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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Suggested Citation:"6 Training Beyond the State of the Art." Institute of Medicine. 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press. doi: 10.17226/10127.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

108 CONFRONTING CHRONIC NEGLECT 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 vio- lence. 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, prin- ciples 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- 108

TRAINING BEYOND THE STATE OF THE ART 109 ricula. Key competencies may be normatively derived at least in part, but re- search 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, com- petencies evolve. There is then a dynamic between research, practice, and educa- tional 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 prac- tice objectives are achieved and whether stated objectives affect outcomes. Evalu- ation 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 vic- tims. Thus, beyond basic literacy, the committee considers competency levels appropriate to different health care professionals based on variations in per- ceived 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

110 CONFRONTING CHRONIC NEGLECT 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 in- cludes basic knowledge and skills in identifying cases, assessing needs and ser- vices, 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 preven- tion, 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 inter- est; 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 con- ference 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, curricu- lum architects, policy experts, and other experts in this field). The bulk of educa- tion 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 pro- cess. 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 edu- cational 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.

TRAINING BEYOND THE STATE OF THE ART 111 Borrowing from the various approaches in use, the committee divides the development of competencies for addressing family violence into basic, ad- vanced, and leadership competency levels (see Figure 6.1). Determining the spe- cific 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 identi- fied core competencies in delivering care through integrated delivery networks, including “building a delivery system” (discussed below). Advanced compe- tency (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 ad- vanced 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 foren- sic examinations in cases of acute sexual assault (adult and pediatric) is a neces- sary basic competency for physicians, yet an advanced competency for nurses LEADERSHIP Applies to those in family ADVANCED violence specific positions, opinion makers, delivery Applies according to role or system architects and position requirements, directors, and family violence BASIC interest, complexity of cases, researchers and advanced specialty Applies to all health care practice roles professions FIGURE 6.1 Levels of competency for addressing family violence.

112 CONFRONTING CHRONIC NEGLECT (such as for sexual assault nurse examiners). Professional roles, duties, and eth- ics 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 incorpo- rate a host of social risks in their care planning (such as homelessness and sub- stance 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 edu- cation on family violence, the committee could find no evidence to support specific content for them. Research is necessary to determine the effect of estab- lishing core competencies, the degree to which health care providers achieve competencies (through training, education, and practice), and, more importantly, Social work Dentistry Central Nucleus of Competencies Medicine Nursing Psychology FIGURE 6.2 Overlapping professional core competencies for family violence.

TRAINING BEYOND THE STATE OF THE ART 113 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 compe- tencies 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

114 CONFRONTING CHRONIC NEGLECT In a few cases, competency domains specific to family violence are ad- dressed. For example, one review notes that competence in family violence “is now part of the expected standard of care for graduating and practicing physi- cians” (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 compas- sionately, evaluate patients’ concerns in the context of evolving life circum- stances” (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 tol- erance, patience, compassion, honesty, courage, prudence, humility, and integ- rity 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 vio- lence arena. However, competence here is necessary for all health care profes- sionals 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 in- volves not only science but also the artful application of knowledge in interper- sonal relationships and ethical issues with clients. In family violence, this need to attend to interpersonal, ethical, and cultural competencies is considered cru- cial (American Nurses’Association, 1995; Ryan and King, 1998). The foregoing review of the literature does not provide a scientific founda- tion 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 com- petencies. 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 curricu- lar development by consensus processes (e.g., Brandt, 1997), suggests some agreement in the field regarding the appropriate areas for educational interven- tion. 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),

TRAINING BEYOND THE STATE OF THE ART 115 and the multidisciplinary expertise of our committee members, the committee drafted proposed core competencies at the basic level within the domains iden- tified 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 ad- dress 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 cur- ricula 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 vic- tims 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 Associa- tion of Colleges of Nursing (1999, http://www.aacn.nche.edu/publications/posi- tions/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 mate- rial to start to inform their own discussions leading to core competency descrip- tions 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, subspe- cialty residencies have been established for developmental pediatrics and adoles- cent health. Following increased research and a growing recognition of the need for cross-disciplinary training in these areas, the Maternal and Child Health Bu- reau 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

116 CONFRONTING CHRONIC NEGLECT TABLE 6.1 Basic Level of Core Competencies Needed for Addressing Family Violence by Health Care Professionals Competency Performance Indicators Identify, assess, 1. Recognize risk factors for victimization and perpetration of and document abuse 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 1. Assess for immediate danger. and reduce vulnerability 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 1. Communicate nonjudgmentally and compassionately. value factors influence 2. Recognize the cultural factors important in influencing the family violence 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 1. Know state reporting laws and mandates, local and state ethical issues in treating and reporting agencies, and their procedures and regulations, reporting family violence 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).

