Background
Physical | Sexual and reproductive |
- Acute or immediate physical injuries, such as bruises, abrasions, lacerations, punctures, burns, and bites, as well as fractures and broken bones or teeth | - Unintended/unwanted pregnancy |
- Abortion/unsafe abortion | |
- More serious injuries, which can lead to disabilities, including injuries to the head, eyes, ears, chest, and abdomen | - Sexually transmitted infections, including HIV |
- Pregnancy complications and miscarriage | |
- Gastrointestinal conditions, long-term health problems, and poor health status, including chronic pain syndromes. | - Vaginal bleeding or infections |
- Chronic pelvic pain | |
- Death, including femicide and AIDS-related death | - Urinary tract infections |
- Fistula (a tear between the vagina and bladder, rectum, or both) | |
- Painful sexual intercourse | |
- Sexual dysfunction | |
Mental | Behavioural |
- Depression | - Harmful alcohol and substance use |
- Sleeping and eating disorders | - Multiple sexual partners |
- Stress and anxiety disorders (e.g. post-traumatic stress disorder) | - Lower rates of contraceptive and condom use |
- Self-harm and suicide attempts | |
- Poor self-esteem |
Multi-site hospital-based IDVA intervention
Case 1 | Case 2 | |
---|---|---|
Hospital type | Large metropolitan hospital | Smaller rural hospital |
Number of staff | 7000 | 3000 |
ED patient-load | 70 k/annum | 42 k/annum |
Age of service | 5 years old | 3 years old |
Service cost 2014–15 | £90,000 | £40,720 |
Funded by | NHS England, Local Clinical Commissioning Group, City Council Public Health | Primary Care Trust initially, then a charitable trust |
IDVAs employed by | Hospital trust | Third sector domestic violence and abuse organisation |
Institutional integration | Full - staff are Trust employees with NHS badges, access to NHS emails and hospital computer system, able to ‘flag and tag’ cases and receive real-time alerts when patients with a history of domestic violence and abuse attend the emergency department. | High – IDVAs have an honorary NHS contract, enabling them to have an NHS badge, access to NHS emails and ability to ‘flag and tag’ cases on the hospital computer system. However, second IDVA faced six month delay getting contract. |
Visibility | Very high – based in a room in the emergency department, IDVAs regularly use staff room | Very high - based in a room outside the main hospital building, but IDVA visited the emergency department and maternity wards regularly and could see patients in a quiet room in both locations. |
Publicity | Posters widespread in hospital – plus use of other materials (e.g. mouse mats) | Leaflets and posters (after approval by six panels). |
Number of IDVAs | Two full-time, seven days a week 9 am–5 pm | One full-time equivalent (two job-sharing), Monday to Friday 9 am-5 pm |
Number of HCPs trained | 271 in 2014–15 | 200 (plus 35 General Practitioners); 120 in 2015–16 (plus 27 General Practitioners) |
Number of referrals 2014–15 | 365 | 97 |
Referral method | Often face-to-face by calling into IDVAs’ room, by phone, or (out-of-hours) by online referral form (including risk assessment) supplemented by access to the patient’s online hospital notes. | Emergency department staff mostly used paper forms; psychiatric liaison mostly used phone during office hours; maternity mostly used phone or told IDVA face-to-face on her regular ward visits. |
Method
Roles | Number of interviews |
---|---|
Hospital staff | |
- Emergency medicine consultants | 7 |
- Emergency medicine junior doctors/ house officers | 3 |
- Emergency medicine nurses or sisters | 12 |
- Safeguarding children or adults named nurses | 6 |
- Psychiatrists | 3 |
- Mental health nurses | 8 |
- Alcohol and drug nurses | 1 |
- Midwives and midwife managers | 6 |
- Other medical staff | 1 |
- Research and human resources staff | 2 |
- Sub-total | 49 |
Other staff | |
- IDVAs | 6 |
- Commissioners | 5 |
- IDVAs’ managers | 4 |
- Sub-total | 15 |
TOTAL | 64 |
Results
Hospital-based IDVAs fulfil several crucial roles
IDVAs enhance healthcare professionals’ skills, knowledge, and confidence
“Asking around the issue, you get a sense of their world. Gaining someone’s trust and showing interest. You go from that, ‘I am cold at home’, to, ‘I’m not allowed to put the heating on’, to, ‘because John won’t let me'.” (Location 3, Practice Development Nurse)
