Telehealth and domestic and family violence

Guideline number: QH-GDL-497:2022

Effective date: 23 June 2022

Review date: 23 June 2025

Supersedes: First issue

On this page:

Purpose

This guideline provides best practice recommendations when a health professional recognises or suspects that a patient is at risk of Domestic and Family Violence (DFV) before during or after a telehealth appointment. It outlines best practices for the management of disclosure supporting all health professionals to appropriately identify and respond to the needs of any person at risk of or experiencing DFV. It is important that we normalise the reasons that we ask questions about a person’s physical, psychological, and emotional health during a consultation.

Scope

This guideline applies to all Queensland Health employees (permanent, temporary, and casual) and all individuals acting as its agents (including visiting medical officers and other partners, contractors, consultants, volunteers and students or trainees) in the public health sector involved in the provision of health care via telehealth.

Compliance with this guideline is not mandatory, but sound reasoning must exist for departing from the recommended requirements within this guideline.

To respond safely and usefully to DFV in healthcare settings is important to note that:

  • DFV can affect anyone, across all socio-economic, social and cultural groups.
  • While all genders can be both victims and perpetrators of DFV, there is overwhelming evidence that the most harmful and highest risk for DFV (serious harm and homicide) is perpetrated by men against women.
  • Any violence, regardless of who is the victim and who is the perpetrator is unacceptable.

Background

The Queensland Government is committed to the prevention and eradication of DFV through the Queensland Domestic and Family Violence Prevention Strategy 2016 – 2026. The Strategy’s Fourth Action Plan to reduce violence against women and their children has five priority areas. Priority five is 'Improve support and service system responses' by reducing the impact of violence on women and their children, prioritising their safety, and preventing perpetrators from using violence again. Queensland Health is working to improve service responses so that victims and their children have access to help when they need it, including improvement in identification, reducing stigma, and seeking support.

One of the reforms being implemented is educating all front-line health staff to recognise DFV, to respond to DFV, and to prioritise safety of victims and children. Recommendation six suggests that the Queensland Government conducts a system-wide review of the impact of the response to the COVID-19 pandemic on victims of domestic and family violence and consider maintaining any service delivery adaptations that have improved safety for victims and their children.

The COVID-19 pandemic has seen an increase in telehealth use. Telehealth consultations with healthcare workers and frontline staff may be the only external point of contact available to some women and children experiencing DFV.

Healthcare professionals typically enjoy non-judgemental relationships of trust and confidence with patients, and a professional interest in their health and well-being. This gives the health professional a unique capacity to identify and provide support to patients impacted by DFV. Given the widespread use of telehealth-based clinical care, it is important to consider the delivery of telehealth services in the context of DFV.

Cultural considerations

To provide culturally capable services, health professionals should use culturally appropriate processes and communication strategies when working with Aboriginal and Torres Strait Islander people and offer access to Aboriginal and Torres Strait Islander services, such as hospital liaison officers, health workers or health practitioners.

Provision of services to patients from Culturally and Linguistically Diverse (CALD) backgrounds should be in accordance with the Multicultural Queensland Charter as detailed in the Multicultural Recognition Act 2016.

Engage an appropriately qualified interpreter, if required, to effectively communicate with people from non-English speaking backgrounds.

Requirements

Principles

These principles provide a foundation for safety, and a priority for any response in recognising and managing DFV. These principles also align with those in the Telehealth Strategy 2021-2026.

  • Safety is a core priority
  • Empowerment and client / consumer-centred care
  • Confidentiality
  • Integrated, coordinated, collaborative and responsive
  • Diversity - inclusive and equitable
  • Evidence-based and co-designed with users
  • Understanding the dynamics of gender, power and control.

The following information has been developed to help support health professionals to identify and respond to people experiencing DFV when accessing services or supports via telehealth, particularly when delivering care to a patient in their home. Every virtual visit is an opportunity to connect with a patient to learn about their health and concerns. There may be times when the patient is unable to speak for fear of being heard by a perpetrator or other person, so clinicians should be vigilant to a patient’s evasiveness or discomfort to participate, or to make decisions about their healthcare. Telehealth communication may be the only external point of contact available to a patient experiencing DFV.

Every time a person who uses violence interacts with a health service, there is an opportunity to affect change and intervene. If a person discloses to you that they use violence or abuse in a relationship, the safety of the victim and children is paramount, and health professionals should not engage with perpetrators in ways that collude or increase the risk of DFV.

