Strengthening Hospital Responses to Family Violence - Guide 3 Service Model Training Package Facilitators Guide First Edition
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Strengthening Hospital
Responses to Family Violence
Guide 3
Service Model Training Package
Facilitators Guide
First Edition
Acknowledgements
The Royal Women’s Hospital would like to thank the following people for their input into the
Strengthening Hospital Responses to Family Violence (SHRFV) series of Guides;
Allison Kenwood (Executive Director, the Royal Women’s Hospital)
Angela Crombie (Project Manager, Bendigo Health)
Cara Gleeson (Project Manager, Our Watch)
Family Violence and Sexual Assault Unit, Department of Health and Human Services
Professor Kelsey Hegarty (Director of Researching Abuse and Violence Program
Department of General Practice, The University of Melbourne)
Michelle Schwensen (Manager - Engagement, Advocacy and Innovation, the Royal
Women's Hospital)
Office for Women, Department of Premier and Cabinet
Patty Kinnersly (Director, Practice Leadership, Our Watch)
Pippa van Paauwe (Project Manager, the Royal Women’s Hospital)
Planning, Diversity and Integration Division, Department of Health and Human Services
Prue Cameron (Policy and Communications Officer, Domestic Violence Victoria)
Sarah Kearney (Coordinator, Evaluation and Learning, Our Watch)
Sharan Ermel (Project Officer, Bendigo Health)
We would also like to thank the following organisations for their contribution;
Austin Health
Ballarat Health
Berry Street
Domestic Violence Resource Centre Victoria
Domestic Violence Victoria
Gay and Lesbian Health Victoria
Hepburn Health
InTouch Multicultural Centre Against Family Violence
Members to the Strengthening Hospital Responses to Violence Against Women Network
Mercy for Women
Northern Health
The Royal Children’s Hospital
St Vincent’s Health Melbourne
Western Health
Women with Disabilities Victoria
2
Table of Contents
Introduction ...................................................................................................................................... 4
History of this training package ........................................................................................................ 5
How to use the Service Model Training Package ............................................................................ 5
Definition of terms ............................................................................................................................ 6
Abbreviations ................................................................................................................................. 11
About this training .......................................................................................................................... 12
Learning objectives ........................................................................................................................ 12
Delivery Guide Module 1: A Shared Understanding..................................................................... 24
Delivery Guide Module 2: Identifying and responding ................................................................... 38
Sensitive Practice........................................................................................................................... 52
How to apply Sensitive Practice .................................................................................................... 53
Attachment A – Pre and post training survey ................................................................................ 55
Feedback form ............................................................................................................................... 55
Note: This version of the SHRFV series of Guides, published in January 2016, is a first edition
and will be further refined and expanded following feedback and input from hospitals during
2016.
3
Introduction
This training package was designed to respond to a recognised need for hospital staff, at a
minimum, to have a basic understanding of family violence. Staff also need a clear
understanding of their roles and responsibilities in relation to family violence, and an
understanding of essential processes and practices to address family violence, including
sensitive practice and referral processes.
Family violence is a serious health issue and affects the whole community. It is not something
that happens out there, to other people. Victim/survivors of family violence are among us
throughout the community, in workplaces, schools, community groups and in hospitals. As found
in the Australian Bureau of Statistics Personal Safety Survey, two-thirds of Australian women
who report violence from a current partner are in paid employment1. Hospitals are therefore
uniquely placed to address this issue not only at a service delivery level, but at an organisational
one too. This training package does not cover training in relation to managing workplace and
staff concerns of family violence, but this is a necessary consideration for hospitals when
implementing the ‘whole-of-system’ approach. However, the model of sensitive practice remains
applicable. Please refer to Guide 1 Service Model and Toolkit.
Research shows that family violence, and broader violence against women has serious, lasting
health impacts and accounts for substantial repeat presentations in hospitals. The Victorian
public hospital system is an early contact point for many people who have experienced family
violence, presenting an opportunity for earlier identification, and improved responses and referral
of victims, therefore all health care practitioners should be trained2.
In 2011 a report was published on the trial of a screening program based on the Domestic
Violence Identification Tool (DVIT) in the emergency department at South Australia's Flinders
Medical Centre. The screening program found victims used their emergency department up to a
third more often than non-victims3. The Steering Committee for the Review of Government
Service Provision have also found Hospitalisation rates for injuries caused by assault between
2008-2009 to be much higher for Aboriginal and Torres Strait Islanders than other-Australian
men and women; particularly, Aboriginal women experienced 35 times the rate of hospitalisation
due to family violence than non-Aboriginal women (SCRGSP, 2009).4
The National Plan to Reduce Violence against Women and their Children 2010-22 recognised
that health professionals are often an early point of contact for women who have experienced
family violence and sexual assault. It recognised that the first response, of every service, is
pivotal to women’s safety and support.
Clinical and non-clinical hospital staff are keen to respond effectively but often do not know how
to do this. Responding appropriately is partly influenced by a staff member’s level of confidence
and the systems and procedures in place in the hospital setting to support them.
1
Australian Bureau of Statistics (2005) Personal Safety Survey, Australia, (Reissue), Catalogue No. 4906.0.
2
Campbell, J.C., Health consequences of intimate partner violence. Lancet, 2002. 359: p. 1331-36.
3
Power, C., Bahnisch, L., & McCarthy, D. (2011). Social Work in the Emergency Department—Implementation of a
Domestic and Family Violence Screening Program. Australian Social Work, 64(4), 537-554.
doi:10.1080/0312407x.2011.606909
4
Overcoming Indigenous Disadvantage: Key Indicators 2011, Steering Committee for the Review of Government Service
Provision
4
History of this training package
This training package is one of the outcomes from the Strengthening Hospital Responses to
Family Violence (SHRFV) pilot project delivered in 2014-15 through a partnership between Our
Watch, the Royal Women’s Hospital (the Women’s) and Bendigo Health, and the Victorian
Government. It built on the work of these two hospitals, and of the Victorian Government, in
addressing family violence over many years.
