Conference PaperPDF Available

Over the barriers, onto the benefits: How practitioners changed their minds about universal risk screening

  • Relationships Australia SA


Content may be subject to copyright.
From the FRSA 2018 National Conference
FRSA 2018 Conference e-Journal, Edition 3 — November 2018
Be The Change:
Leaving no one behind
Providing Leadership, Linking Services, Supporting Relationships
T [02] 6162 1811
Peer-reviewed papers from the FRSA 2018 National Conference,
20–23 November 2018, Pullman Cairns International Hotel
Be the Change: Leaving no one behind.
The copyright for the papers in this e-Journal is retained by
the individual authors. Unauthorised use is not permitted.
Content was the responsibility of each author or group of
authors. Views expressed in this publication are those of
individual authors and may not reflect those of Family &
Relationship Services Australia (FRSA).
52 Peer reviewed papers from the FRSA 2018 National Conference Be the Change: Leaving no one behind
When people use family and relationships
services, they are often at risk and in need
of a response. For example, 70.9 per cent of
parents affected by physical violence used a family
relationships service before or during separation
such as counselling or Family Dispute Resolution
service (Table 4.3; Kaspiew, Carson, Dunstan,
De Maio, et al., 2015). Of those experiencing
family violence or safety concerns, 45.7 per
cent did not disclose the risk to their mediator
Many practitioners are reluctant to use universal risk screening tools in the family and
relationships services sector. This is despite evidence showing that the tools work
and surveys showing clients may not disclose even significant safety risks. Relationships
Australia Tasmania (RA Tas) planned to launch universal risk screening in 2017 knowing
many of its staff might be equally unconvinced. Therefore the RA Tas implementation
included significant support for staff to get over the barriers and onto the benefits, along
with independent evaluation of the multi-faceted implementation by Relationships
Australia South Australia (RASA). We report here on practitioner attitude shift after
launching universal risk screening. RASA asked RA Tas staff to complete an anonymous
‘Attitudes to screening’ survey nine months before and after launch of universal screening,
with RA Tas staff also giving anonymous qualitative feedback three months after launch.
Sample sizes were 53 (pre survey), 40 (qualitative feedback) and 31 (post survey) and were
all statistically equivalent on key demographics. As expected, before launch we foun d
that RA Tas staff were already broadly confident in their practice and that they indicated
many possible barriers to adopting screening tools. After launch, staff expressed much
greater confidence and knowledge in practice as a result of using the screening tools, and,
crucially, far fewer worries about clients’ reactions to screening and poor engagement.
Qualitative feedback confirmed some staff were invigorated by the implementation and
delighted in using ‘screening to engage’ rather than ‘screening to exclude’ clients. We
conclude that purposeful and supportive implementation has left no RA Tas staff member
behind; instead, they became more convinced, enthused and accepting of screening. We
recommend that other organisations implement universal risk screening with practitioner
attitude change in mind.
How practitioners changed their minds
about universal risk screening
Michael Kelly Jamie Lee Laurel Cuff
Relationships Australia Tas Relationships Australia SA Relationships Australia Tas
53 Peer reviewed papers from the FRSA 2018 National Conference Be the Change: Leaving no one behind
Enablers and barriers for screening
Practitioners give many reasons for why they don’t
ask or use structured screening tools. They often
prefer less structured or unstructured inquiry or
relied on a ‘sense’ something was a risk to trigger
inquiry about risk (Kaspiew, Carson, Coulson, et al.,
2015). Todahl, Linville, Chou and Maher-Cosenza
(2008) suggested this practice of ‘screening to
screen’ relies on the dubious belief that the signs of
domestic violence will be obvious to the practitioner.
This confidence in existing practice and knowledge
can be a barrier to change. A systematic review
into screening practice by Todahl and Walters
(2011) saw ambivalence about screening across
setting and studies, with significant barriers due
to practitioners worrying how screening will affect
their clients. Practitioners expressed many worries
about screening including: the risk of perpetrators
realising they are under scrutiny and then using
violence; or damaging the client-practitioner bond
if clients are offended by inquiry about violence
when it’s not an issue. Practitioners also worried
screening might undermine the task of the session
by confusing therapeutic engagement versus
forensic assessment; and screening would be
impractical in their setting because of time limits
on sessions.
Kaspiew, Carson, Coulson, et al. (2015) asked sector
and family law practitioners about screening and
assessments tools, focusing specifically on DOORS
(McIntosh & Ralfs, 2012). While some practitioners
were enthused by such tools, many also expressed
concerns about practicality, flexibility or fears of
client objections to ‘being screened’ (Kaspiew,
Carson, Coulson, et al., 2015). Practitioners also
believed in their ability to ‘sense’ violence based
on years of experience and training; in other words,
confidence in current practice was a barrier to formal
screening. These practitioner beliefs are significant
barriers to use of screening regardless of what
clients actually say about being screened—which
Todahl and Walters (2011) summarised as clients
being ‘mostly not bothered’. Consequently, these
kinds of attitudes should be evaluated before—and
monitored after—any implementation of evidence-
based screening.
What is clear is that organisational culture and
managerial support are key enablers to doing
screening. For example, Allen, Lehrner, Mattison,
Miles, and Russell (2007) conducted a review
of screening implementation in healthcare and
confirmed that practitioners will adopt screening
when they: ‘perceive their organization to be in
support of universal screening’ (p. 115), indicated
by formal policies, standardised procedures and
ongoing and visible support after implementation.
(Table 5.10; Kaspiew, Carson, Dunstan, De Maio, et
al., 2015). Those who chose not to disclose gave
many reasons for withholding this potentially crucial
information, including: ‘It wasn’t really happening
at the time’, ‘It wasn’t serious enough at the time’,
‘It was happening but I wasn’t worried about it’,
or ‘It wasn’t affecting the kids’ (Kaspiew, Carson,
Dunstan, De Maio, et al., 2015). Parents weren’t
actively hiding the risks but instead ‘discounting’ by
dismissing their needs and lowering expectations
from practitioners (Flandreau-West, 1989). Other
studies confirm that parents may under-report
harmful and even potentially lethal dangers unless
practitioners proactively ask about risk (Ballard,
Holtzworth-Munroe, Applegate & Beck, 2011; Rossi
et al., 2015). In the view of Cleak and Bickerdike
(2016), ‘simply being asked would have led to
disclosure [of risks]’ (p. 18).
