The Readiness of Australian Health Care Students to Encounter Patients Experiencing Partner Abuse

Abstract

Partner abuse is a significant contributor to mortality and morbidity worldwide, and has been identified as a priority health care issue. Most health care students rarely receive education on partner abuse and report not feeling ready to encounter patients experiencing partner abuse. Analysis of the current readiness of health care students and can inform educational needs to address this gap. The READIness to encounter partner abuse patients Scale was delivered to a convenience sample of Australian prequalification health care students. Participant demographics and estimated hours of education were also reported. Mean readiness scores were calculated by discipline. The relationship between hours of education and readiness scores was calculated using linear regression. A total of 926 participants were included in the analysis. Approximately half of the participants (47.5%) reported less than two hours of education. Mean readiness of students was 4.99 out of 7 (SD 0.73, range 4.39–5.95). Linear regression revealed a significant association between hours of education and readiness, r(925) = .497, p < .000. Australian health care students receive little education about partner abuse, and do not report feeling ready to encounter patients experiencing partner abuse. An individual’s confidence and belief in their abilities appear to be the key factor influencing overall readiness. Participants indicated a strong belief that responding to partner abuse was part of their professional role, which is a positive change from previous research. Higher hours of education is associated with higher readiness, though which educational methodologies are most impactful remains unclear.

Keywords

domestic violence intimate partner violence education medical perceived readiness health care allied health

Introduction

Partner abuse (also called intimate partner violence) is a leading cause of mortality and morbidity worldwide (Krug et al., 2002). Partner abuse is defined as any behavior within an intimate relationship causing physical, psychological, or sexual harm, and population surveys have reported that between 10% and 69% of women report physical abuse alone within a relationship at some point in their life (Krug et al., 2002). The impacts of partner abuse on physical and mental health can be profound and long-lasting (Black, 2011), and as such it is a priority health care issue (Garcia-Moreno & Watts, 2011).

While most health care workers are believed to frequently encounter patients experiencing partner abuse (World Health Organization [WHO], 2013), the number of hours spent on education for how to manage these patients is low for most professions (Crombie et al., 2017; Davidson et al., 2001; Sawyer et al., 2018; Waalen et al., 2000). Current evidence indicates that health care students generally receive less than two hours of education as part of their prequalification education (Crombie et al., 2017; Potter & Feder, 2018; Valpied et al., 2017) which may be inadequate to deliver comprehensive education resulting in skilled practitioners. Furthermore, research on educational interventions has focused on building knowledge rather than skills and confidence (Sawyer et al., 2016) and it is known that an individual’s lack of confidence in their abilities is a major barrier to discussing partner abuse with patients (Sprague et al., 2012), which can impact on referral rates to care and support. It is the role of health care providers to refer patients experiencing partner abuse to the right agencies to access care and support (García-Moreno et al., 2015).

The current emphasis in the health care sector is to improve education for students and practitioners on the recognition and referral of all forms of family violence and in particular partner abuse (WHO, 2013). To achieve this, it is necessary to develop effective educational interventions, a process that can be informed by knowledge about the current readiness of health care students to encounter patients experiencing partner abuse. There has been little high-quality research measuring the readiness of the health care workforce to encounter patients experiencing partner abuse, due largely to a lack of outcome measures which have been shown to be valid and reliable for a wide variety of health care professions (Sawyer et al., 2016). Those measures which are available were generally designed for physicians, rather than for the entire health care sector (Leung et al., 2017; Maiuro et al., 2000; Short et al., 2006), or created without robust theoretical underpinnings (Maiuro et al., 2000; Short et al., 2006).

The READIness to encounter partner abuse patients Scale (READI Scale) was designed for use by any health care student or practitioner, and initial psychometric evaluation with a sample of students from eight Australian health care professions demonstrated sound psychometric properties (Simon et al., 2020). In this scale, readiness is defined as a psychological state indicating an individual’s cognitive, motivational, and emotional inclination to respond to a phenomenon, which includes holding the required knowledge, resources, and skills to respond appropriately (Leung et al., 2017). Therefore readiness is a complex set of skills that encompass knowledge, attitudes, and skills. This study reports on data generated during the psychometric evaluation of the READI Scale.