The project aimed to apply an international framework of sensitive practice to increase staff
competence, develop and share resources and improve practice on family violence, in a model
that could be embedded and adapted for a range of hospitals.
Due to the highly varied nature of hospital departments and the availability of the respective staff
to participate in training, this education package has been designed for delivery in a variety of
modalities within the hospital setting. The content developed was aligned to existing training
content that has been well established at the Women’s and Bendigo Health, cognisant of
Victoria’s Family Violence Risk Assessment and Risk Management Framework (also known as
the Common Risk Assessment Framework or CRAF). It is recommended that staff are
encouraged to uptake further training within the integrated family violence system, such as the
CRAF. Where possible, it is also recommended that hospitals expand the modules where time
allows to include further discussion, role plays and case scenarios as this will enhance learning.
How to use the Service Model Training Package
The two clinical training modules outlined in this package have been designed as two x 45
minute sessions.
These modules can be delivered through a range of mediums:
In a training room or ward as small group education as half hour to 45 minute
presentations during staff handovers and double staffing time.
Remote delivery (via Polycom video conferencing for example).
Integrating modules into mandatory professional development days for nursing and
midwifery staff, and
As a stand-alone training session that can be time expanded to allow for facilitated
discussion, role plays and case scenarios.
The package provides a range of educational materials that can be ‘mixed and matched’
according to specific professional requirements within the hospital setting. We recommend that
facilitators review content and adapt this to suite the target audience, clinical discipline and
patient demographics at your hospital. I.e. adapt case scenarios that reflect the nature of
presentations to the relative department receiving training, combined with issues of
intersectionality i.e. disability, race, sexuality etc. which is discussed later in this guide.
5
Definition of terms
Child Abuse Is any action, or lack of action, that significantly harms the child’s
physical, psychological or emotional health and development. The Child
Youth and Families Act 2005 (VIC) enables consideration of the pattern
and history of harm and the impacts on a child’s safety, stability and
development. There is an overwhelming body of evidence which
indicates that chronic neglect, abuse and family violence are harmful
and have a cumulative and detrimental effect on a child’s development.
Child abuse can occur within a single incident or on multiple occasions
and is categorised in the following manner:
(1) Physical abuse
(2) Sexual abuse
(3) Emotional/psychological abuse
(4) Neglect5.
Elder Abuse Any act occurring within a relationship where there is an implication of
trust, which results in harm to an older person. Abuse may be physical,
sexual, financial, psychological, social and/or neglect.6
Family Violence As per the Family Violence Protection Act 2008 (Vic);
(FV)
(a) Behaviour by a person towards a family member of that
person if that behaviour —
i. is physically or sexually abusive; or
ii. is emotionally or psychologically abusive; or
iii. is economically abusive; or
iv. is threatening; or
v. is coercive; or
vi. in any other way controls or dominates the family
member and causes that family member to feel fear for
the safety or wellbeing of that family member or another
person; or
(b) Behaviour by a person that causes a child to hear or witness,
or otherwise be exposed to the effects of, behaviour referred
to in paragraph (a);
(c) The Act also contains a preamble that states that ‘The
Parliament also recognises the following features of family
violence;
(d) That while anyone can be a victim or perpetrator of family
violence, family violence is predominantly committed by men
against women, children and other vulnerable persons’;
(e) That children who are exposed to the effects of family
violence are particularly vulnerable and exposure to family
violence may have a serious impact on children's current and
5
Department of Health and Human Services. (2015). Child Protection Practice Manual. Victoria. Retrieved From
http://www.cpmanual.vic.gov.au/glossary#h3_74
6
Department of Health. (2012). Elder abuse prevention and response guidelines for action 2012-14, Victoria. Department.
6
future physical, psychological and emotional wellbeing;
(f) That family violence— (i) affects the entire community; and
(ii) occurs in all areas of society, regardless of location,
socioeconomic and health status, age, culture, gender,
sexual identity, ability, ethnicity or religion;
(g) That family violence extends beyond physical and sexual
violence and may involve emotional or psychological abuse
and economic abuse;
(h) That family violence may involve overt or subtle exploitation
of power imbalances and may consist of isolated incidents or
patterns of abuse over a period of time.
Family Member As per the Family Violence Protection Act 2008 (VIC)
a) a person who is, or has been, the relevant person's spouse or
domestic partner; or
b) a person who has, or has had, an intimate personal relationship
with the relevant person; or
c) a person who is, or has been, a relative of the relevant person;
or
d) a child who normally or regularly resides with the relevant
person or has previously resided with the relevant person on a
normal or regular basis; or
e) a child of a person who has, or has had, an intimate personal
relationship with the relevant person.
(2) For the purposes of subsections (1)(b) and (1)(e), a relationship
may be an intimate personal relationship whether or not it is sexual in
nature.
(3) For the purposes of this Act, a "family member" of a person (the
"relevant person") also includes any other person whom the relevant
person regards or regarded as being like a family member if it is or was
reasonable to regard the other person as being like a family member
having regard to the circumstances of the relationship, including the
following:
a) the nature of the social and emotional ties between the relevant
person and the other person;
b) whether the relevant person and the other person live together
or relate together in a home environment;
c) the reputation of the relationship as being like family in the
relevant person's and the other person's community;
d) the cultural recognition of the relationship as being like family in
the relevant person's or other person's community;
e) the duration of the relationship between the relevant person and
the other person and the frequency of contact;
f) any financial dependence or interdependence between the
relevant person or other person;
g) any other form of dependence or interdependence between the
relevant person and the other person;
h) the provision of any responsibility or care, whether paid or
unpaid, between the relevant person and the other person;
7
i) the provision of sustenance or support between the relevant
person and the other person.
