Facilitating Intimate Partner Violence Education among Pharmacy Students: What Do Future Pharmacists Want to Know?

Abstract

This paper describes the first step toward creating training tools to improve pharmacy students’ and pharmacists’ ability to identify intimate partner violence (IPV) among patients and facilitate referrals. The paper’s objectives are to evaluate an IPV didactic session adapted for pharmacy students and describe student quantitative and qualitative feedback on the session. Almost 90% of students believed IPV was relevant to their pharmacy careers and that the session improved their ability to recognize IPV. Twenty one percent believed they had encountered a patient they suspected was a victim of IPV. Legal and liability issues, course logistics, skill development, greater specificity and student engagement were themes that emerged. Greater specificity toward pharmacy was recommended to understand the intricacies of legal and professional responsibilities, patient and personal safety risks, and maintaining strong provider/patient relationships. To overcome barriers to screening, assessment and referral, students need opportunities to engage in role-playing and practical application of the knowledge gained.

Background

Intimate partner violence (IPV) is a global public health issue. Both the World Health Organization and United States (U.S.) Healthy People 2020 have made IPV and violence reduction initiatives a priority.¹ IPV is defined as physical, psychological, economic or sexual abuse between intimate partners, either married or dating, or formerly married or dating.² Almost a decade ago, a national telephone survey reported the prevalence of IPV as 22% among women and 7% among men during their lifetimes.³ In a recent survey, 35.6% of women and 28.5% of men reported experiencing victimization through rape, physical assault, or stalking in their lifetime.² Because roughly one in three individuals reports experiencing such violence, it could be useful to determine how widespread the problem actually is and the costs to our community. However, the economic cost estimates for IPV are difficult to calculate given the underreporting of IPV to healthcare providers, criminal justice professionals and social service agencies. In the United States, the estimates of the direct costs of IPV range from 5–8 billion dollars per year, although that is an underestimate.^4–6

The “costs” go beyond economics as victims and survivors of IPV experience a host of physical and mental health consequences. Physical and sexual abuse result in internal and external injuries, such as broken bones, lost teeth, bruising, and obstetrical and gynecological complications. In many situations, abuse goes beyond physical damage. Increased stress can exacerbate conditions such as fibromyalgia⁷ or gastrointestinal disorders.⁸ The mental health ramifications, which often go undetected and untreated, include depression,^9–11 post traumatic anxiety,^12,13 suicidal ideation and attempts,¹⁴ or sleep disturbances including nightmares and insomnia.¹⁵ These physical and mental health consequences, which last long after the violence ceases,^16–19 result in victims utilizing health care resources more than non-IPV involved individuals with increased rates of emergency department use ² and primary care visits.²⁰ This increased contact frequently results in victims being provided prescription medications for treatment of the presenting condition, such as mental health²¹ and pain medications.^7,22–24

To date, limited attention has been paid to pharmacists as potential members of the health care community to address IPV in their practices. An earlier survey of 121 chain community pharmacists documented that 61% believed they had encountered IPV victims,²⁵ yet most felt ill prepared to address IPV in their practice. Given that IPV-involved individuals have increased health care utilization and prescription medication use, it seems important to educate pharmacists in order to enhance their ability to intervene with appropriate identification and referral practices. Although IPV is not specifically addressed in the desired national pharmacy education curricular outcomes,²⁶ they do address preparing students for patient-centered care and public health roles. As pharmacists continue to assume these roles, the issue of IPV is likely to emerge during the establishment of the therapeutic pharmacist-patient relationship. Given a lack of data in the area, the question remains as to pharmacists’ degree of preparation to take on this role.

At present, no literature exists on how to provide pharmacists and student pharmacists with the knowledge and skills needed to aid IPV victims encountered in practice. Researchers from the University of Rochester Medical Center partnered with faculty from Albany College of Pharmacy and Health Sciences to discuss methods to prepare pharmacists who encounter IPV victims in their practice environment. The team’s long-term goal was to create a training program and tools that could be used to provide pharmacy students with the knowledge and skills needed to identify and refer IPV victims. This mixed-method project is the first step toward addressing a pressing issue: how best to prepare future pharmacists to face this public health concern. The objective of this project was to evaluate the quantitative and qualitative survey data about class experiences and curricular content, which was provided by students following a single classroom lecture.

