COURSE PRICE: $30.00
CONTACT HOURS: 3
Wild Iris Medical Education is an approved provider (#PA-54) of continuing nursing education by the Washington State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.
The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.
This course meets the domestic violence continuing education requirement for nurses and other healthcare professionals in the state of Kentucky.
Nancy Evans is a health science writer and editor with more than three decades of experience in healthcare publishing. She served as senior editor at Mosby/Times Mirror, senior editor in the health sciences division of Addison-Wesley, and senior medical editor at Appleton & Lange. She is an honorary member of Sigma Theta Tau International Honor Society of Nursing. A breast cancer survivor since 1991, she currently works with Breast Cancer Fund as health science consultant. She has written and spoken extensively on breast cancer issues in the United States, Canada, Belgium, and New Zealand. Nancy co-produced (with Allie Light and Irving Saraf) the HBO documentary film Rachel's Daughters: Searching for the Causes of Breast Cancer. She is also the co-producer (with Light and Saraf) of Children and Asthma, a KQED documentary film, and the documentary, Good Food, Bad Food: Obesity in American Children.
Copyright © 2007 Wild Iris Medical Education, Inc. All Rights Reserved.
Upon completion of this course, you will be able to:
We have to be very careful when citing statistical reports that we don't create the perception that anyone actually has a handle on the rate of domestic violence in America. The truth is, domestic violence is rampant and diverse, and it's still something no one wants to talk about. —SHERYL CATES, Executive Director, National Domestic Violence Hotline
Domestic violence is the use of physical abuse, verbal or emotional abuse, sexual abuse, or economic abuse (eg, withholding money, lying about assets) to exert power or control over someone or to prevent someone from making a free choice. Three-fourths of domestic violence victims are women. Domestic violence is a major public health problem in the United States and around the world—even more prevalent than rape or assault by strangers or acquaintances.
A landmark international study of 24,000 women in ten countries found that 1 in 6 women has experienced domestic violence, yet the problem remains mostly hidden. Women who experience domestic violence have more than double the risk of poor health and physical and mental health problems than women who are not abused. According to Lee Jong-Wook, director-general of the World Health Organization (WHO), "This study shows that women are more at risk from violence at home than in the street" (WHO, 2005).
The Centers for Disease Control and Prevention (CDC) report that domestic violence affects more than 32 million Americans annually, causing more than 2 million injuries and approximately thirteen hundred deaths (CDC, 2005). Domestic violence strikes all ages, cultural/ethnic/religious groups, and social classes. Rape, incest, and dating violence are forms of domestic violence.
A 2005 report from the U.S. Department of Justice indicates that the rate of domestic violence declined by 50% between 1993 and 2002. At the same time, the National Domestic Violence Hotline (NDVH) reported that the demand for family violence services increased by 15% between May 31, 2004 and May 31, 2005.
The NDVH has seen a 134% increase in the number of calls answered since the hotline was created in 1996 (NDVH, 2005). It is impossible to know the actual incidence and prevalence of domestic violence because many of these crimes are not reported to anyone. Feelings of shame, fear, and hopelessness prevent victims from seeking protection and support.
Victims of domestic violence are usually women and children. Perpetrators of domestic violence are generally, though not always, men. According to the U.S. Department of Justice (2005), 73% of domestic violence victims are women and 76% of perpetrators of domestic violence are men.
Children who witness domestic violence may become victims themselves. One study showed that children of abused mothers were 57 times more likely to have been physically injured because of violence between their parents compared with children of nonabused mothers (Parkinson et al., 2001).
Because the term domestic violence tends to overlook male victims and violence between same-sex partners, the CDC prefers the more specific term intimate partner violence (IPV). Healthcare professionals need to be aware that the state of Kentucky also uses the term family violence as an "all-encompassing term that includes intentional physical, emotional, spiritual, or financial harm against children and adults, including the elderly." In addition, under the overall umbrella of domestic violence, the state includes spiritual abuse, neglect, and exploitation, along with the abuse categories detailed below (KBN, 1997).
Saltzman and colleagues (2002) identified four types of IPV: (1) physical violence, (2) sexual violence, (3) threats of physical or sexual violence, and (4) psychological /emotional violence. They define physical violence as "the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes, but is not limited to, scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, slapping, punching, burning, use of a weapon, and use of restraints or one's body size or strength against another person."
