6
Training Beyond the State of the Art

Moving beyond the current state of health professional training on family violence, the focus of this chapter is twofold: (1) to explore potential training content and (2) to examine behavior change in health professionals. With regard to training content, the committee describes and analyzes the concept of core competencies as an approach to establishing expectations for education and then proposes core competencies for health professionals in relation to family violence. These competencies refer to the basic knowledge, skills, and behaviors needed to respond effectively to family violence. In addition to specific core content areas for the health professions addressed in this report, the need for interdisciplinary core content is considered.

Following the discussion of what should be taught is a discussion of how teaching should proceed. The committee reflects on several key concepts that may affect behavior change and the ability of health professionals to learn about family violence: the diffusion of innovation, principles of adult learning, principles of continuing education, sustaining knowledge, building and maintaining what is effective, and independent forces with the potential to influence the education of health professionals, including evidence-based practice and routine outcome measurement.

Identifying appropriate content and teaching strategies is necessary for the development of effective training programs. In the committee’s view, these tasks are at the very heart of its charge. However, progress is limited by the lack of research. A review of available literature reveals a great deal of expert opinion, and in some cases even consensus, about what is needed, but little scientific evidence about the necessary components or methods of family violence cur-



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence 6 Training Beyond the State of the Art Moving beyond the current state of health professional training on family violence, the focus of this chapter is twofold: (1) to explore potential training content and (2) to examine behavior change in health professionals. With regard to training content, the committee describes and analyzes the concept of core competencies as an approach to establishing expectations for education and then proposes core competencies for health professionals in relation to family violence. These competencies refer to the basic knowledge, skills, and behaviors needed to respond effectively to family violence. In addition to specific core content areas for the health professions addressed in this report, the need for interdisciplinary core content is considered. Following the discussion of what should be taught is a discussion of how teaching should proceed. The committee reflects on several key concepts that may affect behavior change and the ability of health professionals to learn about family violence: the diffusion of innovation, principles of adult learning, principles of continuing education, sustaining knowledge, building and maintaining what is effective, and independent forces with the potential to influence the education of health professionals, including evidence-based practice and routine outcome measurement. Identifying appropriate content and teaching strategies is necessary for the development of effective training programs. In the committee’s view, these tasks are at the very heart of its charge. However, progress is limited by the lack of research. A review of available literature reveals a great deal of expert opinion, and in some cases even consensus, about what is needed, but little scientific evidence about the necessary components or methods of family violence cur-

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence ricula. Key competencies may be normatively derived at least in part, but research is needed to support these norms. The literature on teaching methods and provider behavior change is growing, but little research is available on family violence training specifically. The committee’s recommendations rely on the information available and underscore the need for extensive research. TRAINING CONTENT: CORE COMPETENCIES Competency is the ability to perform a complex task or function (Lane and Ross, 1998) and is closely linked to behaviors used as performance indicators for the accomplishment of competence. Knowledge, skills, and behaviors to be achieved on a particular topic typically define competencies. Competencies are not meant to be static; as new evidence is developed and systems change, competencies evolve. There is then a dynamic between research, practice, and educational competencies. The goal in articulating competencies is to set the current standards regarding expectations for training and practice in a field. Performance indicators provide the means to gather evidence as to whether training and practice objectives are achieved and whether stated objectives affect outcomes. Evaluation of competencies provides a method for measuring success in terms of process, outcome measures, and scope of training. The knowledge, skills, and behaviors necessary for effective health professional response to family violence are not yet established, and existing proposals for core competencies in family violence have not yet been evaluated. Because of the substantial prevalence of family violence victims in health care settings, basic knowledge of all forms of family violence is necessary for all health care professionals who provide patient services. Those who ignore family violence, blame victims, or believe they can make decision about what is “right” without consulting the victim can potentially do additional harm (Brandt, 1995; Short et al., 1998). Basic standardized competencies can provide a powerful means to continue the process of educating and evaluating the ability of health care professionals to provide care to persons, families, and communities in the complex area of family violence. Health care professionals, however, vary in their roles and responsibilities and have different degrees and types of interaction with family violence victims. Thus, beyond basic literacy, the committee considers competency levels appropriate to different health care professionals based on variations in perceived needs. Levels of Competence Differentiating competency levels is a means of acknowledging generalist and specialist foci (Adger et al., 1999; American Association of Colleges of Nursing, 1999; Auslisio et al., 2000; Brandt, 1995). For example, the National

