Nicky Stanley, Eszter Szilassy, Cath Larkins, Jess Drinkwater, Jo Morrish, Jodie Das, Adam Firth, Kelsey

Hegarty, MarianneHester and Gene Feder

 BASPCAN Congress, Edinburgh April 12-15 2015

Working at the interface of domestic violence and child

protection: developing skills and confidence in general practice

Dr Eszter Szilassy

RESPONDS

Researching Education to Strengthen Primary care ON Domestic violence &

Safeguarding

Aim: to understand the barriers to developing practice at the interface of domestic violence and child safeguarding in the context of primary health care

RESPONDS

Analysis of training content

Systematic review

Interview study

Consensus process

Integrating key

messages from

evidence into

guidance

Pilot training and

evaluation

Training curriculum developm

ent

DELIVERY AND EVALUATION

TRAINING DEVELOPMENTRESEARCH

07/2012 12/2014

Interview studyAim: to understand the dilemmas and challenges primary care

clinicians face when confronted with children’s exposure to DVA

Method:

- Semi-structured in-depth phone interviews using vignettes (one vignette per professional group)

- 69 Primary Health Care Professionals (42 GPs, 12 Practice Nurses, 15 Practice Managers)

- 6 sites in England from north, south and midlands - practices selected based on rurality and DVA service development.

- Audio-recorded, transcribed verbatim

- Coded in NVivo

- Analysed using Framework Method

Summary of findings and cross-cutting messages

1. Considerable variation in GPs’ responses to the same vignette within and across practices. Variation in approaches, assumptions and thresholds of harm

2. Great uncertainty about directly responding to the exposure of children to DVA.

3. Some examples of positive practice

4. Poor interagency work; lack of ‘institutional empathy’; unawareness of DVA services, resources

5. Inconsistent, confused and unsafe recording practices and policies

6. Need for greater clarity in guidance and training for GPs in responding to the linked issues of DVA and CS

Dominant themes1. Making links between DVA and child

safeguarding in practice

2. Child protection referral process and threshold for referral

3. Holding difficult conversations with victim and family

4. Interagency work

5. Recording DVA and

confidentiality

1-2. Understandings of risks, processes and procedures

• Low awareness of link between DVA and child safeguarding• Limited experience identifying DVA in families• Physical abuse focus• Struggle to manage families if risks uncertain/low/medium

Reasons for not exploring DVA when there are known child safeguarding concerns:

- DVA not being ‘first on your radar or list of things to ask about’- not having sufficient time- ‘difficult conversation to have’- ‘already passed on’ - social services would already be dealing with the

family

INT: ‘Do you ask about DV when you know there is a child safeguarding issue?’

‘No. I never have thought of that. That is a difficult conversation to have.’ GP

‘We are frequently seeing patients with multiple pathologies, multiple problems, often running late in surgery, in a pressured surgery situation when you've got three other problems to deal

with.’ GP

‘It's the ones in the middle that I struggle with where you think it's not quite right, you can't definitely say that there's something, that the children are at risk or that, that she…needs to go into a refuge or, you know, it's, it's the ones, because you know that you also have the potential … at any moment to kind of get worse and that's very unpredictable…’ GP

3. Talking to children about DV• Would seek to engage with children: 5/47 clinicians• Might engage, but would be ‘quite a way down the line’:

17/47 clinicians

Reasons for not engaging with children:• Not part of primary care role. ‘Examine them or what?’.

