| | Integrating intimate partner violence content across curricula: Developing a new generation of Nurse EducatorsAccepted 24 June 2008. published online 11 August 2008. Summary Abuse between intimate partners can take many forms. Prevalence data analyses confirm that intimate partner violence (IPV) is a widespread problem. Meeting the objectives of World Health Organization’s “Global Campaign on Violence Prevention” will involve many organizations and institutions within and beyond the health care community. Educating prospective Nurse Educators about IPV does, however, present challenges, as most nurses lack awareness of IPV as a public health problem, have limited knowledge and erroneous beliefs about IPV, and are inexperienced in caring for survivors of IPV. Thus providing formal education and training in a supportive environment will enhance Nurse Educators’ knowledge and skills about IPV while helping them to examine the benefits and limitations of various pedagogical approaches for teaching this critical content to students. Hence targeting educational efforts at nurses who are pursuing the academic role is an important first step toward raising the collective consciousness of nurses to the point that IPV education becomes an integral component of the nursing curriculum, and competence in caring for IPV survivors becomes the standard rather than the exception. Introduction  In recent years, the nursing profession has endeavored to improve care practices in several important areas including the care of older persons, end-of-life and cultural competence with intense effort devoted to raising awareness among the nursing community regarding the impact of these practice issues. These initiatives strive to enhance the ability of all nurses to provide competent care in each of these areas, while improving the capacity of educators to teach students the knowledge and skills necessary based on standards, best practices, and research-based evidence. Intimate partner violence (IPV), the focus of this paper, is another important health care issue that urgently demands the attention of the profession. The World Health Organization asserts that IPV “occurs in all countries, irrespective of social, economic, religious or cultural group” (WHO, 2002, p. 89). Although there is an increased awareness of this pervasive public health issue, screening and subsequent intervention continue to be fraught with ongoing social and professional misperceptions. Practicing nurses face legitimate concerns including feelings of inadequacy and perceived lack of competence related to screening and intervention for IPV. The discussion that follows highlights the challenges that practicing nurses may encounter when faced with the need to screen for IPV and intervene appropriately, while also offering pedagogical approaches for preparing Nurse Educators to integrate teaching–learning experiences related to IPV into curriculums. Background and significance Historical facets Historically, the nosology for victims of interpersonal violence has been termed domestic violence (DV); however, cumulative examination and contemporary exploration of this phenomenon, currently thought to be at pandemic levels, has become more accurately and contextually referred to as interpersonal violence or intimate partner violence (IPV) (Lloyd and Emery, 1999, National Center for Injury Prevention and Control, 2007). This contemporization of terminology has contributed toward an expansion in identification, reporting, related research and a larger foundation of both empirical and anecdotal information, all of which have noted that it necessarily, and more broadly, encompasses violence that occurs across a variety of levels of dating and relationships (Coker et al., 2000, Flowers, 2000, Mezey et al., 2002). Specifically, IPV can occur between current and former spouses, those cohabitating or living in separate residences (Lloyd and Emery; Coker et al.), and as more recently documented, between lesbian, gay, bisexual and transgendered (LGBT) partners (Burke et al., 2002, Riviello et al., 2006). Although women can be violent in their relationships with men and IPV may occur in same sex partnerships, the brunt of violence is borne by women at the hands of men (WHO, 2002). Additionally of note is the recent examination of the many instances where certain cultures accept interpersonal violence as normative, where “in some cultures domestic violence is viewed as helping the woman behave according to the standards of the culture” (Zoucha, 2006). The WHO emphasizes that due to cultural norms, violence against women (VAW) is many times viewed as a private or family matter; thus, it does not receive the legal and governmental response that VAW warrants (Garcia-Moreno et al., 2006). Scope of the problem Contemporary trends and issues IPV against women is particularly broad spread and is estimated to affect one in three women globally (WHO, 2002), significantly impacting the rate of maternal mortality in India, Bangladesh, and the United States (Garcia-Moreno et al., 2005). A recent national survey in the United States indicates that approximately 4.9 million intimate partner rapes and physical assaults continue to occur annually (Tjaden and Theones, 2000). In a proactive move toward addressing this significant public health issue, the laws of all 50 US states provide that IPV is a crime and make it easier for victims to obtain protective or restraining court orders that prohibit offenders from having contact with them. In 1994 Congress passed the Violence Against Women Act, which authorized more than $800 million in federal funds for state and local programs to combat domestic violence (US Department of Justice, 1994). Although the title of the law refers to women victims, both male and female victims are subject to its provisions. The vast majority of programs that deal with IPV, such as shelters, police intervention programs, and psychotherapeutic support groups, are implemented only after a severely abusive incident. A few programs and policies attempt to prevent IPV before it occurs yet most widespread prevention programs have resulted from community-based approaches and