Instructional Curriculum Improves Medical Staff Knowledge and Efficacy for Patients Experiencing Intimate Partner Violence

Abstract

Study Objectives

This study assesses VA mental health providers’ understanding of intimate partner violence (IPV) and the perception of patient benefit of routine inquiry and service referral. The impact of an instructional curriculum was also examined following an interactive training.

Methods

An evidence-based curriculum was offered to VA mental health providers. The curriculum utilized didactic methods, case scenarios, and resources regarding referrals and statutes regarding crimes related to violence and abuse. The participants completed pre- and post-training surveys to assess their perceptions about IPV and to evaluate the training.

Results

Seventy-three individuals completed the training. Fifty-four of the participants were female, and thirty-three were over the age of 45. Fifty-one individuals completed both surveys. There were no differences between participants’ views of the seriousness of IPV in the community or their practices before or after the training. However, participants scored significantly higher on the knowledge and efficacy measures after the training (p<.001).

Conclusion

Following an educational intervention, providers demonstrate more knowledge and efficacy regarding routine inquiry and referral for IPV. Barriers to universal implementation still warrant attention.

Introduction

Violence perpetrated by a current or former intimate partner can lead to a variety of both acute and chronic health problems, including physical injuries and chronic pain; urologic, pelvic, gynecological and obstetric complications; gastrointestinal and neurological problems; and mental health conditions (1-2). Intimate partner violence (IPV) is prevalent in the contemporary United States, with over 25% of adult women and nearly 8% of adult men in the United States reporting having been physically assaulted, raped, and/or stalked by a current or former intimate partner in their lifetimes. Rates of IPV victimization are higher among women and men seeking health care, as compared with the general population (3-6).

IPV is a concern for healthcare providers not only because victimization is a health risk and is prevalent among patient populations, but also because patients express a desire for health care providers to recognize and attend to their needs related to experiences of violence in their intimate relationships (3). Health care providers overwhelmingly agree that inquiring about and responding to, their patients’ experiences with IPV is part of their professional role; however, they report barriers to including such assessment and response in their routine practice (7). Lack of knowledge and self-efficacy are key barriers that can be addressed and improved through professional training (7).

Recognizing the potential impact of IPV on health, and the potential utility of healthcare-based interventions, a number of professional and anti-violence organizations, including the American Medical Association, the American College of Obstetricians and Gynecologists, and the Family Violence Prevention Fund, recommend that healthcare providers routinely ask their patients about IPV victimization. It is also increasingly common that health care practices are adopting practices of IPV assessment and response as part of their routine care.

IPV assessment and response may be particularly relevant for care provided through the Veterans Health Administration (VHA), a national integrated health care system providing comprehensive care to adults. Veteran women report particularly high rates of IPV exposure, with a third of veteran women nationally reporting having experienced actual or threatened physical violence or unwanted sex from an intimate partner and greater proportions reported among women veterans seeking care at VHA medical centers (8-10). The VHA has traditionally focused on serving male veterans, who make up the bulk of the patient population. But the female veteran population is rapidly expanding, with women comprising 8% of the veteran population as of September, 2010 (11).

To begin addressing these concerns, the University of Rochester Department of Psychiatry Laboratory of Interpersonal Violence and Victimization (LIVV) partnered with the Department of Veterans Affairs Center of Excellence for Suicide Prevention to provide training to Veteran Administration healthcare providers across four sites in the NYS region: Albany, Syracuse, Canandaigua (and Rochester), and Buffalo (and Batavia). The evidence-based curriculum provides particular emphasis on the overlap between IPV and substance abuse, mental health, suicide, and murder-suicide. The 7-hour interactive training included: handouts, a Power Point presentation, case scenarios, a referral guide, and a statutory guide to crimes related to abuse. There was also an opportunity for role-playing and questions throughout the day.

An important first step in improving care for veterans experiencing IPV (either victimization or perpetration, or both) is to assist with the identification, routine inquiry, assessment and referral of those patients. This study assesses VA healthcare providers’ understanding of IPV and the perception of patient benefit of routine inquiry and service referral. The impact of an instructional curriculum was also examined following the training. We hypothesized that participants would consider IPV an important issue but remain reluctant to screen, assess and refer patients due to obstacles. We also hypothesized participants’ knowledge, attitudes and efficacy would improve as a result of participation in the training.

