Trauma-informed Care for Nursing Education Fostering a Caring Pedagogy, Resilience & Psychological Safety E-Book
Kathleen Stephany
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- Herausgeber: Bentham Science Publishers
- Kategorie: Fachliteratur
- Sprache: Englisch
- Veröffentlichungsjahr: 2024
Trauma-informed care is designed to assist persons who have experienced adversity and focuses on change at the clinical and organizational level. Its goals center around prevention, intervention, and treatments that are evidence-based, encourage resilience, and enhance coping.
This textbook is designed to give a comprehensive overview of trauma-informed care to students and faculty involved in nursing care programs.
Key features:
· Explains the skill sets to assess and care for persons who have experienced trauma.
· Emphasizes key principles of trauma-informed care
· Includes the use of client-centered, person-centered, and resilience-based tools to deal with trauma
· Recommends trauma recovery from a positive psychology and post-traumatic growth perspective
· Utilizes a caring pedagogy intended to foster resilience and help offset the secondary traumatic stress and compassion fatigue experienced by student and practicing nurses.
· Communicates the value of fostering psychological safety, compassion satisfaction, and joy in work
· Includes narrative case studies and learning activities in all chapters to help the reader to actively engage with the subject matter.
· Presents self-care strategies to enhance physical and emotional well-being.
Readership
Students and trainees in nursing care programs (diploma, undergraduate and graduate levels)
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FOREWORD
“Real change is not the sole domain of leaders and so-called heroes; rather, change is driven forward by the choices and actions of each and everyone one of us.”
-Jodie Wilson-Raybould (2022, p. 23)
We are at a pivotal time in our world, perched at the confluence of historically significant movements and events with an ever-increasing awareness of the impacts of our decisions on others and the environment. The Covid-19 pandemic has indelibly changed the landscape of healthcare and continues to affect individuals and teams who care for people, including those who have experienced intentional and unintentional trauma. Research on trauma, and our knowledge of this complex and highly subjective experience, continue to grow and evolve.
As nurses work in many areas beyond acute care settings, including in the community, long-term care, assisted living facilities, forensic systems, and postsecondary institutions, developing an awareness of the prevalence and impacts of trauma, while building on a strengths-based approach that prioritizes psychological safety, is crucial in helping all nursing professionals to work effectively and compassionately. Any client in any healthcare context, and any of our colleagues, may have experienced trauma. Since nursing practice is grounded in connection, it is vitally important we root our praxis in an understanding of how trauma can shape individual experiences and responses, while extending our gaze to consider how the systems in which we practice can more effectively support the physical, cultural, and emotional safety of people accessing care, as determined by clients themselves.
Within postsecondary education, estimates vary, but it is believed that as many as 89% of college students have potentially experienced at least one traumatic event, with the peak age of trauma exposure occurring between the ages of 16-20. Women, particularly racialized women, also report higher rates of trauma (Valdez, 2023). Students experiencing traumatic stress may have difficulties with learning and memory, attention and focus, problem-solving, and executive function, resulting in higher rates of absenteeism (Levi-Gigi, 2012). Therefore, it is vital that educators consider the experiences of learners to help mitigate the potential for retraumatization in the classroom, and help students learn within psychologically safe environments, all the while fostering resilience and building on a learner’s strengths.
This new year will mark a two decade-long milestone since graduating with my nursing degree and starting my first clinical role at a busy trauma and neurosurgery unit at an inner-city hospital in Toronto, ON. I have been reflecting on how much my own understanding of nursing as a profession, and of myself as a nursing professional, has shifted over time. It was during my graduate studies that I started to become aware of the need for creating trauma-and-violence-informed and culturally safe environments for clients, families, and healthcare providers alike while working with Indigenous women who had experienced violence after listening to their experiences of seeking healthcare. As I pursued additional education in forensic sciences, completing my Forensic Nurse Death Investigator micro-credential [FNDI-MC] in 2023, I have developed a keen awareness of how the very systems meant to support and care for people can instead perpetuate violence and retraumatize them. As a society, and especially as nurses, we must move away from blaming survivors and victims of trauma, both in subtle and overt ways, and instead be cognizant of how our understanding of trauma shapes how we show up and engage with clients, colleagues, and society more broadly.
It has been suggested that a career in nursing requires openness, humility, and the ability to embrace the inherent complexity of healthcare systems and relationships. As human beings we integrate and assess vast amounts of information every day and our brains are primed for maximum efficiency. Yet, busy healthcare and teaching environments can create conditions that leave us all vulnerable to bias, stereotyping, and assumptions (Persaud, 2019). In turn, our implicit biases can create barriers to safe and equitable classrooms and healthcare environments even though that may not be our intent (Newlove, 2021) - this is why it is important to continually address and unpack our assumptions, and to operate from a place of moral courage, empathy, and respect.
