Welcome to the International Association of Forensic Nurses video on assessing intimate partner violence in the clinical setting. I'm Jen Pierce Weeks. In this video segment, you'll see how the clinician speaks with the patient about the violence going on in her relationship. It's important to recognize that intimate partner violence can impact both the short and long-term health of the patient experiencing it, so finding a comfort level with speaking about violence in a non-judgmental manner is very important. Not all clinical issues surrounding intimate partner violence are covered in this short video, but important areas of care are highlighted. Hi, Vanessa. My name's Jennifer. I'm one of the forensic nurses here at Memorial, and I'm just going to talk to you about what happened to you today. Make sure you're okay. Make sure we do any tests that we need to do so that you go home and you're okay. Can you talk to me a little bit about what brings you in today? Mm-hmm. Well, me and my husband got into a fight, and he choked me. I'm also pregnant, and I haven't been feeling the baby move, so I just want to make sure everything's okay. Okay. Okay. And did this just happen before you came in, the choking? Yes. Okay. And has he done that to you before? He has. He has done that to you. Okay. So, okay. We're obviously going to make sure the baby's okay, too. Okay. All right? So we're going to check both of you as we go through this process. Did he choke you more than once during this fight that you had? No. Just one time. Just one time. Did you check out during that time? I did. You did. Okay. So I'm going to talk to you very specifically about your relationship with your husband, and very specifically about the choking that happened. I'm going to look at your neck. Okay? If you have any injuries, I'm going to talk to you about maybe taking some pictures of those injuries, so we have that in your record. Okay. But we're also going to make sure that that baby is moving around and doing what it's supposed to be doing. Is this your first pregnancy? It is. I'm just going to take notes as we go. All right? Okay. Getting a clear history regarding the patient's intimate relationship can assist in evaluating the level of violence they may be experiencing. How long have they been in the relationship? Is it a same-sex or opposite-sex relationship? Are they married or not? Are they living together or not? How long has the physical violence been a part of the relationship? All of these questions, and many more, impact the care the patient receives. So tell me first, how long you're married? How long have you been with your husband? We've been together 10 years now. 10 years. Okay. So you've been together a good long time. And this is your first pregnancy. When are you due? January. Okay. And have you been getting medical care? I have. You have a doctor. I do. You're seeing them regularly. Okay. Yes. And have you had any complications so far in your pregnancy? None so far. Very good. You can hardly tell that you're 6 months pregnant. Yeah. Looking at you. And has your husband, you've been married 10 years, so you've been with him a long time. Has he always been physically abusive to you? Or is that new? No. It just started. Just started. Yeah. Okay. When specifically did it start? About the time that we found out I was pregnant. Okay. That's not uncommon. The danger assessment is an instrument that helps to determine the level of danger an abused woman has of being killed by her intimate partner. The tool was originally developed by Jacqueline Campbell in 1986 with consultation and content validity support from battered women, shelter workers, law enforcement officials, and other clinical experts on battering. There are two parts to the tool, a calendar and a 20-item scoring instrument. The calendar helps to assess severity and frequency of battering during the past year. The woman is asked to mark the approximate days when physically abusive incidents occurred and to rank the severity of the incident on a 1 to 5 scale. The calendar, conceptualized as a way to raise the consciousness of the woman and reduce denial and minimization of the abuse. The 20-item instrument uses a weighted system to score yes or no responses to risk factors associated with intimate partner homicide. In 2008, researcher Nancy Glass and colleagues published studies, findings in the American Journal of Public Health that revised the danger assessment to predict re-assault in abusive female same-sex relationships. After using focus groups and interviews to examine the danger assessment with this population and identify new risk factors, a same-sex tool was developed and evaluated. The new tool comprises 8 original danger assessment items and 10 new items and is a predictor of risk of re-assault, not lethality. This instrument is available for download on the website www.dangerassessment.org You may also find specific training in use of the danger assessment tool as well as certification in its use on this site. Different clinical programs utilize the danger assessment tool in different ways. In the next segment, you'll see it used as an educational tool with the patient. Let me ask you some very specific questions about what's been happening since you've been pregnant. First, what's your husband's name? Hector. Hector, okay. Okay, so the questions I'm going to ask you are something called a danger assessment. And it's a series of questions that we ask just to see, get a sense of how risky is the relationship? How is it when the two of you are together when