Content area
Introduction
Despite routine screening for intimate partner violence and validated screening tools for lethality, intimate partner violence assessment and linkage to services remain inconsistent in health care settings. This program aimed to implement and evaluate a lethality assessment program, a nurse-led screening and prevention program for intimate partner violence homicide in an emergency department that partnered with a local community agency.
MethodsA single group pre−post design was used to evaluate changes in knowledge of intimate partner violence and the lethality assessment program protocol and confidence in implementing the protocol among 143 registered nurses in the emergency department. Program outcomes were assessed during a 4-month post-implementation period. Focus group interviews were conducted and analyzed to identify barriers and facilitators of implementation.
ResultsSignificant improvements in the nurses’ knowledge and confidence in implementing the protocol (all P< .001) were observed. Fourteen lethality screens were completed during the 4 months, with 13 indicating high intimate partner violence homicide danger. Eight victims received 20 services (1-5/person) from the local community organization: emergency shelter, safety planning, legal aid, and domestic violence protection order. Barriers to implementation included time, privacy, training, and access to screening forms. Facilitators included champions, resources to allow for implementation, and prompts.
DiscussionThe lethality assessment program is a feasible protocol in a health care setting to increase intimate partner violence awareness, link high-risk intimate partner violence victims to needed services in real time, and potentially reduce intimate partner violence homicides. Programs like this are essential to address this public health concern.
Contribution to Emergency Nursing Practice
- • Training related to intimate partner violence incidence and red flags increases awareness in emergency nurses.
- • The initiation of a lethality assessment program and the use of a lethality assessment screening tool can increase the identification of intimate partner violence at high risk of homicide and access to community services.
- • A nurse-led model can increase services for intimate partner violence victims by connecting them to services that can mitigate and decrease their risk of homicide.
Intimate partner violence (IPV), defined as violence between current or previous romantic partners, 1 is a pervasive public health problem in the United States with an average of 20 people per minute being physically abused by an intimate partner. 2 Since 2014 and holds true today, IPV affects people across all positionalities including but not limited to racialized and ethnic groups, sexualities, abilities, and genders. 3 4 IPV can lead to long-term health consequences, including physical and mental health conditions such as depression, post-traumatic stress disorder manifestations, digestive conditions, cardiovascular conditions, and other chronic health problems. 5 , 6 The most extreme consequence of IPV is homicide. In fact, 16.3% of murder victims in the United States are killed by an intimate partner. 2 The lifetime economic cost of medical services, loss of work, and economic strain of IPV on society is estimated at $3.6 trillion. 7
Although IPV routine screening is recommended and validated screening tools to predict lethality exist, assessment of IPV in emergency departments and follow-up after discharge remain inconsistent. 8–10 Many factors contribute to this, including lack of proper training, attitudes of patients and providers to the violence itself, and lack of support services. 11 Comprehensive programs to educate health care providers and support screening and referral to services for victims of IPV, including partnerships with community resources and access to services, are urgently needed.
Available KnowledgeIndividuals experiencing IPV are more likely to use the emergency department. 5 As stated by Brignone and Gomez, 6 the emergency department is a critical point of intervention and prevention as evidenced by findings that victims of intimate partner homicide are often seen in the emergency department in the year before their death. However, data showing which patients have presented to the emergency department with IPV-related complaints have been challenging to obtain. Many victims present with complaints such as chronic pain, depression, post-traumatic stress disorder, digestive issues, and cardiovascular conditions not explicitly related to their current situation or trauma. 5 , 10 As first responders, registered nurses (RNs) are often the first line of contact for patients and can play a significant role in identifying IPV victims. However, many nurses do not feel prepared to address IPV, 12 and implementation of evidence-based screenings remains poor. 13
Although the lethality assessment program (LAP) is an existing promising practice to prevent IPV-related homicides, the implementation in health care settings has not been well documented. The LAP is an evidence-based lethality assessment and intervention program implemented throughout the United States as a collaboration between police and social services. 4 The LAP protocol requires that trained officers who respond to domestic violence (DV) calls administer the lethality assessment screening (LAS) tool. The LAS is a validated tool to predict IPV homicide and can be used to engage in safety planning for a high-risk population. The tool is a brief 11-item screen based on the Danger Assessment, developed for first responders to predict lethal IPV and increase victim safety by connecting victims to a DV advocacy program. 9 , 11 Despite implementing the LAP in multiple states, empirical literature evaluating the program is limited. 14 Although the LAP was not conducted in the ED setting, Messing et al 4 and Brignone and Gomez 6 support its use in ED settings to facilitate identification and referrals. Systematic screening and early identification by health care providers are essential to improve safety planning and health interventions with patients who disclose IPV. 10 , 15
