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System issues - Chapter 21

Intimate partner abuse and violence: Education and training for healthcare professionals

‘A trained and ready health professional is motivated to make a difference, knows how to ask and respond to patients who are experiencing IPAV, feels well supported in their work environment, and has adequate clinical resources to assist and encourage their work’

Key messages

  • Intimate partner abuse and violence (IPAV) education and training can improve healthcare professionals’ IPAV knowledge, attitudes and beliefs, as well as their clinical readiness to respond to partner violence.1
  • It is unclear which IPAV training methods, content and dose produce the best learning and patient outcomes.1
  • One-off episodes of IPAV education are not enough for consistent or sustained behaviour change.2 Clinician capacity-building to complete IPAV work is more likely to occur using a comprehensive whole-of-practice, systems approach.3
  • Experiential learning activities, like interactive simulated role-play and relevant clinical case studies, may produce better learning outcomes than traditional didactic methods.4,5
    • IPAV education and training content should include best practice methods regarding:6,7
    • when and how to safely ask about IPAV
    • ways to provide an empathic response (eg LIVES – Listen closely, Inquire about needs, Validate her experience, Ensure safety and Support)
    • risk assessment methods
    • safety planning
    • documentation and referral options.
  • Impacts on and the safety of children must be covered in IPAV training, along with provider legal obligations. Content inclusive of diverse populations can help encourage an equity informed approach to practice.6–8
All healthcare professionals should be offered IPAV training, as it improves provider knowledge, attitudes and perceived readiness to engage in IPAV inquiry and care with patients.1
(Strong recommendation: low certainty of evidence)
IPAV training content should include routine inquiry about IPAV (for at-risk patients eg antenatal, mental health), including inquiries about children’s safety and wellbeing, along with basic first-line response (LIVES) to disclosures. Other content includes case documentation, legal requirements, and referral methods and options.6,7
(Practice point, Consensus of experts)
IPAV curricula should be integrated into healthcare provider undergraduate and postgraduate education and delivered to existing, qualified providers as continuing professional development on an ongoing (eg annual) basis.2
(Practice point, Consensus of experts)
Interactive training methods may include practice of IPAV communication/clinical skills through simulated role-play, supported through clinical resources, supervision and mentorship 1,4, 5
(Practice point, Consensus of experts)
Training content to enhance provider readiness should include methods to foster provider commitment, adopting an advocacy approach, developing trusting relationships and team collaboration.9
(Practice point, Consensus of experts)

This chapter provides an overview of IPAV healthcare provider education and training, and outlines the training content, methods and support required for enhancing knowledge, attitudes and behaviours regarding IPAV. It may be used as a resource to guide continuous professional development and improve educational and skill development for care of patients experiencing IPAV.

IPAV is the largest contributor to morbidity and mortality for young women.10 It is associated with poor physical/mental health, developmental and behavioural issues in children, child abuse and intergenerational trauma.11,12

Healthcare providers have a key role in addressing this public health problem, through early identification and supportive care of all family members exposed to IPAV. Therefore, effectively training healthcare providers is one part of the solution to improving the health system response to IPAV.

However, because the health effects of IPAV are poorly recognised, many healthcare providers have had no or very limited undergraduate/postgraduate or professional development in responding to or managing IPAV.13,14

Some providers avoid engaging with patients experiencing IPAV because of lack of time to discuss issues, poor acknowledgement of patient circumstances and/or to avoid complex consultations and disclosures they do not know how to manage.15 Other individual and environmental barriers, like language/cultural differences, partner presence and lack of privacy and resources, can affect provider behaviour to engage in IPAV work.16

Many providers have poor knowledge of IPAV, feel unprepared and lack confidence in asking about IPAV in clinical practice.17–19 IPAV training and education can overcome some of these barriers and lead to improved care and outcomes for victims/survivors. Embracing a reflective practice approach that includes monitoring of clients experiencing IPAV and using feedback from services can inform and enhance future clinical practice.2

Failure to provide adequate healthcare provider IPAV education and training can leave victims/survivors feeling judged, isolated and potentially at further risk of violence.20 An empathic and supportive response from a well-trained healthcare provider can act as a catalyst for patients, motivating them to make changes in their lives.21 Inquiry from a provider who is committed and ready to address IPAV is the first step towards helping patients.9

A meta-synthesis of 41 qualitative studies exploring healthcare provider views (n = 1744) on what enhances their readiness to address domestic violence and abuse found that training embedded within a supportive healthcare system, along with provider commitment, adopting an advocacy approach, trust and team collaboration (the CATCH model, refer to Figure 21.1), all facilitate healthcare provider readiness to practise IPAV work.9

Figure 21.1. The CATCH of model of health practitioner readiness to address intimate partner violence<sup>9</sup>

Figure 21.1. The CATCH of model of health practitioner readiness to address intimate partner violence9

Source: Hegarty K, McKibbin G, Hameed M, et al. Health practitioners' readiness to address domestic violence and abuse: A qualitative meta-synthesis. PLoS One 2020;15:e0234067.

