Implementation of the Identification and Referral to Improve Safety programme for patients with experience of domestic violence and abuse: A theory‐based mixed‐method process evaluation

Abstract

Identification and Referral to Improve Safety (IRIS) is a training and support programme to improve the response to domestic violence and abuse (DVA) in general practice. Following a pragmatic cluster‐randomised trial, IRIS has been implemented in over 30 administrative localities in the UK. The trial and local evaluations of the IRIS implementation showed an increase in referrals from general practice to third sector DVA services with a variation in the referral rates within and across practices. Using Normalisation Process Theory (NPT), we aimed to understand the reasons for such variability by identifying factors that influenced the implementation of IRIS in the National Health Service (NHS). We conducted a mixed‐method process evaluation which included: (a) a case study (100 hr of participant observation, 19 interviews); (b) a survey (n = 118); (c) qualitative analysis of free‐text comments from the survey; (d) qualitative interviews (n = 8); (e) document review (n = 44). Data were collected from NHS and third sector staff across five London boroughs from August 2015 to December 2017, analysed descriptively and thematically and triangulated using the NPT constructs coherence, cognitive participation, collection action and reflexive monitoring. The survey showed wide variation in the extent to which practice staff saw IRIS as a normal part of their daily work. Qualitative data and documents illuminated drivers of DVA work, implementation barriers and suggested solutions. The drivers were related to individual professional's characteristics and relationships. The barriers were linked to the differing sense‐making and legitimisation of DVA work and differing contexts between the NHS and third sector. Solutions were adaptations to IRIS relative to these contextual differences. The suggested solutions can be used to update IRIS commissioning guidance, training for trainers and training for general practice. The updates should reflect the importance of ongoing support of IRIS from practice leads and commissioners, extended funding periods for IRIS and continuity of the IRIS team.

Improving the healthcare response to domestic violence and abuse in UK primary care: interrupted time series evaluation of a system-level training and support programme

“…IRISi using data (nationally collected, analysed and monitored) steers implementation, on-going support, staff recruitment and training, for each local IRIS service. Staff mix is crucial as reported in the implementation process evaluation [24].…”

Disruption of a primary health care domestic violence and abuse service in two London boroughs: interrupted time series evaluation

“…This is the first study that quantifies the impact and significance of disrupting a system-level programme that offers support to woman who experience DVA outside of a trial setting. The analysis we report here extends our previous multi-disciplinary research utilising a rich data set of DVA referrals from a large number of practices across multiple London boroughs [17,19]. We have applied ITS and non-linear regression analysis to make predictions from a data set comprising of DVA referrals from a large number of practices across two London boroughs.…”

“…One quarter of areas that have commissioned IRIS since 2010 are no longer funding IRIS. Different local IRIS services have different referral rates with our process evaluation suggesting that short term funding and temporary IRIS service disruptions due to loss of trust in the service, results in drop in referral rates [19].…”

“…IRIS outside the trial setting is also cost-effective, from the NHS and societal perspective, good value for the NHS, cost saving for societyincremental net monetary benefit was £22 and £42 respectively [18]. A mixed method implementation process evaluation and a qualitative study found that staff mix and IRIS' joined up approach, bridging the planets of general practice and specialist domestic abuse support services is crucial to making IRIS work [19,20].…”

Disruption of a primary health care domestic violence and abuse service in two London boroughs: interrupted time series evaluation

“…have higher referral rates than others. Our mixed-method process evaluation of the IRIS implementation suggests that short-term funding and disruption of the service provision result in the loss of trust in service and drop in referral rates [19]. Securing long-term funding may be a factor in this, but confirming this requires more evidence on the efficacy of IRIS outside of a trial setting and as a continual service provision.…”