TRAINING BEYOND THE STATE OF THE ART 117 TABLE 6.1 (Continued) Competency Performance Indicators Engage in activities to 1. Promote activities to increase public awareness of prevent family violence 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, adoles- cent medicine achieved the formal status of a subspecialty and became a 3-year program. In 1997, the Residency Review Committee for Pediatrics began requir- ing that pediatric residents complete a 1-month block rotation in adolescent medi- cine. 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 adoles- cent faculty was adequate for teaching residents, and while many topics are believed to be adequately covered (e.g., sexually transmitted diseases, confiden- tiality, 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 chal- lenges. 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

118 CONFRONTING CHRONIC NEGLECT 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 sub- specialty. 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 vio- lence and other health professionals, forensic assessment is an important compe- tency 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 sus- pected 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 profes- sionals 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-

TRAINING BEYOND THE STATE OF THE ART 119 fessionals’ opinions and their hearsay testimony and reports, and the frequency with which questions of family violence arise, health professionals often may become involved in legal proceedings related to family violence. Accordingly, all practicing health professionals should have some familiarity with forensic issues, and they should have access to consultation by forensic experts. Such expertise, whether held by or simply easily available to the health professional, is necessary to ensure that the quality of evidence gathered and the validity of opinions offered is maximized and that there is due sensitivity to the special ethical issues that arise in family forensic cases. Such training and consultation appear to be needed especially because of the complexity and ambiguity of roles that health professionals often face in family violence cases. This complexity goes beyond usual role conflicts in forensic practice, because the nature of the role may change as a case goes through the various steps in the family and criminal courts (see Melton, 1994; Melton et al., 1997, § 15.04). In that regard, clinicians need to be especially sensitive to the fact that the nature of the opinions that may be offered ethically and admitted legally is likely to be different amid formal legal proceedings (in comparison with initial reporting, where required). According to generally prevailing eviden- tiary rules, experts make at least implicit representations that their opinions are based on specialized knowledge (Federal Rules of Evidence 702). Therefore, opinions, no matter how valid, should neither be sought by nor offered to legal authorities unless they are based on expert knowledge, not simply a common- sense inference that a layperson might make. Although an answer to the question about the nature of the foundation for an expert witness’s opinion does not end the inquiry about its admissibility, that issue is central with regard to the witness’s meeting his or her ethical obligation to avoid misleading the trier of fact (i.e., the judge or the jury) (see Melton et al., 1997, §§ 1.04 and 18.05). Cultural Competencies Increasingly visible diversity among patients has significant implications for health care delivery and for the education of health care professionals. Racial and ethnic minority populations now constitute fully 28 percent of the U.S. population (http://www.census.gov/population/estimates/nation/intfile3-1.txt). And 31 million U.S. residents are unable to speak the same language as their health care providers (Woloshin et al., 1995). Diversity can be described accord- ing to a number of characteristics, including age, gender, race, ethnic back- ground, disability, religious affiliation, sexual orientation, socioeconomic status, and community setting (e.g., rural, urban, or international). Each of these charac- teristics contributes to the customary beliefs, social groupings, and material traits that account for cultural variations. In all health professional environments, the culture, background, and context of the patient, of clinicians, and of health care institutions converge and affect virtually every aspect of health care, including

