Implementation of health independent Domestic Violence Advisors (hIDVA): A qualitative study in five NHS Trusts.

Implementation of health independent Domestic Violence Advisors (hIDVA): A qualitative study in five NHS Trusts. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementation of health independent Domestic Violence Advisors (hIDVA): A qualitative study in five NHS Trusts. Hayley Alderson, Camilla Forbes, Kausiki Sarma, Anjuli Kaul, Jill Domoney, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8590076/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background People who experience domestic abuse report increased use of healthcare services, compared to those not experiencing abuse. Independent Domestic Violence Advisors (IDVA) are evidence-based programmes that provide emotional and practical support to people experiencing domestic abuse. They are well established in community settings. It remains unclear, however, what the key elements to implementation success are when adapting this model for use in hospital settings. This study therefore aimed to understand the key areas of consideration when implementing health IDVAs (hIDVA) within hospital settings to ensure the hIDVA role can be appropriately commissioned and delivered. Methods Interviews with hIDVAs and NHS staff were conducted at three time points in the evaluation study: baseline, follow-up (around 3 months) and final interview (around 6 months). Data were transcribed verbatim and thematically analysed. Results Four key themes emerged: 1) The nuances of the hIDVA role, 2) Learning to manage competing priorities, 3) Exposure to acute injuries and vicarious trauma, 4) The necessity and consequences of raising the profile of the hIDVA role. Conclusion Our findings and key recommendations highlight the necessity of preparatory work with hIDVAs before they begin their role, including how to navigate the hospital landscape recognising hierarchies and structures and responding to acute and dynamic needs across multiple departments. hIDVAs should receive specific training around exposure to acute injuries and how to manage vicarious trauma, with ongoing clinical supervision. The hIDVA role is demanding and requires practitioners to manage competing priorities. To adequately meet the demands of the role, hIDVAs must have robust line management support and careful monitoring of time and resources to ensure these role objectives can be effectively delivered. domestic abuse health NHS Trusts qualitative implementation IDVA Introduction Domestic Abuse (DA) is defined as any behaviour that includes physical or sexual abuse, violent or threatening behaviour, control and coercion, economic and psychological abuse between individuals over 16 years of age who are personally connected ( 1 ). DA can result in a range of adverse physical, mental and sexual health outcomes ( 2 , 3 ). Intimate partner violence, a major part of DA, is a global public health problem, with a higher prevalence, more severe and more sexual violence experienced by women compared to men ( 4 ). Globally, among those aged 15–49 years, more than one in four (27%) women report experiencing physical and/or sexual intimate partner violence ( 4 ). People who have experienced DA 1 frequently access healthcare services in response to abuse (Halliwell et al 2019), and to a greater extent than those not experiencing DA ( 6 , 7 ). Yet DA in healthcare settings is often not identified ( 8 ). The UK’s National Institute for Health and Care Excellence (NICE) ( 9 ) and the World Health Organisation (WHO) ( 10 ) recommend healthcare staff be trained to identify and respond to DA and to refer those disclosing DA to specialist services. A prerequisite for appropriate treatment and care is the effective identification of DA ( 11 ). Healthcare professionals report several barriers to DA detection, including a lack of training, time constraints, low levels of confidence in responding to disclosures of DA, lack of resources and/or appropriate spaces for inquiry and an absence of policies and protocols on DA ( 12 – 14 ). To address this problem, community-based Independent Domestic Violence Advisor (IDVAs) programmes ( 3 , 15 ) are increasingly being adapted and embedded in healthcare settings. IDVAs are professional case workers who provide advocacy, in the form of practical and emotional support, to people who have experienced DA who are at risk of harm. IDVA programmes in healthcare settings (hIDVAs) comprise of support and advice to people who are experiencing DA, around safety, health and wellbeing; alongside providing training to healthcare professionals to improve their knowledge, skills and confidence around DA ( 16 ). There is growing evidence of IDVAs based in, or connected to health care settings who both train health care professionals and support people who have experienced DA. This can increase rates of DA detection among healthcare professionals and service user referrals to specialist support and enhance the safety of people who have experienced DA ( 6 , 17 ). Despite the implementation of IDVA programmes in healthcare settings, whether in primary care via the Identification and Referral to Improve Safety (IRIS) advocate educators or acute trusts; there are limited data on the factors that are associated with their impact on patients and professionals ( 6 , 17 ). The aim of this study was to understand key areas of consideration when implementing the IDVA role within hospital settings to ensure the hIDVA role can be appropriately commissioned and delivered. Methods COREQ guidelines for reporting qualitative research guided the writing of this research paper ( 18 ). This work is part of a larger programme of research from a study ‘Evaluating models of health-based mate R n I ty V iolence A dvisor provision in maternity services’, referred to as the RIVA study (Home). RIVA aimed to assess the implementation of hIDVA interventions in acute hospital settings with maternity services in England ( 19 ). Within the broader study, interviews were conducted with hIDVAs, midwives, safeguarding leads, doctors, Trust strategic leads and commissioners at three time points: baseline, follow-up (around 3 months) and final interview (around 6 months) and lasted between 30 and 90 minutes. The interview topic guides were developed for use within this study and can be seen within supplementary file A and B. NHS Trust sites were actively involved in the study for approximately five to six months between the years of 2022–2024. Forty five participants were interviewed at baseline and 42 participants were interviewed at follow-up/final interview. When coding the site data, the team identified a need to capture in more detail the nuanced aspects of the hIDVA role and the lived experience of hIDVAs working in hospital contexts, to highlight the key factors of implementing the IDVA role within hospital settings. Several meetings took place between the PI on the study (KT) and two researchers who led the data collection across the case study sites (HA and CF) to establish a consensus on the appropriate selection of cases. For the broader study, the Consolidated Framework for Implementation Research (CFIR) was used to analyse the qualitative data set and present overarching implementation factors for hIDVA interventions in maternity service contexts, based on the key CFIR dimensions (e.g. interventional characteristics, inner and outer settings, and implementation processes) across the five study sites (paper in preparation). Further qualitative analysis was then conducted on a subset of interviews with stakeholders who had direct involvement in the delivery of the hIDVA role and who could provide a detailed understanding of the nuances of delivering the hIDVA role and provide insight into the practicalities of implementing the hIDVA role within the hospital setting. All interviews were audio-recorded and transcribed verbatim with consent. The data presented in this paper are from 28 interviews conducted with 13 participants which included: hIDVAs (n = 8) and NHS staff members directly involved in embedding and supporting the hIDVA (n = 5), brief details are provided in Table 1 . Table 1 Participant identifiers Role Identifier hIDVA Site 1, IDVA 1 Trust Safeguarding lead Site 1, DA lead 1 hIDVA Site 2, IDVA 2 Trust Safeguarding lead Site 2, DA lead 2 hIDVA Site 3, IDVA 3 Trust Safeguarding lead Site 3, DA lead 3 hIDVA Site 4, IDVA 4 hIDVA Site 4, IDVA 5 Named Midwife for Safeguarding & Domestic Abuse Lead. Site 4, DA lead 4 Specialist Advisor – Domestic Abuse and Non-Fatal Strangulation Site 4, DA lead 5 hIDVA Site 5, IDVA/DA lead 6 hIDVA Site 5, IDVA 6 hIDVA Site 5, IDVA 7 Key questions in the research interview topic guides which were examined for this analysis included: enquiring about stakeholders’ involvement in implementation of hIDVAs, enablers and barriers to implementation, experiences of the hIDVA approach in terms of whether it met the needs of people who have experienced DA, and perceived outcomes/impacts of the hIDVA programme. NVivo14 was used to manage the data and support analysis. A ‘codebook’ thematic analysis, combining inductive and deductive approaches, was conducted ( 20 ). Open, line-by-line coding utilising an inductive approach was conducted alongside applying pre-defined codes based on questions in the study topic guides around key lines of enquiry around the specific characteristics of the hIDVAs’ role (utilising a deductive approach). Reflexivity was built into the analysis process to allow for new codes and themes to emerge. The key steps of our analytical approach are outlined below: Initial data familiarisation involved detailed reading and review of the transcripts and interview recordings by one of the authors (CF). Independent open line-by-line coding was then undertaken on 10% of the interview transcripts by two coders (CF, KT). Both coders independently produced their own initial codebook, based on concepts they identified in the transcripts (i.e. inductive approach) and applying pre-defined codes based on questions in the study topic guides (i.e. deductive approach), and then came together to reconcile their codebooks. The two coders then developed an initial agreed coding frame in relation to the identified themes in the data. The coding frame was then applied to the remaining data, and new codes iteratively added, refined and combined throughout the coding process by CF. At several stages in the coding process, the developing coding frame was reviewed to check its suitability and to facilitate further iterations with other researchers in the team (KT, HA). The final coding framework was used to write up each theme, including illustrative quotes, to write an analytical narrative around the data (CF). The write-up was revised accordingly, and further feedback was sought from the wider research and co-applicants on the draft of the paper. Findings have been organised in over-arching conceptual themes and are reported, as follows: 1) The nuances of the hIDVA role, 2) Learning to manage competing priorities, 3) Exposure to acute injuries and vicarious trauma, 4) The necessity and consequences of raising the profile of the hIDVA role. Illustrative quotes are provided. Each site and each participant were given an anonymised ID number, and quotes were assigned with those IDs. Results Our earlier mapping exercise identified that of the 47 Trusts with hIDVA programmes, 28 (60%) of the hIDVA staff worked across the whole Trust, with maternity and emergency services identified as the main departments needing the service (19). This finding was also true within our case study sites and all the hIDVAs worked across all departments in the Trust, although the main department hIDVAs worked within were maternity services and Emergency Departments (ED). The hIDVAs in our case study sites had different contractual arrangements; three sites had hIDVAs employed by the local DA service and seconded to the NHS sites; two sites employed their hIDVAs directly. The five NHS Trusts were at different stages of implementing hIDVAs; two early (less than 2 years) with only one hIDVA employed per site; the other three sites were more established, one site had one full time hIDVA for several years, another site had three full time hIDVAs and one having 2 full time and 1 part time hIDVAs. Within all the case study sites, the hIDVA’ roles were multi-faceted and included providing immediate face-to-face support and advice to people who have experienced DA across the hospital settings; both formal and informal training to hospital staff to increase their confidence in identifying and inquiring about DA and responding appropriately and initiating onward referrals to community-based support. However, despite variations in role, all the interventions adhered to the standardised IDVA advocacy models (21). The nuances of the hIDVA role. Most hIDVAs working in our case study sites did not have a healthcare background. They described how this led them to feel under-prepared for the multifaceted nature of their hIDVA role within the hospital, which they described as distinctly different from the DA advocacy work, they had undertaken in the community. Some participants described the NHS as a ‘creature’ and a ‘beast’- the connotation being that Trusts were large, unwieldy and complex. “ The first IDVA we had in the role…she was absolutely not used to the NHS and the beast that it is……. I don't think you can understand how fast-paced NHS is until you work in it” (Site 4, DA lead 4) ‘I didn't know what was expected of me within the job role…They're very different creatures the NHS and domestic abuse service’ (Site 3, IDVA 3) This participant went on to further explain that due to only having a small DA team available within the NHS settings they undertook a broader range of responsibilities that fell under the general DA umbrella, inclusive of patient contact, training and support for NHS staff. “I came from [community organisation] to this hIDVA role. So, it was a bit of a shock, because it feels like as an hIDVA, you are a domestic abuse service…. So, you're everything, you know, you're housing advice, you’re project worker, you’re MARAC, hIDVA you’re everything. And I think the health IDVA as a role has a lot more to it than any other IDVA role…because you're expected to be so many different things” (Site 3, IDVA 3) The practicalities of being an IDVA within the Trust setting, resulted in hIDVAs often having single, one-off interactions. This left many hIDVAs wondering about the status of people who have experienced DA. Despite onward referrals being made, no updates were provided following discharge to the community. “ I think that's one of the things I've probably struggled with most because I would have had [in the community], I had my outreach case load and my refuge case load, and I was there with them for basically the entire journey…..But here, you see the immediate aftermath of what's happened, whether it's an assault or like a first disclosure or something, and then…. then nothing. So it is, it is really hard just because you're like, oh, what's happened to them?” (Site 5, IDVA 7) When exploring their experiences of working in the NHS, one of the presenting challenges for hIDVAs was learning how to successfully navigate the NHS landscape, inclusive of managing the speed with which patients are seen and moved on, and the quantity and diversity of patients