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a Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
b Harbor-UCLA Medical Center, University of California Los Angeles School of Medicine, Torrance, California
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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METHODS. A 22-item Likert scale questionnaire was administered at baseline (before training), after training, and at 6-month follow-up to PED employee participants in a 2-hour IPV education program. Mean participant responses were compared between baseline/posttraining and baseline/6-month follow-up. Participants also completed a course-satisfaction survey.
RESULTS. A total of 79 PED staff completed the baseline questionnaire before the training. Eighty-seven participants completed the posttraining questionnaire, and 48 completed the 6-month follow-up questionnaire. Participants had consistent, positive changes in attitudes after training that persisted at the 6-month follow-up for 5 items on the questionnaire. Attitudes that did not change showed baseline means already in disagreement with questionnaire statements. Participants reported significant, positive changes for all 7 self-efficacy statements at 1 or both of the posttraining evaluations. The only changes in behavior were observed at 6 months. The majority of participants were satisfied with the training and would recommend it to colleagues.
CONCLUSIONS. Significant, self-reported changes in attitudes, self-efficacy, and behaviors/clinical practice regarding screening for IPV in a PED can be achieved through participation in a brief training curriculum.
Key Words: intimate partner violence • family violence • pediatric emergency department • screening • training • evaluation
Abbreviations: FV—family violence • IPV—intimate partner violence • IOM—Institute of Medicine • PED—pediatric emergency department
Family violence (FV) includes child physical and sexual abuse and neglect, intimate partner violence (IPV), and elder abuse and neglect. It affects as many as 25% of American children and adults annually as victims, witnesses, or perpetrators.1–3 Between 3.3 and 10 million children are exposed to IPV each year, usually committed in the home against 1 of their parents.4,5 Eighty-five percent of the victims of IPV are women, half of whom have children who are younger than 12 years.6,7 The children of battered women are 6 to 15 times more likely to be abused, with concordance rates between maternal and child abuse as high as 77%.8–10 Exposure to IPV also increases the risk for significant emotional, behavioral, and cognitive problems, including poor self-esteem and later risk for substance abuse.9–13
Pediatricians, because of their professional contact and relationship with families, have a unique opportunity to identify, diagnose, treat, and prevent many forms of family violence, including IPV. The American Academy of Pediatrics Committee on Child Abuse and Neglect has stated that "identifying and intervening on behalf of battered women may be one of the most effective means of preventing child abuse" and has recommended that (1) residency training programs and continuing medical education programs incorporate education on FV and IPV into curricula, (2) pediatricians should attempt to recognize evidence of FV or IPV in the office setting, and (3) pediatricians should intervene in a sensitive and skillful manner that maximizes the safety of women and children victims.14 Screening in a pediatric outpatient clinic has been successful in increasing referrals and documentation of previously unrecognized IPV.15
Unfortunately, studies consistently find that lack of education and training is a major barrier to incorporating identification and intervention for FV into practice.16–22 Pediatric residency programs report a mean of 8 hours of training on child maltreatment during the first and third years of residency and 7 hours during the second year.23 Eighty percent of pediatric chief residents reported receiving <4 hours of IPV training and believed that their training was not sufficient to make them comfortable with screening for IPV.24 Results of the American Academy of Pediatrics 1998 and 2003 periodic surveys on a national random sample of members show that pediatricians believe that they have inadequate professional training in IPV.25 The Institute of Medicine (IOM) Committee on the Training Needs of Health Professionals to Respond to Family Violence also noted lack of an evaluation component for most of the existing curricula and recommended that programs be evaluated to determine (1) their impact on the practices of health professionals and (2) their effect on family violence victims.26
We developed an instructional program called It's Time to Ask to aid in the identification and intervention for IPV in the pediatric acute care setting. The 2-hour course consists of 3 modules and includes an evaluation component. The first module presents basic definitions and concepts regarding IPV in the pediatric health care setting. The second module addresses attitudes, beliefs, and behaviors identified as barriers to screening and intervention. The third module presents a model protocol for use in the pediatric acute care setting. The goal of this study was to determine the effect of participation in the It's Time to Ask curriculum on pediatric health care provider attitudes and beliefs, self-efficacy, and reported behaviors/clinical practice concerning identifying and intervening for IPV in the pediatric emergency department (PED).