Role of ‘the team beyond us’, ‘the police’, ‘social work’. • Lack of training• Lack of children’s competence ‘I know how they can

sometimes twist things that adults say’• Fear that talking to children would involve making

accusation or increase risk by breaking confidentiality

‘I would find [talking to a child] quite difficult because they might not understand what I'm, what I'm getting at. And with the acute setting like this it's really, you haven't got enough time to get through that barrier’. Practice Nurse

‘You know, you're making this accusation about [name], or whatever, so I think that [talking to the mother is] how you kind of assess the kind of impact on the kids’. GP

‘I haven't got enough training to really know whether I'm saying the right sorts of things to children... would I be making things worse for them talking about it? …my other work I do a lot of end of life care, so I talk to children a lot about their parents dying and things and I find that a lot easier funnily enough than talking to them about violence.’ GP

3. Engaging with abusive parents

• 34/46 open to the idea of engaging with perpetrators

• 18/46 would be proactive – 7 would confront the perpetrator and share information without no clear understanding of safety and confidentiality risks

• 16/46 would respond to opportunities as they arose

4. Interagency work• Poor relationship with children’s social services• Lack of ‘Institutional empathy’• Uncertainty of own and others’ roles• Reliance on health visitors, but

weakening relationship • Low awareness of local DVA and other resources

‘The trouble with social services…they seem to lack understanding in what a general practitioner's job involves, so they'll often ask for a case conference and only give us two days notice or ask us for a report for a case conference with only a couple of days notice, make times for meeting at times when we're in surgery and not really involve us in a way that we'd like to be involved.’ GP

5. Recording DVA

• Confused and inconsistent approach documenting DVA and child safeguarding

• More confident documenting child maltreatment concerns than DVA

• Great uncertainty about confidentiality and safety issues when documenting DVA in multiple records within same family

What would help?

‘…if you don't know what you're going to do about something if you find out about it, then you don't make any effort to find out about it, the last thing you want to do is get someone to disclose domestic violence and then have no idea what you're going to do about it. ‘GP

What is the problem?

‘You need printed information, a summary sheet of who to contact about what and what the process is’ GP

‘Because it is a fairly uncomfortable area, we also need some protocols and some more directives on what to do’ GP Local knowledge and knowledge of procedures

‘When it’s not an urgent situation or it’s not a, oh gosh, I must do something right this minute, a bit, feeling a bit more comfortable about what to do....Confidence, yeah, and communication...even getting the disclosure in the first place’. GP Communication skills, self-efficacy, attitudes

‘So I think just further down the chain I’d like to know what happens rather than just my end of it if you like.’ GP Institutional empathy, local knowledge and knowledge of procedures

Messages from research RESPONDS TrainingGaps in clinicians’ knowledge and skills and self-efficacyLink from DVA to CS but not CS to DVAUncertainty about referral thresholds and how to support sub-threshold families

Safeguarding level 3 training for general practice clinical staff

Poor Interagency work, lack of institutional empathy Poor relationships with Social Services and worsening relationship with HVNon existent relationships with DVA organisations

Training jointly delivered by Health and Social Care

Unawareness of local DVA and other resources and lack of understanding of the services they offer

Training delivered by local professionals. Emphasis on local interagency work and local child protection procedures and follow-up

Lack of confidence and practice having difficult conversations with victim and children about DVA. Eagerness to engage with perpetrators (competent informants) about DVA and unaware of risks

Watching and discussing film about an unfolding scenario with talking heads on talking to victim, identifying DVA and speaking directly with a child on his own

Patchy, confused and unsafe recording practices and policies

Follow-up action learning exercise. Practices to review/develop their own recording policy and procedures

Trainers Pack This pack was developed in partnership between:

Please do not reproduce without permission. This can be sought from Gene Feder Professor of primary health care, University of Bristol gene.feder@bristol.ac.uk

Researching Education to Strengthen Primary care ON Domestic violence & Safeguarding (RESPONDS)

THINK CHILD – THINK FAMILY – THINK SAFETY

RESPONDS Training Section Tools Duration

1. Welcome and context setting 15 mins

2. Linking child safeguarding and domestic violence in practice

DVD, discussion

ppt

15 mins

3. Holding difficult conversations (incl safety and multi-agency working)

DVD, discussion,

ppt 30 mins 4. Confidentiality and record keeping

5. Speaking directly with children and young people DVD, discussion,

ppt 20 mins6. Child protection thresholds

7. Support victims of DV, negotiating referrals DVD, discussion,

ppt 30 mins8. The role of primary care after disclosure of DVA

9. End of course reflections, comment from each learning participant

10 mins

THINK CHILD – THINK FAMILY – THINK SAFETY

Pilot training delivery

Training delivered to 88 participants across 11 practices in two sites (5 Midlands and 6 south).