An unpublished pilot implementation project to evaluate the LAP conducted by the first author (C.H.) was implemented from 2015 to 2018 in several North Carolina (NC) emergency departments within 1 large metropolitan county. The pilot found benefits to implementation and little negative impact on IPV victims. From 2015 to 2018, more than 200 patients were screened as being at high risk of IPV homicide and received more than 3000 services. Findings from initiatives in emergency departments elsewhere show that the LAP has demonstrated increased safety planning services for victims. 14 Access to the LAP seems to be particularly important in this region given that there have been documented increases in IPV from 2020 to 2022, which may be related in part to the coronavirus disease pandemic that caused economic stressors and exacerbated the risk of IPV owing to lockdown, loss of jobs, and social isolation. 16 Between 2011 and 2020, there were 1100 DV homicides in NC, with 134 (12%) occurring in 2020. 17
Although assessment tools for IPV are available in the emergency department and recommended as part of routine screening, health care professionals do not always adequately and consistently use them. 8–10 Contributing factors are (1) time limitations, (2) discomfort with the subject area, and (3) lack of knowledge in accurately recognizing and responding to IPV. 15 These factors may also affect the patient’s willingness to report IPV. In fact, victims have indicated that health care professionals’ attitudes also play a role in their resistance to reporting. 11 , 14 Furthermore, there is a need for emergency nurses to recognize “red flags” of IPV even when they are not disclosed to provide opportunities for future disclosure and safety planning.
The importance of victim perception of risk when developing safety plans and interventions has been emphasized. 9 Furthermore, health care professionals’ understanding of associated IPV risk factors is imperative. Johnson et al 18 recommended targeted intervention strategies, particularly survivors with high-risk levels and a high perception of lethality threat. Although described as first responders, no literature currently describes the implementation of the LAS by emergency nurses. However, information from LAS implementation in non–health care settings can inform its use by emergency nurses. 9 Implementing a LAP has been shown to increase safety planning and survivor safety for victims of IPV. 11 , 14 , 19
PurposeThe purpose of this program was ultimately to reduce the risk of IPV-related homicides by implementing and evaluating the LAP. This nurse-led screening and prevention program links patients with high-risk IPV to safety planning and community services in a metropolitan hospital emergency department partnered with a local community agency. The project specifically aimed to (1) increase emergency nurses’ knowledge of IPV and its warning signs, (2) increase emergency nurses’ knowledge of and confidence in implementing the LAP protocol in the emergency department, and (3) assess LAP outcomes including referral and use of services during a 4-month post-implementation period.
Methods DesignA single group pre−post design was used to evaluate changes in knowledge of IPV and the LAP protocol and confidence in implementing the protocol among 143 RNs in the emergency department. The project included 3 phases, namely (1) preimplementation education component, (2) implementation of the LAP protocol, and (3) post-implementation of the LAP. For the education component, a single group pre−post design was used to assess change in knowledge of IPV and the LAP and confidence in administering the LAP among emergency nurses who participated in an in-person education session and completed a pre- and post-education survey. Post-implementation outcomes were assessed during a 4-month period in 2023 after the implementation of the LAP in the ED setting. Among adult patients (ages 18 years and older) presenting to the emergency department during this period, LAP outcomes were number and percent of patients (1) screened for IPV using the LAS tool, (2) identified with high-risk IPV using the LAS tool, and (3) receiving real-time facilitation and a referral for IPV support services provided by a local community organization (crisis response center [CRC]). Qualitative data from focus group interviews with emergency nurses were collected at the end of the 4-month period to identify barriers and facilitators to implementing the LAP. In addition, pseudonyms were used to protect the anonymity of participants.
SettingThe program was conducted in the emergency department of a metropolitan, academic, tertiary, and quaternary hospital located in the state of NC. The hospital is a leading provider of health care services in the state and registers approximately 76,000 patients annually in 74 treatment spaces. The hospital serves as a safety net for the community.
