Domestic Violence and Hispanic Women Report

Evidence-Based Practice Protocol: Domestic Violence and Hispanic Women

Evidence-based Practice

Domestic violence (DV) accounts for about 30% of all acute injuries to women treated in emergency departments, as it currently constitutes a critical public health concern, not only in the United States (U.S.), but worldwide. Some studies indicate that Hispanic women are more likely to be injured during intimate partner violence incidents than non-Hispanic women, with scholars agreeing that DV among Latinos must be addressed as it constitutes a serious problem among the Latino growing population.

Research reveals that utilizing emergency room protocols to identify and treat victims of domestic violence increases the identification of victims by medical practitioners. Although a high percentage of female victims of domestic violence visit emergency rooms for treatment, low and underreported incidents, however, complicate current concerns that counter domestic violence detection assessed in clinical environments.

Nevertheless, researchers recognize the value of domestic violence screening in general practice and primary care as an effective method of identifying and responding to domestic violence cases presenting to emergency departments. In light of the need to better assess domestic violence, this Capstone presents considerations for the development and implementation of an evidence-based practice protocol (EBPP) to help fill this critical contemporary need.



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Intimate Partner Violence


Clinical Practice Problem


Assessing DV Concerns


Study Aim and Objectives




Increasing Concerns


Myths and Facts Regarding DV


Studies Reveal


Inadequate Reporting


Need to Educate DV Victims


Domestic Violence and Hispanic Women







Evidence-Based Support








Table 1 Demographic Characteristics of adults with a serious mental illness

Table 2 Disparities for Focus Area 18

Table 3 Demographic Characteristics of adults with a serious mental illness

Tables 5-9 Female deaths by age and race in the U.S., preliminary 2006

Table 10 Deaths and death rates for selected mental health causes in the U.S. 2006



Figure I: Domestic Violence Wheel


Figure 2: Common Factors in Mental Illness and Domestic Violence


Figure 3: Australian Law Concept of DV



APN — Advance Practice Nurse

EBPP – Evidence-Based Practice Protocol

SAMHSA – Substance Abuse and Mental Health Service Administration



“Intimate partner violence is considered a major public health concern in the United States and worldwide”

– Jerry Tello (2008, p. 61).


Intimate Partner Violence

Intimate partner violence (IPV), a component of domestic violence (DV) currently constitutes a critical public health concern, not only in the United States (U.S.), but worldwide, Jerry Tello (2008) stresses in his book, Family Violence and Men of Color: Healing the Wounded Male Spirit. Tello notes that some studies indicate that Hispanic women are more likely to be injured during intimate partner violence incidents than non-Hispanic women. Some studies, however, reflect that no significant difference exists between Latinos and non-Hispanic women. Despite that contradiction, scholars agree that IPV among Latinos must be addressed as it constitutes a serious problem among the Latino growing population. In regard to the current urgency for effective interventions to counter IPV, this Capstone project integrates knowledge from previous coursework in the development and implementation of an evidence-based practice protocol (EBPP) in the researcher’s clinical specialty area.

In the study, “Cross-Lagged Relationships between substance use and intimate partner violence among a sample of young adult women,” Steven C. Martino, Rebecca L. Collins, and Phyllis L. Ellickson (2005) report that approximately 1.5 million women in the United States are victims of intimate partner violence each year, additionally confirming that related research and interventions to this concern are critical. Donna Scott Tilley, Assistant Professor, Texas Tech University (Nursing) and Margaret Brackley (2004), Professor and Director of the Center for Violence Prevention, University of Texas, note in their study, “Violent lives of women: critical points for intervention-phase I focus groups,” that several women/participants equated their abuser to “Dr. Jekyll and Mr. Hyde.” Tilley and Brackley point out that partner violence, frequently accompanied by emotional and verbal abuse, and controlling behavior, also includes physical and sexual violent acts. They confirm domestic violence to be significant health problem in the U.S. And point out that domestic violence infiltrates all socioeconomic and ethnic groups and occurs not only in heterosexual, but also in homosexual relationships. “Advanced practice nurses [APNs] are in a position to identify battered women in varied settings,” Tilley and Brackley note. Consequently, this affords APNs, who observe the symptoms of abuse and post-traumatic stress disorder in the primary care setting, the opportunity to routinely screen and intervene on the behalf of the abused women.

Clinical Practice Problem

The rates of domestic violence detection in clinical settings, however, remain low and underreported despite the fact a high percentage of female victims of domestic violence visit emergency rooms for treatment, which provide opportunities for detection and intervention. Garcia (2004) states that health professionals seldom check for signs of violence or ask women about experiences of abuse. Although certain argument questions the value of domestic violence screening in general practice and primary care, an increasing recognition of the importance of domestic violence screening as an effective method of identifying and responding to domestic violence cases presenting to emergency departments confirms the practice to be valuable. Research reveals that utilizing emergency room protocols to identify and treat victims of domestic violence increases the identification of victims by medical practitioners from 5.6% to 30% (Garcia, 2004, p. 536).

Domestic violence accounts for about 30% of all acute injuries to women treated in emergency departments. Medical expenses each year from domestic violence, one of the leading causes of serious injury to women 15 to 54 years-old (Surgeon General, 1999), total at least $3 to $5 billion. In addition, businesses lose approximately $100 million in lost wages, sick leave, absenteeism and non-productivity. As a number of DV victims do not report the crimes to authorities or healthcare professionals, the severe underreporting of violence against women leads to the belief the problem is less widespread than it actually is. This false representation regarding this critical problem’s severity may hinder healthcare providers from more diligently assessing women for domestic violence.

Assessing DV Concerns

The People’s Law Dictionary defines domestic violence as:

the continuing crime and problem of the physical beating of a wife, girlfriend or children, usually by the woman’s male partner (although it can also be female violence against a male). It is now recognized as an antisocial mental illness. (Hill & Hill, 2006, p.1).

Police and prosecutors frequently feel frustrated as they encounter the problem or a battered woman refusing to press charges or testify against her abuser due to fear, intimidation and/or misplaced “love.” At times, this may evolve from a woman’s fear of leaving, her dependence on her abuser, or her low self-esteem, causing her to endure abusive conduct and/or fail to protect a child. Increasingly domestic violence, however, still attracts the sympathetic attention of law enforcement and the courts, In addition, community services, which include shelters, offer protection for those women in danger, if/when they take advantage of the offer.