Methods

LIVV partnered with the Center of Excellence for Suicide Prevention and medical and behavioral health specialist to deliver an evidence-based curriculum addressing IPV. VA leadership provided an email to providers describing the training, as well as brief biographies about the trainers: a Marriage and Family Therapist and an attorney (CC) who both had extensive experience with IPV as practitioners, educators and researchers. Participants were excused from their patient-care duties to attend the day-long session. Participants were largely behavioral health providers who practice with veteran populations experiencing a host of conditions warranting mental health interventions. The trainees completed a pre-test prior to coming to the session and a post-test immediately after the training. The two surveys were anonymous but linked via a self-selected four-digit number. There was no incentive provided from either LIVV or the Center of Excellence for participation, as this was training as part of their routine jobs.

The sample is comprised of 73 participants who attended the 7-hour IPV training. Changes in knowledge, attitudes and efficacy are reported for those who completed both a pre and a post survey. The last portion of the post-training survey, “last thoughts”, asked participants to answer a series of questions regarding how they felt about IPV and the training session. Participants were also able to write in any comments related to the training. The research team entered all responses into an SPSS database. SPSS was used to conduct bi-variable descriptive analyses, including Chi-Square, Wilcoxon Signed Rank Test, T test and Fisher's Exact Test. Pre-post evaluations of improved knowledge, attitude and efficacy were assessed using Wilcoxon signed rank test. Fifty-one participants completed both the pre and post-survey. However, on occasion, a participant was missing a response, thus the pre-post analyses have varying participant pools. The University of Rochester Institutional Review Board approved all aspects of this study as exempt from informed consent due to the evaluative nature of an educational activity.

Knowledge, attitudes and efficacy were measured with an adaptation of an educational assessment tool designed by Lynne Short and used with permission (12). Knowledge was assessed with a 31-item measure (risk factors, warning signs, safety plan, appropriate inquiry, perpetration), with an alpha of 0.75. Attitudes were measured utilizing a 9-item questionnaire (cultural factors, documentation of suspicion of abuse, patient autonomy), with an alpha of 0.49. Skills were measured with an 8-item measure (protocol awareness, policy awareness, camera availability, referral knowledge), with an alpha of 0.78.

Results

Over the four locations, 73 individuals completed the training. However, not everyone completed a pre and a post survey. Sixty-nine individuals completed the pre-training survey, 55 individuals completed the post-training survey, and 51 individuals completed both. There were no statistical differences for age or gender between the providers who completed only the pre-test or both the pre-test and post-test. There were no differences on any socio-demographic characteristics by region and findings are reported in the aggregate (Table 1).

Table 1.

Subject Sociodemographic Characteristics by Region (n=73)^*

	Total N (%)
Age
Less than 25	4 (6.0)
25-35	22 (32.8)
36-45	8 (11.9)
Over 45	33 (49.3)
Gender
Male	14 (20.6)
Female	54 (79.4)
Field
Psychiatry/Psychology	30 (44.8)
Social Work/Other	37 (55.2)
Degree/Education
PhD	11 (16.2)
MS, MA, /MSW	42 (61.8)
BA/BS/other	15 (22.1)
Tenure at VA
# Months mean (SD)	65.2 (90.6)
Number of Clients Per Week
0-5	8 (11.8)
6-10	13 (19.1)
>10	47 (69.1)
Hours of Previous Training: n=61 mean (SD)	16.7 (29.3)
Overall Preparation Score (Maximum 40) mean(SD)	24.1(6.4)[n=67]
Preparedness Regarding Inquiry(3a) m(SD)	3.2(.9)[n=69]
Preparedness Regarding Response (3b)	3.4(.9)[n=69]
Preparedness Regarding Documentation (3g)	2.6(1.1)[n=67]
Preparedness Regarding Referrals (3h)	3.0(1.1)[n=69]
Knowledge Score (add 4a,b,c,d,h,j) mean, (SD), [n]	17.0(4.7)[n=67]
Action Score (Add 1 for each box checked for question 5)	4.492.0)[n=69]
IPV Protocols in Place
Yes – Utilized	12(18.2)
No/Unsure	54(81.8)

^*Not all totals equal to 73.

