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1Running head: MEASURING CHANGES AFTER AN IPV INTERVENTIONMeasuring Changes in Attitude, Skill and Knowledge ofUndergraduate Nursing Students after Receivingan Educational Intervention in Intimate Partner ViolenceA dissertation submittedbyConnie M. WallacetoCollege of Saint Maryin partial fulfillment of the requirementfor the degree ofDOCTORATE IN EDUCATIONwith an emphasis onHealth Professions EducationThis dissertation has been accepted for the faculty ofCollege of Saint Mary.

2We hereby certify that this dissertation, submitted by your name, conforms to acceptablestandards and fully fulfills the dissertation requirements for the degree of Doctor inEducation from College of Saint MaryName and Title, CredentialChairPeggy L. Hawkins, Ph.D., RNName, Title and CredentialCommittee memberPatricia J. Morin, Ph.D., RNName, Title and CredentialCommittee memberCharlotte M. Herman, Ed.D., RN

3COPYRIGHT DATE, 2009CONNIE M. WALLACE

4AcknowledgementsNine tenths of education is encouragement. Anatole FranceIt is with genuine appreciation and gratitude that I acknowledge my dissertationcommittee members for their time, support and guidance.My heartfelt thanks go to Dr. Peggy Hawkins, the chairperson of my committee,who unfailingly offered positive words of encouragement and unwavering support as Ibegan this educational journey. She was my first mentor in the role of nurse educator;what a great privilege to again receive her continued mentoring while in the doctoralprogram. She gave me confidence when my own was fading. I admire the role modelingshe provided and strive to emulate her!My gratitude also goes to Dr. Pat Morin, who shared a wealth of knowledge, andmade the entire dissertation process appear effortless. I so appreciate her enthusiasm forlearning and writing!I am grateful to the guidance of Dr. Char Herman, who has been not only acolleague and mentor, but a dear friend, for many years. I will always be indebted to her!I am grateful to the Nebraska Methodist College administration, for allowing timeand financial support to obtain my doctoral education. I am also grateful to the NebraskaMethodist Hospital Foundation for awarding me a Carolyn Scott Memorial Scholarshipto further fund this educational undertaking.I would like to thank my friends and colleagues Nebraska Methodist College,who offered support in many forms, and shared their expertise, which I value greatly; aspecial thank you to Dr. Fran Henton, Dr. Marlin Schaich, and Ms. Sonja Maddox.

5Finally, my unending gratitude goes to my family; my mother, who madesacrifices to make herself available to me and offers support in countless ways. And tomy children, Joe and Betsy, now college students themselves, who have been myinspiration, making every single day brighter by their presence and enriching my life inmore ways than one could imagine.

6TABLE OF CONTENTSAbstract . 10CHAPTER I: INTRODUCTION . 12Background .12Purpose of the Study .13Data Collection Methods .14Definition of Terms .14Delimitations and Limitations . 16Significance .16Summary .17CHAPTER II: LITERATURE REVIEW. 18Historical Perspectives .18Definition .19IPV in Health Care .20IPV and Nursing Care .23IPV and Professional Education .23Assessment Tools .28Recommendations for Future Research .31Theoretical Framework .31Summary .35

7CHAPTER III: METHODOLGY . 37Design .37Sample .37Variables .40Ethical Considerations .41Instrumentation .42Summary .44CHAPTER IV: RESULTS. 46Introduction.46Overview.46Data Analysis .46Qualitative Findings.56Summary .58CHAPTER V: DISCUSSION AND SUMMARY . 60Introduction.60Research Questions and Interpretation .60Limitations of this Study .60Discussion .61Recommendations for Future Research .65Summary .66REFERENCES . 67APPENDICES . 78

8LIST OF FIGURESFIGUREPAGE1. Self-Efficacy Model . 342. Age of Participants .383. Gender of Participants .394. Background Knowledge .395. Prior Nursing Education .406. Experimental Group Attitudes .487. Control Group Attitudes .508. Experimental Group Skills. 519. Control Group Skills .5310. Experimental Group Knowledge .5411. Control Group Knowledge .5612. Perceived Confidence .58

9LIST OF TABLESTABLESPAGE1. Descriptive Statistics, Attitude, Time 1, 2, 3 Experimental Group . 472. Descriptive Statistics, Attitude, Time 1, 3 Control Group .493. Descriptive Statistics, Skills, Time 1, 2, 3 Experimental Group .504. Descriptive Statistics, Skills, Time 1, 3 Control Group .525. Descriptive Statistics, Knowledge, Time 1, 2, 3 Experimental Group .536. Descriptive Statistics, Knowledge, Time 1, 3 Control Group .55