there is abuse going on? And we worry when you leave here what's going to happen to you. We don't want anything bad to happen to you when you leave. So this gives us a sense of what the relationship really looks like in regards to the violence. So he never was physical toward you until your pregnancy. So in the last six months then, has the violence increased? Has he been getting more violent toward you? It kind of seems like it's staying the same. Okay. Does he own a gun? Is there a gun in your house that he owns? Yes. Okay. And when this happened, did you leave him or have you left him recently and said you're leaving the relationship? No. No, you're still with him? I'm still. Okay. Does he work? He does. Okay. And he hasn't recently lost his job? No. Okay. Has he ever used a weapon against you? Has he ever taken that gun out and used it against you? No. Okay. Has he ever threatened to kill you? No. No. Okay. In the times that he has hurt you in the last six months, physically hurt you, has he ever been arrested? No, he hasn't. Okay. And do you have, you said you've only been pregnant this one time, which means you don't have any other children, you don't have children that are not his. No, no others. Okay. Has he ever forced you to have sex with him when you don't want to? He has. Has that happened in the last five days? No. Okay. And obviously he has tried to choke you, he tried choking you today. Has he done that before? No. Okay. Does he use illegal drugs, and by illegal drugs I mean like crack cocaine, uppers, amphetamines, drugs like that? No, he doesn't. Is he an alcoholic or does he drink alcohol daily in excess? Okay. Is he very controlling of you, and by this I mean he knows where you are, how long you're there, which friends you're with, follows you around, is very jealous? Yes, he does. Does this sound like him? He does do those things. Okay. Has he ever threatened to kill himself? Told you that he's going to kill himself? No. Have you ever told him that you are going to? No. Okay. Do you believe he's capable of killing you? No. No? I don't think so. Not even during the worst moments? No. No. Okay. Okay, so one of the things I'm going to do is I'm going to give you a calendar so that you can sort of look back. Some women are very good at remembering exactly which days their husband or their partner was physically violent toward them. So I'm going to just hand you this calendar and have you look back over the last few months and see if you can recall. We're just barely in October now, so looking back over September and August and July and you can certainly flip the paper over, see if you can circle any dates you remember him physically hurting you, pulling your hair, pushing you up against a wall, you know, being insulting to you verbally, calling you names, those sorts of things. See if you can identify any of those dates, particularly because he hasn't really, he's only really started physically hurting you since your pregnancy. In the next segment, you will watch the provider, myself, acquire a more detailed history of the violence which helps to clarify for the provider as well as the patient just how much abuse is happening within the relationship. It's important throughout the process of history taking and examination that the provider focus on trauma-informed service delivery, taking an approach that will decrease the likelihood of re-victimization. One of the ways we do that is by offering options to the patient. It's important that you, the provider, know your reporting requirements so that you can clarify what options the patient has with regard to reporting. Equally important that you not suggest the right choice but rather let the patient choose. Additionally, as shown in this video, sexual assault is very common in the context of intimate partner violence. For that reason, it's important that the provider clarify when the last sexual assault took place so that proper evidence collection and treatment options may be offered. And lastly, validate that the behavior of the offender is wrong, that abuse is not part of a healthy relationship. So back on July 8th, right after the July 4th holiday, do you remember what he did? Um, he kind of just pushed me around and was verbally abusive. Okay. And in August, it looks like twice he hurt you. Um, was one of those incidents when he forced you to have sex with him or something else? On the second, um... On the second? Okay. On the second date, you mean? Yes, yes. And you did not talk to the police at that time? I didn't, no. Have you ever spoken to the police about his violence? Okay. Do you feel like that's something you want to do? Or not? No. No? What's your biggest worry about talking to the police about what's happened? Um, I think it's just getting him into trouble. Okay. Yeah. Okay. Well, you talking to the police or not is up to you, right? I'm certainly not going to make you do that. And, um, and we can talk a little bit more about that, but it's really important that you understand that it's not okay for him to hurt you, right? It's not okay for him to hurt the baby growing inside you. And it's certainly also not legal for him to do those things or to force you to have sex. None of those things are legal. So it is against the law. And if you ever feel like I feel too, um, unsafe to stay with him, then I want you to know there are resources available to you. Okay? And in fact, I'm going to, um, I'm going to introduce you to our advocate, Nancy, so that she can talk to you and so you know where to go if you leave here and you're going home to