Learning about trauma has been critical for me not only in my professional roles but in the volunteer work that I do as an investigator supporting families of missing persons. As the current Decolonizing Lead for a nursing program at a postsecondary institution in BC, I have been working closely with other faculty students, and staff in advancing Truth and Reconciliation within our program. Through this work, I have developed a renewed appreciation of the importance of self-compassion, mindfulness, self-awareness, and self-reflection in how I engage and help to lead this work under the guidance of indigenous elders, knowledge-keepers, scholars, and collaborators. The recent indigenous cultural safety, cultural humility, and anti-racism standard from the British Columbia College of Nurses and Midwives [BCCNM], for example, draws attention to the expectations of the regulatory body for registrants on providing culturally safe and anti-racist care for indigenous clients. The standard considers Canada’s shameful history of colonialism and the legacy of intergenerational trauma that continues to reverberate through Indigenous communities negatively impacting healthcare experiences and outcomes for many Indigenous peoples (In Plain Sight, 2020). Developing awareness of the various forms of trauma, and how trauma impacts health, benefits not only everyone seeking care but is also deeply transformative for healthcare providers. It is crucial that all nurses be willing to learn and unlearn while leaning into the discomfort of how we are complicit in some of the healthcare policies and practices that continue to perpetuate trauma and violence, and in doing so, cause harm.
I very much appreciate how the opportunity for deep reflection and engagement is woven throughout the pages of this book, and how Dr. Stephany provides numerous opportunities for readers to consider specific examples to help bring the concepts and ideas she explores within its pages to life. There are questions for further consideration that educators can build on for rich classroom discussions, as well as recommended strategies that help provide readers with helpful scripts and actions they can incorporate into their communication with peers, instructors, and clients. In my experience as an educator, providing learners and faculty with opportunities to consider and work through examples can help consolidate learning, and over time, shift one’s practice. Dr. Stephany also centers on self-care in this book, normalizing some of the more challenging aspects of nursing school and providing an affirmative, validating, and thoughtful approach by focusing on strengths, resilience, and on finding joy in one’s work. While there can be a tendency to pathologize trauma in some of the literature, I have found a more useful reframe to look at trauma as a normal response to abnormal events (Haskell & Randall, 2009) as Dr. Stephany does in this book as well.
Being a nurse has been an honour and a privilege. My life has been forever changed in innumerable positive ways by the beautiful mosaic of connections and experiences I have had with colleagues, clients, and learners throughout my career. I am delighted to say that nearly twenty years on, I continue to learn and grow with every new role I take on and I am certainly never bored. Despite the many challenges within healthcare and postsecondary settings, it is an exciting time to be a nurse and a nurse educator. The opportunity and potential for nurses to follow their curiosities and their passions and to create the nursing roles of tomorrow are limited only by our imaginations.
I finished reading Dr. Stephany’s book with a renewed sense of possibility and inspiration and I am grateful that someone with her training and expertise, and her heart, is doing this work. I found her approach to this book both compelling and timely. Engaging with the book’s content will help readers start to build an awareness of the complexity of trauma and trauma experiences while appreciating the role of the nurse’s unique and privileged position in providing compassionate, non-judgemental care that extends its focus beyond the individual to the broader systems at large. Much work remains to be done and I remain ever hopeful as to what we can achieve when we all work together.
References
Haskell L., Randall M.. Impact of trauma on adult sexual assault victims: What the criminal justice system needs to know (January 1, 2019). Available at SSRN: https://ssrn.com/abstract=3417763 10.2139/ssrn.3417763In Plain Sight report (2020). Addressing Indigenous-specific racism and discrimination in BC health care. Retrieved from: https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Full-Report-2020.pdfLevy-Gigi, E. Kéri S., Myers CE., (2012). Individuals with post traumatic stress disorder show a selective deficit in generalization of associative learning. Neuropsychology, 26(6), 758-767. 10.1037/a002936122846034Newlove, T. (March 2021). Partnering for pediatric pain: Why what we think matters. Pain BC – Symposium Presentation Notes. Vancouver, BC.Persaud, S. (2019). Addressing unconscious bias: A nurse leader’s role. Nurs Admin Q, 43(2), 130-137. 10.1097/NAQ.000000000000034830839450Valdez, C. in Stromberg, E. (ed). (2023). Trauma-informed pedagogy in higher education: A faculty guide for teaching and learning. New York: Routledge.Wathen, C.N. & Varcoe, C. (eds). (2023). Implementing trauma-and-violence informed care: A handbook. Toronto: University of Toronto Press.Wilson-Raybould, J. (2022). True reconciliation: How to be a force for change. McLelland & Stewart: Penguin Random House Canada.PREFACE
“Although the world is full of suffering, it is also full of the overcoming of it. My optimism, then, does not rest on the absence of evil, but on a glad belief in the preponderance of good and a willing effort always to cooperate with the good, that it may prevail.” Helen Keller, American Author and Educator.
