Domestic and Community Violence Nursing CE Course

3.0 ANCC Contact Hours AACN Category B


Please note: This course is not yet approved for providing the newly required Domestic and Sexual Violence training in Massachusetts. If you would like notification for when this approval is issued please contact [email protected]

If you are not licensed in Massachusetts, this course is still accredited to provide 3 contact hours of CE.

Violence permeates every aspect of our society. Millions of people suffer the physical, emotional, and economic consequences of violent acts each year. Violence is defined as the deliberate use of physical or mental force or power to intentionally control another person, group, or community often resulting in injury, emotional trauma, neglect, maldevelopment, or death.   Violence can be directed toward an individual, family, stranger, or acquaintance, depending on its form. Mass events, either man-made or natural, are becoming more common with significant effects at the community level. 

Although nursing has been considered one of the most trustworthy and ethical professions, it is unfortunate that workplace violence occurs in the various practice settings.  Nurses are compassionate and caring individuals, but bullying and incivility are occurring too often in our workplaces. 

Violence against a person who has a mental illness is more likely to occur when factors such as poverty, transient lifestyle, or a substance use disorders are present.  A person who has a mental illness is no more likely to harm others than a person who does not have a mental illness. A history of mental illness does not necessarily predispose an individual to violence.  The factors most likely to predict violence between strangers are a history of violence and involvement in criminal activity.

The purpose of this presentation is to familiarize the nurse with the various types of violence and how these acts affect individuals, families, and communities. This information, combined with the nurse’s experience, will help foster creative and strategic thinking about the recognition of various types of violence, risk factors, and interventions including preventive measures that can be taken.

Types of ViolenceDomestic, Workplace, and Community


According to the Centers for Disease Control:

  • Victims of one form of violence are at higher risk of becoming a victim of other forms of violence
  • Those who have been victimized are at higher risk for behaving violently themselves.
  • Perpetrators of one form of violence are more likely to commit other forms of violence.
  • In 2014, nearly 16,000 people were victims of homicide. Suicides accounted for more than 42,000 deaths.
  • In 2014, emergency departments reported treating more than 534,000 young people, aged 10–24 years, for nonfatal injuries sustained from assaults.
  • In 2013, 678,932 children were found to be victims of maltreatment by child protective services; 1,484 of those children died from abuse and/or neglect.


Domestic violence is defined as a pattern of behavior, threatened or real, used by a perpetrator to gain power or control over another. Domestic violence takes many forms most commonly occurs within family groups. Domestic violence occurs across all economic and educational backgrounds and racial, ethnic and sexual groups in the United States, although social and economically disadvantaged groups exhibit higher rates of domestic violence than other groups. Gender and sexual orientation do not preclude violent behavior; although men are less likely to be physically abused than women.  Abusive behaviors can occur against children, intimate partners, or vulnerable adult family members, such as the elderly or disabled.  For the child under the age of three, the perpetrator often perceives the child as being different than expected.  Other risk factors include the child being the result of an unwanted pregnancy, being physically or developmentally disabled, or having a chronic illness.


Physical Violence occurs when physical pain or harm is directed toward another.

  • Behaviors include, but are not limited to, hitting, slapping, shaking, grabbing, pinching, and burning,
  • Examples:
    • An infant or child, as is the case with shaken baby syndrome (caused by violent shaking of young infants) 
    • An intimate partner, such as striking or strangling the partner 
    • A vulnerable adult in the home, such as pushing an older adult and causing him/her to fall 
    • A vulnerable child or adult who is denied medical care

Sexual Violence occurs when coercive sexual contact or behavior takes place without consent, whether the vulnerable person is able or unable to give that consent. It transcends gender and sexual orientation.

  • Examples of sexual violence include, but are not limited to, marital rape, attacks on sexual parts of the body, or treating the victim in a sexually demeaning manner

Emotional/Psychological Violence occurs when an individual is exposed or subjected to behavior that may result in mental trauma including anxiety, chronic depression, or post-traumatic stress disorder.

  • Examples of these behaviors include, but are not limited to, constant criticism, threats and intimidation, name-calling, humiliation, and depreciation of one’s worth.
  • Gaslighting is a term used to describe a form of emotional manipulation where false information is presented that causes a victim to question his/her memory, perception, or even sanity.

Neglect includes the failure to provide adequate care such as:

  • Physiological care (food, water, shelter, clothing)
  • Emotional care, such as interacting with a child, or stimulation necessary for a child to develop normally
  • Education, such as enrolling a young child in school 
  • Necessary health or dental care, such as immunizations
  • Abandonment, where a child has been left alone in circumstances that are potentially harmful, is considered a form of neglect.

Economic Maltreatment occurs when the needs of a vulnerable person are not met when adequate funds are available or when another controls a vulnerable individual’s financial resources.

  • Common in the elderly population with loss of financial control or access to money 
  • Examples include:
    • Unpaid bills, resulting in disconnection of heat or electricity
    • Forbidding one’s attendance to events or employment



  • Includes physical abuse, neglect, sexual abuse, and behavioral/emotional abuse usually in combination but may be found independently. Emotional abuse is almost always present.
  • The likelihood of child maltreatment increases in the presence of significant stress in the family unit.
  • Family stressors may include:
    • Social stressors such as unemployment, poverty, divorce, or death
    • Health crises including family illness, the presence of alcohol and other substance abuse
    • Mental health issues

According to the U.S. Department of Health and Human Services, Children’s Bureau, Child Welfare Information Gateway:

  • Child abuse is reported on average every 10 seconds, with half of substantiated cases related to parental alcohol or substance abuse.
  • Four children die on average every day from abuse or neglect in the United States; those most likely to die are ages four and younger.
  • Although girls are sexually abused more than boys, boys have a greater risk of emotional neglect and more serious physical injuries.
  • Existing evidence indicates that neglect may be more detrimental to a child’s early brain development than physical or sexual abuse.
  • Risk for physical abuse and neglect is higher in single parent families.
  • Perpetrators in abuse deaths are primarily fathers and mothers’ boyfriends, although mothers are more often at fault when death is due to neglect.

Manifestations of Child Abuse and Neglect Associated with Specific Age Groups


Warning signs and symptoms depend on the type of abuse.  Since an infant cannot communicate with the nurse, the nurse must be highly diligent in assessment techniques. Sometimes the only sign that something is wrong is inconsolable crying, which unfortunately has many causes.


