger, and assessing the patient’s mental health needs  Providing support in a respectful and non-judgmental manner  Documenting properly  Developing a safety plan and intervening without placing patients in greater danger

Relationships with community organizations  Local agencies and organizations that handle domestic violence and sexual assault  Example of successful healthcare and community models for addressing partner violence

*Adapted from Short & Osattin, 1998. 56 5. Patient Education While there are many ways to educate patients about domestic violence, it is critical that information be widely distributed throughout the organization. For example, brochures and posters can be placed in waiting rooms and women’s restrooms. In addition, providers, social workers and other staff can give patients resource cards when those patients disclose either past or current exposure to domestic violence.

Patient Education Checklist

 Distribute information to all patients when screening for domestic violence  Provide information in prenatal, childbirth, parenting and health education classes  Make information available in waiting areas and exam rooms  Post information in rest rooms -- particularly on the door inside the stall  Exhibit information on domestic violence at health fairs  Host a resource table during Domestic Violence Awareness Month (October) and participate in the Family Violence Prevention Funds’ Health Cares About Domestic Violence Day

6. Community Linkages One of the most important components of a domestic violence program is developing a good working relationship with local community agencies that address domestic violence. The healthcare organization’s program should be part of a larger coordinated community response, which aims to improve domestic violence prevention and intervention through collaborative efforts and partnerships with other organizations. A community response to domestic violence is needed for several reasons. While most communities have services that meet some of abused women’s needs, they rarely have the resources and services in place to meet all of them. Services may not be structured or coordinated to help women in the most effective way possible. Furthermore, in times of diminishing program resources, it is critical that organizations work together to share resources and avoid duplication of effort.

57 A coordinated community response should include community and professional education, systems advocacy, and advocacy for policy changes. Community education raises awareness about the causes and effects of domestic violence, the needs of abused women, means of meeting those needs, and the need to hold batterers accountable for their actions.

Effective community education will promote:

 A change in community attitudes about domestic violence  Earlier intervention with domestic violence victims and perpetrators  Prevention of domestic violence

A comprehensive effort can result in women acknowledging the problem of violence in their lives sooner, while helping service providers to be more prepared to provide assistance.

Collaborating with Local Domestic Violence Agencies

Collaboration with domestic violence advocacy programs is key to improving the healthcare system and community response to domestic violence. Creating a healthcare-based program with input and cooperation from local programs can help build trust and communication.

Cooperative activities with domestic violence programs include:

. Co-facilitating support groups or a treatment program at the healthcare organization’s facility . Co-present lectures on domestic violence for medical societies, civic groups . Help domestic violence programs to improve shelter health services . Provide CPR and first aid training to shelter staff . Work with domestic violence programs to train healthcare providers in other settings . Co-sponsor community educational forums on domestic violence . Co-sponsor information sessions at schools . Include a representative from the DV agency on the multidisciplinary team . Serve on the board of the local domestic violence program

58 7. Determining Program Success

As you plan your program, consider the types of information you will need to determine how and why your program is or is not working effectively. This type of information can be used to help monitor the domestic violence patient load, tailor the program to the needs of the patients and clinical staff, improve the program over time, build and maintain organizational support for the program, and obtain external and internal funding. By planning ahead, this important information can be collected from a variety of sources without too much added effort. This is discussed in more detail on pages 62-65. Healthcare organizations can feel free to modify the form used by the Beacon Program Nurse Advocate to obtain patient demographics and information provided in Appendix D.

Data Collection Checklist  Develop data collection methods  Coordinate with quality assurance departments regarding protocols

59

Chapter IV

Program Implementation

Program Implementation

After the planning and development of program components, the next step is implementation of the program. There are five primary phases to program implementation, which include:

Phase 1: Developing a budget and acquiring necessary resources Phase 2: Institutionalizing routine screening Phase 3: Administering provider training Phase 4: Marketing the program Phase 5: Determining program success

In order to avoid frustration, it is important that administrators, providers, and program staff keep in mind that fully implementing a domestic violence response program in a healthcare setting is a time-consuming process that can take many months or even years.

Phase 1: Developing a Budget and Acquiring Necessary Resources Because programs vary in size, services offered, and other important characteristics, the budgets of several healthcare organizations which currently operate domestic violence response programs are provided below in order to give the reader some examples of annual expenditures.

Organization Location Budget # Served Annually

WomanKind Mpls, MN $250,000 1300 Domestic Violence Project Kenosha, WI $100,000 200 Hospital Crisis Intervention Project Chicago, IL $133,000 300 Medical Advocacy Project Pittsburgh, PA $80,000 300

After determining your budgetary needs, the hardest task is identifying funding sources for your program and acquiring resources. While there are many different funding sources, they

59 have varying application guidelines, eligibility criteria, funding cycles, and submission dates. Determine which funding mechanisms are appropriate Funding Resources for the program. Many existing programs receive some funding from the healthcare organization itself $ Federal grants combined with outside funding from foundations or $ State grants other sources. $ Local community grants Once funding is secure, determining staffing $ Individual foundations needs is the next major hurdle. Staff who are hired or $ Hospital resources designated to provide victim services should have $ Fundraising experience serving domestic violence victims, familiarity with healthcare settings, knowledge of community systems, and skills in assessment and counseling. Staff who are hired or designated to coordinate the program should likewise have skills in assessment, planning, training, administration, and evaluation. These roles are performed by separate staff in some programs, such as The Beacon Program at the University of North Carolina Hospitals, which employs a Program Coordinator and a Nurse Advocate. In other programs, these roles are combined into one staff position. Some existing programs use extensive networks of volunteers to provide victim services (for more detailed information on program model examples, refer to page 27). Determine any additional resources that are necessary. If the program is onsite, locate office space and acquire any necessary equipment and supplies. Much of this may be donated by the organization. Special funding for victim services is ideal, but not required for models using existing staff. For example, Surry County Health and Nutrition Center includes domestic violence counseling in the array of services for which they receive reimbursement from North Carolina’s Baby Love program. They have trained all their clinicians to provide some victim services and call the local domestic violence program to help victims who need additional assistance. For additional information about this program, call (336) 401-8888.

Phase 2: Institutionalizing Routine Screening Protocols and procedures for routine clinic screening need to be implemented in order for the program to prove successful. While Chapter III discussed methods for screening patients for domestic violence, a systematic plan should be developed to prioritize and phase-in the

60 implementation of screening methods in various clinics. Consider the clinic flow in your organization in order to facilitate screening and identification of domestic violence patients.

Phase 3: Administering Provider Training Certainly, provider training is key to implementing screening and appropriate victim services. Administrative buy-in and approval from various clinics and departments will be necessary to implement provider training. While it may take numerous planning meetings to obtain such approval, the effort will pay off in the long run. Based on experience, provider training will simply not be as useful unless there is documentation that requires providers to perform specific screening duties. Develop a schedule for training providers. While such a schedule will ultimately be determined by provider availability, think about which clinic areas would be most receptive to the training and more likely to follow-through on identification after the training. Setting up a schedule for the first year may help sustain momentum.

Phase 4: Marketing the Program Consistent and effective marketing of the domestic violence response program is key during the implementation phase. Promote the program to staff, patients, community agencies and the public.

Marketing Checklist  Request top management write letters of support for the program to providers  Meet with clinic managers to discuss training and protocol development  Present information about the program at staff meetings  Post program information in staff and patient restrooms, lounges, and snack bars  Place flyers about the program in all staff mailboxes or pay stubs  Promote the program to various community agencies that serve battered women  Market the program through local news releases

61 Phase 5: Determining Program Success Proof of the program’s effectiveness may be needed for continued funding and community support. In addition, healthcare providers will likely desire evidence that the intervention helps women before they are willing to incorporate it into their practice. There are a number of relatively easy things that can be done to determine whether or not the program is working. Questions to consider when assessing the overall program include:

Is the program being implemented as planned? If not, why not?

Are the clinicians doing what they need to be doing? If not, why not? If clinicians are not doing what is necessary, what changes can be made to improve the clinical response?

Are the patients benefiting from the program? If so, what are the benefits? If not, what changes are necessary to improve the benefits to the patients?

Understanding Program Implementation No matter how hard planners work to bring a program to the point of implementation, problems will likely surface. For this reason, it is important to try to identify any potential problems with the program as soon as possible, so that those issues can be appropriately addressed and rectified. Additional questions that should guide the determination of the quality and effectiveness of the program are:

If the program is not being implemented as planned, does this represent a problem or an improvement to the program plan?

Are there differences in how the program is implemented across various clinics/departments?

Which aspects of the program are being implemented and which are not?

In order to answer these questions, consider the following issues:

62  Review program documentation such as meeting minutes, brochures, and guidelines

 Interview staff to determine if proposed actions were taken

 Identify whether or not policies and protocols were developed and implemented

 Observe training sessions and ask training participants for feedback to assure that the training is relevant and effective

 Interview patients to determine whether they were asked about domestic violence and/or offered services

 Review patient charts for documentation

 Develop and review a “tracking” form or a computerized database that collects important information on domestic violence patients (as appropriate for your setting) to supplement patient medical records

Understanding Clinician Behavior A key to good program implementation is the extent to which clinicians are screening women appropriately, engaging in appropriate “usual practice” (as defined in the program plan), documenting correctly, and conducting appropriate discharge planning and follow-up. The following are issues to consider when trying to determine clinician behavior:

 Interviewing patients  Surveying or interviewing clinicians  Reviewing medical records for documentation, services, and referrals  Interviewing domestic violence service providers from local agencies

In order to determine if clinician practice changes over time, it is important to interview clinicians before and after any program training is implemented. If clinicians are not screening or engaging in appropriate practice, it is important to find out why. Keep in mind that it can be very difficult to change the way clinicians currently practice. A “one-time” training program is likely to be inadequate. Hence, one important reason why clinical practice may be less than optimal is that the training was not adequate.

