Week 7

Question 1

WHO Defines Violence As

Answer 1

-The intentional use of physical force or power against yourself, another person, or a group or community
-This violence can be threatened or actual
-Can result in or is likely to result in injury, death, psychological harm, maldevelopment, or deprivation
-Can include threats and intimidation

Question 2

Who is more at risk

Answer 2

Women and children
First nations, inuit, metis people
People with disabilities
People who identify as 2SLGBTQIA+

Question 3

Canadian Statistics on Violence (family)

Answer 3

Estimated over 323,000 Canadians were victims of violent crimes where the perpetrators were family members (2014)

Two-thirds of victims of intimate partner violence (IPV), and family-related homicide are women

⅓ Canadians report having experienced abuse before the age of 15

Question 4

Canadian Stats on Violence (children)

Answer 4

In 2016, approx. 54 900 children and youth lived with family violence (age 17 and younger)

Approx. 16 200 (30%) were victims of family violence perpetrated by a parent, sibling, spouse or other family member

Majority (59%) of children and youth were abused by their parents
From 2011-2016 rates of family-related sexual assault against children remained 4-5 times higher among female victims

Children with physical or mental disability were at an even greater threat of experiencing physical and psychological abuse + sexual abuse

Question 5

Canadian Stats on Violence (older adults)

Answer 5

More than 10 300 seniors (age 65+) were victims of police-reported violence crime in Canada

58% were women which was 19% higher than older adult men

Overall, older adult victims were likely to have been victimized by their child (32%), spouse (27%), or other family member (29%)

Question 6

Violence and Health

Answer 6

Violence is an integral aspect of life for all whether experienced directly or not

We are all impacted by war and related crimes

Sexualized violence is endemic in Western cultures
Mass rape of women and girls is a well-documented weapon of war.

Micro-aggressions associated with ageism, genderism, heterosexism, sexism, and racism are also common forms of violence
For example: LGBT youth experience verbal homophobic abuse that is often preceded by physical abuse

Question 7

Violence and Health (indigenous)

Answer 7

For example: In Canada, the violence of genocide, including cultural genocide against First Nations, Inuit, and Metis people is a well-documented form of violence that impacts Indigenous people and the country

Violence is a complex social and public health problem that is strongly associated with the distribution of social + structural determinants of health

It is related to historical and contemporary patterns of thought, perspective, attitudes and behaviours
Deep roots in cultural, political, and economic contexts

For example: Mass media + communication on the ways we perceive different forms of violence

Question 8

The Cost of Violence

Answer 8

Lifelong ill health
Early death
Costs the health, criminal justice, social and welfare, and economic sectors billions of dollars per year
ACE Pyramid

Question 9

ACE Pyramid*****

Answer 9

Adverse Childhood Experience (ACE) study is one of the largest investigations of childhood abuse and neglect + household challenges and later-life health and well-being
Conducted from 1995-1997 in two waves
Over 17 000 people from southern California completed confidential surveys
Data collection remains ongoing
ACE events are categorized into three groups: abuse, neglect, household challenges
Participant demographics are available by age, gender, race, and education

Question 10

Root Cause of Societal Violence

Answer 10

Although CHN’s do and can intervene in these situations, we must also address the root cause of violence —-> larger systemic power structures
Approaching from a structural perspective enables us to think about the role of systemic processes and how they create violence.
Violence is framed and organized by health care systems, legal systems, and other societal institutions
Structural violence is also called systemic violence
Privilege happens in tandem with power

Question 11

Privilege

Answer 11

Examples of privilege include: white privilege, settler privilege, heterosexual privilege, male privilege, and class privilege
These are some of the underlying structures that create and sustain the many forms of violence
Privilege gives people/groups access to unearned power more than others
It is very difficult to see for some people

Question 12

Contextual Examples of Priviledge

Answer 12

White privilege includes and is NOT limited to:
Finding children’s books that overwhelmingly present caucasian race
Learning about caucasian race in school curriculum
Media biased towards caucasian race (humanizing white killers while dehumanizing people of colour)

