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. 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. It is recommended that the nursing# Table of Contents
Interpretation of Evidence...................................................................... 2.0 Routine universal screening be implemented for all females 12 years of age IV and older.

# Nursing Best Practice Guideline

# Summary of Recommendations
- 0 Nurses develop skills to foster an environment that facilitates disclosure. IV This necessitates that nurses know: I how to ask the question; and I how to respond. 4.0 Nurses develop screening strategies and initial responses that respond to the III needs of all women taking into account differences based on race, ethnicity, class, religious/spiritual beliefs, age, ability or sexual orientation.
- 0 Nurses use reflective practice to examine how their own beliefs, values, IIa and experiences influence the practice of screening.
Nurses know what to document when screening for and responding to abuse. IV 7.0 Nurses know their legal obligations when a disclosure of abuse is made. IV Education 8.0 Mandatory educational programs in the workplace be designed to: Ib Recommendations I increase nurses' knowledge and skills; and I foster awareness and sensitivity about woman abuse.
- 0 All nursing curricula incorporate content on woman abuse in a III systematic manner.
Organization & Policy 10.0 Health care organizations develop policies and procedures that support IV Recommendations effective routine universal screening for and initial response to woman abuse.
- 0 Health care organizations work with the community at a systems level Ib to improve collaboration and integration of services between sectors.
- 0 Nursing best practice guidelines can be successfully implemented only where IV 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: I An assessment of organizational readiness and barriers to education. I Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. I Dedication of a qualified individual to provide the support needed for the education and implementation process. I Ongoing opportunities for discussion and education to reinforce the importance of best practices. I Opportunities for reflection on personal and organizational experience in implementing guidelines.
In this regard, 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 RNAO guideline Woman Abuse: Screening, Identification and Initial Response.  For interpretation of evidence see p. 10

# Interpretation of Evidence

# Levels of Evidence
The following framework depicts the levels of evidence that have been used to classify the research that has been used in the development of this guideline.
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.
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.
The underlying assumption implicit in this schema is that the randomized controlled trial (RCT) is the 'gold standard' against which all other forms of evidence are evaluated and compared. While this assumption may have a great deal of utility in the biomedical sciences, its relevance to the health and human sciences is less clear. In nursing, where multiple ways of knowing are not only valued, but desired, a hierarchical chart that ascribes a lower place to qualitative research is problematic. More importantly, the chart does not reflect the nature of nursing knowledge, particularly as it exists in the area of violence against women. Understanding health and human experiences requires a knowledge base that extends beyond the establishment of cause and effect relationships, the collection of quantitative data, and the conduct of intervention studies. While all of these are valued, they do not represent the sum total of desired or existing nursing knowledge. Rather, consideration must be given to the nuances and particularities of everyday lived realities. Such knowledge embraces the broader social and political contexts that shape health experiences in general, and those related to violence in particular. To date, much of the knowledge related to violence against women has been generated utilizing various research methodologies, including qualitative (stories) and quantitative (numbers) methods. Consistent with the panel's value of the importance of both stories and numbers, multiple sources of knowledge have been used to inform the development of this best practice guideline. The Levels of Evidence framework has been used within the context of these remarks.

# Responsibility for Development
The Registered Nurses' Association of Ontario (RNAO), with funding from the Government of Ontario, has embarked on a multi-year program of nursing best practice guideline development, pilot implementation, evaluation and dissemination. This guideline fits within the priority areas of mental health, gerontology, home health care, primary health care and emergency care. This guideline was developed by a multidisciplinary panel convened by the RNAO, conducting its work independent of any bias or influence from the Government of Ontario.

# Purpose & Scope
Best practice guidelines (BPG) are systematically developed statements to assist practitioners' and clients' decisions about appropriate health care (Field & Lohr, 1990).
The overall purpose of this guideline is to facilitate routine universal screening for woman abuse by nurses in all practice settings. The intended outcome is increased opportunity for disclosure, which will promote health, well-being, and safety for women. Using evidence-based approaches and recommendations, this guideline offers nurses a repertoire of strategies that can be adapted to various practice environments.
The scope of this guideline is on screening women for intimate partner abuse. The guideline includes all women in intimate relationships, 12 years of age or older and identifies: I Who should do the screening; I What should be included in screening; and I How and under what circumstances screening should occur.
While it is recognized that men may also be victims of intimate partner abuse, the incidence, nature and impact of that abuse is more severe for women.
Although this guideline has been developed primarily for Registered Nurses (RNs) and Registered Practical Nurses (RPNs), it may also be used by other health care practitioners. As well, the recommendations included in this guideline are consistent with current legislation such as the Child and Family Services Act (Ontario), the Criminal Code of Canada and the Regulated Health Professions Act (RHPA) (Ontario). While the guideline may be used outside of Ontario, prior consultation with relevant provincial legislation is encouraged.
It is acknowledged that individual competence in screening varies between nurses and across categories of nursing professionals (RPNs and 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.

# Development Process
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 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.
Twenty-four published guidelines related to Woman Abuse/Domestic Violence were identified through a systematic search, the details of which are described in Appendix A. These guidelines were reviewed according to a set of inclusion criteria, which resulted in the elimination of 10 guidelines. The inclusion criteria were: I Guideline was in English; I Guideline was dated no earlier than 1999; I Guideline was strictly about the topic area; I Guideline was evidence-based; I Guideline was available and accessible for retrieval; I Guideline was developed for populations similar to Canada.
The resulting fourteen guidelines were critically appraised with the intent of identifying existing guidelines that were current, developed with rigour, evidenced-based and which addressed the scope identified by the development panel for the best practice guideline. A quality appraisal was conducted on these 14 clinical practice guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument (AGREE 3. Family Violence Prevention Fund (FVPF) (2004). National consensus guidelines on identifying and responding to domestic violence victimization in health care settings. Available:  4.. A handbook dealing with woman abuse and the Canadian criminal justice system: Guidelines for physicians. Available:  5. Middlesex-London Health Unit (MLHU) (2000). Task force on the health effects of woman abuse -Final report. London, Ontario: Author.
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.
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 this 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 90-100% 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.

# Nursing Best Practice Guideline
Woman Abuse: Screening, Identification and Initial Response  the intentional and systematic use of tactics to establish and maintain power and control over the thoughts, beliefs, and conduct of a woman through the inducement of fear and/or dependency. The tactics include, but are not limited to, emotional, financial, physical, and sexual abuse, as well as, intimidation, isolation, threats, using the children and using social status and privilege. ...Woman abuse includes the sum of all past acts of violence and the promise of future violence that achieves enhanced power and control for the perpetrator over the partner. ...Abusive behaviour does not result from individual, personal or moral deficits, diseases, diminished intellect, addiction, mental illness, poverty, the other person's behaviour, or external events. (p. 3.) This definition extends aspects of the definition from the United Nations Declaration on the Elimination of Violence Against Women (1993).
For a visual depiction of the power and control dynamics, see Appendix B.
The development panel determined by consensus that in the case of screening for woman abuse, screening means imbedding questions about abuse in a health history or incorporating validated screening instruments into the history/assessment process.
Universal screening refers to the characteristics of the group to be screened and occurs when nurses ask every woman over a specified age about her experience of abuse.
Routine screening refers to the frequency with which screening is carried out. Routine screening is performed on a regular basis regardless of whether or not signs of abuse are present.
Indicator-based screening refers to screening whereby nurses observe one or more indicators that suggest a woman may have been abused and subsequently question her about the indicator(s).
The most comprehensive approach is one that combines routine and universal screening. This approach is recommended throughout this best practice guideline.

# Background Context
Rationale for a Best Practice Guideline on Screening for Woman Abuse

# Significance of the Problem
Estimates regarding woman abuse are varied, and depend, in part, on the definitions used, the questions that are asked, and the format used to ask the questions (e.g., questionnaire, survey, etc.). Other factors that contribute to inconsistencies in prevalence rates include socio-demographic characteristics of the sample, the nature and context of the abuse, and whether it is past or current. Similarly, the presence or absence of a socio-political context that allows and encourages women to name the violence in their lives influences reporting rates.
The World Health Organization Declaration (2002b) states "violence is a leading worldwide public health problem" (p. 2).  goes on to say "intimate partner violence is one of the most common forms of violence against women" (p. 315). Between "17-30% of all women treated in hospital emergency departments are victims of domestic violence" (Waller, Hohenhaus, Shah, & Stern, 1996, p. 755), and that "worldwide, 10-50% of women report having been hit or physically assaulted by an intimate partner" (Taket et al., 2003, p. 673).

# Nursing Best Practice Guideline
While early advocates suggested that approximately one in ten women experience violence by their intimate partners each year, subsequent Canadian surveys revealed that the actual figures are, in fact, much higher than these early estimates. The 1993 Violence Against Women Survey (Statistics Canada, 1994) reported that of the 12,300 women surveyed, 25% of women 16 years of age and older reported they had been abused by an intimate partner and 10% had been assaulted at least once during the previous 12 months. According to the 1999 General Social Survey (Statistics Canada, 2000), 8% of women and 7% of men had experienced violence by an intimate partner at some time during the five years prior to the survey. While these latter figures would seem to suggest a decrease in violence against women, it is particularly noteworthy that in this survey, women reported more serious forms of violence, with more serious consequences, than did men (Pottie. As well, many of those who might be considered most vulnerable were excluded from the survey, namely those from the Yukon, Northwest Territories, Nunavut, those without telephones, and homeless persons.  assert that threats, intimidation and battering escalate over time and that "unrelenting battering of women leads to homicides" (p. 1357). Abuse knows no boundaries; no cultural group, ethnic background, lifestyle, educational or socio-economic background is spared. However, it is important to be mindful that "harm comes to the most vulnerable" (Graham, 2000, p. 33) including, but not limited to, lesbian women, lone mothers, women with mental health issues, women with disabilities, and elderly women Eckert, Sugar, & Fine, 2002;Larkin, Hyman, Mathias, D'Amico, & MacLeod,1999;.
In this guideline, the development panel recommends that screening be conducted with all women, ages 12 and older. Current statistics regarding the prevalence of dating violence support the screening of young women. According to the results of a Canadian survey, 8% of female respondents reported that, during high school, their partners had threatened to use physical force if they did not engage in sexual activities; 14% reported that they were forced to engage in sex acts; 50% reported that they had been hurt emotionally; and 9% said that their dating partners had physically hurt them (DeKeseredy & Schwartz, 1998). Although some researchers have suggested that rates of dating violence, victimization, and perpetration are comparable among young men and young women, it is generally agreed that these findings may be attributed to methodological limitations with attention to the number of violent acts, rather than on the context and consequences of the violence. As is the case among older women, violence against younger women typically has more lasting and serious consequences than those experienced by men.
The significance of the problem is further highlighted in the following reports: Family Violence in Canada: A Statistical Profile (Statistics Canada, 2004) and the General Social Survey (Statistics Canada, 2000). According to Statistics Canada (2004) an analysis of data provided by 94 reporting police agencies across Canada showed that women continue to far outnumber men as victims of assault by a spouse or partner. Females were the victims in 85% of reported cases of spousal violence and half of all family homicides involved spouses with 62% of female homicides committed by male spouses, either current or estranged. This figure is three times the number of men killed by their spouses.

# Woman Abuse: Screening, Identification and Initial Response
The General Social Survey (Statistics Canada, 2000) also validated this information by showing that when compared to males, females were: I seven times more likely to be sexually assaulted (20% vs. 3%); I three times more likely to report physical injury (40% vs. 13%) and five times more likely to require medical attention as a result of a violent incident; I more likely to fear for their lives (38% vs. 7%); and I more likely to be killed by someone with whom they had an intimate relationship (52% vs. 8%).
Estimates of woman abuse in Ontario are equally compelling. Findings from The Women's Safety Project  revealed that, depending on the particular type of violence measured, between 27% and 51% of women endured one or more physically or sexually abusive incidents. Sudbury Regional Hospital in Ontario conducted a prospective cohort study that interviewed a random sample of women age 16 years and older in the emergency department (ED) to determine the incidence and prevalence of abuse. Of the 983 women surveyed, 51% disclosed experiencing violence at the hands of an intimate partner in their lifetime and 26% of these disclosed violence within the last year (Cox et al., 2004).
Cornwall Community Hospital in Ontario currently implements screening in their emergency room (ER) and is in the process of expanding the program hospital wide. The program involves mandatory training of ER staff and screening is implemented by RN's with all persons 16 years of age and older. Program evaluation determined rates of disclosure of abuse to be 4.8% with 611 clients disclosing abuse. Despite the low disclosure rate of this new program, community collaboration and requests for information by clients and staff are some of the additional outcomes that have been realized. Clearly the problem remains an important public health concern.

# Consequences of Woman Abuse

# Health Consequences
The physical and emotional health consequences of violence against women are profound and enduring. Even for women who are able to leave abusive relationships, the consequences often persist long after the violence has ended, and in some cases continue throughout the woman's lifetime (Felitti et al., 1998). In general, research findings suggest that the more prolonged and severe the abuse, the greater its impact on a woman's physical and mental health. Further, there is evidence that the impact of different types of abuse and of multiple episodes of abuse is cumulative over time. Women who have experienced violence suffer a multitude of adverse physical and psychological health outcomes. Abused women have more physical symptoms, are more frequent users of health care services, are more likely to suffer chronic pain, have increased rates of depression, anxiety, low self-esteem and attempted suicide and experience abuse during pregnancy and have increased pregnancy-related complications. Women who experience abuse are also more likely to report their physical and mental health as fair to poor. While no research has been conducted to establish causal relationships between violence and health consequences, the associations are strong and convincing. A full discussion of the health responses to violence is beyond the scope of this guideline. However, a summary of the most salient outcomes can be found in Table 1.