him, that you know where to go should you need services down the road, should things get more out of control than what you describe now. Although I have to say choking's pretty serious. We call it strangulation. And it's pretty serious. So we're going to talk now more in depth about that episode of him choking you. Okay? First, intimate partner violence advocates are one of the most important resources you can offer your patient. Advocates are able to provide many services that health care cannot. From 24-hour crisis lines to court advocacy for restraining orders to legal support, safety planning and shelter. It's likely that without your introduction the patient may never reach out to those available services. In the next segment, you'll see me employ the use of a strangulation assessment tool. There are many variations of the tool but often the assessment includes documentation of the strangulation event or events in the patient's own words, a Glasgow coma scale and cranial nerve assessment, pain scale and very specific questions regarding the manner of strangulation and the signs or symptoms the patient experienced at the time or since. For instance, were you incontinent of urine during the strangulation event? Additionally, body maps and diagrams are employed to document any physical findings. Okay, so today is October 5th and it's about 10 o'clock in the morning now. Do you remember what time it was that he did this to you? Was it today or yesterday? It was today. And what time in the morning do you think it was when this happened? It was probably around 7. Okay. So just sort of tell me what he did. In your own words, just tell me what he did specific to the choking. Okay. Well, he pushed me against the wall. He had one hand wrapped around my neck. Okay. And you said you blacked out. Yes. Did he lift you up off the ground against the wall? Sometimes that happens. He did. And he only used one hand. Okay. If you had to guess and I know it's a guess how many seconds do you think he had his hand on your throat? I would probably say 20 to 30. Okay. And he was standing in front of you now? Yes. And he just did it once you said, right? Not multiple times. Okay. And did you have any jewelry on your neck at the time? I didn't. Okay. Did he cover your face or mouth with anything at the time? No. Okay. And we know that you blacked out just once. Blacked out just one time? Mm-hmm. Okay. Sometimes people don't want to tell us about this. They're embarrassed about this but it's something really important for us to know because it tells us what happened in the brain during the strangulation. Did you wet yourself, pee your pants, or have a bowel movement in your pants during the choking? I did. Which one of those things? I peed my pants. Okay. And did you change before you came in to see us? That's really common and you don't have to be embarrassed. You can't control that when somebody is choking you. Did you feel like or did you actually throw up at any point during the choking episode? No. No, okay. And I know you said that your throat is sore and you feel like you have a hoarse voice since this happened. On a scale of zero to ten, zero is no pain or pressure on your neck and ten is the worst you can imagine. When he was strangling you, what number on that scale of zero to ten was that pressure pain? I would have to say about a nine. A nine, okay. Sometimes people describe different things about when they wake up. So you are being strangled up against the wall like you described and you black out. When you came to, were you in the same place? Were you on the floor? Were you in a different room? I was on the floor. On the floor, in the same place, right by the wall there, okay. And was he still there or had he left? He was, okay. Okay, so what I'm gonna do now, Vanessa, is I'm actually gonna, first I'm going to just check your oxygen level. And we're gonna do this more than once while you're here with me. But I just want to get a sense of where it is right now. I'm just gonna slide that onto your finger. And are you a smoker at all? No, I'm not. Assessment of the head and neck post strangulation is critical. This allows for documentation of injury as well as identification of more serious physical injuries such as skull fractures to be recognized. Assessment should also always include serial vital signs and oxygen saturations because of the risk of delayed lethality. I'm just gonna take a look at your head and your neck and see what you have going on for injury because I see some bruising on your eye but sometimes there's hidden injuries on your neck. Okay. So just take a look back here. That all looks good. I'm gonna take a look back here. Whoops, behind your ear. Yeah, you have a little bruise behind your ear. And did you get hit in the head at all? I don't think so. You don't think so? Okay, and when you blacked out, it was definitely because his hands were around your neck, not because your head got slammed against the wall. Okay, and you have a little bruise there. So I'm gonna have you do a series of a couple of things for me. First I'm gonna have you look way down at the floor and then up at the ceiling and over toward your nose and then the other side. Okay, I'm gonna have you do the same thing with this side. Look down, look up, look over to your nose and over to the other side. Very good. Okay, and now I'm gonna hold your eyes open. I'm gonna have you squeeze them shut as hard as you can. Very good. Okay, now raise your eyebrows for me. Okay, and close your eyes as tight as you can. All right, and stick your tongue