Some professional bodies have advised practitioners
to ask formally about risks or called for a review of
practices (Association of Family and Conciliation
Courts, 2016; Toumbourou et al., 2017). The 2012
Family Law Act amendments also emphasised
practitioners asking about risks and encouraging clients
to disclose them and not dismiss them (Kaspiew,
Carson, Dunstan, Qu, et al., 2015). Indeed, surveys
of Australian non-legal practitioners and lawyers found
that they overwhelmingly and consistently asked
about key risks like family violence or child abuse—or
at least they said they did (Kaspiew, Carson, Coulson,
Dunstan & Moore, 2015). When probed, though,
practitioners were inconsistent about tools used or
how they asked about risk, with most relying on their
senses to spot when to ask about risk—despite poor
evidence for this method—and few were using a
validated tool like the Detection of Overall Risk Screen
(DOORS; McIntosh & Ralfs, 2012; Wells, Lee, Li, Tan,
& McIntosh, 2018). Similarly, less than a half of US
relationships practitioners routinely used structured
screening tools and even fewer followed best practice
like individual screening of couples (Schacht, Dimidjian,
George & Berns, 2009; Todahl & Walters, 2011; Tower,
2006). Finally, a recent Family & Relationships Services
Australia (FRSA) survey found some practitioners
were clearly confused by screening or assessment
practices, with some saying they used ‘DSS SCORE’
and ‘Penelope’ as tools for assessing risk when these
are an outcomes assessment platform and a client
information system respectively (A. Heaton, personal
communication, August 15, 2018).
In summary, clients using our services face
significant risks and should be screened for
them. Peak bodies recommend this happen and
practitioners say they are doing this. Despite a clear
imperative, good practice in screening is variable
and can be poor.
54 Peer reviewed papers from the FRSA 2018 National Conference Be the Change: Leaving no one behind
The RA Tas reasons for change
RA Tas strives to be client-centred across all
operations; the implementation of universal
screening has been identified as a key step to
ensuring that client safety and wellbeing is assessed
in a consistent and effective way. Universal
screening is a thorough and robust assessment
tool that allows the practitioner to determine the
possible range of risks to which a client may be
exposed, and therefore assess safety concerns.
It can open the conversation around serious and
complex situations involving suicide, safety,
parenting and child wellbeing. That then allows for
a sophisticated, holistic support response to be
activated around that client.
It is widely established that one of the most important
elements for the successful implementation of
organisational change is a compelling reason to
move from the current, established practice to
the one which is desired. In the provision of family
and relationship services there is not a reason that
is more compelling than to ensure the safety of
clients accessing our services. There is a range
of reasons that prompted the implementation of
universal screening at RA Tas that are set out in the
following paragraphs.
The results of RASA’s use of universal screening
since 2013, have confirmed international research
demonstrating that clients disclose more information
about safety concerns when asked directly (Ballard
et al., 2011; Rossi et al., 2015). The demonstrated
effectiveness of this tool at RASA made the
incorporation of the tool into RA Tas’ process a priority.
We were able to look at years’ worth of evidence
showing not only that a structured screening tool
was the most effective way to identify and assess
family safety risks, but also that RASA clients saw the
forms as ‘beneficial’ and, in many cases, preferable
to disclosing directly to the practitioner in the first
instance (Lee & Ralfs, 2015, 2016).
Screening for risk is a shared responsibility; we
wanted staff to be able to go home at the end of
the day knowing they had done what was needed
in terms of identifying and responding to risk.
Universal screening provides a way to move risk
identification, assessment and response from the
individual to the organisation through elevation and
sign off. This enables the organisation to better
support the work of practitioners in the area of risk.
Getting over the barriers at RA Tas
Whilst practitioners are highly qualified and skilled
at identifying, assessing and responding to risk,
there is the potential, when one risk is identified,
for this to become the predominate focus. In many
instances, there may be a number of risks that could
go unidentified until subsequent sessions. The use
of universal screening presents an opportunity to
capture the overall range of risks to which a client
may be exposed, and then allows for elaboration and
prioritisation of risks and response. Eliciting the full
range of possible safety concerns on paper at the
initiation of service delivery also provides the RA Tas
with empirical evidence of the increasing complexity
of cases being presented; an issue often limited to
practitioners’ anecdotal reports. Further, universal
screening forms a baseline from which to establish
whether risks are diminishing or escalating, and this
can be used in future service delivery responses
and safety planning; with individual clients and at
a program level.
Some of the barriers that emerged to implementation
of universal screening were specific to the RA Tas
context. For example, due to limitations in privacy
and physical space in the reception area of our main
service delivery site at Clare St, New Town, a full
refurbishment of that space had to be undertaken.
It was vital to ensure clients had sufficient space in
the waiting room to be able to engage comfortably
with the screening tool.
The timing of screening also presented a challenge;
clients are required to arrive at the service site 30
minutes prior to their first appointment, with some
needing all of this time and others only requiring
a few minutes to complete the screening survey.
A possible solution to this issue being trialled is
for clients to receive the screening tool via email
a number of days before their appointment and
return it before attending. In this situation however,
responding to serious risks disclosed in screening
would become problematic, as the client may be
several days away from actually engaging with the
service, and in some cases may even cancel or miss
their first appointment. This raises significant issues
regarding duty of care and the ability of the service
to respond to safety concerns in a timely manner.
Another issue faced at RA Tas was possible resistance
from practitioners to the use of screening. This largely
centred around the perception that their professional
autonomy and judgement were being undermined;
the risks covered in universal screening were already
being addressed by practitioners as a matter of course.
However, significant attitude change became apparent
after implementation of the changes.
55 Peer reviewed papers from the FRSA 2018 National Conference Be the Change: Leaving no one behind
Leading through change
The senior management team at RA Tas were
highly supportive of the implementation of universal
screening. It was identified that a clear and consistent
communication and implementation plan would be
instrumental in gaining staff support and effective
use of the tool. To assist in this a project leadership
team was established consisting of staff from across
the organisation including senior practitioners,
coordinators, senior workers and managers. This team
acted as critical decision-makers and champions for
change, but also greatly assisted managers in ensuring
staff readiness for the introduction of universal
screening. They consulted widely with staff and
provided recommendations to senior management
on all aspects of implementation.