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Association for Children of Alcoholics recently published core competencies using a structure with levels (Adger et al., 1999). The first of three levels of competency is presented as the minimum for all health care providers and includes basic knowledge and skills in identifying cases, assessing needs and services, expressing concern, and offering support and referral. Health professionals who choose this role are “not expected to solve, manage, or treat the problem by themselves.” However, they must “be able to collaborate with and refer to those who have the skill and expertise to provide these specialized services” (Adger et al., 1999, p. 1083). Competencies for persons at the next level include prevention, assessment, intervention, and coordination of care. At level three, long-term treatment is added to the list. By not prescribing roles, this leveling schema has the advantage of allowing flexibility. Some health care professionals may need or be required to achieve competence at the advanced, specialized level based on the responsibilities of their roles and positions; others will choose to advance based on personal interest; and others may advance to fill local system gaps in services. The complexity of cases differentiates the need for varying levels of competence, defined in terms of amount of knowledge about the specified area (Auslisio et al., 2000). The Oklahoma Principles, based on a multidisciplinary family violence conference of experts (Brandt, 1995, 1997), provide a detailed set of goals and objectives for three levels: Family Violence 101 includes core competencies to be mastered prior to graduating from a health professions school (e.g., medical school, nursing school, dental school). Family Violence 201 includes curricular principles for practicing primary care providers and for specialty-trained health professionals. Family Violence 301 includes curricular principles for scholars and leaders in family violence (expert clinicians, educators, researchers, curriculum architects, policy experts, and other experts in this field). The bulk of education for the 101 course or level is expected to take place during and within professional school, so that all graduating students can be assumed to have a stable foundation in the field. Education for the 201 level is expected to occur during postgraduate training (residency, advanced clinical work, or first-level graduate study) and is differentiated for primary care providers and specialty trainees, who would be expected to acquire more detailed expertise in more limited areas. Development of the 301 level expertise begins during fellowship or other advanced training and would continue as a dynamic, career-long process. These levels were formulated to guide curriculum development, program evaluation, career development, and policy formulation. The American Association of Colleges of Nursing (1999) offers another scheme, classifying competencies for intimate partner violence according to educational program, baccalaureate versus master’s. The master’s education level moves beyond basic knowledge and skills to leadership competencies, such as developing, analyzing, and evaluating intimate partner violence programs.

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Borrowing from the various approaches in use, the committee divides the development of competencies for addressing family violence into basic, advanced, and leadership competency levels (see Figure 6.1). Determining the specific content of each level for family violence requires further examination and explication. Assigning Competency Roles Who should bear responsibility for providing specialized, advanced care in family violence care is an issue for both national policy and local health care systems. Definition of competencies thus is entwined with the need to build a system of care delivery (Curran, 1995; Lane and Ross, 1998). Curran has identified core competencies in delivering care through integrated delivery networks, including “building a delivery system” (discussed below). Advanced competency (and the necessary education and training) may be distributed among health professionals in a community, as well as within community systems (such as criminal justice and victim advocates) to ensure that the complete spectrum of services is provided. For example, sexual assault nurse examiners provide advanced care for sexual assault victims in many communities, while in other communities other health professionals provide similar care. In any locality, what is vital is that roles are clarified and that health care professionals are adequately trained to provide competent care for victims of sexual assault (both familial and extrafamilial). Advanced competencies may be profession specific or multidisciplinary. With regard to sexual assault, for example, knowledge of normal and abnormal genital anatomy is a basic competency for physicians and nurses but is not within the scope of social work, dentistry, or psychology. The ability to perform forensic examinations in cases of acute sexual assault (adult and pediatric) is a necessary basic competency for physicians, yet an advanced competency for nurses FIGURE 6.1 Levels of competency for addressing family violence.

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence (such as for sexual assault nurse examiners). Professional roles, duties, and ethics influence differences in specialized care. Both the number of providers in any single profession and the competencies themselves may vary by profession and type of family violence. For example, social workers may be likely to incorporate a host of social risks in their care planning (such as homelessness and substance abuse); physicians may focus their expertise on diagnosing and treating injuries and illnesses; nurses may focus on the complex interplay of physical, psychological, and social issues on health. Geriatricians may have advanced competence in elder abuse but only basic competence in child abuse. Health professionals working in primary and secondary prevention may focus on access and system-wide collaboration. However, there will still be a central nucleus of competencies that are the same for any health care professional at any level in any setting (see Figure 6.2). Evidence Supporting Core Competencies While core competencies have been suggested for health professional education on family violence, the committee could find no evidence to support specific content for them. Research is necessary to determine the effect of establishing core competencies, the degree to which health care providers achieve competencies (through training, education, and practice), and, more importantly, FIGURE 6.2 Overlapping professional core competencies for family violence.

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence whether client outcomes are improved when provided care by a “competent” provider. The specification of core competencies can provide a platform for learning, service delivery, and evaluation that proves quite useful in situations in which there is a limited scientific base. Evaluation should include both outcome and process measures to allow refinement of core competencies, including the addition of competencies as needs are identified. However, in the committee’s view, domains exist from which core competencies can be developed beginning with the basic level. A review of existing health professional curricula offers a starting point for identifying and detailing these domains. The committee’s review indicates overlap in a number of content areas developed for health professionals (see Box 6.1). BOX 6.1 Areas of Overlap Among Existing Family Violence Curricula Common objectives include: To recognize family violence as a significant health problem. To develop a comprehensive understanding of the medical implications of family violence, including the signs and symptoms of abuse and neglect, associated health problems, and common treatments. To develop the skills necessary to detect, screen, treat, and protect victims of family violence. To understand and adhere to legal requirements for reporting situations of family violence. To identify and learn to use medical, legal, social, and community services resources appropriately. Common content: Dynamics of family violence Data on the magnitude and prevalence of the problem in various health care settings Family violence as a health care issue—physical and mental health symptoms and patterns of presentation Techniques for identifying victims of family violence Screening tools Documentation and encouragement to document all cases and suspected cases State mandatory reporting legal requirements Other legal issues (e.g., victims’ rights, criminal sanctions, the role of the police and social services, the role of the courts, medical testimony for the courts in civil and criminal prosecutions, and child and adult protection) Referral services Collaborative health care team composition and roles Cultural issues, particularly with regard to variations in acts considered abusive

