Art & science | The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
HELPING PEOPLE WHO HAVE BEEN SUBJECTED TO ABUSE Punita Morris describes how independent domestic violence advisers can support people who have experienced domestic violence when they present to emergency departments Correspondence [email protected] Punita Morris is an independent domestic and sexual violence adviser in the emergency department at Bristol Royal Infirmary Date submitted April 29 2014 Date accepted May 29 2014 Peer review This article has been subject to double-blind peer review and has been checked using antiplagiarism software Author guidelines en.rcnpublishing.com
Abstract Independent domestic violence advisers (IDVAs) are professionals who support service users by assessing their level of risk, discussing options, developing safety plans, providing time-limited crisis intervention, and directing them to other specialist services. This article describes the work of an IDVA service based in the emergency department (ED) of an inner city hospital. It discusses the benefits of the service for clients and hospital staff, and shows how basing the service in an ED has positive outcomes. Keywords Domestic abuse, violence, independent advisers DOMESTIC VIOLENCE and abuse are considered a major public health concern in the UK because of the long-term consequences for people who experience it (Royal College of General Practitioners 2011). National Institute for Health and Care Excellence (NICE) guidelines (NICE 2014) define domestic violence and abuse as ‘any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or are family members’. Domestic violence and abuse includes psychological, physical, sexual, financial and emotional abuse, as well as ‘honour’-based violence and forced marriage. Independent domestic violence advisers (IDVAs) are professionals who support victims to assess their level of risk, discuss suitable options,
16 July 2014 | Volume 22 | Number 4
develop safety plans and provide short‑term crisis intervention before directing them to other specialist services such as those concerned with housing, legal services, refuge provision and home-safety services. Some IDVAs are funded by statutory sources but the role’s independence from criminal‑justice and other bodies is crucial to its success (Co-ordinated Action Against Domestic Abuse (CAADA) 2012) and to achieving optimum trust and service-user engagement. Clients should be aware from the outset that the IDVA service is separate from those of other agencies, such as the police, with which many people are reluctant to engage. Although the police have an essential role to play in protecting people who experience abuse, a recent survey concludes that most victims experience poor attitudes at some point from responding officers (Her Majesty’s Inspectorate of Constabulary 2014). This article describes the implementation of an IDVA service in an inner-city hospital emergency department (ED), one of only a handful in the UK that have designated IDVA services. The article also describes the collaborative approach adopted by staff in the IDVA service and ED to tackle domestic violence and abuse, and shares findings from CAADA Insights, a data collection and outcomes measurement service designed specifically for the domestic abuse sector. Uniquely, the IDVA team members are NHS trust employees rather than community service team members. The service is funded by Public Health England, so no costs have been incurred by the hospital. EMERGENCY NURSE
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Art & science | violence The immediate objective of the IDVA service are to ensure that patients receive safe and appropriate screening for domestic violence and abuse in the ED. If such violence and abuse are disclosed, the service offers interventions, and appropriate advice and support, to the people involved. In the long term, the IDVAs’ objectives are to reduce the incidence of repeat violence and abuse against patients who access the service, and consequently decrease the number of repeat attendances. Despite sustained efforts to raise awareness and tackle domestic violence and abuse, the problem persists. In 2011/12, 7.3% of women (1.2 million) and 5% of men (800,000) reported domestic abuse (Office for National Statistics 2013). Domestic violence accounts for 10% of emergency calls to the police (Labour Party 2013) and, on average, two women a week in the UK are killed by their current partner or former male partners (Coleman and Osborne 2010). Recent NICE (2014) guidelines call for greater awareness of domestic violence and abuse in health and social care services. The guidelines also call for front line staff in high-risk areas to receive specialist training so that they can ask about abuse, respond effectively, and help the people concerned to access specialist support, such as that provided by IDVAs. Such advisers are said to be ‘an essential part of an effective health and social care response to domestic violence and abuse’ (NICE 2014). Adopting a concerted approach to detection and screening of domestic violence and abuse in healthcare environments could be an effective public health strategy given that a survey by Sethi et al (2004) found that 76% of women (n=198) said they felt comfortable about being questioned, and 61% said they should always or usually be asked about domestic violence and abuse.