Practices in South had previous DVA training (IRIS)

Multiagency delivery (local social worker and health professional)

Scenario from RESPONDS film

GP Scenario #1

GP Scenario #2

GP Scenario #3

GP Scenario #4

For discussion….

• What was done well?

• What was done badly?

• If you were directing this scenario, how would you strengthen the actors’ performances?

• If you were a GP viewing this, what would you take away from it?

Training evaluation methods1. Impact evaluation: Domestic Violence and Child

Safeguarding in Primary Care (DVCSPC) scale

• Self-report (82 participants enrolled in the survey). Repeated-measures design (before training, soon after training, 3 months follow-up)

• Knowledge, skills, attitudes, self-efficacy

2. Process/impact evaluation: • Training observations (11)• Interviews with trainers (6) and training participants (9)

Training evaluationTraining objectives:•provision of engaging and trustworthy training materials and delivery styles•provision of opportunities for reflection •group engagement by all training participants •provision of local and multi-agency information •promotion of a follow-up activity to embed learning

Anticipated training outcomes:•Increased self-efficacy, self confidence•Improved attitudes towards DVA and child safeguarding•Increased knowledge (internal policy, procedure and role expectations; better understanding of other agencies' roles and procedures)•More reflection on own role/ practice

Training evaluation results • Delivery of that intervention to 11 general practices was well received by participants • Training increased training participants’ self-reported knowledge and self-efficacy about DVA and child safeguarding.• Effects persisted three months after training• No evidence of an improvement in participants’ beliefs/attitudes

Voices of training participants

‘ …seeing the GP actually talk to the child and all the different stages, … and then discussing it, …that was really useful, very different from just talking about it.’ GP

‘I think it's absolutely fantastic having professionals who are dealing with this day and day out …you [frontline workers] become the specialists …then we can ask, you know, what happens through the different pathways.’ GP

‘I now have confidence to be able to ask these questions rather than think that's kind of where I'm, I'm not going to go there. I'm more than happy to, to discuss the, the issues, and that's made a big difference.’ GP

Voices of training participants‘if I saw children with disturbed behaviour I tended not to think, you know, could it be due to difficulties at home? Which is awful isn't it? And I think that [training] completely changed my mind, so I actually always ask that now every time I see a child with behaviour problems. So, I was very comfortable dealing with patients with domestic violence...but I haven't seen many who've had children with them or who have indicated that the children are having problems...’ GP

‘before that [training] I might have felt very uncomfortable, I might have glossed over it a bit, you know, we always do, we're pushed for time and not picked them up on it but I was able to say to Mum, can you tell me about the shouting he's talking about? Which was quite a tense moment for all of us, [laughs] you know, and she was quite honest about it.’ GP

Future of RESPONDS For discussion…

Possible trajectories (or a combination of these)

1.Free package with guidance in the public domain

2. Integrating components into existing GP training

3.Rolling it out as a stand alone training module

4. Investigate effectiveness/feasibility (randomised controlled trial with nested qualitative study – process/impact evaluation)

REPROVIDE (integrated DVA training and trial. NIHR PGfAR grant application under review)

Acknowledgements

This presentation reports independent research commissioned and funded by the Department of Health Policy Research Programme (Bridging the Knowledge and Practice Gap between Domestic Violence and Child Safeguarding: Developing Policy and Training for General Practice, 115/0003). The views expressed in this presentation are those of the author and not necessarily those of the Department of Health.