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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6 months after participation. The questionnaire included demographic information including age, profession, years in practice, and gender; participants were otherwise not identifiable. Therefore, baseline (before training), posttraining, and follow-up responses were not matched. The questionnaire was designed to assess the attitudes and beliefs, self-efficacy, and behaviors/clinical practice of the course participants for identifying and coping with families in which IPV is known or suspected. A 5-point Likert scale was used to assess the responses (1, strongly agree with statement; 5, strongly disagree with statement). The questionnaire was modeled on the 39-item instrument developed and validated by Maiuro et al27 to measure knowledge, attitudes, beliefs, and behaviors in identifying and managing IPV. Our original instrument contained 35 items and included both positive and negative statements regarding some attitudes and beliefs to assess bias in answering. On the basis of course participant feedback, the 6-month follow-up survey was revised by eliminating 13 redundant items. Only the 22 items that were included on the baseline, posttraining, and 6 month follow-up questionnaire were analyzed. This follow-up questionnaire included 11 items regarding attitudes and beliefs, 7 items on self-efficacy, and 4 statements regarding behaviors/clinical practice. The 6-month follow-up questionnaire was distributed to all ED physician, nurse, and social worker staff members after a screening program for IPV had been implemented in the PED. Respondents were asked to indicate whether they had taken the It's Time to Ask training program 6 months earlier. Only the surveys of those who had previously been trained were included in the final analysis.
Data analysis was performed using SPSS 11.0 (SPSS Inc, Chicago, IL). Questions with responses on a Likert scale were treated as continuous variables with means and SDs calculated for 3 measurement periods (baseline, posttraining, and 6-month follow-up). Posttraining and 6-month follow-up groups were compared with baseline using independent t tests. Differences between the means with 95% confidence intervals for the differences are presented. P 
.05 was chosen as indicative of statistical significance. The t test was chosen as the preferred significance test as it allows expression of quantification of the effect (mean difference) as well as precision (95% confidence intervals). Because there is not consensus within the research community on the appropriateness of the test for examining Likert scale data, we also performed the nonparametric Kruskal-Wallis test for comparison.
A second 9-item questionnaire evaluated participant satisfaction with the training program and was administered immediately after training. This group included a larger number of participants who completed the training course, including those who were not permanent staff of the PED (eg, pediatric residents). Responses on the course-satisfaction questionnaire ranged from 1 (not in agreement) to 5 (full agreement). Participants who provided responses of 4 or 5 were grouped and reported as being in agreement.
The study was assigned an exempt status that did not require written informed consent by the Children's Mercy Hospital Institutional Review Board, because it was considered minimal risk and no personal identifiers were collected.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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For 4 statements, there were no measurable changes in attitudes and beliefs between the baseline and both posttraining evaluations. These included "People are only victims if they choose to be" (baseline: 4.3; posttraining: 4.6; 6-month follow-up: 4.5) and "It is inappropriate to ask about IPV in the pediatric setting" (baseline: 4.3; posttraining: 4.3; 6-month follow-up: 4.6).
At baseline, participants disagreed with the statement, "I think that trying to determine the cause of a parent/caregiver's injury is not part of pediatric emergency care" (mean response: 4.2). Posttraining, the mean response was 4.6 (P < .01); at 6-month follow-up, the mean response was 4.4 (not significant). Participants agreed (mean: 2.1) with "Even if the child is not in immediate danger, I am mandated to report an instance of a child witnessing IPV to child protective services." The mean posttraining response was 2.7 (P < .01), whereas the 6-month follow-up response did not show significant change from baseline (mean: 1.8).