  • Bruises on the soft tissue of the body, ears, neck, and trunk need further evaluation; any bruising on a non-ambulating infant is suspicious
  • Burns covering “glove” or “stocking” areas of the hands or feet can indicate forced immersion into boiling water; small, round burns can be from lit cigarettes. 
  • Fractures with unusual features, such as forearm spiral fractures, could be a result of twisting the extremity forcefully; the presence of multiple fractures (old or new) is suspicious. 
  • Inflicted traumatic brain injury, such as Shaken Baby Syndrome (SBS) may present with a wide range of symptoms.
  • Glassy-eyed, difficult in focusing or lifting the head
  • Bulging fontanels; increased head circumference
  • Appear rigid, lethargic, or irritable
  • Diminished appetite with difficulty feeding or vomiting 

In severe cases, the infant may be unconscious, have respiratory distress, retinal hemorrhage, or seizures


  • Evidence of genital injury or trauma may be present
  • Blood in the diaper
  • Evidence of sexually transmitted infection


  • Listlessness
  • Fear


  • Delayed or poor growth or weight gain; poor hygiene
  • Lack of proper clothing or supplies
  • Lack of necessary health or dental care, such as immunizations

Preschoolers to Adolescents

Warning signs and symptoms depend on the type of abuse and the age of the child.  Presence of these warning signs and symptoms do not necessarily constitute abuse. During an encounter, a child may be uncomfortable with being touched, appear frightened of parents or other adults, afraid to go home, behave in a hostile manner, or be withdrawn. Consequences can be serious and long term, with lifelong patterns of depression, anxiety, low self-esteem, inappropriate or troubled relationships, or lack of compassion for others.


  • Unusual or unexplained bruising, fractures, or burns particularly occurring on the abdomen, back, and buttocks. Determine the mechanism of injury to determine congruency with the physical appearance of the injury.
  • Bruising on arms and legs is not uncommon in this group – particularly in active children. 
  • Numerous bruises at different stages of healing can indicate ongoing physical abuse. Be suspicious of bruises or welts that resemble the shape of a belt buckle or other object. 
  • Burns covering “glove” or “stocking” areas of the hands or feet can indicate forced immersion into boiling water; small, round burns can be from lit cigarettes. 
  • Fractures with unusual features, such as forearm spiral fractures, could be a result of twisting the extremity forcefully; the presence of multiple fractures (old or new) is suspicious. 
  • Evidence of human bite marks.
  • Head injuries may present with a change in the level of consciousness, equal and reactive pupils, and nausea or vomiting.


  • Signs of depression or anxiety, feelings of shame or guilt with low self-confidence
  • Sexually abused children may exhibit no physical findings; may not verbalize any complaints; or may verbalize he/she was sexually abused/touched in the genital area
  • Inappropriate sexual behavior or knowledge; highly sexualized play; unexplained fear of a specific person or place
  • Pregnancy or sexually transmitted infection
  • Blood noted in the child’s underwear
  • Difficulty walking or sitting or complaints of genital pain
  • The victim may sexually abuse another child


  • Signs of depression, loss of self-confidence, or self-esteem
  • Avoidance of certain situations; lack of interest or enthusiasm for previously enjoyed activities; a decrease in school performance
  • Emotional development delays
  • Attention/affection seeking; conduct disorders; extreme behaviors; cruelty, and delinquency
  • Medical symptoms with no discernible cause


  • May appear undernourished
  • Present with sleep disorders
  • Delayed or poor growth or weight gain; poor hygiene
  • Lack of proper clothing or supplies
  • Binge eating or hiding food for later; begging for or stealing food
  • Failure to enroll a young child in school; poor school attendance 
  • Lack of necessary health or dental care, such as immunizations
  • Inappropriate mood swings; indifference; poor self-esteem
  • The older child may be involved in promiscuity, drugs, or delinquency

Vulnerable Adult Abuse

Vulnerable adults are persons who are dependent on others to provide for their basic needs including:

  • The elderly
  • The disabled (physical, emotional, or developmental disorders)
  • Those with chronic diseases

Vulnerable adults also include those who live in long-term care facilities or receive care in their own home

Adult abuse includes physical or sexual abuse, financial exploitation or neglect, abandonment, and behavioral/emotional abuse. Financial exploitation is reported more frequently than emotional, physical and sexual abuse, or neglect.

Perpetrators typically include family members (children/grandchildren, spouse, or others) and other caregivers in nursing facilities or the home.

According to the National Council on Aging:

  • Elders who are abused have a 300% higher risk of death compared to those without abuse.
  • Approximately 1 in 10 Americans aged 60 or older have experienced some form of elder abuse.
  • Both women and men abuse the elderly; nearly 60% of the abusers are family members, particularly adult children or spouses


  • Bruises, lacerations, abrasions, burns, fractures or other injuries in which the physical appearance does not match the history or mechanism of injury.
  • Important to remember: as people age, their bodies typically become frailer and are subject to injury; therefore, physical injuries are not necessarily a sign of abuse.

[Hardest to verify given diminished cognitive function or inability to communicate by the vulnerable adult]

  • Pregnancy of reproductive-age non-consenting vulnerable adult
  • Evidence of a unexplained sexually transmitted infection
  • Unexplained vaginal or anal bleeding
  • Torn, stained, or bloody underclothing
  • Bruises around the breasts or genitals


  • Sudden change in behavior or level of alertness that cannot be explained
  • Unexplained abandonment of normal activities
  • Isolation of the adult when not medically necessary
  • Personal freedoms limited or strictly controlled by caregiver
  • Caregiver use of threats, intimidation, or belittling
  • Arguments with caregiver; guarded, strained, or tense interactions


  • Basic daily needs are not being met: lack of sufficient supplies such as food, season appropriate clean clothing, hygiene
  • Environment is unhealthy/unsanitary
  • Unusual weight loss, malnutrition, dehydration
  • Unmet medical needs such as access to needed services or medical aids (hearing aids, glasses, walker, or wheelchair)
  • Untreated physical problems (i.e. pressure ulcers)
  • Unsafe living conditions (lack of heat, running water and others)
  • Abandonment at a public place


  • Reported loss of financial control or access to money
  • Signing important documents under coercion
  • Creating a new will with new beneficiary
  • Signing property transfer papers; power of attorney
  • Substantial withdrawals from the vulnerable adult’s bank accounts
  • Missing items or cash from the household
  • Reported loss of utilities due to unpaid bills 
  • Financial activity that the vulnerable adult could not have performed independently
  • Unnecessary services, goods, or subscriptions

Intimate Partner Violence

Intimate Partner Violence (IPV) is defined as the use of coercive behaviors by a perpetrator to establish power and control over an intimate partner. Fear and intimidation, as well as the threat of violence, are the behaviors frequently used, often repeated over time. Intimate partners can be current or former spouses or significant others; heterosexual, gay, or lesbian; or living together, separated, or dating.

