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It changes their outlook on everything : staff perspectives on the impacts of trauma- and violence- informed… Levine, Sarah 2016

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	  “IT	  CHANGES	  THEIR	  OUTLOOK	  ON	  EVERYTHING”:	  STAFF	  PERSPECTIVES	  ON	  THE	  IMPACTS	  OF	  TRAUMA-­‐	  AND	  VIOLENCE-­‐	  INFORMED	  CARE	  ORIENTATION	  AND	  TRAINING	  IN	  TWO	  PRIMARY	  CARE	  SETTINGS	  by	  Sarah	  Levine	  B.Sc.N.,	  The	  University	  of	  Victoria,	  2002	  	  	  A	  THESIS	  SUBMITTED	  IN	  PARTIAL	  FULFILLMENT	  OF	  THE	  REQUIREMENTS	  FOR	  THE	  DEGREE	  OF	  	  MASTER	  OF	  SCIENCE	  IN	  NURSING	  	  in	  The	  Faculty	  of	  Graduate	  and	  Postdoctoral	  Studies	  (Nursing)	  	  	  THE	  UNIVERSITY	  OF	  BRITISH	  COLUMBIA	  (Vancouver)	  	  	  April	  2016	  ©	  Sarah	  Joanne	  Levine,	  2016	   	  	   ii	  Abstract	  Trauma	  and	  violence	  are	  common,	  and	  they	  are	  linked	  to	  multiple	  health	  problems.	  Trauma	  survivors	  may	  be	  re-­‐traumatized	  when	  seeking	  health	  care.	  Trauma-­‐	  and	  Violence-­‐	  Informed	  Care	  (TVIC)	  is	  care	  that	  is	  safe	  and	  accessible	  to	  trauma	  survivors.	  While	  there	  is	  a	  growing	  body	  of	  literature	  on	  trauma-­‐informed	  care	  (TIC),	  prior	  studies	  have	  not	  explored	  how	  nurses	  and	  other	  multidisciplinary	  health	  care	  staff	  understand	  TVIC,	  which	  has	  an	  explicit	  focus	  on	  structural	  violence	  and	  ongoing	  interpersonal	  violence.	  Furthermore,	  few	  researchers	  have	  studied	  either	  TIC	  or	  TVIC	  in	  primary	  health	  care	  (PHC)	  settings.	  This	  analysis	  explores	  the	  perspectives	  of	  PHC	  staff	  on	  the	  impacts	  of	  orientation	  and	  training	  sessions	  on	  TVIC.	  These	  TVIC	  sessions	  were	  one	  component	  of	  a	  larger	  intervention	  to	  promote	  equity.	  This	  secondary	  analysis	  uses	  interpretive	  description	  to	  analyze	  fourteen	  in-­‐depth	  interviews	  with	  multidisciplinary	  staff	  at	  two	  PHC	  clinics.	  	  While	  the	  impact	  of	  the	  TVIC	  sessions	  varied	  greatly	  across	  different	  participants	  and	  sites,	  all	  of	  the	  staff	  described	  enhancements	  in	  their	  awareness,	  knowledge	  and/	  or	  confidence	  about	  trauma	  and	  violence.	  For	  some,	  this	  contributed	  to	  a	  shift	  in	  perspective	  that	  impacted	  their	  personal	  lives,	  their	  clinical	  practice,	  their	  organizational	  culture,	  and	  their	  motivation	  to	  address	  structural	  determinants	  of	  health.	  Intrinsic	  factors	  including	  presentations	  of	  data,	  facilitated	  discussions,	  the	  presence	  of	  researchers,	  and	  the	  timing	  of	  sessions	  influenced	  how	  participants	  understood,	  remembered	  and	  prioritized	  TVIC.	  Importantly,	  structural,	  organizational	  and	  personal	  contexts	  significantly	  influenced	  how	  participants	  took	  up	  and	  enacted	  TVIC	  in	  practice.	  	   iii	  This	  study	  contributes	  to	  knowledge	  about	  TVIC	  in	  PHC,	  and	  explores	  how	  health	  care	  providers	  understand	  and	  enact	  TVIC	  concepts.	  The	  findings	  point	  to	  the	  importance	  of	  challenging	  the	  biomedical	  paradigm	  in	  PHC	  and	  surface	  some	  of	  the	  difficulties	  health	  care	  providers	  may	  face	  when	  using	  a	  structural	  lens	  to	  inform	  clinical	  practice.	  Recommendations	  include	  assessing	  and	  planning	  for	  diverse	  contexts	  for	  TVIC	  implementation;	  explicitly	  attending	  to	  the	  biomedical	  paradigm	  that	  shapes	  PHC	  practice,	  framing	  TVIC	  as	  a	  paradigm	  shift	  but	  incorporating	  concrete	  tools	  and	  mentorship	  into	  TVIC	  sessions;	  attending	  to	  clients’	  voices;	  and	  research-­‐practice	  collaborations	  for	  sustainability	  and	  evaluation	  of	  TVIC.	  	  	   	  	   iv	  Preface	  This	  thesis	  is	  a	  secondary	  study	  of	  a	  subset	  of	  qualitative	  data	  from	  staff	  interviews	  conducted	  for	  the	  Equity-­‐oriented	  Quality	  Primary	  Health	  Care	  study	  (EQUIP).	  The	  identification	  and	  design	  of	  the	  research	  program	  was	  done	  by	  the	  primary	  author	  of	  this	  thesis,	  Sarah	  Levine,	  in	  collaboration	  with	  my	  thesis	  committee	  members	  Dr.	  Colleen	  Varcoe	  and	  Dr.	  Annette	  Browne,	  primary	  investigators	  (PIs)	  on	  EQUIP.	  The	  data	  examined	  here	  is	  from	  in-­‐depth	  interviews	  with	  fourteen	  primary	  care	  staff	  members	  at	  two	  of	  the	  four	  sites	  participating	  in	  EQUIP.	  	  The	  EQUIP	  PIs	  developed	  and	  delivered	  the	  TVIC	  training	  and	  orientation	  sessions,	  and	  I	  observed	  one	  of	  these	  sessions.	  Working	  with	  the	  EQUIP	  team,	  I	  developed	  prompts	  for	  the	  interview	  guide	  about	  the	  TVIC	  orientation	  and	  training	  and	  its	  impacts.	  These	  prompts	  were	  embedded	  in	  an	  interview	  schedule	  prepared	  by	  the	  EQUIP	  team	  focusing	  on	  impacts	  of	  the	  EQUIP	  intervention	  as	  whole.	  I	  conducted	  seven	  of	  the	  fourteen	  interviews	  in	  my	  role	  as	  an	  EQUIP	  research	  assistant.	  Other	  researchers	  or	  research	  assistants	  on	  EQUIP	  conducted	  the	  other	  seven	  interviews.	  I	  conducted	  this	  qualitative	  analysis	  of	  a	  subset	  of	  EQUIP	  research	  data	  with	  ongoing	  input	  and	  feedback	  from	  my	  thesis	  committee:	  Drs.	  Coleen	  Varcoe,	  Annette	  Browne	  and	  Vicky	  Bungay.	  	  The	  UBC	  Research	  Ethics	  Board	  for	  Human	  Ethics	  approved	  this	  secondary	  study	  in	  December	  2014,	  under	  the	  project	  title	  “Levine	  Thesis”	  and	  the	  certificate	  number	  H14-­‐02065.	  	  	   	  	   v	  Table	  of	  Contents	  Abstract	  ............................................................................................................................................	  ii	  Preface	  .............................................................................................................................................	  iv	  Table	  of	  Contents	  ...........................................................................................................................	  v	  List	  of	  Figures	  ...............................................................................................................................	  vii	  Acknowledgements	  ...................................................................................................................	  viii	  Dedication	  ......................................................................................................................................	  ix	  Chapter	  One:	  Introduction	  .........................................................................................................	  1	  Statement	  of	  the	  problem	  .....................................................................................................................	  2	  Purpose	  of	  study	  ......................................................................................................................................	  3	  Research	  questions	  .................................................................................................................................	  3	  The	  EQUIP	  study	  .......................................................................................................................................	  3	  The	  EQUIP	  TVIC	  orientation	  and	  training	  sessions	  ......................................................................	  5	  Organization	  of	  the	  thesis	  .....................................................................................................................	  6	  Chapter	  Two:	  Review	  of	  the	  Literature	  .................................................................................	  8	  Trauma-­‐	  and	  violence-­‐informed	  care	  ...............................................................................................	  8	  Health	  inequities	  ......................................................................................................................................	  8	  Trauma	  and	  health	  ..................................................................................................................................	  9	  Trauma-­‐informed	  care	  (TIC)	  ............................................................................................................	  10	  Structural	  violence	  and	  ongoing	  interpersonal	  violence:	  the	  “V”	  in	  trauma-­‐	  and	  violence-­‐	  informed	  care	  ......................................................................................................................	  11	  Health	  care	  staff	  orientation	  and	  training	  on	  trauma	  and	  violence	  ....................................	  12	  Summary	  ..................................................................................................................................................	  13	  Chapter	  Three:	  Research	  Design	  ...........................................................................................	  15	  Theoretical	  framework	  ......................................................................................................................	  15	  Research	  approach	  ...............................................................................................................................	  16	  Setting	  for	  study	  ...................................................................................................................................................	  17	  Sampling	  and	  recruitment	  ...............................................................................................................................	  18	  Study	  sample	  ..........................................................................................................................................................	  19	  Data	  collection	  method	  .....................................................................................................................................	  19	  Data	  analysis	  ..........................................................................................................................................................	  20	  Assessing	  Validity	  in	  Qualitative	  Analysis	  ....................................................................................	  21	  Authenticity	  ............................................................................................................................................................	  22	  Criticality	  .................................................................................................................................................................	  23	  Integrity	  ...................................................................................................................................................................	  23	  Thoroughness	  ........................................................................................................................................................	  23	  Congruence	  .............................................................................................................................................................	  24	  Moral	  defensibility,	  disciplinary	  relevance	  and	  pragmatic	  application	  .......................................	  24	  Limitations	  ..............................................................................................................................................	  25	  Summary	  ..................................................................................................................................................	  27	  Chapter	  Four:	  Findings	  ..............................................................................................................	  28	  1.	  What	  are	  staff	  members’	  perspectives	  on	  the	  impacts	  of	  TVIC	  orientation	  and	  training?	  ...................................................................................................................................................	  28	  Enhanced	  awareness,	  knowledge,	  confidence	  about	  trauma	  and	  violence	  ...............................	  29	  	   vi	  Awareness:	  Putting	  trauma	  and	  violence	  “front	  and	  center”	  ........................................................................	  29	  Knowledge:	  Sessions	  contributed	  to	  enhanced	  knowledge	  for	  some	  staff,	  but	  did	  not	  provide	  the	  anticipated	  skills	  training	  ..............................................................................................................................................	  30	  Confidence:	  Validation,	  reinforcement,	  and	  confidence	  to	  speak	  up	  .........................................................	  31	  A	  shift	  in	  perspective:	  Seeing	  through	  a	  TVIC	  lens	  has	  impacts	  on	  multiple	  levels	  ................	  32	  Personal	  level:	  Caring	  for	  self	  and	  family	  ...............................................................................................................	  32	  Clinical	  practice	  level	  .......................................................................................................................................................	  33	  Organizational	  level	  .........................................................................................................................................................	  35	  Structural	  level:	  Momentum	  to	  advocate	  for	  structural	  change	  ...................................................................	  38	  2.	  What	  are	  the	  intrinsic	  and	  contextual	  factors	  that	  influence	  the	  impacts	  of	  TVIC	  orientation	  and	  training?	  ...................................................................................................................	  40	  Intrinsic	  factors:	  Data,	  discussions,	  presence,	  and	  timing	  influence	  how	  participants	  understand,	  remember	  and	  prioritize	  TVIC	  .............................................................................................	  41	  Data	  from	  local	  patient	  populations:	  “A	  really	  really	  important	  reminder”	  ............................................	  41	  Externally	  facilitated	  discussions:	  Getting	  “closer	  to	  the	  truth”	  ...................................................................	  42	  The	  presence	  of	  external	  researchers	  at	  the	  site:	  Support	  and	  surveillance	  ..........................................	  43	  Timing	  of	  sessions	  was	  a	  challenge	  ...........................................................................................................................	  44	  Contextual	  influences:	  Structural,	  organizational	  and	  personal	  contexts	  influenced	  how	  TVIC	  was	  understood	  and	  taken	  up	  in	  practice	  ......................................................................................	  45	  “The	  system	  that	  we	  have”:	  Structural	  factors	  were	  both	  barriers	  and	  facilitators	  to	  enacting	  TVIC	  .........................................................................................................................................................................................	  45	  Organizational	  context:	  Clinic	  mandate	  and	  culture	  influenced	  how	  easily	  TVIC	  was	  taken	  up	  and	  what	  kinds	  of	  differences	  it	  made	  ..............................................................................................................................	  47	  Personal	  context:	  Values,	  knowledge,	  learning	  styles	  and	  engagement	  influenced	  how	  participants	  understood	  and	  enacted	  TVIC	  ...........................................................................................................	  50	  Summary	  ..................................................................................................................................................	  53	  Chapter	  Five:	  Discussion	  and	  Recommendations	  ............................................................	  55	  Summary	  of	  findings	  ............................................................................................................................	  55	  Discussion	  ...............................................................................................................................................	  55	  Consistency	  of	  the	  findings	  with	  TIC	  literature	  ......................................................................................	  56	  Client	  voice:	  Lost	  in	  the	  discussion?	  ............................................................................................................	  56	  TVIC	  as	  a	  vehicle	  for	  disrupting	  biomedical	  dominance	  ....................................................................	  57	  The	  dilemma	  of	  taking	  a	  structural	  lens	  to	  a	  clinical	  setting	  ............................................................	  59	  Summary	  of	  discussion	  .....................................................................................................................................	  60	  Recommendations	  ................................................................................................................................	  60	  Assess	  for	  and	  tailor	  TVIC	  sessions	  to	  specific	  site	  contexts	  ............................................................	  61	  Explicitly	  attend	  to	  practice	  paradigms	  and	  how	  they	  affect	  and	  are	  affected	  by	  TVIC	  .......	  61	  Frame	  TVIC	  orientation	  and	  training	  as	  a	  paradigm	  shift,	  but	  include	  tools	  and	  frontline	  mentors	  ....................................................................................................................................................................	  62	  Plan	  for	  sustainability	  and	  evaluation	  through	  ongoing	  research	  collaborations	  ..................	  63	  Attend	  to	  client	  input,	  empowerment	  and	  voice	  ...................................................................................	  63	  Summary	  of	  recommendations	  .....................................................................................................................	  64	  Conclusion	  ...............................................................................................................................................	  64	  References	  .....................................................................................................................................	  67	  Appendix	  A:	  Interview	  Guide	  ..................................................................................................	  74	  Appendix	  B:	  Agenda	  for	  EQUIP	  TVIC	  sessions	  ...................................................................	  81	  	   	  	   vii	  List	  of	  Figures	  Figure	  1:	  EQUIP	  Intervention	  Theory	  (Browne	  et	  al.,	  2015,	  p.	  5)	  (reproduced	  with	  permission)	  ........................................................................................................................................	  5	  	  	   	  	   viii	  Acknowledgements	  I	  would	  like	  to	  express	  my	  gratitude	  to	  the	  faculty,	  staff	  and	  students	  at	  the	  UBC	  School	  of	  Nursing	  for	  sharing	  their	  knowledge	  and	  experience	  with	  me	  over	  the	  course	  of	  this	  degree.	  I	  am	  also	  grateful	  for	  financial	  support	  from	  the	  Graduate	  Student	  Initiative	  and	  the	  BC	  Nurses’	  Union.	  	  Thank	  you	  to	  my	  thesis	  committee	  members,	  Dr.	  Annette	  Browne	  and	  Dr.	  Vicky	  Bungay,	  for	  their	  profound	  insights	  on	  and	  input	  into	  this	  research.	  To	  my	  thesis	  supervisor,	  Dr.	  Colleen	  Varcoe:	  I	  cannot	  imagine	  a	  better	  mentor	  in	  nursing	  research	  and	  scholarship.	  Thank	  you	  for	  your	  dedication	  to	  nursing	  research,	  equity	  and	  social	  justice,	  and	  to	  your	  graduate	  students	  besides.	  Thank	  you	  to	  Jo	  Parker	  and	  to	  all	  of	  the	  other	  staff,	  students	  and	  researchers	  on	  the	  EQUIP	  study,	  for	  the	  opportunity	  to	  learn	  from	  them,	  analyze	  EQUIP	  data,	  and	  generally	  disrupt	  their	  office.	  	   I	  am	  grateful	  for	  the	  support	  of	  my	  manager,	  Miranda	  Compton,	  and	  the	  Vancouver	  Coastal	  Health	  Educator	  Pathway	  Sponsorship,	  which	  allowed	  me	  the	  time	  to	  write	  this	  thesis.	  Thanks	  as	  well	  to	  Shannon	  Riley	  and	  Meaghan	  Thumath	  for	  keeping	  me	  going	  in	  the	  final	  stretch,	  and	  to	  Dr.	  Thea	  Cacchioni	  for	  her	  insights	  as	  I	  was	  writing	  the	  final	  chapter.	  	   I	  would	  like	  to	  thank	  my	  parents	  Ev	  and	  Phil	  Levine	  and	  my	  brother	  Josh	  Levine	  for	  their	  lifelong	  support	  and	  encouragement,	  and	  especially	  my	  mother	  for	  doing	  much	  of	  the	  childcare	  that	  made	  it	  possible	  for	  me	  to	  work	  on	  this	  degree.	  Finally,	  I	  would	  like	  to	  thank	  my	  dearly	  loved	  husband	  Aaron	  Pettigrew,	  the	  best	  editor,	  best	  listener,	  and	  best	  co-­‐parent	  I	  could	  ever	  wish	  for.	   	  	   ix	  Dedication	  For	  Liz	  James	  and	  the	  Street	  Nurse	  Team,	  who	  exemplify	  trauma-­‐	  and	  violence-­‐	  informed	  nursing,	  and	  for	  my	  daughter	  Deborah	  Tova	  Pettigrew.	  	  	   	  	   