4
Forces Influencing Health Professionals’ Education

Health professional curricula evolve in the larger societal context and may be influenced by a number of factors. The committee identified a number of forces with the potential to influence curriculum development, implementation, and sustainability and explored the impact of each. The factors considered include training environment issues; accreditation, licensure, and certification requirements; individual issues for health professionals; the influence of health professional organizations and other stakeholder groups; laws mandating reporting and education about family violence; and funding.

Throughout its discussion of challenges to training, the committee struggled with two issues. First, little research has been published regarding factors that challenge or become barriers to educational efforts or the relationship between such factors and education. Second, some research has been published to provide empirical support for the impact of various factors on health professional practice. The committee often had difficulty distinguishing among effects on practice and education, as the experiences of individual committee members suggest that factors that become barriers to practice are also barriers to education. Many teaching faculty are also clinically active practitioners in their fields, and much education received by health professional students takes place in clinical settings (either inside or outside the academic institution). Thus challenges to training are difficult to distinguish from issues related to the clinical care of patients at risk for family violence. Despite perceptions of a relationship or similarities between challenges to education and barriers to practice, without further research, only



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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence 4 Forces Influencing Health Professionals’ Education Health professional curricula evolve in the larger societal context and may be influenced by a number of factors. The committee identified a number of forces with the potential to influence curriculum development, implementation, and sustainability and explored the impact of each. The factors considered include training environment issues; accreditation, licensure, and certification requirements; individual issues for health professionals; the influence of health professional organizations and other stakeholder groups; laws mandating reporting and education about family violence; and funding. Throughout its discussion of challenges to training, the committee struggled with two issues. First, little research has been published regarding factors that challenge or become barriers to educational efforts or the relationship between such factors and education. Second, some research has been published to provide empirical support for the impact of various factors on health professional practice. The committee often had difficulty distinguishing among effects on practice and education, as the experiences of individual committee members suggest that factors that become barriers to practice are also barriers to education. Many teaching faculty are also clinically active practitioners in their fields, and much education received by health professional students takes place in clinical settings (either inside or outside the academic institution). Thus challenges to training are difficult to distinguish from issues related to the clinical care of patients at risk for family violence. Despite perceptions of a relationship or similarities between challenges to education and barriers to practice, without further research, only

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence inferences can be made. The committee has attempted to distill those concerns pertinent to the education and training of health care professionals.1 INTRINSIC INFLUENCES ON THE TRAINING ENVIRONMENT Forces intrinsic to settings of health professional training may shape curricula. Such factors include: (1) curricular time and educational priorities and (2) institutional culture and norms. Curricular time refers to the specific course(s), hours, or other time allotted to training on family violence. How the time is used is dictated in part by the recognition of educational needs and determinations of the extent to which those needs will be met, involving setting priorities for the limited time available. Institutional culture and norms refers to the professional values and beliefs within the training environment. The following discussion relies on the data available, the experience of committee members, and reports of others in health professional education elicited during a public forum the committee held on this topic, as well as other communications. The majority of the available literature focuses on physician and nurse education. Curricular Time and Educational Priorities Recognition of the Need for Training on Family Violence Family violence, although of ancient origins, is newly recognized as a substantial concern for the public health and health care systems. For many in health care, it is perceived more easily as a social or legal problem. In fact, historically, society in general and some health professions in particular have considered family violence to be primarily a social or legal problem and have been slow to recognize its significant health component. As recently as 15 years ago then-Surgeon General C. Everett Koop convened the first workshop linking violence and public health. In Dr. Koop’s words: Identifying violence as a public health issue is a relatively new idea. Traditionally, when confronted by the circumstances of violence, the health professionals have deferred to the criminal justice system. . . . [Now] the professionals of medicine, nursing, and the health related social services must come forward and recognize violence as their issue. (1991:v) 1   The committee refers the reader to a number of references that do discuss barriers to practice (e.g., Chamberlain and Perham-Hester, 2000; NRC and IOM, 1998; Parsons et al., 1995). The Parsons et al. study, for example, does indicate that a lack of education is commonly identified as a barrier to screening practices and suggests the importance of training. However, this study relied on a questionnaire in which a sample of obstetrician-gynecologists were asked to rank a series of potential barriers to screening. It suggests that training is an important factor in screening practices but does not establish a cause-and-effect relationship between education (or lack thereof) and practice.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Koop’s 1985 Conference on Violence as a Public Health Problem (DHHS, 1986) provided leadership in recognizing violence in general, including all forms of family violence, as a health problem. Recommendations from that conference covered inclusion of information about all forms of family violence in basic and continuing education for all health professionals and in certification, licensing, credentialing, and board examinations. The conference also recommended that the professions develop standards of practice and care, to be incorporated into family violence education. Progress appears to have been made on health professionals’ recognition of family violence as a health issue. For example, in 1991, the American Nurses Association published guidelines for identifying and treating intimate partner violence (ANA, 1991); the American Medical Association did the same in 1992 (AMA, 1992). Some evidence that the attitudes of individual health professionals have begun to shift also exists. For example, in a 1995 survey of obstetrics-gynecology physicians, 86 percent reported a belief that intimate partner violence is a medical problem (Parsons et al., 1995). This belief appears to be even stronger in the nursing profession. One survey shows that fewer than 4 percent of private office nurses, 5 percent of public health nurses, and 3 percent of hospital nurses agreed with the statement that intimate partner violence is not a medical problem (Moore et al., 1998). In a survey of 107 nursing educators representing associate degree (38 percent) as well as baccalaureate and higher programs, all respondents agreed that all nursing students need to be taught the signs of abuse across the age span (Woodtli and Breslin, 1997). More than 75 percent felt that content on family violence was inadequate, and only 15 percent felt that faculty had adequate knowledge and skills to teach the topic competently. The majority (86 percent) were of the opinion that the content should be integrated throughout the curriculum, but only 33 percent said that resources for faculty and students on the subject were accessible. Only a few programs have a specific course on family violence, and those are generally elective courses. Some clinicians assert that, while family violence is indeed an important health problem, it is not something they themselves encounter (Sugg and Inui, 1992; Reid and Glasser, 1997). Currently, the sentiment among health care providers that family violence lies outside the purview of the health professions seems most persistent among dentists and dental hygienists. Studies demonstrate that dental professionals vary in their response to receiving education on child abuse in dental school (Ramos-Gomez et al., 1998; Von Burg and Hibbard, 1995). In a 1994 survey of dentists, dental hygienists, physicians, nurses, psychologists, and social workers, providers were asked to respond to the statement: “Professionals in my discipline have as much responsibility to deal with problems of family violence as they do to deal with other clinical problems.” In this study, 98 percent of psychologists, 97 percent of social workers, 87 percent of nurses, and 85 percent of physicians