Approximately 80% (54) of the participants were female and they represented between 74-84% of the participants in each region. Approximately half the sample (33) was over 45 years old; with the remaining participants 45 years old or younger. All participants were educated with a college degree or higher, with 62% being masters prepared and 16% PhD prepared. Nearly seventy percent (47) see more than 10 clients per week and reported having heavy caseloads, as self-defined. These practitioners see both male and female patients, and periodically engage with the patient's families and partners. Participants were largely behavioral health providers.

There was support for the first hypothesis that participants considered IPV a serious issue but did not feel they adequately addressed it. For those who completed the pre-training evaluation items regarding this (n=64), the large majority (83%, 53) believe IPV is a serious problem in the community. When asked about the seriousness of IPV in their practices, 49% indicated it was serious, 49% indicated moderate to minor, and only 2% indicating it was not a problem (Figure 1). There were no differences by region for previous IPV training or their reported preparedness regarding inquiry, response or documentation of IPV prior to the training. However, the entire cohort reported knowing IPV protocols were in place, but only 12 participants, or 18%, reported utilizing those protocols. There were no significant differences before or after the training regarding the seriousness of the issue or the importance of routine inquiry.

Figure 1.

Considerations Regarding IPV: Pre and Post Survey Results: Routine Inquiry, Practice and Community Importance

There was partial support for our second hypothesis that the training would result in improved knowledge, attitudes and efficacy post-training. Participants’ knowledge increased from a total of 24.7 (sd. 3.8) to 28.1 (sd. 2.0) with a Wilcoxon signed rank test of -5.277, p<.001. Likewise, there was an increase in efficacy by 3.3 points, -5.153, p<.001. However, there was no difference between participants’ pre and post attitude scores.

At the conclusion of the training, almost all (96%, 52) participants understood the nature of IPV to be complex with abuse including emotional, sexual, and physical violence. Ninety-six percent of the participants agreed that they learned new information about IPV, and 98% said they would be likely to use what they learned for routine inquiry about IPV.

The participants also reported their preferred mode of learning by ranking lecture, interactive learning, films and group work. Of the 4 modes interactive activities ranked highest (mean =2.81). The lecture ranked second (mean=2.58), followed by group work (mean=2.42) and films last (mean=2.29). Curriculum improvement with additional information on isolation and power and control dynamics appears indicated given that some participants (17%) still believed post-participation that it is acceptable for one party in a relationship to make all the decisions. Time constraints (50%), lack of knowledge about appropriate referrals (11%), and opening Pandora's Box (8%) are still perceived as limiting factors when advocating for patients experiencing IPV.

Participants were also provided the opportunity to provide additional information regarding their experiences on a five-point scale (strongly disagree=1 to strongly agree= 5). All participants with the exception of one person agreed that this curriculum experience would be helpful to their work with their clients (mean 4.25). All but two participants agreed that this training increased their knowledge regarding IPV (mean=4.29). Participants also expressed agreement that the instructors (mean 4.32), setting (3.60) and materials (3.89) were agreeable.

Eighteen of the 55 participants whom completed a post-training survey provided qualitative comments regarding the training. These comments clustered into logistics and content. Logistical comments included improving the order of presentation. The trainings began with statistics about prevalence and risk factors. The participants requested the clinical assessment and legal information to be presented earlier. Constructive criticisms about the content also suggested less focus on statistics and more focus on clinical assessment, intervention and the legal aspects of the curriculum. To that end, participants noted more case discussion and the inclusion of Child and Adult Protection system information would be helpful.

Discussion

Over 15 years ago, the American Medical Association (AMA) first recommended routine inquiry for IPV. Declaring the epidemic of family violence as “sufficiently prevalent to justify addressing this concern with all women patients,” the AMA officially endorsed active physician involvement (13). Despite the AMA's Campaign Against Family Violence, provider compliance is suboptimal (14).

While models of IPV curricula exist (15-16), there is little published data on how to train medical providers. The optimal model and amount of time for IPV training to ensure understanding and acceptance of the health effects of IPV is still unclear (17). Efforts to create an integrated family violence curriculum, using standardized patients and resource individuals from hotlines, shelters, legal advocacy and law enforcement, to educate about IPV, child abuse, sexual assault and elder abuse have been described (18). There are conflicting reports on the superiority of multi-component compared with single component interventions (19). In one study, physicians reported more frequently inquiring about and documenting IPV after completing several teaching modules. However, physician post-intervention scores on a printed IPV knowledge test in this study did not change appreciably (20).