The Domestic Violence Handbook. (N.d.), created through the efforts of the Oakland County Coordinating Council Against Domestic Violence, defines domestic violence and emotional abuse as behaviors one person uses in a relationship to control the other person. “Partners may be married or not married; heterosexual, gay, or lesbian; living together, separated or dating” (The Domestic Violence, ¶1).

Examples of abuse include:

name-calling or putdowns keeping a partner from contacting their family or friends withholding money stopping a partner from getting or keeping a job actual or threatened physical harm sexual assault stalking intimidation (The Domestic Violence…, N.d., ¶1).

Domestic violence may be criminal; particularly when it involves one person physically assaulting the other (hitting, pushing, shoving, etc. The DM act may also be sexual abuse, including undesired or forced sexual activity, as well as stalking. Emotional, psychological and financial abuse do not constitute criminal behaviors, nevertheless these acts depict forms of abuse and may lead to criminal violence (The Domestic Violence…, N.d.).

Figure 1 depicts the “Violence Wheel,” a tool those who assess DV may utilize to help the one experiencing DV better communicate the abusive behavior(s).

Figure I: Domestic Violence Wheel (The Domestic Violence…, N.d.).

Domestic Violence appears in a myriad of forms and may occur all the time or occasionally. A vital step those who assess DV, as well as victims/survivors, is to understand that preventing or stopping violence involves first recognizing the warning signs listed on the “Violence Wheel” (The Domestic Violence…, N.d.).

Anyone may be a victim of DV, as they may be any age, sex, race, culture, religion, education, employment or marital status. Even though both men and women may be abused, however, women make up the majority of DV victims. Children in homes where domestic violence occurs will more likely be abused and/or neglected. . Even when the child in a home where DV occurs is not physically harmed, most of the time, these children know about the violence. As a result, they may experience emotional and behavior problems (The Domestic Violence…, N.d.).

A victim of DV needs to be reminded:

She is not alone.

She is not at fault.

Help is available.

In The physician’s guide to domestic violence, P.R. Salber and E. Taliaferro (N.d.). about stress that DV evolves from the aim for power and control. They define domestic violence as “a pattern of controlling behaviors aimed at gaining power in order to control an intimate partner. It is not just about hitting or punching. It is a pattern of assaultive and coercive behavior, including psychological, sexual and physical abuse” (Salber & . Taliaferro). The syndrome of dominance and control the perpetrator initiates leads to the victim’s increasing entrapment, also known as the “battering syndrome.”

Domestic violence, “Practice standards for working with women affected by domestic and family violence (2002), an Australian publication explains, denotes violence between individuals indicated in the domestic violence legislation. DV encompasses physical abuse such as hitting, punching, slapping, shoving, as well as other varieties of physical and sexual assault. DV includes:

Determined injury;

Determined damage to property;

harassment or intimidation, includes stalking;

Indecent behavior toward the spouse/partner without the spouse consenting; and A threat or effort to commit whichever of the above (“Practice standards…,” 2002).

In addition to physical abuse, DV may include various other behaviors to gain/maintain power and control over the victim and/or frighten the victim, for example, the abuser may threaten “to injure or otherwise harm the spouse or the spouse’s children, or constantly following a spouse. It is the important elements of fear and intimidation that distinguishes between conflict in a relationship and domestic violence” (“Practice standards…,” 2002, p. 8). Physical violence, one major risk factor for the development of mental illness in women, may contribute to anxiety disorders such as post traumatic stress disorder (PTSD). According to Baca-Garcia, Perez-Rodriguez, Mann and Oquendo (2008), higher rates of domestic violence or sexual abuse link to increased risk for mental health disorders, suicidal ideation and attempts. Pailler et al. (2007) concur that those individuals who suffer repeated physical violence report more symptoms of posttraumatic stress disorder and depression. Therefore, the researcher asserts, identifying the risk factors which increase the probability of women becoming victims of recurring violent acts, along with identifying those currently being abused, proves vital. The development and implementation of evidence-based practice protocol to identify victims of DV, the primary focus of this capstone, the literature reveals, comprises a significant study effort.

Study Aim and Objectives

As this Capstone project investigates the development and implementation of an evidence-based practice protocol in the researcher’s clinical specialty area, domestic violence and Hispanic women, the researcher also identifies and describes this current critical concern. The objects for this study include:

To review and analyze the current research and clinical literature pertinent to the key issues of an EPBB, relating to domestic violence and Hispanic women, including published standards.

To implement an existing EBPP in the researcher’s clinical setting in work as an APN.

To provide a theoretical base for the proposed EBPP: physiological/psychological/pathophysiological, behavioral, developmental theories.

To describe/develop the EBPP, and describe the process for its implementation in the researcher’s practice setting, including EBPP document as appendix.

To identify ways in which the effectiveness of the EBPP will be evaluated and documented; to identify outcomes.

To describe the cost implications of the new EBPP, and how the implementation of this EBPP will be financed.

To summarize the significance of this case to the APN role, e.g., identify relevant specialty competencies.

To create a letter of inquiry for submission to relevant journal to determine possibility for publication of project paper.

The next section of this Capstone relates a synopsis of literature related to this study’s focus to fulfill the aim and objectives. During the process, the reader’s understanding of DV, as well as IPV, confirmed to be a primary public health concern, not only in the U.S., but worldwide will increase. The researcher’s hope for this study includes the desire that the related information regarding EBPP will ultimately contribute to helping decrease reported and unreported statistics regarding DV.


“My abuser didn’t learn it [to be an abuser] off the TV.

My husband learned it from his dad”

(Tilley & Brackley, 2004, Developmental critical…section, ¶ 4).

Increasing Concerns

The prevalence of domestic violence among Hispanic women in the United States reportedly increases each year, simultaneously posing a high threat for the development of mental illness among this population. According to Rodriguez, Heilemann, Fielder, Ang, Nevarez, and Mangione (2008), Hispanic women who experience physical violence are at increased risk for mental and physical problems including depression, anxiety and substance abuse. To increase reports of domestic violence, it proves crucial on understand sthe cultural beliefs and practices of Hispanic women. This knowledge and awareness consequently will facilitate healthcare providers to specifically assess Hispanic women who present with signs and symptoms of physical abuse.

