Archives of Academic Emergency Medicine. 2019; 7 (1): e68 OR I G I N A L RE S E A RC H What Victims of Domestic Violence Experience in Emer- gency Departments; a Cross Sectional Study Brieana Rodriguez1, Madalyn Mandich1∗ 1. Medical College of Wisconsin, Milwaukee, Wisconsin, USA. Received: September 2019; Accepted: October 2019; Published online: 24 November 2019 Abstract: Introduction: Domestic violence (DV ) is a problem defined as physical, sexual, and/or mental abuse used by one person in a relationship in order to gain control over the other. This study aimed to investigate what victims of domestic violence are experiencing when they present to the emergency department (ED). Methods: The survey was conducted during the women’s initial visit to Sojourner Family Peace Center (SFPC) in Milwaukee, WI. It included 22 questions assessing women’s encounters with screening and treatment for domestic violence in the ED. Results: 24 surveys were collected over 7 months. Thirteen women presented for treatment of injuries related or not related to abuse. Problems with abuse-related care they received were identified. 31% of women presenting with obvious signs of abuse, such as human bite wounds or head injury, were not screened. Four of 11 women were screened with family or law enforcement present. Nine of 11 were screened by a nurse, social worker, or police officer, not a physician. Four women felt rushed by healthcare professionals and that they did not genuinely care. Most noticeably, women were not screened at all. Conclusion: DV screening must be done with no family present. Removing law enforcement from rooms is noted to make women feel more comfortable. If a family member is adamant about remaining with the patient, the patient can be removed for a blood draw or sensitive exam to attain privacy. Standardizing screening could aid in making DV victims feel less rushed and more at ease. The courageous women sharing personal stories help pave the way to better treatment for future victims of DV presenting to the ED. Keywords: Domestic violence; emergency service, hospital Cite this article as: Rodriguez B, Mandich M. What Victims of Domestic Violence Experience in Emergency Departments; a Cross Sectional Study. Arch Acad Emerg Med. 2019; 7(1): e68. 1. Introduction Domestic Violence is a continuing and devastating problem defined as physical, sexual, and/or mental abuse used by one person in a relationship in order to gain control over the other. Over 10 million people in the United States will ex- perience domestic violence at some point in their lifetime, and an estimated 34% will seek medical care for their injuries (1). Domestic violence victims seeking care will likely present to primary care clinics, urgent care clinics, OB/GYN clinics, EDs, and almost every other specialty for treatment and help. Domestic violence is an issue all healthcare professionals will encounter at some point throughout their career. It is imperative that healthcare professionals are trained to ade- quately and respectfully identify and treat patients present- ∗Corresponding Author: Madalyn Mandich; 8365 Watertown Plank Road, Wauwatosa, WI 53213, Wisconsin, USA. Email: mmandich@mcw.edu. Tel: 001(262) 501-9980 ing to them for domestic violence related health problems. This is an issue so vital that the Joint Commission (2), the American College of Emergency Physicians (3), and the US Preventive Services Task Force (4) have strongly encouraged screening for domestic violence. However, even after years of medical organization’s advocacy, only about 30% of women who presented to the Emergency Department have actually been screened (5). This is in contrast to physicians caring for pregnant women who report routine screening 11-39% of the time, no matter the healthcare setting (6). Numerous factors play a role in this process and all need to be taken into consideration when screening for this sensitive topic. For example, it must be taken into account where the conversation takes place, how it takes place, and the appropriate response or follow up to anything a domestic violence victim discloses. Studies have shown that this process, which is supposed to be meaningful and private, is often hindered by having a third party present, lack of referral and appropriate resources, and lack of empa- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem B. Rodriguez et al. 2 thy (7). In order to gain a better understanding of this process and the pitfalls that are continuing to occur, it is timely and of critical importance to get the perspective of the women who are in this vulnerable position. Previous studies involv- ing targeted interventions toward pregnant and postpartum women found decreased episodes of domestic violence, re- duced reproductive coercion, and improved birth outcomes (6). This evidence of a positive effect of domestic violence screening in an obstetrics setting warrants further investiga- tion in the ED setting as they are often the healthcare setting that victims initially present to for care, safety, and treatment. In addition, the unique characteristics