63 If there is not an increase in the identification of abused women, it may be that clinicians are not screening appropriately. First, providers may still be screening selected populations of women on the basis of symptoms only. Second, their screening questions may be too vague or they may appear uncomfortable to their patients when asking questions about violence. Providers may have also stopped screening altogether because they were uncomfortable asking about violence, they did not get any “yes” answers when they did screen, or they did not see any positive patient or clinician outcomes when a patient was identified. Remind clinicians that healthcare providers have an obligation to ask about domestic violence, but that patients don’t have an obligation to talk about abuse in their lives. Therefore, it is critical that providers are well trained in screening methods so that they appear comfortable, sensitive and open to the issue. When evaluating clinician practice and behavior related to domestic violence, it is also important to consider whether or not they are making appropriate referrals. Providers may not refer appropriately if they believe that they are able to directly provide a patient with the services needed, they are not sure what the response program provides that is different, or they don’t want the patient to have to see another provider. Suggestions for overcoming these issues include more clinician education, additional literature and packets for patients, and closer follow-up.

Understanding Benefits to Patients Determining in what ways, if any, the program is benefiting battered women is absolutely critical. Unfortunately, this type of information is rarely collected. For this reason, there is very little evidence as to how battered women benefit from healthcare programs, or even what they like and don’t like about them. While the long-term effects of domestic violence intervention programs on women’s health and safety can be difficult to determine, there are some things that can probably help identify how women are benefiting from the program. These include surveying or interviewing patients who have received some services and documenting and reviewing medical record information to determine what agencies were contacted, any safety planning steps that were taken, specific health behaviors or other outcomes of interest. Reasons why patients may not be benefiting from the program:

 Level of service is very low

64  Services provided are not what the patients need or want  Evaluators are not assessing the right program outcomes

If the level of service is low or does not meet patient needs, determine methods for enhancing or modifying those services. This may require changes in training, how services are provided, or both. In addition, seek to assess a variety of possible benefits to patients when evaluating the program. Remember to consider both health related and domestic violence related outcomes.

Benefits of Task for Determining Program Success Assess program Measure change in Determine patient Task implementation clinicians’ behavior satisfaction

Review policies & X protocols

Review program X documentation

Interview staff X X

Interview patients X X X

Interview staff from local domestic X X X violence agencies

Evaluate training X

Review patient X X charts

Develop patient X X X tracking form

65

References

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67 Appendices

Appendix A

Effective Practices for Healthcare Response to Domestic Violence

The Beacon Program of the University of North Carolina Hospitals is the first hospital- based domestic violence intervention program in North Carolina. Working toward improving the healthcare response to women throughout the state, the Beacon Program has formed a multidisciplinary team providing a number of healthcare organizations with technical assistance in planning, implementation, and evaluation of their own domestic violence programs. The team includes members from the North Carolina Medical Society, Interact, UNC Hospitals, the Surry County Health and Nutrition Center, the UNC Department of Emergency Medicine, and UNC- Greensboro. Technical assistance is provided in a number of key areas, including:

 Assessing each healthcare organization’s strengths and needs  Conducting workshops on planning, implementation, training, and patient services  Training of appointed direct service staff by the Beacon Program Nurse Advocate  Providing telephone and on-site consultation and assistance

Following the list of the five selected healthcare organizations (inset) is a detailed outline of the steps used to provide technical assistance to each site.

Lenoir Memorial Hospital, P.O. Box 1678, Kinston, NC 28503 Contact: Vickie Turner, Lighthouse Program Coordinator (252) 522-7245

Cleveland Regional, 201 Grover Street, Shelby, NC 28150 Contact: Nancy Porter, Director of Women’s and Children’s Services (704) 487-3913

New Hanover Regional, P.O. Box 9000, Wilmington, NC 28402 Contact: Barbara Buechler, Director of Women’s and Children’s Services (910) 343-7000

Rural Health Group, P.O. Box 644, Jackson, NC 27845 Contact: Kathy Richardson, CSW (252) 586-5151

Robeson Healthcare, 1211 S. Walnut Street, Fairmont, NC 28340 Contact: Delores Vasquez, Perinatal Coordinator (910) 521-8641

68 Goal: Improve the health of battered women by improving the healthcare response to domestic violence in North Carolina

This project has two strategies: Strategy 1: Develop and provide a manual to healthcare facilities which can serve as a guide to improving their response to domestic violence Strategy 2: Assist five healthcare facilities in developing their response to domestic violence (the Beacon Program will work with two facilities during the first year of funding and three facilities during the second year).

Objectives for Strategy 2 For each of the healthcare facilities:  Improve clinician domestic violence-related knowledge, attitudes, and behaviors  Increase the screening of domestic violence in clinical settings  Increase the number of battered women identified  Increase the number of clinicians that document domestic violence in medical records  Increase referrals from the healthcare facility’s providers to appropriate community domestic violence services

Funding: The Beacon Program has received a two-year grant from the Governor’s Crime Commission for this project. The funding provides for a staff person to write the manual and work with the healthcare facilities (a statewide multidisciplinary team will also work with the healthcare facilities).

Statewide team includes:  The Beacon Program  North Carolina Medical Society  University of North Carolina at Greensboro-Department of Public Health Education  University of North Carolina at Chapel Hill-Department of Emergency Medicine  Interact  Surry County Health and Nutrition Center

Benefits to participating healthcare facilities  Technical assistance in developing and institutionalizing a response to domestic violence  Coordination of services to help battered women  Provision of information on national and state domestic violence resources  Contribution to developing domestic violence manual for healthcare facilities  Reduction of time and cost in treating battered women for health issues related to domestic violence

69 Project Steps

These steps are based on a public health model of identifying needs using data, developing and implementing a response based on identified needs, and evaluating the response.

Step 1: Select healthcare facility  Obtain administrative support  Provide and receive letters of agreement to collaborate on project

Step 2: Form a domestic violence team  Team should be multidisciplinary and should include representatives from various departments within the healthcare facility and the local domestic violence program  Team members will participate in the workshop  Team members should have authority to make policy changes within the organization  The team should be responsible for the needs assessment, program planning, implementation, and evaluation

Step 3: Conduct needs assessment of healthcare facility  A needs assessment is a systematic set of procedures undertaken for the purpose of setting priorities and making decisions about program or organizational improvement and allocation of resources Areas to assess:  Patients -- willingness and barriers to talking to healthcare providers about domestic violence; barriers to receiving help; history of experience with healthcare system  Staff -- domestic violence-related knowledge, attitudes, and behaviors; barriers to identifying and assisting battered women  Organization -- number of patients seen; types of patients seen (migrant, Spanish-speaking, out-patient, etc.) geographic service region, connection with other domestic violence programs in service region; connection with other services that serve battered women; what domestic violence policies are currently in place; available funding for staff training and program implementation  Community -- community resources for domestic violence victims and perpetrators (legal services, social services, mental health, etc.); community support for healthcare facility-based program How to assess:  Survey patients  Survey staff  Gather data on population served  Obtain current policies from administration  Gather information about institutional resources  Talk to community organizations that serve battered women

70 Step 4: Conduct a planning workshop with each healthcare facility and local domestic violence program  The workshop will be facilitated by the Beacon Program’s statewide team  Participants should include leadership from the health facility nursing, medical, social work, and allied health staff as well as the local domestic violence program and other relevant community agencies

The workshop agenda will be tailored to the needs of the organization. In general, at the workshop the facilitators and participants will:  Discuss the dynamics of domestic violence and the needs of battered women  Discuss components of appropriate healthcare response to domestic violence (screening, assessment, documentation, referral, follow-up)  Present JCAHO standards for addressing domestic violence  Provide model policies, procedures, and programs from other healthcare facilities  Analyze and synthesize needs assessment data (patient and staff surveys, current policies, etc.)  Set priorities based on needs assessment data  Present guidelines for program implementation and evaluation  Begin developing hospital policies to identify and assist victims of domestic violence (this is a process that will require more review and input from the staff and community, and will require additional meetings)  Develop plan for training staff

Step 5: Train staff on domestic violence and policies and procedures  Training should include: dynamics of domestic violence; health effects of domestic violence on victims and their children; clinical skills and hospital protocol for identifying and assisting domestic violence victims; and community resources  Training should be conducted by the local domestic violence program and hospital leadership  The Beacon Program will provide technical assistance in developing the training

Step 6: Implement policies and procedures  Assure that administration supports the plan  Promote the program/plan to staff, patients, and the community  Allow for staff, patient, and community input to refine the program/plan

Step 7: Evaluate project  The Beacon Program will provide guidance to the healthcare facility so that the healthcare facility may evaluate its own services  The healthcare facility will provide feedback to the Beacon Program about the technical assistance it has provided

71 Expectations

The project’s statewide team will:

 provide technical assistance in forming a multi-disciplinary domestic violence task force

 assist the healthcare organization in conducting a needs assessment (will provide assessment tools, including staff and patients surveys and an organizational assessment tool); enter survey data into a database; analyze the data; and present the findings at the workshop

 organize and facilitate a workshop for the healthcare organization’s domestic violence team

 make two additional on-site visits to provide additional guidance

 provide additional technical assistance with planning and implementation as needed

 evaluate healthcare organization’s progress after one year

The healthcare organization will:

 send a letter agreeing to work with the Beacon Program over the course of the grant

 form a multidisciplinary team within the organization (including representation from the local domestic violence program) to plan, implement, and evaluate the organization’s response to domestic violence

 conduct the needs assessment

 have the team attend the workshop

 organize and conduct staff training on domestic violence

 participate in an evaluation of the hospital’s domestic violence initiatives after one year

 give feedback to the Beacon Program regarding the technical assistance provided throughout the process

72

Appendix B

Domestic Violence Resources

General Resources

The American College of Nurse Midwives 818 Connecticut Ave. NW, Suite 900 Washington, DC, 20006 (202) 728-9863 (202) 728-9879 (to order publications) www.acnm.org

The American College of Nurse Midwives (ACNM) assumes a leadership role in the development and promotion of high quality healthcare for women and infants. ACNM has domestic violence resources available for both individual women (an awareness packet) and healthcare providers (video and manual).

