Intimate Partner Violence Screening and Referral Practices in an Outpatient Care Setting

Abstract

Health care providers who screen for intimate partner violence (IPV) and counsel patients can reduce victimization and positively impact women’s health and well-being; yet only 2% to 50% of medical professionals report routinely screening female patients. The purpose of this study was to identify current practices, policies, barriers, and opportunities for a coordinated and routinized response to IPV in an outpatient academic primary care clinic. Data were collected through interviews and the Physician Readiness to Manage Intimate Partner Violence questionnaire. Data on IPV screening practices over a 5-month period were also available through the electronic health record. Study participants expressed that there was no uniform method of documenting screening results and great variability in the patient populations and circumstances that prompted screening. Over two thirds of the survey respondents reported either a lack of IPV protocol or a lack of knowledge about one if it existed. Providers and staff who participated believed it was within their scope of work to screen for IPV and recognized IPV as a serious health threat; however, they cited an absence of patient education resources, a lack of staff training and awareness, and no established IPV referral network as barriers to screening for IPV. The results of the pilot are in line with existing research highlighting a general lack of screening, variability in process, and the absence of systems-level policies and protocols and linkages to community resources. Pilot findings have been used to initiate a project which encompasses routinized screening, documentation, and care coordination between providers and community organizations to improve patient well-being.

Keywords

domestic violence intimate partner violence health care screening

Background

Intimate partner violence (IPV) affects one in three women in the United States (Breiding, Chen, & Black, 2014). IPV is associated with high medical care costs, high rates of health service utilization (Bonomi, Anderson, Rivara, & Thompson, 2009; Rivara et al., 2007), and substantial physical and mental health consequences (Michele C. Black, 2011). Increasingly, researchers have shown that health care providers who screen for IPV and counsel patients can reduce victimization and positively impact women’s health and well-being, although the evidence is not unequivocal (Moyer, 2013; O’Doherty et al., 2014). Still, the U.S. Preventive Services Task Force (Moyer, 2013) and the Institute of Medicine (2011) recommend screening and counseling in health care settings for women of childbearing age.

Despite recommendations to screen and counsel for IPV in the health care setting and the fact that coverage of these services is part of the Patient Protection and Affordable Care Act (Health Resources and Services Administration, 2012), only 21% of females report disclosing IPV to a health care provider (M.C. Black et al., 2011) and only 2% to 50% of medical professionals report routinely screening female patients (Alvarez, Fedock, Grace, & Campbell, 2017), although selective screening rates are higher (45%-85%) (Alvarez et al., 2017). Systematic reviews highlight common barriers including lack of privacy, time, reimbursement, training, protocols, and response options, as well as discomfort with the issue, fear of offending patients, and perceptions that such inquiry is outside their scope of work (Alvarez et al., 2017; Sprague et al., 2012). Patients, on the other hand, are generally open to the inquiry (Todahl & Walters, 2011).

To shed light on current practices and identify potential gaps with recent guidelines, the authors undertook a pilot study (October 2014-May 2015) examining IPV screening, response, and referral practices in an outpatient academic primary care clinic, which is part of a large multi-specialty tertiary health care system. The objective was to identify current practices, policies, barriers, and opportunities for a coordinated and routinized response to IPV in the outpatient health setting in preparation for a subsequent implementation research project. We applied the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) to the findings as a formative evaluation of clinic readiness to adopt a formal intervention focused on screening and responding to adult IPV and to provide an understanding of issues likely to be encountered when scaling up to other clinics in the system.

Method

The pilot study utilized an exploratory sequential mixed methods design (Fetters, Curry, & Creswell, 2013) including interviews with key clinic personnel to ascertain current policies and practices related to screening, response, and documentation of IPV followed by the administration of a knowledge, attitude, and behavior survey to clinic health care providers (physicians, nurses, and medical assistants). Although not originally intended, an assessment of IPV screening practices over a 5-month period using data from the electronic health record (EHR) was also possible because universal screening of all adult patients became a clinic initiative prior to the conclusion of the pilot study.

