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Mandatory reporting of intimate partner violence by health care professionals: A policy review
Mandatory Reporting of Intimate Partner Violence by Health Care Professionals: A Policy Review Nancy Glass, MSN, MPH, RN Jacquelyn C. Campbell, PhD, RN California and 5 other states have adopted a policy that requires health care professionals to report suspected intimate partner violence to law enforcement agencies. This policy presents challenges to nursing regarding implementation of the policies, influencing future policy direction, and ensuring that a research base is developed.
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ebate is ongoing among policymakers, health care professionals, and advocates for battered women and their children c o n c e r n i n g the most effective responses to the epidemic of intimate partner violence in the U n i t e d States. The public's awareness of the effects of i n t i m a t e p a r t n e r v i o l e n c e on abused women and their children has significantly increased during the past decade. I Increasingly, the public is dem a n d i n g that policy-makers be more sensitive to this public health issue and find solutions to this n a t i o n a l crisis. With the focus on this issue intensifying, policy-makers have turned their attention to health care providers and to m a n d a t i n g their response to battered women who seek medical care. 2
INTIMATE PARTNER VIOLENCE AS A PUBLIC HEALTH ISSUE Intimate partner violence is now recognized as a serious and widespread public health problem for women in the U n i t e d States. According to a recent n a t i o n a l r a n d o m survey, at least 4.4 m i l l i o n
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women are battered by a partner or expartner each year in the U n i t e d States. 3 T h e 1992-1993 N a t i o n a l Crime Victimization Survey reported that 29% of all violence against women is perpetrated by an intimate partner and that women were more likely to be injured as a result of violence by an intimate partner t h a n by a stranger. 4 According to a 1993 Federal Bureau of Investigations report, 31% of female homicide victims were murdered by their spouses, ex-spouses, or boyfriendsS; the n a t i o n a l data do not inc l u d e e x - b o y f r i e n d s as p e r p e t r a t o r s . Recent statewide data from N o r t h Carolina suggest that current or former male i n t i m a t e p a r t n e r s are r e s p o n s i b l e for more t h a n 50% of female murders. 6 Research suggests that at least 1 million women seek medical care for abuserelated injuries each year in the U n i t e d States. 7's Several studies have suggested that i n t i m a t e partner violence is common among women who visit emergency d e p a r t m e n t s (EDs). Earlier studies reported that 6% to 30% of women who visited EDs were abused, s~° In more rec e n t ED studies, A b b o t t et al ~ found that the incidence of physical trauma from abuse was 2.7% for all women with a current partner who went to the ED.
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According to a combined medical record review and confidential p a t i e n t survey, a 3.1% rate of injury from abuse was reported in 10 EDs in the Midwest. 12 In a n o t h e r study of 12 c o m m u n i t y hospitals it was found that the p r e v a l e n c e of abuse by an i n t i m a t e p a r t n e r t h a t resuited in acute trauma was 2%. T h e lifetime prevalence of i n t i m a t e p a r t n e r violence reported in the a f o r e m e n t i o n e d studies ranged from 11% to 54%, and past year prevalence was approximately 10% to 15%. 813 P l i c h t a ~ f o u n d t h a t w o m e n who had been physically abused by a spouse or live-in p a r t n e r were significantly more likely t h a n other w o m e n to define their health as fair or poor. In the same survey, battered w o m e n also were more likely to name the ED as their primary source of health c a r e ) T h u s battered women are less likely to have an ongoing relationship with a h e a l t h care provider. Battered w o m e n come to the h e a l t h care system s e e k i n g h e l p , b u t most often they are treated for their immediate injuries or symptoms and are n e v e r asked about the u n d e r l y i n g cause. As few as 5% of battered w o m e n who seek medical care are correctly identified as battered women by their providers2 In a recent study c o n d u c t e d in 12 c o m m u n i t y hospitals, no d o c u m e n t a t i o n of abuse was found in medical records for ahnost half of the women who reported visiting an ED because of abuse. 14 T h e failure to identify battered women results in a p o t e n t i a l added cost to an already overwhelmed health care system. W h e n battered women are n o t identified, the abuse is not d o c u m e n t e d for future reference and an opportunity is missed to provide education about p r e v e n t i o n and
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safety planning, along with options for getting away from the abuse and referrals to resources in the community. 1 The children of abused women also are affected when their mothers are not identified as battered by health care providers. Research indicates that 3 million to 10 million children witness their mothers being treated violently each year. 15-18 These children are at an increased risk for emotional, behavioral, and cognitive delays17; they also are at risk for being abused by a partner or being abusive to their partner in the future) 9'2°Rath et a121 found that children of battered women used health services 6 to 8 times more often than other children. Providing early intervention and prevention programs for children who witness violence is a potential cost.effective measure by the health care system.
CALIFORNIA L A W Policy-makers are justified in looking for new and effective policies to address this public health crisis. In 1994, California was the first state to require that health care providers report to law enforcement officials when medical services were provided to a patient who they "know or reasonably suspect to suffer from any wound or other physical injury inflicted upon a person where the injury is a result of assaultive or abusive conduct. ''22 The definition of assaultive and abusive conduct includes rape, sexual assault, and abuse by a spouse or co-habitant. = Six states (California, Colorado, Kentucky, New Hampshire, New Mexico, Rhode Island) have mandatory reporting laws specific to the identification of intimate partner violence in a clinical setting, > and many other states are considering such legislation. Too often, legislated health policy is based on public response to a perceived crisis or it imitates other initiatives without a thorough review of principles and research on which to base new directions. We offer a retrospective review of this particular legal policy adoption process and a discussion of policy objectives, outcomes, principles, and the needed research base. In addition, we offer a suggestion for possible changes in the policy and discuss the challenges to nursing regarding implementation of mandatory reporting policies and influencing future direction of these policies. 280
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THE LEGISLATIVE PROCESS
Policy Objectives Laws mandating that health care providers report suspected intimate partner violence seek to (1) enhance the safety and care of the patient, (2) collect incidence and prevalence data for intimate partner violence, (3) provide d o c u m e n t a t i o n of i n t i m a t e p a r t n e r violence to strengthen the legal case against the perpetrator, (4) improve health care providers' response to and identification of intimate partner violence, (5) aid law enforcement officials in the prosecution of perpetrators of intimate partner violence, z4 (6) remove the responsibility for contacting law enf o r c e m e n t officials from the battered woman, and (7) make clear that the h e a l t h care system and society do not c o n d o n e intimate partner violence.
