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ED physician house staff response to training on domestic violence
Research ED physician house staff response to training on domestic violence A u t h o r s : F i l o m e n a F. V a r v a r o , RN, PhD, a n d S h a r y n O e s m o n d , RNC, BSN, MSN, P i t t s b u r g h , P e n n s y l v a n i a
Objective A b o u t one f o u r t h of p h y s i c i a n s r e p o r t h a v i n g r e c e i v e d t r a i n i n g on d o m e s t i c violence. The p u r p o s e of this s t u d y w a s to d e t e r m i n e t h e r e s p o n s e of t h e ED h o u s e staff to an e d u c a t i o n a l p r o g r a m on d o m e s tic v i o l e n c e a g a i n s t w o m e n . T h e r e s e a r c h q u e s t i o n s in this s t u d y w e r e as follows: (1) W h a t training topics did t h e h o u s e staff r a t e as m o s t i m p o r t a n t a n d r e l e v a n t to t h e i r p r a c t ic e ? (2) W h a t topics did t h e h o u s e staff r a t e as m o s t u s e f u l to t h e ir d a y - t o - d a y pr a c t i ce? (3) W h a t w e r e t h e h o u s e staff's a t t i t u d e s a nd beliefs b e f o r e training? (4) Did t h e m e t h o d of training on d o m e s t i c v i o l e n c e influence t h e h o u s e staff's a t t i t u d e s an d beliefs? (5) W h a t w e r e t h e h o u s e staff's p e r c e p t i o n s in t e r m s of sociodemogr a p h i c v a r i a b l e s ?
Methods An exploratory descriptive study with a three-group p r e t e s t an d p o s t t e s t d e s i g n w a s used. The s a m p l e c o n s i s t e d of 37 residents, interns, a n d m e d i c a l stud e n t s a s s i g n e d to their clinical rotation in t h e e mer g e n c y d e p a r t m e n t in a l a r g e u r b a n hospital t r a u m a center. The a g e r a n g e of t h e p a r t i c i p a n t s w a s 25 to 40 years. Th e i n s t r u m e n t s u s e d i n c l u d e d I m p o r t a n c e of Training Topics for Domestic Violence Questionnaire (ITTDVQ), U s e f u l n e s s of Training Topics for D o m e s t i c Violence Q u e s t i o n n a i r e (UTTDVQ), I n v e n t o r y of Beliefs A b o u t Wife B e a t i n g (IBWB), a n d t h e Self-Efficacy Scale for B a t t e r e d W o m e n Professional Version (SESFBW-PV).
Results Topics on d o m e s t i c violence a g a i n s t w o m e n t h a t t h e h o u s e staff r a t e d as m o s t important, relevant, a n d m o s t useful in their day-to-day p r a c t i c e w e r e a w a r e n e s s of t h e problem, referral as i n t e r v e n ti o n , docum e n t a t i o n of a b u s e , a n d r e f e r e n c e s / r e s o u r c e s . A t t i t u d e s a n d beliefs after training s u g g e s t e d an i n c r e a s e d (1) c o n f i d e n c e in t h e self-efficacy b e h a v iors of w o m e n w h o are a b u s e d by i n t i m a t e others, Filomena Varvaro is assistant professor, Acute/Tertiary Care, Nursing Department, University of Pittsburgh School of Nursing. Sharyn Gesmond is geriatric outreach emergency liaison, Psychiatric Center, McKeesport Hospital, McKeesport, Pennsylvania. For reprints, write Filomena E Varvaro, RN, PhD, 310 Kenyon Ave., Pittsburgh, PA 15229. Copyright © 1997 by the Emergency Nurses Association. 0099-1767/97 $5.00 + 0 18/1/77602
(2) n e e d for t h e a s s e s s m e n t , t r e a t m e n t , and referral for d o m e s t i c v i o l e n c e in w o m e n w h o e n t e r t h e emergency department with medical problems/ injuries, an d (3) belief t h a t help should b e g i v e n to w o m e n w h o are ab u sed . T h e r e w a s v e r y little variation in p e r c e p t i o n s of t h e h o u s e staff in t e r m s of age, gender, education, ethnic origin, or marital status.
Discussion Th e m aj o r conclusion of t h e s t u d y w a s t h a t t h e h o u s e staff h ad a positive r e s p o n s e to training on v i o l e n c e a g a i n s t w o m e n . Sixty-five p e r c e n t of t h e h o u s e staff h ad no p r e v i o u s training on d o m e s t i c violence. Implications for p r a c t i c e include c o n t i n u i n g e d u c a t i o n an d r e s e a r c h on d o m e s t i c v i o l e n c e training in t h e e m e r g e n c y d e p a r t m e n t . (J E m e r g Nurs 1997;23:17-22)
b o u t o n e fourth of e m e r g e n c y d e p a r t m e n t s report h a v i n g p r o v i d e d a t r a i n i n g s e s s i o n on d o m e s t i c v i o l e n c e for p h y s i c i a n s . 1 E v e n f e w e r e m e r g e n c y d e p a r t m e n t s (6%) h a v e p r o v i d e d r e s i d e n t s w i t h t r a i n i n g on v i o l e n c e a g a i n s t w o m e n , I, 2 Th er ef o r e t h e p u r p o s e of this s t u d y w a s to report t h e r e s p o n s e of t h e ED h o u s e staff (residents, interns, m e d i c a l s t u d e n t s ) to a t r a i n i n g p r o g r a m on d o m e s t i c v i o l e n c e a g a i n s t w o m e n . T h e s p e c i f i c a i m of this r e s e a r c h w a s to d e t e r m i n e t h e h o u s e staff's evaluation of t h e i m p o r t a n c e a n d u s e f u l n e s s of t h e t r a i n i n g p r o g r a m to their clinical p r a c t i c e , as well as to determ i n e w h e t h e r t h e t r a i n i n g i n f l u e n c e d their beliefs and attitudes toward domestic violence against women. P h y s i c i a n s h a v e h e s i t a t e d to identify, treat, a nd p r o v i d e referral for w o m e n w h o h a v e b e e n a b u s e d b y an i n t i m a t e other for a v a r i e t y of reasons, beliefs, a nd a t t i t u d e s . We b e l i e v e t h a t w h a t h a s n o t b e e n s t u d i e d e x t e n s i v e l y is t h e s y s t e m a t i c e v a l u a t i o n of t r a i n i n g p r o v i d e d p h y s i c i a n s on d o m e s t i c v i o l e n c e a g a i n s t w o m e n . T h u s t h e following r e s e a r c h q u e s t i o n s w e r e e x p l o r e d in this study: (1) W h a t t r a i n i n g t o p i c s on d o m e s t i c v i o l e n c e w e r e r a t e d by t h e h o u s e staff as m o s t i m p o r t a n t a n d r e l e v a n t to t h ei r clinical pract i c e ? (2) W h a t t r a i n i n g t o p i c s on d o m e s t i c v i o l e n c e w e r e r a t e d by h o u s e staff as m o s t useful in their day-
A
February 1997
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JOURNAL OF EMERGENCYNURSING/Varvaroand Gesmond
Table 2 Training topics on domestic violence a g a i n s t w o m e n rated as most important b y at least 50% of house staff in the e m e r g e n c y d e p a r t m e n t
Table 1 Training topics on v i o l e n c e a g a i n s t w o m e n provided for house staff in the e m e r g e n c y d e p a r t m e n t
Awareness of the problem of abuse Definition of abuse Ask patient directly about abuse Indicators of abuse Cycle of violence Cultural differences Assessment process: physical examination Assessment process: mental status examination Danger assessment Referral as intervention Documentation of abuse Simulated case Legal aspects References/resources
to-day clinical p r a c t i c e ? (3) W h a t w e r e the h o u s e staff's a t t i t u d e s a n d beliefs before t r a i n i n g ? (4) Did t h e m e t h o d of t r a i n i n g (lecture only, lecture plus p o c k e t t r a i n i n g m a n u a l ) on d o m e s t i c violence influe n c e the h o u s e staff's a t t i t u d e s a n d beliefs? (5) W h a t w e r e t h e h o u s e staff's p e r c e p t i o n s r e g a r d i n g s o c i o d e m o g r a p h i c variables?