120 CONFRONTING CHRONIC NEGLECT access to services, adherence to recommended treatment regimens, continuity of care, preventive care, screening practices, patient-clinician communication, im- munization rates, and prescription practices (Flores, 2000). Patient diversity occasions the need for cultural and linguistic competence. Such competence involves the knowledge and interpersonal skills that allow clinicians to understand and respond effectively to individuals from cultures and backgrounds other than their own (Campinha-Bacote, 1998, 1999). Culturally influenced definitions of abuse may influence patients’ and also clinicians’ ex- pectations concerning interventions around family violence in the health care setting. When the health care professional does not speak the primary language of the patient, difficulty with identifying and intervening in family violence in- creases. For abused individuals with limited English proficiency, the use of fam- ily members as interpreters can present particular barriers to disclosure, confidentiality, assessment, reporting, safety, and referral. In addition, the health care professional’s own cultural background and social class may influence the clinical care that is provided to patients experiencing family violence and their families. An understanding of the sociocultural backgrounds of individual pa- tients and of their physical, cultural, social, and community environments is crucial to addressing family violence; therefore, clinicians who have limited cultural and linguistic competence also may have limited effectiveness in the assessment and management of family violence patients (Campbell and Campbell, 1996; Bell and Mattis, 2000). Various ethnic groups comprise a large percentage of the American popula- tion. For example, in California, New Mexico, and Hawaii, “minority” groups make up more than 50 percent of the population (U.S. Census Bureau, 2000). These changing demographics pose a challenge to practitioners involved in of- fering services to abused immigrants. Victims of family violence who have im- migrated illegally or who have recently relocated to the United States as refugees are in a particularly problematic situation, since their predominant fear of depor- tation may prevent them from contact with appropriate helping agencies, either governmental or private (Gelles, 1997; McGoldrick et al., 1996). Of particular relevance to health care professionals, cultural practices can be mistaken for abuse, especially in the pediatric population (Bullock, 2000, 2001). For example, cupping or spooning (a method used to treat upper respiratory infections that leaves discrete markings on the skin) and certain treatments for empacho (a gastrointestinal illness) can be misunderstood by Western practi- tioners and labeled as abuse. A culturally sensitive physician familiar with some of these indigenous therapies may be able to address these issues, educating parents about negative effects on health, rather than reporting abuse. Beyond these issues of ethnic cultures, community cultures may also create difficulties for health professionals. Family violence within rural, remote, or wilderness communities may present challenges distinct from those in urban settings. Although studies have shown that rates of abuse may be the same,

TRAINING BEYOND THE STATE OF THE ART 121 unique features are associated with small communities in which family violence occurs, which may be due to socioeconomic differences, increasing isolation, dependence on geography, and more entrenched patriarchal sex-role stereotypes, among other factors. Providers may need an understanding of and appreciation for rural cultural and social life and other issues specific to the particular setting in order to be effective in nonurban environments (Websdale, 1998). Despite the importance of providing culturally and linguistically competent health care to diverse patient populations, education about social and cultural factors that affect patients and influence the clinician-patient relationship is un- common. One study documented that only 8 percent of U.S. medical schools offer separate instruction in cultural issues (Flores et al., 2000). While research is increasingly addressing issues of diversity in health care, more research is needed to identify effective components and methods for educational programs for health professionals (Loudon et al., 1999). Cultural competency instruction that is either infrequent or insufficient poses a major challenge to optimal intervention in family violence, in which quality care depends on clinicians’ sensitivity and understanding of patients’ cultural backgrounds, complemented by self-reflection on personal cultural values and biases. Insufficient sensitivity and understanding of other cultures can lead to incorrect assessment and treatment, particularly when stereotypical and prejudi- cial notions about minority groups abound. Furthermore, culturally formed defi- nitions of abuse can limit patients’ ability to disclose information and can also affect patient expectations of treatment. A national survey of intimate partner violence treatment programs found that a deficiency in cultural understanding of minority populations was a major obstacle to better diagnosis and care (Williams and Becker, 1994). Thus, cultural “incompetence” can undermine the patient- provider relationship and jeopardize the delivery of quality health care, espe- cially to ethnic minority populations. Training and sensitizing health care professionals about cultural and lin- guistic issues is an important aspect of family violence education. The Ameri- can Academy of Pediatrics and the Society of Teachers of Family Medicine each have published guidelines for the education and training of health care providers in cultural competency (AAP, 1999; Like et al., 1996). Recommenda- tions to address the challenges of training health care professionals in the areas of family violence to include cultural and linguistic diversity have also been published (Pinn and Chunko, 1997). These recommendations include: (1) pro- vision of training to help clinicians achieve and communicate a level of comfort with patients’ cultures and environments and (2) inclusion of case study and standardized patient material that is representative of the racial, cultural, and linguistic groups in the community. In addition, the U.S. Department of Health and Human Services recently issued written policy guidance to assist health and social services providers in ensuring that persons with limited English skills can effectively access critical health and social services (Office of Minority Health,