10AbstractThe purpose of this quasi- experimental study was to determine whetheran educational intervention had an effect on nursing students' perceivedattitudes, skills, and knowledge regarding Intimate Partner Violence (IPV). Theresearch question was as follows: Is there a difference in nursing students'perceived attitudes, skills, and knowledge after an educational intervention thanbefore the educational intervention?The nursing profession is uniquely positioned to make a difference in thelives of adults and children who experience the harsh reality of IPV. Literaturefindings indicated nurses often believe themselves to be ill-equipped to offerappropriate and beneficial interventions.This study employed an educational intervention in the form of a twocredit hour elective nursing course and assessed its effectiveness as measuredthrough perceived change in student attitudes, skills, and knowledge. A variety ofactive learning strategies were used in the elective nursing course designed forthis study.The experimental sample had a total of 20 participants, and the controlsample had a total of six participants. Repeated measures ANOVA were used toanalyze the data. Qualitative responses were obtained through the use of shortanswer questions.The experimental group mean scores indicated an improvement inattitude, skills, and knowledge. There was a statistically significant difference in

11the mean scores for attitude (P .01). The mean scores for skills and knowledgeincreased, but were not statistically significant.Findings from this study suggested that students who received educationand structured learning experiences related to IPV intervention have a positivechange in attitude, skills and knowledge. Further research is recommended toassess whether these changes diminish over time, after completion of thecourse. It may also be of interest to examine the effects of personal experienceswith IPV in students and nurses who provide care to clients who experience IPV.

12CHAPTER 1BackgroundIntroductionThis quasi-experimental study explored the change in student attitudes,skills, and knowledge pertaining to Intimate Partner Violence (IPV) afterparticipating in an educational intervention. The educational intervention was atwo-credit hour elective course on IPV.BackgroundIntimate partner violence (IPV) is viewed as a highly prevalent andpervasive issue (Belknap, 2003; Bryant & Spencer, 2002; Campbell, 1992;Caralis & Musialowski, 1997; Gielen et al., 2000; Grogan, 2003; Hinderliter,Doughty, Delaney, Pituala, & Campbell, 2003). Alpert (2002) voiced this concernvery eloquently in the following statement: "Over the course of human history,virtually no other public health problem has been as prevalent or as challengingto the health and well-being of humanity" (p. 162).The occurrence and effects of IPV have been identified by governmentalentities, national health agencies, health care organizations, nursing practiceorganizations, and nursing education organizations. In addition, health careproviders in numerous nursing specialties, including women's health, mentalhealth, pediatrics, school nursing, geriatrics, and community health, havedocumented the need for increased, expanded, and consistent identification andintervention (Bryant & Spencer, 2002; Vandermark & Mueller, 2008; Knapp,Dowd, Kennedy, Stallbaumer-Rouyer, & Henderson, 2006; Amar & Gennaro,

132005; Davila, 2006; Kingston, Penhale & Bennet, 1995). Due to the highincidence of IPV and associated sequelae of "poorer physical mental health, andthe increased use of health care resources, it is reasonable to anticipate that allhealth care providers will come into contact with survivors of abuse" (Campbell,Laughon, & Woods, 2006, p. 52).Yet, literature has indicated nurses often perceive themselves as being illequipped to intervene effectively in situations pertaining to intimate partnerviolence due to a lack of education. In a study of public health nurses andhospital staff nurses, Moore, Zaccaro and Parsons (1998) reported that "onlyslightly more than 50% of practicing nurses reported having any educationrelated to abuse" (p. 180). Additional research by Woodtli (2000) indicated therewas a "lack of violence related content" in nursing education curricula (Woodtli,2000, p. 175). The review of literature clearly indicated there is a need for IPVcontent in basic undergraduate nursing curricula.Purpose/Research QuestionThe purpose of this quasi-experimental study was to determine whetheran educational intervention had an effect on nursing students' perceivedattitudes, skills, and knowledge regarding IPV.The research question was as follows: Is there a difference in nursingstudents' perceived attitudes, skills, and knowledge after an educationalintervention than before the educational intervention?Research HypothesisThe research hypothesis was as follows:

