Domestic Violence (Kentucky)

House Bill 309 (enacted 1996) requires all nurses licensed as of July 15, 1996, to complete a one-time, mandatory course addressing domestic violence before July 1, 1999. The statute mandates that the 3-hour Domestic Violence training course includes:

• Dynamics of domestic violence
• Effects of domestic violence on adult and child victims
• Legal remedies for protection
• Lethality and risk issues
• Model protocols for addressing domestic violence
• Available community services/victim services
• Reporting requirements.

Domestic violence remains a persistent problem in the United States. It encompasses a range of abuses including economic, psychological, sexual, and physical. Victims are primarily women. From primary care offices to Urgent Care centers, victims of domestic violence routinely appear across healthcare settings; therefore, it is essential that healthcare providers, particularly nurses and advanced practice nurses, recognize its symptoms and understand how to establish a plan of care.

Domestic violence is also referred to as spousal abuse, batter, or intimate partner violence, and it is defined as the victimization of a person within whom the abuser has had a romantic relationship. Domestic violence is a serious, yet preventable public health concern. An intimate partner is defined as a person with whom one has had a close relationship characterized by emotional connectedness, regular contract, and familiarity about each other’s lives.¹

While the term domestic violence is still widely used, more recently, physical, psychological, or sexual violence in the context of a relationship is called intimate partner violence. The World Health Organization (WHO) defines intimate partner violence as “any behavior within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship.²”

Specifically, the Centers for Disease Control and Prevention identifies five main types of intimate partner violence¹:

• Physical violence: Physical violence refers to the intentional use of physical force that leads to death, disability, injury or harm. Physical violence includes all forms of physical force from scratching and biting to choking and punching.
• Sexual violence: Sexual violence refers to any forced unwanted sexual contact that occurs without the victim’s freely given consent including cases in which the victim is unable to give consent due to being too intoxicated. Sexual violence includes rape, unwanted penetration, and other unwanted sexual experiences such as exposure to sexual situations or dissemination sexual media of that person.
• Stalking: Stalking refers to a pattern of repeated and unwanted attention that results in fear or concern for one’s own safety. Examples of stalking include unwanted phone calls, leaving unwanted gifts, and damaging the victim's personal property.
• Psychological aggression: Psychological aggressions refers to the use of verbal or nonverbal communication with the intent to harm the victim emotionally or exert control over them. Examples include name-calling, humiliation, limiting access to money or friends, refusal to use birth control, and coerced pregnancy termination.
• Financial/Economic Abuse: Economic abuse refers to the use of money to harm the victim emotionally or exert control over them. Examples include withholding money and refusing to allow the victim to work or open a bank account.

The state of Kentucky has written its own definitions for terms related to domestic violence.³ These definitions encompass the terms domestic violence and abuse, family member, and member of an unmarried couple.

• Domestic violence and abuse include physical injury, serious physical injury, stalking, sexual abuse, assault, or the infliction of fear of imminent physical injury, serious physical injury, sexual abuse, or assault between family members or members of an unmarried couple.
• Family member, which is defined as a spouse (including a former spouse), a grandparent, a grandchild, a parent, a child, a stepchild, or any other person living in the same household as a child if the child is the alleged victim.
• Member of an unmarried couple refers to a member of an unmarried couple that allegedly has a child in common, any children of that couple, or a member of an unmarried couple who is living together or has formerly lived together.

Abuse tends to occur in cycles. It does not just go away and tends to get worse over time. Domestic violence and intimate partner violence typically, but not always, follows a pattern. There is a period of tension building; there is an episode of violence; and there is a time calm, or a "honeymoon".⁴ Unfortunately, there is evidence that suggests the more severe the violence, the more chronic it is and the more likely it is to worsen over time.⁵

The cycle of violence is as follows:

1. Tension Building
   1. Tension mounts in the relationship.
   2. The batterer is irritable, frustrated, and unable to cope with everyday stresses.
   3. The victim attempts to appease the batterer by becoming compliant, nurturing, or staying out of the way
   4. The victim often assumes responsibility for controlling the abuser’s anger
   5. The victim denies the inevitability of the beating and the terror.
   6. The batterer fears that the victim will leave and their fears are reinforced by the victim’s coping strategy of withdrawing and avoiding.
2. The Battering Incident 
   1. The batterer's intent is to teach a lesson, not to inflict injury. In the process, they lose control of their rage
   2. Only the batterer can end this phase
   3. The victim needs a safe place during this phase
   4. Once over, the victim will deny the incident, injuries, and terror
3. The Calm Respite of "the Honeymoon."
   1. The batterer is kind and charming, while terrified the victim will leave
   2. The victim wants to believe that the suffering is over
   3. Then the cycle continues and returns to stage one

There are many theories as to why some people are abusers. However, the reason abusers use this behavior is that violence is an effective method for gaining and keeping control over another person. In a domestic situation, the abuser traditionally hasn't suffered adverse consequences as a result of violent behavior.