1	  Chapter	  One:	  Introduction	  	   The	  prevalence	  and	  profound	  health	  impacts	  of	  trauma	  and	  violence	  are	  well	  documented	  in	  health	  and	  nursing	  literature	  (Anda	  et	  al.,	  2006;	  Muskett,	  2014).	  Many	  clients	  of	  health	  care	  services	  are	  survivors	  of	  past	  or	  ongoing	  physical	  or	  psychological	  trauma	  (Elliott,	  Bjelajac,	  Fallot,	  Markoff	  &	  Reed,	  2005).	  Tragically,	  trauma	  survivors	  may	  face	  being	  triggered	  or	  re-­‐traumatized	  in	  their	  interactions	  with	  the	  health	  care	  system	  (Elliot	  et	  al.,	  2015).	  This	  can	  be	  harmful	  in	  itself,	  and	  may	  also	  have	  the	  effect	  of	  decreasing	  access	  to	  health	  care	  for	  trauma	  survivors,	  who	  feel	  unsafe	  seeking	  care	  (Browne,	  Varcoe,	  Ford-­‐Gilboe,	  Walthen,	  and	  on	  behalf	  of	  the	  EQUIP	  Research	  Team,	  2015).	  	  A	  growing	  body	  of	  literature	  underscores	  the	  importance	  of	  Trauma-­‐Informed	  Care	  (TIC)	  in	  nursing	  practice	  and	  health	  care	  more	  generally	  (Cleary,	  2015;	  Kassan-­‐Adams	  et	  al.,	  2015,	  Muskett,	  2014).	  TIC	  is	  care	  that	  is	  safe,	  accessible	  and	  appropriate	  for	  trauma	  survivors	  (Harris	  &	  Fallot,	  2001).	  As	  key	  providers	  in	  health	  administration,	  policy,	  education	  and	  direct	  care,	  nurses	  are	  increasingly	  being	  called	  to	  employ	  TIC	  to	  better	  support	  clients	  and	  to	  avoid	  re-­‐traumatizing	  survivors	  of	  trauma	  and	  violence	  (Cleary,	  2015;	  Kassan-­‐Adams	  et	  al.,	  2015).	  Trauma-­‐and	  Violence-­‐Informed	  Care	  (TVIC)	  is	  an	  approach	  to	  health	  care	  that	  takes	  into	  account	  the	  impacts	  of	  trauma	  and	  violence	  on	  health	  and	  works	  to	  create	  health	  services	  that	  are	  safe	  and	  accessible	  for	  trauma	  survivors	  (Browne	  et	  al.,	  2012).	  TVIC	  builds	  on	  TIC,	  but	  places	  additional	  emphasis	  on	  the	  impacts	  of	  structural	  violence	  	   2	  and	  ongoing	  interpersonal	  violence	  in	  clients’	  lives	  (Ponic,	  Varcoe,	  &	  Smutylo,	  in	  press).	  As	  part	  of	  the	  Equity-­‐oriented	  Quality	  Primary	  Health	  Care	  (EQUIP)	  research	  project,	  Browne	  et	  al.	  (2015)	  developed	  and	  implemented	  a	  theory-­‐	  and	  evidence-­‐	  based	  orientation	  and	  training	  on	  TVIC	  at	  four	  primary	  care	  sites.	  The	  study	  described	  in	  this	  thesis	  is	  a	  secondary	  analysis	  of	  data	  from	  EQUIP,	  exploring	  the	  perspectives	  of	  primary	  care	  staff	  on	  the	  EQUIP	  orientation	  and	  training	  to	  TVIC.1	  	  Statement	  of	  the	  problem	  Primary	  health	  care	  is	  the	  first	  point	  of	  health	  care	  contact	  for	  many	  trauma	  survivors	  (Browne	  et	  al.,	  2015).	  While	  TIC	  has	  been	  studied	  in	  mental	  health	  and	  substance	  abuse	  services	  (Markoff,	  Reed,	  Fallot,	  Elliott	  &	  Bjeljac,	  2005),	  little	  is	  known	  about	  the	  implementation	  of	  TIC	  in	  primary	  health	  care	  settings.	  In	  addition,	  despite	  a	  growing	  body	  of	  knowledge	  on	  TIC,	  few	  studies	  have	  looked	  at	  the	  impacts	  of	  staff	  training	  in	  this	  area	  (Hopper,	  Bassuk	  &	  Olivet,	  2010).	  Finally,	  the	  TVIC	  orientation	  and	  training	  developed	  for	  EQUIP	  differs	  from	  most	  TIC	  curricula	  in	  that	  it	  has	  an	  explicit	  focus	  on	  the	  effects	  of	  structural	  violence	  and	  ongoing	  interpersonal	  violence	  (Browne	  et	  al.,	  2015).	  Prior	  studies	  have	  not	  explored	  how	  nurses	  and	  other	  multidisciplinary	  health	  care	  staff	  understand	  and	  enact	  these	  concepts	  in	  practice.	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  1	  Throughout	  this	  thesis	  I	  refer	  to	  the	  orientation	  and	  training	  on	  TVIC	  as	  the	  TVIC	  sessions.	  	   2	  Concurrent	  to	  the	  qualitative	  interviews,	  EQUIP	  collected	  quantitative	  survey	  data	  on	  the	  impacts	  of	  this	  training	  for	  staff	  members,	  which	  showed	  some	  statistically	  	  	   3	  Purpose	  of	  study	  The	  purpose	  of	  this	  analysis	  is	  to	  explore	  the	  perspectives	  of	  multidisciplinary	  primary	  care	  staff	  on	  the	  impacts	  of	  the	  TVIC	  orientation	  and	  training	  component	  of	  the	  EQUIP	  study.	  As	  outlined	  above,	  this	  study	  addresses	  a	  gap	  in	  the	  literature	  on	  trauma-­‐informed	  care	  in	  the	  area	  of	  primary	  health	  care.	  This	  study	  contributes	  to	  an	  understanding	  of	  how	  health	  care	  staff	  interpret	  and	  implement	  curriculum	  on	  TVIC	  for	  marginalized	  populations.	  The	  results	  of	  this	  study	  allow	  for	  appraisal	  and	  improvement	  of	  this	  new	  evidence-­‐	  and	  theory-­‐based	  curriculum	  on	  trauma	  and	  violence	  informed	  care.	  	  Research	  questions	  	  	   The	  research	  questions	  that	  guided	  the	  study	  were:	  	   1. What	  are	  staff	  members’	  perspectives	  on	  the	  impacts	  of	  TVIC	  orientation	  and	  training?	  2. What	  are	  the	  intrinsic	  and	  contextual	  factors	  that	  influence	  the	  impacts	  of	  TVIC	  orientation	  and	  training?	  The	  EQUIP	  study	  The	  TVIC	  orientation	  and	  training	  sessions	  studied	  here	  were	  embedded	  within	  the	  larger	  EQUIP	  intervention	  and	  study.	  EQUIP	  is	  an	  “innovative	  multi-­‐component,	  organizational-­‐level	  intervention	  designed	  to	  enhance	  the	  capacity	  of	  PHC	  clinics	  to	  provide	  equity-­‐oriented	  care,	  particularly	  for	  marginalized	  populations”	  (Browne	  et	  al.,	  2015,	  p.	  2).	  EQUIP	  was	  implemented	  at	  four	  PHC	  sites	  in	  British	  Columbia	  and	  Ontario	  	   4	  beginning	  in	  2014.	  The	  intervention	  combined	  staff	  education	  on	  TVIC,	  equity-­‐oriented	  primary	  care,	  and	  Indigenous	  Cultural	  Safety	  (ICS)	  to	  build	  staff	  capacity	  to	  address	  inequities.	  Along	  with	  staff	  education,	  each	  site	  underwent	  a	  process	  of	  organizational	  integration	  and	  tailoring	  (OIT)	  through	  which	  they	  assessed	  their	  policies	  and	  practices	  with	  regard	  to	  equity,	  set	  priorities	  for	  change,	  and	  implemented	  practice	  and	  policy	  changes	  with	  support	  from	  a	  practice	  consultant.	  EQUIP	  has	  provided	  a	  grant	  to	  each	  organization	  to	  assist	  them	  in	  implementing	  their	  priority	  changes.	  The	  theory	  guiding	  the	  EQUIP	  intervention	  posited	  that	  combining	  staff	  education	  on	  equity,	  ICS	  and	  TVIC	  with	  the	  OIT	  process	  would	  increase	  the	  organizational	  capacity	  to	  provide	  equity-­‐sensitive	  care	  (see	  Figure	  1:	  EQUIP	  intervention	  theory,	  Browne	  et	  al.,	  2015,	  p.	  5,	  reproduced	  with	  permission	  below).	  Specifically,	  researchers	  theorized	  that	  staff	  education	  on	  equity,	  TVIC,	  and	  ICS	  would	  to	  contribute	  to:	  	  1)	  Enhanced	  knowledge,	  confidence,	  and	  awareness	  of	  these	  concepts,	  and	  	  2)	  Shifts	  in	  attitudes	  and	  perspectives	  among	  PHC	  staff.	  	  Researchers	  further	  theorized	  that	  these	  shifts,	  along	  with	  changes	  in	  clinic	  structures	  and	  policies,	  would	  contribute	  to	  improved	  equity-­‐oriented	  care	  for	  clients	  in	  the	  short	  term	  and	  improved	  health	  outcomes	  and	  reduced	  health	  inequities	  in	  the	  long	  term.	  The	  EQUIP	  study	  used	  a	  participatory,	  mixed	  methods,	  multiple	  case	  study	  design	  to	  examine	  the	  impacts	  of	  this	  intervention	  for	  both	  patients	  and	  staff	  members.	  	  	   5	  	   	  Figure	  1:	  EQUIP	  Intervention	  Theory	  (Browne	  et	  al.,	  2015,	  p.	  5)	  (reproduced	  with	  permission)	  The	  EQUIP	  TVIC	  orientation	  and	  training	  sessions	  	  The	  EQUIP	  TVIC	  orientation	  and	  training	  was	  developed	  by	  the	  EQUIP	  Primary	  Investigators,	  and	  delivered	  in	  a	  workshop	  format	  to	  multidisciplinary	  staff	  at	  each	  participating	  site	  (Appendix	  B:	  Agenda	  for	  EQUIP	  TVIC	  sessions).	  An	  initial	  6-­‐hour	  face-­‐to-­‐face	  workshop	  included	  pre-­‐readings	  from	  trauma	  literature,	  group	  discussion	  and	  case	  studies.	  A	  2-­‐hour	  face-­‐to-­‐face	  follow-­‐up	  session	  was	  held	  2	  weeks	  to	  2	  months	  later	  at	  each	  site.	  The	  course	  objectives	  stated	  that	  on	  completing	  the	  sessions,	  participants	  should	  be	  able	  to:	  	   6	  1. Explain	  how	  multiple	  forms	  of	  structural	  violence	  (e.g.,	  racism,	  poverty)	  intersect	  with	  interpersonal	  violence	  (e.g.,	  sexual	  assault,	  partner	  violence,	  child	  abuse).	  	  2. Identify	  the	  short	  and	  long-­‐term	  health	  consequences	  of	  various	  and	  multiple	  forms	  of	  violence,	  for	  example,	  the	  emergence	  of	  chronic	  pain.	  	  3. Understand	  the	  physiological	  and	  health	  effects	  of	  trauma	  and	  violence.	  4. Understand	  how	  trauma	  and	  violence	  underlie	  many	  of	  the	  physical	  and	  mental	  health	  disorders	  that	  people	  present	  with	  at	  primary	  healthcare	  organizations.	  5. Understand	  how	  various	  contexts,	  values,	  and	  ideologies	  shape	  social	  and	  health	  care	  responses	  to	  violence	  and	  trauma.	  	  6.	  	   Understand	  the	  implications	  of	  the	  differences	  between	  trauma-­‐informed	  care	  and	  standard	  approaches	  to	  health	  care	  for	  practice	  with	  individual	  clients	  and	  for	  organizational	  practices,	  including	  the	  implications	  for	  prescribing	  practices.	  (Appendix	  B:	  Agenda	  for	  EQUIP	  TVIC	  sessions).	  	  Organization	  of	  the	  thesis	  In	  this	  chapter	  I	  have	  discussed	  the	  background	  for	  this	  research	  project,	  outlined	  the	  problem	  I	  wish	  to	  address,	  and	  stated	  the	  purpose	  of	  this	  research.	  Chapter	  two	  outlines	  the	  research	  literature	  related	  to	  this	  problem,	  situating	  my	  study	  within	  what	  is	  currently	  known	  about	  TVIC.	  In	  chapter	  three	  I	  explain	  the	  design	  of	  this	  research	  project,	  including	  the	  theoretical	  framework,	  research	  approach,	  methods,	  and	  limitations.	  In	  chapter	  four	  I	  describe	  the	  findings	  of	  my	  analysis.	  In	  chapter	  five,	  I	  	   7	  discuss	  the	  implications	  of	  these	  findings,	  and	  make	  recommendations	  for	  future	  research	  on	  and	  practice	  of	  TVIC.	  	   	  	   8	  Chapter	  Two:	  Review	  of	  the	  Literature	  In	  the	  previous	  chapter	  I	  introduced	  the	  problem	  of	  trauma-­‐	  and	  violence-­‐informed	  care	  (TVIC)	  in	  primary	  health	  care	  (PHC)	  settings,	  and	  I	  outlined	  my	  study	  of	  the	  impacts	  of	  health	  care	  staff	  orientation	  and	  training	  on	  TVIC.	  In	  order	  to	  develop	  an	  understanding	  of	  the	  issues	  relevant	  to	  TVIC,	  I	  have	  also	  conducted	  a	  review	  of	  the	  literature	  using	  the	  CIHAHL	  and	  Web	  of	  Science	  database	  search	  engines.	  This	  review	  situates	  my	  study	  within	  the	  existing	  literature	  on	  health	  inequities,	  trauma,	  trauma-­‐informed	  care,	  and	  structural	  and	  ongoing	  violence.	  Finally,	  I	  review	  the	  literature	  on	  health	  care	  staff	  education	  on	  trauma	  and	  violence.	  Trauma-­‐	  and	  violence-­‐informed	  care	  Trauma-­‐	  and	  Violence-­‐	  Informed	  Care	  (TVIC)	  is	  “respectful,	  empowerment	  practices	  informed	  by	  understanding	  the	  pervasiveness	  and	  effects	  of	  trauma	  and	  violence”	  (Browne	  et	  al.,	  2012,	  p.	  5).	  TVIC	  has	  been	  identified	  as	  a	  key	  dimension	  of	  equity-­‐oriented	  primary	  health	  care	  for	  populations	  who	  are	  marginalized	  by	  poverty,	  racism	  or	  other	  structures	  (Browne	  et	  al.,	  2012).	  	  Health	  inequities	  Health	  inequities	  are	  avoidable,	  unfair	  differences	  in	  health	  status	  between	  groups	  in	  society	  (Whitehead	  &	  Dahlgren,	  2006).	  	  In	  Canada,	  we	  continue	  to	  see	  stark	  health	  inequities	  for	  groups	  of	  people	  who	  are	  marginalized	  by	  structures	  such	  as	  poverty,	  racism	  and	  colonialism	  (Browne	  et	  al.,	  2012).	  	  Because	  of	  these	  inequities,	  there	  have	  been	  repeated	  calls	  for	  health	  care	  that	  is	  “equity	  oriented”	  –	  that	  is,	  for	  	   9	  policies	  and	  practices	  that	  prioritize	  the	  needs	  of	  disadvantaged	  groups	  (Browne	  et	  al.,	  2012).	  	  Trauma	  and	  health	  The	  concept	  of	  trauma	  has	  particular	  relevance	  when	  working	  with	  people	  who	  are	  marginalized	  by	  poverty,	  stigma,	  racism	  and	  colonialism,	  many	  of	  whom	  are	  trauma	  survivors	  (Elliott,	  Bjelajac,	  Fallot,	  Markoff,	  &	  Reed,	  2005;	  Hopper	  et	  al.,	  2010;	  Pearce	  et	  al.,	  2008).	  	  Trauma	  has	  been	  defined	  as	  “an	  experience	  that	  is	  emotionally	  painful,	  distressful	  or	  shocking…	  that	  includes	  an	  overwhelming	  experience	  of	  helplessness	  or	  powerlessness”	  (Centre	  for	  Addiction	  and	  Mental	  Health,	  2009,	  para.	  1).	  While	  much	  of	  the	  trauma	  literature	  focuses	  on	  individual	  experiences	  of	  trauma,	  trauma	  can	  also	  be	  conceived	  of	  on	  other	  levels.	  Intergenerational	  traumas,	  such	  as	  that	  experienced	  by	  children	  of	  Aboriginal	  residential	  school	  survivors,	  may	  impact	  families;	  historical	  traumas	  such	  as	  war,	  genocide	  and	  colonialism	  may	  traumatize	  entire	  communities	  and	  populations	  (Urquhart	  et	  al.,	  2013;	  Waldron	  &	  McKenzie,	  2008).	  	  Numerous	  studies	  have	  established	  the	  connections	  between	  trauma	  and	  mental	  health	  problems	  such	  as	  post-­‐traumatic	  stress	  disorder	  (PTSD),	  substance	  use	  disorders,	  depression,	  and	  suicide	  (Anda	  et	  al.,	  2006;	  Corso,	  Edwards,	  Fang	  &	  Mercy,	  2008;	  Gilbert	  et	  al.,	  2009;	  Liebschutz	  et	  al.,	  2007;	  van	  Ameringen,	  Mancini,	  Patterson	  &	  Boyle,	  2008).	  Furthermore,	  trauma	  is	  associated	  with	  a	  panoply	  of	  other	  health	  conditions,	  including	  heart	  disease,	  chronic	  pain,	  obesity,	  liver	  disease,	  smoking,	  diabetes	  and	  HIV	  risk	  (Dong,	  Dube,	  Felitti	  &	  Giles,	  2003;	  Edmondson,	  Kronish,	  Shaffer,	  Falzon	  &	  Burg,	  2013;	  Gilbert	  et	  al.,	  2009;	  Liebschutz	  et	  al.,	  2007;	  Pearce	  et	  al.,	  2008).	  	  	   10	  According	  to	  Elliot	  et	  al.,	  (2005)	  “trauma	  survivors	  are	  the	  majority	  of	  clients	  in	  human	  service	  systems”	  (p.	  462).	  Despite	  its	  prevalence	  and	  impact,	  trauma	  often	  goes	  unrecognized	  or	  is	  denied	  in	  health	  care	  (Elliott	  et	  al.,	  2005;	  Liebschutz	  et	  al.,	  2007).	  Trauma	  symptoms	  may	  interfere	  with	  care	  or	  cause	  survivors	  to	  avoid	  care	  out	  of	  a	  fear	  of	  being	  re-­‐traumatized	  (Elliot	  et	  al.,	  2005).	  This	  has	  led	  to	  a	  call	  to	  make	  health	  settings	  “trauma-­‐informed.”	  	  Trauma-­‐informed	  care	  (TIC)	  Although	  there	  is	  no	  one	  model	  of	  TIC,	  Hopper	  et	  al.,	  (2010)	  synthesized	  the	  following	  consensus-­‐based	  definition	  from	  themes	  in	  the	  literature:	  	  	  Trauma-­‐informed	  care	  is	  a	  strengths-­‐based	  framework	  that	  is	  grounded	  in	  an	  understanding	  of	  and	  responsiveness	  to	  the	  impact	  of	  trauma,	  that	  emphasizes	  physical,	  psychological,	  and	  emotional	  safety	  for	  both	  providers	  and	  survivors,	  and	  that	  creates	  opportunities	  for	  survivors	  to	  rebuild	  a	  sense	  of	  control	  and	  empowerment.	  (p.	  82).	  	  TIC	  is	  distinct	  from	  trauma-­‐specific	  services	  (TSS)	  such	  as	  psychotherapy	  or	  trauma	  counseling	  offered	  by	  specialists	  (Harris	  &	  Fallot,	  2001).	  In	  fact,	  TIC	  is	  meant	  as	  an	  overarching	  “paradigm	  shift”	  for	  all	  staff	  in	  an	  organization	  -­‐	  from	  receptionists	  to	  administrators	  to	  clinicians	  -­‐	  challenging	  them	  to	  incorporate	  an	  understanding	  of	  trauma	  into	  their	  work	  (Harris	  &	  Fallot,	  2001).	  Principles	  of	  TIC	  include	  an	  awareness	  of	  the	  impacts	  of	  trauma;	  an	  emphasis	  on	  safety;	  relationships	  of	  trust	  and	  respect;	  greater	  integration	  of	  services;	  increased	  access	  to	  and	  engagement	  with	  services;	  	   11	  attention	  to	  cultures	  and	  contexts;	  family-­‐centered	  services;	  and	  the	  use	  of	  an	  empowerment	  model	  that	  solicits	  guidance	  and	  feedback	  from	  trauma	  survivors	  (Drabble,	  Jones	  &	  Brown,	  2013;	  Elliot	  et	  al.,	  2005;	  Hopper	  et	  al.,	  2010;	  McKenzie-­‐Mohr,	  Coates	  &	  McLeod,	  2012).	  	  Best	  practices	  in	  implementing	  TIC	  include	  an	  organizational	  commitment	  to	  TIC,	  a	  “trauma	  walk	  through”	  that	  looks	  at	  the	  organization’s	  policies	  and	  day-­‐to-­‐day	  work	  through	  a	  trauma	  lens,	  trauma	  awareness	  training	  for	  all	  staff,	  follow-­‐up	  support	  and	  consultation,	  changes	  to	  hiring	  practices,	  and	  concrete	  strategies	  for	  involving	  service	  users	  in	  designing	  services	  (Drabble	  et	  al.,	  2013;	  Harris	  &	  Fallot,	  2001;	  Hopper	  et	  al.,	  2010;	  Elliot	  et	  al.,	  2005).	  TIC	  models	  have	  now	  been	  implemented	  in	  many	  settings,	  including	  mental	  health	  and	  substance	  abuse	  treatment	  services,	  homeless	  services,	  psychiatric	  inpatient	  units,	  and	  family	  courts	  (Hopper	  et	  al.,	  2010;	  Drabble	  et	  al,	  2013;	  Markoff	  et	  al.,	  2005).	  As	  research	  on	  TIC	  develops,	  preliminary	  studies	  suggest	  that	  TIC	  improves	  health	  outcomes,	  is	  cost	  effective,	  and	  is	  highly	  valued	  by	  both	  staff	  and	  service	  users	  (Hopper	  et	  al.,	  2010).	  	  Structural	  violence	  and	  ongoing	  interpersonal	  violence:	  the	  “V”	  in	  trauma-­‐	  and	  violence-­‐	  informed	  care	  The	  EQUIP	  TVIC	  curriculum	  builds	  on	  existing	  trauma-­‐informed	  models,	  but	  makes	  explicit	  reference	  to	  violence-­‐informed	  care.	  This	  draws	  attention	  to	  the	  traumatic	  effects	  of	  ongoing	  violence,	  including	  structural	  violence	  (Browne	  et	  al.,	  2015).	  Primary	  health	  care	  recipients	  may	  be	  both	  ‘survivors’	  of	  various	  forms	  of	  	   12	  violence	  with	  traumatic	  effects,	  and	  experiencing	  current	  and	  ongoing	  interpersonal	  violence	  (including	  intimate	  partner	  violence,	  interpersonal	  racial	  violence)	  and	  ongoing	  structural	  violence,	  including	  systemic	  and	  organizational	  racism,	  absolute	  poverty,	  and	  other	  forms	  such	  as	  colonialism	  (Browne	  et	  al.,	  2015).	  Farmer	  (2006)	  describes	  structural	  violence	  as	  “social	  structures—economic,	  political,	  legal,	  religious,	  and	  cultural—that	  stop	  individuals,	  groups,	  and	  societies	  from	  reaching	  their	  full	  potential”	  (Farmer,	  2006,	  Box	  1).	  Trauma-­‐and	  violence-­‐informed	  approaches	  are	  those	  that	  acknowledge	  that	  violence	  is	  not	  only	  in	  clients’	  pasts,	  but	  may	  be	  an	  ongoing	  part	  of	  their	  lives.	  Such	  an	  approach	  also	  highlights	  the	  impacts	  of	  trauma	  and	  violence	  beyond	  the	  level	  of	  individual	  pathologies,	  such	  as	  PTSD	  (Ponic	  et	  al.,	  in	  press).	  Browne	  et	  al.	  (2012)	  give	  the	  following	  example	  of	  a	  trauma-­‐	  and	  violence-­‐	  informed	  approach	  taken	  at	  a	  health	  centre:	  “in	  recognition	  of	  the	  devaluing	  of	  Aboriginal	  culture	  as	  a	  result	  of	  Canada’s	  colonial	  history,	  one	  of	  the	  Centres	  featured	  signage	  in	  a	  local	  Indigenous	  dialect	  to	  convey	  a	  valuing	  of	  Aboriginal	  identity”	  (p.	  11).	  	  	  Health	  care	  staff	  orientation	  and	  training	  on	  trauma	  and	  violence	  	  Training	  on	  violence	  has	  been	  shown	  to	  increase	  clinicians’	  confidence,	  knowledge	  and	  efficacy	  in	  providing	  care	  for	  patients	  who	  have	  experienced	  violence	  (Baird,	  Salmon	  &	  White,	  2013;	  Edwardsen,	  Dichter,	  Walsh	  &	  Cirulli,	  2011).	  However,	  health	  professional	  training	  and	  continuing	  education	  curricula	  vary	  widely	  in	  their	  coverage	  of	  the	  topics	  of	  trauma	  and	  violence	  (Wathen,	  2009).	  For	  example,	  a	  study	  of	  931	  physicians	  and	  nurses	  in	  Ontario	  found	  that	  over	  60%	  reported	  they	  had	  no	  formal	  training	  on	  dealing	  with	  patients	  who	  have	  experienced	  intimate	  partner	  violence	  (IPV)	  	   13	  (Gutmanis,	  Beynon,	  Tutty,	  Wathen	  &	  MacMillan,	  2007).	  Conversely,	  a	  study	  of	  232	  American	  pediatric	  nurses	  found	  that	  nurses	  were	  knowledgeable	  about	  and	  favourable	  toward	  trauma-­‐informed	  care,	  and	  showed	  the	  most	  variability	  in	  their	  confidence	  in	  teaching	  clients	  about	  trauma	  (Kassam-­‐Adams	  et	  al.,	  2015).	  	  Staff	  training	  in	  the	  prevalence	  and	  effects	  of	  trauma	  and	  the	  principles	  of	  TIC	  is	  a	  fundamental	  step	  in	  creating	  trauma-­‐informed	  services	  (Elliot	  et	  al.,	  2005;	  Harris	  &	  Fallot,	  2001;	  Hopper	  et	  al.,	  2010).	  