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

Coercive control is the use of fear, intimidation, and isolation to mentally and psychologically dominate another person, often resulting in the loss of liberty and a sense of self (Lohmann et al., 2024).

Coercive control can look like behaviors such as watching, checking, and controlling finances, whom someone can be friends with or talk to, where and when they can drive or have access to a car, or threatening to harm someone’s pet. Coercive control can occur with or without physical acts of violence (Lohmann et al., 2024).

Nurses can be a key point of intervention for coercive control survivors, many of whom can be seen in clinics or hospitals and appear high-functioning due to their clothing and verbal compliance, but in reality, are being held hostage through psychological means.

Kentucky is one of 10 states with the highest rates of IPV. According to the CDC’s National Intimate Partner and Sexual Violence Survey, more than 45% of women and nearly 35% of men in Kentucky have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner during their lifetime (Kentucky Justice and Public Safety Cabinet, 2024; Leemis et al., 2022). Rural survivors face additional barriers to accessing care and safety, including lack of transportation, high rates of firearm ownership, and social isolation.

Kentucky’s domestic violence and sexual assault programs served over 22,000 people in 2023, according to the Kentucky Coalition Against Domestic Violence (Kentucky Justice and Public Safety Cabinet, 2024). Shelter staff also report a trend of increased complexity of needs in the people they serve, with many survivors experiencing concomitant substance use, unstable housing, and chronic medical conditions (Center on Trauma and Children, n.d.).

On the national scale, about 1 in 4 women and 1 in 10 men will experience IPV during their lifetime (CDC, 2024). According to the CDC, other alarming statistics show that homicide is the third leading cause of death for women in the United States—and IPV accounts for a large proportion of female homicide victims, with over half of women murdered by a current or former partner (2024). Healthcare utilization among survivors is substantially higher, including emergency department visits, mental-health care, and pregnancy complications (Leemis et al., 2022).

IPV also creates ripples in communities and costs the economy. The total lost productivity, healthcare, and criminal justice involvement due to IPV exceeds $5.8 billion each year in the United States (CDC, 2024). For nurses, knowing these facts emphasizes that screening for IPV is not about personal tragedies, but an issue of public health.

IPV is more than a social problem—it is a diagnosable clinical condition with associated physical and psychological sequelae:

• Physical health: Chronic pain, migraines, gastrointestinal issues, and hypertension are common among survivors. Even a single episode of strangulation elevates risk of fatal injury six-fold.
• Reproductive health: IPV is a risk factor for unintended pregnancy, sexually transmitted infections (STIs), miscarriage, and inadequate prenatal care. Nurses should screen for reproductive coercion as a form of control.
• Mental health: Depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal ideation commonly co-occur with IPV. Kentucky’s rural isolation may contribute to increased hopelessness.
• Child and family impact: Nearly 60% of children exposed to domestic violence will witness or overhear abuse (Andreescu & Redman, 2025). Affected children may have higher rates of behavior problems and adverse childhood experiences (ACEs).

Kentucky’s multicultural communities face distinct nuances with IPV:

• Rural survivors often lack shelters in a geographically reasonable distance. Many local survivors know the same police officers or healthcare workers for years, compounding fear of consequences of coming forward.
• Faith-based traditions can have significant influences on choices to stay or leave a relationship. Nurses should honor religious perspectives while also reinforcing autonomy and safety.
• Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, Asexual/Ally, plus other people of diverse sexual orientations and gender identities (LGBTQIA+) community members experience dual stigmas and potential lack of affirming services.
• Immigrant and refugee families have elevated fears of deportation and cultural mistrust of authorities, so they may need culturally and linguistically specific advocacy.
• In Appalachia, the common reasons survivors returned to abusers were lack of affordable housing and transportation. Recognizing these community and economic factors help nurses avoid judgmental biases and solutions that may not be feasible for patients.

Taken together, IPV epidemiology reveals the obvious: healthcare settings are a critical point of intervention. Survivors of IPV are rarely in clinics and hospitals to report themselves as “victims of domestic violence.” They arrive with headaches, anxiety, nonspecific abdominal pain, or chronic fatigue. Nurses must learn to see the red flags in these somatic complaints and uncover the stories of trauma hiding behind them.

Identification of IPV begins with definitions but is fully realized through application in patient care. Nurses armed with information, observation, and empathy will be equipped to identify IPV and support survivors to safety.

IPV is one of the most under-reported crimes in the country, with only a small number of survivors reporting reaching out to a healthcare professional for help. Increasing use of internet-connected devices, shared email accounts, and surveillance applications like Life 360 can make safety planning complex. In Kentucky, as noted, there are trends and noticed data gaps that exacerbate a continued and growing problem among all populations (Kentucky Justice and Public Safety Cabinet, 2024). Here is an example of these trends and noticed data gaps:

• COVID-19: COVID-related lockdowns increased IPV cases nationwide (Piquero et al., 2021). Kentucky’s domestic violence shelters reported unprecedented call volumes in 2020–2022.
• Substance use: Opioid and methamphetamine use frequently co-occur with IPV and can both complicate disclosure and service linkage (Armstrong, 2023).
• Costs to Kentucky: Kentucky’s annual healthcare expenditures and productivity loss associated with IPV is more than $200 million, per CDC cost-projection methods (CDC, 2024).

Kentucky previously had a law mandating universal reporting of suspected adult domestic violence to the Cabinet for Health and Family Services (CHFS). The goal was to be protective, but the result was counterproductive, and survivors were often hurt more by reporting.

CHFS could then use that report to engage law enforcement (without notifying the individual), which had two main consequences (Andreescu & Redman, 2025):

1. Police frequently showed up at the home to investigate, and it was often the abuser who answered the door and got questioned.
2. The police response did not always match the survivor’s readiness for intervention. An officer’s arrival and actions were sometimes the precipitating event that finally convinced the person to leave their partner.

The Kentucky General Assembly realized this law was creating more harm and passed KRS 209A to redefine professional responsibilities around adult domestic and dating violence as “educate, inform, and refer” rather than “mandatory reporting” (KY Rev Stat § 209A.100, 2017/2024).

