The SATELLITE Sexual Violence Assessment and Care Guide for Perinatal Patients

 Abstract

Sexual violence (SV) is a prevalent public health problem affecting millions of women across the lifespan. Poor pregnancy outcomes have been shown to be related to SV experiences; therefore, the perinatal period is an important time for healthcare practitioners (HCPs) to intervene. Various healthcare organizations suggest or even mandate screening for SV. Although SV screening tools are available, many practitioners do not routinely screen their patients. Barriers to screening include lack of comfort with or knowledge about how to screen and intervene, and reluctance on the part of the patient to disclose information. The SATELLITE Sexual Violence Assessment and Care Guide for Patients in the Perinatal Period was designed to overcome these barriers. The guide leads practitioners through the process of setting the context for screening, the screening itself, and the interventions after a positive screen finding, including specific questions to be asked and statements to be made by the practitioner in providing care for an SV survivor. By using this guide, nurse practitioners can increase their feelings of comfort and confidence as they assess and care for SV survivors during the perinatal period.

Sexual violence (SV), including childhood sexual abuse (CSA) and adult sexual assault (ASA), is a major public health problem that affects the lives of millions of females every year.1 A large-scale study reported that 11.7 million girls and women were forced to have sex during their lifetime and that, among these females, 64% (~7 million) were aged ≤17 years at the time of the first forced sexual experience.2 Another study showed that 11.5%–14.6% of women had a history of CSA when they presented for prenatal care.3

The perinatal period, which begins at 20 weeks’ gestation and ends at 28 days after delivery, is a time when women who have experienced SV have been shown to be at risk for a variety of health problems and poor pregnancy outcomes.4,5 Many SV-exposed women do not obtain early and/or adequate prenatal care and are likely to experience perinatal complications, including hyperemesis, hypertension, bleeding, preterm delivery, low-birth-weight infants, low infant Apgar scores, and perinatal death.3,6–9 Women with a history of SV, compared with women lacking such a history, are at greater risk for developing depression and anxiety during the postpartum period;8,10 of note, some women experience their first recollection of past abuse during the postpartum period.11,12 Although they are twice as likely to demonstrate an interest in breast-feeding and to begin breast-feeding as their non-abused counterparts, SV survivors who recall their abuse for the first time during the postpartum period have indicated that this recall affects their ability to nurse their infant.12

Although screening for SV is recommended or mandated by various healthcare organizations,13–15 an SV assessment and care guide for use during the perinatal period does not exist. The purpose of this article is to describe the development and use of an SV assessment and care guide for NPs caring for women in the perinatal setting.
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Literature Review

The perinatal period, especially during pregnancy, is an opportune time to screen for and identify SV.16 Research has shown that pregnancy is a life stage during which abuse of various types, including SV, is triggered in relationships.17 Also, pregnant women tend to be seen by a healthcare practitioner on a regular basis, which provides an environment conducive for building a trusting relationship wherein practitioners can “chip away” at barriers18 and women can feel safe to disclose violence.19

Despite practitioners’ knowledge about the high prevalence of SV in women, the increased incidence of SV during pregnancy and postpartum, and the adverse health outcomes associated with SV, a high percentage of practitioners do not screen for SV. This failure to screen is due, at least in part, to fears of not knowing what to say or do when women disclose the SV.20–22

Ross and colleagues22 conducted semi-structured interviews with nurses (23 nurse managers and 12 advanced practice nurses) and used interpretive phenomenology to describe the experiences of these nurses as they provided care for SV survivors. Findings in this study showed that, although the participants were experienced nurses, most of them described barriers to screening for SV. One participant used the image of a patient crossing a bridge as the patient attempted to reveal her SV experience to the nurse. This metaphor of a bridge suspended over a deep gully was subsequently used to describe the experiences of these 35 nurses. Participants indicated that the patient crosses the bridge when she discloses a history of SV; nurses cross the bridge when they assess for a history of SV and provide care for survivors.