Program DescriptionFull-time and part-time RNs employed in the emergency department participated in a didactic LAP education session before the implementation of the LAP protocol. The education session was designed specifically for emergency nurses who would be administering and interpreting the LAS tool. The education was required by emergency nursing leadership for RNs and 1.5 continuing education credit hours were awarded.
The LAP was implemented for 4 months (120 days). As per LAP protocol, emergency nurses were trained to administer the LAS tool to all adult ED patients with signs of IPV during the ED visit, regardless of whether the LAS had been administered at a previous visit. For each ED visit, any patient identified as high-risk IPV by the LAS tool and who provided both verbal and written consent was immediately placed in contact with a LAP coordinator from the CRC. A written consent was obtained by asking the patient to sign the bottom of the LAS tool, indicating the patient gave the emergency nurse consent to contact the LAP coordinator. In addition, the patient signed a release of information form, which allowed the nurse to share the patient’s information with the CRC. This referral served as the first step for safety planning.
The LAS tool 20 is an 11-item questionnaire used to screen for high-risk IPV and was administered only to patients identified by the emergency nurse as having red flags that were reviewed in the education session (eg, overbearing, jealous, and possessive partner; physical signs of unexplained injuries such as bruising, petechia, and ligature marks of IPV). Each question was answered using a no/yes format. The tool identifies high risk if the victim answers yes to any question (1-3) or at least 4 of 8 questions (4-11) on the screening tool. This screening tool has been validated for use in women, demonstrating a high predictive value in detecting near-fatal violence (95.83%). 4
As a final step, a purposive sample 21 of 12 emergency nurses, 6 adopters (those who completed 1 or more LAS screenings) and 6 nonadopters (those who did not have an opportunity to complete a LAS screening), participated in focus groups.
Measures Education Session SurveyEmergency nurses who participated in a preimplementation education session were asked to complete a 10-item survey in person immediately before (pre) and after (post) the education session participation. The same survey was administered at both time points. The survey included an 8-item knowledge section, followed by a 2-item confidence section.
The multiple-choice knowledge questions were developed by the authors who are experts in the field of IPV and reviewed for face validity to assess emergency nurses’ understanding of (1) IPV and its warning signs and red flags and (2) the implementation of the LAP protocol, particularly the administration and interpretation of the LAS tool. Each item was scored as correct (1) or incorrect (0). If an item response was missing, the item was then coded as incorrect. A knowledge total score was calculated by summing the correct answers (range = 0-8). The confidence section included 2 items, namely “ How confident do you feel in screening for Intimate Partner Violence (IPV)?” and “How confident do you feel implementing the Lethality Assessment Protocol?” The nurse rated each item using a 5-point Likert scale (1 = not at all confident; 5 = extremely confident).
LAP Post-Implementation OutcomesEach month, the LAP coordinator at CRC was contacted by the chief nursing officer (CNO) to determine the number and types of community services received by the patient. The LAP coordinator retrieved these data from the CRC documentation system. However, there is a possibility that the patient did not follow up with the services to which they were referred by the LAP coordinator.
LAP outcomes included the number and percent of adult patients screened for IPV and identified with high-risk IPV using the LAS tool. Among those identified with high-risk IPV, the number and percent who received real-time facilitation and referral for IPV support services and types of services to which each patient was referred were determined. The number of times a high-risk patient was referred to a type of service was assessed 30 days after each referral. Among those referred to a community service, the number and percent of those who received the service were determined.
Focus Group InterviewsA semistructured interview guide was used to collect data about the LAP protocol from emergency nurses at the end of the 4-month post-implementation period. Exemplar questions included “What was your experience implementing the LAP?”, “What factors facilitated the implementation of the LAP?”, and “What were some barriers to implementation?”
Data CollectionUsing Qualtrics, tests were administered immediately before and after the 90-minute educational session.
Four months (120 days) after implementing the LAP protocol into practice, focus groups were conducted. Two in-person sessions were held, facilitated by an external member of the team with experience in qualitative research. A semi-structured interview guide was used to generate discussion around facilitators and barriers to the implementation of the LAP. Participants were asked to use a pseudonym to protect confidentiality and help participants feel more comfortable. Sessions were recorded and transcribed verbatim in preparation for analysis.
