• Registered Nurses Association of Ontario (RNAO). Woman abuse: screening, identification and initial response. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 88 p. [112 references]

This is the current release of the guideline.

Woman abuse (including, but not limited to, emotional, financial, physical, and sexual abuse, as well as, intimidation, isolation, threats, using the children, and using social status and privilege)

Management
Prevention
Screening

Emergency Medicine
Family Practice
Internal Medicine
Nursing
Obstetrics and Gynecology
Pediatrics
Preventive Medicine

Advanced Practice Nurses
Nurses

• To facilitate routine universal screening for woman abuse by nurses in all practice settings
• To increase opportunity for disclosure, which will promote health, well-being, and safety in women
• To offer nurses a repertoire of strategies that can be adapted to various practice environments

Women aged 12 and older

Screening

1. Implement routine universal screening of women 12 years of age and older
2. Foster environments that facilitate disclosure
3. Use screening strategies that respond to the needs of all women taking into account differences
4. Use reflective practice
5. Document screening practice

Initial Management

1. Acknowledge the abuse
2. Validate the woman's experience
3. Assess immediate safety
4. Explore options
5. Refer to violence against women services at the woman's request
6. Document response to interaction
7. Understand legal obligations

• Incidence and prevalence of abuse
• Health consequences of woman abuse on women and on children of abused women
• Benefits of routine universal screening
• Effectiveness of screening strategies at identifying abuse
• The health, well-being, and safety of women

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Searches of Unpublished Data

A database search for existing guidelines on Woman Abuse/Domestic Violence was conducted by a university health sciences library. An initial search of the MEDLINE, EMBASE, and CINAHL databases for guidelines and articles published from January 1, 1996 to December 31, 2003 was conducted using the following search terms: "domestic violence (physical or sexual abuse of spouse or intimate partner)," "violence against women," "intimate partner violence," "partner abuse," "spouse abuse," "screening," "assessment," "practice guideline(s)," "clinical practice guideline(s)," "standards," "consensus statement(s)," "consensus," "evidence-based guidelines," and "best practice guidelines."

One individual searched an established list of 49 Web sites for content related to the topic area. This list of sites, reviewed and updated in Fall 2003, was compiled based on existing knowledge of evidence-based practice Web sites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched as well as date searched. The Web sites at times did not house a guideline but directed to another web site or source for guideline retrieval. Guidelines were either downloaded if full versions were available or were ordered by phone/email.

A Web site search for existing guidelines on woman abuse was conducted via the search engine "Google," using the search terms identified above. One individual conducted this search, noting the search term results, the Web sites reviewed, date, and a summary of the findings. The search results were further critiqued by a second individual who identified guidelines and literature not previously retrieved.

Additionally, panel members were already in possession of a few of the identified guidelines. In some instances, a guideline was identified by panel members and not found through the previous search strategies. These were guidelines that were developed by local groups or specific professional associations. Results of this strategy yielded one additional guideline.

The above search method revealed twenty-four guidelines, several systematic reviews, and numerous articles related to woman abuse.

The final step in determining whether the clinical practice guideline would be critically appraised was to have the development panel screen the guidelines based on the following criteria, which were determined by panel consensus:

• Guideline was in English.
• Guideline was dated no earlier than 1999.
• Guideline was strictly about the topic area.
• Guideline was evidence-based (e.g., contained references, description of evidence, sources of evidence).
• Guideline was available and accessible for retrieval.
• Guideline was developed for populations similar to Canada.

Fourteen guidelines met the screening criteria and were critically appraised.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Systematic Review

Not stated

Expert Consensus

In January of 2004, a multidisciplinary panel of health care professionals with expertise in woman abuse from institutional, community, and educational settings was convened under the auspices of the Registered Nurses Association of Ontario (RNAO). The panel established the scope of the guideline through a process of discussion and consensus. It was decided to focus on screening, identification, and initial response for women experiencing abuse.

The development panel divided into subgroups to engage in specific activities using the short-listed guidelines, other literature, and additional resources for the purpose of drafting recommendations for nursing interventions. This process yielded a draft set of recommendations. The panel members as a whole reviewed the recommendations, discussed gaps and available evidence, and came to consensus on a draft guideline.

Not applicable

A published cost analysis was reviewed.

External Peer Review
Internal Peer Review

This draft was submitted to a set of 69 external stakeholders for review and feedback. An acknowledgement of these reviewers is provided at the front of the original guideline document. Stakeholders represented various health care disciplines, clients and families, as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. Forty-five stakeholders returned comments and suggestions to the development panel representing a 65% response rate. For each of the recommendations, the percentage of "agreement with the recommendation" was calculated. Of the 45 respondents, there was 90 to 100% agreement depending on the specific recommendation. The final results of the stakeholder feedback were compiled and reviewed by the development panel. Discussion and consensus resulted in revisions to the draft document prior to publication.

