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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence 7 Priorities for Health Professional Training on Family Violence The committee’s review of the current state of health professional training on family violence reveals that some efforts are being made to train health professionals to respond to family violence; however, the evidence base provided by the available information overall is too thin to indicate clear directions for training. Existing curricula are quite diverse; in general, they tend to focus on only one type of violence, target only specific health professionals or students, and usually lack evaluation. As a result, little evidence exists to indicate what, when, or how to teach health professionals about responding to family violence, the success of current educational programs, or the impact of the training on victims of family violence. BUILDING A FIELD Several reports (U.S. Advisory Board on Child Abuse and Neglect, 1990, 1991, 1993; NRC and IOM, 1998) over the last decade have eloquently described the paucity of research findings to inform practice in the area of family violence. This report is not the first to note difficulties in addressing the issue. For example, the U.S. Advisory Board on Child Abuse and Neglect in its 1991 (p. 109) report summarized the state of research in the field: Although progress has been made, child maltreatment may still be the most underresearched social problem. Research on child maltreatment has grown unsystematically. When major findings have occurred, there have been few efforts to pursue them.
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Public support for research on child abuse and neglect may actually have fallen over the last 15 years. There is a serious shortage of researchers in the field and some important researchers have left the field. Some particular research topics important to the development of effective prevention and treatment programs have been especially understudied. Another study, by the Education Development Center and Children’s Hospital and funded by the Robert Wood Johnson Foundation, examined the health care system’s response to family violence in five communities. It found that, despite recognition in the health care community that family violence is an important problem, health care systems are not playing a central role in responding to it. Health care professionals pay little attention to the identification, treatment, follow-up, or prevention of family violence, and those who do are often marginalized (De Vos et al., 1992). These previous reports and studies raise the question of how to build the field of family violence in order to create the capacity to address the problem effectively. A number of approaches are possible. Efforts may focus on producing scholars, supporting research, developing training capacity, encouraging collaborative efforts, or some combination of these goals. To facilitate the growth of scholars in particular research areas, for example, the National Institutes of Health offer awards called K Awards for individual career development in new areas of research. Health professional organizations and federal agencies have developed subspecialty training to develop clinical scholars in particular fields (see Chapter 6 for a discussion of the developmental pediatrics and adolescent medicine subspecialties). Private foundations sponsor fellowships to develop clinical scholars in specific areas. Examples of these include the Robert Wood Johnson Clinical Scholars program and the W.K. Kellogg Foundation Fellowships in Health Policy Research. To encourage research, a number of federal agencies and private foundations have offered grant programs in family violence, calling for research proposals and funding a select few. This research support has been offered through grant programs that specify topics or allow investigators to propose topics within general categories. Other efforts have the primary goal of developing training programs and providing training. For example, geriatric education centers were created to develop, support, and provide health professionals with training in geriatrics. Each of these approaches offers advantages and disadvantages. The benefits of a focus on developing scholars include the creation of a core of individuals who are competent to handle working with family violence victims and possess the knowledge and experience to provide training to other health care professionals. However, this approach is limited in the number of scholars that can be produced; other health care professionals and interested parties in need of training may not have access to these experts. Developing research opportunities can generate information