Historically, domestic violence in many cultures and societies has not been treated as a "real" crime. This lack of regard to violence is evident in the lack of severe consequences, like incarceration or financial penalties.² Some cultures support the man’s right and just cause to punish their spouse by beating, in some circumstances.^2,8,7

Risk factors for violence against their spouse or significant other are^2,8,9:

• Family history of violence
• Alcohol and drug use
• Emotional dependency, insecure and low self-esteem
• Lack of impulse control
• Antisocial, aggressive, and borderline personality disorders
• Poverty
• Marital discord or conflict

Numerous studies from both industrialized and developing countries produced a consistent list of events triggering spouse or significant other violence. They are¹⁰:

• Not obeying the man;
• Arguing back;
• Not having food ready on time;
• Not caring adequately for the children or home;
• Questioning the man about money or girlfriends;
• Going somewhere without the man’s permission;
• Refusing the man sex;
• The man is suspecting the woman of infidelity.

Batterers come from all social classes, races, cultures, religions, backgrounds, and countries.² The following behaviors may be warning signs:

• Extreme jealousy;
• Blames others for their faults and circumstances for their problems;
• Unpredictable behavior;
• Verbally abusive;
• Unable to control their anger;
• Always asking for a second chance, saying they’ll change and won’t do it again;
• their family resolves problems with violence;
• Plays on your guilt;
• Their way is the only way;
• Behavior often worsens when using alcohol or drugs; and
• Cruelty to animals.

Why do victims stay? All too often that question is answered with a victim-blaming attitude. Victims of abuse often hear that they must like or need abusive treatment, or else they would leave. Sometimes, victims are told that they “love too much" or have low self-esteem. The truth is that no one likes being beaten, regardless of his or her emotional state or self-image. The reasons that a victim stays are many and complex.^11,12,13

1. Lack of resources
   1. Responsibility for dependent children.
   2. Not employed outside of the home.
   3. The victim does not solely own any property. 
   4. Lack of access to cash or bank accounts.
   5. Fear of being charged with desertion; therefore, losing children or joint assets.
   6. Fear of a decline in living standards for herself and her children.
2. Institutional responses
   1. Clergy and secular counselors are often trained to see only the goal of saving the marriage at all costs.
   2. Police officers treat domestic violence as a dispute instead of a crime.
   3. Police may try to dissuade women from filing charges.
   4. Prosecutors are reluctant to prosecute cases and judges are lenient with the sentencing.
   5. Even with a restraining order, there is little to prevent a released abuser from returning and repeating the assault.
   6. There are not enough shelters to keep victims safe.
3. Traditional ideology
   1. The belief that divorce is not a viable alternative.
   2. The belief that a single parent family is unacceptable, and that even a violent father is better than no father at all.
   3. Many women are socialized to believe that they are responsible for making their marriage work.
   4. The isolation of a victim contributes to a sense that there is nowhere to turn.
   5. Rationalization of their abuser’s behavior by blaming stress, alcohol, problems at work unemployment, or other factors.
   6. Many women feel that their identity and worth are contingent upon getting and keeping a man.
   7. During the non-violent phases, the abuser may fulfill the woman’s dream of romantic love. She believes that he is basically good.

Both domestic violence abusers and victims come from all socioeconomic background, races, and religions. Healthcare works must remain vigilant and aware that even seemingly supportive family members may, in fact, be abusers. Abusers and victims of low socioeconomic status typically present in emergency rooms or community clinics, whereas those of higher socioeconomic status typically present to their primary care provider.

There is a strong association between substance abuse and domestic violence.¹⁴ Research demonstrates that nearly 22% of all perpetrators of intimate partner violence suffer from alcohol abuse. Additionally, about 31% of all the perpetrators suffer from a substance abuse problem. Overall, the use of alcohol in conjunction with incidents of intimate partner violence has been estimated to be between 22-60%.¹⁵

Some research suggests that abusers and victims are highly dependent on each other. Each person in the relationship believes they cannot survive without the other, which causes the cycle of violence to continue. Their belief in dependency on each other arises from a negative self-image and doubt in their own ability to live independently or find other partners. Both the abuser and the victim deny or minimize the severity of the violence, which again perpetuates the cycle.¹⁵

According to the Centers for Disease Prevention and Control, since the 1970s, domestic violence has emerged as the most serious public health issues facing women in the United States.1 Over their lifetime, 1 in 3 women (35.6%) and 1 in 4 men (28.5%) in the United States have experienced intimate partner violence.¹⁶ Each year, intimate partner violence results in 2 million injuries and 2,340 deaths.¹⁶