122 CONFRONTING CHRONIC NEGLECT 2000). Although cultural competency can potentially improve outcomes of health care services, little research has been done to discern the need for cul- tural competency of health care providers in the delivery of care to patients who experience family violence (Brach and Fraser, 2000). However, cultural and linguistic competencies are important components of the education and training of health care professionals generally and appear relevant to family violence education. ACHIEVING COMPETENCY THROUGH EDUCATION AND TRAINING Training to achieve competency involves not only the relevant content and curricular space but also the timing, methods and strategies, and environment for conveying the content in ways that maximize comprehension, sustainability, and use. Thus, in addition to exploring the content of health professional training on family violence, the committee examined how such training might be accom- plished. This section begins with a discussion of the diffusion of knowledge, goes on to address techniques for overcoming cognitive biases, moves to the literature on behavior change for health professionals, and then explores some strategies for enhancing education. How Do People Get Knowledge? People, including health care professionals, obtain knowledge in many ways, but some form of communication, generally defined as the provision of informa- tion (Tones, 1997, p. 794), is necessary. Theories about the provision of infor- mation may prove helpful in developing educational approaches for effecting behavioral changes in health professionals (NRC, 1999). Several behavioral models populate the literature of change in health care. Among them are Rogers, Diffusion of Innovations (1995); Green and Kreuter, precede/proceed model (1991); Bandura, The Social Foundations of Thought and Action: A Social Cognitive Theory (1986); and Prochaska and Norcross, Systems of Psychotherapy: A Transtheoretical Analysis (1998). Need is a concept central to each of the models, both behavioral and learn- ing. Rogers reports that successful diffusion of innovations is dependent in part on compatibility, the degree to which an innovation is perceived as being consis- tent with the existing values, past experiences, and the needs of potential adopt- ers. He notes that engaging the opinion leaders in a health care facility in order to convey the message about screening for family violence can boost prospects for the success of a training or intervention effort. These individuals have informal or formal influence in an institution, irrespective of their titles, and are recruited and trained to assist in making changes. Green and Kreuter suggest that attitudes that predispose systems to adopt innovations include appreciation of the impor-

TRAINING BEYOND THE STATE OF THE ART 123 tance of behavioral risk factors, the importance of intervening to modify risk factors, and the physician’s diffidence in carrying out the intervention. Bandura explains that one needs to exercise control over events to accomplish desired goals. Prochaska and Norcross assert that increasing awareness of the causes, consequences, and cures for a particular problem behavior is required to enable successful change. Some key innovation characteristics influence the acquisition of knowledge. Among these are simplicity, an accessible format with readily observable results, compatibility with existing norms, demonstration of a clear advantage compared with the status quo, and modest costs (Rogers, 1995; Tones, 1997). In addition, the social system, including structure, norms, and the roles or potential roles of change agents, are important factors in determining how knowledge is received. For example, in institutions in which the importance of screening for family violence is not modeled by supervising health professional educators or written guidelines do not exist, students may perceive them as unnecessary. Adult Education Principles The principal message from research on the diffusion of knowledge is that most transfer of knowledge, including transfer to and among health professionals, occurs informally, based on perceived needs. And diffusion is maximized through informal communication by the early adopters or trailblazers. Such efforts are likely to be informed by attention to principles dominating the field of adult education, though general guidance for increasing participation in and the meaning of educa- tion is also derivable from learning principles generically (NRC, 1999). Among the most influential approaches in that regard is that of Knowles (1990), called andragogy (i.e., the methods of techniques used to teach adults).1 For the most part, the andragogy principles reflect the roles and expectations of and for adults in our society, rather than developmentally specific learning principles per se. Six assump- tions are basic to andragogy: 1. Adults must have a reason to learn something before they will undertake to do so. 2. Adults expect to be treated as self-directed beings. 3. Because of their life experience, adult learners themselves may possess the richest resources for learning. However, they may also have to overcome prejudices and experiences that they have incorporated into their own identity. 1There is some controversy about whether the principles are unique to adults and whether they have actually been widely used in practice (see Knowles, 1984, for examples of applications, includ- ing the University of Southern California’s 1984 medical curriculum).