Although there is a lack of high-quality evidence regarding the effect of healthcare practitioner training on women’s experiences of care, there is some data demonstrating that training and education can have a positive impact on practitioner knowledge, attitudes and readiness to respond to IPAV.

Evidence from several systematic reviews,1,5,22–24 including a Cochrane review, indicate that healthcare provider IPAV training can enhance IPAV knowledge, attitudes and preparedness to undertake IPAV work. However, the Cochrane review findings show that the evidence quality is low and the sustained effect of these outcomes beyond 12 months post-training is unknown.1

Furthermore, training alone has not been clearly shown to change clinician behaviour or clinical practice (eg safety planning, improved documentation of cases or referrals).1,22 In the Cochrane review, there was no clear improvement for women in outcomes (eg mental health or experience of IPAV) post provider training; however, no studies reported adverse effects from training interventions (for providers or women).1

There is inadequate evidence to determine the most effective type of IPAV training method, duration, intensity and content.1 However, the little existing evidence suggests that educational methods that use problem-based, experiential and interactive approaches can lead to improved practice application.4,5

This includes:

  • group discussion
  • simulated role-play/patients
  • online resources such as videos and case studies
  • clinical placements
  • peer-facilitated training.

There is also some evidence to suggest that longer, more practical training sessions are more effective than short interventions.5,23

In 2019, the World Health Organization (WHO) released a ‘violence against women’ competency-based training curriculum that aims to guide health/practice managers,25 educators and providers.7 According to the WHO, successful healthcare provider education and training programs:

  • adopt a consistent approach
  • have a firm theoretical framework
  • ensure interactive and person-centred methods are used
  • are programs of longer duration.

WHO training objectives include:

  • Demonstrate awareness of violence against women as a public health problem
  • Develop helpful responsive behaviours to victims/survivors
  • Demonstrate skill development in response to women victims/survivors
  • Identify and use resources for victims/survivors and self

The WHO curriculum is flexible and can be delivered over two or more continuous days. It covers 13 topics and 10 core competencies. These competencies are:7

  • Violence against women as a health issue
  • Survivor experiences and how practitioner attitudes impact on care provided
  • The health system response to violence against women
  • Practitioner–survivor communication skills
  • Identification of patients experiencing violence
  • LIVES (Listen, Inquire, Validate, Ensure safety, Support ) first-line support
  • Local referral pathways and understanding the legal and policy context
  • Clinical and forensic care for survivors of sexual violence
  • Documentation
  • Health professional self-care

This curriculum is delivered using adult learning principles. This approach actively engages the participant learner, rather than relying only on lectures or more traditional, didactic methods. Learning is facilitated through ‘case studies, guided discussions, participatory reflection exercises, videos and readings. This process supports critical reflection, emotional engagement, skills development and the ability to put knowledge into practice’.7 Regular sessions (eg annually) can help consolidate learning, update provider IPAV knowledge and skills, and sustain best practice.

A trauma-informed care framework is useful to embed in IPAV training, particularly as it is recommended for responding to IPAV including sexual violence.8 The framework centralises psychological and physical safety by acknowledging and incorporating the various and complex needs of victims/survivors. To do this, there is attention to discretion, autonomy, connection, partnerships and reconstructing a perception of control.8

A trauma-informed care lens suggests that IPAV education and training should include a focus on vicarious trauma, as healthcare providers can be exposed to traumatic storytelling when responding to IPAV.8 Refer to the chapters on trauma informed care and on health professional self-care.

Educators must be sensitive to the possibility that health professionals may themselves have experienced IPAV. Recent Australian evidence indicates that one in 10 hospital-based practitioners have lived experience of IPAV,26 are more likely to attend IPAV education, and provide a more comprehensive and sensitive response to patients.27

During education sessions, opportunities for reflection and emotional support should be made available to participants, with an emphasis on management of personal experiences, supportive resources and self-care.

  • What are the potential individual and structural barriers you experience in relation to your ongoing IPAV professional development?
  • What can you do to address these barriers?
  • List your own learning needs for best practice identification and response to patients experiencing IPAV.
  • What self-care activities can you undertake to prevent vicarious/cumulative trauma?

