Workstream 1: confidentiality of remote or online consultations
Workstream 1 explored potential difficulties of ensuring confidentiality when seeking to identify domestic abuse during remote consultations. In theory, excepting the first few weeks from 23rd March 2020 when all general practices were closed, general practitioners could continue to address domestic abuse in consultations (regardless of the consultation method). In practice, however, losing the assured confidentiality of face-to-face consultations raises concerns about whether it is safe to ask about domestic abuse. The patient may not be alone; the perpetrator may be present or able to overhear. Secondly, body language cues become limited or non-existent by video/phone, making it more difficult for clinicians to accurately gauge a situation or a patient’s response.
To understand the impact of moving to remote consultations on clinicians’ ability to identify and refer patients affected by DA we compared daily referrals from January 2020 to July 2020.
Figure 1 shows daily referrals from 1 January to 1 July 2020. After an initial decline in late March / early April, referrals began increasing again in late April. By July 2020, referral numbers had nearly reached pre-pandemic levels. While the long-term impact was outside the scope of this study, an interrupted time series analysis of the impact of the first COVID-19 national lockdown on referrals into IRIS services has been published elsewhere [28].
We pursued several lines of enquiry in the surveys with clinicians and CLs to explore their confidence to address domestic abuse during telephone/video consultations. Tables 2 and 3 summarise the results.
Table 2
Confidence level in addressing DA in remote consultations
|
Confidence level in identifying and asking about DA in phone/video consultations
|
Confidence level in responding to disclosures of DA in phone/video consultations
|
|
IRIS Clinical Leads (n. 25)
|
Clinicians
(n.115)
|
IRIS Clinical Leads
(n.25)
|
Clinicians
(n.115)
|
Very confident
|
36% (n.9)
|
13.9% (n.16)
|
68% (n.17)
|
22.6% (n.26)
|
Somewhat confident
|
44% (n 11)
|
48.7% (n.56)
|
20% (n.5)
|
47.8% (n.55)
|
Neither confident nor unconfident
|
16% (n.4)
|
21.7% (n.25)
|
12% (n.3)
|
19.1% (n.22)
|
Somewhat unconfident
|
4% (n.1)
|
14.8% (n.17)
|
0% (n.0)
|
9.6% (n.11)
|
Very unconfident
|
0% (n.0)
|
0.9% (n.1)
|
0% (n.0)
|
0.9% (n.1)
|
Table 3
Confidence level addressing DA in remote consultations compared with confidence addressing DA in face-to-face consultations
|
Identifying and asking about DA
|
Responding to disclosures of DA
|
|
Clinical Leads
(n.25)
|
Clinicians
(n.115)
|
Clinical Leads
(n.25)
|
Clinicians
(n.115)
|
I am much more confident in face-to-face consultations
|
32% (n.8)
|
37.4% (n.43)
|
20% (n.5)
|
30.4% (n.35)
|
I am somewhat more confident in face-to-face consultations
|
28% (n.7)
|
44.3% (n.51)
|
20% (n.5)
|
33.9% (n.39)
|
I have the same level of confidence for both face-to-face consultations and phone/video consultations
|
28% (n.7)
|
13% (n.15)
|
60% (n.15)
|
34.8% (n.40)
|
I am somewhat less confident in face-to-face consultations
|
12% (n.3)
|
4.3% (n.5)
|
0% (n.0)
|
0.9% (n.1)
|
I am much less confident in face-to-face consultations
|
0% (n.0)
|
0.9% (n.1)
|
0% (n.0)
|
0% (n.0)
|
Table 2 illustrates that four in five (80%) Clinical Leads, and nearly two thirds (62.6%) of clinicians felt confident identifying and asking about DA during telephone/video consultations. A key concern prompting this rapid study had been that the lack of assured confidentiality of remote consultations may lead fewer clinicians to feel confident in identifying and asking about domestic abuse, although they may still feel confident responding to unprompted disclosures. Consequently, we differentiated between actively identifying and asking about DA as opposed to responding to a disclosure. As hypothesised, a slightly greater proportion of both Clinical Leads (88%) and clinicians (70.4%) felt confident responding to disclosures of DA during telephone/video consultations.
Additionally, we asked clinicians and CLs how their confidence in a) identifying and asking and b) responding to disclosures of DA in remote consultations compared with their confidence in addressing DA in face-to-face consultations. Table 3 summarises the results.