Process Review A retrospective review of the process of the development and passage of the law in C a l i f o r n i a reveals t h a t longtime advocates for battered women and battered women themselves were left out of the discussion about mandatory reporting (Nudelman J, Family Violence Prev e n t i o n Fund. Oral c o m m u n i c a t i o n . Dec 1996). According to Mooney and Rodriquez, 25 prenatal nurses working in an outreach program in California wrote a letter requesting that Assemblywoman Jacqueline Speier address "serious flaws" in an existing medical workers reporting law from the early 1900s. T h e nurses asked for a law to provide protection from liability when reporting cases of suspected intimate partner violence and to clearly explain who among health professionals has a duty to report the suspected cases. 25 Interest in a law to clarify liability may have been caused in part by the 1992 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, which mandated that protocols for the assessment, documentation, and intervention for intimate partner abuse be present in certain units (ED, ambulatory care, and substance abuse treatment). Also, providers or hospitals may have been worried about prosecution or lawsuits stemming from a failure to report intimate partner violence under J C A H O guidelines, z Since the first J C A H O man-
date, the 1995 guidelines have been expanded to include protocols for assessment, documentation, and intervention for intimate partner violence in all departments in all health care settings. 26
Assembly Bill 1652 In 1994, Assembly Bill 1652, written by Jacqueline Speier, was approved by the governor of California only 9 months after the original request was written. 25 The new law provides for immunity from liability for reporting by health care practitioners and payment for attorney fees for legal action against practitioners who report and prohibits any interference in reporting by administrators or superiors, z5 The law identified nurses as health care workers who are required to report, 25 and recommends--but does not require--that health care practitioners document in medical records any comments made about the injury or perpetrator, include a body map showing injuries, include a law enforcement reporting form, and refer patients to intimate partner violence service agencies. 25 The California law mandates that any health practitioner employed in a health facility, clinic, physician's office, local or state public health department or clinic, or other facility operated by the local or state public health department report cases of suspected intimate partner violence to law enforcement officials immediately or as soon as practically possible. 27
PRINCIPLES A N D RESEARCH BASE
Child Abuse and ElderAbuse Mandatory Reporting Laws Mandatory reporting laws are modeled after state laws that mandate reporting of s u s p e c t e d c h i l d abuse and elder abuse. In cases of child abuse, the state can act as g u a r d i a n to p r o m o t e the child's safety. Whereas it is reasonable to assume that a child is unable to make an informed decision concerning his or her life, advocates maintain that it is paternalistic to assume women are unable to make informed decisions about their lives and safety. 2 Some advocates for the elderly oppose mandatory reporting laws for elder abuse because they believe that the assumption that
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the elderly are unable to make informed decisions about their need for assistance and safety is based solely on their advanced age. 2s Child abuse and elder abuse laws may not be the most appropriate models to use when designing policies regarding intervention in cases of intimate partner violence. It is important to note that agencies handling reports, such as child protective services and adult protective services, are underfunded and overworked. The cases reported may never be investigated; therefore, the abused person may be further harmed by having his or her hopes raised that someone will intervene in their situation. 29 Data reported in the literature by Hampton and Newberger 3° reveal biases in the reporting of child abuse by health care providers. A n analysis of child abuse reporting revealed that black and Latin American families were disproportionately identified as abusive and reported to authorities. 3° Poor families had the highest rate of child abuse reports by providers. It is possible that mandatory reporting of intimate partner violence could result in the same biased reporting. Health care providers often have a stereotypical view of an abused woman's appearance and of abuse risk factors; many providers believe that intimate partner violence occurs almost exclusively in poor minority families.
Mandatory Reporting Outcomes Health care professionals, advocates for battered women, and battered women are concerned that mandatory abuse reporting ignores women's autonomy and decision-making abilities. If battered women were afforded full autonomy, the decision to report the violence would be made by the woman herself, because she has specific knowledge related to her s i t u a t i o n and her risk for f u r t h e r abuse. Abused women are at risk for revictimization by the system when a report is made without her consent to a criminal justice system that may be overburdened and underfunded. Empirical evidence shows that the arrest of the abuser may increase the risk of further violence for some women. ~) Until research clearly shows for whom arrest may pose increased risk rather than decreased risk, the woman's perception of the situNURSING OUTLOOK
ation should be given full consideration. In addition, mandatory reporting of abuse diminishes the confidential patient-provider relationship and may result in an abused women delaying medical t r e a t m e n t or refusing to disclose abuse because of fear that the case will be reported. This situation will make it more difficult for providers to adequately intervene in the lives of abused women and their children. A l t h o u g h the policy is intended to enable abused women to be cared for more effectively, advocates and abused women believe that the provider and state actually are imposing the same form of power and control over the woman as her abuser. She may be disempowered by having her decisionmaking ability taken away by the people to whom she has come for assistance and empowerment. W o m e n should be able to feel that the information they give to their provider will remain confidential and that they can trust the provider. Many health care professionals and advocates believe that mandatory abuse reporting is not accomplishing the stated objectives but instead is raising serious ethical questions. 22'32 Although mandatory reporting of suspected intimate p a r t n e r v i o l e n c e by health care providers has not been formally evaluated, it may not be fulfilling the objectives of enhancement of patient care and safety, collection of data about the incidence and prevalence of intimate partner violence, documentation of intimate partner violence, improvement of provider response, and assistance to law enforcement officials in prosecution of perpetrators. A review of each policy objective reveals examples of possible outcomes that are the opposite of those intended by the policy.
