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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence 1 Introduction Conservative estimates indicate that family violence affects as many as one in four children and adults in the United States during their lifetimes (Centers for Disease Control [CDC], 2000a, 2000b; Tjaden and Thoennes, 1998). Family violence results in a wide array of injuries, chronic medical conditions, and psychiatric and psychological disorders (National Research Council [NRC] and Institute of Medicine [IOM], 1998). The national data on health care service utilization by victims of child abuse and neglect, intimate partner violence, and elder maltreatment, though limited, indicate considerable contact between victims and health professionals. In 1994, 1.4 million persons were treated in emergency departments for injuries resulting from confirmed or suspected cases of interpersonal violence. Of these, 25 percent (350,000) were victims of family violence: 7 percent had been injured by a spouse or ex-spouse; 10 percent by a current or former boyfriend or girlfriend; and 8 percent by a parent, child, sibling, or other relative (Rand, 1997).1 While the numbers of victims of family violence seen in emergency departments are significant, the available data do not address the full extent of the problem. The emergency room data do not address the numbers of victims seen in other health care settings, such as primary care, pediatrics, obstetrics and gynecology, dentistry, and nursing homes. Research suggests that they are underreported (Ganley, 1996; Moore et al., 1998; Parsons et al., 1995; Rand, 1997; Rudman and Davey, 2000; Sabler, 1995, 1996). In addition, injuries and other health problems related to family violence often are not seen by health 1 Data inclusive of all health care settings are not available, nor are more recent data.
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence professionals at all. For example, only about 1 in 10 women victimized by an intimate partner seeks professional medical treatment (Greenfeld et al., 1998). Therefore, the true size of the problem is larger than what available data suggest. A comparison of incidence data suggests that family violence is equally or more prevalent than other serious health conditions (Putnam, 1998, 2001). For example, 1996 data reveal 3,195,000 reported cases of child abuse, of which 1,054,000 were substantiated. Based on substantiated cases, the incidence rate was 15 per 1,000 children/year, which represents a 47 percent increase over about a decade (Department of Health and Human Services [DHHS], 1998). Data on cancer from the same year reveal 1,339,156 cases with an incidence rate of 3.95 per 1,000 individuals/year, reflecting a 2.7 percent decrease over about 3 years (Ries et al., 1999). In addition to the medical implications for individuals, family violence has been recognized as a public health problem that requires attention to its societal impact and opportunities for intervention (Mercy et al., 1993; White, 1994). Family violence is associated with numerous other problems that affect health, such as homelessness, alcohol and substance abuse, and delinquency (NRC and IOM, 1998). The nature of their work suggests that health care professionals play a particularly important role in addressing health conditions associated with family violence. Beyond their role in direct treatment of health problems, the long-term and privileged nature of the provider-patient relationship creates unique opportunities to identify family violence victims and respond to their needs. Contact with actual and potential victims affords health professionals the occasion to screen, diagnose, treat, refer, and even prevent abuse and neglect. For example, health care professionals account for the reporting of up to about 23 percent of cases of child abuse and neglect (Administration for Children and Families [ACF], 1998). Work in the context of public health could move health professionals and others beyond the treatment of individual symptoms resulting from family violence to addressing the problems underlying the violence itself (Marks, 2000). Yet studies consistently describe the lack of education for health professionals on family violence as a major barrier to the identification, treatment, and provision of assistance to family violence victims (e.g., Chiodo et al., 1994; Ferris, 1994; Hendricks-Matthews, 1991; King, 1988; Reid and Glasser, 1997; Sugg and Inui, 1992; Tilden et al., 1994). Some health professionals have expressed concern that they have never had the opportunity to learn how to ask patients about possible abuse; even with training, many report that they are ill equipped or are not encouraged in the practice setting to address family violence (Cohen et al., 1997; Schechter, 1996). Others express anxiety and frustration regarding their ability to respond appropriately if abuse is suspected or disclosed (e.g., Ferris, 1994; Sugg and Inui, 1992).
