HOSPITAL POLICY AND INFORMATION MANUAL Date Issued: Date Last Revised: Next Review Date: Approved By:

of 12 Policy Applies to: All Mercy Hospital staff. Compliance by Credentialed Specialists or Allied Health Professionals, contractors, visitors and patients will be facilitated by Mercy Hospital staff. Related Standard: New Zealand Standard 8006:2006 Screening, Risk assessment and Intervention for Family Violence including Child Abuse and Neglect. Crimes Act 1961 Crimes Amendment Act (No.4) 2011 Crimes Amendment Act (No. 8) 2012 Rationale: Mercy Hospital is committed to ensuring that those patients who suffer from any form of family violence are identified and offered appropriate care and referral to relevant agencies. Mercy Hospital has followed the Ministry of Health s recommendation that hospital settings adapt the Family Violence Intervention Guidelines for the identification, assessment and referral of persons experiencing intimate partner violence. Definitions: Family/whanau violence covers a broad range of controlling and harmful behaviours commonly of a physical, sexual, and/or psychological nature which typically involve fear, intimidation and emotional deprivation. Violence includes spouse/partner violence, dating violence, child abuse and neglect, abuse of teenagers by parents, elder abuse and neglect, sibling abuse, and abuse committed by another family member or person with whom there is a close personal or domestic relationship. Routine Screening is the routine enquiry (written or verbal) by healthcare providers of patients about their personal history of partner abuse, child abuse or neglect. This means routine questioning of ALL individuals about abuse.. Risk assessment is a process allowing for a full examination of circumstances and interactions to begin to form an opinion about a person s risk of harm either to themselves or others. Safety planning and intervention is a process for identifying and planning to minimise harm and maximise safety Section 195A Section 195A - Failure to protect child or vulnerable adult. This section renders it an offence to fail to protect a child or vulnerable adult from risk of death, grievous bodily harm, or sexual assault. A person is liable if that person is a member of the same household or is a staff member of a hospital, institution, or residence where the child / vulnerable adult resides; and fails to take reasonable steps to protect the child or vulnerable adult from the actions / omissions of a third party.

of 12 Objectives: Clinical Staff are trained and supported in; Screening to identify at risk individuals. Risk assessments to identify, evaluate, monitor and document level of risk. Ensuring appropriate resources are accessed and available. Referral to appropriate personnel/agencies. Non clinical staff are trained and supported in; Understanding of family violence Awareness of family violence in there day to day interactions with patients Knowledge of procedure to follow to ensure appropriate referral to clinical staff. Implementation: Appropriate resources available in all ward areas. 1. Child abuse assessment and response flow chart ( Appendix1) 2. Partner abuse assessment and response flow chart ( Appendix 2) 3. Guidelines for identifying victims of abuse (Appendix 3, Steps 1-5) 4. Elder abuse and neglect guidelines - Ministry of Health document 2007 5. Elder abuse or neglect: assessment and response summary flowchart (in resource box) 6. Child and partner abuse guidelines - Ministry of Health document 2002 Senior Nursing staff undergo extended education programme to enable them to act as resource for staff. This includes completion of the online Intimate Partner Violence Screening Healthcare Worker programme. All Nursing staff undertake a programme that includes; 1. Theories and models of victimization 2. Why and how to screen for partner abuse and what to do if a patient discloses that he / she has been abused 3. The epidemiology of family violence and how it affects children 4. Child abuse principles and practice 5. Professional dangerousness responses that don t help 6. The role of community agencies, partner abuse, and child abuse and neglect. 7. Legislative requirements 8. Pre and post education questionnaires Nursing assessment of patients will include screening for violence as prompted in assessment documentation. Support staff education programme will include; Context and identification of abuse Acknowledging disclosure of abuse Referral to a clinical member of staff Knowledge of Mercy Hospital s staff support programme Evaluation of education programme

of 12 Access to relevant reading material/signage for patients/visitors in waiting areas and throughout the hospital. Evaluation All staff have received education and training appropriate to their role in the identification, assessment and management of family violence including partner and child abuse. Documentation shows that where appropriate identification, assessment and management have been carried out are evident in clinical notes. Working relationships are developed and maintained between referral agencies and Mercy Hospital Staff are aware of how to access Staff Support Programme. Planned regular updates of all staff, including access to the online Intimate partner violence training programme (scheduled on Mandatory Training and Update calendar) Resources: (Written resources in all clinical areas are held in the Family violence resource box) Ministry of Health Family Violence resources located at : http://www.health.govt.nz/our-work/preventative-health-wellness/family-violence Elder Abuse and Neglect- family violence intervention guidelines Ministry of Health 2007 Child and Intimate Partner Abuse Family violence intervention guidelines - Ministry of Health 2002 CD Dunedin Collaboration against Family Violence 2008 Access to on line education programme Intimate partner violence screening for healthcare workers accessed at -http://www.ednurse.org/certificationnz/index.htm Dunedin Violence Services Directory 2008 Hine Forsyth Mandated Runanga representative Associated Legislation: Care of Children Act 2004 Children, Young Persons and Their Families Act 1989 Domestic Violence Act 1995 Domestic Violence(Programmes) Regulations 1996 and Amendments 2002 Privacy Act (1993) Crimes Act ( 1961) Crimes Amendment Act (No.4) 2011 Crimes Amendment Act (No. 8) 2012