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence agreed. However, 47 percent of dentists and 46 percent of dental hygienists disagreed (Tilden et al., 1994). Educational Needs and Priorities Health professional curriculum development occurs in an environment of competing needs in which diverse curricular objectives must be sorted and prioritized. With the continuing increase of knowledge and expertise in health care as more research is conducted and published, potential topics for education increase while the educational time available remains the same. The need to add any “new” topic, such as family violence, to an already-packed curriculum may mean reducing or eliminating some other topic. Despite the increasing belief that family violence is an important issue for health care, training efforts on family violence may be perceived as displacing other more established educational topics long considered necessary to prepare health care professionals for clinical practice (Alpert, 1995). Historically, clinical practice and the education that informs it have focused on acute trauma, physical injury, and disease. The U.S. health care system currently reflects the medical needs of the mid-20th century, when most Americans sought care for acute illness, injury, or childbirth (IOM, 1997). The American health care system is well suited to handle physical illnesses and injuries that used to be the predominant causes of morbidity and mortality, but it is not so well prepared to handle complex health issues with social underpinnings that are in the legitimate purview of health care and of public health (Fox, 1993; Wilkinson and Forlini, 1999). Family violence is a complex, multifactorial problem that extends beyond these traditional focuses of medicine to social and ethical issues. Treating an acute injury per se does not require that the provider investigate the cause of the injury or evaluate the predisposing factors (analysis of which may help to prevent a subsequent injury in the same patient or a similar injury in a different individual). Symptoms of family violence (e.g., injuries, suicide gestures) can be treated without identification of the underlying cause, leaving the patient at risk for subsequent episodes. Furthermore, some physicians feel that it is ill advised to commit time toward learning how to evaluate a frustrating and often incurable situation, especially when there are other, more pressing treatable issues that can be addressed (Mashta, 2000, http://www.bmj.com/cgi/content/full/320/7229/208/a). According to one physician (Sugg and Inui, 1992): I think we tend to look more on the technical side of medicine, things we can help, like appendicitis. Domestic violence is a big morass which we will never escape. I get a headache thinking about it. And that attitude translates into the type of care we give those patients. (p. 3159) Existing clinical care and education around family violence issues attend disproportionately to physical injury, despite the broad spectrum of abuse pre-

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence sentations seen in pediatric, adult, and elder populations (Talley et al., 1994; McCauley et al., 1995; Domino and Haber, 1987; Drossman et al., 1990; Drossman et al., 1995; Walker et al., 1999; Post et al., 1980; Schei, 1990; Jacobson and Richardson, 1987; Longstreth and Wolde-Tsadik, 1993; McCauley et al., 1997; Eby et al., 1995; Eisenstat and Bancroft, 1999). Even when physical injury is documented, clinicians tend to record facts (injury location) without sufficient context (e.g., who inflicted the injury and the circumstances surrounding the event; Warshaw, 1989). Determining educational needs and priorities becomes even more difficult when little is known about a particular condition, treatment, or outcome. Thus, existing research gaps may limit education on a subject or suggest that it is not a priority. The research base on family violence interventions is deficient (NRC and IOM, 1998). For example, little is currently known about effective methods to detect intimate partner violence, and no data are available to determine the impact of screening and treatment on the incidence, morbidity, and mortality of intimate partner abuse (Cole, 2000). Without such knowledge, providers may be ill equipped to detect intimate partner violence in the health care setting, and appropriate education is difficult to determine (Abbott et al., 1995). As the perceptions about important topics for health professional education continue to grow, prioritization is likely to become even more difficult. The figures on the magnitude of family violence in society, the health care implications for patients, and the health care services provided by health professionals (discussed in Chapter 2) indicate that family violence is a significant issue for health care, and the available research provides content that can be taught. While the need for family violence education does not ameliorate the need for education on other important topics, neglecting health professional training on family violence will not make the need for it disappear. Allocation of Training Time and Adequacy of Training Despite the numbers of existing curricula and beliefs about the need for family violence education, the amount of time allocated to this subject matter has been minimal (MMWR, 1989; Alpert, 1995; Alpert et al., 1998; Kassebaum, 1995). A total of 33 percent of a sample of physicians, nurses, social workers, psychologists, dentists, and dental hygienists reported that they have received no education about child abuse, intimate partner violence, or elder abuse during graduate school, residency training, or continuing professional education (Tilden et al., 1994). Sugg and Inui (1992) found that 61 percent of their sample of primary care physicians reported having had no training on intimate partner violence in medical school, residency training, or continuing education. Although the percentage of subjects who reported having some family violence education increased as the year of graduation became more recent, the lack of training appears to remain prevalent, with social workers reporting the most overall