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence In a few cases, competency domains specific to family violence are addressed. For example, one review notes that competence in family violence “is now part of the expected standard of care for graduating and practicing physicians” (Alpert et al., 1998, p. 278). It describes the goal of curricula on family violence as competence in screening (how to ask the right questions), assessment (how to listen to the patient’s responses and concerns), intervention (offering information, advice, and support), and referral for services. It also addresses some important interpersonal competencies, such as to “efficiently, yet compassionately, evaluate patients’ concerns in the context of evolving life circumstances” (p. 277), appreciation for diversity, and awareness of one’s own attitudes, beliefs, values, and history. Another report identifies some traits for ethics consultations, including tolerance, patience, compassion, honesty, courage, prudence, humility, and integrity as being important and closely related to such skills as active listening and the communication of interest, respect, support, and empathy (Auslisio et al., 2000). These appear to be quite applicable to family violence as well. The complexity of addressing rights for individual autonomy while at the same time ensuring patient safety is a formidable task to be achieved in the family violence arena. However, competence here is necessary for all health care professionals encountering all forms of family violence (NRC and IOM, 1998). The American College of Nurse Midwives similarly supplemented knowledge, skill, and behavior competencies with the “hallmarks of midwifery” (1997), which include, for example, skillful communication, guidance, and counseling. In these and other cases, those proposing competencies acknowledge that practice involves not only science but also the artful application of knowledge in interpersonal relationships and ethical issues with clients. In family violence, this need to attend to interpersonal, ethical, and cultural competencies is considered crucial (American Nurses’Association, 1995; Ryan and King, 1998). The foregoing review of the literature does not provide a scientific foundation for core competencies on family violence for health professionals. The committee struggled with the lack of a scientific evidence base from which to propose core competencies for health professionals and the need for such competencies. What and how much each type of health professional needs to know about family violence remains a matter of debate. However, the literature does suggest important elements and common themes. In the committee’s judgment, the overlap it found in the literature, as well as the literature describing curricular development by consensus processes (e.g., Brandt, 1997), suggests some agreement in the field regarding the appropriate areas for educational intervention. The consensus opinions and products of the formal consensus panels that have developed core competencies provide a very valuable starting point from which to launch evaluative research. Based primarily on the work of the American Association of Colleges of Nursing (1999), Alpert et al., (1998), Brandt (1995, 1997), Heise et al. (1999),

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence and the multidisciplinary expertise of our committee members, the committee drafted proposed core competencies at the basic level within the domains identified in the literature (see Table 6.1). These core competencies reflect the committee’s consensus on best practice, the ideal state of knowledge and skills, published expert opinion, and existing curricula. They were developed to address multidisciplinary care and to be inclusive of family violence across the life span. Content was specified in accord with the areas of overlap found in the curricula the committee examined and proposals offered in the literature. As such, these proposed competencies build on the collective wisdom of those working in family violence. They are not intended as a definitive set of competencies but are offered as a springboard for research and evaluation. The committee emphasizes the need for research on these competencies, or any set that is chosen, to provide a scientific basis and to determine effectiveness. It is our judgment that current training initiatives and educational development should be suspended awaiting scientific evidence, but the need for such evidence must be addressed in the short term. The review of existing curricula and the literature indicate that much of the curricular development to date has largely been done within schools or particular professional groups or by organizations concerned specifically with one type of violence. Thus it appears that much “reinventing the wheel” occurs. In the committee’s view, the various professions and organizations involved with victims of family violence could benefit greatly from collaboration in developing, testing, and evaluating core competencies on family violence. Advanced competencies for responding to family violence have yet to be developed, with some notable exceptions. For example, the American Association of Colleges of Nursing (1999, http://www.aacn.nche.edu/publications/positions/violence.htm) recently published nursing education competencies for domestic violence (see Appendix H). To date, neither child abuse and neglect nor elder maltreatment have been addressed. The basic competencies set forth in Table 6.1 and the advance practice competencies of the American Association of Colleges of Nursing may provide all health professions with some helpful material to start to inform their own discussions leading to core competency descriptions and research. In addition, the list may provide a starting point from which collaborative work across professions can begin. Advanced practice education does exist in other areas. For example, subspecialty residencies have been established for developmental pediatrics and adolescent health. Following increased research and a growing recognition of the need for cross-disciplinary training in these areas, the Maternal and Child Health Bureau of the Health Resources and Services Administration funded advanced-level training programs. The adolescent health program, for example, grew out of research on adolescence that began in the 1950s. In 1967, the Maternal and Child Health Bureau funded adolescent programs at 6 sites that included 14 physicians. In 1976, the bureau funded 9 new sites and extended training to

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence TABLE 6.1 Basic Level of Core Competencies Needed for Addressing Family Violence by Health Care Professionals Competency Performance Indicators Identify, assess, and document abuse 1. Recognize risk factors for victimization and perpetration of violence. 2. Recognize physical and behavioral signs of abuse and neglect, including patterns of injury (including unusual forms of abuse such as Munchausen syndrome by proxy and poisoning), across the life span. 3. Screen for family violence experiences using valid and reliable instruments that are developmentally appropriate. 4. Assess clients via interview and appropriate health examination processes. 5. Document injuries and health effects, using forensic guidelines in obtaining and recording evidence (such as recording specific, concise, and objective information utilizing body maps and photographs). 6. Identify and address problems of emotional, physical, and sexual abuse and neglect. Intervene to secure safety and reduce vulnerability 1. Assess for immediate danger. 2. Develop a safety plan with victims and families. 3. Consult with and refer to specialists and community resources for safety, education, caretaking, and support services (such as protective services, social work, shelter, child abuse hotlines, legal, mental health, substance abuse, and criminal justice) as appropriate. 4. Maintain appropriate clinical follow-up. Recognize that cultural and value factors influence family violence 1. Communicate nonjudgmentally and compassionately. 2. Recognize the cultural factors important in influencing the occurrence and patterns of responses to family violence. 3. Provide culturally competent assessment and intervention to victims and perpetrators of family violence. 4. Explain culturally normative behaviors and relationship patterns that could be misconstrued as dysfunctional and/or violent. Recognize potential dilemmas in providing care and accessing resources that may arise from cultural differences. Recognize legal and ethical issues in treating and reporting family violence 1. Know state reporting laws and mandates, local and state reporting agencies, and their procedures and regulations, including potential liability for failure to report. 2. Know ethical principles that apply to patient confidentiality for victims as well as the limits of that confidentiality. 3. Understand the need to balance respect for individual autonomy with concerns for safety of vulnerable persons when making reporting decisions. 4. Understand the health professional’s role in court testimony (as either a regular or an expert witness).