Healthcare professionals particularly valued the fact that IDVAs signposted them to further training opportunities outside of the core training, such as training on responding to male survivors.“You are not putting words in their mouth but empowering them to say it. ‘We have seen these injuries that have been based on domestic violence in the past. Is there anything you would like to tell me?’ A lot of that has come from our IDVA here: from taboo to routine.” (Location 1, Emergency Department Consultant)
Healthcare professionals and commissioners said that referring to IDVAs saved time, and so despite the costs associated with setting up the IDVA service, it was economically beneficial to the health service:“It’s a complex and emotive subject [so] it is really nice to have a person when we know we have concerns … sometimes we have a hunch and we have somebody to say, ‘Can I just run it past you?’” (Location 2, Hospital Midwife)
“It’s really helpful to have input from IDVA … [previously] one of my nurses spent a whole day and I spent a whole afternoon trying to find one refuge.” (Location 4, Consultant Psychiatrist)
“We can extrapolate the money saved by the hospital IDVA service. ‘Spend to save’ agenda.” (Commissioner)
Immediate referral and support stops survivors being lost along a referral pathway
“[Staff] wanted to feel they could do something there and then about it. Not ‘thank you for telling me. Here’s the information. Call them without me.’ You could lose them.” (Location 3, Senior Sister)
The IDVA quoted below reiterates this point: the offer of direct referral and immediate support was crucial for enabling healthcare professionals to feel more confident that enquiring about domestic violence and abuse was worthwhile:“Having the IDVA means we have a clear pathway of referral which is important. There’s a big difference between identifying abuse and knowing there is something they can do.” (Location 4, Emergency Department Consultant)
Direct referral and immediate support was important also because healthcare professionals often saw survivors at a unique time: when they were physically injured to the point of needing hospital care or when they were in a mental health crisis (e.g. with “psychiatric presentations, overdoses” (Emergency Department consultant)). healthcare professionals felt that the seriousness of the situation might make survivors more likely than usual to seek support. It was a rare ‘window of opportunity’ that healthcare professionals wanted to seize and as the below quote illustrates, co-location made this seizing more possible:"Knowing that we are on site [is beneficial]. A lot of practitioners are worried about disclosures. 'We have opened a can of worms. What can we offer?'" (Hospital IDVA)
“We are catching people at point of crisis, at the time. Otherwise they have gone home and been reluctant to engage. We are getting there earlier.” (Hospital IDVA)
Co-location moreover meant that IDVAs could more promptly refer to other hospital-based services, e.g. mental health, hospital-based child protection, and other wards:“We should have [IDVAs] here as much as we are here. When someone starts to open up, we really want to hit right there and then and say, ‘we’ve got specialist people here to give really good advice, options, and pathways.’” (Location 1, Clinical Nurse Specialist)
Thus, according to interviewees, co-location of IDVAs facilitated more holistic, multi-disciplinary, and integrated support.“There is a lot more liaison with other specialists, which can be harder to do in community-based service – we are in the same building.” (Senior IDVA)
IDVAs support hidden and disadvantaged survivors
Hidden survivors included men, older survivors, and survivors from higher-income households:“You get people ‘admitting’ to violence at home after two years in maternity, whereas it’s more than four years in the community.” (Commissioner)
IDVAs noted that compared with their community caseload, survivors they saw in hospitals seemed to have more complex needs, especially mental health problems:“I saw lot of very wealthy middle-class women who suffered terrible domestic abuse from their husbands.” (Location 3, Matron of Emergency Department)
“Hospital clients – I think their needs are higher because they come in with overdose, attempted suicide, injuries, or alcohol-related issues.” (Senior IDVA)
