A trust’s safeguarding teams developed a unique training package for staff using a family-focused approach and simulation
To ensure a family-focused approach to safeguarding, Dartford and Gravesham NHS Trust purchased virtual-reality headsets and used them to deliver safeguarding training. These allow participants to experience various scenarios, enabling them to think beyond the presenting patient and identify opportunities to safeguard family members who are vulnerable. After attending training, participants reported better knowledge and made more referrals for at-risk children of adult patients.
Citation: Stocker S et al (2022) Pioneering the use of virtual reality in safeguarding training. Nursing Times [online]; 118: 10.
Authors: Sonya Stocker is senior sister for safeguarding; Sue Govier is named nurse for safeguarding children; Gina Tomlin is adult safeguarding lead; all at Dartford and Gravesham NHS Trust.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
The staff at Dartford and Gravesham NHS Trust (DGT) attended regular safeguarding training sessions, during which they were able to demonstrate that they could correctly identify risks to children and vulnerable adults, and understand the processes they should follow in various scenarios. However, this did not appear to be evident during clinical practice.
Inspection found that safeguarding was often carried out in silos at the trust, and health professionals did not always think beyond the presenting patient. Although staff recognised the actions to take when they identified risks for the adult or child they were treating, there were times when they did not appear to look at the wider picture and safeguard other vulnerable members of the family. As an example, during its inspection, the Care Quality Commission (CQC) observed that when an adult patient presented with concerns related to drug, alcohol use and mental health problems, it did not consider whether there were concerns for children or whether there were any vulnerable adults who were missed. This meant appropriate referrals – and, therefore, safeguarding – for children or vulnerable adults were missed.
Having experienced innovative virtual-reality (VR) technology at a recent conference of the National Society for the Prevention of Cruelty to Children, the senior sister for safeguarding recognised the potential of the immersive simulations to enhance the trust’s safeguarding training programme. It was felt that simulation could help strengthen the perspective of the family and make training more realistic and meaningful.
Simulation is now widely used in healthcare: Health Education England’s (2020) ‘national vision’ for an integrated approach to simulation-based interventions highlighted that these can enhance learning opportunities for the workforce. Our project would be the first time that simulation was used in safeguarding training in the NHS.
A changing approach to safeguarding
The Cabinet Office’s Social Exclusion Task Force (2008) introduced the Think Family approach as part of its review into families at risk. Before this, approaches were increasingly fragmented: the focus tended to be on individuals, often parents, with children’s voices going unheard (Munro, 2011). However, subsequent policy has sought to encourage a more holistic and contextualised approach to understanding how vulnerabilities can be interrelated, affecting all family members.
If we empower frontline practitioners to consider the wider support needs of a family, risks will be identified earlier and outcomes improved. The model recognises that adult services should explore the support needs of children whose parents are experiencing mental health problems, domestic abuse or substance misuse, just as children’s services should be aware of adults who are vulnerable (Social Care Institute for Excellence, 2012).
Antser, a company that pioneered VR-enabled behaviour change, developed scenarios to enable a professional to experience abusive, neglectful situations from a child’s perspective through the immersive nature of VR. Its simulations create an emotional response to the experience of childhood trauma and were originally intended for use in the care system to create a genuine understanding and empathy for looked-after children, thereby creating the desired behaviour change in professionals that previous training appeared unable to achieve.
In 2020, the nurse leads for adult and children’s safeguarding at DGT collaborated to develop a joint, family-focused safeguarding training programme in line with the Royal College of Nursing’s (2019; 2018) intercollegiate documents for safeguarding children and adults. We purchased 12 Antser VR headsets through Darent Valley Hospital’s charity; these fundamentally changed how we approach safeguarding our most vulnerable patients.
Training through simulation
Following a pre-briefing, the VR simulations are used at the beginning of the training day (Fig 1) to create a stark reminder of the lived experiences of children who are abused. This sets the tone for the training and establishes the importance of identifying and acting on risk factors.
The simulation scenario initially allows participants to experience what it is like to be a foetus in the womb, hearing an abusive relationship and encountering the effects of stress hormones that cross the placental barrier. The scenario then changes to life through the eyes of a toddler, who feels vulnerable and afraid of caregivers who are under the influence of drugs and alcohol; the participant is verbally abused, receives threats of being cleaned with a scrubbing brush and experiences a lack of nutritious food. They see a dirty, messy home environment (Fig 2) and self-neglecting parents who are unable to provide good, safe care for the child. They then see what it is like to be a school-aged child who experiences bullying and reacts to the memories of being called dirty.
After the simulations, there is an open discussion about what participants thought and felt, followed by a debrief. The participants are asked to use the experience of the scenarios throughout the rest of the day.
Participants’ psychological safety
Training in the safeguarding and protection of adults and children who are vulnerable can be highly emotive and, sometimes, evoke intense feelings among participants. Psychological safety is essential for maximum engagement with, and learning through, simulation; it is also vital to allow time to regularly check in with participants and debrief about any anxieties and emotions raised. Our teams use this strategy throughout the day.
To fully consider staff wellbeing, they also provide information about counselling, the trust’s Time to Talk team and other occupational health support services. This ensures participants feel safe and supported in their learning, which uses a trauma-informed approach.
Adverse childhood experience training
Adverse childhood experiences (ACEs) include:
- Abuse and neglect;
- Domestic violence;
- Parental substance abuse;
- Parental mental illness;
- Parental separation or divorce;
- Parental incarceration (Wave Trust, nd).