Under KRS 209A, the Educate, Inform, and Refer standard, when a nurse has reasonable cause to believe an adult has been or may be at risk of domestic violence or dating violence, the nurse must:

• Provide educational materials in a discreet manner that describes how to contact a regional domestic violence program or rape crisis center.
• Provide information on how to obtain a protective order.
• Document that educational and referral resources were discreetly offered or provided.

CHFS offers a statewide brochure called “Help Is Here” as a standard, written resource for nurses to use that contains domestic violence and rape crisis center contact information. It meets the state requirements for the Educate, Inform, and Refer, but in a way that is discrete, confidential, and does not further endanger adult patients who are not ready to leave their abuser. Hospitals and clinics are encouraged to keep copies in every exam room and attach them to discharge instructions.

There is no report to law enforcement or CHFS unless another mandatory reporting law applies (vulnerable adult, child abuse, or other) or the individual specifically requests that the nurse contact law enforcement.

The new law has a higher burden of proof (reasonable cause to believe rather than suspicion) and takes a more gradual, multi-step approach. Safety is a process rather than an event. Adults must have autonomy and control over their own disclosures, choice of safety measures, and time frame. Nurses must remember that the person is the expert on their own level of danger and readiness to act.

The Kentucky Coalition Against Domestic Violence publishes the “Help Is Here” brochure as a convenient way to meet the mandate in KRS 209A (KY Rev Stat § 209A.100, 2017/2024) (ZeroV, n.d.). The statewide, multilingual resource provides local contact numbers for domestic violence and rape crisis programs, information on how to obtain emergency and long-term protective orders, crisis hotlines and shelter locations, and LGBTQIA+ inclusive resources.

Brochures are distributed by ZeroV, CHFS regional offices, and online. All hospitals and clinics should have a discreet but accessible supply. Keep them in exam rooms or attach to discharge packet templates rather than a public location where a partner or caretaker could see them.

KRS 209A requires a lower burden of proof than reasonable suspicion or probable cause (KY Rev Stat § 209A.100, 2017/2024). It just means a prudent professional could suspect or conclude domestic or dating violence had occurred or might occur. Nurses do not need to know for sure or have proof. Reasonable cause to believe is often inferred from objective observations and physical or emotional indicators such as:

• Injuries that do not match the stated mechanism
• Reluctance to speak in front of a partner
• Repeat visits to the ED for “accidents”
• Fear, hypervigilance, or emotional distress when a partner or caretaker is present

Kentucky is home to large rural, immigrant, and refugee populations who may face stigma or other obstacles to disclosure or help-seeking. Nurses working in these communities should be aware of potential barriers like:

• Fear of being deported, losing children, or having no place to go
• Social pressure to uphold a marriage regardless of abuse
• Past negative experiences with government programs or agencies

Precisely documenting the actions taken under KRS 209A protects both the nurse and agency by providing legal cover and demonstrating compliance (KY Rev Stat § 209A.100, 2017/2024). This documentation should be stored in the same location as a protective order. Even if the individual refuses the brochure, note in the chart that it was offered. This satisfies the minimum requirement of the statute.

Documentation should include the following items:

• The individual’s stated disclosure (preferably in quotes).
• Documentation that educational materials were offered or provided.
• The individual accepted or declined the offer of law enforcement contact.
• Immediate safety concerns and objective findings if present.

Example: “Adult female disclosed ongoing emotional and financial control by spouse. Declined law enforcement contact. Provided ‘Help Is Here’ brochure and discussed protective order options. No acute safety threat identified.”

In addition to KRS 209A, three areas of mandatory reporting still remain in Kentucky: vulnerable adults, children, and certain deaths. Mandatory reporting laws are carefully worded to place certain obligations on nurses and healthcare agencies when specific harm is identified or suspected. The following are the Kentucky revised statutes that include information regarding the additional mandatory reporting requirements:

• Child Abuse or Neglect (KY Rev Stat § 620.030, 2024)
• Abuse, Neglect, or Exploitation of Vulnerable Adults (KY Rev Stat § 209.030, 2005/2024)
• At the Individual’s Request (KY Rev Stat § 209A.100, 2017/2024)
• Deaths Related to Domestic or Dating Violence

Kentucky lawmakers are considering naming and defining coercive control for the first time in statute, specifically as a form of domestic violence, in House Bill 96 (2025).

Abuse is not always the presence of a bruise. Not for decades of domestic violence law. Not for years of healthcare screening. Coercive control is a pattern of tactics to punish, frighten, isolate, and maintain total control over a partner. Control is about the power that one person in a relationship uses to dominate the other.

Some of the most common examples of coercive control can include:

• Controlling access to money, transportation, prescriptions
• Constant GPS, video, and electronic monitoring
• Threatening to harm pets, kids, or immigration status
• Limiting who a person can see and when and where they can work
• Gaslighting, or making a person doubt reality (“you’re crazy,” “it never happened”)
• Micromanaging daily activities (“send me a picture,” “don’t wear that,” “don’t talk to your sister”)

Kentucky has criminalized physical abuse in KRS 508. Domestic violence (DV) offenses (primarily assault) are some of the most commonly charged violent crimes, so violent that homicide offenders often have a prior history of violent assault. For DV offenders with this escalation to lethal violence, the median previous DV offense date was 18 months prior.

Despite its long criminalization, physical abuse is only one aspect of an abusive relationship. Survivors often stay in abusive relationships for many reasons; being hit is not one of them. Many victims are victims for years before disclosure. Expanding the legal definition of domestic violence to include language that implies controlling behaviors, intimidation, and isolation in House Bill 96 (HB 96) beyond physical assault to include coercive control can help survivors identify their experiences.

The broader term covers a wider variety of abuse and also implies why people stay. That behavior creates the very real fear that leaving will make abuse worse. (“Trust me,” she said, “it’s safer to stay.”)

Kentucky’s HB 96 would add coercive control as a statutory basis for an Interpersonal Protective Order (IPO) alongside physical violence, sexual abuse, and stalking. HB 96 uses two separate definitions of abuse, domestic violence and dating violence, that include elements of coercive control but do not define it separately.

Currently, anyone can obtain an IPO based on “coercive control” if they meet the statutory relationship requirements. The problem is that courts and individuals do not know coercive control is already actionable. Naming and defining coercive control in KRS 209A would validate it as legally actionable abuse.