14Participants who take a non-clinical elective course on IPV will scorehigher on attitudes, skills, and knowledge than those participants who didnot take a non-clinical elective on IPV.Data Collection MethodsData were collected three times during the study period for theexperimental group. Data were obtained through a survey which was conductedbefore the implementation of the two-credit elective nursing course, at week nine,and after the completion of the elective course. The survey was administered inthe first class session and during the last class session for the control group.Findings were analyzed using repeated measures analysis of variance (repeatedmeasures ANOVA).The control group was surveyed two times during their non-clinicalelective. Data were obtained using the same survey, and were administeredduring the first week of class and again in the last week. The class used for thecontrol group did not address any content related to IPV.Definitions of TermsThe following operational definitions were used in this research study:1. Intimate Partner Violence: "a pattern of purposeful coercivebehaviors that may include inflicted physical injury, psychological abuse, sexualabuse, progressive isolation, stalking, and threats. These behaviors may beperpetrated by someone who is, was, or wishes to be in an intimate or datingrelationship with the adult or adolescent, are aimed at establishing control by onepartner over the other (Family Violence Prevention Fund, 2004, p. 3).

152. Self-efficacy: "the belief in one's capabilities to execute the course ofaction required to manage prospective situations" (Bandura, 1995, p. 2). For thepurpose of this study, efficacy referred to attitudes, skills, and knowledge used toachieve the tasks of understanding and intervening in IPV.3. Quasi-experimental design: a design for an intervention study inwhich subjects are not randomly assigned to treatment conditions (Polit & Beck,2008, p. 763).4. Undergraduate nursing students: students enrolled in a Bachelor ofScience in Nursing program.5. Educational intervention: a two-credit, non-clinical elective includingdidactic content and community-based experiences.6. Attitude: mental position, emotion, or feeling toward a fact or state(Merriam-Webster Online Dictionary, 2009).7. Skill: the ability to use one's knowledge effectively and readily inexecution or performance (Merriam-Webster Online Dictionary, 2009).8. Knowledge: the fact or condition of knowing something with familiaritygained through experience or association (Merriam-Webster Online Dictionary,2009).9. Non-Clinical elective course: A course students elect to take, as itnot required in the curriculum. The course does not include an actual clinicalcomponent.Delimitations and Limitations

16According to Bryant (2004) delimitations are "factors that limitgeneralization" to other people, times, and places; limitations are "restrictionscreated by your methodology" (Bryant, 2004, pp. 57-58). Delimitations for thisstudy included:1. The participants all attended a baccalaureate nursing program in asmall, private, Midwestern college.2. Some participants may have already received prior IPV education inprevious coursework.3. Participants may have very similar clinical experiences upon which todraw.4. This study had a limited number of participants.Limitations of this study may have included:1. Participants elect to take the non-clinical elective and this may reflect apersonal interest in the subject matter.2. Participants may have prior, personal experience with the subjectmatter.3. Participants may encounter personal experience with the subjectmatter during the time they are enrolled in their coursework.4. Generalizability is limited due to the small sample size.SignificanceBecause nurses often provide the first exposure to health care experiencefor recipients of IPV, it is crucial that they be knowledgeable in factors associatedwith intimate partner violence and appropriate resource referral, skillful in

17screening and assessment protocol, and empathetic in creating a therapeuticinterpersonal environment. However, many nurses have not had the experienceor guidance to become adept in these areas, so they may not be prepared tointervene. For these reasons, nursing education must design appropriate,responsive curricula which foster the development of sensitive skilled nursingcare delivery.SummaryIn summary, the literature indicated IPV is a multi-faceted issue whichcarries pervasive, far-reaching consequences for society. The occurrence of IPVhas been identified in many health care settings; therefore, it is imperative thatnurses be skilled at recognizing IPV and possess the ability to intervene. Nursingresearchers reported that nurses perceive themselves as lacking preparation tointervene effectively (Moore, Zaccaro & Parsons, 1998; Woodtii, 2000). Thus,nurse educators must provide their students the educational preparation todevelop the knowledge and skills to compassionately care for those whoexperience IPV. Therefore, the research question in this study is: Is there adifference in nursing students' perceived attitudes, skills, and knowledge after aneducational intervention than before the educational intervention?