Three working groups were created from within the
project leadership team; training and communications,
policy and procedures, and implementation. Terms of
reference were agreed for each group, including the
leadership team itself, to ensure focus and a clear
purpose. A project support role was also funded
to progress actions from the working groups and
provide regular communication to staff.
In terms of practitioner support and supervision, a
range of measures were put in place to assist their
preparation for, and operation of, universal screening.
Following the initial training provided by RASA,
simulations were held at Clare St, in which other staff
members acted as clients; being given appointment
times, completing the survey and then elaborating on
their responses with a practitioner. Subsequently, the
whole process was piloted to allow for refinements.
The implementation team consulted with practitioners
regularly during the pilot and early implementation
phase to anticipate, identify and work through issues,
and as will be outlined later, practitioners were also
surveyed on their attitudes to the screening process.
The optimisation of universal screening at RA Tas
is an ongoing process. While screening surveys
were initially administered on paper, a later iteration
involved the introduction of an app; and the screening
tool is now fully digital allowing clients to easily
enter their responses on dedicated tablets. This
streamlines the process of data entry and creates a
much easier client experience.
Formative evaluation to support
In July 2016, RA Tas formally invited RASA to
support its evaluation of the implementation of
universal screening. Because the implementation
was agency-wide and covered significant changes
in practice, the evaluation had three wide-reaching
components. These were: staff change in client
safety practices; staff attitudes to universal
screening and risk assessment; and client attitudes
to screening (see Table 1).
Additionally, there was a ‘failsafe’ option for
evaluating the implementation, namely to audit
existing information sources (such as paper file
reviews or analysis of client information systems)
to explore change. However, this option was not
needed because the other components were
successfully evaluated, as shown in Table 2.
This report focuses on the practitioner attitude
change after the launch of universal screening at RA
Tas. However there are several important findings
about the setting and the immediate impact on
practice which are summarised here. Briefly, RA
Tas staff already see complexity and risk in everyday
practice, shown by the Practitioner Safety Log
confirming significant risks in at least 2.2 of every
10 sessions due to FDV, child harms, serious mental
health and/or suicide (Kelly, French & Lee, 2017). The
Log also showed that risks typically were identified in
RA Tas first when clients named them unprompted,
then when practitioners spotted them, finally when
a tool identified it. The relative ratio of these formats
was roughly 3:2:1 (for clients:practitioners:tools
respectively). This confirmed the opportunity to
rethink when and how risks are detected in RA Tas.
Table 1. Implementation evaluation components
Evaluation component Intention of evaluation Indicator
Primary outcome: change in
identification and response
to family safety risks (staff
Show effect of screening on
detection of risks
Log of practitioner safety
responses before and after
Secondary outcome: change
in practitioner attitudes to
screening (staff attitudes)
Identify possible barriers to
use of screening and what
overcomes them
Practitioner attitude survey
before and after review with
post-launch qualitative review
Secondary outcome: change
in client experience of service
quality (client attitudes)
Explore acceptability of screening
as a practice for clients
Client attitudes survey after
‘being screened’
56 Peer reviewed papers from the FRSA 2018 National Conference Be the Change: Leaving no one behind
In the initial (pre) attitudes survey, 53 RA Tas staff
responded to the anonymous Survey Monkey
link hosted by RASA but promoted by RA Tas
management. Seventy-seven per cent were female
and the modal age (43%) was 36–47 years. The main
professional background (52%) was social work with
55% having post-graduate qualifications. There was
a bimodal response on experience in role, with 31%
having both less than two years and 5–10 years of
experience. RA Tas staff were asked a series of
questions about factors that could potentially act as
barriers to the use of screening, from both informal
feedback and in published literature (Kaspiew, Carson,
Coulson, et al., 2015; Todahl et al., 2008; Todahl &
Walters, 2011). The survey is shown in Appendix 1.
The key results were that many practitioners (around
half) were very comfortable in their risk practices
after years of experience; and some further worried
about client reactions to universal screening tools
and extra administrative hassles. This group was
clearly unsure about the ‘why’ of the launch. Finally,
a small group—about a quarter of staff—couldn’t
see screening adding any value or simply would
not work for clients, based on their attitudes to
universal screening. This group would need strong
evidence that it did not harm client engagement
or interfere with their practice. These beliefs were
similar to those described in the literature above
and may have presented significant barriers if
practitioners were able to refuse to adopt universal
screening in their practice at RA Tas. However, RA
Tas’ management and executive had formed the
view that universal screening was critical to family
safety and therefore must be rolled out throughout
the agency. Consequently, these pre-survey findings
gave insights for supporting staff through the change.
Part of the post-launch evaluation strategy was to
monitor any difficulties staff were experiencing
with using screening—again with an intention of
formative evaluation rather than leaving staff to
work it through themselves.
Table 2. Evaluation studies, timings and samples
Pre-launch Post-launch
(Evaluation 1)
(Evaluation 2)
Staff practices Post-launch time 1 Nov 17: Interim qualitative
staff feedback on launch
(n = 40 staff)
Jan–Feb 18: Safety log
(n = 266 sessions)
Staff attitudes Post-launch time 2
Jan–Feb 18: Staff attitudes
to screening survey
(n = 32 staff)
Client attitudes
May 17: Client attitudes
(n = c. 375)
Nov 17: Client attitudes
(n = c. 375)
Therefore, staff were given opportunity to provide
anonymous qualitative comments on both
positives and negatives about ‘doing DOORS’.
This opportunity was taken by 38 staff who wrote
4,270 words in response to five short questions.
This is reported more fully elsewhere (Kelly et al.,
2017) therefore a brief summary of key themes is
provided here.
‘It’s just procedure’: for better or for worse, most
staff were surprised by how clients ‘just get on
with it’ when given a universal screening form—
despite the deeply personal and sensitive questions
that are asked. A few staff were surprised at how
quickly universal screening had been integrated into
practice and showed surprise at how useful it was.
‘Provides efficiency and a quick heads up’:
Many staff thought screening was helping them
focus in on key client issues more quickly, though
a few maintained they’d have identified the risks
eventually anyway. A few staff said it also gave
permission to follow up about difficult areas that
might otherwise be hard to inquire (such as firearms
‘Creates engagement, mostly’: A couple of staff
thought the questions helped orient their clients
towards key issues and signalled to clients that it’s
ok to raise issues with practitioners with confidence.
However, the issue of clients’ engagement (or lack
of it) with universal screening remained problematic
for a few staff.