It is more likely that a perpetrator may state they are having problems with stress, anger, relationship issues, depression, alcohol, or drugs instead of disclosing domestic violence.

If a person discloses that they are using violence, never breach the confidentiality of victims and their children, by sharing any information the victim may have provided to you - only engage with the person about their individual circumstances.

Approach

Where it is known that a patient is currently experiencing DFV or a health professional has identified concerns related to DFV, service provision should preference face to face interaction where possible.

Other considerations need to be explored to continue with a telehealth appointment for a patient experiencing DFV or suspected of experiencing DFV including:

  • current or existing protective factors
  • whether the perpetrator is living with the patient
  • access to safe devices for telehealth
  • access to other locations to do a telehealth appointment
  • utilising a safe time or window of opportunity for the appointment to occur
  • whether telehealth is the only option for a patient to attend the appointment.

Clinician responsibilities

  • Assess the capacity of, and barriers to, the patient participating in a telehealth consultation using the patient technology checklist (PDF 156 kB).
  • Acknowledge that DFV could be occurring and be aware of personal biases.
  • Understand risk and vulnerabilities and wide-ranging impacts on a person’s life from DFV.
  • Understand increased DFV risk associated with isolating events such as natural disasters and pandemics.
  • Know the increased risks and barriers of priority populations (people from culturally and linguistically diverse backgrounds, First Nations peoples, people with a disability, young people, LGBTQ+ people).
  • Understand the psychosocial risk factors that increase the risk of DFV (mental health, pregnancy, isolation, lack of social supports, substance misuse).
  • Be aware of a previous history of DFV, by reviewing the medical record or alerts before the first appointment.

Scheduling telehealth

  • Ask the patient for the best time for their appointment, and if they have access to a private space where they cannot be overheard, and suggest that privacy is important for this appointment.
  • Ask the patient what their preferred method is of connecting (computer or phone) and ask if they can connect a headset.
  • Where possible, plan an approach to assess safety including using non-verbal cues and setting up a safe word (see Definitions section).
  • The use of telehealth (videoconferencing) as opposed to telephone in all first appointments will assist with establishing rapport, safety and trust as the provider and the patient can see each other.
  • Advise the patient about privacy and confidentiality limitations of your role and legal responsibilities under legislation such as mandatory reporting of child harm concerns.
  • Explain that Queensland Health telehealth platforms are secure however, it is possible that sessions may be monitored by someone in their home or location using other devices and apps.
  • If the patient feels that their home device is compromised or being monitored, invite the patient to attend a health facility, another local facility or another person’s place to conduct the telehealth appointment.
  • If a patient continues to cancel or not attend their telehealth appointment, consider alternative options such as a face-to-face appointment.

The telehealth visit

  • Ask the patient if they are safe to talk and if they are alone
  • Assess the patient readiness to meet
  • Assess if others are present, ask to be introduced if you can see them in the background
  • Develop a plan if the call or video is suddenly disconnected, including who should re-initiate the call, and explore if there are other family or friends that could be called if unable to reconnect
  • Develop a safe word (see Definitions section)
  • Where the patient indicates it is not safe to talk or to talk further about DFV, use their safe word and continue the engagement relating to other health matters and the need to book their next appointment as a face-to-face consultation
  • Reassess the suitability of telehealth as a modality following any DFV disclosure or when the health professional identifies DFV risks
  • Be familiar with DFV high risk factors (see Definitions section) which are known to relate to a higher likelihood of violence, injury or death in the context of DFV
  • Make a safety plan with the patient - a minimum for all health professionals is a plan for follow-up
    • With the patients consent, provide referrals to support services
    • Provide information about support services
    • Consider various support services – DFV national phone numbers, Queensland phone numbers, 24-hour support services numbers
    • Only provide referrals and information if it is safe to do so
  • Complete any legal requirements as a health professional such as reporting concerns of significant risk of physical or sexual harm of children to child safety agencies
  • Follow-up:
    • Reassess
    • Review
    • Re-evaluate
  • Consult with the hospital social worker or DFV Specialist for further support and advice.