Sexual violence has three categories: "(1) use of physical force to compel a person to engage in a sexual act against his or her will, even if the act is not completed; (2) attempted or completed sex act involving a person who is unable to understand the nature or condition of the act, to decline participation, or to communicate unwillingness to engage in the sexual act because of illness, disability, or the influence of alcohol or other drugs, or because of intimidation or pressure; and (3) abusive sexual contact."
Threats of physical or sexual violence include the use of "words, gestures, or weapons to communicate the intent to cause death, disability, injury, or physical harm."
Psychological/emotional violence "involves trauma to the victim caused by acts, threats of acts, or coercive tactics." Psychological/emotional abuse can include, but is not limited to, humiliation, controlling what the victim can and cannot do, withholding information, deliberately embarrassing the victim, isolating the victim from family and friends, and denying access to money or other basic resources.
Stalking is considered by some states (including Kentucky) as a type of IPV. Stalking generally refers to repeated behavior, such as following someone, that evokes a high level of fear in the victim (Tjaden & Thoennes, 2000).
Intimate partner violence is one of the most common and least reported crimes. According to the National Violence Against Women Survey (National Institute of Justice, 2000):
Risk of becoming a victim of IPV is highest among American Indian and Alaskan Native women and men, African American women, Hispanic women, young women, and those below the poverty line (Tjaden & Thoennes, 2000). Other risk factors include alcohol and drug use, high-risk sexual behavior, witnessing or experience violence as a child, being poorly educated, and unemployment. Women whose male partners are verbally abusive, jealous, or possessive are at high risk for IPV, as are those women who have more education than their partner. Couples with disparities in income, education, or job status are also at higher than normal risk of IPV (Crandall et al., 2004).
Congress enacted the Violence Against Women Act (VAWA) in 1994 to expand efforts to raise awareness of domestic violence and increase the number of shelters and other resources for battered women. In December 2005, Congress reauthorized the VAWA programs as part of the Victims of Trafficking and Violence Prevention Act of 2000 (NOW, 2005). Additional information about the federal programs funded by VAWA can be found on the Department of Health and Human Services website: http://www.hhs.gov.
Research by Lenore Walker (1984) indicates that intimate partner violence (IPV) occurs in a three-phase cycle:
When stress and conflict begin to build, the cruel cycle begins again. Over time, the first two phases grow longer and the honeymoon phase diminishes and eventually disappears.
It is not uncommon for those outside of abusive relationships to wonder both why a perpetrator abuses and why a victim of abuse remains in such a relationship. It is important for healthcare professionals to understand the complexity of factors in these relationships in order to make accurate assessments and offer appropriate assistance. Abusers want power and control, and all their various behaviors are intended to achieve that end.
While it is possible that an abuser's behavior arises from or is exacerbated by a mental illness, that is not usually the case; however, abusive behaviors may be complicated by substance abuse problems. Healthcare professionals should be alert to any signs of these complicating factors when making assessments.
There are many reasons why victims stay in abusive relationships, and in any given relationship there may be numerous factors that form an interrelated web. It may be useful to view these reasons as falling into three categories: situational factors, emotional factors, and those stemming from personal beliefs (WRAP, n.d.).
Situational factors may include:
Emotional factors often include:
Personal beliefs may factor heavily into these reasons for staying in an abusive relationship and may center around:
While most victims of domestic violence are women, men are sometimes victims and, like women, remain in these relationships for a variety of reasons. The most frequent seem to be:
It is important for healthcare professionals to understand the many reasons why victims remain in these relationships, in order to provide appropriate treatment, assistance, and referrals. However, it is also important to note that it has been effectively argued that to speculate on the reasons with a victim or within their earshot is to turn the focus onto the victim's behavior when it should always remain on the abuser's behavior.
Injuries sustained during episodes of violence are only part of the damage to victims' health. Physical and psychological abuse are related to other adverse effects, including back pain, pelvic pain, gynecologic disorders, gastrointestinal disorders, problem pregnancies, sexually transmitted diseases (STDs), headaches, central nervous system disorders, and heart or circulatory conditions (Coker et al., 2002; Campbell et al., 2002; Heise & Garcia-Moreno, 2002; Plichta, 2004; Tjaden & Thoennes, 2000).
