Evaluation of a curriculum for intimate partner violence screening in a pediatric emergency department

A Systematic Review of Empirical Studies Measuring Training Effects on Biases Evidenced by Professionals toward Intimate Partner Violence

A professional's response to a client's disclosure of intimate partner violence (IPV) is shown to significantly impact client outcomes. The quality of a professional's response is largely influenced by that professional's beliefs or biases surrounding IPV. This systematic review examined empirical studies conducted in North America and published between 2000 and 2020 evaluating training effects on biases held by professional groups toward victim-survivors of IPV. Search and extraction were conducted in accordance with preferred reporting items for systematic reviews and meta-analyses standards across seven electronic databases. A total of 17 studies met inclusion criteria. Participant groups included professionals from medical, academic, and social/community service disciplines. All included studies reported significant gains on at least one measure of bias. Upon visual inspection, we found no correlations between characteristics of training interventions and reported outcomes on measures of bias. We discuss results in terms of challenges to measuring bias and functional relationships between training interventions, measures of bias, and professional behavior. Variation presented across studies within and between disciplines in regards to training methodology and measurement of bias. Experts in the field of IPV call for a more cohesive approach. We propose the behavior analytic conceptualization of bias as a framework through which interdisciplinary efforts might be unified toward addressing IPV-related biases. Through this lens, we discuss environmental cues within professional settings that might be influencing problematic IPV-related bias. We offer preliminary recommendations for curricular enhancements. We advocate for revision of terms commonly used in IPV-related research and intervention to better reflect and honor diversity across persons experiencing IPV.

What Are We Missing?: Evaluating an Intimate Partner Violence Screening Program in a Pediatric Emergency Department

OBJECTIVES

Our study sought to explore and assess pediatric emergency department (ED) health care providers' knowledge, attitudes, and behaviors surrounding an existing intimate partner violence (IPV) screening program 4 years after initial implementation.

METHODS

We used anonymous electronic surveys and telephone interviews to obtain provider perspectives using a mixed-methods analysis. We used χ2 tests to analyze the quantitative survey results, and an unstructured qualitative approach to analyze the telephone interviews.

RESULTS

We analyzed 141 survey responses, which correlated to a response rate of about 35% of all the providers reached, and 20 telephone interviews. Our results demonstrate that pediatric ED providers have some knowledge of our existing caregiver IPV screening program in the pediatric ED and universally endorse routine caregiver IPV screening, which both are suggestive of postimplementation cultural shifts. However, reported provider behaviors still indicate selective/targeted screening. For example, many providers reported screening males and nontraditional caregivers less often compared with female caregivers. Reported barriers potentially explaining such screening habits mirror those in existing literature: patient acuity, time, multiple caregivers being present, and more.

CONCLUSIONS

Our study indicates that more research must be done to assess root causes of provider barriers to IPV screening in pediatric ED settings because trainings and a long-standing program do not seem to be changing screening practices. Addressing these issues may lead to truly sustainable and effective IPV screening programs in pediatric ED settings.

Violence against women: knowledge, attitudes and beliefs of nurses and midwives

AIMS AND OBJECTIVES

To describe the knowledge, attitudes and beliefs of nurses and midwives who have attended to women who suffered violence. This study further analyses the possible changes of attitude that have occurred over the past five years.

BACKGROUND

Gender violence or violence against women is the largest problem with regard to public health and violated human rights all over the world. In Italy, it is estimated that 31·5% of women suffer physical or sexual violence during their life. Healthcare operators play a crucial role in recognising the signs of the violence suffered when taking care of victims.

DESIGN

A cross-sectional study was conducted.

METHODS

A questionnaire was administered; this was used in a previous survey of a convenience sample of 51 nurses and midwives who work in an emergency room or in an obstetrics emergency room and gynaecological ward.