Example
A relationship between a person with a disability and the person's carer
may over time have come to approximate the type of relationship that
would exist between family members.
(4) For the purposes of subsection (3), in deciding whether a
person is a family member of a relevant person the relationship between
the persons must be considered in its entirety.
Intimate Partner This refers to behaviour by an intimate partner that causes “physical,
Violence sexual or psychological harm, including acts of physical aggression,
sexual coercion, psychological abuse and controlling behaviours”. 7
This definition covers violence by both current and ex-partners and
other intimate partners.
Partner A person’s spouse or domestic partner irrespective of gender
Example
Two women living together in an intimate personal relationship
Victim/Survivor A term used in conventional practice and throughout this document to
refer to those that may have identified as experiencing family violence. It
is in recognition of language on our patterns and behaviours. ‘Victim’ is
commonly understood as emphasising the innocence of one against
who a crime is perpetrated, the term ‘survivor’ alone does not alert us to
this major actor.8
Gender Equitable A gender equitable organisation is a workplace in which women and
Organisation men are equally represented, valued and rewarded9. For example
committing to regularly report on pay equity, family friendly policies that
promote men and women in the caring roles outside of work and gender
equitable leadership. In the area of primary prevention, working to
promote gender equity and respectful relationships are ways that an
organisation can address the key determinants of violence against
women.
Guidelines or Also known as standard procedures
Protocols
Patient Generally refers to the consumer/client of the health service who is
experiencing violence, also known as the ‘victim/survivor’.
Policy Statements of principle that guide decision-making and service delivery
Procedures More detailed instructions about how policies should be carried out by
staff
7
World Health Organization. (2013). Responding to intimate partner violence and sexual violence against women - WHO
clinical and policy guidelines. Geneva. World Health Organization.
8
Centre Against Sexual Assault House. (1990). Margins to mainstream: Pioneering a feminist model of management in a
traditional hospital/medical organisation (p. 6). Melbourne: CASA House. Paper presented at NCASA Conference, Denver,
Colorado, July 1990.
9
Workplace Gender Equality Agency. (2015). Gender Strategy Toolkit. Retrieved from
https://www.wgea.gov.au/sites/default/files/Gender_Strategy_Toolkit.pdf
8
Primary Refers to the efforts of society to promote, protect and sustain the health
Prevention of the population. In family violence and violence against women it
involves seeking to prevent violence before it occurs by addressing the
root causes; the unequal distribution of power between men and
women, rigid gender roles and attitudes, norms, behaviours and
practices that support violence.10
A holistic approach to prevention involves also challenging structural
inequalities, negative stereotypes and discrimination, including those
based on Aboriginality, disability, class and socio-economic status,
ethnicity, religion, sexual identity and refugee status11.
Secondary Secondary prevention within the context of family violence and violence
Prevention against women is targeted towards individuals and groups who display
early signs of perpetrating violent behaviour or of being subject to
violence12.
Tertiary Tertiary prevention in relation to family violence and violence against
Prevention women involves providing intervention, support and treatment to those
who are affected by violence or to those who use violence. Intervention
strategies are implemented after violence occurs13.
Response Action or strategy to prevent or minimise risks of family violence from re-
occurring.
Sensitive Practice The framework14 for a way of operating as a health professional that is
designed to increase a patient’s sense of safety, respect and control,
ultimately reducing the risk of re-traumatisation for victim/survivors, who
may chose not to disclose it.
Sensitive Inquiry An approach of routinely asking patient’s about their experience(s) of
family violence underpinned by a framework of sensitive practice. The
approach used here is based on the World Health Organization’s
clinical15 enquiry approach and Health Canada’s principles of sensitive
practice, which drew on lessons from victim/survivors of childhood
sexual abuse.16
10
Our Watch. (2015). Policy Brief 3: International Evidence Base. Retrieved from
http://www.ourwatch.org.au/MediaLibraries/OurWatch/our-publications/Policy_Brief_3_International_Evidence_Base.pdf
11
Our Watch. (2015). Change the Story: A Shared framework for the primary prevention of violence against women and
their children in Australia. Retrieved from
https://www.ourwatch.org.au/getmedia/1462998c-c32b-4772-ad02-cbf359e0d8e6/Change-the-story-framework-prevent-
violence-women-children.pdf.aspx
12
VicHealth. (2007). Preventing Violence Before it Occurs: A framework and background paper to guide the primary
prevention of violence against women in Victoria. Retrieved from
https://www.vichealth.vic.gov.au/media-and-resources/publications/preventing-violence-before-it-occurs
13
Ibid.
14
Schachter, C.L., Stalker, C.A., Teram, E., Lasiuk, G.C., Danilkewich, A. (2008). Handbook on Sensitive Practice for Health
Care Practitioners: Lessons from adult survivors of childhood sexual abuse. Ottawa. Public Health Agency of Canada.
Retrieved from
http://www.integration.samhsa.gov/clinical-practice/handbook-sensitivve-practices4healthcare.pdf
15
World Health Organization. (2014). Health care for women subjected to intimate partner violence or sexual violence.
Geneva. World Health Organization. Retrieved from
http://apps.who.int/iris/bitstream/10665/136101/1/WHO_RHR_14.26_eng.pdf
16
Schachter, C., et. al. (2008). Op. cit.