The National Intimate Partner and Sexual Violence Survey (NISVS) is an ongoing survey developed by the Centers for Disease Control and Prevention to collect data on intimate partner violence, sexual violence and stalking victimization in the United States. Key findings of the 2016 publication include:

  • About 27% of women and 11% of men have been subjected to sexual violence, physical violence, or stalking by an intimate partner.
  • 22.3% of women experience at least one act of severe physical violence by an intimate partner during their lifetime; 14% of men experience at least one act of severe physical violence by an intimate partner during their lifetime.
  • Women typically experience several forms of IPV including rape, physical violence and stalking, whereas men typically only experience physical violence.
  • Those who have experienced an attempted or completed rape during their lifetime using force or with alcohol/drugs: 1 in 5 women and 1 in 59 men.
  • Approximately 32% women and 13.3% men are victims of some form of non-contact unwanted sexual incident during their lifetime.
  • It is estimated that 6.8 million men were forced to penetrate another person in their lifetime.

Cycle of violence between intimate partners

The pattern of IPV consists of three phases: the tension-building phase, the acute battering incident, and the honeymoon phase.

  • Tension-building phase: The abuser has minor episodes of anger and can be verbally abusive and responsible for some minor physical violence. The vulnerable person is tense during this stage and tends to accept the blame for what is happening.
  • Acute battering phase: The tension becomes too much to bear, and serious abuse takes place. The vulnerable person can try to cover up the injury or try to get help.
  • Honeymoon phase: The situation is defused for a while after the violent episode. The abuser becomes loving, promises to change, and is sorry for the behavior. The vulnerable person wants to believe this and hopes for a change. Eventually, the cycle begins again.

Periods of escalation and de-escalation usually continue with shorter and shorter periods of time between the two. Emotions for the abuser and vulnerable person (fear, anger) increase in intensity. Repeated episodes of violence lead to victim feelings of powerlessness.

Major types of IPV behavior include:

Physical Abuse

  • Exists in all communities and is not limited to any age, gender, sexual orientation, race/ethnicity, religion, or nationality
  • Does not typically occur in isolation; physical abuse is the perpetrator’s push to establish power and control over the intimate partner.
  • Abusive actions may include, but are not limited to, hitting, biting, slapping, punching, kicking, burning, choking, throwing, shoving, or other physical force. The use of a weapon, restraints, or one’s body, size, or strength can also occur in conjunction with other actions; abusive actions usually do not occur in isolation.
  • Battering, a form of physical abuse, is a pattern of repeated physical violence by a perpetrator with the intent to coerce, intimidate, and oppress the partner.

Sexual Abuse

  • Occurs when forcing a partner to engage in a sexual act without their consent or when they are unable to consent or refuse.   
  • Ranges from unwanted coercive sexual intercourse (rape) to nonphysical sexual experiences that make an individual engage in sex against their will.
  • The many forms of sexual violence within an intimate partner relationship include marital, date, and acquaintance rape. Marital rape is forced intercourse within a marriage.
  • Elements of legal definition of rape:
    • Lack of consent
    • Penetration – completed or attempted
    • The use of force, threat of bodily harm, or when a person is incapable of giving consent, due to alcohol/drugs or mental disability.

Other intimate partner violence/sexual abuse acts include sexual degradation, sexual harassment, intentional harm of someone during sex, assault upon the genitals (use of sex objects), and initiating sex when someone is not fully conscious or afraid to say no; or forcing someone to have unprotected sex.

Stalking Behavior

Stalking is also associated with IPV, and is defined as a pattern of repeated, unwanted attention and contact that produces fear of harm or concern for one’s safety or the safety of the their family or friends.  Stalking is used to intimidate and control the victim.

Stalking is often an indicator of other forms of IPV. According to the National Coalition Against Domestic Violence, 81% of women who were stalked by an intimate partner were physically assaulted by that partner, while 31% were sexually assaulted.

Stalking behaviors include, but are not limited to, watching or following; spying; making unwanted phone calls, emails, or texts; leaving written items; sending unwanted flowers or other gifts; accosting or showing up at the same places; sneaking into the victim’s home or car; damaging the victim’s property; harassing and threatening the victim’s pets; and threatening to physically harm the victim.

Emotional/Psychological Abuse

Involves psychological aggression to harm another person mentally or emotionally to obtain control. The perpetrator uses verbal and non-verbal communication to threaten an intimate partner, threaten the intimate partner’s belongings or loved ones, or cause damage to the partner’s sense of self-esteem or self-worth. 

Examples include expressive aggression, coercive control, threats of physical or sexual violence, control of reproductive or sexual health, exploitation of an intimate partner, and/or gaslighting.

  • Expressive aggression includes name-calling, behavior intended to make the partner feel diminished or embarrassed, and humiliating the partner in front of others
  • Limiting the intimate partner’s access to transportation, money, friends and family, as well as excessive monitoring of whereabouts are examples of coercive control
  • Threats of physical or sexual violence as previously discussed
  • The perpetrator may refuse to use birth control or force pregnancy termination in order to control reproductive or sexual health
  • The intimate partner may be exploited in the presence of a vulnerability such as immigration status or disability 
  • Lyinh, or presenting false information to the victim, with the intent of making them question his/her memory, perception, or sanity
  • Stalking includes repeated harassing or threatening behavior as previously discussed


Defined as a committed or attempted sexual act without freely given consent of the victim, or against someone unable to consent or refuse.

The perpetrator may or not be an intimate partner; the perpetrator may be a friend, acquaintance, or stranger - it may be physically forced or facilitated with the use of alcohol or drugs.