The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.

Practice Recommendations

Recommendation 1.0

Nurses implement routine universal screening for woman abuse in all health care settings.

(Level of Evidence = IIb)

Recommendation 2.0

Routine universal screening be implemented for all females 12 years of age and older.

(Level of Evidence = IV)

Recommendation 3.0

Nurses develop skills to foster an environment that facilitates disclosure.

This necessitates that nurses know:

• how to ask the question
• how to respond

(Level of Evidence = IV)

Recommendation 4.0

Nurses develop screening strategies and initial responses that respond to the needs of all women, taking into account differences based on race, ethnicity, class, religious/spiritual beliefs, age, ability, or sexual orientation.

(Level of Evidence = III)

Recommendation 5.0

Nurses use reflective practice to examine how their own beliefs, values, and experiences influence the practice of screening.

(Level of Evidence = IIa)

Recommendation 6.0

Nurses know what to document when screening for and responding to abuse.

(Level of Evidence = IV)

Recommendation 7.0

Nurses know their legal obligations when a disclosure of abuse is made.

(Level of Evidence = IV)

Education Recommendations

Recommendation 8.0

Mandatory educational programs in the workplace be designed to:

• increase nurses' knowledge and skills
• foster awareness and sensitivity about woman abuse

(Level of Evidence = Ib)

Recommendation 9.0

All nursing curricula incorporate content on woman abuse in a systematic manner.

(Level of Evidence = III)

Organization & Policy Recommendations

Recommendation 10.0

Health care organizations develop policies and procedures that support effective routine universal screening for and initial response to woman abuse.

(Level of Evidence = IV)

Recommendation 11.0

Health care organizations work with the community at a systems level to improve collaboration and integration of services between sectors.

(Level of Evidence = Ib)

Recommendation 12.0

Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational, and administrative support, as well as appropriate facilitation.

Organizations may wish to develop a plan for implementation that includes:

• An assessment of organizational readiness and barriers to education.
• Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.
• Dedication of a qualified individual to provide the support needed for the education and implementation process.
• Ongoing opportunities for discussion and education to reinforce the importance of best practices.
• Opportunities for reflection on personal and organizational experience in implementing guidelines.

In this regard, Registered Nurses Association of Ontario (RNAO) through a panel of nurses, researchers and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of the Registered Nurses Association of Ontario guideline Woman Abuse: Screening Identification and Initial Response.

(Level of Evidence = IV)

Definitions:

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Algorithms are provided in the original guideline document for the routine universal comprehensive screening (RUS) protocol and for an example of emergency department decision flow chart.

The type of evidence is identified and graded for each recommendation (see "Major Recommendations").

• Some of the many benefits of routine universal screening include:
  • Increasing opportunities for women to disclose abuse
  • Increasing opportunities for nurses to identify women who have been abused
  • Linking health consequences to abuse, thereby positioning violence as a legitimate health concern
  • Identifying the health impacts of abuse and providing early intervention
  • Avoiding stigmatization by asking all women about abuse
  • Reducing the sense of isolation abused women experience
  • Affording opportunities to assist children of abused women
  • Giving a strong message that abuse is wrong
  • Informing women about violence against women services and other options that are available
  • Fostering healthy communities
• The overall intended outcome is increased opportunity for disclosure, which will promote health, well-being, and safety for women.
• Nurses, other health care professionals, and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessment and documentation tools, etc.

Not stated

• This nursing best practice guideline is a comprehensive document providing resources necessary for the support of evidence-based nursing practice. The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
• These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
• It is acknowledged that individual competence in screening varies between nurses and across categories of nursing professionals (registered practical nurses [RPNs] and registered nurses [RNs]) and is based on knowledge, skills, attitudes, critical analysis and decision-making skills, which are enhanced over time by experience and education. Individual nurses will perform screening for woman abuse following appropriate education and experience. It is expected that nurses will seek appropriate consultation when client care requirements exceed the nurse's ability to act independently. Effective health care depends on a coordinated interdisciplinary approach incorporating ongoing communication between health professionals and clients, ever mindful of the personal preferences and unique needs of each individual client.

Best practice guidelines can only be successfully implemented if there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. In this light, Registered Nurses Association of Ontario (RNAO), through a panel of nurses, researchers, and administrators has developed Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a health care organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline:

1. Identifying a well-developed, evidence-based clinical practice guideline
2. Identification, assessment, and engagement of stakeholders
3. Assessment of environmental readiness for guideline implementation
4. Identifying and planning evidence-based implementation strategies
5. Planning and implementing evaluation
6. Identifying and securing required resources for implementation

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.