Setting

The study took place in one academic university hospital-based primary care clinic in an urban Midwest setting with a mix of Internal Medicine, Family Medicine, and Internal Medicine-Pediatrics board certified physicians and nurse practitioners. The clinic is of medium size with 23 providers, though most of these providers work on a part-time clinical schedule. It is a member of a large specialty and quaternary referral driven multi-practice facility and its policies and practices serve as a window into this wider network. At the time of the study, the practice was preparing to move into a new facility where standardized intake processes and patient flows were to become the norm. Focusing the pilot in the Primary Care Clinic was an ideal opportunity to begin to build an essential relationship as well as to obtain information needed to support the development of a future practice-wide approach. The patient population served includes a diverse mix of insured, underinsured, and uninsured patients of varied socioeconomic, educational, and cultural backgrounds from across the state that receive both primary and specialty care within the organization.

Sample

Health care providers and staff who served in roles pertinent to screening and responding to IPV survivors were the targets of semistructured quality interviews. Interviewees included the clinic nurse manager, the clinic medical director, a licensed practical nurse, and a social worker whose experience collectively would be useful to ascertaining the potential for a health care team approach to identification and response. Twenty-three health care providers and staff (65% female, 48% providers [physician/nurse practitioner], 52% staff [nursing/medical assistant]) completed a knowledge, attitudes, and behaviors survey. The surveys were distributed to all available clinical staff over a 3-week period and collected anonymously and voluntarily, yielding a response rate of approximately 38% among providers and 75% among medical staff. EHR data of all adult (18+) patient encounters between January and May 2015 (N = 9,044) were retrieved from the university’s Clinical Data Repository which stores patient demographics, health-related information (e.g., medical history), and visit related information (e.g., tests, screens) for all patients seen at this clinic.

Measures

The clinic nurse manager completed the Agency for Healthcare Research and Quality’s Delphi Instrument for Hospital-Based Domestic Violence Programs (Coben, 2002) to assess the clinic’s institutional response to IPV. The nurse manager was subsequently interviewed again, in addition to the social worker, practical nurse, and clinic director to examine (a) general roles and responsibilities; (b) perceptions of screening in relation to their/their staff’s scope of work; (c) policies, protocols, and resources available to support screening and survivor support; and (d) prior experience supporting an IPV survivor. Health care providers self-administered the Physician Readiness to Manage Intimate Partner Violence questionnaire (Short, Alpert, Harris, & Surprenant, 2006), which inquired about the provider’s knowledge, opinions, and practices related to the identification and response to IPV survivors in their clinic settings. EHR elements retrieved for this analysis include patient sex, date of the encounter, and all three screening items including “Are you safe at home?” “Are you safe in your relationship?” and “Have there been any threats or direct abuse to you or your children?” Response choices for each item included “yes,” “no,” and “did not ask.” A screen was considered to have occurred if a “yes” or a “no” response was recorded in the EHR. The screening rate was calculated as the total number of administrations divided by the total number of encounters.

Analysis

The data were analyzed separately and sequentially, but iteratively to allow insights from one data source to inform inquiry in the others. Interpretation and reporting of findings is accomplished by weaving findings from all sources together into key themes (Fetters et al., 2013). Thematic analysis (Boyatzis, 1998) was used to identify key themes in the interview data. All authors read and identified key concepts for the codebook and one author generated memos to document and facilitate the analytic process. Two research assistants repeated the process, adding to and adjusting the codebook as needed. The final codebook was approved by the first author, and one of the research assistants applied the codes to the data. Key themes addressing the study objectives were identified for further integrated analysis alongside the quantitative data. The survey, EHR, and Delphi Instrument data were analyzed descriptively (means, frequencies). The t tests and chi-square tests were used to examine differences in PREMIS subscale scores by professional role, and general linear models were constructed to examine the association of sex, professional role, and years in practice on the PREMIS subscale scores. The study was deemed exempt by the university’s Institutional Review Board.

