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:
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:
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.
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:
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 are2,8,9:
Numerous studies from both industrialized and developing countries produced a consistent list of events triggering spouse or significant other violence. They are10:
Batterers come from all social classes, races, cultures, religions, backgrounds, and countries.2 The following behaviors may be warning signs:
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
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
Half of the female domestic violence victims live in a home with a least one child under the age of 12. Research suggests that children who witness intimate partner violence are more likely to become abusers or victims of this violence than a child who has harmed themselves, which perpetuates the cycle of violence.28 For example, one research study found that adolescents who witnesses abuse were more likely to become perpetrators of abuse (42%) compared with non-witnesses (15%).29 Furthermore, research demonstrates that children exposed to domestic violence are more likely to exhibit aggression and anxiety and have more academic and social problems.
Although males are victims, females are the victim in 85% of abuse by a spouse or significant other.18 The lifetime risk for U.S. women of suffering from intimate partner violence has been estimated to be between 22% - 39%.17 Elder abuse, child abuse, and same-sex abuse are also significant problems.
The traditional image of domestic violence/intimate partner violence has been a man abusing a woman. However, women can be the perpetrators of violence in a relationship. There is controversy about how common women-initiated violence is. The reported incidence of abused men varies widely, but in 2010, Black et al. stated in the WHO reports that 1 in 4 men have been abused by their female partner, and this appears to be confirmed by other studies.30
Research demonstrates that violence by women in the context of an intimate relationship is relatively common. But the consequences to the victims and the motives of the female perpetrator do appear to be different. The violence perpetrated by women seems to be less frequent, but any particular incident is likely to be more severe.31
Domestic violence affects lesbian, gay, and bisexual persons as well. In fact, the National Intimate Partner and Sexual Violence Survey found that 43.8% of lesbian women, 61.1% of bisexual women, 26% of gay men, and 37.3% of bisexual men report experiencing intimate partner violence.16 Men who reside with men experience statistically significant more domestic violence than men who reside with women.
Intimate partner violence impacts more than 324,000 pregnant women every year, which is about 8% of all pregnant women in America.32 Domestic violence against pregnant women is more common than other pregnancy-related conditions like preeclampsia and gestational diabetes. Risk factors that increase a pregnant woman’s likelihood to be abused include:
Approximately four out of 10 African American women, American Indian women, and Alaska Native women have experienced physical violence, rape, or stalking in their lifetime by an intimate partner.33 Mixed race non-Hispanic women experience these crimes at an incidence of 53.8%. The rate for white women is 34.6%, for Hispanic women 37.1%, and 19.6% for Asian and Pacific Islander women.33
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
The U.S. Preventative Services Task Force recommends that healthcare providers, including nurses and advanced practice nurses, screen all women of childbearing age for intimate partner violence, including physical, sexual, psychological, and economic abuse. Importantly, this recommendation applies to all women, not just high-risk groups or women presenting with signs and symptoms of abuse.37
Implementing this recommendation has been challenging because healthcare workers often forget to screen women without signs of abuse. In addition, healthcare workers often underestimate the prevalence of abuse and lack the appropriate education on the topic. To address these barriers, the U.S. Department of Health and Human Services required that screening and treatment for domestic violence be covered by insurance at no cost. Furthermore, states like Kentucky have thus enacted legislation that requires specific domestic violence education in order to be licensed as a healthcare provider.
All individuals with evidence of trauma need to be questioned directly about the potential for domestic abuse using a structured non-judgmental, confidential interview conducted in privacy and safety.
Victims of domestic violence often present to healthcare settings with physical injuries such as bruises, cuts, black eyes, concussions, and broken bones. They may also present with damaged joints, partial hearing or vision loss, and/or scars from knife wounds, bites, or burns. The typical pattern of injury includes minor lacerations or bruises to the abdomen, breast, neck, and face. Accidental injuries occur on the periphery of the body, compared with abusive injuries which occur more centrally.15
Due to the complex relationship dynamics between the abuser and victim, healthcare workers can feel uncertain about screening. It is important to use a proper screening tool that can help the clinician to navigate the complex relationship and maintain awareness of the signs and symptoms of abuse. Screening should occur in any healthcare settings where a victim may come in contact with a healthcare profession, including but not limited to pediatric care, obstetric and gynecologic care, psychiatric care, emergency services, and/or primary care.
