Should we be concerned? A qualitative study of educators’ perceptions of medical student wellbeing in domestic violence training

Abstract Introduction Domestic violence (DV) is common in the Australian community so it is likely that there will be medical students who are affected personally by DV. Some of these students may find DV training confronting or even re-traumatising. A trauma-informed medical education (TIME) framework utilising trauma-informed care principles may minimise this risk to students. We aimed to explore educators’ perceptions of student well-being in Australian medical school DV training. Method This descriptive qualitative study interviewed 13 educators with experience teaching DV in Australian medical schools using an interpretivist methodology and a TIME framework. Interview data was thematically analysed to identify themes. Results Four key themes included (1) educators thrown in at the deep end; (2) keeping students emotionally safe; (3) a trauma-informed learning environment and; (4) challenges of student DV disclosures. Few of the participants had received training in DV. Educators used methods such as trigger warnings and ground rules to improve student’s emotional safety. Experienced educators dealt with disclosures of DV by students which led to role confusion. Discussion There is a need for increased training of medical educators that includes awareness and implementation of TIME principles when training medical students in DV as well as increased supports and resources for educators.


Introduction
Domestic violence (DV) is recognised as a major public health problem in Australia and globally (World Health Organisation 2013).DV is defined as any behaviour within a domestic relationship that causes physical, psychological or sexual harm (World Health Organisation 2013).Australian prevalence studies in the general practice setting range from 8.0% to 28% of women being subject to DV in the previous 12 months (Mazza et al. 1996;Hegarty and Bush 2002).Therefore, it is common for doctors to encounter survivors of DV, often unknowingly, as victim-survivors frequently utilise health services (Ansara and Hindin 2010).
Health care professionals face many barriers, exacerbated by a lack of education, in routinely identifying and supporting victim-survivors of DV (Sprague et al. 2018;Tarzia et al. 2021;Hudspeth et al. 2022).A 2017 review of Australian university medical programs found that of 15 medical schools, 13 taught DV but the median hours devoted to this topic was only two hours despite its' prevalence (Valpied et al. 2017).The teaching of DV in medical schools is not without risk to the wellbeing of students.For example, a recent Australian study found that 45.2% of female health professionals were personally affected in some way by violence from a partner and/or family member during their lifetime either by directly being a victim-survivor or by witnessing violence (McLindon et al. 2018).Two US studies reveal a lifetime prevalence of violence in medical students of both genders between 34% and 53% (DeLahunta and Tulsky 1996; Ambuel et al. 2003).Given this prevalence, it is highly likely that there will be students within each medical school cohort that have been affected by DV in some way (Russell et al. 2008).Although some students may find the teaching personally helpful, it is possible that students who have been personally affected may find sensitive content like DV training challenging or even

Practice points
Domestic violence (DV) is common and medical students who have been affected by violence may find DV training re-traumatising A trauma-informed medical education (TIME) environment may increase the safety and wellbeing of medical students Educators who teach DV to medical students would benefit from training in DV and TIME principles Resources and avenues for support for educators are suggested to reduce any vicarious trauma potentially re-traumatising (Durfee and Rosenberg 2009;Collins 2013;Scriver and Kennedy 2016).
A trauma-informed medical education (TIME) framework, which stems from a trauma-informed care (TIC) framework (Substance Abuse and Mental Health Services Administation 2014) (see Table 1) has been recognised as filling a crucial educational gap and could inform the curricular content of all medical schools (Brown et al. 2021).TIC is a framework which aims to reduce the adverse health consequences of trauma by reducing the risk of retraumatisation and enhances the psychological safety of all those in an organisation including staff, students, and patients.A TIC organisation adopts a universal traumainformed approach that is based on the six domains of safety as outlined in Table 1 (Substance Abuse and Menta Health Services Administration 2014; Brown et al. 2021).A TIME approach, using TIC principles, minimises risks to student well-being when it informs all aspects of teaching including curriculum development, delivery of teaching, environmental factors, and assessments (Kennedy and Scriver 2016;Brown et al. 2021).
Much of the literature about teaching DV to university students is from the social sciences, is anecdotal and does not always use a trauma-informed framework (Russell et al. 2008;Carello and Butler 2014).There is little literature specific to experiences of teaching medical students DV or how educators perceive the well-being of medical students in DV training (Congdon 1997;Hendricks-Matthews 1997;Kennedy and Scriver 2016).This study aims to fill this gap by exploring educators' experiences teaching the DV curriculum and their perceptions of student wellbeing during DV training using a TIME theoretical framework (Brown et al. 2021).Our research question was 'How do educators perceive medical student wellbeing in domestic violence training?'