The American College of Obstetricians and Gynecologists Women’s Healthcare Physicians P.O. Box 96920 Washington, DC 20090-6920 (202) 863-2487 www.acog.org

The American College of Obstetricians and Gynecologists provides advice on how to leave an abusive relationship and talk to your doctor about your situation. The ACOG website also provides a checklist to determine if abuse is occurring and a fact sheet regarding domestic violence. Items such as posters, tent cards (for waiting rooms, bathrooms, and exam rooms) and a patient education brochure are available free of charge in small quantities and on an at-cost basis in larger quantities. Other materials for providers, like the slide show “Domestic Violence: The Role of the Physician in Identification, Intervention, and Prevention” and a general information packet regarding domestic violence, can be ordered from the College.

American Medical Association 515 North State Street Chicago, IL 60610 (312) 464-5000 www.ama-assn.org

The American Medical Association has published guidelines for physicians on domestic violence and other types of family abuse (child, elder, sexual, etc.). In addition, the association has established a coalition of physicians and other healthcare professionals interested in violence issues

American Medical Women’s Association 801 N. Fairfax Street, Suite 400 Alexandria, VA 22314 Phone: 703- 838-0500 www.amwa-doc.org/index.html

73 THE AMWA is an organization of women physicians and medical students dedicated to serving as the unique voice for women’s health and the advancement of women in medicine.

Asian and Pacific Islanders Institute on Domestic Violence c/o Asian and Pacific Islanders American Health Forum 942 Market street, Suite 200 San Francisco, CA, 94102-4008 Phone: 415-945-9988 www.apiahs.org

The Asian and Pacific Institute on Domestic Violence is a national coalition of domestic violence experts, shelter workers, health educators, and policy activists working to eliminate domestic violence in Asian and Pacific Islander communities through supportive networks, increasing awareness and prevention of domestic violence and informing and promoting research and policy.

Association of American Indian Physicians 1225 Sovereign Row, Suite 103 Oklahoma City, OK 73108 Phone: 405-946-7072 www.aaip.com

AAIP’s mission is to pursue excellence in Native American health by promoting education in the medical disciplines, honoring traditional healing practices and restoring the balance of mind, body, and spirit.

Battered Women’s Justice Project Criminal Justice Center 4032 Chicago Ave., South Minneapolis, MN 55407 1-800-903-0111 (ext. #1) www.vaw.umn.edu/BWJP

The Battered Women’s Justice Project (BWJP) consists of three components: civil justice, criminal justice, and issues concerning battered women charged with crimes. The criminal justice aspect focuses on how effective intervention requires inter-agency coordination and policy development that guides individual practitioners in the use of arrest, prosecution, sentencing of abusers, victim safeguards, and batterers’ intervention programs. The National Clearinghouse for the Defense of Battered Women provides technical assistance, resources and support to battered women who kill their abusers in self-defense or who are coerced by their abusers into committing a crime. The final component of the BWJP, that of civil justice, is housed in the office of the Pennsylvania Coalition against Domestic Violence. It aims to improve battered women’s access to civil court options and legal representation in civil court processes and usually deals with issues like protection orders, mediation, separation violence, the Violence Against Women Act, etc. Information regarding the Battered Women’s Justice Project and its various components is available upon request.

74 California Alliance Against Domestic Violence 926 J Street, Suite 1000 Sacramento, CA 95814 Phone: 916-444-7163

CAADV works to eliminate domestic violence, and all forms of violence, by promoting social change through leadership and advocacy.

Center for the Prevention of Sexual and Domestic Violence 936 North 34th Street, Suite 200 Seattle, WA 98103-1903 (206) 634-1903 www.cpsdv.org

The Center for the Prevention of Sexual and Domestic Violence is an interreligious resource that engages theological leaders in the task of stopping sexual and domestic violence. Founded in 1977, the Center links a foundation of religious knowledge with a firm understanding of the dynamics of abuse, comprehensive training and management skills, and experience in developing education and prevention programs. A resource catalog summarizing available books, videos, etc. is provided upon request.

Community Policing Consortium 1726 M Street, NW, Suite 801 Washington, DC 20036 Phone: 800-833-3085

The Consortium is committed to helping law enforcement agencies and other community organizations extend and refine efforts to promote public safety and enhance the quality of life in our communities. The Consortium recognizes the role that law enforcement can play in preventing domestic violence and the advantages that partnering with health care practitioners can have in addressing this societal issue.

DHHS Office of Women’s Health 200 Independence Avenue SW Room 728E Washington, DC 20201 Phone: 202-690-6373

The Office of Women’s Health works to redress the inequities in research, health care service, and education that have placed the health of women at risk, coordination women’s health research, and collaboration with other government organizations, and consumer and health care professional groups.

Gay and Lesbian Medical Association 459 Fulton Street, Suite 107 San Francisco, CA 94102 Phone: 415-255-4547 www.glma.org

GLMA promotes quality health care for LGBT and HIV-positive people, fosters a professional and diverse climate for members, and supports members challenged by discrimination on the basis of sexual orientation.

75 International Nursing Network on Violence against Women PMB 165 1801 H Street B5 Modesto, CA 95354-1215 (888) 909-9993 www.nnvawi.org

Provides nurses and other practitioners interested in violence against women and opportunity to share resources and support.

National Coalition Against Domestic Violence P.O. Box 18749 Denver, CO 80218 Phone: (303)839-1852 Fax: (303) 831-9251 Web Site: www.ncadv.org

NCADV serves as a national information and referral center for the general public, the media, battered women and their children, agencies, and organizations. It provides information and technical assistance and also promotes the development of innovative model programs. NCADV sponsors national conferences on domestic violence as well and most notably is the sponsor of “National Domestic Violence Awareness Month.” Pins, posters, flashlights (for candlelight vigils, fact sheets, magnets and other products are available for a small fee, and a list of publications for providers of services for battered women is available as well.

National Domestic Violence Hotline P.O. Box 161810 Austin, TX 78716 1-800-799-SAFE (7233) (Admin.) (512) 453-8117 www.ndvh.org

The National Domestic Violence Hotline, a project of the Texas Council on Family Violence, receives 10,000 calls a month and provides information regarding crisis intervention, referrals to local programs, and information on domestic violence shelters, legal advocacy and assistance services, and social service programs. The hotline is operational twenty-four hours a days, seven days a week and is offered in many different languages. A list and description of free hotline materials, including a poster, a checklist identifying an abusive relationship, and a tape of the organization’s PSAs, are available upon request.

National Center for Injury Prevention and Control Division of Violence Prevention Family and Intimate Violence Prevention Team Mailstop K60 4770 Buford Highway NE Atlanta, GA 30341-3724 (770) 488-4362 www.cdc.gov/ncipc

The Family and Intimate Violence Prevention Team, a project of the Centers for Disease Control and Prevention, was established in 1994, and several activities have been undertaken to reach its goal, the prevention of violence against women. CDC is supporting professional training and education to identify, treat, and refer victims of family and intimate violence. It is also developing monitoring systems that will reveal how often family and intimate violence occurs, who faces the greatest risk, and whether the problem is getting better or worse over time at national

76 and local levels. Other CDC projects include combining specific interventions into effective programs and increasing public recognition that domestic violence is unacceptable and that all individuals can take steps to prevent it.

National Hispanic Medical Association 1411 k Street, N.W. Suite 200 Washington DC 20005 Phone: 202-628-5895

The National Hispanic Medical Association works to address the issues and concerns of Hispanic medical faculty dedicated to teaching medical and health services research

National Indian Women’s Health Resource Center 328 E. Dowling Avenue Tahleguah, OK 74464 Phone: 918-456-2309

The National Indian Women’ s Health Resource Center is focused on improving Indian women’s health by assisting the efforts of tribes, urban, and Indian health Service Programs and to promote advocacy, policy development, appropriate research and encourage healthy lifestyle behavioral changes within a cultural context.

National Network on Behalf of Battered Immigrant Women 383 Rhone Island Street, # 304 San Francisco, CA 94103 Phone: 415-252-8900

The National Network on Behalf of Battered Immigrant Women is a broad-based coalition of more than four hundred organizations and individuals that advocate and provide services for immigrant victims of domestic violence

National Network to End Domestic Violence and the National Network Fund 66 Pennsylvania Avenue SE, # 303 Washington, DC 20003 Phone: 202-543-5566

The National Network to End Domestic Violence is a membership organization of state domestic violence coalitions. Their mission is to ensure that national public policy is responsive to the needs of battered women and their children, provide technical assistance and educate the public about issues concerning domestic violence.

National Resource Center on Domestic Violence 6400 Flank Drive, Suite 1300 Harrisburg, PA 17112-2778 1-800-537-2238

The National Resource Center, a project of the Pennsylvania Coalition Against Domestic Violence, is a source of comprehensive training, information, and technical assistance on community response to and prevention of domestic violence. Its primary goal is to proactively support the work of national, state, and local domestic violence programs. Particular emphasis is placed on enhancing organizational responsiveness to the needs pertaining to

77 communities of color and other comparatively underserved populations. Upon request, a list of videos, manuals, brochures, and posters is available.

National Rural Health Association One West Armour Blvd. Suite 203 Kansas City, MO 64111 Phone: 816-756-3140 www.nrharural.org

The National Rural Health Association is national membership organization whose mission is to improve the health and health care of rural Americans and to provide leadership on rural issues.