Various types of sexual violence include:

  • Rape or penetration of a victim includes unwanted vaginal, oral, or anal sexual acts completed or attempted, forced or facilitated by drugs/alcohol. The perpetrator uses physical force against the victim or threatens the victim with physically harm.
  • Forcing a victim to penetrate the perpetrator or someone else includes unwanted vaginal, oral, or anal sexual acts completed or attempted, forced or facilitated by drugs/alcohol.
  • Consent to penetration by virtue of non-physical pressure includes verbal pressure, intimidation, or misuse of authority to get the victim to agree.
  • Unwanted sexual contact includes deliberate touching of the victim or making the victim touch the perpetrator in the genital, anus, groin, breast, inner thigh, or buttocks areas. Done directly or indirectly through the clothing.
  • Unwanted sexual experiences not involving physical contact include unwanted exposure to sexual situations (i.e. pornography); verbal or behavioral sexual harassment; and/or unwanted filming, taking or disseminating photographs of a sexual nature.


A form of human trafficking and is defined as “the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act” by the Trafficking Victims Protection Act of 2000.

Sex Traffickers use violence, threats, lies, force, fraud, or other forms of coercion to make victims perform commercial sex acts against their will; often give false promises, promote a sense of protection, isolate the victim, and perpetuate a sense of debt.

Although victims are typically women and girls, men and boys may also be targeted. Victims represent all races, ethnicities, sexual orientation, gender identities, and income levels. Any victim under the age of 18 years of age who is forced to perform commercial sexual acts are victims of sexual trafficking.

Traffickers target vulnerable populations, including runaway and homeless youth, victims of domestic violence, war, or social discrimination. Recruitment efforts are through social media, hanging out at train/bus stations, truck stops, or at hotels/motels. 


[KW1] Domestic violence occurs throughout all age groups, ethnicities, income levels, and educational levels. However, there are risk factors associated with the abuse of power and control by a perpetrator. These risk factors are shared among the different types of violence.

  • Family conflict is a shared risk factor for multiple types of violence.
  • Young people are at a higher risk for violence when they associate with [KW2] friends or peers who are involved in criminal activities.
  • A victim of one type of violence is more likely to experience other types of violence.
  • A female partner is the usual vulnerable person in intimate partner violence, but a male partner can also be a victim. 
  • Vulnerable people are at the greatest risk for violence when they try to leave or have recently left a relationship.
  • Pregnancy, especially if unplanned, tends to increase the likelihood of violence toward the woman; the reason for this is unclear.
  • Older adults or adults with a physical or mental disability are vulnerable because they may be in poor health, exhibit disruptive behavior, or are dependent on a caregiver. The potential for violence against these individuals is highest in families in which violence has previously occurred.


  • Demonstration of low self‑esteem and feelings of helplessness, hopelessness, powerlessness, guilt, and shame
  • Attempts to protect the perpetrator and accept responsibility for the abuse 
  • Possible denial of the severity of the situation and feelings of anger and terror 
  • Isolation from family and friends


Perpetrators of domestic violence use various forms of violence to achieve what they want through power and control of another. Although the following perpetrator characteristics identified are indications of an increased likelihood of violence, the presence of these characteristics does not necessarily mean a person is going to be violent. Violence is never justified in spite of anger or rage.

  • A person who uses threats, intimidation, or physical violence to control a vulnerable person; violence is often used to get what they want 
  • Usually an extreme disciplinarian who believes in physical punishment 
  • Someone who has poor impulse control 
  • Witnessed abuse as a child or was a victim of abuse
  • Abuses alcohol or other substances
  • Unemployed or underemployed
  • Abuses pets



Nurses provide an important link in the detection of domestic violence since they are often the first or only healthcare providers to have contact with the victim. Learning about the manifestations of domestic violence, as well as best practices in data collection and identification of risk factors, are essential skills in detecting and preventing domestic violence.

Nurses are included in most, if not all, Federal and State mandatory reporting laws. These laws require certain individuals, particularly those in the healthcare field who work with vulnerable populations, to report a reasonable suspicion of child abuse or neglect, medical neglect of children and/or the elderly, elder abuse in the community or in long-term care facilities, and/or domestic violence.

Nurses should be familiar with their state’s mandatory reporting laws in order to report a suspicious case correctly. Nurses should also be aware of their organization’s policy regarding reporting suspected cases.  Reporting  suspicions to a supervisor does not necessarily comply with the mandatory reporting laws unless specified in an institution’s policy.

The confidentiality rules of the Health Insurance Portability and Accountability Act (HIPAA) allow state mandated healthcare providers to report suspected abuse, neglect, or domestic violence to the appropriate authorities (45CFR §164.512(b)).

Failure to report suspected abuse as mandated may result in civil and criminal penalties.

A forensic nurse has advanced training in the collection of evidence for suspected or actual cases of sexual assault or other forms of physical abuse.


  • Conduct a thorough nursing history
  • Provide privacy when conducting interviews about family abuse. 
  • Be direct, honest, and professional. 
  • Ask at each patient encounter if he/she has been harmed by someone else.
  • Use language the client understands. 
  • Be understanding and attentive. 
  • Use therapeutic techniques that demonstrate understanding. 
  • Use open‑ended questions to elicit descriptive responses. 
  • Instruct clients regarding normal growth and development. 
  • Inform the client if a referral must be made to child or adult protective services, and be sure to explain the process. 
  • Provide basic care to treat injuries. 


Nursing interventions for victims of domestic violence must include the following: 

  • Ensuring a safe environment 
  • Mandatory reporting of suspected or actual cases of infant, child, or vulnerable adult abuse according to state requirements 
  • Complete and accurate documentation of subjective and objective data obtained 
  • Make appropriate referrals for further care and support, including skill development, such as self‑care and empowerment skills
  • Instruct clients about ways to manage stress/post traumatic stress syndrome

Preventive measures that nurses can take:

  • Provide patients with the information they need to prevent and recognize abuse, neglect, and other forms of violence.
  • Provide information on available resources and important support services and determine when referrals are needed.
  • Support early home visitation programs to prevent maltreatment of children; early prenatal care; encourage participation in parenting classes
  • Recommend programs that enhance self-esteem and empowerment
  • Referrals to safe environments
  • Support positive family dynamics

Care after Discharge

  • Help clients develop a safety plan, identify behaviors and situations that might trigger violence, and provide information regarding safe places to live
  • Encourage participation in support groups 
  • Use case management to coordinate community, medical, criminal justice, and social services
  • Use crisis intervention techniques to help resolve family or community situations where violence has been devastating



The Joint Commission states “intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.”  These are a result of incivility and there are many terms to describe these behaviors such as lateral violence, disruptive behavior, abuse, conflict, and incivility.  No matter what the term, these types of behavior are inappropriate but unfortunately occur frequently in the workplace.  Often times, we are so used to hearing and seeing these types of behavior that it is sometimes hard to identify but even still, these behaviors cannot be ignored.  There are various types of abuse including verbal, nonverbal, sexual harassment, passive aggressive behaviors, and bullying. The consequences of incivility affect the goal of achieving and providing comprehensive safe patient care, where teamwork and collaboration come into play.  Nurse must lead by example, and recognize and report these types of behaviors when they are seen in the workplace.  The American Nurses Association (ANA) has set a “zero tolerance” policy for workplace violence and bullying.  They have further stated that the nursing profession “will no longer tolerate violence of any kind from any source.”  This is a strong statement for the profession of nursing and should be considered by both victims and perpetrators. 