9
Sexual Assault Sexual assault or sexual violence is any sexualised behaviour
perpetrated against a victim/survivor whereby informed consent is not
given by the victim/survivor. It can include rape, sexual assault with
implements, being forced to watch or engage in pornography, enforced
prostitution, and being made to have sex with friends of the
perpetrator.17
17
Council of Australian Governments. (2010). National Plan to Reduce Violence against Women and their Children 2010‐
2022. Canberra. Australian Government
10Abbreviations
CEO Chief Executive Officer
CRAF Family Violence Risk Assessment and Risk Management Framework,
also known as the Common Risk Assessment Framework
DHHS Department of Health and Human Services
ED Emergency Department
FV Family violence
FVIO Family violence intervention order
HIS Health Information Services
IFVS Integrated Family Violence Sector
ICT Information, Communication and Technology
IPV Intimate Partner Violence
MOU Memorandum of Understanding
MH Mental Health
OH&S Occupational Health and Safety
PAS Patient Administration System
PP&Gs Policies, Procedures and Guidelines
RIC Family Violence Regional Integration Coordinator
SHRFV Strengthening Hospitals Response to Family Violence
The Women’s The Royal Women’s Hospital
WHO World Health Organisation
VAED Victorian Admitted Episodes Dataset
VCAT Victorian Civil and Administrative Tribunal
VEMD Victorian Emergency Minimum Dataset
VINAH Victorian Non-Admitted Health dataset
11About this training
All hospital staff should have an understanding of the key determinants of family violence and
violence against women. Clinical staff also need to understand; how family violence and violence
against women impacts or contributes to negative health outcomes; how to use sensitive practice
as a framework for response, and the roles and responsibilities each professional has in relation
to family violence and referral to specialist services.
Clinical staff need to be confident and competent in identifying, enquiring, assessing, responding
to, and recording family violence in the hospital setting. The identification of consumers
experiencing or at risk of experiencing violence is often dependent on the clinician’s awareness
of signs and symptoms that are indicative of abuse, as well as their level of confidence to
sensitively inquire.
Learning objectives
The objectives of the Service Model Training Package include:
Module 1: Shared understanding
A sound and practical understanding of family violence, particularly intimate partner
violence as a health issue, its prevalence and impact
Awareness of the gendered nature and impact of family violence
Identification of the key determinants that underpin family violence and violence against
women
Module 2: Identifying and responding
Identification of those experiencing or at risk of experiencing intimate partner violence
Introduction to the six step model of Sensitive Inquiry for responding to those
experiencing or at risk of experiencing intimate partner violence.
Module content
Module 1: Shared understanding
Welcome and Setting the Scene
Learning Objectives
Demystifying Family violence
o Prevalence
o Risk Factors
o Gender Analysis
o Myths
o Health Impacts
Professional Responsibility
Module 2: Identifying and responding
Welcome and Setting the Scene
Learning Objectives
Clinical Risk Indicators
Principles of Sensitive Practice
12 6 Step Brief Intervention
o Identify (sensitive inquiry)
o Brief Supportive Response
o Identify Risk Factors/Assessing Risk
o Action Planning and Steps Towards Safety
o Referral
o Documentation
Staff Support
Target audience
Module 1: Shared Understanding
All hospital staff including doctors, nurses, midwives, other health professionals and non-clinical
staff
Module 2: Identifying and Responding
Clinical staff: doctors, nurses and midwives and other health professionals only
Suite of materials
The suite of materials includes:
Facilitators Guide
Participant notes/pre-reading
PowerPoint slides
Various interactive learning activities such as quizzes or activities, suitable for the diverse
range of health professionals, which can be implemented in small groups
Video resources highlighting family violence statistics, key issues of family violence and
professional commentary from a wide range of community members
Two x 45 minute teaching modules
Participant pre and post survey
Participant feedback sheet
Participant evaluation
As discussed in the SHRFV Guide 1 – Service Model and Toolkit prior to delivery of the
training, the Facilitators might choose to collect baseline data on the level of clinical and
administrative staff knowledge and experience in this area.
An efficient way to collect information is to devise a staff survey of 5-6 questions that will
identify:
Level of current knowledge about the prevalence, causes and impact of family violence
Level of confidence and capability in identifying a consumer who is experiencing family
violence
Level of confidence and capability identifying clinical risk indicators of family violence
Level of knowledge of referral agencies and referral processes
Familiarity with the hospitals relevant policy and protocols in relation to family violence
Familiarity with the referral process to specialist family violence service providers
13An example of a pre and post training survey is at Attachment A.
Once training has been delivered it is recommended that this survey is repeated after the training
to measure any change that has taken place through the training. The post training survey asks
the same questions of the clinical and non-clinical staff and invites them to rate their level of
confidence and knowledge. The pre and post scores can then be analysed to assess change.
In addition the Facilitator might seek feedback from the participants after each module is
delivered. For example, asking the group to discuss what they found surprising or useful from
that module and how they could implement any learning’s into their practice.
The Facilitator would note the reflections and feed these back to the FV Coordinator and/or the
Implementation Team for two purposes - if changes need to be made to the program and any
issues emerging that may need a response.
Observation and the attendance of the Facilitator at clinical staff meetings or handover sessions
between clinical staff who have completed training, might reveal how well the training has been
integrated into everyday practice and also offer an opportunity to further embed the training.
Attachment A – Pre and Post Training Survey
14Preparing for module delivery
Below are a few suggestions for the Facilitators if the delivery of these modules is face to face in
a training room or ward as a group session.
Facilitators and staff may have personal experiences of violence and this could trigger reactions -
advise them to take care and seek support if needed via your Employee Assistance Program
(EAP) and local family violence service/s and have brochures available in training.
Facilitators
The Service Model Training Package has been developed with the assumption that the
Facilitator who leads the delivery has experience in working with family violence and a
sophisticated understanding of the topic i.e. a Social Worker, or someone who has undertaken
CRAF (or similar) to a sufficient level. This may or may not be someone who has health sector
experience, but this would also be advisable. If not, it may be worth considering that the Co-
facilitator have specific health knowledge i.e. a medical professional such as a doctor, nurse or
midwife from within the hospital to co-present with the experienced family violence lead is the
best and most appropriate way to offer quality professional education in relation to this complex
topic.
