Strengthening Hospital Responses to Family Violence Module 2: Identifying and Responding

Session Summary Clinical Risk Indicators Sensitive Practice Six step Brief Intervention Identify through Sensitive Inquiry Brief Supportive Response Identify Risk Factors Action Planning Referral Documentation Staff Support

Learning Objectives Identification of patients experiencing or at risk of experiencing family violence Introduction to the six step Sensitive Inquiry model of responding to patients experiencing or at risk of experiencing family violence.

Recap Family Violence is a serious health issue Family Violence is a fundamental human rights issue and a crime in Australia We are in a position of opportunity to identify, respond and prevent

Case Study A woman presents to Emergency with a Urinary Tract Infection (UTI) You review her previous history and note several other similar presentations with a UTI. What relevant health related questions would she be asked? What about asking if she is experiencing any form of violence? ?

Clinical Risk Indicators Physical Suicidality or self-harm Alcohol and other substance use Gastrointestinal symptoms Pelvic pain, sexual dysfunction Multiple unintended pregnancies and/or terminations Frequent bladder or kidney infections Vaginal bleeding and sexually transmitted infections Chronic pain (unexplained) Traumatic injury CNS - headaches, cognitive problems, hearing loss Adverse birth outcomes Mental Depression anxiety PTSD sleep disorders Social Delayed pregnancy care Frequent presentations (possibly for physical and psychological health reasons) Intrusive partner in consultations WHO (2013), Responding to Intimate Partner Violence and Sexual Violence Against Women: WHO Clinical and Policy Guidelines

Diversity and Family Violence Aboriginal communities Culturally and Linguistically Diverse (CALD) communities, Refugee, Asylum Seeker Women with disabilities Women with mental health issues Homelessness Incarcerated Women Older women Lesbian, Bisexual, Transgender and intersex people Pregnancy Individual Disability Sexual Orientation Language/Culture Community Attitudes Access Systemic Legislative Control Access to resources

Health Impacts Source: VicHealth (2004) The health costs of violence: Measuring the burden of disease caused by intimate partner violence

Health Impacts Source: VicHealth (2004) The health costs of violence: Measuring the burden of disease caused by intimate partner violence

Sensitive Practice ……. is an approach to engage with patients and clients in a way that increases or elicits their feelings of safety, respect and control The primary goal of sensitive practice….is to facilitate feelings of safety, choice and control for the victim/survivor during their interaction with health professionals It does not rely on victim/survivors disclosing in order to receive appropriate health care The Royal Women’s Hospital (2014). Preventing Violence Against Women Strategy 2014-2016, adapted from Schachter, C.L., et al (2008). Handbook on Sensitive Practice for HealthCare Practitioners: Lessons from adult survivors of childhood sexual abuse. Ottawa: Public Health Agency of Canada.

Principles of Sensitive Practice Respect Taking time Rapport Sharing information Supportive Respectful Creates a sense of control These principles are ‘universal’ Adapted from Schachter, C.L., Stalker, C.A., Teram, E., Lasiuk, G.C., Danilkewich, A. (2008). Handbook on Sensitive Practice for HealthCare Practitioners: Lessons from adult survivors of childhood sexual abuse. Ottawa: Public Health Agency of Canada.

Six Step – Sensitive Inquiry Step 1 – Identification Step 2 – Supportive Response Step 3 – Identify Risk Factors Step 4 – Action Planning & Steps Toward Safety Step 5 – Offer Referral Step 6 – Documentation   An adapted model of practice piloted in the Strengthening Hospital Responses to Family Violence project and based on the World Health Organizations case finding or clinical enquiry approach (WHO, 2013), the principles of sensitive practice (Schachter et al., 2008) and the New Zealand Ministry of Health Family Violence Intervention Guidelines (Ministry of Health,2002).

Step 1 – Identify Where safe to do so: Sensitively inquire about family violence Minimum requirements for enquiry Policy, procedure and guidelines Training on how to identify and respond Private setting (when the patient is on their own) Confidentiality Referral systems

Framing Statements “Family violence is a health issue, so I ask about it routinely.” “Because we know family violence affects your health we are routinely asking patients about it.” The Royal Australian College of General Practitioners. (2014). Abuse and violence: Working with our patients in general practice (4th Ed). Melbourne. The Royal Australian College of General Practitioners. Retrieved from http://www.racgp.org.au/download/Documents/Guidelines/Whitebook/whitebook-4thedn.pdf .

Prompting Questions Are you feeling safe at home? Are you ever afraid of someone in your family or household? Has someone in your household ever put you down, humiliated you or tried to control what you can or cannot do? Has someone in your household ever threatened to hurt you? Has someone in your household ever pushed, hit kicked, punched or otherwise hurt you? Are you worried about your children or someone else in your family or your household? Would you like any help with this now? Department of Human Services (DHS). (2012). Family Violence Risk Assessment and Risk Management Framework and Practice Guides 1-3. Victoria. Department of Human Services

Step 2 –Supportive Response Acknowledge what they have told you. Be empathic, non-judgmental and non-blaming. “That must have been terrifying. You are a strong person to have survived that.” Educational message “You are not alone – others experience abuse in their homes.” “You are not to blame for the abuse.” Provide information/support that may help you. “You have the right to live free of fear and abuse.” Listen Acknowledge Inform Believe

Step 3 – Identify Risk Factors Risk Factors for Patients Pregnancy Post Natal Mental Health Substance Use Isolation Perpetrator Factors Threats to kill Strangulation Access to/Use of weapons Substance use Stalking Sexual violence Threats or direct harm to children Suicidality Threats or harm to animals and pets Breach of intervention order Jealous , controlling behaviour Unemployment History of violence Relationship Factors Escalation – increase in severity and/or frequency of violence Recent Separation Plans to separate Financial hardship

Step 4 – Action Planning & Steps Toward Safety Evidence Base Professional Judgment Patient’s Assessment + + What is the victims own level of fear? What risk factors have I identified? Is there an acute need for safety? = Action Plan Partnership Respectful Appropriate

Step 5 – Referral Social Worker CASA House Aboriginal Liaison Officer Internal Social Worker CASA House Aboriginal Liaison Officer Mental Health Worker Counsellor/Advocate A/H Coordinator External Safe Steps (State-wide FV response centre) Local FV specialist [Insert here] CASA [Insert here] Community Mental Health [Insert here] Legal [Insert here] Police [Insert here] Child FIRST Child Protection http://www.thelookout.org.au/ Insert a link or title of your hospitals PP&G here (which should house a site specific algorithm for referral pathways here – see Guide 1 Service Model and Tool-kit).

Step 6 – Documentation When documenting sensitive information remember to: Be factual Be succinct Ensure the safety of patient records ‘(your hospitals) Documentation Form’ ‘(your hospitals) Internal Alert Systems (where applicable)

Staff Support Consult Senior staff Expert Staff i.e. Social Workers, Clinical Champions Self Care 1800 RESPECT SW, CASA & SACL Access EAP Speak to a trusted colleague/friend/family member