Question 13

Heterosexual Privilege

Answer 13

Not being identified or labeled - politically, socially, economically, or otherwise by your sexual orientation
No one questions the “normality” of your sexuality or believes it was “caused” by psychological trauma, sin, or abuse
Not having fear that family/friends/coworkers will find out about your sexual orientation, and it will have negative consequences
Can walk in public holding your partner’s hand/hug/kiss infant of others without disapproval, comments, laughter, harassment or threats of violence
Can easily find a religious community that will welcome both you and your partner

Question 14

Settler Privilege

Answer 14

Not being forcefully relocated to a different area
Not being denied the right to vote on decisions affecting land owned by your ancestors for a millennia (FN people didn’t have the right to vote federally until 1960)
Being able to access clean drinking water in your community
Having your medical concerns listened to in hospital
Knowing that if a member of your family went missing, an effort would be made to find them

Question 15

Male Privilege

Answer 15

Being less likely to be interrupted when you’re speaking
People automatically assume you know what you’re talking about
Social norms allow you to take up more physical space
You can buy clothes with functional pockets at better prices
You’re less likely to experience IPV, stalked, or be a victim of revenge porn

Question 16

Class Privilege

Answer 16

Buying what you want without worry
Knowing people of similar class background by exclusively frequenting places people gather (school, clubs, workplace)
Being in control of how you spend your time
Can live where you choose, and move when/ where you choose + expect to be welcomed
Believed to be innocent by the criminal justice system at least until proven guilty
We don’t see the root cause of violence because they are hidden below the surface in systemic structures

Question 17

Systemic Opression

Answer 17

Systemic oppressions include heterosexism, racism, and sexism are all examples of these structures
Systemic oppression is a broad term describing systemic injustice that intersect and impede people’s aspirations, progression, and quality of life

Question 18

Role of the CHN

Answer 18

Be aware of the language used to describe violence
When we discuss individuals, families and communities who are struggling with violence and inequities - we often think of the most vulnerable populations
CHN’s need to also focus on tackling the root, or structural, systemic cause of violence and inequities
It’s important to re-frame vulnerable people as people under threat
The language of vulnerability implies that an individual/community is somehow more prone to experiencing health inequities.
Similar to saying someone might be prone to catching a cold

Question 19

Pivotal Role in Violence Prevention

Answer 19

Screening and early detection of violence
Prevention at all levels
Expanded collaboration across sectors
Work with community partners to intervene at all levels of health prevention and promotion

Question 20

People, Poverty, Power Model**

Answer 20

Provides an overarching way for CHN’s to understand and intervene
Enables CHN’s to act for social change
Addresses violence and its economic, psychological, spiritual, and physical health impacts
This model demonstrates that violence involves more than individual behaviour
The model is a result of direct interaction between oppressive societal structures and social conditions ie. poverty
How people perceive power imbalances informs how they see their value and position in the world
Central to this model is trauma, poverty, power, violence, and people

Question 21

Trauma

Answer 21

Results from people’s cumulative stressful experiences
It is different from stress, trauma is long-term, and has greater physiological, psychological, and spiritual impact
Makes people more sensitive to perceived risk
Different kinds of trauma intersect and can compound

Question 22

Poverty

Answer 22

Central to experiences of community violence
Related to factors and conditions usually found in poor neighbourhoods
Directly + indirectly linked to structural oppression
Power + poverty are supporting foundations of peoples trauma
Can also experience social poverty as a result of inequities like lack of social support, connection, community support, access to culturally safe care

Question 23

Violence

Answer 23

Not only an output or outcome, but also input
Model allows us to pay attention to the way violence manifests not only on the person, but through the intersection of poverty and power
Poverty, privilege, and oppression lead to violence + are acts of violence themselves
The Model: ***
Highlights the importance of empathy to both address and prevent violence
Encourages us to ask “how” and “why”
Promotes systemic empathy and self empathy to prevent violence

Question 24

Sexual Violence

Answer 24

Includes sexual harassment and sexual assault, defined as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts of traffic, or otherwise directed against a person’s sexuality, using coercion by any person regardless of their relationship to the victim in any setting.

Question 25

Sexual Violence Stats

Answer 25

Disproportionately impacts women
Violence is rooted in gender inequity
More than 635 000 incidents of sexual assault reported by Canadians in 2014
Rates of sexual assault are highest amongst: single women, FNIM individuals who rate their mental health as fair/poor, students, and individuals who identify as gay, lesbian, or bisexual, and women aged 15-24.