Methods

The 1.5-hour large classroom didactic session was an evidence-based lecture adapted for pharmacy students from an IPV training created for interdisciplinary audiences, which included dental, medical, and psychology graduate students, psychiatric residents, and social work students. The curriculum was modified specifically for pharmacy students by adding a module about the importance of pharmacists understanding the basic fundamentals of IPV. The core content areas included: the prevalence of IPV reported from health and criminal justice perspectives, risk factors for IPV, recognition of IPV, the effects on children, cultural issues, medical considerations, and how to ask and refer someone when IPV is suspected. The curriculum content was selected after an interdisciplinary team reviewed the IPV literature related to education of healthcare professionals and selected best practices for screening, assessment and referral. The educational objectives of the lecture indicated that at the conclusion of the lecture, student pharmacists should be able to define IPV, identify the risk factors for IPV, understand factors associated with varied prevalence rates of IPV, identify physical and mental health consequences, and describe the pharmacist’s potential role in identifying and referring IPV victims.

An attorney with a Doctor of Philosophy (Ph.D.) in Criminal Justice and extensive experience in the IPV field presented the lecture at Albany College of Pharmacy and Health Sciences utilizing a PowerPoint presentation and an outline handout. The IPV session was provided in the spring of the first professional year in the required three-credit self-care course, which provides students with the knowledge and skills to conduct patient assessment and provide recommendations in areas of self-care, including cough and cold, pain, herbal therapies, dermatologic conditions, gastrointestinal disorders, women’s health, and nutritional therapies. The self-care course was chosen because IPV patients often self-treat the physical injuries incurred. In addition, the course coincides with a one-credit laboratory course, which reviews community pharmacy prescription preparation, dispensing, and counseling. Together, these courses prepare students for their first summer of licensed internship and introductory pharmacy practice experiences (IPPEs).

Following the lecture, students engaged in an anonymous questionnaire to assess their opinions regarding the course objectives, suggestions for expanding the training, and their experiences with the material presented. Using the Blackboard learning management system (LMS), students were asked to respond to nine survey questions (Table 1). Completion of the survey was worth 2% of their overall course grade. Students were notified the survey was anonymous, and although the LMS can determine an individual student entered and completed the survey for credit in the grade book, their individual responses to questions could not be discriminated.

Table 1.

Class Evaluation Quantitative Results (n=237 respondents)

Question	N (%) Responding
Do you feel your ability to recognize domestic violence has improved since this class?
Yes	213 (89.9)
No	24 (10.1)
Do you believe this is relevant to your career as a pharmacist and as such an important part of your educational training?
Yes	213 (89.9)
No	24 (10.1)
Do you believe an opportunity to conduct a mock patient engagement would be helpful in enhancing your competency?
Yes	152 (64.1)
No	85 (35.9)
Have you ever encountered a patient you suspected was a victim? a
Yes	49 (20.7)
No	188 (79.3)
What lecture features were most useful? (Select all that apply)
Recognition of partner violence and prevalence	112 (47.3)
How to ask about IPV	80 (33.8)
Risk factors for IPV	73 (30.8)
Medical considerations	60 (25.3)
Effects on children	46 (19.4)
Cultural issues	42 (17.7)
Program content
Poor	3 (1.3)
Fair	7 (3.0)
Satisfactory	27 (11.4)
Good	118 (49.8)
Excellent	81 (34.2)
No opinion. I did not go to class.	1 (0.4)
Instructor Quality
Poor	6 (2.5)
Fair	7 (3.0)
Satisfactory	18 (7.6)
Good	73 (30.8)
Excellent	132 (55.7)
No opinion. I did not go to class.	1 (0.4)

^aQuestion adapted from reference 25.