In a statewide survey of South Carolina nurses, 85% of respondents reported being victims of workplace violence, with experienced nurses often listed as perpetrators.  The Nevada Nurses Association developed a seminar to seek solutions surrounding lateral/vertical violence.  After the seminar, survey results found that a failure of leadership contributes to disruptive behaviors by staff nurses.  They also found that 69% of the nurses indicated that vertical violence directed downward ranged from somewhat serious to very serious.  Nurses felt that leaders were not willing to intervene in workplace violence and 73% indicated that targeted nurses were not willing to stand up to workplace violence.  Furthermore, nearly half of nurses feared retaliation if they reported violence directed downward. As a result, 12.4% of the nurses reported leaving a nursing position because of vertical violence. 


The nursing profession has been described as an oppressed group with mostly female members. The actual incidence and prevalence of workplace violence in nursing are unknown, as this violence is often unrecognized and underreported.  Many nurses choose to not act because they believe it is a problem for someone else to deal with and they do not want to get involved.  Workplace violence continues due to this silence. Ignoring the problem will only exacerbate the problem and hurt the profession.



The Joint Commission has recognized 5 categories of workplace violence

  • Threat to professional status (public humiliation)
  • Threat to personal standing (name calling, insults, teasing)
  • Isolation (withholding information)
  • Overwork (impossible deadlines)
  • Destabilization (failing to give credit where credit is due)

Horizontal/Vertical violence occurs when there is any unwanted abuse or hostility within the workplace.  This may include bullying behavior among coworkers and administration as well as abuse from violent patients.  Vertical violence is directed from someone in a position of power toward a coworker who has less power (nurse administrator or manager to nurse, nurse to student, faculty member to student, physician to nurse) and can be devastating to the targeted person, unsafe for patients, and costly to the facility.

Bullying behavior is deliberate with the intention to cause physical or psychological stress to the victim.  The American Nurses Association (ANA) defines workplace violence as “repeated, unwanted harmful actions intended to humiliate, offend, and cause distress in the recipient.”

  • Bullying is repetitive behavior that happens a minimum of twice a week and continues for a minimum of 6 months.
  • Coworkers may use behaviors such as criticizing, intimidation, blaming, fighting among co-workers, refusing to lend assistance, public humiliation, withholding behaviors, and undermining the efforts of targeted individuals.
  • Other actions by perpetrators include name calling, threatening, gossiping, isolating, ignoring, unreasonable assignments, using silence, and making observable physical expressions such as eye rolling

The Joint Commission (2016) has identified several examples of bullying including a manager who is never pleased with performance, gossiping or spreading rumors, intentionally excluding an employee from team meetings, being told “you are too thin skinned” or being repeatedly called to unplanned meetings with the manager where the employee is denigrated. 

Bullies tend to target employees who have inadequate support or are not able to defend themselves from the aggression.  Lack of confidence can cause some student nurses and recent graduates to be more prone to bullying by others.  The targeted victim finds self-defense difficult and cannot stop the abuse. 

The typical victims of bullying are employees who are under the age of 40, female physicians, and unmarried, female employees with less education and who have children at home. 

The most common sites in healthcare facilities where bullying occurs are the critical care units, emergency rooms, and behavioral health care units. 

Bullies may have personality traits where they feel they need to be in control, inability to belong to a group, abusive behavior, lack of self-restraint, or exhibit poor self-esteem. Bullies often rally support from others as a means of endorsing their behaviors. 

Powerlessness, anger, and frequent work absences, along with related suicides, have been reported with repeated acts of bullying. The ANA also advocates preventing bullying and to “promote healthy interpersonal relationships” and for nurses to become “cognizant of their own interactions, including action taken and not taken.”  They recommend the following:

  • Provide a mechanism for RNs to seek support when feeling threatened;
  • Inform employees about available strategies for conflict resolution and respectful communication; and
  • Offer education sessions on incivility and bullying, including prevention strategies.

Violent patients

  • Patients with cognitive impairment may act violently regardless of the cause of impairment (intoxication, dementia, or emerging from anesthesia)
  • Patient violence may also be triggered when providing patient care, especially when the nurse is in close proximity to the patient
  • Patients who are restrained may actually cause further violence as the patient resists the restraint. 
  • 4.5% of violent encounters in 2014 were against emergency services personnel with patients accounting for 90% of this violent behavior.
  • Inpatient mental health units are also areas of higher risk for violence.  The annual incidence for all staff members working on mental health units units was 70% for physical assault. Mental health aides have 69 times the national rate of violence in the workplace.
  • Aides working in long-term care facilities are also at high risk with 59% reported being assaulted weekly and 16% daily.; Aides who work in dementia units experience the most violence. Slightly over 50% of these aides reported being physically injured by a patient, with 38% requiring medical attention.


Nurses often work in stressful environments and bullying behaviors increase this stress.  Bullying behaviors contribute to burnout and ultimately push nurses out of the healthcare profession, which exacerbates the current nursing shortage.  According to the Joint Commission, the estimated cost of replacing a nurse is $27,000 to $103,000. 

Nurses who are victims of workplace violence are in poor positions to care for patients and patient safety is compromised.  The victim often feels incompetent as a nurse, which leads to suboptimal nursing care.  This can result in increased costs to patients, families, and the institution due to compromised care.

A patient who witnesses nurses or physicians being openly uncivil to one another may be concerned about the impact this behavior has on the care they will be receiving.