that are support in acute hospital Trusts. When trying to implement and embed the hIDVA role, an NHS staff member, who is IDVA trained and now supports hIDVAs in their Trust stated that: “Business is the biggest barrier, the strain and the pressures on all services within the NHS. Their [healthcare staff] main focus is medical health and that should be the way it is. There's a lot of secondaries that come along with that responsibility. They have a lot of responsibilities, but the pressure has been absolutely immense, just the sheer amount of people coming through the doors” (Site 5, DA lead 6) In four out of the five case study sites, hIDVAs were asked to work across multiple departments/services within the acute Trust. This meant they had to establish working partnerships with multiple departments and staff teams (potentially across more than one Trust site) alongside navigating different hierarchical structures and roles within the hospital environment, which could alter between different wards. ‘I think it's difficult to understand hierarchy and there shouldn't be hierarchy, but there is. You need to know who to go to, who to be respectful to, who you can talk to in certain ways ( Site 4, DA lead 4) “ IDVA 6 and 7 [Site 4] already were health based, so they already kind of know, kind of the health setting and how the hospital works…that's really important because it's hard, isn't it, to take somebody that is community based and put them in a very different environment … ……….It is, it's completely different and we found that because [previous IDVA name], IDVA 6's predecessor was community based prior and on her exit interview had really openly said “I've struggled, I really have getting to grips with health and getting to grips with the hierarchy within health”. (Site 4, DA lead 5) NHS staff who had responsibility for supporting the implementation of hIDVA programmes discussed the importance of having the ‘right person’ in post. They described that once a worker understood the clinical setting and its many pressures, they could better communicate with hospital staff to bring them on board and ensure they will work with the hIDVA. ‘I think there's a confidence to actually be able to have engaging conversations with teams that are, you know, clinically very, very busy. I think you know; I think there are power dynamics still, you know, in terms of you know roles and so I think there's a skill in terms of how [hIDVA name] explains the role and actually utilises her knowledge to kind of find ways to kind of engage with people. (Site 3, DA lead 3) Once embedded within Trusts, the hIDVAs discussed that they saw one element of their role was to take pressure off clinicians. This was done through the provision of DA advice and information to patients, taking the lead in liaising with community services and progressing onward referrals such as Multi- Agency Risk Assessment Conference (MARAC), DA support and housing therefore alleviating non-medical tasks for NHS staff. Learning to manage competing priorities The hIDVAs recognised that in a hospital setting there are competing priorities for professionals depending on their role. Some hIDVAs described a perception that often medical staff prioritise responding to the immediate physical health needs of patients: “When I've gone and done walk arounds, people are just saving lives. People are like patching people up, so they don't necessarily have the time, yeah, or the capacity really to talk to me, but we're nudging our way in there” (Site 1, IDVA 1) ‘It's time [for hIDVAs] to give effort to engage with the individual and form a working relationship…it's a physical health hospital and once the bruises and cuts are addressed then their [NHS staff] work is done’ (Site 2, DA lead 2) However, the above view contrasts that of other hIDVAs, who describes NHS staffs’ work as regularly responding to and managing psycho-social and mental health presentations alongside physical needs. The illustrative quote from hIDVA 6, acknowledges that in many scenarios people who have experienced DA have multiple needs and so are supported by numerous professionals simultaneously. Therefore, hIDVAs must navigate situations sensitively, initiating conversations with people who have experienced DA alongside their work with other professional colleagues. “So, a lot of it is sometimes, especially in ED [Emergency Department], it's quite hard when you get a referral because you're probably not the only person they have been referred to. So, there's probably a consultant that's on ED wanting to have a look or maybe speak to the patient, you've got the IDVAs wanting to speak to the patient, you maybe got the psychiatric liaison team to do an assessment on their mental health. You might have the alcohol care team as well that want to do an assessment and speak to them about the alcohol and substance use.” (Site 5, IDVA 6) To alleviate some of the pressures in relation to DA presentations, both hIDVAs and healthcare staff described the importance of building good working relationships across the Trust. Other competing priorities described by hIDVAs was the need to be both proactive and reactive within their role. It was discussed that due to the environment within the hospital setting, hIDVAs needed to be hypersensitive to recognising when the appropriate time was to approach someone. For instance, even if DA had been identified, it was recognised that it was not always appropriate to approach a patient immediately on admission to an emergency department, due to medical treatment needing to be prioritised by NHS staff. A key element of the hIDVA role reported by participants was the recognition that any support provided was done so within the duration of time an individual was in receipt of medical care within the hospital. This meant hIDVAs had to initiate contact, establish relationships, risk assess and safety plan within restricted periods of time before the patient was discharged from the acute service back to community care. There was a recognition that hIDVAs conducted tasks at speed within the hospital setting. “ I think that the window of opportunity is like the key phrase, I think because we work in the hospital setting, we've got that constraint of once they’re like community ready that, that's it…… you've got to think about safety planning. If they don't consent to a community IDVA referral, does that mean the risk is still going to be there? Does it need a MARAC referral? You've got all of this going on and you do sometimes get that, it is a very, sometimes it is a rush, sometimes you are scrambling to just make sure there's at least some thing in place for when they leave to mitigate the risk or ensure that another agency is fully aware of that risk so they can take over that that safety plan in that further risk assessment ” (Site 4, IDVA 5) Participants explained that as staff became increasingly familiar with hIDVAs, their trust in the hIDVA role increased, which in turn led to increased referrals. When positive relational practices were established, it facilitated medical staff to utilise and draw upon the knowledge and expertise of the hIDVAs and enabled them to focus on the medical needs of patients. ‘Yeah [hIDVA], enables me to get on with my job... It enables me to focus on, my attention on, you know, other patients because I'm, I know that there's somebody there who can have a meaningful conversation in the right moment with this individual who needs space for somebody just to listen and give them that specialist advice and support’ ( Site 3, DA lead 3) Both hIDVAs and NHS staff articulated the value of the hIDVA role and recognised how important it was to have that level of expertise in the hospital setting to support people who have experienced DA. The combination of medical expertise and DA expertise was recognised to be complimentary to each other. ‘I think it's the mutual respect for our [DA] expertise, I think we both appreciate where we've come from, and both appreciate our knowledge’ (Site 1, IDVA 1) Additionally, having an hIDVA available on site at the Trust was felt to expediate the process of people experiencing DA receiving support in a timely manner. This was beneficial to both the person experiencing DA and NHS staff, who could transfer the process of eliciting specialist support to the hIDVA rather than initiate time consuming referrals themselves. “I think having a DV service in the hospital it's more, it's quicker, rather than calling a helpline or emailing a generic kind of team email. It's coming direct to me and it's like, right, OK, we've got this person. What do you do with them? Can you either sign post them? Can you work with them? Can you come and have a chat? A general chat with them. So, I think having a specific named person or a named service within the hospital is definitely beneficial” (Site 1, IDVA 1) hIDVAs recognised that within their role they met people for the first (and sometimes only time) via an unplanned interaction. They had little opportunities to establish relationships, build up trust and assess an individual’s needs over a prolonged period of time. Instead having to work efficiently to assess an individual’s needs regarding DA, alongside medical treatment being administered. Exposure to acute injuries and vicarious trauma All hIDVAs expressed how in their hospital role they were frequently exposed to acute and severe physical injuries of people who have experienced DA, something that contrasted with the IDVA role in the community. “Certainly, in my role, I see a lot more injuries than I have, you know, in the rest of my career…The lady that I went to see that the police sent me to see, she had lacerations like everywhere” (Site 2, IDVA 2) “ Being in the hospital setting, it is really interesting. And you do see things that probably the community IDVAs don't see as well. You know people right after quite nasty physical assaults as well, which is something I'm not sure a lot of them have seen ” (Site 4, IDVA 5) In all sites, many referrals came from the ED. This environment by default resulted in hIDVAs witnessing medical emergencies on a frequent basis, inclusive of medical interventions such as resuscitations. It was stated by healthcare participants across all sites that it was extremely hard to prepare a hIDVA for situations such as this and it was often only experienced once ‘on the job’. “ I think that you'd have to work in a hospital environment to be able to train somebody for that exposure…... I suppose it's like if you're going on ED and there's a resuscitation going on, I don't think you can prepare people for that. But I think if you've worked in the hospital before that becomes background noise to you ” (Site 4, DA lead 4) The majority of the hIDVAs described not feeling prepared or trained to deal with the acute and severe physical injuries presented by people who have experienced DA. “I think sometimes it has been difficult. I'm not a very, like squeamish person, so kind of like injuries and blood and stuff that, that doesn't bother me at all. But sometimes it is a shock because normally I think in the community it'd be very rare that I would see… I might see some, maybe some bruising, but they would be like old bruising that's fading away. Whereas here it's like some people, you do see it is like they might have lacerations in their face, the blood might still be all over them and they are in that kind of very like heightened state. So it is, it is very different” (Site 5, IDVA 7) Most participants mentioned either indirectly or directly the level of trauma they had been exposed to within the hIDVA role and the impact on their own mental health: “ I really didn’t think about the vicarious trauma when I took this job on ” (Site 2, IDVA 2). Situations that could be emotionally hard to witness and respond to for hIDVAs spanned numerous hospital wards inclusive of maternity services. A few healthcare participants described experiences of hIDVAs attending maternity wards and witnessing deceased babies or babies who had sustained injuries as a direct consequence of DA. “ I think that it that was highlighted to us by one of the members of staff we recruited, who only stayed very briefly, who attended maternity, and there was a, you know, unfortunately the baby hadn’t survived and was in the room and she wasn't quite prepared for that. And that’s something we take for granted and we had to reflect on that…… And I think it is big difference, there's a big difference between reading about trauma and seeing trauma first hand, a huge difference ” (Site 5, DA lead 6) Linked to this, some hIDVAs themselves described how emotionally challenging such maternity service cases could be: “ They (healthcare staff) contacted me, and they said that they had a lady who they had domestic abuse concerns about. She was in labour, so it wasn't appropriate to go and see her that day. ‘Would I go and see her the next day?’ And then they disclosed that baby had a lot of foetal abnormalities and probably was not going to survive. That story is incredibly close to home, and I just thought to myself, I'm not the right person to see her. I'm not going to be able to remain professional ” (Site 2, IDVA 2) The necessity and consequence of raising the profile of the hIDVA role One mechanism to enhance awareness of the hIDVA service was reported to be through the delivery of DA training. Training was provided in a formal capacity as part of safeguarding training but also as informal training responding to identified gaps in knowledge by the hIDVAs. For hIDVAs who were working on their own, taking time out to deliver training impacted on their availability to directly provide advice and support to patients and this was described as a challenge and something that can detract from their core role of advocacy support: ‘As an IDVA I thought I was going to be working directly with people. And they're all about training, training, training…. There’s literally nothing like, no guidance at all. And I still haven't delivered any training because I'm creating it…. It was kind of an expectation that I would know, so there has been lots of barriers in that sense that I'm just one person in a huge hospital, yet you want me to go and train everyone with just me on my own….’ (Site 3, IDVA 3) hIDVAs who delivered training identified that it provided an opportunity to update NHS staff regarding the latest terminology, patterns of abuse, changes in practice and legislation. The training enabled NHS staff to be upskilled and more prepared to identify and respond to DA patients when in the hospital setting. This was especially noted when hIDVAs could accompany staff during consultations with patients, to support the provision of DA support in an empathic way. “ They [the hIDVAs] get a lot of beautiful feedback from staff who have never heard some of the things that you hear in domestic abuse. But we'll go do it with the staff. So, we wouldn't necessarily take over a case but lead it, so they learn and upskill as well ” (Site 4, DA lead 4). The importance of training trust staff regarding DA and the hIDVA role was viewed as essential as they were the main conduit to identifying and referring patients who would benefit from hIDVA support. However, this was identified to be a time and resource intensive task. ‘ So, I guess it's the consistency. OK, this is me. What can I do? How can we work together? This is me. How can we work together and just kind of keep going and going. OK, I'm still here and I still wanna work with you’ ( Site 1, IDVA 1) All participants recognised that Trusts are large organisations, and it was highlighted that it can be hard for hIDVAs to be known throughout the Trust. Therefore, hIDVAs discussed how important it was for them to be physically visible in the Trust, to build relationships with staff and to continually be promoting their service across departments within the Trust. ‘So, I think that you know, trying to embed people, they need to be visible, don't they? They need to be present, and they need to be around’ ( Site 1, DA lead 1) Despite the recognition of the importance and necessity to promote the hIDVA role, awareness of the service was perceived to be hindered by the high turn-over of staff in the NHS. Consequently, hIDVAs action to ensure their visibility and presence was a continuous process. ‘I think that the difficulty is always going to be there's such a high turnover of staff. So just as your face gets known somewhere, if you go somewhere else and blink and you go back, the staff have completely changed. So, it's just making sure that that's out there.’ (Site 2, IDVA 2) Due to delivering DA training across the Trusts and promoting the available hIDVA support, an unanticipated consequence occurred across all five sites in terms of the amount of support that hIDVAs were providing to staff within the Trust who had their own lived experiences of DA: “ We've had staff they've [hIDVAs] supported over the last year, we've managed to refer some staff members to them for support and they've been really good. You know, they'll come and meet staff members at work…. they’ve been really good and accepting of supporting our staff as victims ” (Site 1, DA lead 1) Participants recognised that when hIDVAs were supporting a staff member they often had to be creative in how they offered support, to ensure that confidentiality could be maintained. “ I think sometimes I find that harder to find a safe space to talk with them where there is other staff members on the ward to over hear what they're saying. And being aware, because then if they know our job role, they're like, oh, what, why are they here? Why are they talking to, to them? So, I think sometimes that brings up a few more kind of confidentiality issues. But we've got around it, like I've met with people at like the education centre or on like, some of the little picnic benches outside. Or it'll all be through like e-mail and stuff. Yeah. So, it does, it does look different ” (Site 5, IDVA 7) When discussing disclosures made by NHS staff members, one hIDVA described the necessity to uphold confidentiality. There was a recognition that if information was shared unnecessarily, it had the potential to undermine the confidence of staff accessing support via the hIDVA. “ I’ve had two staff members come and approach me and say, “I need to talk to you.” I have had staff members approach me and say, “I do not give my consent, I do not want safeguarding to know what’s going on.” I have to respect that ” (Site 2, IDVA 2) One Trust stated that they had developed a new specific internal process to support staff members, who had been identified as experiencing DA since the hIDVA was in place. This process had been implemented to ensure that the professional team around the staff member who had experienced DA was aware of potential risks and could help to safeguard that individual. “ I think at the very beginning naive as it may be, I don't think we quite realise the support that we'd be delivering to staff……. and now we do something for our high-risk members of staff that we do support. We do what we call a risk mitigation meeting. And we say what can we put in place to make sure this staff member’s safe at work or if they're off sick, how can we support them to be returning to work safely. So that's something that's that we didn't quite envisaged doing, but has actually been really, really beneficial and really helpful ” (Site 4, DA lead 5) Due to the number of DA disclosures among healthcare staff at all the Trust sites, healthcare participants reported that their hIDVA services had to be adapted to incorporate providing support for staff members. Discussion The conceptual themes reported on throughout the paper were: 1) The nuances of the hIDVA role, 2) Learning to manage competing priorities, 3) Exposure to injuries and vicarious trauma, 4) The necessity and consequences of raising the profile of the hIDVA role. People who have experienced DA demonstrate a pronounced and often escalating use of both primary and secondary healthcare ( 22 ). Therefore, when a hIDVA is available within an NHS Trust environment, it provides an opportunity for people who had experienced DA to receive advice, information and support regarding DA (where appropriate) alongside them receiving necessary healthcare treatment. The availability of hIDVAs within hospital settings, introduces the potential to identify ‘hidden’ survivors such as individuals who are not in receipt of support from community services, this included patients and NHS Trust staff. Whilst the specific mechanisms underlying the benefit of DA support is unclear, a recent systematic review by Carlisle at al ( 15 ) reported that the most commonly accessed support accessed via the IDVA role was safety planning and that accessing support may improve the mental health, wellbeing and feeling of empowerment experienced by people who have experienced DA. Availability of hIDVAs enabled earlier intervention, education, information, safety planning advice and the provision of onward referrals to take place as required. There was acknowledgement that patients being able to receive support from a hIDVA had the potential to expediate support to people who had experienced DA. Our findings highlighted that by having hIDVAs within the Trust, healthcare professionals enhanced their skills, knowledge, and confidence in identifying and responding to DA. Our findings resonate with a previous study by Dheensa et al ( 16 ) which found that having hIDVAs present within the hospital made staff more aware of what constituted DA, staff were more comfortable with enquiring about DA and had a clearer understanding of how to respond, inclusive of how to initiate onward referrals. This in turn supported effective risk assessment and management of DV being promoted as good clinical practice ( 22 ). Kirk and Bezzant ( 23 ) reported that inadequate training is the single most frequently cited barrier to routine DA inquiry across healthcare settings resulting in professionals feeling unprepared to respond to positive disclosures. Our findings emphasised that a key element of the hIDVA role was to provide training either formally or informally to healthcare professionals within the Trust setting. However, unlike the guidance in the Pathfinder toolkit, which recommends a DA coordinator or safeguarding lead deliver training ( 6 ), or the IRIS Advocate Educator training programme which makes training integral to the Advocate role, and ensures Advocates have the necessary skills to train healthcare colleagues ( 24 ), the participants often did not feel prepared to deliver training and yet had to do so. Furthermore, previous research recognises that training cannot be delivered as a single session; there is a necessity for ongoing training opportunities to respond to the high turnover of staff and to reinforce learning and support staff to remain competent within the practice regarding DA ( 11 ). Our current findings identify that training was an integral and implicit part of the hIDVA role and, therefore, hIDVAs need to be trained in how to deliver the educative component of their role. Our findings identified that the consequences of the hIDVA increasing their visibility through conducting ward rounds and delivering DA training, were that of increased levels of staff disclosure following training attendance; this resonates with the findings of the study by McGarry (2017). The levels of disclosure within our study are hardly surprising given that the NHS in England employs over 1.5 million people, is one of the largest employers of women in the world ( 25 , 26 ) and research by the Cavell Nurses’ Trust ( 27 ) has shown that healthcare professionals are three times more likely than the average person in the UK to experience DA. Therefore, the potential need to support NHS colleagues as people who have experienced DA throughout the Trust should be acknowledged as this may require a different process to be followed than when care is being delivered to patients. There was direct acknowledgement of both the necessity to develop mechanisms to support these colleagues and recognise the impact that their own lived experiences could have on their ability to respond to people who have experienced DA within their daily practice. It is of importance to recognise that hIDVAs do not align neatly with health hierarchies, which can result in levels of expertise not being recognised in the same way as medical qualifications. For the hIDVA role to be most effective, our findings highlight the necessity for NHS Trusts to undertake preparatory work with hIDVAs. The study identifies that factors for NHS Trusts to implement when preparing to embed a hIDVA include: In line with the Pathfinder toolkit, NHS Trusts should plan to have more than one hIDVA. However, if commissioning arrangement only allow one hIDVA, Trusts need to recognise that a single individual cannot effectively cover the entire Trust. Therefore, hIDVA capacity needs to be strategically planned with focus being placed on wards that experience the highest level of patients potentially requiring support such as Emergency Departments and maternity. When hIDVAs are employed within a Trust, they need to have a clearly defined role from the start, including training responsibilities and referral pathways. This is to ensure that both the hIDVA and colleagues within the Trust understand the parameters of the hIDVA role. If hIDVAs are co-located across an NHS Trust and a community setting, a clear agreement should be in place with the lead organisation, so all parties are clear on the expectations of the role, including the time/capacity within each setting, who the hIDVA reports to and what service are being provided. Findings have identified the importance and necessity to provide hIDVAs with specific health based training to prepare individuals for the nuances of working within a Trust setting. A comprehensive training programme should be developed, covering all aspects of the hIDVA role. This should include an orientation to NHS structures, lines of accountability and processes regarding safeguarding and onward referrals, how to manage exposure to acute injuries and trauma. Additionally, hIDVA should be trained in how to competently deliver DA training to health care professionals and how to support health care professionals with lived experienced of DA. It is of paramount importance that appropriate clinical supervision is in place and regular opportunities are scheduled to ensure that support is in place for hIDVAs to discuss the health trauma that they witness. This will enable hIDVAs to remain in the role over a prolonged duration rather than experiencing compassion fatigue or burnout. Processes need to be considered regarding how systems can provide care to NHS staff accessing support for their own experiences of DA, inclusive of whether 1:1 support can be facilitated. Additionally, guidance should be considered as to how hIDVAs can support NHS Staff with their own lived experience to manage disclosures from patients in a safe and supportive way. Strengths and Weaknesses Qualitative research is often criticised as not transferable to wider settings; however, we would argue that a strength of this case study research is the diverse range of participant perspectives collected and the depth of understanding the interviews provide to highlight key aspects of the hIDVA role across 5 different geographical sites in England ( 28 ). A limitation of the study is that we did not manage to interview as many individuals with lived experience of abuse, as we had hoped. Future research should focus on capturing the voices of adult victims of DVA, regarding their experience of being supported by a hIDVA. Conclusion The availability of hIDVAs within hospital Trusts provides an opportunity for people who have experienced DA to access support often at times of high need and facilitate individuals potentially to disclose earlier than they might otherwise. While the healthcare system plays a key role in the response to DA, the hospital setting requires hIDVAs to learn to navigate the NHS landscape which hIDVAs reported feeling under prepared for. There is more NHS Trusts could do to ensure the embedding of hIDVAs, as once embedded into the Trust, the availability of hIDVAs could provide high levels of DA expertise within the hospital setting. Abbreviations CFIR Consolidated Framework for Implementation Research COREQ Consolidated criteria for reporting qualitative research DA Domestic Abuse ED Emergency Department hIDVA health Independent Domestic Violence Advisors IRIS Identification and Referral to Improve Safety MARAC Multi- Agency Risk Assessment Conference NHS National Health Service NICE National Institute for Health and Care Excellence PI Principal Investigator RIVA Evaluating models of health-based mate R n I ty V iolence A dvisor provision in maternity services WHO World Health Organisation Declarations Ethical approval and consent to participate Ethics approval and consent to participate. This study adhered to the Declaration of Helsinki. All methods were carried out in accordance with King’s College London ethical guidelines and regulations. Protocols were approved by King’s College London ethics committee and informed consent was obtained from all participants. This study received full ethical approval from King’s College London reference number: MRA-20/21–26162. Consent for publication was obtained. Consent for publication Not applicable Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to the sensitive and personal nature of the material but are available from the corresponding author on reasonable request. Competing interests NS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no conflicts of interest to declare. Funding This report is independent research funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaborations South West Peninsula, Yorkshire and Humber and North East and North Cumbria as part of the Child Health and Maternity and Prevention with Behavioural Risk Factors National Priority Programmes. NS’ research is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King’s College Hospital NHS Foundation Trust. NS is a member of King’s Improvement Science, which offers co-funding to the NIHR ARC South London and is funded by King’s Health Partners (Guy’s and St Thomas’ NHS Foundation Trust, King’s College Hospital NHS Foundation Trust, King’s College London and South London and Maudsley NHS Foundation Trust), and Guy’s and St Thomas’ Foundation. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Authors’ contributions HA, CF and KT wrote the main text of the manuscript. All authors read, edited, and approved the final manuscript. Acknowledgements We would like to thank our Public and Patient Involvement and Engagement Group who have advised on this project throughout and all those who participated in the data collection activities across the case study sites. Clinical trial number : Not Applicable References UK Parliament. Domestic Abuse Act 2021 legislation.gov.uk2021. Trevillion K, Oram S, Feder G, Howard LM. Experiences of domestic violence and mental disorders: a systematic review and meta-analysis. PLoS ONE. 2012;7(12):pe51740. Feder G, Ramsay J, Dunne D, Rose M, Arsene C, Norman R et al. How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria. Health Technol Assess. 2009;13(16):iii-iv, xi-xiii, 1-113, 37–347. Sardinha l, Maheu-Giroux M, Stöckl H, Meyer S, García-Moreno C. Global, regional, and national prevalence estimates of physical or sexual, or both, intimate partner violence against women in 2018. Lancet. 2022;399:803–13. Perot C, Chevous J. Turning Pain into Power: A charter for organisations engaging abuse survivors in projects, research & service development. Survivors’ Voices; 2018. Melendez-Torres G, Pell B, Buckley K, Couturiaux D, Trickey H, Young H et al. Health pathfnder: full technical report. 2021. Elvey R, Mason T, Whittaker W. A hospital-based independent domestic violence advisor service: demand and response during the Covid-19 pandemic. BMC Health Serv Res. 2022;22:865. Heron R, Eisma M. Barriers and facilitators of disclosing domestic violence to the healthcare service: A systematic review of qualitative research. Health Soc Care Community. 2021;29:612–30. National Institute for Health and Care Excellence. NICE guidance: domestic violence and abuse. https://www.nice.org.uk/guidance/qs116/resources/domestic-violence-and-abuse-pdf-75545301469381 .; 2019. World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. https://www.who.int/reproductivehealth/publications/violence/9789241548595/en/ ; 2018. García-Moreno C, Hegarty K, d'Oliveira A, Koziol-McLain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet. 2015;18:1567–79. Ramsay J, Rutterford C, Gregory A, Dunne D, Eldridge S, Sharp D, et al. Domestic violence: knowledge, attitudes, and clinical practice of selected UK primary healthcare clinicians. Bri J Gen Pra. 2012;62:e647–55. Halliwell G, Dheensa S, Fenu E, Jones S, Asato J, Jacob S, et al. Cry for health: a quantitative evaluation of a hospital-based advocacy intervention for domestic violence and abuse. BMC Health Serv Rev. 2019;19:718. Rose D, Trevillion K, Woodall A, Morgan C, Feder G, Howard L. Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study. Br J Psychiatry. 2011;198(3):189–94. Carlisle S, Bunce A, Prina M, McManus S, Barbosa E, Feder G, et al. Effectiveness of UK-based support interventions and services aimed at adults who have experienced or used domestic and sexual violence and abuse: a systematic review and meta-analysis. BMC Public Health. 2025;25(1):1003. Dheensa S, Halliwell G, Daw J, Jones S, Feder G. From taboo to routine: a qualitative evaluation of a hospital-based advocacy intervention for domestic violence and abuse. BMC Health Serv Res. 2020;20(129). Feder G, Davies R, Baird K, Dunne D, Eldridge S, Grifths C, et al. Identifcation and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet Psychiatry. 2011;378(9805):1788–95. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. Forbes C, Alderson H, Domoney J, Papamichail A, Berry V, McGovern R et al. A survey and stakeholder consultation of Independent Domestic Violence Advisor (IDVA) programmes in English maternity services. BMC Pregnancy Childbirth. 2023;23(404). Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006;5(1):80–92. Ministry of Justice. Independent Domestic Violence Adviser Guidance Statutory Guidance. https://assets.publishing.service.gov.uk/media/6822fcddc66deec8488f7f90/idva-guidance.pdf : Ministry of Justice.; 2025. Greenfield P, Calcia M, McCree C, Sahota M, Thomas H, Kirkpatrick K, et al. Identifying, assessing and responding to perpetration of domestic abuse: practice guide for mental health professionals. BJPsych Adv. 2025;31:8–19. Kirk L, Bezzant K. What barriers prevent health professionals screening women for domestic abuse? A literature review. Br J Nurs. 2020;29(13):754–60. Barnes S, Smith K, Downes L, Johnson M, D’avo G. Improving the healthcare response to domestic abuse and sexual violence: Annual Impact Report 2023–2024. https://irisi.org/wp-content/uploads/2024/11/IRISi-Impact-Report-2023-2024.pdf ; 2024. NHS England. NHS Workforce Statistics - July. 2025 https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics/july-2025#2025 [. Mallorie S. NHS workforce in a nutshell. https://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/nhs-workforce-nutshell ; 2024. Cavell Nurses’ Trust. Skint, shaken yet still caring but who is caring for our nurses? https://cavell.org.uk//wp-content/uploads/2019/06/Skint-shaken-yet-still-caring-Cavell-Nurses-Trust-Final.pdf ; 2016. Yin R. Case Study Research and Applications: Design and Methods. London: Sage; 2017. Footnotes We recognise that people who experience domestic violence and abuse (DVA) use different phrases to describe their experiences e.g., victim, survivor, person with lived experience of domestic abuse. As identified by the Survivor’s Voices Charter (Perot and Chevous. 2018) many people may not identify with commonly used terms in the academic literature, such as “victim” or “survivor”. They may either not have heard of these terms or do not feel their experiences are adequately summed up by these phrases. For this reason, we use the wording “people who have experienced DVA” throughout this paper. Additional Declarations Competing interest reported. NS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no conflicts of interest to declare. Supplementary Files SupplementaryfileAClinicalStaffTopicguideBaselineV110.05.22.docx SupplementaryfileBClinicalstaffTopicGuideFollowUpV110.5.22.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 20 Apr, 2026 Reviewers agreed at journal 19 Apr, 2026 Reviewers agreed at journal 19 Apr, 2026 Reviews received at journal 19 Apr, 2026 Reviewers agreed at journal 06 Apr, 2026 Reviewers agreed at journal 20 Mar, 2026 Reviews received at journal 26 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers invited by journal 29 Jan, 2026 Editor assigned by journal 23 Jan, 2026 Editor invited by journal 21 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 19 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8590076","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":582706711,"identity":"72057372-1d68-48b5-b920-3f4f35a1f309","order_by":0,"name":"Hayley Alderson","email":"data:image/png;base64,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","orcid":"","institution":"Newcastle University","correspondingAuthor":true,"prefix":"","firstName":"Hayley","middleName":"","lastName":"Alderson","suffix":""},{"id":582706712,"identity":"9fd3cfd2-0fb2-43df-b815-ec971c5e3af3","order_by":1,"name":"Camilla Forbes","email":"","orcid":"","institution":"University of Exeter","correspondingAuthor":false,"prefix":"","firstName":"Camilla","middleName":"","lastName":"Forbes","suffix":""},{"id":582706718,"identity":"d33972f2-af05-4fcc-9517-26b3dff7703c","order_by":2,"name":"Kausiki Sarma","email":"","orcid":"","institution":"Newcastle University","correspondingAuthor":false,"prefix":"","firstName":"Kausiki","middleName":"","lastName":"Sarma","suffix":""},{"id":582706724,"identity":"5302b97a-3630-4dff-a6b7-7183ec5a4a62","order_by":3,"name":"Anjuli Kaul","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Anjuli","middleName":"","lastName":"Kaul","suffix":""},{"id":582706731,"identity":"509ab310-db52-42f9-80ac-326d2ac49535","order_by":4,"name":"Jill Domoney","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Jill","middleName":"","lastName":"Domoney","suffix":""},{"id":582706732,"identity":"5b123484-8c68-4294-82e4-7aeb5aa78444","order_by":5,"name":"Gene Feder","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Gene","middleName":"","lastName":"Feder","suffix":""},{"id":582706735,"identity":"a702f359-a4c0-4279-b309-9591bf9cbdc8","order_by":6,"name":"Vashti Berry","email":"","orcid":"","institution":"University of Exeter","correspondingAuthor":false,"prefix":"","firstName":"Vashti","middleName":"","lastName":"Berry","suffix":""},{"id":582706736,"identity":"95002986-2e51-4321-ae5f-052e8f936f45","order_by":7,"name":"Ruth McGovern","email":"","orcid":"","institution":"Newcastle University","correspondingAuthor":false,"prefix":"","firstName":"Ruth","middleName":"","lastName":"McGovern","suffix":""},{"id":582706742,"identity":"6d4a9d84-d8ac-4885-8577-8ac4b032278a","order_by":8,"name":"Nick Sevdalis","email":"","orcid":"","institution":"National University of Singapore","correspondingAuthor":false,"prefix":"","firstName":"Nick","middleName":"","lastName":"Sevdalis","suffix":""},{"id":582706746,"identity":"0ed71422-8270-479e-877b-96ec56705918","order_by":9,"name":"Judith Rankin","email":"","orcid":"","institution":"Newcastle University","correspondingAuthor":false,"prefix":"","firstName":"Judith","middleName":"","lastName":"Rankin","suffix":""},{"id":582706754,"identity":"bab1bdee-4909-49ab-8568-aee70ab20579","order_by":10,"name":"Andy Healey","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Andy","middleName":"","lastName":"Healey","suffix":""},{"id":582706758,"identity":"d74c11d4-33f4-4c0b-b06f-7be1ea985e77","order_by":11,"name":"Abigail Easter","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Abigail","middleName":"","lastName":"Easter","suffix":""},{"id":582706759,"identity":"d8610baf-dec9-4c12-b9c5-281eef3814df","order_by":12,"name":"Margaret Heslin","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Margaret","middleName":"","lastName":"Heslin","suffix":""},{"id":582706764,"identity":"6715e271-4571-4e70-968f-7d9e6af3dfcc","order_by":13,"name":"Kristian Hudson","email":"","orcid":"","institution":"Improvement Academy","correspondingAuthor":false,"prefix":"","firstName":"Kristian","middleName":"","lastName":"Hudson","suffix":""},{"id":582706773,"identity":"6e9b24a9-3b8a-4690-ac5f-f30004fa33ce","order_by":14,"name":"Claire Wilson","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Claire","middleName":"","lastName":"Wilson","suffix":""},{"id":582706780,"identity":"5730623a-4f1d-4df5-854e-4663f8d3017f","order_by":15,"name":"GJ Melendez-Torres","email":"","orcid":"","institution":"University of Exeter","correspondingAuthor":false,"prefix":"","firstName":"GJ","middleName":"","lastName":"Melendez-Torres","suffix":""},{"id":582706783,"identity":"10eba18f-88f4-4296-8f17-046b9421c110","order_by":16,"name":"Louise M Howard","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Louise","middleName":"M","lastName":"Howard","suffix":""},{"id":582706786,"identity":"5254bd2a-ed23-4ad6-9514-0dcebe37d596","order_by":17,"name":"Kylee Trevillion","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Kylee","middleName":"","lastName":"Trevillion","suffix":""}],"badges":[],"createdAt":"2026-01-13 09:38:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8590076/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8590076/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101755592,"identity":"391b1ec6-14f4-4174-8201-4919a047b334","added_by":"auto","created_at":"2026-02-03 10:53:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":692488,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8590076/v1/39992b3f-a049-45f6-a919-bd011ac2023c.pdf"},{"id":101675829,"identity":"49390241-31f7-4865-96cf-9eb8f03a842f","added_by":"auto","created_at":"2026-02-02 13:36:22","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":39009,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryfileAClinicalStaffTopicguideBaselineV110.05.22.docx","url":"https://assets-eu.researchsquare.com/files/rs-8590076/v1/ffa560ab9abe8370805f4c86.docx"},{"id":101753322,"identity":"763b4395-4e5f-401a-9906-4bc3b5f8aa94","added_by":"auto","created_at":"2026-02-03 10:39:42","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":37351,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryfileBClinicalstaffTopicGuideFollowUpV110.5.22.docx","url":"https://assets-eu.researchsquare.com/files/rs-8590076/v1/4d1d044ed5f2b1d3c194770b.docx"}],"financialInterests":"Competing interest reported. NS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no conflicts of interest to declare.","formattedTitle":"Implementation of health independent Domestic Violence Advisors (hIDVA): A qualitative study in five NHS Trusts.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDomestic Abuse (DA) is defined as any behaviour that includes physical or sexual abuse, violent or threatening behaviour, control and coercion, economic and psychological abuse between individuals over 16 years of age who are personally connected (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). DA can result in a range of adverse physical, mental and sexual health outcomes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Intimate partner violence, a major part of DA, is a global public health problem, with a higher prevalence, more severe and more sexual violence experienced by women compared to men (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Globally, among those aged 15\u0026ndash;49 years, more than one in four (27%) women report experiencing physical and/or sexual intimate partner violence (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePeople who have experienced DA\u003csup\u003e1\u003c/sup\u003e frequently access healthcare services in response to abuse (Halliwell et al 2019), and to a greater extent than those not experiencing DA (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Yet DA in healthcare settings is often not identified (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The UK\u0026rsquo;s National Institute for Health and Care Excellence (NICE) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and the World Health Organisation (WHO) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) recommend healthcare staff be trained to identify and respond to DA and to refer those disclosing DA to specialist services.\u003c/p\u003e \u003cp\u003eA prerequisite for appropriate treatment and care is the effective identification of DA (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Healthcare professionals report several barriers to DA detection, including a lack of training, time constraints, low levels of confidence in responding to disclosures of DA, lack of resources and/or appropriate spaces for inquiry and an absence of policies and protocols on DA (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). To address this problem, community-based Independent Domestic Violence Advisor (IDVAs) programmes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) are increasingly being adapted and embedded in healthcare settings. IDVAs are professional case workers who provide advocacy, in the form of practical and emotional support, to people who have experienced DA who are at risk of harm. IDVA programmes in healthcare settings (hIDVAs) comprise of support and advice to people who are experiencing DA, around safety, health and wellbeing; alongside providing training to healthcare professionals to improve their knowledge, skills and confidence around DA (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). There is growing evidence of IDVAs based in, or connected to health care settings who both train health care professionals and support people who have experienced DA. This can increase rates of DA detection among healthcare professionals and service user referrals to specialist support and enhance the safety of people who have experienced DA (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Despite the implementation of IDVA programmes in healthcare settings, whether in primary care via the Identification and Referral to Improve Safety (IRIS) advocate educators or acute trusts; there are limited data on the factors that are associated with their impact on patients and professionals (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe aim of this study was to understand key areas of consideration when implementing the IDVA role within hospital settings to ensure the hIDVA role can be appropriately commissioned and delivered.