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

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