IPV = intimate partner violence

The first three were dichotomous (yes/no) questions that addressed students’ opinion of the relevance of IPV to their career and their ability to recognize IPV, the primary educational objective. The next four questions asked for feedback on program content and instructor quality. The final two open-ended questions (not shown on Table 1) asked for qualitative feedback regarding course improvement and included, “What lecture features could be improved?” and “What additional topics would you like to have addressed regarding domestic violence in a future lecture?” Responses to these questions provided the data for qualitative analysis. The qualitative data was transported into a Word document from the LMS and uploaded into Atlas.ti, a qualitative software program.²⁷

The research team was comprised of two attorneys (one with a Ph.D. in Criminal Justice), a pharmacist, and an Information Analyst, assisted by a student intern. Because the two questions regarding course improvement were open ended, grounded theory²⁸ was used to see what themes emerged. Grounded theory, developed by Glaser and Strauss, is a method of analyzing qualitative data to provide a means to create theory while in the process of analyzing data using three steps.²⁹ The team individually coded the student responses to the open-ended questions, developing themes line-by-line in the transcript. Each author reviewed all the comments, created a structure, and then met to validate the coding structure and reach consensus on outliers. The team then agreed upon five themes using constant comparative methods, through an inductive process.³⁰ The information analyst then entered the codes into Atlas.ti.

The Human Subjects Review Boards for both institutions involved reviewed this retrospective analysis of de-identified course feedback and deemed the assessment of the educational endeavor as exempt.

Results and discussion

Overall, 241 students participated in the class and 237 completed the questionnaire for a response rate of 98.3%. One student who responded to the questionnaire reported in the quantitative questions that he or she did not attend class. Eight students did not complete the open-ended question regarding lecture features that could be improved and 14 did not answer what additional topics they wished to learn. Due to the nature of the LMS anonymous survey tool, we were unable either to determine whether these were the same students or remove the response of the student who did not attend the lecture.

When students were asked open-ended questions regarding what lecture features could be improved and what topics they would like to see addressed, they provided similar information to both questions. When the students’ comments were coded for emerging themes, the same themes emerged in both sets of responses and therefore were combined. Twenty-seven primary codes were identified and discussed until consensus was reached on five overarching themes including legal and liability issues, course logistics, skill development, greater specificity, and student engagement (Table 2). These codes were not mutually exclusive, meaning that passages of student comments could fall under multiple codes depending on content. Though the codes were also not completely matched to specific educational objectives, many appeared in line with the educational objectives, thus functioning as thematic guides for future development of an IPV training program. Researchers agreed upon all responses. Students also provided information on the quality of the class, and more details regarding the themes that emerged are provided below.

Table 2.

Coding Approach

Quantitative Survey Results

For overall class program content and instructor quality, over 80% of students rated these as either good or excellent (Table 1). Additionally, 89.9% believed the information was relevant to their career as a pharmacist and an important part of their educational training. Many students (64.14%) agreed that it would be helpful to be able to conduct a mock patient engagement. Of the core lecture features, students chose the general recognition of IPV (47.25%) and how to ask about IPV (33.75%) as the most useful.

Overwhelmingly, 89.9% of the students responded that they felt their ability to recognize IPV was improved as a result of the class; however, 79.33% of the participants did not believe they had ever encountered IPV-involved patients. These students are still early in their professional careers and some of the students may not have worked in pharmacy settings before they participated in the course. A prior community pharmacist survey (n=122) regarding IPV indicated that 61% reported they had encountered an IPV victim in their practice.²⁵ Yet, 60% felt unprepared to intervene in such matters. Our study, coupled with this decade-old study, underscores the need for pharmacy education to begin to address this issue with evidence-based, empirically grounded curricular tools. The themes provided great insight as to content that should be considered moving forward.

Open-Ended Question Results

Legal and Liability Issues

Ten students submitted comments regarding legal and liability issues. The students were concerned about engaging in IPV identification and referral because they were uncertain what was required of them under the state and federal laws, including the Health Insurance Portability and Accountability Act (HIPAA). The students would have liked additional information on whether the state in which they were located had a “good neighbor” law¹ and the specific parameters regarding pharmacists’ roles in intervening with IPV and interacting with law enforcement. Lastly, the students indicated concern about their professional liability if they do, or do not, engage with an IPV-involved patient or suspected child abuse. Student comments that captured their concerns with legal issues included:

• The lecture should go more into HIPAA because I am unsure if it would be against HIPAA rules for a pharmacist to involve the police or any outside source if the patient has admitted to being a victim of domestic violence.”