Methods We u s e d a n exploratory descriptive m e t h o d w i t h a t h r e e - g r o u p p r e t e s t a n d p o s t t e s t d e s i g n to d e s c r i b e the r e s p o n s e of ED h o u s e staff on t r a i n i n g on d o m e s tic violence. A p p r o x i m a t e l y one third (n = 11) of t h e h o u s e staff r e c e i v e d t e s t i n g a n d no e d u c a t i o n , o n e third (n = 13) r e c e i v e d lecture only, a n d t h e final third (n = 13) r e c e i v e d lecture plus the p o c k e t - s i z e d traini n g m a n u a l 3 on d o m e s t i c violence. T h e groups w e r e n o n r a n d o m i z e d . The i n c l u s i o n criteria i n c l u d e d giving informed consent, and being a medical student, intern, or r e s i d e n t a s s i g n e d to medical~stirgical rotation in the e m e r g e n c y d e p a r t m e n t during-~ithe s t u d y period. T h e s a m p l e c o n s i s t e d of 37 r e s i d e n t s , interns, a n d m e d i c a l s t u d e n t s a s s i g n e d to their clinical rotation in the e m e r g e n c y d e p a r t m e n t in a large, u r b a n , level 1 t r a u m a center. The p h y s i c i a n s r a n g e d in age from 25 to 40 years. T h e m e a n age of t h e p a r t i c i p a n t s w a s 28 years (SD 2.28). The majority of t h e h o u s e staff w e r e m e n (60%) a n d w h i t e (76%). A p p r o x i m a t e l y o n e half (n = 20) of the p a r t i c i p a n t s w e r e married. After approval of t h e ED r e s e a r c h c o m m i t t e e a n d t h e i n t e r n a l r e v i e w board, a s c h e d u l e of the h o u s e staff rotation to t h e e m e r g e n c y d e p a r t m e n t w a s o b t a i n e d from the ED a d m i n i s t r a t i v e office. A traini n g s c h e d u l e w a s d e v e l o p e d so t h a t the p r e t e s t i n g
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Volume 23, Number 1
Training topics
%
Awareness of problem Documentation of abuse
92 76 67 67 67 60 60 58 52 50
References/resources
Danger assessment Referral as intervention Legal aspects
Assessment process: mental status examination Assessment process: physical examination Definition of abuse Ask patient directly
a n d t r a i n i n g o c c u r r e d d u r i n g a h o u s e staff m e m b e r ' s first 8 days of the ED rotation. A s c h e d u l e w a s determ i n e d to p e r m i t p o s t t e s t i n g to occur d u r i n g t h e last 2 w e e k s of the clinical rotation. On e a c h of t h e s c h e d u l e d t r a i n i n g days, t h e p r i n c i p a l i n v e s t i g a t o r or designee met with the attending physician in charge for the d a y to finalize h o u s e staff a t t e n d a n c e for the t r a i n i n g session. T h e t r a i n i n g on d o m e s t i c violence w a s b a s e d on the r e v i e w of the literature 2-14 a n d t h e first a u t h o r ' s 16 years of e x p e r i e n c e in d o m e s t i c v i o l e n c e counseling. T r a i n i n g topics were selected (Table 1). The t r a i n i n g w a s v a l i d a t e d by three p r e v i o u s lectures g i v e n to health professionals, i n c l u d i n g p h y s i c i a n s . T h e t r a i n i n g s e s s i o n s were held i n t h e c o n f e r e n c e room located in t h e e m e r g e n c y d e p a r t m e n t . T h e seco n d a u t h o r w a s the p r i m a r y t e a c h e r for the training. The first author w a s p r e s e n t at all classes. T h e t r a i n i n g s e s s i o n s w e r e i hour. T h e classroom t r a i n i n g format for t h e two groups (lecture a n d the lecture plus p o c k e t - s i z e d t r a i n i n g m a n u a l ) i n c l u d e d (1) the p r e t e s t i n g session, (2) t h e i n t r o d u c t i o n b y one of t h e a t t e n d i n g p h y s i c i a n s on the s c o p e of d o m e s t i c v i o l e n c e a n d t h e i m p o r t a n t n e e d to identify a n d treat w o m e n w h o are a b u s e d , (3) a 1-hour p r e s e n t a t i o n of c o n t e n t (Table 1), a n d (4) the p o s t t e s t i n g s e s s i o n 2 to 3 w e e k s after t h e i n s t r u c t i o n . The d a t a d e s c r i b e d in this article were collected d u r i n g a 3 - m o n t h period. We u s e d the following i n s t r u m e n t s for d a t a gathering: •
Importance
of Training
Topics for Domestic
(ITTDVQ), which m e a s u r e s the h o u s e staff's p e r c e i v e d r a t i n g of t h e overall i m p o r t a n c e of v a r i o u s t o p i c s of i n s t r u c t i o n on d o m e s t i c violence. Developed b y t h e first author, t h e scale is scored on a 7-point Likert scale from O = no opinion, 1 = little imporViolence
Questionnaire
Varvaro and Gesmond/jOURNALOF EMERGENCYNURSING
t a n c e to 6, i n d i c a t i n g e x t r e m e i m p o r t a n c e . This 17-item scale is s e l f - a d m i n i s t e r e d a n d t a k e s a b o u t 1 to 3 m i n u t e s to complete. A C r o n b a c h ' s alpha v a l u e of 0.88 w a s o b t a i n e d for t h e c u r r e n t sample. •
Usefulness
of Training
Topics
for Domestic
This scale w a s developed b y the first author to m e a sure t h e h o u s e staff's beliefs a b o u t t h e usefuln e s s of various t r a i n i n g topics p r e s e n t e d on d o m e s t i c violence to their daily practice. The UTTDVQ is scored on a 7-point Likert scale from 0 = n o opinion, 1 = little u s e f u l n e s s to 6 = e x t r e m e l y useful. T h e 1 5 - i t e m scale is selfa d m i n i s t e r e d a n d takes a b o u t 1 to 3 m i n u t e s . A C r o n b a c h ' s alpha value of 0.88 w a s o b t a i n e d for the scale. Violence
•
Inventory
Questionnaire
Of Beliefs
About
Wife
Beating
This scale m e a s u r e s the beliefs a n d a t t i t u d e s about the a b u s e of women. 15 The IBWB has 31 items a n d is self-administered. Scored on a 7-point Likert scale from strongly agree to strongly disagree, lower scores indicate that wife b e a t i n g is not justified a n d that w o m e n do not gain from beating. Higher scores indicate the offender should b e responsible, the offender should b e punished, a n d help should b e o b t a i n e d for w o m e n who are abused. Alpha Cronbach values on the subscales ranged from 0.62 to 0.90 for the s t u d y sample. Self-Efficacy
Scale
for
Battered
Women-
This is a p o p u l a t i o n - s p e c i f i c tool to m e a s u r e t h e h o u s e staff's p e r c e p t i o n of self-efficacy in b a t t e r e d w o m e n . 14 T h e SESFBW-PV h a s 12 i t e m s on a n analog scale in w h i c h 0 = very low self-efficacy, 50 = m o d e r a t e efficacy, a n d 100 = very h i g h selfefficacy. A C r o n b a c h alpha of 0.89 w a s o b t a i n e d on the professional v e r s i o n for t h e s t u d y sample. T h e i n s t r u m e n t is s e l f - a d m i n i s t e r e d a n d t a k e s a b o u t 3 to 5 m i n u t e s to complete. Professional
Version
IBWB variable
Time 1" Mean SD
Time 2 t Mean SD
Wife b e a t i n g justified$ Control Lecture Lecture plus
1.23 1.32 1.23
0.24 0.59 0.35
1.08 1.34 1.14
0.22 0.60 0.22
W i v e s g a i n from beating~ Control Lecture Lecture plus
1.38 1.61 1.46
0.44 0.34 0.47
1.24 1.45 1.79
0.30 0.37 1.79
Help should be given ~ Control Lecture Lecture plus
6.47 6.25 6.39
0.45 0,68 0.56
6.58 6.08 6.41
0,53 0.81 0.65
Offender should be punished ~ Control Lecture Lecture plus
5.24 4.93 5.31
1.19 0.80 1.39
5.51 4.83 5.71
0.76 0.93 1.14
Offender responsible ~ Control Lecture Lecture plus
5.53 5.09 5.47
1.26 0.89 1.11
5.89 4.97 5.97
0.81 0.70 0.89
(UTTDVQ).
