Interpersonal Violence: Assessment and Healthcare Response

Executive Summary:

This briefing document summarizes key concepts and information from a chapter on Interpersonal Violence (IPV) Assessment. The chapter covers various forms of IPV, including intimate partner violence, sexual assault, child abuse and neglect, and elder abuse and neglect. It emphasizes the impact of violence on health, the role of healthcare providers (HCPs) in assessment and response, and provides guidance on trauma-informed care, collaborative assessment, risk assessment (including homicide risk), and documentation. The chapter also highlights common misconceptions and biases that HCPs need to be aware of and provides self-assessment questions and audience response questions to reinforce learning.

Main Themes and Important Ideas/Facts:

1. Defining Interpersonal Violence (IPV):•

IPV encompasses a range of abusive behaviors within close relationships.

•Intimate Partner Violence (IPV): Defined as "spousal violence and violence committed by current or former dating partners." This includes "physical/sexual violence, psychological violence, or financial abuse within current/former marital or common-law relationships, including same-sex spousal relationships." Examples include "physical/sexual assault, verbal abuse, imprisonment, humiliation, stalking, denial of access to financial resources, shelter, or services." The chapter notes that "Gender is a key risk factor," although it does not elaborate further within these excerpts.

•Sexual Assault: Recognized as a crime under the Canadian Criminal Code, including "sexual assault and sexual touching." Four levels are identified: forced sexual activity without physical injury, sexual assault with a weapon or verbal threats, sexual assault causing bodily harm, and aggravated sexual assault.

•Child Abuse and Neglect: Involves physical, sexual, neglect, and emotional abuse. The chapter highlights the legal obligation in "most provinces/territories" for the public and HCPs to report suspected child abuse and notes that "Child abuse and IPV often overlap."

•Elder Abuse and Neglect: Includes "physical abuse or neglect, failure to provide basic services, psychological abuse or neglect (failure to provide stimulation), and financial abuse or neglect." Perpetrators are often "any persons in a situation of power or trust," and abuse can occur in "homes or institutions." The chapter points out that "Older women [are] at higher risk than older men."

2. Effects of Violence on Health:

•Violence has both immediate and long-term health consequences.

•Direct effects include "direct effects of physical injury (bruises, fractures)."

•Chronic health problems can also arise, including "Chronic pain, Neurological, Gastrointestinal, Gynecological, [and] Mental health" issues.

3. Healthcare Providers' (HCPs) Role and Responses:

•The effectiveness of routine IPV screening is "inconclusive." Increased detection did not always translate to meaningful support, and "Women report negative experiences with HCPs who focus on physical consequences, rather than wider effects and context of IPV."

•A trauma-informed approach is crucial for all care related to violence. This involves "listening" and maintaining a "high index of suspicion for abuse."

•Assessing for IPV should be "collaboratively, using a relational approach," and include "Physical examination" and "Documentation." HCPs should "assume that a majority of patients will have a history of abuse of some form" and "assume some may be currently experiencing abuse." Care should be "appropriate for those with histories of abuse, whether or not abuse has been disclosed," and HCPs should "routinely inquire about home/work life effects on health."

•Listening nonjudgementally requires HCPs to reflect on their own biases and understanding of IPV: "Listening nonjudgementally requires health care providers to evaluate social judgements commonly made about abused women: What do I know about IPV? What are its causes? What are my own experiences? How do my beliefs influence the care I give? What groups are most vulnerable?"

•HCPs should have a "high index of suspicion" for abuse when patients present with "direct injuries, chronic pain, and substance use." It's noted that "Up to 50% of all women have experienced some form of abuse" and "7% of Canadian women are currently in abusive relationships," with more isolated individuals being "more vulnerable."

•Collaborative Assessment involves "Following the woman’s lead," "Listening for cues of abuse," self-reflection on biases, "Pattern recognition," and "Naming and supporting capacity."

•When Abuse Is Disclosed: HCPs should "Assess level of risk and develop a safety plan," "Identify personal strengths and supports," "Identify appropriate goals with the woman, in collaboration with other health care providers," "Conduct a thorough assessment," ensure "objective, unbiased documentation," "Take photos of injuries," and "Use verbatim statements in documentation, where possible."

•Responding to Elder Abuse and Neglect is "complicated when multiple health, physical, and cognitive challenges are present." HCPs need to consider the difference between "Long-term abusive relationships versus new abuse." Provincial mandatory reporting is "varied and controversial."