Results

The CFIR (Damschroder et al., 2009) is made up of five domains, each with multiple constructs. Our results fall under three of the domains: outer setting, inner setting, and characteristics of the individuals involved. The outer setting includes the extent that patient needs are known and prioritized, the degree to which an organization is networked with external organizations and external policies. The inner setting includes formal and informal communication within an organization, norms and values of an organization, and the implementation climate. Characteristics of the individual that influence the success of an intervention include knowledge and beliefs about the intervention, self-efficacy to execute the necessary action steps, one’s readiness toward ongoing use of the intervention, and other personal attributes. The study findings focus on current practice and reveal both barriers and opportunities across these three domains.

Current Practice

Collectively, findings revealed a lack of policies and procedures regarding IPV screening, documentation, and referral. This finding was consistent across the different methods of inquiry. The Delphi instrument revealed a lack of organizational policies, programs, training plans, or visual cues indicating an openness to discuss partner violence in the clinic, as well as a formalized response and referral process. The survey respondents and interviewees corroborated these findings. Over two thirds (69%; n = 16) of the survey respondents reported either a lack of IPV protocol or a lack of knowledge about one if it existed.

Interviewees highlighted the presence of self-administered screening items in certain circumstances (e.g., a health history form used for annual physicals and preoperative exams). Nearly half (48%; n = 11) of the survey respondents reported they had at least one disclosure of IPV in the prior 6 months. Only 27% (n = 6) of respondents reported not assessing at all for IPV. However, there was no uniform method of documenting screening results and great variability in the patient populations and circumstances that prompted screening.

In January 2015, the clinic experienced a policy change. Universal screening of all adult patients was reinforced in the organization leading to a brief online training module and activation of prompts in the EHR. Licensed practical nurses and medical assistants were required to ask the screening questions during the rooming process which normally includes other routine measurements (e.g., blood pressure) and health screening items (e.g., smoking, depression). Summary of the EHR data over a 5-month time period coinciding with this change revealed that 35% of adult patient encounters included a screen for IPV, a percent that did not differ between male and female patients. However, the clinic made considerable progress in their readiness to identify partner violence by institutionalizing the screening process and initiating a brief online training module.

Barriers

Several barriers were identified across the data collection mechanisms. The Delphi revealed a lack of patient education resources and no established IPV referral network. The majority of the survey respondents (87%; n = 20) were either unsure or believed there were no patient education or resource materials at the clinic. Although the screening policy and expectations changed, there was little change in the response options available to clinic staff if/when a patient screened positive. Most respondents (83%; n = 19) reported a lack of or unawareness of on-site resources for IPV and only 13% (n = 3) reported having adequate knowledge of community-based services.

Based on the interviews, the typical response to IPV was to call the clinic social worker. However, the one social worker’s duties spanned numerous clinics and patient needs. “You know if there’s a need that other people can’t meet and I can’t figure out somebody else who can and I can do it, I do it” (social worker). The need to address most nonmedical patient issues and across a large number of clinics limited the social worker’s accessibility for immediate response, in-depth assessment, and follow-up. The lack of an on-site victim advocate and formalized connection to community-based services further limited the potential response and supports available to the social worker. Ultimately, though, very few cases of IPV were being identified due to the general lack of or insufficient effectiveness of existing methods of inquiry.

Another commonly identified barrier was a lack of training. The Delphi revealed the lack of a training program and all interviewees reported a need for training and resources to support a response to a positive IPV screen. Although most survey participants reported some prior IPV training (providers = average of 7 hr, SD = 13; staff = average of 3 hr, SD = 3), the majority of these experiences were passive learning activities, such as reading an institutional IPV policy or attending a lecture, and approximately half of providers (45%; n = 5) and staff (50%; n = 6) surveyed felt they did not have sufficient training to assist individuals in addressing situations of IPV.

