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Domestic abuse on your doorstep?

27 April 2017

Domestic abuse can present a tough situation for health visitors. They need to know about it in a timely manner and decide how to respond. Michelle Moseley evaluates an initiative in Wales that sets out to offer support.

Evaluating a ‘Domestic Abuse Conference Call’ on health visitor practice

Michelle Moseley: Programme manager, SCPHN, School of Healthcare Sciences, Cardiff University

Abstract

Domestic abuse is high on national government agenda, not least because it is a child protection issue. Domestic Abuse Conference Call (DACC) has been developed to target low-medium risk victims of domestic abuse. The initiative involves lead members of relevant agencies cascading information to frontline practitioners with an aim of informing them of an incident at an early stage in the domestic abuse cycle. This enables an informed assessment to take place, and signpost the victim to local domestic abuse support services.

A work-based project was undertaken to evaluate the influence of the DACC on health visiting practice. The DACC is a positive step in coordinating a joint approach to deliver an effective service to victims of domestic abuse. Information sharing of low-medium risk victims has the potential to reduce the numbers of high-risk victims and improve their life chances.

Introduction

Domestic abuse and its links to safeguarding children is well documented (Holt and Whelan, 2007; Welsh Assembly Government (WAG) 2011; Erikson and Nasman, 2012). Children are placed at significant risk of harm during domestic abuse incidents. It is an adverse childhood experience and potentially can have a significant impact on the child’s physical and emotional wellbeing later in life (Bellis et al. 2015). This harm potentially crosses all categories of child abuse and, therefore, addressing domestic abuse has become a national issue (National Institute for Health and Care Excellence (NICE), 2014). The Home Office (2013, p3) defines domestic 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 family members regardless of gender or sexuality. This can encompass but is not limited to the following types of abuse: Psychological, physical, sexual, financial, and emotional.’

Victims of domestic abuse can be any sexuality and either gender. Early identification of domestic abuse is paramount in safeguarding those involved.

Background

A multi-agency project was undertaken within the author’s locality in 2010. This involved an external researcher exploring the thoughts and feelings of victims of domestic abuse, and identifying if and how agencies may work collaboratively and improve support provided. Areas of development were identified within the locality and the findings of the project included:

  • A lack of information sharing between agencies
  • Missed opportunities in relation to rehousing the victim
  • Lack of supervision and control – this referred to police actions and there being no multi-agency response to support low level victims of domestic abuse (Hart and Fortey, 2011).

Due to the need identified, especially lack of information-sharing and support of low level victims of domestic abuse, the police developed the DACC initiative, which provided opportunities for all relevant agencies to share information at a local level when a domestic abuse incident occurred. The police were well-equipped to provide and coordinate the information-sharing process as all domestic incidents are logged centrally and tracked via the force command and control system.

In 2010, 8075 domestic abuse incidents were reported to the local police. This figure equates to approximately 22 incidents being recorded on a daily basis. Police officers attended 2600 of the 8075 incidents (Hart and Fortey, 2011). Anecdotal evidence identified that, out of these incidents, only four or five incidents were communicated to the lead nurse for safeguarding children (LNSC) by the police, via telephone or email. These figures indicated that health visitors were not being made aware of all incidents.

A pilot of DACC involved the sharing of information via a telephone conference call on a daily basis. Police, social services, education, health, housing, and probation have access to a SharePoint account, which allows access to information regarding all domestic abuse incidents electronically, prior to the conference call. The incidents shared at conference call are generally low and medium risk cases. The categorisation of risk is based on the criteria set by the co-ordinated action against domestic abuse risk indicator checklist (CAADA-RIC, CAADA, 2009). All high or very high-risk cases were directly referred into the multi-agency risk assessment conference (MARAC). The LNSC is a member of the DACC and he or she then informs health visitors about the information shared, Monday to Friday. The sharing of information via the DACC allows the health visitor to be aware of recent domestic abuse incidents and allows support to be given to the victim if required. This could be signposting to domestic abuse agencies, suggesting safety plans and the provision of support contact numbers.

The sharing of information at an early stage facilitates effective early intervention and support to low level victims of domestic abuse, potentially minimising the escalation of risk. The conference call information is cascaded to the health visitor to inform them of all domestic incidents relating to their clients within at least 24-48 hours of it occurring. There is an expectation that the health visitor will record the information and liaise with the victim if it is safe to do so. Information received from the DACC is recorded within health visitor documentation.

