Background
Screening for family violence
Maternal and child health nursing and family violence
MOVE: enhanced MCH nurse care for vulnerable families experiencing violence
Normalization process theory
Constructs of NPT
Methods
Study design
Setting and participants
Intervention
Data collection
Interim evaluation
NPT constructs | |
---|---|
Coherence
| It is important to screen all women for FV |
MCH nurse interventions can make a difference to the lives of women and children experiencing FV | |
I think asking questions about FV at the 4-week consultation is important | |
It is important to have a consultation at 3 to 4 months specifically addressing the mother’s health and wellbeing | |
I am fulfilling an important community role in discussing FV with my clients | |
The FV screening protocol in the new government framework has been very welcome | |
I have a good understanding of the issues for women and children experiencing FV | |
It is part of my job to have the time to support women experiencing family violence | |
I feel uncomfortable when I have to ask all women about FV | |
I feel frustrated when women who are abused don’t act on my advice | |
I am busy enough without also having to screen all women for FV | |
It is the role of the Enhanced nurse team to deal with issues of FV, not mine | |
Cognitive participation
| In the past 6 months, I have experienced barriers to asking about FV at 4 weeks |
Overall, what percentage of women have you been able to ask about FV at any time in the past 6 months? | |
At what visit are you most likely to ask about FV? | |
I ask women who disclose FV about the impact on, and safety of, their children | |
I have used the following resources in talking with women about FV | |
• Government practice guidelines | |
• The Common Risk Assessment Framework (CRAF) | |
• Websites | |
Intervention group only | |
• Nurse mentor | |
• FV liaison worker | |
• MOVE maternal health and wellbeing checklist | |
• MOVE clinical practice guidelines | |
• MOVE clinical pathway | |
Collective action
| I feel our team of nurses as a group is seriously trying to improve our engagement with clients experiencing FV |
Interactional workability | There are people in my MCHN team who encourage the team’s FV work |
Relational integration | I get professional support from my MCH colleagues in FV work |
I feel supported by my team leader in doing this work | |
I can turn to my colleagues for emotional support when I am doing this work | |
I don’t feel safe visiting women in their homes by myself when there may be FV | |
I feel safe in my workplace asking women about FV | |
I feel that our work practices mean I feel safe when visiting women at home | |
Skill set workability | I have enough training and skills to ask and respond to women when screening for FV |
I know how to ask women about their safety | |
I know how to make a safety plan with women | |
I prefer to have a rapport with women before I ask her about FV | |
I understand why women don’t leave partners who are abusing them | |
If women ask me for help for their abusive partners, I know what information to give women | |
I know how to ask women from CALD communities about FV and respond in a culturally sensitive manner | |
I know how to ask women from ATSI communities about FV and respond in a culturally sensitive manner | |
I can confidently document situations where FV is discussed | |
I understand how FV services work | |
I am aware of the role of community police in working with women experiencing FV | |
I know how to make a referral to Child FIRST | |
I know how to make a referral to Child Protection | |
I understand the rights of women experiencing FV to access legal, financial and housing support | |
Contextual integration | The CRAF is easy to use |
I have used the CRAF in the past 6 months | |
I find FV services responsive when I make a referral | |
In the past 6 months I have had difficulty getting appropriate support for women experiencing FV | |
I have the time to ask women about FV during the 4 week consultation | |
I find Child FIRST services responsive when I make a referral | |
I find Child Protection services responsive when I make a referral | |
I play my part in addressing the Councils goal of responding to FV in our area | |
I feel that the Council does not recognise the importance of the work that we nurses do in relation to FV | |
Reflexive monitoring
| We get useful feedback about how well we are doing in our work with FV at team meetings |
Our team has adequate opportunities for supervision with this difficult work |
Impact evaluation
Analysis
Quantitative data
Qualitative data
Proposition statements for FV work | NPT constructs and sub components | Interpretation in MCH context |
---|---|---|
Nurses and stakeholders have a shared understanding and value the FV work. | Coherence (sense making work) | Do MCH nurses think FV is a problem? What practices define FV screening? What is the meaning attributed to screening and FV work? Is there an understanding of the differences between case finding and routine screening? Is the MOVE model easy to describe and distinguish from routine practice? |
FV work requires engagement with the model to manage FV in clinical practice. | Cognitive participation (participation work) | How do participants engage in the work? Is it valued? Is there evidence of commitment? Have stakeholders invested time, energy and work into MOVE? |
All participants work to operationalize the model within the services. Who is doing the work and the interactions involved? | Collective action (enacting work) | IW - Do MCH nurses think screening at 3–4 months is acceptable? Is it preferred to 4 weeks? Are nurses using the clinical tools and are they worthwhile? How has the use of the clinical tools impacted on the nurse /client interaction? |
• Interactional workability (IW) | ||
• Relational integration (RI) | ||
• Skill set workability (SSW) | ||
• Contextual integration (CI) | ||
RI - Is NM knowledge and expertise around FV trusted and understood by nurses? What is the functionality /relationship of the teams and FV services? Are they working, supportive and connected in relation to the work? | ||
SSW- Do NM feel their role is recognised? Do nurses feel adequately trained and competent to screen women? Do they have confidence in the FV liaison worker to perform secondary consultations? | ||
CI - How is the FV work funded and supported by local and state government? Have teams successfully negotiated change to incorporate the work? | ||
FV work requires ongoing monitoring of the work. | Reflexive monitoring (appraisal work) | What quality assurance measures are team leaders performing? How is FV work monitored by MCH team leaders? Is there allocated appraisal of the FV work in meetings and with FV services? How are nurses reflecting on their work? Is there evidence of modified practice to improve FV work? |
Results
Participation
All respondents | |||||||||
---|---|---|---|---|---|---|---|---|---|
INTERIM (127/160) - 79% | IMPACT (114/160) - 71% | ||||||||
MOVE | Comparison | MOVE | Comparison | ||||||
n
| % |
n
| % |
n
| % |
n
| % | ||
68 |
42.5
| 59 |
37
| 58 |
36
| 56 |
35
| ||
Work status
| |||||||||
MCH full time | 21 |
16.5
| 13 |
10.2
| 14 |
12.3
| 11 |
9.6
| |
MCH part-time | 36 |
28.3
| 36 |
28.3
| 36 |
31.6
| 39 |
34.2
| |
MCH nurse reliever | 11 |
8.7
| 5 |
3.9
| 5 |
4.4
| 2 |
1.8
| |
Enhanced MCH nurse | 1 |
0.8
| 5 |
3.9
| 3 |
2.6
| 4 |
3.5
| |
Other | 1 |
0.8
| 1 |
0.8
| 0 |
0.0
| 2 |
1.8
| |
Years working as MCH nurse
| |||||||||
Less than 1 year | 1 |
0.8
| 3 |
2.4
| 3 |
2.6
| 6 |
5.3
| |
1–9 years | 28 |
22.0
| 19 |
15.0
| 18 |
15.8
| 18 |
15.8
| |
10–20 years | 18 |
14.2
| 17 |
13.4
| 19 |
16.7
| 19 |
16.7
| |
Greater than 20 years | 21 |
16.5
| 20 |
15.7
| 18 |
15.8
| 13 |
11.4
|
NPT construct | Influencing factors |
---|---|
Coherence or
‘sense making work’
|
Enablers:
|
• Previous FV work | |
• Increased discussion of the FV work in team meetings | |
Barriers:
| |
• Time of significant change with introduction of KAS framework | |
• Some participants misunderstood their role and in several areas, frequent staff changes impacted on implementation | |
Cognitive participation or
‘participation work’
|
Enablers:
|
• Favourable responses of women and the perceived client consciousness raising (primary prevention) | |
• Continual team discussions on FV work | |
Barriers:
| |
• Lack of privacy to screen in consultations | |
• Heavy workloads and competing client demands | |
• Limited FV service support | |
Collective action or
‘enacting work’
| |
Enablers:
| |
• Use of the maternal health and wellbeing checklist at 3–4 months enhanced client-nurse interaction and was a ‘good fit’ into the government guidelines | |
• Planting a seed by multiple asking points | |
• FV liaison worker | |
• Adequate knowledge and skill set | |
Barriers:
| |
• Poor organisational structure - limited ability to link with other team members or services | |
• Low funding and disproportionate allocation of FV liaison worker support to some teams | |
Reflexive monitoring or
‘appraisal work’
|
Enablers:
|
• Clinical supervision allowed for individual reflection | |
Barriers:
| |
• Lack of awareness that evaluation and monitoring was required | |
• Absence of formal reporting systems in both MCH and FV service |
Understanding the MOVE model and FV work: sense making work (coherence)
I think it was just by the more discussion that there was around family violence issues and just becoming more familiar and more confident with your expertise in dealing with these things. (Team leader 3 Intervention Group)
….at that time some people weren’t very receptive to, you know, anything else at that time as much as they might be on another occasion. (Nurse mentor 3)
Engaging with the MOVE model: participation work (cognitive participation)
They (nurses) liked the checklist, even to the point where they didn’t … when they didn’t have to use it anymore they decided that they would continue to use it. (Team Leader 4 Intervention Group)
…what they expect us to do in that timeframe (four week visit) was very overwhelming…. and when you have got an issue, it might be a breastfeeding issue, that’s so important to deal with that and sometimes the time to do anything else is gone. (Nurse mentor 3)
Organising change and relationships: enacting work (collective action)
Interactional workability - how the complex intervention was operationalised by nurses
The checklist was great. I think that was very…I know a lot of the nurses found that really helpful, rather than actually having to verbally ask the question. (Nurse Mentor 10)
Relational integration -how the work is mediated and understood within social networks
… a lot of them would still go their local, … a neighbouring nurse because that’s who they catch up with more and it was more feasible to catch up, at lunch time or on the phone or something because … we have those networks in our own little area.. (Nurse Mentor 3)
.. I mean I went out and I sat in on a child protection assessment and the nurses trusted me with things like that and rang to do consultations … (FV liaison worker)
Skill set workability - division of labour and distribution/conduct of the work
.. well my concern is that the department has given the training like they’ve ticked off a box, here it is, go out and do it without that ongoing support or updating. (Team Leader 3 CG)
Contextual integration - work within the organisational setting
I think the MCH nurses don’t have a lot of time either, so even going to meetings is difficult and certainly I think we were trying to get some of the nurses to come over here. That was almost impossible. (FV service manager 1)
Assessment and monitoring FV work: appraisal work (reflexive monitoring)
I’m not sure how many incidences of disclosure the team have even come across in their work. (MOVE Team leader 1)