Many Hispanic women believe their role in the family and community is inferior in comparison to males. Some of these women are brought up in homes with male role models who controlled and manipulated other family members. A number of these women also suffered sexual abuse when a child. It is common for Hispanic women to perceive violence as acceptable since many grew up in abusive homes. Young females who become involved in abusive relationships during early adulthood often come from a family with history of intimate partner violence (Pailler, Kassam-Adams, Datner, & Fein, 2007).

For Latino women, the family is of utmost importance. Therefore, women frequently neglect their own health needs. Maternidad Latina (2008) observes that pressure to “keep the family together” may come from family or church members, even if it means suffering more abuse. Religious and societal beliefs may contribute to woman feeling guilty if/when she leaves her abusive partner or acts against his will. Hispanic women, particularly immigrants, may not be familiar with U.S. laws that protect women and children against violence, and not realize these laws may differ considerably from those in other countries. The Hispanic woman may also fear involving the law because of her immigration status. Other factors which may restrain Hispanic women from seeking help include the language barrier and lack of financial means.

One vital element for developing an evidenced-based protocol for Hispanic women suffering from domestic violence and mental illness involves providing cultural sensitive interventions. According to National Alliance of Mental Illness, the first component is the education of Hispanic women about domestic violence, as well as the negative effects of DV on mental and physical health. The women also need to be advised of specific available community resources for victims of domestic violence and treatment options.

In 2006, statistics reported the percentages of females with mental health disorders to be higher than in males. Furthermore, Hispanics reportedly have the highest percentage for mental illness and substance abuse. During 2006, this was noted be as high as 86.9% for the Hispanic population, according to the Substance Abuse and Mental Health Service The percentage of women treated for psychiatric disorders, reportedly has increased each year. The researcher presents a significant amount of quantitative data on this population, accessed from the Substance Abuse and Mental Health Service Administration (SAMHSA) in this Capstone’s Appendices. SAMHSA reports include demographic data such as gender, age distribution, race/ethnic distribution, employment status, and living situation (Table 1, 3 & 4).

Studies indicate that mental health disorders are more prevalent among females than in males. A large volume of this researched evidence suggests the reason relates to the higher rate of sexual and physical abuse in females. According to Dixon, Howie, and Starling (2005), as noted in this Capstone’s introduction, abuse serves as an overwhelming risk factor for depression and posttraumatic stress disorder in females. In the study Dixon, Howie, and Starling conducted, 70% the female participants who suffered from posttraumatic stress were victims of domestic violence and sexual assault.

Due to the physical abuse they experience, many adolescent females, Dixon, Howie, and Starling note, also have dual diagnosis of depression, panic disorder, and/or substance abuse. Several interventions that will impact and improve the health and quality of life of this population include:

Prompt and accurate assessment of physical abuse through a domestic violence assessment tool; and Proper use of mental health resources and referrals.

Myths and Facts Regarding DV

The online publication, “Myths and facts about domestic violence” (2009) clarify the following five myths relating to DV:


Domestic violence does not affect many people.


A woman is beaten every 15 seconds. (Bureau of Justice Statistics, Report to the nation on Crime and Justice. The Data. Washington DC Office of Justice Program, U.S. Dept. Of Justice. Oct 1983)

Domestic violence is the leading cause of injury to women between ages 15 and 44 in the United States – more than car accidents, muggings, and rapes combined. (Uniform Crime Reports, Federal Bureau of Investigation, 1991)

Battered women are more likely to suffer miscarriages and to give birth to babies with low birth weights. (Surgeon General, United States, 1992)


Battering is only a momentary loss of temper.


Battering is the establishment of control and fear in a relationship through violence and other forms of abuse. The batterer uses acts of violence and a series of behaviors, including intimidation, threats, psychological abuse, isolation, etc. To coerce and to control the other person. The violence may not happen often, but it remains as a hidden (and constant) terrorizing factor. (Uniform Crime Reports, Federal Bureau of Investigation, 1990)

“One in five women victimized by their spouses or ex-spouses report they had been victimized over and over again by the same person.” (The Basics of Batterer Treatment, Common Purpose, Inc., Jamaica Plain, MA)


Domestic violence only occurs in poor, urban areas.


Women of all cultures, races, occupations, income levels, and ages are battered – by husbands, boyfriends, lovers and partners. (Surgeon General Antonia Novello, as quoted in Domestic Violence: Battered Women, publication of the Reference Department of the Cambridge Public Library, Cambridge, MA)

“Approximately one-third of the men counseled (for battering) at Emerge are professional men who are well respected in their jobs and their communities. these have included doctors, psychologists, lawyers, ministers, and business executives. (For Shelter and Beyond, Massachusetts Coalition of Battered Women Service Groups, Boston, MA 1990)


Domestic violence is just a push, slap or punch – it does not produce serious injuries.


Battered women are often severely injured – 22 to 35% of women who visit medical emergency rooms are there for injuries related to ongoing partner abuse. (David Adams, “Identifying the Assaultive Husband in Court: You be the Judge.” Boston Bar Journal, 33-4, July/August 1989)

One in four pregnant women have a history of partner violence. (Journal of the American Medical Association, 1992)


It is easy for battered women to leave their abuser.


Women who leave their batterers are at a 75% greater risk of being killed by the batterer than those who stay. (Barbara Hart, National Coalition Against Domestic Violence, 1988)

Nationally, 50% of all homeless women and children are on the streets because of violence in the home. (Senator Joseph Biden, U.S. Senate Committee on the Judiciary, Violence Against Women: Victims of the System, 1991)

There are nearly three times as many animal shelters in the United States as there are shelters for battered women and their children. (Senate Judiciary Hearings, Violence Against Women Act, 1990). (Myths and facts about…,” 2009)

Studies Reveal

Of the 2,043 women ages 18 to 59, who participated in the 1998 Centers for Disease Control and Prevention: Behavioral Risk Factor Surveillance System, the study found, women experiencing intimate partner violence were more than three times more likely than other women to have been depressed for over half of the past month. These women were approximately twice as likely to have been anxious or suffered insomnia for over half of the past month, compared to women without a history of violence. A study of 84 women diagnosed with depression, who disclosed intimate partner violence, revealed that 18.6% of abused women reported post traumatic stress disorder, compared to 6.7% of non-abused women (Dienemann, Boyle, Baker, Resnick, Wiederhorn and Campbell, 2000). According to the same study, 53.5% of abused women reported sleeping problems and nightmares, compared to 23.3% of non-abused women.