Study design
A descriptive, qualitative study design was used following the approaches of Crabtree (Crabtree and Miller 1999), Creswell (Creswell 2013) and reported drawing from the American Psychological Association Qualitative Design Journal Article Reporting Standards (APA JARS-Qual) (American Psychological Association 2020).APA JARS-Qual are a set of guidelines for qualitative research designed to enhance scientific rigor in research reporting, increasing accuracy and transparency.Following these guidelines allowed us to determine what information to report to enhance integrity.The study was conducted from an interpretivist perspective (Creswell 2013) with interviews conducted by (JN) who is an experienced medical educator teaching into a DV training program in an Australian University.This allowed the interviewer to draw upon their position as an insider to gain a deep understanding of the participant's perceptions.JN had previously noticed while teaching medical students DV that several students were affected emotionally by the teaching which gave rise to our research question.This position as an insider was managed by frequent reflexive discussions with her co-authors including CB who was an 'outsider' which allowed different perspectives to be aired as well as keeping a reflexive journal (Olmos- Vega et al. 2022).Discrepancies with authors were resolved through discussion.
Ethics approval for the study was received from the Monash University Human Research Ethics Committee #2020-24596.

Participants and sampling
Purposeful sampling was used to select participants for interviews (Pope and Mays 2006).Medical doctors with experience teaching the DV curriculum to medical students were invited to take part either directly through an email from the authors or from the curriculum leads at their university.Analysis of data occurred concurrently with recruitment and further purposeful sampling occurred until there was sufficient diversity in the population of study and a richness in data had been collected (Braun et al. 2019).The data was informed by information power whereby the size of the sample was dependent on a number of variables as outlined by Malterud et al. (Malterud et al. 2016).
All participants taught a DV component of their curriculum to medical students in an Australian University.Participants were assured that they would not be identified, and all data would be kept confidential and not linked to an individual educator.A consent form and explanatory statement were emailed after interest was expressed and a signed consent form was obtained prior to the interview occurring.A fiftydollar gift voucher was offered to participants for their time.

Data collection
A semi-structured interview guide was developed and informed by the experience of JN as a DV educator (see Supplementary Material).JN was not in a position of power over the participants as she was not the line manager for any of the interviewees.Pilot interviews were held with the first two participants and transcribed and discussed amongst JN and CB.The quality of the information generated was reflected upon and small refinements were made to the interview guide such as changing the order of the questions, but the quality of these pilot interviews was deemed to be good and so the data was retained for analysis.
All interviews took place using video conferencing (Zoom TM ) between August 2020 and November 2021 due to COVID-19 restrictions that were in place and the geographical distance of participants.The audio from the interviews was transcribed verbatim by the interviewer or professionally transcribed.Participants were interviewed concurrent with data analysis such that there was an iterative process of data collection, transcription and analysis.The data exhibited a richness that enabled it to answer the research question as judged through peer debriefing and discussion with the co-authors (Lincoln and Guba 1985).

Data analysis
Transcripts were entered into QSR NVivo TM software to support the thematic analysis.This analysis was guided by Braun and Clark (Braun and Clarke 2006) and involved reading and re-reading the transcripts multiple times, identifying codes, and organising them into a preliminary coding frame.This initial coding frame was developed by the interviewer (JN) and then discussed with the other authors.From these discussions the coding frame was refined and revised and the transcripts re-coded.These codes were then grouped into themes and further refined through discussion with the authorship team.Reflexive discussions and the contents of the reflexive journal were utilised during the analysis.

Results
Participants had a range of ages and genders (Table 2).All participants were medical doctors with ten general practitioners, two training in medical specialties, and one a sexual health/forensic medicine physician.There was a wide range in years of experience teaching DV from one to 26 years with a median of six years teaching experience.The educators all taught into programs where teaching was not confined to DV and teaching involved both preclinical and clinical years of the medical degree.They taught into five different universities.Teaching methods included lectures, tutorials, and clinical supervision.Only four participants were involved in giving lectures.Twelve participants gave tutorials.Tutorial content included roleplays, student-led discussion, and case-based discussions.Clinical supervision involved seeing patients with the student and leading case-based discussions.The average interview duration was 22 min and interviews lasted between 14 min and 37 min.
Four main themes were identified: educators thrown in at the deep end, keeping students emotionally safe, trauma-informed learning environment, and challenges of student DV disclosures.