Three aspects of the nurse–patient interaction are suggested by the bridge metaphor: (1) at first, nurses feel disconnected from SV survivors, as if they were standing on opposite shores; (2) both the nurse and the patient move cautiously, as if they were testing the bridge when beginning the discussion about sexual violence; and (3) the nurse experiences a meaningful connection with the patient when SV is disclosed and care is provided; they meet on the bridge and cross the gully together. Findings in the study by Ross et al indicated that nurses do not feel comfortable screening for SV or providing care for survivors. They feel disconnected from survivors and unsure about how to approach them. They want to feel confident in engaging with SV survivors in such a way as to increase the likelihood of disclosure and helpful encounters while decreasing the likelihood of negatively-perceived encounters.

Tools exist to assist NPs in the SV screening process. To date, at least 12 SV screening tools are used in different healthcare settings.23–35 In general, these tools differ in terms of their method of delivery; their appropriateness for screening for females, males, or both; the setting in which screening is to occur; the total number of questions they contain; and the number of questions that are specific to SV.

Ten of these tools have specific questions related to violence and have 2–14 items on the entire tool.25–30,32–35 Two tools have areas (rather than specific questions) to assist healthcare workers in their assessment for violence.24,31 Ten tools assess for sexual, physical, and/or emotional violence—most commonly perpetrated by an intimate partner.24,26–30,32–35 Only two tools are designed to screen for sexual assault exclusively.25,31 The tool developed by Stevens31 is appropriate for screening both men and women. The tool developed by the American College of Obstetricians and Gynecologists (ACOG)25 is for use with teenage and adult women in primary care settings and is not unique to the perinatal period. Although this tool is clinician-administered and has a list of questions to open the conversation, it does not have a step-by-step assessment and care guide to assist clinicians in intervening. To meet this practice need, the authors developed an SV assessment and care guide to assist NPs who see women in more than one encounter throughout the perinatal period.
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The SATELLITE Sexual Violence Assessment and Care Guide
Development of the Guide

The development team included 4 advanced practice nurses (2 in women’s health and 2 in psychiatric/mental health) who are also experienced researchers. Prior research conducted by the team22 convinced them that they needed to develop a guide that met certain criteria. First, the guide would be designed to be used by a select group of practitioners—those who provide care for women during regularly scheduled visits throughout the perinatal period. Second, the guide would lead practitioners through the entire process of setting the context for screening, the screening itself, and the interventions after a positive screening. Finally, the guide would provide detailed information including specific questions that can be used during the assessment process, statements that can be made, and interventions that can be taken by the practitioner in providing care for an SV survivor.

The team determined that its first task was to verify that no existing tools met the criteria for the project. Although they acknowledge that literature searches can never be truly exhaustive, the first and second authors conducted an extensive literature review during which they read more than 200 documents related to SV or domestic violence (governmental and non-governmental, peer-reviewed and non–peer-reviewed articles, books, and tools). This literature search yielded the 12 tools described above. The “Screening Tools–Sexual Assault” developed by ACOG26 came closest to meeting the team’s criteria. However, ACOG’s tool does not include steps for intervention after a positive screening. After the team had determined that its task was to develop a new tool to meet its own criteria, the members developed the guide based on (1) the literature review; (2) team meetings; (3) an Internet search of local services, laws, and customs related to sexual violence; and (4) a focus group interview.

The first two authors each developed an assessment and care guide separately, based on the literature review, their clinical practice in women’s health, and their prior research.22,36 The two guides were compared and combined to form The SATELLITE Sexual Violence Assessment and Care Guide for Perinatal Patients. Next, the guide was reviewed separately by the fourth and fifth authors, whose expertise is in the area of SV. The project team held meetings in which team members discussed the guide and provided feedback. Based on these discussions, the guide was revised.