Abuse is a clinical, not legal, standard. Nurses must be able to name what they see in patients regardless of whether it is codified in statute or not. Survivors of coercive control live with the health impacts of abuse even if they have no visible injuries.

Clinicians must also recognize the role that coercive control plays in barriers to care. Partners often control where people go, what they do, and who they see. If healthcare enters that list, they are less likely to be able to leave the abuse cycle at all.

The Kentucky Board of Nursing (KBN) has a one-time, three-hour continuing education (CE) requirement that all nurses take domestic violence content and can be satisfied with any one course upon graduation or entry into practice (Kentucky Board of Nursing [KBN], 2025). KBN requires CE in domestic violence to ensure all nurses understand the legal limits of reporting in Kentucky and can recognize domestic violence even when there are no visible signs. KBN has audit authority for these requirements, and CE certificates should be saved for three years. No additional CEs are required for this topic after the one-time certification.

The KBN mandates learning the following content areas when taking a course (Kentucky Board of Nursing, 2025):

• Dynamics and signs of domestic violence
• Kentucky statutes, protective orders, and reporting obligations
• Risk and lethality factors
• Trauma-informed and cultural safety approaches
• Available state and national resources

A Domestic Violence Order (DVO) is for someone who has been abused by another family member or intimate partner. KRS 403 authorizes DVOs.A DVO covers current or former spouses, parents and children, stepparents and stepchildren, grandparents and grandchildren, individuals who live together or have formerly lived together as a couple, and individuals who have a child in common.

A DVO is preceded by an Emergency Protective Order (EPO), which offers short-term protection until the court hearing (usually within 14 days).The petitioner (the person filing for protection) does not need a lawyer and can apply at the local county courthouse or after-hours with law enforcement. A judge can tailor the order to meet the specific situation. Orders can include no-contact or stay-away requirements (home, work, school, child-care facility), exclusive possession of a residence or order for the other person to move out of a shared home, temporary child custody, visitation, and support orders, protection for pets or livestock, and orders prohibiting further threats, harassment, or abuse.

The order should clearly identify the respondent (the person against whom the order is granted), the person(s) to be protected, the expiration date, and the conditions of the order. The maximum duration of a DVO was recently extended (2022) to three years with the option to renew it for subsequent three-year terms when on-going risk is shown.

Before 2015, Kentucky’s protective order law was limited to family or household members. Survivors of dating violence, stalking, or sexual assault had no civil protection remedy available. The Interpersonal Protective Order (IPO) fills that gap. An IPO can be sought by a person who:

• Has been the victim of dating violence and abuse, stalking, or sexual assault.
• And, has or had a romantic or intimate relationship with the respondent or is being targeted by stalking or sexual assault, regardless of relationship.

IPOs have the same general terms as DVOs, to restrict contact and communication. And IPO may order the respondent to stay away from the person’s home, work, school, or child-care facility. In place, the IPO prohibits threats or surveillance and protects against digital and online harassment.

IPOs are now (2022) available for up to three years with the option to renew for subsequent three-year periods when risk is shown.

The process of obtaining a Protective Order:

1. Petition Filed: At the circuit or district courthouse, or through law enforcement after hours.
2. Judge Review (EPO): A judge may issue an Emergency Protective Order based on the statements in the affidavit only.
3. Service of Order: Law enforcement provides notice to the respondent.
4. Hearing (DVO/IPO): Within 14 days, both parties may appear before a judge.
5. Order Entry and Enforcement: Once issued, the order is enforceable statewide and is entered in the Law Information Network of Kentucky (LINK) database.

Firearms are a major risk factor for lethality in domestic violence situations. Federal law 18 U.S.C. § 922(g)(8) prohibits possession or purchase of firearms or ammunition by persons subject to qualifying protective orders. To qualify, the order must be issued after notice and a hearing, restrain the respondent from harassing, stalking, or threatening an intimate partner or child, and include specific findings that the person presents a credible threat.

In 2024, the U.S. Supreme Court in United States v. Rahimi upheld this prohibition as constitutional. The Court ruled that temporary firearm restrictions tied to protective orders are consistent with longstanding safety measures and do not violate the Second Amendment (U.S. Department of Health and Human Services, 2025).

Protective orders interact with nursing care in several key areas:

• Emergency Departments: Verify EPO or DVO status before discharge in the presence of safety concerns.
• Primary Care and Obstetric (OB) Settings: Screen during annual exams and prenatal visits.
• Home Health: Document observed violations (e.g., abuser present, despite stay-away clause) and consult supervisors.
• Behavioral Health: Coordinate with case managers for advocacy and legal support referrals.

Even with strong statutes, barriers to enforcing protective orders remain, such as limited awareness among survivors about eligibility or renewal and backlogs in court scheduling. Respondents ignore the order and test boundaries, with survivors limited in further action due to fear of retaliation or job loss.

While nurses are not law enforcement officers, they do have a role in risk assessment and safety education.During a lethality assessment, include questions about firearms. Encourage safe-storage practices, provide referrals to law enforcement for voluntary surrender, and document these discussions objectively (Futures Without Violence, 2024). Use neutral phrasing, such as “Let’s talk about safety around firearms,” rather than “You should give up your gun.” This can reduce defensiveness while addressing risk.

Nurses cannot give legal advice, but they should:

• Explain options in clear, neutral language.
• Provide resources (ZeroV hotlines, CHFS regional contacts, court-based victim advocates).
• Support autonomy (respect the person’s readiness to pursue an order).
• Document thoroughly (all information shared, any stated intent).

Intimate partner violence (IPV) is not only an issue between two adults; it also involves the impact that these violent acts have on children, adolescents, and family systems (Andreescu & Redman, 2025). It is essential to know the effects of IPV not only on direct victims but also on the children around them.

IPV has been found to have both short- and long-term effects on children. It has been shown to have an impact on the child’s developing brain as well as increase a child’s (Bogat, Levendosky, & Cochran, 2023):

• Anxiety
• Depression
• Aggression
• Impulsivity
• Conduct problems

It has also been shown to impact a child’s attention span, concentration, and is associated with increased academic difficulties (Bogat, Levendosky, & Cochran, 2023).