AnalysisDescriptive statistics were used to summarize the characteristics of the emergency nurses participating in the education session, pre- and post-education session results, and post-implementation outcomes. For each nurse completing an education session, a difference (pre−post) score was calculated for the knowledge total score and each confidence item, with higher scores indicating greater improvement. Paired t tests were used to test for changes in the nurses' knowledge total scores and confidence scores. Nondirectional statistical tests were conducted with significance set at 0.05. The expected sample size of 100 emergency nurses completing the pre- and post-education surveys provided at least 80% statistical power to detect a statistically significant change in each summary score, assuming small effects and 2-tailed tests. Quantitative analyses were conducted using SAS 9.4 software (SAS Institute Inc., Cary, NC). Qualitative interview data were coded for the implementation themes using a rapid content analysis approach. 22 Two members of the team independently coded the transcripts using a table that was built based on Consolidated Framework for Implementation Research Implementation Framework, which identified barriers and facilitators across the domains: adoption, implementation, and sustainability. 22
Ethical ConsiderationsThis project was reviewed by the institution review board and determined it to meet exemption from research. To protect the confidentiality of individuals who were assessed for IPV, the LAS was not included in the electronic medical record and was used in paper form only. Once completed, the form was placed in a sealed envelope and placed in a locked box that was accessible only by the CNO. The collected forms were kept in a locked cabinet in the CNO’s office.
Results Education SessionsA total of 143 (78%) of the 183 RNs employed in the emergency department participated in an education session and completed a pre- and post-session survey ( Table 1 ). Of those, 96% were full-time employees. The 143 nurses were primarily women (83%), aged 20 to 29 years (59%), and White (78%) and had less than 2 years of clinical experience (58%).
The nurses’ knowledge total scores significantly improved after participating in the education session ( Table 2 ; pre, mean = 4.8, SD = 1.1; post, mean = 6.9, SD = 0.7). The mean post−pre difference score was 2.1 (SD = 1.2), indicating a significant increase in the total number of correct items after the nurse completed the session (P< .001). Post-session improvements in the percent correct occurred on most questions on the 8-item knowledge test. Although improvement was observed for Question 6 regarding lethality screening items that trigger a referral after the session, only 20% of the nurses correctly answered this item on the post-session survey.
In addition, significant improvements were observed for the nurses’ confidence scores after participating in the session ( Table 3 ). With regard to confidence in screening for IPV (item 1), the mean post−pre difference score was 1.7 (SD = 1.0; P< .001; pre, mean = 2.2, SD = 1.1; post, mean = 3.8, SD = 0.7). Furthermore, the percent of nurses who reported “quite or extremely” confident for this first item was 14% before and 72% after the education session. In terms of confidence in implementing the LAP (item 2), the mean post−pre difference score was 2.1 ( SD = 1.9; P< .001; pre, mean = 1.8, SD = 1.0; post, mean = 3.9, SD = 0.7). The percent of nurses who reported “quite or extremely” confident for this second item was 8% and 74% after the education session.
Post-Implementation OutcomesA total of 18,391 adult ED patients presented to the emergency department during the post-implementation period. Of those, 14 (0.08%) were screened for IPV and 13 (0.07%) were determined to be high-risk IPV using the LAS tool. Thus, 13 of the 14 screened (92.9%) were at high risk of homicide-related IPV. The high-risk victims are representative of this large metropolitan county, nurses were trained to screen based on “red-flags” which includes people of all genders, races and ethnicity.
Among the 13 high-risk IPV patients, 8 (61.5%) received real-time facilitation and referral for IPV support services and 5 refused to speak with the CRC LAP advocate. The 8 patients referred received 20 services (1-5 services/person) from the local community organization. Services included emergency shelter (n = 1), safety planning (n = 7), legal aid (n = 1), counseling (n = 8), and DV protection order (n = 3).
Barriers And FaciliatorsThe analysis of the qualitative data identified 3 themes: nurse comfort and time to address IPV, patient’s readiness and ability to disclose, and the environmental conditions to support implementation. For each theme, both barriers and facilitators were discussed.