The aims of this study are to report on the current readiness of health care students to encounter partner abuse patients, to report on the number of hours dedicated to family violence education reported by participants, and to evaluate the impact of hours of this education on overall readiness. Evidence presented in this research may highlight educational needs of health care students, and enhance the creation and delivery of educational interventions by identifying gaps in readiness.

Methods

Study Design

This study utilized a survey design, using a convenience sample of participants currently enrolled in a nine health care courses at one Australian university. Ethical approval was granted by the Monash University Human Research Ethics Committee.

Participants and Recruitment

Recruitment was undertaken between March and October 2018 at a large Australian university. Participants consisted of students undertaking undergraduate or postgraduate health care-related degrees in eight separate occupational disciplines (refer to Table 1 for full details). Participants were undertaking accredited bachelor and postgraduate programs that are required to practice in Australia within the respective disciplines. Recruitment was performed just before or just after scheduled classes. All domestic students attending classes who were 18 years or older were eligible to take part in the study. Students were asked to complete the READI Scale, which was accessible online via internet capable devices. Participation was voluntary and anonymous and all participants gave informed consent.

Instrumentation

This study used the READI Scale, a validated tool of readiness to encounter patients experiencing partner abuse (Simon et al., 2020). The READI Scale is a self-reported measure of readiness to encounter patients experiencing partner abuse and contains four subscales: Self-efficacy (confidence in abilities), Attitudinal-readiness (belief that partner abuse is a health care issue that should be considered when assessing patients), Emotional-readiness (comfort discussing partner abuse and reacting to disclosures), and Partner abuse knowledge (general knowledge of partner abuse). The scale has 27 items and uses a Likert-type scale, anchored by strongly agree and strongly disagree, with neutral as the central value. The scale contains both positively and negatively scored items. After reverse scoring negatively scored items, a mean score is derived with higher scores intended to reflect greater readiness to encounter patients experiencing partner abuse. In addition to scale items, participants were also asked demographic questions, and to estimate how many hours of family violence education they had previously received. The term “family violence” was used instead of “partner abuse” when estimating hours of education, as students would generally receive education on all aspects of family violence, and it would be difficult for respondents to estimate the hours dedicated to partner abuse as opposed to other family violence presentations. As students do not have compulsory attendance and there is some variation in content delivered within programs due to elective units it is not expected that students in the same program will be exposed to the same amount of education in this area.

Statistical Analysis

Data analysis was performed using SPSS version 24 by the lead author. Mean scores for total readiness and for each of the subscales were calculated for each student cohort in their final year of study. Hours of education was measured using interval options, and as the final interval option was “more than 8 hours” it was not possible to calculate a total mean hours of education. However, as only 6.78% of participants (n = 20) in their final year of study reported more than 8 hours education, using median interval values, with 8.5 hours for the final interval, an estimated mean hours of education was calculated. Linear regression was used to determine the relationship between hours of education and readiness scores.

Results

Demographic Characteristics

Across the 10 different health care courses represented in the data, a total of N = 944 responses were received, with n = 926 remaining after removing incomplete responses. The majority of participants were female (73.3%) and aged between 21 and 30 years (50.9%). Table 1 presents the demographic data of participants.

Table 1.

Participant Demographic Characteristics.

		n	%
	Total records	926
Student group	Medicine Ug	62	6.7
	Nursing Ug	105	11.3
	Occupational therapy Ug	71	7.7
	Occupational therapy Me	26	2.8
	Paramedicine Ug	315	34.0
	Physiotherapy Ug	67	7.2
	Psychology M	27	2.9
	Psychology PhD or D	16	1.7
	Radiography	198	21.4
	Social Work M	39	4.2
Year level	1	304	32.83
	2	174	18.79
	3	260	28.08
	4	188	20.30
Sex	Male	247	26.7
Sex	Female	679	73.3
Age range	18–20	374	40.4
	21–30	471	50.9
	31–40	46	5.0
	41–50	26	2.8
	51–60	6	.6
	Missing	3	.3

Note. Ug = Undergraduate; M = Masters; Me = Masters entry; PhD = Philosophical doctorate; D = Doctorate.

