The EDUCATE Program: Intimate Partner Violence Training For Fracture Clinics Template Slide Developed by: Sheila Sprague, PhD Mohit Bhandari, MD, PhD, FRCSC Diana Tikasz, MSW, RSW Taryn Scott, MSW McMaster University & Hamilton Health Sciences Presented by: Insert name(s) of presenter Insert Institution

Acknowledgements The EDUCATE Program was made possible by the following individuals: Sheila Sprague, Mohit Bhandari, Gina Agarwal, Deborah J. Cook, Vanina Dal Bello–Haas, Samir Faidi, Diane Heels- Ansdell, Norma MacIntyre, Paula McKay, Angela Reitsma, Patricia Schneider, Taryn Scott, Patricia Solomon, Lehana Thabane, Andrew Worster (McMaster University, Hamilton ON) Prism S. Schneider, Richard E. Buckley, Leah Schultz, Tanja Harrison (University of Calgary, Calgary AB) Anthony Adili (St. Joseph's Healthcare, Hamilton ON) Douglas Thomson, Trinity Wittman (Canadian Orthopaedic Association, Montreal QC) Andrew Furey, Kayla Cyr, Erin Baker (Memorial University of Newfoundland, St. John’s NL) Aparna Swaminathan (University of Toronto, Toronto ON) Jeremy A. Hall, Aaron Nauth, Milena Vicente (St. Michael’s Hospital, Toronto ON) Ari Collerman (Hamilton Health Sciences, Hamilton ON) Brad A. Petrisor, Diana Tikasz (Hamilton Health Sciences, Hamilton ON) Debra L. Sietsema (The CORE Institute, Phoenix AZ) Nneka MacGregor (Women’s Centre for Social Justice, Toronto ON) Gerard P. Slobogean (University of Maryland, Baltimore MD) Emil H. Schemitsch, Melanie MacNevin (London Health Sciences Centre, London ON) Sarah Resendes Gilbert (Domestic Assault Review Team, Waterloo ON)

Acknowledgements The evaluation of the program was funded by the Canadian Institutes for Health Research and Hamilton Academic Health Sciences Organization

The EDUCATE Program

EDUCATE Program Mission To provide orthopaedic surgeons, health care professionals, and non- health care professional staff working in fracture clinics with training that will allow them to develop and enhance knowledge and skills required to successfully identify and assist women who are experiencing intimate partner violence.

A Few Important Points All information contained in this program may not appear to be directly relevant to your clinical practice To be comfortable identifying and assisting patients with IPV, it is necessary to have an understanding beyond your role Some examples may not be directly applicable to your practice, but it is important to take pieces from each that are relevant to your practice and role within your fracture clinic

The EDUCATE Program Speakers Note: Click play button in slide show mode to view video. If this does not work, you may access the video through this URL: https://www.youtube.com/watch?v=AkmBwX-xaXo

Intimate Partner Violence

Intimate Partner Violence (IPV) Any behaviour within an intimate relationship that is used to exert power and control that causes physical, psychological, or sexual harm to the woman in the relationship Intimate partners can include current or former: Spouses Common-law partners Boyfriends or girlfriends Ongoing dating/sexual partners

Types of IPV Physical Violence Sexual Violence e.g. slapping, hitting, kicking, beating Sexual Violence e.g. forced intercourse or other sexual acts, sexual coercion Emotional/Psychological Abuse e.g. insulting, belittling, humiliating, intimidating, threatening harm, threatening to take away children Controlling Behaviours e.g. isolating from family and friends, monitoring movements, restricting access to financial resources, employment, education, medical care

Prevalence in Female Fracture Clinic Patients 1 out of 50 Acute Prevalence 1 out of 6 12 Month Prevalence 1 out of 3 Lifetime Prevalence PRAISE Investigators et al., 2013

Consequences of IPV for Women IPV negatively impacts many areas of women’s lives by increasing the likelihood of: Death Injuries Poor physical and/or mental health Engaging in poor health behaviours (e.g. substance use/abuse, high-risk sexual behaviour, over/under eating) Social problems (e.g. homelessness, isolation) Center for Disease Control, 2015

Why Focus on Women? While both men and women can be victims of IPV, women are victimized both more frequently and more severely than men Women are much more likely than men to be murdered by their intimate partners or to sustain severe injuries (such as fractures, sprains, and dislocations) from abuse