Abuse is also linked to mental health problems, including depression, anxiety, antisocial behavior, low self-esteem, inability to trust men, fear of intimacy, and post-traumatic stress disorder (Heise & Garcia-Moreno, 2002; Roberts, Klein, & Fisher, 2003). Women who have experienced IPV also have an increased risk of substance abuse and suicide (SOGC, 2005).
On average, more than three women are murdered by their intimate partners each day in the United States. According to a Bureau of Justice Statistics Crime Data Brief (2003), in 2000, 1,247 women were murdered by an intimate partner. That same year, 440 men were killed by an intimate partner.
Research indicates that 10% to 20% of American children witness IPV within their families each year—perhaps as many as 10 million children altogether (Carlson, 2000). These children report numerous fears about their mothers, including fear of serious harm to her and to themselves, as well as fear of abandonment. Living with intense anger and unpredictable behaviors creates a chronic and corrosive anxiety state. Child victims of violence, particularly boys, often grow up to become batterers themselves.
Domestic violence, child abuse, and youth violence are inextricably connected, and our nation urgently needs strategies and programs that will prevent and address them all.
—FAMILY VIOLENCE PREVENTION FUND, 2005
Women ages 16 to 24 have the highest per capita rate of IPV (Reinnison & Welchans, 2003). Twenty-five percent of female high school students in Massachusetts reported experiencing physical or sexual abuse by a dating partner (Silverman et al., 2001).
In the 2003 national Youth Risk Behavior Surveillance report, nearly 9% of students in grades 9 to 12 reported having been hit, slapped, or physically hurt on purpose by a boyfriend or girlfriend during the twelve months preceding the survey.
Dating violence was more prevalent among black students than among white or Hispanic students. Nearly 12% of female students reported having been physically forced to have sex against their will at least once (Grunbaum et al., 2004).
Many older Americans also experience domestic violence. Reports to Adult Protective Services (APS) agencies of domestic elder abuse increased 150% between 1986 and 1996 (Administration on Aging, 2001), even though the older population increased only 10%. An estimated 80% of abused elders are women and those over age 80 are the most frequent victims of abuse. A national incidence study in 2000 found that:
Between 1 and 2 million Americans age 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection (Bonnie & Wallace, 2003).
"According to the National Violence against Women Prevention Research Center, 1 out of 9 women in Kentucky has been a victim of forcible rape sometime in her life. A study of domestic violence in Kentucky reveals 1 of every 3 women has been victimized by an intimate partner" (CHFS, 2006). The economic impact that accompanies the personal and emotional ones is clear when we consider that 75% of battered women use work time to deal with the violence in their lives: 64% are late to work; 50% miss at least three days of work per month; and 20% lose their jobs as a result of the violence (KDVA, 2006).
In 1978 the Adult Protection Act (KRS 209), which had been passed in 1976, was expanded to include mandatory reporting and provision of voluntary protective services to spousal abuse victims (KSP, 2005). The Department for Community Based Services (DCBS) (a subunit of the Kentucky Cabinet for Health and Family Services) is the agency mandated by the act to receive reports of adult abuse, neglect, or exploitation. In 1996 House Bill 309 was enacted, and among its provisions is mandatory training about domestic violence for nurses and many other healthcare professionals.
In fiscal year 2005 the DCBS investigated 19,693 allegations of domestic violence. This was a 13.1% decrease over 2004; however, it was a smaller decrease than that experienced between 2003 and 2004 (KSP, 2005).
According to the statistics compiled by the Kentucky State Police (KSP) for its annual report Crime in Kentucky 2005, for fiscal year 2005, 26,959 petitions were filed by people seeking domestic violence protective orders and emergency temporary orders, and protective orders reported to the Law Information Network of Kentucky (LINK) reflected a 0.6% drop over 2004, but for both types of orders the ones bearing a "caution" notation, indicating involvement of known or suspected weapons, rose (KSP, 2005).
"Community awareness of the pervasiveness and severity of domestic violence in Kentucky heightened in the late 1970s. The YWCA in Louisville opened Kentucky's first spouse abuse shelter in 1977. By 1980 there were six shelter programs serving battered women and their children in Kentucky" (KDVA, 2007a).
