Executive Summary

Family violence—child abuse and neglect, intimate partner violence, and elder abuse—is seen as a widespread and deeply troubling problem in American society. Studies consistently report that family violence affects as many as 25 percent of children and adults in America during their lifetimes—as victims, witnesses, or perpetrators. Combating such a major societal problem necessarily requires the involvement of multiple sectors, including the justice system, social services, and the health professions. For both practical and ethical reasons, health care professionals play a particularly important role in addressing family violence. They are often the first to encounter victims of family violence and consequently can play an important role in ensuring that victims, and also perpetrators, get the help they need.

Health professionals provide care for the physical and psychological problems associated with abuse and neglect, ranging from acute injuries to chronic medical conditions to psychiatric and psychological disorders. Because of their contact and relationship with actual and potential victims, health care professionals have a unique opportunity to screen for, diagnose, treat, and even prevent abuse and neglect. Despite this pivotal role, the training and education of health professionals about family violence are often inadequate to enable them to intervene effectively. Health professionals commonly report lack of support and feeling ill equipped and frustrated in dealing with family violence victims.

THE COMMITTEE CHARGE

At the request of Congress, and with support from the Centers for Disease Control and Prevention, the Institute of Medicine and the National Research



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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Executive Summary Family violence—child abuse and neglect, intimate partner violence, and elder abuse—is seen as a widespread and deeply troubling problem in American society. Studies consistently report that family violence affects as many as 25 percent of children and adults in America during their lifetimes—as victims, witnesses, or perpetrators. Combating such a major societal problem necessarily requires the involvement of multiple sectors, including the justice system, social services, and the health professions. For both practical and ethical reasons, health care professionals play a particularly important role in addressing family violence. They are often the first to encounter victims of family violence and consequently can play an important role in ensuring that victims, and also perpetrators, get the help they need. Health professionals provide care for the physical and psychological problems associated with abuse and neglect, ranging from acute injuries to chronic medical conditions to psychiatric and psychological disorders. Because of their contact and relationship with actual and potential victims, health care professionals have a unique opportunity to screen for, diagnose, treat, and even prevent abuse and neglect. Despite this pivotal role, the training and education of health professionals about family violence are often inadequate to enable them to intervene effectively. Health professionals commonly report lack of support and feeling ill equipped and frustrated in dealing with family violence victims. THE COMMITTEE CHARGE At the request of Congress, and with support from the Centers for Disease Control and Prevention, the Institute of Medicine and the National Research

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Council of the National Academies established a multidisciplinary committee to examine what is currently known about the training needs of health professionals to respond to family violence. The Committee on the Training Needs of Health Professionals to Respond to Family Violence was asked to examine existing curricula for health professionals on family violence and current efforts to foster their knowledge and skills in this area. The committee focused its review on the six professional groups it considered most likely to encounter family violence victims early in the evaluative process and thus to have significant educational needs related to screening, diagnosing, treating, and preventing family violence. The six groups are: physicians, physician assistants, nurses, psychologists, social workers, and dentists. This focus on these professions is not intended to suggest that other professions do not have important roles in responding to family violence. A CASE OF CHRONIC NEGLECT This committee is not the first to address the issue of family violence or to make recommendations for research, education, and practice to address it. Many of the difficulties identified in this report have been encountered before. Time and again in the past decade, groups of researchers, government officials, law enforcement professionals, social service providers, and health care professionals have convened to discuss the research and policy needed to address family violence. To date there has been little response to calls for improvements in the research base, increased funding, or collaboration among those concerned about family violence. The problems identified by previous groups have not abated. In fact, the conclusions and recommendations in this report underscore problems that have been known to exist for decades. Building on the work of previous groups, we focus here specifically on the issues with the greatest impact on the training and education of health professionals to respond to family violence. On the basis of its assessment and deliberations, the committee draws a number of conclusions regarding the current state of health professional training on family violence and makes recommendations to direct future efforts. These conclusions and recommendations address two major concerns: resources and coordination for education research and curricular development to expand the knowledge base and inform policy and practice, and curricular content and teaching strategies. EDUCATION RESEARCH AND CURRICULAR DEVELOPMENT Although the committee’s review of available data suggests that family violence is widespread in the United States, its actual prevalence is unknown. Several critical examinations have eloquently described the paucity of data and