The training programs and training materials are all based on adult learning principles and create
education that will promote participation and interaction among the participants. The lead
Facilitator is assumed to be familiar with facilitating group discussions, interactive exercises and
small group activities.
Continuous learning and development for the Facilitator is also recommended to ensure they
keep abreast of emerging practice.
Hospitals role in responding to family violence
It is important for the Facilitator and Co-facilitator when delivering this training, that each is fully
cognisant of the causes and drivers of family violence and how this is best communicated to
hospital staff.
Whilst the definition of family violence used across the three Guides is consistent with the Family
Violence Protection Act 2008 (Vic), the focus is in recognition of family violence incidence data
that highlights that the experience of family violence is often gendered. In the year to March
2015, there were 69,446 family violence incidents reported to Victoria Police. Of these incidents
75.24 per cent of victims were identified as female, and 76.8 per cent of ‘other parties’ were
identified as male. Of female victims, a current or former partner was identified as the ‘other
party’ at 68.7 per cent.18
The gendered nature of family violence is important to communicate to hospital staff whilst
acknowledging that men also can be victims of family violence.
The broader issue of violence against women and children at a societal level is described by
international agencies, such as the United Nations and World Health Organisation, and centres
on broader violence against women than family violence19. It tells us there is no single cause of
violence against women, however, key drivers are low support for gender equality and
adherence to rigid gender roles and stereotypes. These two factors, particularly when combined
with broader support for violence, foster the conditions for violence against women to occur.
Gender inequality and violence-supportive attitudes are the core of the problem and it is the heart
of the solution.
18 Crime Statistics Agency, Affected family members by sex and relationship between Affected family members and Other
Party and Other parties by sex and relationship between Affected family member and Other Party, July 2015.
19 Unwomen.org. (2015). Retrieved from:
http://www.unwomen.org/~/media/headquarters/attachments/sections/library/publications/2012/9/csw57-egm-
prevention-background-paper.pdf
15In addition, the statistics for family violence are changing daily and require constant updating and
referencing. With the increased attention and focus on family violence across Australia, new
evidence on prevalence, and research in effective intervention and prevention is emerging
frequently. Keeping abreast of these developments and ongoing engagement with key
stakeholders (including consumers) and experts in the field will ensure your training remains
current with contemporary, evidence based best practice.
Scope of practice
It is important for the Facilitator to be cognisant of, and clearly communicate with, the range of
clinical and non-clinical staff who may attend this training.
The expertise of clinical staff will vary depending upon their training; confidence and years of
experience.
It is crucial in delivering module 2 training to reiterate that clinical staff are not being trained to be
experts in family violence. It is about learning how to identify patients experiencing family
violence and provide appropriate first-line supportive care.
This training serves to equip frontline staff with the capacity to better identify and respond with
brief intervention to family violence.
This particularly applies when introducing the Sensitive Practice Model. For an experienced
social worker, exploring and assessing the risks to the patient based on their engagement,
assessment and observation may be routine procedure.
However, for a nurse/midwife who is less familiar with or has limited experience in family
violence, the experience of sensitive inquiry could be entirely new to their scope of practice.
For this reason, the Facilitator is asked not to provide detailed or comprehensive instruction for
each of the 6 steps; rather only guidelines to assist clinicians in providing first-line supportive
care. Emphasis should surround staff creating a sense of safety, support and respect, while
remaining direct in their inquiry. Inquiry and response should be empathic and is therefore not
prescriptive; furthermore, providing too much detail may inadvertently create anxiety amongst
hospital staff that they are expected to be experts in the field, which is not the case for the
majority of staff.
Module 2 training is targeted to clinical staff only; clinical staff may have personal experiences
of violence and this could trigger reactions - advise them to take care and seek support if needed
i.e. Employee Assistance Program (EAP) - have these brochures available.
Reflective practice
Reflective practice, like adult learning principles, is fundamental to professional development in
any context. It involves consideration of the impact of one’s own experience and personal frame
of reference on our responses to any given issue20.
In this context it includes recognising that hospital staff bring individual and professional values,
beliefs and cultures to their analysis of family violence issues.
This is particularly relevant when examining family dynamics, relationships, gender and power.
Everyone, including health care professionals, bring their own values and experiences to this
topic, and therefore these sessions require Facilitators who can tactfully respond to, unpack and
even challenge different perspectives and biases that clinicians may bring to the subject matter
(conscious or unconscious).
Responding appropriately and working effectively in diverse contexts necessarily means
addressing one’s own attitudes, knowledge, skills and actions as an ongoing learning process. It
may sometimes mean confronting difficult issues arising from assumptions, power and privilege.
20 N. Thompson & J. Pascal (2012). Developing Critically Reflective Practice, Reflective Practice, 13:2, 311-325, DOI:
10.1080/14623943.2012.657795
16Being thoughtful about the circumstances of others as well as self-reflective about where and
how we come to hold our own values, is an extremely positive and open way of approaching
professional practice. It enables the practitioner to move beyond paralysis when faced with
challenges such as unfamiliar cultural or socioeconomic situations. It also supports sensitive and
sophisticated responses to the diversity of children and families involved.
At best, adopting reflective practice assists in connecting with people – both with their needs and
strengths – to enable effective action.
Pre-requisite for delivery
Below is information that is important for both the facilitator and co-facilitator to be fully briefed on
as a pre-requisite to delivering the content of the two modules. In addition, incorporating this
knowledge into their delivery styles will maximise the learning opportunities for participants in this
area.
Cultural competency
Cultural competence refers to a set of “congruent behaviours, attitudes and policies that come
together in a system or agency or among professionals that enable that system, agency or those
professionals to work effectively in cross-cultural situations (Cross, et.al. 1989)”21. In this
instance work colleagues and patients from different cultural/ethnic backgrounds presenting at
your hospital.