Elliot	  et	  al.,	  (2005)	  specifically	  recommend	  that	  basic	  training	  on	  trauma	  for	  all	  staff	  is	  a	  priority	  over	  specialized	  trauma	  training	  for	  clinicians.	  Brown,	  Harris	  &	  Fallot	  (2013)	  and	  Drabble	  et	  al.,	  (2013)	  advocate	  a	  “trauma	  walk-­‐through”	  as	  a	  collaborative,	  non-­‐judgemental	  approach	  to	  improving	  practice	  and	  making	  trauma-­‐	  informed	  organizational	  change.	  A	  2015	  study	  found	  that	  health	  staff	  trained	  on	  the	  use	  of	  a	  tool	  for	  screening	  and	  intervening	  for	  IPV	  and	  reproductive	  coercion	  both	  “value	  and	  struggle	  with”	  using	  the	  tool	  in	  practice	  (Burton	  &	  Carlyle,	  2015).	  Staff	  in	  this	  study	  recommended	  “reminders”	  and	  “championing”	  as	  strategies	  in	  improve	  the	  training	  (Burton	  &	  Carlyle,	  2015).	  A	  2012	  Cochrane	  review	  of	  81	  trials	  on	  the	  impacts	  of	  continuing	  education	  meetings	  and	  workshops	  in	  medicine	  found	  that	  meetings	  and	  workshops	  can	  improve	  practice,	  but	  are	  likely	  to	  have	  small	  effects,	  and	  that	  “educational	  meetings	  alone	  are	  not	  likely	  to	  be	  effective	  for	  changing	  complex	  behaviours”	  (Forsetlund	  et	  al.,	  2012,	  p.	  2).	  	  Summary	  	   In	  this	  review	  of	  the	  literature,	  I	  have	  outlined	  concepts	  relevant	  to	  TVIC	  and	  reviewed	  previous	  studies	  on	  trauma-­‐informed-­‐care.	  This	  literature	  review	  reveals	  	   14	  several	  gaps	  in	  our	  knowledge	  about	  trauma-­‐	  and	  violence-­‐informed	  care.	  First,	  trauma-­‐informed	  approaches	  have	  been	  implemented	  in	  specialized	  mental	  health,	  addictions	  and	  court	  settings,	  but	  little	  is	  said	  about	  the	  adoption	  of	  TIC	  in	  primary	  care,	  general	  healthcare	  settings	  or	  in	  nursing.	  Second,	  existing	  trauma-­‐informed	  approaches	  have	  been	  largely	  focused	  on	  improving	  care	  for	  individual	  clients	  who	  are	  known	  survivors	  of	  past	  trauma.	  Little	  is	  known	  about	  how	  to	  equip	  health	  care	  practitioners	  to	  address	  ongoing	  or	  structural	  violence.	  Finally,	  as	  Drabble	  et	  al.	  (2013)	  point	  out,	  there	  is	  a	  need	  for	  studies	  that	  explore	  the	  outcomes	  of	  trauma-­‐informed	  systems	  change,	  from	  the	  perspectives	  of	  both	  service	  providers	  and	  service	  users.	  	  EQUIP	  researchers	  have	  drawn	  on	  the	  literature	  on	  inequities,	  trauma-­‐	  informed	  care,	  and	  structural	  violence	  to	  develop	  TVIC	  orientation	  and	  training	  sessions	  for	  staff	  working	  in	  primary	  care.	  My	  own	  secondary	  study	  of	  interviews	  with	  participating	  PHC	  staff	  explores	  their	  perspectives	  on	  the	  impacts	  of	  these	  sessions,	  what	  influences	  these	  impacts,	  and	  what	  this	  can	  teach	  us	  about	  future	  implementations	  of	  TVIC	  in	  health	  care	  settings.	  	  	  	   	  	   15	  Chapter	  Three:	  Research	  Design	  	   In	  the	  previous	  chapter	  I	  reviewed	  the	  literature	  that	  relates	  to	  TVIC	  and	  the	  TVIC	  curriculum	  being	  studied	  here.	  In	  this	  chapter	  I	  outline	  the	  design	  of	  my	  research	  project.	  I	  describe	  the	  critical	  social	  justice	  framework	  and	  constructivist	  learning	  theory	  that	  underpin	  my	  study.	  I	  then	  describe	  my	  sample,	  recruitment	  and	  data	  collection	  methods.	  	  Finally	  I	  explain	  the	  interpretive	  description	  approach	  I	  took	  to	  analyzing	  the	  data,	  the	  efforts	  I	  made	  to	  ensure	  the	  quality	  of	  my	  findings,	  and	  some	  of	  the	  limitations	  of	  this	  study.	  	  Theoretical	  framework	  As	  outlined	  in	  chapter	  one,	  my	  study	  was	  a	  secondary	  analysis	  of	  data	  from	  the	  EQUIP	  study,	  and	  my	  approach,	  methods	  and	  findings	  remain	  connected	  to	  the	  other	  components	  of	  the	  larger	  study.	  The	  EQUIP	  study	  as	  a	  whole	  is	  grounded	  in	  critical	  social	  theory,	  feminist	  intersectionality,	  and	  complexity	  theories	  (Browne	  et	  al.,	  2015).	  These	  approaches	  have	  informed	  the	  development	  and	  implementation	  of	  the	  TVIC	  curriculum.	  In	  particular,	  this	  theoretical	  grounding	  necessitates	  a	  focus	  on	  structural	  violence	  and	  the	  contribution	  that	  violence	  makes	  to	  trauma	  and	  health	  inequities	  (Browne	  et	  al.,	  2015).	  	  Similarly,	  my	  secondary	  study	  adopts	  a	  social	  justice	  perspective	  based	  on	  critical	  social	  theory	  (Kirkham	  &	  Browne,	  2006).	  A	  social	  justice	  perspective	  attends	  to	  fair	  distribution	  of	  benefits,	  burdens,	  and	  representation	  of	  groups	  in	  society	  (Rawls,	  1971).	  It	  prioritizes	  the	  needs	  and	  voices	  of	  people	  who	  are	  most	  socially	  and	  	   16	  economically	  disadvantaged,	  while	  attending	  to	  social	  systems	  and	  structures,	  in	  particular	  focusing	  on	  health	  inequities (Bell,	  2007;	  Kirkham	  &	  Browne,	  2006). Emphasis	  is	  placed	  on	  the	  experience	  of	  people	  as	  situated	  in	  social	  groups,	  on	  the	  structural	  causes	  of	  inequities	  and	  harms,	  and	  on	  changes	  that	  can	  be	  made	  at	  a	  systemic	  level	  (Kirkham	  &	  Browne,	  2006).	  	  I	  also	  drew	  on	  constructivist	  learning	  theory	  to	  design	  my	  evaluation	  of	  the	  EQUIP	  TVIC	  orientation	  and	  training.	  Constructivist	  learning	  theory	  sees	  all	  learning	  as	  “context-­‐bound,”	  with	  learners	  incorporating	  new	  knowledge	  into	  existing	  mental	  constructs	  (Vandeveer	  &	  Norton,	  2005).	  In	  keeping	  with	  constructivist	  approaches,	  this	  study	  examines	  the	  impacts	  of	  the	  TVIC	  orientation	  and	  training	  and	  also	  the	  context	  for	  staff	  learning	  about	  TVIC	  and	  implementing	  what	  they	  learn	  in	  practice.	  	  Research	  approach	  In	  this	  study	  I	  was	  interested	  in	  examining	  the	  perspectives	  of	  staff	  on	  the	  impacts	  of	  the	  TVIC	  orientation	  and	  training.	  Through	  an	  analysis	  of	  qualitative	  interviews	  with	  staff	  members,	  I	  had	  an	  opportunity	  to	  learn	  about	  the	  staff	  members’	  perspectives	  on	  the	  impacts	  of	  the	  TVIC	  sessions,	  exploring	  how	  this	  training	  brought	  about	  some	  of	  these	  impacts,	  and	  what	  influenced	  these	  outcomes.2	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  2	  Concurrent	  to	  the	  qualitative	  interviews,	  EQUIP	  collected	  quantitative	  survey	  data	  on	  the	  impacts	  of	  this	  training	  for	  staff	  members,	  which	  showed	  some	  statistically	  significant	  increases	  in	  staff’s	  self-­‐reported	  knowledge,	  confidence	  and	  attitudes	  about	  	   17	  I	  took	  an	  interpretive	  description	  approach	  to	  this	  study.	  Interpretive	  description	  is	  a	  qualitative	  research	  approach	  that	  was	  developed	  to	  examine	  practice-­‐based	  questions	  in	  the	  applied	  health	  disciplines	  (Thorne,	  2008).	  According	  to	  Thorne,	  Kirkham	  and	  McDonald-­‐Emes	  (1997),	  this	  approach	  “acknowledges	  the	  constructed	  and	  contextual	  nature	  of	  much	  of	  the	  health–illness	  experience,	  yet	  also	  allows	  for	  shared	  realities.”	  (p.	  172).	  I	  felt	  this	  was	  a	  useful	  research	  approach	  that	  could	  combine	  a	  social-­‐justice	  based,	  constructivist	  lens	  with	  a	  method	  to	  develop	  insights	  about	  “what	  nursing	  can	  do	  to	  make	  a	  difference”	  (Thorne	  et	  al.,	  1997,	  p.173).	  	  Although	  I	  was	  studying	  the	  impacts	  of	  TVIC	  orientation	  and	  training	  on	  a	  multidisciplinary	  PHC	  team,	  the	  insights	  gained	  about	  how	  staff	  take	  up	  TVIC	  concepts	  can	  inform	  nursing	  practice	  in	  many	  settings.	  Setting	  for	  study	  The	  EQUIP	  study	  was	  implemented	  at	  four	  primary	  health	  clinics	  in	  two	  provinces.	  This	  secondary	  analysis	  analyzes	  data	  from	  interviews	  with	  staff	  members	  from	  the	  two	  British	  Columbia	  sites.	  Both	  of	  these	  sites	  are	  “inner-­‐city”	  primary	  care	  clinics	  that	  offer	  multidisciplinary	  services	  to	  patients	  who	  face	  barriers	  to	  health	  care	  such	  as	  poverty,	  homelessness,	  substance	  use,	  and	  other	  forms	  of	  marginalization	  (Browne	  et	  al.,	  2015).	  These	  sites	  operate	  within	  not-­‐for-­‐profit	  societies,	  and	  their	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  trauma	  and	  violence	  following	  the	  EQUIP	  intervention	  (Browne,	  Varcoe,	  Ford-­‐Gilboe	  &	  Wathen,	  in	  progress).	  	   18	  funding	  comes	  from	  regional	  health	  authorities,	  other	  funders,	  and	  from	  directly	  billing	  for	  services	  from	  provincial	  Ministries	  of	  Health	  (Browne	  et	  al,	  2015).	  	  Sampling	  and	  recruitment	  For	  this	  analysis	  I	  drew	  on	  a	  subsample	  of	  EQUIP’s	  data	  from	  interviews	  with	  staff	  members	  at	  the	  two	  British	  Columbia	  (BC)	  sites	  in	  EQUIP.	  I	  chose	  the	  sites	  in	  BC	  because	  I	  was	  able	  to	  visit	  them,	  participate	  in	  EQUIP	  data	  collection,	  observe	  one	  of	  the	  TVIC	  sessions	  and	  personally	  conduct	  interviews	  with	  staff.	  EQUIP	  investigators	  and	  research	  assistants	  (of	  which	  I	  was	  one)	  conducted	  semi-­‐structured	  interviews	  with	  nineteen	  staff	  members	  from	  these	  sites.	  Staff	  members	  were	  recruited	  by	  purposive	  sampling	  for	  a	  variety	  of	  disciplines	  and	  levels	  of	  involvement	  with	  EQUIP:	  all	  of	  the	  staff	  were	  invited	  to	  participate	  in	  qualitative	  interviews	  by	  EQUIP	  through	  an	  invitation	  letter	  sent	  out	  by	  the	  administrative	  leaders	  at	  each	  site.	  Staff	  were	  also	  invited	  to	  participate	  in	  person	  at	  staff	  meetings.	  Because	  the	  EQUIP	  team	  were	  interested	  in	  the	  impact	  of	  this	  education	  on	  staff	  coming	  from	  various	  backgrounds,	  EQUIP	  researchers	  attempted	  to	  interview	  staff	  from	  as	  many	  different	  disciplines	  as	  possible.	  	  I	  chose	  to	  analyze	  seven	  interviews	  from	  each	  site	  from	  the	  EQUIP	  data	  set.	  I	  chose	  these	  particular	  interviews	  though	  an	  iterative	  process	  that	  was	  ongoing	  during	  my	  analysis.	  Guided	  by	  my	  supervisors,	  I	  initially	  looked	  at	  interviews	  with	  participants	  who	  had	  been	  heavily	  involved	  in	  EQUIP	  at	  each	  site,	  and	  who	  could	  provide	  rich	  data	  on	  their	  experience	  in	  the	  study.	  As	  my	  analysis	  proceeded,	  I	  looked	  for	  cases	  	   19	  (particularly	  from	  different	  sites	  and	  disciplines)	  that	  could	  confirm	  or	  contradict	  the	  patterns	  that	  I	  was	  finding	  in	  the	  data	  (Thorne,	  2008).	  	  Study	  sample	  	   The	  final	  sample	  for	  this	  study	  is	  comprised	  of	  fourteen	  staff	  from	  a	  wide	  variety	  of	  disciplines	  in	  primary	  care,	  including	  medicine,	  nursing,	  pharmacy,	  social	  work,	  counseling,	  administration	  and	  leadership.	  Ten	  of	  the	  staff	  interviewed	  were	  full	  time	  employees	  and	  four	  were	  part-­‐time	  employees	  at	  the	  clinics.	  Twelve	  of	  the	  staff	  in	  the	  sample	  were	  female	  and	  two	  were	  male.	  There	  was	  a	  wide	  variation	  in	  how	  long	  staff	  had	  worked	  in	  the	  clinics	  with	  an	  average	  length	  of	  seven	  years	  (range:	  1-­‐14	  years).	  One	  staff	  member	  in	  the	  sample	  self-­‐identified	  as	  Aboriginal.	  Data	  collection	  method	  Qualitative	  data	  were	  collected	  through	  semi-­‐structured	  interviews	  with	  staff	  conducted	  ten	  to	  twelve	  months	  after	  the	  implementation	  of	  the	  EQUIP	  TVIC	  sessions.	  Interviews	  lasted	  approximately	  sixty	  minutes	  and	  took	  place	  at	  each	  PHC	  centre.	  Working	  with	  the	  EQUIP	  team,	  I	  developed	  prompts	  for	  the	  interview	  guide	  about	  the	  TVIC	  session	  and	  its	  impacts.	  These	  were	  embedded	  in	  an	  interview	  schedule	  covering	  the	  entire	  EQUIP	  intervention,	  including	  education	  on	  TVIC,	  Equity	  and	  Indigenous	  Cultural	  Safety,	  and	  the	  process	  of	  Organizational	  Integration	  and	  Tailoring	  (OIT).	  I	  personally	  conducted	  seven	  of	  the	  interviews	  in	  my	  role	  as	  an	  EQUIP	  research	  assistant	  and	  other	  research	  assistants	  or	  the	  EQUIP	  primary	  investigators	  conducted	  the	  other	  seven	  interviews.	  Analysis	  and	  data	  collection	  occurred	  concurrently.	  Thus,	  as	  I	  conducted	  and/or	  listened	  to	  recorded	  interviews	  I	  began	  to	  develop	  hunches	  and	  	   20	  ideas	  about	  the	  data.	  This	  led	  me	  to	  seek	  out	  participants	  from	  different	  sites	  and	  disciplines	  and	  probe	  on	  certain	  questions	  in	  subsequent	  interviews.	  Along	  with	  the	  EQUIP	  team,	  I	  revised	  the	  interview	  schedule	  between	  conducting	  interviews	  at	  the	  first	  site	  and	  the	  second	  (See	  Appendix	  A:	  Interview	  Guide).	  Data	  analysis	  Qualitative	  interviews	  were	  recorded,	  transcribed	  verbatim	  and	  checked	  for	  accuracy.	  I	  then	  read	  through	  all	  of	  the	  data	  line	  by	  line,	  making	  memos	  of	  units	  of	  meaning.	  As	  I	  began	  to	  notice	  patterns	  in	  the	  data,	  I	  noted	  potential	  theoretical	  codes	  in	  the	  margins	  as	  well.	  After	  two	  initial	  passes	  through	  the	  data,	  I	  wrote	  a	  summary	  of	  each	  interview	  that	  captured	  the	  gestalt	  of	  the	  interview	  from	  each	  participant,	  paying	  attention	  to	  anything	  that	  was	  related	  to	  my	  phenomenon	  of	  interest:	  the	  outcomes	  of	  TVIC	  training	  in	  PHC	  practice.	  I	  then	  worked	  with	  the	  summaries	  and	  the	  list	  of	  preliminary	  theoretical	  codes,	  asking	  myself	  “what	  is	  going	  on	  here?”.	  	  I	  developed	  a	  preliminary	  diagram	  of	  my	  analysis	  of	  the	  data	  from	  each	  site.	  I	  initially	  represented	  three	  main	  themes	  -­‐	  “Context”,	  “EQUIP	  intervention”,	  and	  “TVIC	  impacts”	  -­‐	  as	  three	  intersecting	  “gears”.	  I	  then	  essentially	  started	  over.	  Building	  on	  the	  scaffolding	  provided	  by	  the	  EQUIP	  theory,	  I	  revised	  my	  research	  questions	  to	  focus	  on	  the	  impacts	  of	  the	  TVIC	  session,	  the	  contextual	  influences	  on	  these	  impacts,	  and	  the	  implications	  for	  the	  future.	  I	  went	  back	  and	  coded	  the	  interviews	  and	  the	  summaries	  again.	  To	  get	  beyond	  the	  semantic	  level	  of	  what	  participants	  were	  saying,	  I	  asked,	  “What	  is	  this	  an	  example	  of?”	  for	  each	  code.	  I	  began	  trying	  to	  organize	  an	  outline	  of	  what	  I	  saw	  as	  the	  most	  	   21	  important	  themes,	  asking	  myself	  “What	  ideas	  are	  starting	  to	  take	  shape	  such	  that	  I	  think	  they	  will	  have	  to	  have	  a	  place	  in	  my	  final	  analysis	  if	  it	  is	  to	  do	  justice	  to	  the	  research	  question?”	  (Thorne,	  2008,	  p.	  160).	  This	  iterative	  process	  of	  refining	  and	  revising	  my	  themes	  and	  subthemes	  continued	  as	  I	  began	  to	  articulate	  in	  writing	  what	  I	  had	  learned	  from	  the	  data.	  	  Assessing	  Validity	  in	  Qualitative	  Analysis	  	   I	  made	  several	  efforts	  to	  ensure	  the	  validity	  of	  this	  study.	  Although	  the	  issue	  of	  validity	  in	  qualitative	  research	  remains	  a	  topic	  of	  intense	  debate,	  it	  is	  important	  for	  qualitative	  nurse-­‐researchers	  to	  ensure	  that	  their	  conclusions	  go	  beyond	  mere	  “opinions”	  and	  represent	  some	  credible	  knowledge	  useful	  to	  the	  discipline	  of	  nursing	  (Thorne,	  2008).	  Several	  authors	  have	  advanced	  criteria	  for	  ensuring	  and	  assessing	  the	  quality	  of	  qualitative	  research.	  For	  this	  study,	  I	  took	  Whittemore,	  Chase	  and	  Mandle’s	  (2001)	  synthesis	  of	  validity	  criteria	  as	  a	  guide.	  I	  employed	  techniques	  to	  address	  Whittemore	  et	  al.’s	  (2001)	  four	  primary	  criteria	  of	  validity:	  credibility,	  authenticity,	  criticality,	  and	  integrity.	  Whittemore	  et	  al.	  (2001)	  further	  synthesized	  several	  secondary	  criteria	  that	  may	  be	  applied	  in	  a	  more	  flexible	  way	  depending	  on	  the	  nature	  of	  the	  study.	  In	  this	  study	  about	  the	  impacts	  of	  TVIC	  orientation	  and	  training	  for	  PHC	  staff,	  it	  was	  important	  to	  focus	  on	  secondary	  criteria	  of	  thoroughness	  and	  congruence.	  I	  have	  also	  considered	  some	  additional	  criteria	  suggested	  by	  Thorne	  (2008):	  moral	  defensibility,	  disciplinary	  relevance	  and	  pragmatic	  application.	  	  Credibility	  	   22	  Credibility	  in	  qualitative	  research	  refers	  to	  whether	  the	  data,	  interpretations	  and	  conclusions	  are	  represented	  in	  a	  manner	  that	  is	  believable	  (Whittemore	  et	  al.,	  2001).	  I	  employed	  techniques	  of	  data	  triangulation	  to	  enhance	  credibility	  in	  my	  study	  on	  TVIC,	  seeking	  data	  from	  multiple	  informants	  from	  multiple	  sites	  and	  disciplines.	  I	  was	  able	  to	  continually	  check	  the	  themes	  I	  was	  developing	  against	  confirming	  or	  contradictory	  data	  by	  engaging	  in	  constant	  comparative	  analysis	  and	  by	  memo-­‐ing	  and	  maintaining	  a	  clear	  audit	  trail.	  I	  worked	  to	  refrain	  from	  making	  truth	  or	  generalizability	  claims	  based	  on	  the	  experiences	  of	  this	  limited	  sample	  of	  participants.	  Finally,	  credibility	  of	  the	  analysis	  was	  assessed	  by	  inviting	  my	  thesis	  committee	  members	  to	  analyze	  some	  of	  the	  interviews	  with	  a	  view	  to	  discussing	  different	  “readings”	  of	  the	  data,	  and	  working	  toward	  a	  shared	  understanding	  of	  how	  to	  make	  sense	  of	  the	  themes	  represented	  in	  the	  data.	  	  Authenticity	  	   Authenticity	  refers	  to	  the	  extent	  to	  which	  a	  researcher	  faithfully	  represents	  the	  multiple	  realities	  and	  voices	  of	  the	  participants	  (Whittemore,	  2001).	  According	  to	  Whittemore	  et	  al.,	  (2001),	  “multiple,	  socially	  constructed,	  and	  sometimes	  conflicting	  realities	  may	  ultimately	  be	  exposed	  through	  attention	  to	  authenticity.”	  (p.	  530).	  To	  maintain	  authenticity	  in	  this	  study,	  I	  continually	  reflected	  on	  my	  own	  social	  location	  and	  the	  positionality	  of	  each	  of	  the	  participants,	  considering	  what	  this	  revealed	  about	  how	  TVIC	  concepts	  are	  taken	  up	  in	  different	  contexts.	  I	  worked	  to	  hold	  myself	  back	  from	  wrapping	  my	  findings	  up	  into	  a	  “tidy	  package”	  that	  would	  obscure	  the	  multiple	  experiences	  of	  this	  intervention.	  	   23	  Criticality	  	  	   Restraining	  myself	  from	  a	  “tidy”	  interpretation	  of	  the	  impacts	  of	  this	  curriculum	  also	  contributed	  to	  criticality	  in	  this	  study.	  In	  order	  to	  ensure	  that	  I	  was	  reflecting	  critically	  on	  my	  own	  analytical	  hunches	  and	  theories,	  I	  kept	  memos,	  notes	  and	  journals	  tracking	  my	  ideas	  and	  my	  preconceptions.	  I	  considered	  alternative	  hypotheses,	  sought	  contradictory	  cases,	  and	  at	  one	  point	  started	  my	  analysis	  over	  almost	  from	  scratch.	  	  Integrity	  	  	   The	  criterion	  of	  integrity	  relies	  on	  the	  researcher’s	  capacity	  to	  interrogate	  and	  critique	  her	  own	  analysis.	  	  While	  a	  researcher’s	  own	  thoughts	  and	  ideas	  are	  integral	  to	  qualitative	  analysis,	  a	  study	  demonstrating	  integrity	  must	  build	  in	  checks	  to	  ensure	  the	  analysis	  remains	  grounded	  in	  the	  data	  rather	  than	  in	  the	  preconceptions	  of	  the	  researcher.	  In	  this	  study	  I	  maintained	  an	  audit	  trail	  of	  my	  memos,	  codes	  and	  ideas	  so	  that	  anyone	  can	  clearly	  follow	  how	  I	  arrived	  at	  my	  final	  set	  of	  themes	  and	  subthemes.	  	  Thoroughness	  	   The	  criterion	  of	  thoroughness	  refers	  to	  how	  effectively	  the	  researcher	  is	  able	  to	  answer	  the	  research	  question	  through	  adequate	  sampling	  and	  data	  collection	  and	  an	  in-­‐depth	  analysis	  that	  can	  explore	  the	  connections	  between	  themes	  (Whittemore	  et	  al.,	  2001).	  In	  order	  to	  enhance	  thoroughness	  in	  this	  study,	  I	  sought	  a	  relatively	  large	  and	  diverse	  sample	  from	  two	  PHC	  sites.	  In	  analyzing	  my	  themes,	  I	  pushed	  beyond	  my	  initially	  simplistic	  diagram	  of	  themes	  and	  subthemes	  to	  find	  connections	  among	  themes.	  	   24	  Congruence	  	   Congruence	  refers	  to	  the	  fit	  between	  the	  researcher’s	  approach,	  the	  research	  question,	  the	  research	  methods,	  and	  the	  conclusions	  (Whittemore	  et	  al.,	  2001).	  