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Competency Performance Indicators Engage in activities to prevent family violence 1. Promote activities to increase public awareness of family violence. 2. Promote activities to address populations at risk. 3. Participate in health policy activities to address family violence. 4. Promote community action to establish and enhance programs to support victims and family members and for perpetrator interventions, especially at early stages. 5. Understand the impact of services (such as home visitation nurses) on the prevention of physical abuse and neglect. 6. Understand the principles of prevention of family violence (including sexual abuse of children). professionals in nursing, social work, nutrition, and psychology. In 1994, adolescent medicine achieved the formal status of a subspecialty and became a 3-year program. In 1997, the Residency Review Committee for Pediatrics began requiring that pediatric residents complete a 1-month block rotation in adolescent medicine. Because of these requirements, 96 percent of programs report having an adolescent medicine block rotation, 90 percent of which are required (Emans et al., 1998). However, only 39 percent of programs felt that the number of adolescent faculty was adequate for teaching residents, and while many topics are believed to be adequately covered (e.g., sexually transmitted diseases, confidentiality, puberty, contraception, and menstrual problems), many others continue to be inadequately covered (e.g., psychological testing, violence in relationships, violence and weapon-carrying, and sports medicine) (Emans et al., 1998). The development of such training programs demonstrates an approach to the advanced-level training necessary in family violence, but it also reveals the challenges. The programs became possible only with the increase in attention to and research on adolescent health needs and the subsequent availability of funds. Research indicated that adolescents have unique health care needs and a high rate of health problems (Athey et al., 2000). With funding from the Maternal and Child Health Bureau, support from the American Academy of Pediatrics, and the creation of the Society for Adolescent Medicine, appropriate training content was identified and training programs were implemented. Growth in the evidence base, increased support, and the availability of funding for research and training development appear to be critical factors for the evolution of such an advanced-level training program. Such a foundation does not yet appear to exist in family violence. For example, recent petitions to the American Board of Pediatrics to establish a subboard on child abuse and neglect (to be called Child Abuse and Forensic Pediatrics) have been deferred to allow time to document the scientific

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence base of the field and to determine whether other medical organizations would have objections to the development of child abuse and neglect as a formal subspecialty. To date, no efforts have been made to develop an intimate partner violence, elder abuse, or family violence subspecialty. Competency in Forensic Services In addition to competencies related to working with victims of family violence and other health professionals, forensic assessment is an important competency domain due to the role of health professionals in screening and referring family violence victims. Although there are both ethical and practical reasons to try to separate forensic practice and other health services as much as possible (Melton et al., 1997, § 5.02), health professionals usually do not—and perhaps should not—have the luxury of avoiding involvement in legal processes related to cases of family violence. Two reasons support the likelihood of such involvement and therefore the idea that health professionals in general should have some training in forensic practice, though the degree to which training is needed is likely to vary by profession, specialty, and practice setting. First, reporting laws mandate that all health professionals report suspected child maltreatment, most must report suspected elder abuse, and a few must report intimate partner violence itself or the abuse of any adult (see Chapter 3). In effect, such reports indicate suspicions that a crime has occurred, and they also trigger investigations that often may result in civil actions that involve coercive action for victim protection. Because such investigations are typically obligatory, health professionals are effectively in the position of legal decision makers at the initiation of the process. Second, because health professionals may be among the first to see evidence that violence has occurred, they may be particularly credible fact witnesses, revealing exactly what they observed. Under some circumstances, health professionals may also be asked to testify as expert witnesses regarding their opinions about the meaning of particular observations—for example, at the adjudicatory phase, whether specific injuries could have resulted from particular abusive or neglectful actions by an intimate partner, a parent, or an adult child and, at dispositional phases, whether coercive action should be taken to prevent further harm to the victim. Furthermore, in many jurisdictions health professionals may be asked to testify about hearsay evidence (e.g., statements made by victims or colleagues). Because statements made to health professionals for the purpose of securing treatment are presumed to be especially reliable, clinicians often can provide hearsay testimony about what they were told by victims or other key informants. The relevant records, including opinions of other professionals on whom the clinician relied, may also be admissible. Given the legal relevance of clinical evidence for various forms of family violence, the potential expansion of admissible evidence to include health pro-

