Module 5: Trauma, Violence, and Cultural Safety – Topic G Provide care or services to persons using opioids or experiencing opioid use disorder that support choice, voice, and empowerment.

Learning Objectives

By the end of this topic, the student should be able to:

• Explain the concept of cultural safety and its role in person-centred care.
• Explain the concepts of trauma-informed and trauma- and violence- informed practice and why they are important in the provision of services.
• Identify the key components of trauma-informed care (TIC) and trauma- and violence- informed care (TVIC).

Key Concepts

• Cultural safety is an overarching term to challenge and disrupt oppressive practices that marginalize and stigmatize groups of people; it is an anti-racist, anti-oppression stance.
• Trauma-informed care (TIC) is framed by five key principles: safety, trust, choice, collaboration, and empowerment.
• Trauma- and violence-informed care (TVIC) builds on the principles of TIC and is inextricably linked with cultural safety.
• TVIC includes four principles:
• Understand trauma and violence and their impacts on peoples’ lives and behaviours.
• Create emotionally and physically safe environments for both clients and service providers.
• Foster opportunities for choice, collaboration, and connection.
• Provide strengths-based and capacity-building approaches to support client coping and resilience.
• TVIC and cultural safety are key dimensions of equity-oriented approaches in health care, alongside harm reduction.
• Health and social service organizations and providers play a key role in ensuring equity-oriented health care that incorporates TVIC and culturally safe care. Developing a therapeutic relationship that minimizes power imbalances, promotes shared decision-making, and responds to institutional racism and social determinants of health inequities is an important aspect of TVIC and culturally safe care.

What Is Cultural Safety?

For more information, see Module 5, Topic E.

Cultural safety (CS) is an anti-racist, anti-oppressive, and anti-discriminatory stance. It can help reduce experiences of racism within health and social services while promoting better health outcomes.

Terms related to but also different from cultural safety include:

• cultural competency,
• cultural awareness,
• cultural sensitivity,
• cultural humility, and
• cultural appropriateness.

Some authors have conceptualized cultural safety as part of an evolving continuum of terms. Although the notion of culture is central to the concept, cultural safety is not about conducting a cultural inventory. Rather, cultural safety (CS) is about relational engagement that is respectful, nonjudgmental, and authentic.

NOTE: CS is not about focusing on a person and on cultural difference as the source of an encounter or a problem; it is a focus on the culture of health care as a place where health providers can take action to create safety for all.

More Notes on The Value and Importance Of CS

• CS moves beyond cultural sensitivity or cultural awareness to place responsibility on health and social service providers to create culturally safe environments.
• CS foregrounds the aim of shaping health and social service practices, policies and organizations.
• CS takes into account the inherent power imbalance a health and social service provider and the person coming to them for care.
• CS begins with the self, that is, a provider’s reflection on their own biases and assumptions, and what they are bringing to the health and social service encounter.

Indigenous Cultural Safety

The harms of everyday racism in the health sector in relation to Indigenous people has been clearly documented. These events have brought renewed attention to the harms of Indigenous-specific racism.

What Is Equity-Oriented Health Care?

For more information, see Module 5, Topic C.

Equity-oriented approaches can be implemented at multiple levels, including within health services, and have been shown, through prior and ongoing research in primary health care (i.e., Browne et al., 2015; Ford-Gilboe et al., 2018), to be related to key health outcomes, including better quality of life, less chronic pain, and fewer depressive and posttraumatic stress symptoms over time.

Equity-oriented approaches comprising three intersecting key dimensions—cultural safety, trauma- and violence-informed care, and harm reduction—have demonstrated positive outcomes.

© Course Author(s) and University of Waterloo

What Is A Trauma- And Violence-Informed Care That Includes Cultural Safety?

A trauma-informed approach works across individual, interpersonal, and system levels of care, and concentrates on:

• relationship building,
• engagement and choice,
• awareness,
• and skills building.

The V in TVIC is a reminder of the fact that violence and its traumatic impact is ever-present in our society, occurs at the intersection of interpersonal and systemic or structural violence, and requires attention at individual, organization/agency, and system levels. It does not simply reside in an individual’s psychological state, and it is different from trauma incurred, for example, as a result of a natural disaster (Ponic et al., 2016).

Basic Principles of TIC

To be effective, the principles of TIC – safety, trust, collaboration and empowerment – need to occur at both the individual and structural level for effective and sustainable change.

Safety

Emotional safety can be promoted through:

• compassionate care,
• respectful language, and
• provider relationships that are consistent and predictable and where confidentiality is stressed and upheld.

Policies must:

• appropriately address health inequities within organizations and practice, and
• be well explained, clear, and make sense to the person to whom they pertain.

Physical safety can be promoted by:

• offering accessible spaces of care,
• providing adequate space that is bright with sufficient seating and a welcoming ambiance through people and furniture, and
• displaying art and signage that is welcoming of the people who access the services (this can also serve to promote emotional safety).