In	  this	  study	  I	  worked	  to	  bring	  a	  social	  justice	  and	  constructivist	  perspective	  to	  a	  question	  about	  the	  impacts	  and	  implication	  of	  TVIC	  education	  in	  primary	  care.	  This	  approach	  led	  me	  to	  seek	  out	  and	  take	  note	  of	  data	  about	  social	  location,	  power,	  voice,	  and	  context.	  I	  took	  an	  interpretive	  description	  approach	  to	  my	  research	  questions,	  seeking	  results	  that	  could	  answer	  pragmatic	  questions	  about	  how	  TVIC	  education	  can	  be	  done	  well.	  Although	  my	  aim	  was	  not	  to	  generalize	  my	  findings	  as	  in	  quantitative	  studies,	  my	  hope	  is	  that	  I	  have	  arrived	  at	  conclusions	  that	  can	  influence	  future	  practice	  in	  other	  settings.	  Moral	  defensibility,	  disciplinary	  relevance	  and	  pragmatic	  application	  	   In	  addition	  to	  considering	  criteria	  for	  quality,	  Thorne	  (2008)	  calls	  for	  a	  critique	  of	  research	  products	  in	  terms	  of	  their	  moral	  defensibility,	  disciplinary	  relevance	  and	  pragmatic	  application,	  among	  other	  criteria.	  As	  I	  understand	  them,	  these	  three	  imperatives	  ask	  certain	  questions	  of	  any	  piece	  of	  research:	  Why	  do	  we	  need	  this	  knowledge?	  What	  do	  we	  plan	  to	  do	  with	  it?	  What	  good	  could	  come	  out	  of	  it?	  How	  is	  it	  of	  use	  to	  nursing?	  What	  new	  angle	  does	  it	  offer	  on	  practice?	  What	  would	  be	  the	  implications	  of	  applying	  this	  knowledge?	  These	  criteria	  were	  very	  much	  in	  my	  mind	  at	  every	  stage	  of	  this	  study.	  	  I	  am	  a	  practicing	  nurse,	  nurse	  educator	  and	  researcher.	  I	  have	  been	  working	  with	  populations	  marginalized	  by	  poverty,	  racism	  and	  discrimination	  for	  the	  last	  15	  years.	  My	  goal	  in	  doing	  this	  study,	  above	  all,	  was	  for	  my	  small	  piece	  of	  research	  to	  	   25	  contribute	  in	  some	  useful	  way	  toward	  reducing	  inequities.	  This	  goal	  drew	  me	  to	  work	  on	  the	  EQUIP	  study	  and	  to	  work	  on	  a	  secondary	  analysis	  rather	  than	  produce	  primary	  research.	  Working	  this	  way	  created	  some	  wonderful	  opportunities	  and	  also	  some	  limitations	  to	  my	  ability	  to	  design	  an	  “ideal”	  study.	  In	  the	  end,	  my	  hope	  is	  that	  asking	  about	  how	  to	  do	  TVIC	  well	  and	  connecting	  my	  research	  to	  the	  ongoing	  research	  program	  of	  my	  supervisors	  means	  that	  this	  work	  will	  do	  more	  than	  just	  advance	  my	  own	  capacity	  to	  do	  research.	  I	  hope	  that	  this	  study	  can	  contribute	  to	  implementing	  TVIC	  in	  other	  sites	  in	  the	  future.	  Limitations	  There	  are	  several	  limitations	  to	  this	  study	  that	  should	  be	  taken	  into	  account.	  First,	  this	  study	  draws	  from	  a	  small	  sample	  of	  staff	  in	  two	  particular	  clinics.	  Small	  samples	  like	  this	  one	  are	  not	  uncommon	  in	  qualitative	  research,	  which	  aims	  to	  gain	  in-­‐depth	  insights	  into	  the	  nature	  of	  the	  phenomenon	  under	  study	  rather	  than	  to	  prove	  or	  disprove	  a	  hypothesis	  (Thorne,	  2008).	  In	  this	  case	  my	  aim	  was	  to	  explore	  how	  and	  why	  orientation	  and	  training	  on	  TVIC	  impacted	  these	  participants	  with	  an	  eye	  to	  improving	  future	  efforts	  at	  TVIC.	  With	  this	  in	  mind	  I	  sought	  a	  sufficiently	  large	  and	  varied	  sample	  to	  synthesize	  a	  meaningful	  description	  of	  the	  impacts	  of	  this	  these	  TVIC	  sessions	  for	  different	  individuals,	  sites,	  and	  disciplines.	  A	  second	  limitation	  is	  that	  although	  the	  larger	  EQUIP	  intervention	  is	  a	  multi-­‐year	  study,	  this	  secondary	  study	  is	  limited	  to	  interviews	  at	  one	  time	  point	  only,	  representing	  a	  limited	  engagement	  in	  the	  field.	  Follow-­‐up	  interviews	  might	  have	  revealed	  more	  information	  about	  the	  longer-­‐term	  impacts	  of	  the	  TVIC	  sessions.	  	   26	  However,	  I	  was	  able	  to	  get	  a	  broader	  sense	  of	  the	  context	  at	  these	  sites	  by	  observing	  one	  of	  the	  TVIC	  sessions,	  visiting	  each	  site,	  and	  participating	  in	  data	  collection	  for	  EQUIP	  more	  generally	  (including	  conducting	  some	  of	  the	  client	  surveys).	  This	  analysis	  is	  limited	  by	  my	  own	  inexperience	  as	  a	  researcher.	  Thorne	  (2008)	  writes	  that	  in	  good	  qualitative	  analysis,	  “findings	  never	  ‘emerge’	  from	  the	  data	  on	  their	  own,	  and	  if	  they	  are	  to	  be	  worth	  something	  in	  the	  end,	  they	  always	  come	  about	  because	  a	  human	  mind	  has	  engaged	  strategically	  and	  constructively	  in	  the	  business	  of	  active	  analysis.”(p.155).	  As	  a	  novice	  analyst,	  I	  was	  vulnerable	  to	  making	  “rookie	  mistakes”:	  jumping	  to	  premature	  conclusions,	  remaining	  at	  a	  surface	  level	  of	  analysis,	  or	  allowing	  my	  own	  biases	  to	  dominate	  my	  thinking.	  In	  particular,	  my	  disciplinary	  orientation	  and	  long	  experience	  as	  a	  community	  and	  public	  health	  nurse	  working	  in	  clinics	  very	  similar	  to	  those	  studied	  meant	  that	  I	  had	  my	  own	  preconceptions	  about	  the	  practice	  of	  the	  people	  I	  interviewed.	  I	  worked	  to	  mitigate	  this	  by	  tracking	  my	  preconceptions,	  critically	  reflecting	  and	  journaling,	  and	  seeking	  input	  from	  more	  experienced	  researchers.	  	  Finally,	  because	  the	  TVIC	  sessions	  were	  being	  implemented	  alongside	  other	  components	  of	  the	  larger	  intervention,	  it	  is	  not	  possible	  to	  tease	  out	  the	  impacts	  of	  the	  TVIC	  curriculum	  alone.	  In	  particular,	  the	  process	  of	  Organizational	  Integration	  and	  Tailoring	  is	  explicitly	  meant	  to	  integrate	  the	  three	  training	  components	  and	  catalyze	  organizational	  changes	  that	  support	  applying	  this	  training	  in	  practice.	  While	  this	  study	  focuses	  on	  the	  TVIC	  component,	  the	  sessions	  on	  TVIC	  were	  not	  meant	  as	  a	  “stand	  alone”	  component	  and	  were	  not	  implemented	  as	  such.	   27	  Summary	  	   In	  this	  chapter	  I	  have	  outlined	  the	  design	  of	  this	  research	  project.	  I	  have	  defined	  the	  theoretical	  frameworks	  of	  social	  justice	  and	  constructionism	  that	  underpin	  this	  study.	  I	  have	  described	  the	  setting	  for	  the	  study;	  sampling,	  recruitment	  and	  data	  collection	  procedures;	  and	  the	  interpretive	  description	  approach	  I	  took	  to	  data	  analysis.	  I	  have	  further	  outlined	  the	  techniques	  I	  employed	  to	  ensure	  the	  quality	  of	  my	  findings,	  and	  clarified	  some	  of	  the	  limitations	  of	  this	  study.	  In	  the	  next	  chapter,	  I	  explain	  the	  findings	  from	  my	  analysis	  of	  the	  study	  data.	   	  	   28	  Chapter	  Four:	  Findings	  This	  study	  looks	  specifically	  at	  the	  impacts	  of	  the	  TVIC-­‐related	  aspects3	  of	  the	  EQUIP	  intervention	  through	  an	  analysis	  of	  interviews	  with	  14	  staff	  members	  at	  2	  participating	  sites.	  In	  this	  analysis,	  I	  explore	  the	  impacts	  of	  the	  TVIC	  sessions	  and	  the	  possible	  influences	  on	  these	  impacts.	  In	  this	  chapter,	  I	  will	  describe	  my	  findings	  from	  this	  analysis.	  First,	  I	  explain	  the	  two	  broad	  themes	  that	  address	  my	  first	  research	  question	  about	  the	  impacts	  of	  the	  TVIC	  sessions.	  Second,	  I	  will	  describe	  the	  two	  themes	  addressing	  my	  second	  research	  question,	  which	  asks	  what	  influenced	  the	  impacts	  of	  the	  TVIC	  sessions.	  1.	  What	  are	  staff	  members’	  perspectives	  on	  the	  impacts	  of	  TVIC	  orientation	  and	  training?	  Through	  my	  analysis	  I	  identified	  two	  broad	  themes	  on	  the	  impacts	  of	  the	  TVIC	  sessions	  that	  were	  common	  across	  practitioners	  and	  sites.	  The	  first	  theme	  was	  that	  the	  TVIC	  sessions	  contributed	  to	  changes	  in	  awareness,	  knowledge	  and/or	  confidence	  about	  trauma	  and	  violence.	  The	  second	  theme	  was	  that	  these	  changes	  led	  to	  shifts	  in	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  3	  Although	  I	  look	  specifically	  at	  TVIC,	  I	  want	  to	  emphasize	  that	  orientation	  and	  training	  about	  TVIC,	  Indigenous	  Cultural	  Safety	  (ICS),	  and	  Equity,	  along	  with	  the	  process	  of	  Organizational	  Integration	  and	  Tailoring	  (OIT),	  were	  all	  interconnected	  in	  the	  EQUIP	  intervention.	  The	  impacts	  of	  these	  different	  components	  are	  similarly	  interconnected	  with	  one	  another.	  	  	  	   29	  perspective	  for	  some	  staff,	  which	  had	  impacts	  at	  multiple	  levels	  in	  participants’	  lives:	  personal,	  clinical,	  organizational	  and	  political.	  	  Enhanced	  awareness,	  knowledge,	  confidence	  about	  trauma	  and	  violence	  	  	  	   While	  the	  impact	  of	  the	  TVIC	  sessions	  varied	  greatly	  across	  different	  participants	  and	  sites,	  all	  of	  the	  staff	  described	  enhancements	  in	  their	  awareness,	  knowledge	  and/	  or	  confidence	  about	  trauma	  and	  violence.	  I	  have	  divided	  this	  broad	  theme	  into	  three	  separate	  but	  related	  subthemes:	  awareness,	  knowledge	  and	  confidence.	  Awareness:	  Putting	  trauma	  and	  violence	  “front	  and	  center”	  One	  theme	  common	  to	  all	  the	  staff	  interviewed	  was	  an	  increase	  in	  their	  awareness	  of	  trauma	  and	  violence.	  Although	  some	  staff	  were	  already	  familiar	  with	  TVIC	  concepts,	  participating	  in	  EQUIP	  raised	  the	  profile	  of	  these	  issues	  for	  them	  and	  their	  teams.	  As	  one	  physician	  explained:	  “I	  may	  have	  thought	  about	  [trauma	  and	  violence]	  but	  this	  put	  it	  more	  front	  and	  center	  for	  me,	  to	  really	  start	  noticing	  it	  when	  it	  happened.”	  However,	  some	  practitioners	  described	  increased	  awareness	  as	  having	  a	  fairly	  minor	  impact	  on	  their	  thinking	  and	  practice.	  One	  nurse	  explained;	  “I	  mean	  the	  point	  again	  that	  really	  sticks	  to	  me	  is	  the	  idea	  about	  not	  treating	  trauma	  but	  using	  it	  as	  a	  context.	  But	  beyond	  that	  I	  didn’t	  get	  a	  ton	  out	  of	  it.”	  While	  all	  of	  the	  respondents	  spoke	  of	  increases	  in	  their	  awareness	  of	  trauma	  and	  violence,	  this	  had	  profound	  impacts	  for	  some,	  and	  minor	  impacts	  for	  others.	  	   30	  Knowledge:	  Sessions	  contributed	  to	  enhanced	  knowledge	  for	  some	  staff,	  but	  did	  not	  provide	  the	  anticipated	  skills	  training	  Several	  participants	  described	  an	  increase	  in	  their	  knowledge	  about	  trauma	  and	  violence.	  This	  increase	  was	  modest	  for	  some,	  and	  for	  some	  did	  not	  match	  with	  their	  expectations	  of	  “skills	  training”	  on	  TVIC.	  For	  some	  staff,	  learning	  about	  the	  prevalence	  and	  impacts	  of	  trauma	  and	  violence	  gave	  them	  more	  information	  about	  the	  contexts	  of	  their	  clients’	  lives.	  One	  Medical	  Office	  Assistant	  (MOA)	  explained,	  	  I	  feel	  like	  I’m	  a	  very	  open	  person	  but	  I	  just	  didn’t	  realize	  all	  the	  things	  that	  have	  kind	  of	  happened,	  right?	  	  So	  going	  through	  all	  that	  I	  think	  personally	  for	  myself	  has	  made	  me	  be	  even	  more	  accepting	  of	  our	  clientele.	  Participants	  also	  commented	  on	  learning	  about	  the	  differences	  between	  the	  concepts	  of	  “equality”	  and	  “equity”:	  	  Something	  I	  think	  was	  good	  to	  learn	  was	  not	  so	  much	  about	  being	  non-­‐biased	  but	  being	  sensitive.	  	  So	  not	  to	  just	  have	  like,	  yeah,	  like	  equality	  but	  sort	  of	  being	  sensitive	  to	  the	  different	  cultural	  needs	  of,	  yeah,	  people	  as	  opposed	  to	  coming	  at	  it	  from	  just	  like	  everyone	  is	  equal	  like	  which	  isn’t	  necessarily	  the	  case.	  One	  nurse	  explained	  that	  she	  had	  already	  learned	  about	  trauma	  in	  university,	  but	  that	  EQUIP	  was	  an	  opportunity	  to	  learn	  more	  about	  structural	  violence:	  “it	  was	  good	  to	  look	  at	  [trauma	  and	  violence]	  in	  more	  detail	  and…	  look	  at	  it	  from	  a	  point	  of	  structural	  like	  what	  the	  client	  would	  perceive	  as	  structural…	  prejudices,	  roadblocks	  to	  them.”	  	  	  Some	  staff	  members	  had	  expected	  to	  come	  out	  with	  a	  more	  concrete	  “toolkit”	  for	  TVIC,	  rather	  than	  an	  orientation	  to	  concepts.	  A	  social	  worker	  said:	  	  	   31	  I	  mean	  I	  try	  to	  approach	  people	  now	  in	  a,	  with	  that	  kind	  of	  awareness	  of	  the	  trauma	  and	  structural	  violence	  kind	  of	  informed	  practice	  but	  really	  do	  I	  really	  know	  what	  that	  is	  really	  supposed	  to	  look	  like	  in	  practice?	  	  You	  know,	  maybe	  I	  need	  more	  guidance	  around	  like,	  like	  specifics.	  This	  kind	  of	  experience	  was	  particularly	  notable	  amongst	  staff	  who	  explained	  they	  were	  already	  familiar	  with	  the	  concepts	  of	  trauma,	  violence	  and	  structural	  through	  previous	  training	  or	  experience.	  	  Confidence:	  Validation,	  reinforcement,	  and	  confidence	  to	  speak	  up	  Several	  participants	  described	  TVIC	  orientation	  and	  training	  as	  a	  reinforcement	  or	  validation	  of	  their	  existing	  knowledge.	  A	  counselor	  described	  the	  impact	  as	  “validation	  that	  our	  awareness	  is	  the	  same,	  the	  EQUIP	  study	  is	  actually	  examining	  some	  of	  the	  stuff	  that	  we	  run	  into	  as	  a	  hazard,	  as	  a	  problem	  on	  a	  daily	  basis.”	  A	  nurse	  described	  how	  TVIC	  concepts	  are	  foundational	  to	  her	  approach,	  and	  said	  that	  EQUIP	  reinforced	  this:	  “I	  think	  that	  in	  the	  sense	  of	  justice,	  where	  it’s	  always	  been	  my	  foundation	  actually	  where	  I	  work	  from.	  	  But	  that	  [EQUIP]	  really	  influences	  me	  more	  and	  more	  to	  be	  quite	  bold.”	  	  Some	  participants	  described	  how	  participating	  in	  EQUIP	  made	  it	  easier	  for	  them	  to	  speak	  up	  about	  trauma	  and	  violence	  with	  their	  colleagues.	  A	  counselor	  described	  how	  she	  had	  been	  trying	  to	  raise	  the	  issue	  of	  trauma	  with	  her	  colleagues,	  and	  how	  after	  the	  team	  participated	  in	  EQUIP	  she	  was	  finally	  able	  to	  do	  so:	  	  I	  was	  going	  to	  do	  this	  hour	  and	  a	  half	  presentation	  or	  whatever	  it	  is	  to	  the	  staff	  on	  trauma.	  	  And	  so	  it	  kept	  getting	  postponed	  and	  it	  kept	  getting	  postponed	  and	  I	  just	  kept	  getting	  really	  frustrated	  and	  finally	  it	  did	  happen.	  	  	   32	  In	  this	  case,	  EQUIP	  and	  the	  TVIC	  sessions	  may	  have	  validated	  the	  perspective	  and	  amplified	  the	  voices	  of	  staff	  that	  were	  raising	  issues	  of	  trauma	  and	  violence.	  	   	  The	  first	  main	  theme	  that	  I	  identified	  in	  the	  data	  about	  the	  impact	  of	  the	  TVIC	  sessions	  was	  that	  there	  were	  changes	  in	  awareness,	  knowledge	  and/or	  confidence	  about	  TVIC	  concepts	  for	  these	  staff	  members.	  The	  extent	  and	  effect	  of	  these	  changes	  varied	  greatly	  across	  staff	  and	  sites.	  For	  some	  staff,	  shifts	  in	  awareness,	  knowledge	  and	  confidence	  were	  the	  main	  impact	  of	  the	  TVIC	  sessions.	  For	  others,	  these	  shifts	  led	  to	  a	  shift	  in	  perspective,	  or	  “seeing	  through	  a	  TVIC	  lens”	  –	  the	  second	  broad	  theme	  in	  this	  analysis.	  A	  shift	  in	  perspective:	  Seeing	  through	  a	  TVIC	  lens	  has	  impacts	  on	  multiple	  levels	  The	  second	  broad	  theme	  was	  that	  some	  practitioners	  experienced	  a	  shift	  in	  their	  perspectives	  which	  had	  impacts	  in	  multiple	  aspects	  of	  their	  lives.	  One	  participant	  commented	  on	  how	  seeing	  through	  a	  trauma-­‐	  and	  violence-­‐informed	  lens	  had	  broad	  impacts	  for	  her	  colleagues	  that	  went	  beyond	  their	  work	  with	  clients:	  “what	  it	  does	  is	  it	  changes	  their	  outlook	  on	  everything.”	  I	  have	  conceptualized	  these	  impacts	  as	  shifts	  on	  four	  different	  levels:	  personal,	  clinical	  practice,	  organizational	  and	  structural.	  	  Personal	  level:	  Caring	  for	  self	  and	  family	  	   Many	  practitioners	  described	  changes	  in	  their	  personal	  lives	  as	  they	  increasingly	  saw	  through	  a	  lens	  of	  trauma	  and	  violence.	  A	  counselor	  explained	  that	  she	  saw	  that	  learning	  about	  TVIC	  made	  these	  abstract	  concepts	  personal	  for	  her	  colleagues:	  “when	  they	  dealt	  with	  patients	  they,	  they	  could	  see	  it	  and	  they…	  knew	  that	  it	  was	  trauma-­‐related	  but	  what	  they	  didn’t	  tie	  it	  to	  was	  themselves”.	  Learning	  more	  about	  TVIC	  	   33	  spurred	  some	  staff	  to	  seek	  support	  to	  cope	  with	  their	  own	  reactions	  to	  vicarious	  trauma.	  A	  physician	  explained,	  “I	  mean	  [the	  EQUIP	  training]	  for	  me	  is	  a	  big	  opportunity	  to	  look	  at	  myself	  and	  how	  I	  deal	  with	  things.	  And	  I	  mean	  the	  only	  real	  way	  that	  I	  have	  to	  change	  the	  system	  is	  to	  look	  at	  myself	  first.”	  Another	  staff	  member	  explained	  how	  she	  has	  prioritized	  taking	  time	  to	  listen	  and	  connect	  with	  others	  in	  her	  family	  life:	  “So	  it’s	  played	  in	  at	  work,	  it’s	  played	  in	  at	  home	  where	  I	  just	  go	  ‘those	  things	  really	  don’t	  matter,	  take	  five	  minutes	  and	  sit	  down	  and	  have	  a	  cup	  of	  tea	  with	  your	  kid.’”	  	  While	  the	  TVIC	  sessions	  were	  directed	  toward	  practice	  in	  primary	  care,	  they	  had	  impacts	  on	  several	  participants’	  personal	  and	  family	  lives.	  This	  underscores	  how	  for	  some	  practitioners,	  learning	  about	  TVIC	  led	  to	  a	  shift	  in	  perspective	  rather	  than	  the	  acquisition	  of	  a	  new	  “skill”.	  For	  many,	  this	  TVIC	  lens	  carried	  over	  into	  their	  clinical	  practice	  in	  a	  similar	  way	  –	  as	  a	  new	  view	  on	  practice,	  rather	  than	  a	  clinical	  tool.	  Clinical	  practice	  level	  	   Seeing	  through	  a	  TVIC	  lens	  also	  had	  impact	  on	  clinical	  practice.	  I	  identified	  two	  subthemes	  about	  the	  impact	  of	  the	  TVIC	  sessions	  on	  the	  clinical	  practice	  of	  the	  participants.	  Firstly,	  some	  practitioners	  began	  seeing,	  naming	  and	  addressing	  structural	  violence	  in	  their	  practice.	  Second,	  some	  practitioners	  made	  efforts	  to	  take	  more	  time	  with	  clients,	  despite	  the	  challenges	  this	  presented	  in	  busy	  clinics.	  Seeing,	  naming	  and	  addressing	  structural	  violence	  in	  the	  practice	  setting	  Several	  staff	  described	  how	  they	  became	  more	  attuned	  to	  structural	  violence	  and	  began	  to	  connect	  structural	  violence	  to	  health	  and	  their	  work	  as	  health	  care	  providers.	  Conceiving	  of	  structural	  inequities	  as	  a	  form	  of	  violence	  seemed	  to	  increase	  	   34	  some	  practitioners’	  abilities	  to	  describe	  and	  react	  to	  some	  of	  the	  inequities	  they	  were	  seeing	  –	  or	  contributing	  to	  –	  in	  practice:	  Whereas	  before	  it	  was	  like,	  okay,	  I	  know	  I’ve	  got	  to	  get	  all	  this	  stuff	  done	  before	  I	  go….	  but	  then	  I	  realize	  I’m	  going	  well	  wait	  a	  minute,	  if	  I’m	  just	  spewing	  something	  back	  or	  I’m	  not	  making	  eye	  contact,	  you	  know,	  or	  I’m	  typing	  like	  whatever	  that	  is,	  I’m	  causing	  that	  person	  trauma,	  you	  know.	  (MOA)	  	  I	  think	  it	  made	  me	  more	  aware	  of	  to	  keep	  it	  in	  the	  forefront	  of	  my	  mind	  how	  it	  makes	  clients	  feel	  when	  I	  say	  no,	  I	  can’t	  see	  you	  today…They	  see	  it	  as	  you’re	  being	  racist	  because	  you	  don’t	  have	  time	  to	  see	  me	  right	  now.	  So	  it	  made	  me	  more	  aware	  of	  that	  perception.	  (Nurse)	  	  Here	  again,	  seeing	  through	  a	  TVIC	  lens	  shifted	  how	  practitioners	  saw	  structural	  inequities.	  Perceiving	  poverty,	  racism	  or	  discrimination	  as	  forms	  of	  violence	  encouraged	  staff	  to	  take	  these	  on	  as	  issues	  to	  address	  in	  primary	  care	  practice.	  	  Taking	  more	  time	  Similarly,	  several	  staff	  members	  described	  how	  “seeing	  through	  a	  TVIC	  lens”	  encouraged	  them	  to	  take	  more	  time	  with	  clients.	  A	  nurse	  described	  this	  change	  and	  the	  tension	  this	  created	  for	  her	  in	  a	  busy	  clinic:	  	  I’m	  aware	  of	  also	  when	  I’m	  to	  slow	  down	  and	  give	  people	  ample	  time	  to	  respond	  to	  me.	  	  And	  that	  was	  a	  bit	  of	  a	  challenge	  because	  you’re	  in	  a	  hurry,	  right,	  especially	  when	  there’s	  eight	  people	  waiting	  to	  be	  seen.	  While	  workload	  and	  other	  structural	  constraints	  made	  this	  a	  challenge,	  “seeing	  through	  a	  TVIC	  lens”	  encouraged	  practitioners	  to	  prioritize	  taking	  enough	  time	  to	  help	  clients	  feel	  safe	  and	  heard.	  	  	   