It started in Dayton, Ohio. Early in her career, Jacquelyn (Jackie) Campbell, PhD, RN, FAAN, took a job at an inner-city high school. The students were Black and poor, and many came by her office, sharing the troubles they faced at home.
At the time, Campbell was working on a master's degree at Wright State University and looking for a research topic that might benefit the teens she'd come to know and love. She invited a group of eight to nine girls to join her for cookies and conversation after school and did some background research as well.
"I looked at the mortality tables to see what the biggest health problem was for these young women, and the number one cause of death for Black women ages 18 to 25 was homicide." The statistic was a revelation, and it gave Campbell a thesis topic.
She reviewed five years of Dayton homicide records and discovered that most women who are murdered, regardless of race or background, die at the hands of a current or former husband or boyfriend, and domestic violence was a precursor. She published her findings in 1981 in Advances in Nursing Science under the title "Misogyny and Homicide of Women." "I was enraged," Campbell recalls.
A couple of years later, Campbell received a call that cemented her decision to make intimate partner homicide the focus of her career. "One of the counselors at the high school called me and said-it still makes me cry-that Annie, who was a young woman who had gotten pregnant in high school, had been murdered by her boyfriend and the father of the baby. I adored her, but the other piece of it was that I also adored him."
After Annie's death, Campbell began volunteering at a shelter for abused women in Detroit, where she had moved. "They would tell me their stories. Some of them would tell me things-risk factors that I had seen in my thesis. I kept thinking, that's really scary, but you don't seem to be as scared as I am."
THE DANGER ASSESSMENT
Although, at the time, there were tools to assess whether domestic violence might recur, Campbell wanted a way to determine which abused women were at risk for losing their lives. She knew adults don't respond well to people telling them how to interpret their own experiences, so she decided to develop a tool that would allow women to see for themselves just how much risk they faced. The result was the Danger Assessment-an instrument a woman could fill out on her own or with an advocate.
In its original form, the Danger Assessment contained a series of 15 yes or no questions aimed at determining an abused woman's risk of being killed by her intimate partner. Among them: "Is he violently or constantly jealous of you?" "Does he own a gun?" "Has he avoided being arrested for domestic violence?"
The assessment also asked women to mark a year-long calendar with the dates of abuse incidents and their severity. "You don't have to ask, 'Are you sure it hasn't gotten worse?'" Campbell notes. After filling out the calendar, "they can see it for themselves."
To find out if the assessment was useful, she began using it in the shelter. She also shared it with her graduate students at Wayne State University, where she'd taken a teaching job. They suggested additional questions: "Does he ever try to choke/strangle you or cut off your breathing?" "Has he ever forced you to have sex when you did not wish to do so?" Campbell incorporated these, and soon other nurses were using the assessment as well.
In May 1981, a letter to the editor from forensic nurse Daniel Sheridan appeared in AJN, sparking the creation of a network of nurses working with abused women. The members of what has since become the Nursing Network on Violence Against Women International put the Danger Assessment to work. Their results gave Campbell preliminary data on its validity and reliability-"enough to get me funding to look at it more rigorously," she says.
In 1996, Campbell, by then a professor at the Johns Hopkins University School of Nursing in Baltimore, Maryland, received funding from the National Institutes of Health (NIH) to study the predictive validity of the risk factors in the Danger Assessment.
She and her colleagues conducted an 11-city study to compare the risk factors associated with intimate partner femicide cases with the risk factors of abused women in the same cities, who served as controls. The researchers used the results to revise the questions in the assessment and develop a scoring algorithm that could be used to calculate four levels of danger: variable, increased, severe, and extreme.
Campbell and her colleagues then tested the ability of the revised assessment to correctly identify an independent set of attempted femicides. They found that 1.3% of the attempted femicide cases (compared with 53.1% of the abused controls) scored at the increased danger level prior to their worst incident of abuse. Conversely, 54.5% of attempted femicide cases (compared with 3.5% of abused controls) scored at the extreme danger level. Results of this study were published in the April 2009 Journal of Interpersonal Violence.
"People have done studies to see if women are better barometers of how much danger they're in, and oftentimes, they are very good at saying, 'He's likely to do this again.' But there are a lot of women who don't see homicide coming," Campbell says. The Danger Assessment is meant for them.
USE AND IMPACT
In its current form, 20 questions plus the calendar, the Danger Assessment (http://www.dangerassessment.org/DATools.aspx) is used in 48 states and nine foreign countries. In recent years, roughly 1,000 people a year have accessed in-person or online training and become certified in its use, including all nurses providing home visitation through the Nurse-Family Partnership. Campbell and her colleagues also worked with a California judge to develop a judicial "bench card" judges can refer to in domestic violence proceedings, and cocreated with the Maryland Network Against Domestic Violence a short lethality screening version of the Danger Assessment tool used by law enforcement officers in 30 states to determine whether abuse victims need immediate referral to a domestic violence advocate. The Danger Assessment is also accessible directly to consumers through the myPlan safety decision app (http://www.myplanapp.org/en/our-story) developed by Campbell's Johns Hopkins colleague Nancy Glass, PhD, MPH, MS, RN.
Nurses and others are also putting the full assessment and a shorter version, the Danger Assessment-5 (http://www.dangerassessment.org/uploads/DA-5_Format_2019_r1.pdf), to use in health care settings, where time for patient encounters is notoriously short. "We've worked hard to help providers ask about abuse in a way that women feel they can say 'yes,'" Campbell says. For example, the original assessment asked if the man was violent toward the woman's children, but if she answered "yes," her response triggered a mandatory report to Child Protective Services. The current assessment asks if he threatens to harm her children. "I didn't feel like it was fair to women to say, 'We're doing a risk assessment of how much danger you are in of being killed,' and then say, 'Oh, and by the way, I now have to report you to CPS.'"
The Danger Assessment can prove valuable even for women who realize how much danger they face. Campbell recalls one woman telling her, "You know, this is not a news flash to me, lady. I knew he was dangerous, but this gives me evidence. I can use this in persuading other people that he's dangerous.'"
LOOKING AHEAD
Campbell is currently a professor and the Anna D. Wolf Chair at the Johns Hopkins University School of Nursing and holds a joint appointment at the Johns Hopkins Bloomberg School of Public Health. As the Friends of the National Institute of Nursing Research's Ada Sue Hinshaw Award winner and American Academy of Nursing's Living Legend nears the end of her career, she remains committed to her research and wishes more nurses would follow in her footsteps. She would also like to see greater collaboration across the researcher/practitioner divide, so the two perspectives are "together in designing the research and figuring out what the practice implications are from the beginning."
Despite its widespread use, the Danger Assessment has only been studied with abused women living in urban settings. Campbell hopes research will eventually demonstrate its effectiveness in more settings and with additional populations. In 2020, she received funding from the NIH to compare the risk of firearm-related intimate partner homicide and homicide-suicide in Texas and Maryland. A separate NIH grant will fund her and her colleagues to continue training and mentoring pre- and postdoctoral students in research on trauma and violence.
To learn more about the Danger Assessment, visit http://www.dangerassessment.org.-Nicole Fauteux