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A Hospital's Educational Program Assesses Values and Beliefs

Summary
To answer questions about staff's ability to identify, assess, and support victims of woman abuse, St. Joseph's Hospital, Hamilton, Ontario, Canada, organized a task group that included a cross section of staff and representatives of a local women's shelter. A comprehensive literature review strongly confirmed the need for a program that would provide staff with relevant information about abused women and challenge them to examine their values and beliefs. The task group constructed a questionnaire that included six different scales measuring various aspects of respondents' beliefs and attitudes about woman assault.

The educational program for the pilot units included a training video, in-service workshops, a resource training manual, and an assessment tool to assist staff in screening female patients.

The survey identified some key areas of concern, including some widely held misconceptions about the causes of abuse. After the educational program, test scores showed significant changes, particularly on scales that measured belief in popular myths and the degree to which respondents held perpetrators responsible for their actions. Overall, the project demonstrated that values and beliefs related to woman assault can be significantly affected by an educational approach that combines information sharing with the opportunity for dialogue and questions.

These observations came from a counselor at Martha House, a local women's shelter, regarding St. Joseph's Hospital's care of one of their clients in December 1990. In her view, St. Joseph's staff had communicated inappropriate information to their client's husband because of the lack of effective protocol.

As is frequently the case, a crisis can be an effective stimulus to action. After addressing the specific problems of this case, staff at St. Joseph's, which is located in Hamilton, Ontario, Canada, asked themselves some difficult questions. Many had considered themselves sensitive to and knowledgeable about issues related to woman abuse. And they had recently completed a participatory process of rewriting the hospital's mission statement, a document that explicitly espouses the values of sensitive communication, personal integrity, and special responsibility to the vulnerable. But did St. Joseph's staff in fact know how to identify, assess, and support victims of abuse? What were their attitudes, their values, their beliefs about abused women, and how did these beliefs affect their interactions with them?

To answer these questions, St. Joseph's leaders organized a task group that included a cross section of staff (nursing, medicine, social work, mission) from four units particularly important in serving abused women — Maternal and Newborn, Emergency, Psychiatry, and Pediatrics. Recognizing the knowledge and skills of staff in community shelters, they also invited representatives of Martha House to join in further exploring these issues.

Fortunately, just as this process began, grant monies became available through the provincial Ministry of Health to develop and implement educational programs to help healthcare staff identify and support abused women. St. Joseph's used the grant to hire a project coordinator, who conducted a comprehensive literature review, developed a staff educational program, and constructed and implemented evaluative tools to determine the program's effectiveness.

Statistics and Misconceptions
The literature review provided invaluable information needed to focus both the educational program and information-gathering tools. The statistics about woman abuse and its presentation within the healthcare setting were startling and disturbing.

Statistics Canada's national survey on violence against women indicates that 29 percent of women currently or previously married have experienced physical or sexual violence at the hands of their partners, with 15 percent reporting abuse from their current partners ("Wife Assault: The Findings of a National Survey," Statistics Canada Cat. 86-002, vol. 14, no. 9, March 1994). Three percent of the women surveyed had been assaulted by their partners in the 12 months prior to the survey. One-third of these women were physically beaten at least once a week — and these statistics relate only to physical or sexual abuse, not emotional and psychological intimidation, coercion, and threat. Although many abused women do enter the healthcare system, frequently the physician does not link the presenting problem and its cause. Thus medical records often describe a history of physical or emotional complaints of undiagnosed origin. This failure to recognize abuse can lead physicians to diagnose psychosomatic disorders, including neurosis, hypochondria, and hysteria, or to overprescribe analgesic, sedative, and anxiolytic medications.

Even when healthcare providers are aware of abuse, misconceptions can affect the care provided (see "Common Myths About Woman Abuse" at the end of this article).

