PEARR: Treating Abuse and Violence Victims, Step by Step

Nurse Leader Insider, February 7, 2019

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By Patient Safety Montior Journal

Holly Austin Gibbs has been the director of Dignity Health’s Human Trafficking Response Program since 2015. She is also a survivor of child sex trafficking, recovered by law enforcement when she was 14. After her rescue, she was taken to an emergency department for assessment.

“What I remember most about this experience,” she says, “is that I was left alone in a room—I felt very isolated. The healthcare staff didn’t talk to me. I felt like they were disgusted by me, like I wasn’t worth their time. In reality, the staff probably didn’t know what to say to me.”

The Dignity Health system, HEAL Trafficking, and the Pacific Survivor Center teamed up to create a tool that could identify and care for victims/survivors of any form of abuse, neglect, or violence, including human trafficking. Together, they published the PEARR Tool, a suite of procedures to guide providers in providing assistance to possible abuse victims.

The worst thing a care provider can do when they suspect victimization, Gibbs says, is ignore the patient’s needs and concerns. “This is why we developed the PEARR Tool,” she says. “It offers step-by-step guidance for healthcare professionals to offer assistance to victim/survivors of violence. And it offers example statements to help get the conversation started. The best approach someone can take is one that prioritizes the potential victim’s wishes, safety, and well-being.”

Released in 2018, PEARR reflects principles of a trauma-informed and victim/patient-centered approach. It also provides additional instructions at various points where a conversation with a patient might come to an end.

The letters in PEARR stand for:
Provide privacy
Respect & Respond

1.    Provide privacy
The first step is to provide a patient with a safe and private setting, she says. Ideally, that’s a private room with closed doors. And before discussing any sensitive topics, you need to explain your limits of confidentiality. That includes your legal requirements to report suspicions of abuse, neglect, or violence to internal staff and/or external agencies according to law or regulation. This will require that staff know their federal, state, local, and facility reporting requirements. (If you asked a random provider in your facility, would he or she know those requirements?)

There may be cases where the patient has a guest or companion that refuses to be separated from the patient—a potential sign of abuse. Staff will need to learn strategies on how to separate patients from their companions. PEARR states this should be done in a nonthreatening manner, such as:

  •     Asking the companion to help fill out registration forms in the lobby
  •     Say there’s a requirement or need for a private exam, such as a radiology or urine test

If staff are unable to begin a private conversation with a patient or have difficulty dealing with the companion once the private conversation ends, PEARR calls for additional steps:

  •     Report safety concerns to appropriate personnel (e.g., nurse supervisor, patient safety, security  officer)
  •     Report risk factors or indicators as required or permitted by law/regulation
  •     Continue health services in a victim-centric and trauma-informed manner

2.    Educate
The next step is to educate the patient about abuse, neglect, or violence in a nonjudgmental and normalized manner. You don’t want the person to feel singled out for questioning. PEARR uses the following as an example conversation opener: “I educate all of my patients about [blank] because violence is so common in our society, and violence has a big impact on our health, safety, and well-being. Let’s review some information together.”

You can use a brochure or card to review information about abuse, neglect, or violence. That way, you can offer it to the patient after the conversation.

You should determine which types of abuse, neglect, or violence to talk about based on the risk factors at hand. A patient could be dealing with child abuse and neglect, domestic violence, sexual violence, human trafficking, or other problems that will require different information. PEARR offers several risk factor resources on its site.

3.    Ask
After going over the information with the patient, allow time for an open discussion. You can ask the patient something like, “Is there anything you’d like to share with me? Do you feel like anyone is hurting your health, safety, or well-being?”

If the patient is willing to answer, then PEARR recommends using an evidence-based tool or screener to follow up. And if the patient exhibits a high amount or pattern of risk factors or victimization indicators, then directly ask about what you’ve noticed:

“I’ve noticed [insert risk factor/indicator] and I’m concerned for your health, safety, and well-being. You don’t have to share details with me, but I’d like to connect you with victim support services. Would you like to speak with [insert victim advocate/service provider]? If not, and you change your mind, you can let me know anytime. I’m here to help.”

4.    Respect & Respond

If the patient accepts or requests assistance, provide a referral (with a personal introduction) to a local victim advocate or service provider, per the patient’s wishes.

It’s imperative to identify any local, state, or national resources ahead of time, including both public and private agencies.

If the resources in your area are limited, arrange a private setting for the patient to call a national hotline. For example:

  •     National Domestic Violence Hotline, 1-800-799-SAFE (7233)
  •     National Sexual Assault Hotline, 1-800-656-HOPE (4673)
  •     National Human Trafficking Hotline, 1-888-373-7888

If the patient denies victimization or declines assistance, then respect the patient’s wishes. This may be the most difficult step for a healthcare professional to take, Gibbs says, but it is key to providing a trauma-informed and patient-centered approach.

“It is not appropriate for healthcare professionals to assume the role of rescuing victims, especially if the patient/victim is a competent adult,” she says. “We can offer them a way out, but they must accept or request the help.”


What Is a Trauma-Informed Approach?
According to the Substance Abuse and Mental Health Services Administration (SAMHSA) definition, a “trauma-informed approach” is a program, organization, or system that:

  •     Realizes the widespread impact of trauma and understands potential paths for recovery
  •     Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system
  •     Responds by fully integrating knowledge about trauma into policies, procedures, and practices
  •     Seeks to actively resist re-traumatization

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