‘It ain’t relevant for all clients’: When asked about
times universal screening made things harder,
‘relevance’ was one significant issue for many
staff who still worried (understandably) about their
client’s experience of ‘being screened’, especially
for clients who are low or negligible risk.
‘Practicalities annoy me and/or my clients’: A
few staff described issues with the ‘nuts and bolts’
of doing universal screening at a practical level such
as scheduling of times and handling of paperwork.
57 Peer reviewed papers from the FRSA 2018 National Conference Be the Change: Leaving no one behind
Again, as intended by the formative nature of this
evaluation, many of the ‘niggles’ were explored
and worked through by providing further support
for RA Tas staff before the summative evaluation
component of post-practitioner attitudes.
Summative evaluation of
For the summative evaluation of attitude change, RA
Tas practitioners were invited again to anonymously
complete the ‘Attitudes to screening’ survey
prepared and collected by RASA and shared via
RA Tas management and executive. Post surveys
were completed by 58.5 per cent of participants
those who completed the pre survey. Because
the majority of participants were anonymous,
it was not possible to check formally who was
in the repeat sample and who had dropped out,
or which surveys to link. Nevertheless, it was
possible to compare demographics between the
two samples, as in Table 3.
Any differences in demographics were not statistically
significant (p > 0.05) meaning that comparison is
robust without paired observations. Attitude change
was evaluated using independent t -tests for each
question with effect sizes identified by Cohen’s d. The
full findings are shown in Appendix 2 and summarised
in Table 4.
Table 4 shows that on average, the RA Tas
implementation of DOORS lead to meaningful change
on 13 of the 18 attitude items. The largest effects of
launching screening were found in increased practitioner
knowledge of screening and risk assessment (60.4%
agree before vs 96.8% agree after launch); routine
practice of screening (56.6% vs 93.5%); and self-belief
in doing best practice (50.0% vs 73.3%). The launch
also had a large effect on decreasing practitioner worries
about clients’ reactions to ‘being screened’ (32.2% vs
6.4%) and that clients would prefer disclosing risks to
a practitioner and not on a screening form (71.1% vs
20.0%). Practitioners did not become any more (or less)
worried about the practicalities of screening after launch
such as length of intake (40.4% vs 50.0%), hassle for
clients (39.7% vs 42.0%) or files being subpoena’d
(9.4% vs 12.9%).
Table 3. Comparison of pre and post attitude samples
Modal response for: Before launch:
pre-attitudes survey (n=53)
After launch:
post-attitudes survey (n=31)
Gender 77% female 77% female
Age 43% 36–47 yrs 54% 36–47 yrs
Main background 52% social work 46% social work
Experience in role
31% < 2 years 28% < 2 years
31% 5–10 years 24% 2–4 years
24% 5–10 years
Highest qualification 55% post-graduate 65% post-graduate
Table 4. The effects of doing screening on practitioner attitude (summary table)
Effect on ‘Attitudes
to Screening’ Item (effect size)
Practitioners agree
less after launch
Client prefer face-to-face not forms’ (large), ‘Clients object to universal
screening’ (large), ‘Agency unable respond to cope with new risks from
universal screening’ (medium), ‘Clients won’t reveal DV on forms’ (medium),
‘Clients won’t reveal parenting risks’ (small), ‘Screening interferes with
rapport’ (small), ‘More files will be subpoena’d’ (small), ‘Prefer practice
wisdom only, not do screening’ (small)
No effect of launch
on attitudes
Partners/couples will contradict’, ‘Intake much longer’, ‘Clients will tell us
anyway if risk is significant’, ‘Extra hassle for clients’, ‘Reassured did my bit
for client safety’
Practitioners agree
more after launch
Confident know difference between screening and risk assmt’ (large),
‘Current screen all clients’ (large), ‘Currently doing best screening practice
for DV and child risks’ (medium), ‘Launching screening will/has helped
me identify risks’ (small), ‘On balance, screening will probably help me (or
probably has helped me)’ (small)
Note: Effect sizes are Cohen’s d with cut offs at 0.2 (small), 0.5 (medium) and 0.8 (large)
58 Peer reviewed papers from the FRSA 2018 National Conference Be the Change: Leaving no one behind
Discussion of attitude change
Practitioners at RA Tas changed their minds about
screening in similar ways to those reported in the
literature where a purposeful management team led
change to overcome the barriers. Despite staff already
feeling confident in their practice, implementation
has further increased this confidence as has been
seen in other settings (Lee & Ralfs, 2017). Also, the
experience for staff of seeing clients ‘be screened’
proves to staff how clients engage wholeheartedly
with screening and again fits with client surveys
elsewhere (Lee & Ralfs, 2015; 2016). Nevertheless,
a small number of staff remained worried about the
‘hassle’ and subpoenas being issued, yet became
less worried by ‘floodgates’ of risks that cannot be
managed. Many RA Tas staff anticipated intake would
be longer for clients after launch as the new procedure
required clients to attend 30 minutes earlier for
appointments (with no change in practitioner time).
Clearly the balance between effectively checking
client safety and ‘moving through the case load’
remains on practitioners’ minds, though the question
of ‘How much time do we allow for safety?’ would be
a tricky question to answer definitely. Furthermore,
the launch appeared to have no clear negative effect
on practitioners’ approach to clients or micro-skills
and no change in their views on the effectiveness
of screening. Maybe practitioners overall are slowly
building faith in the practice.
The limitations of the evaluations include the
independent samples design of the pre and post
launch analyses. RASA invited RA Tas staff to
provide sufficient identifying details to link pre-
post responses but not enough for the external
RASA staff to be able to re-identify anyone (similar
to the Statistical Linkage Linkage Key or ‘SLK’
that links clients using DSS services without easy
re-identification). However, the method used of
getting driver’s licence details was ineffective and
not enough RA Tas staff provided details, hence the
design had less power as independent samples.
Though sample demographics were broadly the
same (see Table 3), nearly 4 in 10 of the pre group
did not reply to the survey, which may be a source
of random error or bias. Again a paired samples
design would have helped identify any possible bias
from selective attrition. Finally, another limitation
on having a ‘clean’ pre-post design may have
come from using anonymous formative qualitative
feedback from RA Tas soon after the launch to fine
tune practice (Kelly et al., 2017) and then later on
doing the quantitative post-survey. This was seen
as acceptable given the primary focus of evaluation
was always intended as supporting RA Tas staff
to achieve change rather than how good was the
implementation or training.