North Carolina State Bureau of Investigation P.O. Box 29500 3320 Garner Rd. Garner, NC, 27626 (919) 662-4500 http://sbi.jus.state.nc.us/sbimain/ncsbi.htm

The North Carolina State Bureau of Investigation provides kits to gather evidence of sexual assault. As soon as the evidence is collected, the kit should be sealed with tape and kept refrigerated until it can be given to law enforcement officials. The kit will then be sent to a state lab for analysis.

Physicians for a Violence-free Society San Francisco General Hospital San Francisco, CA 94110 Phone: (415) 821-8209 Fax: (415) 282-2363 www.pvs.org

Established in 1993 by two emergency room physicians, Physicians for a Violence-free Society is a national, non- profit organization of doctors, nurses, allied healthcare professionals, and other citizens concerned with reducing violence in our society. The organization is designed to support and train people in the medical profession to incorporate violence prevention and intervention into their medical practice. They raise awareness of violence- related issues as well, having been featured on CNN, ABC, and NBC and in The New York Times and the Journal of the American Medical Association. A publication list of relevant materials is available upon request.

Polaroid Corporation 784 Memorial Drive Cambridge, MA 02139 (781) 386-2000 1-800-811-5764 xL069 (ordering materials) www.polaroidwork.com/

Polaroid Corporation offers a discount purchase and training program aimed at professional healthcare membership associations to provide substantial price breaks on quantity purchases of Polaroid’s Spectra Camera Kits. These kits are used to document domestic violence injuries in the healthcare setting and are available through the company’s Association Program. In addition, Polaroid provides education and training materials (including a video on proper documentation techniques). This information can be obtained by either contacting the company directly or accessing their website.

78 Resource Center on Domestic Violence: Child Protection and Custody 1041 N. Virginia Street Reno, NV 89507 Phone: (775) 784-6012 www.ncjfcj.unr.edu

Operating through the National Council of Juvenile and Family Court Judges, this organization provides information and access to technical assistance to those involved in the area of domestic violence and child protection and custody. The Center also develops model policies, protocols, and programs that are sympathetic to the psychological, cultural, and legal dynamics of child custody cases involving family violence. A list of publications is available, and a video library provides tapes for loans or, in some cases, purchase.

Unidos Against Domestic Violence University of Wisconsin, School of Nursing Madison, Wisconsin 53792 Phone: 608-262-0051

Unidos Against Domestic Violence is a statewide organization that promotes education, technical assistance and advocacy for a culturally appropriate response to domestic violence in the Latino community and works towards elimination the barriers that Latino and migrant/seasonal farmworker families face in accessing DV services.

79 North Carolina Resources

Lesbian Health Resource Center P.O. Box 1589 Durham, NC 27702 (919) 956-9900 www.lesbianhealth.org

The Lesbian Health Resource Center is a grassroots, volunteer organization assisting lesbians and women who partner with women to obtain quality health information and services. As part of their Education & Outreach Program, the organization provides education and information about same-sex domestic violence.

North Carolina Council on Women 526 N. Wilmington Street 1320 Mail Service Center Raleigh, NC 27699-1320 Phone: (919) 733-2455 www.doa.state.nc.us/doa/cfw/welcome.htm

The North Carolina Council on Women is the official state advocacy agency for women and is a division of the N.C. Department of Administration. Overseeing state funding for domestic violence programs throughout the state, the Council disburses funds to programs that provide 24-hour crisis services, counseling and advocacy for victims, emergency transportation and shelter, and community education and referral. The organization maintains a list of domestic violence programs throughout North Carolina (available on the web page or by contacting the office directly).

North Carolina Coalition Against Domestic Violence 115 Market Street, Suite 400 Durham, NC 27701 (888) 232-9124

The NC Coalition Against Domestic Violence provides information and referral for the general public, the media, battered women and their children, agencies, and organizations throughout North Carolina.

Safe Dates UNC School of Public Health Campus Box 7400 Rosenau Hall Chapel Hill, NC 27599-7400 (919) 966-6353 Contact: Dr. Vangie Foshee

The Safe Dates Program aims to prevent adolescent dating violence through both primary and secondary prevention. Developed from a study on the prevention of dating violence, this program involves a comprehensive educational curriculum including a script for a student play, study guide, and exam. The program is designed to assist communities in addressing adolescent dating violence by serving as a model. Upon request, Safe Dates will provide the material of the program as well as tools to evaluate the process.

80 Web-Based Resources

American Academy of Pediatrics

The Academy of Pediatrics’ web page contains a model policy statement entitled “The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women.” www.aap.org/policy/re9748.html

American Bar Association Commission on Domestic Violence

This site offers both general information on domestic violence (statistics, myths, facts, etc.), as well as important legal information.

www.abanet.org/domviol.cdv.html

Battered Women and Their Children

This site offers information on the link between domestic violence and child abuse and neglect. Reports and training materials are provided on the subject, as well as resources for professionals interested in assisting their clients or patients. http://cwolf.uaa.alaska.edu/~afrhm1/index.html

Community United Against Violence Same Sex Domestic Violence

This site offers valuable information about same sex domestic violence, as well as links to other sites on the subject of gay and lesbian intimate partner violence.

www.xq.com/cuav/domviol.htm

Family Violence Prevention Fund (FVPF)

This site, sponsored by the FVPF national non-profit organization for domestic violence, provides easy access to information on domestic violence education, prevention and policy reform. This site also contains information specific to immigrant women who are battered.

www.fvpf.org

81 Gay Men’s Domestic Violence Project

The Gay Men’s Domestic Violence Project is a grassroots, non-profit organization providing community education on domestic violence in gay relationships. This site also offers links to other domestic violence resources targeting gay, lesbian and bisexual survivors.

www.gmdvp.org

Justice Information Center National Criminal Justice Reference Center

This site offers general information about domestic and family violence, including document lists and links to other violence-related sites. www.ncjrs.org/victdv.htm

Metro Nashville Police Department Domestic Violence Division

Extensive information available at this site on the warning signs of domestic violence, the progression of violence, the cycle of violence, the long term effects of abuse, and the characteristics of the battered and batterer. This site also offers information on how to make a safety plan.

www.telalink.net/~police/abuse/index.html

Nonviolent Alternatives Counseling Services

Nonviolent Alternatives is a private company offering services and information to men who batter. www.nonviolentalternatives.com

San Francisco Medical Society Online Library

The San Francisco Medical Society has developed a domestic violence brochure Designed to assist healthcare practitioners in offering assistance to patients experiencing abuse. Copies of the brochure can be requested by calling 415-561-0850. The brochure is also available on line. www.sfms.org/domestic.html

82 The Standard Times Shattered Love Broken Lives Domestic Violence Main Menu

This site contains more than 60 articles on domestic violence that the New Bedford Standard Times ran as a series in 1995. In addition to the articles, which cover a wide range of issues related to domestic violence, the site also provides a guide to domestic violence resources on the internet. www.s-t.com/projects/DomVio/

Stop Abuse For Everyone

Non-profit organization providing advocacy, information and support for men and women who experience domestic violence. This site focuses on men and women within both heterosexual and same-sex violent relationships. www.dgp.toronto.edu/~jade/safe/

US Department of Justice Violence Against Women Office

This site offers extensive information on resources, publications, legislation, and research on violence against women, including intimate partner violence. This site also offers links to other related Federal Government Web Sites. www.ojp.usdoj.gov/vawo

83

Appendix C.1 Patient Survey

We are troubled about the abuse that many women experience because it often leads to health problems. By abuse, we mean: (1) when women feel owned, controlled, or scared of their partner; (2) when their partner makes them feel unsafe in their own home; (3) when their partner hits them or hurts them physically or emotionally; or (4) when their partner forces them to have sex against their will. This abuse may not result in injuries and may not be seen as a crime. We would like you to complete this questionnaire so we can learn how to better respond to the needs of abused women. Please answer each question as honestly as possible. Your responses are anonymous. Your healthcare provider will not know how you respond.

1. Please darken with a pencil the one answer that best shows how you Yes No Don’t know feel or what you know a) Does the county you live in have a special agency that provides    services to victims of domestic violence? b) If yes to # 1 a) above, what is the name of that agency? ______c) Do you think your healthcare provider should ask his or her patients if   their partners are abusing them? d) Has any healthcare provider ever asked you if your partner was   abusing you? e) Were you asked today by your healthcare provider if your partner was   abusing you?

2. If your partner were abusing you, how comfortable would you feel talking about the abuse with your healthcare provider?

 Very comfortable  Somewhat comfortable  Not very comfortable  Not at all comfortable

3. Do you know somebody who is being abused by her partner?  Yes  No

4. Would you like to know more about how to help a woman being abused?  Yes  No

5. If you answered yes to # 4, would you like information on: Yes No a) How to help her and keep yourself safe?   b) How to help her find resources?   c) What she can and should expect from police response?   d) Why women often stay in a relationship with someone who hurts them?  

84 6. If your partner were abusing you, which of the following might keep you from Yes No talking to your healthcare provider about the abuse? a) I’d be afraid my partner would find out that I had told someone.   b) I’d be afraid other people I know might find out.   c) I’d be too embarrassed or ashamed.   d) I think my healthcare provider would blame me.   e) I think my healthcare provider wouldn’t believe me.   f) I think my healthcare provider wouldn’t care.   g) It wouldn’t do any good.   h) I think it’s too personal to talk about.   i) I think the staff here gossips about people’s personal business.   j) If I were pregnant I would be less likely to want to discuss it.  