"The Kentucky Domestic Violence Association was founded in 1981 by the staff of the six existing programs as a statewide coalition whose membership was to include all domestic violence programs in Kentucky. It's purpose was to provide mutual support, information, resource sharing, and technical assistance; to coordinate services; and to collectively advocate for battered women and their children on statewide issues" (KDVA, 2007a).
"An early goal of the coalition was to work with the Department for Social Services to ensure that domestic violence services were available across the state. Kentucky is divided into 15 multi-county Area Development Districts (ADDs). These districts are used for planning and service provision for a variety of programs It made sense to use these ADDs as targeted areas for domestic violence services. In 1985 Kentucky reached the goal of having a domestic violence program in each ADD" (KDVA, 2007a).
In fiscal year 2004, the Kentucky Domestic Violence Association received 27,095 domestic violence-related calls and 62,999 calls asking for information and/or referrals. While the former was a decrease over 2004 the latter was an increase (KSP, 2005). Domestic violence is an ongoing and critical problem in Kentucky.
Kentucky now has seventeen domestic violence programs. While they began as safe shelters for domestic violence victims, they now provide a variety of related support services. Over time the staff at these agencies has come to understand the complexity of the situation for victims of domestic violence, which continues to grow, and they are especially concerned to provide a variety of support services to residents and nonresidents that include:
"The programs are also committed to preventing future domestic violence through public awareness and community education efforts. Domestic violence programs are working with schools, local professionals, and community groups to increase understanding of domestic violence issues" (KDVA, 2007b).
Domestic violence has an enormous impact on the healthcare system. Homicide, injury, mental illness, substance abuse, and the legacy of violence from generation to generation may all be related to domestic violence. Women are the most frequent consumers of healthcare services and the most common victims of domestic violence. This puts healthcare providers in the best position to identify victims of domestic violence and make appropriate referrals to protect them against further harm.
"As the single most important and most accessed institution in the lives of women, the healthcare setting can provide a unique opportunity to intervene, making it one of the newest and most critical areas of the domestic violence movement today" (Family Violence Prevention Fund, 2001).
The shame and fear surrounding domestic violence silences many victims. Research shows that at least 4 out of 10 incidents of domestic violence are not reported to the police (Durose et al., 2005). Many abused women do not report IPV to their physicians or to anyone else.
Even though many healthcare providers are alert to signs of potential child abuse, too few screen for IPV. According to a recent poll, one-third of U.S. physicians surveyed said that they don't record patients' reports of domestic violence and 90% don't document whether patients are offered information or other support. One-third of physicians surveyed admitted that they did not feel confident about counseling patients who reported IPV (Gerber, 2005)
A survey of managed care organizations showed that less than one-third of HMOs in the United States have policies, protocols, guidelines, or materials on screening for domestic violence (National Health Resource Center on Domestic Violence, 1999).
Poverty damages health and well-being in countless ways—exposure to domestic violence is just one. Research shows that between 9% and 23% of women receiving welfare report being abused within the past 12 months. More than 50% of women receiving welfare report having experienced physical abuse at some point during their adult lives (Lyon, 2000).
Poor women in abusive relationships have complicated lives and inadequate coping resources. They face risks from the batterer and risks resulting from their poverty. Risks from the batterer include physical injury, threats and loss of security, housing, and income, and potential loss of their children. Risks resulting from poverty include lack of access to health insurance and health care, possibly racism, unsafe neighborhoods, and poor schools for their children (Davies, 2002).
These risks pose complex challenges to abused women and to the healthcare and social-service professionals responsible for protecting them. Intervening to stop the violence is only the first step. Issues of income, housing, and healthcare—both mental and physical—must also be addressed.
Families stressed by illness, unemployment, alcohol, and/or drug use are more likely to experience violence. This is particularly true with elder abuse, especially if the older person is frail or mentally impaired, the caregiver is ill-prepared for the task, or if needed resources are unavailable. Adult children who abuse their parents frequently suffer from mental and emotional disorders, alcoholism, drug addiction, and/or financial problems that make them dependent on the parents for support.
Violence is a learned behavior and creates a painful legacy in some families. These families respond to tension or conflict with violence because they have not learned any other way to response.