35	  Organizational	  level	  	   Shifts	  in	  perspective	  had	  many	  impacts	  at	  the	  organizational	  level	  as	  well.	  I	  identified	  four	  subthemes	  on	  the	  impacts	  of	  seeing	  through	  a	  TVIC	  lens	  for	  the	  two	  PHC	  organizations	  studied	  here.	  These	  were:	  challenging	  the	  dominance	  of	  the	  biomedical	  paradigm;	  connecting	  trauma	  and	  violence	  to	  colonialism;	  taking	  a	  new	  view	  on	  clinic	  spaces	  and	  policies;	  and	  incorporating	  new	  modalities	  to	  address	  the	  health	  effects	  of	  trauma	  and	  violence.	  Challenging	  dominance	  of	  the	  biomedical	  paradigm	  In	  one	  clinic	  in	  particular,	  open	  discussions	  about	  trauma,	  violence	  and	  particularly	  structural	  violence	  led	  to	  some	  shifts	  in	  power	  dynamics	  among	  staff.	  Several	  participants	  described	  how	  these	  discussions	  brought	  psychosocial	  aspects	  of	  health	  into	  the	  foreground,	  challenging	  the	  dominance	  of	  the	  biomedical	  paradigm	  in	  PHC	  practice.	  One	  counselor	  said:	  [Our	  team	  meetings]	  didn’t	  work	  because	  it	  was	  so	  medically	  oriented,	  and	  I	  said	  that.	  	  And	  one	  of	  the	  doctors	  really	  asked	  me	  about	  that	  and	  he	  asked	  me	  if	  that’s	  what	  I	  believed	  and	  I	  said,	  yeah.	  	  And	  it,	  it’s	  true	  and	  it’s	  always	  been	  like	  this.	  	  Another	  staff	  member	  explained	  that	  impacts	  of	  this	  shift	  for	  her	  team	  were	  both	  subtle	  and	  profound:	  “But,	  doctors,	  and	  others,	  are	  also	  aware	  that	  the	  psychosocial	  component	  is	  extremely	  important,	  and	  maybe	  sometimes	  more	  important	  than	  medical….	  but	  there’s	  a	  slight,	  some	  insight	  that	  I	  do	  see	  that	  I	  haven’t	  seen	  before,	  ever.”	  	  For	  this	  staff	  member’s	  organization,	  seeing	  through	  a	  TVIC	  lens	  led	  to	  fundamental	  discussions	  about	  the	  scope	  and	  purpose	  of	  PHC	  and	  the	  importance	  of	  the	  psychosocial	  aspects	  of	  health.	  	   36	  Connecting	  trauma	  and	  violence	  to	  colonialism	  The	  TVIC	  sessions,	  alongside	  the	  interconnected	  component	  of	  Indigenous	  Cultural	  Safety	  (ICS),	  also	  helped	  staff	  to	  connect	  trauma,	  intergenerational	  trauma,	  and	  ongoing	  violence	  with	  racism	  and	  colonialism.	  An	  Aboriginal	  staff	  member	  described	  how	  structural	  violence	  operates	  in	  her	  workplace	  and	  how	  EQUIP	  raised	  challenging	  questions:	  	  Structural	  violence	  is	  everywhere	  and	  I	  think	  even	  in	  the	  clinic	  here	  …	  it’s	  like	  there’s	  a	  certain	  control	  when	  people	  at	  the	  top	  control	  things	  and	  make	  it	  to	  the	  way	  that	  they	  want	  it.	  Even	  if	  they’re	  nice,	  it	  still	  impacts	  everybody	  in	  a	  negative	  way…	  if	  we’re	  serving	  native	  people	  it	  needs	  to	  have	  native	  people	  in	  leadership.	  Both	  PHC	  sites	  made	  efforts	  toward	  indigenizing	  their	  organizations	  after	  orientation	  and	  training	  on	  TVIC	  and	  ICS.	  This	  included	  acknowledging	  local	  Indigenous	  territory	  and	  displaying	  Aboriginal	  maps	  and	  art	  in	  clinic	  spaces.	  However,	  some	  staff	  raised	  concerns	  that	  these	  changes	  might	  be	  too	  superficial.	  I	  think	  that	  it	  needs	  to	  be	  more	  client-­‐led,	  more	  client-­‐driven.	  	  So,	  you	  know,	  the	  superficial	  stuff	  about	  like	  the	  [Aboriginal]	  art	  and	  …the	  map	  and	  all	  that	  sort	  of	  stuff	  is,	  is	  good,	  but	  [I	  wonder]	  whether	  there’s	  client	  involvement	  in	  deciding	  those	  changes	  and	  what	  its	  going	  to	  look	  like?	  An	  administrator	  described	  her	  concern	  that	  Aboriginal	  perspectives	  could	  be	  taken	  on	  in	  a	  tokenistic	  way:	  	  What	  I’m	  hearing	  is	  that	  it’s	  not	  okay	  that	  we’re	  ninety-­‐five	  percent	  western	  and	  we’ve	  got	  this	  culture	  piece	  that	  we	  can	  say	  we	  do…	  In	  this	  place	  what	  	   37	  [Aborginal	  perspectives]	  should	  do	  is	  it	  should	  be	  infused	  throughout	  everything	  that	  we	  do.	  	  And	  it	  should	  be	  really	  a	  foundational	  value	  that	  we	  have.	  At	  this	  site,	  efforts	  toward	  fundamentally	  indigenizing	  the	  organization	  included	  grappling	  with	  the	  complexities	  of	  addressing	  tensions	  within	  their	  Aboriginal	  advisory	  and	  trying	  to	  re-­‐instate	  a	  position	  for	  an	  Aboriginal	  elder	  on	  staff.	  	  Taking	  a	  new	  view	  on	  clinic	  spaces	  and	  policies	  In	  one	  of	  the	  TVIC	  sessions,	  the	  staff	  were	  asked	  to	  map	  how	  clients	  move	  through	  their	  sites	  and	  to	  reflect	  on	  how	  their	  spaces	  could	  be	  made	  more	  trauma-­‐	  and	  violence-­‐informed.	  Staff	  began	  to	  see	  more	  fully	  how	  their	  clinic	  spaces	  and	  policies	  might	  contribute	  to	  trauma,	  structural	  violence,	  and	  a	  feeling	  for	  clients	  of	  being	  unwelcome	  or	  unsafe.	  As	  a	  result	  both	  organizations	  made	  changes	  to	  their	  waiting	  rooms.	  One	  clinic	  made	  a	  very	  significant	  change,	  eliminating	  the	  morning	  line	  up	  by	  opening	  their	  doors	  earlier.	  One	  MOA	  described	  how	  she	  saw	  this	  impacting	  the	  clients	  at	  the	  clinic:	  	  They’re	  definitely	  more	  relaxed	  in	  the	  morning	  so	  that	  would	  make	  them,	  you	  know,	  feel	  a	  little	  happier	  and	  more	  comfortable.	  	  Just	  to	  have	  a	  place	  to	  come	  in	  and	  relax	  and	  not	  have	  to	  stand	  outside	  in	  a	  lineup	  on	  the	  street.	  	  So	  it	  sort	  of	  changes	  just	  like	  that	  concept	  of,	  you	  know,	  lining	  up	  like	  cattle.	  For	  both	  sites	  studied	  here,	  seeing	  their	  organization’s	  spaces	  and	  procedures	  through	  a	  trauma-­‐and	  violence-­‐	  informed	  lens	  underscored	  how	  their	  services	  might	  traumatize	  or	  re-­‐traumatize	  their	  clients.	  This	  led	  organizations	  to	  make	  some	  significant	  changes	  to	  the	  way	  clients	  moved	  through	  their	  spaces.	  	   38	  Incorporating	  new	  modalities	  to	  address	  the	  health	  effects	  of	  trauma	  and	  violence	  	  Organizations	  also	  made	  changes	  to	  the	  clinical	  services	  they	  offered.	  Seeing	  through	  a	  TVIC	  lens	  opened	  the	  organizations	  to	  new	  and	  diverse	  modalities	  for	  addressing	  pain,	  trauma	  and	  addiction	  in	  primary	  care.	  A	  physician	  explained	  how	  thinking	  has	  shifted	  about	  clients	  who	  complain	  of	  vague	  symptoms:	  “Just	  think	  about	  the	  context	  where	  all	  this	  stuff	  is	  coming	  up	  and	  let’s	  talk	  to	  [a	  client]	  about	  some	  of	  those	  traumatic,	  painful,	  violent,	  abusive	  things	  that	  happened	  to	  her.”	  	  Practitioners	  described	  how	  they	  began	  making	  more	  use	  of	  services	  such	  as	  physiotherapy,	  group	  counseling,	  and	  mindfulness	  to	  address	  the	  links	  between	  trauma,	  chronic	  pain	  and	  addiction.	  	  At	  one	  site,	  participating	  in	  the	  Organizational	  Integration	  and	  Tailoring	  (OIT)	  process	  through	  EQUIP	  led	  to	  the	  formation	  of	  a	  client	  group	  focused	  on	  managing	  chronic	  pain.	  A	  staff	  member	  explained	  the	  importance	  of	  this	  change:	  “The	  pain	  group	  [would	  not	  have	  been	  started]	  without	  [EQUIP].	  And	  it’s	  such	  a	  predominant	  issue	  in	  our	  clinic	  that	  it	  really	  should	  have	  been	  addressed	  earlier	  in	  a	  more	  systematic	  way.	  So	  I	  appreciate	  that.”	  At	  both	  of	  the	  sites	  studied	  here,	  shifting	  perspectives	  to	  focus	  on	  trauma	  and	  violence	  led	  to	  the	  use,	  or	  increase	  in	  use	  of	  diverse	  modalities	  and	  services.	  Structural	  level:	  Momentum	  to	  advocate	  for	  structural	  change	  	   	  Finally,	  seeing	  through	  a	  TVIC	  lens	  had	  impacts	  on	  a	  structural	  level,	  orienting	  practitioners	  to	  focus	  on	  health	  on	  a	  societal	  scale.	  Several	  respondents	  spoke	  of	  EQUIP	  increasing	  “momentum,”	  “acuity,”	  or	  “focus”	  to	  take	  on	  structural	  inequities	  in	  society.	  A	  social	  worker	  described	  the	  TVIC	  sessions	  as	  a	  reminder	  to	  be	  an	  advocate:	  	   39	  “reminding	  me	  that…	  I	  really	  should	  be	  doing	  more	  around	  advocating…	  for	  the	  change	  piece	  right,	  because	  that	  stuff	  needs	  to	  change.”	  A	  physician	  gave	  an	  example	  of	  addressing	  structural	  violence	  at	  work:	  	  It	  made	  me	  sort	  of	  feel	  confident	  enough	  to	  start	  doing	  something	  about	  [trauma	  and	  violence]	  when	  I	  see	  it.	  So	  we	  had	  a	  discussion	  today	  about,	  in	  a	  sharing	  circle,	  about	  First	  Nations	  people	  and	  their	  interactions	  with	  police.	  	  Several	  participants	  acted	  on	  this	  momentum	  by	  bringing	  a	  TVIC	  perspective	  into	  hospitals	  and	  health	  authorities.	  One	  physician	  described	  the	  “snowball	  effect”	  she	  has	  seen	  after	  raising	  issues	  related	  to	  trauma	  and	  addiction	  with	  her	  colleagues	  in	  the	  hospital:	  	  You	  can	  almost	  see	  a	  light	  click	  on	  for	  them.	  	  And	  it’s	  like	  oh,	  oh,	  that	  changes	  everything.	  	  And	  they	  go,	  okay,	  for	  a	  patient	  who	  is	  not	  following	  the	  rules	  and	  being	  difficult	  to	  a	  patient	  who	  has	  a	  struggle…	  And,	  having	  those	  discussions,	  and	  then	  what	  was	  really	  interesting	  to	  me	  was	  the	  snowball	  effect,	  I	  had	  that	  discussion	  with	  one	  nurse	  and	  then	  she	  had	  it	  with	  another	  nurse,	  and	  that	  nurse	  had	  it	  with	  a	  nurse	  so	  then	  all	  of	  a	  sudden	  [this	  client]	  got	  more	  compassionate	  care,	  because	  people	  had	  a	  better	  understanding	  of	  his	  addiction.	  While	  this	  momentum	  to	  take	  advocate	  galvanized	  some	  staff	  into	  action,	  others	  struggled	  with	  how	  to	  address	  structural	  violence	  within	  their	  roles	  in	  the	  clinic.	  One	  nurse	  explained:	  “I	  mean	  all	  of	  these	  things	  around	  pain	  and	  suffering	  and	  trauma,	  they’re	  structural,	  they’re	  much	  bigger	  than	  any	  of	  us	  so,	  you	  know,	  it’s	  hard	  to	  deal	  with	  those	  at	  that	  level	  as	  well.”	  This	  nurse	  further	  described	  the	  struggle	  to	  balance	  the	  	   40	  immediate	  needs	  of	  clients	  with	  the	  imperative	  to	  address	  trauma	  and	  structural	  violence:	  	  You	  know,	  when	  you’re	  dealing	  with	  trauma	  sometimes	  you	  wonder	  how	  much	  you	  should	  be	  doing	  at	  any	  particular	  moment.	  	  And	  somebody	  comes	  in	  because	  their	  ankle	  is	  sprained	  and	  they	  sprained	  their	  ankle	  fleeing	  an	  abusive	  partner….	  do	  you	  just…	  help	  the	  person	  with	  the	  ankle	  because	  that’s	  what	  they	  came	  in	  for	  or	  do	  you	  try	  to	  remove	  them	  from	  a	  violent	  situation?	  	  Momentum	  to	  take	  action	  on	  structural	  violence	  created	  a	  dilemma	  for	  some	  practitioners,	  who	  were	  unsure	  how	  to	  take	  concrete	  action	  on	  a	  structural	  level,	  while	  continuing	  to	  meet	  the	  needs	  of	  their	  clients.	  In	  summary,	  I	  identified	  two	  broad	  impacts	  of	  the	  TVIC	  sessions.	  First,	  these	  sessions	  contributed	  to	  enhanced	  awareness,	  knowledge	  and/or	  confidence	  about	  the	  concepts	  of	  trauma	  and	  violence	  for	  some	  PHC	  staff.	  	  Second,	  this	  led	  to	  shifts	  in	  perspective	  that	  had	  effects	  on	  multiple	  levels	  in	  participants’	  lives.	  These	  effects	  included	  personal	  changes	  in	  self-­‐care	  and	  relationships;	  new	  approaches	  in	  individual	  practice	  with	  clients;	  shifts	  in	  organizational	  paradigms,	  practice,	  and	  policy;	  and	  an	  increased	  sense	  of	  momentum	  to	  advocate	  for	  structural	  change.	  	  	  2.	  What	  are	  the	  intrinsic	  and	  contextual	  factors	  that	  influence	  the	  impacts	  of	  TVIC	  orientation	  and	  training?	  The	  impacts	  described	  above	  were	  influenced	  by	  factors	  that	  were	  both	  intrinsic	  and	  contextual	  to	  the	  TVIC	  sessions.	  Intrinsic	  influences	  included	  the	  strengths	  and	  challenges	  connected	  to	  the	  TVIC	  sessions	  themselves:	  data,	  discussions,	  researchers’	  	   41	  presence	  and	  the	  timing	  of	  sessions.	  Contextual	  influences	  included	  structural,	  organization	  and	  personal	  factors	  which	  either	  facilitated	  or	  constrained	  participants’	  abilities	  to	  enact	  TVIC	  in	  practice.	  	  Intrinsic	  factors:	  Data,	  discussions,	  presence,	  and	  timing	  influence	  how	  participants	  understand,	  remember	  and	  prioritize	  TVIC	  Certain	  aspects	  of	  the	  way	  the	  TVIC	  sessions	  were	  delivered	  were	  described	  as	  having	  a	  major	  influence	  on	  participants’	  how	  participants	  understood,	  remembered	  and	  prioritized	  what	  they	  learned	  about	  TVIC.	  Data	  on	  local	  patient	  populations,	  externally	  facilitated	  discussions,	  and	  the	  presence	  of	  researchers	  were	  described	  as	  supporting	  participants	  to	  understand	  and	  enact	  TVIC,	  while	  the	  timing	  of	  sessions	  was	  described	  as	  a	  challenge.	  Data	  from	  local	  patient	  populations:	  “A	  really	  really	  important	  reminder”	  Because	  the	  TVIC	  sessions	  were	  provided	  as	  part	  of	  the	  broader	  EQUIP	  intervention,	  the	  researchers	  who	  had	  facilitated	  the	  TVIC	  sessions	  visited	  PHCs	  at	  regular	  intervals	  to	  collect	  data	  from	  patients	  as	  well	  as	  from	  staff.	  As	  part	  of	  the	  EQUIP	  intervention,	  researchers	  presented	  baseline	  patient	  data	  on	  trauma	  symptoms	  and	  prevalence,	  satisfaction	  with	  care,	  and	  other	  TVIC-­‐related	  measures	  to	  staff	  meetings	  and	  leaders	  at	  the	  sites	  during	  these	  visits.	  	  This	  data	  had	  a	  profound	  influence	  on	  many	  practitioners	  at	  both	  of	  the	  sites	  studied	  here.	  Staff	  members	  were	  struck	  by	  the	  prevalence	  and	  severity	  of	  trauma	  symptoms	  or	  chronic	  pain	  in	  their	  client	  populations,	  and	  they	  were	  curious	  about	  the	  	   42	  differences	  between	  the	  sites	  in	  the	  study.	  One	  staff	  member	  commented	  on	  how	  patient	  data	  motivated	  the	  team	  and	  helped	  them	  focus	  their	  efforts:	  	  I	  really	  like	  the	  feedback	  from	  the	  patient	  surveys,	  client	  surveys;	  getting	  that	  data	  has	  been	  tremendous.	  	  Having	  the	  really	  skilled	  researchers	  around	  to	  give	  us	  an	  idea	  about	  what	  the	  issues	  are,	  finding	  out	  the	  levels	  of	  pain	  and	  disability	  in	  our	  clients	  that	  were	  from	  that	  first	  survey	  was	  a	  really,	  really	  important	  reminder	  of	  what	  we’re	  working	  with	  and	  maybe	  some	  shortcomings.	  Local	  client	  data	  also	  provided	  leaders	  with	  a	  tool	  in	  advocating	  for	  increased	  funding	  for	  TVIC	  and	  for	  other	  services.	  One	  leader	  commented:	  	  I	  think	  there’s	  a	  lot	  of	  value	  in	  having	  things,	  things	  that	  you,	  you	  sort	  of	  instinctively	  know	  and	  you	  see	  every	  day	  when	  talking	  to	  patients.	  	  But	  to	  have	  it	  documented….	  I	  think	  to	  have	  those	  kinds	  of	  figures	  in	  black	  and	  white	  and	  to	  see	  the	  amount	  of	  trauma,	  to	  see	  the	  levels	  of	  mental	  health	  issues	  is	  very	  valuable.	  Presentations	  of	  data	  were	  part	  of	  the	  broader	  EQUIP	  intervention,	  and	  were	  not	  explicitly	  part	  of	  the	  curriculum	  for	  the	  TVIC	  sessions.	  However,	  multiple	  participants	  saw	  these	  presentations	  as	  important	  factors	  in	  their	  thinking	  about	  trauma	  and	  violence.	  Local	  data	  underscored	  the	  impacts	  of	  trauma	  and	  violence	  for	  the	  specific	  population	  of	  clients	  at	  each	  site.	  	  Externally	  facilitated	  discussions:	  Getting	  “closer	  to	  the	  truth”	  A	  second	  influence	  that	  was	  common	  to	  both	  sites	  was	  that	  staff	  members	  saw	  profound	  impacts	  from	  participating	  in	  externally	  facilitated	  team	  discussions	  about	  TVIC.	  Although	  some	  staff	  members	  struggled	  to	  recall	  the	  content	  of	  the	  presentations	  	   43	  at	  the	  TVIC	  sessions,	  almost	  all	  the	  staff	  interviewed	  commented	  on	  the	  impact	  of	  the	  discussions	  they	  had	  with	  their	  team	  members	  during	  the	  session.	  Several	  staff	  made	  particular	  note	  of	  the	  value	  of	  having	  “outsiders”	  host	  these	  discussions,	  ensuring	  that	  multiple	  voices	  and	  perspectives	  were	  heard.	  A	  staff	  member	  explained,	  “There	  seemed	  to	  be	  lots	  of	  room	  to	  hear,	  you	  know,	  from	  the	  docs	  and	  the	  nurses,	  from	  counselors	  and	  nutritionists,	  everybody	  was	  given	  an	  opportunity	  to	  get	  in	  there	  if	  they	  had	  something	  to	  say.”	  Another	  staff	  member	  described	  how	  revolutionary	  one	  such	  discussion	  was	  for	  her:	  “we	  probably	  went	  as	  a	  team	  like	  my	  colleagues	  and	  I	  closer	  to	  the	  truth	  than	  at	  any	  point	  where	  I’ve	  worked	  in	  the	  clinic.”	  	  At	  one	  site	  in	  particular,	  group	  discussions	  in	  the	  TVIC	  session	  opened	  up	  complex,	  honest	  conversations	  about	  different	  perspectives	  on	  trauma,	  violence,	  and	  PHC	  practice.	  At	  both	  sites	  externally	  facilitated	  discussions	  enabled	  participants	  were	  able	  to	  consolidate	  their	  learning	  about	  TVIC	  and	  conceptualize	  how	  TVIC	  could	  work	  in	  their	  practices.	  	  The	  presence	  of	  external	  researchers	  at	  the	  site:	  Support	  and	  surveillance	  Another	  aspect	  of	  the	  intervention	  that	  participants	  noticed	  was	  the	  impact	  of	  having	  trauma-­‐	  and	  violence-­‐	  focused	  researchers	  (who	  were	  also	  the	  TVIC	  session	  facilitators)	  make	  regular	  visits	  to	  their	  sites.	  Having	  researchers	  on-­‐site	  was	  described	  as	  a	  both	  a	  support	  and	  a	  reminder	  to	  staff	  to	  pay	  attention	  to	  these	  issues.	  One	  leader	  described	  how	  researchers	  collaborated	  with	  clinic	  staff:	  	  Having	  the	  research	  team	  here,	  it’s	  like	  having	  like	  five	  really	  smart	  people	  on	  our	  team…	  we	  feel	  as	  if	  we’re	  very	  much	  part	  of	  the	  team	  and	  that	  you	  want	  to	  make	  a	  difference	  in	  the	  work	  that	  we	  do.	  	  	   44	  A	  nurse	  explained	  that	  the	  presence	  of	  researchers,	  and	  the	  knowledge	  that	  they	  are	  collecting	  data	  on	  patient	  satisfaction	  puts	  TVIC	  front-­‐of-­‐mind	  for	  her	  team:	  	  Well,	  I	  think	  for	  one	  thing,	  that	  the	  fact	  that	  you	  are	  coming	  and	  doing	  this,	  really	  puts	  us	  all	  who	  work	  at	  [clinic],	  in	  a	  bit	  of	  a	  more	  acute	  state…	  especially	  when	  you	  come,	  or	  we	  have	  e-­‐mails,	  you	  think,	  yeah,	  you	  know,	  we	  do	  need	  to	  look	  at	  our	  own	  practice;	  we	  do	  need	  to	  look	  at	  the	  sensitivities	  and	  the	  barriers	  that	  we	  still	  do	  put	  up.	  For	  many	  participants,	  being	  engaged	  in	  an	  ongoing	  relationship	  with	  trauma-­‐	  and	  violence-­‐	  focused	  researchers	  helped	  them	  remember	  and	  prioritize	  what	  they	  learned	  in	  the	  TVIC	  sessions.	  	  Timing	  of	  sessions	  was	  a	  challenge	  Several	  staff	  members	  noted	  the	  importance	  of	  how	  the	  intervention	  was	  timed.	  Some	  touched	  on	  the	  practical	  challenge	  of	  closing	  their	  clinics	  for	  educational	  sessions	  for	  the	  whole	  team	  at	  the	  same	  time.	  Many	  also	  commented	  on	  the	  long	  time	  between	  EQUIP	  sessions,	  which	  may	  have	  led	  to	  a	  loss	  of	  momentum:	  	  It’s	  a	  fairly	  lengthy	  timeframe	  between	  when	  you’re	  here	  and	  when	  you’re	  not	  here.	  	  That	  the	  whole	  idea	  of	  trauma	  and	  structural	  trauma	  somehow	  or	  other	  in	  people’s	  mind	  got	  separated,	  it	  was	  a	  disconnect	  somehow.	  	  And	  probably	  had	  we	  had	  an	  intensive	  week	  we’d	  have	  all	  been	  exhausted	  collectively	  but,	  but	  I	  think,	  I	  think	  it	  might	  have	  helped.	  Overall,	  most	  staff	  members	  suggested	  sessions	  be	  timed	  closer	  together,	  and	  shortened	  if	  possible.	  At	  one	  site,	  participants	  remarked	  that	  it	  was	  difficult	  to	  take	  on	  	   45	  difficult	  and	  emotional	  concepts	  late	  in	  the	  week	  when	  practitioners	  were	  already	  exhausted.	  	  Contextual	  influences:	  Structural,	  organizational	  and	  personal	  contexts	  influenced	  how	  TVIC	  was	  understood	  and	  taken	  up	  in	  practice	  Contextual	  factors	  influenced	  how	  TVIC	  was	  conceptualized,	  taken	  up	  and	  enacted	  at	  each	  site	  and	  by	  each	  participant.	  