A randomized controlled trial using insinuated standardized patients to assess residents' domestic violence skills following a two-hour workshop

Teen Actors Teaching Communication Skills

Introduction

To provide high-quality care, physicians must effectively communicate with adolescents while addressing difficult and sensitive subjects. Our program aimed to (1) cost-effectively incorporate teenage actors into a pediatric simulation program and (2) increase residents' self-perceived comfort level with adolescent patients by practicing interview skills with teens.

Methods

In 2013, the authors established a Teen Acting Program, in which volunteer theater students created and simulated patient characters and provided feedback to learners. Residents on the adolescent medicine rotation participated in the program, completed a survey on self-perceived comfort level with adolescent patients, and answered open-ended questions regarding the program.

Results

A total of 70 residents participated in the program and pre-survey; 46 completed both the pre- and the post-survey. Of 46 participants, 37 (80%) reported that the program was helpful and four (9%) stated it was the best thing about the rotation; 35 (80%) described the program as “high-yield” for the time spent. Between the pre- and post-surveys, residents demonstrated statistically significant improvement in comfort interacting with adolescent patients, addressing confidentiality, and taking histories on sexuality, substance use, mental health, diet, and safety, whether they were the interviewer or observer. Residents that reported the teens taught them specific skills and concepts related to communication. A calculation of program costs demonstrated a 10-fold decrease in cost from traditional simulation patient encounters.

Conclusion

The Teen Acting Program was cost-effective and improved resident comfort with interviewing adolescents about sensitive topics, while giving adolescent actors experience honing their acting skills.

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes

BACKGROUND

Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review.

OBJECTIVES

• To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016).

SELECTION CRITERIA

We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots.

MAIN RESULTS

We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques.

AUTHORS' CONCLUSIONS

Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.

Nurse-Family Partnership nurses' attitudes and confidence in identifying and responding to intimate partner violence: An explanatory sequential mixed methods evaluation

AIMS

To evaluate the effect of an intimate partner violence intervention education component on nurses' attitudes in addressing intimate partner violence; complementary aims included understanding nurses' perceptions of the education and how it influenced their attitudes and confidence to address intimate partner violence in practice.

DESIGN

An explanatory sequential mixed methods design embedded within a 15-site cluster randomized clinical trial that evaluated an intimate partner violence intervention within the Nurse-Family Partnership programme.

METHODS

Data were collected between February 2011 and September 2016. Quantitative assessment of nurses' attitudes about addressing intimate partner violence was completed by nurses in the intervention (n = 77) and control groups (n = 101) at baseline, 12 months and at study closure using the Public Health Nurses' Responses to Women Who Are Abused Scale. Qualitative data were collected from nurses in the intervention group at two timepoints (n = 14 focus groups) and focused on their perceptions of the education component. Data were analysed using content analysis.

RESULTS

Nurses in the intervention group reported large improvements in their thoughts, feelings and perceived behaviours related to addressing intimate partner violence; a strong effect of the education was found from baseline to 12 months and baseline to study closure timepoints. Nurses reported that the education component was acceptable and increased their confidence to address intimate partner violence.

CONCLUSION

Nurses reported improved attitudes about and confidence in addressing intimate partner violence after receiving the education component. However, these findings need to be considered together with trial results showing no main effects for clients, and a low level of intervention fidelity.

IMPACT

These evaluation findings underscore that improvement in nurses' self-reported educational outcomes about addressing intimate partner violence cannot be assumed to result in adherence to intervention implementation or improvement in client outcomes. These are important considerations for developing nurse education on intimate partner violence.

Training healthcare providers to respond to intimate partner violence against women

BACKGROUND

Intimate partner violence (IPV) includes any violence (physical, sexual or psychological/emotional) by a current or former partner. This review reflects the current understanding of IPV as a profoundly gendered issue, perpetrated most often by men against women. IPV may result in substantial physical and mental health impacts for survivors. Women affected by IPV are more likely to have contact with healthcare providers (HCPs) (e.g. nurses, doctors, midwives), even though women often do not disclose the violence. Training HCPs on IPV, including how to respond to survivors of IPV, is an important intervention to improve HCPs' knowledge, attitudes and practice, and subsequently the care and health outcomes for IPV survivors.