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence TABLE 6.2 Continuing Education to Change Behavior: What Works? Interventions directed to predisposing factors: changing health professionals’ knowledge, attitudes, and beliefs ■ Measuring and addressing barriers at the outset Basch, 1987; Ward et al., 1991; Davis, Thomson et al., 1992, 1995; Grol, 1997; Haines and Donald, 1998; Haynes and Haines, 1998; Shekelle et al., 2000 ■ Interactive educational meetings: small-group training with role playing; start-and-stop action videos; interactive role modeling Wenrich et al., 1971; Eisenberg, 1982; Stross et al., 1983; Rich et al., 1985; Maiman et al., 1988; Davis, Thomson et al., 1992; Katon et al., 1995; Davis, O’Brien et al., 1999 ■ Academic detailing Davis, Thomson et al., 1995; Bero et al., 1998; Thomson et al., 2001a ■ Use of opinion leaders Becker, 1970; Haynes et al., 1984; Davis, Thomson et al., 1995; Bero et al., 1998; Berwick and Nolan, 1998; Thomson et al., 2001a; Larson, 1999 ■ Cooperation/collaboration between the different professionals involved Berwick and Nolan, 1998; Shekelle et al., 2000 Interventions directed to environmental enabling factors For patients: ■ Financial incentives Shekelle et al., 2000 ■ Reminders Larson et al., 1979, 1982; Thompson, 1986; McDowell et al., 1986; Mullooly, 1987; Leininger et al., 1996; Brimberry, 1988; Shekelle et al., 2000 ■ Posters in clinical areas Lane et al., 1991; Savage, 1991 For health professionals: ■ Practice environment—clinical decision support     ■ Computerized decision support Bero et al., 1998; Haynes and Haines, 1998 ■ Checklists, flow sheets Cohen et al., 1982; Prislin et al., 1986; Madlon-Kay, 1987; Cheney and Ramsdell, 1987; Shank et al., 1989; Dietrich et al., 1992; Johns et al., 1992 ■ Health questionnaires Thompson et al., 2000 ■ Reminders Barnett et al., 1983; McDonald et al., 1984; Tierney et al., 1986; McPhee et al., 1991; Rind et al., 1994; Davis, Thomson et al., 1995; Oxman et al., 1995; Overhage et al., 1996; Shekelle et al., 2000 ■ Chart stickers Cohen et al., 1987, 1989; Solberg et al., 1990

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence ■ Practice environment—process redesign Pommerenke and Dietrich, 1992a, 1992b; Berwick, 1996, 1998; Berwick and Nolan, 1998; Nelson et al., 1998   ■ The Plan, Do, Study Act (PDSA) cycle and others ■ Clear roles ■ Patient flow ■ Organized follow-up   ■ Organizational environment—to make identification of the need for and delivery of the services a routine part of care Shekelle et al., 2000   ■ Rules or policies McGowan and Finland, 1974; Durbin et al., 1981; Vayda and Mindell, 1982; Ruchlin et al., 1982; Martin et al., 1982; Gryskiewicz and Detmer, 1983; Wong et al., 1983 ■ Top management support, such as enlisting the aid of the CEO Shekelle et al., 2000 ■ Clinical computing systems Thompson, 1996; Nelson et al., 1998 Interventions designed to reinforce the program ■ Measurement and feedback Schroeder et al., 1973; Griner, 1979; Hillman et al., 1979; Young, 1980; Check, 1980; Eisenberg and Williams, 1981; Myers and Schroeder, 1981; Eisenberg, 1982; Rosser, 1983; Thompson et al., 1983; Wong et al., 1983; Fineberg et al., 1983; Haynes et al., 1984; Winickoff et al., 1984; Gehlbach et al., 1984; Marton et al., 1985; McPhee et al., 1989; Nattinger et al., 1989; Oxman et al., 1995 ■ Financial incentives for professionals Larson, 1999 ■ Requirement for accreditation measurement: Healthplan Employer Data and Information Set (HEDIS) and other accrediting organizational requirements Dalzell, 1998, 1999; Eddy, 1998

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence health professionals, and accreditation-driven measurement of care, such as the Healthplan Employer Data and Information Set (HEDIS). Creating and Sustaining Behavior Change Through Systems Approaches: Case Studies from the Field As reviews of continuing medical education illustrate, conventional continuing education workshops using lectures alone have shown little effectiveness in improving practice or even increasing knowledge that is retained over the long term. However, when a systematic approach is used for the application of information, positive effects on health outcomes can be achieved. Three examples of the process and tools used in systems successes are described below. Example 1. The University of Virginia Institute of Law, Psychiatry & Public Policy had been involved for some time in training community mental health professionals about forensic issues (Melton et al., 1985). However, information was acquired, retained, and applied only after a system was put into place that included a joint memorandum from the state authorities about payment for evaluations, drafting of model orders, and meetings with key court constituencies to allay concerns about the quality of community-based evaluations. After those steps were taken, in just a few days of didactic workshops, the community clinicians acquired a level of forensic expertise commensurate with professionals in the field, and their reports were evaluated by legal authorities as substantially superior to those produced by hospital-based forensic clinicians. Furthermore, the clinicians expanded their expertise on their own, and they began to be used as experts on issues that were not included in the original training. Example 2. The domestic violence prevention project at Kaiser Permanente, Northern California, utilizes the precede/proceed planning model and involves an assortment of tools for change in their program to improve the identification and management of family violence. Predisposing factors are addressed through a training program for the team of health care providers, including small group training with role modeling and role playing, reinforced by video presentation. Enabling factors in the clinic practice environment include posters, brochures, member wallet cards, provider toolkits with checklists and assessment forms, referral information, and linkages to community advocacy groups. Safe telephone numbers for subsequent contact with victims are elicited at the time of identification. Reinforcing factors include departmental meetings with feedback and process measurement data and pay incentives for performance.

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence This program addresses personal and environmental factors in patient care and encompasses some of the multifaceted strategies that have higher success rates for behavior change. Example 3. At Group Health Cooperative, the approach, funded by grants, includes use of the precede/proceed planning model and, to the maximum extent possible, the application of evidence-based intervention components. Predisposing factors were addressed by provider team training for the entire team for two half days. The training used role modeling and role playing. Start-and-stop action videos were used. Opinion leaders were recruited and received additional training. Enabling factors included placing and replacing posters in the reception areas, cue cards for providers, two questions about intimate partner violence incorporated on physical exam questionnaires and information pamphlets for patients placed in the bathrooms. The care guideline for intimate partner violence was placed on the cooperative’s internal web site. Booster sessions included four additional training sessions conducted at each of the clinics. The opinion leaders helped in the conduct of these additional sessions. A newsletter containing clinic-level results and new information from the literature was circulated on a regular basis. The results of this work have been published (Maiuro et al., 2000; Sugg et al., 1999; Thompson et al., 1998, 2000) and are now being adapted for system-wide application. The Melton et al. (1985) study and the Kaiser Permanente and Group Health Cooperative initiatives provide examples of systematic efforts to communicate a specific body of knowledge and to integrate it into ongoing processes of care. Another strategy is to develop an organizational culture that rewards ongoing searches for, and syntheses of, knowledge germane to practice. Learning organizations are typified by “hallway learning” (Merriam and Caffarella, 1999): The heart of the learning organization is the willingness of organizations to allow their employees and other stakeholders related to the organization to suspend and question the assumptions within which they operate, then create and examine new ways of solving organizational problems and means of operating. . . . Creating learning organizations could allow educators of adults, whether they are associated with formal or nonformal settings, to develop learning communities in which change is accepted as the norm and innovative practices are embraced. (p. 44) A climate of reflective practice is highly consistent with the general movement toward evidence-based health practice (see discussion below). Such an approach may be particularly important in relation to family violence for two reasons. First, family violence and the resulting response by the community are unusually complex phenomena. Not only is there a multitude of causes and correlates to be considered in interaction, but numerous community institutions (e.g., law enforcement, social services, health and mental health services, victim

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence assistance programs, housing agencies, grassroots organizations) have roles in responding to the problem. Second, family violence is a politically charged topic (Melton, 1987; Nelson, 1984) in which advocates (often including health professionals themselves) have strongly held beliefs about what “everybody knows” (or should know). INFLUENCING FAMILY VIOLENCE EDUCATION IN THE FUTURE Based on the committee’s understanding of the adult learning, continuing education, and systems change literature, it suggests and explores two emerging forces in health care, which have the potential to influence the training of health professionals about family violence. These forces are evidence-based practice and routine outcome measurement and reporting, as exemplified by the Healthplan Employer Data Information Set (HEDIS). The committee considers the following questions: What are the effects of these movements, when encompassed in a broader view of continuing education as described above, on teaching for the health professions in general? Does their adoption change health professionals’ behavior or lead to improved patient outcomes? What do we know about their specific application to family violence? What might their effects be in the future? Evidence-Based Practice Evidence-based practice, also known as evidence-based medicine, can be broadly defined as the attempt to take the best-available scientific evidence and apply it to day-to-day practice.4 It involves converting information needs into focused questions, identifying and critically appraising the evidence available to answer each question, applying the results in clinical practice, and evaluating the clinical application. Evidence-based practice can be understood as “a shift in thinking from an authoritarian model to an authoritative model” (Liberati et al., 1999, p. 363). The formal evidence-based practice movement is relatively new, but the roots can be traced back to the late 1960s (see McKeown, 1968). Major advances in the approach have been made in Canada (Evidence-Based Medicine Working Group, 1992), the United Kingdom (Guyatt et al., 1997; Sackett et al., 1996), and the United States (e.g., Eddy, 1996). The intense interest in the subject is demonstrated by a web site devoted to definitions of evidence-based medicine (http://www.shef.ac.uk/scharr/ir/defe.html). In addition, a sizeable number of electronic databases devoted to evidence-based practice have emerged; three examples 4   The committee uses evidence-based practice synonymously with evidence-based medicine, judging these concepts to be applicable to all health care professionals.