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence education in each type of abuse and dentists and dental hygienists the least (Sugg and Inui, 1992). Another survey of 705 academic emergency physicians indicated that only 25 percent could recall receiving any training about elder abuse during their residencies, only 20 percent during continuing education, and only 31 percent had a written protocol for the reporting of elder abuse in their current environment (Jones et al., 1997). Since 1998, the Association of American Medical Colleges (AAMC) has surveyed graduating medical students to assess the treatment of the topic of domestic violence in their medical school curricula. Nationally, the student perception of inadequate treatment decreased from 33 percent in 1998, to 31 percent in 1999, and 28.4 percent in 2000 (AAMC, 2000). The survey addresses only student perceptions and does not evaluate the content or intensity of the curricula. In another study, 86 percent of 111 medical schools reported existing curricula in adult intimate partner violence, yet a comparison of deans’ and students’ perceptions about curricular coverage of intimate partner violence yielded significant differences about the adequacy of coverage (Alpert et al., 1998). Even in professions expressing concern about inadequate training in family violence, training may not be inadequately addressed. The American Psychological Association’s (APA) Presidential Task Force on Violence and the Family (1996) has addressed the issue, yet most clinical psychologists in a national sample rated their graduate training on child maltreatment as poor and their internship training about the issue as only slightly better (Pope and Feldman-Summers, 1992). In a 1992 study, approximately 90 percent of clinical, counseling, and school psychology programs reported that they had no courses specifically addressing child abuse and neglect (Howe et al., 1992). In addition, approximately two-fifths of mental health workers reported that they had not received any training on intimate partner violence (Campbell et al., 1999). Recognizing these issues, the APA Working Group on Implications for Education and Training of Child Abuse and Neglect (Haugaard et al., 1995) noted a number of impediments to curricular reform to reduce the gap between psychologists’ modal and optimal levels of expertise in responding to child maltreatment. Among these was a “lack of appreciation of the importance of including information about child abuse and neglect in current curricula by administrators, teachers, and trainers” (p. 79). Institutional Culture and Norms Institutional culture can create subtle messages regarding the educational and practical value of particular topics to health professionals and the status of those who teach and work with those topics (see, e.g., Hafferty, 1998; Hundert et al., 1996; Marinker, 1997). Challenging cultural issues include inertia or resistance to change, the dynamics of power, the need for leadership, professional socialization, multidisciplinary collaboration, and marginalization. Curricular revision requires attention to the culture and norms within the institution.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Studies suggest that faculty resistance to change is a major barrier to curricular reform, as the drive to maintain the status quo often overrides the desire to make educational innovations (Bloom, 1989; Robins, 2000). Even when medical curricula do undergo major reform, the changes that are instituted tend to revert or “drift” back to previous educational patterns (Robins, 2000). The drift that is observed is quite consistently in the direction of a decrease in social science, humanities, and ethics instruction in the first-year curriculum, due at least in part to a feeling among basic scientists that this material is taught prematurely at the expense of essential basic science(s). Moreover, establishing programs is more challenging if the topic is not embraced by academic leaders or widely recognized by the faculty (Hendricson et al., 1993; Kendall and Reader, 1988). Unless there is an internal mandate from an influential institutional leader (e.g., the dean or a department chair) or an external mandate from an accrediting body or legislative authority, curricular innovation may be difficult to achieve (Alpert et al., 1997a; Bussigel et al., 1988). Health care professional students and trainees are socialized within this culture and power structure to emulate the beliefs and practice patterns of their teachers and role models in the clinical setting. Norms reinforced through practices that students observe in clinical training may reflect beliefs about professional roles and functions (Brandt, 1997). Issues such as family violence, often requiring multifaceted responses, frequent interdisciplinary cooperation, and attention to social or personal issues may challenge the norms underlying the professional socialization of many health care professionals, such as those related to independent practice, clinician-patient relationships, and awareness of social issues (Warshaw, 1997). In addition, these professional norms can be understood against a backdrop of deeply embedded social norms and values regarding family violence in society. Like the general public, health professionals are raised and trained in a society in which public intervention in “private” family matters has been proscribed until recent years and in which victims of family violence, particularly women and children, historically have had relatively little public recourse. American society has a long history of maintaining the privacy of family matters. For example, from the early colonial period onward, American courts affirmed a husband’s right to physically “discipline” his wife (O’Faolain and Martines, 1974, p. 188). It was not until the late 19th century that states finally began to move away from actually condoning a husband’s use of physical force against his wife (e.g., Fulgham v. State, 46 Ala. 143, 146-47 [1871]; Commonwealth v. McAfee, 108 Mass. 458, 461 [1971]; Gorman v. State, 42 Tex. 221, 223 [1875]). No such laws exist on the books today, and over the past 30 years every state has enacted a protective order statute that allows judges to prohibit batterers from assaulting or threatening their intimate partners and to provide victims with a broad range of protective measures (Epstein, 1999). However, remnants of the reluctance to intervene on behalf of victims persisted into the 1990s. For example, a nation-

