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Guidance for violence, abuse and neglect risks and vulnerabilities and use of telehealth

The response to COVID-19 and the introduction of physical distancing and isolation measures can significantly compromise the safety and privacy of survivor victims of violence, abuse and neglect and their ability to access services. Additionally, the transition towards the provision of services via telehealth, raises additional risks for survivors and may provide them with fewer opportunities to safely disclose violence and abuse.

This guidance has been developed to support health services and practitioners address and respond to the increased safety risks that people experiencing violence, abuse and neglect experience when accessing support via telehealth. In doing this, it seeks to support health services and practitioners:

  • awareness and understanding of the unique risks to the safety of clients, families and carers where telehealth services are proposed or being delivered
  • develop and implement local health services processes and practices to assess the suitability of telehealth for clients at increased risk of, or experiencing violence, abuse and neglect
  • deliver safe practices for responding to disclosures or suspected domestic and family violence and other forms of violence, abuse and neglect through the delivery of telehealth services

Please note that this document complements the Telehealth section of Violence, abuse and neglect and COVID-19.

Planning for and assessing whether telehealth services are suitable for people and families experiencing, or at risk of domestic and family violence and other forms of violence, abuse and neglect (VAN)

Service policy and procedures should generally preference face to face service provision rather than telehealth where it is known a client is currently experiencing violence, abuse or neglect or a clinician has identified concerns related to these issues. Please note that a blanket exclusion is not recommended as there will be a range of considerations that clinicians and services should consider. Including, for example:

  • existing protective factors, for example:
    • If the client is not currently living with the perpetrator (noting that this should not be considered a protective factor on its own)?
    • Are they already receiving support from domestic and family violence or other VAN services?
    • What strategies/plans do they already have in place to support safety, including access to safe devices for telehealth consultations and communications?
    • Does the client have strategies to communicate safely while at home or are they able to leave the home and access safe devices/phones at a trusted friend or neighbour’s house?
  • client preference or inability to attend face to face services
    • In these circumstances clinicians should use their clinical judgment as to how the provision of services are offered.
    • Consultation is encouraged with specialist NSW Health VAN services and practitioners in their district/network to support appropriate risk assessment and safety planning.

Planning for service delivery via telehealth

The following list provides insight into what local service protocols and procedures should promote when assessing the appropriateness of telehealth services for individual clients.

  • Understanding of the risks and vulnerabilities related to violence, abuse and neglect, including:
    • increased risks for women and children experiencing violence, abuse and neglect within the context of COVID-19. As the drivers and reinforcing factors for the violence are exacerbated1
    • increased challenges and barriers that priority population groups 2 may experience when seeking support. This can increase the likelihood, impact or severity of violence3 and may be exacerbated by limited access to face to face services.
  • Holistic assessment that include a range of psychosocial factors. The presence of psychosocial risk factors can increase a person’s vulnerability to experiencing violence, abuse and neglect. Or contribute to an increase in frequency and severity of violence where it is already present.
    • Key psychosocial risk factors are set out in Factors contributing to increased risk of violence, abuse and neglect. Please note that the presence of one or more of these risk factors does not mean that a person is, or will experience violence, abuse or neglect. However, these factors should be considered by clinicians along with potential barriers to help seeking, presence of protective factors and other health needs of the client. 
  • Consultation with the client regarding privacy and confidentiality if safe to do so.
    • This should highlight that whilst NSW Health platforms are secure, it is possible that sessions may be monitored within the home either by someone at the location or through the use of monitoring devices. 
    • Where the client expresses concern, clinicians should discuss with the client other options including, for example, face to face sessions or telehealth services from a different location with safe devices.
  • Reassessment of the suitability of telehealth services following the disclosures or identification of warning signs/indicators 4 of violence, abuse and neglect.
  • Support clinicians to prepare for, and to undertake telehealth sessions as per the relevant service considerations set out in ACI’s Telehealth in Practice Guide (in addition to the specific risks related to violence, abuse and neglect). Including:
    • provision of patient information and resources while using telehealth
    • procedures to promote privacy during the sessions at both the clinician’s location and client’s location. This should ensure that the client (where participating from home) has access to a quiet room and they feel safe to talk, and that their privacy will be maintained.
    • reminding clients of the service modalities options available, and of their rights to change service modality, including changing back to face-to-face 5 services
    • confirming the location of the client at the commencement of the telehealth session, this will be important where clinicians need to follow up on concerns regarding the health and safety of the client
    • guidance about consultation and referral pathways and support services for people experiencing violence, abuse and neglect. Health services are encouraged to speak with their district/network specialist NSW Health VAN Services and practitioners to discuss and confirm local consultation and referral pathways.