Reported Hours of Education for Students in Final Year of Study by Course

Of the participants who were in their final year of study (n = 297), 47.5% reported less than 2 hours of education. Social work students had the highest reported estimated mean hours of education (6.76 hours), with physiotherapy students reporting the lowest (.39). Using an estimated mean of hours of education, it was calculated that the mean hours of education for the final year students was 2.66 hours (refer to Table 2).

Table 2.

Hours of Education by Course for Participants in Final Year of Study (n = 297).

		Hours of Education											Estimated Mean Hours of Education
Cohort	Year	n	0	0–1	1–2	2–3	3–4	4–5	5–6	6–7	7–8	>8
Medicine Ug	4	62	11.3%	22.6%	17.7%	17.7%	16.1%	3.2%	3.2%	4.8%	3.2%	.0%	2.27
Nursing Ug	3	35	20.0%	20.0%	31.4%	8.6%	8.6%	.0%	.0%	5.7%	2.9%	2.9%	1.91
Occupational therapy Ug	4	13	7.7%	.0%	.0%	23.1%	7.7%	15.4%	23.1%	15.4%	7.7%	.0%	4.38
Occupational therapy Me	2	26	.0%	3.8%	3.8%	23.1%	26.9%	7.7%	11.5%	7.7%	.0%	15.4%	4.38
Paramedicine Ug*	2	85	9.4%	9.4%	23.5%	29.4%	20.0%	8.2%	.0%	.0%	.0%	.0%	2.21
Physiotherapy Ug	4	19	52.6%	36.8%	5.3%	5.3%	.0%	.0%	.0%	.0%	.0%	.0%	0.39
Psychology M	2	7	14.3%	.0%	14.3%	14.3%	.0%	.0%	14.3%	.0%	14.3%	28.6%	4.86
Psychology PhD	4	9	11.1%	33.3%	22.2%	.0%	22.2%	.0%	.0%	.0%	.0%	11.1%	2.22
Radiography Ug	4	22	13.6%	31.8%	36.4%	9.1%	.0%	.0%	4.5%	.0%	.0%	4.5%	1.57
Social work M	2	19	.0%	.0%	5.3%	5.3%	5.3%	5.3%	15.8%	5.3%	.0%	57.9%	6.76
All students		297	12.8%	15.8%	18.9%	17.8%	13.8%	4.7%	4.4%	3.4%	1.7%	6.7%	2.66

Note. Ug = Undergraduate; M = Masters; Me = Masters entry; PhD = Philosophical doctorate; D = Doctorate shaded numbers represent mode.

*2nd year paramedicine students undertook family violence education for the first time in 2018, meaning they had more education than 3rd year (final year) students, and therefore values for the 2nd year students are shown.

Participants who estimated a whole number of hours were instructed to respond in the upper interval (e.g., participants estimating 2 hours of education were instructed to respond in the 2–3 interval).

Mean READI Scores for Students in Final Year of Study by Course

The mean readiness of respondents was 4.99 (SD 0.73) out of 7 on the Likert scale. Social Work students reported the highest readiness (5.96), with Physiotherapy, Radiography, and Medical students reporting the lowest readiness score (4.40, 4.44, and 4.63 respectively). As can be seen from the subscale results, the largest range of variance in results was found in the Self-efficacy and Emotional-readiness subscales (2.27 and 2.11 respectively), with both the Motivational-readiness and Partner abuse knowledge subscales showing less than 1 point difference in the range of responses (.35 and .98 respectively). Refer to Table 3 for mean readiness results.

Table 3.

Mean (SD) Total Readiness and Mean Total Subscale Scores for Participants in Their Final Year by Cohort.