(IBWB),
•
Table 3 H o u s e staff p r e t r a i n i n g and p o s t t r a i n i n g s c o r e s on I n v e n t o r y of Beliefs A b o u t Wife B e a t i n g for control, lecture, a n d lecture plus groups
(SESFBW-PV).
B e c a u s e of the small s a m p l e size, d e s c r i p t i v e statistics of p e r c e n t a g e s , ranges, m e a n s , a n d s t a n d a r d d e v i a t i o n s w e r e u s e d to analyze the p r e t e s t a n d p o s t t e s t i n g scores for the three g r o u p s a n d to determ i n e the h o u s e staff's p e r c e p t i o n s a c c o r d i n g to g e n der, age, e d u c a t i o n , e t h n i c origin, a n d marital status. Results
Topics on d o m e s t i c violence t r a i n i n g rated b y the h o u s e staff as m o s t i m p o r t a n t a n d r e l e v a n t to their clinical p r a c t i c e are listed in Table 2. In order of their importance/relevancy, t h e s e topics were as follows: (1) a w a r e n e s s of the problem of violence a g a i n s t w o m e n ,
The IBWB is scored on a scale of 1 to 7. *Pretraining time.
tPosttraining time. *Lower scores indicate "disagree to totally disagree" that wife beating is justified or that wives gain from beating. §Higher scores indicate "agree to strongly agree" that help should be given, offender should be punished, and t h e offender is responsible.
(2) d o c u m e n t a t i o n of abuse, (3) references/resources, (4) d a n g e r a s s e s s m e n t , a n d (5) referral as intervention. T h e topics rated as m o s t useful to t h e h o u s e staff's d a y - t o - d a y clinical practice, in order of usefulness, i n c l u d e d (1) g a i n i n g a w a r e n e s s of t h e p r o b l e m of d o m e s t i c v i o l e n c e a g a i n s t w o m e n , (2) a s k i n g p a t i e n t directly, (3) d i s c u s s i n g i n d i c a t o r s of a b u s e , (4) r e v i e w i n g t h e p h y s i c a l a s s e s s m e n t for b a t t e r e d w o m e n , (5) r e v i e w i n g criteria for d o c u m e n t a t i o n of a b u s e , (6) u s i n g referral as i n t e r v e n t i o n , p r o v i d i n g r e f e r e n c e s / r e s o u r c e s , a n d (7) h i g h l i g h t i n g of legal aspects. O n t h e IBWB scale, t h e h o u s e staff (in all groups) w e r e similar in their beliefs t h a t t h e r e w a s no justifi.cation for d o m e s t i c v i o l e n c e a g a i n s t w o m e n , t h a t w o m e n did n o t g a i n from b e a t i n g , a n d t h a t help
February 1997 19
JOURNAL Ot: EMERGENCY NURSING/Vaiwaro and Gesmond
Table 4 House staff scores before and after training on Perceived Self-Efficacy Behaviors of Abused Women as measured l e c t u r e a n d l e c t u r e p l u s g r o u p s o n S e l f - E f f i c a c y S c a l e for B a t t e r e d W o m e n - P r o f e s s i o n a l V e r s i o n * Variable on SESFBW-PV
Belief that
women
Pretest Mean
for
Posttest Mean SD
SD
can:
Ask RN/MD about abusive situation Lecture Lecture plus Tell RN/MD about abusive situation Lecture Lecture plus Call shelter hotline to ask for help Lecture Lecture plus Plan a h e a d for safety Lecture Lecture plus Do normal things t h e y normally enjoy Lecture Lecture plus Shrug off self-doubts Lecture Lecture plus Make plans for living alone without abusive relationship Lecture Lecture plus Can accept a b u s e not w o m a n ' s fault Lecture Lecture plus Make up mind about small c h a n g e s in her life Lecture Lecture plus Make up mind about large c h a n g e s in her life Lecture Lecture plus Carry out normal activities of daily living Lecture Lecture plus Say w h a t thinking/feeling without fear Lecture Lecture plus
58.85 37.36
19.39 21.85
64.04 51.19
11.99 19.95
68,46 57.10
16.05 24.73
66.90 53.24
15.88 20.54
62.70 59.76
18.07 22.65
69.43 64,02
16.80 20,66
47.55 59.49
27.22 23.26
46.15 62.39
21.45 21.73
31.58 24.79
26.77 14.18
45.56 36.67
24.82 14.32
29.25 25.72
16.20 16.60
35.00 31.28
14.15 14.70
52.54 48.11
18.66 17.45
45.66 58.30
17.57 22.84
53.28 40,68
23.66 9.80
50.29 56.41
17.59 20.47
66.29 70.34
19.14 17,25
63.75 65.83
20.81 22.06
44.76 59.31
21.93 22.05
47.00 55.82
17.21 17.73
63.46 74.53
25.14 13.92
58.09 63.51
27.04 17.26
37.84 30.61
20.48 16.14
39.84 45.48
18.11 23.41
On t h e SESFBW-PV, scores of 0 to 49 indicate-louver self-efficacy belief about b a t t e r e d women; 50 to 71 indicate m o d e r a t e self-efficacy, and scores of 72 a n d above incii'cat~e a higher self-efficacy.
s h o u l d b e g i v e n to w o m e n
who are abused. There
showed
an increase
was a strong belief the offender was responsible and
behaviors
should be punished
these
(Table 3). M e a n s c o r e s o n t h e
in a w a r e n e s s
of b a t t e r e d
groups
showed
of s e l f - e f f i c a c y
women.
Posttest
the
physicians
s c o r e s for had
an
IBWB w e r e s i m i l a r for b o t h m e n a n d w o m e n . W o m e n
increased belief that battered women
h a d a s l i g h t l y l o w e r m e a n for w i f e b e a t i n g is j u s t i f i e d a n d t h a t w o m e n g a i n from b e a t i n g . Also, w o m e n h a d
r e g i s t e r e d n u r s e , (2) call a s h e l t e r h o t l i n e t o a s k for
a slightly higher mean that help should be given. Men had a slightly higher mean score on the offender
h e l p , (3) s h r u g off s e l f - d o u b t s , (4) d o n o r m a l t h i n g s t h e y n o r m a l l y enjoy, a n d (5) e x p r e s s h o w t h e y t h i n k or
was responsible scale.
f e e l w i t h o u t fear. In a d d i t i o n , a f t e r t r a i n i n g , t h e p h y s i -
After training,
the
group
of h o u s e
staff who
r e c e i v e d t r a i n i n g b y l e c t u r e or l e c t u r e p l u s b o o k l e t
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Volume 23, N u m b e r 1
c o u l d : (1) a s k
a b o u t t h e i r a b u s i v e s i t u a t i o n w i t h t h e p h y s i c i a n or
c i a n s in t h e l e c t u r e plus g r o u p h a d
an increased
awareness
can
that the
abused
woman
p l a n for
Vm'varo and Gesmond/.JOURNALOf~"EMERGENCYNI_JRSING
safety, p l a n to live on her own, a n d that a b u s e w a s not the w o m a n ' s fault (Table 4). After training, the p h y s i c i a n s in the lecture only group s h o w e d a higher i n c r e a s e in the self-efficacy behaviors for b a t t e r e d w o m e n in a s k i n g the p h y s i c i a n or registered n u r s e a b o u t a b u s i v e situations, telling the n u r s e or physician a b o u t t h e a b u s i v e situation, calling the shelter hotline, d o i n g normal t h i n g s they enjoy, a n d shrugg i n g off self-doubts t h a n the h o u s e staff who received tire lecture plus t e a c h i n g strategy. Very little variation in t h e h o u s e staff's p e r c e p t i o n s on t h e self-efficacy b e h a v i o r s of b a t t e r e d w o m e n w a s associated with sociodemographic variables of gender, age, education, ethnic origin, or marital status. T h e m e a n average scores on the self-efficacy behaviors d e m o n s t r a t e d the h o u s e staff a p p r o a c h e d a moderate efficacy score of 47 to 59 (on a scale of 0 = very little efficacy to 100 = very high efficacy) across the sociodemographic variable. At posttesting, on average, slightly higher m e a n scores on the SESFBWPV were o b t a i n e d for house staff who were first- or second-year male medical s t u d e n t s y o u n g e r t h a n 30 years of age.