The health and economic impacts of domestic violence are immense. Domestic violence victim suffers from severe physical and psychological injuries. The annual costs of domestic violence/intimate partner violence have been estimated to be between $2 and 7$ billion a year.¹⁷

According to the Bureau of Justice Statistics, domestic violence accounts for approximately 17% of all violent crime in the United States.18 Most victims of domestic violence are spouses, but children and other family members are often victimized as well. The incidence of child physical abuse and child neglect associated with intimate partner violence has been estimated to be between 30%-60%.¹⁹

Fifty percent of domestic violence occurs at or near the victim’s home.20 Simple assault is the most common domestic violence offense, but domestic violence can be lethal: approximately 22% of homicides are domestic murders.²¹

There is a strong association between substance abuse and domestic violence.¹⁴ Research demonstrates that almost 22% of all perpetrators of intimate partner violence had an alcohol abuse problem.¹⁴ About 31% of all the perpetrators had a substance abuse problem (alcohol, illicit drugs), and the use of alcohol in conjunction with incidents of intimate partner violence has been estimated to be between 22-60%.^14,15

Women in the state of Kentucky are more likely to experience domestic violence compared with those who live in other states.²² Nearly 37% of women in Kentucky report being a victim of domestic violence and 1 in 9 reports being the victim of sexual assault. Domestic violence is a serious problem for residents of Kentucky, and as a result, the Kentucky State Legislature requires all mental providers, nurses, and advanced practice nurses to take additional continuing education on this topic.

Since 2004, domestic violence against women has appeared to decline from 5.9 victimizations per 1,000 females in 1994 to 1.6 per 1,000 females in 2011.²⁰ Likewise, the rate of family violence decreased by one-half during this same time. Research suggests that this decrease may be due to the decline in the marriage rate, a decrease of domesticity, greater access to federally funded domestic violence shelters, improvement in women’s economic status, and the aging of the population.^23,24

About 22% of murder victims in 2007 were family members. Family members were most likely to kill a young child, while a friend or acquaintance was most likely to murder an older child age 15 to 17. 43% of murder victims were related to or acquainted with their assailants.²⁵ Intimate partners committed 14% of all homicides in the US in 2007, and 64% of all women killed in 2007 were murdered by a family member or an intimate partner.²⁰

Intimate partner violence is relatively common. Approximately 15% of employees in the workplace are suffering the effects of intimate partner violence.²⁶ Women lose roughly 8 million days of work a year due to intimate partner violence²⁷, and their emotional and psychological issues and their work absence affect co-workers and the places they work, as well.

Intimates (current and former spouses, boyfriends and girlfriends) were identified by the victims as the perpetrators of 1.7% of all workplace violent crime against females and 0.8% of males.²⁶ About 59% of the female victims of violence in the workplace reported that they knew their offender.²⁶

While healthcare professionals are adept at recognizing and interpreting symptoms and behaviors commonly associated with domestic abuse, they are sometimes uncertain how to specifically ask about such violence. Research demonstrates that a mere 7% of women report ever being asked by their healthcare worker about domestic or family violence.³⁴

Missed cases may also be due to healthcare professionals simply not screening³⁴, and many nurses are not prepared to provide care to a woman who is a victim of violence from her partner.³⁵ There are many reasons nurses, physicians, and other healthcare professionals may not screen for intimate partner violence.³⁶

• Lack of time
• Lack of training
• Lack of resources
• Language barriers
• Cultural barriers
• Emotional discomfort
• Behavior of the victim, e.g., uncooperative, unwilling to accept help

Healthcare providers, including nurses and advanced practice nurses, are legally obligated to report domestic violence to the appropriate authorities. Specifically, the state of Kentucky requires healthcare workers to report cases of actual or suspected spousal abuse or neglect to the Cabinet for Health and Family Services.^41,42 These laws only apply in situations where the abuse is committed by the spouse; however, if the healthcare worker is unable to determine who is committing the abuse and the victim is suffering mentally, physically, and unable to carry out their activities of daily living, then reporting the abuse is also mandatory.

Of note, reporting is mandatory even without the victim's consent and is a legislative exception to the patient-provider confidentiality rule. If a nurse or advanced practice nurse knowingly and willingly fails to report instances of spousal abuse in the state of Kentucky he or she can be subject to criminal penalties. In addition, a healthcare worker who report suspected abuse in good faith is protected from both criminal and civil liability.^41,42

The Kentucky State Board of Nursing Model Curriculum for Domestic Violence declare⁴⁰,

without proper identification and intervention, the natural course for domestic violence is escalating in nature. It is essential that the healthcare worker who recognizes or suspects a potential domestic violence victim be concerned with the safety of the victim and other family members. Presentation for medical health and/or planned separation from partner is the time of greatest potential risk for the victim.