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eCOREQ guidelines for reporting qualitative research guided the writing of this research paper (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis work is part of a larger programme of research from a study \u0026lsquo;Evaluating models of health-based mate\u003cb\u003eR\u003c/b\u003en\u003cb\u003eI\u003c/b\u003ety \u003cb\u003eV\u003c/b\u003eiolence \u003cb\u003eA\u003c/b\u003edvisor provision in maternity services\u0026rsquo;, referred to as the RIVA study (Home). RIVA aimed to assess the implementation of hIDVA interventions in acute hospital settings with maternity services in England (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Within the broader study, interviews were conducted with hIDVAs, midwives, safeguarding leads, doctors, Trust strategic leads and commissioners at three time points: baseline, follow-up (around 3 months) and final interview (around 6 months) and lasted between 30 and 90 minutes. The interview topic guides were developed for use within this study and can be seen within supplementary file A and B. NHS Trust sites were actively involved in the study for approximately five to six months between the years of 2022\u0026ndash;2024. Forty five participants were interviewed at baseline and 42 participants were interviewed at follow-up/final interview.\u003c/p\u003e \u003cp\u003eWhen coding the site data, the team identified a need to capture in more detail the nuanced aspects of the hIDVA role and the lived experience of hIDVAs working in hospital contexts, to highlight the key factors of implementing the IDVA role within hospital settings. Several meetings took place between the PI on the study (KT) and two researchers who led the data collection across the case study sites (HA and CF) to establish a consensus on the appropriate selection of cases. For the broader study, the Consolidated Framework for Implementation Research (CFIR) was used to analyse the qualitative data set and present overarching implementation factors for hIDVA interventions in maternity service contexts, based on the key CFIR dimensions (e.g. interventional characteristics, inner and outer settings, and implementation processes) across the five study sites (paper in preparation). Further qualitative analysis was then conducted on a subset of interviews with stakeholders who had direct involvement in the delivery of the hIDVA role and who could provide a detailed understanding of the nuances of delivering the hIDVA role and provide insight into the practicalities of implementing the hIDVA role within the hospital setting.\u003c/p\u003e \u003cp\u003eAll interviews were audio-recorded and transcribed verbatim with consent. The data presented in this paper are from 28 interviews conducted with 13 participants which included: hIDVAs (n\u0026thinsp;=\u0026thinsp;8) and NHS staff members directly involved in embedding and supporting the hIDVA (n\u0026thinsp;=\u0026thinsp;5), brief details are provided in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant identifiers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRole\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdentifier\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehIDVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 1, IDVA 1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrust Safeguarding lead\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 1, DA lead 1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehIDVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 2, IDVA 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrust Safeguarding lead\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 2, DA lead 2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehIDVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 3, IDVA 3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrust Safeguarding lead\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 3, DA lead 3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehIDVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 4, IDVA 4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehIDVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 4, IDVA 5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNamed\u0026nbsp;Midwife for Safeguarding \u0026amp; Domestic Abuse Lead.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 4, DA lead 4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist Advisor \u0026ndash; Domestic Abuse and Non-Fatal Strangulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 4, DA lead 5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehIDVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 5, IDVA/DA lead 6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehIDVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 5, IDVA 6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehIDVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSite 5, IDVA 7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eKey questions in the research interview topic guides which were examined for this analysis included: enquiring about stakeholders\u0026rsquo; involvement in implementation of hIDVAs, enablers and barriers to implementation, experiences of the hIDVA approach in terms of whether it met the needs of people who have experienced DA, and perceived outcomes/impacts of the hIDVA programme.\u003c/p\u003e \u003cp\u003eNVivo14 was used to manage the data and support analysis. A \u0026lsquo;codebook\u0026rsquo; thematic analysis, combining inductive and deductive approaches, was conducted (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Open, line-by-line coding utilising an inductive approach was conducted alongside applying pre-defined codes based on questions in the study topic guides around key lines of enquiry around the specific characteristics of the hIDVAs\u0026rsquo; role (utilising a deductive approach). Reflexivity was built into the analysis process to allow for new codes and themes to emerge. The key steps of our analytical approach are outlined below:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eInitial data familiarisation involved detailed reading and review of the transcripts and interview recordings by one of the authors (CF).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIndependent open line-by-line coding was then undertaken on 10% of the interview transcripts by two coders (CF, KT). Both coders independently produced their own initial codebook, based on concepts they identified in the transcripts (i.e. inductive approach) and applying pre-defined codes based on questions in the study topic guides (i.e. deductive approach), and then came together to reconcile their codebooks. The two coders then developed an initial agreed coding frame in relation to the identified themes in the data.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe coding frame was then applied to the remaining data, and new codes iteratively added, refined and combined throughout the coding process by CF. At several stages in the coding process, the developing coding frame was reviewed to check its suitability and to facilitate further iterations with other researchers in the team (KT, HA).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe final coding framework was used to write up each theme, including illustrative quotes, to write an analytical narrative around the data (CF). The write-up was revised accordingly, and further feedback was sought from the wider research and co-applicants on the draft of the paper.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFindings have been organised in over-arching conceptual themes and are reported, as follows: 1) The nuances of the hIDVA role, 2) Learning to manage competing priorities, 3) Exposure to acute injuries and vicarious trauma, 4) The necessity and consequences of raising the profile of the hIDVA role. Illustrative quotes are provided. Each site and each participant were given an anonymised ID number, and quotes were assigned with those IDs.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur earlier mapping exercise identified that of the 47 Trusts with hIDVA programmes, 28 (60%) of the hIDVA staff worked across the whole Trust, with maternity and emergency services identified as the main departments needing the service (19). This finding was also true within our case study sites and all the hIDVAs worked across all departments in the Trust, although the main department hIDVAs worked within were maternity services and Emergency Departments (ED). The hIDVAs in our case study sites had different contractual arrangements; three sites had hIDVAs employed by the local DA service and seconded to the NHS sites; two sites employed their hIDVAs directly. The five NHS Trusts were at different stages of implementing hIDVAs; two early (less than 2 years) with only one hIDVA employed per site; the other three sites were more established, one site had one full time hIDVA for several years, another site had three full time hIDVAs and one having 2 full time and 1 part time hIDVAs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWithin all the case study sites, the hIDVA’ roles were multi-faceted and included providing immediate face-to-face support and advice to people who have experienced DA across the hospital settings; both formal and informal training to hospital staff to increase their confidence in identifying and inquiring about DA and responding appropriately and initiating onward referrals to community-based support. However, despite variations in role, all the interventions adhered to the standardised IDVA advocacy models (21).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe nuances of the hIDVA role.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost hIDVAs working in our case study sites did not have a healthcare background. They described how this led them to feel under-prepared for the multifaceted nature of their hIDVA role within the hospital, which they described as distinctly different from the DA advocacy work, they had undertaken in the community. Some participants described the NHS as a ‘creature’ and a ‘beast’- the connotation being that Trusts were large, unwieldy and complex.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“\u003c/em\u003e\u003cem\u003eThe first IDVA we had in the role…she was absolutely not used to the NHS and the beast that it is……. I don't think you can understand how fast-paced NHS is until you work in it” (Site 4, DA lead 4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e‘I didn't know what was expected of me within the job role…They're very different creatures the NHS and domestic abuse service’ (Site 3, IDVA 3)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis participant went on to further explain that due to only having a small DA team available within the NHS settings they undertook a broader range of responsibilities that fell under the general DA umbrella, inclusive of patient contact, training and support for NHS staff.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I came from [community organisation] to this hIDVA role. So, it was a bit of a shock, because it feels like as an hIDVA, you are a domestic abuse service…. So, you're everything, you know, you're housing advice, you’re project worker, you’re MARAC, hIDVA you’re everything. And I think the health IDVA as a role has a lot more to it than any other IDVA role…because you're expected to be so many different things” (Site 3, IDVA 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe practicalities of being an IDVA within the Trust setting, resulted in hIDVAs often having single, one-off interactions. This left many hIDVAs wondering about the status of people who have experienced DA. Despite onward referrals being made, no updates were provided following discharge to the community.\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eI think that's one of the things I've probably struggled with most because I would have had [in the community], I had my outreach case load and my refuge case load, and I was there with them for basically the entire journey…..But here, you see the immediate aftermath of what's happened, whether it's an assault or like a first disclosure or something, and then…. then nothing. So it is, it is really hard just because you're like, oh, what's happened to them?”\u003c/em\u003e (Site 5, IDVA 7)\u003c/p\u003e\n\u003cp\u003eWhen exploring their experiences of working in the NHS, one of the presenting challenges for hIDVAs was learning how to successfully navigate the NHS landscape, inclusive of managing the speed with which patients are seen and moved on, and the quantity and diversity of patients that are support in acute hospital Trusts. When trying to implement and embed the hIDVA role, an NHS staff member, who is IDVA trained and now supports hIDVAs in their Trust stated that:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Business is the biggest barrier, the strain and the pressures on all services within the NHS. Their [healthcare staff] main focus is medical health and that should be the way it is. There's a lot of secondaries that come along with that responsibility. They have a lot of responsibilities, but the pressure has been absolutely immense, just the sheer amount of people coming through the doors” (Site 5, DA lead 6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn four out of the five case study sites, hIDVAs were asked to work across multiple departments/services within the acute Trust. This meant they had to establish working partnerships with multiple departments and staff teams (potentially across more than one Trust site) alongside navigating different hierarchical structures and roles within the hospital environment, which could alter between different wards.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e‘I think it's difficult to understand hierarchy and there shouldn't be hierarchy, but there is. You need to know who to go to, who to be respectful to, who you can talk to in certain ways\u003c/em\u003e (\u003cem\u003eSite 4, DA lead 4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“\u003c/em\u003e\u003cem\u003eIDVA 6 and 7 [Site 4] already were health based, so they already kind of know, kind of the health setting and how the hospital works…that's really important because it's hard, isn't it, to take somebody that is community based and put them in a very different environment …\u003c/em\u003e\u003cem\u003e……….It is, it's completely different and we found that because [previous IDVA name], IDVA 6's predecessor was community based prior and on her exit interview had really openly said “I've struggled, I really have getting to grips with health and getting to grips with the hierarchy within health”.