Self-Efficacy
Five of the 7 statements regarding self-efficacy showed consistent, significant changes between the posttraining and 6-month follow-up comparisons with baseline, indicating an increase in self-efficacy. A few examples include the following: "I have ready access to information describing management of IPV" (baseline: 2.7; posttraining: 1.7 [P < .001]; 6-month follow-up: 1.6 [P < .001]), "I feel confident that I can make appropriate referrals for victims of IPV" (baseline: 2.5; posttraining: 1.6 [P < .001]; 6-month follow-up: 1.7 [P < .001]), and "I feel comfortable asking parents/caregivers about the possibility of IPV" (baseline: 2.8; posttraining: 1.9 [P < .001]; 6-month follow-up: 1.8 [P < .001]). Two statements, one of which was "I feel confident that we are identifying as many victims of IPV as we can in my work setting," had significant changes toward greater self-efficacy between the baseline and 6-month follow-up alone.
Behaviors/Clinical Practice
Two statements showed significant changes toward agreement at the 6-month evaluation alone. These included the following: "In the past year, I have seen a parent/caregiver with an injury and have asked about IPV" (baseline: 3.4; 6-month follow-up: 2.7 [P < .05]) and "In the past year, I have seen an abused child and have asked about IPV" (baseline: 2.6; 6-month follow-up: 1.8 [P < .01]). There were not significant changes between baseline and both follow-up evaluations for "I have seen a parent in the past year with disturbing behavior and asked about IPV" and "I have seen a parent in the past year with depression/anxiety and asked about IPV." Kruskal-Wallis tests performed for all above comparisons revealed the same significant differences (data not shown).
Satisfaction With Training
A total of 121 participants completed the 9-item course-satisfaction questionnaire. Ninety-six percent of the respondents agreed with the statement "The training program presented information that is relevant to my clinical education/practice." Two thirds of the participants agreed that the course changed their attitude toward screening mothers for IPV. Eighty-eight percent would recommend the training to colleagues, and 93% agreed that they were going to use the information presented in current or future clinical practice.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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We previously published the findings of a study that described the perspectives of mothers and child health care providers on screening for IPV in a PED.28 This focus group study identified a number of barriers to screening for IPV in a PED. Erickson et al29 published the results of a survey of child health care providers that identified similar barriers to screening. Health care provider barriers are summarized in Table 3. Many barriers involve attitudes and beliefs about IPV and self-efficacy with regard to identification and intervention.
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Successfully overcoming barriers to screening for IPV is dependent in part on the teaching methods and strategies used during training. The It's Time to Ask course was planned with the belief that achieving positive attitudinal changes and improvements in self-efficacy are critical to overcoming the identified barriers for screening for IPV. The core components of the curriculum were developed to be taught with a multidisciplinary, experiential approach using video, case discussion, and role play. Using these techniques, participants learned practical methods for screening, basic competency skills for screening, and procedures for obtaining ready access to resources and services.
The results of the evaluation demonstrate that many of the currently recognized barriers to screening for IPV in a PED can be overcome and that changes can persist over time. In general, most of the responses that changed were consistent at the 6-month follow-up evaluation. The participants in our curriculum showed significant, consistent, favorable changes in many attitudes and beliefs. Among these are those involving time constraints and fear of offending. These are important findings for a high-volume, emotionally charged health care setting such as the PED. Self-efficacy improved from baseline to posttraining/6-month follow-up or baseline/6-month follow-up for all 7 statements. These changes in self-efficacy indicate that effective education can be successful in providing basic competency skills for screening and knowledge of the resources that health care providers need for IPV intervention.
That certain attitudes, beliefs, and behaviors changed with time and others did not warrants closer examination. The statements "People are only victims if they choose to be," "When it comes to domestic violence victimization, it usually ‘takes two to tango,’" and "It is inappropriate to ask about IPV in the pediatric setting," for example, had fairly strong disagreement baseline scores (4.3, 4.1, and 4.3, respectively). That is, participants came to the course disagreeing with these statements and disagreement did not change significantly over time. This dispels the assumption that pediatric emergency health care providers are against screening or have negative attitudes toward screening for IPV. Certain behaviors (eg, "I have seen a parent in the past year with disturbing behavior and asked about IPV," "I have seen a parent in the past year with depression/anxiety and asked about IPV") showed no significant change from baseline. Others (eg, "I have seen an abused child in the past year and asked about IPV," "I have seen a parent with an injury and asked about IPV") showed change only after 6 months. These results are more difficult to interpret, but we believe that they may represent subtle differences in how the health care provider who works in a PED believes that IPV will present. It is possible that health care providers believe that IPV is more likely to be present when the visit involves child abuse or the parent has suspicious injuries, such as facial or forearm contusions.