OBJECTIVES

To assess the effectiveness of training programmes that seek to improve HCPs' identification of and response to IPV against women, compared to no intervention, wait-list, placebo or training as usual.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and seven other databases up to June 2020. We also searched two clinical trials registries and relevant websites. In addition, we contacted primary authors of included studies to ask if they knew of any relevant studies not identified in the search. We evaluated the reference lists of all included studies and systematic reviews for inclusion. We applied no restrictions by search dates or language.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials comparing IPV training or educational programmes for HCPs compared with no training, wait-list, training as usual, placebo, or a sub-component of the intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures outlined by Cochrane. Two review authors independently assessed studies for eligibility, undertook data extraction and assessed risks of bias. Where possible, we synthesised the effects of IPV training in a meta-analysis. Other analyses were synthesised in a narrative manner. We assessed evidence certainty using the GRADE approach.

MAIN RESULTS

We included 19 trials involving 1662 participants. Three-quarters of all studies were conducted in the USA, with single studies from Australia, Iran, Mexico, Turkey and the Netherlands. Twelve trials compared IPV training versus no training, and seven trials compared the effects of IPV training to training as usual or a sub-component of the intervention in the comparison group, or both. Study participants included 618 medical staff/students, 460 nurses/students, 348 dentists/students, 161 counsellors or psychologists/students, 70 midwives and 5 social workers. Studies were heterogeneous and varied across training content delivered, pedagogy and time to follow-up (immediately post training to 24 months). The risk of bias assessment highlighted unclear reporting across many areas of bias. The GRADE assessment of the studies found that the certainty of the evidence for the primary outcomes was low to very low, with studies often reporting on perceived or self-reported outcomes rather than actual HCPs' practices or outcomes for women. Eleven of the 19 included studies received some form of research grant funding to complete the research. Within 12 months post-intervention, the evidence suggests that compared to no intervention, wait-list or placebo, IPV training: · may improve HCPs' attitudes towards IPV survivors (standardised mean difference (SMD) 0.71, 95% CI 0.39 to 1.03; 8 studies, 641 participants; low-certainty evidence); · may have a large effect on HCPs' self-perceived readiness to respond to IPV survivors, although the evidence was uncertain (SMD 2.44, 95% CI 1.51 to 3.37; 6 studies, 487 participants; very low-certainty evidence); · may have a large effect on HCPs' knowledge of IPV, although the evidence was uncertain (SMD 6.56, 95% CI 2.49 to 10.63; 3 studies, 239 participants; very low-certainty evidence); · may make little to no difference to HCPs' referral practices of women to support agencies, although this is based on only one study (with 49 clinics) assessed to be very low certainty; · has an uncertain effect on HCPs' response behaviours (based on two studies of very low certainty), with one trial (with 27 participants) reporting that trained HCPs were more likely to successfully provide advice on safety planning during their interactions with standardised patients, and the other study (with 49 clinics) reporting no clear impact on safety planning practices; · may improve identification of IPV at six months post-training (RR 4.54, 95% CI 2.5 to 8.09) as in one study (with 54 participants), although three studies (with 48 participants) reported little to no effects of training on identification or documentation of IPV, or both. No studies assessed the impact of training HCPs on the mental health of women survivors of IPV compared to no intervention, wait-list or placebo. When IPV training was compared to training as usual or a sub-component of the intervention, or both, no clear effects were seen on HCPs' attitudes/beliefs, safety planning, and referral to services or mental health outcomes for women. Inconsistent results were seen for HCPs' readiness to respond (improvements in two out of three studies) and HCPs' IPV knowledge (improved in two out of four studies). One study found that IPV training improved HCPs' validation responses. No adverse IPV-related events were reported in any of the studies identified in this review.

