Using the PEARR Tool
Step one – Provide privacy
The first step of the PEARR Tool is to provide a patient with a safe and private setting, ideally a private room with closed doors. If a companion refuses to be separated from a patient, then this may be an indicator of abuse, neglect, or violence. Consider strategies to separate the patient from the companion in a non-threatening manner, e.g., state the requirement for a private exam or state a need for the patient to accompany you alone for a radiology or urine test. Or, request the companion’s assistance with completing registration forms in the lobby.
If a companion still refuses to be separated from a patient and you suspect abuse, neglect, or violence may be a concern, then it may not be safe to insist on separation. A victim-centered approach means the person’s wishes, safety, and well-being are prioritized in all matters and procedures. In this case, it may not be safe to separate the patient. Instead, continue health services as normal but notify appropriate staff (e.g., nurse supervisor, patient safety, security officer) about any safety concerns and report concerns of abuse, neglect, or violence as required or permitted by law or regulation.
If you are able to speak with the patient alone, explain any limits to confidentiality with the patient before beginning a sensitive discussion about abuse, neglect, or violence. Limits to confidentiality include your legal requirements to report suspicions of abuse, neglect, or violence to internal staff and/or to external agencies according to law or regulation. In order to explain limits of confidentiality, you must fully understand your mandated reporting requirements as outlined by federal, state, or local law and regulation.
Step two – Educate
The next step is to educate the patient about abuse, neglect, or violence in a nonjudgmental and normalized manner. For example, you may begin a conversation as follows: “I educate all of my patients about [fill in the blank] because violence is so common in our society, and violence can have a big impact on our health, safety, and well-being. Let’s review some information together.” Beginning a conversation with a patient in this way can reduce tension between the health care professional and the patient, and it can encourage open communication.
Determining which types of abuse, neglect, or violence are discussed should be based on the health care setting and on the presence of any risk factors or indicators of victimization. To learn more about risk factors and indicators associated with child abuse or neglect, please see the Child Welfare Information Gateway. For risk factors and indicators associated with the abuse or neglect of vulnerable adults (e.g., elder and dependent adults), see the National Association of Adult Protective Services (NAPSA) and the Centers for Disease Control and Prevention (CDC).
Risk factors and indicators associated with DV/IPV are provided by the National Domestic Violence Hotline and the CDC. For risk factors and indicators associated with sexual violence, see the Rape Abuse & Incest National Network (RAINN) and the CDC. For risk factors and indicators associated with labor and sex trafficking, see the National Human Trafficking Hotline.
Click here to review Dignity Health’s educational module, Human Trafficking 101: Dispelling the Myths, which provides basic education to health care professionals about human trafficking, including common misconceptions, risk factors, and indicators.
Use of a brochure or safety card is recommended when reviewing information about abuse, neglect, or violence with a patient. Ideally, this brochure or safety card will include information about resources (e.g., national hotlines). For example, the National Runaway Safeline offers free downloadable brochures in English and Spanish. Their general brochure describes an overview of services available to runaway, homeless, and at-risk youth, and their LGBTQ brochure offers additional guidance to lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth.
Futures Without Violence (FUTURES) also offers numerous free resources for patients in various languages, including safety cards that provide information about health and safety issues related to DV/IPV. Many of these safety cards are designed for specific populations, e.g., American Indians/Alaska Natives, Hawaiians, and persons who identify as LGBTQ or gender non-conforming (GNC). You can search for safety cards from FUTURES here.
In partnership with the National Survivor Network and Eleven Inc., Dignity Health is developing a brochure that will include information about human trafficking for patients who may be victims/survivors. Until this brochure is completed, the following resources are available:
- The Federal Bureau of Investigation (FBI) offers a brochure, Help for Victims of Trafficking, in English, Spanish, Chinese, Japanese, Korean, and Tagalog.
- The Office on Trafficking in Persons, an Office of the Administration for Children and Families, offers the following brochures to health care and related professionals:
- Human Trafficking: Information for Health Care Providers, available in English and Spanish.
- FACT SHEET: Human Trafficking, available in English.
- Child Exploitation Brochure available in English, Indonesian, Korean, Spanish, Thai, and Vietnamese.