Factors contributing to increased risk of violence, abuse and neglect

Substance misuse and mental health

  • Parental substance misuse and mental health problems are described as key risk factors for child abuse and neglect1.
  • Both substance misuse and mental health problems can also increase people’s vulnerability to experiencing domestic and family violence2 .
  • Perpetrator substance misuse and suicide threats are also recognised as high risk/lethality indicators for domestic and family violence. See High risk/lethality indicators for domestic and family violence for further information.

Isolation and lack of social supports

  • Isolation and lack of social supports for individuals, families and communities is a risk factor for child abuse and neglect.
  • It is also often a tactic used by perpetrators of domestic and family violence. Perpetrators of DFV may increase their use of these tactics in the context of COVID-19 by for example telling victims that all support services are closed3
  • Social supports are also recognised as protective factors against DFV perpetration and victimisation4

Recent stressors for example, financial stress, unemployment, separation and other transition points such as family law proceedings

  • Economic exclusion and financial pressures are a risk factors for child abuse and neglect. 
  • Economic abuse may be a tactic used by perpetrators of domestic and family violence which, in the context of COVID-19 is likely to further exacerbated. 
  • Increases in financial, employment and housing insecurity in the context and aftermath COVID-19 may increase the likelihood, frequency and severity of domestic and family violence. Access to stable employment for men who use violence can act as a protective factor for victims of violence 5 .
  • Separation can increase the likelihood, frequency and severity of domestic and family violence. 

Previous history of violence being perpetrated against them

  • Evidence demonstrates that different forms of violence, abuse and neglect are often of commonly cooccurring and heighten vulnerability to re-victimisation for survivors of abuse6.

Responding to disclosures of people experiencing violence, abuse and neglect during telehealth consultations

If client discloses and violence, abuse or neglect either directly, or by describing behaviours that constitute it, practitioner’s response should include:

  1. Acknowledge the disclosure and check that it is safe to talk further
    Practitioners may like to say something such as
    • “Is it safe for you to talk about this now?”
    • “I want to talk more with you about what you have just told me but before we do I just need to check whether you think it might be possible for others in your house to hear our conversation or if you feel it is safe to talk?”
    1. Where the client indicates it is not safe to talk further
      Practitioners should not continue to ask questions about the violence or abuse.
      Depending on the nature of the telehealth consultation it may be possible to continue to talk with the client about other health matters. In these circumstances, the practitioner should check in with the client about whether they would like to continue with the telehealth consult.
      It may also be possible for the practitioner to discuss with the client the need for face to face meeting for their other health matters, and to ask the client whether they may be able to attend the service. Establishing a face to face consultation will provide an opportunity to talk to the client in a safer environment.
      Where the client indicates, or the worker has reasonable grounds to suspect that there is a serious and imminent risk to the client’s or other people’s safety, call 000 or the local police station. Based on the details of the disclosure or clinician’s observations during the session ambulance may also need to be requested.
    2. Where a client indicates that it is safe to talk
      Practitioners should:
      1. Check on the client, and others immediate safety
        Practitioners may like to say something such as:

        • “Your safety is our priority, so I need to ask whether you have any immediate safety concerns for yourself or anyone you are caring for?”
        • “What you are telling me sounds like [domestic violence/sexual assault/child abuse] and that is never ok and not your fault. I want to check whether you feel that you or anyone else in the home are in immediate danger?”
        Where the client indicates or the practitioner otherwise identifies that there is a serious and imminent risk to the client or other people’s safety, call 000 or the local police station. Based on the details of the disclosure or clinician’s observations during the session ambulance may also need to be requested.
        Consistent with Domestic Violence: Identifying and Responding (PD2006_084), you should also advise the client that this will occur, unless there is reasonable belief that providing that information will place the client or others at increased risk.
        Where a child or young person is suspected to be at risk of significant harm, health workers must respond. During COVID-19,  staff are encouraged to use eReporting (instead of phoning reports) to both the Child Protection Helpline and to NSW Health CWUs.
      2. Work with the client to plan for safety during the telehealth consultation
        Acknowledge that there are risks that the conversation may be overheard or monitored and that this may place them at risk. The practitioner should seek to mitigate against these risks by:
        • Asking the client if they are worried that their devices (phones or computers) are being monitored?
          • Clients should trust their instincts on this. Some signs of technology abuse through spyware include: poor battery life, unknown apps, and perpetrator knowledge of victims’ movements and activities. Some tips for communicating safely include calling services and support from a landline or a trusted friend or neighbour’s phone. Accessing services and information from the internet in ‘private’ or ‘incognito’ mode.
          • Where a client is concerned about the security of the device they are calling from practitioners should discuss with the client other options including rescheduling for a face to face sessions, whether they can trusted neighbour or friends phone/device. 
        • advise the client “if at any point they feel unsafe during the call they can end the call, or change the subject. If this occurs that they can contact 000 in an emergency and they can also contact 1800 RESPECT on 1800 737 732 or online.
          • practitioners should be aware that current social distancing and isolation requirements might lead to client believing that they cannot call Police, practitioners should assure clients’ they can still call Police or seek support from other agencies like Department of Communities and Justice. For example, practitioners might say:
            • “Your safety comes first – Police and other services are still providing assistance and support” or “There are still services available to provide support and you won’t get into trouble from authorities for calling 000 or other services for support”
        • The practitioner should continue to check in throughout the consult.
        • Explain to the client that:
          • Our health service prioritises client’s safety and that everyone has the right to be safe and to seek support where their or their children’s safety or welfare is at risk.
          • Domestic violence [and other forms of violence, abuse and neglect] is serious and can include a range of abusive and controlling behaviours which, can but does not always include physical violence.
          • Talking about these experiences can be very difficult, so you don’t have to answer the questions if you don’t want to.
          • Everything will remain confidential to the Health Service except where you tell me something that indicates that there are serious safety concerns for you or your children. If this happens, we will make every effort to tell you and provide you with support.
      3. Assess risk and plan for safety
        • Practitioners should undertake an initial assessment of risk, by asking:
          • Is the client or their children still living with the person using violence/abuse, or has the person been returning to the home?
        • When considering the actions of people using domestic and family violence, practitioners may ask:
          • Have they physically harmed you or anyone else in your care such as children or elderly parents?
            • [If, yes to the above] Has the physical violence involved the use of a weapon?
          • Have they threatened to hurt you, your children or pets (including threats to cause you or your children to contract COVID-19)?
            • [If, yes to the above] Have the threats to harm included threats to kill the victim or others?
          • Are they controlling your communications and activities, access to money, essential items? 
          • Have they threatened to harm themselves or suicide?