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence wide survey of intimate partner violence service providers documents that some judges hearing civil protection order cases apply artificially heightened standards of proof (e.g., requiring physical evidence or unbiased witnesses) that make it more difficult for victims to succeed (Kinports and Fischer, 1993). Similarly, courts have long tolerated parental authority to discipline children in the name of family privacy (e.g., State v. Jones, 95 N.C. 588, 588 [1886]). However, in the 1960s, the United States began to take an active approach to decreasing violence against children. Since then, every state has designated a wide range of behaviors as illegal child abuse and neglect and has enacted mandatory reporting legislation, requiring certain professionals to report instances of child maltreatment. But the emphasis on the private domain of families persists; for example, most states still exempt parents from sanctions for forms of corporal punishment that otherwise would constitute criminal assaultive conduct (e.g., Johnson, 1998). The beliefs about private family matters reflected in the legal system also appear to affect health professionals. Health professionals have expressed concern or discomfort with intervening in situations they view as private matters and may demonstrate these reservations when teaching or supervising students. Studies of the values and beliefs of emergency service staff, including physicians, physician assistants, and social workers at four hospitals, indicate that 90 percent of the study subjects believed that they should try to identify battered women, and 82 percent considered this to be “part of their job.” But the same group failed to respond to intimate partner violence in any way in 40 percent of cases and responded only partially in 49 percent. The study’s investigators hypothesized that medical staff want to help but feel uncomfortable doing so because they view inquiry and intervention about intimate partner violence as invading their patients’ personal affairs (Kurz and Stark, 1988; Yllo and Bograd, 1998). Open-ended interviews of primary care physicians regarding attitudes about intimate partner violence suggest that privacy concerns were among the most frequently identified barriers to identification and intervention (Sugg and Inui, 1992). Fear of offending the victim “often originated in the physician’s discomfort with areas that are culturally defined as private. . . . The uncertainty of whether patients would consider domestic violence a legitimate area to probe was distressing. . . . Physicians felt that by even broaching the subject of violence, the patient would take offense.” Reluctance to “overstep the bounds of what is private . . . leaves the physician wary of how to approach the issue” (Sugg and Inui, 1992, pp. 1358-1359). In a study of pediatric emergency medicine fellows, 40 percent labeled a reluctance to invade family privacy as either a major (7.7 percent) or a minor (32.8 percent) obstacle to identifying and reporting suspected battering of a child-patient’s mother (Wright et al., 1997). And 58 percent of these physicians also reported some degree of personal discomfort with intimate partner violence cases. The nursing and social work literature also identify concerns about intrusions into private or family matters when approaching issues of family violence.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence For example, a survey of social workers, physicians, and nurses found that 63 percent of those surveyed cited personal discomfort and 57 percent cited concern about family privacy when asked about barriers to their own effective responses in intimate partner violence and sexual assault cases2 (McGrath et al., 1997). Even if intervention on behalf of victims of family violence is accepted, contrary practices may suggest a different message. Instructional settings create learning environments in which what students learn may vary from what is taught (Hafferty, 1998). So, even if taught to intervene, students may not observe or be involved with practicing health professionals who do intervene. Thus, they may not learn to do what they were taught. In addition to concerns about privacy, the need for multidisciplinary collaboration in responding to family violence may create challenges to training. For example, multidisciplinary and nonclinical teaching partners are considered important to health professional education on family violence, as intervening in abusive situations usually involves interaction among the health, social, and legal systems (e.g., American Academy of Family Physicians, 1994). However, the committee’s review of existing health professional curricula indicates that collaborative practice may be discussed, but it is not usually demonstrated. The materials may suggest a health care team model for responding to family violence victims and may provide information on referral services but rarely involve members of other professions (e.g., social workers, district attorneys) in the educational efforts. What is taught is not reinforced in clinical experiences. For example, while nurses were more than twice as likely as physicians to consult with another professional when detecting situations of abuse, physicians were more likely to try to handle the situation alone with the patient (Tilden et al., 1994). Social norms may also result in the marginalization of health professionals who do assume leadership roles in family violence. Students may make their career choices, in part, based on others’ perceptions of particular fields (Hunt et al., 1996). A study of the response to family violence in five diverse communities indicates that health care professionals who chose to work consistently with family violence victims were marginalized by their colleagues and institutions. These professionals also reported economic, social, and psychological disincentives to providing care to this population (Cohen et al., 1997). The presence and efforts of a singular charismatic faculty leader paradoxically can be an impediment to curricular innovation. That leader may singlehandedly take responsibility for family violence curricula or extracurricular activities. However, once the leader moves on to other pursuits, the programs generally wither due to insufficient institutional commitment (Cohen et al., 1997). Although charismatic 2   The researchers did not break down the response rates among the different health professions represented in the sample.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence leaders are an important impetus for curriculum development, alone they are insufficient for establishing permanence for education and training in family violence without concurrent institutional changes. Sole dependence on such individuals can create challenges for stability, given the fluidity of American society and the frequency with which individuals change their institutional affiliations. An example of this phenomenon has been published in the intimate partner violence literature (McLeer et al., 1989). The initial success of a novel emergency department screening program for intimate partner violence reverted to its inadequate baseline screening rate following the departure of the individuals primarily involved with the intervention. To maintain such efforts, the reform must be institutionalized. The challenge is to establish systems and procedures that help create a foundation that is sufficiently flexible to sustain innovations and behavioral changes. ACCREDITATION, LICENSURE, AND CERTIFICATION REQUIREMENTS Health professions are subject to numerous legal and voluntary requirements or guidelines related to ensuring the competence of practicing professionals, practice standards, and professional and patient protections. These requirements can serve as leverage points for the inclusion of particular educational content in a profession’s various modes of training. For example, students may be more likely to receive training on a particular topic if the requirements for professional accreditation demand it or subspecialty certification exams include it. Even without explicit requirements, a health professional organization can exert influence on training content by encouraging or supporting such efforts. The committee reviewed existing accreditation, licensure, and certification requirements to identify family violence components. Accreditation Accreditation of professional disciplines determines the course of study required to be part of the profession.3 In some cases, this may be as explicit as indicating the number of didactic hours of a particular subject area or as broad as specifying the requisite focal areas of study for a profession. Thus, requirements for the accreditation of professional disciplines can influence, if not in part define, the educational content in health professional schools. The committee reviewed the accreditation standards as of December 2000 3   This process is different from the general accreditation of colleges and universities, in which the principal purpose is to ensure that the college or university is meeting the broader goals of postsecondary education.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence for the professions included in this study to identify requirements related to family violence of any or all types (see Appendix A). The review indicates that, overall, few accreditation requirements related to family violence exist. The standards for medicine suggest that programs should (rather than must) assert the ramifications of family violence as a social problem. While social work requirements include no specific mention of family violence in its curriculum guidelines, it does allude to those who are at risk of victimization or are oppressed. Similarly, nursing, dentistry, psychology, and physician assistants do not specifically include family violence education as part of their accreditation process. Certain subspecialty areas do have education or training requirements in specific types of family violence. For example, the American Board of Obstetrics and Gynecology requires intimate partner violence training, and the American Board of Pediatrics requires training on child abuse and neglect. Licensure Licensure is the process by which a state, usually through an examination, regulates the practice of a specific profession. This examination can be administered on a national level, medicine being the principal example, but more often is administered by the state issuing the license. This state-directed exam may be a combination of both a nationally developed test and questions specific to certain state laws and regulations, or it may be state generated, with some questions drawn from a national data bank. The exam content can reflect required and desirable areas of study. While a comprehensive review of state licensing laws for each health profession was beyond the scope of this report, the committee reviewed national exams for content on family violence, with the understanding that these exams play different roles with regard to licensure within the professions. This review revealed that licensure exams from the National Board of Medical Examiners and the National Council on Boards of Nursing provide the most explicit reference to family violence content. The National Board of Medical Examiners issues a three-step United States Medical Licensing Exam, the third step of which may include some questions related to child abuse, elder abuse, and sexual abuse.4 The National Council on Boards of Nursing’s Nursing Certification Licensure Exam contains a psychosocial adaptation section (5-11 percent of the questions). The content includes child abuse and neglect, elder abuse and neglect, and sexual abuse, as well as behavioral interventions, chemical dependency, crisis intervention, and psychopathology. Other organizations also indicate content on family violence on their exams but do not explicitly delineate the breakdown of components. 4   For proprietary reasons, the National Board of Medical Examiners does not release the number or percentage of questions on family violence on the exam or a range of potential questions.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Mandatory Education Laws Requirements Child Abuse and Neglect. Only three states—California, Iowa, and New York—mandate education on child abuse for health professionals. The training requirements appear to be driven at least in part by mandatory reporting laws; in all three states, training must focus on child abuse identification and the local statutory reporting requirements. The amount of required training varies. New York requires a one-time, 2-hour training session. California has a one-time training requirement of 7 hours over the course of a professional’s career; Iowa goes further and requires at least 2 hours every 5 years. Iowa requires physicians, dentists, mental health workers, nurses, and social workers to receive this form of education; New York does the same with the exception of social workers. California imposes this requirement only on its mental health professionals and social workers. Intimate Partner Violence. Three states—Alaska, Florida, and Kentucky— mandate that health professionals receive education about intimate partner violence. The states require training on such topics as the nature and extent of such violence, safety planning, lethality and risk issues, and available community resources. The amount of training required varies greatly: Florida mandates 1 hour every 2 years; Kentucky requires a one-time-only 3-hour training session; and Alaska does not specify. Florida and Kentucky require training for doctors, dentists, mental health workers, nurses, social workers, and allied health workers. Alaska does the same, except for allied health workers. Elder Maltreatment. Iowa is the only state that requires its health professionals to receive training on elder maltreatment. Its law mandates education regarding identification and reporting dependent elder abuse, with a 2-hour initial session followed by two additional hours every 5 years. The education requirement applies to doctors, dentists, mental health professionals, nurses, social workers, and allied health workers. Impact The committee could find no formal evaluations of the impact of legally mandated family violence education. Studies demonstrate that health professionals who have obtained any continuing education (not necessarily mandated) about child maltreatment are no more likely—and in some samples are less likely—to report child abuse and neglect than are those who have not attended such workshops (Beck and Ogloff, 1995; Kalichman and Brosig, 1993; Reiniger et al., 1995). Accordingly, although one can hypothesize that such laws may have an array of positive as well as negative effects, until sound process and outcome