Pregnancy can also initiate or intensify domestic violence, particularly if the male partner is unemployed or sees the child as a rival for the woman's time and attention. Violence occurs in an estimated 4% to 8% of pregnancies and is particularly associated with unplanned pregnancy. More than 300,000 women each year experience IPV during their pregnancy (Gazmararian et al., 2000). Battering can lead to miscarriage, preterm labor, low birthweight, or other injury to the developing fetus. The stress of abuse also may cause pregnant women to continue such unhealthy habits as smoking and drug or alcohol use.
Researchers at the CDC found that homicide was a leading cause of injury deaths among pregnant and postpartum women in the United States during the 1990s (Chang et al., 2005). Risk factors for pregnancy-related homicide included: age younger than 20 years, being African American, and late or no prenatal care. Firearms were the most common method of homicide. Earlier studies in Maryland and Massachusetts also identified homicide as a leading cause of pregnancy-related death (Horon & Cheng, 2001; Nannini et al., 2002).
People with disabilities may be at higher risk for IPV, particularly sexual violence, than people without disabilities. Sexual violence includes sexual abuse, sexual assault, and rape. Disability is defined as "limitations in physical or mental function, caused by one or more health conditions, in carrying out socially defined tasks and roles that individuals generally are expected to be able to do" (Institute of Medicine, 1991).
According to the CDC, between 25% and 67% of adults with cognitive impairments experience sexual violence. Rates of sexual violence among women with disabilities range from 51% to 79%. Reported rates among adolescent boys with disabilities range from 4% to 6%; reported rates for adolescent girls with disabilities are about 24%.
Research indicates that women with disabilities have similar rates of IPV compared with women who do not have disabilities. However, those who have a disability experience abuse for longer periods of time. Having a disability limits a woman's options for escaping or resolving the abuse. For example, if an abusive partner withholds needed equipment, such as a wheelchair, or assistance with dressing or getting out of bed, it prevents access to programs that could help end the abuse (Nosek et al., 2001).
Women living with HIV also can be at increased risk for IPV. According to the National Women's Health Information Center, many HIV-positive women report emotional, physical, or sexual abuse at some time after their diagnosis.
Rural living may present additional problems for women who are victims of domestic violence, as well as for rural healthcare providers who may come in contact with them or be called upon for assistance.
As noted above, isolation (emotional, physical, and economic) may be a factor in some victims staying in abusive relationships, and the geographical circumstances of rural living often makes isolation an even more critical factor. Among other things, an abuser may limit a victim's access to family vehicles or prevent her from obtaining a driver's license; ridicule her in front of others or accuse her of flirting, thus making her even less likely to invite others to the home or go out herself; or even remove the telephone when leaving the house so she has no means to communicate with others.
These abuser behaviors, in conjunction with factors common to rural living, can make it extremely difficult for abused women to escape. Factors include:
Rural healthcare providers not only need to be able to identify domestic violence victims but also to be prepared offer assistance that addresses the particular needs and problems of rural women. Clients suffering from abuse may have complaints or injuries that include arthritis, irritable bowel syndrome, stomach ulcers, chronic pain, migraines, and eating disorders, and one study found that approximately 64% of rural women with an STD are involved in an abusive physical and sexual relationship.
Other closely associated complaints include insomnia, depression, post-traumatic stress disorder, panic disorder, and substance abuse (Clifford, 2003). Safety plans or escape options for rural women need to be adjusted to meet the specific realities of their situations.
Without any sort of intervention, abuse tends to escalate, as noted in the earlier discussion of the cycle of abuse (chain of violence). While not all abuser's kill, and there are no perfect predictors of time and place, research has revealed some patterns. The time of separation—when an abuse victim leaves her abuser and just afterward—presents the greatest threat to the abuser's ability to maintain power and control.
A number of other factors have been identified as contributing to increased threat of lethality in an abusive situation:
An effective response to domestic violence by nurses and other healthcare professionals depends on three elements—recognition, intervention, and prevention.
DOMESTIC VIOLENCE: RECOGNITION, INTERVENTION, AND PREVENTION
AWARENESS (TOOL):
Source: Kentucky Nursing Association Model Curriculum for Nursing Continuing Education, 1997. Developed by Carol McGuire, RN, MS.