Objectives and Unintended Outcomes The first objective of mandatory abuse reporting is to enhance the safety and care of the abused woman. Many women turn to the health care system only as a last resort. Abused women who turn to the h e a l t h care system for assistance need assurances that they are not at fault for the abuse. T h e y need information and education about safe alternatives to returning home and referrals for counseling, shelter, and legal services. :4
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Abused women often do not trust an overburdened system to respond to their needs. They may have had experiences in which the police did not enforce a restraining order or the judicial system refused to prosecute the abuser. 33 Furthermore, abused w o m e n d o u b t t h a t the police can provide them with the protection they need from their abuser. 34 Abused women fear that the violence will escalate if they report the abuse to the police. Even in cases in which the health care provider is actually responsible for reporting the suspected abuse, w o m e n have no g u a r a n t e e t h a t t h e abuser will not hold t h e m responsible and retaliate against them and their children. W o m e n who fear retaliation from abusers when their cases are reported to law enforcement officials may not seek medical care or be honest with providers about symptoms and injuries. The second objective of the policy is data collection. Mandatory reporting is useful in collecting d e m o g r a p h i c and clinical data regarding the incidence and prevalence of intimate partner violence. 24 Researchers may be able to use this data to identify areas for funding and intervention; however, inaccurate data related to provider noncompliance and biases in the reporting of intimate partner violence is likely. Clearly, accurate and useful data on intimate partner violence is needed. A funded anonymous study conducted by knowledgeable and trained researchers probably would yield better data t h a n mandatory reporting; however, anonymity of responses may interfere with linkages to medical records for review. The third objective, d o c u m e n t a t i o n by health care providers, can be very effective in strengthening the woman's case against her abuser. Documentation should be made in a medical chart that provides a complete history, assessment, diagnosis, and plan for follow-up care. However, documentation that can be used in court does not have to be linked to mandatory reporting. It would be more useful if documentation was standardized among the different types of providers and health care settings; this would permit aggregating data from multiple sources to evaluate prevention programs. A t this time, the amount of information provided to law enforcement and social service agencies depends on the providers and the Glass and Campbell
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guidelines of the health care facility in which they practice. The fourth objective is to enhance the provider's ability to respond effectively to battered women and their children. The development of a curriculum to be taught to health care providers while they are in training as well as continuing education courses, are effective ways to sensitize providers to the issue of intimate partner violence. Mandatory reporting of intimate partner violence may increase the number of in-service training sessions for health care providers and increase attendance. In addition to education, health care facilities will need to establish protocols and procedures based on J C A H O guidelines for the assessment, intervention, and documentation of intimate partnet violence. In the recently completed case.control study of 12 community hospitals in California and Pennsylvania, the case hospitals in California (baseline rate of 17%) increased the rate of documentation of intimate partner violence in medical records to 20% after a training intervention with key personnel from the
The development o f a curriculum to be taught to health care providers while they are in training, as well as continuing education courses, are effective ways to sensitize providers to the issue o f intimate partner violence.
EDs. Documentation of self-identified abused women continued to improve during the next 12 months, with a 55% documentation rate at the completion of the study. The Pennsylvania case hospitals (baseline rate of 50%) demonstrated an initial improved rate of documentation (88%) after the training intervention, but the rate declined during the next 12 m o n t h s , with 60% of self-identified abused women documented in the medical records34 Training ED staff members to document intimate partner violence results in improved medical record documentation initially, but follow-up training may be necessary to assist providers 282
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in continuing to appropriately document intimate partner violence. The fifth objective of facilitating criminal prosecution through mandatory reporting is possible only in a law enforcement system that handles reports of intimate partner violence in a timely manner. Women who report intimate partner violence become frustrated when police officers refuse to intervene and arrest the abuser. Some police officers do not consider intimate partner violence to be a serious offense. Mandatory reporting will increase the number of cases reported but may not result in more effective prosecution of those cases. Education and collaboration among health care providers, law enforcement officials, social service agencies, advocates for battered women and their children, and battered women would better meet the objective of facilitating criminal prosecution.
Suggestion for Change in Mandatory Reporting Law
may be most effective in obtaining informed consent from the battered woman and providing referrals to community resources. Nurses are trained not only to manage the injuries or symptoms of the patient at the time the patient seeks health care, but also to look at the patient holistically. The nurse is trained to ask probing questions that will assess the environments in which the woman lives and works. Nurses know how to ask questions that will address the underlying causes of injuries and symptoms. Skilled nurses should lead the health care team in the assessment of intimate partner violence for every woman who seeks medical care. We are advocating for nursing to join the National Research Council of the Institute of Medicine in their recommendation for all states to refrain from enacting mandatory reporting laws for domestic violence until such systems be tested and evaluated by research. 3s
Challenges to Nursing
Advocates for abused women and their c h i l d r e n m a i n t a i n that u n i n t e n d e d policy outcomes will continue until the law is amended to require informed consent by the abused woman before her case can be reported to law enforcement by health care providers. The advocates in California indicate they are working with the legislature to amend the California law to require informed consent for reporting of abuse. The process of informed consent is a basic premise for the health care provider. 24It is believed that informed consent would empower the woman to be an active participant with the provider in making the decision. If informed consent were required for reporting, health care providers would need to be well informed and sensitive to issues relevant to intimate partner violence. The provider would be responsible for educating the patient about safe alternatives for leaving the abuse and providing options that are useful in her situation. The provider would need to be knowledgeable about resources for battered women and their children in the community and have contacts to gain entrance into these agencies. Many health care providers do not have the skills, knowledge, or contacts to adequately advise battered women. Nurses
Even though not every state mandates reporting of intimate partner violence by health care providers, nurses need to be
Skilled nurses should lead the health care team in the assessment of intimate partner violence for every woman who seeks medical ca re.