of the ED setting call for both helping victims, as well as, taking extra caution to provide such care due to the acute nature of the visit. Due to this, focusing on the ED will provide valuable informa- tion that can set a basis for all other healthcare settings when screening for domestic violence. For the above-mentioned reasons, this study aimed to ivestigate what victims of do- mestic violence are experiencing when they present to the ED. 2. Methods 2.1. Study design and setting This cross sectional study was conducted from November 2018 to June 2019 on the clients of Sojourner Family Peace Center in Milwaukee, WI, who reported presenting to the ED for abuse-related or non-abuse-related services. Sojourner Family Peace Center is the largest nonprofit provider located in Wisconsin, serving over 9,500 victims each year (8). They offer resources, such as helping obtain a restraining order and providing a case manager, that help women affected by domestic violence receive justice. In addition to legal help, they also offer an ample amount of references and follow- up care to aid women in gaining independence and self- sufficiency once they leave the safety and shelter of Sojourner Family Peace Center. Due to the significant amount of care Sojourner Family Peace Center provides to the women of Southeastern Wisconsin, we decided to partner with them in order to gain first-hand insight into what victims of domes- tic violence are experiencing when they present to the ED through a 22 questions survay. In order to keep the data secured and to protect confidential- ity, no personal health information was stated on the survey. The information gathered was anonymous and any woman who had not previously presented to the Emergency Depart- ment was excluded. The methods of study were reviewed and approved by the Institutional Review Board, and the data from this study will be used to develop recommendations for improving ED treatment of domestic violence victims. 2.2. Participants All females aged 18 years and older who presented to So- journer Family Peace Center for an initial interview process, regardless of whether or not they had ever presented to an Emergency Department for treatment of injuries sustained due to domestic violence, were included. This is in congru- ence with the guidelines that Sojourner Family Peace Center has for individuals who qualify for their interview process. 2.3. Data gathering The survey included 22 questions, ranging from yes/no to open-ended (Appendix 1). The questions directly measured the opinion of the women and their encounters with the screening process for domestic violence, as well as the treat- ment for their symptoms in any Emergency Department visit. The women also provided their opinion on any im- provements they believed could be made during their en- tire visit to an Emergency Department. The survey was con- ducted during the women’s initial visit to the center. The written survey was completed by the participant with the help (if needed) of a Sojourner representative during their in-person interview process. Our survey was placed within the interview Sojourner conducts for their own purposes. It was presented to the woman interviewed as being part of one long question process. Data gathering and interviews were done by Dr. Erin Schu- bert, Director of Outcomes & Evaluation at Sojourner Fam- ily Peace Center. Dr. Erin Schubert is also currently the Sojourner Representative who completes each interview So- journer distributes. Dr. Schubert is trained in performing in- terviews, distributing surveys, and working with abuse vic- tims. Dr. Erin Schubert made it clear to the participants that, this survey was a voluntary research activity distinct from the rest of the standard interview. If the domestic violence sur- vivor reported having been to an Emergency Department for abuse-related or non-abuse-related care since her last inter- view/survey completion, we conducted another survey. If she had not, then no survey was conducted. Each of these interviews were independent of each other and any previous visit to the Emergency Department did not play a role in a subsequent visit. This follow up interview/survey was again anonymous. The interviews were conducted and recorded by Erin Schu- bert in a private room at Sojourner. The surveys were then stored in a locked, limited access area, available to only Dr. Erin Schubert and minimal Sojourner Representatives. The surveys were stored separately from any other forms or sur- veys Sojourner distributes. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2019; 7 (1): e68 3. Results 24 surveys were collected over the course of 7 months. Thir- teen women presented to the ED for treatment of physical injuries related or not related to abuse. The remaining 11 de- nied ever presenting to an ED for treatment related to injuries from abuse. Ten out of the thirteen (77%) women who com- pleted surveys identified problems with the abuse-related care they received. For example, women were screened for domestic violence while a family member was present in the room with them. Others were screened while law enforce- ment was present. Most were screened by either a nurse, so- cial worker, or police officer, not a physician. A handful of women felt as though they were being rushed by their health- care professionals and that they did not genuinely care. How- ever, the most noticeable complaint was that these women were not screened at all. Eleven women were screened for domestic violence when they presented to the Emergency Department. Of these eleven, seven were screened privately, three were screened with another family member present in the room with them, and 1 was screened with her husband, the abuser, in the room. Amber recalled an encounter while her husband was in the room. The doctor just "asked me about my knee. I said I fell down." Even if she had been able to speak about it, "I was totally unaware that anyone could have even helped me. I would have needed someone to clue me in." Three out of the 13 women who presented to the Emergency Department stated they were not comfortable being around, or talking to people in law enforcement. They stated that they had negative attitudes about police, and that they felt that the police did not care about them or their safety. Comments from Brianna stated the following. "Police = bad. Didn’t care. Didn’t believe me. Took forever to get to the house then they didn’t even arrest him." "It wasn’t their fault (doctors/nurses) at all but keep that officer outta there." One woman in particular, Chelsea, stated the following in re- gards to law enforcement: "I went there a few times. The nurse woman who was asking all the questions about my relationships so I could tell that they were suspicious and kind of know what was up. She just turned around her badge and was telling me how she dates a guy in the police and all that. She was very nice and open and all that. I just wasn’t going to open up to them. My ex-fiance was so smart and manipulative and was in law enforcement so who knows who he knew and what they were telling him" Four women reported they either felt rushed while being screened or that the person screening them did not genuinely care. One also felt as though the provider screening them felt uncomfortable asking the questions. Diana reported, "I did feel comfortable at first and told them all that until I realized they really didn’t care and weren’t be- lieving so then I was just like okay whatever." Another comment from Eva stated, "I would’ve felt safer if they took their time and didn’t rush. I mean I understand they got other patients and all that, but it just takes a minute to ask." Francesca recalls, "They did ask a lot of questions. It seemed like they were sometimes trying to avoid the subject or avoid crossing the line or something." During an encounter Giovanna remembers, "They just sent me on my way like they don’t care at all about it." Out of the 13 women who presented to the ED with symp- toms related to domestic violence; four were not screened. This included Heidi who reported the following: "I was pistol whipped and had a split open head. No one there asked me about DV." As well as Ingrid who stated, "I had a sprained ankle and sprained wrist from a domestic violence incident. When I went in, I just said I fell down the stairs doing laundry." Jennifer also recalled, "My husband and I were fighting and he bit my finger, so I went in. Just asking me instead of brush- ing it off. I mean I had a human bite on me. . . like DUH!" Two women stated they were not given any community re- sources to contact following their stay in the Emergency De- partment and they felt as though if they would have had re- ceived resources it would have been extraordinarily helpful and maybe they would not have had to go back to an abusive home after discharge. And finally, Kalie stated the following: "Maybe if they could provide some sort of housing information or funds so I didn’t feel like I had to go back to home.’ 4. Discussion From this data collection, we have started to gain valuable insight on the interactions between healthcare personnel and victims of domestic violence in the Emergency Depart- ment. The most valuable information is that there is still the possibility of women presenting with obvious symptoms of abuse, such as a human bite wound or head injury, not be- ing screened. Presenting to an Emergency Department with a head injury or human bite wound should warrant screen- ing of domestic violence. Another important piece of infor- mation we have gathered is that when screening is done, it is often not completed in a private or secure manner. The majority of screening is being done by either a nurse, so- cial worker, or law enforcement. It is rarely being done by physicians. While the sample size gathered may be small, the 13 survivors surveyed represent a significant portion of women who have experienced domestic violence and have beneficial insight to help improve care and treatment in the Emergency Department. Even with the relatively small sam- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem B. Rodriguez et al. 4 ple size, it is evident that