Healthcare agencies should have protocols for handling situations in which abuse has been positively identified or the client is requesting specific immediate assistance. Your facility should have protocols that address: interviewing, physical assessment, safety assessment, treatment plan(s), referrals to resources of all types, and a thorough understanding of reporting requirements and methods. These may be best addressed in conjunction with other local agencies, including law enforcement, medical, mental health, and community service (KBN, 1997).
Nurses and other healthcare professionals should follow a regular procedure with all clients:
Every healthcare facility serving women, children, and older adults needs to screen for potential domestic violence. This screening need not be lengthy. In fact, researchers have developed an effective two-minute assessment screen for early detection of abuse of women (Brown et al., 1996) (see table). The screening can be part of the intake interview or included as part of the written history.
| Question | Circle Best Answer | ||
|---|---|---|---|
| Source: Centre for Studies in Family Medicine, n.d. | |||
| 1. In general, how would you describe your relationship? | a lot of tension | some tension | no tension |
| 2. Do you and your partner work out arguments with ... | great difficulty | some difficulty | no difficulty |
| 3. Do arguments ever result in you feeling put down or bad about yourself? | often | sometimes | never |
| 4. Do arguments ever result in hitting, kicking, or pushing? | often | sometimes | never |
| 5. Do you ever feel frightened by what your partner says or does? | often | sometimes | never |
| 6. Has your partner ever abused you physically? | often | sometimes | never |
| 7. Has your partner ever abused you emotionally? | often | sometimes | never |
| 8. Has your partner ever abused you sexually? | often | sometimes | never |
Healthcare providers should be alert for signs and symptoms that may be related to IPV. Delay in seeking care, missed appointments, and vague or inconsistent explanation of injuries or nonspecific somatic complaints should be noted. Depression and social isolation are common, as are substance abuse and use of alcohol or drugs. Be especially attuned to signs of abuse in pregnant clients because abuse often escalates during pregnancy.
During the appointment, be aware of lack of eye contact and/or a husband or boyfriend who is reluctant to leave the woman alone with the healthcare provider. Suicide attempts may be directly related to IPV.
Emotional or sexual abuse may present itself differently in different age groups. The young or teens may exhibit behavior problems, while older adults may be withdrawn or exhibit a fear of authority. Adults in general often have complaints commonly associated with chronic stress or anxiety (KBN, 1997).
During the physical examination, look for injuries on many areas of the body, especially the face, throat, neck, chest, abdomen, and genitals. Note any bruises, burns, or wounds shaped like objects such as teeth, hands, belts, or cigarette tips. Be alert for puncture wounds, fractures and dislocations, and scars on the vulva or rectum. Be aware that the woman may wear a glove or sock to conceal a scalded hand or foot. Be alert to any pattern of non–life threatening injuries at various points in the healing process. And, in children and the elderly, spiral fractures may also indicate abuse (KBN, 1997).
Following an established procedure for examination will ensure that no critical information is overlooked:
Accurate, thorough documentation of the patient's injuries is essential in cases of suspected abuse because it can serve as objective, third-party evidence in legal proceedings. For example, medical records can help victims to obtain a restraining order, or to qualify for public housing, welfare, health and life insurance, and immigration relief.
To be admissible in a court of law, medical documentation should include the following (Isaac & Enos, 2001):
Health professionals should avoid any phrases that cast doubt on the patient's reliability; for example: the patient claims or the patient alleges.
Avoid legal terms such as alleged perpetrator or assailant. Do not use conclusive terms such as assault and battery or domestic violence in documenting a case.
Let the factual information speak for itself.
When assessment and examination are complete, review any therapeutic protocols with the client and provide a supportive and encouraging environment in which the client can seek help and get support. Be prepared to:
Use the following questions to evaluate immediate safety issues:
Be sure you understand and can implement your agency's established safety protocols.
In 1978 the Adult Protection Act (KRS 209), which had been passed 1976, was expanded to include mandatory reporting and provision of voluntary protective services to spousal abuse victims (KSP, 2005).
All suspected cases of domestic violence (including child, elder/adult, and spouse abuse) are to be reported to the Cabinet for Health and Family Services (CHFS). During normal working hours local Protective Services should be contacted but at all other times call 800-752-6200.
"If you believe a child is being abused, neglected or is dependent, you should call the Child Protection Hot Line at (800) 752-6200 or the Protection and Permanency office in your county" (CHFS, 2006a). A list of those offices is available on the website at http://www.chfs.ky.gov/dcbs/dpp/Child_Safety.htm.