Setting up the service In 2011, two IDVAs (1.8 whole-time equivalents) were appointed to provide a service in an inner-city ED. One had more than ten years’ experience of supporting people who had experienced domestic violence and abuse, working in organisations such as the police and the charity Women’s Aid. The other IDVA had been a midwife. Neither were from a nursing background or had worked in an ED before, but both were accredited IDVAs. They were appointed at band 6 level. The IDVAs initially took referrals from emergency medical and nursing staff only, but since the development of new policies and referral pathways the service now receives trust-wide referrals. 18 July 2014 | Volume 22 | Number 4
Integration of the IDVAs into the ED, introduction of practice guidelines and some support of day-to-day practice were managed initially by the IDVA project lead, who was a senior nurse in the ED and led the service. However, during its second year, the IDVA service incorporated managerial elements into a band 6 senior IDVA post, supported by a band 5 IDVA and one bank IDVA to cover all unallocated shifts. The service runs daily from 9am to 5pm, including weekends and bank holidays, in recognition of the fact that the number of domestic violence and abuse reports to police typically increases at weekends; Sunday is the busiest day for new IDVA referrals. The IDVAs’ primary work is to construct safety plans for complex cases in which clients are typically at high risk of serious harm or being killed, severe abuse including violent behaviour causing injuries, strangulation, rape and other sexual abuse, stalking or extreme controlling behaviour. Full engagement with the IDVA service can result in mobilisation of up to 15 local agencies to protect clients and their children (CAADA 2012), and having the service on site ensures that interventions can be implemented as soon after the crisis as possible. A case study involving an IDVA is presented opposite. The name of the patient has been changed to preserve her anonymity. A national charity that supports professionals and organisations that work with people who have experienced domestic abuse and their children, CAADA aims to protect those at risk of, for example, serious harm or murder. The charity has set up an outcomes-measurement service, CAADA Insights, that gathers evidence about the outcomes of domestic abuse. One of these outcomes is the effect that domestic abuse services have on clients’ safety before and after IDVA intervention. One important function of the ED IDVA service is to collate data through CAADA Insights. This is useful at national level as it has identified that hospital IDVA services are more likely to be accessed by vulnerable, marginalised groups such as women from black and minority ethnic (BME) backgrounds, pregnant women, younger patients and those with complex needs including those with mental health, or substance or alcohol misuse issues who are ‘slipping through the net of other agencies, for example the police or social services’ (CAADA 2012). Additionally, CAADA Insights reveals that on average it takes people at high risk of domestic violence and abuse five years to seek effective help and support, but that clients who are identified EMERGENCY NURSE
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through health-based IDVA services experience shorter lengths of abuse, about two and a half years, than those identified by the criminal justice system or who self-refer. In particular, pregnant women who access IDVA support through healthcare professional referrals do so much earlier (CAADA 2012). Independent domestic violence and abuse advisers try to help pregnant clients. This is important because 30% of domestic violence involves pregnant women (McWilliams and McKiernan 1993, Lewis and Drife 2001), and between 4% and 9% of women are abused systematically during their pregnancies or in the months after they have given birth (Taft 2002). The CAADA Insights also recognisesthat health-based IDVAs have access to immediate support services such as those offered by psychiatric liaison and substance misuse specialists, in hospitals and off site. In recent years, it has become apparent that ‘multiple agencies working together are the only way to reduce domestic violence’ (Against Violence and Abuse 2010). To reduce the incidence of repeated domestic violence and abuse, therefore, IDVAs formulate safety plans for highrisk patients alongside other agencies at multi agency risk assessment conferences (MARACs), at which information on highest-risk cases of domestic violence and abuse are shared between
various criminal justice, health, housing and child protection agencies. There is evidence that up to 60% of people who have experienced domestic violence and abuse report no further violence after MARAC and IDVA interventions have been undertaken (CAADA 2010). The IDVA intervention undertaken at the hospital under discussion takes between four and six weeks for clients at high risk, but stops 69% of all types of abuse. This represents a higher cessation rate than at other hospitals (64%) and nationally (63%). In terms of sustainability of risk reduction, 80% of clients supported by this IDVA service have a medium- or long-term risk reduction, compared with 77% of clients in the national dataset. The ED IDVA service has received 816 referrals over three years, of which 40% have been professionally assessed by the IDVA service as being at high risk, generating 335 MARAC referrals. Education of ED staff in recognising signs and symptoms of abuse, appropriate methods of screening and onward referral to IDVAs has been an important part of this service. Engaging support from colleagues through training, and exercising a co-ordinated team approach, has contributed to a 50% increase in IDVA referrals since the first year of the service. In total, 89% of clients were female and 11% male, while 95% were heterosexual and 5% lesbian or gay.
Case study Selima attended the emergency department (ED) after an assault by her husband and, with support from the on-site independent domestic violence adviser (IDVA), called the police for assistance. Although Selima did not wish to report the matter formally, the police agreed to flag her address with a domestic violence and abuse marker to ensure a prompt response in the event of any future call outs. A specialist domestic violence and abuse police officer would support Selima if she contacted them in future. The IDVA arranged an appointment with a solicitor the next day to explore the application of a non‑molestation order or civil injunction. She also assessed Selima as ‘high risk’ and agreed to co-ordinate specific actions with other agencies to keep her and her two children safe. The local authority agreed to change Selima’s locks and make her home safer if she pursued a non‑molestation order. After referral from the IDVA, an outreach service for Asian women agreed to EMERGENCY NURSE