In another study, a cross-sectional survey by Coker, Smith, Thompson, LcKeown, Bethea and Davis (2002) of 1,152 women aged 18 to 65 conducted between 1997 and 1999 found that 36.8% of women who ever experienced domestic violence reported having considered suicide, compared to 25.9% for all the women in the sample. Similarly, 18.6% of those who ever experienced violence reported having attempted suicide, compared to 11.8% for all the women in the sample.

Psychosocial stressors, negative environmental influences and traumatic experiences unfortunately, inevitably regularly surface in the lives of some women. The way women deal with these experiences sets up coping mechanisms for future stressful events. All these risk factors in women pose an enormous threat not only to the development of mental illness, but also to the progression and deterioration of mental health. In the initial physical, mental, and psychosocial assessment of women, healthcare providers should be meticulous to exclude any suspicion of domestic violence and mental illness.

Research repeatedly finds that women who experience domestic violence routinely experience negative health consequences, resulting from DV. “Compared with women who had never experienced domestic violence, those who had suffered any type were nearly three times more likely to report symptoms of severe depression (odds ratio= 2.6; 95% confidence interval=1.9 to 3.6),” Amy Bonomi, Ph.D., of the Group Health Center for Health Studies in Seattle, reports. Bonomi and colleagues analyzed data from telephone interviews of more than 3,500 women enrolled in the Group Health Cooperative. They found women that who had experienced recent physical or sexual violence likely reported being in only fair or poor health three times as often as those women who had not experienced these types violence.

Inadequate Reporting

During 2005, approximately one third of U.S. doctors surveyed in reported they did not keep a record when their patients report domestic violence. New research reveals that approximately 90% of doctors surveyed reported they do not adequately document domestic violence. The admitted inadequate reports doctors complete also do not record whether the doctors offered support and information about domestic violence to their patients who may have needed this type assistance (From the CAPEV…,” 2006).

The November 20, 2005 issue of the journal, BMC Family Practice, reports that researchers Megan Gerber, of Harvard Medical School, led analyzed doctors’ reports on 90 patients, all reported victims of domestic violence. In 26 of those 90 cases, the study revealed, the doctor’s report neglected to document patient’s account of any domestic violence. Only 10% of the medical reports noted that the doctor proffered any information to specifically help patients, including directing them to where to obtain help for domestic violence. The report also noted the neglect of doctors to help the abused patients to develop a list of steps to remove themselves from the situation. One third of surveyed doctors surveyed admitted they did not feel confident in counseling patients in regard to reported domestic violence (From the CAPEV…,” 2006).

Need to Educate DV Victims

Somebody needs to educate domestic violence victims, research asserts. The questions arises, if not physicians, who? Education, research shows, serves as a significant intervention to help decrease DV, as well as prevent some violent instances from occurring. One woman who recounted that grew up watching violence occur in her home and did not even know what it was called. Young women and children need to not only know what domestic violence is, and when it occurs in their home, they need to know where to go for help and whom tell if it occurs. School counselors, teacher, principals, nurses, including APNs, and other individuals entrusted with this information need to be educated regarding how to discover when DV is occurring and how to best address the situation when an individual divulges it to them. People who know about DV also need to know that domestic violence is a crime. As it devastates family members, DV crosses all socioeconomic and ethnic boundaries. Resources, however, are available for the families of DV. Someone educated in securing help for victims, nevertheless, has to educate them (Tilley, & Brackley, 2004, Discussion section, ¶ 4).

Findings from the study Tilley and Brackley (2004) completed indicate that DV toward females occurs before and throughout the childbearing years; verified through additional research. As APNs serve in positions giving them opportunities to identify battered women in varied settings, during their routine screenings, they may utilize frequently routine screening and intervention for abuse in the women they treat.

Domestic Violence and Hispanic Women

Sherry Lipsky, PH.D., M.P.H, Raul Caetano, M.D., PH.D., Craig A. Field, PH.D., M.P.H., and Gregory L. Larkin (2005), M.D., M.S.P.H. purport in the study, “Is there a relationship between victim and partner alcohol use during an intimate partner violence event?” find that 1/3 of IPV incidents involve alcohol use. At the time of the DV incident, men were more frequently drinking at the time than women, with alcohol linked to more severe IPV. More significant, “an increase in the number of IPV acts and an increase in IPV severity has been associated with drinking-in-the-event by a male perpetrator” (Lipsky, et al., 2005, ¶ 1). Alcohol-related IPV, studies confirm, is frequently facilitated via psychopharmacologic effects of alcohol on the perpetrator’s cognitive processing, expectancies or excuse functioning. The majority of studies addressing drinking-in-the-event status, albeit, in regard to DV have been implemented among men.

From the study, which included a sample of 182 IPV victims, drawn from a larger case-control study of white, black and Hispanic adult female patients, seen in an urban ED from May through October 2002, Lipsky, et al. (2005) found that results suggest that alcohol-related behavior of both couples and individuals constitute significant factors to consider in the relationship between IPV and alcohol use. Alcohol use and misuse, however, proves consistent with the theory women may self-medicate to try to assuage the effects of DV.

Often, a survivor of DV may find she needs help when facing the ominous task of negotiating the numerous organizational structures of the various particular services. Lisa Colarossi, (2006), assistant professor and Mary Ann Forgey (2006), associate professor, Graduate School of Social Service, Fordham University point out in “Evaluation study of an interdisciplinary social work an law curriculum for domestic violence,” that an array of services have been developed to address the legal, social service, and mental and physical health needs that survivors, perpetrators, and child witnesses possess. To create a more holistic and less fragmented domestic violence response system, several developments within the service delivery system have been crafted to try to facilitate service coordination and collaboration among the numerous involved different professions involved.