Healthcare providers can help by screening for domestic violence, documenting abuse in the medical record, safeguarding evidence, providing medical advice, referrals, and safety planning, and showing empathy and compassion. Victims of domestic violence/intimate partner violence may not discuss the violence unless they are asked directly.36,38 However, many victims of domestic violence/intimate partner violence will talk about the abuse if they are asked in a direct, caring, and non-judgmental manner.39
Screening questions should always be asked in a private room, away from the batterer and preceded by assurances of strict confidentiality. The spouse or partner should be separated from the patient if they demand to accompany the patient into the examining room.4
During the initial screening, the healthcare worker should focus on gathering a detailed history including the patient's needs, resources, and priorities. Determining whether or not the injuries are related to domestic violence are less important than gathering a history. Sometimes, the victim will present with injuries that must be treated immediately; however, after the patient is stabilized, the healthcare worker is obligated to perform a detailed assessment.
The Kentucky State Board of Nursing Model Curriculum for Domestic Violence states40,
Overall, healthcare providers should be vigilant at recognizing the signs and symptoms of abuse. The Kentucky State Board of Nursing identifies common signs of different forms of abuse:
While the patient may be avoidant when asking about the causes of their injuries, it is important to build rapport and reduce the victim’s anxiety. Explain the entire evaluation process before beginning and allow the patient to dictate the pace of the interview. In order to gather accurate information, give the patient some control over the interview and pay close attention to their nonverbal responses, which might indicate discomfort. The history and treatment plan should be thoroughly documented in the patient medical record. This documentation helps establish the credibility of the victim’s report if/when he or she seeks legal aid.
Finally, "a community-based multidisciplinary team should help develop Domestic Violence Protocols that provide appropriate evaluation and intervention during the care of a patient suffering from actual or suspected domestic violence. These protocols should include interviewing strategies, physical assessment guidelines, safety assessment, treatment plan, and referral resources.40"
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:
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:
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:
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.
Chelsea is a 43-year-old Caucasian female living with her second husband. She arrives at the clinic appearing shaky and nervous. During the initial physical assessment, she begins to cry explaining that her husband is aggressive towards her. She describes his various behaviors, which could be classified as emotional, physical, and financial abuse. She has two children, ages three and six who both at the clinic with her.
She denies any current suicidal thoughts and any current drug or alcohol misuse. Assessment of the children does not reveal any evidence of abuse towards them, and Chelsea denies witnessing any aggression towards them in the past. The healthcare worker completes an assessment and explains to Chelsea her legal options. Chelsea agrees to go with her children to a local shelter where she can begin more specialized treatment and receive adequate community resources.
Nitya, a 28-year-old immigrant from India living in the Midwest, left her husband and moved into her friend’s house after three instances of physical abuse. Nitya has obtained a restraining order, but her husband is attempting to retaliate by filing for a modification of custody for their children, citing frivolous allegations and inappropriate parenting. Her lawyer continues to represent her, and she has recently begun seeing a social worker for cognitive-behavioral therapy. This counseling has helped her emotionally process her situation and previous trauma.
Stephanie, a 21-year-old college student, broke up with her violent boyfriend about a month ago; however, he continues to stalk her. He continues to show up on campus and will appear outside her classes, the cafeteria, and the library. He calls and text messages her daily saying threatening and hurtful things. Stephanie is scared and has been considering dropping out of school. She decides to seek help through a legal aid, who documents his stalking behavior and facilitates a meeting with the college dean. Her attorney represents her in a court hearing, and she is able to obtain a protective order so she can continue her education.
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.
Adult Protection Branch
275 East Main Street, Frankfort, KY 40621
Attorney General's Office of Victim Advocacy
Capitol Suite 118, 700 Capitol Avenue, Frankfort, KY 40601
Department for Behavioral Health, Developmental and Intellectual Disabilities
100 Fair Oaks Lane, 4E-B, Frankfort, KY 40621
Kentucky Coalition Against Domestic Violence
111 Darby Shire Circle, Frankfort, KY 40601
Barren River Area Safe Space (BRASS), Inc.
