I read with interest the "Call for Action" posted on the International Association of Forensic Nurses Web site in September of this year. Although the call specifically addressed the need to provide survivors of sexual assault with trauma-informed care, I would like to take this one step further and suggest that, given the pervasive nature of trauma, all forensic nurses provide the patients and clients they encounter in their professional lives with trauma-informed care. However, what exactly does that mean? Is trauma-informed care something we simply pay "lip service" to? How is it actualized in practice?
When adopting a trauma-informed approach to patient and client care, the first step is to recognize how common trauma is. Viewing trauma in this manner helps practitioners to understand that the potential for trauma exists in every person's life and further supports the need for adopting a trauma-informed approach in all their professional encounters. The word "trauma" originated in the late 17th century and comes from the Greek word meaning "to wound." Forensic nurses understand the profound and debilitating nature of trauma encountered by their patients and clients, for example, trauma experienced (or witnessed) in response to a natural disaster, sexual assault, physical assault, domestic violence, catastrophic accidents, war/combat, or terrorism. Such traumatic events, life threatening in nature, are often referred to as large "T" traumas. Conversely, small "t" traumas are those events that are better described as ego threatening, as opposed to life threatening, and include such things as bullying, harassment, emotional abuse, loss of a significant relationships, or financial hardship. Although such events may be experienced as highly distressing, they do not fall into the big "T" category (Barbash, 2017).
Regardless if one has experienced a big "T" trauma or a small "t" trauma, at its most basic level, trauma is simply understood as those "experiences that overwhelm an individual's capacity to cope" (BC Provincial Mental Health and Substance Use Planning Council, 2013, p. 5). Further factors to consider when becoming trauma informed include understanding the magnitude of the trauma, the frequency, its complexity, the duration, and the source (BC Provincial Mental Health and Substance Use Planning Council, 2013). Viewing the world through a trauma-informed lens, one readily recognizes that trauma comes in many forms and that a traumatic event may or may not be traumatizing depending on the person's perspective regarding resources and ability to cope with the trauma. Trauma is also accumulative in nature, which is important for forensic nurses to comprehend, as Shakespeare noted in The Tempest, "What is past is prologue" (Act 2, Scene 1, Line 261). In essence, one's personal history not only influences but also sets the context for his or her present circumstances. Safely and sensitively engaging patients and clients with empathy and compassion are key ingredients to preventing further traumatization. The circumstances in which forensic nurses encounter patients and clients are harrowing, and the places in which such encounters take place are frequently perceived as "terrifying places" (Tello, 2018).
Although several definitions of trauma-informed care exist, as per the Substance Abuse and Mental Health Services Administration (2014a), a trauma-informed approach
includes an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecological and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic. It involves four key elements of a trauma-informed approach: (a) realizing the prevalence of trauma; (b) recognizing how trauma affects all individuals involved with the program, organization, or system, including its own workforce; (c) responding by putting this knowledge into practice; and (d) resisting retraumatization. ([P] 4).
The Substance Abuse and Mental Health Services Administration (2014b) has further defined six principles of trauma-informed care: safety; trustworthiness and transparency; peer support and mutual self-help; collaboration and mutuality; empowerment, voice, and choice; and consideration of cultural, historical, and gender issues. Although discussion of each of these principles is beyond the scope of this editorial, additional trauma-informed resources can be found in Table 1.
This brief editorial was written in response to the International Association of Forensic Nurses's trauma-informed care, Call for Action, as a way of raising awareness of trauma experienced by patients, clients, and communities. Moreover, it is included now as a way of setting the stage for our forthcoming special issue dedicated to trauma-informed care. I am delighted to announce that Drs. Annie Lewis-O'Connor, senior nurse scientist with Brigham and Women's Hospital in Boston, MA, and Kathryn Laughon, associate professor of nursing, University of Virginia, School of Nursing, have agreed to serve as the guest editors for this special issue that will be published in 2019. Articles addressing forensic nursing's response to trauma-informed care with a focus on innovations in research, practice, and administration will be featured.
Forensic nurses, unfortunately, are all too familiar with the impact of trauma in the lives of those whom they serve. As such, they have a significant role to play in the adoption of trauma-informed practices and advocating for trauma-informed organizational changes. In a recent reflective piece, Rittenberg (2018), a primary care physician, concluded that as health care providers we have the "responsibility to dig deep into ourselves and commit to actively resisting retraumatization, to develop the resources to support survivors, and to support each other as we do this work. We can strive to make our organizations trauma-informed places of healing" (p. 2). I know forensic nurses are up to this challenge.
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