national public awareness campaigns that identify IPV as an important social problem. Internationally, the WHO has proffered that the development of policies that address IPV will have a significant impact on the achievement of the Millennium Development Goals set forth by the 191 member states of the United Nations. Although many agencies, governments, and policy makers view IPV as an inconsequential social problem, the WHO declares that IPV must be eradicated (Garcia-Moreno et al., 2005). Thus, global policies must be implemented as part of public health, social development, and economic development agendas. IPV and pedagogy The WHO has launched a “Global Campaign for Violence Prevention”; the objectives of the campaign are to raise awareness about the prevalence and impact of IPV, to highlight the role of public health initiatives in addressing the causes and consequences of IPV, and to encourage action at every level of society (WHO, 2008). Violence within the community can occur inside and outside the home; perhaps the most misunderstood form of prevalent violence within contemporary society is what takes place inside the home. Meeting the WHO objectives will involve many organizations and institutions within and beyond the health care community. For nursing education, this initiative supports an ongoing review of current programmatic and curriculum approaches toward enhanced assessment and intervention with survivors of IPV. Hence integrating education about IPV into Nurse Educator curriculums has the potential for broad social impact since adequately preparing nurses to effectively screen and intervene appropriately for IPV will position nurses to be at the forefront of moving forth public health initiatives that are designed to reduce and prevent IPV. The following case study demonstrates the importance of equipping Nurse Educators with the knowledge and skills needed to prepare competent nursing graduates with the ability to effectively screen clients for IPV and appropriately intervene. Case study John H.3 a women’s health nurse practitioner (WHNP) program works in a busy suburban obstetrics and gynecology practice. Sarah J.3 is a 32 year old married Caucasian female who comes to see John with a primary complaint of lower abdominal pain. Upon entering the exam room, John notes that Sarah appears to be somewhat apprehensive, repeatedly pulling at the hem of her suit jacket and does not establish eye contact for more than a few seconds. John takes a detailed patient history including symptom analysis. The review of systems is negative. The gynecological history reveals that Sarah has never been pregnant, has used oral contraceptive pills for four years, has not had any changes in vaginal discharge or new sexual partners, and had a normal menstrual period two weeks prior to the visit. Sarah reports that the abdominal pain began approximately three months ago. Sarah’s initial responses to questions about the characteristics of the pain are vague; only after extensive probing does she describe the pain as “dull and constant but [it] seems worse just before I get up in the morning”. Sarah states that sleep is the only thing that relieves the pain. A psychosocial history reveals that Sarah has been married for 4 years, works as a primary school teacher, and relocated to the region five months ago. When asked about social relationships, Sarah states that she is somewhat lonely because she is new to the region and has not formed any friendships. “I left all my family and friends where we used to live. My husband says that we have each other so we don’t really need anyone else”. After completing the patient history John performs a comprehensive physical examination. The physical exam is negative for abdominal masses, tenderness, lymphadenopathy, CVA tenderness, and/or suprapubic tenderness. The external and internal genitalia are normal to inspection and with no tenderness or masses noted upon palpation. The rectal exam is negative for masses or occult blood. The microscopic examination of vaginal secretions and urine is within normal limits. The urine pregnancy test is negative. John orders gonorrhea and chlamydia cultures and a urine culture and sensitivity. While listening to Sarah’s breath sounds, John takes note of a 5 cm by 3cm bruise on her left shoulder that is tender to palpation. When questioned about the bruising, Sarah states “I bruise easily and I can be clumsy”, further qualifying that she fell from a ladder last week while painting the kitchen and hit her shoulder on the counter. All other physical parameters were negative. Thus John counsels Sarah to return to the office for further diagnostic tests if the abdominal pain continues. One week later, during the practice’s weekly case review, John presents Sarah’s case. After a brief discussion, several of John’s colleagues raise questions about screening for IPV. As a result, John acknowledges that he may have missed some important clues during his assessment and may not have provided the best quality of health care. Although he was exposed to the concept of IPV, including the “cycle of violence,” during his graduate nursing education, John states that he felt ill prepared to intervene with Sarah. A colleague suggests that John ask Sarah to return for a follow-up health care appointment during which he specifically inquires about IPV. John consults with that colleague regarding appropriate screening questions and referrals for IPV. Approximately two weeks later Sarah returns to the office and responds honestly when John requires about IPV. Stating, “I need someone to talk to about this. I feel so alone”. John then helps Sarah to develop a safety plan and refers her to a community-based domestic violence service. Though John was ultimately able to assist Sarah, he feels that his nursing education left him ill prepared to screen for IPV and to intervene when appropriate. John is not alone as many health care providers often underestimate the incidence and prevalence of IPV and are not adequately prepared to effectively screen or subsequently develop a plan of care (even when IPV is recognized). For example, Kothari and Rhodes (2006) examined emergency