          • Have any of these behaviours been increasing in frequency and/ or severity?
          • Have they done anything else to hurt you or make you feel unsafe?
        • What is the client’s own assessment of risk? What safety strategies have they identified:
          • Where the client believes they are in immediate danger, will they contact the police or would they like you to contact the police on their behalf?  Where the practitioner believes that the client is at serious threat they should encourage the client to contact police or offer to call the police on the client’s behalf.
          • Have they thought about the quickest and safest place in the house to contact 000?  Or the safest way to leave the house in an emergency?
          • Is the client wanting to access further support services?  If so, are they happy for you to make referrals to local support services and what is the safest way to communicate with them? The practitioner should explore with the victim whether it is possible to leave the home to attend face to face services, or if there is a safe time to call and what the preferred method might be, and can they call support services from somewhere else?
          • Talk further with the client about the strategies to communicate safely via technology.
            • Please note that the violence or the risk of violence may escalate if the perpetrator becomes aware that the client is seeking help or information on DFV. 
            • A range of resources can be accessed to support discussions with clients about online safety, as well as apps that work to help protect the online safety of users. Links to key sites are in the Resources section.
          • Is it safe to prepare a bag with essential items in case they need to leave in an emergency?
            • For example: keys, money (cash, bank cards), documents, medication, support aides, prescriptions? Can these be stored safely in the house without being noticed, or can they be given to someone you trust?
        • Have they been able to leave the house to access essential services, such as supermarkets, pharmacies, schools, childcare, health or other community services? Talk to the client about how they may use these outings in the future as an opportunity to talk safely with police or support services.
        • Have they (or can) they reach out to someone close by that they trust (e.g. friend or neighbour)? If so, what is that person’s role? Can they be contacted to call police if needed, can they help them leave the house?
      4. Note for practitioners:  The victim may feel that due to COVID-19 and the perpetrator’s use of coercion and control, that they may not be able to leave the home. It may be important to reinforce to the client that:
        • self-isolating or quarantine rules permit people to leave their house in emergencies or to access medical care.
        • where the client is not in self-isolation or quarantine they are able to leave the home.
        • Violence and abuse is never ok and not their fault.
        • There are services available to provide support, including accommodation options if they need somewhere safe to stay
      5. Reporting and information sharing
        • If a child or young person is suspected to be at risk of significant harm health workers must respond. Use the online NSW Mandatory Reporter Guide to guide decision making about the safety, welfare and wellbeing concerns related to children and young people and follow the actions required.
        • Where the client has indicated that they do not want to access other services or to contact police, but have disclosed information that indicates there is a serious threat to the client or other victims including children, the Health worker may need to consider reporting to police regardless of the victim’s wishes. Consistent with Domestic Violence: Identifying and Responding (PD2006_084) practitioners should seek to advise the client that this will occur, unless there is reasonable belief that providing that information will place the client or others at increased risk.
        • When assessing risk and considering sharing information without consent, practitioners are encouraged to consult with their supervisor and District VAN Services staff (where available). They should also familiarise themselves with the evidence based high risk/lethality risk factors by men against their female intimate partners in High risk/lethality indicators for domestic and family violence below.
        • Practitioners must adhere to relevant legislative and policy requirements when sharing information, including where it is not possible to obtain the victims’ consent or a decision is made to override the victim’s refusal to provide consent.
      6. Consult and document following a disclosure
        • Clinicians should seek support from the clinical lead/manager after they have managed a disclosure on telehealth.
        • Remember that the intervention must be documented in accordance with usual health policy and procedures.