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence evaluation data are acquired, in the committee’s view these mandates are driven by assumptions and good intentions, rather than by a sound evidence base. What is known about continuing education for health professionals (summarized in Chapter 6) is that didactic instruction may result in increases in knowledge or changes in attitudes, but there is limited evidence that it influences practice behaviors. Therefore, there is no reason to believe that 1- to 3-hour instructional programs, the form that many of the mandates take, will result in lasting positive effects on screening or intervention in family violence. Critical evaluation questions for any educational program, particularly for those that are required by state statute or agency mandate, include: whether knowledge improvements can be demonstrated, whether any knowledge improvements are sustained over time, whether attitudes about family violence are affected, whether any attitudinal changes are sustained over time, whether and to what extent clinicians’ practice behavior changes, and whether any such behavioral changes are sustained over time. Furthermore, questions are needed to assess the adequacy of the program, from the provider perspective, including measures of acceptance and satisfaction with the program and suggestions for improvement. Whether costs of care, severity of presentation, case mix, morbidity, and ultimately mortality are affected by mandatory training must be determined. Finally, it is necessary to question if any changes observed can be attributed to the education program itself. RESOURCE ISSUES Funding Education development, implementation, maintenance, and evaluation require funding; however, federal funds for such activities appear to be meager, and state governments have actually decreased such funding (Reiser, 1995). Private investor funds appear be decreasing as well. Private investors tend to concentrate capital in areas that can demonstrate promising financial returns or, at the very least, clear savings to teaching institutions or society. Education and training programs often cannot produce such concrete results, especially in the short term, and therefore are at a serious and chronic disadvantage in terms of securing sufficient funding to develop and evaluate educational interventions (Mechanic, 1998; Blumenthal and Meyer, 1996). Federal funding10 may be provided through agencies such as the Health Resources and Services Administration of the Department of Health and Hu- 10   A number of foundations (e.g., Commonwealth, Conrad-Hilton) have previously funded or currently fund family violence research and training initiatives. However, comprehensive search mechanisms for this type of support are not available. The committee chose to focus it discussion on federal funding sources.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence TABLE 4.1 Selected Recent Federal Research Grant Opportunities Agency Title Grant No. (Date) Funding Allocation Agency for Healthcare Research and Quality Violence Against Women: Evaluating Health Care Interventions RFA:HS-00-006 (FEB 2000) $1 million FY2000 Centers for Disease Control and Prevention Extramural Injury Research Grants for the Prevention of Intimate Partner Violence and Sexual Assault PA: 00042 $1.2 million FY2000 Office of Community Services, Administration for Children and Families Family Violence Prevention and Services Program FA OCS-2000-06 (FEB 2000) Varies (four priority areas) Children’s Bureau, Administration on Children, Youth, and Families Administration for Children and Families: Child Abuse and Neglect (2000B) CB-2001-01 (FEB 2000) $3.5 million FY 2000 man Services when specific health professional training needs are identified.11 Funds are provided for general health care professional training through the Public Health Services Act, but the act does not require training in family violence. In 1998, however, language was added that encourages grantees to “prepare practitioners” (physicians) or “provide care” (nurses) to “underserved populations and other high risk groups such as the elderly, individuals with HIV-AIDS, substance abusers, homeless, and victims of domestic violence [emphasis added].” Federal agencies do occasionally fund family violence-related research in health care (see Table 4.1). However, for the most part these calls for proposals do not specify health professional training in family violence. A review of individual federally funded projects indicates that few involve the training of health professionals in family violence research. The National Institute of Mental Health currently funds five pre- or postdoctoral research training grants related to family violence (see Table 4.2). General violence training grants (such as those from the National Consortium on Violence Research) may also include fellowships addressing family violence. Family violence rarely emerges in a review of funding priorities among the 11   Current goals for federally supported health professional training include (1) increasing underrepresented populations in the health professional workforce and (2) providing care to underserved communities. To meet these needs, the Bureau of Health Professions requested $103 million for fiscal year 2001.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence TABLE 4.2 Family Violence Training Grants Funding Source Site Principal Investigator Title (grant number) Funding Period Doctoral Fellows Pre Post NIMH University of New Hampshire Straus, Murray A. Family Violence Research Training (T32MH15161) SEP 77– JUN 02   X NIMH Johns Hopkins University Campbell, Jacquelyn C. Interdisciplinary Research Training on Violence (T32MH20014) JUL 99– JUN 04 X X NIMH Northern Illinois University Milner, Joel S. Family Violence and Sexual Assault Research Training (T32MH19952) AUG 96– JUN 01 X   NIMH Boston University Keane, Terence M. Post-Doctoral Training on Post Traumatic Stress Disorder (T32MH19836) AUG 96– JUN 01   X NIMH Medical University of South Carolina Kilpatrick, Dean G. Child and Adult Trauma Victims: A Training Program (T32MH18869) JAN 98– JUN 03 X X NSF, HUD, NIJ Carnegie Mellon University Blumstein, Alfred National Consortium on Violence Research (SBR-9513040) MAY 95– APR 03 X X NIMH = National Institute of Mental Health; NSF = National Science Foundation; HUD = Department of Housing and Urban Development; NIJ = National Institute of Justice. various institutes at the National Institutes of Health (NIH) (A.A. Perachio, personal communication, March 27, 2001). Among the seven research priorities of the National Institute of Nursing Research for 2001, for example, none specifically applies to developing new knowledge for nurses in the area of family violence (or to any other violence category). Although the National Institute on Aging included elder abuse and neglect as a Selected Future Research Direction, that topic is not named in the list of Areas of Special Emphasis (biology of brain disorders, new approaches to pathogenesis, new preventive strategies against disease, new avenues for the development of therapeutics, genetic medicine, and health disparities). Other federal sources of training funds include projects set up in response to routine funding cycles (in which investigators submit proposals in their area of competency) and projects in direct response to requests for proposals (RFPs) or program announcements (PAs), the government’s mechanism to encourage research in priority areas. A search of the NIH Health Information Index for family