Evaluation and Monitoring

Organizations implementing the recommendations in this nursing best practice guideline are encouraged to consider how the implementation and its impact will be monitored and evaluated. A table found in the original guideline document, based on a framework outlined in the Registered Nurses Association of Ontario Toolkit: Implementation of Clinical Practice Guidelines (2002) illustrates some indicators for monitoring and evaluation.

Implementation Strategies

The Registered Nurses Association of Ontario and the guideline development panel have compiled a list of implementation strategies to assist health care organizations or health care disciplines who are interested in implementing this guideline. See the original guideline document for a summary of strategies.

Staying Healthy

Effectiveness
Patient-centeredness

• Registered Nurses Association of Ontario (RNAO). Woman abuse: screening, identification and initial response. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 88 p. [112 references]

The Registered Nurses Association of Ontario (RNAO) panel selected the following guidelines to adapt and modify for the current guideline:

• Department of Health (DH) (2000). Domestic violence: A resource manual for health care professionals.
• Education Centre Against Violence (ECAV) (2001). Routine screening for domestic violence in NSW health: An implementation package. Parramatta: Author.
• Family Violence Prevention Fund (FVPF) (2004). National consensus guidelines on identifying and responding to domestic violence victimization in health care settings.
• Health Canada. (1999a). A handbook dealing with woman abuse and the Canadian criminal justice system: Guidelines for physicians.
• Middlesex-London Health Unit (MLHU) (2000). Task force on the health effects of woman abuse -- Final report. London, Ontario: Author.

2005 Mar

Registered Nurses Association of Ontario - Professional Association

Funding was provided by the Ontario Ministry of Health and Long Term Care.

Not stated

Development Panel Members

Daina Mueller, RN, BScN, MSN
Team Leader
Program Manager
Hamilton Public Health and
Community Services Department
Hamilton, Ontario

Debbie Aylward, RN, BScN, MScN
Perinatal Coordinator
Perinatal Partnership Program of Eastern and
Southeastern Ontario
Transport Nurse, Neonatal Intensive Care Unit
Children's Hospital of Eastern Ontario
Ottawa, Ontario

Helene Berman, RN, PhD
Associate Professor
University of Western Ontario
School of Nursing
London, Ontario

Mary Carter, RN, BScN, SANE
Domestic Violence/Sexual Assault Treatment Program
Sudbury Regional Hospital
Sudbury, Ontario

Mary Dempsey, RN, BA, SANE
Sexual Assault/Domestic Violence Care Centre
Nurse Facilitator
Hamilton Health Sciences Centre
McMaster University Medical Centre
Hamilton, Ontario

Kathleen Fitzgerald RN, BN, MHScN, SANE
Manager, Sexual Assault/Partner Abuse
Treatment Program
Lake of the Woods District Hospital
Kenora, Ontario

Lisebeth Gatkowski, RN
Community Liaison Program
St. Joseph's Healthcare:
Centre for Mountain Health Services
Hamilton, Ontario

Sarah Kaplan, MSW
Coordinator
Partner Abuse Sexual Assault Care Team
Cornwall Community Hospital
Cornwall, Ontario
Sheila Macdonald, RN, MN, CNS
Provincial Coordinator
Ontario Network of the Sexual Assault/Domestic Violence Care Treatment Centres
Sunnybrook and Women's College
Health Sciences Centre
Toronto, Ontario

Rosemary Rak, RN, CPMHN(C)
Clinical Nurse Educator
Mental Health Addiction Program
Royal Victoria Hospital
Barrie, Ontario

Susan Ralyea, RN, BScN, MHSc
Consultant and Educator
Dorchester, Ontario

Jane M. Schouten, RN, BScN, MBA
RNAO Program Staff -- Facilitator
Program Coordinator
Best Practice Guidelines Program
Registered Nurses Association of Ontario
Toronto, Ontario

Jody Stasko, RN, BSc, BScN, SANE
Sexual Assault Nurse Examiner
Sunnybrook and Women's College Health
Sciences Centre
Sexual Assault/Domestic Care Centre
Toronto, Ontario

Declarations of interest and confidentiality were made by all members of the guideline development panel. Further details are available from the Registered Nurses Association of Ontario.

This is the current release of the guideline.

None available

This summary was completed by ECRI on June 3, 2005. The updated information was verified by the guideline developer on June 21, 2005.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses Association of Ontario (2005). Woman abuse: screening, identification and initial response. Toronto, Canada: Registered Nurses Association of Ontario.