Question 26

MeToo

Answer 26

The phrase #MeToo was coined in 2006 by Tarana Burke, a woman who had experienced sexual assault and wanted to prevent other incidents against African American women
In the last decade, the #MeToo movement has become the slogan for the anti-sexual harassment movement
The movement has sparked conversations and created pressure to influence Canadian Policy
Through public pressure, more than 37,000 sexual assault cases have been reviewed and some agencies have pledged to revamp their approach to policing sexual violence

Question 27

Family Violence

Answer 27

The CPHO of Canada released a report in 2016 focusing on family violence, including intimate partners
Defined as violence, abuse, unhealthy conflict, or neglect by a family member towards another family member that has the potential to lead to ill health
Common types of family violence include physical, sexual, emotional, and financial abuse, as well as neglect and exposure to intimate partner violence
More common among women, children, older adults, FNMI people, people with disabilities, and 2SLGBTQIA+ community members
FNMI people family violence has roots in the impacts of generational trauma related to residential schools + historical and political contexts that have contributed to generations of oppression
Physical impacts of IPV + family violence are compounded by chronic stress and responses used to cope with chronic stress
Women are more likely than men to experience health impacts of IPV
Social impacts include diminished capacity to have healthy social relationships, poor academic performance in school, missing work or being less productive —> all of which have can lead to unemployment and financial instability

Question 28

Intimate Partner Violence

Answer 28

Women are more likely to experience the most severe forms of spousal violence (sexual assault, being beaten or choked), have injuries, and suffer long-term psychological consequences including PTSD
CHN’s have a role in caring for women experiencing IPV
Universal screening is recommended for all girls + women >12 y/o (RNAO, 2012)
We also need to identify men and boys who are under threat of violence as well such as trans men and 2SLGBTQIA+ men, and people regardless of gender who work in the sex trade
There is no single cause, but there is a strong association between social determinants of health. Chronic stress of housing, food, and heat insecurity should be considered

Question 29

Mandatory Reporting

Answer 29

In Canada there is no mandatory obligations to report IPV unless the person experiencing violence decides this is what they want to do
Age of consent to sexual activity is 16 years
“Close-in-age” exceptions include people between 12-13 y/o where the age differences between two people engaging in sexual activity is greater than 2 years, or the other person is in a position of trust/authority must be reported
For those 14-15 y/o the nurse must report the age difference if it is greater than 5 years, or the position is in a position of trust/authority
If IPV is happening in the home, and children are exposed emotionally, verbally or physically it must be reported to CAS
Important to advise the person of this obligation

Question 30

Interviewing for IPV

Answer 30

It is important to interview people in a private location when they are alone
The following are some example ways to ask about IPV according to RNAO (2012)
“Because violence against women is so common in many people’s lives, I now ask all my clients about it. May I ask you a couple of questions?”
“Many of the women I see are dealing with abuse in their relationships. Some are afraid and uncomfortable to bring it up themselves, so I’ve started asking about it routinely. May I ask you a couple of questions?”
“Have you ever been emotionally, physically, or sexually abused by your partner or someone important to you?”

Question 31

The Power and Control Wheel

Answer 31

The “Power and Control Wheel” is a key tool for CHNs to assess and intervene in violence
The wheel describes ways interpersonal power can operate
Designed to help you think about the many forms of violence and how they operate in every day life
Coercion and threats, intimidation, emotional abuse, isolations, and minimizing, denying, and blaming are some of the well-known forms of violence that occur in interpersonal relationships
Other forms include using children, male privilege, and economic abuse

Question 32

The Social-Ecological Model

Answer 32

Four level social-ecological model to better understand violence and the effect of prevention strategies
Considers the complex interplay between individual, relationship, community, and societal factors
Allows us to understand the range of factors that put people at risk for violence, or protect them from experiencing or perpetuating violence
There can be overlap, as evidenced by the rings in the model
It is necessary to act across multiple levels of the model at the same time, this is more likely to sustain prevention efforts over time and achieve population-level impact

Question 33

Individual

Answer 33

Identifies biological and personal history factors that increase the likelihood of becoming a victim, or perpetrator of violence Includes: age, education, income, substance use, or history of abuse
Prevention struggles: promote attitudes, beliefs, and behaviours that prevent violence
Specific approaches: conflict resolution and life skills training, social-emotional learning, and safe dating and healthy relationship skills programs