Educators thrown in at the deep end
Participants felt that their readiness to teach this topic reflected their past training experiences in sensitive issues and clinical exposure to DV. Participants often compared their approach to teaching DV with teaching other sensitive topics like suicide, self-harm, and palliative care.They also drew on their clinical experiences to inform their teaching although several participants had neither training nor clinical experience of DV.
A shared narrative was that initially they had been thrown in at the deep end.As they were not provided with any formal training or resources, they had to look up the topic or speak to previous lecturers on the phone to find more information about it: So at (University) they had a specific domestic violence day.And I just taught that once actually because the person who was going to give it was sick that morning and so I just kind of got thrown in to give the seminar.ID9, F, 31-40, 9 yrs exp This led to educators doing their own research and identifying appropriate resources prior to teaching it.Having mostly received either ad hoc training or no training at all in DV, less experienced participants wanted more training while those with more experience reported increased confidence in approaching DV teaching.Participants noted that prior to teaching DV, it is likely that they may have missed cases in their own clinical work with one educator reflecting on how teaching had informed their own clinical practice: I have found myself being a better GP because of my teaching.So, an example of that … some of the things I was saying in Whilst many educators felt like they had been thrown in the deep end they also described the strategies that they used to keep students emotionally safe.

Keeping students emotionally safe
Preparing teaching to keep students emotionally safe is an important part of teaching DV and for the educators in this study involved structuring the timing of teaching sessions and contacting students to prepare them for this sensitive topic.Most participants did not have any control over the timing of their teaching arrangements or curriculum.They did, however, discuss the importance of the placement of teaching sessions within the timetable.
Participants noted that having lengthy teaching sessions, particularly at the beginning of the day was problematic as many students felt distressed engaging in sensitive DV topics and would find it difficult to go on to other teaching sessions later in the day: Too long … you know I had to go home after the session.Doing 5 hours … maybe it was 3 or something, but I had to go home because it was so draining.And then the students were supposed to go on to something else but a lot of them went home after that session … .I don't think they do it like that anymore because of the level of student distress around it.ID9, F, 31-40, 9 yrs exp Participants noted clear benefits to having established a longer-term relationship with students prior to conducting DV training.For example, educators found they were better able to pick up cues on student well-being if they were familiar with the group compared to having no previous relationship: The third years, I just picked them up on zoom and I otherwise didn't know them from a bar of soap.Which makes it a lot harder to be really sure about the safety.ID6, F, 31-40, 1 yrs exp Participants who taught both lectures and tutorials agreed that small group teaching in tutorials provided an emotionally safer environment than lectures.In tutorials it was much easier for participants to get to know the students, notice if they were struggling, appropriately debrief with them, and respond to their individual needs.
Participants were mindful of the sensitivity of the topic and aware that some students may have been affected personally by DV.For this reason, participants used a variety of techniques to prepare students prior to teaching including sending trigger warning emails, DV support numbers, and inviting students to contact them if they felt distressed.Some educators also gave students the opportunity to either miss the tutorial altogether or leave if they were feeling distressed by the content.I'm in frequent email contact with the students setting them tasks … , so prior to the tutorial I send them a note to say the next session is on domestic violence and if you feel uncomfortable in any way absolutely then you can excuse yourself.ID2, M, 60þ, 3 yrs exp In addition to preparing students to keep them emotionally safe, educators made attempts to integrate a trauma-informed learning environment.

Trauma informed learning environment
The integration of TIC principles into teaching was ad hoc and Universities did not offer any formal training in this area.Despite this lack of training, participants discussed the importance of setting ground rules for teaching sessions to ensure a safe teaching environment.To reduce anticipatory anxiety, experienced educators would acknowledge the sensitivity of the topic at the commencement of the teaching session.This would occur alongside setting ground rules to establish a trauma-informed learning environment.Ground rules included permission for students to switch cameras off, leave or take a break as well as reminding students about a respectful teaching environment including confidentiality.
And we have phone numbers to ring and so on, and actually I've started putting a trigger warning at the beginning … that's become a trauma informed sort of teaching.ID13, F, 60þ, 26 yrs exp Some participants discussed the use of roleplays to teach DV content.Whilst they recognised the usefulness as a learning tool, educators noted that some students may become distressed if they were cast in the role of the victim-survivor or expected to run a full case as the 'doctor' in front of their peers.To avoid this, some participants described alternatives, including employing a simulated patient to play the role of the victim-survivor and rotating the students through the case as 'doctor,' 'fishbowl' style.
We have simulated patients, so we are not getting for example students to role play the patient … I wouldn't have one student roleplaying that consultation so I have them in teams roleplaying the consultation and then they tag team, so that you know there might be 5 students taking it in turns so that it's not so intense … ID8, F, 41-50, 4 yrs exp Most participants were involved in the rapid transition to online teaching during COVID-19 in 2020-2021.There were both pros and cons to teaching this content online, particularly in relation to monitoring medical student wellbeing.Perceived benefits by participants included being able to send a private message to a student during a teaching session and for students to be able to switch off their camera if they were finding the content distressing.It was also felt that the roleplays had lower fecundability when held online and for this reason, the environment was more depersonalising.
There were, however, many concerns identified by the participants in using online learning to teach this sensitive content.Educators felt that online teaching made it much more difficult to read student's body language, so educators didn't know if students were being triggered by the content.Eye contact was also difficult to achieve online with many educators reporting difficulty in picking up cues on students' wellbeing: I don't know, I mean, it may be a less supportive environment, you know you can see much more body language when you are in person to person, you can miss those cues that mean that people are uncomfortable and uneasy in situations.So, it maybe does make it a less supportive environment.ID2, M, 60þ, 3 yrs exp Despite attempting to create safe learning environments to teach DV, educators encountered some challenges when students disclosed personal experiences of DV.