18CHAPTER 2Literature ReviewIntroductionThis chapter reviews relevant literature pertaining to the study. This reviewof the literature describes the following topics: (a) historical perspective andsignificance of the issue, (b) definitions of IPV, (c) the association between IPVand health care, (d) IPV issues in nursing care, (e) IPV in nursing education, (f)assessment tools applicable for nursing education interventions, (g) selectedtheoretical framework, and (h) recommendations for future research.Historical Perspective and SignificanceIntimate partner violence (IPV) has long been recognized as a health careepidemic (Belknap, 2003; Bryant & Spencer, 2002; Caralis & Musialowski, 1997;Campbell, 1992; Gielen, et al., 2000; Freedberg, 2008; Grogan, 2003; Hegarty,2006; Hinderliter, Doughty, Delaney, Pituala, & Campbell, 2003). In 1999, theCommonwealth Fund reported an estimated three million women are recipientsof intimate partner violence per year (Commonwealth Fund, 1999). The NationalCenter for Injury Prevention and Control (2003) reported that IPV victimizes 5.3million women and results in 1,300 deaths per year. The Bureau of JusticeStatistics (2004) estimated that between 1.5 and 4.4 million women arephysically or sexually assaulted by an intimate partner every year. This statementwas supported by the Centers for Disease Control and Prevention (CDC) whichreported IPV affects 5.3 million women annually on a national level (CDC, 2003).

19Furthermore, Stinson and Robinson (2006) stated that nearly 50% of women inAmerica will experience intimate partner violence at some point in their lives.Interestingly enough, while history outlined the evolution of awareness ofIPV, it was not until the mid-to-late 1970's that IPV, and ensuing communityresponses, gained recognition (Minnesota Center Against Violence and Abuse[mincava], 1995). The health care community started to identify IPV as asignificant "medical and public health problem" at this time (Alpert, 2002, p. 162).However, in 1992 the U.S. Surgeon General identified abuse by husbands as theleading cause of injury to women 15 to 44 years of age, thus bringing IPV to theattention of medical practice (mincava, 1995).DefinitionSeveral definitions of IPV have emerged over time. The American NursesAssociation (ANA) in its 1992 position statement, referred to physical violenceagainst women, defining it as "behavior intended to inflict harm and includesslapping, kicking, choking, punching, pushing, use of objects as weapons, forcedsexual activity and injury or death from a weapon" (American Nurses Association,1992). There is much literature documenting the extent of intimate partnerviolence in the 1990's, and as awareness and sensitivity grew, the definition ofIPV expanded, taking on additional dimensions. The American Association ofColleges of Nursing (AACN) issued its position statement identifying violence asa public health problem in 2000. In this document IPV was defined in thefollowing manner:

20Domestic violence is defined as sexual, or emotional/psychologicalviolence directed toward men, women, children, or elders occurring incurrent or past familial or intimate relationships whether the individuals arecohabiting or not and including violence directed toward dating partners.(AACN, 2000, p. 63).For the purpose of this study, the definition put forth by the FamilyViolence Prevention Fund (2004) will be used:Intimate partner violence is a pattern of purposeful coercive behaviors thatmay include inflicted physical injury, psychological abuse, sexual abuse,progressive isolation, stalking, deprivation, and threats. These behaviorsmay be perpetrated by someone who is, was, or wishes to be in anintimate or dating relationship with an adult or adolescent, are aimed atestablishing control by one partner over the other (p. 3).IPV in Health CareThe literature indicated that devastating effects of IPV are seen in virtuallyevery health-care setting (Carbonell, Chez, & Hassler, 1995; Minsky-Kelly,Hamberger, Pape, & Wolff, 2005; Gutmanis, Beynon, Tutty, Wathen, &MacMillan, 2007), both large and small (Woodtli, 2000). Such settings includecollege health settings (Amar & Gennaro, 2005), women's health care (Bryant &Spencer, 2002), obstetrics and gynecology (D'Avolio et al., 2001; Furniss,McCaffrey, Parnell, & Rovi, 2007; Moore, Zaccaro, & Parsons, 1997), VeteransAffairs Medical Centers (Caralis & Musialowski, 1997), public health departments(Davila, 2006; Shattuck, 2002), the emergency department (Davis & Harsh,