Perceived knowledge and preparation to identify and respond to IPV did not differ between providers and staff (Table 1) who similarly scored an average of 3 (SD = 1; range: 1 = not prepared to 7 = quite well prepared) on each of these subscales, although providers had slightly more actual knowledge regarding IPV than staff and had a greater understanding of victim autonomy, they were less aware of legal requirements around IPV. This likely reflects the fact that while providers are responsible for discussing and counseling patients regarding IPV during the course of the patient visit, clinical staff share a large burden of the care coordination for those patients that do screen positive, including providing referral resources and facilitating immediate connection to social services when appropriate. Both staff and providers perceived they had the necessary skills to discuss IPV among females (68%, n = 15/22) and males (67%, n = 14/21); but, fewer felt prepared to discuss abuse with a person of a different culture or ethnic background from themselves (41%, n = 10/22), with differences in provider type only in the preparedness to discuss the issue with males where providers were more comfortable than staff (82% vs. 50%, respectively).

Table 1.

Clinic Provider and Staff Preparedness to Address Intimate Partner Violence (N = 23).

PREMIS Scales	Staff(n = 12)	Provider (n = 11)	p Value
PREMIS Scales	M (SD)	M (SD)	p Value
Background
Perceived preparation	3.28 (1.25)	3.27 (1.33)	.98
Perceived knowledge	3.42 (1.33)	3.08 (1.42)	.56
Actual knowledge	26.00 (4.11)	28.64 (2.54)	.08
Opinions
Preparation	3.57 (0.79)	3.96 (1.23)	.38
Legal requirements	4.69 (1.05)	3.80 (1.22)	.08
Workplace issues	4.50 (1.06)	4.12 (1.04)	.40
Self-efficacy	4.25 (0.94)	3.88 (1.25)	.43
Alcohol/drugs	4.54 (0.61)	4.70 (1.04)	.67
Victim understanding	4.83 (0.59)	4.92 (0.41)	.67
Victim autonomy	4.44 (0.64)	5.00 (0.60)	.04
Constraints	5.21 (1.25)	4.18 (1.55)	.10
Practice	8.45 (6.49)	11.13 (8.07)	.39

When controlling for sex and years in the field in the regression analyses, providers were found to have greater knowledge (β = 2.95, SD = 1.47, p = .06) and to report screening more often than staff (β = 5.74, SD = 2.46, p = .03). Females reported greater screening self-efficacy (β = 0.91, SD = 0.50, p = .09), screening more often (β = 11.25, SD = 2.59, p < .01), and demonstrated greater victim understanding (β = 0.61, SD = 0.20, p = .01); although, they also perceived greater constraints (β = 1.08, SD = 0.55, p = .07), perhaps due to more experience identifying and supporting survivors. Noteworthy is the inverse relationship between time in the field and knowledge about IPV (β = –0.12, SD = 0.06, p = .04) and victim understanding (β = –0.01, SD = 0.01, p = .09), suggesting that future interventions toward raising awareness and knowledge of IPV might target male staff and providers further removed from their core training in addition to supporting greater cultural competency regarding IPV identification and response.

Opportunities

Overall, study findings point to the feasibility of a more substantial clinic response to IPV. The location of the clinic within an academic health setting provides opportunities for the establishment of a strong training program aligned with its tripartite mission of education, research, and patient care. The clinic’s location within a large multi-specialty practice, which is linked to the same EHR, and undergoing a transition to standardized procedures across clinics affords an opportunity for a unified protocol and a consolidated health care team approach; however, the reliance on academic part-time faculty requires extra consideration in the constitution of a health care team approach.