of 12 APPENDIX 3 GUIDELINES FOR IDENTIFYING VICTIMS OF ABUSE (STEP 1) When assessing for partner abuse, in most circumstances, it is best to use simple, direct questions, asked in a non-threatening manner. 1.1 Asking Adults About Possible Abuse Framing statements: Because violence is so common in many peoples lives, I routinely ask patients about it Many women I see as patients are dealing with family violence, therefore I ask all women this question. I notice I m worried statements, e.g. I notice you look sad/ have a bruise. I m worried someone might be hurting you/ have caused this. Validated partner violence screening questions: i. Have you been hit, kicked, punched, forced to have sex or otherwise hurt by someone within the past year? If so, by whom. A Yes response to this question is considered positive to partner abuse if the perpetrator was a current or former spouse or other intimate partner. ii. Do you feel safe in your current relationship? iii. Is there anyone making you feel unsafe now?

of 12 GUIDELINES TO SUPPORT AND EMPOWER VICTIMS OF ABUSE (STEP 2) 2.1 Identified Victims 2.1.1 Listen to the person s story Encourage them to go on. Example, Tell me about that. Acknowledge what they have told you, be empathetic, non judgemental and non-blaming. Example That must have been terrifying. You are a strong person to have survived that. 2.1.2 Validate You are not alone, others experience abuse in their homes too You are not to blame for abuse. You did nothing to deserve or provoke this, abuse is never justified. 2.1.3 Inform You have a right to feel safe, and live free of abuse I can provide some information, which may help/support you. Do not pressure the person to leave their situation. A person needs to feel well resourced and supported before they can leave safely. However with patient consent you can initiate a call to the Women s Refuge. The patient needs to talk to the refuge on their own behalf With patient consent a transfer to the Refuge can be facilitated at time of discharge Where the patient/staff believe there is a security risk, on site security personnel are accessed by contacting First Security 2.2 Suspected Victims 2.2.1 If partner abuse is suspected, but the individual does not acknowledge that it is a problem Provide opportunities for further contact while they are in hospitaland state that if abuse does become a concern, you are available to discuss it with them if they would like to. Provide them with a means of contacting appropriate support agencies, e.g. community resource card.

of 12 3.1 Danger Assessment GUIDELINES FOR RISK ASSESSMENT (STEP 3) Because of the associated risk of homicide in partner abuse an assessment of risk is necessary. However, there are no absolute indicators that can predict risk. Assessment of the following factors can assist in danger assessment, particularly if the woman is minimising or denying the extent of violence experienced. The greater the number of indicators, the greater the risk. Immediate Safety Risk Is the abuser present? Is the patient afraid of their partner? Is the patient afraid to go home? High Danger Risk Life threatening injuries, or severe/ life threatening assaults, e.g. choking, strangling, beatings Children, elders or disabled at risk A threat to kill or a threat with a weapon has been made The person has recently separated from the abusive partner, or is considering separation Physical violence has increased in severity (upward trend) Perpetrator s access to weapons, particularly firearms. Other factors to consider Is alcohol or substance abuse involved? Other factors that increase risk of chaotic/ irrational behaviour, e.g. uncontrolled mental illness. 3.2 Risk of Suicide or Self-Harm There is a strong association between victimisation from a partner and self-harm or suicide. Health care providers need to consider assessing possible suicide of identified victims. Signs associated with high risk of suicide include: Previous suicide attempts Stated intent to die/attempt to kill oneself A well developed concrete suicide plan, or access to a method to implement their plan Planning for suicide (for example, putting personal affairs in order) Other factors that are frequently associated with the risk of suicide or self-harm may themselves be symptoms of abuse. Factors include depression, extreme anxiety, agitation or enraged behaviour, excessive drug and/or alcohol use or abuse. Make direct inquires to assess if the abused person is thinking about committing suicide, or has attempted suicide in the past.