212001; Davis, Parks, Kaups, Bennink, & Bilello, 2003; Furniss et al., 2007; Gielenet al., 2000; Hurley et al., 2005; Reisenhofer & Seibold, 2007; Yonaka, Yoder,Darrow, & Sherck, 2007), pediatrics (Knapp et al., 2006), primary care clinics(McFarlane, Groff, O'Brien, & Watson, 2006), Planned Parenthood clinics(McFarlane, Christoffel, Bateman, Miller, & Bullock, 1991), and behavioral health(Minsky-Kelly et al., 2000; Vandemark & Mueller, 2008). According to Freedberg(2008), one could expect that "nurses will have contact with victims orperpetrators of violence in all practice settings" (p. 202).The U. S. Department of Justice, Bureau of Justice Statistics, (2004)reported that while men can also be victims of domestic violence, at least 85% ofdomestic violence victims are female. Intimate partner violence remains theleading cause of injury and death among American women in their child-bearingyears (D'Avolio et al., 2001; Stinson & Robinson, 2006). Clearly, intimate partnerviolence has been recognized as a major health concern for women (Davis,Parks, Kaups, Bennick, & Bilello, 2001) and carries significant implications for thenursing profession. Intimate partner violence has moved beyond "closed doors"as a family matter, and has been identified as a social and public health concernwherein sectors such as health care providers, educators, and legislators haveobligations to intervene (Freedberg, 2008; Hinderliter et al., 2003; Sekula, 2005 ).National objectives were identified in Healthy People 2010, including anobjective to reduce intimate partner violence through detection and intervention(U.S. Department of Health and Human Services, 2000). This concept waspreviously articulated by the ANA in its 1992 position statement. The ANA

22endorsed "education for nurses, health care providers, and women in skillsnecessary for prevention of violence against women" (p. 8). The ANA went on todocument support for "assessment of women in health care institutions andcommunity settings, and research on violence against women" (p. 8). Thisstatement was made in 1992, yet it remains a pressing issue in professionalpractice of nurses in 2009. The American Association of Colleges of Nursing(AACN) formulated its position statement in 2000, with the recommendation that"faculty in educational institutions preparing nurses in baccalaureate and higherdegree programs ensure that the curricula contains opportunities for all studentsto gain factual information and clinical experience" (AACN, p. 63) pertaining tointimate partner violence.Hinderliter et al. (2003) articulately expressed the responsibility of nursingfaculty, "Nurse educators must provide students with the words, body language,and screening measures" in order to become effective caregivers with clientswho have experienced IPV (p. 449). Warshaw, Tart and McCosker-Howard(2006) identified that educators have far-reaching obligations, among them, theability to "provide training experiences that foster the development of . . .understanding and skills, institutional structures that support their integration intoroutine practice, and faculty who model non-abusive behavior in all aspects oftraining and clinical care" (p. 63). Freedberg (2008) clearly affirms "It is time forfaculty to closely examine current violence prevalence statistics, make curriculardecisions that are data driven and based on empirical research" and develop

23original and creative teaching strategies to equip nurses to respond to societalissues related to violence ( p. 204).IPV and Nursing CareNurses are in an exceptional role to intervene with recipients of intimatepartner violence (AACN, 2000; Carney & McKibbin, 2003; Davila, 2005;Freedberg, 2008; Roberts, 2006; Shattuck, 2002). Such interventions may takethe form of routine physical and emotional assessments, assisting with safetyplanning, and accurate, appropriate documentation. Additionally, nurses are inthe position to offer referrals to suitable, and often life-saving, resources. WhileIPV has been identified as a public health and nursing curricula priority, literatureindicated that nurses in professional practice report a lack of education related toIPV in their nursing education programs (Hinderliter, et al., 2003; Warshaw, Taft,& McCosker-Howard, 2006; Woodtli, 2000; Woodtli & Breslin, 2002).IPV and Professional EducationA study of public health nurses and hospital staff nurses reported that"only slightly more than 50% of practicing nurses reported having any educationrelated to abuse", (Moore, Zaccaro & Parsons, 1998, p. 180). In addition, Woodtli(2000, p. 175) identified there was a "lack of violence-related content" in nursingprogram curricula.Woodtli (2000) conducted a qualitative study to identify attitudes, essentialskills, and knowledge required by nurses in order to offer appropriate, sensitivecare to survivors of IPV. That study interviewed 13 nurses regarding theirexperiences in caring for clients in violent relationships. Themes included

24feelings, judgments, and actions taken by nurses. When asked, "What do nursesneed to know about domestic violence?" answers reveale

Science in Nursing program. 5. Educational intervention: a two-credit, non-clinical elective including didactic content and community-based experiences. 6. Attitude: mental position, emotion, or feeling toward a fact or state (Merriam-Webster Online Dictionary, 2009). 7. Skill: the ability to use one's knowledge effectively and readily in