Children exposed to IPV at home are at a higher risk for various mental health issues, and they are more likely to experience health, behavioral, and academic problems. Healthcare providers are in a place where they can make a difference for these families, and it is crucial that we are aware of the signs in our pediatric, school health, or emergency clinic settings. Children’s behaviors at home and school may be completely different, so it is also essential to know how to effectively assess and question these individuals.

Children may not be the direct victims of violence, but they are still victims of the situation, as they are also at risk of developing serious health issues in the future. They can be directly or indirectly exposed to violence, but the main impact of IPV on a child is through the level of anxiety and fear that a caregiver is showing at home (Bogat, Levendosky, & Cochran, 2023). This affects children’s health and well-being and also disrupts the homeostasis of the family system. One caregiver may become isolated and controlled in the family system, where the abusive partner holds all the money and financial assets, as well as using children to monitor and control the other parent’s actions, through the care of the children. Children can also become pawns in an abusive relationship when parents fight over custody and visitation rights (Bogat, Levendosky, & Cochran, 2023).

It is crucial to talk about not only IPV between adults but also the children and families affected. We need to know what to look for in these patients and their families, as well as be able to counsel the adults in the home on what effect this is having on their children, and ways to help both them and their children.

In June 2025, the United States Preventive Services Task Force (USPSTF) posted an updated recommendation statement on screening for IPV in women of reproductive age and screening for caregiver abuse in older or vulnerable adults (United States Preventative Services Task Force [USPSTF], 2025). The following are the specific USPSTF recommendations for 2025 (USPSTF, 2025):

• USPSTF recommends screening women of reproductive age (including pregnant or postpartum women) for IPV.
• They are not recommending screening every adult or older person, unless there are signs or suspicion of abuse.
• Under the Affordable Care Act, IPV screening is a preventive service that should be covered by many health insurance plans.
• USPSTF suggests using a brief validated questionnaire to assess for current or recent abuse (e.g. in the past year).
• If a patient screens positive for IPV or caregiver abuse, the clinician should provide or refer them to “multicomponent interventions with ongoing support” instead of just a one-time referral.
• Screening followed by referral to ongoing support services can reduce IPV exposure and improve physical or mental health outcomes among women of reproductive age.
• Connecting women survivors to services earlier can reduce repeat violence, injury, and downstream health consequences.
• Screening studies did not always show significant reductions in IPV outcomes versus no-screening arms, which suggests that screening alone is insufficient without a robust support system.
• There is insufficient current evidence to support routine screening in men. However, some men do experience IPV so use clinical judgment if other risk indicators are present.
• If concerns or behavioral indicators are present, screening and referral may be justified among populations of older and vulnerable adults.

Kentucky nurses should interpret and apply this recommendation considering state law, resource availability, and practicalities of their clinical setting. Note that while this recommendation applies to women of reproductive age, men and persons outside of that age group can also experience IPV. Kentucky nurses can (Melendez-Torres et al., 2023):

• Routinely screen women within the reproductive age range (e.g., 15–49 years) as well as pregnant or postpartum patients.
• Screen others using clinical judgment and triggers (e.g., older women, partners of pregnant women, patients with injury or mental health concerns).
• Recognize that screening is not a one-size-fits-all mandate and that patient safety, privacy, and setting constraints are important considerations.

Some of the most commonly validated tools include short (3 to 8 items) questionnaires and have been used in prior research that informed practice. Validated means the questions have been tested for reliability and sensitivity to abuse (Melendez-Torres et al., 2023).

A positive screening test is not a diagnosis of violence, but rather a bridge to a conversation with supportive referral resources. Some tips for embedding screening into a routine workflow include:

• Screen for IPV, but do not force it if it is clearly contraindicated.
• Screen in a private place at every visit or certain key visits (e.g., annual physical, prenatal, mental health visit).
• Embed screening into standard assessments (e.g., add a yes/no screen to intake form, triage assessment, or EHR flow sheet).
• Never screen unless in a private setting (e.g., no one within earshot).
• If positive, do a warm handoff to advocacy or social work (in person or by phone).
• Document carefully, including exact verbatim responses, which tool used, and any referrals made.

All tools below are validated for use in outpatient, emergency, or inpatient settings, and can be administered verbally, on paper, or digitally (as long as privacy is ensured) (USPSTF, 2025):

1. HITS (Hurt, Insult, Threaten, Scream)
2. HARK (Humiliation, Afraid, Rape, Kick)
3. PVS (Partner Violence Screen)
4. WAST (Woman Abuse Screening Tool)
5. E-HITS (extended with questions on sexual violence)

Please review the following table to see the included elements and questions in each of these listed screening tools.

A positive answer is not the end of nursing work, it is the beginning of the supportive conversation. The nurse or provider should immediately:

• Ensure privacy and safety (away from partner).
• Validate the disclosure: “You don’t deserve to be hurt or controlled.”
• Provide resources per KRS 209A (brochure “Help Is Here”)
• Document objective information (tool used, score, education given).
• Offer referral or warm handoff to advocacy services.

Asking the questions is only half the battle: it’s the how, the follow-through, and the team response that makes a true difference. The best screening tool will not change culture if a clinic is perceived as hurried, unsafe, or punitive (Melendez-Torres et al., 2023). Many clinicians know what to ask but not how to ask. Inflection, posture, and privacy signal whether it’s a safe space to share abuse. A nurse’s tone and inflection can create or dissolve a rapport that takes months to build (Melendez-Torres et al., 2023).

Whether novice or experienced, the nurse has an opportunity to change lives and create that safe space needed for therapeutic communication. Practice and engagement take only minutes and can be done quickly, with one or two peers to role-play.

In absence of the time and space to practice language in this low-stakes setting, use the following scenarios as an opportunity to reflect on translating this important skill into practice. Note phrases that worked well or sounded awkward. Screening is not an interrogation; it is an invitation to safely discuss fears and feelings.

IPV may manifest in a wide variety of somatic symptoms without recent injury. Nurses need to be able to connect the dots between physical and psychosocial causes without making assumptions through reflection questions they can pose to themselves during or after triage/assessment or later when more privacy is possible:

• What nonverbal clues were observed?
• Were they nervous, sorry, or withdrawn?
• Were they chronically late or distracted when partner present?
• In what ways might fear, control or trauma affect sleep, appetite, or pain?