• I would like to learn more about New York State’s ‘good neighbor’ laws, and how they apply to pharmacists.”

• I think more stress should be placed on how to proceed after suspecting IPV without creating liability issues or undesired outcomes.”

• I would like to know how we (pharmacists) can approach suspected abuse cases from a legal stand-point. That is are there any laws that support an intervention?”

Clearly students needed more information on the statutory landscape surrounding IPV. As young future pharmacists, they are naturally worried about their liability and staying within the bounds of their professional obligations, while balancing patient care. Although only one participant noted the tension in invading patient privacy and potentially ruining the therapeutic alliance due to legal intervention, it remains an important consideration. This student wrote, “People look at the pharmacist as a person they can trust and if we go nosing around in their business, instead of allowing them to come to us if they are seeking help, then won’t we lose the trust factor that we have with our patients? We don’t want our patients being afraid to come to talk to us about issues if they think we are going to turn them into authorities if we suspect abuse. I would like, in future lectures, we have it explained more clearly when is the point that it’s ‘none of your business’ and when is the point that you should intervene.”

This student’s concern mirrors sentiments expressed by community pharmacists who had mixed beliefs when asked if intervention in recognized abuse is, or could be, a health care obligation for pharmacists.²⁵ To create a more uniform understanding of pharmacists’ legal obligations and how to use evidence-based tools to screen and intervene in professionally responsible ways, national pharmacy associations may want to consider adopting policies similar to other professional organizations, such as the American Medical Association and American Bar Association, both of which discuss IPV at a national level and encourage screening and dialogue.^31,32 In future training endeavors, the need for pharmacists to understand the legal ramifications of identification and referral of all types of abuse need to be reviewed on a state-by-state level. After covering legal ramifications of intervention, future training programs should engage participants in dialogue regarding their thoughts about balancing patient trust with patient health and safety to be sure that students understand the risk of not engaging their patient in IPV interventions.

Course Logistics

The most numerous comments (n=136) centered on class logistics, including suggestions for additional topical content, session length, and the learning materials provided. Related to topical content, the students thought the general IPV information offered in the lecture would resonate more for them if better bridges were made to pharmacy-specific IPV issues. Another student provided an extremely insightful suggestion to include more information on how culture impacts IPV, writing, “I feel that more emphasis be given to cultural perceptions about violence within the home. This would help us to approach the issue more objectively and with better sensitivity.”

Students requested more information about IPV risk factors because they were not sure they would be able to identify patients who were not forthcoming about the violence in their lives. One student wrote, “It’s not so much the lecture, as much as its the subject, it’s hard to truly find a IPV victim because they try their hardest to hide it so well, and when you do find one, usually its them asking for help, so I’m not sure how much this lecture could help us ‘spot’ one.”

Others expressed the need to understand IPV risk factors in more detail to benefit people they encounter in their private lives. One student wrote, “I would like to learn more about the risk factors or signs that someone could be abused or an abuser. I also think that information on how to help friends or people you know get through this type of situation would also be good.”

Prior to the class, the presenter provided the students with a Microsoft Word® document outlining the material to be covered. The students suggested that for future courses, the actual slides should be provided in Microsoft PowerPoint® format. Given that the content was identical, this is notable and may reflect the school culture where numerous courses use and provide the slides. The students reported that one and a half hours was not enough time for this material to be presented and, in some ways, felt saturated. Because IPV information was new to the students, many reported feeling overwhelmed by the number of statistics provided and perhaps rather than presenting the legal, medical and social service information, the health care information alone would have sufficed with inclusion of the legal ramifications of pharmacist involvement. Again, perhaps due to the culture of this particular school, the students wished they had been provided a test study guide to distill the most pertinent information regarding this course. These pragmatic suggestions are paramount when presenting sensitive, new information to students. Discovering the best modes and materials to facilitate student learning and information retention may be program-specific.