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence that all health professionals need in order to address family violence. But the applicability of the research is limited without dissemination and training, especially given the overwhelming amount of health care research being published. Usually, research centers not only conduct and fund research but also disseminate their findings. They do not usually provide training, however. Education centers can fill this gap, but they may be dependent on other mechanisms for the research on which the training programs are to be based. No definitive evidence indicates the best approach to building a field. The committee’s examination of existing mechanisms suggests that each appears to have arisen from the needs perceived by those working in the field or other interested parties. Individual or organizational champions work to engender financial and political support from government and private funders. In recommending an approach for the field of family violence, the committee explored suggestions from previous reports and studies on family violence as well as reports of successful approaches in other fields. A brief review of efforts to develop the field of family violence reveals some consensus on the needs of the field and how they might be addressed. For example, the U.S. Advisory Board on Child Abuse and Neglect called for the development of a new data system; creation of a U.S. Department of Health and Human Services-wide research advisory committee; and a primary or lead 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. The advisory board also recommended establishment of state and regional resource centers for training, consultation, policy analysis, and research on child protection. A few months after the advisory board’s report was issued, the commissioner for children, youth, and families (who had received the 1990 and 1991 reports of the advisory board) asked the National Academies “to convene an expert panel to develop a research agenda for future studies of child maltreatment.” The report, Understanding Child Abuse and Neglect, made a series of wide-ranging recommendations, many of which expanded on the advisory board’s recommendations. Importantly, the panel stated as a research priority (NRC, 1993): When a sufficient research budget is available to support an expanded corps of research investigators from multiple disciplines, multidisciplinary research centers should be established to foster collaboration in research on child maltreatment. The purpose of these centers should be to assemble a corps of researchers and practitioners focused on selected aspects of child abuse and neglect, including medical, psychological, social, legal, and cultural aspects of child abuse and neglect. The proposed centers could provide a critical mass in developing long-term research studies and evaluating major demonstration projects to build on and expand the existing base of empirical knowledge. The proposed centers should have a regional distribution, be associated with major academic centers, have the capacity to educate professionals of various disciplines, and launch
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence major research efforts. Examples of the cancer and diabetes centers funded by the National Institutes of Health could serve as models, as could the Prevention Intervention Research Centers of the National Institute of Mental Health. (pp. 358-359) In 1993, another group of researchers, government officials, law enforcement professionals, social service providers, and health care professionals convened at the Wingspread Conference Center in Racine, Wisconsin, to discuss the research and policy needed to address family violence. This group recognized the need to identify and analyze existing evaluations of relevant programs to inform future practice. The National Research Council and the Institute of Medicine established the Committee on the Assessment of Family Violence Interventions to do just that. That committee’s report noted a lack of rigorous evaluation, insufficient resources, and failure of the research and practice communities to collaborate (NRC and IOM, 1998). It recommended that evaluation be integral to all family violence interventions and that policy incentives and leadership foster coordination among policy, program, and research agendas. A study of the response of health professionals to family violence in five communities resulted in similar recommendations (De Vos et al., 1992). That report recommended improving victim access to care, increasing health professionals’ knowledge and improving attitudes, implementing institutional policies that provide incentives for improving detection and care, improving coordination among health care institutions and community services, developing the knowledge base on family violence, and stimulating health professionals organizations to address the issue. In the years since these reports were published, their dozens of recommendations have largely been ignored, although the problems identified have not abated. One analysis suggests that a lack of champions in the legislative and executive branches of the federal government and an inability to create for the public an ongoing sense of crisis have contributed to the inattention these recommendations have received (Krugman, 1997). According to this analysis, a coherent collaborative policy, leadership at the national level, and a continuing program of research and evaluation are necessary to develop the field. There is significant correspondence between the needs of the field and all these proposals for addressing them. Commonly noted needs include the need to build the knowledge base, to evaluate programs, to develop scholars, to provide training, to increase health professionals’ response, to facilitate collaborative efforts, and to develop ongoing support for the field. In the committee’s judgment, confronting the long history of ignored recommendations and the broad array of needs requires a multipronged approach. Resources should be focused in a way that provides a locus of attention to the problem; facilitates interdisciplinary collaboration; bridges science, practice, and policy in the various disciplines, professions, and agencies that address family violence; and establishes systems for preprofessional and continuing education.
