Confronting Chronic Neglect The Education and Training of Health Professionals on Family Violence (2002) / Chapter Skim
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6 Training Beyond the State of the Art
6 Training Beyond the State of the Art
Pages 108-140
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From page 108... ...
to examine behavior change in health professionals. With regard to training content, the committee describes and analyzes the concept of core competencies as an approach to establishing expectations for education and then proposes core competencies for health professionals in relation to family violence.
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From page 109... ...
The knowledge, skills, and behaviors necessary for effective health professional response to family violence are not yet established, and existing proposals for core competencies in family violence have not yet been evaluated. Because of the substantial prevalence of family violence victims in health care settings, basic knowledge of all forms of family violence is necessary for all health care professionals who provide patient services.
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From page 110... ...
. Family Violence 201 includes curricular principles for practicing primary care providers and for specialty-trained health professionals.
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From page 111... ...
For example, sexual assault nurse examiners provide advanced care for sexual assault victims in many communities, while in other communities other health professionals provide similar care. In any locality, what is vital is that roles are clarified and that health care professionals are adequately trained to provide competent care for victims of sexual assault (both familial and extrafamilial)
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From page 112... ...
Health professionals working in primary and secondary prevention may focus on access and system-wide collaboration. However, there will still be a central nucleus of competencies that are the same for any health care professional at any level in any setting (see Figure 6.2~.
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From page 113... ...
A review of existing health professional curricula offers a starting point for identifying and detailing these domains. The committee's review indicates overlap in a number of content areas developed for health professionals (see Box 6.1~.
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From page 114... ...
The foregoing review of the literature does not provide a scientific foundation for core competencies on family violence for health professionals. The committee struggled with the lack of a scientific evidence base from which to propose core competencies for health professionals and the need for such competencies.
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From page 115... ...
In the committee's view, the various professions and organizations involved with victims of family violence could benefit greatly from collaboration in developing, testing, and evaluating core competencies on family violence. Advanced competencies for responding to family violence have yet to be developed, with some notable exceptions.
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From page 116... ...
3. Consult with and refer to specialists and community resources for safety, education, caretaking, and support services (such as protective services, social work, shelter, child abuse hotlines, legal, mental health, substance abuse, and criminal justice)
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From page 117... ...
Research indicated that adolescents have unique health care needs and a high rate of health problems (Athey et al., 2000~. With funding from the Maternal and Child Health Bureau, support from the American Academy of Pediatrics, and the creation of the Society for Adolescent Medicine, appropriate training content was identified and training programs were implemented.
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From page 118... ...
First, reporting laws mandate that all health professionals report suspected child maltreatment, most must report suspected elder abuse, and a few must report intimate partner violence itself or the abuse of any adult (see Chapter 3~. In effect, such reports indicate suspicions that a crime has occurred, and they also trigger investigations that often may result in civil actions that involve coercive action for victim protection.
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From page 119... ...
Such expertise, whether held by or simply easily available to the health professional, is necessary to ensure that the quality of evidence gathered and the validity of opinions offered is maximized and that there is due sensitivity to the special ethical issues that arise in family forensic cases. Such training and consultation appear to be needed especially because of the complexity and ambiguity of roles that health professionals often face in family violence cases.
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From page 120... ...
Beyond these issues of ethnic cultures, community cultures may also create difficulties for health professionals. Family violence within rural, remote, or wilderness communities may present challenges distinct from those in urban settings.
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From page 121... ...
medical schools offer separate instruction in cultural issues (Flores et al., 2000~. While research is increasingly addressing issues of diversity in health care, more research is needed to identify effective components and methods for educational programs for health professionals (Loudon et al., 1999~.
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From page 122... ...
Thus, in addition to exploring the content of health professional training on family violence, the committee examined how such training might be accomplished. This section begins with a discussion of the diffusion of knowledge, goes on to address techniques for overcoming cognitive biases, moves to the literature on behavior change for health professionals, and then explores some strategies for enhancing education.
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From page 123... ...
For example, in institutions in which the importance of screening for family violence is not modeled by supervising health professional educators or written guidelines do not exist, students may perceive them as unnecessary. Adult Education Principles The principal message from research on the diffusion of knowledge is that most transfer of knowledge, including transfer to and among health professionals, occurs informally, based on perceived needs.
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From page 124... ...
There is an emerging consensus that the general principles of adult education, as embodied in continuing medical education, apply to health professionals as well. The consensus is linked to the principles of adult learning (Abrahamson et al., 1999; Barrows, 1983; Green and Ellis, 1997; Knowles, 1984, 1990; Neame et al., 1981)
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From page 125... ...
Debiasing Clinicians' biases in judgment and decision making thus can present major obstacles to accurate predictions of violent behavior and to resulting forensic decisions and safety planning. Educational programs for health professionals about family violence should take such obstacles into account.
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From page 126... ...
Formal Continuing Medical Education: Implications for Health Professional Training In a recent systematic review of formal continuing medical education for the years 1970 to 1999, Davis, O'Brien et al.
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From page 127... ...
In addition to integrating components of family violence into health professional education, the literature also suggests incorporating multidisciplinary resources into training efforts. Given the complexity of family violence as a medical and social issue, no amount of training will allow health professionals alone to solve the problems of family violence.
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From page 128... ...