Why Focus on Women in Canada? A woman is murdered every 6 days by her intimate partner 3,491 women and their 2,724 children sleep in shelters because they are not safe at home The majority of intimate partner homicides perpetrated between 2003 and 2013 involved female victims Statistics Canada, 2014

Asking about IPV: How to Create a Safe Space for Disclosure

Who to Ask about IPV Being a woman is the strongest single predictor for becoming a victim of IPV IPV affects women of all: Races/ethnicities SES backgrounds Ages Relationship statuses The best way to consistently identify IPV, is to ask all female patients

When to Ask about IPV Ask about IPV at anytime during a fracture clinic appointment, however, mid-appointment may be most appropriate (once a rapport has been established) Develop a routine and conversation starter that is comfortable for you and fits with your practice Speaker’s note: Explain how it may be helpful to have an introductory statement about how you routinely ask all women. For example, “I ask all women in my practice whether they have experienced being hurt in their intimate relationship. Is this something that you are experiencing?” Introductory statements about asking all women help women not to feel singled out when they are asked.

When to Ask about IPV Important to ask about IPV at each appointment Women may need to be asked multiple times before they feel comfortable enough to disclose IPV

Where to Ask about IPV Ensure environment is safe to ask (e.g. no others present, including partners) If partners won’t leave, you can make a statement that reflects routine practise (even if it is not something you specifically need to have done)   e.g. “Mr. Smith, at this point in time we need to take Mrs. Smith in for an x- ray.  Could you please wait in the waiting room until we call you?”   Speaker’s note: Let participants know that if a patient’s partner objects or resists leaving the room, HCPs should remain matter of fact and emphasize that this is standard procedure where no one but the patient can be present.

How to Ask about IPV Injuries suggestive of IPV “The injuries you have, suggest to me that someone hit you. Is that possible?” “In my experience, often women get these kind of injuries when someone has hit them. Has this happened to you?” Don’t use the words “abused” or “battered” Women may not identify with these labels or recognize their partners’ behaviours as abusive

How to Ask about IPV Injuries not suggestive of IPV “From my experience, I know that being hurt physically or emotionally at home is a problem for many women. Is it a problem for you in any way?” “We know violence in the home affects many women and directly affects health. Have you ever experienced being hurt physically or emotionally at home?” “Violence can be a problem in many women's lives, so I now ask every female patient I see about their safety in their relationships. Do you feel safe in your relationship?”

Tips for Asking about IPV Do Be confident Be comfortable Be supportive Don’t Use judgmental words Use the words “battered” or “abused” Press women to disclose IPV

If She Doesn’t Disclose IPV It could mean that the patient is: Not experiencing IPV Experiencing IPV but is not ready to disclose If a women says “no”: Accept the response – the woman is the expert in her own life Do not push for a disclosure

If She Doesn’t Disclose IPV If you feel a patient is saying “no” because she is not ready to disclose you can make a general statement: e.g. “I’m glad this isn’t a problem for you now, but if you or someone you know, were ever to need help, the assaulted women’s helpline is listed in the phone book.” e.g. “Sometimes women are afraid to tell someone that they are being hurt, but if this is happening to you, I want you to know that there is help available that I can help you access in the future if you would like.” Speaker’s Note: Stress the importance of asking multiple times. A woman who is experiencing abuse may not be ready to disclose when you ask initially, but she may be ready to disclose to you or another HCP at a subsequent visit if she is asked again.

If She Doesn’t Disclose IPV Document your reasons for concern about IPV in the patient’s chart This information can help a woman should she decide to disclose IPV or take action later on Speaker’s Note: Stress the importance of asking multiple times. A woman who is experiencing abuse may not be ready to disclose when you ask initially, but she may be ready to disclose to you or another HCP at a subsequent visit if she is asked again.

Benefits of Asking About IPV Even when a woman does not disclose IPV, there are still benefits to asking: “Opens the door” to considering options for help Plants the seed that certain behaviors are abuse, and are wrong Shows you view IPV as a health issue and care about patient well-being Provides an opportunity to educate patients about the health impact of IPV A positive experience with an HCP increases likelihood of disclosing to another HCP in the future

Take Home Messages Ask all female patients about IPV at each visit Ensure you ask in a private and safe location Be comfortable and confident when asking Do no push women to disclose if they are not ready Remember, women may need to be asked multiple times before they disclose

Assisting with IPV: How to Provide Support After a Disclosure

Respond Supportively Convey to the patient that you believe her Validate the disclosure “No one has the right to hurt you. You didn’t cause this; it isn’t your fault.” “You do not deserve to be hit or hurt, no matter what happened.” “I am concerned about your safety and well being.” Continue to provide clinical care for injuries