When I was completing a mandatory course in Trauma Counselling during Graduate School, I was exposed to the types of adversity that exist in the world, their prevalence, and the personal stories of endless human suffering. I felt overwhelmed with sadness and started to view the world as a cruel place of indifference. I confided in the professor teaching the course at the time about my feelings of despondency. He quoted the message relayed above by Helen Keller. Helen Keller was a blind and deaf woman who persevered despite obstacles, got a degree, became a writer, educator, and advocate, and believed in the capacity of good to overcome evil. Helen’s words of wisdom helped me to understand that although the world is full of anguish, it also is full of opportunities to help alleviate suffering. I subsequently felt compelled to integrate theories associated with caring into my practice, especially the ethic of care, and the therapeutic merits of empathy and compassion because I believe that they are the hallmarks of nursing. I was thrilled when I was introduced to trauma-informed care because, for people who have experienced adversity, it offers hopeful and useful strategies that facilitate healing and assist them in living more fulfilling lives.
As a nurse educator, I was eager to teach trauma-informed care to students because as future practitioners they needed these skills when caring for people who have been traumatized. However, what became apparent was that nursing students were also a risk group for trauma because they may have a history of personal loss and are in danger of developing secondary trauma during training while caring for the injured, seriously ill, or dying. These revelations became the impetus for this book with the goal of equipping student nurses with the tools to care for people who have been traumatized, but also ensuring that we make their learning experiences more psychologically safe. In the planning and design of this work, I purposely incorporated caring strategies into each Chapter because taking care of others is the essence of what we do as nurses, and it is an integral component of trauma-informed care. I also encouraged self-awareness through ongoing reflection to assist nurses and student nurses in becoming more aware of inherent biases, so they can purposefully transform them into tolerance and acceptance. A caring pedagogy that integrates caring components into teaching, that are engaging, inclusive, genuine, and student-centered, is also an essential theme of this book. At the end of each chapter, strategies are recommended that promote self-care. However, these ideas are not intended as a substitute for medical or psychological advice. Furthermore, some of the material presented in this book may negatively impact the reader, and if that occurs you are strongly advised to reach out for professional support.
ACKNOWLEDGEMENTS
I would like to acknowledge past, current, and future nursing students. I wrote this book with all of you in mind.
CONSENT FOR PUBLICATION
Not applicable.
CONFLICT OF INTEREST
The author declares no conflict of interest, financial or otherwise.
DEDICATION
The Prevalence and Impact of Trauma and Why Trauma-informed Care is Needed in Nursing Education
Kathleen StephanyAbstract
Chapter one explores the reasons why student nurses need to be educated in trauma-informed care. Trauma-informed care endeavours to help people who have experienced trauma and targets change at the organizational and clinical level with the aim of improving client/patient outcomes. Various forms of adversity that exist are presented, and we are informed that trauma is not merely a childhood occurrence but may occur at any point across the lifespan. Stereotypical biases and racial stigma experienced by the following special populations are explored, those with differing sexual orientation or gender identity, older adults, refugees and immigrants, people of colour, and Indigenous people. The role that bias and implicit bias play in structural trauma aimed at specific populations is explained. An overview is given of the following specific trauma-related responses, trauma triggers, acute stress disorder, post-traumatic stress disorder, secondary traumatic stress, vicarious traumatization, and compassion fatigue. The Four Core Assumptions of Trauma-informed Care as recommended by the Substance Abuse and Mental Health Services Administration (SAMHSA are explored, because they are foundational for providing trauma-responsive care, and consist of realizing, recognizing, responding, and resisting re-traumatization. Healthcare professionals are strongly encouraged to practice in a trauma-responsive and trauma-sensitive manner. Incorporating trauma-informed approaches into the Nursing School curriculum is recommended for the following reasons. Adversity is prevalent in society, and high number of people who access health services have experienced trauma. Student nurses are not currently learning these skills in a comprehensive way in all schools. Student nurses may have a history of trauma, and they are exposed to adverse and stressful events in clinical training. Two Narrative Case Studies are presented. The first shares the story of a Counsellor who developed compassion fatigue, and the second one reveals the complexity of the trigger response. The following learning activities are suggested: connecting with the goodness in life; changing prejudices and stigma; and participating in a trauma-sensitive practice challenge. A self-care strategy that promotes self-compassion is included at the end of the chapter.