Nurses also need to be aware of past experiences that may lead to incivility.  These may include home and work life experiences, training characteristics, cultural, ethnic, generational, and gender biases, hierarchy and role perceptions, personal values, communication styles, and other issues that affect a coworker’s mood, attitude, and actions.

Impairment may be another cause for incivility such as substance abuse, mental illness, or personality disorders.  

Certain traits can be identified in perpetrators of violence.  Many of these individuals feel that they are above the rules and regulations in a workplace and that rules do not apply to them.  They may have been in a certain workplace for a long time and feel privileged and entitled to behave in certain ways.  Perpetrators often lack insight into how their behavior may be affecting their coworkers.  These individuals may become defensive toward those who question their work and they are not considered team players.  Committing workplace violence is a way that the perpetrator attempts to display some type of control over a situation, which may be due to low self-esteem.

Feelings of inadequacy and depression may develop after exposure to workplace violence.  Physical symptoms such as fatigue and insomnia may occur producing a feeling of dread prior to reporting to work.



The American Nurses Association Code of Ethics indicates that professional nurses are responsible for attaining and maintaining work environments consistent with professional values.  Providing opportunities for education and professional development is important in preventing violence in the workplace.

The ANA asks nurses and employers to jointly create and nurture a healthy, safe, and respectful work environment.  Based on the “zero tolerance” policy, the ANA has suggested ways for healthcare organizations to prevent and mitigate violence by:

  • Establishing a shared and sustained commitment by nurses and their employees to a safe and trustworthy environment that promises respect and dignity;
  • Encouraging employees to report incidents of violence, and never blaming employees for violence perpetrated by non-employees;
  • Encouraging RNs to participate in educational programs, learn organizational policies and procedures, and use “situational awareness” to anticipate the potential for violence; and
  • Developing a comprehensive violence prevention program aligned with federal health and safety guidelines, with RNs input. 

Cultures of respect should be fostered to promote recruitment, retention, and positive patient outcomes. Nurse leaders need to demonstrate trusting behaviors allowing staff to feel supported. Nursing leaders must hold themselves and their peers accountable for modeling acceptable professional behaviors.

Nurses should be aware of these behaviors and recognize that they undermine the culture of safety.  Nurses need to become empowered to address, confront, and move beyond bullying.  This awareness requires nurses to examine their own behaviors and think about whether they are the victim or the perpetrator in actions that are occurring in the workplace.  Being empowered allows nurses to look at what is going on in the workplace and make a substantial change in the environment. 

Nursing staff must take a role in combating this problem and must know policies that govern professional conduct and feel empowered.  Strategies for empowerment consist of confronting and teambuilding, mentorship program, and role-playing as to how to deal with the situation.

Exhibiting assertive behaviors – actions regarding bullying should be confronted during or immediately following the incident.  The conversation must remain empathetic and factual.  The victim should be specific about the behavior that was exhibited and insist that the bullying behavior cease.   The victim should remain calm and focus on the desire to return to a more respectful and professional working relationship.  The victim should not try to rationalize the bully’s behavior but walk away and get help from a third party if necessary.  The nurse can also use the organization’s employee assistance program for additional support and assistance.

Nurses should maintain a healthy view of self so as not to personalize attacks of workplace violence.  A hostile work environment influences the nurse’s confidence level and can prevent an individual from being a competent nurse.

Victims need to be able to discuss workplace violence with another individual and establish a witness to the event;

  • Counseling may be indicated to support emotional needs of the victim and should be initiated early to avoid unnecessary turmoil.
  • Journaling may also be used to document situations as well as provide an emotional outlet for the psychological distress.
  • Reporting workplace violence through proper channels is encouraged.

The victim should not retaliate against the bully in order to avoid escalating the incident into legal action.  Nurse leaders must work with staff to distinguish subjective information from the objective facts and ensure the appropriate disciplinary action is taken.

Nurses should be encouraged to model appropriate behaviors:

  • Demonstrate mutual respect and solidarity; patients and other caregivers will appreciate this.
  • Nurture an environment where others are free to ask questions about each other as well as nursing practices.
  • Be open and accepting of others’ behaviors; make sure communication is open and clear.
  • Remain cognizant of how the professional’s behavior is perceived by the patient.


Watch the following video from American Nurses Association’s (ANA) President, Pam Cipriano.

Review the following evidence-based practices to Preventing Bullying and Civility Best Practices:



Community violence is a broad term used to describe a wide range of intentional or unintentional man-made acts that result in violence that impact individuals, groups and/or larger communities. Persons who are not closely linked to the victim perpetrate intentional man-made events. Typically occurring without warning or understanding, the victims of man-made community violence, particularly children and adolescents, are not only impacted by the violence itself, but are also impacted by witnessing and/or hearing about acts of violence by others. This can result in sudden and often severe physical and/or emotional distress, injuries, or even death among the victims. 


Common types of man-made community violence include individual and group conflict such as youth violence (bullying, gang-related activities, cyber bullying, school shootings), crimes against others (robberies, burglaries, homicides), and social issues (civil unrest, racial tension, terrorist attacks, mass shootings, war related conditions). Man-made violence is also the result of human-caused accidents or events including chemical spills, oil spills, nuclear accidents, and others. Unintentional man-made violence typically results from accidents or events such as chemical spills, oil spills, or nuclear accidents.


Community violence also includes natural events/disasters resulting in physical and emotional distress for victims. Defined as any devastating event instigated by nature or natural processes of the earth, natural disasters may occur with or without warning. Severity is measured in the number of lives lost, the economic loss, and the ability to rebuild. Those events that can be predicted in advance allow individuals time to prepare. Natural disasters result in a wide-range of emotional, physical, and cognitive reactions.  



  • Youth Violence
  • School Violence
  • Gang-violence
  • Bullying/Cyber bullying


  • Hate Crimes
  • Terrorism/Terrorist Activities
  • Human Trafficking



  • Severe Weather Related including damaging winds, drought, extreme temperatures, hurricanes and tropical storms, ice storms/winter weather, tornadoes, thunderstorms and lightning, tsunamis, flooding, landslides, wildfires.
  • Avalanches
  • Agricultural Disease and Pests
  • Disease Epidemics
  • Earthquakes
  • Residential Fires



Defined as the deliberate use of physical force or power by young people between 10 and 24 years of age to terrorize and hurt others. Examples of youth violence include bullying, fighting, cyber bullying, teen dating violence, the use of weapons, and gang violence.