# Nursing Best Practice Guideline

# Economic Consequences
The economic costs related to violence against women are staggering and place a tremendous burden on society, both with respect to lost productivity and increased demands on health and social services. In a report published by Health  it was estimated that the measurable health-related costs of violence against women in Canada exceed $1.5 billion a year. These costs include short-term medical and dental treatment for injuries, long-term physical and psychological care, lost time at work, and use of transition homes and crisis centres. This figure is consistent with an earlier report prepared by the Centre for Research on Violence Against Women and Children that estimated the health costs of woman abuse at $1.54 billion per year (Day, 1995).
Although abuse does not explicitly prevent women from being employed, there is some evidence that women who have experienced violence have diminished earnings and greater difficulty maintaining steady employment. Research in the United States has demonstrated that women with a history of abuse have more frequent periods of unemployment, lower personal incomes, greater job turnover, more physical and mental health problems that affect job performance, and were more likely to receive public assistance as compared to women who had not experienced abuse.
In addition to the direct economic costs associated with woman abuse, indirect costs include the increased utilization of health care services in the immediate and long-term aftermath of abuse. Women who have experienced physical or sexual assault, either during childhood or adulthood, have a greater number of surgeries, visits to health providers, hospital stays, and mental health consultations than those who have not been similarly victimized.
Woman Abuse: Screening, Identification and Initial Response

# Impact on Children
Determining how many children are witnesses to the abuse of their mothers is a complex and controversial undertaking for a variety of conceptual and procedural reasons. While an in-depth discussion of these reasons is beyond the scope of this guideline, most significant is that there are no national prevalence studies in either Canada or the United States that directly measure the number of children who are exposed to violence in their homes. In a recent national survey of child development, parents were asked how often their children, ages to 11 years, observed violence perpetrated in the home by older siblings and parents. Parents reported that 8.6% or approximately 330,000 children witnessed some form of violence in the home (Human Resources Development Canada, 1996).  reported that Canadian children were present during almost 40% of wife assault cases; that women feared for their lives in approximately 52% of these cases; and that 61% of the attacks witnessed by children had resulted in serious injury to the women.
The research on child witnesses to the abuse of their mothers offers convincing evidence that many, though not all, of these children are at risk for many of the same physical, emotional and behavioural problems as those who experience violence directly Jaffe, Wolfe, & Wilson, 1990). While it is important to note that not all children suffer long-term adverse effects, and that many exhibit a range of strengths and appear remarkably resilient, the range of potential negative responses is summarized in Table 2. As adults, children who come from violent homes often experience violence in future relationships.

# Why Nurses Should Screen for Abuse
Nurses are well-positioned to screen for woman abuse because they are accessible, enjoy a high degree of public trust, and work in a variety of settings. Nurses interact with women during times of stress and illness, as well as during developmental transitions such as adolescence, pregnancy, and parenthood. Nurses utilize a holistic health promotion framework, incorporating strategies of empowerment and advocacy. This approach is especially important when intervening with abused women. Supporting the abused woman's choice is critical so as not to replicate a relationship of coercion and control.
Nurses are frequently the first member of the health care team to interface with women experiencing abuse
Nursing Best Practice Guideline and as such must have the knowledge and skills necessary to screen and respond appropriately and effectively (Davidson et al., 2001;. Nurses may hesitate to screen for a variety of reasons, however, it is important to remember that nurses are part of an integrated community response. The nurse is not solely responsible for the development of a comprehensive plan of action. While nursing knowledge and skill are applied to the identification and initial response, there are specially trained individuals/women's advocates in most communities and health care settings that can be readily accessed by the nurse or the woman. Identifying the abuse and linking the woman to specialized services, if that is her choice, is the central process to follow.

# Why Routine Universal Screening
The development panel acknowledges the lack of consensus concerning universal versus indicator-based screening for woman abuse by health care providers. Guidelines from Canada (MLHU, 2000;Perinatal Partnership Program of Eastern and Southeastern Ontario (PPPESO), 2004), New Zealand (Ministry of and the United States (U.S.) (Family Violence Prevention Fund (FVPF), 2004) were reviewed for this best practice guideline. All endorse universal screening in some or all practice settings. In contrast, systematic evidence reviews for the Canadian Task Force on Preventive Health Care  and the U.S. Preventive Services Task Force  both concluded that there is not enough evidence to recommend for or against universal screening. In addition to these documents, the panel also considered qualitative and quantitative studies, program evaluations, anecdotal data, and expert opinion, including that of abused women themselves to ultimately determine the recommendation for routine universal screening.
This conclusion is based on a framework that differs from the systematic evidence reviews  in four significant ways: 1) the outcome of screening; 2) the use of validated tools; 3) the reliance on randomized control trials; and 4) the potential for harm. Each is briefly discussed.
First, in terms of outcome, both the Canadian Task Force and the U.S. Task Force use "reduction in violence" as their outcome measure. The panel embraces a harm reduction approach. Recommendations consistent with this approach have been put forth and widely accepted for numerous other social problems that have health implications. Examples include assessment of tobacco and alcohol use and pregnancy counselling (FVPF, 2004;. The goal is to help women move from a stage of precontemplation ("I don't have a problem"), to contemplation ("Maybe I do, maybe I don't"), or preparation ("Yes, I do, what can I do about it?"). Seen in this light, screening creates opportunities for women to disclose and discuss violence in their lives.
Woman Abuse: Screening, Identification and Initial Response Second, both systematic reviews examined standardized tools for accuracy in detecting abuse. While individual nurses or institutions may decide to use a standardized tool, some of which are included in this document, the panel places high value on the nursing history/assessment interview, the demeanor and skill of the nurse, and the normalization of "asking the question". As well, the panel recognizes and supports a woman's right to choose whether or not to disclose abuse. The failure to disclose is not viewed as a failure in the screening process. Even when a woman does not disclose, the act of screening signals the nurse's willingness to assist in a safe and confidential manner. This process fosters a trusting relationship and increases the possibility of a disclosure in the future.
Third, as noted above, the panel based its recommendations on multiple sources of knowledge. The lack of randomized control trials (RCTs) is not viewed as a limitation in the literature on screening. The panel's views regarding the hierarchy of evidence are described earlier in this document (please see Interpretation of Evidence, p. 10).
Lastly, the development panel considered the benefits of routine universal screening in relation to any possible harm. Some of the many benefits are: I Increasing opportunities for women to disclose abuse; I Increasing opportunities for nurses to identify women who have been abused; I Linking health consequences to abuse, thereby positioning violence as a legitimate health concern; I Identifying the health impacts of abuse and providing early intervention; I Avoiding stigmatization by asking all women about abuse; I Reducing the sense of isolation abused women experience; I Affording opportunities to assist children of abused women; I Giving a strong message that abuse is wrong; I Informing women about violence against women services and other options that are available; and I Fostering healthy communities.
In recommending routine universal screening, the panel considered these benefits in relation to any possible harm associated with screening. Based on current knowledge, our conclusion is consistent with that of the Family Violence Prevention Fund's Research Committee (2004) that stated, with respect to screening, "we know of no research to suggest that assessment and/or interventions in health care settings are harmful to patients" (p. 5). Further, failure to implement routine, universal screening could result in more dire health outcomes for abused women, including femicide.
The panel also discussed changing the word, "screening", to "behavioural assessment" in order to differentiate our framework from a more traditional medical model as reflected in the Canadian and the U.S. Task Force reports. In the end, the term "screening" was retained as it is most commonly used and understood at this time.
In conclusion, based on current knowledge and practice in its entirety, panel members assert that routine universal screening, in conjunction with comprehensive staff education and ongoing agency and managerial support, constitutes best practice at this time. As with any best practice guideline, these recommendations will be reviewed and revised as new evidence becomes available.

# Nursing Best Practice Guideline
Practice Recommendations Recommendation 1.0
Nurses implement routine universal screening for woman abuse in all health care settings.

# Level IIb

# Discussion of Evidence
Woman abuse, as previously discussed, is a significant health problem with serious health consequences. The health care system plays an important role in identifying and preventing public health problems. Routine universal screening, with a focus on early identification of women experiencing abuse, whether or not symptoms are immediately apparent, is a primary starting point for this improved approach to health care practice for woman abuse DH, 2000;FVPF, 2004;MLHU, 2000;PPPESO, 2004;. Routine universal screening, as opposed to indicator-based screening, increases opportunities for both identification and effective interventions, validates woman abuse as a central and legitimate health care issue and enables providers to assist both victims and their children (FVPF, 2004, PPPESO, 2004. Screening has been demonstrated to be most effective when conducted in a face-to-face format rather than using self-administered questionnaires. Therefore, routine universal screening should be standard practice as a component of a complete nursing health history.
Screening is particularly important as the proportion of women seeking medical assistance as a result of abuse is estimated to be between 8% and 39%. These estimates are a compilation of abuse-related visits to both emergency rooms and family practice settings. Inspite of the prevalence of abuse and the high rates of visits for medical care, detection rates by medical practitioners are low.
The following criteria are used to determine when screening is useful: I The condition must have a significant effect on the quantity and quality of life; I Acceptable methods of treatment must be available; I The condition must have an asymptomatic period during which detection and treatment significantly reduce morbidity and mortality; I Treatment in the asymptomatic phase must yield a therapeutic result superior to that obtained by delaying treatment until symptoms appear; and I Tests that are acceptable to patients must be available, at a reasonable cost, to detect the condition in the asymptomatic period.
It is evident that screening for woman abuse fits these criteria. Specific to screening for woman abuse, the following conditions also need to be considered: I Screening questions are incorporated into routine health history/intake process; I Nurses consider the immediate safety of the women; I Screening occurs when the woman's condition is stable; I Questions are asked face-to-face and where privacy can be assured; I Women should be screened alone and never in the presence of their partner, other family members, or children over the age of 3 years; and I In cases where language is a barrier, only trained cultural interpreters are used (ECAV, 2001;MLHU, 2000).

# Woman Abuse: Screening, Identification and Initial Response
Abused women may not recognize their partner's behaviour as abusive particularly in the instance of unwanted sexual behaviour. Screening tools use specific terminology that describe the actions of abusers rather than using general terminology like "abuse". Therefore, screening questions need to be clear and examples of abusive behaviour may be needed to help the client understand what constitutes abusive behaviour. There are validated tools that can be used in screening (e.g., the Abuse Assessment Screen (AAS), the Abuse Assessment Screen -Disability (AAS-D), and the Woman Abuse Screening Tool (WAST)), or nurses can develop their own style keeping in mind these principles. See Appendix C for examples of the aforementioned screening tools.
As many women do not disclose abuse the first time they are asked, nor do they recognize violence as a health issue, screening for woman abuse should occur not only on the initial health history but also each time the health history is updated.
Women presenting with any health issue may be victims of abuse.  screened 159 women in an antenatal clinic and had a 10.7% disclosure rate.  screened 239 women with gastrointestinal disorders in primary care settings and found 66.5% had experienced some form of sexual and/or physical abuse.  reported the findings of a survey sponsored by the National Institute for Justice and the Centers for Disease Control and Prevention that revealed a community prevalence rate for intimate partner violence of 24.8%. These findings highlight the importance of screening women for abuse in all health care settings, regardless of the presenting health issue. It also sends a message that nurses' concerns for women go beyond their immediate medical needs.

# Recommendation 2.0
Routine universal screening be implemented for all females 12 years of age and older.

# Discussion of Evidence
The panel reached consensus on the age of 12 for the implementation of routine universal screening, recognizing that this adds to the complexity of implementing this recommendation. Twelve-year olds are involved in relationships, and the Criminal Code of  recognizes that young women between the ages of 12 and 16 are able to consent to sexual activity. Young women are at high risk for abuse in intimate relationships. A study by  examined prevalence rates for physical assault by intimate partners among 724 pregnant adolescents 12-18 years of age. Of the women interviewed, 29% had experienced some form of physical violence in the previous 12 months and almost 12% reported being physically assaulted by the fathers of their babies. Therefore, screening for violence at an early age provides an opportunity for early intervention in order to reduce violence in young women's lives, increase awareness about the dynamics of abusive relationships and foster healthy relationships between young women and their dating partners. Young girls are at the beginning of their dating experience and often do not understand the relationship dynamic of control. For example, a study of adolescent girls found that violence was misunderstood as being about anger (71%), confusion (40%) and love (27%) (Hyman,1999).
Additionally, Toward a Healthy Future: Second Report on the Health of Canadians  found that girls were the victims of reported assaults by family members more than boys; victims were female in 80% of sexual assaults and in over 50% of physical assaults. Furthermore, girls were more likely to be sexually assaulted between 12-15 years of age.

# Nursing Best Practice Guideline
The legal implications for screening young women are addressed in Recommendation 7.0.

# Recommendation 3.0
Nurses develop skills to foster an environment that facilitates disclosure. This necessitates that nurses know: I how to ask the question; and I how to respond.