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence violence research by NIH or NIH-supported scientists revealed no entries for “family violence,” “spouse abuse,” “domestic violence,” or “child abuse.” The only family violence entry was for “elder abuse,” accompanied by a link to the National Institute on Aging. The Computer Retrieval of Information on Scientific Projects (CRISP) database revealed 93 projects including the phrase “child abuse,” 63 including “spouse abuse” (38 for “domestic violence”), and 4 for “elder abuse” currently (1999-2000) funded by several federal agencies (the National Institutes of Health, the Substance Abuse and Mental Health Administration, the Health Resources and Services Administration, the Food and Drug Administration, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and the Office of Assistant Secretary of Health). Some projects are listed twice (due to multiyear funding across the reporting year) and some projects only mention, rather than focus on, family violence. In other cases, currently funded projects are not included in the database. Funding amounts for these projects are not disclosed. The allocation of federal funds for child abuse and neglect has been primarily in response to federal legislation, the Child Abuse Prevention and Treatment Act of 1974 (CAPTA—P.L. 93-247), which was reauthorized in 1996. As mentioned earlier, CAPTA established the National Center on Child Abuse and Neglect (NCCAN), defined child abuse and neglect, and supported other demonstration programs and projects to prevent, identify, and treat child abuse and neglect. In addition to allocating funds directly, CAPTA authorizes aid to states for child abuse and neglect programs. The program authorizes funds through 2001 and $99.3 million has been requested for 2001. These funds finance four broad programs, none of which explicitly include training: child abuse state grants, child abuse discretionary grants, community-based family resource and support grants, and an adoption opportunities program. The discretionary grants may include training. NCCAN did do a one-time funding of multidisciplinary training programs, a few of which remain (e.g., the Center on Child Abuse and Neglect, University of Oklahoma Health Sciences Center). NCCAN was reorganized as the Office of Child Abuse and Neglect (OCAN) in 1996 with 80 percent fewer staff. Among other activities, OCAN published the “Child Abuse and Neglect State Statutes Series” (NCCAN, 1997) to provide some information for health care providers about reporting mandates for child abuse and neglect. OCAN does not actively disseminate the information to health care providers or evaluate the impact of the information provided. State Victim Compensation and Assistance and Victim Assistance and Law Enforcement funds, allocated through the U.S. Department of Justice, have sometimes been used for the continued training of professionals in evaluating criminal forms of maltreatment, but the focus is not on health professionals. Funding for health professional training for child abuse and neglect appears to be decreasing in proportion to the growth of the problem (Theodore and Runyan, 1999). For example, between 1980 and 1986, while the reported inci-