out at me. Straight on out. Right, very good. And puff up your cheeks like that for me. Very good. Okay, and I know you said you're having pain in your neck. I'm just gonna feel your neck and throat here. Okay. In the next segment, you will see me conduct part of the typical review of systems that should occur with this patient. This review includes a neurological assessment, head, ears, eyes, nose, and throat assessment with special attention to any signs that suggest a skull fracture, cardiac and respiratory system assessment, including auscultating the carotid arteries, listening for bruise, or any other abnormalities, the genitourinary, gynecological, or obstetrical assessments as warranted and necessary, the entire body surface of the skin, and a psychosocial assessment as well. While you will not see me conduct all of this on video, you will want to include them in your own assessment. I'm just gonna take a look in your mouth and make sure you didn't bite the inside of your mouth or your lip at all. I'm just gonna pull down your lip here a little bit. Okay. I'm just gonna take a look back in your throat a little ways. Okay, all right, that looks good. And given that you have that nice bruise behind your ear, I'm just gonna take a peek in both your ears. Okay. Because I am thinking that they may want to, given the bruise behind your ear, I think they may want to do a CAT scan of your head. Okay. But they may not. They may put that off with your pregnancy, but we'll let the doctor take a peek. Your ears look good. You don't have any blood in your ear canals. I'm gonna listen to your neck and your heart and your lungs, but first I'm just gonna have you. Okay. I'm gonna listen under here too. There you go. I'm gonna just have you take a deep breath in and out and again and again. And one more time. Thanks. Okay. How about we listen to your baby's heart rate? Okay. How about we do that? It's important to recognize that while the research regarding miscarriage post-strangulation is relatively small, it does exist. And for certain, we are seeing post- strangulation miscarriages in clinical practice. It is impossible to say with a hundred percent certainty that the miscarriage is a result of the strangulation, but the risk exists. Part of your assessment will always include a fetal heart rate if the pregnancy is far enough along to assess that. In some instances, you will also need to be actively engaging the maternity unit or other appropriate personnel in order to assess things like contractions, etc. So depending on your location, you will want to keep in mind what you will do in the event of an obstetrical emergency. Well, he's there. I can hear him. Okay. So even though he seems like he's not moving compared to before, he's definitely, his heartbeat is strong, and you're not feeling like you're having any contractions, right? Okay. Okay, we can give you this back, and if you want to sit back up, you can. Okay, so the baby sounds fine and is moving around in there. The heartbeat is good, but I want you to pay attention to that pretty closely in the next few weeks. When do you see your doctor again? In three weeks. So if sometime between now and your doctor's visit, you can't feel him move at all, and that goes on for, you know, longer than a couple of hours, an hour or two, if you have vaginal bleeding or spotting, both of those things you should either come back in and see us or see your doctor for, okay? Because when you're strangled, you lack oxygen. Your oxygen is taken away from you. When you don't have oxygen, the baby doesn't have oxygen, so it can be a problem. So we really kind of want to keep an eye on you for the next few weeks to see that both you're okay and the baby's okay. Does that make sense? Yes. Okay. What I would like to do also is take some photographs of the injuries that you have behind your ear, on your neck, you have a little bruise here, and then the bruising you have on your eye. Is that okay with you? Okay. I'm just going to have you sign right there, and these photographs will stay with your medical record, which can only be released with your permission, okay? So they're not going to go anyplace else unless you need them. But if you change your mind and you decide to report to the police, you want to tell them that you have some photographs in your file, because that could help your case, okay? Okay. Another aspect of care in intimate partner violence is the provision of photo documentation. Photos for this patient population assist in accurately depicting the injury, but also assist in court should the patient wind up entering the criminal justice system. Cameras are no longer expensive and provide excellent quality images. Health care providers should recognize the images as an additional form of documentation, and make sure accompanying written descriptions are with them. Lastly, photos documented by health care providers must remain a part of the medical record with the same applicable HIPAA rules associated. The first picture that I'm going to take is just you sitting there. You don't even have to look at me. You can actually look this way. It's not like going to have your picture taken someplace else, because it's for a different reason entirely. Okay. And then the next photograph I'm going to take is of your eye, okay? And I'm going to take it with this ruler in the picture and without. So I'm going to actually have you shut your eye for this. And hang on, I'm just going to put my ruler up against it. In the last segment, you will see me do some, not all, of the discharge