A chronology of significant events is recommended within all health visitor documentation. This provides a snapshot of significant events, which can guide a response if required (box 1). The safeguarding team identified a need for evaluation of the role of the health visitor in this initiative together with their response to the information received from DACC.

Box 1: Recommended significant events for inclusion into a chronology.

Chronology of significant incidents should include:

Missed appointments
Injuries to the child
A&E attendances
Domestic abuse incidents (indicate low, medium or high)
Attendance at child protection meetings
Child protection and child in need referrals
Referrals to any early intervention and support services/parenting support services Unable to access visits

 

Study aim/purpose

The purpose of the evaluation was to critically review the literature on a multi-agency response to domestic abuse, analyse the impact of the DACC on current record keeping practices of health visitors, develop and implement a new guidance to address any identified shortfalls in record keeping practice, and to evaluate the effectiveness of the new policy on health visiting practice.

Ethical Approval

Ethical approval was sought and gained from the Local Health Board (LHB) Research, Development and Risk Review Committee (Reg: SA/232/11) to carry out an audit to evaluate and review health visitor records. An equality and impact assessment was also completed. An audit tool was developed by the author based on local audit standards (Local Health Board, 2011a).

Method

An audit of health visiting records was undertaken. Its aim was to assess health visitor documentation to identify the recording of domestic abuse information. Audit is a common process, which can be used to assist in the assessment of service provision, the evaluation of services, and as a tool to scope practice. Therefore, audit has the potential to improve client care (Patel, 2010). There was an expectation that the recording of the domestic abuse information would be in 100% of health visiting records. An audit tool was developed to scope health visitor practice in the recording of the information. The audit tool aimed to identify if the information was being recorded, where the information was being recorded within the health visiting record, and if there was any subsequent action by the health visitor, for example, a home visit, telephone call or clinic contact.

Health visitor records were examined during January to March 2011. The health visitor records were cross-referenced with the DACC information about any incidents to establish if any recording had taken place and if any action had been taken. When a domestic indecent had occurred, each individual health visitor base was visited to audit those records.

Results

The data collected clearly showed a lack of recording of DACC information by health visitors over a three-month period. The information was not necessarily recorded in the correct section of the health visitor records. Health visitors had been verbally instructed to record information within the chronology section, expanding on the detail of the call within the family record. This information was provided as the DACC was launched. The audit identified chronologies were not up to date and initial figures were particularly poor - only 47% of health visitors recorded the information at all.

This lack of recording of pertinent information has the potential to place the family and the health visiting team at increased risk. Poor record keeping could misinform practitioners, which may place the domestic abuse victim at increased risk with the potential to inadequate signposting to relevant services. There could be a missed opportunity to assess or even question the victim. Poor record keeping has been a misdemeanor identified in previous serious case reviews/child practice reviews (Welsh Government (WG), 2013). It is unacceptable and contravenes Local Health Board and NMC guidelines (NMC, 2015).

Any action taken by the health visitor was also captured to allow analysis of the impact on their workload. Within this first period of audit, minimal action was taken (14% to 21%). Any action would depend on the specific incident, and a decision to act was left to the individual health visitor’s professional judgment. Some health visitors deemed low risk incidents as low priority, in comparison to the remainder of their caseloads and recorded the information only. There was a varied response with some health visitors undertaking home visits or making contact in clinics.

Actions arising from the Audit of Practice

Following the initial audit, the results were shared with the health visitors, public health nursing managers, and the safeguarding team. Health visitors requested guidance to inform their practice. This led to a plan to providing written guidance for health visitors in the recording of DACC information and what comprises appropriate action. It also allowed discussion around the impact of the DACC on the health visitors, the LNSCs and implications for the health board.

The guidance (Local Health Board, 2011b) was launched with presentations to the health visiting service to facilitate a full understanding of what was required in terms of inputting the information as well as any subsequent action. Attendance was compulsory for all health visitors. Five could not attend and they had the guidance explained to them on a one-to-one basis.

The guidance (box 2) allows the health visitor to use their professional judgment in determining whether or not to contact the victim. Some health visitors felt this was too broad so explanation was provided in relation to the incidents being low risk – medium risk and the safeguarding lead was available to offer support and advice. Health visitors became more informed, and domestic abuse training was updated in the area, which included training on the completion of the Domestic Abuse Stalking and Harassment (DASH) risk indicator checklist (RIC), (CAADA, 2009).