RESULTS

Of the respondents, 51 (80·4%) have taken care of women who suffered violence, and 25 (49%) believe they can detect violence. The relational/communicative approach presents the most difficulty, and all the operators believe they need more knowledge. The number of operators who suggest women be observed in an emergency room and file a complaint or who primarily consider listening to women has decreased. A tendency to 'blame' women, although decreasing, persists; it is higher among male nurses and, in general, among male operators.

CONCLUSION

Knowledge of this issue has not been completely recognised among operators despite training and the emergence of the phenomenon in the mass media. Difficulties in receiving and in relational procedures continue to exist, in addition to 'blaming' the woman.

RELEVANCE TO CLINICAL PRACTICE

Awareness paths and cultural changes regarding the phenomenon of violence need to be developed, as does a specific training programme on the approach to and assessment of the abused woman.

Interventions to Improve the Response of Professionals to Children Exposed to Domestic Violence and Abuse: A Systematic Review

Exposure of children to domestic violence and abuse (DVA) is a form of child maltreatment with short- and long-term behavioural and mental health impact. Health care professionals are generally uncertain about how to respond to domestic violence and are particularly unclear about best practice with regards to children's exposure and their role in a multiagency response. In this systematic review, we report educational and structural or whole-system interventions that aim to improve professionals' understanding of, and response to, DVA survivors and their children. We searched 22 bibliographic databases and contacted topic experts for studies reporting quantitative outcomes for any type of intervention aiming to improve professional responses to disclosure of DVA with child involvement. We included interventions for physicians, nurses, social workers and teachers. Twenty-one studies met the inclusion criteria: three randomised controlled trials (RCTs), 18 pre-post intervention surveys. There were 18 training and three system-level interventions. Training interventions generally had positive effects on participants' knowledge, attitudes towards DVA and clinical competence. The results from the RCTs were consistent with the before-after surveys. Results from system-level interventions aimed to change organisational practice and inter-organisational collaboration demonstrates the benefit of coordinating system change in child welfare agencies with primary health care and other organisations. Implications for policy and research are discussed. © 2015 The Authors. Child Abuse Review published by John Wiley & Sons Ltd. 'We searched 22 bibliographic databases and contacted topic experts'.

KEY PRACTITIONER MESSAGES

We reviewed published evidence on interventions aimed at improving professionals' practice with domestic violence survivors and their children.Training programmes were found to improve participants' knowledge, attitudes and clinical competence up to a year after delivery.Key elements of successful training include interactive discussion, booster sessions and involving specialist domestic violence practitioners.Whole-system approaches aiming to promote coordination and collaboration across agencies appear promising but require funding and high levels of commitment from partners. 'Training programmes were found to improve participants' knowledge, attitudes and clinical competence up to a year after delivery'.

Using simulation to identify sources of medical diagnostic error in child physical abuse

Little is known regarding sources of diagnostic error at the provider level in cases of possible child physical abuse. This study examines medical diagnosis as part of medical management and not as part of legal investigation. Simulation offers the opportunity to evaluate diagnostic accuracy and identify error sources. We aimed to identify sources of medical diagnostic error in cases of possible abuse by assessing diagnostic accuracy, identifying gaps in evaluation, and characterizing information used by medical providers to reach their diagnoses. Eight femur fracture simulation cases, half of which were abuse and half accident, were created. Providers from a tertiary pediatric emergency department participated in a simulation exercise involving 1 of the 8 cases. Performance was evaluated using structured scoring tools and debriefing, and qualitative analysis characterized participants' rationales for their diagnoses. Overall, 39% of the 43 participants made an incorrect diagnosis regarding abuse. An incorrect diagnosis was over 8 times more likely to occur in accident than in abuse cases (OR=8.8; 95% CI 2 to 39). Only 58% of participants correctly identified the fracture morphology, 60% correctly identified the mechanics necessary to generate the morphology, and 30% of ordered all appropriate tests for occult injury. In misdiagnoses, participants frequently falsely believed the injury did not match the proposed mechanism and the history provided by the caregiver had changed. Education programs targeting the identified error sources may result in fewer diagnostic errors and improve outcomes. The findings also support the need for referral to child abuse experts in many cases.