In practical terms competence comprises four components:
Awareness of one's own cultural worldview
Attitude towards cultural differences
Knowledge of different cultural practices and worldviews, and
Cross-cultural skills.
Developing cultural competence results in an ability to understand, communicate with, and
effectively interact with people across cultures. It requires examining biases and prejudices,
developing cross-cultural skills, searching for role models, and spending as much time as
possible with other people who share a passion for cultural competence.
Attitudes towards family violence
Violence-supportive attitudes are those that “justify, excuse, minimise or trivialise physical or
sexual violence against women, or blame or hold women at least partly responsible for violence
perpetrated against them”22. Evidence from the findings of the National Community Attitudes
Survey by VicHealth in 2013 suggests that such attitudes can create a culture in which violence
is “at best not clearly condemned and at worst condoned or encouraged”23.
These attitudes are the beliefs and values gained from family, culture and a lifetime of
experiences that heavily influence how a person views and evaluates both themselves and
others.
In the hospital setting, a hospital staff member can sometimes have a negative view of a
victim/survivor presenting in emergency that may have experienced family violence.
This categorisation of people can result in routine and automatic sorting of survivors, victims, and
perpetrators into groups. This tends to override rational decisions, logical thinking and the
professional attitude of a hospital staff member, however these thought patterns, assumptions
21 Health.vic.gov.au. (2015). Retrieved from:
http://www.health.vic.gov.au/__data/assets/pdf_file/0008/381068/cultural_responsiveness.pdf
22 VicHealth. (2014). Australians’ attitudes to violence against women. Melbourne: Victorian Health Promotion
Foundation.
23 Ibid.
17and interpretations – or biases –have built up over time, often to process information quickly and
efficiently.
Myths
One of the key aims of Module 1 is to gently challenge any myths held by participants around
family violence myths are borne from ‘our beliefs and attitudes (that) are shaped by many
influences and can be held without conscious thought. When we unpack the building blocks of
our attitudes we can identify certain myths or false truths upon which our attitudes are based’24.
Prejudicial myths are dangerous because they influence how we think and feel about violence
against women and their children. These beliefs and attitudes then influence how we act when
confronted with violent behaviour or how we respond when we hear about violence25.
In the family violence context, there are many myths (or incorrect assumptions) about
victim/survivors that have been perpetuated by families, communities and media that have
influenced how this topic is viewed and understood, for example the myths below:
Men should make the decisions and take control in relationships…
There’s nothing wrong with a sexist joke…
Domestic violence is ok if the perpetrator gets so angry they lose control…
Women could leave a violent relationship if they wanted to…
Supporting participants affected by sensitive content
Be prepared to find that the content of these modules may cause both male and female
participants to become upset or uncomfortable. The content may be perceived by some as unfair
and one-sided; however, statistics tell us clearly that family violence is gendered in nature (see
earlier text on the hospital’s role in responding to family violence). Women, of course, can be
violent however, compared with men, women are:
more likely to experience violence from someone known to them
more likely to experience sexual assault since the age of 15
more likely to experience fear and anxiety26
Likely to experience more serious harms27
The above points, strengthened by the recommendations of the World Health Organisation28, are
the rational for why training in the SHRFV project pilot areas was initially focussed/targeted in
areas such as women’s health, mental health, and emergency. The project team recommends
that health care professionals in hospitals should inquire about violence when assessing
conditions that may be caused or complicated by intimate partner violence. This should be
undertaken in order to improve diagnosis and care as these clinical conditions largely surround
adverse reproductive health outcomes and mental health29.
Background information to risk factors
Particular groups experience greater vulnerability that puts them at increased risk of family
violence. Risk factors can impact on:
24 Ourwatch.org.au. (2015). Our Watch - Our Watch . Retrieved from http://www.ourwatch.org.au/Understanding-
Violence/Myths-about-violence
25 Ibid.
26 Abs.gov.au. (2015). 4906.0 - Personal Safety, Australia, 2012. Retrieved from
http://www.abs.gov.au/ausstats/abs@.nsf/mf/4906.0
27 Bagshaw, D & Chung, D., 2008. Women, Men and Domestic Violence. University of South Australia
28 WHO. (2013). Responding to Partner Violence and Sexual Violence Against Women: Clinical and Policy Guidelines.
Geneva: WHO Press.
29 Ibid.
18 prevalence, severity and form of domestic violence
access to services, and capacity for continued safety differs within a community and due
to social determinants where some groups are more vulnerable than others30.
These particular groups can be of any age, ethnicity, income level, or level of education.
The biggest risk factor for those experiencing family and/or sexual violence is gender; however
socio-economic and social determinant factors as listed below can compound impacts.
Gender
Women are far more likely to experience family violence than men. While anyone can be a
victim/survivor of family violence, it is most commonly committed by men, towards women,
children and other vulnerable persons31.
Key determinants of violence against women are the unequal distribution of power and resources
between men and women, an adherence to rigidly defined gender roles combined with violent
supportive attitudes (VicHealth 2007)32.
Poverty
Family Violence does not discriminate with wealth. However, low incomes (less than that
required to provide for basic needs) and financial stress including a gambling addiction are risk
factors for family violence and may contribute to and impact on the likelihood and severity of
family violence.
Aboriginal family violence
For Aboriginal Australians and Torres Strait Islanders, the definition of family violence includes
physical, emotional, sexual, social, spiritual, cultural, psychological and economic abuse that
occurs within families, intimate relationships, extended families, kinship networks and
communities.
Aboriginal women experience disproportionately high levels of family violence, with significant
under-reporting of family violence in Aboriginal communities. Nationally, Aboriginal women
experienced 35 times the rate of hospitalisation due to family violence than non-Aboriginal
women33. From an Aboriginal perspective, the prevalence is associated to a number of factors
many that relate to the impact of colonisation on Aboriginal culture34.