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Taking such a comprehensive approach, family violence can become an integral part of education, the relevant service systems, and communities of research. Individual research grant and training programs can help, but they cannot individually meet the broad goals that have been repeatedly described in this and previous reports. The committee recommends a more comprehensive approach involving the development of education and research centers, greater responsibility for the health care sector in health professional training, increased attention to evaluation, and improved collaboration. This chapter summarizes the conclusions the committee drew from our review of available information. Detailed recommendations based on these conclusions suggest ways to improve the training of health professionals to respond to family violence. These conclusions and recommendations are congruent with those offered in previous reports but are focused intensively on health professional training. CONCLUSIONS Responding to its charge, the committee’s conclusions address what is known about health professionals’ training needs to respond to family violence, available training programs and program evaluation, and particular challenges to and opportunities for training development and implementation. Each of the previous chapters includes specific conclusions relevant to its content. What follows is a summary of these 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, few studies describe the total and marginal patterns of utilization or the costs of health care, or the cross-sectional and longitudinal effects on health status from the point of view of the patient (or victim). The results of such studies could indicate the full extent to which the health care system and professionals encounter family violence and the health care needs of victims. A better understanding of the baseline problems, health care needs, and costs associated with family violence could reinforce the need for health professionals’ attention to the issue, provide guidance as to how 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
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence evidence about its magnitude and severity, as well as its effects on the health care system and society. The definitions, data sources, and research methods used for research on family violence vary from study to study. As noted in previous National Research Council and Institute of Medicine reports (NRC, 1993, 1996; NRC and IOM 1998), definitional clarity for family violence terminology is necessary to understand the extent to which data can be reliably compared between studies or reliably generalized to other situations. The same holds true for clarity and consistency in data sources and research methods. Clear and consistent definitions, data sources, and methods are important for developing the evidence base to detail the prevalence of the problem as encountered in health care settings and the health care needs of victims, as well as to indicate the opportunities and roles of health professionals to address family violence. Such an evidence base is necessary to provide a foundation for effective health professional education. 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 experience. Moreover, studies indicate that health professionals and students in the health professions often perceive curricula on family violence to be inadequate or ineffective. Although a number of curricula exist, training does not appear to be consistently offered and is usually of short duration at only one point in the training program, is usually targeted to one professional group, and is frequently limited to one type of family violence. Elder maltreatment appears to be the most neglected type of family violence in existing curricula. Health care professionals who have received training on family violence frequently describe it as insufficient (e.g., Biehler et al., 1996; Wright et al., 1999) or report that they cannot recall having had such training (e.g., Jones et al., 1997). 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 utilize the experimental designs necessary to provide an adequate understanding of effects. At present, a majority of 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, re-
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence quired 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 effects without considering implementation. Other experimental designs, particularly randomized experiments, would be useful in demonstrating the effects of training on health professionals’ behavior or 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. In addition to effective training on family violence, a supportive environment appears to be critically important to producing desirable outcomes. The available evidence from evaluation studies indicates that an evaluated curriculum, while critical, is not sufficient to produce the desired outcomes. That is, 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. 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 indicates some similarities in objectives, content, and teaching methods, suggesting some coherence in domains across disciplines in which core competencies could be developed or tested for health professional education. While the committee could find little research to determine specific core competencies and content, these content areas regularly appeared in existing curricula and in the literature on health professional training on family violence. In our view, these areas offer useful starting points for research to specify core competencies for health professional training and educational con-
