Around one in five children in the UK have been exposed to domestic violence or abuse between their parents or caregivers. When adults are involved in an abusive relationship, their children bear the consequences.
The effects of domestic violence on a child can range from emotional and behavioural problems to physical injury and death when children are caught up in the violence between adults.
Even when not directly involved, children’s exposure continues through witnessing and being aware of the violence – and through its health, social and financial consequences.
Health and social care workers are often the first professionals to have contact with a child experiencing these situations. This could be when the abused parent seeks help, or when children undergo health checks. It can happen during assessments for emotional or behavioural problems, or when social services, a child’s school or the police become involved.
The World Health Organisation (WHO) recommends that health professionals who see women with clinical signs of domestic violence should ask them about safety in their relationship and at home. They advise that responses to disclosure should follow what is known as the “LIVES” principles: Listen, Inquire about needs and concerns, Validate, Enhance safety, and provide Support.
But there are no equivalent recommendations for children, and there is no agreed approach regarding how best to identify and respond to children who are exposed to domestic violence. So far, there has also been only limited evidence on which to base future guidance.
Now researchers at universities in the UK (Bristol, Queen Mary and Cambridge) and Canada (McMaster and Western) have combined existing evidence on the best ways to identify and respond to children experiencing domestic violence. This synthesis, the first of its kind, integrates findings from 11 studies with 42 children, 220 parents, and 251 health care and social services professionals.
We found that study participants’ opinions were strikingly consistent, and matched the LIVES principles. Children, parents (mostly mothers) and professionals agreed that identification of the problem should happen in the context of a good patient-professional relationship, and in a safe and supportive environment.
Health care professionals should enquire about the child’s safety when they see clinical signs of domestic violence and abuse in children. The ideal initial response should include emotional support, discussion about domestic violence and advice on local specialist services.
We also discovered that a professional’s ability to identify and respond to children’s exposure to domestic violence was heavily influenced by constraints within the health and social service system. Lack of time, funding cuts and poor inter-agency collaboration all have an impact. Professionals needed more training and resources to be able to respond to these children and their families in an appropriate and safe way.
However, there was a difference of opinion when it came to engaging directly with children and managing their safety.
A direct approach?
Children and mothers wanted professionals to talk to children directly and engage them in safety planning. Professionals, on the other hand, preferred to engage with children via the parent – and did not perceive children exposed to domestic violence as patients or clients in their own right. Also, professionals were not happy with existing safety guidelines and practices for children and mothers exposed to domestic violence. These elements are certainly subjects for future research and training.
Given the scale of the problem, and the long-term emotional, behavioural and physical impacts on children, we hope that the results of this study can form the basis of new, internationally agreed guidelines.
Our research findings have already been used to inform point-of-care responses to adults and children in Canada’s VEGA (Violence, Evidence, Guidance, Action) Project. That program is already developing the “Recognising and Responding Safely to Family Violence” Handbook for health and social care professionals.
And we hope our evidence will inspire development of professional training and resources elsewhere – so that front line practitioners feel better equipped to appropriately and safely respond directly to the needs of children. Too many children’s lives and futures could depend upon it.
Part of the CLAHRC’s mission is to raise awareness of new research evidence, and get it to the front-line where it can used by NHS staff. We are working with our host Trust NHS Bart’s Health to translate the new knowledge we generate into everyday practice among NHS professionals.
Bart’s Education Academy has developed an eCPD app available to download for free for users of Android and iPhone smartphones. The eCPD app aims to reduce the time staff have to leave the frontline to attend training courses in person, and give them more flexible learning they can fit around their busy schedules. The app allows staff to log in and create personal and professional development plans (including mandatory training) and optional learning modules. Once completed a notification is sent to both the member of staff and their supervisor, to show they have carried out the necessary training and are credited with CPD points where appropriate.
The CLAHRC has provided learning modules focused on our research findings, and more of our work will appear on the App in the near future.
We are now rolling out some of our popular CLAHRC Academy courses so that they can be accessed via the App – our Academy Director Dr Nora Pashayan (below right) and Academy Teaching Fellow Dr Silvie Cooper (below left) recently met Director of Academic Health Sciences at Barts Health NHS Trust Professor Jo Martin to launch our Introduction to Evaluation course via the App.