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence THE CHARGE TO THE COMMITTEE In response to a congressional mandate under P.L. 105-392, the Health Professions Education Partnerships Act of 1998, the Board on Children, Youth, and Families of the Institute of Medicine (IOM) and the National Research Council (NRC) of the National Academies convened a committee to assess the training needs of health professionals with respect to the detection and referral of victims of family and acquaintance violence, including child physical abuse and sexual abuse and neglect, intimate partner violence, and elder abuse and neglect. The study was supported by the Centers for Disease Control and Prevention. The multidisciplinary committee included individuals with scientific, clinical, and policy expertise in the fields of pediatrics, obstetrics-gynecology and women’s health, family medicine, emergency medicine, geriatrics, nursing, academic health education, mental health, social work, public health, family violence, evaluation, law, and ethics. The 15-member committee was asked to review and synthesize available research on: the training needs of health care providers from the various disciplines that come into contact with family or acquaintance violence, including but not limited to physicians, nurses, and social workers, and the appropriateness with which providers are receiving training; available curricula for screening, detecting, and referring family and intimate partner violence in health care delivery settings and the effectiveness of these curricula and training activities, as well as outcomes associated with these interventions; and existing efforts, coalitions, and initiatives intended to foster the knowledge and skills base of health care providers. When possible, the committee has looked for other opportunities and settings for training, including schools of medicine and nursing, graduate education programs for psychology and social work, clinical training, and continuing medical education. In addition, the committee has examined the strengths and limitations of indicators and outcome measures, as well as evaluation methodologies that are commonly used to assess curricula and training programs. Finally, the committee has worked to address issues regarding the implementation of these programs in light of competing patient-level needs and existing barriers and system-level disincentives for screening, detecting, and referring family violence. THE COMMITTEE’S APPROACH The committee began its work with an examination of the extent to which health professionals receive training about family violence. To do this, we identified and assessed existing curricula across health professions and educational
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence levels. An exploration of the meaning of family violence and its impact on society and the health professions provided the background for this assessment. After reviewing the content and methods currently employed, the committee sought an understanding of how curricula have evolved, identifying and examining factors that potentially shape them. Then, an examination of available evaluation data provided insight into what is and is not working, as well as the limitations of the evaluation efforts to date. To determine the next steps in ascertaining and addressing health professional training needs, the committee considered the competencies necessary for training on family violence. Reflecting on principles of adult education and methods of behavior change, the committee also investigated effective training strategies. To accomplish these tasks, the committee surveyed the published literature; unpublished health professional curricula on family violence; and existing requirements, policy statements, and guidelines for family violence education. We also consulted with numerous health professional organizations; policy makers; family violence advocacy groups; and researchers and scholars on family violence, education, law, and related issues. Our review of the available literature, consultation with experts, and input from other interested parties reveal severe limits on the evidence base needed to develop the guidance requested by Congress. A number of training efforts exist, but little evidence supports their content, design, or methods and little is known about their effects. Nonetheless, the committee decided to adopt an approach used in previous reports that encountered a similar situation: we assess and build on the existing, though limited, evidence. For example, a previous study of interventions for victims of family violence2 concluded that the research base was insufficient to yield any policy recommendations (NRC and IOM, 1998, pp. 289, 294). However the report recognized that the existing array of interventions offers a valuable body of experience and expertise from which lessons could be drawn to inform future interventions. Education cannot wait until definitive research is available, but must be improved by future research findings. In the judgment of the current committee, existing efforts at training health professionals on family violence offer an important and instructive body of experience from which scientific determinations of efficacy can be made. Educators, education researchers, and curriculum architects will be challenged to develop rigorous evaluations and build on the results. We endeavored to make the most of the little evidence and substantial experience that are available. With this foundation, in our view, significant progress can be made to develop the field of family violence and training initiatives to address it. To emphasize the 2 We refer the reader to the report, Violence in Families: Assessing Prevention and Treatment Programs, for a discussion about existing family violence interventions and their effects, as this material is not addressed in this report.
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence importance of research and evaluation for this development, the committee devotes an entire chapter to evaluation research and makes recommendations that target the development of the field and educational efforts. DEFINITIONAL ISSUES Addressing health professional training on family violence is complicated by several definitional issues. The use and meaning of the terms family violence, health professionals, training, and response are not consistent in the existing literature. The definitions of family violence and each of its subtypes also vary widely and are laden with controversy. The task of identifying and assessing all existing family violence curricula for every type of health professional across all education and practice settings proved to be enormous and was compounded by the lack of consensus about what constitutes a training program. To carry out its task, the committee established common descriptions and terms for its work, described below. Family Violence According to the committee’s charge, family violence is defined to include “child physical and sexual abuse and neglect, intimate partner violence, and elder abuse and neglect.” To inform this definition, the committee relied primarily on the description offered by the National Research Council/Institute of Medicine Committee on the Assessment of Family Violence Interventions. According to its report, the term family violence is applied to “a broad range of acts whose presence or absence results in harm to individuals who share parent-child or adult intimate relationships” (NRC and IOM, 1998, p. 18). The current committee understands violence to include physical, emotional, psychological, and sexual harms; the potential for harms; intentional and unintentional injury; and abuse and neglect. In addition, the committee reviewed some commonly referenced definitions, including those in both federal and state legislation, and drew on the descriptive overlap that emerges for our work. Among these are the types of abuse with which this report is concerned: child abuse and neglect, intimate partner violence, and elder maltreatment. The committee considered whether to examine family violence as a single entity or to address the traditionally defined demographic groups separately. The charge suggests that family violence be considered as a single entity, and the need for health professional training on family violence generally suggests a unified approach. However, child abuse and neglect, intimate partner violence, and elder maltreatment are studied, described, and discussed separately in the majority of the literature. The committee opted to consider family violence both in the aggregate and by type. For example, in describing our review of the literature regarding the magnitude of family violence and existing curricula, gen-