	Year	SE Mean	ER Mean	MR Mean	PK Mean	Mean Total Readiness
Medicine Ug	4	3.78 (1.15)	3.49 (1.41)	6.57 (0.38)	5.86 (0.52)	4.63 (0.72)
Nursing Ug	3	4.48 (0.86)	4.30 (1.37)	6.62 (0.53)	5.70 (0.76)	5.07 (0.61)
Occupational therapy Ug	4	4.65 (0.85)	4.60 (1.02)	6.72 (0.28)	5.89 (0.81)	5.26 (0.64)
Occupational therapy Me	2	4.55 (0.99)	4.62 (1.41)	6.55 (0.87)	5.83 (0.61)	5.17 (0.68)
Paramedicine Ug	2	4.42 (0.89)	4.86 (1.14)	6.59 (0.39)	5.55 (0.66)	5.11 (0.58)
Physiotherapy Ug	4	3.38 (1.05)	3.43 (1.64)	6.51 (0.39)	5.71 (0.72)	4.40 (0.74)
Psychology M	2	4.82 (1.35)	4.66 (2.02)	6.86 (0.22)	6.34 (0.49)	5.45 (0.90)
Psychology PhD	4	4.67 (0.57)	4.40 (1.09)	6.76 (0.28)	5.98 (0.61)	5.25 (0.42)
Radiography Ug	4	3.60 (0.89)	3.41 (1.23)	6.58 (0.39)	5.36 (0.62)	4.44 (0.56)
Social work M	2	5.64 (0.64)	5.52 (0.74)	6.77 (0.34)	6.34 (0.61)	5.96 (0.42)
All students		4.28 (1.09)	4.30 (1.44)	6.61 (0.46)	5.75 (0.68)	4.99 (0.73)
Range		3.37–5.64	3.4–5.51	6.5–6.85	5.36–6.34	4.39–5.95
Difference		2.27	2.11	0.35	0.98	1.56

Note. Ug = Undergraduate; M = Masters; Me = Masters entry; PhD = Philosophical doctorate; D = Doctorate; SE = Self-efficacy; ER = Emotional-readiness; MR = Motivational-readiness; PK = Partner abuse knowledge.

Relationship Between Readiness and Hours of Education

To evaluate the relationship between hours of education and readiness a linear regression was used. The model indicated a significant association, r(925) = .497, p < .000. The adjusted R square of .247 indicates that 24.7% of the variance is explained.

As can be seen from Figure 1, the slopes suggest the increase in readiness as hours of education increases is most pronounced in the Self-efficacy and Emotional-readiness subscales, while the Motivational-readiness and Partner abuse knowledge subscales remain relatively constant.

Figure 1.

Relationship between readiness and hours of education by total readiness and subscale results (N = 926).

Discussion

This study aimed to report on the current readiness to encounter patients experiencing partner abuse in a cohort of Australian health care students, to report on student reported hours of education dedicated to family violence within each health care course, and to examine the impact of hours of education on overall readiness to encounter patients experiencing partner abuse. The results indicate that the mean hours of education dedicated to family violence is low and that Australian health care students do report being ready to encounter patients experiencing partner abuse, although they believe that responding to partner abuse is part of their role. Results indicate that as hours of education increased so does overall readiness.

Hours of Education

Approximately half (47.5%) of all respondents in their final year of study reported less than two hours of education, and the estimated mean hours of education for final year students was 2.66 hours (range .39–6.76 hours). This is consistent with current research showing that approximately two hours of family violence content are included in Australian (Valpied et al., 2017) and United Kingdom (Potter & Feder, 2018) medical degrees, and in nursing degrees internationally (Crombie et al., 2017). Considering the complexity of the task of recognizing the indicators of partner abuse and responding appropriately, it is unlikely that two hours would be enough education to create skilled practitioners, which is evidenced by the low reported readiness of the cohort.

While the efficacy of education, rather than the hours spent, should be the primary indicator, hours of education may be a useful initial indicator of the importance each health care degree places on partner abuse education. Future research should examine the minimum hours of education necessary to properly prepare students, and evaluate the impact of different educational methodologies to ensure efficient use of allocated time.