Structural	  contexts	  served	  as	  both	  barriers	  and	  facilitators	  to	  enacting	  TVIC.	  Organizational	  mandates	  and	  cultures	  influenced	  trauma-­‐	  and	  violence-­‐informed	  practice	  at	  each	  site.	  On	  a	  personal	  level,	  practitioners’	  values,	  knowledge,	  learning	  styles	  and	  engagement	  with	  facilitators	  influenced	  their	  experiences	  of	  learning	  about	  TVIC.	  	  	  “The	  system	  that	  we	  have”:	  Structural	  factors	  were	  both	  barriers	  and	  facilitators	  to	  enacting	  TVIC	  	   External	  factors	  functioned	  as	  both	  barriers	  and	  facilitators	  to	  enacting	  TVIC	  at	  these	  sites.	  For	  example,	  one	  practitioner	  noted	  the	  amplifying	  influence	  of	  other	  trauma-­‐informed	  initiatives	  in	  the	  community,	  saying:	  “There’s	  been	  lots	  of	  information	  and	  training	  within	  the	  community,	  the	  community	  organizations	  just	  like	  us	  and	  I	  think	  that	  it’s	  making	  a	  difference	  in	  how	  we	  work.”	  	  Conversely,	  practitioners	  discussed	  how	  structural	  constraints,	  particularly	  a	  lack	  of	  time	  and	  funds,	  counteracted	  efforts	  to	  provide	  trauma-­‐and	  violence-­‐informed	  care.	  One	  participant	  explained	  how	  heavy	  workloads	  leave	  practitioners	  with	  little	  energy	  to	  reflect	  on	  and	  change	  their	  practices:	  	  	   46	  Everybody,	  their	  days	  are	  very	  full	  and	  so	  creating	  time	  and	  space	  for	  reflection,	  for	  new	  programming	  is	  very	  difficult.	  	  When	  people	  get	  to	  work	  and	  then	  they	  run	  their	  asses	  off	  until	  they	  leave	  it’s	  very	  hard	  to	  say	  ‘hey	  can	  you	  also	  think	  about	  your	  practice	  and	  make	  some	  changes’.	  	  Another	  participant	  described	  how	  funding	  shortages	  can	  mean	  that	  best	  practices	  are	  not	  implemented	  in	  trauma-­‐informed	  care	  for	  people	  with	  substance	  use	  problems:	  	  We	  know	  what’s	  needed	  in	  terms	  of	  treatment	  centers	  and	  addictions	  sort	  of	  support	  and	  work	  and	  it	  doesn’t	  happen,	  it	  just	  doesn’t	  happen.	  	  So	  it’s	  not	  that	  we	  don’t	  have	  the	  information,	  it	  just	  that	  it’s	  not	  followed	  through	  at	  a	  higher	  level	  and	  generally	  speaking	  the	  funding,	  you	  know,	  legislated	  poverty	  and	  people	  put	  into	  situations	  where	  they	  can’t	  possibly	  survive.	  	  And	  then	  the	  question	  is	  asked	  ’well	  how	  come	  it’s	  not	  working?’	  Well,	  it’s	  not	  funded.	  Political	  and	  regulatory	  structures	  were	  also	  described	  as	  barriers	  to	  providing	  TVIC.	  A	  physician	  explained	  how	  regulations	  requiring	  drug	  screens	  from	  his	  clients	  prevent	  him	  from	  being	  as	  trauma-­‐	  and	  violence-­‐informed	  as	  he	  would	  like	  to	  be:	  	  I	  really	  try	  to	  say	  this	  is	  not	  about	  you,	  and	  this	  is	  not	  about	  what	  I	  am	  thinking	  or	  assuming	  about	  you,	  this	  is	  unfortunately,	  you	  know,	  the	  system	  that	  we	  have	  to	  operate,	  and	  the	  government	  is	  funding	  us	  to	  provide	  care	  for	  people	  with	  addictions	  issues,	  and	  not	  everybody	  here	  has	  issues	  of	  addictions	  but,	  you	  know,	  that’s	  part	  of	  what	  we	  need	  to	  do	  and	  it’s	  part	  of	  me	  being	  able	  to	  continue	  to	  be	  able	  to	  provide	  these	  medications	  for	  you,	  there	  are	  things	  unfortunately	  we	  need	  to	  do	  from	  time	  to	  time.	  It’s	  not	  about	  punishing	  you…	  	   47	  Participants	  at	  these	  two	  sites	  described	  how	  the	  structural	  contexts	  for	  practice	  could	  be	  both	  supportive	  and	  inhibiting	  of	  TVIC.	  Increased	  awareness	  of	  trauma	  throughout	  the	  health	  and	  social	  service	  sectors	  supported	  participants	  to	  use	  TVIC	  concepts	  in	  their	  work.	  At	  the	  same	  time,	  structural	  factors	  such	  as	  funding	  and	  legislation	  also	  constrained	  practitioners’	  abilities	  to	  practice	  TVIC.	  Organizational	  context:	  Clinic	  mandate	  and	  culture	  influenced	  how	  easily	  TVIC	  was	  taken	  up	  and	  what	  kinds	  of	  differences	  it	  made	  	  	   Multiple	  participants	  spoke	  about	  how	  the	  contexts	  at	  their	  particular	  clinics	  helped	  or	  hindered	  their	  efforts	  at	  TVIC.	  	  The	  fact	  that	  the	  clinic	  mandates	  and	  culture	  often	  aligned	  with	  TVIC	  concepts	  facilitated	  TVIC	  at	  these	  sites.	  Furthermore,	  the	  extent	  to	  and	  ways	  in	  which	  TVIC	  was	  taken	  up	  in	  each	  organization	  was	  influenced	  by	  the	  existing	  tensions	  and	  power	  dynamics	  at	  each	  site.	  	  Alignment	  with	  clinic	  mandate:	  “We	  are	  a	  little	  bit	  different	  here”	  Several	  participants	  explained	  these	  “inner-­‐city”	  PHC	  clinics	  were	  particularly	  receptive	  to	  TVIC,	  as	  they	  were	  already	  oriented	  to	  concepts	  of	  trauma,	  marginalization	  and	  equity.	  One	  nurse	  said:	  “With	  our	  staff	  we’re	  preaching	  to	  the	  choir.”	  Several	  staff	  members	  contrasted	  the	  support	  for	  TVIC	  at	  these	  sites	  with	  “mainstream”	  health	  services	  where	  they	  might	  have	  a	  less	  supportive	  group	  of	  staff,	  or	  less	  time,	  resources,	  support,	  or	  voice:	  “We	  are	  a	  little	  bit	  different	  here,	  we	  are	  not	  for	  profit,	  we	  have	  time”	  explained	  one	  staff	  member.	  Another	  said:	  	  	   48	  I	  know	  for	  myself	  I’ll	  never	  ever	  work	  at	  a	  regular	  GP’s	  office.	  I	  love	  it	  here	  because	  the	  people	  that	  I	  work	  for	  and	  work	  with	  we’re	  just	  an	  open	  team,	  you	  know,	  like	  no	  one	  is	  better	  than	  anyone.	  Practitioners	  and	  leaders	  noted	  that	  TVIC	  was	  easier	  to	  bring	  into	  these	  sites	  than	  would	  be	  the	  case	  in	  a	  more	  conventional	  PHC	  context	  because	  of	  the	  congruence	  of	  TVIC	  concepts	  with	  their	  mandates	  and	  the	  populations	  they	  serve.	  One	  nurse	  explained	  that	  advocacy	  is	  a	  point	  of	  pride	  in	  her	  clinic:	  “It’s	  absolutely	  what	  we	  should	  be	  doing	  is	  being	  that	  voice	  for	  the	  patient	  and	  being	  an	  advocate	  for	  patients…	  [Isn’t	  that]	  what	  makes	  us	  different?”	  Others	  noted	  that	  they	  didn’t	  see	  dramatic	  changes	  at	  their	  sites	  because	  TVIC	  principles	  were	  already	  guiding	  their	  work:	  “I	  think,	  the	  trouble	  is	  that	  the	  majority	  of	  my	  colleagues	  are	  people	  at	  this	  point	  who	  …	  who	  have	  already	  started	  thinking	  this	  way.”	  Another	  participant	  highlighted	  how	  the	  particular	  mandate	  and	  context	  at	  their	  clinic	  allows	  for	  the	  time	  to	  practice	  TVIC,	  giving	  the	  example	  of	  supporting	  a	  client	  while	  she	  made	  a	  very	  difficult	  report	  to	  the	  police.	  “I’m	  lucky	  enough	  to	  work	  in	  [clinic	  D]	  where	  I	  have	  the	  time	  to	  do	  this.	  	  Regular,	  a	  regular	  family	  practice	  does	  not	  offer	  people	  opportunities	  to	  do	  this.”	  	  “It	  has	  to	  be	  into	  a	  receptive	  organization”:	  Leadership	  and	  organizational	  culture	  The	  particular	  leadership	  and	  cultural	  context	  at	  each	  site	  also	  had	  a	  profound	  influence	  on	  how	  TVIC	  was	  interpreted	  and	  taken	  up	  at	  different	  clinics.	  One	  leader	  described	  how	  she	  saw	  her	  role	  in	  creating	  a	  culture	  that	  was	  receptive	  to	  TVIC:	  	  It’s	  not	  education	  as	  much	  as	  helping	  to	  develop	  a	  culture,	  a	  culture	  where	  staff	  are	  open	  to	  sometimes	  examining	  themselves	  but	  also	  of	  feeling	  everybody	  has	  a	  	   49	  voice	  to	  some	  degree	  within	  that,	  within	  the	  organization.	  So	  it’s	  a	  style	  of	  leadership	  but	  the	  style	  of	  leadership	  also	  perhaps	  develops	  the	  culture.	  In	  a	  site	  with	  a	  cohesive	  team	  and	  strong	  support	  from	  leadership,	  the	  clinic	  was	  able	  to	  implement	  trauma-­‐	  and	  violence-­‐	  informed	  policies	  and	  practices	  fairly	  quickly.	  Staff	  at	  this	  site	  noted	  that	  the	  supportive,	  flexible	  culture	  and	  common	  philosophy	  at	  their	  clinic	  enabled	  them	  to	  provide	  TVIC:	  	  We	  have	  a	  supportive	  staff	  and	  we	  have	  a	  type	  of	  work	  environment	  that	  allows	  us	  to	  be	  supportive	  of	  each	  other	  so	  that	  we	  can	  have	  the	  emotional	  reserves	  to	  be	  able	  to	  provide	  trauma	  informed	  care.	  	  I	  think	  we’re	  flexible	  if	  you	  have	  somebody	  that	  comes	  in	  that’s	  in	  a	  particular	  trauma	  or	  crisis	  our	  colleagues	  are	  always	  really	  good	  about	  accommodating	  that	  time.	  ….	  so	  I	  think	  we’re	  conscious,	  we	  trust	  that	  we’re	  practicing	  from	  the	  same	  philosophy	  and	  that	  the	  things	  that	  we’re	  doing,	  the	  clients	  are	  appropriate	  for	  that	  particular	  visit.	  At	  another	  site,	  TVIC	  was	  superimposed	  onto	  existing	  tensions	  and	  perceived	  dichotomies	  in	  the	  team,	  for	  example,	  between	  “psychosocial”	  and	  “medical”	  staff,	  and	  between	  Aboriginal	  and	  non-­‐Aboriginal	  staff.	  One	  staff	  member	  paints	  this	  picture	  of	  the	  diverse	  and	  competing	  perspectives	  at	  this	  site:	  I	  think	  it’s,	  it’s	  challenging	  because,	  you	  know,	  we’re	  not	  Aboriginal	  people	  that	  are	  calling	  a	  lot	  of	  the	  shots.	  	  And	  then	  the	  doctors	  [who	  are]	  calling	  the	  shots	  for	  the	  patients	  are	  not	  Aboriginal.	  	  And that’s	  always	  about	  the	  right	  fit	  and	  the	  willingness	  of	  people	  to	  experience	  things	  in	  a	  different	  way	  or	  behave	  in	  a	  different	  way	  and	  be	  open	  to	  different	  ways	  of	  being.	  	  And,	  you	  know,	  getting	  to	  be	  the	  right	  kind	  of	  person	  where	  I	  don’t	  know	  if	  we	  have	  all	  the	  right	  kind	  of	  	   50	  people.	  	  And	  that’s	  a	  challenge	  because	  people	  were	  sort	  of	  set	  in	  their	  ways	  …	  So,	  you	  know,	  it’s	  not	  that	  we’re	  all	  on	  the	  bus	  for	  the	  same	  purpose.	  In	  this	  context,	  TVIC	  was	  taken	  up	  as	  a	  foundational	  conversation	  about	  the	  vision	  and	  values	  of	  the	  organization.	  Another	  staff	  member	  describes	  this	  change:	  	  I	  mean	  the	  change	  has	  been	  slow	  and	  gradual	  so	  it’s	  kind	  of	  hard	  to	  really	  see	  because	  what	  it	  also	  does	  I	  think	  it	  upsets	  the	  apple	  cart…	  I	  think	  with	  this	  trauma	  stuff	  and	  the	  other	  stuff	  it’s	  like,	  it	  brings	  out	  the	  issues	  I	  guess,	  it	  brings	  out	  the	  issues	  where	  you	  talk	  about	  them	  and	  maybe	  deal	  with	  them	  but	  there’s	  other	  stuff	  it	  brings	  out.	  These	  tensions	  and	  discussions	  made	  it	  difficult	  to	  see	  immediate	  impacts	  from	  the	  TVIC	  sessions	  at	  this	  site.	  However,	  these	  conversations	  led	  to	  significant	  shifts	  in	  organizational	  culture,	  centering	  the	  voices	  –	  notably,	  Aboriginal	  voices	  –	  that	  had	  previously	  been	  marginalized	  in	  the	  organization.	  	  Personal	  context:	  Values,	  knowledge,	  learning	  styles	  and	  engagement	  influenced	  how	  participants	  understood	  and	  enacted	  TVIC	  Alignment	  with	  practitioner’s	  values:	  Validation,	  struggles,	  resistance	  Individual	  staff	  members	  also	  brought	  their	  diverse	  personal,	  educational	  and	  professional	  backgrounds	  to	  the	  TVIC	  sessions,	  which	  influenced	  how	  they	  reacted	  to	  learning	  about	  TVIC	  concepts.	  For	  some	  staff,	  TVIC	  concepts	  aligned	  closely	  with	  their	  values	  and	  their	  motivations	  for	  practicing	  and	  provided	  some	  validation	  and	  language	  for	  the	  way	  they	  approached	  practice.	  A	  social	  worker	  explained	  her	  reaction	  to	  the	  	   51	  material	  on	  structural	  violence:	  “It	  kind	  of	  justifies...	  I	  mean	  it	  sort	  of	  like	  frames…	  what	  the	  whole	  crux	  of	  my	  work	  is	  like.”	  	  For	  others,	  TVIC	  concepts	  such	  as	  harm	  reduction	  were	  a	  challenge	  to	  their	  values.	  One	  practitioner	  who	  was	  in	  recovery	  from	  addiction	  talked	  about	  the	  struggle	  to	  reconcile	  the	  abstinence-­‐based	  approach	  that	  worked	  for	  him	  personally	  with	  TVIC	  and	  harm	  reduction:	  	  I	  mean	  the	  harm	  reduction	  concept	  is	  so	  much	  bigger	  than	  I	  even	  understand,	  I’m	  still	  struggling	  with	  some	  aspects	  of	  it.	  So	  [EQUIP]	  really	  sort	  of	  took	  it	  to	  another	  level	  for	  me.	  	  So	  that	  opened	  my	  eyes	  and	  actually	  I	  mean	  my	  initial	  response	  was	  like	  “Are	  you	  nuts?”	  	  And	  my	  second	  response	  was	  “well	  wait	  a	  second,	  listen	  to	  the	  reality	  that	  they’re	  dealing	  with,	  number	  one,	  and	  what	  are	  they	  doing?”	  	  They’re	  trying	  to	  engage	  this	  person	  and	  like	  if	  they	  succeed	  in	  getting	  a	  relationship	  with	  this	  person	  maybe	  this	  person	  will	  sort	  of	  come	  with	  them	  over	  to	  the	  clinic	  and	  have	  some	  blood	  work	  or	  I	  don’t	  know	  what.	  TVIC	  met	  resistance	  from	  practitioners	  when	  it	  clashed	  with	  their	  perspectives	  and	  experiences.	  One	  staff	  member	  discussed	  the	  challenges	  he	  saw	  for	  colleagues	  in	  incorporating	  a	  trauma-­‐	  and	  violence-­‐	  informed	  approach	  to	  pain	  and	  opioid	  prescription:	  	  People	  have	  their	  own	  philosophies	  about	  how	  you	  manage	  pain	  and	  suffering	  and	  having	  somebody	  come	  in	  and	  hold	  a	  couple	  of	  talks	  is	  not	  going	  to	  change	  that,	  when	  their	  philosophies	  are	  based	  on	  decades	  of	  experience	  as	  well	  as	  their	  own	  personal	  values	  and	  beliefs.	  	   52	  In	  summary,	  structural,	  organizational,	  and	  personal	  contexts	  influenced	  the	  ways	  that	  TVIC	  was	  understood	  and	  taken	  up	  at	  each	  site.	  These	  factors	  functioned	  as	  both	  barriers	  to	  and	  facilitators	  of	  providing	  trauma-­‐	  and	  violence	  informed	  care.	  As	  noted	  above,	  practitioners	  brought	  their	  own	  personal	  and	  disciplinary	  orientations	  to	  education	  on	  TVIC,	  and	  their	  individual	  reactions	  to	  TVIC	  education	  varied	  widely.	  	  Alignment	  with	  previous	  knowledge	  and	  learning	  styles:	  Need	  for	  clear	  goals	  Some	  staff	  members	  wanted	  a	  more	  concrete	  idea	  of	  the	  learning	  objectives	  of	  the	  TVIC	  session.	  One	  participant	  explained:	  	  I’m	  the	  type	  of	  person	  that	  likes	  learning	  goals	  laid	  out,	  I	  want	  to	  know	  what	  the	  content	  is,	  I	  want	  to	  know	  what	  I’m	  supposed	  to	  be	  getting	  out	  of	  this	  and	  how	  it’s	  going	  to	  apply	  to	  my	  practice.	  As	  discussed	  in	  theme	  one	  above,	  some	  participants	  were	  expecting	  a	  more	  concrete	  “toolkit”	  on	  TVIC,	  and	  many	  people	  at	  these	  clinics	  were	  already	  familiar	  with	  some	  of	  the	  concepts.	  One	  participant	  noted,	  “I	  think	  maybe	  some	  people	  felt	  like,	  you	  know,	  they	  weren’t	  sure	  what	  exactly	  they	  were	  getting	  out	  of	  it	  like	  more	  than	  what	  they	  were	  already	  doing.”	  It’s	  possible	  that	  the	  TVIC	  sessions	  were	  not	  meeting	  the	  needs	  of	  participants	  who	  were	  already	  knowledgeable	  about	  trauma	  and	  violence.	  Engagement	  with	  facilitators:	  A	  strength	  for	  some,	  a	  weakness	  for	  others	  Some	  staff	  members	  also	  commented	  on	  the	  degree	  to	  which	  the	  session	  facilitators	  themselves	  were	  able	  to	  engage	  participants.	  One	  staff	  member	  commented	  on	  this	  as	  a	  strength	  of	  the	  intervention,	  saying:	  “You	  have	  to	  have	  the	  personality	  to	  do	  that…	  you	  might	  have	  a	  different	  person	  do	  it	  and	  it	  might	  not	  be	  as	  good.”	  Another	  	   53	  participant	  had	  a	  contrasting	  experience,	  and	  suggested	  more	  involvement	  from	  frontline	  providers:	  	  I	  think	  sometimes	  front	  line	  workers	  respond	  better	  to	  other	  frontline	  workers	  that	  are	  kind	  of	  in	  the	  trenches…	  People	  want	  to	  know	  that	  you’re	  legit…	  how	  have	  you	  earned	  your	  stripes...	  “If	  I’m	  going	  to	  change	  my	  practice	  then	  the	  person	  that’s	  telling	  me	  to	  change	  my	  practice	  or	  asking	  me	  to	  reflect…	  I	  need	  to	  value	  their	  opinion.”	  In	  conclusion,	  both	  the	  delivery	  of	  and	  the	  context	  for	  the	  TVIC	  sessions	  influenced	  their	  impacts.	  Local	  data,	  externally	  facilitated	  discussions,	  and	  the	  presence	  of	  researchers	  on	  site	  were	  described	  as	  impactful	  aspects	  of	  the	  intervention,	  whereas	  a	  long	  time	  frame	  was	  seen	  as	  a	  challenge.	  In	  addition,	  the	  structural,	  organizational	  and	  personal	  contexts	  for	  the	  TVIC	  sessions	  shaped	  how	  these	  concepts	  were	  taken	  up	  at	  each	  site	  and	  by	  each	  practitioner.	  Summary	  	   In	  this	  chapter	  I	  have	  described	  my	  findings	  from	  an	  analysis	  of	  interviews	  with	  fourteen	  staff	  members	  at	  two	  PHC	  sites	  participating	  in	  the	  EQUIP	  study.	  I	  identified	  two	  broad	  themes	  about	  the	  impacts	  of	  the	  EQUIP	  TVIC	  sessions	  for	  these	  staff	  members.	  First,	  the	  TVIC	  sessions	  enhanced	  some	  participants’	  awareness,	  knowledge	  and/	  or	  confidence	  about	  trauma	  and	  violence.	  Second,	  this	  contributed	  to	  a	  shift	  in	  perspective	  for	  some	  participants,	  that	  had	  effects	  on	  personal,	  clinical,	  organizational,	  and	  structural	  levels.	  I	  also	  identified	  several	  intrinsic	  and	  contextual	  factors	  that	  influenced	  these	  impacts.	  Intrinsic	  factors	  -­‐	  data,	  discussions,	  researchers’	  presence,	  and	  timing	  -­‐	  influenced	  how	  TVIC	  was	  understood,	  remembered	  and	  prioritized	  by	  	   54	  participants.	  Structural,	  organizational,	  and	  personal	  contexts	  influenced	  how	  participants	  took	  up	  and	  enacted	  TVIC	  in	  their	  practice.	  In	  the	  next	  chapter,	  I	  discuss	  these	  findings	  and	  their	  implications	  for	  future	  work	  in	  this	  area.	  	   	  	   55	  Chapter	  Five:	  Discussion	  and	  Recommendations	  Summary	  of	  findings	  	   In	  this	  analysis	  I	  have	  identified	  several	  impacts	  of	  the	  TVIC	  orientation	  and	  training	  component	  of	  the	  EQUIP	  intervention.	  	  Many	  of	  these	  impacts	  were	  consistent	  with	  the	  outcomes	  that	  researchers	  expected	  in	  designing	  the	  EQUIP	  intervention	  (see	  Figure	  1:	  EQUIP	  Intervention	  Theory	  (Browne	  et	  al.,	  2015,	  p.	  5)	  (reproduced	  with	  permission)).	  In	  keeping	  with	  EQUIP’s	  hypothesis,	  several	  staff	  members	  described	  that	  their	  awareness,	  confidence	  and/or	  knowledge	  of	  trauma	  and	  violence	  were	  enhanced	  by	  participating	  in	  the	  TVIC	  sessions.	  In	  addition,	  EQUIP	  researchers	  had	  expected	  to	  see	  “shifts	  in	  perspective	  and	  attitudes”	  with	  TVIC	  orientation	  and	  training.	  In	  this	  analysis	  I	  identified	  a	  shift	  in	  perspective	  that	  I	  conceptualized	  as	  “seeing	  through	  a	  TVIC	  lens”.	  This	  shift	  had	  impacts	  in	  multiple	  aspects	  of	  practitioners’	  lives.	  	   My	  analysis	  also	  explored	  the	  intrinsic	  and	  contextual	  factors	  that	  influenced	  the	  impacts	  of	  TVIC	  education.	  I	  found	  that	  presentations	  of	  local	  data,	  externally	  facilitated	  discussions,	  the	  presence	  of	  researchers	  on	  site	  and	  the	  timing	  of	  sessions	  were	  all	  influences	  on	  how	  TVIC	  concepts	  were	  understood,	  remembered	  and	  prioritized	  by	  participants.	  I	  also	  identified	  structural,	  organizational	  and	  personal	  contexts	  influenced	  the	  extent	  to	  and	  the	  ways	  in	  which	  TVIC	  was	  taken	  up	  and	  enacted	  at	  each	  site	  and	  by	  each	  practitioner.	  	  Discussion	  	   These	  findings	  give	  rise	  to	  several	  issues	  for	  discussion.	  Many	  of	  the	  themes	  identified	  in	  this	  study	  are	  consistent	  with	  the	  findings	  of	  other	  studies	  on	  trauma-­‐	   56	  informed-­‐care	  (TIC).	  However,	  the	  findings	  of	  my	  study	  differ	  from	  the	  TIC	  literature	  in	  some	  interesting	  ways.	  First,	  the	  importance	  of	  client	  empowerment	  or	  “client	  voice”,	  which	  is	  prominent	  in	  the	  TIC	  literature,	  did	  not	  seem	  to	  be	  taken	  up	  as	  a	  central	  feature	  of	  TVIC	  in	  this	  study.	  Second,	  in	  this	  study,	  I	  identified	  that	  TVIC	  concepts	  posed	  a	  challenge	  to	  the	  dominant	  biomedical	  paradigm,	  an	  issue	  that	  I	  have	  not	  seen	  explored	  in	  the	  TIC	  literature.	  