Although the enhanced service delivery modes provide assistant to those involved in DV, the ensuing developments require more interdisciplinary collaboration. The professionals participating in these developments, however, may not have received the necessary education to do so. The implicit assumption that the developing models where professionals work side by side or work, where they communicate with each other and collaborate effectively, ultimately better serving the client is not usually true. Those professionals who work in a variety of fields, such as medicine, law, social work, education, require effective, specialized interdisciplinary training. This in turn, helps foster multidisciplinary teamwork in and outside specific professional arenas (Colarossi & Forgey, 2006).

Domestic Violence and Mental Health Disorders

During the study, “The Empowerment Program: An application of an outreach program for refugee and immigrant women,” Johanna E. Nilsson, Ph.D. An assistant professor in the Division of Counseling and Educational Psychology at the University of Missouri-Kansas City, Supavan Khamphakdy-Brown, Leslie N. Jones, Emily B. Russell, and Carissa L. Klevens (2006), doctoral candidates, investigate how to effectively provide mental health services to the refugee and immigrant women population. This study, based on a mental health program developed to meet the specific needs of refugee and immigrant purports that research reveals that immigrant and refugee women become victims of domestic violence more frequently than U.S. women. Problems arising due to the stress of migration exacerbate domestic violence situations Nilsson, et al. (2006).

The majority of the 128 first-year women participants, as well as of the second year 172 participants who sought counseling, Nilsson, et al. (2006) report, were Hispanic. “The refugee women seeking help have presented with very severe and complex situations, and often required crises intervention, similar to what has been noted by others” (Nilsson, et al., 2006, Clients section, ¶ 2). Findings from the study’s participants confirmed a positive response to the provided services. The study notes that the presentation of information in a group format appears to threaten the women less, while it offers a venue for them to socialize and support each other. In a safe space, the refugee and immigrant women more readily share their struggles, acknowledge progress, and empower one other.

In “Common mental health correlates of domestic violence,” Gina Robertiello, (2006), an associate professor, Coordinator of Criminal Justice, Department of History and Social Sciences, Felician College, Lodi, New Jersey, reviews the research literature on mental health correlates of domestic violence, emphasizing posttraumatic stress disorder (PTSD). This study identifies clues, symptoms, and indicators to alert “practitioners in mental health or criminal justice of indicators of the onset and severity of depression, anxiety disorders, substance abuse, and/or PTSD among battered women” (Robertiello, ¶ 1). The psychological impact of domestic violence, Robertiello stresses, may sometimes debilitate the victim/survivor even more than physical injuries.

Harmful correlates of woman battering include depressive symptoms, suicide ideation, and PTSD symptoms. Studies document the fact that a significant association exists between “the extent and intensity of battering experiences and the severity of PTSD symptoms” (Robertiello, 2006, ¶ 3). In addition, 74% of women who experienced DV also suffered from various forms of PTSD . PTSD may continue for a lifetime, particularly among battered women who lethally retaliate. Little focus, albeit has been attributed to the minute number of women victims of DV who ultimately kill their male partners.

Robertiello (2006) reports that many of the victims she studied experienced abuse as children. They later engaged in abusive adult relationships with friends, boyfriends, and spouses. Even when parents, these individuals frequently permitted their children to “walk over them and bore the brunt of the blame when their abusive husbands abused their children” (Robertiello, 2006, Experience with…section, ¶ 2).

Robertiello (2006) addressed the following two questions:

1. Does abuse as a child lead to abusive behavior as an adult?”

2. Does experiencing abuse as a child lead to experiencing further abuse as an adult? (Robertiello, 2006. Experience with… section, ¶ 2).

According to research Robertiello (2006) completed:

…Demonstrated that children growing up in violent homes (where parents are abusive) are likely to be violent and to experience abuse themselves. Of the 48 million children who live in two parent homes, 17.8 million may be exposed to marital violence. Although studies show that exposure to domestic violence does not have the same effect on all children, some studies have found that children exposed to domestic violence exhibited higher levels of PTSD symptomatology, In general, “studies indicate that 15% to 43% of girls and 14% to 43% of boys have experienced at least one traumatic event in their lifetime. Of those children, 3% to 15% of girls and 1% to 6% of boys could be diagnosed with PTSD.” Similarly, “90% of sexually abused children, 77% of children exposed to school shootings and 35% of urban youth exposed to community violence develop the disorder.” (Robertiello, 2006, Effect of…section, ¶ 1).

Hispanics rate the highest in percentage for mental illness, which was 86.9% in 2006 according to the Substance Abuse and Mental Health Service. In 2006, the percentages of females with mental health disorders ranked higher than in males, with the percentage of women treated for psychiatric disorders continuing to increase each year. The researcher presents a large amount of quantitative data on this population in Appendix A, Tables 1, 3 and 4, obtained from the Substance Abuse and Mental Health Service Administration (SAMHSA) reports. SAMHSA reports include demographic data such as gender, age distribution, race/ethnic distribution, employment status, and living situation

Research studies repeatedly indicate that mental health disorders prove more prevalent in females than in males. A large volume of this evidence suggests the reason(s) to relate to the higher rate of sexual and physical abuse females experience. Dixon, Howie, and Starling (2005), along with Baca-Garcia, et al. (2008) find that abuse constitutes an overwhelming risk factor for depression and posttraumatic stress disorder in females. Dixon, Howie, and Starling found that 70% of the females in their study who suffered from posttraumatic stress are victims of domestic violence and sexual assault. Due to the physical abuse, any adolescent females also receive dual diagnoses of depression, panic disorder, and/or substance abuse. Prompt and accurate assessment of physical abuse through a domestic violence assessment tool and proper use of mental health resources and referrals, nevertheless, serve as effective interventions to impact and improve the health and quality of life of this population.


Two contemporary screening tests currently utilized to assess domestic violence include the HITS and the Woman Abuse Screening Tool (WAST).


During 1997, Dr. K. Sherin of the UIC-Christ Hospital, Department of Family Medicine introduced HITS, a brief domestic violence screening tool. Sherin and his colleagues developed HITS to easily and more effectively screen for domestic violence. HITS, an acronym, poses the following four question to individuals suspected to victims of DV.