LEARNING GUIDE
After completing this chapter, the reader should be able to:
Briefly be introduced to trauma-informed care.Understand that caring is an embedded theme in this book.Become aware that the content of this book is supported by evidence, which includes the thematic analysis of narratives, which are a specific form of qualitative, phenomenological study.Describe what the ethics of care and trauma-informed care have in common.Define trauma, describe the effects of psychological trauma, and be cognizant of trauma’s widespread prevalence in society.Gain an understanding of specific types of traumas such as historical, intergenerational, violent, structural, and those due to adverse childhood experiences (ACEs).Become knowledgeable of the stereotypical biases experienced by specific special populations.Gain an awareness that nursing students and practicing nurses must never discriminate for any reason.Recognize stereotypical biases toward others through the process of increased self-awareness.Learn about specific trauma-related responses, the role of trauma triggers, and traumas associated with working in healthcare.Understand The Four Core Assumptions of Trauma-informed Care.Be cognizant of the fact that all health professionals should practice in a trauma-responsive and trauma-sensitive manner.Identify two essential features of trauma-sensitive approaches that a practitioner should adopt.Understand why trauma-informed care should be incorporated into the nursing school curriculum.Review two narrative case studies and ensuing thematic analysis. The first one concerns the subject of compassion fatigue, and the other one explores the relationship between a trigger response and past trauma.Participate in the following suggested learning activities (e.g., Connecting with the Goodness in Life; Changing Prejudices and Stigma; and Participation in A Trauma-Sensitive Practice Challenge).Be encouraged to take part in a self-care strategy that promotes self-compassion.INTRODUCTION TO THE BOOK
“Be kinder than necessary because everyone you meet is fighting some sort of battle.” Sir John Mathew Barrie, Scottish Novelist and Playwright.
According to Haskin (2019), we should assume that every person accessing health services has a history of trauma and that they need kindness, acceptance, and compassion (Fig. 1.1). It is therefore highly recommended that all healthcare professionals be trained to recognize the symptoms of trauma, the impact it has had on people’s lives, and how to practice trauma-informed care (Haskin, 2019; Substance Abuse and Mental Health Services Administration (SAMHSA), 2014; The Institute on Trauma and Trauma-informed Care (ITTIC), 2022).
Fig. (1.1)) Kindness and Acceptance. Source: www.pixabay.com.Trauma-informed care endeavours to help people who have experienced adversity and targets change at the organizational and clinical level with the aim of improving client/patient outcomes (Menschner & Maul, 2016). It focuses on prevention, intervention, and treatments that are evidence-based and holistically assist with coping (Knight, 2015; Levenson, 2020; Purkey et al., 2018). Trauma-informed care does not place any blame on the individual who has experienced adversity but focuses on how they have been affected by it. For instance, instead of asking the question, “What is wrong with you?” we are advised to use a more suitable, empathetic, and responsive question such as, “What has happened to you?” (Young et al., 2019).
A Brief Overview of the Book
The purpose of Chapter One is to explore the many reasons why trauma-informed care is needed in nursing education. The discussion begins by discussing the prevalence of trauma in society, its many forms, and its negative ramifications. Stereotypical biases and racial stigma experienced by special populations are explored, including the role of implicit bias. Trauma-related responses like trauma triggers, acute stress disorder, post-traumatic stress disorder, secondary traumatic stress, vicarious traumatization, and compassion fatigue are discussed. Crucial components associated with the delivery of trauma-informed care are introduced, including the importance of being trauma-informed, trauma-responsive, and designing a trauma-sensitive practice, followed by key objectives and assumptions. Integrating trauma-informed approaches into the Nursing School curriculum is highly recommended.
The remainder of the book provides an in-depth overview of the following topics. The key principles of trauma-informed care are emphasized along with tools that are client-centered, person-centered, and resilience-based. Trauma recovery from a positive psychology and post-traumatic growth perspective is recommended. Utilizing a caring pedagogy and fostering resilience, are offered to help offset the secondary traumatic stress and compassion fatigue experienced by student and practicing nurses. Lastly, the benefits of fostering psychological safety, compassion, satisfaction, and joy in work are revealed. All of the chapters include narrative case studies and learning activities to help the reader to actively engage with the subject matter. At the end of each chapter, self-care strategies are suggested as a means to enhance physical and emotional well-being. It is crucially important to also remind the reader that some themes of trauma-informed care explored earlier in the book are reintroduced. However, when that occurs, new information is added to the topic, or it is examined in an alternative way.