124 CONFRONTING CHRONIC NEGLECT 4. “Adults become ready to learn those things that they need to know and be able to do in order to cope effectively with their real-life situations” (p. 60). 5. Adults’ learning is life (or task or problem) centered rather than subject based. Adults are motivated to learn when they perceive that the effort will enable them to perform tasks or solve problems in their daily lives. Accordingly, adults’ education is most effective when information is presented in the context of appli- cation to real-life situations. 6. Adults respond best to intrinsic motivators, such as increased job satisfac- tion. There is an emerging consensus that the general principles of adult educa- tion, as embodied in continuing medical education, apply to health professionals as well. The consensus is linked to the principles of adult learning (Abrahamson et al., 1999; Barrows, 1983; Green and Ellis, 1997; Knowles, 1984, 1990; Neame et al., 1981), emphasizing an adult’s need to know why they should learn about a particular topic, how this knowledge or skill helps them cope with real-life situ- ations; and that the learning is task centered (problem based) (Abrahamson et al., 1999; Boud and Felitti, 1991; Carlile et al., 1998; Dolmans and Schmidt, 1994; Schmidt, 1993; Slotnick et al., 1995). Overcoming Cognitive Biases Health professionals, like other individuals, possess belief systems that in- clude prejudice, and these biases can affect their professional behavior, poten- tially resulting in errors in clinical judgment in family violence cases. Health professionals need to know about and improve the sensitivity, specificity, and positive predictive value of efforts to screen for or otherwise detect family violence. Cognitive Heuristics Errors result from ignorance about the relevant facts and how to pursue them efficiently and effectively, as well as from cognitive biases to which clinicians are subject. Although many health professionals may have substantially greater knowledge than laypersons about family violence, their process of judgment and decision making is likely to be similar to that of laypersons. The relevant body of research has grown from the recognition that cognitive heuristics—mental short- cuts that people learn to use to enable them to deal efficiently with information overload—sometimes lead to systematic biases in judgments and decision mak- ing (Kahneman and Tversky, 1982; Tversky and Kahneman, 1974).2 Research on 2 A thorough review of this literature is beyond the scope of this report.

TRAINING BEYOND THE STATE OF THE ART 125 cognitive heuristics does suggest several ways that biases are especially likely to affect clinicians’ judgments in cases of actual or suspected family violence. These include overconfidence about assessments (Arkes, 1989; Lichtenstein and Fischhoff, 1980; Oskamp, 1965); the lack of objective feedback (Dawes, 1989); the vividness or emotional charge of personal experiences (Tversky and Kahneman, 1973); the tendency not to use statistical information (Plous, 1993; Melton et al., 1997); the format of the information (Slovic et al., 2000); and errors of attribution based on personal experiences (Heider, 1958). Debiasing Clinicians’ biases in judgment and decision making thus can present major obstacles to accurate predictions of violent behavior and to resulting forensic decisions and safety planning. Educational programs for health professionals about family violence should take such obstacles into account. A body of re- search has begun to develop about effective techniques of debiasing to help prevent these errors of assessment (see, e.g., Arkes, 1981). For example, Plous (1993) has provided steps that research suggests should reduce tendencies to make errors as a result of cognitive heuristics. Although some biases are difficult to correct even with training (see, e.g., Slovic et al., 2000), a theme of debiasing research is to increase accountability. Clinicians are less likely to reach erroneous conclusions when they are subject to divergent opinions, required to examine actuarial data, and given feedback about the validity of their judgments. These findings suggest that training pro- grams on family violence should include exercises in comparing the participat- ing clinicians’ judgments with statistical information, including feedback about the accuracy of their own judgments. Research is also needed to increase the development and testing of actuarial measures available to make predictions specific to family violence (Campbell et al. 1995, 2000). These advances, coupled with better training for health care professionals, will lead to combinations of truly “expert” (debiased clinical experience and advanced knowledge base) judgment and valid actuarial predictions that are thought to be the optimal com- bination for accurate predictions of violence (Hess and Weiner, 1999; Campbell et al., 2000). Training for Behavior Change: Continuing Education Principles That Work At present for undergraduate and graduate education in the health profes- sions, educational needs are determined largely by faculty members who develop and present the curriculum to persons interested in acquiring the knowl- edge, skills, and attitudes necessary to enter professional practice. In deliberat- ing on the changing needs of society and the responsibility of preparing students

126 CONFRONTING CHRONIC NEGLECT for a future of lifelong professional learning, faculty select goals, content, and instructional methods, as they devise instructional objectives and compile the sequence of curricular activities (Ferren and Mussell, 2000). When the effects of continuing medical education on physician practices and patient outcomes have been systematically examined, some insights emerge (see the systematic reviews of Haynes et al., 1984; Davis, Thomson et al., 1992, 1995; Davis, O’Brien et al., 1999). This group of researchers from McMaster University and the University of Toronto has noted that there is a wide range of rigorously tested interventions that substantially broaden the traditional defini- tion of continuing medical education (Davis, Thomson et al., 1992). From this work, formal continuing medical education is defined as varying from “passive, didactic, large group presentations to highly interactive learning methods such as workshops, small groups and individual training sessions. Examples of such educational activities include rounds, educational meetings, conferences, re- fresher courses, programs, seminars, lectures, workshops and symposia” (Davis, O’Brien et al., 1999, p. 868). The broader view of continuing medical education also includes educational materials, outreach visits, local opinion leaders, pa- tient-mediated interventions, audit and feedback, and reminders. Formal Continuing Medical Education: Implications for Health Professional Training In a recent systematic review of formal continuing medical education for the years 1970 to 1999, Davis, O’Brien et al. (1999) found 64 studies of which 14 met their selection criteria (only randomized controlled trials). The education approaches were divided into three categories: didactic only, interactive, and mixed. In their conclusions the authors state that “the use of traditional [continu- ing medical education] activities such as lectures has been widely criticized. This criticism appears justified because didactic interventions analyzed in this review failed to achieve success in changing professional performance or health care outcomes. In contrast studies that used interactive techniques such as case discussion [e.g., problem-based learning approaches] role-play, or hands on prac- tice sessions were generally more effective in changing those outcomes docu- mented in this review” (p. 870). The research suggests that independent lecture-based courses are unlikely to be sufficient; rather if such courses or lectures occur, the knowledge provided must be reinforced at later points during the degree or certification program and throughout the learner’s practical educational exposures to their profession. In the committee’s view, such an approach is appropriate for family violence train- ing as well. Family violence content may be integrated across courses and rein- forced with clinical instruction. For example, students may learn to screen and identify family violence victims during coursework on patient interviewing or communication skills; to document suspected or actual cases of family violence

