The American College of Obstetrics and Gynecology (ACOG) recently recommended that “ob-gyns should routinely screen all women for Intimate Partner Violence (IPV) at periodic intervals including during prenatal visits, offer them support, and have referral and resource information handy for those being abused.” Easy to say, but, some say, it can be hard to do. You need to train people, make provisions for patient safety, understand mandatory reporting laws, have systems to track responses and to ensure follow-up.
A timely publication in the Spring 2012 issue of Family Violence and Health Practice eJournal, titled “Lessons Learned in Implementing a Psychosocial Screener in a High-Risk Obstetrics Clinic” provides some guidance.
Nursing compliance with screening
Beginning in March of 2008, the nursing staff at the University of Kentucky Department of Obstetrics initiated a program to screen all new obstetric patients for psychosocial issues, including current and prior psychological, physical, and sexual abuse. A screening instrument with 24 questions was embedded into the clinic’s EMR. Nurses had to respond to those questions before being allowed to access the rest of the visit record. Because answers were entered directly into the EMR, it was easy to determine how successful the nurses were in screening all new patients. The screening instrument, based on ACOG screening guidelines and the Edinburgh Postnatal Depression Scale, is reproduced in the Appendix of the article.
Nurses attended a one day workshop with an expert in psychosocial screening and health effects of violence on pregnancy outcomes. The workshop was designed to increase their skills in the following areas:
- Being able to perceive abuse clues when taking a patient’s history
- Feeling comfortable in screening patients for current and past abuse
- Knowing how to make appropriate referrals for further services
- Understanding how to correctly comply with Kentucky’s mandatory reporting of current spouse abuse law while ensuring patient safety
During the study timeframe (March 2008 thru February 2009), 534 new obstetric patients were seen in the clinic. Seventy percent were exclusively Spanish-speaking requiring the use of certified Spanish-speaking interpreters. Twelve percent were between the ages of 16 and 19, 28% were 20-24, 47% were 25 to 34, and 13% were 35 or older. Eighty-four percent were insured by Medicaid.
Did it work?
Within two months of initiating the screening program, 75% of all new patients were consistently being screened for housing security, personal safety, and abuse. Let me repeat that, within two months, 75% of new patients were being screened. That is remarkable.
Screening for depression was delayed related to some required software programming. Substance abuse screening rates were low, presumably because the clinic uses urine screens for substance and the results were already in the EMR.
The results of the screening:
- 6% disclosed current physical, sexual, or psychological abuse (being threatened, stalked, controlled, or in any other way made to feel unsafe); 10.7% disclosed lifetime abuse.
- 8.5% disclosed that they did not want the pregnancy
- 7.5% were experiencing very high current stress
- 12% had depressive symptoms
- Exposure to or use of alcohol, drugs, tobacco were also reported
One or more psychosocial risk factors were reported by 40% of those screened and almost 8% reported more than two risk factors.
When queried, 50% of nurses and 20% of attending physicians, residents, or fellows responded that they thought their patients benefitted from screening. Many noted, however, that it is hard to find time and a private place to do the screening and most thought having a social worker or on-site counselor available to provide immediate help, particularly with development of a safety plan would be beneficial. [Hopefully, a further study will explore why so many of the docs didn’t think the program was beneficial, particularly since they really didn’t have to do much to make the program work.]
The challenges of a universal screening program
The authors of the paper conclude by discussing four challenges that need to be addressed when setting up a universal screening program:
1. Understand your State’s Mandatory Reporting law. In Kentucky, spousal abuse must be reported to the Kentucky Department of Community Based Services. Not only were the nurses provided education on the law, they were also provided with a script to help them appropriately comply with the law while still keeping the patient and in control of what happens with respect to the response to the reporting. An example of the script can be found in the article.
2. Finding a private time/space to safely screen. Because family members, including the abuser, may accompany the patient to the clinic visit, it was important to establish a “solo” visit policy whereby family members are not allowed in the examination room
3. Finding the time needed to screen and refer patients. Screening itself only took about 2 minutes, however responding to disclosures, developing a safety plan, and making appropriate referrals could be quite time consuming. [Here, I would like to suggest that the clinics enter into a contract with local service providers to do this part of the intervention. It would free clinic staff from this time consuming task and provide the patient with access to an expert in the topic. Another benefit would be a contractual revenue stream for the service providers that could allow them to increase staff and spend less time fund-raising….altogether a win-win-win.]
4. Building comfort and confidence in nurses’ ability to screen and refer. During the course of the study, the nurses asked for and received additional in-services in which community based providers participated, including the Executive Director of the local domestic violence shelter, representatives of the local Rape Crisis Center, police, social workers, and in-patient substance abuse treatment facilities staff. [Again, perhaps some of this effort could be minimized by contracting with service providers instead.]
What I like about this study is that it shows that taking a systems approach to psychosocial screening can rapidly lead to impressive compliance with the goal of universally screening all new obstetrics patients. This approach was obviously greatly facilitated by embedding the screening instrument in the EMR. By studying the implementation, the authors have identified some areas where further work needs to be done to get the universal screening functioning as smoothly and efficiently as possible.
But it shows that screening can be done. We know it should be done. Now, we just have to do it.