Skill Development

Students also voiced the need for additional methods to develop the necessary skills to identify and aid an IPV victim. While the course did include case scenarios, the victims’ stories that were presented largely involved the victims’ interactions with legal and social service agencies. The students also indicated a wish for video clips, case discussion and an opportunity to role-play with mock pharmacy-related scenarios, with one student writing, “An additional topic that I would like to have addressed regarding IPV in a future lecture would be a presentation of a mock patient that enters the pharmacy and is suspected of being a victim of IPV. The presentation would show how to thoroughly question the patient and effectively refer them to the help and resources that they need.”

Additionally, they wanted the presentation to include how to approach a patient, how to ask a patient about IPV, and how to facilitate a referral. Some students never considered that IPV is a potential issue for their patients. One student wrote, “I think just a mock counseling session would have been nice. But the real life stories were great to emphasize that this does happen and it’s important that we recognize it. It also gave me hope that I can help my patients in ways I had never thought of.”

The students’ concerns and questions about engaging with a patient in the pharmacy setting underscored the importance of seeing and testing these skills. The questions centered on “how” to ask, regarding the words to use, and negotiating patient engagement in the non-private lay out of a typical pharmacy area. The students also indicated a need for the course to more directly address what to do once a patient disclosed IPV and how to facilitate an intervention given the time demands of their future career. For example, students might develop and practice offering a number of good, accessible referral options. Role-plays would allow the students to take the place of a pharmacist, victim and perhaps observer to become more familiar with the topic of IPV and more comfortable asking intimate questions to assess patients for risk while considering the environment they are in (community pharmacy vs. office based practice).

Specificity

Student comments indicated that they desired more specificity about certain victim populations, such as children, elders, and men. They also desired more specific acknowledgement and discussion of pharmacists’ personal safety concerns. Because the course was less than two hours, child abuse, elder abuse and other forms of domestic violence were not addressed in the same detail as IPV. However, many of the students requested additional information regarding these populations, with one student writing, “I think discussing child abuse would be a good to go over as this is just as important.”

Given that pharmacists provide care to people of various age groups, student responses suggest that a training program that includes violence across the lifespan may be warranted to include elder abuse, child abuse, and other forms of violence. Very little literature exists regarding pharmacists’ roles in various forms of family violence. ^25,33 With the continued expansion of programs such as medication therapy management (MTM) for Medicare part D seniors, elder abuse must be on the radar of practitioners and educators as the incidence of elder abuse is increasing.

Male victims were another specific victim population that was not covered in the training that students expressed interest in knowing more about. One student wrote, “We didn’t really ever discuss a woman abusing a man. What would be the signs to look for?” A recent survey revealed that 5.9% of women versus 5% of men reported being victimized by an intimate partner in the past year, but men experienced less severity and injury.³⁴ Given this surprising prevalence rate, male victimization should not be overlooked in the development of an IPV educational program.

Though patient safety was emphasized in the lecture content, a few students expressed the desire for more specific dialogue about provider safety concerns. One student wrote, “Perhaps more discussion of ramifications of getting involved in a real-life IPV situation. While I’m sure we all can see now that we, as pharmacists, can be involved and can possibly save a person’s life, we also need to see the potential risks VERY clearly.” While this student appreciated the need to understand this issue, the comment also speaks to some concerns about potential risks. While others may have been thinking about their own safety, only a handful of students mentioned it.

Nonetheless, as with any other violence-related training, personal safety should also be addressed in the curriculum. One student wrote, “I am hesitant to say that I am confident to deal with this issue in the professional arena. Whether right or wrong, I am concerned that approaching the subject with a patient may create a situation where their aggressor may attempt to seek revenge by harming me or my family. I feel as though the topic of IPV may generally lay outside the realm of a pharmacist’s obligation to their patients. There are many other professions which explicitly train extensively on the issue of IPV (i.e.: Social workers, law enforcement officials, etc.) Therefore, I feel the lecture could have been improved if there was a greater acknowledgment that we as pharmacists may be justified in our hesitancy to get involved.”

Student Engagement

Students expressed the desire to have more opportunity for engagement during the class, as opposed to being the recipient of a lecture coupled with a slide set. This was a large didactic class, without role play or open discussion opportunities. The students wanted not only engagement, but also an opportunity to voice their opinions, some in smaller groups. They also expressed that the content was important to them and the sensitive and thought provoking nature of the content required some time to discuss and debrief. One student wrote, “I think engaging us more with questions or if we had a smaller class she could have tried to have us share more of our experiences. I think putting things on a more personal level would help to improve the lecture. Just from talking to students after the lecture I could tell the topic really impacted some of them.” Another wrote, “It was an outstanding lecture, however, it could be improved by including the element of discussions, namely expression of opinions by students and their point of view about the matter as well as their anecdotal inputs.”