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence tent that reflects stages of learning, educational setting, profession, specialty, intensity of educational need, and patient populations likely to be encountered. In addition, the specification of core competencies could facilitate the development of sound measures for assessing them. This, in turn, would lead to better measures for assessing outcomes and competencies in training evaluation studies. 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 health care delivery systems, the use of techniques to address practitioners’ biases or beliefs about victims, and the use of health care outcome measurement (e.g., Health Employer Data Information Set measures) to inform evidence-based practice. Studies demonstrate that traditional forms of didactic education intended to increase knowledge about a particular topic are insufficient to enhance skills and change clinical practice to improve patient outcomes. The research literature on behavior change and strategies and principles of adult learning indicate that teaching methods that employ multifaceted, skill-building, practice-enabling strategies are more effective at changing behavior in health care delivery. Such strategies involve interactive techniques, such as case discussion, role play, hands-on practice sessions, and guided clinical experiences and provide evaluative feedback to trainees about their behavior in these situations. Evidence from research on continuing medical education further reveals that these teaching methods are effective at changing professionals’ behavior and health care outcomes, particularly when they are supported and reinforced in both training and practice settings, when the outcomes associated with the trainee’s behaviors are measured, and when the trainees are given positive feedback when positive outcomes are achieved (Bero et al., 1998; Berwick and Nolan 1998; Davis et al., 1995; Haynes et al., 1984; Oxman et al., 1995; Shekelle et al., 2000; Thompson, 1996; Thomson et al., 2001a, 2001b, 2001c). Strategies—referred to as systems change models—for changing practices within institutions are based on findings about effective ways to change behavior. A number of such models exist, generally involving identifying areas in which change is needed, determining objectives for change, testing approaches for achieving those changes, assessing the impact of those approaches, and making further adjustments. Kaiser Permanente of Northern California, the Group Health Cooperative, and the University of Virginia have demonstrated success with the use of systems change models in health care institutions (Melton et al., 1985; Maiuro et al., 2000; Sugg et al., 1999; Thompson et al., 1998, 2000). A few managed care organizations and hospitals are beginning to apply such approaches to the education and training of health professionals to identify and
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence manage cases involving family violence (Thompson et al., 2000; Campbell et al., 2000). Early experiences with these techniques are demonstrating positive effects. In addition to efforts to change systems, techniques to reduce health professionals’ biases—the assumptions health professionals have about who family violence victims are and why they are maltreated—may be useful in developing effective education on family violence. As with other professions that deal with family violence, cognitive biases held by health practitioners may have particular effects on the identification of victims and attributions of risk in cases of actual or suspected family violence. Research on techniques to address these assumptions or biases, known as “debiasing,” suggests that errors in identifying victims and assessing risk could be reduced if training programs on family violence included exercises in which trainees compared their own judgments and assumptions about victims with data describing real victims. Research on outcome measurement, such as measures included in the Healthplan Employer Data Information Set (HEDIS), and evidence-based practice suggest potential for the creation of a standard set of measures for effective practice for family violence. HEDIS measurement, in its short existence, has demonstrated profound effects on the behavior of health care delivery organizations and on practitioners (Bader et al., 1999; Eddy, 1998; Epstein, 1998; Harris et al., 1998; Hill and Spoeri, 1997; Kelly, 1997). For example, managed care organizations have made major changes to meet new requirements, and training of health care personnel is widely conducted as part of this process (National Committee for Quality Control, 1999). Examples of the success of HEDIS measures include changing health care delivery for immunizations (Hughes, 1997; Family Violence Education, 1996; Thompson, 1996), the management of hypertension (Elliott et al., 1999), and diabetes care (Peters et al., 1996). Currently, no HEDIS measures exist for diagnosing and treating family violence. Evidence-based practice currently appears to be another strong and emerging force in health care professional education. Evidence-based practice is recognized as essential to ensure quality health care (e.g., Green and Ellis, 1997; Norman and Shannon, 1998). As it involves efforts to apply the best-available scientific evidence to day-to-day practice, the drive for it could serve as a stimulus for effectiveness research on family violence interventions. Yet research shows that even in areas in which best-practice standards are well established, incorporation into practice is extremely slow and uneven (IOM, 2001). Challenges to developing, implementing, and sustaining training programs for health professionals on family violence include the nature of accreditation, licensure, and certification; characteristics of health professional organizations; views of stakeholder groups; 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 A number of factors may influence whether or not as well as the extent to which family violence is included in health professional training. Accreditation, licensure, and certification requirements do not consistently and explicitly address family violence and thus do not appear to be significant influences encouraging such training for health professionals. 