prioritise support for Selima in her first language. Emergency department and GP patient records were flagged with markers to ensure clincial staff were informed and would offer treatment and screening for domestic violence and abuse away from her husband if she attended again. Children and young people’s services agreed to assess the risks to the children, and their schools were charged with providing extra emotional support. As a result of the safety plan and work with the IDVA, Selima gained immediate non-molestation and occupation orders to protect her and allow her and her children to remain in the family home. With these orders in place, her husband is not permitted to contact Selima or access the family home; if he does, the police can arrest him. Selima and her children felt safer, she continued to receive short-term structured support from the IDVA and longer term from the women’s outreach service, and she is filing for divorce. July 2014 | Volume 22 | Number 4 19
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Art & science | violence Figure 1
Proportion of clients of different ages
40 -
At Bristol Royal Infirmary Nationally
35 Percentage
30 25 20 15 10 5-
Un
de
r1 8 18 -2 0 21 -3 0 31 -4 0 41 -5 0 51 -6 0 Ov er 61
0
Age in years In terms of ethnicity: ■ 75% of clients were white British or Irish. ■ 9% were black. ■ 5% were other white. ■ 4% were of Asian background. ■ 3% were mixed race. ■ 4% were ‘other’. The percentages of clients in different age ranges are shown in Figure 1, percentages with different problems and needs are shown in Figure 2, and the percentages of interventions made are shown in Figure 3. In each case, the percentages are compared with the national equivalents (CAADA 2014). Data show that people who experience domestic violence and abuse are more likely to use alcohol and drugs, and have mental health issues including self-harm and threatened or attempted suicide. This has implications for ED staff education in terms of targeting patient groups. The IDVAs sustain strong links with alcohol liaison nurses, drug specialist nurses and the on-site Figure 2
Proportions of different problems or needs among clients
70 -
At Bristol Royal Infirmary Nationally
Percentage
60 50 40 30 20 10 -
Dr ug
ab us Al e co ho lm isu se M en ta lh Po is ealt te sue h nt ia s ls ui cid e Se lfFi ha na rm nc ia lp ro bl em Be s ne fit sa dv ice ca Co re m pa mu ym n en ity ts
0
Problem or need 20 July 2014 | Volume 22 | Number 4
psychiatry liaison unit to support and treat clients through collaborative care pathways. Referrals from BME communities make up 24% of total referrals; this figure is high, given that the BME population in Bristol makes up 21% of the total population. This suggests equality of opportunity for clients to access this service irrespective of cultural or ethnic background. Data also show that the number of ED IDVA interventions accessed by clients is higher that the national dataset.
Service delivery As trust employees, the ED IDVAs have additional responsibilities, including flagging high-risk patient records to inform fully all practitioners who might come into contact with the clients concerned. The flags expire after six months unless patients are still regarded to be at high risk. This is especially useful to people who disclose domestic violence and abuse in the ED but choose not to seek help and support from the IDVAs. This scenario can be frustrating for healthcare professionals, but the IDVAs’ response is that flagging high-risk but disengaged patients post-disclosure is a positive course of action when options are limited. It is widely recognised that, even if victims refuse referrals, offering them repeatedly helps them to understand they are not alone and that they can accept referrals later (Medics Against Violence 2014). Healthcare professional enquiries are thought to be enough to deliver a message that domestic violence and abuse are wrong, and offering services ‘plants the seed’ in people’s minds about how and where to seek help and support. Post-disclosure, patients in this ED are offered safe domestic violence and abuse take-away material, such as lip balms with the IDVA telephone numbers hidden along the barcode. These provide discreet and convenient access to contact numbers without raising suspicion in the perpetrators if found. High-risk patients who present at the ED out of IDVA service hours are offered an overnight stay in the observation unit, depending on the unit’s capacity, to ensure engagement with an IDVA team member by 9am the next day. This approach is expected to prevent unsafe discharge from hospital. The IDVAs’ location in the ED means that all ED staff have access to extensive training on domestic violence and abuse (NICE 2014) including appropriate methods of screening, for example in a private one-to-one setting, and how to assess risk. All education delivered by the IDVA team is up to date and relevant to emergency care. Topics include common injuries, multiple bruises or lacerations at various stages of healing, patterned injuries, defence EMERGENCY NURSE
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Figure 3
Proportions of different interventions
100 -
At Bristol Royal Infirmary Nationally
90 80 Percentage
70 60 50 40 30 20 10 -
as
Po lic e se M ss u Ho m lti en -a usi n t c ge on nc g y fe Cr ren risk im ce in al co ur t Ch Fi na ild nc re n ia lb en ef its Ci vil or de rs Pr ob at io Im n m igr at io n
0
Sa fe He ty pl al an th ni an ng d we llb ein g
wounds to the hands and arms, injuries to the breasts and genitals, strangulation marks, and how to recognise emotional signs and symptoms of domestic violence and abuse, such as depression, anxiety, suicidal thoughts and substance misuse (Royal College of Nursing 2000). Consultant feedback on the IDVA service includes the following: ‘From a department perspective, having an IDVA around not only raises the awareness of domestic abuse but, because you are willing to do training sessions and come and see the patients directly, the staff have benefitted. Not only are they more aware of domestic abuse, but they can safely screen patients and also have been able to learn from the example set by yourselves in how to deal with patients of domestic abuse.’ On-site specialist training by the IDVAs also helps to dispel myths about domestic violence and abuse screening, such as that ‘it takes too long’, that ‘patients will be insulted when asked’, and that ‘asking patients about domestic abuse will open a “Pandora’s box”’. One message conveyed during training is that, because many women try to hide or minimise the violence they experience, staff should create open and safe environments for disclosing. Staff must also respond to disclosures sensitively and in ways that ensure people’s safety (NICE 2014). Since the service began, the senior IDVA has been part of the consultation on and implementation of domestic violence and abuse clinical guidelines for the ED and trust training materials, which now include two further subjects that fall within the definition of domestic violence and abuse: ‘honour’-based violence and forced marriage. Specific training on these issues ensures greater engagement of marginalised groups, many of whom find services difficult to access, while helping staff to understand equality and diversity (NICE 2014). Targeting high-risk patient groups is a particular focus for this IDVA service, so the ED mental health assessment matrix has been used. This is an assessment tool for patients presenting in ED with mental health issues; it helps staff to understand the background and complexities of each patient, such as drug or alcohol misuse issues. The matrix has been adapted by colleagues from the psychiatry liaison unit to devise a routine method of identifying patients who are risk of domestic violence (NICE 2014), which enables the IDVA service to capture high-risk referrals that can otherwise be missed. This method has been adapted for Figure 4. Delivering training to staff across the trust is a huge task and cannot be achieved with only
Intervention
two team members. This has been overcome, however, by the development of strong links with the adult safeguard and child protection teams that deliver training on domestic violence and abuse as part of their existing curriculum, and during which they highlight the IDVA service, its remit and referral pathways. The development of domestic violence and abuse ‘link nurses’ on high-risk wards such as gynaecology helps to maximise the number of staff informed of domestic violence and abuse training and best-practice guidelines through one contact. This process is at the planning stage. Figure 4
Method of identifying patients at risk of domestic abuse and violence
Inpatient’s name ............................................................................................... Community team .............................................................................................. No Don’t know Has there been a diagnosis? Yes If yes, what is it?............................................................................................... At the time of attendance was the patient receiving psychiatric treatment? Yes No Don’t know If yes, what service is involved? ......................................................................... For example, the local inpatient team or local community mental health team
Is the patient at risk of domestic violence or abuse? Yes No Don’t know If yes, please refer the patient to the Bristol Infirmary independent domestic violence advisory service July 2014 | Volume 22 | Number 4 21
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Art & science | violence Conclusion Having an IDVA team based in the ED ensures that victims are more readily identified and are offered a full care package from immediate clinical assistance and support to alcohol and substance misuse services and psychiatric care, where appropriate. As recommended in the recent NICE (2014) guidelines, IDVAs can support and encourage the development of safe and confidential environments in which patients can disclose domestic violence and abuse. Robust and consistent mechanisms for referral into the service can be implemented, which will benefit staff and service users. Through training, the detection of domestic violence and abuse in this ED has increased. This suggests that, when healthcare professionals are better informed about domestic violence and abuse they engage more with patients, and that offers of support and care help to protect clients.
It is important for healthcare professionals to listen to and act on patient disclosures of domestic violence and abuse (NICE 2014), and implementation of this IDVA service has been recognised as a positive move. According to CAADA’s founder and chief executive, Diana Barran: ‘We feel that your approach is potentially the single most important step forward to address the safety and wellbeing of victims of domestic abuse… particularly those who do not call the police. The quality of your service and the model that you represent could and should be understood at a national level and replicated across the country’ (CAADA 2012). This ED IDVA service is fortunate to be part of Project Themis, to be run by CAADA to evaluate the model of domestic violence advocacy that bases IDVAs in hospital settings. This multi-site evaluation will include IDVAs from several hospital sites and departmental settings, and data collection will begin in the summer of 2014.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Against Violence and Abuse (2010) Co-ordinated Community Response Model. www.ccrm.org.uk (Last accessed: June 11 2014.) Coleman K, Osborne S (2010) Homicide. In Smith K, Flatley J, Coleman K et al (Eds) Homicides, Firearm Offences and Intimate Violence 2008/09: Supplementary Volume 2 to Crime in England and Wales 2008/09. Home Office, London. Co-ordinated Action Against Domestic Abuse (2010) Saving Lives, Saving Money. CAADA, Bristol. Co-ordinated Action Against Domestic Abuse (2012) A Place of Greater Safety. CAADA, Bristol.
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Co-ordinated Action Against Domestic Abuse (2014) CAADA Insights Outcome Measurement: Bristol Royal Infirmary IDVA Service. May 2011 to January 2014. CAADA, Bristol. Her Majesty’s Inspectorate of Constabulary (2014) Everyone’s Business: Improving the Police Response to Domestic Abuse. HMIC, London. Labour Party (2013) Freedom of Information Requests. Labour Party, London. Lewis G, Drife J (2001) Why Mothers Die 1997‑1999: Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. Royal College of Obstetricians and Gynaecologists, London.
Medics Against Violence (2014) AVDR Model. tinyurl.com/nrapwzb (Last accessed: June 11 2014.) McWilliams M, McKiernan J (1993) Bringing It Out Into The Open: Domestic Violence in Northern Ireland: A Study Commissioned by the Department of Health and Social Services. The Stationery Office, London. National Institute for Health and Care Excellence (2014) Domestic Violence and Abuse: How Services Can Respond Effectively. NICE, London. Office for National Statistics (2013) Focus On Violent Crime and Sexual Offences: Statistical Bulletin 2011/12. ONS, London.
Royal College of General Practitioners (2011) Guidelines on Domestic Violence. RCGP, London. Royal College of Nursing (2000) Domestic Violence Guidance for Nurses. RCN, London. Sethi D, Watts S, Zwi A et al (2004) Experience of domestic violence by women attending an inner city accident and emergency department. Emergency Medicine Journal. 21, 2, 180-184. Taft A (2002) Violence Against Women In Pregnancy and After Childbirth: Current Knowledge and Issues In Health Care Responses. Issues Paper 6. Australian Domestic and Family Violence Clearinghouse, Sydney NSW.