\u0026nbsp;(Site 4, DA lead 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNHS staff who had responsibility for supporting the implementation of hIDVA programmes discussed the importance of having the ‘right person’ in post. They described that once a worker understood the clinical setting and its many pressures, they could better communicate with hospital staff to bring them on board and ensure they will work with the hIDVA.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e‘I think there's a confidence to actually be able to have engaging conversations with teams that are, you know, clinically very, very busy. I think you know; I think there are power dynamics still, you know, in terms of you know roles and so I think there's a skill in terms of how [hIDVA name] explains the role and actually utilises her knowledge to kind of find ways to kind of engage with people.\u003c/em\u003e (Site 3, DA lead 3)\u003c/p\u003e\n\u003cp\u003eOnce embedded within Trusts, the hIDVAs discussed that they saw one element of their role was to take pressure off clinicians. This was done through the provision of DA advice and information to patients, taking the lead in liaising with community services and progressing onward referrals such as Multi- Agency Risk Assessment Conference (MARAC), DA support and housing therefore alleviating non-medical tasks for NHS staff.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLearning to manage competing priorities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe hIDVAs recognised that in a hospital setting there are competing priorities for professionals depending on their role. Some hIDVAs described a perception that often medical staff prioritise responding to the immediate physical health needs of patients:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“When I've gone and done walk arounds, people are just saving lives. People are like patching people up, so they don't necessarily have the time, yeah, or the capacity really to talk to me, but we're nudging our way in there” (Site 1, IDVA 1)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e‘It's time [for hIDVAs] to give effort to engage with the individual and form a working relationship…it's a physical health hospital and once the bruises and cuts are addressed then their [NHS staff] work is done’ (Site 2, DA lead 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, the above view contrasts that of other hIDVAs, who describes NHS staffs’ work as regularly responding to and managing psycho-social and mental health presentations alongside physical needs. The illustrative quote from hIDVA 6, acknowledges that in many scenarios people who have experienced DA have multiple needs and so are supported by numerous professionals simultaneously. Therefore, hIDVAs must navigate situations sensitively, initiating conversations with people who have experienced DA alongside their work with other professional colleagues.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“So, a lot of it is sometimes, especially in ED [Emergency Department], it's quite hard when you get a referral because you're probably not the only person they have been referred to. So, there's probably a consultant that's on ED wanting to have a look or maybe speak to the patient, you've got the IDVAs wanting to speak to the patient, you maybe got the psychiatric liaison team to do an assessment on their mental health. You might have the alcohol care team as well that want to do an assessment and speak to them about the alcohol and substance use.” (Site 5, IDVA 6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo alleviate some of the pressures in relation to DA presentations, both hIDVAs and healthcare staff described the importance of building good working relationships across the Trust.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther competing priorities described by hIDVAs was the need to be both proactive and reactive within their role. It was discussed that due to the environment within the hospital setting, hIDVAs needed to be hypersensitive to recognising when the appropriate time was to approach someone. For instance, even if DA had been identified, it was recognised that it was not always appropriate to approach a patient immediately on admission to an emergency department, due to medical treatment needing to be prioritised by NHS staff.\u003c/p\u003e\n\u003cp\u003eA key element of the hIDVA role reported by participants was the recognition that any support provided was done so within the duration of time an individual was in receipt of medical care within the hospital. This meant hIDVAs had to initiate contact, establish relationships, risk assess and safety plan within restricted periods of time before the patient was discharged from the acute service back to community care. There was a recognition that hIDVAs conducted tasks at speed within the hospital setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eI think that the window of opportunity is like the key phrase, I think because we work in the hospital setting, we've got that constraint of once they’re like community ready that, that's it……\u0026nbsp;you've got to think about safety planning. If they don't consent to a community IDVA referral, does that mean the risk is still going to be there? Does it need a MARAC referral? You've got all of this going on and you do sometimes get that, it is a very, sometimes it is a rush, sometimes you are scrambling to just make sure there's at least some thing in place for when they leave to mitigate the risk or ensure that another agency is fully aware of that risk so they can take over that that safety plan in that further risk assessment\u003c/em\u003e” (Site 4, IDVA 5)\u003c/p\u003e\n\u003cp\u003eParticipants explained that as staff became increasingly familiar with hIDVAs, their trust in the hIDVA role increased, which in turn led to increased referrals. When positive relational practices were established, it facilitated medical staff to utilise and draw upon the knowledge and expertise of the hIDVAs and enabled them to focus on the medical needs of patients.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e‘Yeah [hIDVA], enables me to get on with my job... It enables me to focus on, my attention on, you know, other patients because I'm, I know that there's somebody there who can have a meaningful conversation in the right moment with this individual who needs space for somebody just to listen and give them that specialist advice and support’\u003c/em\u003e (\u003cem\u003eSite 3, DA lead 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBoth hIDVAs and NHS staff articulated the value of the hIDVA role and recognised how important it was to have that level of expertise in the hospital setting to support people who have experienced DA. The combination of medical expertise and DA expertise was recognised to be complimentary to each other.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e‘I think it's the mutual respect for our [DA] expertise, I think we both appreciate where we've come from, and both appreciate our knowledge’\u003c/em\u003e (Site 1, IDVA 1)\u003c/p\u003e\n\u003cp\u003eAdditionally, having an hIDVA available on site at the Trust was felt to expediate the process of people experiencing DA receiving support in a timely manner. This was beneficial to both the person experiencing DA and NHS staff, who could transfer the process of eliciting specialist support to the hIDVA rather than initiate time consuming referrals themselves.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I think having a DV service in the hospital it's more, it's quicker, rather than calling a helpline or emailing a generic kind of team email. It's coming direct to me and it's like, right, OK, we've got this person. What do you do with them? Can you either sign post them? Can you work with them? Can you come and have a chat? A general chat with them. So, I think having a specific named person or a named service within the hospital is definitely beneficial” (Site 1, IDVA 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ehIDVAs recognised that within their role they met people for the first (and sometimes only time) via an unplanned interaction. They had little opportunities to establish relationships, build up trust and assess an individual’s needs over a prolonged period of time. Instead having to work efficiently to assess an individual’s needs regarding DA, alongside medical treatment being administered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExposure to acute injuries and vicarious trauma\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll hIDVAs expressed how in their hospital role they were frequently exposed to acute and severe physical injuries of people who have experienced DA, something that contrasted with the IDVA role in the community.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Certainly, in my role, I see a lot more injuries than I have, you know, in the rest of my career…The lady that I went to see that the police sent me to see, she had lacerations like everywhere” (Site 2, IDVA 2)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eBeing in the hospital setting, it is really interesting. And you do see things that probably the community IDVAs don't see as well. You know people right after quite nasty physical assaults as well, which is something I'm not sure a lot of them have seen\u003c/em\u003e” (Site 4, IDVA 5)\u003c/p\u003e\n\u003cp\u003eIn all sites, many referrals came from the ED. This environment by default resulted in hIDVAs witnessing medical emergencies on a frequent basis, inclusive of medical interventions such as resuscitations. It was stated by healthcare participants across all sites that it was extremely hard to prepare a hIDVA for situations such as this and it was often only experienced once ‘on the job’.\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eI think that you'd have to work in a hospital environment to be able to train somebody for that exposure…... I suppose it's like if you're going on ED and there's a resuscitation going on, I don't think you can prepare people for that. But I think if you've worked in the hospital before that becomes background noise to you\u003c/em\u003e” (Site 4, DA lead 4)\u003c/p\u003e\n\u003cp\u003eThe majority of the hIDVAs described not feeling prepared or trained to deal with the acute and severe physical injuries presented by people who have experienced DA.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I think sometimes it has been difficult. I'm not a very, like squeamish person, so kind of like injuries and blood and stuff that, that doesn't bother me at all. But sometimes it is a shock because normally I think in the community it'd be very rare that I would see… I might see some, maybe some bruising, but they would be like old bruising that's fading away. Whereas here it's like some people, you do see it is like they might have lacerations in their face, the blood might still be all over them and they are in that kind of very like heightened state. So it is, it is very different” (Site 5, IDVA 7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost participants mentioned either indirectly or directly the level of trauma they had been exposed to within the hIDVA role and the impact on their own mental health:\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eI really didn’t think about the vicarious trauma when I took this job on\u003c/em\u003e” (Site 2, IDVA 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSituations that could be emotionally hard to witness and respond to for hIDVAs spanned numerous hospital wards inclusive of maternity services. A few healthcare participants described experiences of hIDVAs attending maternity wards and witnessing deceased babies or babies who had sustained injuries as a direct consequence of DA.\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eI think that it that was highlighted to us by one of the members of staff we recruited, who only stayed very briefly, who attended maternity, and there was a, you know, unfortunately the baby hadn’t survived and was in the room and she wasn't quite prepared for that. And that’s something we take for granted and we had to reflect on that…… And I think it is big difference, there's a big difference between reading about trauma and seeing trauma first hand, a huge difference\u003c/em\u003e” (Site 5, DA lead 6)\u003c/p\u003e\n\u003cp\u003eLinked to this, some hIDVAs themselves described how emotionally challenging such maternity service cases could be:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eThey (healthcare staff) contacted me, and they said that they had a lady who they had domestic abuse concerns about. She was in labour, so it wasn't appropriate to go and see her that day. ‘Would I go and see her the next day?’ And then they disclosed that baby had a lot of foetal abnormalities and probably was not going to survive.\u0026nbsp;That story is incredibly close to home, and I just thought to myself, I'm not the right person to see her. I'm not going to be able to remain professional\u003c/em\u003e” (Site 2, IDVA 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe necessity and consequence of raising the profile of the hIDVA role\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne mechanism to enhance awareness of the hIDVA service was reported to be through the delivery of DA training. Training was provided in a formal capacity as part of safeguarding training but also as informal training responding to identified gaps in knowledge by the hIDVAs. For hIDVAs who were working on their own, taking time out to deliver training impacted on their availability to directly provide advice and support to patients and this was described as a challenge and something that can detract from their core role of advocacy support:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e‘As an IDVA I thought I was going to be working directly with people. And they're all about training, training, training…. There’s literally nothing like, no guidance at all. And I still haven't delivered any training because I'm creating it…. It was kind of an expectation that I would know, so there has been lots of barriers in that sense that I'm just one person in a huge hospital, yet you want me to go and train everyone with just me on my own….’ (Site 3, IDVA 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ehIDVAs who delivered training identified that it provided an opportunity to update NHS staff regarding the latest terminology, patterns of abuse, changes in practice and legislation. The training enabled NHS staff to be upskilled and more prepared to identify and respond to DA patients when in the hospital setting. This was especially noted when hIDVAs could accompany staff during consultations with patients, to support the provision of DA support in an empathic way.\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eThey [the hIDVAs] get a lot of beautiful feedback from staff who have never heard some of the things that you hear in domestic abuse. But we'll go do it with the staff. So, we wouldn't necessarily take over a case but lead it, so they learn and upskill as well\u003c/em\u003e” (Site 4, DA lead 4).