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, as for other individuals, 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 (e.g., Sugg and Inui, 1992; Newberger, 1977; Cohen et al., 1997). Overcoming these concerns is another challenge to be addressed. In addition, health care professionals may themselves have had personal experience with victimization (e.g., Ellis, 1999) or be affected by trauma experienced by their patients (“vicarious traumatization”; McCann and Pearlman, 1990; Neumann and Gamble, 1995; Talbot et al., 1992). 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. Reporting suspected abuse and neglect has become common in health practice (Zellman, 1990a), but some health care professionals express concerns that reporting can be more harmful than helpful to the victim. The advantages of mandatory reporting include the 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, with regard to intimate partner violence in particular (Rodriguez et al., 1999; Tilden et al., 1994), some health professionals and others voice concern that mandatory reporting is a breach in confidentiality that undermines autonomy, trust, and privacy in the health care setting (Kalichman and Craig, 1991; Kalichman et al., 1989; NRC and IOM, 1998; Rodriguez et al., 1998, 1999; Vulliamy and Sullivan, 2000; Warshaw and Ganley, 1998); interferes with efforts to ensure the safety of victims (Levine and Doueck, 1995; NRC and IOM, 1998; Rodriguez et al., 1998, 1999; Tilden et al., 1994; Warshaw and Ganley, 1998; Zellman, 1990b); serves to deter perpetrators from obtaining treatment (Berlin et al., 1991; Kalichman et al., 1994); precipitates violent retaliation by perpetrators (Gerbert et al., 1999; Gielen et al., 2001; Rodriguez et al., 1999); decreases victims’ use of health care services (Gerbert et al., 1999; Rodriguez et al., 1999); and discourages inquiries by health care professionals who believe that if they do not ask, they have nothing to report (Gebert et al.,1999). Although the relationship between mandatory reporting requirements and
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence education is unclear, the committee found that existing curricula, particularly on child abuse and neglect, often focus in part or in whole on legal reporting requirements. While reporting requirements may be useful in promoting health professional education about screening and reporting family violence, it appears that existing curricula may focus on required reporting procedures to the detriment of health professionals’ roles in treating, referring, and preventing family violence. A previous report of the National Research Council and Institute of Medicine, Violence in Families, recommended that “states initiate evaluations of their current reporting laws” and that they “refrain from enacting mandatory reporting laws for domestic violence until such systems have been tested and evaluated by research” (NRC and IOM, 1998, pp. 295-296). Such research continues to be necessary and should include the impact of reporting laws on health professional training. A few states mandate family violence education for health professionals, but 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 (Beck and Ogloff, 1995; Kalichman and Brosig, 1993; Reininger et al., 1995). In addition, the legal requirements tend to take the form of lecture-based programs that education research suggests have little effect on influencing practice behaviors (e.g., Davis et al., 1999). Mandated education requirements provide an opportunity for evaluation to determine whether changes and improvements in knowledge, attitudes, and skills related to family violence result from such requirements and whether they can be sustained over time; whether costs of care, severity of presenting health problems, case mix, morbidity, and mortality are affected; and whether any changes observed can be attributed to the education program itself. 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. The fragmented information on funding is particularly 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 education re-
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence search on family violence to design and test innovative and responsive models for health professional education or to evaluate existing models. RECOMMENDATIONS 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. In recommending the creation of education and research centers, the committee reiterates and builds on recommendations from previous reports on family violence (U.S. ABCAN, 1990, 1991; NRC, 1993; NRC and IOM, 1998). In addition, there are some indications that the use of centers is effective in building a field. For example, Tony Phelps, director of the Alzheimer’s disease centers program of the National Institute on Aging, reports: While there has been no comprehensive formal evaluation of the Alzheimer’s Disease Centers Program, there is substantive agreement that the ADCs have played and will continue to play a major role in Alzheimer’s disease research by providing an infrastructure and core resources around which institutions can build innovative research programs. Centers not only conduct research projects and provide resources locally, but also join together with other ADCs to perform collaborative studies on important research topics and serve as regional or national resources for special purpose research. Among the accomplishments of the centers Phelps describes are multidisciplinary undertakings in research that have significantly advanced understanding of Alzheimer’s disease; the development of new lines of research; the dissemination of research findings to the professional and lay communities; and support for professional education through training programs, conferences, presentations, collaboration with state and local agencies and other Alzheimer’s professional groups, and technology-based information dissemination. Of note, he writes, “By pooling resources and working cooperatively, the Centers have produced research findings that could not have been accomplished by individual investigators working alone” (Phelps, personal communication to the committee, July 7, 2001). Similarly, David Hemenway, director of the Harvard Youth Violence Prevention Center, reports that centers offer the advantages of coordination