Third,	  I	  identified	  a	  dilemma	  faced	  by	  staff	  trying	  to	  take	  a	  structural	  perspective	  to	  a	  clinical	  role.	  This	  is	  another	  issue	  I	  have	  not	  seen	  in	  the	  TIC-­‐related	  literature.	  The	  ways	  that	  this	  study	  on	  TVIC	  aligns	  with	  and	  yet	  differs	  from	  the	  TIC	  literature	  sheds	  some	  light	  on	  the	  differences	  between	  TVIC	  and	  TIC,	  and	  gives	  rise	  to	  some	  recommendations	  for	  future	  efforts	  at	  implementing	  TVIC.	  	  Consistency	  of	  the	  findings	  with	  TIC	  literature	  The	  impacts	  of,	  and	  influences	  on	  implementing	  TVIC	  in	  this	  study	  echo	  many	  themes	  in	  the	  literature	  on	  implementing	  TIC.	  The	  impacts	  of	  “seeing	  through	  a	  TVIC	  lens”	  described	  in	  this	  study	  align	  with	  literature	  describing	  TIC	  as	  a	  “trauma	  lens”	  or	  a	  “paradigm	  shift”	  (Drabble	  et	  al.,	  2013;	  Harris	  &	  Fallot,	  2001).	  As	  in	  Elliot	  et	  al.,	  (2005),	  many	  of	  the	  impacts	  that	  I	  identified	  in	  the	  study	  were	  shifts	  at	  an	  organizational	  level.	  In	  addition,	  themes	  on	  the	  influences	  of	  social	  and	  organizational	  contexts,	  values,	  and	  visions	  have	  been	  described	  in	  other	  studies	  that	  emphasize	  the	  importance	  of	  leadership	  and	  organizational	  commitment	  to	  TIC	  (Hopper,	  2010;	  Markoff	  et	  al.,	  2005).	  	  Client	  voice:	  Lost	  in	  the	  discussion?	  The	  literature	  on	  TIC	  places	  great	  emphasis	  on	  the	  empowerment	  of	  clients	  or	  service	  users	  as	  a	  central	  component	  of	  TIC	  (Harris	  &	  Fallot,	  2001;	  Hopper	  et	  al.,	  2010).	  	   57	  In	  other	  settings,	  adopting	  a	  trauma-­‐informed	  approach	  has	  included	  establishing	  formal	  systems	  for	  soliciting	  client	  feedback	  or	  including	  clients	  in	  the	  design	  of	  services.	  In	  contrast,	  client	  voice	  did	  not	  seem	  to	  be	  taken	  up	  as	  a	  theme	  or	  priority	  for	  organizational	  change	  for	  most	  of	  the	  participants	  interviewed	  for	  this	  study.	  	  This	  does	  not	  necessarily	  imply	  that	  client	  empowerment	  is	  not	  a	  concern	  for	  these	  organizations.	  One	  of	  the	  two	  sites	  studied	  here	  already	  has	  formal	  mechanisms	  in	  place	  to	  get	  input	  from	  clients,	  and	  might	  not	  have	  seen	  a	  need	  to	  make	  any	  further	  changes.	  It’s	  also	  possible	  that	  these	  sites	  saw	  EQUIP’s	  collection	  of	  patient	  data	  as	  a	  sufficient	  mechanism	  for	  gaining	  clients’	  perspectives.	  It	  may	  simply	  reflect	  that	  this	  topic	  was	  not	  adequately	  probed	  in	  the	  interviews	  studied	  here.	  However,	  it	  is	  notable	  that	  that	  such	  a	  central	  feature	  of	  TIC	  (as	  described	  in	  the	  literature)	  did	  not	  appear	  as	  a	  prominent	  feature	  of	  TVIC	  implementation	  at	  either	  of	  these	  sites.	  TVIC	  as	  a	  vehicle	  for	  disrupting	  biomedical	  dominance	  Conversely,	  a	  separate	  issue	  arose	  in	  this	  study	  that	  I	  have	  not	  seen	  explored	  in	  the	  TIC	  literature.	  In	  this	  study,	  TVIC	  seemed	  to	  challenge	  the	  dominance	  of	  the	  biomedical	  paradigm	  in	  these	  clinics.	  	  The	  biomedical	  model	  has	  been	  the	  dominant	  paradigm	  in	  medicine	  since	  the	  turn	  of	  the	  20th	  century	  (Duffy,	  2011).	  According	  to	  Baum	  et	  al.	  (2013),	  “Biomedicine	  sees	  diseases	  as	  residing	  in	  the	  bodies	  of	  individuals	  and	  so	  actions	  to	  address	  them	  are	  directed	  at	  curing	  the	  individual	  or	  persuading	  them	  to	  reduce	  their	  risk	  factors	  for	  disease,	  emphasizing	  curative	  and	  rehabilitative	  therapies”	  (p.	  1).	  This	  paradigm	  grows	  out	  of	  European	  scientific	  rationalism	  and	  it	  is	  reinforced	  by	  individualism	  (Baum	  et	  al.,	  2013).	  In	  addition,	  this	  paradigm	  supports	  a	  	   58	  hierarchy	  in	  healthcare	  that	  places	  medicine	  and	  physicians	  in	  a	  dominant	  position	  over	  other	  disciplines	  (Anaf	  et	  al.,	  2014;	  Baum	  et	  al.,	  2013;	  Bleakley,	  2013).	  	  While	  biomedicine	  has	  enabled	  major	  scientific	  advances	  and	  reductions	  to	  global	  morbidity	  and	  mortality,	  this	  paradigm	  has	  come	  under	  increasing	  criticism	  for	  imposing	  a	  narrow,	  a-­‐contextual	  view	  of	  health	  and	  illness	  (Baum	  et	  al.,	  2013;	  Duffy,	  2011;	  Fertonani	  et	  al.,	  2015).	  Comprehensive	  PHC—community-­‐based,	  multidisciplinary	  care	  that	  addresses	  social	  determinants	  of	  health—is	  among	  the	  alternative	  models	  that	  some	  suggest	  may	  address	  the	  limitations	  of	  biomedicine	  (Baum	  et	  al.,	  2013;	  Fertonani	  et	  al.,	  2015).	  However,	  tensions	  between	  biomedicine	  and	  alternative	  perspectives	  persist	  in	  PHC	  settings,	  with	  biomedicine	  often	  maintaining	  dominance	  (Baum,	  2013;	  Fertonani,	  2015).	  	  This	  context	  of	  ongoing	  tension	  around	  biomedical	  dominance	  was	  evident	  to	  some	  extent	  at	  both	  sites	  in	  this	  study,	  and	  it	  contributes	  to	  many	  of	  the	  personal,	  organizational	  and	  structural	  influences	  on	  TVIC	  seen	  here.	  For	  example,	  the	  biomedical	  perspective	  marginalizes	  the	  care	  and	  control	  of	  pain	  (Duffy,	  2011);	  upholds	  a	  “culture	  of	  busy-­‐ness”	  (Thomson,	  et	  al.	  2008);	  and	  underpins	  funding	  models	  that	  make	  physical	  health	  care	  more	  accessible	  than	  mental	  health	  services	  (World	  Health	  Organization,	  2003).	  A	  biomedical	  paradigm	  may	  have	  also	  contributed	  to	  some	  practitioners	  seeking	  a	  “trauma	  and	  violence	  skill	  set”	  rather	  than	  a	  “trauma	  and	  violence	  lens”	  from	  the	  TVIC	  sessions.	  	  Multidisciplinary	  discussions	  about	  TVIC	  concepts	  challenged	  the	  hegemony	  of	  the	  biomedical	  paradigm	  at	  one	  site	  in	  particular.	  Other	  studies	  have	  shown	  that	  open	  discussions	  and	  common	  language	  can	  serve	  to	  flatten	  hierarchies	  among	  PHC	  staff	  	   59	  (Hilts	  et	  al,	  2013,	  Supper	  et	  al.,	  2014).	  However,	  other	  authors	  describe	  how	  health	  professionals	  in	  multidisciplinary	  settings	  may	  resist	  alternatives	  to	  biomedicine	  (Supper	  et	  al.,	  2014).	  Furthermore,	  multidisciplinary	  settings	  may	  be	  sites	  for	  overt	  or	  latent	  conflict	  between	  professions	  making	  competing	  claims	  to	  legitimacy	  (Sanders	  &	  Harrison,	  2008).	  As	  TVIC	  is	  brought	  into	  other	  PHC	  or	  health	  settings,	  it	  is	  worth	  considering	  how	  it	  will	  come	  up	  against	  dominant	  paradigms	  and	  how	  this	  may	  influence	  its	  implementation.	  	  The	  dilemma	  of	  taking	  a	  structural	  lens	  to	  a	  clinical	  setting	  	   	  A	  related	  issue	  arising	  from	  these	  findings	  is	  the	  tension	  created	  for	  practitioners	  taking	  a	  structural	  lens	  to	  their	  day-­‐to-­‐day	  work	  in	  clinical	  practice.	  Taking	  such	  a	  lens	  to	  practice	  can	  create	  a	  “dilemmatic	  space”	  for	  PHC	  practitioners:	  “They	  understand	  the	  importance	  of	  a	  social	  view	  of	  health	  but	  work	  in	  a	  broader	  health	  system	  that	  reinforces	  a	  largely	  bio-­‐medical	  view.”	  (Baum	  et	  al.,	  2013,	  p.	  10).	  Moreover,	  clients’	  immediate	  needs	  often	  take	  precedence	  over	  action	  on	  the	  social	  determinants	  of	  health	  (Baum	  et	  al.,	  2013).	  	  The	  TVIC	  curriculum	  in	  this	  study	  placed	  particular	  emphasis	  on	  structural	  violence	  and	  social	  determinants	  of	  health.	  Respondents	  described	  how	  learning	  about	  TVIC	  assisted	  them	  in	  naming	  and	  acting	  on	  structural	  violence	  and	  oriented	  them	  toward	  advocacy	  at	  a	  structural	  level.	  At	  the	  same	  time	  they	  explained	  how	  structural	  constraints	  such	  as	  regulations,	  funding,	  and	  time	  pressures	  limited	  their	  abilities	  to	  put	  these	  ideas	  into	  practice.	  	  Respondents	  at	  these	  PHC	  clinics	  negotiated	  this	  dilemma	  by	  taking	  action	  largely	  at	  the	  organizational	  level,	  re-­‐orienting	  their	  services	  to	  take	  structural	  violence	  	   60	  into	  account.	  They	  also	  described	  how	  learning	  about	  TVIC	  created	  a	  sense	  of	  momentum	  to	  press	  for	  broader	  structural	  change.	  Future	  efforts	  at	  TVIC	  may	  want	  to	  consider	  strategies	  such	  as	  reflexivity	  or	  alliance-­‐building	  to	  cope	  with	  this	  dilemma	  and	  harness	  momentum	  for	  structural	  action	  (Baum	  et	  al.,	  2013;	  Commission	  on	  Social	  Determinants	  of	  Health,	  2008).	  	  This	  might	  involve	  prompting	  practitioners	  to	  journal	  about	  contradictions	  they	  face	  in	  practice,	  for	  example,	  or	  to	  seek	  out	  partnerships	  with	  research,	  practice	  and	  policy	  actors	  who	  take	  action	  on	  the	  social	  determinants	  of	  health.	  Summary	  of	  discussion	  This	  study	  explored	  the	  impacts	  of	  TVIC	  education	  in	  two	  PHC	  clinics.	  The	  findings	  of	  “seeing	  through	  a	  TVIC	  lens”	  and	  seeing	  impacts	  at	  organizational	  levels	  were	  aligned	  with	  much	  of	  the	  TIC	  literature.	  However,	  while	  other	  TIC	  models	  focus	  on	  client	  voice	  or	  empowerment,	  this	  did	  not	  emerge	  as	  a	  strong	  theme	  in	  this	  study.	  The	  findings	  in	  this	  study	  also	  raised	  the	  issue	  of	  biomedical	  dominance	  and	  show	  the	  dilemma	  that	  can	  arise	  for	  practitioners	  taking	  a	  structural	  lens	  to	  clinical	  practice.	  	  Recommendations	  The	  findings	  of	  this	  study	  and	  the	  ensuing	  discussion	  give	  rise	  to	  several	  recommendations	  for	  future	  study	  and	  implementation	  of	  TVIC.	  The	  findings	  here	  and	  suggest	  that	  the	  EQUIP	  approach	  to	  TVIC	  orientation	  and	  training	  was	  successful	  in	  raising	  awareness	  of	  trauma	  and	  violence	  and	  in	  shifting	  the	  perspectives	  of	  some	  PHC	  staff.	  This	  analysis	  has	  also	  explored	  the	  complexity	  of	  bringing	  TVIC	  to	  PHC	  settings,	  describing	  the	  intrinsic	  and	  contextual	  factors	  that	  may	  influence	  TVIC	  implementation.	  	   61	  As	  TVIC	  is	  brought	  into	  diverse	  health	  care	  and	  human	  service	  settings,	  what	  are	  the	  implications	  of	  these	  findings	  for	  future	  implementations	  of	  TVIC?	  	  Assess	  for	  and	  tailor	  TVIC	  sessions	  to	  specific	  site	  contexts	  	  	   The	  findings	  from	  this	  study	  underscore	  the	  importance	  of	  considering	  the	  structural,	  organizational,	  clinical,	  and	  even	  personal	  contexts	  for	  introducing	  TVIC.	  In	  the	  case	  of	  this	  study,	  both	  of	  the	  clinics	  studied	  here	  are	  explicitly	  mandated	  for	  underserved	  inner-­‐city	  populations.	  By	  virtue	  of	  their	  leadership,	  care	  models	  or	  organizational	  cultures,	  the	  staff	  at	  these	  sites	  were	  already	  familiar	  with	  many	  of	  the	  concepts	  central	  to	  TVIC.	  Indeed,	  some	  practitioners	  felt	  validated	  by	  TVIC	  education,	  and	  some	  felt	  it	  was	  “preaching	  to	  the	  choir.”	  Nevertheless,	  one	  effect	  of	  TVIC	  sessions	  in	  these	  settings	  was	  to	  “upset	  the	  apple	  cart,”	  stirring	  up	  personal	  and	  organizational	  tensions	  and	  dilemmas	  at	  the	  sites.	  	  	   Future	  efforts	  to	  implement	  TVIC	  ought	  to	  take	  personal,	  organizational	  and	  structural	  contexts	  more	  thoroughly	  into	  account	  before	  orienting	  staff	  to	  TVIC	  or	  engaging	  staff	  in	  training.	  This	  would	  entail	  a	  thorough	  assessment	  of	  each	  site,	  taking	  note	  of	  structural,	  organizational,	  and	  leadership	  barriers	  and	  facilitators.	  Such	  an	  approach	  would	  also	  call	  for	  flexibility	  and	  tailoring	  of	  any	  TVIC	  to	  the	  context	  at	  each	  organization.	  Further,	  TVIC	  education	  should	  take	  diverse	  individual	  backgrounds,	  values,	  and	  learning	  styles	  into	  account	  in	  curriculum	  design.	  Explicitly	  attend	  to	  practice	  paradigms	  and	  how	  they	  affect	  and	  are	  affected	  by	  TVIC	  	   This	  study	  has	  highlighted	  the	  ways	  that	  TVIC	  concepts	  can	  challenge	  the	  dominant	  paradigms	  of	  biomedicine	  and	  individual-­‐level	  care	  in	  PHC.	  	  The	  findings	  in	  	   62	  this	  study	  further	  highlight	  how	  working	  in	  a	  biomedical	  paradigm	  can	  hinder	  practitioners’	  efforts	  to	  take	  action	  to	  address	  structural	  violence.	  Future	  efforts	  at	  TVIC	  should	  assess	  and	  explicitly	  attend	  to	  the	  dominant	  worldviews	  in	  practice	  settings,	  and	  consider	  how	  a	  biomedical	  paradigm	  might	  impact	  or	  be	  impacted	  by	  looking	  at	  practice	  through	  a	  TVIC	  lens.	  Further	  research	  is	  warranted	  to	  explore	  how	  practitioners	  and	  organizations	  manage	  TVIC	  in	  the	  context	  of	  conflicting	  worldviews.	  Frame	  TVIC	  orientation	  and	  training	  as	  a	  paradigm	  shift,	  but	  include	  tools	  and	  frontline	  mentors	  	   While	  TVIC	  orientation	  and	  training	  should	  be	  flexible	  and	  tailored,	  educators	  should	  also	  be	  clear	  with	  practitioners	  about	  what	  they	  can	  expect	  from	  TVIC	  education	  and	  how	  it	  may	  benefit	  their	  practice.	  One	  finding	  in	  this	  study	  was	  that	  some	  participants	  were	  expecting	  a	  TVIC	  “toolkit”	  to	  use	  in	  individual	  practice,	  when	  in	  fact	  the	  emphasis	  in	  this	  curriculum	  was	  on	  perspective	  shifts	  and	  organizational	  change.	  This	  points	  to	  the	  importance	  of	  carefully	  considering	  how	  TVIC	  is	  framed,	  both	  for	  practitioners	  and	  organizations.	  The	  goals	  of	  TVIC	  orientation	  and	  training	  could	  be	  more	  explicitly	  framed	  as	  an	  organizational	  shift	  rather	  than	  as	  an	  individual	  clinical	  skill.	  	  	   Without	  taking	  away	  from	  the	  importance	  of	  a	  paradigm	  shift	  for	  organizations,	  however,	  TVIC	  sessions	  could	  be	  strengthened	  with	  the	  addition	  of	  some	  concrete	  “take-­‐aways”	  for	  practitioners.	  The	  practitioners	  in	  this	  study,	  particularly	  those	  who	  were	  already	  familiar	  with	  TVIC	  concepts,	  were	  hungry	  for	  concrete	  TVIC	  tools	  and	  for	  advice	  from	  frontline	  staff	  experienced	  in	  TVIC.	  Future	  TVIC	  sessions	  could	  include	  or	  simply	  point	  to	  scripts	  or	  tools	  for	  TVIC,	  and	  could	  incorporate	  experienced	  frontline	  	   63	  staff	  who	  could	  provide	  clinical	  mentorship	  in	  TVIC.	  However,	  training	  in	  concrete	  skills,	  scripts	  or	  tools	  should	  never	  detract	  from	  the	  importance	  of	  TVIC	  as	  a	  shift	  in	  perspective	  at	  an	  organizational	  level.	  Plan	  for	  sustainability	  and	  evaluation	  through	  ongoing	  research	  collaborations	  	   This	  study	  found	  that	  the	  presence	  of	  researchers	  and	  access	  to	  local	  client	  data	  at	  both	  sites	  were	  important	  influences	  that	  raised	  the	  profile	  of	  trauma	  and	  violence	  for	  practitioners.	  In	  the	  case	  of	  EQUIP,	  these	  factors	  were	  enabled	  because	  TVIC	  was	  one	  component	  of	  a	  large,	  multi-­‐year	  study	  at	  these	  sites.	  Future	  research-­‐	  or	  practice-­‐	  based	  efforts	  at	  TVIC	  will	  need	  to	  incorporate	  feasible	  strategies	  to	  ensure	  trauma-­‐	  and	  violence-­‐informed	  changes	  are	  sustained	  and	  build	  in	  means	  of	  evaluating	  these	  changes	  both	  for	  staff	  and	  for	  clients.	  Diverse	  organizations	  may	  take	  this	  up	  in	  different	  ways,	  collecting	  their	  own	  data,	  gathering	  client	  feedback,	  or	  working	  with	  practice	  consultants.	  	  Building	  on	  the	  success	  of	  EQUIP,	  one	  possible	  model	  is	  to	  foster	  long-­‐term	  collaborative	  relationships	  between	  researchers	  and	  practitioners	  working	  to	  end	  inequities.	  Such	  a	  model	  would	  give	  sites	  access	  to	  data	  on	  their	  own	  patient	  populations,	  assisting	  them	  to	  set	  priorities	  and	  evaluate	  quality	  improvement	  initiatives.	  Research	  collaborations	  may	  also	  provide	  an	  opportunity	  for	  practitioners	  to	  contribute	  to	  data	  that	  has	  impacts	  on	  a	  policy	  level.	  	  Attend	  to	  client	  input,	  empowerment	  and	  voice	  Although	  client	  empowerment	  is	  a	  key	  component	  of	  TVIC,	  the	  data	  studied	  here	  was	  limited	  on	  the	  concept	  of	  client	  input	  on	  services.	  This	  suggests	  that	  client	  voice	  	   64	  might	  be	  emphasized	  more	  strongly	  in	  future	  TVIC	  orientation	  and	  training.	  	  Further	  research	  is	  warranted	  on	  practitioners’	  perspectives	  on	  involving	  service	  users	  in	  service	  design	  and	  oversight.	  	  Summary	  of	  recommendations	  Based	  on	  the	  findings	  of	  this	  study,	  I	  have	  made	  six	  recommendations	  for	  future	  efforts	  at	  implementing	  TVIC	  in	  PHC	  or	  other	  settings.	  First,	  I	  recommend	  assessing	  and	  tailoring	  for	  diverse	  contexts	  for	  TVIC	  at	  each	  organization.	  Second,	  I	  suggest	  that	  TVIC	  facilitators	  and	  researchers	  explicitly	  attend	  to	  practice	  paradigms,	  and	  how	  they	  may	  impact	  or	  be	  impacted	  by	  TVIC.	  Third,	  I	  propose	  that	  TVIC	  sessions	  are	  best	  framed	  as	  a	  paradigm	  shift,	  but	  should	  include	  some	  concrete	  tools	  and	  mentorship.	  Fourth,	  I	  recommend	  that	  future	  efforts	  at	  TVIC	  education	  build	  in	  mechanisms	  for	  sustainability	  and	  evaluation	  through	  ongoing	  research	  collaboration.	  Finally,	  I	  advocate	  that	  the	  client	  voice	  receive	  more	  attention	  in	  future	  research	  on	  and	  implementations	  of	  TVIC.	  Conclusion	  	   Trauma	  and	  violence	  have	  wide-­‐ranging	  impacts	  on	  health	  (Anda	  et	  al.,	  2006).	  Because	  trauma	  survivors	  can	  be	  re-­‐traumatized	  when	  seeking	  health	  care,	  nurses	  and	  other	  health	  care	  providers	  have	  been	  encouraged	  to	  take	  trauma	  and	  violence	  into	  account	  in	  their	  practice	  (Elliot	  et	  al.,	  2005;	  Muskett,	  2014).	  TVIC	  is	  an	  approach	  that	  recognizes	  the	  impacts	  of	  trauma,	  structural	  violence	  and	  ongoing	  interpersonal	  violence,	  and	  aims	  to	  make	  health	  services	  safe	  and	  accessible	  for	  survivors	  (Browne	  et	  al.,	  2015).	  TVIC	  orientation	  and	  training	  sessions	  for	  health	  care	  providers	  were	  developed	  and	  implemented	  in	  two	  PHC	  clinics	  as	  one	  part	  of	  a	  multi-­‐component	  	   65	  equity-­‐promoting	  intervention.	  This	  secondary	  analysis	  of	  qualitative	  interviews	  with	  fourteen	  PHC	  providers	  has	  explored	  what	  can	  be	  learned	  from	  perspectives	  of	  primary	  care	  providers	  on	  the	  impacts	  of	  these	  TVIC	  sessions.	  	   The	  findings	  of	  this	  analysis	  suggest	  that	  the	  TVIC	  sessions	  contributed	  to	  increases	  in	  some	  PHC	  providers’	  awareness,	  knowledge	  and/	  or	  confidence	  about	  trauma	  and	  violence.	  The	  findings	  further	  suggest	  that	  this	  constituted	  a	  shift	  in	  perspective	  for	  some	  of	  these	  PHC	  providers,	  shifting	  their	  views	  on	  personal,	  clinical,	  organizational,	  and	  structural	  aspects	  of	  their	  practice.	  	   In	  this	  analysis	  I	  also	  explored	  the	  intrinsic	  and	  contextual	  influences	  on	  the	  impacts	  of	  the	  TVIC	  sessions.	  	  I	  identified	  that	  site-­‐specific	  data,	  externally	  facilitated	  discussions,	  the	  presence	  of	  researchers,	  and	  the	  timing	  of	  the	  TVIC	  sessions	  influenced	  how	  participants	  understood,	  remembered	  and	  prioritized	  TVIC.	  I	  have	  also	  explored	  the	  ways	  that	  structural,	  organizational,	  and	  personal	  context	  influenced	  how	  TVIC	  was	  understood	  and	  taken	  up	  in	  practice.	  	   This	  analysis	  adds	  to	  a	  growing	  body	  of	  literature	  on	  implementing	  trauma-­‐	  informed	  approaches	  in	  health	  care	  settings.	  The	  findings	  echo	  some	  of	  the	  themes	  in	  the	  literature,	  including	  the	  impact	  of	  “seeing	  through	  a	  trauma	  lens”	  and	  the	  importance	  of	  considering	  personal,	  organizational,	  and	  structural	  contexts	  when	  implementing	  TIC.	  In	  contrast	  to	  some	  of	  the	  TIC	  literature,	  this	  study	  did	  not	  find	  that	  efforts	  to	  increase	  “client	  voice”	  or	  autonomy	  were	  a	  major	  impact	  of	  having	  been	  oriented	  to	  TVIC	  concepts.	  However,	  this	  study	  highlighted	  how	  TVIC	  orientation	  and	  training	  problematized	  the	  dominance	  of	  the	  biomedical	  paradigm	  in	  these	  PHC	  sites,	  which	  has	  not	  been	  found	  in	  previous	  literature	  on	  TIC.	  