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Working at the interface of domestic violence and child protection

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  1. 1. 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
  2. 2. 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
  3. 3. 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
  4. 4. Interview study Aim: to understand the dilemmas and challenges primary care clinicians face when confronted with childrens 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
  5. 5. 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
  6. 6. Dominant themes 1. 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
  7. 7. 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
  8. 8. 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 sheneeds 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
  9. 9. 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 childrens 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
  10. 10. 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
  11. 11. 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
  12. 12. 4. Interagency work Poor relationship with childrens 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 servicesthey 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
  13. 13. 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
  14. 14. 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?
  15. 15. 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 its not an urgent situation or its 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 Id like to know what happens rather than just my end of it if you like. GP Institutional empathy, local knowledge and knowledge of procedures
  16. 16. Messages from research RESPONDS Training Gaps in clinicians knowledge and skills and self-efficacy Link from DVA to CS but not CS to DVA Uncertainty 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 HV Non 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
  17. 17. 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 [email protected] Researching Education to Strengthen Primary care ON Domestic violence & Safeguarding (RESPONDS) THI NK CHI LD THI NK FAMI LY THI NK SAFETY
  18. 18. 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 10 mins THINK CHILD THINK FAMILY THINK SAFETY
  19. 19. 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)
  20. 20. Scenario from RESPONDS film GP Scenario #1 GP Scenario #2 GP Scenario #3 GP Scenario #4
  21. 21. For discussion. What was done

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