•Responding to Child Abuse: While approaches are "similar to IPV," greater attention is needed to the "greater vulnerability of children" and the "need for accommodation of developmental stage of child." The chapter also cautions against "Race and class stereotypes" and highlights that "Neglect and emotional abuse [are] most common," with "Parents not only possible perpetrators." It also notes that "Most allegations are not substantiated" and the stress of child removal, emphasizing the need to provide good care to parents as well.

•The nursing role should avoid being solely the child "rescuer" at the expense of relationships with parents or the child-parent relationship.

4. Physical Examination and Documentation:

•A "Complete head-to-toe examination" is necessary.

•For elder abuse, HCPs should be aware of factors contributing to bruising (medications, disorders, accidental bruising) and include "baseline laboratory tests."

•For child abuse, "Significant trauma" is defined as any injury more severe than temporary redness. Suspicion should be raised by "bruising in infants who are not yet ‘cruising,’ bruising in ‘atypical’ places, or bruising that takes the shape of an object."

•History and Documentation should include prior abuse, traumatic injuries, mental health examination, and "Detailed, objective, unbiased notes." Key elements of documentation include:

◦"Include ‘exceptionally poignant’ statements that specify the perpetrator and the threat."

◦"Do not sanitize language, either used by the patient or quoted by the patient and attributed to the perpetrator."

◦"With children, use the words of the child."

◦"Use of injury maps."

◦"Photographic documentation."

•Photographic Documentation examples include patterned abrasions, lacerations, avulsion injuries, contusions, and bruising.

5. Assessing for Risk of Homicide:

•"In Canada, spousal homicide of women [is] three or four times higher than that of men."

•The Danger Assessment (DA) is a tool to "Map abuse on a calendar" and "Note overall score" to assess risk.

•Follow-up is crucial in these situations.

6. Key Considerations for HCPs (Based on Questions and Answers):

•Abuse is not solely physical or sexual; it "can include neglect" (Answer to Question 1).

•Objective and unbiased documentation avoids judgmental language and focuses on observable facts (Answer to Question 2). An example of a clear note is: "Displays bruises in several different stages of resolution, including several in a defensive pattern on both forearms."

•Universal domestic violence screening policies should start at age 14, not 18 (Answer to Question 3).

•The Danger Assessment (DA) is the appropriate tool to assist in assessing a patient's risk for homicide (Answer to ARQ Question 1).

•When a patient blames themselves for the abuse, the best response is to reassure them that "It’s not your fault that your husband lost control. Changing your actions will not prevent him from abusing you again" (Answer to ARQ Question 2). This emphasizes that the abuser is responsible for their actions and avoids victim-blaming.

Quotes:

•On IPV Definition: "Spousal abuse: physical/sexual violence, psychological violence, or financial abuse within current/former marital or common-law relationships, including same-sex spousal relationships."

•On Gender as a Risk Factor: "Gender is a key risk factor."

•On Sexual Assault Definition: "The Canadian Criminal Code identifies sexual assault and sexual touching as crimes."

•On Mandatory Reporting of Child Abuse: "Most provinces/territories require the public and health care providers (HCPs) to report suspected child abuse."

•On Elder Abuse Perpetrators: "Inflicted by any persons in a situation of power or trust."

•On Negative Experiences with HCPs: "Women report negative experiences with HCPs who focus on physical consequences, rather than wider effects and context of IPV."

•On Assumption of Abuse History: "assume that a majority of patients will have a history of abuse of some form."

•On Verbatim Documentation: "Use verbatim statements in documentation, where possible."

•On Spousal Homicide Rates: "In Canada, spousal homicide of women three or four times higher than that of men."

•On the Purpose of the Danger Assessment: "The DA is designed to assess for the risk of homicide."

•On Addressing Self-Blame: "It’s not your fault that your husband lost control. Changing your actions will not prevent him from abusing you again.”

Conclusion:

This chapter provides a foundational understanding of various forms of interpersonal violence and emphasizes the critical role of healthcare providers in assessment and response. It underscores the importance of trauma-informed care, collaborative assessment, accurate documentation, and awareness of personal biases. The information presented aims to equip HCPs with the knowledge and tools to better identify, support, and ensure the safety of individuals experiencing IPV across different age groups and relationship dynamics. The inclusion of self-assessment and audience response questions serves to reinforce key learning points and promote critical thinking in this sensitive and crucial area of healthcare.