Intimate-Partner Violence and the Danger Assessment

IPV screening tools, the evidence-based Danger Assessment instrument, lethality risk factors, universal screening rationale, safe documentation, and safety planning across global and Indian legal contexts.

Last updated: 19 Jun 2026

Intimate-partner violence (IPV) screening in clinical settings relies on validated instruments such as HITS, WAST, and the Abuse Assessment Screen, combined with the Danger Assessment (DA) developed by Dr. Jacquelyn Campbell at Johns Hopkins University, which estimates the risk of intimate-partner homicide across four risk levels using a 20-item weighted battery and a calendar of abuse. Universal screening -- asking all patients regardless of presenting complaint -- is recommended by the WHO because targeted screening based on provider perception misses most affected patients and introduces demographic bias. In India, the Protection of Women from Domestic Violence Act 2005 (PWDV Act) provides civil remedies including protection orders, residence orders, and monetary relief without requiring criminal prosecution, covering physical, sexual, emotional, and economic abuse within domestic relationships.

Intimate-partner violence (IPV) is a leading cause of injury in women worldwide, and the healthcare setting is often the only place an affected person has contact with a professional who could ask. Studies consistently show that without direct, non-judgmental screening, most IPV patients do not disclose -- not because they do not want help, but because no one asked, the environment did not feel safe, or they did not connect their experience with what they thought the question was about.

Forensic nursing practice places the nurse in a direct position to screen, document, and connect patients with safety resources. The skills required are relational as much as procedural: establishing a private environment, using structured language that removes stigma, and applying validated tools that produce actionable risk information. Among those tools, the Danger Assessment developed by Jacquelyn Campbell is one of the few instruments that estimates the risk of being killed by an intimate partner; prospective research supports its use as a structured component of safety planning.

This topic covers the evidence-based screening tools used in practice, the Danger Assessment instrument in detail, the established lethality risk factors, how to document without endangering the patient, and the safety-planning conversation. It situates the clinical work inside both an international framework and the specific Indian legal context of the Protection of Women from Domestic Violence Act 2005.

By the end of this topic you will be able to:

Identify and distinguish the validated IPV screening tools used in clinical settings (HITS, WAST, AAS, SAFE questions) and select the appropriate instrument for a given patient population.
Administer the Danger Assessment instrument, interpret the four risk-level scores, and explain the significance of high-weight items such as prior strangulation, weapon access, and explicit threats to kill.
Identify the established lethality risk factors for intimate-partner homicide and explain why the separation period represents the highest-risk window.
Document IPV findings using objective clinical language and restricted-note strategies that protect the patient from record-based harm.
Conduct a safety-planning conversation and apply relevant Indian legal protections under the PWDV Act 2005, including the Protection Officer network and Domestic Incident Report process.

Key terms

Intimate-partner violence (IPV): Physical, sexual, or psychological harm by a current or former partner or spouse. Encompasses physical assault, sexual coercion, emotional abuse, and coercive control. Not limited to any gender, though women are disproportionately represented as survivors of severe physical IPV.
Universal screening: Asking all patients in a clinical setting about IPV exposure, regardless of presenting complaint or risk appearance. Contrasted with targeted screening, which applies only when the provider judges the patient to appear at risk.
Danger Assessment (DA): A 20-item validated instrument developed by Dr. Jacquelyn Campbell for estimating the risk of intimate-partner homicide or near-lethal assault. Combines a weighted item battery with a calendar rating abuse severity and frequency over the past year.
Coercive control: A pattern of behaviour that constrains the victim's liberty and autonomy -- monitoring movements, isolating from support networks, controlling finances, enforcing compliance through fear. Often more predictive of severe violence than isolated physical incidents.
Safety planning: A collaborative process in which the nurse and patient identify practical steps to reduce immediate danger: documents to keep accessible, people to contact, where to go, what resources exist, and how to exit quickly if danger escalates.
PWDV Act 2005: Protection of Women from Domestic Violence Act 2005 (India). Provides civil remedies -- protection orders, residence orders, monetary relief -- for women experiencing physical, sexual, verbal, emotional, or economic violence within domestic relationships. Does not require the victim to pursue criminal prosecution.

Validated IPV screening tools

Several short, validated instruments have been developed for IPV screening in clinical settings. They share a common goal: ask efficiently and sensitively, produce a threshold score or response pattern, and act as a structured prompt for further conversation. None replaces the clinical relationship, but all outperform unstructured intuition.

Tool	Items	Population	Key feature
HITS	4 items (Hurt, Insult, Threaten, Scream)	Community, primary care	Simple, brief, high completion rate; score >=11 suggests abuse
WAST	2 initial items (screener) + 6 further items	Community, family practice	Two-item screener can be administered in minutes; high specificity
AAS (Abuse Assessment Screen)	5 items including pregnancy-related item	Pregnant and reproductive-age women	Addresses pregnancy-related violence; visual body map for injury location
SAFE questions	4 open-ended questions	General clinical settings	Qualitative rather than scored; useful for follow-up after positive screen

Screening should occur privately, with no partner or family member present. It is introduced as a routine question asked of all patients. The wording matters: 'Because violence is very common and can affect anyone's health, I ask all my patients...' reduces the stigma of being singled out.