Mandatory reporting

Responding to a disclosure

Information to guide all health professionals in responding to disclosure of DFV, including referral of patient and perpetrators to specialist support services, is detailed in the Queensland Health Domestic and Family Violence Referral to specialist support services model (PDF 1824 kB) and Response to disclosure flowchart (PDF 132 kB).

  • A suggested script for use by any health professional can be found in the Factsheet - Telehealth and DFV - suggested script.

If the patient does not disclose but you suspect they may be at risk

  • Discussion of DFV requires rapport between the clinician and the patient. The patient experiencing abuse may not speak up when the subject is first raised but may choose to disclose later when they feel enough trust and confidence in the clinician, possibly at a subsequent follow up appointment with the same health professional.
  • Not all patients will disclose DFV, and of those who do, not all will want help or referral. However, referral is not the only reason for conducting screening; if awareness is the only outcome, this can still be beneficial.
  • Respect the patient’s answers and provide local specialist DFV service or helpline information and support that is available (only if safe to do so) should they ever require it.
  • Remind the patient that hospitals are open 24 hours, 7 days a week and they can present to any hospital to seek support and safety.
  • Offer other appropriate referrals as per the patient’s presenting issues.
  • Document in the patient’s clinical record that DFV was suspected but the patient did not disclose.
  • Document in the patient’s clinical record to screen for DFV again at future presentations.

Consult as required with a social worker, a nurse or another health professional or specialist agency who are trained in responding to DFV.

If the patient is the perpetrator of violence or you suspect your patient’s partner is a perpetrator

  • Research shows that health professionals are one of the few groups of people that a perpetrator may disclose to about DFV, and they do this because they are seeking help or believe their abuse is a symptom of a medical condition.
  • Perpetrators may state that they are having problems with stress, anger, depression, alcohol, drugs, relationship problems, or temper issues, instead of specifying DFV. They may also disclose behaviours and acknowledge using force while seeking medical treatment because they do not believe that what they did was wrong, for example “she used the knife at me after I punched and pushed her and that’s how I got cut”.
  • Acknowledge the disclosure and behaviour as a first step.
  • Health professionals can categorise the behaviours as DFV and using a matter-of-fact approach is best when gathering information and conveying concerns about the violence to the (perpetrator) patient.
  • If a person discloses that they are using violence, never breach the confidentiality of victims and their children, by sharing any information the victim may have provided to you - only engage with the person about their individual circumstances.
  • Consider the risk they are posing to their partner or children and what steps need to be taken to reduce this risk.
  • Be respectful, empathetic and matter of fact, but do not collude.
  • Document into the medical record details about the behaviours disclosed, when they happened, any relevant context, influences, and risk to self and others.
  • Determine what supports are required and, with consent, make appropriate referrals.
  • Share information about DFV with relevant agencies where there is an ongoing risk, or to manage serious threats (refer to the Queensland Health Information Sharing for Domestic and Family Violence Guideline).

Education and training

All health professionals are expected to complete the mandatory training Recognise Respond and Refer as well as the Understanding DFV online module.

Certain healthcare professionals are encouraged to complete the Clinical response to Domestic and Family Violence blended learning package within six months of commencing their role and refresh the training every three years. These groups are:

All health professionals, working in the following areas:

  • Emergency departments
  • Mental health services
  • Alcohol and other drugs services
  • Sexual health services
  • Multicultural health services
  • First Nations health services
  • Maternity and child health services, and
  • Healthcare professionals qualified in:
    • Social work
    • Psychology
    • Welfare assistance
    • Allied health.

This online training module outlines the Queensland Health six step sensitive inquiry model to identify and respond to DFV as a routine part of healthcare provision.

The face-to-face training element of the Clinical response to Domestic and Family Violence learning package can be delivered flexibly as a single session or a series of short sessions. Contact your DFV specialist health professional in your Hospital and Health Service for more information about training opportunities and upskilling.

Documentation

Health professionals should refer to local policy and guidelines to guide documentation relevant to their profession. Documentation of relevant information about what a person has disclosed to you or something you have seen or heard during your appointment is important for ongoing care and legal purposes. Documentation may also include placing a DFV alert on the person’s record.

Understand how the different digital systems interact with each other. A confidential disclosure of DFV attached to documents that are uncontrolled such as an ieMR discharge summary or the MyHealthRecord can increase the risk of harm or lethality to victims and children.

Always document details about the perpetrator (name, date of birth, and relationship). Knowing this can assist with further risk assessments if the patient presents with injuries or other DFV-related health issues.