Trust

When a person’s basic needs for safety, respect, and acceptance in the helping relationship are understood and responded to accordingly, an atmosphere of trust can be established. Trust also is based upon predictability and transparency, such as taking the time to explain concepts such as confidentiality and allowing time for questions.

Choice

Trauma-informed services are person-centred and support client decision-making and a sense of control over their own recovery.

• Through time, people gain a new sense of control and mastery, holding the potential to transform feelings of powerlessness and being overwhelmed to that of a person with power who directs and owns their life decisions and associated outcomes.
• Encouraging mastery through choice involves asking people about their preferences in service delivery, supporting them to identify options suitable to their life experience, and guiding them in their own informed decision-making. For example, instead of shaming or labelling a person as resistant, service providers can work to understand the broader contextual factors contributing to a person’s refusal of help and support.

Collaboration

Trauma-informed programming is based on shared power between the worker and client so that the relationship offers a true alliance in healing; this requires recognizing the power imbalance and the presence of privilege in the helping relationship.

• Collaboration requires constant attention to the many subtle ways feelings of vulnerability can be reproduced.
• Individuals who have had abuse and violence in their past are particularly vulnerable to instinctive compliance and difficulties in placing their needs first, including asking questions or disagreeing.

Collaboration means understanding each person’s life history and cultural background and encouraging the person to be active in determining what interventions might be helpful. In this way, barriers to change are addressed and the helping relationship becomes a therapeutic tool.

Empowerment

Empowerment means adopting a strengths-based approach that reframes symptoms as adaptation and highlights achievements. Resilience instead of pathology is emphasized; for example, reframing trauma responses as normal reactions to threatening encounters.

Language plays a key role in empowerment as the individual is viewed as a survivor rather than a victim.

Basic Principles of TVIC

TVIC includes four basic principles to be applied at both the service provider and organizational levels:

1. Understand trauma and violence and their impacts on peoples' lives and behaviours.
2. Create emotionally and physically safe environments for both clients and service providers.
3. Foster opportunities for choice, collaboration, and connection.
4. Provide strengths-based and capacity-building approaches to support client coping and resilience.

(Ponic et al., 2018; Public Health Agency of Canada, 2018)

Four Ways a Provider Can Enact TVIC

1. Build awareness and understanding.
2. Emphasize safety and trust.
3. Adapt language.
4. Consider trauma a risk factor.

(EQUIP Health Care: https://equiphealthcare.ca/)

Questions

Cultural safety is a term created in New Zealand in response to glaring health inequities between Māori (the Indigenous people of NZ) and non-Māori persons.e

a. Yes, this is true.

b. No, it was a term that originated with the Indigenous Peoples in Canada.

c. The origin of the term is unclear.

Correct! Cultural safety was conceptualized by Irihapeti Ramsden, a Māori nurse in New Zealand (NZ), in the late 1980s in response to the glaring health inequities between Māori (the Indigenous people of NZ) and

Incorrect. The correct answer is a. Cultural safety was conceptualized by Irihapeti Ramsden, a Māori nurse in New Zealand (NZ), in the late 1980s in response to the glaring health inequities between Māori (the Indigenous people of NZ) and

---

Trauma-informed care is guided by which of the following principles. (Select all that apply.)

a. Safety

b. Choice

c. Autonomy

d. Collaboration

Check

Please select an answer.

Correct! Safety, choice, and collaboration are key components. Autonomy is important to support choice

Incorrect. The correct answers were a, b, and d. Safety, choice, and collaboration are key components. Autonomy is important to support choice.

---

True or false: Trauma- and violence-informed care (TVIC) replaces trauma-informed care (TIC).

a. True

b. False

Correct! TVIC builds on the principles of TIC by adding the V, that is, attention to the intersection of interpersonal and systemic/structural violence and its ongoing and cumulative traumatic impact. Violence of this nature is not the same as trauma attached to events such as natural disasters. They are both traumatic but different. TVIC is founded on four basic principles.

Incorrect. The correct answer is b. TVIC builds on the principles of TIC by adding the V, that is, attention to the intersection of interpersonal and systemic/structural violence and its ongoing and cumulative traumatic impact. Violence of this nature is not the same as trauma attached to events such as natural disasters. They are both traumatic but different. TVIC is founded on four basic principles.

---

Re-traumatization occurs only in the health and social service provider relationship and not in the health care system.

a. Yes, it is individually focused.

b. Yes, it is relationally focused.

c. No, it occurs in both the relationship and the system.

d. None of the above are true.

Correct! Re-traumatization occurs throughout the health care experience, ranging from the individual interaction (e.g., racism, stigma, and discrimination) to not feeling welcome in the waiting room to not having equal access to services because of financial, geographical, or linguistic factors or the lack of other social determinants of health.

Incorrect. The correct answer is c. Re-traumatization occurs throughout the health care experience, ranging from the individual interaction (e.g., racism, stigma, and discrimination) to not feeling welcome in the waiting room to not having equal access to services because of financial, geographical, or linguistic factors or the lack of other social determinants of health.

---

References