The self-efficacy statement, "I feel confident that we are identifying as many victims of IPV as we can in my work setting," did not show change after training but showed significant change toward agreement at 6 months. This may be explained by the fact that our screening program was implemented in the PED after the training. A positive 6-month change after training and implementation is consistent with our belief that participants gained confidence with experience and practice in screening.
The IOM noted that the relationship between mandatory reporting requirements and education is unclear. In the protocol portion of our curriculum, students learned that Missouri and Kansas law does not mandate a report to child protective services for children who witness IPV. At all 3 measurement periods, participants as a group tended to agree with the statement, "Even if the child is not in immediate danger, I am mandated to report an instance of a child witnessing IPV to child protective services." A slight shift toward neutral was demonstrated immediately after training but did not persist at 6 months. This is understandable, because mandatory reporting of exposure to IPV is controversial among experts.26 Perhaps this finding serves to emphasize that many dilemmas remain concerning screening for IPV in a pediatric setting. On the basis of our results, the ethical obligation to protect the child is very strong among pediatric emergency care providers.
One other pediatric-focused IPV screening education program has been evaluated. Berger et al30 implemented a course in which residents and faculty attended an initial 30-minute didactic session, followed by a 90-minute teaching session 3 months later. The teaching session consisted of a 15-minute didactic, 12-minute videotape of testimony from IPV victims, and a 45-minute role-play session. As in our study, they used a 5-point Likert scale to assess changes in attitudes and beliefs at baseline and after the training. They found no changes in attitudes regarding whether respondents believed that it was their role as a pediatrician to ask about IPV, whether they felt comfortable discussing IPV, or whether they believed that they had adequate time to screen for IPV. In our study, we found that respondents' attitudes changed positively when compared with baseline for statements regarding adequate time to screen, feeling comfortable with asking about IPV, whether screening for IPV was appropriate in the pediatric setting, and whether it was part of pediatric emergency care. Changes for the first 2 statements persisted at the 6-month evaluation. Several factors could explain the discrepancy in findings between the 2 studies. These factors may relate to course content and/or design; may relate to method of implementation of the screening program; or may also reflect a difference in course participants, because our course included nurses and social workers in addition to physicians. A relatively small number of physicians precluded a reliable subanalysis of the physician-only group compared with the nonphysicians. The results of the course-satisfaction survey show that the majority of participants were positive about the training curriculum and would recommend it to colleagues.
Limitations
There are limitations to our study. Because a screening program in the PED was implemented after the training and before the 6-month follow-up, it is impossible to gauge the effect of the training alone on responses at the 6-month follow-up. It is likely that the sustained pro-screening attitudes and increased self-efficacy in intervening in IPV were influenced by putting the learned skills into practice soon after training.
The group size was small and prevented reliable subgroup comparisons. It was limited by the number of employees in the ED and that we chose to offer the training on a voluntary basis.
Because participants were not identifiable, it was impossible to match baseline, posttraining, and 6-month follow-up responses by participant. The entire group did not complete the 6-month survey, which might limit the significance of the responses. In addition, the 6-month follow-up period is short, and it is possible that the results will not persist long-term. The setting for this course was a PED; therefore, the observed changes may not occur in other settings.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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ACKNOWLEDGMENTS |
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We acknowledge Steve Simon, PhD, for statistical assistance and expertise.
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FOOTNOTES |
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Address correspondence to Jane F. Knapp, MD, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: jknapp{at}cmh.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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