# Level IV

# Discussion of Evidence
The nurse's initial response to a woman experiencing abuse is of great importance. Due to the complexity of the issue, even when directly asked, abused women may not disclose their experiences for many months, or in some cases, years. Guilt, shame, embarrassment, fear of not being believed, fear of being blamed for what has happened, and fear of escalation of violence often prevent women from openly discussing abuse (DH, 2000). Furthermore, this may be the first time the woman has been screened for abuse by a nurse and she may not feel safe to disclose any information. It is therefore necessary to adapt the environment to facilitate disclosure.
In order to facilitate a disclosure the nurse needs to create an environment of openness, safety and trust. It is paramount for each nurse to develop an approach that feels appropriate and comfortable in order to encourage clients to be "frank and open in their response" (MLHU, 2000, p. 33). Maintaining a supportive and non-judgmental approach is essential.
A supportive and non-judgmental approach to screening can be fostered by an environment that openly displays materials that inform women of the staff's willingness to discuss abuse. Strategies include: I Practitioners having information (posters and educational materials) about violence available and on display; I Displaying information in both public and private areas of the office environment (i.e., in the washroom where women can read it without being seen); and I Staff wearing buttons that indicate that they are willing to talk about violence.  found physicians who wore buttons with an anti-abuse message had more conversations about domestic violence than those who did not wear buttons.
When developing an appropriate response to a woman disclosing abuse, it is important for nurses to maintain a flexible screening protocol. Developing a personal style that appropriately fits the context of the particular encounter is imperative. The process will likely vary, depending upon: I The health care setting; I The relationship of the professional to the woman; I The presenting problem; I The client's history; and I The role of the nurse in meeting the client's health needs.

# Woman Abuse: Screening, Identification and Initial Response
Nurses are members of a multi-disciplinary team and screening responsibilities of team members may differ among practice settings. While one nurse may screen the woman initially, it is the responsibility of all nurses to ensure that the screening steps are followed to ensure optimum care and safety for women.

# Asking the Question
Asking the question creates an environment for discussion about violence and allows women to disclose their personal experiences if they so choose. How the question is asked is equally important. Institutions can choose validated tools (Appendix C), or individual practitioners can develop their own style of questioning as part of a health history, provided the following points are included: I Explain that all women are being asked about abuse because violence is so prevalent in society and there are significant health consequences to abuse (MLHU, 2000); I Tailor your approach to the woman; I Inform women that they can expect to be screened each time a health history is taken; and I Send a clear message that violence is unacceptable.
For specific examples of framing introductory questions see Appendix D.
Responding when she says "YES"  Nurses should be aware that safety is never guaranteed nor can the most detailed safety plan ensure that the violence will end. The woman experiencing violence is ultimately the only one who can reliably predict the risks she faces and the likelihood for further violence (DH, 2000). Therefore, the "best safety plan is the woman's own plan, one that she views as achievable in her circumstances and one she has a personal commitment to follow" (MLHU, 2000, p. 41).
Responding when she says "NO" and you suspect "YES":
For the woman's safety: I Discuss what you have observed and explain why you continue to be concerned about her health and safety; I Offer educational information about the health effects and prevalence of abuse; I Highlight referral services; and I Document her responses (MLHU, 2000).
These considerations illustrate nurses' commitment to respect a woman's choice to disclose and give women the power and control over their own situation.

# Responding when she says "NO":
In the event that there is no disclosure: I Share general information/provide education about woman abuse; and I Document the woman's response (MLHU, 2000).

# 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.

# Discussion of Evidence
Nurses must be cognizant of the cultural diversity of the populations with whom they work. Cultural diversity in this instance is used broadly and may be derived from one's race, ethnicity, class, religious/spiritual beliefs, age, ability or sexual orientation. The College of Nurses of Ontario (CNO) ( 2003) describes culture as "the learned values, beliefs, norms and way of life that influence an individual's thinking, decisions and actions in certain ways"(p. 3). "Client-centred care requires that nurses recognize the client's culture, the nurse's culture and how both affect the nurse-client relationship" (CNO, 2003, p. 3). Everyone has their own perception of the health care system and past experiences could impact on a woman's willingness to seek help.
Culturally diverse women may be reluctant to answer questions about and/or disclose abuse due to the following factors: I Isolation from one's community of support; I General mistrust due to racism, sexism and classism; I Religious factors; I Language/communication barriers; and I Lack of culturally sensitive services Maher, Zillmer, Hadley, & Leudtke, 2002;.

# Woman Abuse: Screening, Identification and Initial Response
When screening for abuse, it is recommended that nurses use gender-neutral language, as not all women are in heterosexual relationships. Women with physical/mental disabilities are at greater risk for all types of abuse as they experience abuse in higher proportions than the general population (DisAbled Women's Network (DAWN), 1996).  highlighted the importance of screening for woman abuse in the language most appropriate for the woman."If a clinician does not understand the meaning of words used...a breakdown in communication can result. Asking what unfamiliar words mean demonstrates a willingness to learn and appreciate cultural nuances rather than pretending that such differences do not exist or are related to a lack of education" (p. 459).
A study conducted by  found that acceptance of woman abuse varied by ethnic background and that cultural norms may keep women from recognizing abuse. Therefore, nurses need to be aware of ethnocentric biases in nursing practices that may impact on the woman's willingness to disclose abuse. Appendix G outlines some barriers to disclosure.
When screening a teen woman, the nurse will need to use different skills and language to promote an environment of comfort and safety. To communicate effectively, it is important to gain an understanding of the young woman's level of understanding of the question(s) being asked. Affirm with the young woman that she has the right to feel safe and confirm that she is not to blame for any incident that she may have experienced. The nurse should also discuss limits of confidentiality with the teen woman. Under certain conditions, nurses may be obligated by law to report abuse. See Recommendation 7.0 for reporting requirements. Offer reassurance that you will refer the young woman to other community resources in order to provide further support.
The nurse is responsible for developing a communication plan to make the woman an informed partner in the provision of care. A Guide to Nurses for Providing Culturally Sensitive Care (CNO, 2003) provides information on communication strategies including working effectively with an interpreter in the event of a language barrier. This practice standard also guides nurses in providing culturally sensitive care through self-reflection, acquiring cultural knowledge, facilitating client choice, and establishing mutual goals.

# Recommendation 5.0
Nurses use reflective practice to examine how their own beliefs, values, and experiences influence the practice of screening.

# Level IIa

# Discussion of Evidence
Self-reflection assists nurses to identify the values and biases that underscore their approach and interventions. Nurses need to honestly examine their reactions to different situations to discover why they respond in a particular way. In some circumstances, a nurse may seek help from others to assist in reflection (CNO, 2004a). For more information on reflective practice, the College of Nurses of Ontario (2004a) has prepared a fact sheet entitled Quality Assurance Reflective Practice.

# Nursing Best Practice Guideline
The Department of Health report (2000) states 25% of women from professional backgrounds have experienced abuse at some time in their lives. Since nursing is largely made up of women, this would suggest a probability that many nurses have experienced or are experiencing violence at the hands of their intimate partners. In a survey of ER nurses, Ellis (1999) found that 57.5% of the respondents had personal experience with woman abuse; 25% reported they experienced the abuse themselves, while 32.5% reported that the abuse was experienced by a parent, friend, spouse or other. As stated in if trauma from abuse has not been worked through, screening may trigger unanticipated responses by the nurse. As a result, barriers to effective intervention with abused women may surface. Attitudes and beliefs about woman abuse have long been identified as a barrier to effective clinical response.  determined staff responses to battered women in the ER demonstrated definite patterns/correlations between characteristics of women experiencing violence and the staff response to these women. The study found that staff were more reluctant to engage with women who presented with "discrediting attributes" such as alcohol use, evasiveness, reluctance to talk to staff or behaviour deemed inappropriate by staff. Additionally, staff felt that although they gave the woman information, they were not sure if the information was acted upon.  state "male nurses were significantly less likely to identify a woman as positive for partner violence...it may be that either male providers are less comfortable or  are less willing to confide in male providers, since perpetrators themselves are typically male" (p. 674).
Vicarious trauma (VT) is defined as a change that occurs to the trauma nurse as a result of compassionate care given in response to the client's traumatic experiences. VT can impact nurses emotionally, socially, physically, spiritually and professionally. Nurses and organizations must be aware of the development and the effects of VT. Symptoms may be manifested by profound changes in the nurse's sense of meaning, identity, worldview, and beliefs about self and others. Nurses need to recognize the cumulative impact of trauma work. VT is interactive -it ties the nurse's responses to client trauma and is shaped by both characteristics of the situation, as well as the nurse's unique psychological needs and cognitive belief system. Nurses need to become aware of their reactions by gaining insight into their own somatic signals of distress  and should develop a support network in which they can safely share their experiences in order to mitigate the effects of VT.

# Recommendation 6.0
Nurses know what to document when screening for and responding to abuse.

# Level IV

# Discussion of Evidence
Prior to initiating screening the nurse needs to inform the woman of the scope and limits of confidentiality. While nurses ensure privacy and confidentiality of health information that they collect through their practice, it is important to note that confidentiality and disclosure of pertinent personal health information cannot be guaranteed in the following cases: I When the nurse suspects child abuse/neglect; I When the nurse learns of possible harm to self (client) or others; and I When documents are subpoenaed by the courts (Ontario Ministry of Information and Privacy (OMIP), 2004).

# Woman Abuse: Screening, Identification and Initial Response
Documentation is an integral aspect of safe, effective nursing practice (CNO, 2004c) and must be comprehensive, legible and accurately reflect screening practice MLHU, 2000) as it may be used by the justice system as evidence during legal proceedings As with all nursing documentation, the record should be non-biased, containing direct observations by the nurse. Use of non-biased terms such as "chooses", "declines" or "patient states" are more appropriate than using judgmental terms like "alleges" or "victim" MLHU, 2000). An example would be "patient states 'my husband beat me'" (non-judgmental) rather than "victim alleges she was assaulted by partner" (judgmental).
Referral services and secondary intervention would include more detailed documentation such as: I Relevant health history; I History of abuse including the first, worst and most recent incident; I Where and when the abuse took place; I Name and relationship of abuser; I Detailed description of injuries and photos (if taken); and I All health care provided and information and/or referrals to resources provided to the woman MLHU, 2000).
When no disclosure of abuse is made the nurse should document "no disclosure to abuse screening" MHLU, 2000.
Nurses have legal, ethical and professional requirements that guide the management of client records CN0, 2004bCN0, 2004cCNPS, 1996a;OMIP 2004;Rozovsky & Inions, 2003). Policies and procedures concerning access to the woman's health information need to be developed as part of the screening protocol in all health settings. Women need to be aware, prior to screening, that the interaction will be documented and the documentation will be part of her health record that she can access at a later date should it be required. Disclosure of health information to individuals or agencies outside of the health care team needs the woman's expressed consent, except in cases previously discussed.
Nursing Best Practice Guideline Recommendation 7.0
Nurses know their legal obligations when a disclosure of abuse is made.

# Level IV

# Discussion of Evidence
There are three main considerations when a disclosure of abuse is made: I Reporting woman abuse; I Young women and disclosures of abuse; and I Children who witness woman abuse.
All nurses have learned that respecting client confidentiality is a critical aspect of the nurse-client relationship. It is important for nurses to realize when there are ethical, professional and legal exceptions to client confidentiality (CNPS, 1996a). Nurses need to be aware of their professional Code of Ethics (Canadian Nurses Association (CNA), 2002), practice standards related to confidentiality and health information (CNO, 2004b) and the policies related to confidentiality specific to their workplace. The new Ontario legislation on the protection of health information also has implications for nurses. Within the new Personal Health Information Protection Act (OMIP, 2004), there are guidelines related to documentation and disclosure of personal health information as discussed in Recommendation 6.0.

# Reporting Woman Abuse
There is no mandatory obligation to report woman abuse to the police. It is the woman's right to choose if she wishes to have police involvement and she must consent to this involvement prior to the nurse initiating such action. Nurses must respect the woman's decision and advocate for her right to choose.

# Young Women and Disclosures of Abuse
Since this best practice guideline recommends screening for woman abuse for women ages 12 and over, disclosure of abuse by a teen woman may necessitate the involvement of the Children's Aid Society (CAS). The following information is a general guide to practice in this area.
According to the Criminal Code of Canada (Department of Justice, 2003) young women over the age of 12 are able to consent to sexual activity in the following circumstances: I When she is between the ages of 12-14 and the age difference between the two persons is not more than 2 years; and I When the young person is age 14 or older and the other person is not in a position of trust or authority.
While teen sexuality may pose a challenge for the individual nurse, it is not necessarily a reportable event as illustrated in the above circumstances. The factors that define a report to CAS are: I When the young woman is under 16 years of age and the alleged abuser is a person in a care-giving role; or I When the young woman is under 16 years of age and the alleged abuser is in a role of authority or trust.
Assaults by a boyfriend are reportable only if these conditions apply or if the teen's parent(s)/caregiver(s) know of the abuse and do nothing to provide appropriate supervision to protect the young woman from harm.

# Woman Abuse: Screening, Identification and Initial Response
There is no age of consent for treatment or for collecting information to establish a health record, so young women are entitled to make their own health decisions (OMIP, 2004;Rozovsky & Inions, 2003;), provided the health care professional feels they understand the circumstances and can make an informed choice. Once the capable young woman has made a treatment decision, parent(s)/caregiver(s), or CAS can not have assess to the health record without her consent (OMIP, 2004). In the case of a conflict, the capable young woman's decision always takes precedence. As this is recent legislation that will impact nursing practice, it is advised that nurses consult with their nurse-manager and/or their agency's privacy officer.