Assess Immediate Safety Indicators of high risk for severe assault or homicide include: Physical violence that has increased in frequency or severity over the past 6 months Partner has used a weapon or threatened the patient Woman believes partner is capable of killing her Woman has been beaten by partner while she was pregnant Partner is violently and constantly jealous

Patient in Immediate Danger If you feel the patient is in immediate danger, offer to connect her with immediate services such as: Hospital social worker or IPV expert IPV crisis line Shelter services Police

Patient Not in Immediate Danger If the patient is not in immediate danger, ask her how she would like to proceed Referral to hospital social worker or IPV expert Connect with a shelter Information on community resources (counselling services, legal services, financial assistance, etc.) Nothing at this time

Patient Not Yet Ready For Assistance Respect the patient’s choice for however she would like to proceed Remember, it is important to respect a woman’s own assessment of her risk – she is the expert of her own situation

Patient Doesn’t Want to Leave At This Time Women may choose to stay in abusive relationships for many different reasons e.g. children, financial dependence, immigration status, family pressure, hope for change etc. Staying does not indicate acceptance of the abuse and leaving does not mean that the abuse will stop Most dangerous time for abused women is when they leave a relationship 67% of intimate partner homicide cases in Ontario involved partners with an actual or pending separation (Domestic Violence Review Committee, 2017)

Patient Doesn’t Want to Leave At This Time Important that women have a safety plan in place to: Stay in abusive relationships and remain as safe as possible Leave abusive relationships as safely as possible Services you refer women to can help them formulate safety plans Leaving an abusive relationship is a process, not an event It can take time for women to put proper supports in place to leave safely

Document Abuse Document the abuse in patient’s medical record Notes should include: Details about injury characteristics (e.g. location, size, colour) Causes of injury, threats, weapons, events leading up to the assault A body map of injuries Photographs of injuries (if consent is obtained from the woman) Current and past abuse history

Document Abuse Be objective (document what you observe, don’t guess) Let the patient know her injuries have been documented should she require it for court proceedings Documentation will only be released to police with consent of the woman, or if the police have a search warrant Speaker’s note: Please confirm accuracy of information for your specific jurisdiction.

Tips for Assisting with IPV Do Acknowledge the patient’s feelings Allow the patient to make her own decisions Be respectful of the patient’s choices Treat the patient as an expert in her own life Don’t: Be judgmental or threatening Blame the patient in anyway Ask her “why”

Take Home Messages Convey to the patient that you believe and support her Validate the disclosure, assess immediate safety, and offer a connection to local resources and services Respect patient wishes on how to proceed, the woman is the expert in her own life Document the abuse in the medical record Remember, abuse is complicated and has no quick fix – it is a process – you are a part of the process

Video Demonstration Insert videos you would like to show from the EDUCATE video library: http://www.ipveducate.com/videos Template Slide

Reporting Requirements: When to Report IPV

Reporting Requirements It is a breach of confidentiality to report IPV without informed and voluntary consent from the patient Should be written or documented verbal consent Actual or suspected child abuse must be reported to a child protection agency Discuss or notify a patient prior to a call to child protective services so she is not surprised by their follow up call Note to speaker: Review your jurisdictional guidelines and update this slide as needed based on laws.

Reporting Requirements Use the following guidelines to assist in your decision to report: Child has suffered physical harm as a result of IPV Child has been threatened with harm Child has become directly involved in domestic disputes Parent is unable to care for the child due to her physical or emotional condition as a direct result of the IPV Pattern or degree of violence is severe

Reporting Requirements IPV may also intersect with other mandatory reporting requirements e.g. abuse of an elderly adult living in a long-term care facility or retirement home, a gunshot wound victim, etc. Template Slide Note to speaker: Review your jurisdictional guidelines and update this slide as needed based on laws. You may wish to list common examples of situations that must be reported that may overlap with IPV victims.