The Danger Assessment instrument

Jacquelyn Campbell at Johns Hopkins University developed the Danger Assessment in the 1980s and has refined it through decades of research, including a large prospective study comparing abused women who were killed by partners to those who were not. The result is a 20-item instrument with empirically derived weights for each risk factor based on its association with femicide.

Danger Assessment administration sequence.

The calendar component asks the patient to mark on a one-year calendar the incidents of abuse and rate each for severity on a 1-5 scale. This visual record helps the patient see the pattern of escalation (or non-escalation) and establishes a shared baseline for the conversation. Research shows it helps patients recognise the severity of their situation in a way that verbal questions alone often do not.

Key high-weight DA items include: access to a gun, prior strangulation (the strongest single predictor in multiple studies), threats to kill, forced sex, stepchild in the home, and the patient's own belief that the partner is capable of killing her.
Score interpretation: level 1 (variable danger, score 0-7), level 2 (increased danger, 8-13), level 3 (severe danger, 14-17), level 4 (extreme danger, 18+). Higher levels are used to guide urgency of safety planning and referral intensity.
The DA does not assign a probability of death. It assigns a relative risk category. It is a clinical tool for guiding conversation, not a definitive predictor.

Lethality risk factors

Several risk factors for intimate-partner homicide have been identified through case-control and prospective research. They are the basis for the weighted items in the Danger Assessment and inform safety planning conversations. A forensic nurse should be able to identify them quickly and communicate their significance to the patient.

Strangulation history: a previous non-fatal strangulation by the partner is one of the strongest predictors of subsequent homicide, with a risk multiplier of approximately 7x in Campbell's research.
Weapon access: partner's access to a firearm (where applicable) is a strong predictor; access to any weapon (knife, blunt instrument) raises risk. Ask directly.
Escalating severity or frequency: an acceleration in violence is a recognised warning sign even if current incidents appear moderate.
Separation or threatened separation: the period immediately after leaving or announcing intention to leave is the highest-risk period for intimate-partner homicide. This is critical for safety planning.
Explicit threats to kill: should be taken seriously and documented verbatim using the patient's own words.
Patient's own fear assessment: 'Do you believe your partner could kill you?' -- the patient's own perception has predictive validity independent of objective risk factors.

Documentation that does not endanger the patient

Documentation of IPV has to balance two competing needs: creating a clinical and legal record of what was found and discussed, and not creating a document that the perpetrator can access and use against the patient. In settings where partners attend together, have shared insurance records, or have access to patient portals, an overly explicit clinical note may put the patient in danger.

Describe injuries clinically: document wounds using objective wound terminology (see wound documentation topic) rather than attributing causation explicitly in the chief complaint, e.g., 'multiple contusions, mechanism as per history' with the perpetrator's name in a restricted section where possible.
Use the patient's own words: for disclosures, quotation marks signal that the clinical language is the patient's statement, not the nurse's conclusion.
Know your facility's access policies: inform the patient who can see the record (partner with proxy access, insurance reviewers, etc.) before they decide what to disclose.
Safety plan in a restricted note or separate document where the facility allows it: do not include the refuge address, escape plan details, or names of support contacts in the open record.
Mandatory reporting obligations vary by jurisdiction: in India, medical professionals may have reporting obligations under specific statutes or institutional policies; know the local requirements and inform the patient before reporting.

Safety planning and the India PWDV Act 2005 context

Safety planning is a collaborative conversation between the nurse and patient that acknowledges the patient is the expert on their own situation. It does not assume the patient will leave the relationship or can safely do so. It builds a set of options the patient can activate at different levels of danger.

Identify immediate danger indicators
Is the patient safe to go home tonight? Has the partner threatened more violence? Does the partner have a weapon? Are there children at risk? This assessment determines whether the plan is for imminent exit or for longer-term preparation.
Identify resources and safe contacts
Who does the patient trust? What local shelter or support organisation can be contacted? Provide local hotline numbers in written form (or verbally if written materials are unsafe to carry). In India: iCall, iHave, and state-specific 181 Womens Helplines.
Important documents and go-bag
Aadhar card, passport, children's documents, medications, a small amount of cash, and a phone charger. If documents are controlled by the partner, discuss how to obtain copies.
Discuss the PWDV Act 2005 (India)
Explain that civil protection is available without requiring criminal prosecution. A Protection Officer can be accessed through the District Magistrate's office. A Domestic Incident Report initiates a process that can include protection orders, residence orders (allowing the survivor to remain in the shared household), and monetary relief. The Act covers women in domestic relationships, including unmarried partners and live-in relationships.

Safety planning decision pathway.