screening for domestic violence is dire and needs to occur more often than what is currently happening. Our research shows the importance of continu- ing research on domestic violence screening and what can be done to improve care in the Emergency Department. These courageous women who have shared their personal stories with us can help pave the way to better treatment for future victims of domestic violence who present to the Emergency Department hoping for care and safety. From this collabora- tion, we hope to gain information that will describe the ways Emergency Department personnel interact with domestic vi- olence victims when providing care. This information will help us identify desirable behaviors of physicians and other professional care givers, as well as ways they can improve their behavior/attitude/treatment of domestic violence vic- tims when they present to the Emergency Department. This data will help us understand what is working well and what needs improvement in regards to domestic violence victims in the Emergency Department. We hypothesize that there will be characteristics of the Emergency Department that are working well, but that there will also be areas that need im- provement to provide the most beneficial care for domestic violent victims during their visit. We recommend universal screening of domestic violence to all women who present to Emergency Department. This screening must be done privately. It is extremely important to screen patients secluded from people who may influence their conversations and safety. There are multiple opportu- nities for healthcare professionals to pull their patients in a private room in order to make them feel safe enough to open up. If a family member or abuser is adamant about not leaving the patient’s side, then personnel can tell them they need the patient for an x-ray, blood draw, or sensitive exam in order to get the patient alone for an opportunity to screen them. Domestic violence screening should always be done in a safe environment, private room, with no other family mem- bers or personnel with them. Most victims of domestic vio- lence do not feel comfortable interacting with law enforce- ment and removing them from the patient’s room could be the first step to making the women feel safe in the Emergency Department and possibly allow them to open up about their experiences. Standardizing who screens patients for domes- tic violence may be a way to properly train healthcare per- sonnel to adequately and respectfully screen. This could also help improve the way personnel ask the questions to hope- fully make the domestic violence victim feel less rushed and more at ease. Having an appointed person or advocate to screen for domestic violence will also ensure that every per- son who presents to the Emergency Department is screened. This advocate may then be able to stay with a woman who has confirmed she is a victim of domestic violence so she can feel safe throughout her entire stay in the Emergency Depart- ment. They can also present standardized community re- sources to ensure her safety following her discharge from the Emergency Department. 5. Limitation Limitations to this study include the small sample size. There was a relatively lower number of women who presented to Sojourner Family Peace Center for initial interviews during the time period of our data collection. 6. Conclusion We gained valuable insight on interactions between health- care personnel and DV victims. DV screening must be done with no family present. Removing law enforcement from rooms is recommended to make women feel more comfort- able. If a family member is adamant about remaining with the patient, the patient can be removed for a blood draw or sensitive exam to attain privacy. Standardizing screening could aid in making DV victims feel less rushed and more at ease. The courageous women sharing personal stories help pave the way to better treatment for future victims of DV pre- senting to the ED. 7. Appendix 7.1. Acknowledgements We would like to acknowledge Dr. Stephen Hargarten, Asso- ciate Dean, Director, Comprehensive Injury Center, Profes- sor of Emergency Medicine at the Medical College of Wiscon- sin, and Dr. Kevin Hamberger, Professor of Family and Com- munity Medicine, Medical College of Wisconsin for being our esteemed mentors and guiding us through the research and publication process. We would also like to acknowledge Dr. Erin Schubert and Sojourner Family Peace Center for giving us the opportunity to collect this data in their walls and for being a safe haven for domestic violence victims. 7.2. Author contribution Management and analysis of data was done by Brieana Rodriguez and Madalyn Mandich, medical students at the Medical College of Wisconsin. The entire research project was overseen by Dr. Stephen Hargarten, Associate Dean, Director, Comprehensive Injury Center, Professor of Emer- gency Medicine at the Medical College of Wisconsin, and Dr. Kevin Hamberger, Professor of Family and Community Medicine, Medical College of Wisconsin. Authors ORCIDs Brieana Rodriguez: 0000-0002-0436-8668 Madalyn Mandich: 0000-0002-4379-255X This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2019; 7 (1): e68 7.3. Funding/Support No funding was used in this project. 