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence research findings to reliably guide practice in the area of family violence. Previous reports have pointed specifically to the lack of a base of scientific findings sufficient to inform education and practice for health professionals, as well as inadequate funding for the teaching and evaluation of family violence curricula. For example, in 1990, the U.S. Advisory Board on Child Abuse and Neglect reported that, although progress had been made, child maltreatment “may still be the most under-researched social problem.” It identified as problems the unsystematic nature of the research on child maltreatment, a decline in public support for it from 1975 to 1990, a shortage of researchers in the field, and specific topics that have been especially understudied. The Advisory Board recommended establishment of state and regional resource centers for training, consultation, policy analysis, and research on child protection. Among its other recommendations were the development of a new data system, the creation of a U.S. Department of Health and Human Services-wide research advisory committee, a major role for the National Institute of Mental Health in research planning, implementation, and coordination, as well as in providing research training and career development awards. In 1998, the National Research Council/Institute of Medicine’s Committee on the Assessment of Family Violence Interventions noted a lack of rigorous evaluation, insufficient resources, and the failure of the research and practice communities to collaborate. The committee recommended that evaluation be integral to all family violence interventions and that policy incentives and leadership foster coordination among policy, program, and research agendas. The conclusions and recommendations in this report echo these calls for action to address a disturbing societal problem. Conclusions While family violence is understood to be widespread across the United States and to have significant health consequences, its full effects on society and the health care system have not been adequately studied or documented. The available data are inadequate to determine the full magnitude and severity of family violence in society or its impact on the health care professions. Furthermore, estimates of the scope of the problem vary according to the data source and research methods used. With respect to its impact on the health system, few studies have been conducted to trace the patterns of utilization or the costs of health care for conditions associated with family violence or its effects on the health status of the patient (or victim). A better understanding of baseline problems, health care needs, and costs associated with family violence could reinforce the need for more focused attention by health professionals, provide guidance on

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence how best to respond, and inform and improve the education and practice of health care professionals. Variation in the definitions, data sources, and methods used in research on family violence has resulted in inconsistent and unclear evidence about its magnitude and severity, as well as its effects on the health care system and society. As noted in previous reports published by the National Research Council and Institute of Medicine (Understanding Child Abuse and Neglect, Understanding Violence Against Women, Violence in Families: Assessing Prevention and Treatment Programs), clarity regarding definitions used to describe family violence is essential in order to compare studies and generalize from one setting to another. Similarly, clarity and consistency in data sources and research methods are needed to accurately describe the prevalence of family violence as encountered in health care settings and the health care needs of victims. Such an evidence base could shed new light on the roles of health professionals and their opportunities to intervene and respond more effectively to family violence and also provide a foundation for their more effective education. Funding for research, education development and testing, and curricular evaluation on family violence is fragmented, and information about funding sources is not systematically available. No consistent federal sources of support for education research on family violence appear to exist. As the committee’s review of existing programs and funding sources revealed, program development and funding for family violence programs are scattered among agencies of the U.S. Department of Health and Human Services and the U.S. Department of Justice. Among these agencies are the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, the National Institutes of Health, the Administration on Children and Families, the National Institute of Justice, and the Office of Justice Programs. These federal agencies, departments, and offices share a mandate to address family violence, but the committee found that often one agency was unaware of either projects or funding opportunities for research and programs on family violence in other agencies. The fragmented information on funding is difficult to access for researchers and educators and others attempting to develop and conduct research, design training and practice interventions, and evaluate programs. The information must be collected piecemeal from numerous web sites and federal agency officials, making it difficult to determine if and when funds are available. Furthermore, while the committee was able to identify some sources of funding for intervention and training, we could find no consistent sources for federal support of education research on family