Factors associated with potential lethality include:

1. Children in the home
2. Threats to kills the partner or children
3. Availability of a weapon
4. Alcohol and drug dependency
5. Escalation of the violence

Homicide is a risk for any victim of domestic violence; therefore, safety planning is of the utmost importance. The victim should be given information about safe shelters and legal options. If the abuser is in the vicinity of the treating facility, institutional safety policies must be followed.

Additionally, safety plans should include:

• Documenting a plan created in collaboration with the victim about what to do if the violence in the home escalates again.
• Encouraging the victim to be aware of whether there are weapons in the residence.
• Advising victims to create a code word that signals to children that they should implement an escape plan.
• Advising victims to create copies of important documents and keep on hand if needed.
• Encouraging victims to keep a bag packed and hidden with necessities in case they need to leave immediately.

If a victim of domestic violence requests or requires legal assistance, local shelters often provide free referrals and support. Kentucky residents have a variety of options available to them including an emergency protective order.

Kentucky Revised Statute 403.740 provides that a judge can create an emergency protective order for domestic violence victims.⁴³ This emergency protective order is effective for up to 14 days, and a copy of the order is served to the abuser. If the abuser violates any condition of the order, criminal penalties will be levied. Specifically, the emergency protective order:

• Restrains the batterer from any contact or communication with the abused party, except as directed by the court
• Restrains the batterer from committing further acts of domestic violence and abuse
• Restrains the batterer from disposing of or damaging any of the property of the parties
• Directs the batterer to vacate the residence shared by the abused party
• Grants temporary custody of minor children under certain circumstances
• Restrains the batterer from coming within a certain distance of specifically described locations or persons

When the court reviews petitions for protective orders, the abuser is given notice and allowed to attend and present witnesses. If the court determines that a protective order is necessary, a domestic violence order will be created, and the abuser will be barred from future contact with the victim. A domestic violence order is effective for up to three years, at which time a new order can be issued. Abusers who violate a domestic violence order are subject to criminal penalties and incarcerations.

If a victim presents to a healthcare setting and their abuser has violated a protective order, the police must be contacted immediately. The victim will be asked to present the police a copy of the protective order. The police will write a report of the order violation, and then the victim will need to contact the prosecutor's office to request an arrest warrant be issued due to this specific violation.

Healthcare workers should warn the victim that abuses are often arrested for a misdemeanor and either given a citation or released from custody within a few hours. Nurses and advanced practice nurses must advise their patients to gather their personal belonging and find a safe place to stay such as a shelter or family member’s house. An important role of the healthcare worker is to inform victims about the criminal justice system and their role in it.

If the prosecuting attorney pursues a criminal complaint, an arraignment occurs. During this time, the court must inform the abuser of the charges and get him or her legal representation. Often, victims must testify at the hearing or trial, and even if they don’t want to, the court can issue a subpoena and order the victim to give testimony. If the abuser is convicted the judge sentences him or her to a combination of a fine, incarceration, victim restitution, mandatory counseling, meditation, substance abuse treatment, and/or public service.

Once the healthcare worker has identified the victim and their abuser, they should immediately implement a treatment plan that includes a referral to a local domestic violence shelter. More acute or life-threatening scenarios should be referred immediately to local law enforcement officials.

In the state of Kentucky, there are many domestic violence shelters that provide counseling, casework, children’s services, 24-hour crisis lines, legal advocacy, and additional referral services. A list of statewide services is provided below. Additionally, Kentucky residents have access to national reporting hotlines, also listed below.

The Kentucky State Board of Nursing encourages and supports it nurses and advanced practice nurses to remain vigilant to the profound impacts of domestic violence on Kentucky residents.⁴⁰  They recommend that nurses remember the acronym AWARENESS⁴⁰:

1. Assessment and remaining alert for signs of battery or abuse
2. Witness and document the patient's physical condition
3. Ask directly about domestic and family violence
4. Respect and validate the individual
5. Evaluate the patient’s family situation and risk potential
6. Network and refer to community services
7. Empower and education victim and their care providers
8. Safety of client is of paramount importance
9. Statutory (legal) mandate to report

Healthcare professionals, including nurses and advanced practice nurses, are in a unique position to address domestic and family violence; however, this epidemic public health problem is frequently unrecognized and not treated adequately in healthcare settings. While battery is considered the leading cause of injury for women, only 4 to 5 percent of the cases of domestic violence are correctly identified and addressed. Research supports that abused women expect healthcare providers to initiate discussions about abuse, and because nurses work in a variety of settings, they are at the front lines of these discussions. Improved awareness and appropriate nursing intervention can help interrupt the cycle of domestic and family violence

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