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence dence of child abuse and neglect increased by 74 percent, the federal research budget for this topic increased only 2 percent (Kessler and New 1989), and between 1981 and 1995, while reported incidence increased by 150 percent, research funds decreased by 44 percent (Thompson and Wilcox 1995). Few efforts support training researchers and professionals (Jenny, 1997). For example, in 1996, the federal government spent $29.9 million or $28.47 per case on child abuse (Putnam, 1998, 2001) while spending $2.26 billion or $1,734.61 per case on cancer, despite the higher incidence of child abuse (NCI, 1996). In terms of research expenditure per lost life, violence accounted for $31, cancer for $794, heart and lung disease for $441, and AIDS for $697 (NRC, 1993). Much of the funding for initiatives related to intimate partner violence is provided under the Violence Against Women Act (VAWA) of the Violent Crime Control and Law Enforcement Act (P.L. 102-322) of 1994. The goals of the legislation include preventing violence against women, increasing penalties for batterers, and supporting programs to prosecute offenders and assist women victims of violence. It is administered by the Department of Health and Human Services and the Department of Justice, and in fiscal year 2000, $223.6 million was appropriated to the Department of Health and Human Services for VAWA programs. The VAWA reauthorization bill, passed in October 2000, requested an increase to $660 million each year for the next 5 years. Services to victims account for the majority of the funds, and none is earmarked for health care professional training. The act does acknowledge (and dictate) funds for training for persons in the judicial and law enforcement domains. The Older Americans Act (OAA) and the Social Security Act provide services for elders, including nutritional and caregiver services, and, to a limited extent, for abuse prevention. Pursuant to the OAA, the Department of Health and Human Services created the National Center on Elder Abuse in 1993 to help promote understanding among state and local networks of community workers, physicians, elderly volunteers, and others working to prevent elder abuse; it was reorganized in 1998. The center involves a consortium of six partners led by the National Association of State Units on Aging and was funded at $400,000 in 1998-1999, a similar amount for 1999-2000, and $800,000 for 2000-2001, under HHS grant no. 90-AP-2144. One purpose of the center is to facilitate training on elder abuse recognition and services through educational materials and technical assistance. Title IV-E of the Social Security Act also provides for training in the area of elder welfare. That training can include activities to educate health professionals collaborating with workers in social services. Table 4.3 summarizes the federal legislation authorizing funding for initiatives related to family violence. Two National Research Council reports (1993, p. 318; 1996, pp. 152-155) have recommended that centers be funded to address family violence research needs, specifically that each of three centers be funded at $1 million. In actuality, a single center was funded by the Centers for Disease Control and Prevention,

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence TABLE 4.3 Family Violence Federal Funding Acts Type of Violence Legislation Authorizing Funding for Initiatives on Family Violence Provision of Funding Years Funding Intimate partner violence Violence Against Women Act DHHS DOJ-OJP (1994-2000) 2000 435.75 million Child abuse and neglect Child Abuse Prevention and Treatment Act; Social Security Act Child Protective Services     Elder maltreatment Older Americans Act (Titles III and VII) Social Services Block Grant FY2000 (for all sx)a $1.5 bil Social Security Act (Title XX) Adult Protective Services Family violence Family Violence Prevention and Services Act   (1984) 1984 0 Victims of Crime Act aThrough appropriation laws. the National Violence Against Women Prevention Research Center. That center award, a consortium of the Medical University of South Carolina, the University of Missouri at St. Louis, and Wellesley College, was funded at approximately $500,000. Federal funds for health professional training are closely linked to the priorities that are named by institutions such as HHS. However, earmarking of federal funds for health professional training in family violence is dependent on political considerations, not just on evidence that such training will make a difference. Moss recently stated, “It may be closer to the reality to say that politics is the basic science of public health,” rather than epidemiology (Moss, 2000). Documents such as Healthy People 2000 (and Healthy People 2010) and federal agency strategic plans set the health agenda for the nation in writing, reflecting, at least in part, the political priorities of the nation.12 Even with such priorities, 12   The Healthy People 2000 objectives related to family violence are predominantly found in Priority Area 7: Violent and Abusive Behavior. They include for example: “[to] extend protocols for routinely identifying, treating, and properly referring suicide attempters, victims of sexual assault, and victims of spouse, elder and child abuse to at least 90% of hospital emergency departments” (National Center for Health Statistics, 2001).