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence erally we considered each type of family violence separately. The discussion reflects what we perceive to be an imbalance in attention to each of the types of family violence in research, current interventions, and educational initiatives. In drawing conclusions and making recommendations, the committee considers family violence in the aggregate, with the idea that evidence specific to training about one form of family violence may also be instructive for other forms. Health Professionals Victims of family violence seek help from a broad array of health professionals. Among these are physicians of many specialties; physician assistants; nurses and advanced-practice nurses of many specialties; certified nursing assistants; social workers; psychologists and other mental health professionals; dentists; emergency medical service providers; public health professionals; alternative and complementary medicine providers; allied health professionals, such as physical therapists, occupational therapists, and others; home health care personnel of various types; pharmacists; dieticians and nutritionists; medical assistants; veterinarians; hospital chaplains; patient advocates; case workers; clinical office and hospital receptionists; health educators; clinical administrators; and human resources personnel. This list is not intended to be comprehensive but illustrative of the diversity of health professionals involved in addressing family violence and the variety of roles they play, including prevention, recognition, treatment, education, and referral. This report focuses on the following health professions: physicians, physician assistants, nurses (including advanced-practice nurses), social workers, psychologists, and dentists, because, in the committee’s view, these health professional groups are among the most likely to encounter victims of family violence early in the evaluative process and to have a role in screening, diagnosing, treating, and preventing family violence. By limiting the focus, we do not mean to suggest that other health professional groups or disciplines are not important in the health care response to family violence. The commentary, conclusions, and recommendations in this report will be of value to a wide array of health professionals. Training and Education The terms training and education may be used synonymously or to express different meanings. Training is often described as practically useful skills development, while education refers to the promotion of conceptual understanding (e.g., Moran Campbell, 2000). The committee chose to use these terms inter-changeably throughout the report to refer to formal efforts to provide information and experience about family violence to health professionals or students. Based on the understanding of learning advanced by the National Research
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Council (1999) and following the example of the Centers for Disease Control and Prevention (Osattin and Short, 1998), the committee elected to concentrate on formal curricula and agreed on the following working definition of curriculum: “a deliberate program of study, with explicit goals and objectives, that is designed for use as a regular component of professional education/training.” This definition was used to collect information and examples of existing training programs. The committee limited its review of programs to those with formally developed curricula. Curricula were collected via a literature review, a web search, an extensive mailing to health professionals and organizations likely to be involved in family violence education, listserves, individual member knowledge, and word of mouth. The illustrative collection of existing curricula is available in Appendix E. While relying on the previously described definition of curriculum for its review of programs, the committee did not limit its review of program evaluations to those that evaluated programs fitting the definition. Rather we reviewed all available literature on the evaluation of educational programs on family violence for health professionals, in order to garner as many lessons as possible. Because in the committee’s judgment successful training requires both appropriate content and effective educational methods, we also examined teaching practices: both traditional teaching approaches and newer approaches based on the emerging principles of the dissemination of knowledge and adult learning theory. Responses of Health Professionals to Family Violence The charge to the committee is very specific with regard to the meaning of the response of health professionals to family violence. According to the charge, response includes “detecting,” “screening,” and “referring” victims of family violence. Reflecting on the use of these terms in health care practice, the committee understands them to mean the following: detection refers to identification of the victims of various forms of abuse and neglect; screening refers to the clinical strategies used to detect and learn about a patient’s specific situation of abuse; and referral means developing an action plan that involves locating, contacting, and providing appropriate and necessary services, such as community shelters, social services, safety planning, and law enforcement. Although prevention is not explicitly included in the charge, the committee notes its importance and found that there is extensive and contentious debate about the roles of health professionals in preventing family violence. In limited instances, this report does address prevention, primarily in descriptions of existing and recommended curricular components.
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence ORGANIZATION OF THE REPORT Report Content Following this Introduction, Chapter 2 discusses definitions of the types of family violence addressed by health professional training, the magnitude of family violence in American society, and an estimate of the effects of family violence on health care professionals and the health care system. Chapter 3 describes current educational activities. In Chapter 4, the committee assesses forces that may affect health professional training. Evaluation data are the primary focus of Chapter 5, which identifies the methods used and what evaluation reveals. Chapter 6 moves from what is known about health professional education to what the evidence and expert opinion suggest it should be; the chapter includes a discussion of content issues, educational strategies, and techniques of behavior change. The concluding chapter provides the committee’s recommendations on training health professionals about family violence. Areas Not Addressed in the Report The content of this report reflects the committee’s fidelity to its explicit charge. Although we discussed a number of important and often controversial areas during our deliberations, those falling outside the scope of our charge do not appear in the report. Among these are the causes of family violence, the actual impact of training on the problem of family violence, the relationship between education and practice, the roles of health professionals in prevention, and the relationship of health professionals to their colleagues in law enforcement, social services, and broader community services systems. The committee also considered issues relating to the identification and treatment of batterers or perpetrators, distinctions between intentional and unintentional injuries as they relate to educational content, the impact of fragmented care on victims, and the overall meaning of health, but we did not explicitly address these issues in the report. The breadth of these issues associated with family violence both underscores the committee’s firm view that health professional training alone cannot fix the problem of family violence and reinforces our position on the importance of health professional training on this issue. This report addresses these issues, suggesting directions for a comprehensive and collaborative approach necessary to understand and move toward resolution of the problem of family violence.
Representative terms from entire chapter: