Care starts with asking

By Michelle Patch, PhD, MSN, ACNS-BC, AFN-C, APRN-CNS, CNE, Johns Hopkins School of Nursing

You’re seeing a young adult for contraception counseling. She says she wants to “get ahead of things” before a new relationship becomes more serious. In private, her answers are careful and brief. Only after a few more gentle questions do you learn that her partner is pressuring her about pregnancy and monitoring her phone.

Another day, an older patient comes in with shoulder pain after what’s described as a minor fall. The story changes a little each time you hear it. When you ask to speak with him alone and ask about safety at home, he admits he’s been afraid for months.

These visits are reminders that domestic abuse can hide behind ordinary medical concerns.

Screening matters

Intimate partner violence (IPV) and domestic abuse affect patients across all ages genders. IPV isn’t limited to younger patients—older adults can be affected too, and abuse may be mistaken for frailty, dementia, caregiver stress, or family conflict.

People may come in with injuries, chronic pain, headaches, anxiety, sleep problems, reproductive concerns, GI issues, or vague symptoms that don’t fit neatly into one diagnosis. Sometimes the clues are subtle: repeated falls, missed appointments, fearfulness, or a story that doesn’t quite add up. These things indicate that you should screen for IPV. It’s also important to think about possible brain injury from head trauma or strangulation. Symptoms such as headache, dizziness, confusion, memory changes, or neurologic concerns may be present even when the exam seems benign.

How to ask

There’s no single best screening tool for every setting. Brief tools such as HITS, HARK, and WAST may be useful—the key is to ask about IPV privately, respectfully, and with a plan for what comes next. Whenever possible, speak with the patient alone and begin broadly before getting more specific. You can ask:

1. “How are things going at home?”

2. “Are any relationships causing you stress or worry?”

3. “Do you ever feel unsafe with anyone close to you?”

If concerns arise, ask about control, threats, physical harm, sexual pressure, pregnancy pressure, finances, and whether transportation, medications, or communication are being controlled or limited. To assess immediate danger, ask directly about strangulation or “choking,” head injuries, weapons use, and signs that the situation is escalating.

Importantly, believe the patient. Avoid shock, judgment, or pressure them to leave an unsafe relationship or home. Survivors may not be ready for big decisions yet. Your job is to listen, support, and reduce risk.

Treating the whole patient

Care goes beyond identifying abuse. Disclosure changes the care plan—treat injuries and symptoms, validate the patient’s experience, help choose the safest next step, and arrange follow-up and support. If strangulation or head injury is possible, assess for urgent complications. Older adults may need extra attention to medication access, mobility, finances, transportation, and safe discharge planning. Explain what you’re doing, offer choices when possible, and restore a sense of control. If the patient would like support, make a warm, direct connection with advocacy, social work, behavioral health, and legal resources, and help coordinate shelter and safety planning.

Additionally, reporting requirements vary by state and circumstance, so know the rules that apply where you practice. If a report is required, explain what information you must share and with whom, involve the patient in the process when possible, and share only what’s necessary. Continue to listen, discuss safety, and connect the patient with support.

Practical tips for all clinicians

1. Ask about possible abuse privately and routinely.

2. Speak calmly using nonjudgmental language.

3. Keep a high index of suspicion for strangulation, head trauma, reproductive coercion, and elder abuse.

4. Know your next steps, local resources, referral pathways, and state’s mandated-reporting requirements/processes before you ask about abuse.

5. Document carefully and objectively.

6. Protect confidentiality by limiting unnecessary detail in notes, portals, and discharge paperwork.

Exceptional care means noticing what may be hidden, asking about IPV in a way that invites honesty, and responding with steadiness and compassion. When you do that, you can help patients feel safer, seen, and supported.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.