# Children who Witness Woman Abuse
As noted in the background section, child witnesses to woman abuse may experience immediate and long term adverse effects. According to the Child and Family Services Act (Ministry of Children and Youth Services, 2003), this situation may be reportable to the Children's Aid Society as it can represent a condition of harm for the child. Nurses are advised to consult their local CAS to discuss individual situations. Further, all health care organizations need to have a protocol in place with their local Children's Aid Society.

# Education Recommendations
Recommendation 8.0 Mandatory educational programs in the workplace be designed to: I increase nurses' knowledge and skills; and I foster awareness and sensitivity about woman abuse.

# Discussion of Evidence
Education is the foundation of the success of all activities in the screening for woman abuse. Guidelines are more likely to be effective if they take into account local circumstances and are supported by an ongoing educational program about woman abuse (DH, 2000). Such programs need to be current, relevant and easily translated into practice. Health professionals also need assistance in developing the interviewing techniques that will enhance their comfort level with respect to asking intimate and emotionally sensitive questions about abuse (MLHU, 2000).
Regardless of where they work, nurses in both acute care and community settings are likely to encounter women who have experienced violence. It is therefore essential that nurses have the knowledge and skills to screen and respond appropriately and effectively (Davidson et al., 2001;.
Education of health care providers can increase the number of women who are screened for abuse. According to  there was a "significant relationship between education about  abuse and an individual's level of preparedness, beliefs about how and when to screen, and outcome expectations associated with domestic violence" (p. 49-50).

# Nursing Best Practice Guideline
Through education, nurses and nurse educators can be catalysts for improving nursing care of women in abusive relationships. Education programs need to include an advocacy component. In a randomized controlled trial with a two-year follow up, Sullivan and Bybee (as cited in  found that "advocacy services led to greater effectiveness in obtaining resources, a decrease in physical violence...and an improved quality of life and social support at 10 weeks post shelter" (p. 4). As such, nurses need to advocate on behalf of abused women to improve access to services. Appendices J and K contain several resources to aid educators in developing educational programs.
Effective education programs will utilize a variety of approaches. Drawing on the experiences of the diverse cultures and ethnic groups that nurses represent, health providers can be assisted to understand the cultural health needs of clients. A prerequisite to educating nurses is for the educators themselves to gain awareness of, and sensitivity to, the issue of woman abuse. Such awareness can be gained through a variety of techniques including: I "Train the Trainer" programs; I Role play; I Workshops; I Educational videos and other media presentations (Appendix J); I Preceptorship and mentorship programs; I Written materials, ongoing awareness and reflective practice; and I Guest speakers such as women's advocates.
It is important to include in the design of educational programs the identification of an individual or group of individuals to champion the program. This group will assume responsibility for maintaining and revising program content to reflect current and new knowledge and understanding. This group can also be responsible for the orientation of new staff and the development of ongoing educational programs with respect to screening for woman abuse.
Woman Abuse: Screening, Identification and Initial Response Recommendation 9.0
All nursing curricula incorporate content on woman abuse in a systematic manner.

# Level III

# Discussion of Evidence
According to it is necessary to inform policy makers, educators and researchers about gaps in educational services related to violence and areas of needed research in order that future nurses can be educated about abuse. Women abuse content must be taught in both a theoretical and contextual manner in order "to place violence within the context of social acts that have far-reaching effects on personal and public health, for which perpetrators are considered to be morally accountable" (Ross 2002, p. 8). Hoff and Ross (as cited in reported the results of a survey of Ontario Schools of Nursing that identified the curriculum development needs of faculty. All of the schools reported that they included content on violence issues in their curriculum, if only in readings. Three quarters reported that planned clinical instruction was "incidentally rather than systemically included as part of the curriculum" (Ross 2002, p. 18).
Ellis (1999) states that education on abuse and supporting resources are essential components of nursing school curricula. "Virtually all the literature about screening for the health effects of woman abuse stresses the need to provide adequate education to health care professionals about the nature, prevalence, dynamics, health effects and...interventions...at the undergraduate, graduate, postgraduate and continuing education levels" (MLHU, 2000, p. 47). According to Mezey ( 2001) "greater awareness of the issue and understanding of the problems facing victims of domestic violence can be achieved through incorporating the subject into...post graduate educational programs" (p. 546). Curricula should allow students to gain factual information and clinical experience about domestic violence. "Nursing education must use a two-pronged approach to educate faculty...and prepare students through curricula integration, clinical experience and other means" (Hinderliter et al., 2003, p. 452). Davidson et al. (2001) report that groups who had participated in training programs achieved statistically significant improvements in knowledge, attitudes and skills. Thus, the development panel recommends that content be included in all aspects of the curriculum and implemented in a systematic manner.

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

# Level IV

# Discussion of Evidence
In order for routine universal screening to be effective, organizations need to develop policies that support nursing practice while considering client needs and outcomes (PPPESO, 2004). These policies will reflect the unique setting where the screening is to take place. It is recommended that these policies include "who is (or is not) to be screened, when screening will be undertaken, by whom, how the screening is incorporated into workplace practices and changes to workplace practices which could facilitate routine universal screening" (ECAV, 2001, p. 3). The creation of policy and procedures should address the following:
I Mandatory routine universal screening practice; I Initial and continuing education for nurses (ECAV, 2001;MLHU, 2000; Metro Woman Abuse Council (MWAC), 2003); I Development of screening protocols ; I Routine documentation practice (ECAV, 2001;MLHU, 2000;MWAC, 2003); I Promotion of safety for women and their children (MLHU, 2000;MWAC, 2003); I Confidentiality (DH, 2000); I Structure designed to ensure privacy and supportive environment (DH, 2000;); I Linkages with relevant community agencies (DH, 2000;MLHU, 2000;MWAC, 2003); and I Supportive counselling for staff -such as through Employee Assistance Programs to address the issue of vicarious trauma (ECAV, 2001).
Examples of policies can be found in Appendix L.
Health care organizations work with the community at a systems level to improve collaboration and integration of services between sectors.

# Level Ib

# Discussion of Evidence
With the intent of providing optimal health care, screening interventions proposed to identify abused women must be informed by the experiences of these women as they access health services. Studies exploring abused women's perspectives of barriers to leaving abusive relationships repeatedly report organizational barriers, specifically the lack of co-ordination among all service providers as a hindrance to accessing services. Screening programs within health care settings have the potential to increase case findings of women who are abused  and have demonstrated greater success when implemented in collaboration with other sectors. Not only were screening rates improved, but women participating in these programs reported an increase in their satisfaction with the health care organization's response to partner violence as well as increased self-referral to services. All sectors such as violence against women, health, justice and social services should work together to identify system barriers and improve co-ordination of services for abused women, thereby enhancing the health care response to woman abuse.  Level IV Discussion of Evidence  indicate that in order for guidelines to be implemented successfully, a critical step must be the formal adoption of the guidelines by the organization. One way this can be accomplished is by incorporating recommendations into policies and procedures around routine universal screening for woman abuse. This key step helps to provide direction regarding the expectation of the organization and facilitates integration of the guideline into such systems as the quality management process.
Initiatives such as the implementation of best practice guidelines require strong leadership from nurses who are able to transform the evidence-based recommendations into useful tools that will assist in directing practice. It is suggested that the RNAO Toolkit (2002) be considered to assist organizations develop the leadership required for successful implementation. Refer to Appendix M for a description of the RNAO Toolkit: Implementation of Clinical Practice Guidelines.

# Nursing Best Practice Guideline

# Research Gaps & Future Implications
The panel, in reviewing the evidence for the development of this guideline, has identified several gaps in the research literature related to screening for and initial response to woman abuse. Consistent with our belief in the importance of different types of knowledge, a need for research that includes a variety of approaches including quantitative and qualitative methods has been identified. Further, the panel believes research will have the largest impact when conducted by research teams comprised of community and academic partners. In considering the research gaps, the following research priorities were identified to benefit client outcomes:

# Screening approaches (different approaches):
I What is the most effective way to screen for and respond to abuse for diverse populations including:
I What strategies need to be in place to sustain screening practices in organizational settings once initial education is complete? I What strategies are most effective in educating nursing students to ensure they incorporate screening into their practice?

# Outcomes of Screening:
I What are the long and short-term outcomes of screening for and responding to abuse on the:
G woman G nurse G health care system G community agency G broader community?

# Impact on Children:
I What is the impact on children when women disclose abuse in the context of screening?
Woman Abuse: Screening, Identification and Initial Response

# Evaluation/Monitoring of Guideline
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. The following table, based on a framework outlined in the RNAO Toolkit: Implementation of Clinical Practice Guidelines (2002) illustrates some indicators for monitoring and evaluation.

# Nursing Best Practice Guideline

# 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 that are interested in implementing this guideline. A summary of these strategies follows:
I Have a dedicated person such as an advanced practice nurse or a clinical resource nurse who will provide support, clinical expertise and leadership. The individual should also have good interpersonal, facilitation and project management skills.
I Establish a steering committee comprised of key stakeholders and members committed to leading the initiative. Develop a work plan to track activities, responsibilities and timelines.
I Provide educational sessions and ongoing support for implementation. The education sessions may consist of presentations, facilitator's guide, handouts, and case studies. Binders, posters and pocket cards may be used as ongoing reminders of the training. Plan education sessions that are interactive, include problem solving, address issues of immediate concern and offer opportunities to practice new skills (Davies & Edwards, 2004).
I Provide organizational support such as having the structures in place to facilitate the implementation.
For example, utilizing replacement staff so participants will not be distracted by concerns about work; having an organizational philosophy that reflects the value of best practices through policies and procedures; and developing new assessment and documentation tools (Davies & Edwards, 2004). I % of woman screened.
I Women report:
- knowledge of why screening occurred -feeling listened to, respected; and - feeling their choice was supported.
I Overall resource utilization.

# Structure Process Outcome
Nursing Best Practice Guideline I Identify and support designated best practice champions on each unit to promote and support implementation. Celebrate milestones and achievements, acknowledging work well done (Davies & Edwards, 2004).
I Organizations implementing this guideline should look at a range of self-learning, group learning, mentorship and reinforcement strategies that will, over time, build the knowledge and confidence of nurses.
I Beyond skilled nurses, the infrastructure required to implement this guideline includes access to specialized resources. Orientation of the staff to the use of specific materials must be provided and regular refresher trainings planned.
I Teamwork, collaborative assessment, treatment and interdisciplinary work is beneficial in implementing guidelines successfully. Referrals should be made, as necessary, to appropriate services or resources within the organization or agency and in the community.
I RNAO's Advanced/Clinical Practice Fellowships (ACPF) Project is another way that registered nurses in Ontario may apply for a fellowship and have an opportunity to work with a mentor who has expertise in screening for and responding to woman abuse. With the ACPF, the nurse fellow will have the opportunity to hone their skills in screening for and responding to woman abuse.
I Identify, develop and support BPG Champions and include people who have expertise in the topic area, facilitation skills, and knowledge of adult education principles in order to support, develop, mentor, and train other nurses within organizations to ensure knowledge transfer.
In addition to the strategies mentioned above, RNAO has developed resources that are available on the website. A Toolkit for implementing guidelines can be helpful if used appropriately. A brief description of this Toolkit can be found in Appendix M.
A complete version of the document is available at: .

# Process for Update/Review of Guideline
The Registered Nurses' Association of Ontario proposes to update this best practice guideline as follows:
- Each nursing best practice guideline will be reviewed by a team of specialists (Review Team) in the topic area every three years following the last set of revisions.

# During the three-year period between development and revision, RNAO Nursing Best Practice
Guidelines program staff will regularly monitor for relevant literature.
- Based on the results of the monitor, program staff will recommend an earlier revision period. Appropriate consultation with a team of members comprising original panel members and other specialists in the field will help inform the decision to review and revise the guideline earlier than the three-year milestone.
- Three months prior to the three-year review milestone, the program staff will commence the planning of the review process by: a. Inviting specialists in the field to participate in the Review Team. The Review Team will be comprised of members from the original panel as well as other recommended specialists. b. Compiling feedback received, questions encountered during the dissemination phase as well as other comments and experiences of implementation sites. c. Compiling new clinical practice guidelines in the field, systematic reviews, meta-analysis papers, technical reviews, randomized controlled trial research, and other relevant literature. d. Developing a detailed work plan with target dates and deliverables.
The revised guideline will undergo dissemination based on established structures and processes.

# Woman Abuse: Screening, Identification and Initial Response

# Appendix A: Search Strategy for Existing Evidence

# STEP 1 -Database Search
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".

# STEP 2 -Structured Web Site Search
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 websites, 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 websites 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.

# STEP 3 -Search Engine Web Search
A website 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 websites 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.
Woman Abuse: Screening, Identification and Initial Response STEP 4 -Hand Search/Panel Contributions 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.

# STEP 5 -Core Screening Criteria
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: I Guideline was in English; I Guideline was dated no earlier than 1999; I Guideline was strictly about the topic area; I Guideline was evidence-based (e.g. contained references, description of evidence, sources of evidence); I Guideline was available and accessible for retrieval; and I Guideline was developed for populations similar to Canada.

# RESULTS OF THE SEARCH STRATEGY
The results of the search strategy and the decision to critically appraise identified guidelines are itemized below. Fourteen guidelines met the screening criteria and were critically appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) (AGREE Collaboration, 2001) instrument.

# Nursing Best Practice Guideline
At the centre of the behaviour is the desire of the abuser to maintain power and control over the woman, and the relationship. While each individual abuser will use different patterns of behaviour to maintain power and control, there tends to be many common traits of abusive behaviour. The spokes on the wheel illustrate these common traits and include: emotional abuse; economic abuse; sexual abuse; isolation; intimidation; using gender privilege; threats; and manipulating children or other people.
The outer rim of the wheel depicts the overall threat or actual use of physical violence to coerce compliance, and to keep the abused woman under control.

