NUR 656 Module 7 Milestone Two Example

Milestone Two: Screening for and Responding to Intimate Partner Violence in Primary Care

[Student Name]

Southern New Hampshire University

NUR 656: Primary Care of Women

Module Seven Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: Screening for and Responding to Intimate Partner Violence in Primary Care

Intimate partner violence affects millions of women in the United States and brings them to primary care with injuries, chronic pain, depression, sexually transmitted infections and pregnancy complications, often without disclosure. Clinicians who do not ask, or who ask in front of a partner, miss the chance to help. Clinicians who ask without a plan for what comes next may do little good. Carmen, 34, came to a composite community health center with arm pain after what she describes as a fall. This milestone documents how screening, a trauma-informed response, danger assessment, safety planning and referral were carried out. It argues that screening is worthwhile only as the first step of a prepared response that the patient controls.

The Evidence on Screening

The USPSTF advises clinicians to ask all women of childbearing age about partner violence and to provide or refer women who screen positive to ongoing support services, based on evidence that interventions offering ongoing support, particularly for pregnant and postpartum women, can reduce violence and improve outcomes (Curry et al., 2018). The Task Force found the evidence insufficient to recommend screening all older or vulnerable adults for abuse.

Screening alone is not enough. MacMillan et al. (2009) randomized more than 6,700 women in emergency, primary care and obstetric settings in Ontario to screening with results given to clinicians or no screening. After eighteen months, screening had not significantly reduced recurrence of violence or improved quality of life, although attrition was high. The authors noted that screening was not accompanied by a specific intervention. The lesson for practice is that asking must be linked to effective support: advocacy, safety planning and connection to community services.

Presentation and Private Screening

Carmen came with her husband, who answered several questions for her. She reported falling down stairs two days ago and hurting both arms. On examination, she had oval bruises of different colors on both upper arms in a pattern consistent with gripping and a healing bruise on her left cheek; there were no fractures. The clinic's policy is that every patient spends part of each visit alone with the clinician, so her husband was asked to wait while she had a routine test. Alone, she was told that the clinic asks all women about relationships because violence is common and affects health, and that what she shared would stay confidential except where the law requires otherwise. Using a brief validated screening tool, she was asked whether her partner had ever hit, kicked or otherwise hurt her, whether she felt safe in her current relationship and whether a partner from a previous relationship was making her feel unsafe. She began to cry and said her husband grabbed and shook her during an argument and had slapped her before.

A Trauma-Informed Response

The response began with validation: Carmen was thanked for sharing, told that the violence was not her fault and that help was available. She was asked what she wanted, rather than told what to do. She did not want to leave her husband now, because of their two children and her financial dependence, but she wanted to be safer. Her choices were respected, and she was told that the clinic would support her whatever she decided.

Danger Assessment

Campbell et al. (2003) conducted a case-control study in eleven cities comparing women killed by intimate partners with abused women who were not killed. The factors that most sharply separated the two groups included an abuser who could get a firearm, one who had already threatened her with a weapon, one who was out of work and a woman separating from a partner who controlled her, and these findings informed the Danger Assessment instrument used by advocates and clinicians. Carmen was asked about these factors. Her husband owns a handgun, has recently lost his job and has threatened to hurt her if she ever left. The presence of a firearm, recent unemployment and threats about leaving placed her at elevated risk, which was explained to her carefully and without alarm, together with the fact that the risk is often highest when a woman tries to leave.

Safety Planning, Referral and Documentation

With the clinic's on-site domestic violence advocate, reached by a warm handoff while Carmen was still in the room, a safety plan was developed: a trusted neighbor who will call for help if she signals, an emergency bag with documents, medications and cash kept at the neighbor's home, the national domestic violence hotline number saved under a different name in her phone and a plan for where to go if she needs to leave quickly. The advocate discussed options for asking police to remove the firearm through a protective order if she chooses. Carmen was offered information on local shelters and legal aid.

Documentation used Carmen's own words, a body map of injuries and photographs taken with her consent, stored in the confidential portion of the record, because such records may later help her in legal proceedings. State law was reviewed: reporting is not required for this situation involving a competent adult without weapon injuries, and Carmen was told this. Her children's safety was discussed, and she said they had not been harmed; the clinician explained the circumstances in which child protection reporting would be required.

Follow-Up

Carmen will come back in two weeks for a visit booked under a routine reason she picked, and she agreed to a safe phone number for contact. Depression screening at follow-up will be repeated, since violence often co-occurs with depression and anxiety.

Conclusion

Carmen's injuries did not match her explanation, and a private, routine screening question gave her the chance to disclose. Because the evidence shows screening helps only when paired with support, the visit continued with a trauma-informed response, a danger assessment grounded in femicide research, a safety plan built with an advocate and careful documentation, all shaped by her own decisions.

The clinician also considered her own role going forward. Carmen may not act on the safety plan right away, and she may return with new injuries or none. Each visit is a chance to ask again privately, to check whether her risk has changed, especially if she is considering leaving, and to remind her that the clinic's support does not depend on any particular decision.

References

Campbell, J. C., Webster, D., Koziol-McLain, J., Block, C., Campbell, D., Curry, M. A., Gary, F., Glass, N., McFarlane, J., Sachs, C., Sharps, P., Ulrich, Y., Wilt, S. A., Manganello, J., Xu, X., Schollenberger, J., Frye, V., & Laughon, K. (2003). Risk factors for femicide in abusive relationships: Results from a multisite case control study. American Journal of Public Health, 93(7), 1089-1097. https://doi.org/10.2105/AJPH.93.7.1089

Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., Doubeni, C. A., Epling, J. W., Grossman, D. C., Kemper, A. R., Kubik, M., Kurth, A., Landefeld, C. S., Mangione, C. M., Silverstein, M., Simon, M. A., Tseng, C. W., & Wong, J. B. (2018). Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: US Preventive Services Task Force final recommendation statement. JAMA, 320(16), 1678-1687. https://doi.org/10.1001/jama.2018.14741

MacMillan, H. L., Wathen, C. N., Jamieson, E., Boyle, M. H., Shannon, H. S., Ford-Gilboe, M., Worster, A., Lent, B., Coben, J. H., Campbell, J. C., & McNutt, L.-A. (2009). Screening for intimate partner violence in health care settings: A randomized trial. JAMA, 302(5), 493-501. https://doi.org/10.1001/jama.2009.1089