Discussion Both before a n d after t h e t r a i n i n g , h o u s e staff reflected a general a t t i t u d e of s y m p a t h y t o w a r d the b a t t e r e d w o m a n . Overall, the p a r t i c i p a n t s a g r e e d help should b e g i v e n to a b u s e d w o m e n . This m i g h t b e related to t h e m e d i a coverage a b o u t the d o m e s t i c violence problem. We believe t h e h o u s e staff's i n c r e a s e d scores in t h e self-efficacy of b a t t e r e d w o m e n after t r a i n i n g is related to the t e a c h i n g program. We b a s e this belief on the interest, concern, a n d w i l l i n g n e s s to learn displayed b y the h o u s e staff d u r i n g our t e a c h i n g sessions. Further research is n e e d e d to validate our belief. The p a t t e r n of i n c r e a s e d self-efficacy scores after t r a i n i n g b e t w e e n t h e lecture only a n d t h e lecture plus groups w a s interesting. Further research with a larger s a m p l e size is n e c e s s a r y to d e t e r m i n e w h a t effect, if any, the u s e of different t e a c h i n g strategies (such as lecture or lecture plus) would have on h o u s e staff's self-efficacy beliefs a b o u t b a t t e r e d w o m e n . O n e of t h e limitations of this r e s e a r c h is t h a t w e did n o t i n c l u d e e m e r g e n c y n u r s e s as p a r t i c i p a n t s a n d did n o t i n c l u d e clinical s u p e r v i s i o n for t h e h o u s e staff after t r a i n i n g on d o m e s t i c violence. T h e h o u s e staff offered in their e v a l u a t i v e c o m m e n t s their belief t h a t t h e a s s e s s m e n t , t r e a t m e n t , referral, a n d docum e n t a t i o n of care of w o m e n w i t h a m e d i c a l probl e m / i n j u r y as a result of a b u s e b y a n i n t i m a t e other is a l e a r n e d process, similar to c a r i n g for other p a t i e n t s who e n t e r t h e e m e r g e n c y d e p a r t m e n t .
A n o t h e r limitation of the s t u d y w a s the small s a m p l e size. The s t u d y n e e d s to b e r e p e a t e d with a larger r a n d o m i z e d sample. Also, the s t u d y w a s limited in that the t e a c h i n g h a d to b e s c h e d u l e d a r o u n d t h e h o u s e staff's a s s i g n e d r e s p o n s i b i l i t i e s in the e m e r g e n c y d e p a r t m e n t . In addition, w e did n o t a s s e s s w h e t h e r the h o u s e staff m a d e a n y c h a n g e s in their clinical p r a c t i c e after t e a c h i n g on d o m e s t i c violence. Further r e s e a r c h is r e c o m m e n d e d .
Conclusion F i n d i n g s from this s t u d y s u g g e s t t r a i n i n g on d o m e s tic violence for the e m e r g e n c y p h y s i c i a n should focus on the topics identified as most useful a n d m o s t import a n t to his or her day-to-day practice. These identified topics can b e p r e s e n t e d in class, a n d the other material m a y be distributed on the h o u s e staff's E-mail or m a self-instructional program or included in a small, pocket-sized instructional booklet, s u c h as u s e d in this s t u d y - - "What Every Health Professional Needs to Know A b o u t Domestic Violence. ''3 This pocket-sized booklet was evaluated as .a very effective t e a c h i n g t e c h n i q u e (90% to 99% effective) b y the majority of the r e s p o n d e n t s (78%) in the lecture plus group. The major c o n c l u s i o n of t h e s t u d y is t h a t the h o u s e staff h a d a positive r e s p o n s e to t r a i n i n g on vio l e n c e a g a i n s t w o m e n a n d e v a l u a t e d t h e c o n t e n t to b e i m p o r t a n t a n d useful i n their d a y - t o - d a y practice. This s t u d y u n d e r s c o r e s t h e n e e d for c o n t i n u i n g educ a t i o n for p h y s i c i a n s on d o m e s t i c violence. It is i m p o r t a n t to a s s e s s t h e a m o u n t of t r a i n i n g on d o m e s t i c v i o l e n c e for all h o u s e staff, especially as t h e y b e g i n their clinical rotation in t h e e m e r g e n c y d e p a r t m e n t . Sixty-five p e r c e n t of the h o u s e staff (55% of the w o m e n a n d 68% of t h e m e n ) h a d n o previous t r a i n i n g on d o m e s t i c violence. We r e c o m m e n d t h a t e d u c a t i o n on d o m e s t i c v i o l e n c e b e m a d e part of t h e h o u s e staff's o r i e n t a t i o n to t h e e m e r g e n c y department. F u r t h e r r e c o m m e n d a t i o n s i n c l u d e the following: (1) r e p e a t the s t u d y w i t h a larger sample, (2) provide t r a i n i n g w i t h clinical s u p e r v i s i o n for b o t h t h e emerg e n c y n u r s e s a n d m e d i c a l p e r s o n n e l on the identification, a s s e s s m e n t , a n d care of w o m e n w h o e n t e r t h e e m e r g e n c y d e p a r t m e n t as a result of h a v i n g sust a i n e d a b u s e from a n i n t i m a t e other, a n d (3) provide clinical s u p e r v i s i o n a n d f e e d b a c k as ED p e r s o n n e l identify, assess, a n d care for the w o m a n w h o has a n injury or m e d i c a l p r o b l e m s u s t a i n e d from a n i n t i m a t e other. T h e s e d a t a would g e n e r a t e valuable o u t c o m e m e a s u r e s to m a k e t h e d e t e r m i n a t i o n of a c t u a l c h a n g e s in t h e ED p r a c t i c e related to d o m e s t i c vio.lence a g a i n s t w o m e n .
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T h e a u t h o r s w i s h to a c k n o w l e d g e Jeffrey Coben, MD, a n d William Angeles, MD, for their a d m i n i s t r a t i v e support. References
1. Lee D, Letellier P, M c L o u g h l i n E, Salber P. California Hospital E m e r g e n c y D e p a r t m e n t s R e s p o n s e to D o m e s t i c V i o l e n c e S u r v e y Report-1993. S a n F r a n c i s c o : F a m i l y P r e v e n t i o n Fund, 1993. 2. Loring MT, Smith RW. Health care barriers and interventions for battered women. Public Health Rep 1994;109:328-37. 3. Varvaro FF, Weaver PL. W h a t every health professional n e e d s to know about domestic violence: identification, treatment, a n d referral for t h e victim. Pittsburgh: University of Pittsburgh, 1995. 4. Borkowski M, Murch M, Walker V. Marital v i o l e n c e ~ t h e c o m m u n i t y response. N e w York: Tavistock Publications, 1983. 5. Varvaro FF, Cotman PG. Domestic violence: a focus on t h e e m e r g e n c y room care of a b u s e d women. Pittsburgh: Women's Center a n d Shelter of Pittsburgh, 1986. 6. Morrison LJ. The b a t t e r i n g syndrome: a poor record of detection in t h e e m e r g e n c y department. J E m e r g N e d 1988;6:521-6. 7. Varvaro FE Treatment of the battered woman: effective r e s p o n s e of t h e e m e r g e n c y d e p a r t m e n t . ACEP N e w s 1989;11:8-9, 13.
8. J o i n t C o m m i s s i o n on A c c r e d i t a t i o n of H e a l t h c a r e Organizations. Accreditation m a n u a l for hospitals. Chicago: The Commission, 1992. 9. B o k u n e w i c z B, Copel LC. A t t i t u d e s of e m e r g e n c y n u r s e s before a n d after a 6 0 - m i n u t e e d u c a t i o n a l p r e s e n t a t i o n on p a r t n e r abuse. J E m e r g Nurs 1992;18:24-7. 10. H a m b e r g e r LK, S a u n d e r s DG, Hovey M. P r e v a l e n c e of d o m e s t i c violence in c o m m u n i t y p r a c t i c e a n d rate of physician inquiry. F a m N e d 1992;24:283-7. 11. C a m p b e l l JC, H u m p h r e y s J. Nursing care of survivors of family violence. St. Louis: Mosby-Year-Book, 1993. 12. Family Violence P r e v e n t i o n Fund. California Hospital E m e r g e n c y D e p a r t m e n t s R e s p o n s e to D o m e s t i c Violence: survey report. San Francisco: T h e Fund, 1993. 13. Varvaro FF, Lasko, DL. Physical a b u s e as c a u s e of injury in w o m e n : information for o r t h o p a e d i c nurses. Orthop Nurs 1993;12:37-41. 14. Varvaro FF, Palmer M. Promotion of a d a p t a t i o n in batt e r e d w o m e n : a self-efficacy approach. J A m A c a d Nurse Pract 1993;5:264-70. 15. S a u n d e r s DG, Lynch AB, Grayson M, Linz, D. T h e i n v e n t o r y of beliefs a b o u t wife b e a t i n g : t h e c o n s t r u c t i o n a n d initial validation of a m e a s u r e of beliefs a n d attitudes. Violence Vict 1987;2:39-57.