Challenges of student DV disclosures
The more experienced the educator participant, the more likely they had experienced disclosures by students who had been affected by DV.This usually occurred at the end of a teaching session with experienced educators making sure they were the last to leave the session (online or face to face) in case someone had questions or wanted to disclose.For the most experienced educators, disclosures were a frequent occurrence: I've learnt to hang around at the end, and relatively often they'd be one or two students that came and wanted to talk to me.ID13, F, 60þ, 26 yrs exp One of the downsides to online teaching was that students disappeared as soon as the tutorial is over, creating less pastoral care opportunities.Educator participants in general felt pulled in two directions when it came to counselling students as they tended to use their clinical skills to assist students whilst also referring students to appropriate services and supports within the University.Those that drew on clinical skills acknowledged that they experienced role confusion as they did not have a doctor/patient relationship with the students.
That actually becomes really problematic.You don't want them to have any dependency either.That therapeutic relationship that you might have with them.You can't prescribe any medications or things like that.ID11, F, 51-60, 15 yrs exp The educator's own wellbeing when managing disclosures was also noted with one educator sharing their exhaustion at managing students who were victim-survivors of violence when they were not equipped or supported properly to do so: And I just thought, there's got to be a better system, I mean I'm not a GP and I was referring them for a lot of mental health stuff or for violence stuff and I got really knackered because it shouldn't be just the one person that does it.ID11, 51-60, 15 yrs exp

Discussion
This study looked at how educators perceive medical student wellbeing in domestic violence training.Four themes were found from the interviews with 13 educators who teach DV to university students in Australia.These were, educators, thrown in at the deep end, keeping students emotionally safe, trauma-informed learning environment, and challenges of student DV disclosures.Based on the results, it is clear that educators were ill-prepared to teach DV, similar to many doctors who have undergone little training themselves given the low level of DV education amongst doctors (Feder et al. 2011;Sprague et al. 2018).Improving the training of doctors in DV will likely improve the readiness of medically trained educators to teach DV to the next generation of doctors.
This study found that educators perceive that appropriate preparation needs to take place for students to be emotionally safe in DV training.Educators felt that trigger warnings were important.In general, students also prefer forewarning of sensitive topics (Lowe 2015;Scriver and Kennedy 2016;Nolan and Roberts 2022).Drawing on the TIME framework (Brown et al. 2021), this forewarning of a sensitive topic is known as a 'trigger warning,' (Scriver and Kennedy 2016) and allows the student a chance to prepare themselves psychologically for the teaching and may reduce hyperarousal and distress as well as to promote self-care (Nolan and Roberts 2021).However, trigger warnings may also have potential drawbacks as they may pre-empt a negative response, and perpetuate avoidance culture (Nolan and Roberts 2022).Providing students the option of non-attendance or leaving training sessions early was one strategy educators described using.On the one hand medical students are training to be doctors and will need to understand DV to be able to practice, (Kennedy and Scriver 2016) on the other hand some researchers argue that students should be given the option to avoid something they may find re-traumatising (Dalton 2010;Zurbriggen 2011).However, non-attendance is unlikely to be the objective and trigger warnings should prompt self-care strategies to allow students to prepare and to seek supports (Nolan and Roberts 2021;Cebula et al. 2022;Nolan and Roberts 2022).
Based on the sensitivity of issues around DV and its prevalence across Australia, a TIME framework that integrates TIC principles into the health professions curriculum could be mandated (Brown et al. 2021).In this study, educators described ad hoc approaches to a trauma-informed learning approaches with many participants having to set ground rules to increase the safety of the learning environment to ensure they minimise and/or manage any distress that may arise (Konradi 1993;Durfee and Rosenberg 2009;Kennedy and Scriver 2016).This includes acknowledging that there may be differing opinions in the group, a reminder to be respectful and to uphold confidentiality (Russell et al. 2008).There is a need for increased awareness and implementation of TIME principles when training medical students in DV and this could be achieved through increased formal training of university educators.
Disclosures of DV by students are common for educators who teach sensitive topics, (Hayes-Smith et al. 2010;Zurbriggen 2011;Kennedy and Scriver 2016;Scriver and Kennedy 2016) with experienced educators in this study commonly experiencing disclosures.Importantly, students who feel negative about their disclosure to an educator often increase their level of distress and may reduce helpseeking (Ahrens 2006).For this reason, it is important for educators to have knowledge of support services in their educational institution and community (Zurbriggen 2011;Carello and Butler 2014).This may provide a case for choosing DV educators who are active in clinical practice which may improve their preparedness to not only teach the topic but also manage disclosures.However, as described in this study, educators must be wary of roleconfusion (Zurbriggen 2011;Carello and Butler 2014;Scriver and Kennedy 2016) as they do not have a doctorpatient relationship with their student.Educators also need resources and avenues for seeking their own support as educators are at risk of vicarious trauma due to both role confusion and from empathic engagement with a student who has been affected by violence (Kennedy and Scriver 2016).Vicarious trauma may occur when working with people who have experienced trauma and is a negative transformative process (Huggard and Unit 2013).Vicarious trauma may occur when staff empathetically engage with trauma survivors.Organisations that utilise a TIME framework reduce the risk of vicarious trauma to staff by enhancing psychological safety, empowerment, and peer support (Substance Abuse and Mental Health Services Administration 2014).