Conclusion: Making a difference to
staff and clients
The implementation of universal screening at
RA Tas has resulted in a significant attitude shift
for many staff. Overall, staff have become more
confident in their own knowledge and practice
and in the ability of its services to respond to risks
identified in screening. Staff have become less
worried about client reactions and began to see
the effectiveness of universal screening. Staff have
recognised that universal screening has resulted in
more administration and this remains unchanged,
suggesting staff may need more support and
reassurance that the extra client time for screening
is worth it, and firm guidance around discoverability
of client self-report work.
The implementation of universal screening—namely
routinely asking all clients about risks—is important
given widespread practitioner confidence in their own
risk screening practice, ‘close to 30% of parents ...
reported having never been asked about [family
violence and safety concerns]’ (Kaspiew, Carson,
Coulson, et al., 2015, p. xviii). It’s also important from
a client acceptability angle when done respectfully
and purposefully (Todahl & Walters, 2011). One
forceful conclusion, repeated several times by
Kaspiew, Carson, Dunstan, De Maio, et al. (2015),
is that ‘implementation of consistent screening
approaches has some way to go’ (pp. xix, 133, 189).
This study shows that purposeful leadership and
supportive practice management go a long way in
implementing a consistent screening approach.
So what? Recommendations for other
agencies to consider
It is clearly the case that universal screening places
additional requirements on clients. However, RA Tas
intends to provide the safest possible service for its
clients, and as such, the screening can be seen as
a relatively small imposition with a short, one-off
time requirement, which results in highly valuable
outcomes. It is therefore vital that this process is
communicated effectively to clients to manage
expectations and ensure that they have the best
possible experience when accessing our services.
The implementation of universal screening has
allowed us to compile quite a comprehensive list
of recommendations for consideration of other
agencies looking to adopt the process:
¡Establish an authentic case for change and
clearly communicate the ‘why’, ensuring buy-
in from practitioners and setting the context for
universal screening right from the beginning.
59 Peer reviewed papers from the FRSA 2018 National Conference Be the Change: Leaving no one behind
¡Involve key people early in the project, for example
senior practitioners, coordinators and managers.
¡Have a project leader to drive implementation
and be accountable for the outcome.
¡Invest in a project support role with a clear purpose.
¡Establish working parties, also with a clear
purpose and defined terms of reference.
¡Ensure working parties have genuine input and
engagement, not just consultation.
¡Develop a project timeline with agreed and
shared milestones, including a ‘go-live’ date, and
adhere to this timeline, where practicable.
¡Ensure managers form the project management
group to progress decisions.
¡Identification of the level at which decisions are
made is important; matters requiring decision can
be elevated where required.
¡Provide a clear pathway for questions and ensure
answers are provided in a timely manner, and
¡Share decisions widely, with no ‘secret’ agenda.
¡Communicate to staff regularly and provide
opportunity for feedback (within team meetings),
but a project email address can also be set up.
¡Identify communication for different audiences,
for example the project leadership team,
management and general staff.
¡Invest in training; whole of staff, team, and
¡Produce program documentation such as
policies, procedures, a program manual and a
code of conduct.
¡Plan for compliance of staff, for example file
audits for DOORS elaboration.
¡Celebrate successes and milestones with teams.
Finally, the overarching message is to communicate
authentically and often, during all stages of
The authors are grateful for the comments and
suggestions from two anonymous peer reviewers
coordinated through FRSA.
Allen, N. E., Lehrner, A., Mattison, E., Miles, T., & Russell,
A. (2007). Promoting systems change in the health care
response to domestic violence. Journal of Community
Psychology, 35(1), 103–120. doi:10.1002/jcop.20137
Association of Family and Conciliation Courts. (2016). Guidelines
for examining intimate partner violence: A supplement to the
AFCC Model Standards of Practice for Child Custody Evaluation.
Madison, WI: AFCC.
Ballard, R. H., Holtzworth-Munroe, A., Applegate, A. G., & Beck,
C. J. A. (2011). Detecting intimate partner violence in family
and divorce mediation: A Randomized Trial of Intimate Partner
Violence Screening. Psychology, Public Policy, and Law, 17(2),
241–263. doi:10.1037/a0022616
Cleak, H., & Bickerdike, A. (2016). One way or many ways:
Screening for family violence in family mediation. Family
Matters, 98, 16–25.
Flandreau-West, P. (1989). The basic essentials: Protective
behaviours anti-victimisation and empowerment processes.
Burnside, South Australia: Essence Publications.
Kaspiew, R., Carson, R., Coulson, M., Dunstan, J., & Moore,
S. (2015). Responding to family violence: A survey of family
law practices and experiences (Evaluation of the 2012 Family
Violence Amendments). Melbourne, Australia: Australian
Institute of Family Studies.
Kaspiew, R., Carson, R., Dunstan, J., De Maio, J., Moore, S.,
Moloney, L., . . . Tayton, S. (2015). Experiences of separated
parents study. Melbourne, Australia: Australian Institute of
Family Studies.
Kaspiew, R., Carson, R., Dunstan, J., Qu, L., Horsfall, B., De
Maio, J., . . . Tayton, S. (2015). Evaluation of the 2012 family
violence amendments: Synthesis report. Melbourne, Australia:
Australian Institute of Family Studies.
Kelly, M., French, A., & Lee, J. (2017, November). Universal
screening: the reasons why ... Paper presented at the 2017
Conference of Family and Relationships Services Australia,
Melbourne, Australia.
Lee, J., & Ralfs, C. (2015, December). Truthful, beneficial and
respectful: A survey of client attitudes to universal screening for
safety risks in families. Poster presented at the Inaugural Stop
Domestic Violence, Canberra, Australia.
Lee, J., & Ralfs, C. (2016, February). If you ask, clients will
tell you: The case for universal and holistic screening in family
relationships services. Poster presented at the Inaugural
National Research Conference on Violence against Women
and their Children, Melbourne, Canberra, Australia.
Lee, J., & Ralfs, C. (2017, June). Getting beyond ‘Don’t ask,
don’t tell, won’t know’—the implementation of universal
screening after parental separation to prevent harm to children
and families. Paper presented at the 7th World Congress on
Family Law and Children’s Rights, Dublin, Republic of Ireland.