# Nursing Best Practice Guideline

# POWER AND CONTROL

# USING COERCION & THREATS
Making and/or carrying out threats to do something to hurt her, threatening to leave her, to commit suicide, to report her to welfare, making her drop charges, making her do illegal things.

# USING EMOTIONAL ABUSE
Putting her down or making her feel bad about herself, calling her names, making her think she's crazy, mind games, humiliating her and making her feel guilty.

# USING ISOLATION
Controlling what she does, who she sees and talks to, what she reads, where she goes, limiting her outside involvement, using jealousy to justify actions.

# USING INTIMIDATION
Making her afraid by using looks, actions, gestures, loud voice, destroying her property, abusing pets, displaying weapons.

# USING CHILDREN
Making her feel guilty about the children, using the children to give messages, using visitation to harass her, threatening to take the children away.

# MINIMIZING, DENYING & BLAMING
Making light of the abuse and not taking her concerns about it seriously, saying the abuse didn't happen, shifting responsibility to abuse behavior, saying she caused it.

# SEXUAL ABUSE
Making her to do sexual things against her will, physically attacking the sexual parts of her body, treating her like a sex object.

# USING MALE PRIVILEGE
Treating her like a servant. Making all the "big" decisions, acting like the "master of the castle," being the one to define men's and women's roles.
WOMAN ABUSE SCREENING TOOL 3 (WAST)

# C -CONFIDENTIALITY:
I Interview in private, without her partner or family members being present. I Use a professional interpreter if one is required, not a friend or family member. I Tell her directly about the policies and procedures used in your practice or institution to protect patient confidentiality. I Assure her that you will not release the information unless she gives her written permission. I Outline the exceptions to this pledge of confidentiality: (a) where child abuse or neglect is in question;
(b) where the health professional has reason to fear for the safety of a third party; and (c) where a file is subpoenaed by a court order. I Let her know that you are documenting the information she provides so that it will help you provide appropriate medical services and referrals and so that it will be available to help her later if she should provide you with permission to share it.

# D -DOCUMENTATION:
I Document consistently and legibly. I Distinguish between your observations and her reports. I Record information on the first, the worst, and the most recent abusive incident. I If more than one person has abused the woman, distinguish between the abusers and the specific injuries or health effects of each incident. I Indicate the frequency of abusive incidents, as well as any increase or decrease in frequency and seriousness. I Avoid subjective statements and speculations that might undermine the woman's credibility. I Use the woman's own words, in quotation marks, as frequently as possible. I Use diagrams and/or photographs where possible to document physical injuries.

# E -EDUCATION:
I Educate about abuse and its health effects. I Help her to understand that she is not alone. I Attempt to engage the woman in long-term continuity of care by offering appropriate referrals and follow-up. I Know about available community resources and help her choose the services she needs, when she is ready to seek assistance. I Display posters, brochures and other available information about woman abuse in your office or institution. I Provide her with information about the Abused Women's Help Line.

# Nursing Best Practice Guideline

# R -RESPECT AND RECOGNITION:
I Respect the integrity and autonomy of the woman's life choices. I Recognize that she must deal with the abuse at her own pace. I Recognize that an abused woman is an expert about her own abuse and abuser. I Affirm her strengths and the survival skills she has demonstrated. I Do not try to tell her what to do but help her understand the options available to her; she must choose the options she decides will meet her own goals and priorities. I Offer referrals to other specialized services and follow-up with you. I Do not label her resistant or non-compliant if she decides not to accept your advice; make it clear you respect her right to choose and will continue, as her caregiver, to support her. I Make sure any medications you offer to help her deal with stress and/or sleep problems do not impair her ability to act appropriately on her own behalf. I Help her to recognize that she cannot control the actions of others; she can only decide her own.
Source: Middlesex-London Health. Task force on health effects of woman abuse -Final report. London, Ontario: Author. Reprinted with permission.

# C. Develop a Safety Plan with the woman
Encourage the woman to:
- Tell someone about the abuse.
Have a list of emergency phone numbers.
Plan an escape route -where to go in an emergency situation. 4. Pack a suitcase with essential clothing for self and children. Include comfort items like a favourite toy for the children. Store with someone she trusts.
Collect essential documents and keep in a safe place. Include social insurance number, birth certificates, driver's licence, passport/other photo identification, bank account numbers, copy of marriage licence, and any court documents such as restraining orders/peace bonds, or custody and access papers.
To ensure that staff members are aware of roles and responsibilities related to the Routine Universal Comprehensive Screening Protocol (RUCS).  1.2 During the intake assessment of a female client, 12 and over, the PHN routinely asks if the individual has experienced any form of abuse within the last year or at any time in her life. This assessment will be applied to all clients, whether they are new or are in a long term program.
The Public Health Nurse documents on the individual client record or log sheet that:
(1) the question was asked and ( 2) the client response.
- 4 If abuse of a female client under the age of 12 has been disclosed, the PHN has a legal obligation to report this disclosure verbally to the Children's Aid Society (CAS).
- 5 Education about prevalence of woman abuse, the potential health impact and the types of abuse will be a part of this interview, regardless of disclosure. See p. 79-85 for information on types of abuse and the health effects. The degree and depth of the information shared will be determined by the client situation. -sleeps around -knowingly transmits sexual diseases -treats her as a sex object -pressures her to pose for pornographic photos -displays pornography that makes her feel uncomfortable -uses sex as the basis or solution for an argument -criticizes her sexual ability -unwanted fondling in public -purposely does not wash and expects sex -name calling (whore, slut, frigid, bitch) -accusations of affairs -degrades her body parts -tells sexual jokes or makes sexual comments in public -demands sex for drugs or alcohol, as payment or trade -administers drugs or alcohol for sexual advantage -insists on checking her body for sexual contact

# Religious abuse
-uses religion to justify abuse or dominance -uses church position to pressure for sex or favours -uses her, then demands forgiveness -prevents her from attending church -requires sex acts or drug use as religious acts -mocks her beliefs

# Nursing Best Practice Guideline
The Toolkit is available through the Registered Nurses' Association of Ontario. The document is available in a bound format for a nominal fee, and is also available free of charge from the RNAO website. For more information, an order form or to download the Toolkit, please visit the RNAO website at www.rnao.org/bestpractices.

# Screening, Identification, and Initial
Response is a result of a scheduled revision of the guideline. Current

# Revision Process
The Registered Nurses' Association of Ontario (RNAO) has made a commitment to ensure that this practice guideline is based on the best available evidence. In order to meet this commitment, a regular monitoring and revision process has been established for this guideline.  After appraising these international guidelines using the "Appraisal of

# Review of Existing Guidelines

# Guidelines for Research and Evaluation
Instrument II" (Brouwers et al, 2009), the revision panel identified the following guideline to inform this revision:

# Literature Review
Concurrent to the guideline search, a search for published literature relevant to the scope of the guideline was conducted by a health sciences librarian using the following electronic databases: CINAHL, Medline, EMBASE and Web of Science.
A research assistant with Master's preparation in nursing, conducted the inclusion/exclusion review, quality appraisal and data extraction of the included articles, and prepared a summary of the literature findings.
The comprehensive data tables and summary were provided to all review panel members.

# Review Findings
A review of the most recent literature since the publication of the original guideline does not support changes to the original recommendations, but rather provides additional support to the recommendations related to screening, indentifying and responding to woman abuse. Recent work by MacMillan and colleagues, ( 2006), Rhodes and colleagues, (2006), Kataoka and colleagues, (2010) and Svavarsdottir (2010) examined screening approaches including questionnaires, telephone interviews and automated data collection. While all techniques have been shown to have merit, one-on-one interviewing continues to be the technique chosen for its capacity to give voice to victems of woman abuse (Campbell, Adams, Wasco, Ahrens, & Sefl, 2009). This finding is consistent with previous studies (Kozial-McLean et al., 2010;.

# Review Process Flow Chart
While different methods of screening may be necessary in different settings (Svavarsdottir, 2010), routine universal screening should be standard practice as a component of a complete nursing health history.

# Recommendation 2
Routine universal screening be implemented for all females 12 years of age and older.

# Level of Evidence: IV
The discussion of evidence on page 23 of the original guideline has been revised to reflect additional literature support:

# Discussion of Evidence
The panel reached consensus on the age of 12 for the implementation of routine universal screening, recognizing that this statement adds to the complexity of implementing this recommendation. Twelve-year olds are involved in relationships, and the Criminal Code of Canada (Department of Justice, 2011) recognizes that young women between the ages of 12 and 16 are able to consent to sexual activity. A cross sectional survey by O'Donnell, Agronick, Duran, Myint-U & Stueve ( 2009) found that one in five young women had initiated sexual intercourse by eighth grade, and three in five had reported at least one type of aggressive behaviour during middle school. O'Donnell and colleagues, (2009) reported that there are "links between behaviors in adolescence and intimate partner violence during the teenage and young adult years" (p. 84). This is a concern for urban young women, who report "relatively high levels of peer-directed violence, especially during middle school, a time when such behaviors as fighting often peak among both boys and girls" (O'Donnell et al., 2009, p. 84).
In addition, O'Donnell and colleagues, ( 2009) reported that those who engage in aggressive behaviour during the middle school years are particularly vulnerable to dating violence during adolescence, as well as adult partnership violence, and that those who experience intimate partner violence once are at risk of repeat occurrences. Six percent of respondents reported no sexual partners by the last survey (10 years after the first survey), 22% reported one or two, and the rest said they had had three or more.
A study by  examined prevalence rates for physical assault by intimate partners among 724 pregnant adolescents 12-18 years of age. Of the individuals interviewed, 29% had experienced some form of physical violence in the previous 12 months and almost 12% reported being physically assaulted by the father of their baby. Young girls are at the beginning of their dating experience and often do not understand the relationship dynamic of control. For example, a study of adolescent girls found that violence was misunderstood as being about anger (71%), confusion (40%) and love (27%). Therefore, screening for violence at an early age provides an opportunity for early intervention to reduce violence in young women's lives, increase awareness about the dynamics of abusive relationships and foster healthy relationships between young women and their dating partners.

# Recommendation 3
Nurses foster an environment that facilitates disclosure. This necessitates that nurses:
- ask about woman abuse/intimate partner violence; and - respond to disclosure Level of Evidence: IV Recommendation 3 has been changed to reflect specific actions that nurses can carry out related to woman abuse/IPV.
The second and third paragraphs in the discussion of evidence found on page 24 of the original guideline have been revised to reflect additional literature.

# Discussion of Evidence:
In addition to the nurse creating an environment of openness, safety and trust, Amar and Gennaro (2005), Johnson and colleagues (2009), and McCord-Duncan, Floyd, Kemp, Bailey, & Lang (2006) suggest that the nurse do the following to aid in creating an environment conducive to abuse disclosure: (1) treat the woman with respect; (2) protect the woman; (3) document the interaction; (4) give the woman control; ( 5) respond immediately to any disclosure; (6) offer the woman options; and (7) be physically present. In addition, 'how' questions are asked is more important than the actual wording (SOGC, 2005). Strategies of how questions are asked include use of "normalizing (i.e., I ask all my new patients this), showing connections and concerns (i.e., I wonder if abuse is making your headaches worse), and showing an interest and ability to help" (SOGC, 2005, p. 374).
It is paramount for nurses to develop an approach that feels appropriate and comfortable to each client in order to encourage clients to be "frank and open in their response" (MLHU, 2000, p. 33). Empathetic and nonjudgmental listening should be the first priority for the nurse when dealing with abused women in any healthcare setting (WHO, 2008).
Additional Literature Support: Campbell et al., 2009 Recommendation 4 Nurses develop screening strategies and initial responses that reflect the needs of all women taking into account differences based on culture, race, ethnicity, class, religious/spiritual beliefs, age, ability and/or sexual orientation.

# Level of Evidence: III
Recommendation 4 has been changed with the addition of the term "culture" to more closely reflect the discussion of evidence found on page 26 of the guideline.

# Recommendation 5
Nurses use reflective practice to examine how their own beliefs, values, and experiences influence the practice of screening.

# Level of Evidence: IIa
Additional Literature Support:
College of Nurses of Ontario, Culturally Sensitive Care, 2009
College of Nurses of Ontario, Quality Assurance Reflective Practice, 2011
Nurses know what to document when screening for and responding to abuse. Recommendation 7
Nurses know their legal obligations when a disclosure of abuse is made.

# Level of Evidence: IV
The discussion of evidence found on page 30 of the original guideline has been revised to incorporate new literature.

# Discussion of Evidence
There are four main considerations when a disclosure of abuse is made:
- Reporting woman abuse - Young women and disclosure of abuse - Children who witness woman abuse - Work-place violence as it relates to domestic violence
Respecting client confidentiality is a critical aspect of the nurse-client relationship. It is important for nurses to realize when there are ethical, professional and legal exceptions to client confidentiality within client relationships (CNPS, 2008). Nurses need to be aware of their professional Code of Ethics (Canadian Nurses Association 2008) and the practice standards related to confidentiality and health information (CNO, 2004). Nurses also must have knowledge and understanding of their respective workplace polices related to confidentiality. The Personal Health Information Protection Act (OMIP, 2011) has implications related to documentation and disclosure of personal health information as discussed in Recommendation 6.0 of the original guideline.
unchanged changed additional information new recommendation

# Education Recommendations
Recommendations 5, 6 and 7 have been moved from "Practice Recommendations" to "Education Recommendations" in an attempt to streamline the practice recommendations as directives to the nurse and/or healthcare professional as to what to do in practice.