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence violence to design and test innovative and responsive models for the education of health professionals or to evaluate existing models. Although their mandates differ in focus and scope, in the committee’s judgment these agencies, as well as stakeholders in family violence, would benefit from sharing and coordinating information about their projects and funding opportunities. Recommendation Recommendation 1: The secretary of the U.S. Department of Health and Human Services should be responsible for establishing new multidisciplinary education and research centers with the goal of advancing scholarship and practice in family violence. These centers should be charged with conducting research on the magnitude and impact of family violence on society and the health care system, conducting research on training, and addressing concerns regarding the lack of comparability in current research. The ultimate goal of these centers will be to develop training programs based on sound scientific evidence that prepare health professionals to respond to family violence. The committee suggests that a modest number of centers, three to five, be established in the next five years. That time period should be sufficient to establish and evaluate the early effects of the centers. The initial focus of the centers should be the evaluation of existing curricula on family violence and the expansion of scientific research on magnitude, health effects, and intervention effectiveness. Once the centers are established and the evidence base is developed, additional funding should be phased in to develop, test, evaluate, and disseminate education and training programs; to provide training at all levels of education; to develop policy advice; and to disseminate information and training programs. In recommending the creation of education and research centers, the committee not only reiterates the recommendations of previous reports on family violence but also builds on the reported effectiveness of research and education centers in other fields. For example, centers dedicated to Alzheimer’s disease, injury control research, and geriatric education have reported success in bringing multidisciplinary scholars together, expanding the research in their fields, producing scholars, providing training, and encouraging collaboration. In the committee’s judgment, the reported successes of centers in other fields support this call for centers on family violence. The committee therefore urges the secretary of the U.S. Department of Health and Human Services to instruct its agencies to determine how to allocate resources on a continuing basis to establish multidisciplinary centers on family violence. These centers could be connected to academic health centers, as recommended previously by others, or they could build on related efforts, such as

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence the injury prevention and research centers of the Centers for Disease Control and Prevention. In addition, the centers should be linked to local and community resources and programs to facilitate and support the translation of research results into effective training efforts and real-world practices. By providing a locus of activity, education and research centers can facilitate tracking and coordinating efforts to address family violence among federal agencies as well as those at the state and local levels and private organizations. Such coordination may result in: (1) the development of common research priorities; (2) the distribution of funding to studies and projects that continuously build the evidence base needed for the development of effective education and practice; (3) the broad dissemination of information about current research and programs; and (4) clear sources of information. Coordination would be aided by an analysis, perhaps undertaken by the U.S. General Accounting Office, about where investments are made, their level, and their adequacy. CURRICULAR CONTENT AND TEACHING STRATEGIES The committee’s review indicates that existing curricula on family violence for health professionals are quite diverse. There are few scientific underpinnings to support the content, instructional methodologies, or extent of education now being provided in these training programs. Conclusions Curricula on family violence for health professionals do exist, but the content is incomplete, instruction time is generally minimal, the content and teaching methods vary, and the issue is not well integrated throughout their educational experiences. Moreover, studies indicate that health professionals and students in the health professions often perceive existing curricula on family violence to be inadequate or ineffective. Although a number of curricula exist, training is not consistently offered to those who have the responsibility to care for victims of family violence. When it is, it is typically of short duration, offered at only one point in the training program, and frequently limited to only one type of family violence (e.g., intimate partner violence). Elder maltreatment appears to be the most neglected area. Evaluation of the effects of training has received insufficient attention. Few studies investigate whether curricula on family violence are having the desired impact on the delivery of health care to family violence victims. When evaluations are done, they often do not