Following the simulations, participants discuss ACEs and their effects, not only during childhood but also, potentially, on health in adulthood.
A study by Felitti et al (1998) found that the more ACEs that were experienced, the higher was the risk of disease in adulthood. Subsequent studies supported this:
- Bremner (2003) demonstrated the long-term effects of childhood toxic stress on the neurobiology of adults, resulting in a higher risk of cancers, heart disease and, ultimately, early death;
- Weiss and Wagner (1998) observed that these neurological changes result not only in physical consequences, but also in social, cognitive and behavioural problems;
- Many studies, including those by Campbell et al (2016) and Felitti et al (1998), confirmed the link between ACEs and risk-taking behaviours, such as those involving alcohol misuse, illicit drug use and risky sexual behaviour.
Trainers emphasise the health professional’s role in identifying the risk of ACEs and the importance of making appropriate referrals for support. The primary goal should be prevention but, as practitioners often care for patients who have already experienced trauma, the next training session focuses on trauma-informed practice.
In line with NHS Education for Scotland’s (2017) work, we are training our workforce to recognise individuals affected by trauma and how this may influence their ability to trust professionals and adopt health behaviours. By expressing the importance of adapting environments and working collaboratively with patients, Schulman and Menschner (2018) believed an environment that reduces the likelihood of retraumatisation can be created. It is hoped that encouraging staff to be more trauma informed:
- Better supports our patients’ needs;
- Reduces the barriers to their receiving the care and support they need.
Continuing the joined-up, family-focused approach, the training then includes presentations from the hospital’s independent domestic-violence advisers and the clinical nurse specialist for mental health. The final part of the day focuses on referral forms and systems, so staff feel confident reporting and completing appropriate referrals.
Since October 2020, the safeguarding teams have delivered 20 VR training sessions. To measure their success, the teams analysed staff evaluations of the training and the number of referrals made since the sessions took place. Feedback so far has been overwhelmingly positive: staff members have described the VR scenarios as “powerful” and “informative”, and said that viewing situations virtually has enabled them to gain a better understanding of other people’s experiences.
Since the training started in 2020, there has been a notable increase in the number of referrals to the children’s safeguarding team from health professionals who have identified safeguarding needs in the children of adult patients: the number per year more than doubled compared with the two previous years (Fig 3). The adult safeguarding team has also seen an increase in referrals that note when children or adults with support needs are part of a family home.
Staff members’ evaluations of the training course demonstrated that they felt it had increased their knowledge in many areas of safeguarding (Fig 4). Since they completed the training, the safeguarding teams have observed that health professionals are increasingly recognising the:
- Impact that parents with alcohol- or substance-misuse problems can have on their children in the home;
- Effects of domestic abuse or mental health needs on patients’ family members;
- The need to notify multiagency partners so they can undertake family assessments.
Our trust’s findings are supported by HEE’s (2020) report, which identified the key role that simulation plays in underpinning patient safety – namely, that high-quality training helps develop a capable workforce that feels confident in identifying and addressing a wide range of family risk factors. When the workforce has the knowledge and experience to recognise these situations, it can make the right referrals to social care at the right time.
Simulation offers a unique way to help develop staff to deliver safe, effective care. In safeguarding, this requires sensitive supervision, with effective feedback and debriefing. It allows staff to attain a greater empathy for patients and to improve outcomes for people affected by trauma. By incorporating simulation into training, our trust coordinated the delivery of its safeguarding teams’ services to ensure a whole-family approach is used.
- A trust introduced an integrated training approach to ensure opportunities to safeguard patients’ vulnerable family members were recognised
- The safeguarding teams used virtual-reality simulations in training to demonstrate the experiences of children and adults who were vulnerable
- Adverse childhood experiences can have physical, social, cognitive and behavioural consequences in adulthood
- The joint family-focused training approach has enhanced participants’ safeguarding knowledge and a trauma-informed approach to care
- More referrals are now made for family members of patients considered at risk
Bremner JD (2003) Long-term effects of childhood abuse on brain and neurobiology. Child and Adolescent Psychiatric Clinics of North America; 12: 2, 271-292.
Cabinet Office Social Exclusion Task Force (2008) Think Family: Improving the Life Chances of Families at Risk. Cabinet Office.
Campbell JA et al (2016) Associations between adverse childhood experiences, high-risk behaviours, and morbidity in adulthood. American Journal of Preventive Medicine; 50: 3, 344-352.
Felitti VJ et al (1998) Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine; 14: 4, 245-258.
Munro E (2011) The Munro Review of Child Protection: Final Report. A Child-centred System. The Stationery Office.
NHS Education for Scotland (2017) Transforming Psychological Trauma: A Knowledge and Skills Framework for the Scottish Workforce. NHS Education for Scotland.
Royal College of Nursing (2019) Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff. RCN.
Royal College of Nursing (2018) Adult Safeguarding: Roles and Competencies for Health Care Staff. RCN.
Schulman M, Menschner C (2018) Laying the Groundwork for Trauma-informed Care. Center for Health Care Strategies.
Social Care Institute for Excellence (2012) At a glance 9: think child, think parent, think family. scie.org.uk, May (accessed 30 August 2022).
Wave Trust (nd) What are adverse childhood experiences (ACEs)? wavetrust.org (accessed 30 August 2022).
Weiss MJ, Wagner SH (1998) What explains the negative consequences of adverse childhood experiences on adult health? Insights from cognitive and neuroscience research. American Journal of Preventative Medicine; 14: 4, 356-360.