McIntosh, J. E., & Ralfs, C. (2012). The DOORS Detection of
Overall Risk Screen Framework. Canberra, Australia: Australian
Government Attorney-General’s Department.
Rossi, F. S., Holtzworth-Munroe, A., Applegate, A. G., Beck,
C. J., Adams, J. M., & Hale, D. F. (2015). Detection of intimate
partner violence and recommendation for joint family mediation:
A randomized controlled trial of two screening measures.
Psychology, Public Policy, and Law, 21(3), 239–251. doi:10.1037/
Schacht, R. L., Dimidjian, S., George, W. H., & Berns, S. B.
(2009). Domestic violence assessment procedures among
couple therapists. Journal of Marital and Family Therapy, 35(1),
47–59. doi:10.1111/j.1752-0606.2008.00095.x
Todahl, J. L., Linville, D., Chou, L. Y., & Maher-Cosenza, P.
(2008). A qualitative study of intimate partner violence universal
screening by family therapy interns: Implications for practice,
research, training, and supervision. Journal of Marital and Family
Therapy, 34(1), 28–43. doi:10.1111/j.1752-0606.2008.00051.x
60 Peer reviewed papers from the FRSA 2018 National Conference Be the Change: Leaving no one behind
Todahl, J. L., & Walters, E. (2011). Universal Screening for
Intimate Partner Violence: A Systematic Review. Journal of
Marital and Family Therapy, 37(3), 35–369. doi:10.1111/j.1752-
Toumbourou, J., Hartman, D., Field, K., Jeffery, R., Brady, J.,
Heaton, A., . . . Heerde, J. (2017). Strengthening prevention
and early intervention services for families into the future.
Melbourne, Australia: Deakin University and Family and
Relationship Services Australia.
Tower, L. E. (2006). Barriers in screening women for domestic
violence: A survey of social workers, family practitioners, and
obstetrician–gynecologists. Journal of Family Violence, 21(4),
245–257. doi:10.1007/s10896-006-9024-4
Wells, Y., Lee, J., Li, X., Tan, E. S., & McIntosh, J. E. (2018).
Re-examination of the Family Law Detection of Overall
Risk Screen (FL-DOORS): Establishing fitness for purpose.
Psychological Assessment, 30(8), 1121-1126. doi:10.1037/
Appendix 1. Attitudes to Universal Screening Survey
Item Response range
Q1. When I do universal screening, I (will) feel
reassured that ‘I did my bit’ for family safety.
Disagree Disagree Not Sure Agree Strongly
Q2. If I’m honest, I’d prefer to rely on my
practitioner wisdom about risks and not do
universal screening.
Disagree Disagree Not Sure Agree Strongly
Q3. Universal screening means (will mean) extra hassle
for clients.
Disagree Disagree Not Sure Agree Strongly
Q4. I’m worried clients (will) object to ‘doing’
universal screening.
Disagree Disagree Not Sure Agree Strongly
Q5. Clients don’t (won’t) reveal things like using
violence in relationships (or DV perpetration risk) on
universal screening forms.
Disagree Disagree Not Sure Agree Strongly
Q6. I think files are more likely to be subpoena’d since
we launched (after we launch) universal screening.
Disagree Disagree Not Sure Agree Strongly
Q7. I’m confident I know the difference between
screening and risk assessment.
Disagree Disagree Not Sure Agree Strongly
Q8. Overall, I think that if a risk is significant enough
then clients will generally tell us anyway without
the need for a universal screening form.
Disagree Disagree Not Sure Agree Strongly
Q9. Couples or parents probably (will) contradict each
other’s answers on their universal screening forms.
Disagree Disagree Not Sure Agree Strongly
Q10. I currently screen all clients for risks. Strongly
Disagree Disagree Not Sure Agree Strongly
Q11. Universal screening probably interferes (will
probably interfere) with me building a relationship
with my clients.
Disagree Disagree Not Sure Agree Strongly
Q12. I believe launching universal screening helps (will
help) me identify risks in clients and their families.
Disagree Disagree Not Sure Agree Strongly
Q13. I believe I’m now (currently) doing best practice in
screening for DV and child safety risk.
Disagree Disagree Not Sure Agree Strongly
Q14. Intake is much longer for me now (will be much
longer for me after) universal screening has been
Disagree Disagree Not Sure Agree Strongly
Q15. I don't really expect clients are revealing (will
reveal) things like parenting stress or other risks
they present to children via universal screening
Disagree Disagree Not Sure Agree Strongly
Q16. I believe clients generally prefer to disclose
sensitive information to a practitioner face-to-face,
not via a paper-based universal screening form.
Disagree Disagree Not Sure Agree Strongly
Q17. On balance, I think universal screening has
probably helped (will probably help) me in
my work.
Disagree Disagree Not Sure Agree Strongly
Q18. It concerns me that when (if) clients do reveal
any new risks with universal screening then we
can't respond as an agency.