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence the allocation of funds is another political process and is competitive within and across health care issues. Overall, the information reviewed in this section suggests that funding for family violence is limited and inconsistent and that funds for health professional education research or training development on family violence specifically are even sparser. Until funds are proportionate to the known extent of the problem in society and in health care, progress in the area of health professional training on family violence is likely to be limited. Some potential for additional funding lies in the link between NIH’s mission and the achievement of Healthy People 2000 (and Healthy People 2010) objectives in which family violence has been identified as a national priority. The objectives related to family violence have yet to be achieved. Human Resources Although adequate and sustained financial resources are necessary to support curricular innovation, it is people who drive program development, staff classrooms and clinical practica, work to enhance training programs, and establish the systems needed to sustain education. Institutions are constrained financially by available funds, but they may have more control over the human resources involved. The nation is experiencing a shortage of faculty who are qualified and willing to teach in the health professions (Griner and Danoff, 1995). Furthermore, there are few researchers or educators nationwide who are recognized as scholars in family violence, and few programs appear to exist to prepare researchers or educators to achieve scholarship in this area. Health professional training programs, whether in undergraduate schools, graduate training programs, or continuing education, are in need of experienced, dedicated, sensitive, versatile, and experienced clinician-educators who can effectively teach this material (Alpert, 1995). Given the paucity of experts-educators in the field, it is also difficult to recruit and train educators, monitor their performance, and help them become more effective (Kassirer, 1995; Greenberg, 1995; Lesky and Hershman, 1995). Furthermore, developing the human resources necessary may not be achieved among health professionals at the teaching rates and hours currently evidenced in the literature (Alpert et al., 1998; Woodtli and Breslin, 1996). The problem becomes circular: research and training deficits yield few well-prepared educators, and an inadequate supply of educators and researchers results in inadequate training and research. The committee could find little evidence of the educational infrastructure that is needed to teach about family violence. One study indicates that organized institutional response is not common (Cohen et al., 1997). Teaching about family violence could be enhanced by having an available cadre of survivors, standardized or simulated patients trained to portray actual patients accurately, library and computer resources, and community-based advocates and other direct service providers. Hu-

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence man, computational, and logistical infrastructure support for the evaluation of educational programs also appears to be unavailable in most institutions. The APA Working Group on Implications for Education and Training of Child Abuse and Neglect, for example, noted that “a lack of time and resources for teachers to develop curricula appropriate for the educational level of their students” and a “lack of readily available material to use in conjunction with child abuse and neglect curricula (e.g., textbooks and videotapes)” are impediments to curricular reform to reduce the gap between psychologists’ modal and optimal levels of expertise in responding to child maltreatment (Haugaard et al., 1995, p. 79). An array of resource materials is available, including slide sets, handouts, videos, articles, book collections, and the like, but the extent to which these are distributed and in use is unknown. Attention to developing a research and training infrastructure in other health areas (e.g., muscular dystrophy, alcoholism) appears to have resulted in the growth of targeted funding and of a critical mass of faculty to ensure that the work will go on and the care for patients will improve (see, e.g., http://cysticfibrosis.com/centers.htm; http://www.mdausa.org/clinics/alsserv.html; http://www.niaaa.nih.gov/extramural/ResCtrs1198.htm). CONCLUSIONS The committee’s assessment of the potential influences on health professional training on family violence suggests the following conclusions: Institutional culture, norms, and priorities can influence the education offered, and they may also create challenges for developing, implementing, or sustaining family violence training for health. Common pathways for these challenges appear to include inadequate financial and human resources and institutional commitment to the problem at the national and local levels. Accreditation, licensure, and certification requirements do not consistently and explicitly address family violence and thus do not appear to be a significant influence on family violence training for health professionals. Individual health professional concerns, beliefs, and experiences can create challenges to educating health professionals about family violence. Notable individual concerns include perceptions of inadequate time or preparation, personal values, and personal experience with victimization and traumatization.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence A review of health professional organization statements, guidelines, positions, and policies reveals that the degree to which the various professions call for training differs greatly not only by profession but also by specialties within those professions. Health professional organizations can influence the existence and extent of family violence education within a profession. The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the American College of Nurse Midwives are excellent examples of health professional organizations actively working to encourage and implement education initiatives on family violence among members of their professions. Stakeholder groups, including advocates, victims, and payers, have been or are becoming active in family violence issues, including education, but their impact on family violence education for health professionals is difficult to assess. No studies indicate the impact these efforts have had. However, curricula developed by organizations such as the Family Violence Prevention Fund appear to have been widely disseminated and in use by health professional educators. The impact of mandatory reporting laws on family violence for health professionals is unclear, but the existence of such laws suggests a need for educational content about them. Based on the expressed concerns and research on rates of reporting, the committee sees a need for clear explanations of reporting laws for students and practitioners, as well as the provision of opportunities to discuss and resolve ethical issues that reporting raises for many health care providers. Additional studies are needed to determine whether reporting requirements are the appropriate mechanism for achieving the goals of increasing reporting rates and ensuring the necessary services for victims. Regardless of the existence of legal requirements, in the committee’s view, students must learn to identify, report, and refer cases according to legal requirements, professional practice standards, and patient care goals. In addition, the training needs of health professionals extend beyond fulfilling legal requirements. The committee understands the intent underlying reporting requirements for health professionals generally to be the enhancement of their responses to family violence and ensuring that victims receive needed treatment and services. These goals suggest that health professionals need to know more than just how to report suspected and actual cases of family violence. Given the concerns about mandatory reporting cited by both health professionals and vic-

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence tims, it may be productive to orient training programs more toward planning and delivery of broad-based prevention and treatment services, rather than exclusively on case identification and forensic services. The effect of mandated education requirements on health professional education is unknown. Funding for training programs in family violence education in the health professions does not appear to be a priority and does not appear to be consistently available. Information about funding is fragmented. The extensive effort required even to identify funding sources is noteworthy. The information must be collected piecemeal from numerous web sites for federal agencies and private foundations, rendering it difficult to determine if and when funds are available.