Developing skills and confidence in general practice. Nicky Stanley, Eszter Szilassy, Cath Larkins, Jess Drinkwater, Jo Morrish, Jodie Das, Adam Firth, Kelsey Hegarty, Marianne Hester and Gene Feder.

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. 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. 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. Interview study
Aim: 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

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. 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. 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. 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

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 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

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. 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. 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

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. 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. ‘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

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. 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)
THI NK CHI LD – THI NK FAMI LY – THI NK SAFETY

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. 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. Scenario from RESPONDS film
GP Scenario #1
GP Scenario #2
GP Scenario #3
GP Scenario #4

21. 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?

22. Training evaluation methods
1. 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
1. Process/impact evaluation:
• Training observations (11)
• Interviews with trainers (6) and training participants (9)

23. Training evaluation
Training 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

24. 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

25. 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

26. 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

27. 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)

29. 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.