Interestingly, many students undertaking degrees which do not contain any specific family violence education reported undertaking some education. The survey did not question participants about the source of the education, so it is presumed that these students received the education from sources outside their current degree. For example, there are numerous educational packages available in the public domain, or through professional bodies. Likewise, many students are expected to have lived experiences of family violence (McLindon et al., 2018; Sawyer et al., 2017), and may have sought education for personal reasons. Educators should be aware that students may receive education from external sources that may interact with course delivered educational interventions.

Readiness of Students in Their Final Year

The mean readiness score for all students in their final year was 4.99, meaning that on average they responded Somewhat-agree (5 out of 7 on the Likert scale) to items. This score indicates that students do not report strong readiness, as would be found with the 6 (agree) to 7 (strongly agree) range across all four domains. As students on average reported neutral Self-efficacy and Emotional-readiness it can be concluded that students do not feel adequately prepared.

Cohorts with higher readiness (Social Work, Psychology and Occupational Therapy), had stronger confidence in their abilities (Self-efficacy and Emotional-readiness), but similar strength in their belief that responding is part of their role (Motivational-readiness) and overall knowledge of partner abuse (Partner abuse knowledge). This is not surprising as the Social Work, Psychology, and Occupational Therapy students reported the highest hours of education. Additionally, their courses include skills-based education, which is believed to be more effective in improving confidence than didactic lectures, video lessons, or online education (Sammut et al., 2019; Sawyer et al., 2016).

In the psychometric validation of the READI Scale, it was found that overall readiness was mostly explained by the Self-efficacy and Emotional-readiness subscales (Simon et al., 2020). This finding indicates that a student’s overall readiness is more reflective of their belief in their abilities, rather than their knowledge or willingness to respond. In the present study, the finding that students did not report high readiness implies that interventions should prioritize educational methodology which increases self-efficacy and confidence, such as skills-based education, rather than just attempting to build knowledge.

Interestingly, Motivational-readiness was consistently high for all cohorts, ranging between 6.50 and 6.85 out of 7, meaning students responded Agree tending towards Strongly agree with items pertaining to the role of the health care workforce in responding to partner abuse. This indicates that all studied cohorts believe they should be responding to partner abuse as part of their role. In contrast, previous qualitative research has found that health care practitioners did not feel responding to partner abuse was part of their role (Sprague et al., 2012). This finding may signal a change in attitudes in the health care sector, though it is not clear if this is a difference between student and practitioner groups, or if this attitude will remain as the students’ progress to practitioner roles. Potentially this change may be in part due to increased media reporting within Australia on the prevalence and health consequences of partner abuse (Sutherland et al., 2019). Future research should examine if this belief changes as a student progresses to practitioner phases of practice, or if this is a belief which has permanently shifted. This finding may suggest that educators can devote less time to shaping attitudes around the health care practitioner’s role, which would allow greater emphasis to be placed on activities improving self-efficacy and emotional-readiness.

Partner abuse knowledge was also consistently high across the cohorts, with students responding between 5.36 and 6.64 (Somewhat-agree–Agree), for knowledge items. As can be seen from Figure 1, as hours of education increases Partner abuse knowledge remains relatively constant, which is an unexpected result. Potentially the educational interventions delivered are not impacting knowledge as they are aimed at too low a level of knowledge and students already have a high level of general knowledge about partner abuse. Alternatively, their general lack of exposure to patients in a clinical setting may be creating a false confidence, and students with greater exposure to actual cases may report lesser perceived knowledge. Future research that examines the associations between readiness scores and perceived knowledge versus actual knowledge, and examines the impact of exposure to actual patients experiencing partner abuse, may assist in understanding this finding. Regardless, the results indicate the respondents felt they had a good general knowledge of partner abuse, and therefore educators could devote more time to increasing more discipline-specific knowledge which can enhance skills.

Statistical Relationship Between Readiness and Hours of Education

The multiple linear regression model indicates that there is a significant relationship between hours of education and mean readiness, however it is noted that the relationship is weak. As discussed above, as hours of education increases, the largest increases in readiness are found in the Self-efficacy and Emotional-readiness subscales. This indicates that education is most impactful on confidence in abilities. It would now be useful to evaluate which educational methodologies, rather than simply hours of education, are most impactful on increasing readiness and in particular Self-efficacy and Emotional-readiness.