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence utilize the experimental designs necessary to provide an adequate understanding of effects. At present, most studies appear to rely primarily on quasi-experimental research and short-term measurement of proximal effects and provider outcomes, such as increased knowledge and awareness of family violence. Evaluations required by law, funding agencies, or sponsoring organizations often assess only the process by which a program is implemented or participant satisfaction, without attention to program effectiveness—or they focus on program effects without considering implementation. Other experimental designs, particularly randomized experiments, would be useful in demonstrating the effects of training on the behavior of health professionals or on victims’ health. Also helpful in improving understanding of the relationship between training and outcomes are high-quality quasi-experimental designs. Both could significantly improve the evidence base and its use to provide guidance as to what works best, for whom, and under what conditions. Core competencies for health professional training on family violence can be developed and tested based on similarities in the content of current training programs. The important content areas include: (1) identification, assessment, and documentation of abuse and neglect; (2) interventions to ensure victim safety; (3) recognition of culture and values as factors affecting family violence; (4) understanding of applicable legal and forensic responsibilities; and (5) prevention. The level of competency necessary will vary with professional roles, functions, and interests. Core competencies are areas of knowledge, skills, and attitudes that health care professionals must possess in order to provide effective health care to patients. Currently, no definitive, evidence-based set of core competencies exists. An examination of existing programs, however, suggests some similarities in training objectives, content, and teaching methods. These reveal some common content areas across disciplines in which core competencies could be developed or tested for health professional education. These content areas regularly appeared in the existing curricula and the literature reviewed by the committee. In the committee’s view, research to specify core competencies for health professionals on family violence should begin with the five content areas listed above. Their specification could facilitate the development of sound measures for assessing them. Existing education theories about behavior change suggest useful teaching methods and approaches to planning educational interventions for health professionals tailored to the issue of family violence. These approaches include ways of changing behavior and practice in