Strengths and limitations
Although there were a limited number of participants interviewed, they had taught into at least five different medical school programs, increasing the transferability of the results.This study relies on educator perceptions of student wellbeing, rather than students own accounts.Another limitation of this study was that all interviews took place during the COVID-19 pandemic when all teaching was occurring online, a time of heightened emotional stress and concerns about the health and mental health of young people.This could have influenced the recall and perceptions of participants with a focus on teaching online during the pandemic.There may have been limitations in holding interviews online, especially when discussing a sensitive topic as body language, facial expressions, and eye contact may be difficult to interpret online.This may also reduce the use of active listening skills in the interviewer which may make the interviewee feel less comfortable.However online interviews tend to generate similar themes as in-person interviews and the differences are modest (Krouwel et al. 2019).It was not seen as an impediment in this study as it occurred during COVID-19 pandemic lockdowns and participants were well-practiced in the use of Zoom TM .There was a high level of engagement between the interviewer and participants during the interviews which was reflected in the richness of data that was collected.

Conclusion
This study shows that educators are considering the wellbeing of students during DV training in Australian medical schools by attempting to create a trauma-informed learning environment.However, despite these attempts, educator readiness and the process of creating a traumainformed teaching environment tends to be ad hoc and inconsistent.There is a need for increased DV training amongst medical doctors to improve their readiness to teach DV and there is the need for increased awareness of TIME principles across medical curriculum.Future research could be undertaken to explore student's own perceptions of the emotional safety of being taught DV, or by observation of classes when these or related sensitive topics are being taught.Student and educator well-being has been identified as a key research area in medical education (Palermo et al. 2019).

I
'd love to have some specific training.(laughs) Similarly with a lot of things in general practice training.ID6, F, 31-40, 1 yr exp

Table 1 .
Substance Abuse and Mental Health ServicesAdministration (SAMHSA) Trauma-Informed care (TIC) framework (Substance Abuse and Mental Health Services Administration 2014; Anyikwa 2016).Four key assumptions of a trauma informed organisation Realisation Realises the impact of trauma Recognise Recognises the signs or symptoms of trauma in patients, staff and students Respond Responds by applying TIC principles Resist Actively resists re-traumatisation of all people associated with the organisation Six key principles of a trauma informed organisation Safety All people associated with the organisation feel physically and psychologically safe Trustworthiness and transparency Maintains trust with all people who are associated with it Peer support Lived experiences and stories promote recovery and healing Collaboration and mutuality A sharing of power and decision-making occurs Empowerment, Voice and Choice Builds on individuals' strengths restoring power and control Cultural, historical and gender issues Considers marginalised groups and recognises and addresses historical trauma

Table 2 .
Description of study participants.