The Provider’s Role in Domestic Violence Awareness

The below was written by Heidi Fantasia PhD, RN, WHNP-BC. Dr. Fantasia is an Associate Professor at the Solomont School of Nursing, University of Massachusetts – Lowell, and a member of the NPWH Board of Directors

Every October, we recognize Domestic Violence Awareness. Since 1981, this month has been used to promote awareness, support victims, and advocate for a world with less physical, sexual, and emotional violence. The Violence Against Women Act was passed in 1994 and there has been much progress toward providing services for victims of violence and also holding perpetrators responsible for their actions.

What is domestic violence?

Domestic violence, also known as intimate partner violence, is a broad term that can include many different types of actions. Abusive behavior is used as a way to control a partner, and control is a central component of the relationship. These behaviors can include things such as control of finances, limiting outside relationships, isolation from family and friends, verbal threats or intimidation, stalking, coerced sexual encounters, control over reproduction, and physical violence. Although violence can occur in any relationship and can be committed by both men and women, the most common scenario is a male perpetrating violence toward a female partner.

How common is domestic violence?

It is estimated that 1 in 4 women will experience some type of intimate partner violence during their lifetime and this number may even be higher due to underreporting. Although all women could potentially be exposed to violence in a relationship, younger women between the ages of 18 and 24 are at greatest risk. Relationship violence, combined with a gun in the home, increases the risk of homicide by 500%. Intimate partner violence accounts for 15% of all violent crimes.

Why do women stay in abusive relationships?

Leaving an abusive relationship can be extremely dangerous for the woman. They often face blame for staying and disbelief that violence occurs when they don’t end the relationship. When the abuser senses that he or she is losing control over their partner, the violence can escalate and the risk for lethality increases. If there are dependent children, then leaving becomes even more complex because not only does the woman need to consider her own safety but the also the safety of her children. The process of leaving can be lengthy, and often women have experienced economic control and isolation as part of the abuse. Therefore, they may lack the financial resources and social capital necessary to support themselves and their children independently and safely.

What can health care providers do?

Screen for Intimate Partner Violence

One of the most important things health care providers can do is screen women for intimate partner violence when they present for care. Due to fear, stigma, concern about being believed, and shame, women may be reluctant to initiate a conversation with their provider. Asking women directly if they have experienced violence increases disclosure rates and allows for identification of women who need services and support. Direct questions such as “Have you ever experienced physical, sexual, or emotional violence or threats from a partner?”, “Are you currently afraid of someone?” and “Do you feel safe in your relationship and at home?” are examples of questions that are clear and concise. Letting women know that these questions are asked of everyone prevents women from feeling singled out or targeted due to any sociodemographic factor. These questions also convey that the topic is important and allows for dialogue about safety and physical and emotional health.

Discuss Healthy Relationships

Another important role for health care providers is to discuss healthy relationships, especially with adolescent women who might be starting to navigate dating and romantic partnerships. Inquiring about the nature of the relationship with open-ended questions such as “Tell me about your partner” or “Are you happy in your relationship?” provides an opportunity to gain insight into behaviors that might indicate abuse or the potential for abuse. Adolescent women may perceive constant messages, wanting to know where they are and who they are with, and displays of jealousy as care and concern and not controlling behavior.

Direct Patients to Support Services

All health care providers should be prepared to offer support and assistance to women who disclose violence. It’s important to have a current list of support services in the geographical area, including law enforcement contacts, shelters, safe houses, counseling, and legal aid (especially pro bono). Women may want to end a relationship but need time to arrange housing, finances, transportation and other necessary items. Performing a lethality assessment and helping women to craft a safety plan is essential, especially if there are guns or other weapons in the home.


Although awareness of intimate partner and domestic violence has increased steadily, there is still much more progress to be made. Continued efforts to recognize relationship violence as a prevalent public health issue will help decrease victim blaming and normalize conversations about best strategies for prevention.

Don’t Let Breast Cancer Awareness Fade After October

The below is written by Rachel Gorham, MSN, WHNP-BC, AGN-BC. Ms. Gorham is on the NPWH Board of Directors. 

October is Breast Cancer Awareness Month – an opportunity for us all to focus on breast cancer and its impact on those affected by the disease in our community. Even though we’re nearing the end of the month and the pink ribbons are being put away, we cannot let our dedication to educating patients fade.  Here’s a refresher on the breast cancer risks, symptoms, and screening guidelines that all WHNPs should be familiar with in order to support our patients.