Implications for Future Practice

This research has provided evidence that Australian health care students are only receiving a small number of hours of education on partner abuse and that they have low self-reported readiness to encounter partner abuse patients. The psychometric results indicate that an individual’s Self-efficacy and Emotional-readiness, or their belief in their abilities, are key factors influencing overall readiness, and therefore future research should focus on isolating the educational methodologies which are most impactful at improving these constructs, for example, skills bases education (Sawyer et al., 2016). Australian health care students reported good Motivational-readiness, indicating they believe partner abuse is a health care issue and it is their role to ask patients about partner abuse, which is a positive change from previous research with practitioners. This may improve willingness of students to engage with partner abuse content, and less time may be devoted to motivating students to incorporate responding to suspected partner abuse into their future practice. Some cohorts, for example, Social Work, reported higher hours of education and higher readiness, and it would be useful to study the educational methodologies used with social work cohorts to determine learnings that may be useful for other health care courses.

Limitations

This study was limited in that a convenience sample from a single institution was used. Females made up almost three-quarters of respondents, which is disproportional to student enrolments. Exposure to actual patients experiencing partner abuse whilst on clinical placements was not measured, which may impact readiness scores. This scale used was a self-reporting measure, and therefore self-serving bias may have impacted results, further research demonstrating the association between the READI Scale and actual performance would assist in measuring the impact of this bias. The study did not include all health care student populations, and future research in a wider range of cohorts would be useful, in particular nutrition and dietetics, pharmacy, dentistry, and midwifery. While this study focused on partner abuse, this topic is not covered in isolation from other forms of family violence (e.g., child abuse and neglect, elder abuse, sexual violence) in education typically delivered to these participants. Therefore associations reported were between reported hours of family violence education in general, and not just education on partner abuse, which may impact correlations between hours of education and overall readiness.

Conclusions

Australian health care students are receiving a small number of hours of education on partner abuse, and they do not report being ready to encounter patients experiencing partner abuse. Students reported low self-efficacy and emotional-readiness which indicates they do not feel confident in their abilities. Participants reported high motivational-readiness, meaning that they believe responding to partner abuse is part of their role, which has not been found in previous research with practitioners. There appears to be a link between hours of education and readiness, though it is unclear which educational methodologies are most impactful. Future research should investigate the most effective educational methodologies, specific to each discipline and their role in responding to partner abuse, to ensure efficient use of time to prepare students for clinical placements and future practice.

Footnotes

Author’s Note

Simon Sawyer is also affiliated with Monash University, Clayton, Victoria, Australia and Glenn Melvin is also affiliated with Deakin University, Burwood, Victoria, Australia.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Simon Sawyer

Author Biographies

Simon Sawyer, PhD, is an advanced life support paramedic and lecturer of Paramedicine at Australian Catholic University in Melbourne Australia.

Michal Schneider, PhD, is from Department of Medical Imaging and Radiation Sciences, Monash University.

Deborah Western, PhD, is from Department of Social Work, Monash University.

Helen Bourke-Taylor, PhD, is from Department of Occupational Therapy, Monash University.

Lousie Farnworth, PhD, is from Department of Occupational Therapy, Monash University.

Katherine Lawerence, PhD, is from School of Psychological Sciences, Monash University.

Primrose Lentin, PhD, is from Department of Occupational Therapy, Monash University.

Gayle McLelland, PhD, is from School of Health and Human Sciences, Southern Cross University.

Glenn Melvin, PhD, is from School of Psychology, Deakin University.

Katrina Recoche, PhD, is from Department of Nursing and Midwifery, Monash University.

Ronald Schweitzer, MBBS, is from Department of General Practice, Monash University, Monash University.

Janette Simmonds, PhD, is from Faculty of Education, Monash University.

Michael Storr, BPT, is from Department of Physiotherapy, Monash University.

Nikos Thomacos, PhD, is from Department of Occupational Therapy, Monash University.

Angela Williams, MBBS, is from Victorian Institute of Forensic Medicine, Monash University.

Brett Williams, PhD, is from Department of Paramedicine, Monash University.

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