Because SV is known to occur in all socioeconomic, cultural, and geographic groups, the research team determined that a broadly applicable guide should be developed, with consideration given to community differences. Team members recognized that groups of people and geographic regions vary in community perception and stereotypes related to SV, laws about reporting SV, and in the number, types, and accessibility of resources for responding to the adverse consequences of the violence. Therefore, 10 communities in 10 states were selected by the project team to represent variations in geographic region and population density. These communities were then explored for breadth of available local resources and differences in state laws.

The third author conducted an Internet search that began by accessing US Census Bureau July 2006 population estimates for incorporated areas with more than 100,000 persons in the Pacific, Mountain, Midwest, South, and Northeast regions of the country.37 Two cities, one smaller and one larger relative to population in each region, were selected. Once team members determined that these 10 cities provided adequate variation in region and population, they conducted an Internet search using the terms sexual violence, rape, interpersonal violence, childhood sexual abuse, intimate partner violence, and incest. A second Internet search was conducted using the same search terms with the addition of the name of the city or county for each of the 10 communities to the search term. Websites for national, state, and local organizations for each city provided information on national and community-level resources, community experience with the issue of SV, and applicable state laws. The national websites that offered the most helpful information are included in the Figure. Team members’ experience with this Internet search convinced them that NPs could use the same process to access information about state laws and local resources in their locales.
Figure 1
Figure 1

Finally, a focus group was conducted. Three experienced women’s health nurse practitioners reviewed the revised guide and gave feedback on the guide during an interview conducted by the first and second authors. The interview was tape-recorded. Transcribed comments derived from the interview were incorporated into guide revisions. The whole project team then reviewed the revised guide and developed the guide presented in the Figure.
Use of the Guide

The SATELLITE Sexual Violence Assessment and Care Guide for Perinatal Patients is presented in a five-column chart form. The first column is composed of the acronym “S-A-T-E-LLI-TE,” which serves as a prompt to remind NPs to move through a six-step process. The six-step process is outlined in the second column and includes (1) Setting, (2) Approach, ask, and assess, (3) Treat, (4) Evaluate safety, (5) Laws and Legal Implications, and (6) Thorough Education and documentation. The third column lists specific actions for each step, and the fourth includes a space next to each action where NPs can record that the step has been accomplished on at least one occasion. A list of additional information, helpful hints, and suggested questions to be asked or comments to be made by the practitioner are presented in the final column labeled “Options.”

Setting

The first step in the assessment and care guide involves creating a safe setting in which discussion about SV can occur. Creating a safe setting begins with NPs preparing themselves with enough information about SV and local resources to assist patients when a history of violence is revealed. NPs can begin to create the setting by obtaining pamphlets and posters about SV that are prominently displayed in areas in which perinatal patients wait for appointments and have testing and examinations conducted.

Also, NPs must screen for SV in private. Because childbearing is a family affair, many women are accompanied to prenatal visits by partners or other family members. NPs can explain that they must see the woman alone for internal and breast assessments and can ask the accompanying person to leave the room toward the end of the visit. Other strategies for promoting a private setting for SV screening include accompanying patients to the restroom to obtain a urine specimen or stating that clinic policy dictates privacy for parts of the examination.

Approaching, asking, and assessing

The second step of the assessment and care guide involves approaching patients in a way that fosters trust in the practitioner. A good rapport with patients is a key to success in eliciting disclosure. Trust is developed by showing non-judgmental attitudes and a balance between professionalism and friendliness. NPs should call patients by their preferred name and demonstrate respect (eg, asking for permission before touching).

Asking directly about patients’ SV experience is done with a caring and genuine approach. NPs must approach patients in a way that invites and encourages disclosure (eg, looking a patient in the eye and not focusing on the computer or paperwork). The SATELLITE guide lists several ways that NPs can ask about patients’ SV history. NPs should select the script that is most personally comfortable for them.

Even with the setting well designed, a caring approach, and use of a direct question suggesting that the practitioner truly wants to hear about the patient’s SV history, some patients do not choose to share information. NPs should continue assessing for possible signs of previous SV exposure by looking for red flags during the vaginal examination as a possible indicator of SV experience. NPs should stop the examination and ask a broad question such as “What is happening?” Possible follow-up questions are listed in the Figure.