We had hypothesised that clinicians and CLs would feel more confident addressing DA in face-to-face consultations, where they could be assured of the confidentiality (and therefore the patient’s safety) of asking about DA. As predicted, the majority of Clinical Leads (60%) and clinicians (81.7%) felt more confident identifying and asking about DA face-to-face. From this we can infer that nearly two thirds of Clinical Leads and over three quarters of clinicians feel less confident to ask about DA in remote consultations. In addition, the majority of clinicians (64.1%) also felt more confident to respond to disclosures of DA in face-to-face consultations (and logically less confident to respond remotely), as did 40% of Clinical Leads. The interviews revealed that concerns around safety contributed to this lack of confidence, as “You can never be 100% sure she's on her own” (IRIS Clinical Lead) and also a greater difficulty establishing rapport:
“If you've never seen that patient before, got no relationship, then again I think that's one of the factors that makes me hesitant to say in that first consultation whereas if I'd seen her face-to-face, I would've got that connection straight away and I would've asked her. There's definitely barriers doing it virtually.” IRIS Clinical Lead
Finally, we surveyed clinicians on whether they had actively asked about domestic abuse in phone/video consultations: 61.7% of clinicians responded that they had actively asked about DA in remote consultations. 48.7% of clinicians reported responding to a disclosure remotely and 33.6% had made a referral to an IRIS Advocate Educator during a phone/video consultation. This indicates that, despite lack of confidence, clinicians are still making attempts to actively identify and ask about domestic abuse during remote consultations, and nearly half had indeed received a disclosure from a patient, thereby demonstrating the relevance and importance of asking.
Workstream 2: desirability and acceptability of IRIS online training
Workstream 2 explored the desirability and acceptability of IRIS training delivered virtually. Unfortunately, during the data collection period (August 2020), only 4.3% of clinicians who responded had received IRIS training online. By March 2022, the proportion of clinicians receiving training online had grown substantively, with more than 87.9% of clinicians having received IRIS training online.
Our AE survey revealed mixed perceptions around online training. Nearly half of respondents (48.7%) felt that clinicians would engage better with IRIS training in its current online form due to the perceived increased relevance of the IRIS Programme following greater media coverage of DA, and a quarter (25.6%) believed clinicians would find it easier to commit time for online training, particularly while fewer patients seeking access to general practice had reduced workload. Despite this, nearly half (48.7%) of respondents were concerned about difficulties in concentration, engagement or IT/technological difficulties. Around one quarter (25.6%) were concerned that online training would prove less effective, although only a minority (15.4%) believed training a practice team online would result in fewer patients referred for advocacy and support.
Clinical Leads and clinicians were more positive and pragmatic about online training. Of the Clinical Leads surveyed, 72% of respondents preferred online training to face-to-face. During interviews, Clinical Leads explained their preference for online justifying that blocking out full days is very difficult for clinicians and that more concise sessions, as can be provided online, fit better with clinicians’ other commitments. Secondly, the CLs interviewed all highlighted that online training enables IRIS teams to offer train more efficiently by training multiple practices in different locations at the same time. Thirdly, online sessions give scope for more regular training, which is beneficial given the frequency with which new COVID-19 guidance is published. The following quote illustrates:
“We can offer an online meeting for anybody else across the other 60 practices or even the 90, who wants to come and just do an hour or an hour and a half update about IRIS in COVID-19. Actually, having done that, we should go on doing it year after year, because there are about 10 things that have changed in the last six months.” IRIS Clinical Lead
Although AEs expressed concern about maintaining clinicians’ engagement in online training, clinicians themselves have responded that they were able to engage and absorb online training well. Of the clinicians surveyed, 100% found a quiet place to complete the training, they didn’t have technical difficulties, they managed to dedicate time for training without distractions and they found it straightforward to access materials before and after the training. In the interviews, clinicians acknowledged the difficulties in translating IRIS to a remote service and praised the programme for its responsiveness. Furthermore, clinicians reported feeling comfortable with online training and believed that in the near future no face-to-face trainings would be possible.
I'm just trying to make sure that the program is still running in the best ability that it can be with lockdown and the use of the tele-communications but I think it's also just to make sure that the online training still goes ahead for the GPs
IRIS trained clinician
AE, Clinical Lead and clinician interview participants consistently highlighted the difficulties of reading facial expressions and body language via a screen, with one participant describing this as “talking into a void” (IRIS Clinical Lead). AE and Clinical Lead participants expressed concern about being unable to ascertain (or respond appropriately) if a training participant was distressed by the content because they could not see participants’ expressions. In contrast, “when you've got a room full of people, you can quite easily detect who's struggling with the training or who it's affecting” (IRIS Clinical Lead). CLs and clinicians meanwhile were concerned by the same difficulties when in consultation with patients:
you can't see how the patient's interpreting what you're saying because everything you say is open to interpretation, isn't it? Especially if they're in a bad place.
IRIS Clinical Lead
Workstream 3: desirability and acceptability of IRIS remote advocacy and support
Workstream 3 explored the effectiveness and desirability of IRIS remote advocacy and support. In the survey with AEs (39 responses), the majority of AEs (78.2%) reported that all or most of their service users were happy to transfer from face-to-face to remote support. Only small minorities of AEs reported that most service users chose not to take up remote support (3.1%), that most were unable to find a safe/quiet/confidential space in which to engage with remote support (3.1%), or that most were prevented from accessing remote support because of additional caring responsibilities (3.1%). Similarly small percentages (3.1%) reported that around half of service users could not engage with remote support because of lack of access to an interpreter, or lack of access to the necessary technology. These findings indicate that remote advocacy and support, when offered, is acceptable to the large majority of service users.