EMERGENCY NURSE
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JOSEPHINE G PATERSON
HELPING PEOPLE WHO HAVE BEEN SUBJECTED TO ABUSE Punita Morris describes how independent domestic violence advisers can support people who have experienced domestic violence when they present to emergency departments Correspondence [email protected] Punita Morris is an independent domestic and sexual violence adviser in the emergency department at Bristol Royal Infirmary Date submitted April 29 2014 Date accepted May 29 2014 Peer review This article has been subject to double-blind peer review and has been checked using antiplagiarism software Author guidelines en.rcnpublishing.com
Abstract Independent domestic violence advisers (IDVAs) are professionals who support service users by assessing their level of risk, discussing options, developing safety plans, providing time-limited crisis intervention, and directing them to other specialist services. This article describes the work of an IDVA service based in the emergency department (ED) of an inner city hospital. It discusses the benefits of the service for clients and hospital staff, and shows how basing the service in an ED has positive outcomes. Keywords Domestic abuse, violence, independent advisers DOMESTIC VIOLENCE and abuse are considered a major public health concern in the UK because of the long-term consequences for people who experience it (Royal College of General Practitioners 2011). National Institute for Health and Care Excellence (NICE) guidelines (NICE 2014) define domestic violence and abuse as ‘any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or are family members’. Domestic violence and abuse includes psychological, physical, sexual, financial and emotional abuse, as well as ‘honour’-based violence and forced marriage. Independent domestic violence advisers (IDVAs) are professionals who support victims to assess their level of risk, discuss suitable options,
16 July 2014 | Volume 22 | Number 4
develop safety plans and provide short‑term crisis intervention before directing them to other specialist services such as those concerned with housing, legal services, refuge provision and home-safety services. Some IDVAs are funded by statutory sources but the role’s independence from criminal‑justice and other bodies is crucial to its success (Co-ordinated Action Against Domestic Abuse (CAADA) 2012) and to achieving optimum trust and service-user engagement. Clients should be aware from the outset that the IDVA service is separate from those of other agencies, such as the police, with which many people are reluctant to engage. Although the police have an essential role to play in protecting people who experience abuse, a recent survey concludes that most victims experience poor attitudes at some point from responding officers (Her Majesty’s Inspectorate of Constabulary 2014). This article describes the implementation of an IDVA service in an inner-city hospital emergency department (ED), one of only a handful in the UK that have designated IDVA services. The article also describes the collaborative approach adopted by staff in the IDVA service and ED to tackle domestic violence and abuse, and shares findings from CAADA Insights, a data collection and outcomes measurement service designed specifically for the domestic abuse sector. Uniquely, the IDVA team members are NHS trust employees rather than community service team members. The service is funded by Public Health England, so no costs have been incurred by the hospital. EMERGENCY NURSE
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Art & science | violence The immediate objective of the IDVA service are to ensure that patients receive safe and appropriate screening for domestic violence and abuse in the ED. If such violence and abuse are disclosed, the service offers interventions, and appropriate advice and support, to the people involved. In the long term, the IDVAs’ objectives are to reduce the incidence of repeat violence and abuse against patients who access the service, and consequently decrease the number of repeat attendances. Despite sustained efforts to raise awareness and tackle domestic violence and abuse, the problem persists. In 2011/12, 7.3% of women (1.2 million) and 5% of men (800,000) reported domestic abuse (Office for National Statistics 2013). Domestic violence accounts for 10% of emergency calls to the police (Labour Party 2013) and, on average, two women a week in the UK are killed by their current partner or former male partners (Coleman and Osborne 2010). Recent NICE (2014) guidelines call for greater awareness of domestic violence and abuse in health and social care services. The guidelines also call for front line staff in high-risk areas to receive specialist training so that they can ask about abuse, respond effectively, and help the people concerned to access specialist support, such as that provided by IDVAs. Such advisers are said to be ‘an essential part of an effective health and social care response to domestic violence and abuse’ (NICE 2014). Adopting a concerted approach to detection and screening of domestic violence and abuse in healthcare environments could be an effective public health strategy given that a survey by Sethi et al (2004) found that 76% of women (n=198) said they felt comfortable about being questioned, and 61% said they should always or usually be asked about domestic violence and abuse.