The Barts Education Academy provides clinical placements for 2,500 medical undergraduate students and trains 1,040 junior doctors, over 800 children, adult nursing and midwifery students and 275 allied health professionals. The Education Academy offers resuscitation skills training, moving and handling, simulation and clinical skills training and a range of skills based short courses, as well as ensuring the trust achieves high levels of compliance for its statutory and mandatory training.
CLAHRC researcher Dr Jean Ledger is being honoured for an outstanding research paper on how health care organisations use management knowledge.
Dr Ledger is one of the authors of ‘The Silent Politics of Temporal Work: A Case Study of a Management Consultancy Project to Redesign Public Health Care’ which has won the 2017 Urwick Prize, awarded annually by the Worshipful Company of Management Consultants (WCoMC) for an outstanding recent piece of research relevant to management consultancy, published in the UK. The work addresses the tension generated between consultants and clients through their different perceptions of time.
Lead authors Professors Gerry McGivern, Sue Dopson and Ewan Ferlie attended an Education Supper hosted by WCoMC and were presented with the Cup in April by the Master David Johnson BA FCMA FIMC.
Professor McGivern will be delivering the Urwick Lecture on September 13 and the team will be publishing a book – with a launch scheduled for October.
The Prize is awarded annually to honour the life and work of Colonel Lyndall Urwick, who was a distinguished writer and thinker on the topic of management in the mid-20th century and the founder of Urwick Orr Management Consultants.
Details of the full paper are below
The Silent Politics of Temporal Work: A Case Study of a Management Consultancy Project to Redesign Public Health Care
Gerry McGivern, Sue Dopson, Ewan Ferlie, Michael Fischer, Louise Fitzgerald, Jean Ledger, and Chris Bennett
First Published July 14, 2017
“Patient and Public Involvement (PPI) can often be something bolted on to research in a way that fits with the existing research plan. This makes research much easier to press ahead with, as the conflicting and changing opinions of the public do not need to change the planned course of progression. Unusual then, that PPI was considered to be an integral part of Power Up, and awarded time, resources, and influence. The young people who were involved have made great use of this newfound power. The Power Up app is fantastically tailored to the target audience because the target audience made it. The novel approach to PPI used in the project was important in hearing and using the young people’s views…I would urge future researchers to consider PPI as a vital part of research proceedings, as it has been in Power Up.” Project worker, Power Up
The Power Up study, supported by NIHR CLAHRC North Thames, has made the involvement of young people an integral part of the research process in work to develop an app to support shared decision-making in mental health. Power Up is a four-year research project to develop an app for young people to use from their first assessment with Child and Adolescent Mental Health Services (CAMHS) to empower them to be actively involved in decision-making.
Young people were active participants in taking the concept of a shared decision-making tool through design, prototype, and testing through three different types of involvement: governance of the project; needs and environment analysis; and detailed input for the development of the intervention.
PPI was embedded into the project model from the outset, to be iterative and cyclical informing the development and direction of the digital tool at each stage. Involving service users resulted in the identification and implementation of multiple changes to the app, both conceptual and tangible. Several challenges associated with PPI were also encountered, warranting future research and discussion.
The team has published their involvement experience in a paper published in special themed edition of the Journal of Health Design entitled Patients as co-designers to improve the quality of care
Edridge C L, Edbrooke-Childs J, Martin K, Delane L, Averill P, Feltham A, Rees J, Jeremy G, Chapman L, Craven M P, Wolpert M.
Power Up: Patient and public involvement in developing a shared decision-making app for mental health.
JHD. 2018;3(1):63–74. https://doi.org/10.21853/JHD.2018.40
Using patient information
How will this be operated?
Getting It Right First Time (GIRFT) is a national programme designed to improve care for patients within the NHS, by reducing unwarranted variations. Our evaluation of the NHS Getting it Right First Time programme could not happen without access to patients’ data and this will play a vital role in our ability to get a picture of how the programme is working and the difference it is making to patient care. We want to be clear about how your data is stored, used and protected in our research. One aspect of this study looks at ‘what works and at what cost?’