Question 34

Relationship

Answer 34

Examines close relationships that may increase the risk of experiencing violence as a victim or perpetrator.
A person’s closest social circle-peers, partners, and family members influence their behaviours and contribute to their experience.
Prevention strategies: parenting or family focused prevention programs, mentoring and peer programs designed to strengthen parent-child communication, promote positive peer norms, problem solving skills, and promote healthy relationships

Question 35

Community

Answer 35

Explores the settings ie. schools, workplaces, neighbourhoods in which social relationships occur and seeks to identify the characteristics of these settings that are associated with becoming a victim or perpetrator of violence.
Prevention strategies: improving physical and social environments ie. by creating safe places where people live, learn, work, and play.
Also by addressing other conditions that give rise to violence ie neighbourhood poverty, residential segregation, instability, and high density of alcohol outlets

Question 36

Societal

Answer 36

Looks at broad societal factors that help create a climate in which violence is encouraged or inhibited. These factors include: social and cultural norms that support violence as an acceptable way to resolve conflict.
Other large factors include health, economic, educational, and social policies that help maintain economic or social inequalities between groups in society.
Prevention strategies: efforts to promote societal norms that protect against violence as well as efforts to strengthen household financial security, education, and employment opportunities, and other policies that affect the structural determinants of health

Question 37

Trauma and Violence Informed Care

Answer 37

One treatment approach that aligns well with the diverse and interdependent needs of residents is trauma-informed care (TIC)
TIC is an evidence-based environment of care approach initiated by the Substance Abuse and Mental Health Services Administration (SAMHSA)
TIC emerged as an approach to deliver mental health treatment
TIC should be included in every facet of care delivery, as it establishes an environment of trust, safety, and stabilization

Question 38

How TIC works

Answer 38

To be trauma informed is to possess a thorough understanding of the development, symptoms, and impact of trauma through a culturally sensitive lens
TIC is a way of responding, interacting, and approaching clients that donors complex experiences of trauma to avoid re-traumatization
TIC challenges pathologizing, deficit-based language, treatment, and environments
Instead it promotes growth, hope, understanding, empowerment, safety and healing
In a TIC environment, colleagues hold one another accountable to the use of trauma-informed language, conceptualization, and treatment
TIC should be represented in the physical environment. Buildings and therapy rooms support clients through artwork placed on the walls, and chairs that are comfortable and accommodate individuals of all abilities and needs

Question 39

6 Principles of TIC

Answer 39

Safety
Trustworthiness+Transparency
Peer Support
Collaboration and Mutuality
Empowerment, Voice, Choice
Cultural, Historical, and Gender Issues

Question 40

Safety (TIC)

Answer 40

Trauma experiences often include exposure to abusive systems and power differentials. TIC setting should provide physical and emotional safety for clients + staff. It exceeds standard safety requirements and places emphasis on environmental factors that may retraumatize individuals

Question 41

Trustworthiness and Transparency (TIC)

Answer 41

Many people have experienced boundary violations and chronic feelings of helplessness. Healthcare centres may inadvertently perpetuate feelings of helplessness if intake procedures are unclear and not welcoming to persons with limited literacy skills

Question 42

Peer Support (TIC)

Answer 42

Clients can benefit from receiving empathy, support, and guidance from someone who has successfully navigated their own recovery in addition to medical supports Peer services are evidence-based and have been shown to promote positive health outcomes and control the cost of health care. They should be offered by trained individuals with lived experience and recovery.

Question 43

Collaboration and Mutuality (TIC)

Answer 43

Traditional models of treatment often involve a clinician or case manager who provide referrals to resources with minimal follow up or collaboration.
This results in the client navigating the process alone.
TIC provides one-stop shopping where the client could potentially see multiple providers in the same setting. These providers ideally have access to the same records to develop treatment plans

Question 44

Empowerment, Voice, and Choice (TIC)

Answer 44

Health care environments that enhance a client’s capacity to make decisions about healthcare can avoid re-traumatizing them TIC clinicians and organizations routinely seek to empower clients by being transparent in their communications, providing choices, and listening to the client Mutual respect and collaboration create a client experience with a sense of control and autonomy in the mental health recovery process