aware of the statute and any proposed mandatory reporting legislation in their state. Nurses can contact their state Domestic Violence Coalition, the national Family Violence Prevention Fund, or the national Health Resource Center on Domestic Violence at (888) 792-2873 to educate themselves and their colleagues about the consequences of mandatory reporting for abused women and their children. Nurses can attend intimate partner violence workshops and conferences for continuing education credit. Nurses who are unable to attend conferences outside of their worksite can request that nursing administration develop in-service training on intimate partner violence and offer their assistance. Nurses can collect data on mandatory reporting in their
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h e a l t h care setting from the perspective of b o t h the abused w o m a n and h e a l t h care provider; they can use this data to testify as experts in legislative hearings c o n c e r n i n g the a d o p t i o n of the m a n d a tory reporting law. Nurses also are encouraged to join the Nursing N e t w o r k on Violence Against Women International ( t e l e p h o n e 8 8 8 - 9 0 9 - 9 9 9 3 ) . O n e of the goals of the n e t w o r k is to s t r e n g t h e n the partnership of h e a l t h care professionals and the c o m m u n i t y as they work to end violence against women. W e are urging nurses to take leadership roles in educating the interdisciplinary t e a m about the u n i n t e n d e d o u t c o m e s that m a n d a t o r y reporting can h a v e on the lives of abused w o m e n and their children. W e are advocating for nursing to j o i n t h e N a t i o n a l R e s e a r c h C o u n c i l of t h e I n s t i t u t e of M e d i c i n e in t h e i r r e c o m m e n d a t i o n for all states to refrain from e n a c t i n g m a n datory r e p o r t i n g laws for d o m e s t i c violence until such systems be tested and e v a l u a t e d by research. 35
CONCLUSION Advocates, health care providers, law enforcement officials, and policy-makers must c o m e t o g e t h e r to d e v e l o p policy related to i n t i m a t e partner v i o l e n c e . T h e C a l i f o r n i a law provides an e x a m p l e of l e g i s l a t i o n t h a t c a n be p a s s e d w h e n policy-makers w a n t to find a s o l u t i o n to a crisis t h a t has b e c o m e an i m p o r t a n t public issue. Policy-makers n e e d to c o n sider all t h e r a m i f i c a t i o n s of t h e i r policies and pursue a s o l u t i o n to t h e public h e a l t h p r o b l e m by asking for v a l u a b l e input from advocates, h e a l t h care prof e s s i o n a l s , b a t t e r e d w o m e n , a n d researchers who are d e d i c a t e d to e n d i n g intimate partner violence. •
REFERENCES 1. Campbell JC, Parker B. Review of nursing research on battered women and their children. In: Fitzpatrick R, Taunton R, Jacox A, editors. Annual review of nursing research. New York: Springer; 1992. 2. Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence: do they promote patient well-being? JAMA 1995;273:1781-7. 3. Plichta SB. Violence and abuse: implications for women's health. In: Falik MM, Collins KS, editors. Women's health: the commonwealth survey. Baltimore (MD): Johns Hopkins University Press; 1996.
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4. Bachman R, Saltzman LE. Violence against women: estimates from the redesigned survey. NCJ- 154348. Washington: Bureau of Justice Statistics, US Department ufJustice; 1995. 5. Federal Bureau of Investigation. Uniform crime report. Washington: US Department of Justice; 1993. 6. Moracco KE, Runyon CW. lntra-family homicide of women in North Carolina: using public health and police data to explore female homicide. Proceedings of the 5th International Family Violence Research Conference; 1997 Durham, NH. 7. Plichta SB. Violence, health and use of health services. In: Anonymous. Women's health and care seeking behavior. Baltimore (MD): Johns Hopkins University Press; 1996. 8. Stark E, Flitcraft A, Frazier W. Wife abuse in the medical setting: an introduction for health personnel. Washington: Office of Domestic Violence; 1982. 9. Goldberg WG, Tomlanovich MC. Domestic violence victims in the emergency department. JAMA 1984;251:3259-64. 10. Mcleer SV, Anwar R. A study of battered women presenting to an emergency department. Am J Public Health 1989;79:65-6. 11. Abbott J, Johnson R, Koziol-Mclain J, Lowenstein SR. Domestic violence against women: incidence and prevalence in an emergency department. JAMA 1995;273:1763-6. 12. Muelleman RA, Lenaghan PA, Pakieser RA. Battered women: injury locations and types. Ann Emerg Med I996;28:486-92. 13. Dearwater S, Coben JH, Nah G, Campbell JC, McLoughlin E, Glass NE, et al. Prevalence of domestic violence in women treated at community hospital emergency departments. JAMA In press. 14. Campbell JC, Cohen JH, Glass NE, Dearwater S, James L. Evaluation of the national health initiative to improve ED response to battered women. Proceedings of the Society for Academic Emergency Medicine; 1998 May 18-20; Chicago, IL. 15. Carlson BE. Children's observations of interparental violence. In: Roberts AR, editor. Battered women and their families. New York: Springer; 1984. 16. Strauss MA, Gelles RJ. Physical violence in American families: risk factors and adaptations to family violence in 8,145 families. New Brunswick (NJ): Transaction Press; 1990. 17. Campbell JC, Humphreys J. Nursing care of survivors of family violence. St. Louis (MO): Mosby; 1993. 18. Campbell JC, Lewandowski L. Mental and physical health effects of intimate partner violence on women and children. Psych Clin N Am 1997;20:353-74. 19. Hotaling GT, Sugarman DB. A risk marker analysis of assaulted wives. J Fain Violence 1990;5:1-3. 20. Tolman R, Bhosley G. Abused and battered: social and legal responses of family violence. In: Social Institutions and social change. New York: A de Gruyter; 1991. p. 113-22.
