In total 14 dentists (6 interviews, 3 focus groups), and 22 dental students (4 interviews, 4 focus groups) participated. The main themes are discussed below.
Awareness of IPVA issues
All participants indicated an awareness of physical abuse as an aspect of IPVA. Most participants understood that abuse is complex and often multifaceted with emotional, financial and psychological abuse being highlighted as characteristics of IPVA.
This is such an important subject in everybody's day to day life. that unless we have more knowledge. We don't know there is a problem. If you don't understand the definition of the abuse. – D17, interview, female
IPVA also shares risk factors with child abuse 14, and the presence of either form of violence increases the risk of the other, meaning that early identification of patients experiencing IPVA may benefit family issues 15,16. The majority of dentists were not aware of this link. Being aware of population risk factors could help dentists identify high risk patients.
I didn't really think about the link between domestic violence and child abuse in the same home. That's quite bad, but it's pretty obvious isn't it, I guess […] if they've got kids. So, then it would maybe make me think about reporting it more – D15, interview, female.
Willingness to help
Appropriateness
All participants felt that dentists could play a role in helping patients who have experienced or were experiencing IPVA.
We could identify it. And it's a really good place for somebody to be able to go and open up. And because obviously, they can come alone quite often – D15, interview, female.
Dental students talked about the consistency in the patient-dentist relationship. Benefits included noticing changes in behaviour over time, and developing a trusting environment where patients feel comfortable ‘opening up’.
You might see a different GP every time, but with a dentist you're in like, a position to be able to sort of spot patterns in behaviour if you’ve seen someone for a prolonged period of time – DS6, focus group, male
Preparedness
Perceptions of training
Both groups indicated that the undergraduate education they received did not prepare them to assist patients affected by IPVA. Some stated that they had received no training.
There was nothing, absolutely nothing. This wasn't even on the teaching radar, I would say. The whole idea of safeguarding in general wasn't really on the radar – D6, male, interview.
Like education on the signs of domestic abuse, what to do If you suspect someone's suffering domestic abuse... I'd say we've had very little to no education on that – DS1, female, interview.
Whilst some did remember receiving training there was a general feeling that this did not sufficiently bolster their confidence or preparedness in any meaningful way.
I don't know how you guys felt, but what I learned wouldn’t have helped me – D8, focus group, female.
Although government guidelines ‘Safeguarding in General Practice – a toolkit for the dental team’ 17 are available, the majority of participants were not familiar with this guidance. This suggests a need for more effective dissemination and awareness.
Confidence
All of the dental students stated they felt uncomfortable thinking about acting on their suspicions. All but one dentist indicated a lack of confidence when it came to speaking to patients about challenging and sensitive topics.
I think I’d be able to detect if something was off…But I don’t know if I’d be able to like put my finger on what was going on. And I don’t know if that would…if I would have enough confidence to take that further on just a feeling – DS5, focus group, female.
Participants noted that bringing up IPVA with a patient is more challenging when they are uncertain of what to do next to safeguard the patient. Many indicated this would discourage them from enquiring despite their suspicions, potentially resulting in missed opportunities to provide support to affected patients.
But yeah, we’ve all kind of said like having the conviction in bringing something up when you don’t know what to do next [is difficult]– DS7, focus group, female.
Both groups expressed hesitations about assuming the responsibility of reporting. Many assumed that GPs would be better trained in this area and therefore would likely delegate responsibility.
I think...I kind of a lot of the time already assume, wrongly, that somebody else is taking care of it when that might not be the case at all. […] I think it comes back to like lack of training and understanding -D3, focus group, female.
Desire for more training/resources
All participants felt they could benefit from further training, and accessible, specific resources.
It has to be something part of curriculum. It has to be a part of post-graduate training. and it has to be updated as we explore different worlds. Emotional abuse have to be taken seriously. And controlling abuse has to be taken seriously. So don't look just for bruises in your patient's face…Typical dental attributes we have. But look at the body language when she comes in with a partner – D17, interview, female.
A few dental students did recall some training on IPVA – but unanimously stated that the teaching hadn’t been useful.
I've just like done the quizzes got the training done like been to the lecture, ticked the box, but like we have so much stuff to learn, and that it's not really stuck in my head – DS11, focus group, female.
Both cohorts brought up the complex role that cultural differences (e.g. nationality, religious beliefs) play in how certain behaviours might present, and how this can be challenging. There seemed to be a specific desire for training to include cultural nuances.
I think also an awareness of what is culturally acceptable in like different areas and what is deemed normal. Because I think that is a range and I don’t think it is a one size fits all approach, so I think we need to have more teaching on where that line lies really – DS4, focus group, female.
Barriers to care
Worry
Many participants expressed reluctance in trying to help patients over fear of doing the wrong thing. There was a worry that despite good intentions their lack of training, and confidence in their abilities may inadvertently heighten risk and worsen their patient’s situation.
I think you only get one chance to be there with them and have that conversation, that difficult conversation. And if you get it wrong that could change their trajectory as to how they end up, where they end up – D16, interview, female.
There was also an apprehension about making a patient feel rushed. Participants expressed concern that time pressures within dental appointments might impact their ability to identify and help patients.
I'm worried that I wouldn't notice in such a short amount of time, or they wouldn't feel that comfortable with me at that sort of time to start to then approach me – DS11, focus group, female.
Participants also worried that a patient might react negatively should they attempt to communicate their concerns.
I think it’s a very difficult situation to be in. Just…you don’t know what way they’re going to take it. Some people might be like ‘oh, who’s this?’ like they, they might just react in anger, but they like might just break down – DS3, focus group, female.
Dentists identified additional barriers such as the presence of a partner and gender dynamics. Providing succinct, easy to follow protocols may help to alleviate this.
I think that. Okay, I’m a 6-foot-tall man with a beard and most people that experience domestic violence are going to be women who are potentially going to be quite intimidated by 6 foot tall me – D6, interview, male.
Resilience
Around half of all participants identified lack of resilience training as a barrier to engaging with patients. This highlights the complexity of the link between professional responsibilities and the mental well-being of practitioners.
I find it sort of boundaries and things quite difficult. you know, going home. If someone, when well, when people have sort of disclosed things. You can't help but go home and think about it, and that's where you think let's have a lot better training… Switching off to that isn’t the easiest – D16, interview, female.