"If you suspect elder abuse, you are legally required to report it" (CHFS, 2007a). The DCBS offers this guidance for anyone who is concerned about possible elder abuse:
If you believe that an elderly person is in imminent danger, call (800) 752-6200 or your local law enforcement agency immediately. If the person is not in imminent danger but you are suspicious, watch the way the caregiver acts toward the elderly or disabled person. Look for a pattern of threatening, harassing, blaming or making demeaning remarks to the person — or isolating the person from family members and friends. Watch for an obvious lack of helpfulness or indifference, aggression or anger toward the person. Listen for conflicting stories about the elderly or disabled person's illnesses or injuries. Know the signs of neglect, physical abuse, sexual abuse, emotional/psychological abuse, financial abuse (CHFS, 2007b).
Kentucky Revised Statue 209A.030 states the following:
(1) The secretary may, within his discretion, adopt such rules, regulations, procedures, guidelines, or any other expressions of policy necessary to effect the purpose of this chapter insofar as such action is reasonably calculated to serve the public interest. The secretary may take necessary action and may offer or cause to be offered protective services toward safeguarding the welfare of an adult who has experienced abuse or neglect, inflicted or caused by a spouse.
(2) Any person, including, but not limited to, physician, law enforcement officer, nurse, social worker, cabinet personnel, coroner, medical examiner, alternate care facility employee, or caretaker, having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, shall report or cause reports to be made in accordance with the provisions of this chapter. Death of the adult does not relieve one of the responsibility for reporting the circumstances surrounding the death.
(3) An oral or written report shall be made immediately to the cabinet upon knowledge of the occurrence of suspected abuse, neglect, or exploitation of an adult. Any person making such a report shall provide the following information, if known: The name and address of the adult, or of any other person responsible for his care; the age of the adult; the nature and extent of the abuse, neglect, or exploitation, including any evidence of previous abuse, neglect, or exploitation; the identity of the perpetrator, if known; the identity of the complainant, if possible; and any other information that the person believes might be helpful in establishing the cause of abuse, neglect, or exploitation.
(4) Upon receipt of the report, the cabinet shall take the following action as soon as practical:
(a) Notify the appropriate law enforcement agency;
(b) Initiate an investigation of the complaint; and
(c) Make a written report of the initial findings together with a recommendation for further action, if indicated.
In January 1996, the Kentucky attorney general rendered a written interpretation of the law at the request of a physician. This document known as Ky. OAG 96-6 may also be of help to nurses wishing clarification of the law (KBN, 1997).
In addition to the mandatory reporting requirement laws, Kentucky nurses and other healthcare professionals should keep themselves informed of the current status of related statutes. Establish good communication with local law enforcement and judicial offices in order to stay abreast of any changes. The following are just few of the programs relevant to domestic abuse situations:
Begin by believing any woman who admits being abused. She has shown trust and courage to disclose the facts. Skillful, nonjudgmental interviewing can help build trust and establish a therapeutic relationship. Holtz and Furniss (1993) developed guidelines for care of the abused woman called the ABCDES Framework:
Women with children should take them along to prevent their being abused or held hostage by the abuser. One woman in an abusive relationship had her children go to bed with their shoes on so they could escape at a moment's notice if their alcoholic father became violent. She trained them to run to the neighbors and ask them to call the police. Children whose mothers are being abused need help in protecting themselves. Depending on their age, children can:
A safety plan is something that an abuse victim can begin working on at any time. There are downloadable and printable forms available at a number of locations on the Internet, including the website of the Kentucky Domestic Violence Association (http://www.kdva.org/adultsafetyplan.html). This website provides a detailed discussion of the elements of a safety plan, along with forms that a victim can take with her and use to begin preparing both physically and psychologically to escape her abusive situation while protecting herself and her children.
Children, when appropriate, should be helped to establish their own safety plans, and the KDVA website provides information for that as well. Nurses and other healthcare professionals should keep these forms and/or information about accessing and completing them available with other resources for domestic abuse victims.
Domestic violence exacts a high price on its victims and on families, communities, and society as a whole. In human terms, the costs are impossible to measure. Violence and the injuries, arrests, and harassment that result can destroy health, family, and life itself.