High risk/lethality indicators for domestic and family violence12

Many factors contribute to risk and no one factor is singularly causal. However, the presence of certain evidence-based risk factors can indicate severe or lethal violence by men against their female intimate partners:

Intimate partner sexual violence, history of violence, non-lethal strangulation (or choking), separation, stalking, escalation (frequency and/or severity), coercive control, threats to kill, misuse of drugs or alcohol, pregnancy and early motherhood, court orders and parenting proceedings, victim's self perception of risk, perpetrator's access to or use of weapons, suicide threats and attempts (perpetrator), abuse of pets and other animals, isolation and barriers to help-seeking 

Source: Costello, M. & Backhouse, C. (2019). Avoiding the 3 ‘M’s: accurate use of violence, abuse and neglect statistics and research to avoid myths, mistakes and misinformation – A resource for NSW Health Workers.  Education Centre Against Violence and Prevention and Response to Violence, Abuse and Neglect (PARVAN) Unit (Ministry of Health)

National and State-wide services

NSW Health Violence, Abuse and Neglect services

NSW Health provides a range of specialist Violence, Abuse and Neglect Services across NSW.  For further information visit PARVAN or your local health district's intranet for local referral pathways.

Further information on local DFV referral pathways can be accessed from your LHD’s NSW Health Worker’s Guide to Identifying and Responding to Domestic and Family Violence. Please visit your LHD Intranet or contact your district’s VAN Manager.

Service Description Phone
NSW Police Force and Emergency Services 000
NSW Domestic Violence Line State wide crisis counselling and referral for women experiencing domestic violence. 1800 65 64 63
NSW Child Protection Helpline Reports of suspected risk of significant harm - unborn children, children and young people.
Staff are encouraged to use e-reporting during COVID-19.  Visit NSW Health - VAN COVID-19 for further guidance.
132 111 (24/7)
NSW Health Child Wellbeing Unit For information on what action to take in response to any level of harm to a child or young person, including reporting of significant harm, and for information on relevant prior child protection c​oncerns.
When seeking advice or child protection history information during the COVID-19 pandemic email the NSW Health CWUs. Visit NSW Health - VAN COVID-19 for further guidance.
1300 480 420
Link2Home Referral for clients who are homeless, or at risk of homelessness including women experiencing DFV. 1800 152 152
NSW Rape Crisis 24/7 telephone or online crisis counselling. 1800 424 017
1800 RESPECT National Sexual Assault, DFV Counselling Service 24/7 national sexual assault, domestic and family violence counselling service. For people experiencing or at risk of sexual assault, domestic and family violence, and their family, friends and professionals providing support. 1800 737 732
Men’s Referral Service 24/7 telephone counselling and referral for men who use violence and controlling behaviour, their partners, family, friends and professionals wanting to support their clients who may be using or experiencing family violence. 1300 766 491
Mensline Australia 24/7 telephone and online counselling service for men with emotional health and relationship concerns, including issues of violence (24 hours). 1300 789 978
Women’s Legal Services NSW, Domestic Violence Legal Advice Line Free confidential legal information, advice and referrals for women in NSW with a focus on domestic violence and Apprehended Domestic Violence Orders. 02 8745 6999
1800 810 784
Women’s Domestic Violence Court Advocacy Services
(Also Local Coordination Points for Safer Pathway)
State wide court support, advocacy, referral and case coordination. 1800 938 227
Women’s Legal Services NSW, Indigenous Women’s Legal Program Free confidential legal information, advice and referrals for Aboriginal and Torres Strait Islander women in NSW with a focus on domestic violence, sexual assault, parenting issues, family law, discrimination and victim’s support. (02) 8745 6977
1800 639 784
Wirringa Baiya Aboriginal Women’s Legal Centre Legal advice and court advocacy. 1800 686 587 or (02) 9569 3847
Victims Services Counselling, financial support (including for immediate needs), and recognition payments. Victims Access Line: 1800 633 063
Aboriginal Contact Line: 1800 019 123
NSW Health, Health Care Interpreter Services 24/7 onsite and phone interpreter services Interpreter services for people accessing public health services, who are not fluent in English or who are deaf.
Health practitioners should contact these services first for any interpreting needs
Visit the webpage
Telephone Interpreter Service Phone and onsite interpreting. 131 450
National Relay Service For the hearing impaired. 1800 555 660
Immigration Advice and Rights Centre Free legal advice on immigration matters, including family violence and migration matters. 8234 0700
Inner City Legal Centre, Safe Relationships Project Legal advice and support to people in same sex relationships experiencing domestic violence.
Service includes telephone support for people outside Sydney.
1800 244 481 or
(02) 9332 1966
Intellectual Disability Rights Service Legal advice, court support, support with police for people with cognitive impairment. 1300 665 908 or
(02) 9265 6300
Multicultural Disability Advocacy Association Individual advocacy and support for people with a disability from a CALD background. 1800 629 072
NSW Ageing and Disability Helpline For information or to report concerns about abuse, neglect or exploitation of older people and adults living in their home and community. 1800 628 221
Senior Rights Service Legal advice to older people in NSW. 1800 424 079 (regional) or (02) 9281 3600
The National Disability Abuse and Neglect Hotline Independent and confidential service for reporting abuse and neglect of people with disability. 1800 880 052
National Counselling and Referral Service Supporting people affected by the Disability Royal Commission and people who have experienced or witness abuse, neglect, violence and exploitation. 1800 421 468