1. How often does your partner physically Hurt you?

2. How often does your partner Insult or talk down to you?

3. How often does your partner Threaten you with physical harm?

4. How often does your partner Scream or curse at you?

Respondent’s answer each question of the HITS survey on a five point scale ranging from 1 to 5:

1. Never,

2. rarely,

3. sometimes,

4. fairly often, and

5. frequently. (Shakil, N.d., p.1)

The Score Ranges from a minimum of 4 to a maximum of 20. The patients who fall in the 11 to 20 range score are the ones who should be offered information regarding battered women’s services including emergency shelter places and mental health services. (Shakil, N.d., p.1)

Woman Abuse Screening Tool (WAST)

1. In general, how would you describe your relationship?

__ A lot of tension

__ Some tension

__ No tension

2. Do you and your partner work out arguments with:

__ Great difficulty?

__ Some difficulty?

__ No difficulty?

3. Do arguments ever result in you feeling down or bad about yourself?

__ Often

__ Sometimes

__ Never

4. Do arguments ever result in hitting, kicking or pushing?

__ Often

__ Sometimes

__ Never

5. Do you ever feel frightened by what your partner says or does?

__ Often

__ Sometimes

__ Never

6. Has your partner ever abused you physically?

__ Often

__ Sometimes

__ Never

7. Has your partner ever abused you emotionally?

__ Often

__ Sometimes

__ Never (Brown, et al., 2000)

For an assessor to score this instrument, he/she assigns the responses a number.

For the first question, “a lot of tension” gets a score of 1 and the other 2 get a 0. For the second question, “great difficulty” gets a score of 1 and the other 2 get 0. For the remaining questions, “often” gets a score of 1, “sometimes” gets a score


Problem Identification

A problem depicts the statement of a question needing to be answered or a situation needing a solution. The problem, per se, emerges from a situation in which a knowledge gap or uncertainty exists regarding the “best” response to the situation. The problem for this Capstone is to develop an EBPP to best assess domestic abuse. Points contributing to the identifying the problem include:

Recognizing that a problem exists

Accurately phrasing the problem statement to facilitate the searching for a precise answer.

Developing the Question

Crucial step in the EBP process and therefore,

The right people must be involved in this process and adequate time must be allotted.

Team Members

Design a multi-disciplinary team to work on the entire EBP process.

Group should represent all of the key healthcare providers for the particular clinical situation in question, for example one group may have representatives from medicine, nursing, pharmacy, physical therapy, nutritional support, case management and home care. Some level of administration is also helpul to have represented on the team.

Representation on the team often facilitates support for the recommended practice change that is the outcome of the EBP process.

Co-leaders are accepted more readily. Ideal co-leaders for many groups may be an Advanced Practice Nurse and a physician.


Adequate time must be allotted for this phase in the EBP process.

Adequate time is needed to consider and develop the best question. The more exact the question is, the more focused the search for evidence can be.

Prioritize by asking, “What is the most important issue for this current situation?” Or “What issue should be addressed first?

Essential Components of a Question

Question should contain the following essential components to guide the search for evidence:

1. Patient or situation being addressed

2. Phenomenon being considered

3. Comparison intervention, when relevant

4. Clinical outcomes of interest

Finding the Evidence

The evidence needed in an EBP effort may be found in a variety of sources, from computerized bibliographical databases to your own quality improvement department. In trying to find evidence, nurses are urged to get help. For one reason, finding evidence is very time consuming even when done with maximum efficiency and (theoretically) the more persons involved, the less any one person has to do. And second, those familiar with a method may search and find better sources of information.

A Systematic Approach to Finding Evidence

1. Have a clearly defined topic (What specific question is being asked? What specific clinical problem is to be solved?).

2. Review all existing hospital/agency policies/procedures for current practice standards (What is the recommended practice? Is this happening? What is the basis for the recommended current practice?).

3. Determine if the recommended practice is being implemented. Quality improvement data may give you this information or a QI project may be needed.

4. Check for external standards/policies on the topic (Are there existing clinical practice guidelines on the topic? See

5. Find any systematic or integrative reviews on the topic or meta-analyses (See Critique under Process Model). Depending upon the currency and completeness of systematic review(s) found, you may or may not choose to go to step 6, although it is recommended whenever possible.

6. Search for primary research literature using one of the computerized bibliographic databases described below.


Critiquing evidence leads to its evaluation. Evaluation of the evidence includes determination of its merit, feasibility and utility as a basis for making a practice change. The emphasis in this phase is on appraisal of findings since these are the knowledge products under consideration.(Brown, 1999).


The goal is to evaluate the scientific merit and potential clinical applicability of each study’s findings, and with a group of studies covering similar problem areas, to determine what findings have a strong enough basis to be used in practice.

Manuscripts evaluated

Manuscripts evaluated may be the original research studies or integrative reviews/meta-analyses.


A team approach is best and the work can be divided in many ways. In 1994, at an ONS Congress Symposium “Empowering the Nurse: Applying New Findings to Clinical Practice,” Marie Whedon suggested that an RU Project Group involve two groups with overlapping members.

Literature review group makes recommendations from the literature to the application group.

Application group provides clinical outcomes and implementation strategies.

Summarize the Evidence

Now that you have compiled and read the evidence, what’s next? How can you combine the findings to come up with a solution to the original clinical problem or concern? When you put it together, how do you use it to build a case to support clinical decision-making or to sell the idea to others?


A huge intellectual job involving a move from the literature search and critique phase into the synthesis phase.

Research evidence is combined with other evidence to make concrete practice recommendations.

How to Summarize

Use a multidisciplinary group.

If the planning group was well designed it can continue throughout the process. If you find that you do not have team members who have done such synthesis work in the past you may want to add a member with such experience.

The group leader will need to be a good facilitator, moving the group through the steps of the synthesis work. Early steps that should have been accomplished by the group prior to searching for evidence are determining the status of current practice and the reason that the group thinks it needs change.

Assign readers of primary sources; helpful for continuity; all members may not have read all sources.Group members at this point need to be excellent thinkers who are practical, analytical, and able to use words well. It is important that your group leader or co-leaders reflect this expertise.