Disagree Disagree Not Sure Agree Strongly
Note: wording for pre-attitude is in parentheses where it is different
61 Peer reviewed papers from the FRSA 2018 National Conference Be the Change: Leaving no one behind
Appendix 2. Detailed results of practitioner attitude change
Item Mean before
launch (sd)
Mean after
launch (sd)
size label
Confidence in practice
‘Confident know difference between screening
and risk assessment’ 3.64 (.83) 4.45 (.57) 1.13 Large
‘Currently screen all clients’ 3.36 (1.15) 4.35 (.61) 1.09 Large
‘Currently doing best screening practice for DV
and child risks’ 3.33 (.92) 3.83 (.91) .55 Medium
‘Prefer practice wisdom only, not do screening’ 2.49 (1.03) 2.23 (1.15) .24 Small
‘Reassured did my bit for client safety’ 3.40 (.95) 3.58 (.96) .19 -
Worries about clients
‘Client prefer face-to-face not forms’ 3.73 (1.01) 2.70 (.95) 1.05 Large
‘Clients object to universal screening’ 2.85 (.97) 2.10 (.87) .82 Large
‘Extra hassle for clients’ 3.02 (1.03) 2.84 (1.24) .16 -
Worries about service management
‘Agency unable respond to cope with new risks
from universal screening’ 2.87 (.86) 2.27 (.83) .71 Medium
‘More files will be subpoena’d’ 2.62 (.84) 2.32 (1.01) .32 Small
‘Intake much longer’ 3.27 (.91) 3.33 (1.06) .06 -
Loss of engagement and micro skills
‘Screening interferes with rapport’ 2.49 (.87) 2.16 (.93) .36 Small
‘Clients will tell us anyway if risk is significant’ 2.75 (1.12) 2.61 (.95) .14 -
‘Partners/couples will contradict’ 3.57 (.77) 3.52 (.96) .06 -
The effectiveness of screening
‘Clients won’t reveal DV on forms’ 3.19 (1.06) 2.55 (.99) .62 Medium
‘Clients won’t reveal parenting risks’ 3.04 (.84) 2.67 (.80) .45 Small
‘Launching screening will/has helped me identify risks’ 3.75 (.76) 4.03 (.95) .32 Small
‘On balance, screening will probably help me
(or probably has helped me)’ 3.6 (.82) 3.77 (.86) .20 Small
Note: Means are a scale from 1 to 5 (‘Strongly disagree’ to ‘Strongly agree’)
... Addressing the two needsnamely, enabling a common risk language and screening for a broad range of risksmeant that Family DOORS could provide an important foundation for improved service sector coordination. Relationships Australia Tasmaniaa sister agency to RASAalso employs Family DOORS across its range of services (Kelly, Lee, & Cuff, 2018;Kelly, French, & Lee, 2017). The Children's Welfare Foundation Sweden has used Family Law DOORS to enable multidisciplinary collaboration between family law, health, and child welfare social workers (Eriksson & Gabrielsson, 2019). ...
... On the contrary, we have often received appreciation from our clients for being so thorough about risk screening, particularly for bringing an explicit focus to the safety and wellbeing of their children. Crucially, after implementation of Family DOORS, staff at Relationships Australia Tasmania reported less reluctance to use Family DOORS, fewer worries about their client reactions to screening, and greater confidence in the effectiveness of universal risk screening compared to before implementation (Kelly et al., 2018). These changes in practitioner attitudes suggest that using Family DOORS, in combination with organizational systems that support shared responsibility, has created confidence among practitioners to detect risk. ...
Separation is a high‐risk time in families and for many it marks the onset or escalation of family safety and wellbeing risks like Intimate Partner Violence (IPV). Best practice for identifying such risks in court or community mediation services is systematic inquiry about safety risks with structured tools to overcome under‐reporting of risks. However, turning best practice recommendations into routine practice can take years – even when the evidence is strong that practitioners and their clients will ultimately benefit. Relationships Australia South Australia has addressed this evidence‐practice gap by engaging our leadership and undertaking whole‐of‐organization implementation of the Family DOORS framework. This includes the validated screening tool DOOR 1, that helps practitioners identify and respond to family‐wide risks during peak stress such as separation. In this article, we review our 10‐year implementation journey towards best practice in risk screening, reporting on 28,097 screens completed with clients to date. We describe the initiatives used to address practitioner and infrastructure barriers to implementation. We present both quantitative and qualitative indicators of practitioner change along with client survey data ( n = 1,291), demonstrating changes in practices that have enhanced client engagement and led to an increase in client safety and wellbeing outcomes. We share recommendations for and innovations in translation to other service contexts. We hope that using the following recommendations and adopting the DOORS tools will encourage and enable others to implement best practice risk screening in far less than 10 years.
... Several presentations and publications have described organisational, practitioner and client experiences of 'doing DOORS' at Relationships Australia Tasmania and RASA (Kelly, French & Lee, 2017;Kelly & Lee, 2018;Lee & Ralfs, 2015;, with numbers of DOORS completed across the world now reaching over 30,000. However, published analyses of clients' responses have so far focused on large samples of family law clients (McIntosh, Wells & Lee, 2016;Wells, Lee, Li, Tan & McIntosh, 2018). ...
... Given 'risks run in herds', it's likely that there are many other co-occurring risks in addition to these. Anonymous feedback from relationship counsellors at Relationships Australia Tasmania has showed that learning about these risks with clients in daily practice is very helpful without becoming overwhelming (Kelly, French & Lee, 2017;Kelly & Lee, 2018). This answers our research questions about the levels of risk reported by clients and the utility for practitioners in knowing these risks in advance of meeting their client. ...
Conference Paper
Full-text available
Relationships bring love and contentment. But under strain, relationships can also bring risk of harm to self and others. When people want help for their relationships, relationship practitioners must identify if there are any such possible risks of harm when they are clarifying the presenting issue. This is essential because clients may identify the problem as simply being an inability to talk or communicate when in reality it may be dangerous for them to talk. Relationships Australia SA (RASA) paves the way in facilitating safe conversations with all its clients using the Family DOORS framework. Based on the Family Law DOORS (McIntosh & Ralfs, 2012a), Family DOORS begins with DOOR 1 which is a fifteen-minute universal risk screen developed from the evidence-based and validated Family Law DOOR 1 (McIntosh, 2011a). Clients self-report their risks on DOOR 1 on paper or using the Family DOORS app which selects relevant domains and builds a screen for the client based on client characteristics (like relationships status or being a parent). This paper presents and reviews the findings from the first 675 clients of family and relationship services (FARS) to complete DOOR 1 at RASA. We found high levels of gendered past abuse and current risks of violence. However, other less obvious risks were also revealed as a result of undertaking the screening process including risky alcohol or drug use; parenting stress; child protection notifications about their children; and current suicidal thoughts. We describe the risk screening experience from both the client and organisational perspectives, and for both low and high risk matters. We show how the early identification of risks informs early intervention requirements in response to family safety and wellbeing. We conclude that for many early intervention relationship counselling clients, the risks are real, and that quick, efficient and respectful screening is just as essential as it is for post-separation services. We demonstrate the Family DOORS app and provide participants with the opportunity to access the app to try it themselves.