The participants talked about their willingness and comfort to screen. Although they did not lack the will to perform the screen, they acknowledged it was a difficult topic to discuss with their patients. Greater nursing experience increased comfort level with the screening, as indicated by a nurse screener; “If I was just starting out, I personally don’t think I would feel comfortable approaching a patient and asking these questions.” Nurses also acknowledge the important role that having time to dedicate to patients played in facilitating their implementation of the LAP. In fact, many shared that the only reason they had time to implement the protocol was that they were orienting another nurse who was able to care for the other patients. Finally, the nurses who conducted screens reported that the feedback provided regarding services the patients received after screening improved their motivation and comfort level to conduct future screenings.
Patient comfort was also identified as a factor in the screening process. Emergency nurses at the focus group reported various levels of patient readiness to act and accept intervention. The degree of acuity related to illness also affected the ability to conduct a screen. As 1 participant stated, “I guess for me it was just trying to find a way of actually talking because she was in a lot of distress.” In addition, the presence of others in the room, such as their partner, children, or other family members, hindered the ability of patients to disclose, and nurses made decisions to not implement screening because of this.
The environment and facility also presented barriers to conducting screens. From an environmental perspective, nurse participants of the focus group recommended a private space with ready access to the screening forms. Suggestions were made by an emergency nurse in reference to the environment, including a need for “A dedicated small team to do, in a dedicated space” and to have champions on the units to promote implementation. Additional reported challenges related to the placement and access to screening forms with only 1 location within the emergency department also posed as a barrier. The ability to have screens throughout the emergency department would serve as a visual cue to help facilitate the LAP.
DiscussionThis project contributes to the limited literature on using the LAP in the hospital setting. The use of LAP in the community setting with law enforcement and community DV center resources is widely discussed. 4 However, the consistent use of screening tools and interventions for IPV at trauma centers and emergency departments has not been well described, and the quality of evidence is low. 23 Although increasing the knowledge base of health care workers helps equip the workforce to identify and refer IPV for services, 24 the impact of nurse’s knowledge and confidence in screening and impact on patient outcomes are not well documented. This program addressed these critical gaps in patient care.
This program implementation and evaluation documented improvements in knowledge, confidence, and IPV screening. It is significant to note the low knowledge and discomfort of nurses in screening and addressing IPV before the education. Although improvements were noted in most questions, only 20% of nurses had an increase in the postsession survey question: “Which questions answered ‘Yes’ in the Domestic Violence Lethality Screen automatically triggers the protocol referral?” This question was specific to the LAS tool; therefore, it may have been difficult to recall the level of specificity without having the tool available to reference. Future opportunity exists to change the question or provide the tool during the knowledge test for reference. 25
Multiple services were provided to identified high-risk victims of IPV, including counseling, emergency shelter, safety planning, legal aid, and assistance with DV protection orders. IPV survivors need targeted intervention strategies to help mitigate intimate partner homicide. We partnered with a local agency that uses a family justice approach. Family justice centers often offer a range of services to equip survivors to evaluate their individual situation and mitigate potential risks through safety planning strategies. 18 Educating staff in IPV knowledge and comfort with screening is imperative for service referral. Having services readily available, as in the Family Justice Center model, significantly increases the safety of survivors and reduces homicide. 26 In the absence of comprehensive services on-site, a warm handoff to a community partner provides victims with a strategy.
Although barriers for implementation of the LAP were noted, such as time and other environmental constraints (eg, space, access to screeners), nursing leadership and emergency nurses readily adopted this project. Two weeks after the implementation of this program, a long-time, well-known nurse leader died from injuries sustained after an attack from her long-time partner. This tragic death further brought to life the public health concern that lives silently among peers, friends, families, and communities as a whole. This tragic death was a catalyst to the success of the program, serving as a stark reminder that IPV does not discriminate and that many victims suffer in silence, in the presence of health care professionals, or even as 1 themselves.
LimitationsThis project had some limitations inherent to the quantitative and descriptive qualitative methodology, including sampling and data collection methods. This project focused only on emergency nurses working in 1 metropolitan trauma center, which may limit the contexts for other settings with fewer resources to address trauma. In addition, IPV victims may receive care and services beyond the local CRC and the 30-day time period. As a result, service utilization may have been higher than reported. Finally, because we did not follow patients long term, we were unable to document the long-term health impact of the LAP implementation.