# Reporting Woman Abuse
In Canada, there is no mandatory obligation to report woman abuse to the police. It is the woman's right to choose if she wishes to have police involvement and she must consent to this involvement prior to the nurse initiating such action. Nurses must respect the woman's decision and advocate for her right to choose (Health Canada, 1999).
The example below highlights the obligation of pressing charges of woman abuse:
If the police were dispatched to a home as a result of a call related to domestic violence concerns and the police determine the situation is a case of domestic violence, they have a legal obligation to place such charge(s). The woman involved is not the one to press charges, contrary to popular belief. The police will: (1) encourage the woman to seek medical care; (2) provide information to community services; and, in some situations, ( 3) make a referral to community resources.

# Young Women and Disclosure of Abuse
Since the best practice guideline recommends screening for woman abuse for females ages 12 and over, disclosure of abuse by a young woman may necessitate the involvement of the local Child and Family Services (CFS) agency. The following information is a general guide to assist in this practice.
According to the Criminal Code of Canada (Department of Justice, 2011) young women over the age of 12 are able to consent to sexual activity in the following circumstances:
- When she is between the age of 12-14 and the age difference between the two people is not more than 2 years; and the person is not in a position of trust/ authority or in a relationship of dependency or an exploitive relationship; or - When the young person is between 14 -16 years of age and the other person is less than 5 year older and not in a position of trust/authority or in a relationship of dependency or an exploitive relationship.
While teens having sex may pose a moral/ethical challenge for the individual nurse, it is not necessarily a reportable event as illustrated in the above circumstances. The factors that define a report to CFS are:
- When the young woman is less than 16 years of age and the alleged abuser is a person in a care-giving role; or - When the young woman is less than 16 years of age and the alleged abuser is in a role of authority or trust.
Assaults (physical and/or sexual) by a boyfriend are reportable only if the above conditions apply or if the teen who is 16 years or younger where the parent(s)/caregiver(s) know of the abuse and do nothing to provide appropriate supervision to protect the young woman from harm. If the young woman is 17 years or older and being assaulted by a boyfriend, only with her consent can a report to police be made regardless if she is living at home with parents/caregiver.
There is no age of consent for healthcare/treatment or for collecting health information to establish a health record, so young women are entitled to make their own health decisions (OMIP, 2011;Rozovsky & Inions, 2003), provided the healthcare professional feels the young woman understands the circumstances and can make an informed choice.
Once the young woman has made a treatment choice, parent(s)/caregiver(s) or CFS cannot force the young woman to undergo a treatment/examination. Also the parent(s) or caregiver(s) cannot have access to the young woman's health record unless the nurse has written consent of the young woman. If CFS is involved and doing an investigation they may request access to the health record. Consultation with your agency's privacy officer or manager is advised.

# Children Who Witness Woman Abuse
The Child and Family Services (CFS) Act of Ontario ( 2003) contains legislation that outlines the duty to report as it relates to the protection of children who have been exposed to woman abuse. In the Act, exposure is described as a child who sees, hears or knows of the violence whether it is verbal, emotional or physical. Even if the child is not in the home at the time of the abuse, they often are exposed to the pre and/or post effects of the violence and this too is considered exposure.
There is a legal obligation for nurses to report children's exposure to woman abuse to the local CFS. The nurse should advise the woman of this obligation and ask her some key questions:
- Has the abuser threatened to call CFS to indicate she is a "bad mother"?
- Are CFS involved already and if so who is their worker?
- What has the woman done already to keep the children safe?
When discussing the involvement of CFS, the woman and children may not always view it as a positive offer of assistance. The woman is often afraid that she will lose her children and be viewed as not adequately caring for and protecting the children. The child often fears separation from his/her parent(s), home, family and friends. Children often fear they are to blame because they were not "good" and may have a sense of guilt and/or insecurity.
Often in these abusive situations the welfare of the child/children is strongly linked to the non offending parent.Therefore, it is important to explore the above key questions before making the call to CFS. It is important that the woman appreciate that CFS can assist in making a positive link to services and assistance such as helping to meet their needs such as food/clothing when going to a safe place.
It is important to document a child's reaction to violence. Reactions such as crying, clinging to a parent, increased anxiety if separated and any verbal disclosures about the abuse should be noted. Often when a child makes a disclosure about abuse he/she is revealing what is often a family secret and is indicating that help is needed (Baker & Cunningham, 2005). If healthcare providers fail to listen and to respond to the child's disclosure, it may discourage the child from ever telling anyone about the abuse thus putting him/her at further harm (Baker & Cunningham, 2005).
Consultation with and education from the local CFS agency is strongly advised to gain better understanding about the legislation with regards to children's exposure to woman abuse. Collaboration between agencies to have protocols in place helps to ensure the safe and successful referral for services to protect the children and woman.

# Workplace Violence as it relates to Domestic Violence (IPV/Woman abuse)
With the recent introduction in Ontario of the bill Violence and Harassment in the Workplace (Occupational Health & Safety Amendment Act 2009) there is now a requirement for employees and employers to have education on violence including domestic violence that occurs in the work place setting. Nurses need to be knowledgeable about their facility's policies and procedures when a situation of IPV occurs in the work place or disclosure of woman abuse is made by a coworker. Key to this legislation is the understanding that a nurse needs to make a report to his/her supervisor/manager. If a critical incident happens that results in physical injury to the worker(s) by the abuser, then there are required reporting obligations that the employer must follow as set out by the OHSA ( 2009). Recommendation 8
Mandatory educational programs in the workplace be designed to:
- increase nurses' knowledge and skills; and - foster awareness and sensitivity about woman abuse.

# Level of Evidence: Ib
The discussion of evidence on page 31 of the original guideline has been revised with the addition of the following paragraph:

# Discussion of Evidence
Hamberger and colleagues ( 2004) reported increased self-efficacy, increased endorsements of the role of nurse, and increased comfort in making appropriate community referrals in identifying and helping victims of IPV as a result of training that involved a variety of techniques and messages. Johnson and colleagues (2009) also reported improved nurse self-efficacy for screening, decreased fear of offending IPV victims, and improved perception of resources available for nurses to manage IPV, following a self-efficacy theory based curriculum. Neither study, however, measured behaviour changes in nursing practice. Hamberger and colleagues (2004) noted that while the follow-up levels at 6-months were still high there was a significant drop in the levels. Johnson and colleagues (2009) noted that education alone was insufficient to maintain nurses' knowledge and skills. Hamberger and colleagues (2004) noted on-going booster sessions are necessary to reinforce self-efficacy and comfort in identifying and helping IPV victims.

# Recommendation 9
All nursing curricula incorporate content on woman abuse in a systematic manner.

# Level of Evidence: III Recommendation 10
Health care organizations develop policies and procedures that support effective routine universal screening for, and initial response to, woman abuse.

# Level of Evidence: IIb

# LOE changed IV  IIb
The following paragraph is added to the beginning of the discussion of evidence found on page 33 of the original guideline.

# Discussion of Evidence
According to Haggblom, Hallberg, & Moller (2005), more effort needs to be made by health administrators to prepare point of care nurses in providing care to female abuse victims. Furthermore, health administrators need to demonstrate their "responsibility in evaluating and readdressing the implemented interventions" (Haggblom, Hallberg, & Moller, 2005, p. 241).

# Recommendation 11
Health care organizations work with the community to improve collaboration and integration of service between sectors.

# Level of Evidence: Ib
The recommendation above has been changed with the deletion of "at a systems level". The discussion of evidence on page 34 of the original guideline has been revised to reflect additional literature.

# Discussion of Evidence
Care provided to victims of woman abuse can be greatly enhanced through interventions that are informed by these individuals and provided in collaboration with community services. Developing such an approach can increase a victim's comfort level towards disclosure, reduce fears of re-victimization by the health care system (Postmus, Severson, Berry & Yoo, 2009) and ensure that services are culturally competent (Arnette, Mascaro, Santana, Davis & Kaslow, 2007).
Organizations should recognize that services viewed important by health care providers may differ from what clients value the most (Krugman et al., 2004). Victims of woman abuse are more likely to seek tangible services including shelter and financial support more so than services such as counselling and legal assistance (Postmus et al, 2009). unchanged changed additional information new recommendation

# Organization And Policy Recommendations
Understanding the vastness of supports and services required by victims of woman abuse speaks to the importance of collaboration among care providers. Allen, Bybee and Sullivan (2004) stress the need for advocacy that is individualized and comprehensive to optimize a victim's ability to utilize community resources. Moreover, Pollack and colleagues (2010) noted that client satisfaction was highest when Employee Assistance Program (a workplace benefit that assists employees with a variety of issues that may negatively affect job performance) professionals assisted with referrals to other services compared to those that simply provided information regarding community services. Similar findings were echoed in a multi-community study in which clients deemed domestic violence and sexual assault services to be more helpful when services were linked with other agencies (Zweig & Burt, 2007).
Implementing a systemic approach to addressing woman abuse can have a positive impact for health care providers. Healthcare providers voiced a higher level of confidence to provide service in an environment that prioritized woman abuse as an important issue as demonstrated through the implementation of policies and procedures and through the availability of training and having resources on hand for distribution (Chang, et al., 2009).

# Recommendation 12
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 implementation.
- 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, 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 RNAO guideline Woman Abuse: Screening, Identification and Initial Response.
Level of Evidence: IV Each item is scored from 1-5. Thus, scores for this inventory range from 4-20. A score of greater than 10 is considered positive.
To establish a process for all patients 12 and over to be screened for intimate partner violence because most victims of domestic violence who present to hospitals report that if asked, they would be prepared to discuss their history of abuse.
Early intervention is likely to increase the probability of stopping the violence before it escalates to more serious harm.
The goal is to improve the care provided to victims of intimate partner violence by recognizing and referring patients to the appropriate resources.
Intimate Partner Violence: a behavioural pattern used by one person to gain/maintain power and control over another.
This occurs in all types of intimate partner relationships including common-law and same sex. It may or may not include physical abuse. Abuse can include other forms of mistreatment and cruelty such as constant threatening, psychological, emotional, and verbal abuse.
Routine Universal Screening: Routine refers to the frequency with which screening is carried out. Routine screening is performed on a regular basis regardless of whether or not signs of abuse are present. Universal refers to the characteristics of the group to be screened and occurs when nurses ask everyone over a specific age about experiences of abuse.
1) All patients who are 12 years old or older will be asked about intimate partner violence with each visit to the hospital.
Staff will use the Routine Universal Screening Assessment Tool (appendix D) 1 to guide the process.
2) Routine Universal Screening (RUS) will be done by trained health care professionals who have completed the mandatory in-service on RUS. This education will include:
The health professional doing the assessment will:
- Complete the screening process as outlined in the mandatory training.
To ensure that all female clients, 12 and over, are made aware of the various forms of abuse, and potential health effects of abuse during any assessment in The Clinic.
- Staff members and other health professionals are aware of the various types of abuse to which women can be subjected.
- Staff members and other health professionals are knowledgeable about health effects of woman abuse.
- Staff members and health professionals utilize the above knowledge during health assessments of female clients, 12 years of age and over.

# PROCEDURES 1.0 Guiding Principles for Screening Women
- 1 Through attitude and approachable demeanor, staff and other health professionals treat the client with respect, dignity, and compassion, being sensitive to differences in age, culture, language, ethnicity, and sexual orientation.
- 2 Through words, actions, and facial expressions, staff and other health professionals project a non-threatening, non-judgmental atmosphere, so that the client feels cared for and supported. Moreover, staff members should avoid criticism of the abuser.
- 3 Staff and other health professionals demonstrate belief in the woman's account of her experience.
- 4 As appropriate, staff and other health professionals consistently reinforce to women clients that: a) abuse is not the fault of the woman but rather the responsibility of the abuser b) no one has the right to use abuse on another person, c) physical and sexual abuse are criminal offences in Canada.
- 5 Staff and other health professionals inform the client about the policies and procedures used in The Clinic to protect confidentiality and can clearly outline those instances where this pledge of confidentiality would be exempt.
- 6 Staff and other health professionals document in a clear and concise fashion.
- 7 Staff and other health professionals provide education to the client about the serious health effects of continued abuse and information about community services and resources.
- 8 Staff and other health professionals demonstrate respect for the client's right to make her own decisions and recognize that the woman must be allowed to deal with the identified abuse at her own pace and in her own terms through her own decisions.