of 12 3.3 If Partner Abuse Is Identified, Assess the Children s Safety. Partner abuse and child abuse frequently occur together. If partner abuse is identified or suspected it is essential that an assessment of risk to children is conducted. For example you could ask, Are you ever worried about your children s safety? Are they ever hurt?

of 12 GUIDELINES FOR SAFETY INTERVENTION (STEP 4) 4.1 For A Small Percentage of the Women There May Be Immediate Safety Concerns Is the abuser here now? Is emergency assistance required? (e.g. Police, Women s Refuge) If safety is a concern, access an onsite security presence through First Security Does the abused person have a safe place to go to when leaving the consultation? We can facilitate Women s Refuge and support an early discharge if required in conjunction with the patient s Surgeon. Any decision regarding contacting the police should be made in consultation with the patient. This is to ensure their safety, as reporting the incident may enrage the perpetrator and increase the risk to the women. In the cases where reporting is a requirement e.g. Crimes Act 1961 inform the abused person of the requirement. On the rare occasion that the healthcare provider believes a person s life is in immediate danger, or has good reason to believe that the person is unable to extricate themselves from a high level of ongoing, life-threatening danger, the Police may be notified without patient permission. The Privacy Act 1993 is not breached if the health care provider has acted in good faith to protect the patient from serious harm. The Health Information Privacy Code 1994 is not breached when the disclosure of information is necessary to prevent or lessen a serious and imminent threat to: (i) (ii) Public health or public safety; or The life or health of the individual concerned or another individual For any serious events involving staff or patients/clients, including any events where the police are required to be notified, the Executive On-Call should be notified immediately if after hours. 4.2 The Senior Nurse On-Call with ongoing Safety Concerns If possible, suggest the patient/ client makes contact with a specialist partner abuse service, such as Women s Refuge, during the consultation. The patient will need to speak to them on the phone directly. Identify an ongoing support system, for example family/whanau, friend or community agency. Suggest the person considers legal options, e.g. Protection Orders. Provide a copy of appropriate community contacts and Women s Refuge Safety Plan. 4.3 For All Abused Patients Provide information on the likelihood of the abuse becoming more severe and more frequent without intervention. The impact on children of witnessing abuse may also be relevant.

of 12 Becoming safer is a process, not a single act. Unless there is a risk to a child or a clear and immediate risk to the adult victim, s/he has the right to choose a course of action. The role of the health professional is to support this decision. Supportive risk assessment and counselling can make it easier for that person to seek further assistance in the future when they are ready to act. 4.4 Raising Public Awareness Routine questioning may be facilitated by creating an enabling environment with appropriate posters and pamphlets in waiting and clinical areas. 4.5 Co-Occurrence of Child Abuse and Partner Abuse Joint safety planning and referral processes need to be implemented when both partner abuse and child abuse are identified. For the assessment and management of children who may be at risk of abuse refer to the Child Abuse Guidelines. The emphasis should be on keeping the child(ren) safe and enabling the abused partner to get real and appropriate help.

of 12 GUIDELINES FOR DOCUMENTATION OF FAMILY VIOLENCE (STEP 5) 5.1 Documentation Steps On an incident form with relevant patient label: 5.1.1 Note the stated or suspected cause of the injuries and when they allegedly occurred. Assaulted by partner is not sufficient. A vague history is readily challenged in court and therefore would not help keep a victim safe. Be specific, e.g. Miss X alleges she was hit with a closed fist/ kicked by John Smith. 5.1.2 Record history obtained. Specify aspects you saw and heard, and which were reported or suspected. Use the patient s words as much as possible. Use quotation marks for specific disclosures where appropriate, e.g. John punched me. 5.1.3 State the identified perpetrator s name and relationship to the patient 5.1.4 Mark site(s) of old and new injuries on a body injury map 5.1.5 Describe estimated age of injuries, coloration and measure size 5.1.6 For suspected cases of abuse, record your opinion as to whether the injury is consistent or inconsistent with the patient s explanation 5.1.7 Note the action taken by the clinician, referral information offered and follow-up arranged 5.1.8 Include the date, time, a legible signature and designation. 5.1.9 Incident form to be kept secured in a locked cupboard in the Director of Clinical Services office. 5.2 Collection of Physical Evidence In certain circumstances collection of evidence may be required for legal proceedings. Steps to take in the collection of evidence include: 5.2.1 Place torn or blood stained clothing and/or weapons in individual bags, which are sealed. 5.2.2 Mark bag with date, patients name and the name of the person who collected the items. 5.2.3 Keep the bag(s) in a locked place until they are turned over to the police or the patient s lawyer.