instructions. This will provide you with an example of how to really begin conversation with your patient regarding safety planning. Now that the doctor has talked to you, I'm just going to go over your discharge paperwork with you, okay? The first thing I want to talk to you about is your plan when you leave here. You're going home to your husband? I am. Does he know you were here today? No. Okay. So we won't, you know, send you home with a whole bunch of stuff so that if you need him to not know that you were here, we can certainly respect that. What will you do if you get home and in the next however long, the violence gets worse? Have you thought about that? I honestly have no idea. Okay. Do you have family close by? I don't. Okay. Good friends? Yes. Do any of your friends know this is part, what's going on in your relationship? No. You haven't talked to anybody? No. Okay. Well, you've talked to Nancy here at the crisis center. So Nancy knows what's going on with you. So one thing that you can do is that if things get bad, again, you can call the crisis line. They have someone on the line 24 hours a day, okay? So you can always do that. But sometimes phones get taken away, okay, by people who are abusive. So if your husband takes your phone, we kind of want to come up with a plan for how you're going to, what are you going to be able to do to get away if you need to get away? Do you live in a neighborhood or do you live on 50 acres of land with no neighbors? Okay. All right. So is it possible, can you see yourself if you ever needed to leave your house, going to one of the neighbors to ask to use their phone to call 9-1-1? Yeah. Okay. So there's a good plan, okay? Okay. I do think that if you want to set up time to meet with Nancy to talk about how to make your relationship a little safer for you, that probably is a good idea. And I know she talked to you about what's available, but you can call her anytime. So just know that's an option for you too. So you know what you're going to do when you go home. If you haven't shared this with your obstetrician, your doctor for your pregnancy, you might want to. Does your husband go to your visits with you? Yeah. He does. Okay. So if ever the subject comes up and he's not there, you might just talk to your doctor about it so that they know because it can impact your health, your health and the health of the baby, okay? And sometimes when the baby is born, the violence gets worse, not better. I know for you the violence started with the pregnancy, but sometimes it can continue on into having that baby because the focus is really off of your husband and it's very much on that baby. So then you have yourself to protect plus the baby. So I want to make sure you have all the resources you can should you ever decide to leave, okay? Okay. For sure you don't deserve to have this happen to you. It's not part of a healthy relationship. So and there may be services that Nancy knows about that could help your husband, okay? So all of those are things to consider. Do you have any questions for me? No. No. Okay. Are you driving yourself home? I am. Okay. In regards to the strangulation that happened, if you in the next three days, if you become short of breath, like you feel like you can't breathe right, I want you to come back in. If all of a sudden, you know, those little purple bruises you have going on on your eyelid, if you start developing those on your face, I want you to come back in. Okay. If the injuries that you have now get worse, come back in so we can take some pictures of those. If you start feeling dizzy, lightheaded when you go from laying down to sitting up, come back in, okay? And we talked about coming back in for vaginal bleeding or if you go into labor, obviously, you have contractions. You want to come back in or if you can't feel that baby move, okay? But right now the baby is okay. Okay. Okay. No questions at all? None. Okay. All right. I, you know, good luck and let Nancy know she's still here. She'll walk out with you. Let her know if there's anything else you need. Lastly, give some consideration to safety issues you may have never thought of. For instance, how does your system generate patient satisfaction surveys? Often they are automatically generated and arrive via the postal service to your patient, which can tip off the abuser that they received care recently. There are ways to prevent these surveys from going out, but this requires pre-planning with the folks at your institution so they can flag patients who should not receive them. It is also possible to discuss this up front with the patient and assist her in providing an explanation to the abuser about this document. For instance, you can tell your husband that you went in to be seen to make sure the baby was okay because you couldn't feel him move. Another unexpected way abusers may discover the patient was seen is through arrival of an explanation of benefits form from the insurance provider. It's fair to let the patient know as they may be able to watch and preempt the mail. It's also possible in some locations to have the insurance provider not send the explanation of benefits form due to patient safety concerns. You will want to find out what, if any, available options you have. There are many resources available to health providers as well as patients. We hope this video has been helpful to you improving the care of your intimate partner violence patient.

intimate partner violence

clinical setting

assessing violence

choking incident

pregnancy

non-judgmental approach

patient support