B O U N D VOLUMES AVAILABLE TO SUBSCRIBERS Bound v o l u m e s of t h e Journal of Emergency Nursing are available to subscribers (only) for t h e 1997 i s s u e s from t h e Publisher, at a cost of $38.00 for domestic, $46.01 for Canadian, and $43.00 for international subscribers for Volume 23 (February to December). Shipping c h a r g e s are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 60 days after publication of t h e last i s s u e in t h e volume. The binding is durable buckram with t h e journal n a m e , volume number, a n d t h e y e a r s t a m p e d in gold on t h e spine. P a y m e n t m u s t a c c o m p a n y all orders. Contact
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Volume 23, N u m b e r 1
are not available in place of a
Objective A b o u t one f o u r t h of p h y s i c i a n s r e p o r t h a v i n g r e c e i v e d t r a i n i n g on d o m e s t i c violence. The p u r p o s e of this s t u d y w a s to d e t e r m i n e t h e r e s p o n s e of t h e ED h o u s e staff to an e d u c a t i o n a l p r o g r a m on d o m e s tic v i o l e n c e a g a i n s t w o m e n . T h e r e s e a r c h q u e s t i o n s in this s t u d y w e r e as follows: (1) W h a t training topics did t h e h o u s e staff r a t e as m o s t i m p o r t a n t a n d r e l e v a n t to t h e i r p r a c t ic e ? (2) W h a t topics did t h e h o u s e staff r a t e as m o s t u s e f u l to t h e ir d a y - t o - d a y pr a c t i ce? (3) W h a t w e r e t h e h o u s e staff's a t t i t u d e s a nd beliefs b e f o r e training? (4) Did t h e m e t h o d of training on d o m e s t i c v i o l e n c e influence t h e h o u s e staff's a t t i t u d e s an d beliefs? (5) W h a t w e r e t h e h o u s e staff's p e r c e p t i o n s in t e r m s of sociodemogr a p h i c v a r i a b l e s ?
Methods An exploratory descriptive study with a three-group p r e t e s t an d p o s t t e s t d e s i g n w a s used. The s a m p l e c o n s i s t e d of 37 residents, interns, a n d m e d i c a l stud e n t s a s s i g n e d to their clinical rotation in t h e e mer g e n c y d e p a r t m e n t in a l a r g e u r b a n hospital t r a u m a center. The a g e r a n g e of t h e p a r t i c i p a n t s w a s 25 to 40 years. Th e i n s t r u m e n t s u s e d i n c l u d e d I m p o r t a n c e of Training Topics for Domestic Violence Questionnaire (ITTDVQ), U s e f u l n e s s of Training Topics for D o m e s t i c Violence Q u e s t i o n n a i r e (UTTDVQ), I n v e n t o r y of Beliefs A b o u t Wife B e a t i n g (IBWB), a n d t h e Self-Efficacy Scale for B a t t e r e d W o m e n Professional Version (SESFBW-PV).
Results Topics on d o m e s t i c violence a g a i n s t w o m e n t h a t t h e h o u s e staff r a t e d as m o s t important, relevant, a n d m o s t useful in their day-to-day p r a c t i c e w e r e a w a r e n e s s of t h e problem, referral as i n t e r v e n ti o n , docum e n t a t i o n of a b u s e , a n d r e f e r e n c e s / r e s o u r c e s . A t t i t u d e s a n d beliefs after training s u g g e s t e d an i n c r e a s e d (1) c o n f i d e n c e in t h e self-efficacy b e h a v iors of w o m e n w h o are a b u s e d by i n t i m a t e others, Filomena Varvaro is assistant professor, Acute/Tertiary Care, Nursing Department, University of Pittsburgh School of Nursing. Sharyn Gesmond is geriatric outreach emergency liaison, Psychiatric Center, McKeesport Hospital, McKeesport, Pennsylvania. For reprints, write Filomena E Varvaro, RN, PhD, 310 Kenyon Ave., Pittsburgh, PA 15229. Copyright © 1997 by the Emergency Nurses Association. 0099-1767/97 $5.00 + 0 18/1/77602
(2) n e e d for t h e a s s e s s m e n t , t r e a t m e n t , and referral for d o m e s t i c v i o l e n c e in w o m e n w h o e n t e r t h e emergency department with medical problems/ injuries, an d (3) belief t h a t help should b e g i v e n to w o m e n w h o are ab u sed . T h e r e w a s v e r y little variation in p e r c e p t i o n s of t h e h o u s e staff in t e r m s of age, gender, education, ethnic origin, or marital status.
Discussion Th e m aj o r conclusion of t h e s t u d y w a s t h a t t h e h o u s e staff h ad a positive r e s p o n s e to training on v i o l e n c e a g a i n s t w o m e n . Sixty-five p e r c e n t of t h e h o u s e staff h ad no p r e v i o u s training on d o m e s t i c violence. Implications for p r a c t i c e include c o n t i n u i n g e d u c a t i o n an d r e s e a r c h on d o m e s t i c v i o l e n c e training in t h e e m e r g e n c y d e p a r t m e n t . (J E m e r g Nurs 1997;23:17-22)
b o u t o n e fourth of e m e r g e n c y d e p a r t m e n t s report h a v i n g p r o v i d e d a t r a i n i n g s e s s i o n on d o m e s t i c v i o l e n c e for p h y s i c i a n s . 1 E v e n f e w e r e m e r g e n c y d e p a r t m e n t s (6%) h a v e p r o v i d e d r e s i d e n t s w i t h t r a i n i n g on v i o l e n c e a g a i n s t w o m e n , I, 2 Th er ef o r e t h e p u r p o s e of this s t u d y w a s to report t h e r e s p o n s e of t h e ED h o u s e staff (residents, interns, m e d i c a l s t u d e n t s ) to a t r a i n i n g p r o g r a m on d o m e s t i c v i o l e n c e a g a i n s t w o m e n . T h e s p e c i f i c a i m of this r e s e a r c h w a s to d e t e r m i n e t h e h o u s e staff's evaluation of t h e i m p o r t a n c e a n d u s e f u l n e s s of t h e t r a i n i n g p r o g r a m to their clinical p r a c t i c e , as well as to determ i n e w h e t h e r t h e t r a i n i n g i n f l u e n c e d their beliefs and attitudes toward domestic violence against women. P h y s i c i a n s h a v e h e s i t a t e d to identify, treat, a nd p r o v i d e referral for w o m e n w h o h a v e b e e n a b u s e d b y an i n t i m a t e other for a v a r i e t y of reasons, beliefs, a nd a t t i t u d e s . We b e l i e v e t h a t w h a t h a s n o t b e e n s t u d i e d e x t e n s i v e l y is t h e s y s t e m a t i c e v a l u a t i o n of t r a i n i n g p r o v i d e d p h y s i c i a n s on d o m e s t i c v i o l e n c e a g a i n s t w o m e n . T h u s t h e following r e s e a r c h q u e s t i o n s w e r e e x p l o r e d in this study: (1) W h a t t r a i n i n g t o p i c s on d o m e s t i c v i o l e n c e w e r e r a t e d by t h e h o u s e staff as m o s t i m p o r t a n t a n d r e l e v a n t to t h ei r clinical pract i c e ? (2) W h a t t r a i n i n g t o p i c s on d o m e s t i c v i o l e n c e w e r e r a t e d by h o u s e staff as m o s t useful in their day-
A
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Table 2 Training topics on domestic violence a g a i n s t w o m e n rated as most important b y at least 50% of house staff in the e m e r g e n c y d e p a r t m e n t
Table 1 Training topics on v i o l e n c e a g a i n s t w o m e n provided for house staff in the e m e r g e n c y d e p a r t m e n t
Awareness of the problem of abuse Definition of abuse Ask patient directly about abuse Indicators of abuse Cycle of violence Cultural differences Assessment process: physical examination Assessment process: mental status examination Danger assessment Referral as intervention Documentation of abuse Simulated case Legal aspects References/resources
to-day clinical p r a c t i c e ? (3) W h a t w e r e the h o u s e staff's a t t i t u d e s a n d beliefs before t r a i n i n g ? (4) Did t h e m e t h o d of t r a i n i n g (lecture only, lecture plus p o c k e t t r a i n i n g m a n u a l ) on d o m e s t i c violence influe n c e the h o u s e staff's a t t i t u d e s a n d beliefs? (5) W h a t w e r e t h e h o u s e staff's p e r c e p t i o n s r e g a r d i n g s o c i o d e m o g r a p h i c variables?