Setting up the service In 2011, two IDVAs (1.8 whole-time equivalents) were appointed to provide a service in an inner-city ED. One had more than ten years’ experience of supporting people who had experienced domestic violence and abuse, working in organisations such as the police and the charity Women’s Aid. The other IDVA had been a midwife. Neither were from a nursing background or had worked in an ED before, but both were accredited IDVAs. They were appointed at band 6 level. The IDVAs initially took referrals from emergency medical and nursing staff only, but since the development of new policies and referral pathways the service now receives trust-wide referrals. 18 July 2014 | Volume 22 | Number 4
Integration of the IDVAs into the ED, introduction of practice guidelines and some support of day-to-day practice were managed initially by the IDVA project lead, who was a senior nurse in the ED and led the service. However, during its second year, the IDVA service incorporated managerial elements into a band 6 senior IDVA post, supported by a band 5 IDVA and one bank IDVA to cover all unallocated shifts. The service runs daily from 9am to 5pm, including weekends and bank holidays, in recognition of the fact that the number of domestic violence and abuse reports to police typically increases at weekends; Sunday is the busiest day for new IDVA referrals. The IDVAs’ primary work is to construct safety plans for complex cases in which clients are typically at high risk of serious harm or being killed, severe abuse including violent behaviour causing injuries, strangulation, rape and other sexual abuse, stalking or extreme controlling behaviour. Full engagement with the IDVA service can result in mobilisation of up to 15 local agencies to protect clients and their children (CAADA 2012), and having the service on site ensures that interventions can be implemented as soon after the crisis as possible. A case study involving an IDVA is presented opposite. The name of the patient has been changed to preserve her anonymity. A national charity that supports professionals and organisations that work with people who have experienced domestic abuse and their children, CAADA aims to protect those at risk of, for example, serious harm or murder. The charity has set up an outcomes-measurement service, CAADA Insights, that gathers evidence about the outcomes of domestic abuse. One of these outcomes is the effect that domestic abuse services have on clients’ safety before and after IDVA intervention. One important function of the ED IDVA service is to collate data through CAADA Insights. This is useful at national level as it has identified that hospital IDVA services are more likely to be accessed by vulnerable, marginalised groups such as women from black and minority ethnic (BME) backgrounds, pregnant women, younger patients and those with complex needs including those with mental health, or substance or alcohol misuse issues who are ‘slipping through the net of other agencies, for example the police or social services’ (CAADA 2012). Additionally, CAADA Insights reveals that on average it takes people at high risk of domestic violence and abuse five years to seek effective help and support, but that clients who are identified EMERGENCY NURSE
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through health-based IDVA services experience shorter lengths of abuse, about two and a half years, than those identified by the criminal justice system or who self-refer. In particular, pregnant women who access IDVA support through healthcare professional referrals do so much earlier (CAADA 2012). Independent domestic violence and abuse advisers try to help pregnant clients. This is important because 30% of domestic violence involves pregnant women (McWilliams and McKiernan 1993, Lewis and Drife 2001), and between 4% and 9% of women are abused systematically during their pregnancies or in the months after they have given birth (Taft 2002). The CAADA Insights also recognisesthat health-based IDVAs have access to immediate support services such as those offered by psychiatric liaison and substance misuse specialists, in hospitals and off site. In recent years, it has become apparent that ‘multiple agencies working together are the only way to reduce domestic violence’ (Against Violence and Abuse 2010). To reduce the incidence of repeated domestic violence and abuse, therefore, IDVAs formulate safety plans for highrisk patients alongside other agencies at multi agency risk assessment conferences (MARACs), at which information on highest-risk cases of domestic violence and abuse are shared between
various criminal justice, health, housing and child protection agencies. There is evidence that up to 60% of people who have experienced domestic violence and abuse report no further violence after MARAC and IDVA interventions have been undertaken (CAADA 2010). The IDVA intervention undertaken at the hospital under discussion takes between four and six weeks for clients at high risk, but stops 69% of all types of abuse. This represents a higher cessation rate than at other hospitals (64%) and nationally (63%). In terms of sustainability of risk reduction, 80% of clients supported by this IDVA service have a medium- or long-term risk reduction, compared with 77% of clients in the national dataset. The ED IDVA service has received 816 referrals over three years, of which 40% have been professionally assessed by the IDVA service as being at high risk, generating 335 MARAC referrals. Education of ED staff in recognising signs and symptoms of abuse, appropriate methods of screening and onward referral to IDVAs has been an important part of this service. Engaging support from colleagues through training, and exercising a co-ordinated team approach, has contributed to a 50% increase in IDVA referrals since the first year of the service. In total, 89% of clients were female and 11% male, while 95% were heterosexual and 5% lesbian or gay.
Case study Selima attended the emergency department (ED) after an assault by her husband and, with support from the on-site independent domestic violence adviser (IDVA), called the police for assistance. Although Selima did not wish to report the matter formally, the police agreed to flag her address with a domestic violence and abuse marker to ensure a prompt response in the event of any future call outs. A specialist domestic violence and abuse police officer would support Selima if she contacted them in future. The IDVA arranged an appointment with a solicitor the next day to explore the application of a non‑molestation order or civil injunction. She also assessed Selima as ‘high risk’ and agreed to co-ordinate specific actions with other agencies to keep her and her two children safe. The local authority agreed to change Selima’s locks and make her home safer if she pursued a non‑molestation order. After referral from the IDVA, an outreach service for Asian women agreed to EMERGENCY NURSE