For interventions directed to predisposing factors of health professionals, there is solid support in the literature for measuring and addressing barriers, academic detailing (i.e., a maneuver derived from the practices of drug salespersons, consisting of a series of brief informa3see the web site for Lawrence Green (http://www.lgreen.net/precede.htm) for over 850 applications of the precede/proceed model to a wide range of health conditions.
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From page 129... ...
The evidence for the use of opinion leaders and cooperation/collaboration among health professionals is less substantial. There is firm evidence to support the use of financial incentives and reminders as enablers of change in patient outcomes.
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From page 130... ...
130 CONFRONTING CHRONIC NEGLECI TABLE 6.2 Continuing Education to Change Behavior: What Works? Interventions directed to predisposing factors: changing health professionals' knowledge, attitudes, and beliefs · Measuring and addressing barriers at the outset · Interactive educational meetings: small-group training with role playing; start-and-stop action videos; interactive role modeling · Academic detailing · Use of opinion leaders · Cooperation/collaboration between the different professionals involved Interventions directed to environmental enabling factors For patients: · Financial incentives · Reminders · Posters in clinical areas For health professionals: · Practice environment clinical decision support · Computerized decision support · Checklists, flow sheets · Health questionnaires · Reminders · Chart stickers Basch, 1987; Ward et al., 1991; Davis, Thomson et al., 1992, 1995; Grol, 1997; Haines and Donald, 1998; Haynes and Haines, 1998; Shekelle et al., 2000 Wenrich et al., 1971; Eisenberg, 1982; Stross et al., 1983; Rich et al., 1985; Maiman et al., 1988; Davis, Thomson et al., 1992; Katon et al., 1995; Davis, O'Brien et al., 1999 Davis, Thomson et al., 1995; Bero et al., 1998; Thomson et al., 2001a Becker, 1970; Haynes et al., 1984; Davis, Thomson et al., 1995; Bero et al., 1998; Berwick and Nolan, 1998; Thomson et al., 2001 a; Larson, 1999 Berwick and Nolan, 1998; Shekelle et al., 2000 Shekelle et al., 2000 Larson et al., 1979, 1982; Thompson, 1986; McDowell et al., 1986; Mullooly, 1987; Leininger et al., 1996; Brimberry, 1988; Shekelle et al., 2000 Lane et al., 1991; S avage, 1991 Bero et al., 1998; Haynes and Haines, 1998 Cohen et al., 1982; Prislin et al., 1986; Madlon-Kay, 1987; Cheney and Ramsdell, 1987; Shank et al., 1989; Dietrich et al., 1992; Johns et al., 1992 Thompson et al., 2000 Barnett et al., 1983; McDonald et al., 1984; Tierney et al., 1986; McPhee et al., 1991; Rind et al., 1994; Davis, Thomson et al., 1995; Oxman et al., 1995; Overhage et al., 1996; Shekelle et al., 2000 Cohen et al., 1987, 1989; Solberg et al., 1990
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From page 131... ...
TRAINING BEYOND THE STATE OF THE ART TABLE 6.2 Continued 131 · Practice environment process redesign · The Plan, Do, Study Act (PDSA) cycle and others · Clear roles Patient flow · Organized follow-up _ Organizational environment to make identification of the need for and delivery of the services a routine part of care · Rules or policies · Top management support, such as enlisting the aid of the CEO · Clinical computing systems Interventions designed to reinforce the program · Measurement and feedback Financial incentives for professionals · Requirement for accreditation measurement: Healthplan Employer Data and Information Set (HEDIS)
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From page 132... ...
Example 1. The University of Virginia Institute of Law, Psychiatry & Public Policy had been involved for some time in training community mental health professionals about forensic issues (Melton et al., 1985~.
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From page 133... ...
Opinion leaders were recruited and received additional training. · Enabling factors included placing and replacing posters in the reception areas, cue cards for providers, two questions about intimate partner violence incorporated on physical exam questionnaires and information pamphlets for patients placed in the bathrooms.
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From page 134... ...
. INFLUENCING FAMILY VIOLENCE EDUCATION IN THE FUTURE Based on the committee's understanding of the adult learning, continuing education, and systems change literature, it suggests and explores two emerging forces in health care, which have the potential to influence the training of health professionals about family violence.
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From page 135... ...
Effects on the curricula for other health professionals include reports of its development and use for public health (Brownson et al., 1999) , nursing (French, 1999)
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From page 136... ...
identified eight studies that addressed the link between teaching the general principles of evidence-based practice (not disease-specific) and health professionals' knowledge, behavior, process of care, and patient outcomes (Bazarian et al., 1999; Green and Ellis, 1997; Humphris, 1999; Ibbotson et al., 1998; Michaud et al., 1996; Slawson and Shaughnessy, 1999; Wadland et al., 1999; Wainwright et al., 1999~.
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From page 137... ...
The drive for evidence-based practice could serve as a stimulus for effectiveness research on family violence interventions. Conversely, it is also possible that it may have a negative effect on family violence teaching in some locales, due to the current lack of evidence regarding the ideal content of health professional education on family violence.
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From page 138... ...
A few promising training initiatives for health professionals in family violence merit additional attention. The committee makes the following observations based primarily on reports of expert and consensus opinion and experience: .
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From page 139... ...
. Systems change models that are based on the science of behavior change may be useful in planning educational interventions for health professionals tailored to the issue of family violence.
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From page 140... ...
· Healthplan Employer Data Information Set (HEDIS) measures for health care outcomes and the use of evidence-based practice may have potential for improving health professionals' identification and care processes for family violence.
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