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence and continuity. In addition, they allow a group of people to build a field by collaborating on several projects instead of working project by project. The center focuses on the interdisciplinary study of the causes and etiology of injury and its application for the development and evaluation of prevention and intervention strategies and policy. In its first two years of existence, the Harvard Youth Violence Prevention Center was able to win major grant funding; assemble a multidisciplinary team of faculty; have 78 peer-reviewed articles on injury prevention published or accepted by journals in the field; initiate five major research projects as well as several others; provide graduate student and professional training and research opportunities; offer information and training to community leaders and members; and collaborate with state and local governments and community groups (Harvard Injury Control Research Center, 2001). The Geriatric Education Centers, which are funded by the Health Resources and Services Administration to develop and disseminate curricula and to support training on geriatrics for health professionals, were the subject of a formal national impact evaluation four years after their inception in 1983 (Engle and Jackson, 1991). The number of centers grew from 4 in 1983 to 38 in 1989. The evaluation found that enrollees in the training programs came from a number of disciplines, primarily nursing, social work, and medicine. The majority reported the intensive training experience as excellent to good in providing direct experience with the range of clinical problems related to geriatrics (91.9 percent), in helping develop professional skills in geriatrics (89.3 percent), and in contributing to their decision to begin or continue working in geriatrics (70.9 percent). The enrollee respondents also reported that their impression of geriatric health care had changed positively since their training experience. They indicated that they had made changes to increase their work or activities relating to older adults and that they considered the training to be change producing, although the evaluation does not prove a cause-and-effect relationship. The trainees’ supervisors reported that their institutions did provide some support, with 32 percent reporting financial support and 50 percent reporting the provision of paid leave for the trainees. The responding supervisors also reported that, following training, staff involvement in geriatric-related activities increased and the institution offered more geriatric-related training. Administrators in the trainees’ institutions also reported increased interest in geriatric activities, including increased enrollment in geriatric programs, the development of policies on geriatric-related issues, more courses on geriatrics, and an increase in the number of funded grants related to geriatrics or gerontology. In the committee’s judgment, the reported successes of centers in other fields support the 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
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence connected to academic health centers, as recommended previously by others, or they could build on related efforts in other existing centers. For example, the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention already conducts and funds activities related to health professional training on family violence, among other activities (http://www.cdc.gov/ncipc/about/about.htm). These resource centers should be linked to local and community resources and programs (e.g., domestic violence shelters, community clinics, and local assistance hotlines) as well as the health care delivery system. Such linkage is necessary to facilitate and support translating research results into real-world practices. The committee suggests that a modest number of centers, three to five, be established in the next 5 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 the scientific research on magnitude, health effects, and interventions. 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. Research conducted or funded by these centers should include attention to: an examination of the variability in definitions, data sources, and methods used in research on family violence to determine how to address and overcome the concerns and limitations this variability produces; the epidemiology of family violence, particularly its magnitude, severity, and health consequences in society; the underlying causes and psychodynamics of family violence; ongoing assessment and surveillance mechanisms related to the utilization and costs of health care services associated with family violence; and assessment of current family violence interventions and the development, testing, and evaluation of new intervention programs to determine effective practices. The development of training programs for health professionals should involve educational research on: identification of the range and extent of training needs within and across professions; assessment of current education efforts, including both content and teaching strategies; the development, testing, and evaluation of model educational strategies (including content and methods) for education and training;