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence include the Cochrane Collaboration (http://hiru.mcmaster.ca/COCHRANE); the Centre for Evidence-Based Medicine (http://cebm.jr2.ox.ac.uk); and the Agency for Healthcare Research and Quality Clinical Practice Guidelines (http://www.ahrq.gov/query/query.htm). As evidence of the recent interest and rapid growth in evidence-based practice, a search of the National Library of Medicine, using the term evidence-based medicine either as a medical subject heading (MeSH ) or as a text word, revealed no citations from 1966 through 1991, 33 from 1992 through 1996, and 3,328 from 1997 through the first quarter of 2000. The increased interest in evidence-based practice has been worldwide (Dickson et al., 1998; Garner et al., 1998). In the United States, the Agency for Healthcare Research and Quality has created evidence-based practice centers across the country, sponsored guideline development, and established a guideline clearinghouse (Geyman, 1998). The Centers for Disease Control and Prevention has established a task force to develop evidence-based recommendations for the practice of public health (Pappaioanou and Evans, 1998; Task Force on Community Preventive Services, 2000). Evidence-Based Practice in Health Professional Education With the major new focus in the literature on rules of evidence, experts agree that evidence-based practice is an increasingly important concept in continuing medical education and medical school curricula (Michaud et al., 1996; Geyman, 1998; Estabrooks, 1998). It is a focused approach to interpretation and clinical translation of research findings that provides a valuable tool for managing the knowledge base of medicine by synthesizing and compressing the explosion in available information—over 1 million journal publications a year (Berg et al., 1997; Culpepper and Gilbert, 1999). Straus and Sackett (1998) suggest that using evidence-based practice and other summary sources could cut the clinical literature reading burden by 98 percent. Furthermore, research demonstrates that textbooks are sometimes systematically biased, often inaccurate, and always outdated (Antman et al., 1992). These findings provide additional impetus for incorporating evidence-based practice into teaching curricula. Evidence-based practice is beginning to influence medical school curricula and graduate student medical education in a wide range of teaching hospitals, practice settings, and geographic areas of the United States and Canada (Barnett et al., 1999; Chessare, 1998; Green and Ellis, 1997; Grimes, 1995; Grimes, et al., 1998; Hudak et al., 1997; McCarthy and Zubialde, 1997; Neal et al., 1999; Norman and Shannon, 1998; Poses, 1999; Reilly and Lemon, 1997; Sackett and Straus, 1998; Wadland et al., 1999). Effects on the curricula for other health professionals include reports of its development and use for public health (Brownson et al., 1999), nursing (French, 1999), behavioral scientists (medical

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence social workers, psychologists, and counselors; Gambril, 1999), and dentistry (Newman, 1998). However, general surveys on the degree of curricular institutionalization of evidence-based practice suggest that there is still a long way to go. A survey of 417 internal medicine programs showed that 37 percent of respondents had a freestanding evidence-based practice curriculum, while only 33 percent provided best evidence or the Cochrane Collaboration in their programs, 51-54 percent provided on-site electronic information, and 31-45 percent provided site-specific faculty development in evidence-based practice (Green, 2000). There were only two data-based studies found on evidence-based practice from nursing, (Estabrooks, 1998; Morin et al., 1999), both suggesting that quality evidence is little recognized or used for decision making in nursing, in spite of many calls in their literature to increase evidence-based practice. Effects on Provision of Care and Patient Outcomes The impact of evidence-based practice on health care decisions, provision of services, and patient outcomes remains unclear (Jadad and Haynes, 1998). Norman and Shannon (1998) performed a systematic review of seven studies with a comparison group and reporting measures of performance from 1966 through 1995 and found that evidence-based practice implemented in undergraduate programs resulted in significant gains in knowledge, as assessed by written tests of epidemiology, a mean gain of 17 percent, and a standard deviation of 4 percent. Studies based at the residency level showed minuscule mean gains in knowledge (1.3 percent), leading to the conclusion that the knowledge gain from evidence-based practice was not demonstrably applied in clinical practice. A subsequent search (1996-2000) identified eight studies that addressed the link between teaching the general principles of evidence-based practice (not disease-specific) and health professionals’ knowledge, behavior, process of care, and patient outcomes (Bazarian et al., 1999; Green and Ellis, 1997; Humphris, 1999; Ibbotson et al., 1998; Michaud et al., 1996; Slawson and Shaughnessy, 1999; Wadland et al., 1999; Wainwright et al., 1999). Two studies indicate effects of the use of evidence-based practice.5 The results of one study were moderately suggestive of a positive effect on the use of literature for patient care decisions and perceived competence, using a quasi-experimental group design (Green and Ellis, 1997). In another study (Bazarian et al., 1999) using a quasi-experimental design with before and after measurements, the results were negative. However, the intervention was not strong (a 1-hour journal club that met 5   Using an adaptation of the study design quality rating criteria developed by the Centers for Disease Control and Prevention (Briss et al., 2000; Zaza et al., 2000), these two studies were deemed to be at least moderately appropriate in design and execution for assessing effect.

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence monthly for 1 year), the numbers were small (N = 32), and the outcome assessment measured test-taking skills, not application of evidence-based practice skills. Potential Influences The effects of the evidence-based practice movement on teaching about family violence are presently unclear. The drive to evidence-based practice appears likely to lead to increased interest in proving the effectiveness of various family violence interventions, since present knowledge is limited as to what works beyond the short term. Information on the effects of intervention as measured from the patient perspective is needed, especially in the longer term. The drive for evidence-based practice could serve as a stimulus for effectiveness research on family violence interventions. Conversely, it is also possible that it may have a negative effect on family violence teaching in some locales, due to the current lack of evidence regarding the ideal content of health professional education on family violence. Research shows, however, that even in areas in which best practice standards are well established, incorporating them into practice is extremely slow and uneven (IOM, 2001). The Healthplan Employer Data and Information Set The Healthplan Employer Data and Information Set (HEDIS) is a standard set of performance measures designed to provide purchasers and consumers with information on effectiveness of care. It is used by the National Committee for Quality Assurance (NCQA) to compare the performance of managed health care plans and to provide health care plans and professionals with data needed to improve quality of care (Dalzell, 1998; Hill and Spoeri, 1997; National Committee for Quality Control, 1999; Rulon and Sica, 1997). Since the early 1990s, the use of HEDIS measures as a quality index has grown rapidly. By 1999, 247 health care organizations encompassing 410 health plans and 52 million people were reported to be using the HEDIS performance measures (National Committee for Quality Control, 1999). According to Eddy (1998): Once performance measurement is launched, its importance can be profound. When the [National Committee for Quality Assurance] publishes a HEDIS measure, the effect is as if every health plan in the country went on a retreat to set their clinical goals for the coming year, and all came back with the same answer. I cannot think of a more powerful single instrument for shifting healthcare resources than a national set of performance measurements would be. . . . Science has no effect until it is properly implemented, and measuring performance is one of the most powerful tools for implementation. (p. 8) These views are corroborated by others (Bader et al., 1999; Epstein, 1998; Harris et al., 1998; Hill and Spoeri, 1997; Kelly, 1997).