Interviews with service users also revealed that they felt positively about being asked about domestic abuse, and offered a referral, during a remote consultation in general practice:
“I think it's easier sometimes to do it on the phone because you wouldn't hug a doctor when you're crying anyway. I don't mind it so much on the phone, the doctors.” IRIS Service User
A more nuanced picture emerges about the desirability of remote support and its outcomes. A majority (71.8%) of AEs reported that service users’ self-reported outcomes were just as positive about remote support as compared with past face-to-face support. Nearly half (46.2%) of AEs, however, reported delays or difficulties in access for their service users to survivor’s groups or other relevant services, broadly correlating with a sizeable minority of AEs (39%) who reported that they felt something was lacking in the support they were able to provide. The frequency of topics raised in free text detail on what would have improved this perceived lack were counted and revealed two main trends: better access to technology (for either themselves or their service users), and/or feeling better equipped to provide intensive emotional or therapeutic support, particularly in the temporary absence of many other services (such as counselling or group therapy) functioning.
In interviews, both service users and AEs emphasised the responsiveness of AEs towards their service users. The quote illustrates:
After we've had our phone call, she's giving me a time and a date and if I needed to get hold of her, all I'd have to do was text and she answers really quick.
IRIS Service User
By providing more frequent contact and greater availability via text and Whatsapp, AEs ensured service users felt supported despite being unable to provide face-to-face advocacy. The majority (71.8%) of AEs reported providing additional emotional support to service users, and 41% provided additional advice and information on legal, welfare and housing services. In interviews, service users stated that they felt their advocates had been able to accomplish things on their behalf:
“She's done the referrals for social services. She got me on the Freedom Program.
She did my legal aid for my solicitor, she helped him with his statements for court.
She does do anything she can do remote. She does get it done.”
IRIS Service User
Service users were interviewed about their preference: face-to-face or remote support. The two service users who had been able, pre-pandemic, to meet their advocate face-to-face preferred this. The two newer service users who had not had this option preferred remote support. This suggests that service users who are never offered face-to-face do not perceive a lack, and may indeed see it as more accessible:
I know if remote wasn't going on and it wasn't available, I would just be missing an appointment because I don't fancy going outside that day. I'm just in a low mood.
IRIS Service User
Service users raised the relative ease of hiding emotions during remote advocacy sessions: “it's a lot easier to pretend you are happy on a video call and you've got your shit together” (IRIS Service User). Perceptions on whether this is desirable were mixed. Some viewed this is as a barrier to connection, but others saw it positively. One service user explained how face-to-face support can feel overwhelmingly emotional, and so “if I was going to cry, I’d rather do it on video at least”.
Support for IRIS service users has always been described as ‘patient-led’. Our findings indicate that not only the type or topics of support but also the mode should be patient-led; advocacy cannot be provided using a one-size-fits-all approach.
Framework Analysis results
We carried out a Framework analysis of the interviews focusing on barriers, enablers, benefits, and losses to understand commonalities and differences between Advocate Educators, Clinical Leads, clinicians and service users. Based on the analyses of the interviews, we produced a matrix of emerging findings, presented in Fig. 2. A similar matrix for each of the relevant groups of stakeholders in this research is provided in the supplementary materials.
The theme of technology as a (potential or actual) barrier was the most frequently mentioned across all stakeholders. Each type of stakeholder voiced concerns about technology as a barrier to the aspects of the IRIS Programme for which they are responsible for delivering or engaging with (e.g. AEs with delivering training and providing advocacy, clinicians with identifying abuse during consultations, etc). Three themes of loss resonated across the different interviewee groups. Firstly, remote training and support is perceived as less personable, correlating with technology as a barrier. The second theme concerned the loss of the (physically) embedded status of the IRIS service and AE within IRIS-trained practices. Finally, AEs and CLs highlighted lost networking opportunities.
Furthermore, four themes coalesced as enablers of change. Increased contact between different groups of stakeholders, combined with the speed and responsiveness of those delivering the IRIS Programme, and thirdly combined with greater flexibility of modes for training and support ensured that the IRIS Programme remained effective and desirable. The final enabler was the increase in relevance of the IRIS Programme in the context of increased prevalence and/or reporting of domestic abuse, compounded by usual routes to support being less or unavailable. Finally, the move to online training and remote support also produced benefits. The major themes, both for advocacy and training, were around increased time efficiency for those involved (less/no travel time means more sessions fit into busy working days), greater accessibility, and increased uptake as a result.
Comparing matrices a-d (found in the supplementary materials) illustrates that AEs and CLs (i.e. those delivering the IRIS Programme) more frequently discussed the barriers and enablers of the change from face-to-face to online/remote training and support, while clinicians and service users (the end beneficiaries of the IRIS Programme) focused more on the enablers of change.