department (ED) utilization by police-identified women survivors of IPV to determine the extent of IPV screening and identification by health care providers. Notably they found that only 30.3% of the women had documented IPV screening and that the majority of these women utilized ED services multiple times without ever being identified or linked to community-based or legal intimate partner violence resources, even when they presented with injuries. This case example demonstrates how the ongoing gap in knowledge and skills continues to prevail despite the significant numbers of women who have experienced IPV and who present to health care providers seeking care for stress related somatic symptoms or pain for previous or ongoing abuse (Glass et al., 2001). Education-practice gap Knowledge is the foundation of assessment, and assessment underpins all levels of intervention. An examination of the extant literature reveals an ongoing lack of adequate screening for IPV by healthcare providers. This supports the significance of inclusion, expansion or explication of IPV related facets into nursing education at all program levels including Nurse Educator curriculums. In their study of 1268 women who sought care at emergency departments and primary care facilities, Kramer et al. (2004) found that majority of those who presented with commonly encountered complaints (i.e. headaches, stomach problems, vaginal bleeding, etc.) had reportedly experienced IPV during their lifetime. Additionally, a study by Glass et al. (2001) indicated that of 11 emergency departments surveyed, fewer than 25% of women who sought treatment were questioned about a history of IPV. These studies underpin the importance of nurses being equipped to effectively screen for IPV, provide treatment for injuries and stress related symptoms, and offer referrals to community-based IPV resources. Nursing education related to IPV historically has encompassed the goals of promoting an increased awareness of the prevalence and identification of at risk clients and encouraging non-judgmental attitudes; however, information regarding screening indicates that patients are not routinely screened for IPV (Johnston, 2006). This indicates the need for enhanced educational approaches to be integrated across curricula and clinical practice that prepare graduates with specific skills for screening for IPV and the knowledge necessary to develop effective intervention plans. For example, Hinderliter and colleagues (2003) reported that while 70% of the Nurse practitioners (N=557) surveyed had received 1–4h of IPV education during their basic education or during their advanced practice education, most felt ill prepared to conduct universal IPV screening. Those surveyed stated that the “cycle of violence” including violence during pregnancy, were the topics most likely to be presented during educational sessions, with legal issues and safety planning for IPV survivors being least likely to be presented. Many times IPV education is presented as stand alone lectures and, is not given enough time or importance to impart knowledge, change attitudes, and facilitate the development of the clinical skills necessary for competent IPV screening, intervention, and prevention (Hamberger, 2007). Subsequently, Hinderliter et al. (2003) asserted that Nurse Educators must learn how to screen for IPV themselves and be adequately prepared to educate students at any program level about IPV. Pedagogical approaches to teaching about IPV The growing number of masters and post-masters certificate programs devoted to nursing education offers a prime opportunity to develop the competence of future educators to teach students about IPV. Educating prospective Nurse Educators about IPV does, however, present challenges, as most nurses lack awareness of IPV as a public health problem, have limited knowledge and erroneous beliefs about IPV, and are inexperienced in caring for survivors of IPV (Stinson and Robinson, 2006). Nonetheless, formal education programs provide a prime opportunity for enhancing future educators’ knowledge and skills about IPV as they examine the benefits and limitations of various pedagogical approaches for teaching this critical content to students. The support and safety of the academic environment aids in promoting a collective awareness of IPV, while also highlighting the dynamic nature of IPV information and the fact that nursing education regarding abuse and violence must become the responsibility of Nurse Educators at all program levels (Woodtli, 2000). Curriculum review Integrating IPV content into nursing education programs may seem difficult for new Nurse Educators given the amount of information and limited time available to effectively educate nurses for generalist and advanced practice roles. Part of the process of preparing future Nurse Educators requires they first learn skills to evaluate existing curricular content. In all likelihood there is IPV content in the curriculum; however, there is a need to examine in what course(s) is the IPV content currently being taught? How much time is devoted to presenting content related to IPV? What knowledge and skills are students’ being taught about IPV and how detailed is the information they are receiving? What learning activities are used, and how effective are they in reinforcing information and developing students’ skills to effectively screen for IPV? Where are the gaps in IPV education, and how can these be filled to enhance the learning experience to assure that students are exposed to critical knowledge and skills necessary to provide competent care? These are the questions Nurse Educators must consider in order to devise curricular models and teaching strategies targeted at improving IPV education. Designing teaching-learning strategies A variety of resources are available to guide Nurse Educators in setting instructional goals, identifying competencies, and determining content that should form the basis a comprehensive IPV curriculum (Table 1). Beyond this, creativity and innovation need to be guiding forces for pedagogical approaches to teaching future Nurse Educators about IPV. Learning activities should, therefore, be