Developed in 1990 by the Centers for Disease Control and Prevention (CDC), the Youth Risk Behavioral Surveillance System (YRBS) is a survey conducted every two years with samples of 9th through 12th grade students nationwide. The purpose is to monitor six categories of priority health risk behaviors that contribute to the leading causes of death, disability, and social problems among youth and young adults. The first priority risk behavior involves those behaviors that contribute to unintentional injuries and violence.

According to this survey:

  • Homicide is the 3rd leading cause of death for 10-24 year olds, accounting for 14% of all deaths.
  • Nationwide, 16.2% of students reported carrying guns or other weapons during the 30 days prior to the survey; 4.1 of students reported carrying a weapon on school property.
  • Students (6%) reported being threatened or injured with a weapon on school property at least once during 12 months prior to the survey.
  • Bullying and cyber bullying continues to be a problem with over 20% reporting being bullied on school property, and 15.5% reported they had been electronically bullied.
  • Students (5.6%) reported they did not go to school because of safety concerns at school or on their way to or from school.

School Violence is youth violence that occurs on school property, to and from school, or to, from and/or during school-sponsored events.

  • Teaching-learning process is disrupted
  • Causes fear, absenteeism, or class disruption

Gang Violence generally refers to violent illegal and non-political behaviors carried out by a group of people against youth, persons in the community, other gangs, and law enforcement officers, firefighters, or military personnel. Gang activities are a major factor in the growth of violent crimes on and off school property.

Bullying/Cyber bullying

Bullying is a pattern of unwanted aggressive behavior, threatened or real, used by an individual or group to control or harm others. It can be verbal, physical or social. 

  • Verbal bullying includes teasing, name-calling, taunting, threatening to hurt someone.
  • Social bullying includes behaviors aimed at hurting someone’s reputation or relationships, such as telling others not to be friends with someone, spreading rumors or embarrassing someone in public.
  • Physical bullying involves behaviors that cause harm or hurt to someone or their possessions such as hitting, spitting, tripping or pushing, breaking someone’s possessions, and making rude hand gestures.
  • Cyber Bullying uses digital devices such as cell phones, computers, and tablets to bully an individual through social media, texting or other sources where content is shared. It causes embarrassment or humiliation to the victim when negative, harmful, false, or mean content is shared. Some cyber bullying could be unlawful or criminal.

Warning signs of bullying

  • Loss of interest in school; increased absenteeism
  • Drop in grades
  • Increased physical complaints, such as headaches or stomachaches
  • Change in demeanor – unusually quiet, depressed, or even aggressive in behavior
  • Bruises or other injuries
  • Unexplained missing or damaged belongings
  • A young person can be a victim, an offender, or a witness to a violent event.

The violence affects not only the young person but also his/her family, school, and community; typically involves youth hurting others unrelated to them,  whom they may or may not know well.

 Youth violence results in emotional/psychological harm, physical harm or death, increased health care costs and legal costs, decreased property values, and disruption of community services.



Community violence is often associated with various social characteristics such as race, religion, sexual orientation, economic status or geographic location.

Hate Crimes

Defined by the U.S. Department of Justice as “the violence of intolerance and bigotry, intended to hurt and intimidate someone because of their race, ethnicity, national origin, religion, sexual orientation, or disability.”

In over 7,700 incidents of hate crimes directed at others, the FBI reported these crimes due to:

  1. Race - 52%
  2. Religion – 19%
  3. Sexual Orientation – 16%
  4. Ethnicity/National Origin – 13%

People who commit hate crimes instigate fear in their victims; victims often feel vulnerable to repeated attacks and feel alienated, helpless, suspicious and fearful.

Hate crimes often trigger larger community-wide racial conflict, civil disturbances, and even riots.

Perpetrators use explosives, arson, weapons, vandalism, physical violence and/or verbal threats of violence to create fear. Reasons someone may commit hate crimes:

  • Ignorance of other people who are different and fear of that difference
  • Compensation for their own low self-esteem by finding someone they can look down upon
  • Victim of violence at one time themselves, and now repeating that behavior

Terrorism/Terrorist Activities

The use of random, calculated violence for the purpose of creating fear to realize a political, religious or ideological objective. Terrorism threatens the community with death and disease, incites fear and panic, and disrupts society.

International terrorism is associated with foreign terrorist organizations or nations.

Domestic terrorism is associated with primarily U. S. movements geared to advance extremist beliefs of a political, religious, social, racial, or environmental nature.

Human Trafficking

Considered a modern form of slavery, human trafficking is a global problem, including in the United States. Victims of trafficking in the U. S. are from all over the world; however, many victims are U. S. citizens. Human trafficking does not require movement of a victim from one place to another.

It is difficult to establish an accurate estimate of the numbers affected by human trafficking since it occurs in places disrupted by poverty, war, armed conflicts, natural disasters, and social unrest and the victims are often hidden.

Polaris, a group dedicated to eradicating modern slavery, has compiled 2016 data regarding human trafficking in the United States.

Human trafficking includes those activities that one person or group of persons undertake(s) for profit to obtain or hold another person in forced service. The categories of forced service include sexual exploitation, labor and domestic service, and trafficking child soldiers. 

Victims of human trafficking include an age range of young children to adults; include both men and women; include U. S. citizens, Lawful Permanent Residents, or foreign nationals; and are located in all areas. The commonality is that these individuals are vulnerable to exploitation.


Hurricanes and tropical storms are dangerous and destructive, causing high winds, flooding, heavy rain, and storm surges on coastal areas. They are typically predicted days to weeks in advance, giving potential victims time to prepare, but also time to anticipate the storm with anxiety and fear. The damage left also create risks for further injury and trauma. Prevention of storms is not possible, although actions can be taken to protect health and safety.

Tornadoes are dangerous and destructive rotating winds extending from a thunderstorm to the ground, causing damage from the extremely powerful winds and flying and falling debris. The path of destruction may be one mile to 50 miles long. Although tornadoes occur with virtually no warning, a Tornado Watch is announced when tornadoes are possible in the area while a Tornado Warning is announced when a tornado is either on the ground or has been detected by radar. Prevention of tornadoes is not possible, although actions can be taken to protect health and safety. The damage left also creates risks for further injury and trauma. Potential victims should be prepared to seek shelter on short notice.