\u003c/p\u003e\n\u003cp\u003eThe importance of training trust staff regarding DA and the hIDVA role was viewed as essential as they were the main conduit to identifying and referring patients who would benefit from hIDVA support. However, this was identified to be a time and resource intensive task.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e‘\u003cem\u003eSo, I guess it's the consistency. OK, this is me. What can I do? How can we work together? This is me. How can we work together and just kind of keep going and going. OK, I'm still here and I still wanna work with you’\u003c/em\u003e (\u003cem\u003eSite 1, IDVA 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll participants recognised that Trusts are large organisations, and it was highlighted that it can be hard for hIDVAs to be known throughout the Trust. Therefore, hIDVAs discussed how important it was for them to be physically visible in the Trust, to build relationships with staff and to continually be promoting their service across departments within the Trust.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e‘So, I think that you know, trying to embed people, they need to be visible, don't they? They need to be present, and they need to be around’\u003c/em\u003e (\u003cem\u003eSite 1, DA lead 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDespite the recognition of the importance and necessity to promote the hIDVA role, awareness of the service was perceived to be hindered by the high turn-over of staff in the NHS. Consequently, hIDVAs action to ensure their visibility and presence was a continuous process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e‘I think that the difficulty is always going to be there's such a high turnover of staff. So just as your face gets known somewhere, if you go somewhere else and blink and you go back, the staff have completely changed. So, it's just making sure that that's out there.’\u003c/em\u003e (Site 2, IDVA 2)\u003c/p\u003e\n\u003cp\u003eDue to delivering DA training across the Trusts and promoting the available hIDVA support, an unanticipated consequence occurred across all five sites in terms of the amount of support that hIDVAs were providing to staff within the Trust who had their own lived experiences of DA:\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eWe've had staff they've [hIDVAs] supported over the last year, we've managed to refer some staff members to them for support and they've been really good.\u0026nbsp;You know, they'll come and meet staff members at work…. they’ve been really good and accepting of supporting our staff as victims\u003c/em\u003e” (Site 1, DA lead 1)\u003c/p\u003e\n\u003cp\u003eParticipants recognised that when hIDVAs were supporting a staff member they often had to be creative in how they offered support, to ensure that confidentiality could be maintained.\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eI think sometimes I find that harder to find a safe space to talk with them where there is other staff members on the ward to over hear what they're saying. And being aware, because then if they know our job role, they're like, oh, what, why are they here? Why are they talking to, to them? So, I think sometimes that brings up a few more kind of confidentiality issues. But we've got around it, like I've met with people at like the education centre or on like, some of the little picnic benches outside. Or it'll all be through like e-mail and stuff. Yeah. So, it does, it does look different\u003c/em\u003e”\u0026nbsp;(Site 5, IDVA 7)\u003c/p\u003e\n\u003cp\u003eWhen discussing disclosures made by NHS staff members, one hIDVA described the necessity to uphold confidentiality. There was a recognition that if information was shared unnecessarily, it had the potential to undermine the confidence of staff accessing support via the hIDVA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eI’ve had two staff members come and approach me and say, “I need to talk to you.” I have had staff members approach me and say, “I do not give my consent, I do not want safeguarding to know what’s going on.” I have to respect that\u003c/em\u003e” (Site 2, IDVA 2)\u003c/p\u003e\n\u003cp\u003eOne Trust stated that they had developed a new specific internal process to support staff members, who had been identified as experiencing DA since the hIDVA was in place. This process had been implemented to ensure that the professional team around the staff member who had experienced DA was aware of potential risks and could help to safeguard that individual.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eI think at the very beginning naive as it may be, I don't think we quite realise the support that we'd be delivering to staff……. and now we do something for our high-risk members of staff that we do support. We do what we call a risk mitigation meeting. And we say what can we put in place to make sure this staff member’s safe at work or if they're off sick, how can we support them to be returning to work safely. So that's something that's that we didn't quite envisaged doing, but has actually been really, really beneficial and really helpful\u003c/em\u003e” (Site 4, DA lead 5)\u003c/p\u003e\n\u003cp\u003eDue to the number of DA disclosures among healthcare staff at all the Trust sites, healthcare participants reported that their hIDVA services had to be adapted to incorporate providing support for staff members.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe conceptual themes reported on throughout the paper were: 1) The nuances of the hIDVA role, 2) Learning to manage competing priorities, 3) Exposure to injuries and vicarious trauma, 4) The necessity and consequences of raising the profile of the hIDVA role.\u003c/p\u003e \u003cp\u003ePeople who have experienced DA demonstrate a pronounced and often escalating use of both primary and secondary healthcare (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Therefore, when a hIDVA is available within an NHS Trust environment, it provides an opportunity for people who had experienced DA to receive advice, information and support regarding DA (where appropriate) alongside them receiving necessary healthcare treatment. The availability of hIDVAs within hospital settings, introduces the potential to identify \u0026lsquo;hidden\u0026rsquo; survivors such as individuals who are not in receipt of support from community services, this included patients and NHS Trust staff. Whilst the specific mechanisms underlying the benefit of DA support is unclear, a recent systematic review by Carlisle at al (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) reported that the most commonly accessed support accessed via the IDVA role was safety planning and that accessing support may improve the mental health, wellbeing and feeling of empowerment experienced by people who have experienced DA.\u003c/p\u003e \u003cp\u003eAvailability of hIDVAs enabled earlier intervention, education, information, safety planning advice and the provision of onward referrals to take place as required. There was acknowledgement that patients being able to receive support from a hIDVA had the potential to expediate support to people who had experienced DA. Our findings highlighted that by having hIDVAs within the Trust, healthcare professionals enhanced their skills, knowledge, and confidence in identifying and responding to DA. Our findings resonate with a previous study by Dheensa et al (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) which found that having hIDVAs present within the hospital made staff more aware of what constituted DA, staff were more comfortable with enquiring about DA and had a clearer understanding of how to respond, inclusive of how to initiate onward referrals. This in turn supported effective risk assessment and management of DV being promoted as good clinical practice (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eKirk and Bezzant (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) reported that inadequate training is the single most frequently cited barrier to routine DA inquiry across healthcare settings resulting in professionals feeling unprepared to respond to positive disclosures. Our findings emphasised that a key element of the hIDVA role was to provide training either formally or informally to healthcare professionals within the Trust setting. However, unlike the guidance in the Pathfinder toolkit, which recommends a DA coordinator or safeguarding lead deliver training (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), or the IRIS Advocate Educator training programme which makes training integral to the Advocate role, and ensures Advocates have the necessary skills to train healthcare colleagues (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), the participants often did not feel prepared to deliver training and yet had to do so. Furthermore, previous research recognises that training cannot be delivered as a single session; there is a necessity for ongoing training opportunities to respond to the high turnover of staff and to reinforce learning and support staff to remain competent within the practice regarding DA (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Our current findings identify that training was an integral and implicit part of the hIDVA role and, therefore, hIDVAs need to be trained in how to deliver the educative component of their role.\u003c/p\u003e \u003cp\u003eOur findings identified that the consequences of the hIDVA increasing their visibility through conducting ward rounds and delivering DA training, were that of increased levels of staff disclosure following training attendance; this resonates with the findings of the study by McGarry (2017). The levels of disclosure within our study are hardly surprising given that the NHS in England employs over 1.5\u0026nbsp;million people, is one of the largest employers of women in the world (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) and research by the Cavell Nurses\u0026rsquo; Trust (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) has shown that healthcare professionals are three times more likely than the average person in the UK to experience DA. Therefore, the potential need to support NHS colleagues as people who have experienced DA throughout the Trust should be acknowledged as this may require a different process to be followed than when care is being delivered to patients. There was direct acknowledgement of both the necessity to develop mechanisms to support these colleagues and recognise the impact that their own lived experiences could have on their ability to respond to people who have experienced DA within their daily practice.\u003c/p\u003e \u003cp\u003eIt is of importance to recognise that hIDVAs do not align neatly with health hierarchies, which can result in levels of expertise not being recognised in the same way as medical qualifications. For the hIDVA role to be most effective, our findings highlight the necessity for NHS Trusts to undertake preparatory work with hIDVAs. The study identifies that factors for NHS Trusts to implement when preparing to embed a hIDVA include:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIn line with the Pathfinder toolkit, NHS Trusts should plan to have more than one hIDVA. However, if commissioning arrangement only allow one hIDVA, Trusts need to recognise that a single individual cannot effectively cover the entire Trust. Therefore, hIDVA capacity needs to be strategically planned with focus being placed on wards that experience the highest level of patients potentially requiring support such as Emergency Departments and maternity.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWhen hIDVAs are employed within a Trust, they need to have a clearly defined role from the start, including training responsibilities and referral pathways. This is to ensure that both the hIDVA and colleagues within the Trust understand the parameters of the hIDVA role.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIf hIDVAs are co-located across an NHS Trust and a community setting, a clear agreement should be in place with the lead organisation, so all parties are clear on the expectations of the role, including the time/capacity within each setting, who the hIDVA reports to and what service are being provided.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFindings have identified the importance and necessity to provide hIDVAs with specific health based training to prepare individuals for the nuances of working within a Trust setting. A comprehensive training programme should be developed, covering all aspects of the hIDVA role. This should include an orientation to NHS structures, lines of accountability and processes regarding safeguarding and onward referrals, how to manage exposure to acute injuries and trauma. Additionally, hIDVA should be trained in how to competently deliver DA training to health care professionals and how to support health care professionals with lived experienced of DA.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIt is of paramount importance that appropriate clinical supervision is in place and regular opportunities are scheduled to ensure that support is in place for hIDVAs to discuss the health trauma that they witness. This will enable hIDVAs to remain in the role over a prolonged duration rather than experiencing compassion fatigue or burnout.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eProcesses need to be considered regarding how systems can provide care to NHS staff accessing support for their own experiences of DA, inclusive of whether 1:1 support can be facilitated. Additionally, guidance should be considered as to how hIDVAs can support NHS Staff with their own lived experience to manage disclosures from patients in a safe and supportive way.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eStrengths and Weaknesses\u003c/h3\u003e\n\u003cp\u003eQualitative research is often criticised as not transferable to wider settings; however, we would argue that a strength of this case study research is the diverse range of participant perspectives collected and the depth of understanding the interviews provide to highlight key aspects of the hIDVA role across 5 different geographical sites in England (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). A limitation of the study is that we did not manage to interview as many individuals with lived experience of abuse, as we had hoped. Future research should focus on capturing the voices of adult victims of DVA, regarding their experience of being supported by a hIDVA.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe availability of hIDVAs within hospital Trusts provides an opportunity for people who have experienced DA to access support often at times of high need and facilitate individuals potentially to disclose earlier than they might otherwise. While the healthcare system plays a key role in the response to DA, the hospital setting requires hIDVAs to learn to navigate the NHS landscape which hIDVAs reported feeling under prepared for. There is more NHS Trusts could do to ensure the embedding of hIDVAs, as once embedded into the Trust, the availability of hIDVAs could provide high levels of DA expertise within the hospital setting.