AUTHORS' CONCLUSIONS

Overall, IPV training for HCPs may be effective for outcomes that are precursors to behaviour change. There is some, albeit weak evidence that IPV training may improve HCPs' attitudes towards IPV. Training may also improve IPV knowledge and HCPs' self-perceived readiness to respond to those affected by IPV, although we are not certain about this evidence. Although supportive evidence is weak and inconsistent, training may improve HCPs' actual responses, including the use of safety planning, identification and documentation of IPV in women's case histories. The sustained effect of training on these outcomes beyond 12 months is undetermined. Our confidence in these findings is reduced by the substantial level of heterogeneity across studies and the unclear risk of bias around randomisation and blinding of participants, as well as high risk of bias from attrition in many studies. Further research is needed that overcomes these limitations, as well as assesses the impacts of IPV training on HCPs' behavioral outcomes and the well-being of women survivors of IPV.

Which Violence Against Women Educational Strategies Are Effective for Prequalifying Health-Care Students?: A Systematic Review

Gender-based violence (GBV) is a global public health issue which disproportionately affects women. Health-care providers have an important role in recognizing and addressing GBV in practice, yet research suggests that the issue remains underrecognized, with many qualified professionals reporting lack of confidence and a sense of unpreparedness. Prequalifying GBV educational strategies are inconsistent in both quantity and quality worldwide, and to date, there has been no comprehensive review of those programs' effectiveness. This internationally focused literature review aimed to identify best educational practices in GBV for prequalifying health-care students. A systematic search of six databases yielded 17 studies meeting the inclusion criteria, with all studies examining one or more educational intervention. Quality appraisal was undertaken and data were tabulated to capture relevant information. Thematic findings suggest that interactive educational strategies yield better results than didactic approaches. Similarly, interventions with a focus on practical application of learning are generally preferred over strictly theoretical approaches. Courses of longer duration seem to be more effective in instilling attitudinal changes. Lastly, gendered differences were noted in a number of studies, with female students consistently outperforming males. However, more research is needed before conclusions can be drawn about the effectiveness of single- versus mixed-gender audiences. This review makes a useful contribution to the literature of health education, supporting many findings from previous studies and identifying knowledge gaps to be explored in future research. There are implications for both educators and practitioners in creating discernible change for women in their care.

Simulation in psychiatry for medical doctors: A systematic review and meta-analysis

CONTEXT

Most medical doctors are likely to work with patients experiencing mental health conditions. However, educational opportunities for medical doctors to achieve professional development in the field of psychiatry are often limited. Simulation training in psychiatry may be a useful tool to foster this development.

OBJECTIVES

The purpose of this study was to assess the effectiveness of simulation training in psychiatry for medical students, postgraduate trainees and medical doctors.

METHODS

For this systematic review and meta-analysis, we searched eight electronic databases and trial registries up to 31 August 2018. We manually searched key journals and the reference lists of selected studies. We included randomised and non-randomised controlled studies and single group pre- and post-test studies. Our main outcomes were based on Kirkpatrick levels. We included data only from randomised controlled trials (RCTs) using random-effects models.

RESULTS

From 46 571 studies identified, we selected 163 studies and combined 27 RCTs. Interventions included simulation by role-play (n = 69), simulated patients (n = 72), virtual reality (n = 22), manikin (n = 5) and voice simulation (n = 2). Meta-analysis found significant differences at immediate post-tests for simulation compared with active and inactive control groups for attitudes (standardised mean difference [SMD] = 0.52, 95% confidence interval [CI] 0.31-0.73 [I²  = 0.0%] and SMD = 0.28, 95% CI 0.04-0.53 [I²  = 52.0%], respectively), skills (SMD = 1.37, 95% CI 0.56-2.18 [I²  = 93.0%] and SMD = 1.49, 95% CI 0.39-2.58 [I²  = 93.0%], respectively), knowledge (SMD = 1.22, 95% CI 0.57-1.88 [I²  = 0.0%] and SMD = 0.72, 95% CI 0.14-1.30 [I²  = 80.0%], respectively), and behaviours (SMD = 1.07, 95% CI 0.49-1.65 [I²  = 68.0%] and SMD = 0.45, 95% CI 0.11-0.79 [I²  = 41.0%], respectively). Significant differences in terms of patient benefit and doctors' behaviours and skills were found at the 3-month follow-up.