# Application of the RUCS 2 Protocol in the Clinic for Public Health Nurses
- 1 Any female, 12 years of age and over, who presents at The Clinic for health services will be assessed using the screening question in the RUCS protocol (F1). These health services would include attendance at any of the regularly scheduled Clinics and/or other services provided on a drop-in basis, such as ECP. Clients who visit to purchase contraception will not be assessed unless there are reasonable grounds to suspect abuse.
- 2 During the intake assessment of a female client, 12 and over, the PHN 3 asks if the individual has experienced any form of abuse within the last year or at any time in her life. Prior to this assessment, the PHN must ensure that the client fully understands the legal obligation to report suspected abuse of any person under the age of 16 to the CAS and explains the procedure for reporting, should there be a disclosure (see policy A-300).
To retain a permanent paper record of all RUCS interviews following a disclosure. This RUCS form will become part of the client record.
- Write the client record number and indicate clinic attended at the top of the form.
- Record the information solicited from the client after a disclosure has been made. Documentation can continue on the back of the form as needed.
- Indicate intervention provided including arrangements for client follow-up as applicable in section 2 of form.
- In cases of recent sexual assault or violence, ensure completion of Section 3, documenting details of the situation and PHN intervention. Documentation can continue on the back of the form as needed.
- In cases where the client does not disclose abuse, but indicators are present, the PHN should discuss the indicators causing the suspicion of abuse and record in Section 4 of form.
- The RUCS form shall remain in the client chart. For statistical purposes, cases of abuse shall be tracked on the "RUCS Tracking Form" kept in each PHN office. RUCS Tracking Forms will be collected, and statistical data entry completed by the CTA on a quarterly basis.
- For more detail see Section 7-30 Women Abuse-Guiding Principles and Implementation of RUCS Protocol.
Sample Policy #5: The Routine Universal Comprehensive Screening (RUCS) Protocol
Source: Middlesex-London Health Unit, London, Ontario. Reprinted with Permission.

# The Routine Universal Comprehensive Screening (RUCS) Protocol
Indicate that screening for abuse is now a regular part of assessments and that each woman over age 12 is asked whether she has ever experienced physical, sexual and / or emotional abuse.

# NO YES

# Appendix B: Power and Control Wheel
The Power and Control Wheel, developed by the Domestic Abuse Intervention Project, (Duluth, MN) is a visual aide that demonstrates the dynamics of power and control in abusive relationships.

# USING ECONOMIC ABUSE
Preventing her from getting or keeping a job, making her ask for money, giving her an allowance, taking her money, not letting her know about or have access to family income.  1 = Threats of abuse including use of a weapon _______ 2 = Slapping, pushing; no injuries and/or lasting pain _______ 3 = Punching, kicking, bruises, cuts and/or continuing pain _______ 4 = Beating up, severe contusions, burns, broken bones _______ 5 = Head injury, internal injury, permanent injury _______ 6 = Use of weapon; wound from weapon _______ If any of the descriptions for the higher number apply, use the higher number.  (1994). In. Assessment of women for partner abuse. Journal of Obstetric,Gynecologic,& Neonatal Nursing,27,. Reproduced with permission. 1 Note: this tool is validated Woman Abuse: Screening, Identification and Initial Response ABUSE ASSESSMENT SCREEN -DISABILITY 2

# P H YS ICAL AB U S E p u s h i n g s h o v i n g h i t t i n
The Abuse Assessment Screen -Disability (AAS-D) was developed and tested to address the range of abuse experienced by women with physical disabilities.

# Appendix D: Framing Introductory Questions
Start with a simple explanation as to why the questions are being asked.

# For example:
"Because woman abuse is so common in many people's lives, I now ask all my clients about it." "Many of the women I see are dealing with abuse in their relationships. Some are too afraid and uncomfortable to bring it up themselves, so I've started asking about it routinely."
Then ask specific questions.

# For example:
"Have you ever been hurt or threatened by someone?" "Are you currently or have you ever been in a relationship where you were physically hurt, threatened, or made to feel afraid (or unsafe)?" "Have you ever been emotionally, physically, or sexually abused by your partner or someone important to you?"

# Specific Considerations for Teen Women
"Everyone has a right to be safe and choose what happens to their body." "Sometimes people say and do things to us that can be hurtful and make us feel confused and uncomfortable. Has anyone ever made you feel that way?"

# Let the response guide your next question(s).
I You may need to define 'hurt' using age-appropriate language. Refer to Appendix L (Eight Types of Abuse). I Avoid using words such as "bad". A young person could take the word bad as meaning that they are bad or have done something wrong. I Avoid using leading questions; be direct and to the point; let the young person answer the question in her own words. I With young women, it will be necessary to proceed more slowly to build trust. I It may be necessary to explain that if abuse was of a sexual nature, even though it was an unwanted act, it may have resulted in "feeling good". This does not make the unwanted action acceptable.

# Nursing Best Practice Guideline

# Appendix E: Clinical Pathways

# Appendix F: Mnemonic Tool ABCD-ER
Guiding principles for screening will assist the nurse in implementing effective intervention. The Mnemonic Tool ABCD-ER (MLHU, 2000) outlines the principles.
A -Attitude and Approachability of the health care provider B -Belief in the woman's account of her own experience of abuse C -Confidentiality is essential for disclosure D -Documentation that is consistent and legible E -Education about the serious health effects of abuse R -Respect for the integrity and authority of each woman's life choices Recognition that the process of dealing with identified abuse must be done at her pace, directed by her decisions

# A -ATTITUDE AND APPROACHABILITY:
I Treat the patient with respect, dignity and compassion. I Be sensitive to differences in age, culture, language, ethnicity and sexual orientation. I State clearly that abuse is not the fault of the victim but the responsibility of the abuser. I Reinforce that no one has the right to use physical, sexual or emotional abuse to control another person's actions. I Reinforce that physical and sexual abuse is against the law in Canada. I Convey a non-threatening, non-judgmental stance in words, facial expressions and body language. I Express concern for her safety. I Acknowledge the strength she has shown in surviving abuse and disclosing it to you. I Offer support. I Avoid excessive criticism of the abuser.

# B -BELIEF:
I Show by your words and your actions that you believe her disclosure. I Remember that the fear of not being believed silences many women. The abuser may have convinced her that no one will believe her if she discloses. I Help her to understand that most of us try to block out memories that are too painful to deal with. If she is disclosing retrospective abuse, she may not be sure herself of exactly what happened or where. I Reassure her to encourage her to have confidence in her own perceptions about the abuse.

# Woman Abuse: Screening, Identification and Initial Response

# Appendix G: Barriers to Screening and Disclosure
There are significant barriers to screening and disclosure from both the client's and clinician's perspective. It is necessary for the nurse to understand these barriers. Some barriers for screening from the provider's perspective include:

# Nursing Best Practice Guideline

# Appendix H: Safety Planning
A. Ensure the woman's safety at all times Think -Where is the abuser right now? If the abuser is in the health care facility now, does the woman believe that the abuser may pose a danger to her, her children or the health care providers? Is it necessary to seek help from the police or security? Is the abuser suspicious about the interview? Has the abuser tried to insist that the interview include him/her? (MLHU,2000) B. Complete a safety checklist with the woman
The nurse helps the woman assess: (e.g., "I can't live without you", "You'll be with me or nobody else") I How fearful is the woman of not complying with partner's demands?

# Appendix I: Community Resources

# Community Resource List
Professionals should keep an up-to-date list of referral resources that are available in their own communities to assist abused women. This table contains suggested categories for inclusion.
Adapted from: Health. A handbook for health and social services professionals responding to abuse during pregnancy. Ottawa: Author. Reprinted with permission.
Woman Abuse: Screening, Identification and Initial Response

# Appendix J: Educational Resources
This appendix contains resources that the panel identified as useful but it should not be considered an inclusive or comprehensive list. As a means to get to know the student better, you ask about her general health, how her courses at school are going, her friends, and whether she is in an intimate relationship. You invite her to address any other concerns she might have at this time. The young woman asks about condoms and talks about difficulties with her present method of birth control.

# Appendix K: Teaching Scenarios
How would you screen for woman abuse in this interview?
If the student answered "yes" to your screening question, how would you follow up?

# Hospital Scenario
You are a triage nurse in an emergency department of a hospital. A woman arrives in obvious distress accompanied by her husband. The woman is hyperventilating, and keeps saying, "I can't breathe". The husband states his wife has a history of anxiety attacks, and "often has to come to the Emergency Department to get help, because she does this hyperventilating thing". He states she is depressed and was recently put on medication. He also states that in the past the doctor has given her a white pill to put under her tongue and sends her on her way and this usually helps.
You thank the husband for the information, reassure the patient and ask the husband to take a seat in the waiting room while you complete your assessment. The husband does not want to leave his wife's side. You explain that it is the hospital policy to have family wait in the waiting room until they find a room for the patient and settle her in. The husband again states he does not want to leave; "my wife needs me during these attacks". You again reiterate that the policy is to have the patient settled prior to allowing visitors or family in the room. You tell the husband, "Please take a seat in the waiting room, I will come and get you as soon as she is settled". The husband goes to the waiting room.
How would you screen for woman abuse in this interview in light of her husband's behaviour?
If the woman answered "no" to your screening question, how would you respond? How would you follow up?
If the woman answered "yes" to your screening question, how would you respond? How would you follow up?
To ensure that staff in the relevant Services Areas understand their responsibility to identify and effectively respond to women who have been abused.

# Staff in the relevant Services Areas:
I Are knowledgeable about the dynamics of woman abuse, and its impact on the abused woman and her child(ren). (APPENDIX: STATEMENT OF BELIEFS ABOUT WOMAN ABUSE); I Are skilled in responding effectively to disclosures of abuse; I Are knowledgeable about community resources for abused women and their children; and I Will, where appropriate, routinely screen all women over the age of 12 for woman abuse using the Routine Universal Comprehensive Screening (RUCS) Protocol. PROCEDURE 1.0 Each Services Area will, where appropriate, develop procedures for the routine screening and early identification of woman abuse.

# APPENDIX: STATEMENT OF BELIEFS ABOUT WOMAN ABUSE
We believe... I All women have the right to live free of abuse. I Woman abuse can result in significant physical and psychological harm, including death. I Woman abuse is an abuse of power. I Woman abuse is not the fault of the woman; offenders must be held accountable for their actions. I Woman abuse is against the law. I The safety of abused women and their children is the fundamental priority of intervention. I Women who have been abused have options and the right to choose.
At the same time, service workers have the responsibility to: i. create conditions where a woman is given an opportunity to make informed choices; and ii. assist in safety planning. I Health care workers are not responsible for finding solutions to an incidence of woman abuse, but instead are a part of a coordinated community response.

# Sample Policy #2 -Departmental/Unit Policy: The Eight Types of Abuse
Source: Middlesex-London Health Unit, 2000. London, Ontario. Reprinted with permission.
A bullet (o) indicates actions that are clearly criminal acts, or may be criminal acts depending upon the circumstances.
- o Emotional/psychological/verbal abuse -being forced to do illegal things -false accusations -name calling, finding fault -verbal threats -yelling -intimidation -accused of being stupid -playing on emotions -disbelieving -bringing up old issues -inappropriate expression of jealousy -degradation -turning a situation against her -brainwashing -mockery -silence -refusal to do things with or for -insistence on always being most important -neglect -expectation to conform to a role -real or suggested involvement with other women -invoking a sense of guilt -certain mannerisms, such as finger snapping -threats to get drunk or stoned unless... -manipulation -argumentative -withholding of affection -punishment by not sharing in household chores -never forgiving, holding grudges -lying -treatment as though a child -saying one thing, meaning another -denying/taking away her responsibilities -failure to keep commitments -threats with the loss of immigration status -deliberate creation of a mess for her to clean up -threats to report her to the authorities -forces her to drop charges -tells jokes that belittle or indicate hatred toward women -refusal to deal with issues -minimizes her work or contribution -puts pressure on her to stay while drugs or alcohol are being abused -not coming home -coming home drunk or stoned -possesses pictures that indicate hate or violence again women -egging her on, challenging her to engage in physical violence -friendship or support of men who are abusive -demands an accounting of her time and routine -takes advantage of her fear of something -puts her on a pedestal -ridicules her food preferences -threatens suicide unless... Emotional abuse surrounding reproduction, pregnancy and childbirth -refuses to allow or forces her to use contraception -forces her to have an abortion -refuses sex on the grounds that her pregnant body is ugly -denies that the child is his -refuses to provide support during the pregnancy -refuses to provide support during the birth -denies her access to the newborn child -refuses to provide support or help out with the baby -demands sex soon after childbirth -places blame because the infant is the "wrong sex" -refuses to allow her to breast-feed -sulks/makes her feel bad for the time spent with the baby o chases/hits her with a vehicle o kills/injures her in a deliberate accident o hits her while she's driving -prohibits her from using a vehicle by tampering with the engine, taking the keys, etc.

# Environmental abuse in home or vehicle
-puts his foot over hers on the gas pedal -grabs the steering wheel while she's driving

# Social Abuse
-controls what she does, who she sees and talks to, what she reads and where she goes -fails to pass on messages -puts her down/ignores her in public -blocks access to family or friends -interferes with her family or friends -change of personality with others -is rude to her friends or relatives -dictates her behaviour -habitually chooses friends, activities or work rather than being with her -makes a "scene" in public -makes her account for herself -censors her mail -treats her like a servant -refuses to give her space or privacy -insists on accompanying her into the doctor's office Social abuse involving children o assaults her in front of the children -initiates false child-abuse charges against her -makes her stay at home with the children -teaches children to abuse their mother through name calling, hitting, etc.
-embarrasses her in front of the children -does not share responsibility for the children -threatens to abduct the children or tells her she'll never get custody -puts down her parenting ability

# Social abuse during separation or divorce
-buys the children's affection with expensive gifts -does not show up on time to pick up children or does not have them back on time -pumps children for information about their mother's boyfriends, etc.
-tells children their mother is responsible for breaking up the family -uses children to transport messages -denies her access to the children -fails to supply a valid phone number The Hospital Emergency Department conducts routine universal screening for domestic violence. When it is a case of intimate partner abuse, the patient is referred to the Partner Abuse Sexual Assault Care Team.