A positive IPV screen is a window of opportunity, not a “check-the-box” point-of-care.
Facilities should have developed, practiced, and consistent protocols in place that promote safety, offer “warm referral” to advocacy and includes thorough documentation of the abuse (Melendez-Torres et al., 2023). Take a look at the following table to see a sample script for a “warm referral” or “warm handoff” approach.

Kentucky’s inpatient and outpatient caregivers serve many unique populations. From the Appalachian communities in Eastern Kentucky, to African American families, Latino/a migrants (Mexican, Guatemalan), Arabic-speaking refugees (Iraqi, Syrian), Burmese/Karen and Congolese refugees, West African immigrants, Amish/Mennonite communities, and LGBTQIA+ Kentuckians, among others. Healthcare should always be patient-centered but also consider cultural differences without stereotyping. “Culturally responsive” ≠ assuming beliefs. Ask how their healthcare can make them feel the most comfortable.

Please take a look at the following table to review specifics of some of Kentucky’s cultural communities.

Trauma-informed screening is not just a way to ask questions—it is a way to document the encounter. Every word, phrase, and description captured in the record will be a legal and clinical artifact of that care. For patients who screen positive for IPV, this charting will potentially be seen by police or court officers, entered into the record in support of protective orders or judicial recommendations, or used by other clinicians to follow-up on what they learn.

TIC uses the six principles, one privacy script, one tool (HARK or E-HITS), one warm-handoff pathway, and one documentation template. It is helpful to choose the scripts and patterns that resonate in practice and use those four things every time.

To become an expert in TIC, it may be necessary to shape the system by standardizing 1:1 privacy, interpreter workflows, and tech-safety protocols. With collaboration from all members of the healthcare team, it is possible to create limited-visibility documentation options, and audit charts for quality. Most importantly, nurses are able to drive that change.

Trauma-informed, culturally responsive care increases disclosure, safety, and trust—and it’s fully compatible with Kentucky law (KY Rev Stat § 209A.100, 2017/2024), nursing ethics, and the 2025 USPSTF screening guidance. Take a look at the following table for the “do’s” and “don’ts” of conversations incorporating TIC.

Utilize the following to communicate best in your documentation:

• Objectivity: Write facts and quotes, avoid opinion, interpretation, or speculation.
• Completeness: Include facts that were observed, heard, or did (assessment, education, resources, referrals).
• Privacy: Protect sensitive information that could harm the survivor if someone else accesses it (check shared portals).
• Consistency: Use standardized EHR fields if available for follow-up data tracking.
• Neutral Tone: Delete loaded words like claim, alleges, admits, or denies. Swap with neutral verbs like states or reports.

Take a look at the following table to see some specific documentation examples utilizing the Good/Better/Best model.

Photographing injuries and collecting evidence in suspected or known intimate partner violence (IPV) cases can be lifesaving, but it must be done safely, consistently, and respectfully. Images can preserve critical facts, not just trauma. They are documentation, not an investigation. The legal standard is not the photographer’s skill, it is trauma-informed, standardized process (Chandawarkar & Nadkarni, 2021).

Nurses should always follow their agency’s policy regarding photographs as part of documentation. If a facility does not have a photo policy, individual nurses should not independently be doing forensic photography. Simply document in writing and notify supervisor, social worker, or SANE/FNE (Kentucky Association of Sexual Assault Programs, n.d.). Obtain consent before each image. Obtain consent for storage and ongoing care purposes. Kentucky has no single state-wide mandate for nurses to take photos, but many hospital and health system policies are now consistent with nationally recognized forensic and trauma-informed practices:

• Obtain verbal or written consent prior to taking any photos.
• Photographs should only be taken using agency-owned, secure devices (not personal phones).
• Images should be stored only in secure evidence module or restricted-access section of the EHR.

Documentation should indicate that photos were obtained and stored, but should not describe graphic content of the image in the narrative chart note (Chandawarkar & Nadkarni, 2021). Example: “Photographs of left arm bruising and facial redness obtained with consent using hospital camera. Images stored in secure EHR media file per policy.”

Photographing injuries for evidentiary purposes can feel especially invasive, embarrassing, and/or re-traumatizing to someone who has experienced violence. Best practice trauma-informed care takes this into account while still ensuring evidentiary accuracy.

According to Chandawarkar & Nadkarni, (2021), it is important to explain before, during, and after:

• “This is to document your injuries more accurately. I want to make sure I understand what you are telling me.”
• “Do you have any questions about why we are taking these photos and where they will be stored?”
• “You have the right to say no to these photos or stop at any time. I am documenting them as part of your care, but you are not obligated to allow me to take them.”
• “Are you comfortable if I take this photo?”
• “Would you like to see the photo immediately after I take it?”

Only include staff who are necessary for the process. Minimize presence of others by using privacy curtains or closing the door. Do not include identifiable background features (e.g., other patients, staff, children) in photos. Expose only the specific areas needed to document. Cover other areas of body completely and always provide coverings. Allow the patient to stop, cover, or review each photo. This helps preserve autonomy and reduce re-traumatization. Remain neutral and professional. Facial expressions and reactions to the images may be interpreted as judgmental.

Kentucky laws KRS 620 (child abuse) and KRS 209 (vulnerable adult abuse) are “mandatory reporting” laws that also allow any photographs obtained as part of that report to be subpoenaed or released to investigators without consent or court order. KRS 209A (adult IPV) does not allow any photographs to be automatically shared; a written release or court order is required for release to law enforcement or court. The label “forensic” should not be included in the record unless the facility designates the individual as a forensic examiner. State simply: “Injury photographs obtained with consent for documentation.”

Involve a Sexual Assault Nurse Examiner (SANE) or a Forensic Nurse Examiner (FNE) for high-risk cases or when injuries are complex (Kentucky Association of Sexual Assault Programs, n.d.). These specially trained nurses are familiar with evidence collection and preparing for legal testimony. The Kentucky Association of Sexual Assault Program (KASAP) responds to hospital needs for forensic or SANE nurse examinations.