7. Do you believe that healthcare providers should provide the following for women Yes No who have been abused by their partners? a) Treatment of injuries   b) Pain medicine/tranquilizers   c) Counseling   d) Information about domestic violence   e) Information of community resources   f) Legal information   g) Help finding shelter   h) Help with contacting the police   i) Help them find ways to reduce their stress  

8. How old are you? ______9. What county do you live in? ______

10. What is your race/ethnic group? (check all that apply)

White Black/African AmericanHispanic Native American Asian Other

Thank you for completing this survey. Appendix C.2

85 Clinician Survey

In this study, partner abuse is the physical, emotional and/or sexual abuse of women, aged 18 or older, by a current or former husband or boyfriend. It is also referred to as spouse abuse, domestic violence or battering.

Believ 1. Please fill in the circle next to the response that best indicates how much you agree or disagree with each statement: Agree Agree Disagree Disagree Strongly Somewhat Somewhat Strongly a. It is important for clinicians to communicate their concerns to patients they believe are being abused......     b. Substance abuse by the male partner is generally the underlying cause of domestic violence......     c. It is not reasonable to expect clinicians to address abuse in a clinical setting......     d. Men who abuse their partners are more likely to have an identifiable mental illness than men who do not abuse their     partners...... e. Clinicians should ask all women patients if they are being abused as part of a routine physical exam or history taking ......     f. If both partners had better communication skills domestic violence would not occur......     g. Addressing the needs of abused women is more the responsibility of nurses or social workers than of physicians......     h. Asking women about abuse allows me to more effectively treat abused women......     i. Asking women about abuse opens the door to time-consuming activities for which I won’t be reimbursed......     j. Asking women about abuse is frustrating because of the difficulty in effecting change in the women’s lives......     k. Asking about abuse is an intrusion into women’s lives......     l. Medical and hospital staff can identify most cases of abuse without specific training......     m. Abused women usually have more health problems than non-abused     women...... …………………………………….. n. Abusers would not be violent if they were not provoked......    

86 o. Victims of abuse could just leave the relationship if they really     wanted to......

p. Very few of my patients are abused…………………………..    

Respons 2. Clinician responsibilities when treating abused woman patient should include: Agree Agree Disagree Disagree Strongly Somewhat Somewhat Strongly

a. Talking with her about the abuse......    

b. Talking to the perpetrator about his violent behavior......    

c. Suggesting the woman seeks marital or couples counseling......    

d. Giving her information on community resources......    

e. Discussing her safety and helping her make a safety plan......    

f. Documenting the abuse in medical records with notes or photos    

g. Contacting the police......    

h. Suggesting she seek psychiatric help......    

Obstacles 3. Please circle the response that best indicates how much you agree or disagree that each of the following is an obstacle to your identification and treatment of abused women?

Agree Disagree Disagree Disagree Strongly Somewhat Somewhat Strongly

a. Lack of time………………………………     b. Lack of initiative from patient for help…..     c. Hc c. Not wanting to deal with legal issues…….     d. Do d. Don’t know where to refer patients………     e. Patient unwilling to disclose abuse………     f. Uncomfortable asking about abuse.....……     g. Lack of adequate training......     h. Lack of support from institution......     i. Concern for “false labeling”......    

87 j. Asking won’t change anything......     k. The intervention may increase violence.....     l. Lack of support from community………..     m. Domestic violence is not a health issue……………………………………….…     n. Fear of offending patient………………….    

Prepare 4. Please indicate how well prepared you are to:

Very Somewhat Somewhat Very Prepared Prepared Unprepared Unprepared

a. Ask women if they have been abused......     ` b. Counsel abused women patients......    

c. Document abused women’s injuries......    

d. Assist abused women in preparing a safety plan......    

e. Refer abused women to community resources......    

f. Gather the necessary information to identify how abuse may be contributing to the underlying cause of patients’ symptoms or illness (e.g., pain, depression)......    

g. Assess how abuse may interfere with patients’ abilities to comply with a healthcare plan......    

Outcomes 5. Outcomes that clinicians should expect from identifying and treating abused women include:

Agree Agree Disagree Disagree Strongly Somewhat Somewhat Strongly

a. Enabling them to leave their partners......    

b. Helping them improve their health status......    

c. Documenting the relationship between abuse and their injuries or illness......    

d. Letting them know that somebody cares about them......    

e. Helping them locate helpful community resources......    

88 f. Helping them remain safe......     g. A decrease in the violence......     h. A decrease in women’s use of healthcare services, including emergency room visits......    

Ask 6. Please indicate how frequently you ask patients about abuse:

Always Often Sometimes Rarely Never a. Ask all women patients once, usually first visit......      b. Ask all women patients more than once......      c. Ask all women patients with physical injuries......      d. Ask all women patients with symptoms other than physical injuries..     

Please specify symptoms that might lead you to ask about abuse:

______

If you circled NEVER to question 6a AND 6b AND 6c AND 6d please skip to question 11

NAbused 7. In the past 6 months about how many abused women patients have you cared for?______

Method 8. Please indicate how frequently you use each of the following methods to identify potentially abused women.

Always Often Sometimes Rarely Never

a. I assess the patient looking for “red flags” of psychic distress......     

b. In the context of taking a social history, I ask women about their relationships or how things are going at home......     

c. In the context of taking a social history, I ask women if they feel safe at home......     

d. Ask specific questions that directly ask about assault or abuse.     

Please write the questions you ask here.

89 ______

Effectiv 9. Do you think your method of asking about abuse identifies all, most, some, or few of the women who are actually abused? (Circle the best response)

all most some few    

10. For women you identify as abused, please indicate whether each of the following is part of the “usual care” you provide to these patients: No Yes Refer to domestic violence program   Do not know of one

Assess her risk of suicide  

Refer to couples counseling  

Refer to psychiatry or mental health  

Refer for substance abuse treatment  

Refer for pastoral care  

Refer to law enforcement  

Assess her risk of being killed by her partner   Do not know how to do this

Go over safety planning   Do not know how to do this

Provide educational materials   Do not have any

Document abuse in medical records  

Provide some counseling  

Encourage her to leave the abuser  

Tell her about community resources   Do not know about these

90 Talk about the relationship between abuse and health   Do not understand this

Talk to the abuser about his violent behavior  

Other (Please specify)______

Change 11. I ask women about abuse: (fill in):  more often than last year

 about the same as last year

 less often than last year

Contact 12. Do you find that the more contact you have with abused women patients that you are: (fill in the circle under the word that best describes your feelings):

(a) more frustrated or less frustrated.  

(b) more likely or less likely to continue to ask about abuse.  

(c) more inclined or less inclined to believe abuse is a problem that should be addressed by clinicians.  

13. Does your county currently have an agency that specifically serves victims of domestic violence?

Yes  No  Don’t know 

14. Does your organization have any specialized services for victims of domestic violence?

Yes  No  Don’t know 

15. There are a few things about you that will help us interpret this study. Please indicate your:

Medical Specialty: ______

Are you in private practice? Yes  No 

Do you have privileges at the healthcare organization? Yes  No 

Sex: Male  Female 

Race/ethnicity: White  African-American  Hispanic  Asian  Other ______

Current age ______

91 Marital Status Never married  Married  Separated  Divorced  Widowed 

Are you a: Physician  Physician’s Assistant/NP  Nurse  Social Worker 

Allied health professional  Other (please specify)______

THANK YOU SO MUCH FOR COMPLETING THIS QUESTIONNAIRE.

92

Appendix C.3 Healthcare Organization Assessment

Domestic violence team or task force Yes No Is there a domestic violence team or task force within the healthcare organization?   (If no, skip to “Policies…”) 

Does the domestic violence task force:  include staff from different departments?  

 include staff from different disciplines?  

 have goals and objectives?  

 meet on at least a monthly basis?  

Policies that support domestic violence prevention and intervention Yes No Are there policies that  define domestic violence as a priority for the organization?  

 require screening all female patients for domestic violence?  

 refer to protocols for identifying and assisting battered women?  

 assure that patients are seen alone at some point during their visits?  

 require domestic violence training for staff?  

 address safety of patients and staff from batterers?  

 respond to staff who are either domestic violence victims or batterers?  

 prohibit violence on the organization’s property?  

 prohibit concealed weapons on healthcare organization’s property?  

93 Domestic violence protocols Yes No Are protocols specific to domestic violence  officially adopted? (If no, skip to “Staff Training and Education”)  

 present in the ED in an official policy notebook?  

 present on in-patient floors in official policy notebook?  

 present in outpatient services?  

Do these protocols  meet JCAHO standards?  

 define domestic violence?  

 address screening?  

 address assessment?  

 address documentation?  

 address referral?  

 address follow-up?  

 define procedures for reporting to law enforcement and DSS?  

 define issues of confidentiality?  

 clearly state specific staff responsibility?  

94 Staff training and education Yes No Has clinical staff training been scheduled or been held within the past year? If   yes, which departments:

Has non-clinical staff training been scheduled or been held within the past year?   If yes, which departments:

Has training for the healthcare administration been scheduled or been held within the   past year?

Is staff mandated to attend domestic violence training?  

Is training held during paid working hours on all shifts?  

Is domestic violence training incorporated into new staff orientation?  

Are there other opportunities for staff to learn about domestic violence? If yes,   please describe.

Patient education Yes No Are brochures/pamphlets/posters on domestic violence displayed anywhere in the   healthcare organization? If yes, where?

Are resource cards or women’s health patient information sheets with domestic   violence resources offered to all female patients?

Is information on domestic violence included in health education classes? (e.g.   prenatal, childbirth) If so, which ones?

Is information on domestic violence exhibited at health fairs?  

95 Victims Services Yes No Are domestic violence “Pull Packets” readily available for staff when a victim of   domestic violence is identified?

Is there an on-site person with domestic violence expertise that clinicians can call   to provide services to battered women?

Is there 24-hour coverage for crisis intervention services?  

Are copying and mailing fees for medical records related to abuse waived for   battered women for legal proceedings?