Key NSW Health policies and guidelines

Additional resources

COVID-19 resources

A number of resources about COVID-19 have been developed to provide information for and support to Aboriginal and Torres Strait Islander people, including:

Responding to violence, abuse and neglect in the context of COVID-19 and other disasters

Telehealth and online safety

Support for staff

NSW Health recognises that professional practice of health workers often intersects with personal experiences of violence, abuse and neglect, and that during this time of increased distress, NSW Health staff have access to a range of supports in addition to those including but not limited to domestic and family violence leave provisions and Employee Assistance Programs. Employees are encouraged to speak with their supervisor or human resources team for further information and support

Agency for Clinical Innovation’s - Pandemic Kindness Movement was created by clinicians across Australia, working together to support all health workers during the COVID-19 pandemic. We have curated respected, evidence-informed resources and links to valuable services to support the wellbeing of the health workforce.

Notes

  1. Research into natural disasters and other major emergencies has found that in such times of crisis that there is increased tendency for to revert to stereotypical gender roles as well as an increase tendency to dismiss victims’ experiences and to excuse perpetrators’ behaviour. See for example Victoria Family Vio6ence Framework for Emergency Management.
  2. Priority Populations identified within the NSW Health IPARVAN Framework include Aboriginal people, children, young women and girls, women in pregnancy and motherhood, people with disability and mental illness, lesbian, gay bisexual, transgender, intersex and queer people, Culturally and linguistically diverse people, migrants and refugees, people living in rural and remote areas and, older women
  3. NSW Ministry of Health, 2019, The Case for Change: integrated prevention and response to violence, abuse and neglect in NSW Health,
  4. This Victorian resource summarises some of the key indicators/ warning signs of DFV to be considered in the context of COVID-19; Chapter 7 of PD 2013_007 contains information on indicators of child abuse and neglect
  5. ACI, 2020, Telehealth in Practice Guide, p.23
  6. NSW Ministry of Health, 2019, The Case for Change: integrated prevention and response to violence, abuse and neglect in NSW Health p.14
  7. NSW Ministry of Health, 2019, The Case for Change: integrated prevention and response to violence, abuse and neglect in NSW Health, p.26
  8. Northern Integrated Family Violence Services, 2020, Responding to Family Violence During COVID-19
  9. See: Toivonen, C. & Backhouse, C, 2018, National Risk Assessment Principles for domestic and family violence: Quick reference guide for practitioners, p.8; and McMaster and Associates, 2020, Risk Assessment for Family Harm in relation to COVID
  10. See McMaster and Associates, 2020, Risk Assessment for Family Harm in relation to COVID
  11. 2019, Ministry of Health, 2019, The Case for Change: integrated prevention and response to violence, abuse and neglect in NSW Health
  12. These risk factors have been identified through research examining intimate violence in heterosexual relationships. Their applicability to people in non-heterosexual intimate partner relationships, or for violence occurring more broadly within families, remains unclear.  Consistent with the National Risk Assessment Principles for Domestic and Family Violence risk assessment and management should also consider heightened vulnerability and specific needs of particular cohorts (Toivonen & Backhouse, 2018 National Risk Assessment Principles for domestic and family violence: Quick reference guide for practitioners)
Current as at: Monday 15 June 2020
Contact page owner: Health Protection NSW