A hospital-based curriculum that included a victim testimonial video and practice role-playing to simulate interactions improved self-efficacy, lowered fear of offending patients and improved the perception of resources available (21). Practical information often provided includes safety planning, forms of abuse and risk factors, misconceptions and non-judgmental listening, referral resources, documentation and office systems, clues and barriers to identification of IPV, legal issues, realistic expectations for behavior change, danger assessment (22) and staff support. The topics most frequently included in 2007 U.S. and Canadian dental curricula included the responsibility of the health care professional, risk indicators for abuse and referral recommendations (23). Experiential learning was recommended to enhance interpersonal skills and provider comfort and confidence with issues of partner violence. Routine inquiry for IPV has been shown to increase detection (24). With the high prevalence of IPV, health professionals should maintain a high level of awareness of the possibility of partner violence even though the case for screening is not yet convincing (25).

IPV exposure is known to be prevalent among veteran women and at higher rates in those veteran women seeking health care at VHA medical centers. With the population of veteran women expanding, routinely addressing IPV exposure and subsequent health consequences will be important for VHA medical centers to optimize.

Our study at four VHA medical centers provides insight into positive staff attributes for continuing to address IPV in this patient population and areas for improvement. The strong foundation of understanding the seriousness of IPV and importance of routine inquiry is encouraging for future behavior change efforts. This is clearly an improvement from decades ago when IPV was not even perceived as a healthcare concern, but a private matter.

Providers at the VHA medical centers recognize the need to improve preparedness. While protocols exist in each medical center in this small study, and all staff members universally could identify the existence of these policies, only a small percentage of staff responded that these protocols are utilized. This highlights an opportunity for continuing education and implementation improvement.

In this effort to study continuing education regarding IPV and health care identification and management, our instructional curriculum at the VHA medical centers had multiple components. The curriculum was perceived as helpful and staff indicated intentions to change clinical behaviors to advocate for victims of IPV. The curriculum components perceived as most helpful were the interactive sessions and the lecture. This suggests that VA providers are more receptive to live didactics and interactive education than group work activities and film clips. This may be due to frequency with which they identify IPV with their clients and an eagerness to learn more and ask questions directly of the instructors. It is possible that the film clips, used with the intent of sensitizing the participants to the importance of IPV as an issue was unnecessary given their understanding IPV as a pressing issue in their pre-evaluations. Knowledge improved with new information identified and the VA staff comprehended the complexity of issues surrounding IPV. VA staff indicated an intention to improve advocacy for VA patients experiencing IPV with more routine inquiry and referral. These findings are supported by the qualitative comments requesting more emphasis on the patient assessment/intervention and legal information with less attention on prevalence and risk factors.

While this study provides an important foundation to beginning interventions within the VA system, the study has several limitations. We attribute the sample size and drop-out rate to limited participation due to ongoing clinical responsibilities or incomplete participation due to unknown time conflicts. Some participants left the training prior to the completion of the lecture and role-play. Accordingly, these individuals did not submit a post-test. Future research with the VHA population should identify key educational elements of continuing education curriculum on IPV to maximize instructional time investments. Some sites reported that 7 hours was too long to release healthcare providers from patient care. Also, due to the number of males who participated, we were unable to assess for potential gender differences in the reception of the curriculum. Ongoing studies are needed to assess the translation of understanding, attitudes and knowledge into behavioral change. Because this was a pre and post-evaluation, we are unable to assess whether the predicted efficacy improvement translated into practice, ultimately improving care and outcomes for this patient population. These studies and opportunities may be applicable to the general population as well.

Conclusion

After an evidence-based educational intervention, mental health providers demonstrate increased knowledge and efficacy regarding routine inquiry, assessment and referral for IPV. However, while 96% percent of the participants agreed that they learned more about partner violence, and 98% said they would be likely to use what they learned, barriers to implementation remain. These perceived barriers, similar to other healthcare providers’ concerns (including time perceptions, knowledge about referrals, and fear of opening Pandora's Box) continue to implicate the need for ongoing education and research efforts.