Is there a respite room for victims of domestic violence that cannot go home or   cannot get to a shelter?

Data Collection Yes No Does the healthcare organization review medical records to determine  whether clinicians screen for domestic violence?  

 the number of domestic violence victims identified by clinicians?  

 whether domestic violence is appropriately documented?  

Does the healthcare organization collect demographic and abuse-related data on   identified domestic violence victims?

Community linkages Yes No Does the community have a domestic violence task force?  

If yes, is the healthcare organization on the task force?  

Does the healthcare organization:  collaborate with the local domestic violence program? (If so, describe.)  

 collaborate with other groups that serve battered women? (If so,   describe.)

 involve battered women or domestic violence advocates in planning and   provision of domestic violence-related activities? (If so, describe.)

96 Additional Organizational Assessment Questions

Healthcare organization staff Number Total number of staff Number of staff who are:  physicians  physician assistants/nurse practitioners  nurses  social workers  allied health (e.g. physical therapists, occupational therapists, nursing assistants, pharmacists, nutritionists)

Healthcare organization patients Number Total # of patients served in one year Total # of patient visits in one year # of patients who are:  in-patient  out-patient # of patients who are female  and 18 years old

Race/ethnicity of patients who are Percent female  and 18 years old  White  African-American/Black  Hispanic  Native American  Asian  Other

97 Counties served by % of patients from healthcare organization each county

 Community practices affiliated with healthcare organization

 Clinics/ departments where women patients are seen

98 Appendix C.4 Community Resources Assessment*

Women’s needs Services Provided by Service benefits/limitations

Housing/shelter Emergency shelter for women (with children?)

Transitional/long term housing for women (with children?)

Substance abuse Out-patient treatment treatment

Residential treatment for women (with children?)

Translation Foreign language translation services. Specify language(s)

Disability language translation services

Emergency needs Assistance with cash, food, clothing, household items, changing locks, utilities

Basic adult education/ literacy training

99 Women’s needs Services Provided by Service benefits/limitations

Transportation To shelter

To other services

Counseling 24-hour crisis line

Individual counseling

Career counseling

Legal Assistance Protective orders

Divorce/separation/custody

Batterer’s Programs in area Treatment

Support, Programs in area Therapy, and Education

*Adapted from “Responding to Domestic Violence: A Guide for Local Health Departments.” North Carolina State Department of Environment, Health and Natural Resources. May 1996.

100 Appendix D

Patient Data: Background & Identifying Information

Medical Record Number ______Date of Interview ______Length of Interview (minutes) ______

Last Name______First Name______Street Address______City______State______Zip______Phone (h)______(w)______Safe to Contact? Yes No If yes, when is it safe to call?______

Referral Source______Referral Title______Referral Service______

General Information Age (in years) ______Sex Male____ Female____ Race ______Date of Birth ______Marital Status ______Length of Relationship (in years) ______Insurance ______Inpatient or Outpatient Inpatient_____Outpatient____ Number of Children ______Trauma or Non-Trauma Trauma____Non-Trauma____ Past Domestic Violence Yes______No______Present Domestic Violence Yes______No______Follow-up Yes______No______Number of Follow-up Contacts ______Type of Referral ______Referred to______Notes______

101

Appendix E

Legal Issues for Healthcare Providers*

Many healthcare providers express concern about their lack of knowledge of legal issues for victims of domestic violence. Undoubtedly, many victims are also unaware of the legal options available to them. In every case, healthcare providers can best serve victims by urging them to seek legal counsel with a professional or to call a domestic violence program or women’s organization. Specific procedures, policies and laws vary throughout North Carolina and change often; therefore, professional legal counselors and advocates in domestic violence programs can discuss current alternatives with victims appropriately. However, providers may want to have very basic information about the legal options available to victims of domestic violence (note: the following is based on information current at time of printing only and is subject to change).

Laws Affecting Victims of Domestic Violence

North Carolina has civil and criminal laws that protect and assist battered women. A victim of domestic violence may pursue either civil or criminal proceedings, or both, depending on her needs.

Civil Laws The North Carolina Domestic Violence Act, enacted in 1979, informs batterers that the consequences of their actions are great, and that they have much to lose by resorting to violence. The act provides domestic violence victims and law enforcement officers with options that were not previously available. It also contains provisions expanding the arrest powers of officers responding to domestic violence and mandates the action of law enforcement personnel in specific situations. In addition, it enables domestic violence victims to receive protective orders.

* Developed by Jan Capps, Concerned America and V. Hudson Fuller, University of North Carolina, School of Law.

102 Domestic Violence Protective Orders

Domestic Violence Protective Orders (DVPO) issued by a judge may be granted for a fixed period of time, not to exceed one year. A DVPO may contain one, or a combination of, the following provisions:

Prohibit abusive behaviors. . Order the batterer not to assault, threaten, abuse, follow, harass or interfere with the victim or her children either in person or on the telephone.

. Order the batterer to stay away from the victim’s home, workplace, school, the children’s school and daycare, and any place where the victim may seek shelter.

. Prohibit the batterer from purchasing or possessing a firearm.

Provide for financial security and custody of property and children. . Require the batterer to pay his partner’s legal costs and attorney’s fees.

. Order the batterer to move out and not return to the home.

. Provide the victim and her children with suitable housing.

. Give the victim possession of personal property (i.e., clothing, household goods, etc.).

. Give the victim possession and use of the car.

. Give the victim custody of the minor children and order the batterer to pay child support.

. Order the batterer to provide temporary financial support to the victim.

A victim can seek a DVPO if her partner threatens to kill her, threatens her with a weapon, beats, strikes, or injures her, engages in any other behavior that puts her in fear, or does any of these things to her children. A victim may obtain a DVPO without the assistance of an attorney and most domestic violence programs can help victims with the process. While DVPO’s historically were only granted to victims who were living with or married to their abusive partner, the law has recently been expanded to include heterosexual dating partners who have never lived together and household members (this recent amendment now makes it possible for victims who are in same-sex relationships, who have lived with their partner, to also obtain a DVPO).

103 Once a DVPO has been granted, a batterer can be charged with a crime if he enters the victim’s home or threatens her after being ordered not to do so. The victim should keep a copy of the protective order with her at all times, should keep copies at her home and at her workplace, and should be sure her local sheriff or police department has a copy. If the batterer violates the order, the victim should call the sheriff or police immediately to tell them that the batterer is violating the DVPO, and that they need to come to arrest him.

Criminal Laws If a victim is assaulted or threatened, she may press criminal charges against the batterer even if there is no protective order in place. These charges will be prosecuted by the State of North Carolina through the local District Attorney’s office. The following are possible criminal charges that can be brought against the batterer:

. Simple assault . Felonious assault with a deadly weapon with intent to kill and/or inflict serious injury . Assault by pointing a gun intentionally, whether in fun or not, and whether loaded or not . Discharging a firearm into occupied property . Assault on a female by hitting or by a show of violence . Communicating a threat to physically injure the person or property of another . Misdemeanor assault, battery or affray . Harassing phone calls . Domestic criminal trespass . Stalking . Purchase or attempted purchase of a firearm in violation of a protective order

To start a criminal proceeding, the victim must report the crime to the police as soon as possible. If there is a DVPO in place and the police have probable cause to believe that the batterer has violated it (or if they witnessed the assault), then they are required to make an arrest. If a DVPO is not in place, then the police may arrest without a warrant, but may also require the victim to go to the magistrate’s office to swear out a warrant. Although some police jurisdictions do have pro-arrest policies that require them to make an arrest when they believe a crime has

104 been committed, some jurisdictions do not. A victim should call the police if she is being abused and if she can do so without further endangering herself.

Advantages Disadvantages Civil  Resolve issues such as possession of  Costly if the woman hires an attorney Proceedings property and child custody  Batterer will not be imprisoned or have  Less evidence required criminal record Criminal  May punish the batterer  Woman could be charged with frivolous Proceedings  May order treatment for his behavior prosecution if she drops the charges  May give the batterer a record  Evidence is more closely scrutinized

Collecting Evidence for Criminal or Civil Proceedings

In a judicial proceeding, the judge’s decision is often based only on the testimony of the victim and the batterer. A healthcare provider can play an important role in legal proceedings by providing evidence on the victim’s behalf and may be subpoenaed to testify in court for either civil or criminal proceedings. A well documented and legible (typed, if possible) medical record may help reduce the time the provider is required to spend in judicial proceedings. The American Medical Association recommends the medical record include:

. the chief complaint in the victim's words . description of the abusive event . medical history . relevant social history . detailed description of the injuries (location, size, etc.) . opinion on whether the injuries were adequately explained . results of the laboratory and other diagnostic procedures . any color photographs and imaging studies . names of the police involved.

In documenting domestic violence cases, objective facts are always more helpful than subjective opinions.

105 Healthcare Providers’ Legal Obligations

Since addressing domestic violence is a new role for many healthcare providers, many may be confused about their legal obligations. It is always advisable to seek legal counsel with regards to specific cases of domestic violence. However, the following information may prove helpful:

. Reporting requirements for domestic violence. There is no law requiring healthcare providers to report domestic violence. Healthcare providers may be held liable for breach of patient confidentiality if abuse is reported without the victim's permission. Unauthorized reporting also sends a message to the victim that the healthcare setting is not a safe place and may discourage her from seeking medical treatment in the future. Most domestic violence advocates oppose mandatory reporting of battered women to law enforcement agencies without the victim’s consent.