Legal documents related to risk assessment and managing a serious threat to a patient’s safety, such as a copy of a Domestic Violence Order (DVO), a Temporary Protection Order (TPO) or a Police Protection Notice (PPN) can be supplied by the patient or shared by a prescribed agency and marked confidential and accessible on a patient record.

Use of a DFV alert in ieMR should be used as a quick identifier for all health professionals and initiate further DFV assessment at each subsequent presentation or appointment. For HHSs that do not use ieMR, place alerts for follow-up in the way designated by your HHS.

Information sharing

There are Information Sharing Guidelines under part 5A Section 169B of the DFV Act which allows for information sharing without consent to prescribed entities if it is relevant to assessing risk and or reducing threat.

Health professionals may share information without consent:

  • To support an assessment of DFV risk, or to lessen or prevent a serious DFV threat
  • To avert a serious risk to the life, health or safety of the client or another person or to public safety.

Refer to the Domestic and Family Violence Information Sharing Guideline and flowchart (PDF 343 kB) for more information. If you require further guidance around Information Sharing Provisions, contact the DFV specialist worker or your HHS Legal Services.

Self-care

Working with people who have experienced DFV or perpetrated DFV can be rewarding, but it is also challenging and can affect you. DFV may cause some health professionals to experience strong emotional responses. Effects can include:

  • Invasive thoughts of a patient’s situation or distress
  • Frustration, fear, anxiety, irritability
  • Disturbed sleep or racing thoughts
  • Feeling you need to overstep the boundaries of your role.

If this is the case, you should seek assistance from the Employee Assistance Program (EAP), a general practitioner, professional counsellor, or applicable specialist service.

Legislation

Definitions

Term Definition and explanation
Child in need of protection The Child Protection Act 1999 defines a child in need of protection as a child who:
  1. has suffered harm, is suffering harm, or is at unacceptable risk of suffering harm; AND
  2. does not have a parent able and willing to protect the child from the harm.
Domestic and Family Violence (DFV) In the Queensland Domestic and Family Violence Protection Act 2012, domestic violence means behaviour by a person (the first person) towards another person (the second person) with whom the first person is in a relevant relationship that-
  1. is physically or sexually abusive; or
  2. is emotionally or psychologically abusive; or
  3. is economically abusive; or
  4. is threatening; or
  5. is coercive; or

in any other way controls or dominates the second person and causes the second person to fear for the second person’s safety or wellbeing or that of someone else.

Disclosure Any occasion when an adult or child who has experienced or perpetrated DFV informs a health employee or any other third party.
Health professional The Hospital and Health Boards Act 2011 defines a health professional as –

a) a person registered under the Health Practitioner Regulation National Law; or

a person, other than a person referred to in paragraph (a), who provides a health service, including, for example, an audiologist, dietician, or social worker.

Telehealth Telehealth is the delivery of health services using information communication technologies. Telehealth in the context of this Guideline refers to an interaction between a health professional and a patient via videoconferencing.
Perpetrator A person who carries out a harmful, illegal, or immoral act.
Survivor A person regarded as resilient or courageous enough to be able to overcome harm, hardship or a series of events that threatens safety.
Victim A person harmed, injured, or killed because of a crime, accident, or other event or action.
Safe word A word agreed upon by the victim / patient in advance to alert the clinician that they may need help or that they cannot talk. It could also mean that they need the police to be called. Establishing a safe word and its meaning is planned and designed by the victim / patient with their clinician.
High risk factors
  • Intimate partner sexual violence
  • History of violence
  • Non-lethal strangulation
  • Stalking
  • Escalation of violence
  • Coercive control
  • Threats to kill
  • Misuse of drugs or alcohol
  • Pregnancy and early motherhood
  • Court orders and parenting proceedings
  • Victims’ self-perception of risk
  • Access to or use of weapons
  • Suicide threats and attempt
  • Abuse of pets
  • Separation
  • Isolation and barriers to help seeking

Document approval details

Document custodian

Michael Zanco, Executive Director, Healthcare Improvement Unit, Clinical Excellence Queensland

Approval officer

Dr Helen Brown, Deputy Director-General, Clinical Excellence Queensland

Approval date

23 June 2022

Version control

VersionDateComments
1.0 13/06/2022

Last updated: 23 June 2022