Caring as an Embedded Theme
Caring, the ethic of care, and caring pedagogy are key themes in this book. Caring, in general, is thoroughly embedded in the content because it is foundational for nursing practice and a key component of trauma-informed care (Noddings, 2013; SAMSHA, 2014). Caring involves being empathetic and compassionate, and treating all the people with respect, fairness, and understanding, and is also concerned with taking action to reduce human suffering (Ray, 2018). The ethic of care is a specific component of caring practice that aligns well with trauma-informed care because it is about being aware of and sensing the needs of others, responding to their needs responsibly, while also condemning all exploitation or intentional harm of others (Gilligan, 1982; Slote, 2007: Stephany, 2020). Caring pedagogy is student-focused and cultivates an educational environment of engagement, safety, caring relationships, and cultural diversity (Duffy, 2018; Ray, 2018).
QUALITATIVE RESEARCH, PHENOMENOLOGY, NARRATIVES & THE ETHIC OF CARE
Qualitative Research
The content of this book is evidence-based and includes qualitative research into the phenomenological analysis of narratives. Phenomenology is the research methodology, narratives are the methods used for data collection, and the ethic of care is the theoretical foundation for analysis. Qualitative research in social sciences focuses on gathering information about people through experiential means. Although there are many methods of qualitative research, key aspects of the process may include the analysis of texts, visual or auditory data, and examining stories (Mihas, 2019). Subgoals associated with some forms of qualitative research theorize a process or to identify contexts or themes and the meaning derived from them (Mihas, 2019).
Phenomenology
Methodology in research refers to the approach used in the study to acquire, categorize, and analyze data (Loiselle & Profetto-McGrath, 2011). The form of qualitative methodology that is used in this book is phenomenology. Phenomenology is a theoretical perspective that emphasizes the very substance of lived human experience before any data analysis or theorizing takes place (Mihas, 2019; Morgan & Wise, 2017). Understanding is derived from obtaining a glimpse of how humans live in the present moment and meaning making happens retrospectively (van Manen, 2017).
Narratives
“Share with people who have earned the right to hear your story.” Brené Brown, Researcher, Author, and Storyteller
The method for this research is narratives. Method refers to the actual way in which data is collected for a study including the sequencing, techniques, and strategies that were utilized (Loiselle & Profetto-McGrath, 2011). Narratives are a form of phenomenological inquiry that consists of personal stories. They help us see the world through the unique perspective of others, to understand the essence of their experiences and their personal significance (Morgan & Wise, 2017). Subsequently, this textbook includes many stories as told by people who have either struggled with or experienced trauma. However, considerable details have been altered to protect privacy.
As a nursing instructor, I explain to my students that everyone has a story (Fig. 1.2). When a client/patient trusts you enough to share their story with you, it is a gift to be cherished and protected because revealing personal aspects of their lives makes them vulnerable. That is why we must always endeavor to earn their trust by ensuring privacy, actively listening, and offering empathy, compassion, and non-judgment.
Fig. (1.2)) Everyone has a Story. Source: www.pixabay.com.The Ethic of Care
In research, theory is used to generalize and offer explanations of the relationships between the phenomena under study (Loiselle & Profetto-McGrath, 2011). The ethic of care is the theoretical basis for analyzing the data derived from the narratives in this book. It is a special feature of nursing ethics that values relationships, context, meaning making, the interconnectedness of all of life, and the self-worth of every person. It does not tolerate discrimination, expects nurses to do what they can to end human suffering, and advocates for those who are marginalized. It insists that unbiased caring be incorporated into everything that nurses do (Noddings, 2013; Stephany, 2020; Watson, 2008).
The ethics of care and trauma-informed care have a great deal in common. For instance, they both fit well in nursing practice because they honor the intrinsic self-worth, autonomy, and choice of each person, and promote practice strategies that support and empower people to heal from suffering. They also acknowledge a person’s strengths and abilities to overcome adversity and to change their lives in a positive way.