Earthquakes occur with no warning and prevention is not possible. For those who live in areas prone to earthquakes, preparation, planning, and practice activities can increase survival and reduce injuries.

Floods are a temporary spilling over of waterways onto land that is normally dry. The extent of flooding ranges from a few inches of water to several feet – sometimes enough to completely cover a house. Causes range from weather events, or damage to water retaining systems. Flood leads to destruction of the landscape, properties, and can have a devastating effect on families and communities. Floods can occur and build slowly over several days, or occur suddenly with little to no warning. Prevention is relative to the cause but steps can be taken to reduce the damage floods can bring through preparation, particularly in areas prone to flooding.

Wildfires can happen in a natural area anytime and anywhere, with or without warning. Wildfires can cause death or injury to people and animals, damage or destroy homes, businesses, natural resources, and agriculture in its path, and disrupt community services. For those who live in areas that are prone to wildfires, preparation is essential to reduce risk and increase safety.

Extreme Heat occurs primarily in the summer months when temperatures are hotter and/or more humid than the average temperature. Individuals at highest risk for injury include the elderly, the very young, persons with mental illness or chronic diseases, and those who live in low-income housing. Any individual, regardless of age and health status, may increase their risk when they take part in strenuous physical activity in extreme heat without taking preventive measures. Pets are also at risk for heat-related injury or death. Prevention and preparation are key to reducing heat-related illnesses like heat exhaustion or heat stroke.

Winter Weather can produce extremely cold temperatures causing a number of hazards, from power outages and icy roads to health problems. Hypothermia and frostbite are two health problems that can result from prolonged exposure to the cold. Warnings prior to extreme cold temperatures allows individuals to prepare their home and automobiles in advance. 


  • Low socioeconomic areas particularly in urbanized and inner-city living areas
  • Lack of job opportunities/unemployment
  • High crime areas;
  • Substance abuse; drug, alcohol, and or tobacco use; parental substance abuse or criminality
  • Dysfunctional family dynamics; lack of parental monitoring or supervision of children
  • History of victimization, emotional issues, and aggressive behavior; prior exposure to violence
  • Lack of community togetherness
  • Demographics such as gender, age, race, ethnicity, and sexual orientation
  • Individual traits such as coping skills, lack of resilience, and social isolation
  • Living in certain locations that are at-risk for various natural disasters
  • [KW5][KW6] Previous life experiences


Victims include individuals of all ages, groups, or entire communities.

Common stress reactions typically occur immediately after the event and last for several days to several weeks. Reactions can include: 

  • Emotional reactions may include shock, anger, feelings of helplessness, numbness, sadness, and emotional exhaustion.
  • Cognitive reactions may include confusion, trouble concentrating, and indecisiveness.
  • Physical reactions may include fatigue, insomnia, tension, headaches, general aches and pain, tachycardia, nausea, and changes in appetite.
  • Interpersonal reactions may include distrust, feelings of betrayal, withdrawal, problems with coworkers/peers, or feelings of rejection.

More serious stress disorders, such as Post-traumatic Stress Disorder (PTSD), can affect people of all ages and often require clinical intervention. Functional ability is a key component in determining the risk for developing mental health issues. Individuals who are able to function effectively in the home/work/school environment have less risk for developing stress disorders than individuals who are not functioning well. The following manifestations are associated with severe stress:

  • Reliving the event through nightmares, flashbacks, or terrifying memories
  • Emotional numbing
  • Avoidance of disturbing memories
  • Hyper-reactivity to stimuli as exhibited in panic attacks, control issues, or violence
  • Anxiety
  • Depression
  • Dissociation



Nurses play a pivotal role when assessing, diagnosing, and treating victims of community violence, including disaster planning and response.  Immediate nursing interventions must include the following: 

  • Ensure a safe environment for all. Ensure the safety of the caregiver first, before assisting others.
  • Apply crisis intervention strategies that help restore equilibrium for the affected individuals and minimize potential long-term psychological trauma.
  • Identify and refer those individuals at high risk for developing PTSD to counseling services.
  • Make referrals with appropriate community resources for assistance and/or treatment

Although all nurses play a pivotal role in working with the community when dealing with violence, some nurses play a more specific role.

School nurses:

Should possess the knowledge and expertise to help students build self-esteem, develop problem solving and conflict resolution techniques, and improve coping and anger management skills.

In dealing with school violence situations, school nurses play a key role as a member of the crisis intervention team. 

Public health nurses:

  • Should possess the knowledge and skills to develop disaster policies and plans, conduct and evaluate preparedness and response drills, exercises, and trainings.
  • Play key roles in leadership and management of disaster response activities as well as in front-line population health services.
  • Collaborate with other team members to enhance disaster preparedness, response, and recovery at all levels.

Emergency room nurses:

  • Should possess the knowledge and skills to respond appropriately to a disaster and the injured.
  • Play a key role in mitigating, preparing for, and responding to disasters as first responders.

Preventive measures that nurses can take:

In the school:

  • Provide instruction to parents, students, and other members of the community in developing problem-solving and conflict resolution skills in recognizing early warning signs that lead to violence, and a ways to manage stress/PTSD.
  • Engage parents in school activities that encourage them to make solid connections with their children and promote communication, problem-solving, boundaries and supervision.
  • Support school system activities and strategies to protect students, staff, and the school community.
  • Foster a climate that encourages and practices respect for others and for their property, facilitates respectful communication, and builds social interaction skills such as problem-solving, anger management, coping skills, and conflict resolution skills.  

In the community:

Be knowledgeable of community resources:

  • Agencies that assist with ensuring safe environments
  • Agencies that prepare the community regarding emergency disaster preparedness, response and recovery
  • Community violence prevention programs
  • Youth violence prevention programs
  • School-based anti-bullying and safety programs  
  • Programs that assist with the development of social skills
  • Become active in changing social norms regarding community violence and promote prevention and preparedness for violence of any type.

External sources:

In order to complete the post-course assessment, please watch the following video from American Nurses Association’s (ANA) President, Pam Cipriano.

Click here to view the video

Additionally, please read the following article as reference for the learning material above, and questions in the post-course assessment.

Click here to view the article



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Please note: This course is not yet approved for providing the newly required Domestic and Sexual Violence training in Massachusetts. If you would like notification for when this approval is issued please contact [email protected]

If you are not licensed in Massachusetts, this course is still accredited to provide 3 contact hours of CE.