# Universal Screening:
I To document reason for Emergency Department visit. I To recognize and refer to appropriate resources. I Because most victims of domestic violence who present to hospitals report that if asked, they would be prepared to discuss their history of abuse. I Because earlier intervention is likely to increase the probability of stopping the violence before it escalates to more serious harm. I.1. "It is our duty to be patient advocates and screen for abuse. We know that many individuals experience problems in relationships, which can result in health problems. Are you in a relationship with someone who threatens to or has hurt you in any way?" II. It is not necessary to ask the above question verbatim providing that the central screening message is clear.

# Indicators of Partner Abuse:
If the triage nurse is unable to complete this task s(he) will ensure that the patient is screened before leaving the emergency department.

# IV. The nurse shall:
IV.1. Interview the patient alone; IV.2. Convey that the patient is believed; and IV.3. Convey an attitude of concern, respect and confidentiality.
V. If abuse is strongly suspected ask: "I'm concerned about how you got these injuries. Did someone do this to you?" or "We often see injuries/symptoms like yours when a patient has been hurt by a spouse/partner. Is this happening to you?"

# Recommendation 1
Nurses implement routine universal screening for woman abuse  in all health care settings.

# Level of evidence: IIb
The first paragraph in the discussion of evidence on page 22 of the original guideline has been revised with additional literature support:

# Discussion of Evidence
Woman abuse has serious health consequences and is a significant public health problem. The health care system plays an important role in identifying and preventing public health issues. The World Health Organization's ( 2008) report ''Primary Health Care: Now more than ever'' states that nurses should focus on screening for woman abuse and treating abused women within a healthcare setting as well as within the community. Routine universal screening, with a focus on early identification of women experiencing abuse, whether or not symptoms are immediately apparent, is a primary starting point for this improved approach to health care practice for woman abuse   Trabold, 2007).
Studies have shown that women believe "health care providers should routinely ask all women about difficulties in home life and relationships" (Koziol-McLain et al., 2010, p. 241). Furthermore, studies have shown that: no harm or adverse effects were linked with this type of questioning (Houry et al. 2004;Koziol-McLain et al., 2010;MacMillan et al., 2009); there was no difference in rates of abuse disclosed to a male or female researcher or by self-completion of a questionnaire (Boyle & Jones, 2006); and most abused women would not disclose unless asked directly and may find it a source of huge relief to be able to disclose in a confidential setting (Boyle & Jones, 2006).
Routine universal screening, as opposed to indicator-based screening, increases opportunities for both identification and effective interventions; validates woman abuse as a central and legitimate health care issue; and enables providers to assist both victims and their children (FVPF, 2004;PPPESO, 2004).

# Summary of Evidence
The following content reflects revisions made to the original publication ( 2005) based on the consensus of the review panel. Only changes made to the recommendation and/or discussion of evidence are shown below.
unchanged changed additional information new recommendation
Only appendices that have been changed are listed below.

# Appendix C: Assessment Tools for the Nurse
The following tools are in addition to the tools provided on page 60-62 of the original guideline. The panel selected the following tools to provide options for various practice setting. All the tools identified below have been validated:

# Appendix D: Framing Introductory Questions
Additional information has been added to the existing appendix on page 63 of the original guideline:
Always interview the woman alone and in private and start with a simple explanation as to why the questions are being asked.
"Because woman abuse is so common in many people's lives, I now ask all my clients about it." May I ask you a couple of questions?
"Many of the women I see are dealing with abuse in their relationships. Some are too afraid and uncomfortable to bring it up themselves, so I've started asking about it routinely." May I ask you a couple of questions?
If "yes" to the question above, then ask specific questions.
"Have you ever been hurt or threatened by someone?"
"Are you currently or have you ever been in a relationship where you were physically hurt, threatened, or made to feel afraid (or unsafe)?"
"Have you ever been emotionally, physically, or sexually abused by your partner or someone important to you?"

# Specific Considerations for Young Women
"Everyone has a right to be safe and choose what happens to their body. In my practice I see many young women who are experiencing difficulties in their relationships and with their friends/boyfriends. May I ask you some questions?"
If "yes" to the question above, then ask specific questions.
"Sometimes people say and do things to us that can be hurtful and make us feel confused and uncomfortable. Has anyone ever made you feel that way?"

# Let the response guide your next question(s).
If woman says "No" respect her decision.
 You may need to define 'hurt' using age-appropriate language. Refer to Appendix L (Eight Types of Abuse).
 Avoid using words such as "bad". A young person could take the word bad as meaning that they are bad or have done something wrong.
 Avoid using leading questions; be direct and to the point; let the young woman answer the question in her own words.
 With young women, it will be necessary to proceed slowly in order to build trust.
 You may need to explain that if abuse was of a sexual nature and resulted in "feeling good", it does not make the action acceptable.

# Appendix H: Safety Planning
The following has been inserted at the beginning of this appendix on page 70 of the original guideline:
Always ask what the woman needs to be safe and be willing to listen to her needs. Some key principles to remember are:
- Safety is the priority -is she and/or children in danger; what has she done so far and what does she need.
- Each woman is her own expert on her life -respect it.
- Each woman is unique -do not make assumptions about her safety.
- Offer support, information and choices -NOT ADVICE.
- Provide information on local resources like shelter and crisis/help lines.
Remember your response or lack of response could put the woman and her children at greater risk for harm.

# Appendix J: Educational Resources
The following education resources have been added to the list found on page 73 of the original guideline:

# Appendix K: Teaching Scenarios
The following scenarios are in addition to those provided on page 76 of the original guideline. These scenarios and subsequent questions may provide the nurse with guidance on his/her interaction with the client and family.

# Community setting -Healthy Babies/Healthy Children Program (Ontario)
You are the Public Health Nurse making a postpartum follow-up home visit. The baby and mother were discharged from the hospital two days ago following an uncomplicated delivery. The mother is 24 years old who has one other child -a four year old boy. You notice the house is in disarray with a broken lamp and chair in one corner along with clothes seemingly thrown around. The young child stays right by Mom's side, watching your every move. The mother appears very tired, favouring her right arm as she sits very stiffly on the sofa. The baby is sleeping beside the mother on the sofa.
During the conversation with the mother, the child states, "Daddy hits mommy". The Mom bursts into tears, looking terrified.
How would you respond to this disclosure?
What legal obligations should you consider?
What safety planning would you discuss with the mother?

# Hospital Scenario
You are an emergency room nurse at your community hospital. A woman arrives by ambulance in obvious distress with blood on her face and head. She is being triaged when her husband arrives demanding to be let in to be with his wife. You explain that his wife is being triaged/assessed and once this is done you will come to get him. You ask that he wait in the waiting room.
He continues to loudly demand to be with his wife saying that she is always falling down and hurting herself and that she is an accident prone person. You again explain that the hospital policy is to have family remain in the waiting room until the person is initially assessed and settled into a room. Once this is done you will let him know. He goes to the waiting room issuing threats to report you and the other staff to senior management.
You inform the triage nurse of this situation with the husband. The triage nurse informs you that the wife has stated she was hit, choked and pushed down the stairs by the husband and that she does not want to see him.
Given the husband's behaviour and the woman's disclosure how would you respond?
What further screening would you do?
What safety issues must you consider for the woman and hospital staff while she is in the emergency room?
What services and information would you provide?
What safety planning should take place?
How would you provide follow up care?

# School Scenario
You are the Public Health Nurse at a local junior high school. A 14 year old female student is brought to you by a teacher as she was found crying in the bathroom. As you get to know the student you notice several hickies around her neck. When asked about them, she hesitantly indicates that her boyfriend, the assistant coach (aged 17) of the local hockey team, did this to her on the weekend. He also placed some pictures of her on the internet today -and this is why she was crying.

# Appendix L: Sample Policies
The following policies are additional examples to those identified in pages 77 to 87 of the original guideline. While the content of the policies may not align completely with the recommendations of this best practice guideline, it may provide some guidance on developing policies for other organizations. Some terminology used may be specific to the organization from which the sample policy originated.

# Sample Policy #1: Organization Policy
Source: Middlesex-London Health Unit, London, Ontario. Reprinted with permission.
To ensure that staff in the relevant Services Areas understand their responsibility to identify and effectively respond to women who have been abused.
Staff in the relevant Services Areas:
- Are knowledgeable about the dynamics of woman abuse, and its impact on the abused woman and her child(ren).
- Are skilled in responding effectively to disclosures of abuse
- Are knowledgeable about community resources for abused women and their children - Will, where appropriate, routinely screen all women over the age of 12 for woman abuse using the Routine Universal Comprehensive Screening (RUCS) Protocol.
- 0 Each Services Area will, where appropriate, develop procedures for the routine screening and early identification of woman abuse.

# Appendix M: Responding to Disclosure
The following two scenarios represent situations that could be found in mental health nursing. The questions proposed are to act as guides during the course of the interaction and may need rephrasing (open-ended vs. closed-ended) according to the situation, the clinical setting, and/or the scope of practice of the health care provider.
When responding to a disclosure of woman abuse/IPV, keep the following tips in mind:
Elizabeth, a 23 year old woman is brought to the Emergency Psychiatric Services after neighbours who were concerned about her safety called police. Neighbours report that Elizabeth appeared to be repeatedly walking out in front of traffic.
Elizabeth is angry and insists that others are not keeping her safe. The nurse determines from her old case file that Elizabeth has a history of sexual, physical and emotional abuse. The nurse also notes that Elizabeth has scars on both arms and fresh cuts on both arms. Elizabeth discloses to the nurse that she remembers something bad that happened in her past.
 Always interview in private:
- "Let's go into the interview room or the office to talk about this"
 Believe the client:
- "Would you like to talk with me about what you are feeling?"
- "Did something happen to you before that you are remembering now?"
- "Do you recall what happened to you in your past? Yes/No..." It's OK if you don't remember, that happens sometimes"
- "I notice you have cuts on your arms, do you want to talk to me about that?"
 Assess for safety: (never assume that a past history of abuse precludes a present history as well)
-"Elizabeth, you say 'others are not keeping you safe', do you feel safe now?"
-"Did something happen to make you feel unsafe?"  Offer support:
-"Are you receiving any support in the community for these feelings?"
-"What other supports do you need/require?"
 Ask permission to refer to another resource person:
-"Can I refer you to someone who can help you with your feelings?"

# Always interview in private
Believe the client Assess for safety

# Offer support
Ask permission to refer to another resource person Scenario #2:
A nurse is completing an assessment on a woman with a diagnosis of Schizophrenia, Paranoid Type who is being admitted to a mental health facility. The patient is wringing her hands and looks distressed. The patient frequently stares intently at the nurse but does not seem interested in conversing. The nurse finds it challenging to engage the patient. After several hours, the patient comes up to the nurse and tells her that she was assaulted in her apartment last night and she wants to call the police.
 Always interview in private:
- "Let's go into the interview room or the office to talk about this"
 Believe the client:
- "That must have been a terrifying experience for you, thank-you for sharing this with me" or "Your experience must have been very frightening"
- "It is not easy to talk about this type of thing."
- "It is not unusual to feel angry, embarrassed and fearful afterward"
- "How can I help you now?"
- "Are you experiencing any pain?"
- "Would you like me to sit and talk with you?"
 Assess for safety:
- "What needs to happen to help you feel safe?"  Offer support:
- "Would you like some support when speaking with the police?" If yes, then:
 Ask permission to refer to another resource person:
- "Can I refer you to someone who can support you when speaking with the police?"
Appendix N: Ecological Framework
The following appendix introduces a framework that offers a novel approach to understanding family violence.
By far the most comprehensive approach to understanding and addressing family violence in both local and international contexts is the ecosystemic/ecological framework (Guruge, Tiwari & Lucea, 2010). The ecological/ecosystemic approach was first used to help organize various research findings on the etiology of child abuse (Belsky, 1980), but since has been applied to woman abuse (Carlson, 1984;Dutton, 1988;Edleson & Tolman, 1992). Belsky's ecological framework draws on Tiorbergen's (1951) idea of ontogenic development as well as on Bronfenbrenner's (1977Bronfenbrenner's ( 1979 idea of the ecological framework of human development. Bronfenbrenner (1977Bronfenbrenner ( 1979 hypothesized that in order to understand human behaviour, one needs to move beyond the immediate situation of the individual to consider the environment within which the individual is situated. Garbarino (1977) and Belsky (1980) viewed a person's environment as a series of settings/systems, each nested within the next broader setting/system in the following order: from the micro-environment of the family to the meso/ exo-environment of the immediate social network, to the macro-environment of the society-at-large. Loue and Faust (1998) proposed a framework to understand woman abuse that consists of the following four levels: (a) ontogenic (the individual history of the partners), (b) micro-system (the family setting in which the abuse occurs), (c) meso-system (the social networks in which the family participates), and (d) macro-system (the culture and society-atlarge). People and their environments are understood in the context of their continuous and reciprocal relationships (Guruge, Khanlou, & Gastaldo, 2010).   Individual or ontogenic factors refer to "those features of an individual's developmental experience or personality that shape his or her response to micro-system and exo-system stressors" (Heise, 1998, p. 267). Examples of individual factors include: witnessing domestic violence as a child and experiencing abuse as a child, mental illness, and substance use/abuse.
The micro-system refers to "those interactions in which a person directly engages with others as well as to the subjective meanings assigned to those interactions" (Heise, 1998, p. 269). Some of the micro-systemic factors highlighted in the literature include male authority and dominance in the family, male control of wealth in the family, marital conflict, stress, and use of alcohol.