Limitations

The researchers must acknowledge and present how their own influence on the research could occur either through study design, data collection or interpretation of the data.³⁵ Two of the authors found their professional work, IPV, and pharmacy, could intersect at the pharmacist-patient therapeutic relationship, and believe that the pharmacist could have a potential role in the identification and referral of IPV victims during self-care consultations, prescription medication counseling and medication therapy management activities. Thus, it is possible that the pharmacy students, despite anonymity, responded to the questions asked with this sentiment in mind – that the faculty felt pharmacists have a role. In addition, students may have felt some element of coercion as their evaluation was 2% of their grade. The gender and age of student participants was not asked in this questionnaire to provide as much anonymity to students as possible. Thus, it cannot be generalized to students at other pharmacy colleges whose background and demographics could vary. Future research in this area should explore the effects of gender and age on students’ and pharmacists’ beliefs regarding IPV identification and referral. The prior community pharmacy survey²⁵ detected that younger pharmacists were more likely to agree with the need to intervene. In addition, female pharmacists agreed more often than males that they would feel comfortable helping an abused patient. This suggests perhaps alternative curricular approaches based upon age and gender may be needed, or that when creating small group active learning, ensuring a group of mixed gender and age could provide a variety of perspectives during discussions.

As this is the first phase in a multiphase project, we are unable to report whether the training increased participants’ knowledge, attitudes or efficacy and did not pretest our students. Following curricular enhancement, the next phase includes testing whether the curriculum increases students and pharmacists’ abilities to screen, identify and refer victims appropriately.

Educational implications

Analysis of the student comments provided significant information for the research team in determining both the knowledge content and skill development desired in a pharmacy specific training program, demonstrating the importance of gathering participant/student input to develop an empirically grounded training. Suggested knowledge content included identification of possible legal/liability and safety risks for both victims and pharmacists, including methods to minimize risk. Additional knowledge desired was victim risk factor identification, how culture impacts IPV, topic expansion of IPV across age and gender spectrums (e.g. children, elders, males) and pharmacy specific case scenarios to illustrate victim identification and intervention methods. Skill development activities desired included role playing and group discussions regarding victim identification and referral techniques once disclosure is made. Student responses indicated a need to have group discussions to enable students to explore more complex issues such as questioning if intervention and referral are roles for pharmacists and, if so, how pharmacists can meet legal responsibilities while balancing patient and pharmacist safety within the patient-pharmacist therapeutic relationship.

Although the investigators’ intention was to develop a stand-alone training program, the themes that emerged can be applied to enable IPV topics to be incorporated within a pharmacy curriculum (shown in Figure 1). The active learning exercises could be placed in laboratory or small group sessions to assist those with different learning styles. IPV concepts may be woven into other classes offered, such as ethics, jurisprudence and professionalism courses, seminars and recitations to address concerns about their own safety and staying within the bounds of their professional and legal responsibilities.

Figure 1.

Identified Content Knowledge & Application Activities

Conclusion

IPV-involved patients seek care within the health care system for myriad physical and mental health sequelae associated with their abuse. As pharmacists continue to expand their patient-centered roles in the changing health care system, the likelihood that establishment of pharmacist-patient relationships may lead to IPV identification increases. Preparing pharmacy students well for this potential challenge may be an important step in ameliorating this serious public health problem. Pharmacy students participating in a large lecture class session on IPV felt the topic relevant to their career, providing them an improved ability to recognize IPV. Students provided important feedback for the future design and delivery of pharmacy training programs. Although only a few students expressed concern over legal and safety issues, previous literature echoes pharmacists’ hesitance to become involved. Therefore, curricular interventions must include education on how to minimize legal and safety risks. Including student feedback about their experience during the early stages of the development of a training program will make it more relevant and useable for the students, and better prepare them to face the challenge of IPV in their practice.