Methods We u s e d a n exploratory descriptive m e t h o d w i t h a t h r e e - g r o u p p r e t e s t a n d p o s t t e s t d e s i g n to d e s c r i b e the r e s p o n s e of ED h o u s e staff on t r a i n i n g on d o m e s tic violence. A p p r o x i m a t e l y one third (n = 11) of t h e h o u s e staff r e c e i v e d t e s t i n g a n d no e d u c a t i o n , o n e third (n = 13) r e c e i v e d lecture only, a n d t h e final third (n = 13) r e c e i v e d lecture plus the p o c k e t - s i z e d traini n g m a n u a l 3 on d o m e s t i c violence. T h e groups w e r e n o n r a n d o m i z e d . The i n c l u s i o n criteria i n c l u d e d giving informed consent, and being a medical student, intern, or r e s i d e n t a s s i g n e d to medical~stirgical rotation in the e m e r g e n c y d e p a r t m e n t during-~ithe s t u d y period. T h e s a m p l e c o n s i s t e d of 37 r e s i d e n t s , interns, a n d m e d i c a l s t u d e n t s a s s i g n e d to their clinical rotation in the e m e r g e n c y d e p a r t m e n t in a large, u r b a n , level 1 t r a u m a center. The p h y s i c i a n s r a n g e d in age from 25 to 40 years. T h e m e a n age of t h e p a r t i c i p a n t s w a s 28 years (SD 2.28). The majority of t h e h o u s e staff w e r e m e n (60%) a n d w h i t e (76%). A p p r o x i m a t e l y o n e half (n = 20) of the p a r t i c i p a n t s w e r e married. After approval of t h e ED r e s e a r c h c o m m i t t e e a n d t h e i n t e r n a l r e v i e w board, a s c h e d u l e of the h o u s e staff rotation to t h e e m e r g e n c y d e p a r t m e n t w a s o b t a i n e d from the ED a d m i n i s t r a t i v e office. A traini n g s c h e d u l e w a s d e v e l o p e d so t h a t the p r e t e s t i n g
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Training topics
%
Awareness of problem Documentation of abuse
92 76 67 67 67 60 60 58 52 50
References/resources
Danger assessment Referral as intervention Legal aspects
Assessment process: mental status examination Assessment process: physical examination Definition of abuse Ask patient directly
a n d t r a i n i n g o c c u r r e d d u r i n g a h o u s e staff m e m b e r ' s first 8 days of the ED rotation. A s c h e d u l e w a s determ i n e d to p e r m i t p o s t t e s t i n g to occur d u r i n g t h e last 2 w e e k s of the clinical rotation. On e a c h of t h e s c h e d u l e d t r a i n i n g days, t h e p r i n c i p a l i n v e s t i g a t o r or designee met with the attending physician in charge for the d a y to finalize h o u s e staff a t t e n d a n c e for the t r a i n i n g session. T h e t r a i n i n g on d o m e s t i c violence w a s b a s e d on the r e v i e w of the literature 2-14 a n d t h e first a u t h o r ' s 16 years of e x p e r i e n c e in d o m e s t i c v i o l e n c e counseling. T r a i n i n g topics were selected (Table 1). The t r a i n i n g w a s v a l i d a t e d by three p r e v i o u s lectures g i v e n to health professionals, i n c l u d i n g p h y s i c i a n s . T h e t r a i n i n g s e s s i o n s were held i n t h e c o n f e r e n c e room located in t h e e m e r g e n c y d e p a r t m e n t . T h e seco n d a u t h o r w a s the p r i m a r y t e a c h e r for the training. The first author w a s p r e s e n t at all classes. T h e t r a i n i n g s e s s i o n s w e r e i hour. T h e classroom t r a i n i n g format for t h e two groups (lecture a n d the lecture plus p o c k e t - s i z e d t r a i n i n g m a n u a l ) i n c l u d e d (1) the p r e t e s t i n g session, (2) t h e i n t r o d u c t i o n b y one of t h e a t t e n d i n g p h y s i c i a n s on the s c o p e of d o m e s t i c v i o l e n c e a n d t h e i m p o r t a n t n e e d to identify a n d treat w o m e n w h o are a b u s e d , (3) a 1-hour p r e s e n t a t i o n of c o n t e n t (Table 1), a n d (4) the p o s t t e s t i n g s e s s i o n 2 to 3 w e e k s after t h e i n s t r u c t i o n . The d a t a d e s c r i b e d in this article were collected d u r i n g a 3 - m o n t h period. We u s e d the following i n s t r u m e n t s for d a t a gathering: •
Importance
of Training
Topics for Domestic
(ITTDVQ), which m e a s u r e s the h o u s e staff's p e r c e i v e d r a t i n g of t h e overall i m p o r t a n c e of v a r i o u s t o p i c s of i n s t r u c t i o n on d o m e s t i c violence. Developed b y t h e first author, t h e scale is scored on a 7-point Likert scale from O = no opinion, 1 = little imporViolence
Questionnaire
Varvaro and Gesmond/jOURNALOF EMERGENCYNURSING
t a n c e to 6, i n d i c a t i n g e x t r e m e i m p o r t a n c e . This 17-item scale is s e l f - a d m i n i s t e r e d a n d t a k e s a b o u t 1 to 3 m i n u t e s to complete. A C r o n b a c h ' s alpha v a l u e of 0.88 w a s o b t a i n e d for t h e c u r r e n t sample. •
Usefulness
of Training
Topics
for Domestic
This scale w a s developed b y the first author to m e a sure t h e h o u s e staff's beliefs a b o u t t h e usefuln e s s of various t r a i n i n g topics p r e s e n t e d on d o m e s t i c violence to their daily practice. The UTTDVQ is scored on a 7-point Likert scale from 0 = n o opinion, 1 = little u s e f u l n e s s to 6 = e x t r e m e l y useful. T h e 1 5 - i t e m scale is selfa d m i n i s t e r e d a n d takes a b o u t 1 to 3 m i n u t e s . A C r o n b a c h ' s alpha value of 0.88 w a s o b t a i n e d for the scale. Violence
•
Inventory
Questionnaire
Of Beliefs
About
Wife
Beating
This scale m e a s u r e s the beliefs a n d a t t i t u d e s about the a b u s e of women. 15 The IBWB has 31 items a n d is self-administered. Scored on a 7-point Likert scale from strongly agree to strongly disagree, lower scores indicate that wife b e a t i n g is not justified a n d that w o m e n do not gain from beating. Higher scores indicate the offender should b e responsible, the offender should b e punished, a n d help should b e o b t a i n e d for w o m e n who are abused. Alpha Cronbach values on the subscales ranged from 0.62 to 0.90 for the s t u d y sample. Self-Efficacy
Scale
for
Battered
Women-
This is a p o p u l a t i o n - s p e c i f i c tool to m e a s u r e t h e h o u s e staff's p e r c e p t i o n of self-efficacy in b a t t e r e d w o m e n . 14 T h e SESFBW-PV h a s 12 i t e m s on a n analog scale in w h i c h 0 = very low self-efficacy, 50 = m o d e r a t e efficacy, a n d 100 = very h i g h selfefficacy. A C r o n b a c h alpha of 0.89 w a s o b t a i n e d on the professional v e r s i o n for t h e s t u d y sample. T h e i n s t r u m e n t is s e l f - a d m i n i s t e r e d a n d t a k e s a b o u t 3 to 5 m i n u t e s to complete. Professional
Version
IBWB variable
Time 1" Mean SD
Time 2 t Mean SD
Wife b e a t i n g justified$ Control Lecture Lecture plus
1.23 1.32 1.23
0.24 0.59 0.35
1.08 1.34 1.14
0.22 0.60 0.22
W i v e s g a i n from beating~ Control Lecture Lecture plus
1.38 1.61 1.46
0.44 0.34 0.47
1.24 1.45 1.79
0.30 0.37 1.79
Help should be given ~ Control Lecture Lecture plus
6.47 6.25 6.39
0.45 0,68 0.56
6.58 6.08 6.41
0,53 0.81 0.65
Offender should be punished ~ Control Lecture Lecture plus
5.24 4.93 5.31
1.19 0.80 1.39
5.51 4.83 5.71
0.76 0.93 1.14
Offender responsible ~ Control Lecture Lecture plus
5.53 5.09 5.47
1.26 0.89 1.11
5.89 4.97 5.97
0.81 0.70 0.89
(UTTDVQ).
