Domestic Violence, Sexual Violence, Intimate Partner Violence (Kentucky)

House Bill 309 requires all licensed nurses to complete a one-time, mandatory course addressing domestic violence. The statute mandates that the 3-hour Domestic Violence training course includes (Kentucky Revised Statute, Public Law 403.715 to 403.785):

• 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 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 among family members can take many forms. It may include emotional abuse, economic abuse, sexual abuse, threats, using the threat of removing children, isolation, and other behaviors used to maintain fear, intimidation, and power. Acts of domestic violence are categorized into psychological battering, physical battering, or sexual abuse (Centers for Disease Control and Prevention [CDC], 2020a).

While the term “domestic violence” is still widely used, more recently, physical, psychological, or sexual violence in 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" (World Health Organization [WHO], 2021).

“Intimate partner” typically refers to both current or former partners; however, WHO leaves this a bit more open-ended and does not constrain intimate partner violence to any specific type of relationship (WHO, 2021).

In their detailed report, Intimate Partner Violence: Uniform Definitions, the Centers for Disease Control and Prevention (CDC) (2020a) states that intimate partner violence includes the following behaviors:

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, follow a pattern. The more severe the type of domestic violence, the more chronic it is, the more likely it is to worsen over time.

This pattern generally includes periods of tension building, an episode of violence, and a quiet period (Cline et al., 2020).

The Cycle of Violence is as follows (Cline et al., 2020):

There are many theories as to why some people are abusers. However, abusers demonstrate the behavior they do because violence is an effective method for gaining and keeping control over another person. In a domestic situation, the abuser traditionally has not suffered adverse consequences due to violent behavior.

Historically, domestic violence has not been treated as a "real" crime in many cultures and societies. This lack of regard for violence is evident in the lack of severe consequences, like incarceration or financial penalties (WHO, 2021). Some cultures support the man's right and cause to punish their spouse by beating (WHO, 2021).

Abusers often display immaturity and are dependent and non-assertive (Sadock et al., 2021). They tend to suffer from strong feelings of inadequacy, and they use their bullying behavior to humiliate their partner to support their low self-esteem. They sometimes displace aggression provoked by others onto their partner.

The psychological dynamics of male abusers include identification with an aggressor (father, boss, brother, etc.), testing behaviors (i.e., "Will she stay with me no matter what I do to her?"), distorted desires to express manhood, and dehumanization of women (Sadock et al., 2021).

Victims of domestic violence/intimate partner violence are children, men, and women. 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 otherwise 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 their emotional state or self-image. The reasons that a victim stays are many and complex (DeCapua, 2017):

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines standards for healthcare organizations and monitors compliance with those standards. JCAHO mandates that hospitals must develop criteria to identify possible victims of abuse. The criteria must focus on observable evidence and not just on allegations. It must address physical assault, rape, other sexual molestation; domestic abuse; and abuse or neglect of elders and children (DeCapua, 2017).

Staff must be trained to apply these criteria. They should question whether abuse might have occurred if a patient's story for their injury does not match the actual injury. A hospital must maintain a list of private and public community agencies that provide help for abuse victims. Staff also must be able to make appropriate referrals for victims (DeCapua, 2017).

For example, a child's X-rays may show an unexplained broken bone. Staff should observe the behavior of the people who brought the child to the emergency room. Does the child cling to one parent and avoid the other? Staff members should question the child in a non-threatening manner, look for bruises on the body, and listen to explanations to see if there is congruence between the physical evidence and the story.

New York was the first state to require hospitals to establish protocols to identify and treat domestic violence victims and make referrals to community services. California passed the first state law mandating protocols for hospitals and clinics to detect the presence of violence in the lives of patients.

WHO (2021) recommends the following actions:

• Governments and other donors should be encouraged to invest much more in research on violence by intimate partners over the next decade.
• Programs should place greater emphasis on enabling families, circles of friends, and community groups, including religious communities, to deal with the problem of partner violence.
• Programs on partner violence should be integrated with other programs, such as those tackling youth violence, teenage pregnancies, substance abuse, and other forms of family violence.
• Programs should focus more on the primary prevention of intimate partner violence.

Early identification and intervention with victims of domestic violence can help prevent injuries and save lives (CDC, 2020b; U.S. Department of Health and Human Services, 2010). Many victims of domestic violence seek assistance in healthcare settings, often repeatedly, but are only treated for symptoms and injuries. Unfortunately, healthcare professionals often fail to identify victims. Missed cases of intimate partner violence may be due to the screening method.

The U.S. Preventive 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 (KBN, 2021).

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. The U.S. Department of Health and Human Services required that screening and treatment for domestic violence be covered by insurance at no cost to address these barriers (KBN, 2021). Furthermore, states like Kentucky have thus enacted legislation that requires specific domestic violence education to be licensed as a healthcare provider (KBN, 2021).

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 in 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, or scars from knife wounds, bites, or burns. The typical injury pattern 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 (Taft, 2016).

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 to help the clinician 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, or primary care.

Healthcare providers can help by screening for domestic violence, documenting abuse in the medical record, safeguarding evidence, providing medical advice, referrals, safety planning, and showing empathy and compassion. Victims of domestic violence/intimate partner violence may not discuss the violence unless asked directly (Decapua, 2017). 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 (Decapua, 2017).

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 (Cline et al., 2020).

The healthcare worker should gather a detailed history during the initial screening, including the patient's needs, resources, and priorities.

Determining whether the injuries are related to domestic violence is 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 must perform a detailed assessment.