- Look Beneath the Surface – Health Care Brochure, available in English and Spanish.
- Look Beneath the Surface – Social Services Brochure, available in English, Spanish, Chinese, Korean, Thai, Vietnamese, and Indonesian.
- Homeland Security’s Blue Campaign offers numerous resources for building awareness about human trafficking in the community, including information sheets, pamphlets, and cards in various languages.
Step three – Ask
After reviewing information about abuse, neglect, or violence, allow time for open discussion with the patient, especially if the patient is exhibiting risk factors or indicators of victimization. For example, you may say: “Is there anything you’d like to share with me? Do you feel like anyone is hurting your health, safety, or well-being?” If a patient is open to answering questions, then consider use of an evidence-based tool to screen the patient for abuse, neglect, or violence.
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all women of childbearing age for DV/IPV (Recommendation Grade B). The USPSTF lists several screening tools available for use in the health care setting, including HITS (Hurt, Insult, Threaten, and Scream). For additional information about HITS and other screening and assessment tools, see Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings, a publication from the CDC.
For information about child abuse or neglect screening tools, please see the Child Welfare Information Gateway. For information about tools that screen for elder abuse, see Elder Abuse Screening Tools for Healthcare Professionals, a publication from the National Center on Elder Abuse (NCEA). For information about tools available to screen patients for labor or sex trafficking victimization, please see these resources provided by HEAL Trafficking.
If a patient is exhibiting significant risk factors (e.g., a high number or pattern of risk factors) or other indicators of victimization, then directly ask the patient about safety concerns. For example, you may say, “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.”
Step four – Respect & Respond
If the patient denies victimization or declines assistance, then respect the patient’s wishes. This may be the most difficult step for a health care professional to take; however, this step is key to providing a victim-centered and trauma-informed approach. Education about trauma, including the prevalence and widespread impact of trauma and the potential signs and symptoms of trauma in patients and others, can help a professional better understand a patient’s wishes to protect an abuser or decline services. To request this education from Dignity Health, please contact Petra Stanton, Director of International Health & Human Trafficking, at [email protected].
If a patient denies victimization or declines assistance, and you still have concerns about abuse, neglect, or violence, then offer the patient information about resources that can assist in the event of an emergency (e.g., local service providers, crisis hotlines). Ideally, this information will be printed on a small card or other item which the patient can hide in his or her belongings. For example, the Blue Campaign offers a “shoe card” that provides the National Human Trafficking hotline, and the National DV Hotline offers a “palm card” with their hotline.
Otherwise, if the patient accepts or requests assistance with accessing services for victims, then provide the patient with a warm referral (i.e., a personal introduction) to a local victim advocate or service provider, per the patient’s wishes. It is imperative to identify ahead of time any local, state, or national resources, both public and private agencies that can provide services and support to patients who may be victims/survivors of abuse, neglect, or violence. If local resources are limited, arrange a private setting for the patient to call a national hotline [e.g., the National Domestic Violence Hotline, 1-800-799-SAFE (7233); National Sexual Assault Hotline, 1-800-656-HOPE (4673); and National Human Trafficking Hotline, 1-888-373-7888].
Throughout the PEARR Tool, a double asterisk** indicates points at which this sensitive conversation with a patient may come to an end, e.g., if a patient’s companion refuses to be separated from the patient. If you are unable to begin a private conversation with a patient – or once this private conversation ends – refer to the double asterisk** at the bottom of the PEARR Tool which provides additional steps: 1) Report safety concerns to appropriate personnel (e.g., nurse supervisor, patient safety, security officer), 2) Report risk factors or indicators as required or permitted by law/regulation, and 3) Continue health services in a trauma-informed manner.
Whenever possible, a follow-up appointment should be scheduled in order to continue building rapport with the patient and to monitor the patient’s health, safety, and well-being. Dignity Health is considering strategies to track vulnerable patients in its electronic health record system, particularly those patients with whom a private conversation was not possible. This way, if the patient returns, staff will be alerted to provide education and assistance accordingly. For ongoing information about victim assistance strategies and for training and technical assistance from Dignity Health, please contact Petra Linden, at [email protected].