Full-text available
Conflicted parental separation is associated with escalating risks to wellbeing and safety for all family members. The Family Law DOORS (FL-DOORS, Detection Of Overall Risk Screen) is a three-part framework designed to assist frontline workers to identify, evaluate, and respond to these risks in separated families. The FL-DOORS system includes a 10-domain parent self-report screening measure, covering child and parent wellbeing, cultural and social risks, and safety risks experienced by and initiated by each parent. A first validation study of this screen was conducted with the first 660 separated parents to complete the measure at a frontline community agency, and found robust psychometric properties (McIntosh, Wells, & Lee, 2016). This paper presents a revalidation study of FL-DOORS screening measure with a new cohort of 5,429 separated parents, including 1,642 pairs. Our aim was to evaluate whether FL-DOORS was fit for the purpose of indicating a range of safety and wellbeing risks in separated families. We repeated internal scale reliability and concurrent and external criterion validity analyses. Original subscales were largely confirmed, and validity analyses were extended through a Multi-Trait Multi-Method (MTMM) approach. In this second larger cohort, the FL-DOORS screen was again found fit-for-purpose as an indicator of domestic violence and wellbeing risks in separated families.
Full-text available
Research suggests that screening for family violence among mediation clients has not been very effective, and there is also significant disagreement as to what constitutes best practice for screening in this context. This article discusses the research on these issues, including family law reforms to address family violence, the prevalence of allegations of family violence among separating families, opportunities for and facilitating disclosure, barriers to disclosure, approaches to screening in mediation, Australian and international screening tools, prevalence and severity of partner violence among clients, and needed screening and risk assessment processes. © 2016, Australian Institute of Family Studies. All rights reserved.
Full-text available
Given controversy about whether mediation is a safe option for parties with a history of intimate partner violence (IPV), there is agreement that staffshould conduct systematic IPV screening prior to conducting family mediation sessions; yet, measures to do so are limited and new. The present study is a randomized controlled trial comparing use of a standardized, behaviorally specific screen (Mediator's Assessment of Safety Issues and Concerns, MASIC) to a less specific mediation clinic IPV screen (Multi-Door screen) for rates of IPV detection. We also examined rates of recommendation to joint mediation resulting from use of the 2 screens. The sample was 741 divorcing or never married parties seeking mediation at the D.C. Superior Court's Multi-Door Dispute Resolution Division. Results indicated that parties were at greater odds of reporting IPV and IPV-related risk factors (i.e., injury, fear) on the MASIC compared with the Multi-Door screen. However, overall, neither screen was more likely than the other to lead to a case not being recommended for joint mediation. Regardless of screen, cases identified as higher risk were less likely to be recommended for joint mediation, and relative to the Multi-Door screen, the MASIC identified more high risk cases. Thus, a greater percentage of high risk cases were not recommended for joint mediation when the MASIC was used. In exploratory analyses, findings suggest that type of IPV behavior reported, level of IPV and abuse victimization, and the recency of such behaviors significantly impact recommendation decisions.
Full-text available
Handling mediation cases with a history of intimate partner violence (IPV) is one of the most controversial issues in the field of divorce mediation. Before deciding whether and how to mediate cases with IPV, mediators must first detect violence. Using random assignment of cases to an enhanced screening condition (n = 30) and to a standard screening control condition (n = 31), we compared information gathered from a brief, behaviorally specific IPV screening questionnaire to mediators' independent determination of the presence or absence of violence using standard mediation clinic screening procedures. Mediators did not label as violent about half of the cases reporting IPV on the screening questionnaire. Mediators were more likely to report IPV when fathers were reported (by mothers) to have engaged in a greater number of differing violent behaviors, but a score reflecting severity and frequency of party reported violence did not predict mediator detection of violence. In cases with two mediators, mediators did not always agree on whether or not the case involved IPV. Possible reasons for the differences in mediator and party reports of IPV are considered, and we emphasize the potential importance of using systematic methods to screen for violence in divorce mediation. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Full-text available
Domestic violence (DV) is a pervasive and serious threat to women's lives and well-being. Medical social workers, family practitioners, and obstetrician–gynecologists are in key positions to screen and offer help. Florida NASW members and board certified family practitioners and obstetrician–gynecologists were mailed a psychometrically tested scale. A total of 388 surveys were analyzed. Education (especially the number of in-service hours) and the presence of institutional supports, decreased barriers to screening, increased screening behaviors, and lead to increased victim identification. Only 20.8% of participants always or nearly always routinely screened for DV; 24.0% reported that routine screening did not apply to their role. Self-Efficacy was the strongest predictor of screening behavior with Fear of Offending, Safety Concerns, CEUs/CMEs, and in-service hours contributing approximately equally to the prediction of screening behavior.
Full-text available
Intimate partner violence (IPV) is known to be prevalent among therapy-seeking populations. Yet, despite a growing understanding of the dynamics of IPV and of the acceptability of screening, universal screening practices have not been systematically adopted in family therapy settings. A rapidly growing body of research data-almost entirely conducted in medical settings-has investigated attitudes and practices regarding universal screening for IPV. This article is a systematic review of the IPV universal screening research literature. The review summarizes literature related to IPV screening rates and practices, factors associated with provider screening practice, the role of training and institutional support on screening practice, impact of screening on disclosure rates, client beliefs and preferences for screening, and key safety considerations and screening competencies. Implications for family therapy and recommendations for further inquiry and screening model development are provided.
Community psychologists have a long-standing interest in promoting systems change to improve the lives of individuals and communities. To more fully illuminate a multilevel model of those factors involved in the promotion of systems change, the current study examined individual- and organizational-level characteristics related to health care providers' implementation of a desired reform in the community response to intimate partner violence, namely, universal screening practices. Efforts to reform the health care system's response to domestic violence prove to be difficult. The current study surveyed 209 providers across 12 health care settings to examine those factors related to reform implementation. Findings indicate that individual characteristics (perceived capacity to screen and positive beliefs about screening) and the presence of an organizational climate for implementation (e.g., consequences for implementation or failure to implement, resources to support implementation, policies and procedures consistent with desired practices) affect the extent to which health care providers engage in routine screening practices. The implications of these findings for promoting systems change, in general, and the health care system's response to domestic violence, in particular, are discussed. © 2007 Wiley Periodicals, Inc.
Guidelines for addressing domestic violence (DV) in couple therapy have been published, but reports of whether therapists routinely follow these suggestions are few. A national survey of 620 couple therapists randomly selected from American Association for Marriage and Family Therapy members was conducted in 2000 to assess therapists' strategies for assessing DV and selecting a treatment modality when violence is discovered. Less than 4% of respondents indicated consistently following key published guidelines for DV screening (universal screening using separate interviews and questionnaires). A minority indicated that they consider the victim's safety as a factor in treatment modality selection. DV may be under-identified by couple therapists and therapists may be using conjoint therapy with couples for whom such therapy is contraindicated because of relationship violence.