Overall, healthcare providers should be vigilant in recognizing the signs and symptoms of abuse. The Kentucky State Board of Nursing (KBN) identifies common signs of different forms of abuse (KBN, 2021; Kentucky Revised Statute Protection of Adults, Chapter 209, 2021):

• Physical abuse: The trauma or injuries are inconsistent with event history, or the patient arrives for medical care long after the initial event.
• Emotional or sexual abuse: Adults frequently present with complaints associated with long-term stress and chronic anxiety. Children or adolescents may present with behavior problems, and the elderly appear withdrawn or fearful of authority.
• Patterned injuries: Central injuries to the face, head, neck, breast, abdomen, and genitals are prevalent in contrast to accidental injuries affecting the periphery or extremities. A pattern of multiple, non-life-threatening injuries at varying stages of healing is highly suspicious. Children and older people often present with spiral fractures.
• Pregnancy: Incidence of domestic violence increases in pregnant women.

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. To gather accurate information, give the patient some control over the interview and pay close attention to their nonverbal responses, indicating discomfort. The history and treatment plan should be thoroughly documented in the patient's medical record. This documentation helps establish the credibility of the victim's report if/when they seek 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 (KBN, 2021).

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 (Kentucky Revised Statute, Chapter 209 and 209a). These laws only apply in situations where the spouse commits the abuse; 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 (KBN, 2021).

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 spousal abuse in the state of Kentucky, she or she can be subject to criminal penalties. In addition, healthcare workers who report suspected abuse in good faith are protected from both criminal and civil liability (Kentucky Revised Statute, Chapter 209 and 209a; KBN, 2021).

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 victim's safety and other family members. Presentation for medical health or planned separation from a partner is the greatest potential risk for the victim (KBN, 2021; Kentucky Revised Statute Emergency Protective Order, Public Law 403.740, 2021).

Factors associated with potential lethality include (KBN, 2021):

1. Children in the home
2. Threats to kill 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 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 (KBN, 2021).

Additionally, safety plans should include (KBN, 2021):

• 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 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 them 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 various options, including an emergency protective order (KBN, 2021).

Kentucky Revised Statute 403.740 provides that a judge can create an emergency protective order for domestic violence victims. 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 parties' property.
• 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 court 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 criminal penalties and incarceration (KBN, 2021).

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 with a copy of the protective order. The police will write a report of the order violation. Then, the victim will need to contact the prosecutor's office to request an arrest warrant be issued due to this specific violation (KBN, 2021).

Healthcare workers should warn the victim that abusers 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 belongings 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 (KBN, 2021).

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 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 them to a combination of a fine, incarceration, victim restitution, mandatory counseling, meditation, substance abuse treatment, or public service (KBN, 2021).

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. She describes his various behaviors, which could be classified as emotional, physical, and financial abuse. She has two children, ages three and six, who are 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 to 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 represents her and she has recently begun seeing a therapist for cognitive-behavioral therapy (CBT). 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 send her text messages 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 can obtain a protective order to continue her education.

Once the healthcare worker has identified the victim and their abuser, they should immediately implement a treatment plan to refer 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, many domestic violence shelters 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 its nurses and advanced practice nurses to remain vigilant to the profound impacts of domestic violence on Kentucky residents. They recommend that nurses remember the acronym AWARENESS (KBN, 2021):

• Assessment and remaining alert for signs of battery or abuse
• Witness and document the patient's physical condition
• Ask directly about domestic and family violence
• Respect and validate the individual
• Evaluate the patient's family situation and risk potential
• Network and refer to community services
• Empower and educate victims and their care providers
• Safety of the client is of paramount importance
• Statutory (legal) mandate to report

Healthcare professionals, including nurses and advanced practice nurses, are uniquely positioned to address domestic and family violence; however, this epidemic public health problem is frequently unrecognized and not treated adequately in healthcare settings. While the battery is considered the leading cause of injury for women, only 4 to 5 percent of domestic violence cases are correctly identified and addressed. Research supports that abused women expect healthcare providers to initiate discussions about abuse. Because nurses work in a variety of settings, they are at the frontlines of these discussions. Improved awareness and appropriate nursing intervention can help interrupt the cycle of domestic and family violence (KBN, 2021).

• Centers for Disease Control and Prevention. (CDC). (2020a). Intimate partner violence. Centers for Disease Control and Prevention. Retrieved September 25, 2021. Visit Source.
• Centers for Disease Control and Prevention. (CDC). (2020b). Preventing intimate partner violence. Centers for Disease Control and Prevention. Retrieved September 25, 2021. Visit Source.
• Cline, D., Ma, O., Meckler, G., Stapczynski, J., Thomas, S., Tintinalli, J.., &; Yealy, D. (2020). Tintinalli's emergency medicine: A comprehensive study guide (9th ed.). McGraw-Hill Education. Visit Source.
• DeCapua, M. (2017). Domestic Violence, Sexual Violence, Intimate Partner Violence. Visit Source.
• Kentucky Board of Nursing. (KBN). (2021). Specific content requirements: Domestic violence. Visit Source.
• Kentucky Revised Statute Definition, Public Law 403.715 to 403.785. (2021). Visit Source.
• Kentucky Revised Statute Emergency Protective Order, Public Law 403.740. (2021). Visit Source.
• Kentucky Revised Statute Protection of Adults, Chapter 209. (2021). Visit Source.
• Kentucky Revised Statute Spousal Abuse or Neglect, Chapter 209A. (2021). Visit Source.
• Sadock, B., Boland, R., Verduin, M., & Ruiz, P. (2021). Kaplan & Sadock's Synopsis of Psychiatry (12th ed.). Wolters Kluwer. Visit Source.
• U.S. Department of Health and Human Services. (2010). Compendium of state statutes and policies on domestic violence and healthcare. Family Violence Prevention Fund. Retrieved September 26, 2021, from . Visit Source.
• World Health Organization. (WHO). (2021). Violence against women. World Health Organization. Retrieved September 25, 2021, from. Visit Source.