We are trying to look at whether the Getting it Right First Time programme in orthopaedic surgery has reduced variations in orthopaedic practice and costs, and improved outcomes for patients. To do this, we are requesting confidential patient data for a group of patients who have undergone elective orthopaedic surgery between 1st April 2009 and 31st March 2018.
The data we would like to use include Hospital Episode Statistics (HES), a database containing details of all admissions to NHS hospitals in England, which is collected so that hospitals can be paid for the care they deliver. We would also like to include Patient Reported Outcome Measures (PROMs) for patients who have had hip or knee replacements. NHS patients who have had these procedures have been invited to fill in Patient Reported Outcome Measures (PROMs) questionnaires as part of the Department of Health’s PROMs programme. The NHS asks patients about their health and quality of life before they have their operation, and about their health and the effectiveness of the operation afterwards at six months. These data can also be processed and used for other purposes, such as research and planning health services. We would also like to use data from the National Joint Registry (NJR). The NJR was set up by the Department of Health to collect information on all hip, knee, ankle, elbow and shoulder replacement operations across the NHS, to make sure joint replacement implants were working and to also ensure the different types of surgery for these operations were safe and effective.
Secure storage and processing of patient information
This study has already received research ethics approval – a process designed to make sure researchers’ can benefit from accessing data while minimising risk of any harm to patients – and Health Research Authority Confidential Advisory Group Section 2.51 approvals. The legal basis for processing are covered under Article 6 (1) (e) and Article 9 (2) (j).
Personal data of patients – including NHS number, date of birth, sex, postcode and the study ID will only be securely transferred between two organisations – Northgate Public Services (who control NJR data) and NHS Digital (who control HES and PROMs data). This is considered to be personal data according to European data protection rules – the General Data Protection Regulation (or GDPR). As these two organisations currently hold the data, and are involved in processing, they are called data processors. The purpose of sending this personal data between the two organisations is so NHS Digital can link these data together for the same patients, to provide more accurate and complete information for researchers who can track a patient’s journey through the NHS system. However, researchers will not have access to any personal identifiable data, and will not be able to identify patients, using the information that they are given by the two organisations (Northgate Public Services and NHS Digital).
Both organisations will securely transfer pseudonymised data to researchers at UCL. Pseudonymisation means the most identifying fields within a database are replaced with artificial identifiers, or pseudonyms so patient information can be processed without researchers being able to identify patients. This means that UCL will be the final and only data controller for the data that is disseminated for the purposes of looking at ‘what works and at what cost?’ UCL will determine the purposes for which and the manner in which any personal data are to be processed. All pseudonymised patient information will be stored on a secure network that is password-protected
The data will be stored by researchers at UCL until 2021 for analysis and dissemination purposes, and thereafter will be securely destroyed.
UCL Data Protection:
UCL is required by law to comply with data protection legislation. The UK’s regulator for the legislation is the Information Commissioner’s Office. It is the commitment of the university to ensure that every current employee and registered student complies with this Act to ensure the confidentiality of any personal data held by UCL, in whatever medium. This Act came into force on 25 May 2018.
UCL processes the personal data of living individuals such as its staff, students, contractors, research subjects and customers. UCL has a data protection policy as a commitment to the safeguarding of personal data processed by its staff and students, and to ensure compliance with the legislation. It is the duty of data controllers such as UCL to comply with the data protection principles with respect to personal data. This policy describes how UCL will discharge its duties in order to ensure continuing compliance with the Act in general and the data protection principles and rights of data subjects in particular.
Data Protection Officer Contact details:
Research Department Administrator
PA to Professor Rosalind Raine and Professor Naomi Fulop
Department of Applied Health Research, UCL
Visiting Address: 1-19 Torrington Place, London WC1E 7HB, Rm 112
Postal Address: UCL, Gower Street, London WC1E 6BT
Tel: 020 3108 3269
We are happy to discuss your rights to protect your data, and how exactly it will be used in our research. If you would like further information about the use of your data in this research study, or would like to lodge a complaint to a supervisory authority – please contact us on the details given below. If you would like to request that your confidential patient information is not included in this study, please aim to contact us between 1st May – 24th August 2018 to discuss.
Dr Sarah Jasim
NIHR CLAHRC North Thames
Department of Applied Health Research
University College London
1-19 Torrington Place
London WC1E 7HB
Tel: 020 3105 3233