. Reporting requirements for child abuse. North Carolina General Statute provides that any person or institution that has cause to suspect any child under the age of 18 is being abused or neglected by a parent, guardian or residential caretaker SHALL report the case to the local Department of Social Services. (NCGS 7B-301). This statutory requirement of all persons overrides patient-doctor privilege. However, the provider should keep in mind that if a child is being abused or exploited by someone other than a parent or guardian, then the doctor is not required to report it, may be violating the patient-doctor confidentiality by doing so, and is not protected from liability under the same statute. An example of this is where a fifteen year old girl admits to being physically abused by her boyfriend. The boyfriend is not a parent or a guardian under the statute and therefore this is not child abuse under the statute.

. Reporting requirements for abused disabled adults/elders. North Carolina General Statute provides that any person having reasonable cause to suspect that a disabled adult is in need of protective services SHALL report such information to the local Department of Social Services. (NCGS 108A-102). The words “disabled adult” shall mean any person 18 years of age or over who is physically or mentally incapacitated.

. Reporting Criminal Acts -- North Carolina General Statute 90-21.20 requires physicians to report serious injuries resulting from criminal acts of violence, but there are some visible injuries requiring medical treatment that do not fall within the reporting requirements of this statute. The statute states that physicians are required to report:

Cases of wounds, injuries, or illnesses (that) include every case of a bullet wound, gunshot wound, powder burn or any other injury arising from or caused by, or appearing to arise from or be caused by, the discharge of a gun or firearm; every case of illness apparently caused by poisoning; every case of a wound or injury caused, or apparently caused by, a

106 knife or sharp or pointed instrument if it appears to the physician or surgeon treating the case that a criminal act was involved; and every case of a wound, injury, or illness in which there is grave bodily harm or grave illness if it appears to the physician or surgeon treating the case that the wound, injury, or illness resulted from a criminal act of violence.

Some clinicians may be concerned about liability in helping domestic violence victims. However, as of May 1995, representatives of both the American Medical Association and the American Trial Lawyers Association were unaware of any lawsuits in which a healthcare provider has ever been sued for not responding appropriately to a case of domestic violence. However, healthcare professionals should be aware of the potential for negligence liability if they fail to identify domestic violence and, thereafter, if they fail to properly treat and refer the patient. In most medical negligence cases, the patient must show the healthcare provider failed to exercise the degree of care that a reasonably prudent provider would have practiced in the same specialty in a similar community.

107 Appendix F

Consent to Photograph*

The undersigned hereby authorizes______(Name of Agency) and the attending physician to photograph or permit other persons in the employ of this facility to photograph______(Name of Patient) while under the care of this facility, and agrees that the negatives or prints shall be stored in the patient's medical record (sealed in a separate envelope so that they may be used later for evidence). These photographs will be released only to the police or the prosecutor when the undersigned gives permission to release the medical records. The undersigned does not authorize any other use to be made of these photographs.

Date ______

Patient's Signature ______

Witness ______

Patient's Parent or Legal Guardian______

Street Address______

City______State______Zip Code______

*Adapted from “Responding to Domestic Violence: A Guide for Local Health Departments.” North Carolina State Department of Environment, Health and Natural Resources. May 1996.

108

Appendix G Danger Assessment*

Several risk factors have been associated with homicides (murders) of both batterers and battered women in research conducted after the murders have taken place. We cannot predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of severe battering and for you to see how many of the risk factors apply to your situation. Using the calendar, please mark the approximate dates during the past year when you were beaten by your husband or partner. Write on that date how bad the incident was according to the following scale (If any of the descriptions for the higher number apply, use the higher number):

1. Slapping, pushing; no injuries and/or lasting pain 2. Punching, kicking; bruises, cuts, and/or continuing pain 3. "Beating up"; severe contusions, burns, broken bones 4. Threat to use weapon; head injury, internal injury, permanent injury 5. Use of weapon; wounds from weapon

Mark Yes or No for each of the following: ("He" refers to your husband, partner, ex-husband, ex- partner, or whoever is currently physically hurting you.)

____ 1. Has the physical violence increased in frequency over the past year? ____ 2. Has the physical violence increased in severity over the past year and/or has a weapon or threat from a weapon ever been used? ____ 3. Does he ever try to choke you? ____ 4. Is there a gun in the house? ____ 5. Has he ever forced you to have sex when you did not wish to do so? ____ 6. Does he use drugs? By drugs, I mean "uppers" or amphetamines, speed, angel dust, cocaine, "crack", street drugs or mixtures. ____ 7. Does he threaten to kill you and/or do you believe he is capable of killing you? ____ 8. Is he drunk every day or almost every day? (In terms of quantity of alcohol.) ____ 9. Does he control most or all of the your daily activities? For instance: does he tell you whom you can be friends with, how much money you can take with you shopping, or when you can take the car? (If he tries, but you do not let him, check here: ____) ____ 10. Have you ever been beaten by him while you were pregnant? (If you have never been pregnant by him, check here: ____) ____ 11. Is he violently and constantly jealous of you? (For instance, does he say "If I can't have you, no one can.") ____ 12. Have you ever threatened or tried to commit suicide? ____ 13. Has he ever threatened or tried to commit suicide? ____ 14. Is he violent toward your children? ____ 15. Is he violent outside of the home?

_____ Total "Yes" Answers

*Jacquelyn C. Campbell, Ph.D., R.N. Copyright 1985, 1988.

109 References for Danger Assessment

Campbell, J. (1986). Nursing assessment for risk of homicide with battered women. Advances in Nursing Science, 8, 36-51.

Campbell, J. & Humphreys, J. (1993). Nursing care of survivors of family violence. St. Louis: Mosby.

Campbell, J. (1995). Assessing dangerousness. Newbury Park: Sage.

Campbell, J. & Soeken, K. (1999). Forced sex and intimate partner violence: Effects on women's health. Violence Against Women, 5, 1017-1035.

Campbell, J. (1992). "If I can't have you, no one can": Power and control in homicide of female partners. In J.Radford & D. E. H. Russell (Eds.), Femicide: The politics of woman killing (pp. 99- 113). New York: Twayne.

Campbell, J., Sharps, P., & Glass, N. (2000). Risk Assessment for intimate partner violence. In G.F.Pinard & L. Pagani (Eds.), Clinical Assessment of Dangerousness: Empirical Contributions ( New York: Cambridge University Press.

Goodman, L. A., Dutton, M. A., & Bennett, M. A. Predicting repeat abuse among arrested batterers: Use of the danger assessment scale in the criminal justice system. Journal of Interpersonal Violence (in press).

McFarlane, J., Parker, B., & Soeken, K. (1995). Abuse during pregnancy: Frequency, severity, perpetrator, and risk factors of homicide. Public Health Nursing, 12, 284-289.

McFarlane, J., Soeken, K., Campbell, J., Parker, B., Reel, S., & Silva, C. (1998). Severity of abuse to pregnant women and associated gun access of the perpetrator. Public Health Nursing, 15, 201-206.

McFarlane, J., Campbell, J. C., Wilt, S., Sachs, C., Ulrich, Y., & Xu, X. (1999). Stalking and intimate partner femicide. Homicide Studies, 3, 300-316.

Roehl, J. & Guertin, K. (1998). Current use of dangerousness assessments in sentencing domestic violence offenders Pacific Grove, CA: State Justice Institute.

Stuart, E. P. & Campbell, J. C. (1989). Assessment of patterns of dangerousness with battered women. Issues Mental Health Nursing, 10, 245-260.

Websdale, N. (1999). Understanding domestic homicide. Boston: Northeastern University Press.

Weisz, A., Tolman, R., & Saunders, D. G. Assessing the risk of severe domestic violence: The importance of survivor's predictions. Violence & Victims (in press).

110 Appendix H

Safety Plan I*

The following suggestions may be helpful in developing your safety plan.

When Preparing to Leave: . Decide where you will go when you leave. . Make arrangements before you leave for a place of refuge. Determine who would be able to let you stay with them or lend you money. If possible, do not stay with a male friend. This may be used against you in divorce or child custody proceedings. . Open a savings account and/or a credit card in your own name. . Agree upon a coded message with friends and family to signal your departure. . Rehearse departure with your children. . Plan to depart at a time when the batterer is not present in the home. . Hide money, an extra set of house and car keys, and a bag with extra clothing. . Have available the following items:

 Social Security Numbers (his, yours and the children’s)  Rent and Utility Receipts  Birth Certificates (yours and the children’s)  Drivers License  Bank Account #’s, checkbook, ATM card  Insurance Policies  Marriage License  Valuable Jewelry  Important Telephone Numbers

To Protect Yourself During Violent Incidents: . In the event of an argument, try to stay away from anywhere where weapons might be available and try to stay in a room or area where you have access to an exit. . Confide in a neighbor about your problem with domestic violence. Ask the neighbor to call the police if violence begins. . Remove weapons from the house. . Advise children to stay out of the conflict and instruct them in ways of contacting police. . Devise a code word to use with your children, family, friends, and neighbors when you need the police.

*Adapted from “Responding to Domestic Violence: A Guide for Local Health Departments.” North Carolina State Department of Environment, Health and Natural Resources. May 1996.

111 Safety in your home: . Change the locks on your doors as soon as possible after he leaves. Buy additional locks and safety devices to secure your windows. . Discuss a safety plan with your children for times when you are not with them. . Inform your neighbors and landlord that your partner no longer lives with you and that they should call the police if they see him near your home.

Safety in the workplace and in public places: . Inform your children’s school or day care about who has permission to pick them up. . Inform someone at work about your situation, including office or building security. Provide a picture of the batterer, if possible. . Arrange for a co-worker or answering machine to screen your telephone calls. . Leave your workplace in the company of a co-worker. . Use a variety of routes to go home. . Change the time when you shop and choose different stores and banks.

112 Appendix I Safety Plan II*

Name: ______

Date: ______Review dates: ______

Personalized Safety Plan

The following steps represent my plan for increasing my safety and preparing in advance for the possibility for further violence. Although I may not have control over my partner's violence, I do have a choice about how to respond to him/her and how to best get myself and my children to safety.

