Recognizing the Signs
Most people picture physical abuse, but domestic violence also takes psychological, emotional, sexual, and financial forms, and they often overlap.
Screen Routinely
Jamie Ferrell, director of forensic nursing services at Memorial Hermann Health System in Houston, says a nurse's role starts with understanding that abuse crosses every line of income, education, race, religion, gender identity, and sexual orientation. Look past stereotypes about who abusers and survivors are, and use a trauma-informed, compassionate approach to screen every patient.
"An effective screening is done by creating a safe space with privacy, seeking to understand, not judge, being intentional with communication, and slowing down to hear," she says.
Ferrell recommends folding screening questions into your routine medical history. That keeps the conversation natural and ensures you screen everyone, whether or not you suspect abuse. Lindsay Nelson, MPA, a trauma-informed care trainer, adds that screening should strengthen trust between you and the patient and keep them as safe as possible.
Build Trust
For patients seen regularly by a primary care provider, a checklist of questions can show empathy and knowledge. Do not force disclosure. Build the relationship that lets a patient reveal their situation on their own terms. An interrogation retraumatizes, and disclosing abuse can put a patient in physical danger if the abuser still controls and contacts them.
"A nurse's interaction, even a few minutes, can be supportive by doing certain things that will make the survivor feel safe and empowered, regardless of whether they disclose the abuse they have or are experiencing," Nelson says.
Know the Cycle
Abuse often follows a cycle: a calm phase, then building tension, then an explosion, then a makeup or honeymoon phase. Abusers swing from using tension as an excuse for violence to grand gestures of apology and love. That roller coaster is why a patient may act completely differently right after a violent episode than a day later in the honeymoon phase. Many have been convinced the abuse was their fault, and many show no obvious physical signs at all.
Connect Illness and Abuse
One survey found that women reporting domestic abuse were also more likely to live with several chronic conditions, including back pain, headaches, memory loss, trouble sleeping, depression, diabetes, asthma, anxiety, and digestive disease. The association runs both ways, so a patient presenting with these is not necessarily a survivor, but the pattern is worth noting.
How This Care Is Different
Caring for someone who has experienced domestic or intimate partner violence is not like routine care. Safety comes first, because care itself can trigger the abuser's violence. Ferrell advises a holistic approach: a comprehensive physical assessment alongside psychological support and emotional comfort. Patients often arrive with children whose needs you must explore and address with the patient.
Nelson reminds nurses that patients often see healthcare as a position of power, which can feel intimidating and make it harder to speak up. Counter that by walking the patient through every step of the visit and asking permission or explaining each action before you take it. That helps them feel in control, avoids retraumatizing them, and builds trust.
Be careful with any recorded or written communication the abuser could access, like a voicemail, email, or insurance paperwork. If the abuser learns the patient sought care, it can trigger a violent response and immediate danger.
Navigating the Care
As mandated reporters, nurses carry a legal duty to follow state law and an ethical duty to protect their patients' rights, and the two can conflict in emotionally hard situations. According to the National Association of Mandated Reporters, intimate partner violence does not carry the same reporting requirements as other forms of domestic abuse in many states.
Nelson advises telling the survivor you are a mandatory reporter before asking questions that might prompt disclosure. "Survivors have had their choice taken away time and again, so it is vital that they understand and get to choose whether to disclose abuse and understand the possible consequences," she says.
If there is a language barrier, always use a professional interpreter, never staff or family, to reduce the risk of misunderstanding or of the conversation reaching the abuser. Build relationships with community resources and keep printed materials to share, but make sure the abuser cannot find them, since that places the survivor in real danger. Do not document abuse in records that could be requested by the abuser or relatives or that may become public. Beyond that, Nelson advises:
- Don't talk down to or belittle the patient based on their situation.
- Don't assume whether they are a survivor, what they feel, what is best for them, or that leaving is easy.
- Help with insurance cost estimates, since the abuser may control the money.
- Follow through and be reliable. You may be the only person the patient trusts.
- Stay patient and even-toned.
- Give the patient information and options for treatment.
- Ask permission before touching the patient.
- Remember survivors can be any gender, not just women.
- Ask about the children's health and offer referrals or exams when possible. Many patients stay in abusive situations because leaving can be more dangerous for their kids.
Throughout, keep the focus on patient care, safety, and trust.
Frequently Asked Questions
How common is domestic violence among patients? It is widespread. The CDC reports that about 1 in 4 women and nearly 1 in 10 men experience intimate partner violence in their lifetime, so nurses encounter survivors in every setting whether or not anyone names it.
Should I screen every patient or only those I suspect? Screen everyone. Folding a few questions into your routine medical history keeps the conversation natural, removes the assumption that abuse follows a stereotype, and catches cases you would never have suspected.
Are nurses required to report intimate partner violence? It depends on your state. Nurses are mandated reporters, but intimate partner violence among competent adults does not carry the same reporting requirements as child or elder abuse in many states. Tell the patient you are a mandated reporter before asking questions that might prompt disclosure, and know your own state law.
What if the patient does not disclose the abuse? Do not force it. A few supportive minutes still help, and pushing for disclosure can retraumatize a patient or put them in physical danger if the abuser still controls them. Build trust so they can return when they are ready.
How do I keep a survivor safe during the visit? Use a professional interpreter rather than family or staff, avoid recorded or written communication the abuser could access, do not document abuse in records the abuser could request, and walk the patient through each step so they feel in control.
Who is at risk? Anyone. Abuse crosses every line of income, education, race, religion, gender identity, and sexual orientation, and survivors can be any gender, not only women.