(IBWB),
•
Table 3 H o u s e staff p r e t r a i n i n g and p o s t t r a i n i n g s c o r e s on I n v e n t o r y of Beliefs A b o u t Wife B e a t i n g for control, lecture, a n d lecture plus groups
(SESFBW-PV).
B e c a u s e of the small s a m p l e size, d e s c r i p t i v e statistics of p e r c e n t a g e s , ranges, m e a n s , a n d s t a n d a r d d e v i a t i o n s w e r e u s e d to analyze the p r e t e s t a n d p o s t t e s t i n g scores for the three g r o u p s a n d to determ i n e the h o u s e staff's p e r c e p t i o n s a c c o r d i n g to g e n der, age, e d u c a t i o n , e t h n i c origin, a n d marital status. Results
Topics on d o m e s t i c violence t r a i n i n g rated b y the h o u s e staff as m o s t i m p o r t a n t a n d r e l e v a n t to their clinical p r a c t i c e are listed in Table 2. In order of their importance/relevancy, t h e s e topics were as follows: (1) a w a r e n e s s of the problem of violence a g a i n s t w o m e n ,
The IBWB is scored on a scale of 1 to 7. *Pretraining time.
tPosttraining time. *Lower scores indicate "disagree to totally disagree" that wife beating is justified or that wives gain from beating. §Higher scores indicate "agree to strongly agree" that help should be given, offender should be punished, and t h e offender is responsible.
(2) d o c u m e n t a t i o n of abuse, (3) references/resources, (4) d a n g e r a s s e s s m e n t , a n d (5) referral as intervention. T h e topics rated as m o s t useful to t h e h o u s e staff's d a y - t o - d a y clinical practice, in order of usefulness, i n c l u d e d (1) g a i n i n g a w a r e n e s s of t h e p r o b l e m of d o m e s t i c v i o l e n c e a g a i n s t w o m e n , (2) a s k i n g p a t i e n t directly, (3) d i s c u s s i n g i n d i c a t o r s of a b u s e , (4) r e v i e w i n g t h e p h y s i c a l a s s e s s m e n t for b a t t e r e d w o m e n , (5) r e v i e w i n g criteria for d o c u m e n t a t i o n of a b u s e , (6) u s i n g referral as i n t e r v e n t i o n , p r o v i d i n g r e f e r e n c e s / r e s o u r c e s , a n d (7) h i g h l i g h t i n g of legal aspects. O n t h e IBWB scale, t h e h o u s e staff (in all groups) w e r e similar in their beliefs t h a t t h e r e w a s no justifi.cation for d o m e s t i c v i o l e n c e a g a i n s t w o m e n , t h a t w o m e n did n o t g a i n from b e a t i n g , a n d t h a t help
February 1997 19
JOURNAL Ot: EMERGENCY NURSING/Vaiwaro and Gesmond
Table 4 House staff scores before and after training on Perceived Self-Efficacy Behaviors of Abused Women as measured l e c t u r e a n d l e c t u r e p l u s g r o u p s o n S e l f - E f f i c a c y S c a l e for B a t t e r e d W o m e n - P r o f e s s i o n a l V e r s i o n * Variable on SESFBW-PV
Belief that
women
Pretest Mean
for
Posttest Mean SD
SD
can:
Ask RN/MD about abusive situation Lecture Lecture plus Tell RN/MD about abusive situation Lecture Lecture plus Call shelter hotline to ask for help Lecture Lecture plus Plan a h e a d for safety Lecture Lecture plus Do normal things t h e y normally enjoy Lecture Lecture plus Shrug off self-doubts Lecture Lecture plus Make plans for living alone without abusive relationship Lecture Lecture plus Can accept a b u s e not w o m a n ' s fault Lecture Lecture plus Make up mind about small c h a n g e s in her life Lecture Lecture plus Make up mind about large c h a n g e s in her life Lecture Lecture plus Carry out normal activities of daily living Lecture Lecture plus Say w h a t thinking/feeling without fear Lecture Lecture plus
58.85 37.36
19.39 21.85
64.04 51.19
11.99 19.95
68,46 57.10
16.05 24.73
66.90 53.24
15.88 20.54
62.70 59.76
18.07 22.65
69.43 64,02
16.80 20,66
47.55 59.49
27.22 23.26
46.15 62.39
21.45 21.73
31.58 24.79
26.77 14.18
45.56 36.67
24.82 14.32
29.25 25.72
16.20 16.60
35.00 31.28
14.15 14.70
52.54 48.11
18.66 17.45
45.66 58.30
17.57 22.84
53.28 40,68
23.66 9.80
50.29 56.41
17.59 20.47
66.29 70.34
19.14 17,25
63.75 65.83
20.81 22.06
44.76 59.31
21.93 22.05
47.00 55.82
17.21 17.73
63.46 74.53
25.14 13.92
58.09 63.51
27.04 17.26
37.84 30.61
20.48 16.14
39.84 45.48
18.11 23.41
On t h e SESFBW-PV, scores of 0 to 49 indicate-louver self-efficacy belief about b a t t e r e d women; 50 to 71 indicate m o d e r a t e self-efficacy, and scores of 72 a n d above incii'cat~e a higher self-efficacy.
s h o u l d b e g i v e n to w o m e n
who are abused. There
showed
an increase
was a strong belief the offender was responsible and
behaviors
should be punished
these
(Table 3). M e a n s c o r e s o n t h e
in a w a r e n e s s
of b a t t e r e d
groups
showed
of s e l f - e f f i c a c y
women.
Posttest
the
physicians
s c o r e s for had
an
IBWB w e r e s i m i l a r for b o t h m e n a n d w o m e n . W o m e n
increased belief that battered women
h a d a s l i g h t l y l o w e r m e a n for w i f e b e a t i n g is j u s t i f i e d a n d t h a t w o m e n g a i n from b e a t i n g . Also, w o m e n h a d
r e g i s t e r e d n u r s e , (2) call a s h e l t e r h o t l i n e t o a s k for
a slightly higher mean that help should be given. Men had a slightly higher mean score on the offender
h e l p , (3) s h r u g off s e l f - d o u b t s , (4) d o n o r m a l t h i n g s t h e y n o r m a l l y enjoy, a n d (5) e x p r e s s h o w t h e y t h i n k or
was responsible scale.
f e e l w i t h o u t fear. In a d d i t i o n , a f t e r t r a i n i n g , t h e p h y s i -
After training,
the
group
of h o u s e
staff who
r e c e i v e d t r a i n i n g b y l e c t u r e or l e c t u r e p l u s b o o k l e t
20
Volume 23, N u m b e r 1
c o u l d : (1) a s k
a b o u t t h e i r a b u s i v e s i t u a t i o n w i t h t h e p h y s i c i a n or
c i a n s in t h e l e c t u r e plus g r o u p h a d
an increased
awareness
can
that the
abused
woman
p l a n for
Vm'varo and Gesmond/.JOURNALOf~"EMERGENCYNI_JRSING
safety, p l a n to live on her own, a n d that a b u s e w a s not the w o m a n ' s fault (Table 4). After training, the p h y s i c i a n s in the lecture only group s h o w e d a higher i n c r e a s e in the self-efficacy behaviors for b a t t e r e d w o m e n in a s k i n g the p h y s i c i a n or registered n u r s e a b o u t a b u s i v e situations, telling the n u r s e or physician a b o u t t h e a b u s i v e situation, calling the shelter hotline, d o i n g normal t h i n g s they enjoy, a n d shrugg i n g off self-doubts t h a n the h o u s e staff who received tire lecture plus t e a c h i n g strategy. Very little variation in t h e h o u s e staff's p e r c e p t i o n s on t h e self-efficacy b e h a v i o r s of b a t t e r e d w o m e n w a s associated with sociodemographic variables of gender, age, education, ethnic origin, or marital status. T h e m e a n average scores on the self-efficacy behaviors d e m o n s t r a t e d the h o u s e staff a p p r o a c h e d a moderate efficacy score of 47 to 59 (on a scale of 0 = very little efficacy to 100 = very high efficacy) across the sociodemographic variable. At posttesting, on average, slightly higher m e a n scores on the SESFBWPV were o b t a i n e d for house staff who were first- or second-year male medical s t u d e n t s y o u n g e r t h a n 30 years of age.