Outcome Measures
The literature review strongly confirmed the need to develop a staff educational program that would provide relevant information about abused women and challenge staff to examine their values and beliefs. In developing outcome measures for the project, the task group identified a number of areas particularly important in evaluating effectiveness. One of these was the program's effect on staff's values and attitudes regarding woman abuse. The group constructed a questionnaire that included six different scales measuring various aspects of respondents' beliefs and attitudes about woman assault:

• Justify: measures the extent to which respondents believe that woman abuse may be justified
• Help: taps respondents' attitudes concerning what kinds of assistance should be provided to women who are abused
• Offender: measures the extent to which respondents think perpetrators of woman abuse should be punished
• Responsible: examines the degree to which respondents believe offenders are responsible for their actions
• Nonviolent: evaluates whether respondents think nonphysical assault (e.g., emotional, sexual) constitutes woman abuse
• Popular: examines the extent to which respondents believe popular myths about wife assault (e.g., that perpetrators are mentally ill, that abusers who show remorse are less likely to repeat their behavior)

The questionnaire asked staff to indicate on a Likert-type scale their responses to statements related to each of these measures. The questionnaire was completed by 270 staff on the four pilot units both before and after the educational program (pretest and posttest). In addition to the outcome measures, the questionnaire gathered sociodemographic information about staff and asked questions related to a situational vignette.

The group also conducted a "before and after" randomized chart audit to evaluate behavioral change (contact the authors for the results, which will be reported in a forthcoming article).

Educational Components
To address the different learning styles of staff, the educational program for the pilot units included a training video; round-the-clock in-service workshops coordinated by community resource and hospital social work staff; a resource training manual distributed to all staff members; and an assessment tool to assist staff in screening female patients.

The task group developed in-service workshops — 43 in all — in conjunction with subcommittees on each of the pilot units, comprising the unit social worker, nurse manager, a physician, and staff nurses. A critical component of the educational program, these sessions were reviewed by women's shelter workers and survivors of woman abuse. (See "Workshop Topics" at the end of this article.)

Many of the workshops were facilitated by shelter staff, who provided first-hand experience of the reality of woman abuse. They encouraged St. Joseph's staff to express their own feelings and beliefs about the issue and to discuss the information presented. They also challenged staff to examine how their knowledge, values, and beliefs affected their behavior in identifying and supporting abused women on their units.

Results and Outcomes
The pretest questionnaire scores indicated that, even before the educational package was introduced, most staff on all pilot units had a reasonably high level of knowledge about and sympathy toward abused women. However, the survey identified some key areas of concern, including the following:

• Thirty-five percent of respondents thought men abuse because they are mentally ill.
• Forty-three percent thought drugs or alcohol is the cause of abuse.
• Forty-seven percent believed abuse is related to the changing role of women in society.
• Twenty-five percent believed some women are sexually stimulated when assaulted.

Posttest results had statistically significant differences from pretest scores on all six scales. The changes were most significant on the scales that measured belief in popular myths and the degree to which respondents held perpetrators responsible for their actions. These changes showed that education about woman assault has a significant impact on staff knowledge and attitudes. In addition, respondents who had more components of the educational package than others were significantly more knowledgeable and sympathetic than those with fewer components.

A number of other important variables were found to have a possible effect on attitudes about woman abuse:

• Male respondents differed significantly from female colleagues on three scales. For example, men were more likely to believe in popular myths about woman abuse and to oppose punishment for offenders.
• Tenure of staff was significantly inversely related to pretest knowledge and attitudes — that is, the more years of service, the less sympathetic and knowledgeable. However, this difference disappeared after the educational program, with the greatest attitude shift taking place in the most senior cohort (10 years or more of service).
• Sixty-two percent of staff had no previous formal or informal training regarding woman assault. Only 8 percent of respondents had ever attended a previous in-service on this topic.

Although the educational program had many positive effects, the task group identified important areas for improvement:

• Five percent of respondents still believed there are times when a man is justified in physically assaulting his partner.
• Nine percent believed that women who lie deserve to be abused.
• Ten percent agreed that women who refuse to have sex should expect to be hit.
• Twenty-five percent believed that some women drive their partners to abuse by continual nagging.