These include dispossession of land and traditional culture, breakdown of community kinship
systems and lore, racism and vilification, economic exclusion and entrenched poverty.35
Due to a range of complex reasons, Aboriginal women may or may not wish to access Aboriginal
family violence services. Therefore, options for both Aboriginal specific or general services
should be given.
30 Aic.gov.au. (2015). Key issues in domestic violence. Retrieved from:
http://www.aic.gov.au/publications/current%20series/rip/1-10/07.html
31 Assets.justice.vic.gov.au. (2015). Retrieved from: http://assets.justice.vic.gov.au/justice/resources/c8b0a4b2-814d-4f2c-
89c0-374d41902f66/fvdb_1999_2010_keyfindings%5b2%5d.pdf
32 VicHealth. (2007). Preventing Violence Before it Occurs Retrieved from: https://www.vichealth.vic.gov.au/media-and-
resources/publications/preventing-violence-before-it-occurs
33 SCRGSP (Steering Committee for the Review of Government Service Provision) 2011, Overcoming Indigenous
Disadvantage: Key Indicators 2011, Productivity Commission, Canberra.
34 DHS, 2012. Family Violence Risk Assessment and Risk Management Framework and Practice Guides 1-3 (CRAF).
35 Ibid.
19Family violence in Culturally and Linguistically Diverse (CALD)
communities
It is critical to challenge ideas that family violence is more acceptable in some cultures. All
communities have violence-condoning and violence-supporting values, systems and practices;
these are different in different communities. However, women in some CALD communities face
additional barriers to seeking support, such as language barriers, lack of knowledge about local
laws and support services and visa status. Some CALD communities might have different
definitions of family violence. They might also have community mechanisms for dealing with
family violence, alongside a criminal justice approach.36 Care should also be given to ensure
professional interpreting services are provided, rather than relying on friends or family of the
victim/survivor.
Disability
Women and girls with disabilities experience higher rates of violence. Women with girls with
disabilities – particularly those with intellectual disabilities who are most excluded from social and
economic participation – are at especially heightened risk of experiencing violence37. The FV
Protection Act 2008 (VIC) recognises that women and girls with disabilities may experience
gender based and disability based violence, which may include for example, over/under
medication, breaking a hearing aid or denying disability supports. The Family Violence Protection
Act 2008 (VIC) also recognises that family violence and ‘family like’ relationships may exist
between people with disabilities and paid and unpaid carers.
Pregnancy/new birth
The ABS Personal Safety Survey reports that pregnant women are at increased risk of family
violence during pregnancy. Almost 60 percent of women who had experienced violence
perpetrated by a former partner were pregnant at some time during the relationship; of these, 36
percent experienced the abuse during their pregnancy and 17 percent experienced it for the first
time when they were pregnant38.
36 Ibid.
37 Wdv.org.au. (2015). Retrieved from:
http://www.wdv.org.au/documents/WDV%20Violence%20Position%20Paper%20(web%20version).pdf
38 Aic.gov.au. (2015). Retrieved from: http://www.aic.gov.au/media_library/publications/rip/rip07/rip07.pdf
20Rural communities
People in rural and regional areas experience greater vulnerability due to distance, availability of
professional support, transport options and associated costs in gaining access to resources,
including translators, for support. Extra challenges may also surround the level of privacy in
smaller communities and the potential to re-encounter perpetrators. Additionally, given the nature
of rural settings access to firearms is associated to the disproportionate number of family
violence related homicides in rural areas39.
Lesbian, Gay, Bisexual, Transgender, Intersex (LGBTI)
People who are lesbian, gay, bisexual, transgender, intersex, or questioning their gender or
sexuality, have experienced high levels of domestic violence and may be at greater risk of
violence from family members such as parents, siblings and offspring. The LGBTI community
faces barriers to accessing a range of services which hold traditional views of sexuality and
gender or are feared to do so, including health care and specialist services. Some LGBTI people
are at higher risk of family violence, or have less access to supportive services. These include
people who are transgender, people with a disability, and people from communities or areas with
40
rigid gender roles and conservative views about sexuality .
Age
With older age, people may experience a reduction in social networks, access, loss of economic
power and access to resources, frailty or dependency and limited housing options41. Violence is
typically perpetrated by someone close to them, inclusive of caregivers.
Understanding the context and intersectionality of family violence
Understanding family violence extends to include particular considerations for some specific
contexts. For example, in Aboriginal contexts, or Culturally and Linguistically Diverse
populations, as outlined above.
In other contexts, such as for people with a disability or in need of care, a victim may experience
family violence from a paid or unpaid carer. This is recognised in the Family Violence Protection
Act 2008 (Vic) under 'family-like relationships'.
Older people may be more vulnerable to abuse by adult children or other family members and
experience higher rates of financial abuse. Some communities may have their own
understanding of family violence, or may protect a user of violence due to past trauma or
displacement. It's important to remember that, regardless of the setting in which it occurs, family
violence is a human rights issue and may constitute a criminal offence42.
Intersectionality is a concept or theory used to understand how an individual experiences the
world through overlapping social identities and circumstances related to race, gender, sexuality,
culture, ethnicity, citizenship and economic status, and how such identities are treated as bias
43
. In respect to intersectionality we are able recognise the context of how women’s experiences
of family violence are impacted by these identities (sometimes multiple), and the barriers that
39
Department of Human Services (DHS). (2012). Family Violence Risk Assessment and Risk Management Framework and
Practice Guides 1-3. Edition Two. Victorian Government.