Intimate Partner Violence Programs in a Children's Hospital: Comprehensive Assessment Utilizing a Delphi Instrument

OBJECTIVE

The purpose of this study was to conduct a baseline assessment of intimate partner violence (IPV) practices in a pediatric hospital system.

METHODS

The Delphi Instrument for Hospital-based Domestic Violence Programs was used to assess the structure and components of the hospital system's IPV practices. Through key stakeholder interviews, we also assessed IPV practices in individual patient care areas. Qualitative analysis of interview data used a grounded theory approach.

RESULTS

The hospital scored 17 of 100 points on the Delphi instrument assessment. Key areas of weakness identified by the Delphi instrument and interviews included lack of coordinated provider training and evaluation of IPV-related processes and no standards for IPV screening, safety assessment, and documentation. Most interviewees supported addressing IPV; all identified barriers to IPV screening at individual provider and institutional levels. Institutional barriers included lack of a standardized response to IPV disclosure, need for individualized screening protocols for different patient care settings, lack of standardized provider training, concerns about overextending social work resources, and lack of resources for hospital staff experiencing vicarious trauma. Individual barriers included concern that screening may harm physician-patient-family relationships and the perception that physicians are unwilling to address psychosocial issues.

CONCLUSIONS

The Delphi Instrument for Hospital-based Domestic Violence Programs identified weaknesses and key areas for improvement in IPV practices. Deficiencies revealed by the Delphi instrument were affirmed by individual interview results. Institutional and individual provider level barriers must be addressed to optimize IPV practices in a pediatric hospital system.

Prevalence of intimate partner violence in patients presenting with traumatic injuries to a Guyanese emergency department

Background

Intimate partner violence (IPV) occurs throughout the world, and has both short- term and long- term negative health effects. Little is know about the prevalence of IPV in patients presenting to Emergency Departments (EDs) in the developing world. This information is needed to help delineate the scope of the problem and shape effective interventions to combat IPV. The purpose of this study was to determine the prevalence of intimate partner violence in adult patients with acute traumatic injuries presenting to an ED in Georgetown, Guyana.

Methods

Retrospective descriptive analysis of a prospectively collected ED quality assurance database. Patients 18 years or older who presented with a traumatic injury and answered the question “Was the injury inflicted by a domestic partner?” were included in the analysis.

Results

Overall, 38 of 475 (8%) patients admitted to having injuries inflicted by a domestic partner. Thirty- one (81.6%) patients disclosing IPV were female and 7 (18.4%) were male. The self- reported prevalence of IPV in females presenting with traumatic injuries was 16% compared to 2% for males (RR 6.4; 95% CI 2.9-14.3). IPV was the cause of 31 of the 67 (46.3%) women presenting with assaults.

Conclusions

IPV is thought to be a serious problem in Guyana, and this study confirms a high prevalence (16%) of IPV in women presenting with traumatic injuries to the Georgetown Public Hospital Corporation ED. This is likely a significant underestimate of the true prevalence.

Evaluation of a firearm injury prevention web-based curriculum

BACKGROUND

Firearm injury prevention training is lacking in pediatric residency programs.

DESCRIPTION

This study aimed to evaluate a web-based curriculum teaching residents how to provide injury prevention anticipatory guidance, emphasizing firearm injury prevention. Ninety-two residents participated and completed pretesting. Residents in the intervention group completed the curriculum, posttesting, and 6-month follow-up testing. Residents in the nonintervention group completed 6-month follow-up testing. Pre- and posttest comparisons between and within each group were made.

EVALUATION

Baseline knowledge of the participants was high, and no significant change in knowledge was shown in either group. Changes in attitude were noted regarding physician role in providing firearm injury anticipatory guidance in the intervention group, which persisted at 6 months. Participants completing the curriculum showed significant improvement for all self-efficacy questions in the immediate and 6-month follow-up testing.