A trained and ready health professional is motivated to make a difference, knows how to ask and respond to patients who are experiencing IPAV, feels well supported in their work environment, and has adequate clinical resources to assist and encourage their work.9

IPAV education and training suppliers

Clinical resources

Curricula

Evidence

Violence against women research

  1. Kalra N, Hooker L, Reisenhofer S, et al. Training healthcare providers to respond to intimate partner violence against women. Cochrane Database Syst Rev 2021;5:CD012423.
  2. García-Moreno C, Hegarty K, d'Oliveira AFL, et al. The health-systems response to violence against women. Lancet 2015;385:1567–79.
  3. McCaw B, Berman WH, Syme SL, et al. Beyond screening for domestic violence: A systems model approach in a managed care setting. Am J Prev Med 2001;21:170–76.
  4. Kolb DA. Experiential learning: Experience as the source of learning and development. 2nd edition. New Jersey: Pearson Education, 2015.
  5. Sammut D, Kuruppu J, Hegarty K, et al. Which violence against women educational strategies are effective for prequalifying health-care students? A systematic review. Trauma Violence Abuse 2019;22:339–58.
  6. World Health Organization. Health care for women subjected to intimate partner violence or sexual violence: A clinical handbook. Geneva: WHO, 2014.
  7. World Health Organization. Caring for women subjected to violence: A WHO curriculum for training health-care providers. Geneva: WHO, 2019.
  8. Browne AJ, Varcoe C, Ford-Gilboe M, et al. EQUIP Healthcare: An overview of a multi-component intervention to enhance equity-oriented care in primary health care settings. Int J Equity Health 2015;14:152.
  9. Hegarty K, McKibbin G, Hameed M, et al. Health practitioners' readiness to address domestic violence and abuse: A qualitative meta-synthesis. PLoS One 2020;15:e0234067.
  10. Webster K. A preventable burden: Measuring and addressing the prevalence and health impacts of intimate partner violence in Australian women: Key findings and future directions. Sydney: Australia's National Research Organisation for Women's Safety, 2016.
  11. Holt S, Buckley H, Whelan S. The impact of exposure to domestic violence on children and young people: A review of the literature. Child Abuse Negl 2008;32:797–810.
  12. Vu NL, Jouriles EN, McDonald R, et al. Children's exposure to intimate partner violence: A meta-analysis of longitudinal associations with child adjustment problems. Clin Psychol Rev 2016;46:25–33.
  13. Valpied J, Aprico K, Clewett J, et al. Are future doctors taught to respond to intimate partner violence? A study of Australian medical schools. J Interpers Violence 2017;32:2419–32.
  14. Hooker L, Nicholson J, Hegarty K, et al. Maternal and child health nurse domestic violence training and preparedness to respond to women and children experiencing domestic abuse: A cross sectional study. Nurse Education Today 2020;96:104625.
  15. Sprague S, Madden K, Simunovic N, et al. Barriers to screening for intimate partner violence. Women Health 2012;52:587–605.
  16. Beynon CE, Gutmanis IA, Tutty LM, et al. Why physicians and nurses ask (or don’t) about partner violence: A qualitative analysis. BMC Public Health 2012;12:473.
  17. Ramsay J, Rutterford C, Gregory A, et al. Domestic violence: Knowledge, attitudes, and clinical practice of selected UK primary healthcare clinicians. Br J Gen Pract 2012;62:e647–e55.
  18. Po-Yan Leung T, Phillips L, Bryant C, et al. How family doctors perceived their ‘readiness’ and ‘preparedness’ to identify and respond to intimate partner abuse: A qualitative study. Fam Pract 2018;35:1517–23.
  19. Forsdike K, O’Connor M, Castle D, et al. Exploring Australian psychiatrists’ and psychiatric trainees’ knowledge, attitudes and preparedness in responding to adults experiencing domestic violence. Australas Psychiatry 2019;27:64–68.
  20. Tarzia L, Bohren M, Cameron J, et al. Women’s experiences and expectations after disclosure of intimate partner abuse to a healthcare provider: A qualitative meta-synthesis. BMJ Open 2020;10: e041339.
  21. Chang JC, Dado D, Hawker L, et al. Understanding turning points in intimate partner violence: Factors and circumstances leading women victims toward change. J Womens Health 2010;19:251–59.
  22. Zaher E, Keogh K, Ratnapalan S. Effect of domestic violence training: Systematic review of randomized controlled trials. Can Fam Physician 2014;60:618–24.
  23. Sawyer S, Coles J, Williams A, et al. A systematic review of intimate partner violence educational interventions delivered to allied health care practitioners. Medical Education 2016;50:1107–21.
  24. Crombie N, Hooker L, Reisenhofer S. Nurse and midwifery education and intimate partner violence: A scoping review. J Clin Nurs 2017;26:2100–25.
  25. World Health Organization. Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence: A manual for health managers. Geneva: WHO, 2017.
  26. McLindon E, Humphreys C, Hegarty K. “It happens to clinicians too”: An Australian prevalence study of intimate partner and family violence against health professionals. BMC Womens Health 2018;18:113.
  27. McLindon E, Humphreys C, Hegarty K. Is a clinician’s personal history of domestic violence associated with their clinical care of patients: A cross-sectional study. BMJ Open 2019;9:e029276.
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