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21. Rath GD, Jarrett LG, Leonardson G. Rates of domestic violence against adult women by male partners. J Am Board Faro Pract 1989;2:227-33. 22. Family Violence Prevention Fund. Speaking up: news and tips for the domestic violence community. Family Violence Prevention Fund (FUND) 1997;3(7):2-6. 23. Coulter ML, Chez RA. Domestic violence victims support mandatory reporting: for others. J Faro Violence 1997;12:349-56. 24. Hyman A, Chez RA. Mandatory reporting of domestic violence by health care providers: a misguided approach. San Francisco (CA): Family Violence Prevention Fund; 1994. 25. Mooney DR, Rodriquez M. California health care workers and mandatory reporting of intimate violence. Hastings Women's Law J 1997;7:85-111. 26. Joint Commission of Accreditation of Healthcare Organizations. Accreditation manual for hospitals. Oakbrook Terrace (IL): Joint Commission on Accreditation of Health Care Organizations; 1995. 27. Speier J. California Penal Code 11160, Assembly Bill 1652; 1993. 28. Lynch SH. Elder abuse: what to look for, how to intervene. Am J Nurs 1997;97:26-32. 29. Tilden VP, Shepard P. Increasing the rate of identification of battered women in an emergency department: use of a nursing protocol. Research in Nurs Health
1987;10:209-15. 30. Hampton RI, Newberger EH. Child abuse incidence and reporting by hospitals: significance of severity, class, and race. Am J Public Health 1985;75:56-60. 31. Sherman LW.Policing domestic violence: experiments and dilemmas. New York:Free Press; 1992. 32. Campbell JC, Parker B. Clinical nursing research in battered women and their children: a review. Handbook of clinical nursing research. Newbury Park (CA): Sage; 1997. 33. National Research Conference: Institute of Medicine. Violence in families: assessing prevention and treatment programs. Chalk R, King P, editors. Washington: National Academy Press; 1998. p, 5-6. 34. Okem LE. Women abuse: facts replacing myths. Albany (NY): SUNY Press; 1986. 35. National Research Conference: Institute of Medicine. Violence in families: assessing prevention and treatment programs. Chalk R, King P, editors. Washington: National Academy Press; 1998. p. 5-6.
NANCY GLASS is an instructor at Johns Hopkins University School of Nursing and a doctoral student at the University of Maryland, Baltimore School of Nursing. JACQUELYN C. CAMPBELL is the Anna D. Wolf Endowed Professor and Director of the Doctoral Program at Johns Hopkins University School of Nursing, Baltimore, Maryland.
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D
ebate is ongoing among policymakers, health care professionals, and advocates for battered women and their children c o n c e r n i n g the most effective responses to the epidemic of intimate partner violence in the U n i t e d States. The public's awareness of the effects of i n t i m a t e p a r t n e r v i o l e n c e on abused women and their children has significantly increased during the past decade. I Increasingly, the public is dem a n d i n g that policy-makers be more sensitive to this public health issue and find solutions to this n a t i o n a l crisis. With the focus on this issue intensifying, policy-makers have turned their attention to health care providers and to m a n d a t i n g their response to battered women who seek medical care. 2
INTIMATE PARTNER VIOLENCE AS A PUBLIC HEALTH ISSUE Intimate partner violence is now recognized as a serious and widespread public health problem for women in the U n i t e d States. According to a recent n a t i o n a l r a n d o m survey, at least 4.4 m i l l i o n
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Copyright© 1998 by Mosby, Inc. 002916554198155.00 + 0 3511190912 NURSING OUTLOOK
women are battered by a partner or expartner each year in the U n i t e d States. 3 T h e 1992-1993 N a t i o n a l Crime Victimization Survey reported that 29% of all violence against women is perpetrated by an intimate partner and that women were more likely to be injured as a result of violence by an intimate partner t h a n by a stranger. 4 According to a 1993 Federal Bureau of Investigations report, 31% of female homicide victims were murdered by their spouses, ex-spouses, or boyfriendsS; the n a t i o n a l data do not inc l u d e e x - b o y f r i e n d s as p e r p e t r a t o r s . Recent statewide data from N o r t h Carolina suggest that current or former male i n t i m a t e p a r t n e r s are r e s p o n s i b l e for more t h a n 50% of female murders. 6 Research suggests that at least 1 million women seek medical care for abuserelated injuries each year in the U n i t e d States. 7's Several studies have suggested that i n t i m a t e partner violence is common among women who visit emergency d e p a r t m e n t s (EDs). Earlier studies reported that 6% to 30% of women who visited EDs were abused, s~° In more rec e n t ED studies, A b b o t t et al ~ found that the incidence of physical trauma from abuse was 2.7% for all women with a current partner who went to the ED.
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According to a combined medical record review and confidential p a t i e n t survey, a 3.1% rate of injury from abuse was reported in 10 EDs in the Midwest. 12 In a n o t h e r study of 12 c o m m u n i t y hospitals it was found that the p r e v a l e n c e of abuse by an i n t i m a t e p a r t n e r t h a t resuited in acute trauma was 2%. T h e lifetime prevalence of i n t i m a t e p a r t n e r violence reported in the a f o r e m e n t i o n e d studies ranged from 11% to 54%, and past year prevalence was approximately 10% to 15%. 813 P l i c h t a ~ f o u n d t h a t w o m e n who had been physically abused by a spouse or live-in p a r t n e r were significantly more likely t h a n other w o m e n to define their health as fair or poor. In the same survey, battered w o m e n also were more likely to name the ED as their primary source of health c a r e ) T h u s battered women are less likely to have an ongoing relationship with a h e a l t h care provider. Battered w o m e n come to the h e a l t h care system s e e k i n g h e l p , b u t most often they are treated for their immediate injuries or symptoms and are n e v e r asked about the u n d e r l y i n g cause. As few as 5% of battered w o m e n who seek medical care are correctly identified as battered women by their providers2 In a recent study c o n d u c t e d in 12 c o m m u n i t y hospitals, no d o c u m e n t a t i o n of abuse was found in medical records for ahnost half of the women who reported visiting an ED because of abuse. 14 T h e failure to identify battered women results in a p o t e n t i a l added cost to an already overwhelmed health care system. W h e n battered women are n o t identified, the abuse is not d o c u m e n t e d for future reference and an opportunity is missed to provide education about p r e v e n t i o n and
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safety planning, along with options for getting away from the abuse and referrals to resources in the community. 1 The children of abused women also are affected when their mothers are not identified as battered by health care providers. Research indicates that 3 million to 10 million children witness their mothers being treated violently each year. 15-18 These children are at an increased risk for emotional, behavioral, and cognitive delays17; they also are at risk for being abused by a partner or being abusive to their partner in the future) 9'2°Rath et a121 found that children of battered women used health services 6 to 8 times more often than other children. Providing early intervention and prevention programs for children who witness violence is a potential cost.effective measure by the health care system.