TRAINING BEYOND THE STATE OF THE ART 127 for forensic purposes during diagnosis or history-taking coursework; to recog- nize the emotional and psychological manifestations of family violence during case-based or simulated patient instruction; and to understand culturally relevant issues during clinical rotations in diverse settings. Such an approach may build on knowledge and skills for addressing family violence and emphasize the im- portance of family violence as an important health care issue. Health professional schools appear to be moving from offering specific courses on each topic to an integrated approach. With such an approach, content on a particular issue is woven throughout the curriculum both horizontally (in different courses that occur simultaneously) and vertically (reinforced through- out the length of the curriculum). Current time constraints and limits on financial and human resources may make the addition of another course difficult. In addition to integrating components of family violence into health profes- sional education, the literature also suggests incorporating multidisciplinary re- sources into training efforts. Given the complexity of family violence as a medi- cal and social issue, no amount of training will allow health professionals alone to solve the problems of family violence. Education should include community- based professionals such as law enforcement, legal services, victim advocacy, batterer intervention, elder services, and child protection experts (Alpert et al., 1998). Brandt (1997) pointed out that a curriculum that involves a variety of professionals “models respect and collaboration, attributes that are essential to developing an effective team approach to caring for victims of violence” (p. S55), thus allowing students the opportunity to negotiate community-specific roles and competencies. This point was reiterated by the Committee on the Assessment of Family Violence Intervention Programs (NRC and IOM, 1998, pp. 261-262). The Alaska Family Violence Prevention Project offers an important ex- ample of collaborative work (http://www.hss.state.ak.us/dph/mcfh/domestic violence/Backgnd.htm). Since 1993, the project has developed and provided community-based training to health care and other service professionals, in- cluding those in law, protective services, and education, and to advocates for victims of intimate partner violence throughout Alaska. In addition, the Alaska project is involved in the development of a statewide plan for a comprehensive health care system response to intimate partner violence. Other models of col- laboration also exist. For example, the Pennsylvania Coalition Against Domestic Violence has developed a program to coordinate community and justice system responses to intimate partner violence (http://www.pcadv.org/coalition.html, June 4, 2001). Such collaborative programs have not yet been evaluated. The Use of Systems Change Models While research indicates that education that merely imparts knowledge is often insufficient to lead to improved skills, changed practices, and improved patient outcomes, a consensus is emerging that other strategies are more effec-