P.O. Box 1941, Bowling Green, KY 42102
Barren County Phone: 270-659-0823
Warren County Phone: 270-781-9334
Crisis Only: 800-928-1183 or 270-843-1183
Areas Served: Allen, Barren, Butler, Edmonson, Hart, Logan, Metcalfe, Monroe, Simpson, Warren
Bethany House Abuse Shelter, Inc.
P.O. Box 864, Somerset, KY 42502
Hotline: 606-679-8852 (24/7)
Toll Free: 800-755-2017
Areas Served: Adair, Casey, Clinton, Cumberland, Green, McCreary, Pulaski, Russell, Taylor, Wayne
Green House 17
P.O. Box 55190, Lexington, KY 40555
Crisis Only: 800-544-2022
Areas Served: Anderson, Bourbon, Boyle, Clark, Estill, Fayette, Franklin, Garrard, Harrison, Jessamine, Lincoln, Madison, Mercer, Nicholas, Powell, Scott, Woodford
The Center for Women and Families
P.O. Box 2048, Louisville, KY 40201
Crisis Only: 877-803-7577
Areas Served: Bullitt, Henry, Jefferson, Oldham, Shelby, Spencer, Trimble
DOVES of Gateway
P.O. Box 1012, Morehead, KY 40351
Crisis Only: 800-221-4361
Areas Served: Bath, Menifee, Montgomery, Morgan, Rowan
Family Life Abuse Center
P.O. Box 654, Mount Vernon, KY 40456
Crisis Only: 800-755-5348 or 606-256-2724
Areas Served: Bell, Clay, Harlan, Jackson, Knox, Laurel, Rockcastle, Whitley
P.O. Box 1867, Hazard, KY 41702
Crisis Only: 800-928-3131
Areas Served: Breathitt, Knott, Lee, Leslie, Letcher, Owsley, Perry, Wolfe
P.O. Box 98, Paducah, KY 42002
Crisis Only: 800-585-2686 or 270-443-6001
Areas Served: Ballard, Calloway, Carlisle, Fulton, Graves, Hickman, Marshall, McCracken
Owensboro Area Shelter and Information Services (OASIS)
P.O. Box 315, Owensboro, KY 42302
Crisis Only: 800-882-2873 or 270-685-0260
Areas Served: Daviess, Hancock, Henderson, McLean, Ohio, Union, Webster
P.O. Box 2163, Ashland, KY 41105
Crisis Only: 800-926-2150
Areas Served: Boyd, Carter, Elliott, Greenup, Lawrence
P.O. Box 1165, Hopkinsville, KY 42240
Crisis Only: 800-766-0000
Areas Served: Caldwell, Christian, Crittenden, Hopkins, Livingston, Lyon, Muhlenberg, Todd, Trigg
Sandy Valley Abuse Center, Inc.
P.O. Box 1297, Prestonsburg, KY 41653
Crisis Only: 800-649-6605
Areas Served: Floyd, Johnson, Magoffin, Martin, Pike
P.O. Box 2047, Elizabethtown, KY 42702
Crisis Only: 800-767-5838 or 270-769-1234
Areas Served: Breckinridge, Grayson, Hardin, LaRue, Marion, Meade, Nelson, Washington
Women's Crisis Center, Northern Kentucky
835 Madison Avenue, Covington, KY 41011
Crisis Only: 800-928-3335 or 859-491-3335
Areas Served: Boone, Campbell, Carroll, Gallatin, Grant, Kenton, Owen, Pendleton
Women's Crisis Center, Buffalo Trace
111 East Third Street, Maysville, KY 41056
Crisis Only: 800-928-6708 or
Areas Served: Bracken, Fleming, Lewis, Mason, Robertson
Adult & Child Abuse Reporting Hotline: 800-752-6200
Alcohol & Drug Abuse Information: 800-432-9337
Kentucky State Police Emergency Hotline: 800-222-5555
Prevent Child Abuse Kentucky: 800-CHILDREN (244-5373)
Domestic Violence Hotline: 800-799-SAFE (7233)
National Center for Missing and Exploited Children: 800-843-5678
Rape, Abuse, and Incest National Network (RAINN) National Sexual Assault Hotline: 800-656-HOPE (4673)
Victim Information and Notification Everyday (VINE): 800-511-1670
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:
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
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.