If the agency has forensic nurse colleagues, they should take photos, collect specimens, and maintain chain of custody. Providers should document an assessment of clinical findings, and the forensic nurse can document forensic details. Example: “Forensic nurse examiner notified; arrived at bedside 21:25. Photographs and evidence collection completed. Nursing care continued per plan.” If no forensic nurse is available (common in rural Kentucky hospitals), contact a regional ZeroV domestic violence program or statewide SANE network for advice.

Kentucky and national case reports are increasingly identifying “digital abuse” as an element of IPV. Digital abuse includes threats via text, photographs, GPS tracking, or secret hidden cameras (Futures Without Violence, n.d.). Nurses are now more frequently seeing screenshots, devices, or threatening text messages offered as evidence. Do not photograph these items or store them on healthcare devices. Refer to law enforcement or advocate for guidance on digital evidence preservation. Document in the chart factually, without speculation or judgment: “Patient reports receiving threatening text messages from partner; showed me on phone. No photos taken; education provided about preserving messages for law enforcement.”

Photos should never be taken in lieu of compassionate, trauma-informed patient care (Chandawarkar & Nadkarni, 2021). Done ethically and professionally, however, photographs can become powerful advocacy tools. They help transform trauma into evidence that can accurately and truthfully speak for itself. It is best practice to use secure, agency-owned equipment and obtain consent and explain purpose before, during, and after. When necessary, ensure safety, privacy, and cultural sensitivity and take overview and close-up shots with scale and orientation with the thought of evidence-keeping in mind. Document who, when, where, what in the chart but never substitute photos for compassion.

Photographic evidence and good documentation is charting with a purpose, and a thorough note is the clinical record of a trauma-informed care encounter (Scafide et al., 2023). Clinical decisions are documented, including a nurse’s objective observations and interventions in a patient-centered and trauma-informed manner. Nurses who document from a place of objectivity and compassion keep the patient encounter in mind long after the charting is complete, looking to build a continuity of care and community that aims to keep survivors safer in the long-term.

In Kentucky, making a good faith effort to comply with KRS 209A’s “educate, inform, and refer” provision is an important and often underutilized protection for both nurses and survivors alike. The law’s purpose is not simply to provide these resources at a point in time or to “get the boxes checked” of a particular safety plan, but rather to ensure survivors are provided with meaningful resources and options that can and will persist long after a disclosure or declination has been made. Written in clear, plain language, objective observations, and screening results, combined with consistent follow-up measures, documentation can become a kind of legal and therapeutic firewall against future victimization, allowing survivors to know their options and nurses to have a continued record of the care that was provided.

The CDC and World Health Organization (WHO) both use an ecological model to understand violence as a product of four interconnected layers (World Health Organization [WHO], n.d.). The more risk factors in each level, the more a person is at risk for victimization or perpetration.

Example: In an Appalachian community that has high substance misuse, lacks reliable transportation, and has only one hospital, we may see more IPV risk because of a lack of protective community or societal factors. This type of environment might normalize or enable individual- or relationship-level risk, like alcohol misuse or financial control.
As seen, each level can promote safety or harm. Nurses are in a position to see all four every day, whether at the bedside, in clinics, and/or in Kentucky’s communities.

Kentucky is diversifying. Nurses practice with cultural norms that impact risk and resilience. Practicing cultural humility is admitting that “risk” and “protection” will always look different across communities. It is being aware of how cultural norms can influence one’s thinking and perspective. Remember: what’s non-negotiable is partnership. Meeting people where they are with their belief systems, while prioritizing safety.

Identifying risk factors is only part of the equation; we must intervene when we see patterns of high-risk indicators. Under U.S. v. Rahimi (U.S. Supreme Court, 2024) and 18 U.S.C. § 922(g)(8), individuals under applicable protective orders are prohibited from possessing firearms.

In the presence of firearm danger, nurses can document that safe-storage or surrender information was offered as part of the safety plan. A lethality assessment tool (ex. Danger Assessment (DA) or Maryland Lethality Assessment Program (LAP)) can help determine next steps. Firearm questions are included as part of lethality screening and include note of safe storage counseling in progress notes (Futures Without Violence, 2024). Initiate a warm referral to advocacy or law enforcement if immediate danger is present. Integration of a brief safety plan prior to discharge, and clear, factual documentation is essential.

High-Risk indicators can include:

• Recent separation from partner
• Escalation in frequency/severity of violence
• Threats with or access to firearms
• Strangulation or attempted strangulation
• Forced sex
• Threats of suicide or homicide
• Partner monitoring or controlling daily activities, money, or medications
• Pregnancy or new infant in the home

Protective factors function like safety nets, helping to buffer recovery, autonomy, and stability. Each protective factor should be reinforced with the individual. Protective factors can be clearly documented in the plan of care and communicate work in progress for things like “Connected with advocate,” “Housing application submitted,” or “Counseling referral completed.” This not only supports follow-through of care, but also provides measurable outcomes.

Important protective factors can include:

• Access to stable housing or emergency shelter
• Economic independence (employment, education, childcare support)
• Supportive friends, family or peers
• Connection to advocacy, counseling, and peer support groups
• Access to trauma-informed healthcare
• Legal protection (EPO/DVO/IPO orders)
• Community connection (faith, school, civic engagement)

Protective factors help transform a moment of crisis into an opportunity for recovery when we recognize and build upon them. Small prevention efforts add up, and all support statewide resiliency. Kentucky’s nursing community has already influenced laws, curricula, and crisis response programs through collective voices. Risk factors illuminate why violence occurs; protective factors illuminate how healing occurs. Nurses are poised at the intersection of both.

Risk becomes practice when a public health nurse partners with a local high school to deliver a “Healthy Relationships 101” session. Protection becomes practice when an ED charge nurse creates a quick-reference card for IPV screening questions and referral resources. Nurse leadership becomes practice when a nurse leader participates in statewide coalition meetings to strengthen regional response coordination.

Nurses have three central prevention roles (Palmieri & Valentine, 2021):

1. Clinical Prevention: Routine screening, early identification, trauma-informed response.
2. Educational Prevention: Teaching patients and communities about healthy relationships, stress management, and consent.
3. Advocacy Prevention: Engaging in system-level change–policy development, community partnerships, and institutional training.