Organize multiple results by concepts, setting, and variables.

Creating a visual display of information is often helpful. Group leaders or a core group may have decided the organizational method or the total group may discuss and decide. Have a rationale for the method of organizing results.

Comparative evaluation (Stetler, Morsi et al. 1998): Work by subconcepts to evaluate applicability to practice (e.g., for catheter care, synthesize findings about insertion, insertion sites, catheter type, care of site – cleansing, care of site – dressings, etc.) by substantiating evidence, fit, and feasibility.

Questions to ask throughout: Is there a sufficient rationale to use synthesized findings or recommendations? How should findings/recommendations be used: update for practice, policy or procedure, algorithm, program, position paper? (Information continued in appendix B)


“Domestic Violence is an infection

that has weakened the underpinnings of society’s structure…

a contagion that has ravaged the human spirit for generations.”

– Jane Zeller (2006).

Evidence-Based Support

Survivors of abuse have reported they support primary care professionals inquiring about history of physical abuse and mental health issues. According to Nakell (2007), asking patients about their trauma history may benefit patients in several ways. First, when patients acknowledge their history of trauma, the healthcare provider can provide psycho-education to help patients understand their trauma and its effects, and in response, recommend useful treatment. Second, clinicians who understand patient’s histories of trauma and mental illness may appreciate the patient’s symptoms and therefore treat patients with appropriate care.

The American College of Obstetricians and Gynecologists (ACOG) guidelines on domestic violence recommend that clinicians routinely ask women direct and specific questions about abuse. The American Medical Association also advocates routine screening of intimate partner violence and referrals to community-based services. The American Academy of Family Physicians (AAFP) purports that family healthcare providers may offer early intervention by routine screening and identification of abuse and mental health issues. The AAFP recommends that family clinicians be aware for the presence of family violence in every patient encounter (Falsetti, 2007).

In addition, Falsetti (2007) notes, a number of organizations recommend strategies for working with families to prevent abuse. These include teaching conflict resolution skills that promote respectful and peaceful relationships. The mental health consequences of domestic violence, as repeatedly noted in studies, prove detrimental to survivors; Victims/survivors need help, as DV is repeatedly documented to frequently lead to increased rates of depression, posttraumatic stress disorder, other anxiety disorders, somatization, drug and alcohol abuse, chronic mental illness, and suicide attempts.

Cyleste C. Collins, assistant professor with the Center on Urban Poverty & Community Development at Case Western Reserve University and William W. Dressier (2008), professor at the University of Alabama, purport in their study, “Cultural models of domestic violence: perspectives of social work and anthropology students,” that domestic violence victims may require services from a variety of social service providers. Some research, however, indicates that some social workers possess biases about domestic violence and stereotype victims/abusers. These prejudiced social workers often fail to provide necessary services to victims, particularly to clients in/from some cultures. During the course of the education and training of social work students, Collins and Dressier (2008) stress, the students need to become attuned to aspects of the interaction between a person and his/her environment.

These components will likely include understandings of mental health issues, as well as issues internal to the individual (i.e., contributed by the person), along with aspects considered external, yet integrated in the person’s environment. Better responding to domestic violence should help lead to educational models that, in turn improve service delivery. Positive changes by social workers, as well as individuals in the medical field, could help victims of domestic violence and their families rebuild their lives, prevent social service systems. Instead of being a hindrance of blocking help, the professionals who work DV victims could serve as a stimulus to progress and healing (Collins & Dressier, 2008.)

Figure 2 portrays a number of common components contributing to mental illness and domestic violence.

Figure 2: Common Factors in Mental Illness and Domestic Violence (adapted from Robertiello, 2006, Summary section, ¶ 2).

Figure 3 portrays one definition of domestic abuse, noted by Australia’s legal system.

Figure 3: Australian Law Concept of DV (adapted from “Practice standards…,” 2002).

This Capstone confirms the need for the development for an EBPP to help ensure the promotion of better mental health for Hispanic women. Effectively crafting a worthy EBPP, albeit requires

The researcher’s desire for this study is that will compliment current literature regarding

“Eighty-one percent of men who batter had fathers who abused their mothers.

– New Jersey Dept. Of Community Affairs, Division on Women”

(From the CAPEV, 2006)

“Children who grow up in violent homes have a 74% higher likelihood of committing criminal assaults

– Survey of Massachusetts Dept. Of Youth Services

(From the CAPEV, 2006)


American academy of family physicians (AAFP). (2009). Retrieved August 10, 2008

from Brown JB, Lent B, Schmidt G, & Sas G. (200). Application of the woman abuse screening tool

(WAST) and WAST-short in the family practice setting. J Fam Pract 49(10):896-903.

Retrieved May7, 2009 from

Carrasco, M. (2004). Latino outreach resource manual: national alliance on mental illness. Retrieved July 31, 2008 from

Centers for disease control and prevention: behavioral risk factor surveillance system.

(1998). Retrieved August 10, 2008 from

Centers for disease control and prevention: national center for health statistics. (2008).

Deaths: Preliminary Data for 2006. National vital statistics report. Retrieved July 11,

2008 from

Centers for disease control and prevention: national center for health statistics. (2008). Cause of Death: Preliminary Data for 2006. National Vital Statistics report. Retrieved July 11,

2008 from

Coker A.L., Smith P.H., Thompson M.P., LcKeown R.E., Bethea L., & Davis K.E.

(2002). Social support protects against the negative effects of partner violence on mental health. Journal of Women’s Health and Gender-based Medicine, 11 (5), 465-476.

Colarossi, L., & Forgey, M.A. (2006). Evaluation study of an interdisciplinary social work an law curriculum for domestic violence. Journal of Social Work Education,


307+Retrieved May 5, 2009, from Questia database

Collins, C.C., & Dressier, W.W. (2008). Cultural models of domestic violence: perspectives of social work and anthropology students. Journal of Social Work Education, 44(2), 53+.

Retrieved May 5, 2009, from Questia database:

Dienemann J., Boyle E., Baker D, Resnick W., Wiederhorn N., & Campbell J. (2000).