Question 45

Cultural, Historical and Gender Issues (TIC)

Answer 45

Trauma is best understood within the context in which it took place. Meaning, symptoms associated with trauma may vary across culture, gender, race, ethnicity, historical context, and sociopolitical context.
A TIC clinician attempts to treat trauma through a socioecological lens, considering individual factors (gender, socioeconomic status etc), relationships, community factors, social policies, cultural and developmental factors
A TIC competent provider will honour and respect beliefs, languages, interpersonal styles, and behaviours

Question 46

TIC in Primary Health for First Nations Women Experiencing Violence

Answer 46

Building trust through understanding the intersecting drivers of trauma and violence
Clients must be able to establish trusting relationships with service providers over time
Trust is facilitated when clients felt providers had an understanding of historical and contextual drivers of violence
Happens by providing care that is informed by an understanding of the triggers for First Nations women who experience violence
Varcoe et al. (2017) described an elder and nurse led “sharing circle” as an intervention component that promoted healing from trauma by providing emotional, spiritual, and social support to women
Some women did find hearing stories of loss and trauma to be triggering, and resulted in leaving or tuning out from the circle

Question 47

Raising Awareness and Accessible Healthcare

Answer 47

In many studies there is limited awareness of health services that can support women who have experienced violence and trauma
Posters and pamphlets were helpful in raising awareness, but materials must be culturally appropriate
Prioritizing women’s physical, mental, emotional, and spiritual health ensures patients health is viewed holistically and in the broad context of their lives

Question 48

Culturally Safe care: Engaging Elders

Answer 48

Have been seen as a culturally safe strategy as they provided compassion without judgement and countered negative stereotypes with history, cultural practices, and tradition
Consider using storytelling to counter stereotypes imposed on First Nations people
Cultural practices must be used appropriately and may not resonate with all women

Question 49

Family Centred Care

Answer 49

Family has been seen as an important source of support which could provide practical assistance in the form of a safe place for the woman and her children
The role of the perpetrator within the support and healing process may also be recognized, as women may still be living with the perpetrators - there is a clear need to include perpetrators and/or ensure that appropriate supports are available

Question 50

Culturally Competent Workforce

Answer 50

Characteristics of staff, in particular the importance of having First Nations staff in mainstream and specialist organizations
Not being culturally competent means not being able to establish rapport, trust, and long-term relationships
Being able to speak local Indigenous languages is key in program success
Ongoing cultural competence training for non-Indigenous staff to understand racism and acknowledge white privilege and power imbalance has been proven beneficial in improving cultural competency

Question 51

Confidentiality

Answer 51

The issue of confidentiality can potentially impeded the delivery of culturally safe care
Drawing of staff from small communities or specific neighbourhoods can discourage patients from disclosing when they may have close connections, or do not feel confident privacy will be maintained
The physical consultation space should also ensure confidentiality through sufficient privacy

Question 52

Contextually Tailored Care

Answer 52

Responsive to the needs and priorities of the local community
Understanding the needs and history of the local community was identified in multiple studies
Centred on specific practices that appreciate the importance to community and belonging to a place
Viewing the holistic nature of family and intimate partner violence through contextual dimensions of poverty, health, substance use, historical, and present trauma

Question 53

Community Ownership and Partnerships

Answer 53

Facilitated by community ownership and intersectional partnerships
Means involving local community leaders along with an external advisory board in the oversight of service delivery, partnerships, reporting, and resourcing
Developing productive relationships with mainstream services was identified as critical to ensuring the community is well supported
Can be challenging due to inadequate resourcing for partnership building and short-term funding of services

Question 54

Vicarious Trauma*****

Answer 54

As CHN’s we bear witness to all forms of violence, and honour the complex pathways that lead people to become violent toward each other
Nurses often experience vicarious trauma (VT) as a result of engagement in practice
VT changes our cognition and worldview that result from empathetic response and repeat exposure to narratives of trauma
Responses to VT involve the same experiences as post-traumatic stress including nightmares, fearful thoughts, and intrusive images.
Practitioners may also become more cynical and distrustful. This may result in emotional numbing, nightmares, irritability, distancing, and withdrawal.
It is SO IMPORTANT for nurses to openly discuss and debrief about their experiences of VT