Kentucky’s laws, advocacy network, and healthcare professionals can form a web of safety that has the potential to catch people before they fall through (Kentucky Justice and Public Safety Cabinet, n.d.). Risk factors do not determine destiny, even if they increase vulnerability. Protective factors can be built, one connection at a time, through available resources and strengths counterbalancing the encountered risks. Nurses are in a unique position to recognize both risk and protective factors and to intervene early.

Disclosure (sometimes referred to as ‘confession’) is the last step in a survivor’s journey to accessing services, after they have taken stock of their options, reconciled their fears, and made a plan to stay safe. Disclosure is powerful; it’s also dangerous. Not every survivor will take this step.

Denial can be a form of protection. Someone who is in a domestic violence or dating violence situation may be thinking about many things: the danger of further violence, housing and job concerns, community shame, immigration status, the concern that they will not be believed. Do not take it personally if a patient (or child) says “No.”

The role of the nurse is not a detective, and a confession is not needed to provide patient-centered care for an individual. Although IPV may be suspicioned based on objective findings, affect, or behavior, the nurse does not have the obligation to determine if abuse is happening when the person says, “no violence” or “no problems at home.” Stay neutral and compassionate, without attempting to “convince” the person—they are weighing risks internally. Keep the person safe, document, and consistently offer services and education (Palmieri & Valentine, 2021). Future tense language (“if that ever happens”) works better than questions (“are you sure he didn’t mean to?”) when offering resources without intruding. Trauma-informed documentation reflects this, allowing the chart to “speak” even if the person says “No.” Consider some examples of therapeutic communication for nurses:

• “Sometimes things like this happen in unsafe situations. If that’s ever the case for you, I want you to know there’s help out there, 24/7.”
• “I know you don’t want to talk about that. I’m going to slip a brochure in your papers just in case you need it.”
• “You should feel safe at home. If that’s not the case, you can always come back here.”
• “You don’t have to decide today but know there’s support if you need it.”

Asking why someone would not disclose or reveal their situation is like asking “why did you survive?” Trauma responses are complex and diverse. The reasons for denial or minimization are varied but some of the most common include:

• Fear of increased violence: The person may worry that violence will be worse if their partner knows.
• Fear of shame or loss of community: Especially in smaller or faith-based communities.
• Cultural beliefs: Some cultures place more value on family unity, autonomy, or privacy than outside intervention.
• Fear of financial loss: Loss of partner can mean loss of financial support, childcare, transportation, and/or housing.
• Fear of immigration repercussions or custody loss: Fear of deportation (especially if undocumented) or custody loss.
• Fear of personal safety or further system involvement: They may have previously been disbelieved, blamed, or further endangered after reaching out to systems or services.

Always document facts that support clinical judgment, even if the person does not disclose abuse. The key to language is to stay neutral and descriptive rather than assumptive or judgmental.

Words matter more when a person is denying. Words like “claims,” “refuses,” and “alleged” can seem accusatory or disbelieving. Instead, use factual, objective language. Nurses should avoid language that could imply assumption or bias.

Presence of children or vulnerable adults changes the reporting obligations under Kentucky law. Even when the adult denies any incidence of IPV, if known children or vulnerable adults are in the household and there is suspicion for abuse, legal obligations must be met (Child Welfare Information Gateway, 2020):

• KRS 620 – Mandatory reporting of suspected child abuse or neglect including when domestic violence results in risk of harm to a child.
• KRS 209 – Mandatory reporting of abuse, neglect, or exploitation of vulnerable adults.
• KRS 209A – Adult IPV/DV laws which apply to violence and dating violence but only require education/information/referral, not mandatory reporting (unless 209 or 620 apply).

Please take a look at the following list of the statewide community resources in Kentucky (Kentucky Association of Sexual Assault Programs, n.d.):

• ZeroV (Kentucky Coalition Against Domestic Violence):
  • ZeroV is the statewide domestic violence coalition in Kentucky. It works with 15 regional domestic violence shelters & advocacy programs across the state. It also provides training for these programs and maintains statewide referral tools and a directory of resources.
  • ZeroV has a resource and referral webpage on their website with KRS 209A referral information, legal resources, and forms in multiple languages.
  • ZeroV also has strong ties to state policy advocacy, state-level distribution of grant funds, and public-facing campaigns, such as the “Shop & Share” fundraising initiative.
• KASAP (Kentucky Association of Sexual Assault Programs):
  • KASAP is the statewide coalition of rape crisis centers and sexual assault programs.
  • It provides information on 24/7 hotlines, hospital-based advocacy, counseling, and legal services.
  • Due to the overlap between IPV and sexual violence, nurses should also be aware of any local KASAP member crisis centers that operate in local hospitals for hospital accompaniment and forensic exam referral.
• VOCA (Victim Compensation & Assistance):
  • The Victims of Crime Act (VOCA) is a source of grant funding for victim services in the state of Kentucky, with a focus on providing support and services to survivors of domestic violence, sexual assault, and child abuse (Kentucky Justice and Public Safety Cabinet, n.d.).
  • VOCA distributes funds to local crisis counseling, emergency assistance, legal aid, and victim advocacy programs throughout Kentucky.

Kentucky has dozens of local shelters and domestic violence programs. There are ~20 organizations listed on domesticshelters.org across ~18 cities in Kentucky. Services and support often include emergency shelter, crisis counseling, safety planning, children’s services, case management, and more.

Best practice is to keep an updated list of local victim services units and police departments, regional shelter phone numbers, hotlines, and advocacy contact numbers for the catchment zip codes that are serviced. Even a laminated sheet of paper in an exam room is helpful to provide the referral information for when it is needed.

Counties often have courthouse advocates or legal aid programs that can help with protective orders/restraining orders, divorce/custody, and other legal issues for patients. Nurses should be familiar with the contact information for the local legal aid office or similar. The Kentucky Legal Aid website also has a list of local programs (Hope Harbor, Sanctuary, etc.) (Kentucky Legal Aid, n.d.).

Kentucky law allows victims of crime to apply for financial assistance for related expenses (medical bills, lost wages, relocation, etc.) via state victim compensation programs and is a source of VOCA funds (Kentucky Justice and Public Safety Cabinet, n.d.). Nurses can help educate patients on these programs and eligibility and refer as needed.