Discussion Both before a n d after t h e t r a i n i n g , h o u s e staff reflected a general a t t i t u d e of s y m p a t h y t o w a r d the b a t t e r e d w o m a n . Overall, the p a r t i c i p a n t s a g r e e d help should b e g i v e n to a b u s e d w o m e n . This m i g h t b e related to t h e m e d i a coverage a b o u t the d o m e s t i c violence problem. We believe t h e h o u s e staff's i n c r e a s e d scores in t h e self-efficacy of b a t t e r e d w o m e n after t r a i n i n g is related to the t e a c h i n g program. We b a s e this belief on the interest, concern, a n d w i l l i n g n e s s to learn displayed b y the h o u s e staff d u r i n g our t e a c h i n g sessions. Further research is n e e d e d to validate our belief. The p a t t e r n of i n c r e a s e d self-efficacy scores after t r a i n i n g b e t w e e n t h e lecture only a n d t h e lecture plus groups w a s interesting. Further research with a larger s a m p l e size is n e c e s s a r y to d e t e r m i n e w h a t effect, if any, the u s e of different t e a c h i n g strategies (such as lecture or lecture plus) would have on h o u s e staff's self-efficacy beliefs a b o u t b a t t e r e d w o m e n . O n e of t h e limitations of this r e s e a r c h is t h a t w e did n o t i n c l u d e e m e r g e n c y n u r s e s as p a r t i c i p a n t s a n d did n o t i n c l u d e clinical s u p e r v i s i o n for t h e h o u s e staff after t r a i n i n g on d o m e s t i c violence. T h e h o u s e staff offered in their e v a l u a t i v e c o m m e n t s their belief t h a t t h e a s s e s s m e n t , t r e a t m e n t , referral, a n d docum e n t a t i o n of care of w o m e n w i t h a m e d i c a l probl e m / i n j u r y as a result of a b u s e b y a n i n t i m a t e other is a l e a r n e d process, similar to c a r i n g for other p a t i e n t s who e n t e r t h e e m e r g e n c y d e p a r t m e n t .
A n o t h e r limitation of the s t u d y w a s the small s a m p l e size. The s t u d y n e e d s to b e r e p e a t e d with a larger r a n d o m i z e d sample. Also, the s t u d y w a s limited in that the t e a c h i n g h a d to b e s c h e d u l e d a r o u n d t h e h o u s e staff's a s s i g n e d r e s p o n s i b i l i t i e s in the e m e r g e n c y d e p a r t m e n t . In addition, w e did n o t a s s e s s w h e t h e r the h o u s e staff m a d e a n y c h a n g e s in their clinical p r a c t i c e after t e a c h i n g on d o m e s t i c violence. Further r e s e a r c h is r e c o m m e n d e d .
Conclusion F i n d i n g s from this s t u d y s u g g e s t t r a i n i n g on d o m e s tic violence for the e m e r g e n c y p h y s i c i a n should focus on the topics identified as most useful a n d m o s t import a n t to his or her day-to-day practice. These identified topics can b e p r e s e n t e d in class, a n d the other material m a y be distributed on the h o u s e staff's E-mail or m a self-instructional program or included in a small, pocket-sized instructional booklet, s u c h as u s e d in this s t u d y - - "What Every Health Professional Needs to Know A b o u t Domestic Violence. ''3 This pocket-sized booklet was evaluated as .a very effective t e a c h i n g t e c h n i q u e (90% to 99% effective) b y the majority of the r e s p o n d e n t s (78%) in the lecture plus group. The major c o n c l u s i o n of t h e s t u d y is t h a t the h o u s e staff h a d a positive r e s p o n s e to t r a i n i n g on vio l e n c e a g a i n s t w o m e n a n d e v a l u a t e d t h e c o n t e n t to b e i m p o r t a n t a n d useful i n their d a y - t o - d a y practice. This s t u d y u n d e r s c o r e s t h e n e e d for c o n t i n u i n g educ a t i o n for p h y s i c i a n s on d o m e s t i c violence. It is i m p o r t a n t to a s s e s s t h e a m o u n t of t r a i n i n g on d o m e s t i c v i o l e n c e for all h o u s e staff, especially as t h e y b e g i n their clinical rotation in t h e e m e r g e n c y d e p a r t m e n t . Sixty-five p e r c e n t of the h o u s e staff (55% of the w o m e n a n d 68% of t h e m e n ) h a d n o previous t r a i n i n g on d o m e s t i c violence. We r e c o m m e n d t h a t e d u c a t i o n on d o m e s t i c v i o l e n c e b e m a d e part of t h e h o u s e staff's o r i e n t a t i o n to t h e e m e r g e n c y department. F u r t h e r r e c o m m e n d a t i o n s i n c l u d e the following: (1) r e p e a t the s t u d y w i t h a larger sample, (2) provide t r a i n i n g w i t h clinical s u p e r v i s i o n for b o t h t h e emerg e n c y n u r s e s a n d m e d i c a l p e r s o n n e l on the identification, a s s e s s m e n t , a n d care of w o m e n w h o e n t e r t h e e m e r g e n c y d e p a r t m e n t as a result of h a v i n g sust a i n e d a b u s e from a n i n t i m a t e other, a n d (3) provide clinical s u p e r v i s i o n a n d f e e d b a c k as ED p e r s o n n e l identify, assess, a n d care for the w o m a n w h o has a n injury or m e d i c a l p r o b l e m s u s t a i n e d from a n i n t i m a t e other. T h e s e d a t a would g e n e r a t e valuable o u t c o m e m e a s u r e s to m a k e t h e d e t e r m i n a t i o n of a c t u a l c h a n g e s in t h e ED p r a c t i c e related to d o m e s t i c vio.lence a g a i n s t w o m e n .
February 1997 21
JOURNAL OF EMERGENCY NURSING/Valwaro and Gesmond
T h e a u t h o r s w i s h to a c k n o w l e d g e Jeffrey Coben, MD, a n d William Angeles, MD, for their a d m i n i s t r a t i v e support. References
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8. J o i n t C o m m i s s i o n on A c c r e d i t a t i o n of H e a l t h c a r e Organizations. Accreditation m a n u a l for hospitals. Chicago: The Commission, 1992. 9. B o k u n e w i c z B, Copel LC. A t t i t u d e s of e m e r g e n c y n u r s e s before a n d after a 6 0 - m i n u t e e d u c a t i o n a l p r e s e n t a t i o n on p a r t n e r abuse. J E m e r g Nurs 1992;18:24-7. 10. H a m b e r g e r LK, S a u n d e r s DG, Hovey M. P r e v a l e n c e of d o m e s t i c violence in c o m m u n i t y p r a c t i c e a n d rate of physician inquiry. F a m N e d 1992;24:283-7. 11. C a m p b e l l JC, H u m p h r e y s J. Nursing care of survivors of family violence. St. Louis: Mosby-Year-Book, 1993. 12. Family Violence P r e v e n t i o n Fund. California Hospital E m e r g e n c y D e p a r t m e n t s R e s p o n s e to D o m e s t i c Violence: survey report. San Francisco: T h e Fund, 1993. 13. Varvaro FF, Lasko, DL. Physical a b u s e as c a u s e of injury in w o m e n : information for o r t h o p a e d i c nurses. Orthop Nurs 1993;12:37-41. 14. Varvaro FF, Palmer M. Promotion of a d a p t a t i o n in batt e r e d w o m e n : a self-efficacy approach. J A m A c a d Nurse Pract 1993;5:264-70. 15. S a u n d e r s DG, Lynch AB, Grayson M, Linz, D. T h e i n v e n t o r y of beliefs a b o u t wife b e a t i n g : t h e c o n s t r u c t i o n a n d initial validation of a m e a s u r e of beliefs a n d attitudes. Violence Vict 1987;2:39-57.
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