Step 1: Safety during a violent incident. Women cannot always avoid violent incidents. In order to increase safety, women may employ a variety of strategies.

I can use some or all of the following strategies:

A. If I decide to leave, I will ______. (Practice how to get out safely. What doors, windows, elevators, stairwells or fire escapes would you use?).

B. I can keep my purse and car keys ready and put them (place) ______in order to leave quickly.

C. I can tell ______and ______about the violence and request they call the law enforcement (911) if they hear suspicious noises coming from my house.

D. I can teach my children how to use the telephone to contact the law enforcement (911) and the fire department. My local fire department number is ______.

E. I will use ______as my code word with my children or my friends so they can call for help.

F. If I have to leave my home, I will go ______. (Decide this even if you don't think there will be a next time.)

G. I can also teach some of these strategies to some/all of my children.

*Adapted from “Personalized Safety Plan,” Office of the City Attorney, City of San Diego, California, April, 1990.

113 H. When I expect we are going to have an argument, I will try to move to a space that is lowest risk, such as ______. (Try to avoid arguments in the bathroom, garage, and kitchen, near weapons or in rooms without access to an outside door.)

I. I will use my judgment and intuition. If the situation is very serious, I can give my partner what he/she wants to calm him/her down. I have to protect myself until I/we are out of danger.

Step 2: Safety when preparing to leave. Women frequently leave the residence they share with the battering partner. Leaving must be done strategically in order to increase safety. Batterers often strike back when they believe that a woman is leaving a relationship.

I can use some or all of the following safety strategies:

A. I will leave money and an extra set of keys with ______so I can leave quickly.

B. I will keep copies of important documents or keys at ______.

C. I will open a savings account by ______to increase my independence.

D. Other things I can do to increase my independence include: ______.

E. The domestic violence program's crisis line number in my area is ______. I can seek shelter, help in court, emotional support, and referrals to community resources by calling this crisis line.

F. I can keep change for phone calls on me at all times. I understand that if I use my telephone credit card, the telephone bill the following month will tell my batterer those numbers that I called after I left. To keep my telephone communications confidential, I must either use coins or I might get a friend to permit me to use their telephone credit card for a limited time when I first leave.

G. I will check with ______to see who would be able to let me stay with them or lend me some money.

H. I can leave extra clothes with ______.

I. I will sit down and review my safety plan every ______in order to plan the safest way to leave the residence. ______(domestic violence advocate, friend, or relative) has agreed to help me review this plan.

J. I will rehearse my escape plan, and as appropriate, practice it with my children.

Step 3: Safety in my own residence. There are many things that a woman can do to increase her safety in her own residence. It may be impossible to do everything at once, but safety

114 measures can be added step by step.

Safety measures I can use include:

A. I can change the locks on my doors and windows as soon as possible.

B. I can replace wooden doors with steel/metal doors.

C. I can install security systems including additional locks, window bars, poles to wedge against doors, and electrical system, etc.

D. I can purchase rope ladders to be used for escape from second floor windows.

E. I can install smoke detectors and purchase fire extinguishers for each floor in my house/apartment.

F. I can install an outside lighting system that lights up when a person is coming close to my house.

G. I can teach my children how to use the telephone to make a collect call to me and to ______(friend/minister/family member/other) in the event that my partner abducts the children.

H. I can call my local telephone company and ask that my phone number be changed to an unlisted number.

I. I will tell people who take care of my children exactly which people have permission to pick up my children and that my partner is not permitted to do so. The people I inform about pick-up permission include:

______(school) ______(day care staff) ______(baby sitter) ______(relative) ______(teacher), and ______(others)

J. I can inform ______(neighbor), ______(pastor), and______(friend) that my partner no longer resides with me and they should call law enforcement (911) if he is observed near my residence.

Step 4: Safety with a Domestic Violence Protective Order (DVPO, also know as a 50B Order or Restraining Order). Many batterers obey DVPO's, but one can never be sure which violent partner will obey and which will violate DVPO's. I recognize that I may need to ask law

115 enforcement and the courts to enforce my DVPO. The following are some steps that I can take to help enforce my Domestic Violence Protective Order:

A. I will keep a copy of my DVPO ______and ______(locations). (Always keep a copy of your DVPO on or near your person. If you change purses, that's the first thing that should go in. Always keep a copy at home and at work.)

B. I will give a copy of my DVPO to law enforcement agencies (including police departments and sheriffs departments) in the county where I live and in the county where I work.

C. I will give a copy of my DVPO to ______, ______, and ______. (Always give a copy to all people and/or places that the abuser has been ordered to stay away from, i.e. Day care centers, schools, churches, family residences, etc.)

D. There should be a county registry of DVPO's that all law enforcement agencies can call to confirm the validity of the DVPO. I can check to make sure that my order is in the registry. The telephone number for my county registry of DVPO's is ______.

E. For further safety, if I often visit other counties in my state where family and friends live, I will register my DVPO in the following counties ______, ______and ______.

F. I can call the local domestic violence program if I am not sure about B, C, D or E above.

G. I will inform my employer, my minister, and my closet friend and______that I have a DVPO in effect.

H. If my partner destroys my DVPO; I can get another copy from the Civil Clerk's office at the courthouse located at ______.

I. If my partner violates the DVPO, I should call law enforcement (911) immediately to report the violation. (If law enforcement finds the abuser near you, they should arrest him immediately. Show them a copy of your DVPO.)

J. If my partner violates the DVPO, I can file a Motion to Show Cause in District Court with the Civil Clerk of Court located at ______.

I can also charge the abuser for all the crimes he commits in violating the order by going to the Criminal Magistrates' office located at______.

K. If law enforcement does not help, I can contact my domestic violence advocate or attorney, who can help me file a complaint with the police department or sheriff's department.

Step 5: Safety on the job and in public. Each woman must decide if and when she will tell others that her partner has abused her and that she may be at continued risk. Friends, family and

116 co-workers can help to protect women. Each woman should consider carefully which people to invite to help secure her safety.

I might do any or all of the following:

A. I can inform my boss, the security supervisor and ______at work of my situation.

B. I can ask ______to help screen my telephone calls at work.

C. When leaving work, I can ______.

D. When driving home, if problems occur, I can______.

E. If I use public transit, I can ______.

F. I can use different grocery stores and shopping malls to conduct my business and shop at hours that are different than those when residing with my battering partner.

G. I can also ______.

Step 6: Safety and drug or alcohol consumption. Most people in this culture consume alcohol. Many consume mood-altering drugs. Much of this consumption is legal and some is not. The legal outcomes of using illegal drugs can be very hard on a woman experiencing domestic violence, may hurt her relationship with her children, and put her at a disadvantage in other legal actions with her battering partner. Furthermore, the use of alcohol or other drugs by the batterer may give him/her an excuse to use violence. Therefore, in the context of drug or alcohol consumption, a woman needs to make specific safety plans.

If drug or alcohol consumption has occurred in my relationship with the battering partner, I can enhance my safety by some of the following:

A. If I am going to consume, I can do so in a safe place and with people who understand the risk of violence and are committed to my safety. (Not applicable to women recovering from alcohol or other drug addiction.)

B. I can also ______.

C. If my partner is consuming, I can ______. D. I might also ______.

E. To safeguard my children, I might ______.

Step 7: Safety and my emotional health. The experience of being battered and verbally degraded by partners is usually exhausting and emotionally draining. The process of building a

117 new life for myself takes much courage and incredible energy.

To conserve my emotional energy and resources, and to avoid hard emotional times, I can do some of the following:

A. If I feel down and ready to return to a potentially abusive situation, I can ______.

B. When I have to communicate with my partner in person or by telephone, I can______.

C. I can try to use "I can..." statements with myself and to be assertive with others.

D. I can tell myself,"______" whenever I feel others are trying to control or abuse me.

E. I can read ______to help me feel stronger.

F. I can call ______, ______, and ______as other resources to be of support to me.

G. Other things I can do to help me feel stronger are ______and ______.

H. I can attend workshops and support groups at the domestic violence program or ______or ______to gain support and strengthen my relationships with other people.

Step 8: Items to take when leaving. When women leave partners, it is important to take certain items with them. Beyond this, women sometimes give an extra copy of papers and an extra set of clothing to a friend just in case they have to leave quickly.

118 When I leave, I should take: Important Telephone Numbers

 Identification for myself Domestic violence crisis line ______County registry of DVPO's______ Children's birth certificates Criminal Clerk of Court ______ My birth certificate Supervisor's home number______ Social Security cards Minister ______ Money, Checkbook, ATM card, Credit Civil Clerk of Court ______cards District Attorney______ Keys: house, car, office, Magistrate's office______Others ______ Medications  Welfare identification  Work permits and/or Green card  Passport(s)  Divorce papers  Bank book and statements  Insurance papers  Address book  Pictures  Jewelry  Items of special sentimental value  Medical records - for all family members  Lease/rental agreement, house deed,  mortgage payment book  School and vaccination records  Children's favorite toys and/or blankets  Driver's license and registration

119

Appendix J

Body Map* Instructions: For each separate injury, check the type of injury in the space provided. Draw an arrow from the description of each injury to the actual location on the body.

Injury 1 Injury 2 Injury 3

Cuts___Punctures______Cuts___Punctures______Cuts___Punctures______Bites___Abrasions______Bites___Abrasions_____ Bites___Abrasions_____ Bruises___Bleeding____ Bruises___Bleeding____ Bruises___Bleeding____ Burns___Dislocations___ Burns___Dislocations___ Burns___Dislocations___ Bone Fractures______Bone Fractures______Bone Fractures______Notes______Notes______Notes______

*Adapted from Helton, AS. Protocol of Care for the Battered Woman. (1987). March of Dimes Birth Defects Foundation.

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