Victims of crime also have certain rights under the Victim’s Bill of Rights/ Marsy’s Law in Kentucky and some counties, including rights to information, protection, compensation, and participation (Kentucky Legal Aid, n.d.). Henderson County, for example, has published a handbook of victims’ rights.

Kentucky is also considering an expansion of address confidentiality/ Safe-at-Home protections, to mask the address of survivors in public records. Legal advocacy is available in Kentucky’s two largest cities. The Center for Women and Families, for example, offers legal advocacy and crisis services with 24/7 access in Louisville. In addition, the Domestic Violence Intake Center (DVIC) in Louisville, in the Hall of Justice, can help with the legal intake process for domestic violence cases.

In addition to safety planning and legal/physical protections, survivors also benefit from therapeutic and social support services. Nurses can connect and link survivors to these services, especially patients who may not be able to go to an office physically:

• Counseling & Therapy: Many domestic violence programs and community mental health centers can provide trauma-informed counseling, group therapy, or therapeutic referrals.
• Peer Support/Survivor Groups: Connecting with others who have shared experiences reduces isolation. Many local shelters and advocacy organizations offer support groups.
• Case Management & Transitional Support: Transitional support services can include assistance with housing relocation, job training, childcare, financial literacy, transportation, and legal referrals.
• Children’s & Family Services: Programs also exist to support children who have witnessed violence, parenting education, and family therapy.
• Safe Home Networks/Mobile Advocacy: In some counties, mobile advocates will meet with clients out in rural areas who cannot safely make it to their office.

Even with resources available, survivors of domestic violence in Kentucky face barriers to care and safety. Due to the capacity limitations on both shelter areas, emergency shelters, and mental health facilities, whenever a referral is made for a patient, always confirm the availability first (beds open, access to an interpreter). If the shelter is full or the patient cannot get to it, schedule a call to check in and leave alternative support if possible (use motel vouchers, notify a trusted house of contact). In addition to bed capacity, there are other barriers and considerations in caring for the individual:

• Rural Access & Transportation: A lack of transportation and absence of shelter or advocacy services within driving distance is a problem in some counties; public transportation options are limited.
• Jurisdictional Limitations: Survivors may have to cross county lines to find a courthouse with the capacity for protective orders or to find shelter.
• Language & Cultural Barriers: Non-English speakers, immigrants and refugees, or indigenous language communities may not have access to culturally responsive services.
• System Trust & Fear: System distrust may be an issue, particularly with police, the courts, or other institutions if survivors have experienced discrimination.
• Confidentiality Concerns: Intimate partner abusers may compromise confidentiality by viewing patient portal messages, knowing home addresses, or subpoenaing medical records.

As a nurse, the role as a safety net does not end when the referral is made. In some cases, the nurse remains the patient’s navigator and continuity point.

Whenever possible, provide a warm handoff referral and call the advocacy program with the patient present (and with consent). Offer reassurance to the survivor and help them arrange the first contact. Send a referral note (marked discreetly) to advocacy staff and chart with patient permission. Slip brochures into the after-visit summary or medicine instructions. Label a note in the EHR as “Care Coordination Contact” that is neutral and would not alarm abusers. Schedule a follow-up virtual or in-person check-in or follow-up appointment with the patient. If the survivor agrees, be the point of contact; the nurse can make the check-in phone call to see if the resources helped and pivot if not. Document any contacts made, referrals given, and attempted follow-up in the medical record. Work with the health system’s social work department, advocacy programs, or ZeroV coalition to track referral success and barriers. Also, periodically audit to confirm the resources given to patients are still available.

As we have discussed in previous sessions, there are many long and short-term effects of IPV and many of them not only affect the victim or children, but can also affect the caregivers and healthcare providers themselves.

As the secondary victims to the story of IPV, nurses and healthcare professionals can be at risk of secondary trauma and burnout due to the stress of working with those affected by IPV. Secondary trauma, also known as vicarious trauma or secondary traumatic stress, can affect providers who are caring for others who have been traumatized, and is a normal reaction to hearing about other’s trauma and pain (Melinte & Turliuc, 2023). Secondary trauma can have the same effects as Post-Traumatic Stress Disorder (PTSD) in caregivers, such as emotional exhaustion, depersonalization, and reduced personal accomplishment at work. Signs of secondary trauma in healthcare providers can include (Melinte & Turliuc, 2023):

• Flashbacks
• Difficulty concentrating
• Problems sleeping
• Anxiety
• Irritability
• Feeling isolated or withdrawn
• Lack of empathy

On the other hand, burnout is the result of chronic workplace stress that has not been successfully managed and can also affect the provider’s physical and mental health, as well as their job performance. There are three main areas of burnout in healthcare professionals:

1. Emotional exhaustion (chronic fatigue and inability to cope with workplace stress)
2. Depersonalization (negative or callous feelings towards others in the workplace)
3. Reduced personal accomplishment (feelings of incompetence and lack of achievement and productivity in the workplace)

Like any patient education, providing information to patients on how to identify and cope with secondary trauma is key to recovery. It is equally important to provide this education for all staff members, as it is crucial to the long-term success and efficiency of clinical work. Melinte & Turliuc describe some tools and techniques that can be used to prevent secondary trauma and burnout in healthcare providers (2023):

• As soon as these symptoms are identified in a coworker, it is essential to use brief grounding techniques such as breathing exercises, a short walk, or even using mindful moments, if these resources are available.
• For those experiencing secondary trauma, it is essential to practice self-compassion. This can include journaling and self-care.
• Peer support can be a powerful tool, as talking together about the difficult cases can validate staff feelings and reflect community emotions within those experiences.
• Setting professional boundaries is also an essential strategy to prevent secondary trauma and burnout.
• It is also important to stay connected to a professional purpose and be able to identify and celebrate small accomplishments. This can be something as small as a patient making it to their follow-up visit, connecting their child with a counselor, or even just leaving a bad situation.
• Administrators can help prevent secondary trauma and burnout in their staff by incorporating trauma-informed principles into workplace culture, such as predictable schedules, transparent communication, and staff recognition.

Secondary trauma and burnout are a risk in the field of nursing, but that does not mean we have to accept it as the norm. By following the strategies and techniques listed above, we can ensure the long-term health and happiness of ourselves and our colleagues in the field.