PSYCHOLOGICAL TRAUMA
According to SAMHSA (2014), trauma refers to an event or series of circumstances that are harmful, threatening or a danger to a person’s life and has lasting adverse effects on their ability to function on a mental, physical, or spiritual level. When people have been traumatized, they feel disconnected from a sense of belonging, and safety, and may experience an inability to cope with stress (van der Kolk, 2014). Psychological trauma refers to a disturbing event that is unexpected and beyond what would normally be anticipated and results in a large array of physical, emotional, and psychological responses (Hordvik, 2019). We are aware that psychological trauma interferes with normal biological homeostasis and has negative effects on many of the body’s system functioning and may lead to maladaptive behaviours and psychiatric illnesses (Soloman & Heide, 2005). Evidence indicates that psychological trauma differs from ordinary stress in these specific ways. It is often unexpected, and the person does not feel prepared to deal with it, and there are no actions that the individual can take to prevent it from occurring (Jaffe et al., 2005). Whether a traumatic event will cause emotional suffering in the person depends on the seriousness of the adversity, the person’s ability to cope, and the larger meaning attributed to the event by the individual (Jaffe et al., 2005). As Dr. Bessel van der Kolk (2014) explains, trauma is much more than an event that occurred, but an experience that involves the brain, mind, and body, and affects how a person is able to cope with present-day life.
Following a traumatic event, the person may develop adverse reactions right away or the effects may be delayed. When they do occur, physical or psychological symptoms may manifest in numerous ways, such as sleep disturbances, eating disorders, chronic pain, depression, anxiety, panic attacks, irritability, anger, problems with memory, or emotional withdrawal (Jaffe et al., 2005). The person may also be inclined to re-experience the adverse event through nightmares, flashbacks, intrusive thoughts, and detachment (Jaffe et al., 2005). Increased hypervigilance, or overreacting to normal stress is not uncommon, nor is self-medicating with substances to reduce anxiety and alleviate fear. Problems sustaining intimate relationships or social withdrawal are also not uncommon (Jaffe et al., 2005).
THE PREVALENCE OF TRAUMA
“Trauma is a fact of life, but it does not have to be a life sentence.” Peter A. Levine, Psychotherapist & Author.
Almost everyone experiences some sort of adversity or loss during their lifetime and trauma is more common than most people realize (Haskins, 2019). Research reveals that large numbers of children experience trauma. For example, 25% of children living in the USA have endured physical violence, and 20% report being sexually abused (van der Kolk, 2014). Yet much of the society is still in denial about the frequency of trauma, especially child abuse and neglect, and the long-lasting adverse effects on those who are impacted (Wheeler & Phillips, 2019; van der Kolk, 2014). We also need to be reminded of the fact that adversity can affect anyone at any time in their life regardless of the socioeconomic status, age, or gender (Ravi & Little, 2017; SAMHSA, 2014a; Stephany, 2022). According to Foli and Thompson (2019), the question to ask is not whether a person has experienced or witnessed trauma, but rather when did it occur, what were the circumstances, and how often it occured?
TYPES OF TRAUMA AND TRAUMATIC EXPERIENCES
There are several types of traumas such as historical, intergenerational, violent, structural, and those due to adverse childhood experiences (ACEs) (Burton et al., 2019; Suah & Williamson, 2021) (Fig. 1.3).
Fig. (1.3)) The types of trauma and traumatic experiences (as adapted from Burton et al., 2019; Gaywash & Mordock, 2018; Turney, 2018; Suah & Williamson, 2021; Wynyard et al., 2020).Historical, Transgenerational & Violent Traumas
Historical trauma consists of adversity and oppression that targets a specific group of people and contributes to systemic racism (Burton et al., 2019). The discrimination often occurs repeatedly across generations and has led to a phenomenon we now refer to as transgenerational trauma (Suah & Williamson 2021). Two examples include slavery in the United States and Residential Schools for Indigenous children in Canada, but numerous other examples exist.
Transgenerational trauma, which is also referred to as intergenerational trauma, consists of a transposition of prejudicial attitudes and behaviors from one generation to another (Gaywsh & Mordock, 2018; Suah & Williamson, 2021). Present day experiences are, therefore, interpreted through past experiences that often involve racial or other forms of discrimination. Lack of trust in others, especially strangers, is understandably a key repercussion of this form of trauma (Suah & Williamson, 2021).
Violent trauma includes all forms of abuse and has direct negative consequences for the individual (Burton et al., 2019). Traumatic experiences associated with violence include physical assault, sexual assault, sexual abuse, child neglect, being deprived of basic needs, domestic abuse, other forms of interpersonal violence, elder abuse, being threatened, witnessing violence, exposure to natural disasters, being a victim of war, and all forms of systemic racism or stereotypical biases (Davies et al., 2017; Gerber, 2019; Stephany, 2022).