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Health plans make major improvements in care after new HEDIS measures are devised (National Committee for Quality Control, 1999). For example, at the Group Health Cooperative, after HEDIS measurement was instituted, complete immunization in 2-year-olds improved from 63 percent in early 1993 to 91 percent by 1995 (Thompson, 1996). These changes were driven by the measurement, feedback, and education and training activities for health care professionals of all stripes engendered by the institution of HEDIS measures for immunizations. There are other published examples on immunization (Hughes, 1997; Family Violence Education, 1996), management of hypertension (Elliott et al., 1999), and diabetes care (Peters et al., 1996). Some health professionals claim that “in ten years, we are going to look back at these measures and we will say that their introduction had as much public health significance as almost anything we have been involved in in our careers” (Dalzell, 1999, p. 57). HEDIS measurement and evidence-based practice appear to be directly linked in that most HEDIS measures are based on health conditions posing a significant disease burden and for which intervention can be expected to make a positive difference. The future of HEDIS will increasingly entail its use as a measurement system for the implementation status of evidence-based guidelines and programs. HEDIS measurement and evidence-based practice will become increasingly synergistic. The synergism may well express itself as a new HEDIS process of care measure for family violence. Such a move would provide a major stimulus for training efforts. CONCLUSIONS Although core competencies and teaching methods in family violence education are developing, both their foundation and their effect on professional behavior and patient outcomes are largely unexamined in the research literature. The committee is not able to identify a single educational model but recognizes key areas of overlap in curriculum content that have emerged among existing family violence curricula. These suggest starting points for core competencies that can then be evaluated for effectiveness. In addition, research on teaching techniques now employed for other content areas suggests possibilities for family violence. A few promising training initiatives for health professionals in family violence merit additional attention. The committee makes the following observations based primarily on reports of expert and consensus opinion and experience: Content areas exist in which core competencies for health professional training on family violence can be developed. These areas include: (1) the identification, assessment, and documentation of abuse and neglect, (2) interventions to ensure victim safety, (3) rec-

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence ognition of cultural and value factors affecting family violence, (4) understanding the applicable legal and forensic responsibilities of health care professionals, and (5) action to prevent family violence. Research is needed to verify that this educational content, perceived to be necessary, is in fact necessary, as well as to identify other educational needs to enable health professionals to respond to family violence. In addition, agreement as to the content of specific core competencies and who should develop them is needed. The competency necessary will vary with professional roles, functions, and interests. The appropriate level of competency for a given health care provider is a function of an individual clinician’s roles and responsibilities in the clinical and educational setting. Some basic competencies regarding family violence may serve as a foundation of best practice for further specified, advanced, and leadership competencies. Based on reviews of the scientific evidence base, the committee makes the following observations: Studies demonstrate that traditional didactic education that merely imparts knowledge is often insufficient to lead to improved skills, changed practices, and improved patient outcomes. Research on behavior change and adult learning principles indicates that teaching methods that employ multifaceted, skill-building, practice-enabling strategies are more effective. Research on debiasing may provide helpful methods for overcoming cognitive biases that result in systematic errors in judgment and may affect clinical decision making related to family violence. Cognitive biases may have particular effects on the identification of victims and attributions of risk in cases of actual or suspected family violence. Research on debiasing suggests that such errors could be reduced if training programs on family violence included exercises in which trainees compared their own judgments with statistical information and the integration of feedback into systems of reflective practice, as in learning organizations and evidence-based health care. Systems change models that are based on the science of behavior change may be useful in planning educational interventions for health professionals tailored to the issue of family violence.

OCR for page 108
Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Systems change models build on research about effective behavior change and adult learning. A number of systems change models exist, generally involving the identification of areas in which change is needed, determining objectives for change, trying out approaches for achieving those changes, and testing the impact of those approaches. Such approaches are being applied to the issue of education and training for health professionals in the identification and management of family violence (Campbell et al., 2000; Thompson et al., 2000). The use of these initiatives may result in changes in health professionals’ knowledge and practices and the health outcomes of their patients. Healthplan Employer Data Information Set (HEDIS) measures for health care outcomes and the use of evidence-based practice may have potential for improving health professionals’ identification and care processes for family violence. HEDIS measurement, in its short existence, has had profound effects on the behavior of health care delivery organizations and on practitioners. For example, managed care organizations have made major changes to meet new requirements and training health care personnel is part of this process. Currently, there are no HEDIS measures for family violence. The committee’s review of what is known about the health professional’s response to family violence at this time indicates insufficient evidence on which to base the development and adoption of HEDIS measures for family violence. Given the impact of HEDIS measures, however, the development of a standard set of measures for effective practice for family violence appears to have the potential to drive education, practice, and measurement changes for this issue. Evidence-based practice currently appears to be another strong and emerging force in health care professional education. The linkage between HEDIS measurement and evidence-based practice may increasingly drive the use of HEDIS or HEDIS-like measurement into the education of health care professionals.