CALIFORNIA L A W Policy-makers are justified in looking for new and effective policies to address this public health crisis. In 1994, California was the first state to require that health care providers report to law enforcement officials when medical services were provided to a patient who they "know or reasonably suspect to suffer from any wound or other physical injury inflicted upon a person where the injury is a result of assaultive or abusive conduct. ''22 The definition of assaultive and abusive conduct includes rape, sexual assault, and abuse by a spouse or co-habitant. = Six states (California, Colorado, Kentucky, New Hampshire, New Mexico, Rhode Island) have mandatory reporting laws specific to the identification of intimate partner violence in a clinical setting, > and many other states are considering such legislation. Too often, legislated health policy is based on public response to a perceived crisis or it imitates other initiatives without a thorough review of principles and research on which to base new directions. We offer a retrospective review of this particular legal policy adoption process and a discussion of policy objectives, outcomes, principles, and the needed research base. In addition, we offer a suggestion for possible changes in the policy and discuss the challenges to nursing regarding implementation of mandatory reporting policies and influencing future direction of these policies. 280
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THE LEGISLATIVE PROCESS
Policy Objectives Laws mandating that health care providers report suspected intimate partner violence seek to (1) enhance the safety and care of the patient, (2) collect incidence and prevalence data for intimate partner violence, (3) provide d o c u m e n t a t i o n of i n t i m a t e p a r t n e r violence to strengthen the legal case against the perpetrator, (4) improve health care providers' response to and identification of intimate partner violence, (5) aid law enforcement officials in the prosecution of perpetrators of intimate partner violence, z4 (6) remove the responsibility for contacting law enf o r c e m e n t officials from the battered woman, and (7) make clear that the h e a l t h care system and society do not c o n d o n e intimate partner violence.
Process Review A retrospective review of the process of the development and passage of the law in C a l i f o r n i a reveals t h a t longtime advocates for battered women and battered women themselves were left out of the discussion about mandatory reporting (Nudelman J, Family Violence Prev e n t i o n Fund. Oral c o m m u n i c a t i o n . Dec 1996). According to Mooney and Rodriquez, 25 prenatal nurses working in an outreach program in California wrote a letter requesting that Assemblywoman Jacqueline Speier address "serious flaws" in an existing medical workers reporting law from the early 1900s. T h e nurses asked for a law to provide protection from liability when reporting cases of suspected intimate partner violence and to clearly explain who among health professionals has a duty to report the suspected cases. 25 Interest in a law to clarify liability may have been caused in part by the 1992 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, which mandated that protocols for the assessment, documentation, and intervention for intimate partner abuse be present in certain units (ED, ambulatory care, and substance abuse treatment). Also, providers or hospitals may have been worried about prosecution or lawsuits stemming from a failure to report intimate partner violence under J C A H O guidelines, z Since the first J C A H O man-
date, the 1995 guidelines have been expanded to include protocols for assessment, documentation, and intervention for intimate partner violence in all departments in all health care settings. 26
Assembly Bill 1652 In 1994, Assembly Bill 1652, written by Jacqueline Speier, was approved by the governor of California only 9 months after the original request was written. 25 The new law provides for immunity from liability for reporting by health care practitioners and payment for attorney fees for legal action against practitioners who report and prohibits any interference in reporting by administrators or superiors, z5 The law identified nurses as health care workers who are required to report, 25 and recommends--but does not require--that health care practitioners document in medical records any comments made about the injury or perpetrator, include a body map showing injuries, include a law enforcement reporting form, and refer patients to intimate partner violence service agencies. 25 The California law mandates that any health practitioner employed in a health facility, clinic, physician's office, local or state public health department or clinic, or other facility operated by the local or state public health department report cases of suspected intimate partner violence to law enforcement officials immediately or as soon as practically possible. 27
PRINCIPLES A N D RESEARCH BASE
Child Abuse and ElderAbuse Mandatory Reporting Laws Mandatory reporting laws are modeled after state laws that mandate reporting of s u s p e c t e d c h i l d abuse and elder abuse. In cases of child abuse, the state can act as g u a r d i a n to p r o m o t e the child's safety. Whereas it is reasonable to assume that a child is unable to make an informed decision concerning his or her life, advocates maintain that it is paternalistic to assume women are unable to make informed decisions about their lives and safety. 2 Some advocates for the elderly oppose mandatory reporting laws for elder abuse because they believe that the assumption that
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the elderly are unable to make informed decisions about their need for assistance and safety is based solely on their advanced age. 2s Child abuse and elder abuse laws may not be the most appropriate models to use when designing policies regarding intervention in cases of intimate partner violence. It is important to note that agencies handling reports, such as child protective services and adult protective services, are underfunded and overworked. The cases reported may never be investigated; therefore, the abused person may be further harmed by having his or her hopes raised that someone will intervene in their situation. 29 Data reported in the literature by Hampton and Newberger 3° reveal biases in the reporting of child abuse by health care providers. A n analysis of child abuse reporting revealed that black and Latin American families were disproportionately identified as abusive and reported to authorities. 3° Poor families had the highest rate of child abuse reports by providers. It is possible that mandatory reporting of intimate partner violence could result in the same biased reporting. Health care providers often have a stereotypical view of an abused woman's appearance and of abuse risk factors; many providers believe that intimate partner violence occurs almost exclusively in poor minority families.