prioritise support for Selima in her first language. Emergency department and GP patient records were flagged with markers to ensure clincial staff were informed and would offer treatment and screening for domestic violence and abuse away from her husband if she attended again. Children and young people’s services agreed to assess the risks to the children, and their schools were charged with providing extra emotional support. As a result of the safety plan and work with the IDVA, Selima gained immediate non-molestation and occupation orders to protect her and allow her and her children to remain in the family home. With these orders in place, her husband is not permitted to contact Selima or access the family home; if he does, the police can arrest him. Selima and her children felt safer, she continued to receive short-term structured support from the IDVA and longer term from the women’s outreach service, and she is filing for divorce. July 2014 | Volume 22 | Number 4 19
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Art & science | violence Figure 1
Proportion of clients of different ages
40 -
At Bristol Royal Infirmary Nationally
35 Percentage
30 25 20 15 10 5-
Un
de
r1 8 18 -2 0 21 -3 0 31 -4 0 41 -5 0 51 -6 0 Ov er 61
0
Age in years In terms of ethnicity: ■ 75% of clients were white British or Irish. ■ 9% were black. ■ 5% were other white. ■ 4% were of Asian background. ■ 3% were mixed race. ■ 4% were ‘other’. The percentages of clients in different age ranges are shown in Figure 1, percentages with different problems and needs are shown in Figure 2, and the percentages of interventions made are shown in Figure 3. In each case, the percentages are compared with the national equivalents (CAADA 2014). Data show that people who experience domestic violence and abuse are more likely to use alcohol and drugs, and have mental health issues including self-harm and threatened or attempted suicide. This has implications for ED staff education in terms of targeting patient groups. The IDVAs sustain strong links with alcohol liaison nurses, drug specialist nurses and the on-site Figure 2
Proportions of different problems or needs among clients
70 -
At Bristol Royal Infirmary Nationally
Percentage
60 50 40 30 20 10 -
Dr ug
ab us Al e co ho lm isu se M en ta lh Po is ealt te sue h nt ia s ls ui cid e Se lfFi ha na rm nc ia lp ro bl em Be s ne fit sa dv ice ca Co re m pa mu ym n en ity ts
0
Problem or need 20 July 2014 | Volume 22 | Number 4
psychiatry liaison unit to support and treat clients through collaborative care pathways. Referrals from BME communities make up 24% of total referrals; this figure is high, given that the BME population in Bristol makes up 21% of the total population. This suggests equality of opportunity for clients to access this service irrespective of cultural or ethnic background. Data also show that the number of ED IDVA interventions accessed by clients is higher that the national dataset.
Service delivery As trust employees, the ED IDVAs have additional responsibilities, including flagging high-risk patient records to inform fully all practitioners who might come into contact with the clients concerned. The flags expire after six months unless patients are still regarded to be at high risk. This is especially useful to people who disclose domestic violence and abuse in the ED but choose not to seek help and support from the IDVAs. This scenario can be frustrating for healthcare professionals, but the IDVAs’ response is that flagging high-risk but disengaged patients post-disclosure is a positive course of action when options are limited. It is widely recognised that, even if victims refuse referrals, offering them repeatedly helps them to understand they are not alone and that they can accept referrals later (Medics Against Violence 2014). Healthcare professional enquiries are thought to be enough to deliver a message that domestic violence and abuse are wrong, and offering services ‘plants the seed’ in people’s minds about how and where to seek help and support. Post-disclosure, patients in this ED are offered safe domestic violence and abuse take-away material, such as lip balms with the IDVA telephone numbers hidden along the barcode. These provide discreet and convenient access to contact numbers without raising suspicion in the perpetrators if found. High-risk patients who present at the ED out of IDVA service hours are offered an overnight stay in the observation unit, depending on the unit’s capacity, to ensure engagement with an IDVA team member by 9am the next day. This approach is expected to prevent unsafe discharge from hospital. The IDVAs’ location in the ED means that all ED staff have access to extensive training on domestic violence and abuse (NICE 2014) including appropriate methods of screening, for example in a private one-to-one setting, and how to assess risk. All education delivered by the IDVA team is up to date and relevant to emergency care. Topics include common injuries, multiple bruises or lacerations at various stages of healing, patterned injuries, defence EMERGENCY NURSE
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Figure 3
Proportions of different interventions
100 -
At Bristol Royal Infirmary Nationally
90 80 Percentage
70 60 50 40 30 20 10 -
as
Po lic e se M ss u Ho m lti en -a usi n t c ge on nc g y fe Cr ren risk im ce in al co ur t Ch Fi na ild nc re n ia lb en ef its Ci vil or de rs Pr ob at io Im n m igr at io n
0
Sa fe He ty pl al an th ni an ng d we llb ein g
wounds to the hands and arms, injuries to the breasts and genitals, strangulation marks, and how to recognise emotional signs and symptoms of domestic violence and abuse, such as depression, anxiety, suicidal thoughts and substance misuse (Royal College of Nursing 2000). Consultant feedback on the IDVA service includes the following: ‘From a department perspective, having an IDVA around not only raises the awareness of domestic abuse but, because you are willing to do training sessions and come and see the patients directly, the staff have benefitted. Not only are they more aware of domestic abuse, but they can safely screen patients and also have been able to learn from the example set by yourselves in how to deal with patients of domestic abuse.’ On-site specialist training by the IDVAs also helps to dispel myths about domestic violence and abuse screening, such as that ‘it takes too long’, that ‘patients will be insulted when asked’, and that ‘asking patients about domestic abuse will open a “Pandora’s box”’. One message conveyed during training is that, because many women try to hide or minimise the violence they experience, staff should create open and safe environments for disclosing. Staff must also respond to disclosures sensitively and in ways that ensure people’s safety (NICE 2014). Since the service began, the senior IDVA has been part of the consultation on and implementation of domestic violence and abuse clinical guidelines for the ED and trust training materials, which now include two further subjects that fall within the definition of domestic violence and abuse: ‘honour’-based violence and forced marriage. Specific training on these issues ensures greater engagement of marginalised groups, many of whom find services difficult to access, while helping staff to understand equality and diversity (NICE 2014). Targeting high-risk patient groups is a particular focus for this IDVA service, so the ED mental health assessment matrix has been used. This is an assessment tool for patients presenting in ED with mental health issues; it helps staff to understand the background and complexities of each patient, such as drug or alcohol misuse issues. The matrix has been adapted by colleagues from the psychiatry liaison unit to devise a routine method of identifying patients who are risk of domestic violence (NICE 2014), which enables the IDVA service to capture high-risk referrals that can otherwise be missed. This method has been adapted for Figure 4. Delivering training to staff across the trust is a huge task and cannot be achieved with only
Intervention
two team members. This has been overcome, however, by the development of strong links with the adult safeguard and child protection teams that deliver training on domestic violence and abuse as part of their existing curriculum, and during which they highlight the IDVA service, its remit and referral pathways. The development of domestic violence and abuse ‘link nurses’ on high-risk wards such as gynaecology helps to maximise the number of staff informed of domestic violence and abuse training and best-practice guidelines through one contact. This process is at the planning stage. Figure 4
Method of identifying patients at risk of domestic abuse and violence
Inpatient’s name ............................................................................................... Community team .............................................................................................. No Don’t know Has there been a diagnosis? Yes If yes, what is it?............................................................................................... At the time of attendance was the patient receiving psychiatric treatment? Yes No Don’t know If yes, what service is involved? ......................................................................... For example, the local inpatient team or local community mental health team
Is the patient at risk of domestic violence or abuse? Yes No Don’t know If yes, please refer the patient to the Bristol Infirmary independent domestic violence advisory service July 2014 | Volume 22 | Number 4 21
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Art & science | violence Conclusion Having an IDVA team based in the ED ensures that victims are more readily identified and are offered a full care package from immediate clinical assistance and support to alcohol and substance misuse services and psychiatric care, where appropriate. As recommended in the recent NICE (2014) guidelines, IDVAs can support and encourage the development of safe and confidential environments in which patients can disclose domestic violence and abuse. Robust and consistent mechanisms for referral into the service can be implemented, which will benefit staff and service users. Through training, the detection of domestic violence and abuse in this ED has increased. This suggests that, when healthcare professionals are better informed about domestic violence and abuse they engage more with patients, and that offers of support and care help to protect clients.
It is important for healthcare professionals to listen to and act on patient disclosures of domestic violence and abuse (NICE 2014), and implementation of this IDVA service has been recognised as a positive move. According to CAADA’s founder and chief executive, Diana Barran: ‘We feel that your approach is potentially the single most important step forward to address the safety and wellbeing of victims of domestic abuse… particularly those who do not call the police. The quality of your service and the model that you represent could and should be understood at a national level and replicated across the country’ (CAADA 2012). This ED IDVA service is fortunate to be part of Project Themis, to be run by CAADA to evaluate the model of domestic violence advocacy that bases IDVAs in hospital settings. This multi-site evaluation will include IDVAs from several hospital sites and departmental settings, and data collection will begin in the summer of 2014.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Against Violence and Abuse (2010) Co-ordinated Community Response Model. www.ccrm.org.uk (Last accessed: June 11 2014.) Coleman K, Osborne S (2010) Homicide. In Smith K, Flatley J, Coleman K et al (Eds) Homicides, Firearm Offences and Intimate Violence 2008/09: Supplementary Volume 2 to Crime in England and Wales 2008/09. Home Office, London. Co-ordinated Action Against Domestic Abuse (2010) Saving Lives, Saving Money. CAADA, Bristol. Co-ordinated Action Against Domestic Abuse (2012) A Place of Greater Safety. CAADA, Bristol.
22 July 2014 | Volume 22 | Number 4
Co-ordinated Action Against Domestic Abuse (2014) CAADA Insights Outcome Measurement: Bristol Royal Infirmary IDVA Service. May 2011 to January 2014. CAADA, Bristol. Her Majesty’s Inspectorate of Constabulary (2014) Everyone’s Business: Improving the Police Response to Domestic Abuse. HMIC, London. Labour Party (2013) Freedom of Information Requests. Labour Party, London. Lewis G, Drife J (2001) Why Mothers Die 1997‑1999: Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. Royal College of Obstetricians and Gynaecologists, London.
Medics Against Violence (2014) AVDR Model. tinyurl.com/nrapwzb (Last accessed: June 11 2014.) McWilliams M, McKiernan J (1993) Bringing It Out Into The Open: Domestic Violence in Northern Ireland: A Study Commissioned by the Department of Health and Social Services. The Stationery Office, London. National Institute for Health and Care Excellence (2014) Domestic Violence and Abuse: How Services Can Respond Effectively. NICE, London. Office for National Statistics (2013) Focus On Violent Crime and Sexual Offences: Statistical Bulletin 2011/12. ONS, London.
Royal College of General Practitioners (2011) Guidelines on Domestic Violence. RCGP, London. Royal College of Nursing (2000) Domestic Violence Guidance for Nurses. RCN, London. Sethi D, Watts S, Zwi A et al (2004) Experience of domestic violence by women attending an inner city accident and emergency department. Emergency Medicine Journal. 21, 2, 180-184. Taft A (2002) Violence Against Women In Pregnancy and After Childbirth: Current Knowledge and Issues In Health Care Responses. Issues Paper 6. Australian Domestic and Family Violence Clearinghouse, Sydney NSW.
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