Interviewees across clinic role reported that it was within their scope of work to screen for IPV and recognized IPV as a serious health threat. Nearly all staff (92%; n = 11) and most providers (64%; n = 7) surveyed reported that health care professionals had a responsibility to ask all patients about IPV. In addition, a minority of those surveyed (8% staff; 36% providers) felt that health care staff do not have time to assist patients in addressing IPV. These findings combined with the establishment of a protocol and training opportunity signal the commitment of senior administrators to improve the screening and response to IPV. This policy change and the stated openness of staff and providers to addressing IPV in the health sector provide a strong basis upon which to build a subsequent quality improvement process.

Discussion

This study’s findings are relevant to practitioners and administrators employed in the nearly 100 academic health centers in the United States and in multi-specialty practices, which is a leading health care delivery model throughout the country. The results of the pilot are in line with existing research highlighting a general lack of screening, variability in procedures, and the absence of systems-level policies, protocols, and linkages to community resources (Alvarez et al., 2017) and reflect several domains of the CFIR. Based on needs identified during the pilot study, the study team applied for and received external funding to address these gaps. The recently initiated project is focused on over 35 clinics, including primary care and various specialties, and uses a systems approach which encompasses routinized screening, documentation, and care coordination between providers and community organizations and a formalized system of process improvement to improve patient well-being. The project will also shed light on neglected issues such as the identification and response to male, transgender, racially/ethnically diverse, and older adult survivors in the outpatient health system and will contribute to the ongoing debate regarding the impact of universal screening on patient well-being.

Applying the CFIR to our findings highlights existing strengths and challenges of the inner setting, the outer setting, and the individuals that are essential to explore before the wide-scale screening and response protocol (i.e., the intervention) is introduced within the larger clinic system. Although the clinic in this pilot study had a universal mandate to screen adult patients for IPV, our findings with respect to the outer setting revealed a lack of clinic policy and procedures to aid providers and providers were disconnected from IPV-focused community agencies that would enhance their service network. With respect to the inner setting, indicators of readiness for implementation were lacking in the primary care clinic with respect to leadership engagement, available resources, and access to information and knowledge; however, the compatibility between the intervention and clinic value system and the priority of the intervention appear to reflect opportunities to create positive change in patient care. Finally, with respect to characteristics of the individual, our pilot study revealed that clinic providers believed they had a responsibility to screen for IPV but they lacked formal training and skills in this area.

Screening for IPV in health care settings is a recommended but fairly recent addition to practice. Viewing practices through the CFIR lens is one evaluation of clinic readiness to screen and respond to IPV; and although study participants were employees of a single clinic, the analyses revealed a strengths and challenges to outer and inner settings and diversity among individuals’ knowledge of IPV and screening practices based on employee type (provider or staff), sex, and years in practice. This type of formative evaluation information is key when scaling up an intervention to other clinics in the system.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project received funding from the Office on Women’s Health, Department of Health and Human Services (1 ASTWH150031-01-00) and utilized resources made possible by Grant UL1TR000114 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH).

Author Biographies

Cari Jo Clark, ScD, MPH, is an associate professor at the Rollins School of Public Health. Her research is focused on the health effects of exposure to child maltreatment and intimate partner violence and the design and evaluation of violence prevention strategies. She is currently leading a cluster randomized controlled trial of a multicomponent intervention designed to prevent violence against women and girls in Nepal in collaboration with Equal Access International and is co-leading a secondary prevention intervention to better identify and respond to intimate partner violence in the health sector.

Lynette M. Renner, PhD, MSW, is an associate professor in the School of Social Work at the University of Minnesota. Her scholarship is focused on the co-occurrence of victimization types, identifying risk factors for specific types of violence, and exploring associations between victimization and mental and behavioral health and academic outcomes for children/adolescents, and victimization and mental health and parenting for adults. She focuses on translating research findings into practice strategies to better meet the needs of individuals and families who have experienced violence.

Mary E. Logeais, MD, is an assistant professor in the Division of General Internal Medicine at the University of Minnesota. She is a practicing internist and medical director of the University’s Primary Care Clinic. Her academic interests include health disparities, preventive health, physician burn-out, and medical education. She is assistant professor in the School of Medicine and co-investigator on a federally funded project investigating partner violence assessment and intervention in the health and community sectors.