Once the guidance had been in place for one-month (July) health visitors were informed that another audit would take place over a three-month period (September- November 2011). The same audit tool was used to allow accurate comparison of results, promoting validity and reliability. Health visitors appeared to welcome the audit; it served to inform their public health managers of their increasing workload and, since the implementation of the guidance, they were more comfortable in their practice decision-making. There was a significant increase in the recording of DACC incidents during the second audit period, with October reaching 100% (see diagram 1) although further improvement was needed to ensure they recorded in the chronology section.

Overall Comparison of data- Diagram 1

Evaluating a ‘Domestic Abuse Conference Call’ on health visitor practice GRAPH

Chronologies are particularly useful when working with and maintaining health records. Health information regarding children is sometimes recorded in many areas. A chronology allows health visitors to record significant event information in one document (Powell, 2016). They are utilised by other agencies and often multi- agency chronologies are used to identify child protection concerns.

Chronologies are now used with all families in the area. They need to be an ongoing document and updated as significant incidents occur (box 1). In October and November, the health visitor action to the DACC increased .The results indicate a rise in home visiting in response to the DACC information as well as a slight increase in clinic contact and liaison with agencies, such as social services. Therefore, development of the guidance (box 2) appeared to have a positive impact on the recording of the DACC information.

Box 2:  DACC Guidance content.

“Domestic Abuse Conference Call (DACC) Response Guidance for health visitors” includes:

1 – Purpose of guidance

2 – Record keeping guidance in relation to DACC

3 – Purpose of DACC recording

4 – Monitoring (of HV records)

5 – Conclusion and reference list

6 – Useful contacts/ Local and National Domestic Abuse Information, policy and guidance.

 

Discussion

Health visitors are extremely aware of the safety of children being paramount (Children Act, 1989; WAG 2008, HM Government, 2015, Appleton and Peckover 2015; and Powell, 2016). The results of the September – November audit was fed back to health visitors and local public health managers at their team meetings. They were encouraged by the improved results and discussion took place around the DACC process. Some comments are outlined within box 3.

Health visitors wanted the information and felt the DACC gave it to them quickly. Previously, this information could sometimes arrive a week or so after the domestic abuse incident. Receiving the information within 24 to 48 hours of the incident occurring was deemed effective.

Health visitors felt that the increase in action within the second audit occurred due to training in domestic abuse, and an increased awareness of local domestic abuse agencies. Discussion also took place around caseload capacity and how a DACC action can influence their day-to-day caseload. Health visitors felt more informed about domestic abuse within their caseloads and professional relationships are building amongst partner agencies. These partner agencies include the police, housing, social services and domestic abuse services where joint visiting has been particularly proactive in the development of safety plans and signposting for support.

Box 3: Health visitor comments following the launch of the DACC.

“It worries me; it’s one more thing to think about on top of everything else.”

“It’s good to have the information quickly. I have visited a home previously where a domestic had occurred just days before and I knew about it before going in....”

“We can make a more informed risk assessment if we have this information.”

 

Implications for practice

Poor multi-agency working, which involves lack of information-sharing, contravenes the recommendations made by any serious case review/child practice review, where a deficit in information-sharing and poor communication is a recurring theme (WG, 2013). The knowledge gained in the sharing of information in domestic abuse situations has the potential to improve outcomes for the victim and the children involved (Bradbury-Jones et al, 2016).

One of the main practice issues identified from health visitors was an increase in workload. This increase refers to the recording of the incident and potential for making contact with the victim. Therefore, whatever their response to the DACC, the health visiting team’s workload is affected. The response to victims has the potential to be positive as intervention at the low- medium risk stage could reduce recidivism rates of domestic abuse. This could lead to lower numbers of high-risk victims due to proactive support at an early stage.

Obtaining DACC information at an early stage has the potential for the development of a coordinated approach to domestic abuse. Health visitors are given the opportunity to instigate a routine inquiry – or, in Wales, ‘Ask and act’.

This is a process of targeted inquiry across public services in Wales to offer routine inquiry into domestic abuse across maternal, midwifery and health settings (Welsh Government, 2016: 3). Therefore, the DACC information allows practitioners to offer intervention at a lower level with the long-term aim of reducing high-risk victims, and offering support potentially in the earlier stages of the domestic abuse cycle. The future impact of the DACC should offer a more positive outcome for the victim and the children involved, and continues to be an information-sharing, multi-agency platform.

Recommendations

Health visitors are required to maintain up-to-date chronologies of significant events within their records.

Guidance in maintaining chronologies needs to be provided locally, with regular updates/training provided in relation to domestic abuse, and completing the CAADA DASH RIC (CAADA, 2009).

Health visitors need to be vigilant in maintaining accurate records and take the opportunity, and if safe to do so, to Ask and Act (WG, 2016).

Conclusion

Health visitors are well placed to support victims of domestic abuse. The development of the DACC had practice implications for health visitors and, to scope the impact, an audit was undertaken to evaluate where the DACC information was being recorded and what action was being taken. Health visitors were instructed on how to record the information within their documentation. A gap in service provision was identified as a result of the audit. A DACC guidance was developed to inform health visiting practice in relation to recording the information and advise on subsequent action taken. Additional domestic abuse training took place in the delivery of the CAADA DASH RIC (CAADA, 2009). Following the implementation of guidance for health visitors, a second audit was carried out. The results showed a significant improvement in the recording of the DACC information.

It is evident that the DACC is attempting to offer a coordinated response to domestic abuse, using an inter-agency approach. Communication and information-sharing is the way forward in reducing risk to domestic abuse victims, allowing the victim and their families to change their life chances. It is particularly important to access information in relation to any domestic abuse incident at an early stage. Agencies require documentation to support them in the delivery of services to aid the DACC process. Further improvement is required in the use of chronologies within this process and the recording of the DACC information needs to be maintained. A multi-agency perspective is essential in the promotion of partnership working and improved information-sharing has the potential to improve outcomes for victims and their children.

Key points

  • Earlier intervention for victims of domestic abuse.
  • Improved partnership working and information sharing.
  • Multi-agency decision making for victims of domestic abuse.
  • Effective use of chronologies within records.

References

Appleton, JV. Peckover, S. (2015). (Eds). Protecting children and young people. Child Protection, Public Health and Nursing. Edinburgh: Dunedin.

Bellis, MA., Ashton, K., Hughes, K., Ford, K., Bishop, J.,and Paranjothy, S. (2015). Welsh Adverse Childhood Experiences (ACE) study. Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population. Alcohol use, drug use, violence, sexual behaviour, incarceration, smoking and poor diet. Cardiff: Public health Wales.

Bradbury-Jones, C., Appleton, JV., and Watts, S (2016) Recognising and responding to domestic violence and abuse: the role of public health nurses. Community Practitioner, 89(3): 24-28.

CAADA (2009). http://www.dashriskchecklist.co.uk [accessed 10.07.16] Children Act. (1989). London: HMSO. Available online: http://www.legislation.gov.uk/ukpga/1989/41/contents [accessed 10.07.16]

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NICE (2014). Baseline assessment tool: Domestic violence and abuse. Implementing the NICE guidance on domestic violence and abuse: how health services, social care and the organisation they work with can respond effectively. https://pathways.nice.org.uk/pathways/domestic-violence-and-abuse#content=view-info-category%3Aview-resources-menu [Accessed 30.07.16].

NMC (2015). The Code. Professional Standards of practice and behaviour for nurses. https://www.nmc.org.uk/standards/code/ [Accessed 30.07.16].

Patel, S. (2010). Achieving quality assurance through clinical audit. Nursing Management, 17(3):28-34.

Powell, C. (2016). Safeguarding and child protection for Nurses, Midwives and Health Visitors. A practical guide. Berkshire: Open University Press.

Welsh Assembly Government (2008). All Wales Child Protection Procedures. Cardiff: The Stationery Office.

Welsh Assembly Government (2011). Safeguarding Children and Young People affected by domestic abuse. All Wales Guidance. Cardiff: Crown copyright

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Welsh Government (2016). The National Training Framework on violence against women, domestic abuse and sexual violence. Statutory guidance under section 15 of the violence against Women, Domestic Abuse and Sexual violence (Wales) Act 2015 and section 60 of the Government of Wales Act 2006. Cardiff: Crown copyright.

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