Mandatory Reporting Outcomes Health care professionals, advocates for battered women, and battered women are concerned that mandatory abuse reporting ignores women's autonomy and decision-making abilities. If battered women were afforded full autonomy, the decision to report the violence would be made by the woman herself, because she has specific knowledge related to her s i t u a t i o n and her risk for f u r t h e r abuse. Abused women are at risk for revictimization by the system when a report is made without her consent to a criminal justice system that may be overburdened and underfunded. Empirical evidence shows that the arrest of the abuser may increase the risk of further violence for some women. ~) Until research clearly shows for whom arrest may pose increased risk rather than decreased risk, the woman's perception of the situNURSING OUTLOOK
ation should be given full consideration. In addition, mandatory reporting of abuse diminishes the confidential patient-provider relationship and may result in an abused women delaying medical t r e a t m e n t or refusing to disclose abuse because of fear that the case will be reported. This situation will make it more difficult for providers to adequately intervene in the lives of abused women and their children. A l t h o u g h the policy is intended to enable abused women to be cared for more effectively, advocates and abused women believe that the provider and state actually are imposing the same form of power and control over the woman as her abuser. She may be disempowered by having her decisionmaking ability taken away by the people to whom she has come for assistance and empowerment. W o m e n should be able to feel that the information they give to their provider will remain confidential and that they can trust the provider. Many health care professionals and advocates believe that mandatory abuse reporting is not accomplishing the stated objectives but instead is raising serious ethical questions. 22'32 Although mandatory reporting of suspected intimate p a r t n e r v i o l e n c e by health care providers has not been formally evaluated, it may not be fulfilling the objectives of enhancement of patient care and safety, collection of data about the incidence and prevalence of intimate partner violence, documentation of intimate partner violence, improvement of provider response, and assistance to law enforcement officials in prosecution of perpetrators. A review of each policy objective reveals examples of possible outcomes that are the opposite of those intended by the policy.
Objectives and Unintended Outcomes The first objective of mandatory abuse reporting is to enhance the safety and care of the abused woman. Many women turn to the health care system only as a last resort. Abused women who turn to the h e a l t h care system for assistance need assurances that they are not at fault for the abuse. T h e y need information and education about safe alternatives to returning home and referrals for counseling, shelter, and legal services. :4
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Abused women often do not trust an overburdened system to respond to their needs. They may have had experiences in which the police did not enforce a restraining order or the judicial system refused to prosecute the abuser. 33 Furthermore, abused w o m e n d o u b t t h a t the police can provide them with the protection they need from their abuser. 34 Abused women fear that the violence will escalate if they report the abuse to the police. Even in cases in which the health care provider is actually responsible for reporting the suspected abuse, w o m e n have no g u a r a n t e e t h a t t h e abuser will not hold t h e m responsible and retaliate against them and their children. W o m e n who fear retaliation from abusers when their cases are reported to law enforcement officials may not seek medical care or be honest with providers about symptoms and injuries. The second objective of the policy is data collection. Mandatory reporting is useful in collecting d e m o g r a p h i c and clinical data regarding the incidence and prevalence of intimate partner violence. 24 Researchers may be able to use this data to identify areas for funding and intervention; however, inaccurate data related to provider noncompliance and biases in the reporting of intimate partner violence is likely. Clearly, accurate and useful data on intimate partner violence is needed. A funded anonymous study conducted by knowledgeable and trained researchers probably would yield better data t h a n mandatory reporting; however, anonymity of responses may interfere with linkages to medical records for review. The third objective, d o c u m e n t a t i o n by health care providers, can be very effective in strengthening the woman's case against her abuser. Documentation should be made in a medical chart that provides a complete history, assessment, diagnosis, and plan for follow-up care. However, documentation that can be used in court does not have to be linked to mandatory reporting. It would be more useful if documentation was standardized among the different types of providers and health care settings; this would permit aggregating data from multiple sources to evaluate prevention programs. A t this time, the amount of information provided to law enforcement and social service agencies depends on the providers and the Glass and Campbell
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guidelines of the health care facility in which they practice. The fourth objective is to enhance the provider's ability to respond effectively to battered women and their children. The development of a curriculum to be taught to health care providers while they are in training as well as continuing education courses, are effective ways to sensitize providers to the issue of intimate partner violence. Mandatory reporting of intimate partner violence may increase the number of in-service training sessions for health care providers and increase attendance. In addition to education, health care facilities will need to establish protocols and procedures based on J C A H O guidelines for the assessment, intervention, and documentation of intimate partnet violence. In the recently completed case.control study of 12 community hospitals in California and Pennsylvania, the case hospitals in California (baseline rate of 17%) increased the rate of documentation of intimate partner violence in medical records to 20% after a training intervention with key personnel from the
The development o f a curriculum to be taught to health care providers while they are in training, as well as continuing education courses, are effective ways to sensitize providers to the issue o f intimate partner violence.
EDs. Documentation of self-identified abused women continued to improve during the next 12 months, with a 55% documentation rate at the completion of the study. The Pennsylvania case hospitals (baseline rate of 50%) demonstrated an initial improved rate of documentation (88%) after the training intervention, but the rate declined during the next 12 m o n t h s , with 60% of self-identified abused women documented in the medical records34 Training ED staff members to document intimate partner violence results in improved medical record documentation initially, but follow-up training may be necessary to assist providers 282
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in continuing to appropriately document intimate partner violence. The fifth objective of facilitating criminal prosecution through mandatory reporting is possible only in a law enforcement system that handles reports of intimate partner violence in a timely manner. Women who report intimate partner violence become frustrated when police officers refuse to intervene and arrest the abuser. Some police officers do not consider intimate partner violence to be a serious offense. Mandatory reporting will increase the number of cases reported but may not result in more effective prosecution of those cases. Education and collaboration among health care providers, law enforcement officials, social service agencies, advocates for battered women and their children, and battered women would better meet the objective of facilitating criminal prosecution.