The PWDV Act covers physical, sexual, emotional, verbal, and economic abuse, and includes a residence order remedy that allows a survivor to remain in the shared household rather than being the person required to leave. This is significant in contexts where homelessness is a barrier to seeking help. Forensic nurses working in Indian clinical settings should be familiar with the Protection Officer network and the Domestic Incident Report process.

Worked example

IPV screening, Danger Assessment, and safety planning in a primary care visit

Following the screening-to-safety-plan pathway in a single clinical encounter.

A 28-year-old woman presents for follow-up of recurrent headaches. The forensic nurse screens using HITS as part of routine intake. The patient's score is 14, above the threshold of 11. The nurse continues with the following steps:

Private disclosure and DA administration: the nurse ensures the partner is not in the room and introduces the Danger Assessment as a tool used with all patients who screen positive: 'I'd like to go through a short assessment with you that helps me understand the situation better.' The calendar is completed together. DA score: 16 (severe danger level 3). Key items: prior strangulation (yes), threats to kill (yes), escalating frequency (yes).
Injury examination: the patient agrees to examination. Linear abrasion 4 cm on right forearm (ulnar border), consistent with defensive positioning. Bilateral posterior upper arm contusions in healing stage. Documented using objective wound terminology with body diagram. Photographed.
Documentation: injuries documented clinically. DA result recorded as 'domestic safety assessment completed; score consistent with severe risk level, details in restricted note.' Patient's verbatim statement documented: 'He said last week he would kill me if I called anyone.' Safety plan details placed in restricted section per facility policy.
Safety planning: immediate danger assessed as high given prior strangulation and recent kill threat. Patient declines shelter referral today but accepts written information about local shelter and the 181 helpline. Prior strangulation discussed as high-risk indicator. PWDV Act explained: protection officer contact provided. Follow-up appointment arranged with domestic violence advocate on site.

The encounter combines screening, validated risk assessment, injury documentation, and safety planning without telling the patient what to do or recording information that could be accessed by the partner through the standard notes portal. It gives the patient documented evidence of her situation and real options to act on when she is ready.

Check your understanding

Question 1 of 4· 0 answered

Why is universal IPV screening recommended over targeted screening?

Key Takeaways

Validated screening tools (HITS, WAST, AAS) outperform clinical intuition; universal screening removes demographic bias and is recommended by WHO and multiple national bodies.
The Danger Assessment, developed by Jacquelyn Campbell, is a 20-item validated instrument estimating intimate-partner homicide risk; prior strangulation, weapon access, escalation, and explicit kill threats are among its highest-weight items.
Safety planning is a collaborative process that builds options at different levels of readiness, not a directive to leave; the separation period is the highest-risk time for homicide.
IPV documentation must balance clinical completeness against the risk that the record is accessed by the perpetrator; restricted notes, objective clinical language, and patient education about portal access are the key mitigations.
India's PWDV Act 2005 provides civil protection orders and residence orders without requiring criminal prosecution, covering physical, sexual, emotional, and economic violence in domestic relationships including unmarried partnerships.

What is the Danger Assessment and what does it measure?

The Danger Assessment (DA), developed by Dr. Jacquelyn Campbell at Johns Hopkins University, is a validated 20-item instrument that estimates the risk of intimate-partner homicide or near-lethal assault. It combines a calendar of abuse frequency and severity over the past year with a weighted item list covering empirically derived risk factors. Higher scores correlate with higher homicide risk in prospective research.

Why should healthcare settings use universal IPV screening rather than screening only high-risk patients?

Universal screening identifies patients who do not appear at high risk based on presentation alone. IPV occurs across all socioeconomic, educational, and demographic groups, and patients do not spontaneously disclose in most cases. Targeted screening based on appearance, injury type, or provider intuition misses the majority of affected patients and can introduce bias.

What are the main validated IPV screening tools used in clinical settings?

Commonly used and validated tools include HITS (Hurt, Insult, Threaten, Scream -- four items, community-validated), WAST (Woman Abuse Screening Tool -- two initial items), and AAS (Abuse Assessment Screen -- five items originally designed for pregnant women). Each has a different reading level and administration time. The choice depends on clinical context and patient population.

How should a forensic nurse document IPV findings without endangering the patient?

Documentation should use clinical language for injuries and symptoms, avoid naming the perpetrator as the cause in a way that could be accessed by the perpetrator (e.g., in a shared household with electronic access to the record), record the patient's own words where relevant using quotation marks, and use a separate restricted section of the record for safety planning details where the facility allows it. The nurse should know local record-access policies and inform the patient.

What legal protections exist for IPV victims in India?

The Protection of Women from Domestic Violence Act 2005 (PWDV Act) provides civil remedies including protection orders, residence orders, and monetary relief without requiring criminal prosecution. It covers physical, sexual, verbal, emotional, and economic abuse within domestic relationships. Victims can access Protection Officers and empanelled service providers for assistance. The PWDV Act operates alongside criminal provisions under the Indian Penal Code.

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