128 CONFRONTING CHRONIC NEGLECT tive. These strategies are integral to the broader view of continuing medical education described by Davis and colleagues (Davis, Thomson et al., 1992; Davis, O’Brien et al., 1999). Multifaceted, skill-building, practice-enabling strat- egies that make the identification and receipt of services a routine part of care when combined with feedback mechanisms, including positive reinforcement (for health professionals or patients), have the highest success rates (Bero et al., 1998; Berwick and Nolan, 1998; Davis et al., 1995; Davis, O’Brien et al., 1999; Haynes et al., 1984; Oxman et al., 1995; Shekelle et al., 2000; Thompson, 1996; Thomson et al., 2001a, 2001b, 2001c). Intervention planning models that are conceptually based provide a typol- ogy for categorizing intervention components, in addition to their more custom- ary use in planning interventions (DHHS, 1994; Curry and Kim, 1999; Goodman, 1999; Green and Kreuter, 1991, 1999; Thompson, 1996; Walsh and McPhee, 1992). The exact planning model chosen is important but not paramount. The precede/proceed model (see Figure 6.3) offers one useful example of a planning model (Green and Kreuter, 1991, 1999). It specifies three categories of factors (predisposing, enabling, and reinforcing) supporting behavior change.3 Predisposing factors influence a person’s willingness to change (i.e., barrier identification and other factors); the possession of and the confidence in (sense of self-efficacy) his or her skills to perform a task; the providers’ knowledge, attitudes, and beliefs; and personal health behaviors or experiences. Enabling factors, such as supporting policies or computer systems, are environmental fac- tors at the practice, organization, or community level that make change possible. Reinforcing measures, such as the right incentives or measurement and feed- back, can amplify the intervention. The McMaster-Toronto group used this model to categorize the interventions that they considered to be part of the broader view of continuing medical education (Davis, Thomson et al., 1992). Recognizing that passive conveyance of information in writing or by course is generally an ineffective educational strategy (Bero et al., 1998; Davis, Thomson et al., 1995; Shekelle et al., 2000), the committee sought evidence on effective strategies. Employing the precede/proceed model (Green and Kreuter, 1991, 1999), the committee categorized interventions to change practitioner be- havior, both of the formal continuing medical education variety and those en- compassed in a broader view of continuing education. Table 6.2 provides a list of potential “tools for change” for the precede/proceed planning model chosen, but they can also be applied to other models. The tools listed are those for which there is some evidence of effectiveness. For interventions directed to predispos- ing factors of health professionals, there is solid support in the literature for measuring and addressing barriers, academic detailing (i.e., a maneuver derived from the practices of drug salespersons, consisting of a series of brief informa- 3See the web site for Lawrence Green (http://www.lgreen.net/precede.htm) for over 850 applica- tions of the precede/proceed model to a wide range of health conditions.

TRAINING BEYOND THE STATE OF THE ART 129 Risk Factors & Medical Conditions Identified Practitioner Management Behavior HEALTH Patient OUTCOMES Behavior Process of Care, Morbidity, & ENABLING FACTORS Mortality Community Level Intervention ENABLING FACTORS Organizational Level ENABLING FACTORS Practice Environment Reinforcing Factors PREDISPOSING FACTORS Primary Care Practitioner FIGURE 6.3 Conceptual basis for the intervention: precede/proceed model. SOURCE: Thompson (1996). Reprinted with permission. tional encounters that are built into the practitioner’s daily appointment sched- ule), and the use of interactive educational meetings. The evidence for the use of opinion leaders and cooperation/collaboration among health professionals is less substantial. There is firm evidence to support the use of financial incentives and reminders as enablers of change in patient outcomes. The use of posters is less solidly grounded. The evidence for decision support for providers, including computerized support and reminders, is solid. The evidence for the use of check- lists, flow sheets, health questionnaires, and chart stickers is less well estab- lished. The evidence for process redesign is beginning to emerge. At the organizational level, interventions that make the identification of the need for and the delivery of services routine, the use of rules and policies, and the engagement of top management are supported by research (see Shekelle et al., 2000). The use of clinical computing systems to drive the care process is developing rapidly and holds much promise for the future. There is moderately solid evidence for the use of measurement and feedback, financial incentives for

130 CONFRONTING CHRONIC NEGLECT 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 Basch, 1987; Ward et al., 1991; Davis, at the outset Thomson et al., 1992, 1995; Grol, 1997; Haines and Donald, 1998; Haynes and Haines, 1998; Shekelle et al., 2000 ■ Interactive educational meetings: Wenrich et al., 1971; Eisenberg, 1982; small-group training with role playing; Stross et al., 1983; Rich et al., 1985; start-and-stop action videos; interactive Maiman et al., 1988; Davis, Thomson role modeling 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 Berwick and Nolan, 1998; Shekelle the different professionals involved 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

TRAINING BEYOND THE STATE OF THE ART 131 TABLE 6.2 Continued ■ 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 Shekelle et al., 2000 identification of the need for and delivery of the services a routine part of care ■ 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 Shekelle et al., 2000 ■ enlisting the aid of the CEO ■ 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 Dalzell, 1998, 1999; Eddy, 1998 measurement: Healthplan Employer Data and Information Set (HEDIS) and other accrediting organizational requirements

132 CONFRONTING CHRONIC NEGLECT 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 con- tinuing 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 infor- mation, 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 & Pub- lic 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 evalu- ations, 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 clini- cians 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 assess- ment 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.