7.4. Conflict of interest There are no conflicts of interest that must be declared in re- gards to this study. References 1. Rhodes KV, Frankel RM, Levinthal N, Prenoveau E, Bailey J, Levinson W. "You’re not a victim of domestic violence, are you?" Provider–patient communication about domes- tic violence. Annals of internal medicine. 2007;147(9):620. 2. Joint Commission on Accreditation of Healthcare Organi- zations ( JCAHO) [cited 2019 27.10.2019]. Available from: https://www.omnex.com/members/standards/jcaho/ jcaho.aspx. 3. ACEP. Domestic Family Violence [updated April 2019]. Available from: https://www.acep.org/patient- care/policy-statements/domestic-family-violence/. 4. Moyer VA. Screening for intimate partner violence and abuse of elderly and vulnerable adults: US preventive ser- vices task force recommendation statement. Annals of in- ternal medicine. 2013;158(6):478-86. 5. Larkin GL, Hyman KB, Mathias SR, D’Amico F, MacLeod BA. Universal screening for intimate partner violence in the emergency department: importance of patient and provider factors. Annals of Emergency Medicine. 1999;33(6):669-75. 6. ASPE. Screening for Domestic Violence in Health Care Settings ASPE; 2013. Available from: https://aspe.hhs.gov/report/screening-domestic- violence-health-care-settings. 7. Violence NNCAD. The Nation’s Leading Grassroots Voice on Domestic Violence. Available from: https://ncadv.org/. 8. Center SFP. Our mission. Available from: https://familypeacecenter.org/about/our-mission/. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem B. Rodriguez et al. 6 Appendix 1: Domestic violence screening questions 1. Have you ever gone to an Emergency room for treatment of physical injuries from abuse? YES— NO— 2. Have you ever gone to an Emergency room for treatment of stress-related problems that are related to abuse (for example, headaches, stomach problems, insomnia, etc.)? YES— NO— 3. Have you ever gone to an Emergency room for emotional support because of abuse? YES— NO— 4. Did anyone ask you questions about domestic violence? YES— NO— If yes, did the provider ask the questions in such a way that showed they were interested in what you had to say? YES— NO— 5. Did you feel the physician really listened to you and believed you? YES— NO— 6. Did the hospital staff treat you with respect? YES— NO— 7. Did the hospital staff make you feel safe? YES— NO— 8. Were you asked these questions privately or was a partner, family member, etc. present? —Privately —Partner present —Family present 9. Who asked you the questions about domestic violence? —Doctor —Nurse —Physician’s Assistant —Social Worker—Do not know what their role was 10. Did the person asking you the screening questions about domestic violence make you feel more or less comfortable sharing your current situation? —Comfortable —No opinion —Uncomfortable 11. When they asked you about domestic violence, did they also ask about whether you had a head injury? YES— NO— 12. When they asked you about domestic violence, did they also ask about whether you were choked or strangled? YES— NO— 13. Was your medical exam done in a way that made you feel respected? YES— NO— 14. Were you given any community resources to contact following your stay in the Emergency Department? (check all that apply) For example, domestic violence pamphlets, hotline numbers, etc. —Pamphlet —Hotline Phone Number —Name and contact information for another agency —Other If other, please list: 15. Were you given any information about Sojourner Family Peace Center, Milwaukee Women’s Center, Community Advocates, Bat- tered Women’s Shelter, or any other place you could go to after leaving the Emergency Department? —Sojourner Family Peace Center —Milwaukee Women’s Center —Community Advocates —Battered Women’s Shelter —Other If other, please list: 16. Do you feel that the health care providers in the Emergency Department were helpful? YES— NO— Open Ended Questions: 17. If comfortable, talk me through your Emergency Department visit. 18. On a scale from 1-10, how satisfied were you with your treatment while in the Emergency Department? 1 being highly unsatisfied and 10 being highly satisfied. 1 2 3 4 5 6 7 8 9 10 19. Is there anything you would change on how you were treated in the Emergency Department by the health care providers? 20. Is there anything that a doctor could have done/could do that would help you feel safe telling them about violence or abuse you have experienced? 21. Do you have any other comments about how doctors have been helpful or harmful when you have been treated for abuse related injuries in the emergency department? 22. As a result of your experience(s) in the Emergency Department, did you make any changes to improve your safety? For example, develop a safety plan, change locks, get a restraining order, leave the relationship, connect with community resources, etc. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitation Conclusion Appendix References