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence the identification and evaluation of factors that influence education, research, and practice (e.g., mandatory reporting requirements, mandated education laws, accreditation, advocacy groups) and strategies for overcoming barriers; the determination of training needs for health professionals at all educational levels, including the needs of trainers; and systems or setting changes and educational strategies that promote the institutionalization of appropriate new or changed behaviors by those caring for victims of family violence. The centers should offer training to: translate research findings into educational and clinical practice; expand the number of scholars and educators from multiple disciplines working in the area of family violence who can provide training in health professional schools and other training settings; and provide settings in which multidisciplinary training efforts are modeled. Based on research findings and collaborative experience, advice on policy should be developed regarding a number of issues, including: education funding, including the role of third-party reimbursement in training and infrastructure (human and financial resources and other needs within the training setting) development to support education on family violence. Dissemination should be undertaken to: inform educators, researchers, policy makers, grant funders, and the public about research findings and funding opportunities related to family violence research and education; foster multidisciplinary collaboration on family violence research, education, and practice; encourage public and professional understanding of family violence and its significance in society; and offer leadership in policy development related to family violence research and education. By providing a locus of activity, education and research centers can facilitate the tracking and coordination of efforts to address family violence among federal agencies as well as those at the state and local levels and private organizations. As the committee’s review of existing programs and funding sources revealed, program development and funding for family violence programs are currently scattered
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence among agencies of the U.S. Department of Health and Human Services and the U.S. Department of Justice. Among these 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. 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. 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. In addition to the development of centers, the committee endorses continued funding of individual research and program initiatives that focus on family violence. These efforts can enhance the effectiveness of the proposed centers. 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 Pediat-
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence rics, 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. The organizations provide insight into strategies to overcome barriers to developing, implementing, and sustaining curricula and to promote changes in behavior. In addition, their experiences suggest promising directions for other organizations. The committee encourages other organizations to undertake similar initiatives and evaluate the impact of their efforts. The models developed could help to inform educational efforts. The education and research centers recommended above can undertake further research into these issues as well. 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. In addition to federal efforts supporting research, scholarship, and curriculum development, leadership from the health sector, including health care delivery systems and training settings, is needed to develop, test, and evaluate practical and effective health professional training on family violence. Much health professional training occurs in the health care delivery setting, so these settings provide an opportunity to develop practices that enhance the care of victims of family violence. Efforts to develop training curricula should be linked to clinical evidence, include outcome measurement, provide incentives, and respond to factors that challenge 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; in this way, evaluation becomes integral to training. Evaluation is important to identifying effective curricula and determining areas in which change is needed. The goal of evaluation is not simply to assess a particular program but to determine how to change behaviors and create systems of practice that improve the health outcomes of victims of family violence. Working with evaluated materials is an important step in developing effective and sustainable education efforts. Kaiser Permanente of Northern California, the GroupHealth Cooperative, and the University of Virginia offer examples of health care delivery systems making innovations in education techniques and overcoming barriers to behavior change. These organizations are or have been actively involved in developing, testing, and improving training programs. Other health care delivery system and training leaders can likewise take
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence advantage of the influence they may have with health professions and professionals as part of the broader societal efforts to address the general need for health professional education, determine appropriate content and effective teaching strategies, and provide support for health professional training development and evaluation. Sound development, evaluation, and funding are necessary to ensure that these systems are sustainable, as sustainability in health professional training programs is as important as the development of effective curricula. Recommendation 4: Federal agencies and other funders of education programs should create expectations and provide support for the evaluation of 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. To ensure that evaluation is useful, a number of methodological issues are in need of attention: Measurement development and assessment of quality. In order to add to the evidence base regarding the effectiveness of family violence interventions, future studies should pay greater attention to. Priority should be given to the development of measures with demonstrated reliability, validity, and sensitivity to change, which evaluators could then adopt for more widespread use. Refining