Suggestion for Change in Mandatory Reporting Law
may be most effective in obtaining informed consent from the battered woman and providing referrals to community resources. Nurses are trained not only to manage the injuries or symptoms of the patient at the time the patient seeks health care, but also to look at the patient holistically. The nurse is trained to ask probing questions that will assess the environments in which the woman lives and works. Nurses know how to ask questions that will address the underlying causes of injuries and symptoms. Skilled nurses should lead the health care team in the assessment of intimate partner violence for every woman who seeks medical care. We are advocating for nursing to join the National Research Council of the Institute of Medicine in their recommendation for all states to refrain from enacting mandatory reporting laws for domestic violence until such systems be tested and evaluated by research. 3s
Challenges to Nursing
Advocates for abused women and their c h i l d r e n m a i n t a i n that u n i n t e n d e d policy outcomes will continue until the law is amended to require informed consent by the abused woman before her case can be reported to law enforcement by health care providers. The advocates in California indicate they are working with the legislature to amend the California law to require informed consent for reporting of abuse. The process of informed consent is a basic premise for the health care provider. 24It is believed that informed consent would empower the woman to be an active participant with the provider in making the decision. If informed consent were required for reporting, health care providers would need to be well informed and sensitive to issues relevant to intimate partner violence. The provider would be responsible for educating the patient about safe alternatives for leaving the abuse and providing options that are useful in her situation. The provider would need to be knowledgeable about resources for battered women and their children in the community and have contacts to gain entrance into these agencies. Many health care providers do not have the skills, knowledge, or contacts to adequately advise battered women. Nurses
Even though not every state mandates reporting of intimate partner violence by health care providers, nurses need to be
Skilled nurses should lead the health care team in the assessment of intimate partner violence for every woman who seeks medical ca re.
aware of the statute and any proposed mandatory reporting legislation in their state. Nurses can contact their state Domestic Violence Coalition, the national Family Violence Prevention Fund, or the national Health Resource Center on Domestic Violence at (888) 792-2873 to educate themselves and their colleagues about the consequences of mandatory reporting for abused women and their children. Nurses can attend intimate partner violence workshops and conferences for continuing education credit. Nurses who are unable to attend conferences outside of their worksite can request that nursing administration develop in-service training on intimate partner violence and offer their assistance. Nurses can collect data on mandatory reporting in their
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h e a l t h care setting from the perspective of b o t h the abused w o m a n and h e a l t h care provider; they can use this data to testify as experts in legislative hearings c o n c e r n i n g the a d o p t i o n of the m a n d a tory reporting law. Nurses also are encouraged to join the Nursing N e t w o r k on Violence Against Women International ( t e l e p h o n e 8 8 8 - 9 0 9 - 9 9 9 3 ) . O n e of the goals of the n e t w o r k is to s t r e n g t h e n the partnership of h e a l t h care professionals and the c o m m u n i t y as they work to end violence against women. W e are urging nurses to take leadership roles in educating the interdisciplinary t e a m about the u n i n t e n d e d o u t c o m e s that m a n d a t o r y reporting can h a v e on the lives of abused w o m e n and their children. W e are advocating for nursing to j o i n t h e N a t i o n a l R e s e a r c h C o u n c i l of t h e I n s t i t u t e of M e d i c i n e in t h e i r r e c o m m e n d a t i o n for all states to refrain from e n a c t i n g m a n datory r e p o r t i n g laws for d o m e s t i c violence until such systems be tested and e v a l u a t e d by research. 35
CONCLUSION Advocates, health care providers, law enforcement officials, and policy-makers must c o m e t o g e t h e r to d e v e l o p policy related to i n t i m a t e partner v i o l e n c e . T h e C a l i f o r n i a law provides an e x a m p l e of l e g i s l a t i o n t h a t c a n be p a s s e d w h e n policy-makers w a n t to find a s o l u t i o n to a crisis t h a t has b e c o m e an i m p o r t a n t public issue. Policy-makers n e e d to c o n sider all t h e r a m i f i c a t i o n s of t h e i r policies and pursue a s o l u t i o n to t h e public h e a l t h p r o b l e m by asking for v a l u a b l e input from advocates, h e a l t h care prof e s s i o n a l s , b a t t e r e d w o m e n , a n d researchers who are d e d i c a t e d to e n d i n g intimate partner violence. •
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21. Rath GD, Jarrett LG, Leonardson G. Rates of domestic violence against adult women by male partners. J Am Board Faro Pract 1989;2:227-33. 22. Family Violence Prevention Fund. Speaking up: news and tips for the domestic violence community. Family Violence Prevention Fund (FUND) 1997;3(7):2-6. 23. Coulter ML, Chez RA. Domestic violence victims support mandatory reporting: for others. J Faro Violence 1997;12:349-56. 24. Hyman A, Chez RA. Mandatory reporting of domestic violence by health care providers: a misguided approach. San Francisco (CA): Family Violence Prevention Fund; 1994. 25. Mooney DR, Rodriquez M. California health care workers and mandatory reporting of intimate violence. Hastings Women's Law J 1997;7:85-111. 26. Joint Commission of Accreditation of Healthcare Organizations. Accreditation manual for hospitals. Oakbrook Terrace (IL): Joint Commission on Accreditation of Health Care Organizations; 1995. 27. Speier J. California Penal Code 11160, Assembly Bill 1652; 1993. 28. Lynch SH. Elder abuse: what to look for, how to intervene. Am J Nurs 1997;97:26-32. 29. Tilden VP, Shepard P. Increasing the rate of identification of battered women in an emergency department: use of a nursing protocol. Research in Nurs Health
1987;10:209-15. 30. Hampton RI, Newberger EH. Child abuse incidence and reporting by hospitals: significance of severity, class, and race. Am J Public Health 1985;75:56-60. 31. Sherman LW.Policing domestic violence: experiments and dilemmas. New York:Free Press; 1992. 32. Campbell JC, Parker B. Clinical nursing research in battered women and their children: a review. Handbook of clinical nursing research. Newbury Park (CA): Sage; 1997. 33. National Research Conference: Institute of Medicine. Violence in families: assessing prevention and treatment programs. Chalk R, King P, editors. Washington: National Academy Press; 1998. p, 5-6. 34. Okem LE. Women abuse: facts replacing myths. Albany (NY): SUNY Press; 1986. 35. National Research Conference: Institute of Medicine. Violence in families: assessing prevention and treatment programs. Chalk R, King P, editors. Washington: National Academy Press; 1998. p. 5-6.
NANCY GLASS is an instructor at Johns Hopkins University School of Nursing and a doctoral student at the University of Maryland, Baltimore School of Nursing. JACQUELYN C. CAMPBELL is the Anna D. Wolf Endowed Professor and Director of the Doctoral Program at Johns Hopkins University School of Nursing, Baltimore, Maryland.
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