Intimate partner violence (IPV) is a form of violent trauma that is sexual or physical that may include stalking or purposefully inflicting psychological harm on someone. It could be happening presently or may have occurred in the past. The perpetrator of the abuse is usually known to the victim but is not always a significant partner (Centers for Disease and Prevention (CDP), 2017). IPV causes the person who is affected to feel powerless and isolated. Unfortunately, many IPV survivors also experienced childhood adversity, which decreases their ability to cope and negatively impacts their self-confidence. This often leads to a feeling of disempowerment and an inability to leave the abusive situation Anyikwa, 2016). IPV also results in many negative repercussions, including mental illness and problem substance use (Anyikwa. 2016). Although women are the most identified survivors of IPV, data reveals that members of the LGBTQ community have experienced either equal or higher rates than cisgender heterosexual individuals (Scheer & Poteat, 2021).
Adverse Childhood Experiences (ACEs)
Negative traumatic experiences that occur in childhood are referred to as adverse childhood experiences (ACEs) (Fig. 1.4). Examples of types of ACEs include physical and sexual abuse, neglect, household violence, caregiver mental illness or drug use, parental abandonment, parental death, and parental divorce or separation (Turney, 2018; Wynyard et al., 2020). Other studies have included the following as additional types of ACEs: school bullying, community violence, natural disasters, war, displacement, terrorism, sexual or gender discrimination, sexual harassment, hate crimes, and human trafficking (Grogan & Murphy, 2011; Grossman et al., 2021; Johnson et al., 2013). ACEs are common in children, with approximately 30% of children being exposed to at least one ACE (Turney, 2018). ACEs have both short-term and long-term effects on a child’s psychological development and the inability to cope due to brain changes. This alteration in cognitive functioning contributes to emotional deregulation and poor attachment to primary caregivers (Goddard, 2020). When older, many of these children are at risk of resorting to dangerous behaviors such as smoking, substance use, and promiscuity. Research has also revealed that a higher number of ACEs is correlated with a greater number of physical and mental health challenges experienced in adulthood (e.g., heart disease, respiratory problems, chronic lung disease, cancer, liver disease, major depression, anxiety disorders, and post-traumatic stress disorder (PTSD) (Anda et al., 2010; Grossman et al., 2021). Oftentimes in adulthood, a person will hide or bury their history of childhood adversity as a way of coping, or because they feel guilt or shame (Sweeney et al., 2018). That is why we should not assume that a person has not been exposed to adversity just because, on the surface, they appear to be okay (Stephany, 2022).
Fig. (1.4)) Adverse Childhood Experiences (ACEs). Source: www.pixabay.com.After learning about the prevalence of adversity and some of its types, you may feel somewhat discouraged, and that is why (Box 1.1) offers a suggested learning exercise on connecting with the goodness in life.
STRUCTURAL TRAUMAS EXPERIENCED BY SPECIAL POPULATIONS
Structural trauma is a form of indirect violence toward specific populations by design (Burton et al., 2019). Grossman et al., (2021) make an important point that health professionals have a responsibility to become informed of the facts that many groups of people have been traumatized collectively, either historically, or by past and present systemic oppression and racism. Examples of people who have fallen prey to structural trauma include those with differing gender identity or sexual orientation, ethnic minorities, people of color, people with disabilities, and those of faiths that differ from Christianity (e.g., Judaism and Islamic faiths) (Burton et al., 2019). This is by no means an exhaustive list. There are many other special populations that experience intolerance. However, although it is beyond the scope of this textbook to address all of them, the reader is strongly encouraged to increase their awareness of oppressed groups of people and ways to end discrimination. Nevertheless, the discussion that ensues examines stereotypical biases and targeted acts of adversity towards the following groups: those with differing sexual orientation or gender identity, older adults, refugees and immigrants, people of color, and Indigenous people.
What is Meant by Sexual Orientation & Gender Identity?
Before discussing the trauma experienced by persons with differing sexual orientations or gender identities, it is important to understand what is meant by these and other relevant terms. What is the difference between sex and gender? Sex refers to a person’s biological designation based on the genitalia that they were born with. Sexual orientation refers to the way that a person feels toward people physically, sexually, romantically, or emotionally, and they may be attracted to one or more gender designations (Royal Mental Health Care & Research (RMHCR), 2019). Heterosexuality refers to the feelings of a person toward others of the opposite sex and is only one designation of sexual orientation.