CONCLUSIONS

Participants reported changes in attitudes and in confidence in their ability to provide firearm injury prevention counseling after completion of a web-based curriculum.

Results of a multifaceted Intimate Partner Violence training program for pediatric residents

OBJECTIVE

To evaluate the efficacy of a multifaceted Intimate Partner Violence (IPV) intervention on knowledge, attitudes, and screening practices of pediatric residents.

METHODS

The intervention included: an on-site IPV counselor, IPV training for attending physicians, residents and social workers, and screening prompts. Evaluation included baseline and post-training surveys of residents, assessing their knowledge, attitudes, and comfort with IPV screening, patient chart reviews at baseline, 3 months, and 8 months for documentation of IPV screening, and review of the IPV counselor's client charts.

RESULTS

Baseline chart review showed screening rates of less than 1%. Screening rates were 36.2% at 3 months and 33.1% at 8 months. After training, residents were more likely to know: IPV screening questions (47.1% vs. 100%); referral sources (34.3% vs. 82.9%); and the relationship between child abuse and IPV (52.9% vs. 97.1%). At baseline, barriers to IPV screening included time (50%), lack of knowledge of how to screen (26.5%) and where to refer (23.5%). Post-training, barriers were time (44%), presence of children (25.9%) or other adults (18.5%) in the room, and inappropriate location (18.5%). Post-training, none of the residents listed "lack of knowledge" or "lack of referral sources" as barriers to IPV screening. After 12 months, 107 victims of IPV were identified; most referred from inpatient units and subspecialty clinics.

CONCLUSION

A multifaceted IPV intervention increased identification of IPV victims and markedly improved attitudes, comfort, and IPV screening practices of pediatric residents. IPV screening rates were sustainable with minimal ongoing training.

PRACTICE IMPLICATIONS

Consideration should be given to the training and practice supports necessary to encourage IPV screening in the pediatric setting. Educational efforts that familiarize pediatricians with the content surrounding the risk and potential impact of IPV to children and families along with practice supports that make incorporating screening for IPV as easy as possible have the potential to increase the identification of this problem and promote referrals to IPV agencies for follow-up and intervention where needed.

Evaluation of an intimate partner violence curriculum in a pediatric hospital

OBJECTIVE

Intimate partner violence harms victims as well as families and communities. Many barriers account for limited intimate partner violence screening by nurses. The purpose of this study was to measure how participation in a curriculum about screening parents for intimate partner violence, at a pediatric hospital, affects a nurse's knowledge, attitudes, behaviors, and self-efficacy for intimate partner violence screening.

METHODS

In this interventional, longitudinal study, data were collected before participation in an intimate partner violence screening curriculum, after participation, and 3 months later. The measurement tool was adapted from Maiuro's (2000) Self-efficacy for Screening for Intimate Partner Violence Questionnaire.

RESULTS

Sixty-eight pediatric nurses completed all aspects of the study. At baseline, 18 (27%) nurses self-reported seeing a parent with an injury, and of those only 7 (39%) followed up with intimate partner violence screening. Factor analysis was performed on the baseline Self-efficacy for Screening for Intimate Partner Violence Questionnaire by using varimax rotation. Five factors were identified: conflict, fear of offending parent, self-confidence, appropriateness, and attitude. Only fear of offending parent was significantly different from times 1 to 3, indicating that nurses were less fearful after the training. Cronbach's alpha value for the total questionnaire at baseline was .85. Nurses reported significant improvement (baseline to 3-month follow-up) in several self-efficacy items.

CONCLUSIONS

Participation in a 30-minute curriculum on intimate partner violence screening was associated with improvements in self-efficacy and significantly lower fear of offending parents 3 months after training. Nurses also showed improvement in the perception of resources available for nurses to manage intimate partner violence. Thirty-minute hospital-based curriculums that include victim testimonial video and practice role-playing to simulate parent interactions are recommended.