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence health care delivery systems, the use of techniques to address practitioners’ biases or beliefs about victims, and the use of health care outcome measurement to inform evidence-based practice. Studies demonstrate that traditional forms of didactic education designed to increase knowledge about a particular topic are ineffective to enhance skills and change clinical practice to improve patient outcomes. Research on behavior change and principles of adult learning instead support the use of teaching methods that employ multifaceted, skill-building, practice-enabling strategies as more effective at changing behavior in health care delivery. Such strategies involve interactive techniques, such as case discussion, role play, hands-on practice sessions, guided clinical experiences, and evaluative feedback to trainees about their behavior. Strategies to change behavior are referred to as “systems change models.” A number of such models exist, generally involving identifying areas in which change is needed, determining objectives, testing approaches, and assessing their impact. A few managed care organizations and hospitals are beginning to apply such approaches to the education and training of health professionals to identify and manage cases involving family violence. Early experiences with these techniques are demonstrating positive effects. Techniques to reduce the assumptions that health professionals have about who family violence victims are and why they are maltreated may also be useful in developing effective education curricula. Research suggests that errors in victim identification and risk assessment could be reduced through exercises in which trainees compare their own judgments and assumptions about victims with data describing real victims. Research on outcome measurement and evidence-based practice suggests potential for the creation of a standard set of expectations about effective practice to deal with family violence. Measurement using the Healthplan Education Data Information Set has demonstrated significant effects on the behavior of practitioners and health care delivery organizations in areas other than family violence. And evidence-based practice, which involves efforts to apply the best-available scientific evidence to day-to-day practice, is recognized as essential to ensure quality health care, yet even in areas in which best-practice standards are well established, incorporation into practice is extremely slow and uneven. Challenges to developing, implementing, and sustaining training programs on family violence for health professionals include the nature of accreditation, licensure, and certification; characteristics of health professional organizations; the views of stakeholder groups; the attitudes of individual health professionals; and the existence of mandatory reporting laws and education requirements.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Accreditation, licensure, and certification requirements do not consistently and explicitly address family violence and thus do not encourage training to address it. Without such requirements, health professionals may perceive family violence education as unnecessary, and educators may have little incentive to provide it. The influence of other stakeholder groups, including advocates, victims, and payers, has not been studied and so it is difficult to gauge what impact they may have. For individual health professionals, personal and professional factors may influence beliefs about the desirability of education about family violence and how such education is received and applied. Health care professionals have concerns regarding inadequate time or preparation, discomfort with dealing with family violence, and beliefs that it is a private issue in which they should not be involved. In addition, health care professionals may themselves have had personal experience with victimization or be affected by trauma experienced by their patients. Training programs therefore need to be sensitive to health professionals’ specific needs and concerns. The committee was particularly mindful of the use and effects of mandatory reporting and education legislation. Advantages of mandatory reporting include an increased likelihood that the health care provider will respond to family violence, refer victims for social and legal services, and assist with perpetrator prosecution. However, mandatory reporting is seen by some as a breach in confidentiality that undermines autonomy, trust, and privacy in the health care setting, particularly for intimate partner violence; interferes with efforts to ensure the safety of victims; serves to deter perpetrators from obtaining treatment; precipitates violent retaliation by perpetrators; decreases victims’ use of health care services; and discourages inquiries by health care professionals who believe that if they do not ask, they have nothing to report. Although the relationship between mandatory reporting requirements and education is unclear, the committee found that existing curricula, particularly for child abuse and neglect, often focus in part or in whole on legal reporting requirements. While reporting requirements may encourage education about screening and reporting family violence, given the time constraints on training, that may come at the cost of training about treating, referring, and preventing family violence. A few states mandate family violence education for health professionals. The committee could find no formal evaluations of the impact of the education provided in accordance with those laws. However, studies demonstrate that health professionals who have obtained any continuing education about child maltreatment (not necessarily mandated) are no more likely—and in some study samples are less likely—to report child abuse and neglect than are those who have not attended such training.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence In addition to effective training on family violence, a supportive environment appears to be critically important to producing desirable outcomes. Evaluation of curricula, while critical, is not sufficient to produce the desired outcomes. Having a proven curriculum will not ensure that health professionals receive the necessary training and adapt their practice behaviors. A commitment of time and resources is necessary to make attention to family violence a regular part of training and practice. Without such a supportive environment, the effects of training are likely to be short lived and may erode over time. Recommendations Recommendation 2: Health professional organizations—including but not limited to the Association of American Medical Colleges, the American Medical Association, the American College of Physicians, the American Association of Colleges of Nursing, the Council on Social Work Education, the American Psychological Association, and the American Dental Association—and health professional educators—including faculty in academic health centers— should develop and provide guidance to their members, constituents, institutions, and other stakeholders. This guidance should address (1) competency areas for health professional curricula on family violence, (2) effective strategies to teach about family violence, (3) approaches to overcoming barriers to training on family violence, and (4) approaches to promoting and sustaining behavior changes by health professionals. In addition to federal efforts supporting research, scholarship, and curricular development, leadership and collaboration from the health sector are needed to develop effective training for health professionals on family violence. Health professional organizations are positioned to assist and influence their members who are likely to encounter victims of family violence. Efforts by the American Association of Colleges of Nursing, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the American College of Nurse Midwives provide promising examples of how health professional organizations can actively work to encourage and implement education initiatives on family violence among their members. Recommendation 3: Health care delivery systems and training settings, particularly academic health care centers and federally qualified health clinics and community health centers, should assume greater responsibility for developing, testing, and evaluating innovative training models or programs.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Health professional education often occurs in the health care delivery setting. Therefore, leadership from the health sector, including health care delivery systems and training settings, is needed to develop, test, and evaluate practical and effective training for health professionals on family violence. Training curricula should be linked to clinical evidence, including outcome measurement, should provide incentives, and should respond to factors that challenge the development, implementation, and sustainability of training programs. The literature on the principles of adult education, theories of behavior change, and performance measurement techniques offer informative models. Instruction should be based on clinical evidence and emphasize task-centered (problem-based) learning approaches. Mechanisms for the ongoing collection, analysis, and feedback of process and outcome data are needed for progressive improvements in education and practice. Recommendation 4: Federal agencies and other funders of education programs should create expectations and provide support and incentives for evaluating curricula on family violence for health professionals. Curricula must be evaluated to determine their impact on the practices of health professionals and their effects on family violence victims. Evaluation must employ rigorous methods to ensure accurate, reliable, and useful results. Evaluation of existing and future training programs is necessary to identify effective programs. However, for evaluation to be helpful, it must produce reliable and useful results so that any weaknesses that are discovered in the evaluated programs can be improved and effective programs replicated. Evaluation should include attention to: (a) the development of measurement tools and the assessment of quality, (b) the numbers of individuals being studied to ensure the numbers are sufficient for meaningful study, (c) accounting and controlling for the effect of previous training experiences, (d) the use of more rigorous methods, and (e) examination of trainee and practice characteristics and their interaction. The committee’s review of existing training programs for health professionals and the evaluation of those programs suggest evaluation is often not specifically funded. Funders should require that evaluations be conducted as a condition of funding and should provide funding at appropriate levels or the resources and support to ensure that evaluation is possible. In addition, funds should be allocated specifically for the evaluation of existing programs.

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