Breast Cancer Statistics

First, let’s talk about who is affected by breast cancer:

  • Advancements in breast cancer screening and treatment has improved survival rates dramatically since 1989. According to the American Cancer Society an estimated 268,000 women will be diagnosed with invasive breast cancer, and 62,930 women will receive a diagnosis of noninvasive breast cancer in 2019. ACS reports over 3.1 million breast cancer survivors in the United States.
  • About 1 in 8 U.S. women (about 12%) will develop invasive breast cancer during her lifetime.
  • A man’s lifetime risk of breast cancer is about 1 in 883. Approximately 2,670 new cases of invasive breast cancer are expected to be diagnosed in men during 2019.
  • For women, breast cancer death rates are higher than those for any other cancer, besides lung in the U.S.
  • African American women under the age of 45 are more commonly diagnosed with breast cancer than white women.
  • A woman’s risk of developing breast cancer doubles if she has a first-degree relative (mother, sister, daughter) who has been diagnosed with breast cancer.
  • About 5-10% of breast cancers can be linked to gene mutations inherited from one’s mother or father.
  • The most significant risk factors for breast cancer are gender (being female) and age (growing older).

Risk Factors  

We know a lot about what factors can influence a patient’s risk of breast cancer:

Age: The risk of breast cancer increases with age. At 20 years, the probability of developing invasive breast cancer in the next 10 years is .06%, or 1 in 1,732. This means that 1,732 women in this age group can expect to develop breast cancer. Age 70, the probability of developing invasive breast cancer in the next 10 years is 3.84%, or 1 in 26.

Family history of breast cancer: Up to 10% of breast cancers are due to specific mutation in single genes that are passed down in a family. Multi-gene testing for hereditary forms of cancer has rapidly altered the clinical approach to testing at-risk patients and their families. Genes associated with hereditary breast cancer includes the following that could potentially be included in a multi-gene test: BRCA1, BRCA2, ATM, BARD1, CHEK2, PALB2, TP53, PTEN, STK11, and CDH1.

Personal history of breast cancer: Women who have previously been diagnosed with breast cancer are at risk of developing it again, either in the same breast or the other, and is higher than if you never had the disease.

Dense breast tissue: Dense breasts are common, particularly in younger women. Dense breasts are associated with an increased breast cancer risk and may impair detection, however there are currently no recommendations for screening women with dense breasts.

Exposure to estrogen: Estrogen stimulates breast cell growth and exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer. Some of the risk factors that are nonmodifiable include: starting menstruation before the age of 12, going through menopause after age 55, and exposure to estrogen in the environment.

Body weight: Women who become overweight or develop obesity after menopause may also have a higher chance of developing breast cancer, possibly due to increased estrogen levels. High sugar intake may also be a factor.

Alcohol consumption: A higher rate of regular alcohol consumption appears to play a role in breast cancer development.

Radiation exposure: Prior exposure to high-dose therapeutic chest irradiation at age 10-30 years may increase the risk of developing breast cancer later in life.


It’s critical that patients know and regularly look for these symptoms, and that they know to talk to us if they experience any:

  • new lump or lumpiness, especially if it’s only in one breast
  • a change in the size or shape of your breast
  • a change to the nipple, such as crusting, ulcer, redness or inversion
  • a nipple discharge that occurs without squeezing
  • a change in the skin of your breast such as redness or dimpling
  • an unusual pain that doesn’t go away.
  • peeling, flaking, or scaling of the skin on the breast or nipple

Finally, providers need to know the difference in screening guidelines for women with average breast cancer risk, and women whose risk is above average:

Screening Guidelines for Women at Average Breast Cancer Risk

(no symptoms of breast cancer, no history of breast cancer or atypia, no family history of breast cancer, no suggestion of a hereditary cancer syndrome, and no history of mantle radiation)

  • Women between the ages of 25 and 40 should have an annual clinical breast examination.
  • Women 40 and older should have an annual mammogram in addition to an annual clinical breast examination.
  • Ultrasound may be recommended for women with dense breast tissue.
  • All women should consider performing a monthly self-breast exam beginning at age 20 and become familiar with their breasts so they are better able to notice changes.

Screening Guidelines for Women at Above-Average Breast Cancer Risk

  • A clinical breast exam every six months starting no later than ten years before the age of the earliest diagnosis in the family (but not earlier than age 25 and not later than age 40).
  • An annual mammogram starting no later than ten years before the age of the earliest diagnosis in the family (but not earlier than age 25 and not later than age 40).
  • Possible supplemental imaging (for example, with ultrasound) for women with dense breast tissue.
  • Possibly alternating between a breast MRI and a mammogram every six months, as determined by your provider.


We have made so many advancements in screening for and treating this cancer. As providers, we need to keep up the fight, stay vigilant, and support our patients with the best care we can provide.