Intimate partner abuse among women diagnosed with depression. Issues in Mental Health

Nursing, 21(5), 499-51 The Domestic Violence Handbook. (N.d.). Domestic Retrieved May 7, 2009 from

Falsetti, S.A. (2007). Screening and responding to family and intimate partner violence in the primary care setting. Primary Care: Clinics in Office Practice 34 (3). Retrieved August 18, 2008 from

Family violence and prevention fund (1999). Preventing Domestic Violence: Clinical

Guideline on Routine Screening. Retrived August 10, 2008 from

From the CAPEV update: in the news — study finds almost half of women impacted by domestic violence in their adult lives. (2006). Latest Research Statistics on Domestic Violence.

Retrieved May 7, 2009 from Hill, Gerald & Hill, Kathleen, (2006). The people’s law dictionary. Fine Communications.

Retrieved May 7, 2009 from

Khamphakdy-Brown, S., Jones, L.N., Nilsson, J.E., Russell, E.B., & Klevens, C.L. (2006). The empowerment program: an application of an outreach program for refugee and immigrant women. Journal of Mental Health Counseling, 28(1), 38+. Retrieved May 6, 2009, from Questia database:

Lipsky, S., Caetano, R., Field, C.A., & Larkin, G.L. (2005). Is there a relationship between victim and partner alcohol use during an intimate partner violence event? Findings from an urban emergency department study of abused women. Journal of Studies on Alcohol, 66(3), 407+. Retrieved May 6, 2009, from Questia database:

Manderscheid, R.W., Atay, J.E., Hernandez-Cartagana, M.R., Edmond, P.Y., Male, E., & Parker, A.C.E. (2001). Highlights of organized mental health services in 1998

and major national and state trends. Mental Health, United States, 2000 (135

Washington, DC: U.S. Government Printing Office.

Martino, S.C., Collins, R.L., & Ellickson, P.L. (2005). Cross-Lagged Relationships between Substance Use and Intimate Partner Violence among a Sample of Young Adult Women. Journal of Studies on Alcohol, 66(1), 139+. Retrieved May 5, 2009, from Questia database:

Maternidad Latina (2007). Promoting child and maternal health. Retrieved August 1,

2008 from

McKenzie, J.F., Neiger, B.L., & Thackeray, R. (2009). Planning, implementing, & evaluating health promotion programs. San Francisco: Pearson Benjamin Cummings.

Mental health: a report of the surgeon general (1999). Retrieved July 11, 2008 from

Morgaine, K. (2007). Domestic violence and human rights: local challenges to a universal framework. Journal of Sociology & Social Welfare, 34(1), 109+. Retrieved May 5, 2009, from Questia database:

Myths and facts about domestic violence. (2009). Sound Vision Foundation, Inc. Retrieved May 7, 2009 from

Nakell, L. (2007). Adult post traumatic stress disorder: screening and treating in primary care. Primary Care: Clinics in Office Practice, 34 (3). Retrieved August 18, 2008 from

Pailler, M.E., Kassam-Adams, N., Datner, E.M., & Fein J.A. (2007). Depression, acute stress and behavioral risk factors in violently injured adolescents. General Hospital Psychiatry,

29 (4). April 20, 2008, from


Rodriguez, M.A., Heilemann, M.V., Fielder, E., Ang, A., Nevarez, F., & Mangione, C.


(2008). Intimate partner violence, depression, and PTSD among pregnant Latina women.

(N.d.). Annals of Family Medicine, 6 (1). Retrieved August 1, 2008 from


Robertiello, Gina PhD. (2006). Common mental health correlates of domestic violence. Brief Treatment and Crisis Intervention 2006 6(2):111-121; doi:10.1093/brief treatment/mhj008. Retrieved May 6, 2009 from

Salber, P.R. & Taliaferro, E. (N.d.). The physician’s guide to domestic violence. Volcano Press,

Inc. Retrieved May 7, 2009 from

Shakil, Amer MD. (N.d.). Hurt, insult, threaten and scream brief domestic violence screeningtool. Retrieved May 5, 2009 from

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Health National Outcome Measures (NOMS): CMHS Uniform reporting System. Retrieved July 10, 2008 from

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National Outcome Measures (NOMS): CMHS Uniform reporting System.

Retrieved July

10, 2008 from

Substance abuse and mental health service administration. (2004). United States Mental


National Outcome Measures (NOMS): CMHS Uniform reporting System.

Retrieved July

10, 2008 from

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A national crises. Retrieved May 7, 2009 from



Table 1

Demographic Characteristics of adults with a serious mental illness served by a Statewide Mental Health Agency (SMHA) in the U.S. 2006

Total number of adults with a serious mental illness served by SMHA system



Male: 47.3%

Female: 52.7%

Age Distribution

18 — 20: 3.8%

21- 64: 64%

Race/Ethnic Distribution

American Indian/Alaskan Native: 1.0%

Asian/Island Pacific: 1.6%

Black or African-American: 21.7%

Hispanic or Latino: 86.9%

Native Hawaiian/Pacific Islander: 0.2%

White Caucasian: 61.9%

Multi-racial: 1.6%


Percent Employed: 18%

Percent not in Labor Force: 56%

Percent Unemployed: 26%

Living Situation

Private residence: 66.1%

Foster home: 1.8%

Residential care: 3.7%

Crisis residence: 1.0%

Institutional setting: 2.7%

Jail/Correctional facility: 2.0%

Homeless or shelter: 2.4%

Other living situation: 3.1%

Medicaid Funding Status of the Consumers

Medicaid only: 46%

SMHA funds only (Non-Medicaid): 38%

Both Medicaid and other funds: 16%

Table 2

Disparities for Focus Area 18: Mental Health and Mental Disorders, 2002

Health People 2010


Black Non-Hispanic

White Non-Hispanic

Treatment for serious mental illness:

18+ years

50 to 99%

50 to 99%

The group with the best rate

Treatment for recognized depression:

18+ years

50 to 99%

50 to 99%

The group with the best rate

Treatment for generalized anxiety disorder: 18+ years

Data not available

10 to 49%

The group with the best rate

Employment: 18+ years

With a serious mental illness

10 to 49%

10 to 49%

The group with the best rate

Table 3

Demographic Characteristics of adults with a serious mental illness served by a Statewide Mental Health Agency (SMHA)

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