Survivors with ‘complex needs’, or who face multiple disadvantages—i.e. substance/alcohol use disorder, homelessness, and/or mental ill health—can face numerous barriers to accessing support, such as a lack of suitable services [22]. Healthcare professionals felt that hidden survivors might become visible in a hospital because they see it as “a place of safety and confidentiality” (Emergency Department doctor). They might feel more comfortable talking about domestic violence and abuse and associated issues, such as addictions, in a hospital than in a community service.“[We see] different kinds of clients, for example people with addictions, … A lot have mental health problems. A lot have personality disorders.” (Hospital IDVA)
“You see frequent attenders with chronic pain, psychiatric presentations, overdoses, almost fictitious disorders … a passport to see the doctor. It’s very rarely about woman turning up missing couple of teeth and big black eye.” (Location 4, Emergency Department Consultant)
“Often you see injuries or aches and pains that don’t necessarily correlate with the patient’s complaints.” (Location 3, Senior Emergency Department House Officer)
“Their mental state suddenly changes if talking about partnership: tearfulness or fear.” (Location 2, Psychiatrist)
Having the IDVA on hand meant these hidden survivors could quickly access support.“Mum will sit quite a long way back. Father is telling you all about the child. Mother doesn’t speak. You very rarely see any physical evidence, usually more emotional, and body language. And you can see how the child is reacting with parents.” (Location 3, Paediatric Lead Sister)
Success hinges on a range of structural factors
Need for ongoing training
“It is like painting the Forth Bridge.” (Commissioner).
Healthcare professionals pointed out that training emergency department staff would be particularly tricky, both because of turnover and the number of potential survivors in their patient-load.“Training people to understand the importance of asking questions needs constant work and structure.” (Location 3, Team Leader Mental Health)
To tackle this issue, healthcare professionals suggested embedding domestic violence and abuse training in medical education and in postgraduate training and targeting junior doctors:“The sheer scale of the place. All the different wards knowing about us and how to refer to us … I think we are missing quite a lot of opportunities.” (Hospital IDVA)
“If you get the juniors whilst most relevant to them, that would stick in their memory. Then you are training whole cohort of doctors when juniors.” (Location 1, Junior Doctor)
Having private and dedicated space
Visibility also made healthcare professionals feel more at ease approaching IDVAs, which in turn helped to build relationships between healthcare professionals and IDVAs and improve information-sharing:“Domestic violence is in your mind because we walk past their door. Having them here is a constant reminder to us.” (Location 1, Emergency Department Consultant)
As one IDVA recounted, visibility also made it more likely that patients would know about the service and ask for a referral:“They have lunch in the staff room. They socialise with the team. That is where the success really comes from. They are not seen as a separate and aloof service that we just refer to.” (Location 1, Emergency Department Nurse)
Several IDVAs said they had no permanent physical base, perhaps reflecting the under-resourced nature of clinical departments. IDVAs said that this lack of physical base meant opportunities to build relationships were fewer. It led to some feeling like an outsider to the cultures and subcultures of clinical teams, which in turn affected their morale—as well as their ability to see patients:“We would get multiple clients turn up numerous times in [the emergency department], just to see us. They would walk into reception and say, ‘I’m here to see [service name]’.” (Senior IDVA)
“I felt really lonely just being there in the beginning. Trying to find people to introduce myself to. It still is lonely.” (Hospital IDVA)
As some healthcare professionals pointed out, a lack of privacy increased the risk of confidentiality breaches. However, there was a careful balance to be struck between visibility to healthcare professionals and patients and visibility to perpetrators. Being too visible could lead to retaliation from perpetrators (e.g. if they had accompanied the survivor to hospital) or could lead to other patient companions telling the perpetrator that suspicion of domestic violence and abuse has arisen. IDVAs needed a private and discreet space with tactics for separating survivors from perpetrators:“All of them want me to be there more often – to be visible. But I can’t just loiter. I can’t really see anybody here. I’ve not got a private room to see people in. If I had an office, that might help.” (Hospital IDVA)
“If word gets out that we are running the [service] and a relative or friend sees the IDVA with the client, it can put the client—and the service—at risk. [We] don’t want too much publicity.” (Location 2, Research Nurse)
“[IDVAs] were initially based here. Part of the problem was they were trackable and traceable. They went off-site for their own security because of perpetrators.” (Location 3. Consultant Emergency Medicine)
Importance of embedded infrastructure
Healthcare professionals pointed out several strategies that were helpful for making the IDVA service known. One was for senior healthcare professionals to champion the service and promote strategic plans:“The IDVA can be lone voice in massive organisation. For any new IDVA, going into any hospital, there has to be a plan … you have got to sell yourself … to get across what you are there for, in an easy-to-understand way.” (Location 5, Adult Safeguard Lead)
A second strategy was for IDVAs and healthcare professionals to be able to ‘flag’ patients facing risk of domestic violence and abuse in medical records:"For a hospital IDVA service to run properly and be accepted by hospital staff, you need a medical champion. The higher up the better. Junior doctors want to impress them—they don't want to miss stuff. So, if the senior medic says this is important, then they'll look for it." (Senior IDVA)
However, IDVAs were sometimes unable to do such flagging because it required them to be granted ‘honorary contracts’ with the NHS in order to access patient identifiable data—a time-consuming and bureaucratic process:“In past jobs we haven’t had info because people have been anonymous, talking to us on the phone. Here, if people don’t want to engage, we can flag to the hospital and GP [General Practitioner] without consent and feel we are more effective really.” (Hospital IDVA)
When flags were used, processes were more efficient. IDVAs and healthcare professionals could regularly meet to discuss patients flagged and refer them to the IDVA upon their next attendance:“They [another hospital] can put flags on victim records. Here, unless there is a [safeguarding issue] they wouldn’t be able to do that... [Not being] on the system makes it a lot more difficult for partnership working.” (Hospital Services Manager)
“Repeat attendances at emergency department as a result of the abuse will come up on the system … X number of times in before it’s a red flag, then goes straight to IDVAs.” (Location 1, Emergency Department Nurse)
A third strategy was for hospital-wide domestic violence and abuse policies to clearly communicate the aim of the IDVA service and how to access it. However, healthcare professionals pointed out that there is no standardisation across NHS Trusts of policies about domestic violence and abuse and that policies were clearer and more well-known in some organisations than in others:“We meet all hospital staff concerned with domestic abuse every 1-2 months. Up until about year ago we never had that. I had all this information, but we didn’t really do much.” (Location 4, Emergency Department Nurse)
Finally, healthcare professionals highlighted the importance of joined-up working with other services, agencies, and clinical teams, such as through discussion of cases at regular team meetings. They said that getting feedback on referred patients would be motivating and encourage a better working relationship with the IDVA:“Following disclosure, we follow a flowchart. Some staff probably don’t because they don’t want to do that, or don’t know it is there, or can’t be bothered. A lot of doctors just do their own thing.” (Location 4, Emergency Department Nurse)
As the above quotes illustrate, healthcare professionals valued close communication with the IDVAs and were keen for this communication to continue to improve. Thus, there was more work to be done to develop IDVA service models and this work would need cooperation between commissioners, data officers, as well as healthcare professionals and domestic violence and abuse organisations.“I’d like more knowledge of what happens next … I make an initial referral and never find out what happens next … doesn’t help motivate me to make referrals.” (Location 4, Consultant Psychiatrist)