TRAINING BEYOND THE STATE OF THE ART 133 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 re- ceived additional training. • Enabling factors included placing and replacing posters in the recep- tion areas, cue cards for providers, two questions about intimate partner vio- lence 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 addi- tional 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 ongo- ing 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 oper- ating. . . . Creating learning organizations could allow educators of adults, whether they are associated with formal or nonformal settings, to develop learn- ing communities in which change is accepted as the norm and innovative prac- tices are embraced. (p. 44) A climate of reflective practice is highly consistent with the general move- ment 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

134 CONFRONTING CHRONIC NEGLECT 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 profes- sionals 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 encom- passed in a broader view of continuing education as described above, on teach- ing 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 elec- tronic databases devoted to evidence-based practice have emerged; three examples 4The committee uses evidence-based practice synonymously with evidence-based medicine, judg- ing these concepts to be applicable to all health care professionals.

TRAINING BEYOND THE STATE OF THE ART 135 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 prac- tice, 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 devel- opment, and established a guideline clearinghouse (Geyman, 1998). The Centers for Disease Control and Prevention has established a task force to develop evi- dence-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 con- tinuing 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 manag- ing the knowledge base of medicine by synthesizing and compressing the explo- sion 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 system- atically biased, often inaccurate, and always outdated (Antman et al., 1992). These findings provide additional impetus for incorporating evidence-based prac- tice 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

136 CONFRONTING CHRONIC NEGLECT 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 under- graduate programs resulted in significant gains in knowledge, as assessed by written tests of epidemiology, a mean gain of 17 percent, and a standard devia- tion 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 prac- tice. A subsequent search (1996-2000) identified eight studies that addressed the link between teaching the general principles of evidence-based practice (not dis- ease-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 ef- fects of the use of evidence-based practice.5 The results of one study were mod- erately 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 nega- tive. However, the intervention was not strong (a 1-hour journal club that met 5Using 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.

TRAINING BEYOND THE STATE OF THE ART 137 monthly for 1 year), the numbers were small (N = 32), and the outcome assess- ment 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 ap- pears 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 mea- sured 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 prac- tice 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 Commit- tee 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 Commit- tee 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 mea- sure, 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 an- swer. I cannot think of a more powerful single instrument for shifting health- care resources than a national set of performance measurements would be. . . . Science has no effect until it is properly implemented, and measuring perfor- mance 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).

138 CONFRONTING CHRONIC NEGLECT 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 per- cent by 1995 (Thompson, 1996). These changes were driven by the measure- ment, feedback, and education and training activities for health care professionals of all stripes engendered by the institution of HEDIS measures for immuniza- tions. 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 edu- cation 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 fam- ily violence. A few promising training initiatives for health professionals in fam- ily 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 profes- sional 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-

TRAINING BEYOND THE STATE OF THE ART 139 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 neces- sary, 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, func- tions, 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 educa- tional 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 teach- ing methods that employ multifaceted, skill-building, practice- enabling strategies are more effective. • Research on debiasing may provide helpful methods for overcom- ing 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 judg- ments 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.

140 CONFRONTING CHRONIC NEGLECT 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 measure- ment 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 increas- ingly drive the use of HEDIS or HEDIS-like measurement into the education of health care professionals.

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As many as 20 to 25 percent of American adults—or one in every four people—have been victimized by, witnesses of, or perpetrators of family violence in their lifetimes. Family violence affects more people than cancer, yet it's an issue that receives far less attention. Surprisingly, many assume that health professionals are deliberately turning a blind eye to this traumatic social problem.

The fact is, very little is being done to educate health professionals about family violence. Health professionals are often the first to encounter victims of abuse and neglect, and therefore they play a critical role in ensuring that victims—as well as perpetrators—get the help they need. Yet, despite their critical role, studies continue to describe a lack of education for health professionals about how to identify and treat family violence. And those that have been trained often say that, despite their education, they feel ill-equipped or lack support from by their employers to deal with a family violence victim, sometimes resulting in a failure to screen for abuse during a clinical encounter.

Equally problematic, the few curricula in existence often lack systematic and rigorous evaluation. This makes it difficult to say whether or not the existing curricula even works.

Confronting Chronic Neglect offers recommendations, such as creating education and research centers, that would help raise awareness of the problem on all levels. In addition, it recommends ways to involve health care professionals in taking some responsibility for responding to this difficult and devastating issue.

Perhaps even more importantly, Confronting Chronic Neglect encourages society as a whole to share responsibility. Health professionals alone cannot solve this complex problem. Responding to victims of family violence and ultimately preventing its occurrence is a societal responsibility

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