Violence, abuse and neglect and telehealth

​ On this page

1. Guidance for violence, abuse and neglect risks and vulnerabilities and use of telehealth
2. 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)
3. Planning for service delivery via telehealth
4. Responding to disclosures of people experiencing violence, abuse and neglect during telehealth consultations
5. National and State-wide services
6. Key NSW Health policies and guidelines
7. Additional resources
8. Notes

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 exacerbated^1. 
• 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?
      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
      4. 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.
           • For more information on making reports or contacting the Child Wellbeing Unit in the context of COVID-19 refer to FAQ Will the Child Protection Helpline and the NSW Health Child Protection Wellbeing Units (CWUs) maintain operations during the COVID-19 Pandemic?
         • 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.
           • This includes Part 13A Crimes (Domestic and Personal Violence) Act 2007 and Domestic Violence Information Sharing Protocol or where children are involved, under Chapter 16A of the Children and Young Persons (Care and Protection) Act 1998.
           • For further NSW Health based guidance refer to theUse of Exchange of Information Part 13A Crimes (Domestic and Family Violence) Act 2007 Form and Information Bulletin (IB2016_056) and theChild Wellbeing and Child Protection Policies and Procedures for NSW Health.
           • For more information on sharing information under the Health Records and Information Privacy Act 2002 practitioners should refer to the Privacy Manual for Health Information.
      5. 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:

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.

Key NSW Health policies and guidelines

• Child Wellbeing and Child Protection Policies and Procedures for NSW Health (PD2013_007)
• Domestic Violence — Identifying and Responding (NSW Health)
• Integrated Prevention and Response to Violence, Abuse and Neglect Framework (PD2019_041)
• NSWealth Privacy Manual for Health Information
• Responding to Sexual Assault (Adult and Child) Policy and Procedures PD2020_006
• Telehealth in Practice Guide (Agency for Clinical Innovation, NSW Health)

Additional resources

COVID-19 resources

• Public Health Orders and restrictions
• COVID-19 (Coronavirus): NSW Health information on COVID-19 for health professionals.
• Violence, abuse and neglect and COVID-19: guidance for VAN and other health services responding to VAN.

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

• Australian Government, Department of Health - Coronavirus (COVID-19) resources for Aboriginal and Torres Strait Islander people and remote communities
• NSW Health - Aboriginal Health Resources

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

• ‘Australian Gender and Disaster (GAD) Pod by Women’s Health Goulburn North East (WHGNE), Women’s Health In the North (WHIN), and Monash University Disaster Resilience Initiative (MUDRI)
• COVID-19: online safety help for domestic and family violence workers by the eSafety Commissioner
• Frequently Asked Questions: COVID-19 and Family Violence by The Lookout, Domestic Violence Victoria and Domestic Violence Resource Centre Victoria
• Understanding and responding to violence in times of disaster by 1800 Respect and the Gender and Disaster Pod
• Responding to community trauma and family violence after natural disasters by No To Violence
• Interpersonal violence and mental health outcomes following disaster by Molyneux et al., BJPsych Open 6(1), 2019
• Community Trauma Toolkit by Emerging Minds
• Looking after yourself and your family, tips for taking care of yourself and advice on how to help others when there’s a crisis by The Red Cross
• Coping with disaster factsheet by Network of Alcohol and Other Drugs (NADA)
• Undercurrent have created a community resource on Support and Safety Planning during COVID-19 and provides some tips about communicating with clients over telephone.
• Using technology to communicate with survivors during a public health crisis by Women’s Services Network (WESNET)

Telehealth and online safety

• NSW Health Agency for Clinical Innovation Telehealth Guidelines and Resources
• The E-Safety Commissioner’s website: Online safety planning
• 1800 RESPECT, which includes information on apps and using technology safety. It also provides a range of resources regarding technology facilitated abuse and online safety plans to remain safe on-line.
• Undercurrent have created a community resource on Support and Safety Planning during COVID-19 and provides some tips about communicating with clients over telephone.
• The Women’s Services Network (WESNET) have developed general information on risks and practice tips for using technology when working with victims and survivors can be found within WESNET’s Tech Safety for Agencies Toolkit. Some tips on phone communications can be found in:
• Frontline Services’ Best Practice Guide: Communicating with Survivors via Phone
• Frontline Services’ Best Practice Guide: Texting with Survivors

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

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)