alternative measures of knowledge and attitudes (e.g., the use of vignettes and standardized patients) and strategies for assessing clinical outcomes are also important. The number of individuals studied: strategies to improve statistical power include increasing sample sizes. Evaluations of training interventions have often been based on small samples of trainees (and comparison group members) that lack sufficient statistical power to detect meaningful effects. This is particularly a problem with regard to outcomes involving knowledge and attitude change, for which metaanalyses have found that effects of behavioral interventions are reasonably small. The expectation of small effects, therefore, needs to be considered in the design of evaluations. Conventional statistical estimates point to the fact that large sample sizes of 300 or more are necessary to detect whether desired effects exist (Cohen, 1988). It is unlikely that such sample sizes are possible in most training evaluation studies. Other strategies for improving the power of the design are possible. More reliable measurement can help in terms of reducing the variability within groups caused by measurement error (Lipsey, 1990); examining a training intervention implemented in multiple sites can increase the statistical strength of studies as long as each site adequately implements the key training components. Better information on variation in training received for both the
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence training intervention and comparison groups. In any type of training, particularly those involving multiple sessions and activities, individuals vary in their levels of engagement or participation. Differences in student training experiences and tutor preparation affect changes observed in knowledge, attitudes, and skills. Differences in baseline knowledge and preparation may also influence the magnitude of change in training participants (Short et al., 2000). Measuring training also is important for the nonintervention groups, who may in fact have received different amounts of previous education or have acquired somewhat similar information as those who participated in the training. Rigorous evaluation studies. Well-designed evaluations are urgently needed to expand knowledge of what and how much training should be delivered to whom, when, how often, and at what cost. Properly conducted, they can also highlight the level of other resources necessary for successful implementation (e.g., administrative support). Priority for evaluation funding should be assigned to training interventions designed around strategies shown to be effective in fostering learning and changing provider behaviors (e.g., Davis, O’Brien et al., 1999; NRC, 1999). Randomized field experiments of individuals are difficult. Single-site evaluations that rely on quasi-experimental designs can improve the degree to which they address the relationships between training and outcomes and even rule out certain plausible rival hypotheses. Examples include paying more attention to the timing of follow-ups and, when possible, having multiple pre- and posttest observations of the outcomes of interest. Employing strategies to reduce attrition from measurement is important (e.g., incentives for participants to complete the measures). Finally, both experimental and quasi-experimental designs must attend to assessing the environment in which individuals function and the degree to which it facilitates or impedes translation of the knowledge learned from training to actual practice. This may also be useful in exploring whether training actually results in any system changes. Programmatic research on training. Research is needed that more closely examines how trainee characteristics, their perceptions of training and its quality, and the characteristics of the practice context in which they work (e.g., integrated delivery systems versus small-group practices) interact in effectively translating the knowledge and skills into daily practice (see Huba et al., 2000; Ottoson and Patterson, 2000; and Panter et al., 2000, for examples in HIV/AIDS education and continuing education). With such research, evaluated programs can contribute to enhancing practice by health professionals to improve the health outcomes of victims of family violence. Evaluation is critical to the development of effective training programs on family violence. The committee’s review of existing training programs for health professionals and the evaluation of those programs suggests that even when program development is funded, evaluation is usually not funded. Funders should
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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence require that evaluations be conducted as a condition of funding and should provide funding at appropriate levels or the technical support to ensure that evaluation is possible. In addition, funds should be allocated specifically for the evaluation of existing programs. FINAL THOUGHTS A limited evidence base and the emotional responses that family violence inspires combined to make the committee’s task in responding to its charge complex and difficult. Guided by the judgment that health professional training on family violence is necessary, the committee drew on the existing science to discern important starting points for research and development on training content and teaching methods. These represent opportunities for educators, researchers, and policy makers to address and help reduce, if not resolve, problems related to the responses of health professionals to family violence and to develop the responsive health care system that family violence victims need. With sufficient human and financial investment and collaboration among diverse stakeholders, the committee is confident that significant progress can be made in meeting the training needs of health professionals and the health care needs of family violence victims.
Representative terms from entire chapter: