Putting DVA enquiry into practice

A prompt to ask a question about DVA was embedded within the clinic’s EPR system. While in some instances it could act as an irritant for clinicians or patients (especially in relation to follow-up appointments), the addition to the template was widely seen as a positive tool for prompting enquiry about DVA, compelling clinicians to ask the question:

Because it [DVA prompt] was integrated into the proforma, you don’t really … well, you do have a choice, cause you can just tick that you haven’t asked … I’m the type of person who would feel guilty or that I’d missed something if I hadn’t asked, so I do try and ask most people. (Mrs C)

The majority of clinic staff described how, after receiving the IRIS ADViSE training, they felt knowledgeable and confident about asking patients about DVA in practice. For a few clinicians, some initial concerns were discussed including identifying perpetrators, handling a ‘real-life case’ and causing offence by enquiring. The most common was the challenge of introducing a sensitive question into the flow of the consultation:

If I’m gonna bring up something difficult, then I’ll preface it with something. If I’m gonna ask them about their sexual history I’ll say, ‘I need to ask you some more personal questions. Is that okay?’—or something like that. So I’m quite used to this sort of thing, but I found it hard to work out where to slot it in and how to introduce the question. (Mrs A)

Clinicians worked to modify their approach and this was apparent in four different ways of asking about DVA which often overlapped. First, some clinicians felt that the most comfortable way of asking was emphasising the routine nature of the enquiry and closely following the direct wording of the EPR proforma:

I think my strategy really is to, you know, I’ll explain to people we’ve got lots of things that we ask people. We ask everybody the same questions. We’re not, you know, I make it quite plain that I’m not asking them for any particular reason. (Mrs J)

Second, other clinicians thought that rephrasing or ‘softening’ the question in order to prevent causing offence was more appropriate, for example, by asking ‘if everything is alright at home’ rather than asking directly about DVA. Third, some clinicians asked more targeted questions of those patients who they perceived as ‘at risk’:

If they say ‘no’ and I’ve a very strong suspicion I would be willing to ask more questions. Yeah that’s the other thing you pick it up you see, and where you’d look for it before you, you know, you’d be knowing that that could be a … you’re making it that that’s definitely on your radar. Yeah. Your vulnerable adult you’d be even more worried about. (Mrs M)

Fourth, and relatedly, was the obverse process of deprioritising individuals deemed unlikely candidates of abuse, or in order to manage time constraints within consultations:

I have to admit, being honest, that there are times when I’m doing something like a complex coil fit, which is a very long, complicated appointment, which you don’t really have enough time to do anyway, that there are ways to ask the question to get a negative answer if you’re in a hurry. (Mrs B)

Patient responses to DVA enquiry

The EPR prompt meant that both men and women were asked about DVA. Clinicians described common gendered reactions to enquiry, highlighting a perception that women were more likely to disclose and men (while occasionally disclosing) would either be surprised and annoyed or, more usually, humorously made light of the question.

Notwithstanding some patients who were annoyed or surprised at being asked, most were described as reacting well, were glad to have the opportunity to disclose (even if they did not) and thought it was a positive thing that they were asked:

… they have welcomed being asked about it, even if they’ve not ever been involved in an incident of domestic abuse themselves, that they appreciate that people are asking that question. (Mrs L)

Handling disclosures

Clinic staff stated that they felt prepared and happy to handle perceived ‘low-risk’ cases which they defined as either patients who could (a) be easily referred to the DVA partner agency or (b) who could be provided with information (written or verbal) to support their decision about how to proceed. Clinic staff described their biggest challenge was encountering perceived ‘high-risk’ cases featuring children and the need to instigate associated safeguarding procedures:

… children involved then they start to go ‘Oh hang on a minute, why are you asking me about my children’ and then they get worried … they try and reassure you that it never happens in front of the kids or you know I am sure it doesn’t, but it’s just that how do you know and it’s and it puts us in a tricky position sometimes … this is where it can take all the time up. (Mrs G)

Another significant challenge was the problem presented by the lack of resources for the management of perpetrators (male or female) and male victims:

I mean, there’s very little, isn’t there, support for men who are kind of victims of abuse or violence … but I think sometimes it’s just, you know, being honest with people and kind of saying that. (Mr F)

Impact on clinical practice

Reflecting on the impact of the IRIS ADViSE intervention, all participants maintained the view that routine enquiry and partnership working for referral of DVA was important and fitted with the remit of sexual health services, that participating in the training and delivery of the programme had raised awareness and focus regarding DVA, and improved the ability of clinical staff to detect and manage instances of DVA:

I think the positive side of that would be that they are asked, and I think it’s important to do that, and it’s definitely an area that I think people probably will come to who might not disclose at other places, and that means that you can help people who need that support. (Mr E)

Notwithstanding these benefits, there was a cost for clinic staff: namely eating into the time available to deal with patients. The consequence impacted on two levels. First, in terms of meeting service level agreements:

We’ve got to see specific numbers of people … And so there’s pressure from the Commissioners and from the [NHS] Trust, that we have got to see a certain number of people and as the requirements get bigger, then we are obviously going to need to see less patients. (Mrs G)

Second, by adding to the workloads of clinic staff in a context in which they increasingly are requested to ask contextual questions (such as alcohol and substance use) which entail additional administrative burdens:

If we’re going to be asking about things like domestic violence, cos we’re also being encouraged to ask about drug abuse, alcohol use, risky sex, etc, you know, the list of things that we’re asking about seems to be getting longer, whereas the time allocated to each seems to be getting shorter so there has to be some I think agreement about, you know, where those two things are going to meet, some balance between the two. (Mrs L)

Sustainability facilitators and barriers

Participants suggested an important facilitating strategy to ensure continuation of the IRIS ADViSE approach would be to provide ongoing feedback and training. This included annual full training for new staff, with less frequent ‘refresher’ sessions with feedback on disclosure rates and further discussion. A second need identified by participants is for strong internal leadership and key points of contact to cumulatively drive the initiative forward, maintain positivity and deal with operational queries:

From the point of view of the actual referral process, knowing that there is generally somebody available … within our clinic we’re lucky because we’ve got people who are resources within the clinic that we can always bounce things off. (Mr K)

The final factor revolved around the interaction between policy-level support and provision of service-level agreements from local NHS Trusts and commissioning groups to ensure that financial reimbursement was provided, time allowances were made and support and recognition of the service given:

Mrs G: Everyone’s feeling pressure at the moment you know, I think if they can get, if you can get the Commissioners involved. You know to say that they would like it done and it would be in part of their SLA, you know the agreement …

R: Service Level Agreement, yeah?

Mrs G: Yeah, you know, if they because you know we are happy to do it, it’s just sort of telling the Trust, recognising that this takes time, so we sort of often agree to do things, then it will have an impact on the service.

This concern was shared by the DVA advocates, who identified the need to be resourced to provide provision of their services linked to interventions:

I think obviously it’s sustainable if you have the staff and, you know, managing the caseload obviously there’s funding cuts which you need to worry about. (Mrs P)