Gender is used to describe the way in which a person feels about themselves and may differ from what their biological designation may be. For example, they may feel like a female or, a male or neither (RMHCR, 2019). Gender identity refers to a person’s individual description of their own personal experience of gender, and their gender identity may be the same or different than that assigned at birth (RMHCR, 2019).
People with sexual orientations or gender identities that differ from being heterosexual or gender identified at birth are often referred to as a set of acronyms (RMHCR), 2019). Although there is a variation of types of abbreviations used to represent members of this population, for the purpose of this discussion, the following acronym will be used, LGBTQ2S, which stands for lesbian, gay, bisexual, transgender, queer, and two-spirited. (RMHCR, 2019). Refer to Box (1.2) for a description of these and additional terms. The explanations are meant to be inclusive of differing sexual orientations and gender identities and by no means include all diverse communities. The acronyms may also change with time (British Broadcasting Corporation (BBC), 2015). It is, therefore, considered a good practice to be respectful of a person’s choices by asking them how they would like to be addressed and inquiring about their preferred pronouns (BBC, 2015).
Traumas Experienced by People with Differing Sexual Orientation or Gender Identity
Members of the LGBTQ2S community are known to be exposed to trauma. Even in a society like Canada that legally asserts the rights and privileges of all people, stereotypical biases, stigma, and hatred toward this group prevail and cause harm. For example, youth who identify as LGBTQ2S are known to experience many forms of adversity, such as physical and sexual abuse, interpersonal violence, sexual assault, sexual exploitation, and peer bullying (McCormick et al., 2018). They also experience increased incidences of maltreatment, family and peer rejection, substance use, self-harm, and higher rates of post-traumatic stress disorder (PTSD). The discrimination they experience also often continues into adulthood (McCormick et al., 2018). What is even more troubling is that although young members of this community experience higher than normal rates of all forms of trauma than other youths, they have been largely ignored as a priority population for trauma-informed care (McCormick et al., 2018).
Carabez et al., (2015) point out another disturbing fact that nursing as a profession has been reluctant to openly embrace members of this group, and research has demonstrated that many nurses are unaware of patients who are LGBTQ2S or harbour negative views towards them. Furthermore, nurses, in general, lack an understanding of how to care for persons in this community, and nurse educators are also not always trained on how to address their specific health issues (Carabez et al., 2015).
Traumas Suffered by Refugees & Immigrants
Displacement due to war, persecution, and violence all over the world in recent years has resulted in significant growth in the number of people who have been exiled from their country of origin. In fact, as of 2019, more than 79 million people were displaced, and 20 million of them became refugees (Shi & Tatebe, 2021). These numbers have increased in 2022 due to the mass exodus of women and children leaving war-torn Ukraine. For people who are refugees, the degree of trauma and adversity that they experience begins prior to being displaced and sometimes continues after stressful migration journeys and settlement in a new country (Shi & Tatebe, 2021).
Although new immigrants are not necessarily exposed to all the hardships experienced by people who are refugees, what they have in common is the distress of leaving their way of life behind, including family and social support, and all of the newly added difficulties that occur once they have migrated. For example, refugees and new immigrants often experience post-migration trauma which is due to barriers to access to essential services such as employment opportunities, education, adequate housing, food security, and healthcare (Wylie et al., 2021).
It is also crucially important that healthcare professionals be trained to provide trauma-informed care to people who are refugees or new immigrants because they may present with unique physical and psychological trauma that is complex (Wylie et al., 2021). Acknowledging cultural differences is an important place to begin, followed by avoiding making assumptions based on how things are done in Western culture. However, Ray (2018) suggests that transcultural caring be employed to avoid unintentional harm. In nursing, transcultural caring consists of more than just being sensitive to cultural differences. It involves intentionally and wholeheartedly seeking to understand and respect how a person’s behaviors, wants, and needs are influenced by all aspects of their culture (Ray). Furthermore, Wylie et al., (2021) also highly recommend that healthcare personnel receive ongoing and updated training in trauma - informed care that is transcultural,
mindful, and reflexive and that is tapered to the many diverse needs of those who have recently arrived from another country.
Racial Trauma & People of Color
Racial trauma consists of traumatization that targets ethnicity that is experienced personally or witnessed (Williams et al., 2020). Unfortunately, people of color have historically been subjected to racial trauma. People of color in the USA is a term used to describe persons of African descent who were referred to as African American. However, it is now also used in North America to describe groups of people who identify as ‘non-white’ and includes but is not limited to, Blacks, Latinos, Mexicans, Jamaicans, Chinese, Indigenous people, Asians, Southwest Asians, and Arabs (Perez, 2021; Williams et al., 2020).