Guidance on Reporting For additional guidance on reporting requirements for specific cases consider: Consulting with a colleague Consulting with your clinical manager Contacting your professional association or college to request guidance Making a call to the applicable reporting agency to discuss the situation anonymously and request guidance as to whether a report needs to be made

IPV Case Discussions

Local IPV Case Discussion(s) Insert details about local cases involving IPV Potential points to touch on include: What led you to suspect or identify IPV Whether the patient disclosed IPV What you did to help the patient The outcome of the case Provide time for questions and discussions Template Slide

Case #1 Discussion Mrs. Jameson is a 33 year old woman who is presenting to the fracture clinic for her first visit with a severely displaced clavicle fracture that she sustained 1 week ago. She presented to the emergency room the day of her injury. According to the emergency room notes, the injury was sustained from a fall while gardening. When you meet Mrs. Jameson, she is in the patient exam room with her husband of 5 years. As you interact with the patient, you notice that her husband is answering all your questions, even though you have directed the questions to Mrs. Jameson. You also notice that Mrs. Jameson appears uncomfortable. Template Slide Speaker’s note: potential discussion items include: -Would you suspect IPV in this case? Why or why not? -Would you ask this patient about IPV? How would you ask her? -How would you separate the patient from her husband to ask her about IPV? -If Mrs. Jameson discloses IPV, what would you? -If Mrs. Jameson doesn’t disclose IPV, what would you do?

Case #2 Discussion Ms. Lynn is a 27 year old woman who is presenting to the fracture clinic for her first visit with an undisplaced distal radius fracture that she sustained 2 week ago. She presented to the emergency room 10 days after her injury. According to the emergency room notes, the injury was sustained from falling down the stairs and the patient did not realize the extent of her injury until the pain failed to go away. Radiographs reveal a previous ulna fracture and a physical exam reveals multiple bruises on her arms in various stages of healing. Template Slide Speaker’s note: potential discussion items include: -Would you suspect IPV in this case? Why or why not? -Would you ask this patient about IPV? How would you ask her? -If Ms. Lynn discloses IPV, what would you? -If Ms. Lynn doesn’t disclose IPV, what would you do?

Case #3 Discussion Mrs. Brown is a 30 year old woman who is presenting to the fracture clinic for her first visit with a stable spiral fracture of the tibia that she sustained 5 days ago. She presented to the emergency room the day of her injury. According to the emergency room notes, the injury was sustained from a fall while skiing. Radiographs and a physical exam reveal no other noteworthy findings. Template Slide Speaker’s note: potential discussion items include: -Would you suspect IPV in this case? Why or why not? -Would you ask this patient about IPV? How would you ask her? -If Mrs. Brown discloses IPV, what would you? -If Mrs. Brown doesn’t disclose IPV, what would you do?

IPV Case Sharing Ask trainees if they have ever had a case where they received an IPV disclosure or suspected IPV Ask individuals to share these experiences As a group, discuss the steps they took in asking about and providing assistance with IPV, or the steps they could have taken Template Slide Speaker’s Note: If you are presenting to a large group, you may want to break into smaller groups for small group discussions, and then come back and discuss a few cases together as a larger group.

Local IPV Services: Where to Refer Patients for Support

Local IPV Resources Describe key local resources E.g. 24-hour IPV helplines, IPV support programs, sexual/domestic assault treatment centres, shelters, immigration/newcomer services, LGBTQ services, legal services, police, religious organizations, programs for IPV perpetrators Template Slide

Patient IPV Resource Brochures Brochures are located (insert location) Insert screen shot of brochures Template Slide

IPV Awareness Posters IPV awareness posters let patients know our fracture clinic is a safe place to get help Posters will be displayed (insert location(s) where posters will be displayed) Insert pictures of posters you will display Template Slide Speaker’s note: The poster library can be accessed through http://www.ipveducate.com/posters

Additional Information for HCPs: Where to Learn More

Bi-Monthly Training Updates As part of the EDUCATE program training updates will be distributed about every other month Updates include additional information about training topics, recent publications, and topical issues Training updates will be distributed (add in how updates will be distributed) Template Slide

Site Resources Discuss any site-specific resources for HCPs This may include: IPV identification and assistance protocols Referral pathways Formal policies or procedures related to IPV Identify each resource, where it can be located, and how to use it Template Slide

IPVeducate.com EDUCATE program website Access to all training materials, additional videos, and IPV publication list

DVeducation.ca Developed by Drs. Robin Mason and Brian Schwartz Online source for evidence-based IPV curricula

Public Health Agency of Canada http://www.phac-aspc.gc.ca/sfv-avf/info/rp-education- eng.php#IntimatePartnerViolence Education and awareness materials for IPV

Conclusion

Next Steps Include (if applicable) any recommendations / policies your site has for IPV identification and assistance Include (if applicable) information about what individuals / professions are responsible for conducting IPV identification and providing assistance Template Slide

www.IPVeducate.com