These percentages increased substantially if we include respondents who are uncertain (i.e., who neither agree nor disagree).

In addition to the evaluation results, some other important issues and outcomes emerged during the project. First, before the educational sessions, participants related a high level of discomfort, both within themselves and among their colleagues, in asking questions related to abuse. They reported that the workshop format, which promoted discussion and questions, had increased their openness and comfort with issues of abuse.

They were also more likely to seek help and support for their own abuse. Fifteen percent of female participants reported prior personal abuse. The workshops led many of these individuals to disclose abuse and seek support from the workshop leaders, their colleagues, and nurse managers. This strongly affirmed the validity of information presented during the workshops and underscored the need to prepare and educate management staff before the sessions.

Values and Beliefs Can Change
Overall, the project clearly demonstrated that values and beliefs related to woman abuse can be significantly affected by an educational approach that combines information sharing with the opportunity for dialogue, questions, and interaction. The most significant shift occurred in staff with lengthy tenure, whose attitudes toward abused women were entrenched.

Given the demonstrated efficacy of education, the staff's prior lack of training, and some of the remaining areas of concern, St. Joseph's is now developing a specialized intensive skills program for designated staff in some health services. This core group will become advocates for abused women within their units and will help develop an ongoing in-service curriculum. St. Joseph's is also developing for each individual patient unit a specific protocol (i.e., a how-to, step-by-step guide) to help staff identify and support abused women.

Have the women served by St. Joseph's Hospital noticed the difference? Although it is of course anecdotal, the following letter received in April 1995 from staff members of Martha House is a tribute to the success of St. Joseph's effort to educate its employees.

This letter is written to commend the nursing staff of maternity at St. Joseph's Hospital for their commitment to the needs of women who have been victims of wife assault.

The staff of Martha House recently accompanied and coached one of our clients during the delivery of her child. They were in awe of the level of knowledge surrounding this woman's special security needs and also the level of compassion given by all the nurses. . . . They have taken this horrific social condition [woman abuse] and ensured that they offer their patients safety, non-judgmental care and knowledgeable assistance.

For more information, call Steve Cowley at 905-522-1155, ext. 3235, or fax him at 905-522-6140.

BIBLIOGRAPHY
1. Canadian Centre for Justice Statistics, Juristat, Ottawa, March 1994.
2. Ontario Women's Directorate, Wife Assault: Dispelling the Myths, Toronto, 1992.
3. C. M. King and J. Ryan, "Abused Women: Dispelling Myths and Encouraging Intervention," Nurse Practitioner, May 1989.
4. S. Ahluwalia and B. D. MacLean, "The Medicalization of Domestic Violence," in B. Singh Bolaria, Sociology of Health Care in Canada, Harcourt Brace Jovanovich, Toronto, 1988.
5. E. Stark, A. Flitcraft, and W. Frazier, "Medicine and Patriarchal Violence: The Social Construction of a 'Private Event,'" International Journal of Health Services, vol. 9, no. 3, 1979.

Mr. Cowley is mission coordinator, and Ms. Rush is director of nursing, Maternal and Child, St. Joseph's Hospital, Hamilton, Ontario, Canada. Ms. Lenton is associate professor, Department of Sociology, McMaster University, Hamilton. And Ms. Lukasik-Foss is program supervisor, Good Shepherd Women's Centre, Martha House, Hamilton.

• Women often provoke assaults.
• Assaulted women could leave their partners if they wanted to.
• Alcohol or drugs frequently cause men to be abusive.
• Abuse between partners is a "family matter," equally the responsibility of the partners involved.
• Battering is more common in certain ethnic or cultural groups.
• Women who live in abusive situations have passive or helpless personalities.
• Some women actually enjoy abuse.
• The abuse cannot be too bad, or the woman would leave.

• Definition of and statistics related to woman assault
• Profile of the abused woman and abusive man
• Myths about woman assault
• The socioeconomic and political context of woman abuse
• Effects on the health of abused women
• Role of the health professional
• What health professionals should say to the abused woman, how they should say it, and what they should do