CONCLUSIONS

Despite heterogeneity in methods and simulation interventions, our findings demonstrate the effectiveness of simulation training in psychiatry training.

Measuring the effectiveness of an intensive IPV training program offered to Greek general practitioners and residents of general practice

BACKGROUND

The need for effective training of primary care physicians in the prevention, detection and handling of intimate partner violence (IPV) has been widely acknowledged, given its frequency in daily practice. The current intervention study aimed to measure changes in the actual IPV knowledge, perceived knowledge, perceived preparedness and detection ability of practicing general practitioners (GPs) and general practice residents, following an intensive IPV training program.

METHODS

A pre/post-test design with a control group was employed to compare changes in baseline measures of IPV at the post intervention stage and at 12 months. A total of 40 participants provided full data; 25 GPs (11 in the intervention and 14 in the control) and 15 residents (intervention only). Three scales of the PREMIS survey were used to draw information on the study outcomes.

RESULTS

The training program met high acceptance by both groups of participants and high practicality in clinical practice. The GPs in the intervention group performed better than the GPs in the control group on "Perceived preparedness" and "Perceived knowledge" in both the post-intervention (p= .012, r= .50 and p= .001, r= .68) and the 12-month follow-up (p= .024, r= .45 and p= .007, r= .54) as well as better than the residents in "Perceived preparedness" at post-intervention level (p= .037, r= .41). Residents on the other hand, performed better than the GPs in the intervention group on "Actual knowledge" at the 12-month follow-up (p= .012, r= .49). No significant improvements or between group differences were found in terms of the self-reported detection of IPV cases.

CONCLUSION

Further studies are needed to decide whether residency training could serve as an early intervention stage for IPV training.

Effect of feedback from standardized patients on medical students' performance and perceptions of the neurological examination

BACKGROUND

Feedback can have a powerful influence on the performance of learners, and has traditionally been provided by faculty.

AIM

This study set out to explore whether feedback from a standardized patient (SP) can improve students' performance of the neurological examination.

METHODS

A randomized controlled design was used with final year medical students. The control group did not receive any feedback. The intervention groups received either written feedback or a combination of written and verbal feedback. A written test was given prior to the intervention to assess comparability of the three groups. Pretest and post-test scores on the neurological examination were compared. Attitudinal questionnaires were administered at the time of the posttest, and 6 months later.

RESULTS

Students receiving feedback from the SPs had significantly greater scores on the posttest than the control group. In the intervention groups, students receiving both verbal and written feedback scored significantly higher than those who received only written feedback. More positive perceptions of learning outcomes and the value of SP feedback were noted in the intervention groups.

CONCLUSION

SP feedback was associated with a significant increase in student scores on the neurological examination, as well as more favorable perceptions of the experience.

Are clinicians being prepared to care for abused women? A survey of health professional education in Ontario, Canada

BACKGROUND

The current project undertook a province-wide survey and environmental scan of educational opportunities available to future health care providers on the topic of intimate partner violence (IPV) against women.

METHODS

A team of experts identified university and college programs in Ontario, Canada as potential providers of IPV education to students in health care professions at the undergraduate and post-graduate levels. A telephone survey with contacts representing these programs was conducted between October 2005 and March 2006. The survey asked whether IPV-specific education was provided to learners, and if so, how and by whom.

RESULTS

In total, 222 eligible programs in dentistry, medicine, nursing and other allied health professions were surveyed, and 95% (212/222) of programs responded. Of these, 57% reported offering some form of IPV-specific education, with undergraduate nursing (83%) and allied health (82%) programs having the highest rates. Fewer than half of undergraduate medical (43%) and dentistry (46%) programs offered IPV content. Postgraduate programs ranged from no IPV content provision (dentistry) to 41% offering content (nursing).

CONCLUSION

Significant variability exists across program areas regarding the methods for IPV education, its delivery and evaluation. The results of this project highlight that expectations for an active and consistent response by health care professionals to women experiencing the effects of violence may not match the realities of professional preparation.