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCFIR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Consolidated Framework for Implementation Research\u003c/p\u003e\n\u003cp\u003eCOREQ \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Consolidated criteria for reporting qualitative research\u003c/p\u003e\n\u003cp\u003eDA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Domestic Abuse\u003c/p\u003e\n\u003cp\u003eED\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Emergency Department\u003c/p\u003e\n\u003cp\u003ehIDVA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;health Independent Domestic Violence Advisors\u003c/p\u003e\n\u003cp\u003eIRIS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Identification and Referral to Improve Safety\u003c/p\u003e\n\u003cp\u003eMARAC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Multi- Agency Risk Assessment Conference\u003c/p\u003e\n\u003cp\u003eNHS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;National Health Service\u003c/p\u003e\n\u003cp\u003eNICE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Institute for Health and Care Excellence\u003c/p\u003e\n\u003cp\u003ePI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Principal Investigator\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRIVA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Evaluating models of health-based mate\u003cstrong\u003eR\u003c/strong\u003en\u003cstrong\u003eI\u003c/strong\u003ety \u003cstrong\u003eV\u003c/strong\u003eiolence \u003cstrong\u003eA\u003c/strong\u003edvisor provision in maternity services\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organisation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate. This study adhered to the Declaration of Helsinki. All methods were carried out in accordance with King’s College London ethical guidelines and regulations. Protocols were approved by King’s College London ethics committee and informed consent was obtained from all participants. This study received full ethical approval from King’s College London reference number: MRA-20/21–26162. Consent for publication was obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to the sensitive and personal nature of the material but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNS is the director of the London Safety and Training Solutions Ltd, which offers training in patient safety, implementation solutions and human factors to healthcare organisations and the pharmaceutical industry. The other authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis report is independent research funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaborations South West Peninsula, Yorkshire and Humber and North East and North Cumbria as part of the Child Health and Maternity and Prevention with Behavioural Risk Factors National Priority Programmes. NS’ research is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King’s College Hospital NHS Foundation Trust. NS is a member of King’s Improvement Science, which offers co-funding to the NIHR ARC South London and is funded by King’s Health Partners (Guy’s and St Thomas’ NHS Foundation Trust, King’s College Hospital NHS Foundation Trust, King’s College London and South London and Maudsley NHS Foundation Trust), and Guy’s and St Thomas’ Foundation. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHA, CF and KT wrote the main text of the manuscript. All authors read, edited, and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank our Public and Patient Involvement and Engagement Group who have advised on this project throughout and all those who participated in the data collection activities across the case study sites.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not Applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUK Parliament. Domestic Abuse Act 2021 legislation.gov.uk2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrevillion K, Oram S, Feder G, Howard LM. Experiences of domestic violence and mental disorders: a systematic review and meta-analysis. PLoS ONE. 2012;7(12):pe51740.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeder G, Ramsay J, Dunne D, Rose M, Arsene C, Norman R et al. How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria. Health Technol Assess. 2009;13(16):iii-iv, xi-xiii, 1-113, 37\u0026ndash;347.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSardinha l, Maheu-Giroux M, St\u0026ouml;ckl H, Meyer S, Garc\u0026iacute;a-Moreno C. Global, regional, and national prevalence estimates of physical or sexual, or both, intimate partner violence against women in 2018. Lancet. 2022;399:803\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerot C, Chevous J. Turning Pain into Power: A charter for organisations engaging abuse survivors in projects, research \u0026amp; service development. Survivors\u0026rsquo; Voices; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelendez-Torres G, Pell B, Buckley K, Couturiaux D, Trickey H, Young H et al. Health pathfnder: full technical report. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElvey R, Mason T, Whittaker W. A hospital-based independent domestic violence advisor service: demand and response during the Covid-19 pandemic. BMC Health Serv Res. 2022;22:865.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeron R, Eisma M. Barriers and facilitators of disclosing domestic violence to the healthcare service: A systematic review of qualitative research. Health Soc Care Community. 2021;29:612\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Institute for Health and Care Excellence. NICE guidance: domestic violence and abuse. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nice.org.uk/guidance/qs116/resources/domestic-violence-and-abuse-pdf-75545301469381\u003c/span\u003e\u003cspan address=\"https://www.nice.org.uk/guidance/qs116/resources/domestic-violence-and-abuse-pdf-75545301469381\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/reproductivehealth/publications/violence/9789241548595/en/\u003c/span\u003e\u003cspan address=\"https://www.who.int/reproductivehealth/publications/violence/9789241548595/en/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarc\u0026iacute;a-Moreno C, Hegarty K, d'Oliveira A, Koziol-McLain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet. 2015;18:1567\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamsay J, Rutterford C, Gregory A, Dunne D, Eldridge S, Sharp D, et al. Domestic violence: knowledge, attitudes, and clinical practice of selected UK primary healthcare clinicians. Bri J Gen Pra. 2012;62:e647\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalliwell G, Dheensa S, Fenu E, Jones S, Asato J, Jacob S, et al. Cry for health: a quantitative evaluation of a hospital-based advocacy intervention for domestic violence and abuse. BMC Health Serv Rev. 2019;19:718.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRose D, Trevillion K, Woodall A, Morgan C, Feder G, Howard L. Barriers and facilitators of disclosures of domestic violence by mental health service users: qualitative study. Br J Psychiatry. 2011;198(3):189\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarlisle S, Bunce A, Prina M, McManus S, Barbosa E, Feder G, et al. Effectiveness of UK-based support interventions and services aimed at adults who have experienced or used domestic and sexual violence and abuse: a systematic review and meta-analysis. BMC Public Health. 2025;25(1):1003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDheensa S, Halliwell G, Daw J, Jones S, Feder G. From taboo to routine: a qualitative evaluation of a hospital-based advocacy intervention for domestic violence and abuse. BMC Health Serv Res. 2020;20(129).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeder G, Davies R, Baird K, Dunne D, Eldridge S, Grifths C, et al. Identifcation and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet Psychiatry. 2011;378(9805):1788\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForbes C, Alderson H, Domoney J, Papamichail A, Berry V, McGovern R et al. A survey and stakeholder consultation of Independent Domestic Violence Advisor (IDVA) programmes in English maternity services. BMC Pregnancy Childbirth. 2023;23(404).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006;5(1):80\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Justice. Independent Domestic Violence Adviser Guidance Statutory Guidance. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://assets.publishing.service.gov.uk/media/6822fcddc66deec8488f7f90/idva-guidance.pdf\u003c/span\u003e\u003cspan address=\"https://assets.publishing.service.gov.uk/media/6822fcddc66deec8488f7f90/idva-guidance.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e: Ministry of Justice.; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenfield P, Calcia M, McCree C, Sahota M, Thomas H, Kirkpatrick K, et al. Identifying, assessing and responding to perpetration of domestic abuse: practice guide for mental health professionals. BJPsych Adv. 2025;31:8\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirk L, Bezzant K. What barriers prevent health professionals screening women for domestic abuse? A literature review. Br J Nurs. 2020;29(13):754\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarnes S, Smith K, Downes L, Johnson M, D\u0026rsquo;avo G. Improving the healthcare response to domestic abuse and sexual violence: Annual Impact Report 2023\u0026ndash;2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://irisi.org/wp-content/uploads/2024/11/IRISi-Impact-Report-2023-2024.pdf\u003c/span\u003e\u003cspan address=\"https://irisi.org/wp-content/uploads/2024/11/IRISi-Impact-Report-2023-2024.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS England. NHS Workforce Statistics - July. 2025 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics/july-2025#2025\u003c/span\u003e\u003cspan address=\"https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics/july-2025#2025\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMallorie S. NHS workforce in a nutshell. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/nhs-workforce-nutshell\u003c/span\u003e\u003cspan address=\"https://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/nhs-workforce-nutshell\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCavell Nurses\u0026rsquo; Trust. Skint, shaken yet still caring but who is caring for our nurses? \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cavell.org.uk//wp-content/uploads/2019/06/Skint-shaken-yet-still-caring-Cavell-Nurses-Trust-Final.pdf\u003c/span\u003e\u003cspan address=\"https://cavell.org.uk//wp-content/uploads/2019/06/Skint-shaken-yet-still-caring-Cavell-Nurses-Trust-Final.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYin R. Case Study Research and Applications: Design and Methods. London: Sage; 2017.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e We recognise that people who experience domestic violence and abuse (DVA) use different phrases to describe their experiences e.g., victim, survivor, person with lived experience of domestic abuse. As identified by the Survivor\u0026rsquo;s Voices Charter (Perot and Chevous. 2018) many people may not identify with commonly used terms in the academic literature, such as \u0026ldquo;victim\u0026rdquo; or \u0026ldquo;survivor\u0026rdquo;. They may either not have heard of these terms or do not feel their experiences are adequately summed up by these phrases. For this reason, we use the wording \u0026ldquo;people who have experienced DVA\u0026rdquo; throughout this paper.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"domestic abuse, health, NHS Trusts, qualitative, implementation, IDVA","lastPublishedDoi":"10.21203/rs.3.rs-8590076/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8590076/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePeople who experience domestic abuse report increased use of healthcare services, compared to those not experiencing abuse. Independent Domestic Violence Advisors (IDVA) are evidence-based programmes that provide emotional and practical support to people experiencing domestic abuse. They are well established in community settings. It remains unclear, however, what the key elements to implementation success are when adapting this model for use in hospital settings. This study therefore aimed to understand the key areas of consideration when implementing health IDVAs (hIDVA) within hospital settings to ensure the hIDVA role can be appropriately commissioned and delivered.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eInterviews with hIDVAs and NHS staff were conducted at three time points in the evaluation study: baseline, follow-up (around 3 months) and final interview (around 6 months). Data were transcribed verbatim and thematically analysed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFour key themes emerged: 1) The nuances of the hIDVA role, 2) Learning to manage competing priorities, 3) Exposure to acute injuries and vicarious trauma, 4) The necessity and consequences of raising the profile of the hIDVA role.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur findings and key recommendations highlight the necessity of preparatory work with hIDVAs before they begin their role, including how to navigate the hospital landscape recognising hierarchies and structures and responding to acute and dynamic needs across multiple departments. hIDVAs should receive specific training around exposure to acute injuries and how to manage vicarious trauma, with ongoing clinical supervision. The hIDVA role is demanding and requires practitioners to manage competing priorities. To adequately meet the demands of the role, hIDVAs must have robust line management support and careful monitoring of time and resources to ensure these role objectives can be effectively delivered.\u003c/p\u003e","manuscriptTitle":"Implementation of health independent Domestic Violence Advisors (hIDVA): A qualitative study in five NHS Trusts.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-02 13:36:15","doi":"10.21203/rs.3.rs-8590076/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-20T07:23:15+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"173255641898406149263765528130250117592","date":"2026-04-20T01:08:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234381832797210179235848072599037493157","date":"2026-04-19T21:56:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-19T15:56:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301431830772512526524900587979749600006","date":"2026-04-06T16:13:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"43547235393449473427806692890385967696","date":"2026-03-20T06:22:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-26T23:41:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261327416430561799765709636941078760693","date":"2026-02-16T00:01:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"84605723939482295139263414809964281198","date":"2026-01-29T22:41:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-29T08:06:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-23T17:21:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-21T09:56:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T13:20:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-19T13:14:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bb483f3e-7249-470b-94ee-8234fb5b1dac","owner":[],"postedDate":"February 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T13:53:54+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-02 13:36:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8590076","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8590076","identity":"rs-8590076","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}