Date of Award

January 2024

Document Type

Open Access Thesis

Degree Name

Doctor of Nursing Practice (DNP)


Yale University School of Nursing

First Advisor

David Vlahov


AbstractNonfatal Strangulation and Intimate Partner Violence Decision Tree Protocol Problem and Context Nonfatal strangulation (NFS) is the ultimate form of power and control in intimate partner violence (IPV). Native American women are at an increased risk of intimate partner violence. Symptoms of strangulation are frequently missed by first responders. Victims often decline medical examination. Victims of nonfatal strangulation can have significant long term complications and increased morbidity throughout their lives. Intervention or Innovation This project provided educational training sessions to first responders within a Native American community in the Southwestern United States to increase knowledge and comfort when responding to intimate partner violence or strangulation calls. Targeted first responder departments included the Emergency Department, the Emergency Medical Services Department, and the Tribal Police Department. The training sessions were followed by a four month timeline implementation period of a decision tree protocol which intersected systems pathways and guided the first responders through the forensic nurse activation process. Aims and Methods The aims of this project were to adapt existing protocols and guidelines in the development of an intimate partner violence and nonfatal strangulation decision tree protocol, to implement and evaluate the protocol, and to make recommendations for scaling and sustainability to other Native American communities and health systems throughout the United States. Descriptive and bivariate statistics were used to evaluate findings. Outcomes and Results This quality improvement project began with training to improve the trauma informed approach and recognition of intimate partner violence and nonfatal strangulation. Training was attended by 79% of the targeted systems stakeholders’ department’s staff across and post-tests resulted in statistically significant increase in knowledge acquisition. Initial training was followed by a four month implementation of a decision tree protocol. Participants indicated enthusiasm for recommending the training and protocol use to others. Implications The results of this quality improvement project indicate a high probability of successful integration into daily practice within the targeted departments intersecting multiple systems stakeholders throughout the organization and community. This quality improvement project provided important feedback into recommendations for sustainability and scalability.


This is an Open Access Thesis.

Open Access

This Article is Open Access