In economic terms, the costs of IPV against women in the United States are staggering, exceeding $8.3 billion in 2003 (CDC, 2005). These costs include $460 million for rape, $6.2 billion for physical assault, $461 million for stalking, and $1.2 billion in the value of lost lives (Max et al., 2004). The average medical cost for women who experience domestic violence is $483, compared to $83 for men.
This study found that IPV against women resulted in more emergency department visits and hospitalizations than in cases where men were the victims (Arias & Corso, 2005). Prevention of domestic violence and early identification and treatment of victims would likely benefit all healthcare systems in the long run, and would eliminate much pain and suffering for survivors of IPV.
Healthy People 2010 named injury and violence as one of the ten leading health indicators that will be used to measure the health of the United States during the first ten years of the twenty-first century. Health professionals can make a critical difference in the progress toward ending this costly, destructive epidemic and halting the transmission of violence from generation to generation.
Appended to this course is a list of resources including domestic violence hotlines and websites that may be of help to the health practitioner who is seeking more information on this topic. Healthcare agencies should maintain lists of local resources, including shelters and legal assistance. Be aware of the need to ask a victim if finding such information is likely to upset the abuser. If at all possible, have available a concealable resource list for victims who need it.
Prevention is something everyone can participate in. Empowerment should be the guiding force behind victim advocacy and is something all healthcare professionals can promote. Remember to always:
Communities also benefit from advocacy activities. Your agency may be able to do one or more of the following:
Prevention of abuse situations is always the goal; however, our society finds itself dealing with what has been called an epidemic level of violence in daily life. Regardless of our profession, we all have a civic mandate to raise our awareness and that of others in regard to abuse situations, to learn to recognize the early signs, and to know steps to take for intervention (KBN, 1997).
Adult and Child Abuse Reporting Hotline
(800) 752-6200
Spouse Abuse Shelter Hotline
(800) 544-2022
Kentucky Council on Child Abuse Parent Helpline
(800) 432-9251
Alcohol and Drug Abuse Information
(800) 432-9337
Crime Victim Information Line
(800) 372-2551
V/TDD (502) 573-7600
National Domestic Violence Hotline
(Linea Nacional sobre la Violencia Domestica)
(800) 799-SAFE (1-800-799-7233)
TTY number: (800) 787-3224
National Resource Center on Domestic Violence
(800) 537-2238
Rape, Abuse, and Incest National Network (RAINN)
(800) 656-HOPE
American Academy of Family Physicians
http://www.familydoctor.org/
Battered Women's Justice Project
http://www.bwjp.org
Break the Cycle
http://www.breakthecycle.org
Centers for Disease Control and Prevention
http://www.cdc.gov/ncipc/dvp/
Children's Bureau/Administration for Children and Families
http://www.acf.dhhs.gov/
CONNECT: A Mini-Magazine for Parents
Available in English and Spanish at http://www.connect-endabuse.org
Domestic Violence Digest
http://www.dcf.state.fl.us/domesticviolence/about.shtml
Elder Abuse Center
http://www.elderabusecenter.org
Family Violence Prevention Fund
http://endabuse.org
Healthy People 2010
http://www.health.gov/healthypeople/LHI/lhiwhat.htm
Kentucky Domestic Violence Association
PO Box 356, Frankfort, KY 40602
(502) 209-KDVA
(502) 226-KDVA (fax)
http://www.kdva.org
http://www.kdva.org/memberdvprograms.html (links to regional assistance programs)
Kentucky Medical Association
KMA Model Health Care Protocol on Abuse, Neglect and Exploitation: Child, Spouse/Partner, Adult and Elder
http://www.kyma.org/Committees/Protocol_Index_Public.php
Love Is Not Abuse
http://www.loveisnotabuse.org
National Clearinghouse on Child Abuse and Neglect Information
http://nccanch.acf.hhs.gov/
National Latino Alliance for the Elimination of Domestic Violence
http://www.dvalianza.org
National Women's Health Information Center
http://www.4woman.gov/Violence/
Safe Youth
http://www.safeyouth.org
Senior Victim Advocate Program (Pinellas and Pasco Counties [6th Circuit] only)
http://www.myfloridalegal.com/directory
U.S. Department of Health and Human Services (HHS)
http://www.hhs.gov
Violence Against Women Network
http://www.vawnet.org
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