The acronym TREAT

The third step in the SATELLITE Assessment and Care Guide begins when patients have revealed a history of SV and NPs initiate care. The acronym TREAT (Thank, Reassure, Empower, Assist, and Take notice) is helpful to guide intervention. NPs should first thank patients for sharing the information, then express concern and sorrow, and then acknowledge what patients might be feeling (the Figure lists possible responses). NPs should reassure patients that the violence was not their fault and empower them by giving them control over the situation. NPs should be cognizant of available community services for SV survivors in their locale and assist them to connect with an appropriate agency or individual (eg, support group, counselor, SANE nurse, shelter). Of note, some NPs mistakenly believe that they have completed their interaction with a patient once resource information has been provided. Instead, NPs should take notice of patients’ reactions and determine whether they want to continue a discussion of their experiences. Because women in the perinatal period tend to have multiple encounters with their NP, violence and patients’ reaction to the violence should not be a one-time discussion.

Evaluation

The next step in the Assessment and Care Guide is evaluation of patients’ safety; SV often occurs with physical violence. Suggested questions to be asked by NPs are listed in the Figure.

Laws and legal implications

In the fifth step, when patients reveal that they are not safe, NPs must be aware of the laws and legal implications of the appropriate state. State regulations and implications are different. For example, Ohio does not require reporting of abuse of competent adults unless one of these criteria is met: gunshot wound, stabbing, second-degree burn, or serious injury. Suspected cases are not to be reported. If the presenting injuries do not mandate reporting according to Ohio law, NPs need only contact law enforcement at a patient’s request.38 By contrast, California NPs who treat competent adult victims are unequivocally required to report the occurrence.39

Thorough education and documentation

The final step in the SATELLITE process is thorough education and documentation. NPs should take time to provide patients (both those who have disclosed an SV history and those who have not but who have exhibited some signs of possible violence) with education about SV and references for resources. NPs must educate patients who have experienced SV regarding SV statistics and adverse effects, including depression, hypervigilance, intrusive thoughts, and flashbacks of the abuse. These symptoms are frequently triggered by pelvic examinations conducted in the office setting or on the labor and delivery unit. Also, educational materials containing sources of assistance should be provided to SV survivors. Finally, thorough documentation is essential not only of patients’ disclosures but also of all injuries (including defensive injuries) and behaviors during the pelvic examination (eg, exaggerated response to touch, crying, cramping of the legs).

Although the process outlined in the SATELLITE guide appears to be linear, it is more accurately conceptualized as cyclical or iterative. The process has a defined beginning, but the end of the process is less clear. Opening the discussion of SV may need to occur on several occasions before patients feel that they can safely share their history. Once patients have revealed a current or prior history of SV, NPs need to engage in the SATELLITE steps of Treat, Evaluate, attention to Laws and Legal Implications, and Thorough Education and documentation” on an ongoing basis.
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Summary

Sexual violence can occur at any point in the lifespan and is a prevalent problem for women. Those women who have experienced SV either as children or as adults tend to have adverse outcomes related to pregnancy, including the possibility of an increase in the violence during pregnancy and the postpartum period. Because the typical perinatal period is a time when women have regularly scheduled appointments with NPs, pregnancy is an opportune time for NPs to identify and assist those women who have experienced SV.

Regardless, many practitioners are reluctant to explore issues related to SV, often because they feel uncertain about how to begin a discussion about the topic and how to intervene if a patient reveals a history of SV. SV survivors tend to be equally reluctant to discuss their experience with practitioners because of concern that they will not be believed or that they will be blamed.

Although many tools exist for SV screening, most of them do not give detailed guidance about how to begin a discussion about the topic and which actions to take when an SV history is revealed. The SATELLITE Assessment and Care Guide for Perinatal Patients presented in this article was designed to address this need. By using this guide, NPs can increase their feelings of comfort and confidence as they assess and care for SV survivors in the perinatal period.

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