Implications for Emergency NursesThe findings suggest that the use of the LAP in the ED setting by emergency nurses can increase the identification of IPV victims at risk of homicide and their connection to needed community resources. The screening, through use of the LAS, allows for identification of victims at high risk of homicide and referrals for services can positively affect communities. Emergency nurses are often at the forefront of patient care and serve as gatekeepers in the emergency department and therefore are in a key position to affect IPV homicides in their community. Emergency nurses may use their patient advocacy skills to develop hospital-wide policies and community partnerships to raise awareness related to IPV incidence and homicide risk. Future research is needed to evaluate the long-term impact of the LAP program on IPV homicide.
ConclusionsIPV is a public health concern that must be exposed and addressed. IPV has negative health outcomes that affect individuals, families, and communities. 27 Nurses can play a pivotal role in helping to identify IPV and mitigate IPV homicides by participating in innovative care models. Nurses can lead this effort by being active listeners and establishing therapeutic and patient-centered relationships. Viewed as the most trusted profession, nurses can strongly affect communities. The LAP, a nurse-led model partnered with the CRC, is feasible and transferable to similar settings for addressing IPV consequences. The LAP model provides a comprehensive response to IPV, which includes screening, assessments, referral to community resources, and safety planning. Protocols in health care settings to increase IPV awareness and reduce IPV homicides are essential steps in addressing this public health concern.
Author DisclosuresConflicts of interest: none to report.
| Characteristic | n (%) |
| Age category | |
| | 84 (59) |
| | 38 (27) |
| | 10 (7) |
| | 10 (7) |
| Self-reported sex | |
| | 118 (83) |
| | 24 (16) |
| | 1 (1) |
| Years of clinical experience | |
| | 83 (58) |
| | 29 (20) |
| | 8 (6) |
| | 6 (4) |
| | 8 (6) |
| | 9 (6) |
| Race/ethnicity | |
| | 9 (6) |
| | 12 (8) |
| | 3 (2) |
| | 4 (3) |
| | 111 (78) |
| | 4 (3) |
| Knowledge test correct answers | Pre Mean (SD) | Post Mean (SD) |
| Knowledge total score | 4.8 (1.1) | 6.9 (0.9) |
| Items and correct answers | Correct, n (%) | Correct, n (%) |
| Q1. Intimate partner violence is violence that occurs between romantic partners who live in the same and different household. | 140 (98) | 136 (96) |
| Q2. How many women and men in the United States are victims of domestic violence in their lifetime? Approximately 1 in 3 women and 1 in 4 men | 86 (60) | 138 (97) |
| Q3. The presence of a gun in a domestic violence situation increases the risk of homicide by 500%. | 29 (20) | 134 (94) |
| Q4. What are the warning signs of domestic violence? Isolation, financial control, unexplained injuries, anxiety, depression, stress-related disorders, gastrointestinal symptoms, cardiovascular symptoms, and chronic pain | 137 (96) | 138 (97) |
| Q5. Who can perform a lethality screen at DUH? Only staff trained to perform a lethality screen | 70 (49) | 126 (88) |
| Q6. Which questions answered “Yes” in the Domestic Violence Lethality Screen automatically trigger the protocol referral? Has he/she/they ever used a weapon against you or threatened you with a weapon? | 21 (15) | 29 (20) |
| Q7. After a patient is identified as high risk on the lethality assessment screen when does the Authorization for Release of Information need to be signed before contacting a Durham crisis LAP coordinator? Every time you screen a patient as high risk and a LAP coordinator is contacted | 113 (80) | 142 (99) |
| Q8. How are completed documents handled? Placed in an envelope and put into the lock box for pick up by the CNO or designee | 84 (59) | 137 (96) |
| Confidence item #1 | Pre Mean (SD) | Post Mean (SD) | Post−pre
Mean (SD) | |
| How confident do you feel in screening for intimate partner violence? | 2.2 (1.1) | 3.8 (0.7) | 1.7 (1.0) | < .001 |
| Likert-scale responses | n (%) | n (%) | ||
| 1 = Not at all confident | 48 (34) | 0 (0) | ||
| 2 = Slightly confident | 45 (32) | 5 (4) | ||
| 3 = Somewhat confident | 30 (21) | 35 (25) | ||
| 4 = Quite confident | 18 (13) | 80 (56) | ||
| 5 = Extremely confident | 2 (1) | 23 (16) |
©2025. Emergency Nurses Association