40
Philomena Horsley, May 2015, Family violence and the LGBTI community: Submission to the Victorian Royal Commission
into Family Violence, on behalf of Gay and Lesbian Health Victoria, Australian Research Centre in Sex, Health & Society, La
Trobe University, Melbourne. This submission is based on research and the knowledge shared by individuals and service
providers with Gay and Lesbian Health Victoria. Key sources are cited within the submission.
41
DHS, 2012. Op. cit.
42
Ibid
43
Crenshaw, K. (1991). Mapping the Margins: Intersectionality, Identity Politics, and Violence against Women of Colour.
Stanford Law Review, 43(6), 1241-1299.
21arise because of racism, sexism, homophobia, bigotry and other oppressions44, impacting on
their vulnerability for violence to continue45 .
Suggested pre-reading or key reference documents for Facilitators
ABS (Australian Bureau of Statistics), 2013b. Personal Safety Survey 2012, no. 4906.0,
http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4906.0Chapter2002012
AIC (Australian Institute of Criminology), 2003. Trends & Issues in crime and Criminal
Justice: Family Homicide in Australia.
http://www.aic.gov.au/media_library/publications/tandi2/tandi255.pdf
Australia’s National Research Organisation for Women’s Safety (ANROWS). 2015.
Violence against women: Additional analysis of the Australian Bureau of Statistics’
Personal Safety Survey, 2012. Horizons Research Report. Issue 1. October 2015.
http://www.ourwatch.org.au/Understanding-Violence/Myths-about-violence
Australia’s National Research Organisation for Women’s Safety (ANROWS) and Our
Watch. 2014. Violence Against Women: Key Statistics.
http://www.anrows.org.au/resources/media/for-the-media/key-statistics-violence-against-
women
Department of Human Services (DHS), 2012. Family Violence Risk Assessment and Risk
Management Framework and Practice Guides 1-3
Department of Social Services (DSS), 2010. The National Plan to Reduce Violence
Against Women and Their Children 2010-2022. https://www.dss.gov.au/our-
responsibilities/women/programs-services/reducing-violence/the-national-plan-to-reduce-
violence-against-women-and-their-children-2010-2022
Family Violence Protection Act 2008. (VIC) Part 2 s.4-10 (Austl.).
R.Campbell. (2011). General Intimate Partner Violence Statistics. Australian Domestic
and Family Violence Clearing House. University of New South Wales.
It’s Time to Talk: About Domestic Violence. October 2013. Women’s Legal Service’s New
South Wales. http://itstimetotalk.net.au/gp-toolkit/
A.Morgan and H. Chadwick. 2009. Key issues in domestic violence Research in Practice
no. 7, Canberra: Australian Institute of Criminology, December 2009
The National Council to Reduce Violence Against Women and Their Children, DSS
(Department of Social Services), 2009. The Cost of Violence Against Women and Their
Children.
https://www.dss.gov.au/sites/default/files/documents/05_2012/vawc_economic_report.pdf
Our Watch, 2014. http://www.ourwatch.org.au/Our Watch, National Foundation to
Prevent Violence Against Women Policy Brief, Women’s Experience of Violence
infographic http://www.ourwatch.org.au/MediaLibraries/OurWatch/Images/03-womens-
experience-of-violence.pdf, Policy Brief Number 3 International Evidence,
http://www.ourwatch.org.au/MediaLibraries/OurWatch/our-
publications/Policy_Brief_3_International_Evidence_Base.pdf, and Policy Brief Number
1: Key Terms, Definitions and Statistics,
http://www.ourwatch.org.au/MediaLibraries/OurWatch/our-
publications/Policy_Brief_1_Key_Definitions_and_Statistics.pdf, more information
available at http://www.ourwatch.org.au/
44
Knudsen, S (2006), Intersectionality—A Theoretical Inspiration in the Analysis of Minority Cultures and Identities in
Textbooks. Caught in the Web or Lost in the Textbook (26 November 2007), pp.61–76.
45
DHS, 2012. Op. cit.
22 The Royal Australian College of General Practitioners, 2014. Abuse and violence:
Working with our patients in general practice, 4th ed. Melbourne
The Royal Women’s Hospital. 2014. Preventing Violence Against Women Strategy 2014-
2016.
VicHealth, 2014. Australians’ Attitudes to Violence Against Women: Findings From the
2013 National Community Attitudes Survey (NCAS).
WHO (World Health Organisation) 2013. Responding to Intimate Partner Violence and
Sexual Violence Against Women: WHO Clinical and Policy Guidelines
Women’s Health Loddon Mallee, 2014. http://youtu.be/OySZ9OtwBoA
Women With Disabilities Australia (WWDA), 2004. Double the Odds – Domestic Violence
and Women with Disabilities http://wwda.org.au/issues/viol/viol2001/odds/
23Delivery Guide
Module 1: A Shared Understanding
Welcome & Background
Time Slide (s) Key message (s) Activity Facilitator dialogue
7 mins Show Slide 1 Welcome Project Background
participants,
Advise participants that this session and session 2 form part of
introduce yourself
a training package developed by the Women’s and Bendigo
and the co-
Health in partnership with Our Watch and funded by DHHS.
Facilitator
While the training package has been put together from the
Trigger warning &
experiences of a Victorian pilot it is available for all hospitals
self- care
across Australia.
This training is targeted to any staff (not just clinical).
Warning about Topic
That some staff may have personal experiences and this could
be triggering. Advise them to take care and seek support if
needed i.e. Employee Assistance Programs (EAP) - have these
brochures available.
Remind staff that this is not an ‘endurance test’ and if they
need to take some time aside they are welcome to. Let’s also
not assume that those leaving the room perhaps to use the
bathroom ‘aren’t coping’.
Recognise that for the purposes of this training, we will keep
discussions brief (due to time constraints). Where time allows,
they are welcome to share their professional experiences, as it
can enhance the learning of others. Please ensure however that
the confidentiality of patients is maintained in doing so.
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