designed with a three-fold purpose: to familiarize learners with various instructional methods; to support the development of skills for assessment and intervention for IPV; and, to serve as a model for learning activities that they, as Nurse Educators, can use to teach their students. Teaching–learning strategies particularly suited for IPV education are those that enable learners to apply knowledge and skills to reality-based situations. Experiential, interactive, and simulated activities that emphasize the importance of multidisciplinary and community collaboration also encourage reflective practice, and facilitate learning in a manner that permits behaviors, attitudes, and biases to be exposed in a safe, structured atmosphere in order to interpret past and guide future experiences (Merriman and Caffarella, 1999). The following are examples of learning strategies that can be used to inform future Nurse Educators about IPV include, but are not limited to: •Standardized patient scenarios – A standardized patient is an individual who has been trained to present a clinical scenario by assuming the characteristics of a patient in that situation. This clinical teaching method enables learners to develop skills in conducting bio-psycho-social assessments, while also helping to refine interpersonal communication skills through interaction with a person that is simulating someone who has experienced IPV. Video recording and playback of the interaction provides a valuable opportunity the Nurse Educator to critique his/her assessment and communication skills, while also providing an opportunity to reflect and refine standardized patient scenarios for IPV to ensure that they emphasize defined instructional objectives for future student learning. •Interviews – Comprehensive interviews of IPV survivors and experienced forensic nurses provide an opportunity for those touched by IPV to share their personal stories with Nurse Educators. Interviews offer a chance to gain valuable insight into the “lived experience” associated with IPV and can be done face-to-face on an individual basis or as part of a formal presentation to a class group. The audio recording of interview dialogue allows the conversation to be saved so that Nurse Educators may use it as a resource for creating case studies or problem-based learning activities. However, Nurse Educators may also choose to share the interview as an online podcast that would be available for download and listening at student convenience so that they too could benefit from the first-hand account of one’s experience with IPV. •Service learning – Spending time at a battered women’s shelter or other community agency that provides assistance to IPV survivors provides Nurse Educators with insight into the social impact of domestic violence while also acquainting them with available programs and services that may be used for community and clinical experiences. Awareness, critical thinking, and cultural competence can be enhanced by such an experience that can then be integrated into teaching-learning activities for students at any program level. •Simulation – High-fidelity simulation experiences can highlight for Nurse Educators the assessment skills and intervention strategies needed by nurses to appropriately care for patients who are victims of IPV. However, given that assessment and intervention for IPV demands an interdisciplinary approach, high-fidelity simulation experiences also offer the perfect opportunity for nurses to learn how to interact with other health care providers to practice and evaluate psychomotor skills and decision-making. Nurse Educators that have the opportunity to participate in a multidisciplinary simulation experience related to IPV will develop an appreciation for the value of collaborative teaching and learning. Conclusion IPV has been identified as a significant public health problem that demands the attention of the nursing profession. The WHO (Garcia-Moreno et al., 2006) stresses that IPV is a universal phenomenon. Their interviews of 24,000 women in 10 countries on the African, Asian, European, and South America continents revealed that IPV is quite prevalent and cuts across all sectors of the population. This study also highlights the physical and mental problems that result from IPV (Ellsberg et al., 2008). Hence, all nurses must be prepared to intervene since they are on the front lines of the health care system. Yet, as stated earlier, many nurses are ill prepared to screen for IPV and intervene effectively. Often nurses face barriers that prevent then from intervening including: (1) an inadequate knowledge base; (2) misconceptions about their role in screening and intervening; and (3) myths about the socio-economic status, ethnicity, nationality or culture of perpetrators and victims of violence. Thus, it is essential that Nurse Educators work diligently to help nurses to overcome these barriers so that they may effectively address this widespread public health problem. Preparing future Nurse Educators who have a solid knowledge base related to IPV and who feel well prepared to teach essential knowledge and skills is fundamental to improving nursing practice and health outcomes. Therefore Nurse Educators who teach in academic Nurse Educator programs must become proficient in this area of clinical practice and work to integrate this content throughout curricula. Targeting educational efforts at nurses who will be the next generation of Nurse Educators is an important first step toward raising the collective consciousness of nurses to the point that IPV education becomes an integral component of the nursing curriculum, and competence in caring for IPV survivors becomes the standard rather than the exception. References Burke et al., 2002. 1.Burke TW, Jordon ML, Owen SS. A cross national comparison of gay and lesbian domestic violence. J. Contemp. Crimin. Just. 2002;18:231–257. Coker et al., 2000. 2.Coker AL, Smith PH, McKeown RE, King MJ. Frequency and correlates of intimate partner violence by type: physical, sexual, and psychological battering. Am. J. Public Health. 2000;90:553–559. MEDLINE |
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