References

Alvarez

Fedock

Grace

K. T.

Campbell

(2017). Provider screening and counseling for intimate partner violence: A systematic review of practices and influencing factors. Trauma Violence Abuse, 18, 479-495. doi:10.1177/1524838016637080

Black

M. C.

(2011). Intimate partner violence and adverse health consequences: Implications for clinicians. American Journal of Lifestyle Medicine, 5, 428-439. doi:10.1177/1559827611410265

Black

M. C.

Basile

K. C.

Breiding

M. J.

Smith

S. G.

Walters

M. L.

Merrick

M. T.

. . . Stevens

M. R.

(2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

Bonomi

A. E.

Anderson

M. L.

Rivara

F. P.

Thompson

R. S.

(2009). Health care utilization and costs associated with physical and nonphysical-only intimate partner violence. Health Services Research, 44, 1052-1067.

Boyatzis

R. E.

(1998). Transforming qualitative information: Thematic analysis and code development. Thousand Oakes, CA: Sage.

Breiding

M. J.

Chen

Black

M. C.

(2014). Intimate partner violence in the United States — 2010. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/violenceprevention/pdf/cdc_nisvs_ipv_report_2013_v17_single_a.pdf

Coben

J. H.

(2002). Measuring the quality of hospital-based domestic violence programs. Academic Emergency Medicine, 9, 1176-1183.

Damschroder

L. J.

Aron

D. C.

Keith

R. E.

Kirsh

S. R.

Alexander

J. A.

Lowery

J. C.

(2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, Article 50. doi:10.1186/1748-5908-4-50

Fetters

M. D.

Curry

L. A.

Creswell

J. W.

(2013). Achieving integration in mixed methods designs—Principles and practices. Health Services Research, 48(6, Pt. 2), 2134-2156.

10.

Health Resources and Services Administration. (2012). Women’s preventive services: Required health plan coverage guidelines. Retrieved from http://www.hrsa.gov/womensguidelines/

11.

Institute of Medicine. (2011). Clinical preventive services for women: Closing the gaps. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/Clinical-Preventive-Services-for-Women-Closing-the-Gaps/preventiveservicesforwomenreportbrief_updated2.pdf

12.

Moyer

V. A.

(2013). Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. preventive services task force recommendation statement. Annals of Internal Medicine, 158, 478-486. doi:10.7326/0003-4819-158-6-201303190-00588

13.

O’Doherty

L. J.

Taft

Hegarty

Ramsay

Davidson

L. L.

Feder

(2014). Screening women for intimate partner violence in healthcare settings: Abridged Cochrane systematic review and meta-analysis. British Medical Journal, 348, Article g2913. doi:10.1136/bmj.g2913

14.

Rivara

F. P.

Anderson

M. L.

Fishman

Bonomi

A. E.

Reid

R. J.

Carrell

Thompson

R. S.

(2007). Healthcare utilization and costs for women with a history of intimate partner violence. American Journal of Preventive Medicine, 32, 89-96. doi:10.1016/j.amepre.2006.10.001

15.

Short

L. M.

Alpert

Harris

J. M.

Surprenant

Z. J.

Jr. (2006). A tool for measuring physician readiness to manage intimate partner violence. American Journal of Preventive Medicine, 30, 173-180. doi:10.1016/j.amepre.2005.10.009

16.

Sprague

Madden

Simunovic

Godin

Pham

N. K.

Bhandari

Goslings

J. C.

(2012). Barriers to screening for intimate partner violence. Women Health, 52, 587-605. doi:10.1080/03630242.2012.690840

17.

Todahl

Walters

(2011). Universal screening for intimate partner violence: A systematic review. Journal of Marital and Family Therapy, 37, 355-369. doi:10.1111/j.1752-0606.2009.00179.x