In	  addition,	  this	  study	  surfaced	  	   66	  some	  of	  the	  tensions	  created	  for	  PHC	  staff	  attempting	  to	  address	  structural	  determinants	  of	  health	  in	  their	  roles	  as	  clinical	  care	  providers.	  	  	   Based	  on	  the	  findings	  of	  this	  study,	  I	  make	  five	  recommendations	  for	  implementing	  TVIC	  in	  the	  future.	  First,	  any	  implementation	  of	  TVIC	  should	  assess	  and	  be	  tailored	  to	  the	  personal,	  organizational,	  and	  structural	  contexts	  at	  each	  site.	  Second,	  we	  must	  consider	  and	  explicitly	  attend	  to	  how	  TVIC	  comes	  up	  against	  the	  dominant	  paradigms	  in	  health	  care	  settings.	  Third,	  TVIC	  orientation	  and	  training	  should	  be	  framed	  as	  a	  paradigm	  shift,	  but	  include	  some	  concrete	  tools	  and	  mentorship	  for	  practitioners.	  Fourth,	  future	  efforts	  at	  TVIC	  should	  build	  in	  strategies	  to	  sustain	  and	  evaluate	  the	  impacts	  TVIC	  orientation	  and	  training.	  Lastly,	  TVIC	  orientation	  and	  training	  should	  emphasize	 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 “trauma”:	  Examining	  the	  mental	  health	  impact	  of	  discrimination,	  torture	  &	  migration	  for	  racialized	  groups	  in	  Toronto.	  Retrieved	  March	  30,	  2016,	  from	  http://acrossboundaries.ca/conference/Trauma%20Report.pdf	  	  Whitehead,	  M.,	  &	  Dahlgren,	  G.	  (2006).	  Levelling	  up	  (part	  1):	  A	  discussion	  paper	  on	  concepts	  and	  principles	  for	  tackling	  social	  inequities	  in	  health.	  Retrieved	  March	  30,	  2016,	  from	  http://www.who.int/social_determinants/resources/leveling_up_part1.pdf	  	  Whittemore,	  R.,	  Chase,	  S.	  K.,	  &	  Mandle,	  C.	  L.	  Validity	  in	  qualitative	  research.	  Qualitative	  Health	  Research,	  11(4),	  522.	  	  World	  Health	  Organization.	  (2003).	  Investing	  in	  mental	  health.	  Retrieved	  March	  30,	  2016,	  from	  http://www.who.int/mental_health/media/investing_mnh.pdf	   	  	   74	  Appendix	  A:	  Interview	  Guide	  (Reproduced	  with	  permission	  from	  Annette	  Browne	  and	  Colleen	  Varcoe)	  Purpose	  of	  Initial	  Interviews:	  	  To	  explore	  the	  impact,	  if	  any,	  of	  the	  EQUIP	  intervention,	  particularly	  the	  training	  and	  integration	  components,	  on:	  	  a. staff	  members’	  practices,	  knowledge,	  attitudes,	  ways	  of	  working	  with	  patients	  or	  with	  other	  staff,	  etc.	  b. the	  organization,	  process	  of	  care,	  clinical	  guidelines,	  policies	  and	  structures,	  etc.	  	  Questions	  to	  ask	  all	  participants:	  	  1) Review	  what	  EQUIP	  consists	  of	  and	  which	  components	  of	  EQUIP	  they	  participated	  in	  by	  starting	  with	  a	  review	  of	  the	  EQUIP	  Intervention	  Handout	  listing	  the	  activities:	  	  o Ask	  staff	  to	  identify	  which	  components	  they	  completed	  in	  whole	  or	  in	  part,	  and	  whether	  they	  reviewed	  the	  Site	  reports/narratives.	  	  o EQUIP’s	  3	  Training	  Components	  o The	  various	  integration	  discussions	  led	  by	  the	  Practice	  Consultant	  o The	  PHSA	  Bystander	  module	  offered	  at	  some	  of	  the	  Sites	  o the	  Site	  Reports/Narratives	  	  o Planning	  or	  implementing	  changes	  under	  Organizational	  Integration	  and	  Tailoring	  (OIT)	  Probes:	  	  Explore	  whether	  they	  may	  be	  in	  a	  leadership	  role	  in	  relation	  to	  EQUIP,	  or	  have	  only	  attended	  training	  and	  completed	  the	  staff	  surveys,	  etc	  	   75	  	   2) Tell	  me	  a	  bit	  about	  what	  stands	  out	  for	  you	  overall,	  thinking	  about	  all	  the	  components	  of	  the	  intervention?	  Probe:	  Specifically	  can	  you	  tell	  me	  what	  aspects	  of	  that	  training/	  session/	  information	  most	  impacted	  you?	  	  	  Probe:	  How	  have	  you	  applied	  this	  in	  your	  work?	  	  Can	  you	  give	  me	  an	  example	  of	  how	  this	  has	  impacted	  your	  practice?	  Was	  there	  anything	  else	  about	  that	  component	  that	  stands	  out?	  	  	  These	  were	  the	  key	  areas	  –	  is	  there	  any	  part	  of	  that	  that	  you	  could	  connect	  to	  the	  training?	  What’s	  changed?	  What	  role	  did	  you	  think	  the	  training	  have	  in	  that?	  	  TVIC	  One	  of	  the	  core	  components	  of	  the	  EQUIP	  intervention	  was	  an	  emphasis	  on	  Trauma	  and	  Violence	  Informed	  Care.	  How	  do	  you	  think	  your	  own	  approach	  has	  changed	  over	  the	  past	  year	  in	  terms	  of	  taking	  trauma	  and	  violence	  into	  account	  (if	  at	  all)?	  Can	  you	  give	  me	  an	  example	  of	  something	  you	  are	  doing	  differently?	  Probe:	  How	  do	  you	  think	  your	  organization	  has	  changed	  in	  its	  approach	  to	  trauma	  and	  violence?	  	   76	  Can	  you	  think	  of	  an	  example	  of	  what	  has	  changed	  in	  your	  organization’s	  approach	  to	  trauma	  and	  violence?	  One	  of	  the	  topics	  that	  was	  discussed	  at	  the	  session	  on	  trauma	  and	  violence	  was	  the	  idea	  of	  “structural	  violence”.	  Tell	  me	  about	  what	  you	  made	  of	  that	  idea?	  ICC4	  Another	  core	  component	  was	  culturally	  safe	  care.	  How	  do	  you	  think	  your	  practice	  has	  shifted	  in	  this	  area	  over	  the	  past	  year?	  (Give	  examples,	  ditto	  for	  organization)	  a) TVIC	  and	  ICC	  Training:	  • How	  (if	  at	  all)	  has	  the	  ways	  in	  which	  you	  are	  taking	  trauma	  into	  account	  in	  the	  provision	  of	  care,	  or	  in	  organizational	  processes/	  policies?	  • What	  supported	  this	  change?	  What	  made	  it	  difficult	  to	  use	  what	  you	  learned?	  	  • How	  are	  you	  taking	  into	  account	  the	  experiences	  of	  everyday	  discrimination	  (on	  the	  basis	  of	  being	  poor,	  racialized,	  mentally	  ill,	  substance	  use)	  that	  so	  many	  of	  the	  patients	  experience?	  • What	  role	  do	  you	  have	  in	  articulating	  needs,	  meeting	  needs	  specific	  to	  your	  population?	  • How	  might	  have	  your	  clinical	  practices/	  work	  at	  the	  clinic	  have	  shifted	  or	  changed	  over	  the	  past	  year,	  if	  at	  all?	  • What	  changes	  may	  have	  occurred	  within	  the	  organization	  over	  the	  last	  year?	  	  What	  supported	  this	  change?	  What	  made	  it	  difficult	  to	  use	  what	  you	  learned?	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  4	  At	  the	  time	  of	  the	  interviews,	  the	  Sanyas	  Indigenous	  Cultural	  Safety	  (ICS)	  course	  was	  called	  the	  Indigenous	  Cultural	  Competency	  (ICC)	  training,	  and	  so	  is	  referred	  to	  as	  “ICC”	  through	  this	  interview	  guide.	  	   77	  • Underlying	  the	  ICC	  training	  is	  the	  focus	  on	  anti-­‐racism	  training.	  How	  did	  that	  aspect	  of	  the	  training	  impact	  you,	  the	  organization,	  your	  work	  as	  a	  team,	  etc.?	  	  	  	  b) Clinic	  profile(s)/narrative(s)	  and/or	  presentations	  with	  patient	  data	  and	  contextual	  information	  • Narrative	  profiles:	  • Have	  the	  profile(s)	  been	  useful	  so	  far?	  How	  have	  you	  used	  them?	  (probe	  for	  utility	  specific	  to	  EQUIP	  intervention/OIT,	  and	  other	  uses,	  related	  to	  their	  knowledge,	  attitudes,	  practices)	  • What	  are	  your	  thoughts	  on	  how	  it’s	  presented	  (probe:	  the	  kinds	  of	  information,	  the	  order	  presented,	  the	  mix	  of	  text,	  images,	  graphs	  and	  tables,	  the	  format-­‐hard	  copy	  etc.)?	  • Have	  there	  been	  any	  challenges	  or	  potential	  limits	  or	  downsides	  to	  having	  a	  document	  like	  this?	  • Anything	  else	  about	  the	  Narrative	  Profiles?	  • Presentations	  or	  other	  times	  you	  may	  have	  seen	  EQUIP	  patient	  data:	  • What	  were	  your	  impressions	  of	  the	  data	  you	  saw?	  Was	  this	  helpful	  in	  any	  way?	  If	  so,	  how?	  • What	  are	  your	  thoughts	  on	  how	  the	  data	  was	  presented	  to	  you	  (e.g.	  format,	  who	  was	  included,	  was	  there	  enough	  discussion	  or	  explanation)?	  • Are	  there	  other	  ways	  that	  we	  could	  make	  the	  EQUIP	  patient	  data	  available	  to	  your	  organization?	  What	  might	  be	  helpful?	  	  	   78	  c) Organizational	  changes	  implemented	  with	  support	  from	  EQUIP:	  Part	  of	  the	  EQUIP	  Intervention	  included	  your	  organization	  identifying	  specific	  areas	  for	  organizational	  change	  and	  implementing	  those	  changes	  with	  the	  support	  of	  EQUIP.	  This	  part	  of	  the	  intervention	  is	  referred	  to	  as	  Organizational	  Integration	  and	  Tailoring	  (OIT	  for	  short).	  At	  [clinic],	  you	  chose	  to	  focus	  on	  [briefly	  list	  OIT	  components	  for	  that	  clinic]	  • What	  role,	  if	  any,	  did	  you	  play	  in	  planning	  and	  implementing	  these	  changes?	  • What	  impacts	  do	  you	  expect	  to	  see	  from	  these	  changes?	  [prompt	  re:	  impacts	  for	  staff	  and	  how	  they	  work	  together,	  impacts	  for	  patients,	  other?]	  	  • What	  challenges,	  if	  any,	  have	  you	  encountered	  in	  planning	  and/or	  implementing	  these	  changes?	  your	  interactions	  with	  healthcare	  or	  community	  organizations	  (among	  others)	  outside	  of	  the	  clinic	  Information	  about	  you:	  Please	  tell	  us	  a	  little	  about	  yourself.	  	  8)	  Are	  you	  a	  staff	  member	  or	  board	  member	  in	  this	  clinic?	  	   Staff	  member	  	   Board	  member	  	   Other,	  please	  specify...	  ______________________	  9)	  What	  is	  your	  current	  position?	  	   Administrative	  Leader	  (e.g.,	  Executive	  Director)	  	   Drug	  and	  Alcohol	  Counsellor	  	   79	  	   Medical	  Office	  Assistant	  (MOA)	  	   Nurse	  or	  Nurse	  Practitioner	  	   Office	  Manager	  	   Outreach	  Worker	  	   Physician	  	   Other,	  please	  specify...	  ______________________	  	  10)What	  is	  your	  employment	  status?	  	   Full-­‐time	  	   Part-­‐time	  	   Casual	  	   Other,	  please	  specify...	  ______________________	  	  11)	  How	  long	  have	  you	  worked	  in	  your	  current	  organization?	  Years	   	   	   	   	   Months	  	   	   	   	   	  12)	  How	  do	  you	  identify	  your	  culture	  or	  ethnicity?	  	   	  13)	  If	  you	  identify	  as	  an	  Aboriginal	  person,	  are	  you:	  	   Status	  	   80	  	   Non-­‐status	  	   Metis	  	   Other,	  please	  specify...	  ______________________	  	   I	  am	  not	  Aboriginal	  Thank	  you	  for	  your	  time!	  	   	   	  	   81	  Appendix	  B:	  Agenda	  for	  EQUIP	  TVIC	  sessions	  	  Prepared	  by	  Annette	  Browne,	  Colleen	  Varcoe,	  Marilyn	  Ford-­‐Gilboe	  and	  Victoria	  Smye,	  reproduced	  with	  permission	  	  Trauma/Violence	  Informed	  Care	  (TVIC	  )	  Training	  Schedule/Curriculum	  Assumptions	  	  ! There are multiple and intersecting forms of oppression, including racial, gendered, and sexual.  ! Trauma and violence informed care occurs both at the point of individual interactions and at the level of organizational structures and supports. ! Interpersonal and structural forms of trauma and violence are inseparable. ! People marginalized by social and/or structural inequity who access primary healthcare services often present with a wide range of physical and mental health disorders that are directly attributable to their experiences of violence and trauma.  ! Curriculum supports change at the point of individual interactions as well as organization structures and supports. Overarching	  Purpose	  The overarching purpose of this training curriculum is to support individual staff members and primary healthcare organizations to achieve a ‘vital paradigm shift’ (if not already achieved) (Huntington, Moses, & Veysey, 2005) in how they understand and respond to behaviors and health conditions related to experiences of violence and trauma in the people who access their programs and services.  To enhance awareness among practitioners and organizations who provide PHC services in BC to persons marginalized by social and structural inequity.  Session	  One:	  TVIC	  Preparation	  (Post	  ICC	  Sessions)	  Ends	  in	  View:	  	  After	  reading	  the	  articles	  (2)	  as	  chosen	  by	  the	  participant	  from	  the	  list	  below,	  participants	  will	  be	  able	  to…	  1. Provide	  a	  brief	  synopsis	  of	  two	  of	  the	  required	  readings	  of	  choice.	  2. Have	  the	  foundational	  knowledge	  necessary	  to	  engage	  in	  the	  workshop	  dialogue	  related	  to	  trauma/violence	  informed	  care.	  	  Required	  Pre-­‐reading	  List:	  (List	  Articles)	  	  Canadian Womens’ Foundation. (February, 2011). Report on Violence Against Women, Mental Health and Substance Use. Prepared for the Canadian Womens’ Foundation by the BC Society of Transition Housing.  Cory, J., Godard, L., & Abi-Jaoude, A. (2008). Building Bridges: Linking Woman Abuse, Substance Use and Mental Ill Health. A Summary Report. Prepared by the Woman Abuse Response Program, BC Women’s Hospital and Health Centre, pp. 1-16. Elliott, D.E., Bjelajac, P., Fallot, R.D., Markoff, L.S. & Glover Reed, B. (2005). Trauma-informed or trauma-denied principles and implementation of trauma-informed services for women, Journal of Community Psychology, 33 (4), 461–477. 	   82	  Farmer, P. E., Nizeye, B., Stulac, S., & Keshavjee, S. (2006). Structural violence and clinical medicine, PLoS, 3 (10:October), 1686- 1691. Menzies, P. (2010). Intergenerational trauma from a mental health perspective. Native Social Work Journal, 7, 63-85. Scimeca, M.M., Savage, S.R., Portenoy, R. & Lowinson, J., (2000). Treatment of pain in methadone-maintained patients. Mount Sinai Journal of Medicine, 67(5), 412-422. 	  Time Activity Independently, on the participant’s own time:  Each participant will read two research articles selected from the options above.   Session	  Two:	  Face-­‐to-­‐face	  Training	  (6	  hours)	  Ends	  in	  View:	  By	  the	  end	  of	  Session	  Two	  participants	  will	  be	  able	  to…	  	  (Module	  #1)	  1. Describe the concept and history of psychological trauma.  2. Identify the range of perspectives on trauma/violence including: biomedical, clinical, health services and social determinants of health perspectives, and their implications. 3. Discuss various definitions of trauma, and how they are linked to these perspectives on trauma to increase awareness and understanding of different stances.  4. Describe trauma/violence-informed and trauma/violence-specific practice, and how they are linked in a responsive and effective system of care.  5. Define and discuss trauma/violence informed principles.  (Module	  #2)	  6. Describe	  trauma/violence	  effects	  in	  a	  range	  of	  areas,	  including	  physical,	  mental,	  behavioral,	  relational	  and	  spiritual.	  	  7. Describe	  and	  discuss	  a	  range	  of	  variables	  that	  can	  influence	  trauma/violence	  responses.	  8. Describe	  how	  the	  effects	  of	  trauma/violence	  may	  influence	  how	  survivors	  present	  when	  accessing	  PHC.	  	  	  (Module	  #3)	  9. Discuss	  examples	  of	  how	  trauma/violence-­‐	  informed	  practice	  principles	  might	  be	  applied	  in	  PHC.	  10. Identify	  how	  trauma/violence	  effects	  can	  influence	  interactions	  with	  service	  providers	  and	  demonstrate	  trauma/violence-­‐	  informed	  strategies	  that	  can	  be	  used	  to	  support	  engagement	  and	  safety,	  especially	  during	  early	  interactions.	  11. Describe	  and/or	  demonstrate	  trauma/violence-­‐	  informed	  ways	  of	  safely	  acknowledging	  the	  effects	  of	  trauma	  and	  validating	  experiences	  without	  discussing	  trauma	  details.	  	  	  (Module	  #4)	  12. Identify	  how	  trauma/violence-­‐	  informed	  practice	  is	  implemented	  at	  the	  organizational	  level.	  	   83	  13. Identify	  specific	  ways	  to	  strengthen	  trauma/violence-­‐	  informed	  practice	  at	  the	  organizational	  level	  (within	  the	  scope	  of	  their	  role)	  including,	  ways	  to	  influence	  organizational	  culture	  and/or	  policy.	  14. Describe	  specific	  ways	  that	  organizational	  cultures	  of	  wellness	  can	  be	  supported,	  including	  strategies	  for	  managing	  vicarious	  trauma.	  15. Describe	  a	  personal	  plan	  for	  strengthening	  TVIC	  within	  their	  own	  practice	  and	  discuss	  how	  they	  will	  promote	  TVIC	  within	  their	  organization	   Overarching Ends in View: Participants will be able to… o Explain how multiple forms of structural violence (e.g., racism, poverty) intersect with interpersonal violence (e.g., sexual assault, partner violence, child abuse).  o Identify the short and long-term health consequences of various and multiple forms of violence, for example, the emergence of chronic pain.  o Understand the physiological and health effects of trauma and violence. o Understand how trauma and violence underlie many of the physical and mental health disorders that people present with at primary healthcare organizations. o Understand how various contexts, values, and ideologies shape social and health care responses to violence and trauma.  o Understand the implications of the differences between trauma-informed care and standard approaches to health care for practice with individual clients and for organizational practices, including the implications for prescribing practices.  Time Activity  9:00 – 10:30 a.m.  (Module #1: History and Concepts) • Overview of schedule and ends in view (5 minutes) Small groups  Participants will form groups (4 people in each group, each having read at least one different article) to present a synopsis of key ideas from the pre-readings (Record on Flip Charts).  (see Session One: TVIC Preparation). (20 minutes)  	  Large	  group	  Building on small group work we will clarify fundamental definitions and provide a brief historical look at trauma: e.g., trauma, structural and interpersonal violence; the health and physiological effects of trauma, trauma-informed, violence-informed and trauma-specific practice (15 slides). (25 minutes)  We will illustrate stances on trauma using the following video clips (10 minutes): Dr. Anne Bullock – (Chippewa) http://www.youtube.com/watch?v=Ei95WkHjg_Y OVERVIEW In this module the participant is invited to consider diverse perspectives on trauma and violence, and examples of trauma/violence-informed practice within the context of PHC settings.  Purpose a) To begin establishing a complex historical context, linking multiple perspectives and events as contributors to contemporary thinking about psychological trauma b) To support increased 	   84	  Time Activity  Dr. Bessel van der Kolk http://www.youtube.com/watch?v=0yCzxm4I5fg 	  Large group reflection activity Participants will bring what they have learned about trauma/violence to a group discussion (30 minutes) and reflect on the following questions: 1) What was learned about trauma/violence? 2) What surprised you, if anything? 3) Implications for practice. Would you do anything differently given this knowledge? awareness and understanding of multiple theoretical contributions and perspectives, building on the historical context and supporting awareness of the contributions made by those working within different health and research systems.  c) To introduce the concept and principles of trauma/violence- informed practice.  10:30 – 10:45 a.m. BREAK  10:45 – 11:45 a.m.  (Module #2: Effects of Trauma) Large	  group	  An	  intro	  to	  the	  ‘health	  effects’	  conversation:	  Stilettos	  to	  Moccasins	  –	  Effects	  of	  Trauma	  on	  Spirituality	  http://www.youtube.com/watch?v=1QRb8wA2iHs Participants will reflect on the questions: What do you think about the effects of trauma in this film? – remembering that this could be the stigma of mental health, substance use …. (10 minutes). This discussion will provide the segue to small group work.   Small group  We will begin the small group activity by presenting case studies from practice to provide exemplars of the physical, emotional, behavioral, spiritual and relational effects of trauma and violence (three composite case studies from each of the sites) – (PI will prepare) –  • There is a common framework but we know there will be different foci related to trauma/violence on the different sites but that the health effects will be similar.  • Each group will be asked to contribute 2 concrete perspectives brought to bear on the case studies, bearing in mind the different roles (Physician, RN, NP, dietician, social work, psychologist, counselor, MOA, admin assistant etc.) and they will be asked to bring OVERVIEW In this module the participant will have the opportunity to explore the physical, emotional, behavioral, spiritual and relational effects of trauma and violence and consider the implications for PHC services.  Purpose a) To provide information about the many “symptoms”, responses or effects experienced by people who have been traumatized that will enhance trauma awareness and strengthen capacity for trauma-informed service responses. b) To increase awareness of factors that are known to play a role in shaping how posttraumatic effects (severity) will be 	   85	  Time Activity  them back to the large group. (20 minutes) Large group Report back from each of the four (?) groups (1-2 minutes each) (10 minutes).  We will bring together the work from the small groups to consider implications for PHC and think about the following: unintentional trauma, minimizing the effects or potential effects of trauma, implications for prescribing practices and implications for the management of substance use and mental health. (20 minutes). We will have four flip charts and on these will have the four headings: 1) Unintentional trauma, 2) Minimizing the effects or potential effects of trauma, 3) Implications for prescribing practices, 4) Implications for the management of substance use and mental health.  We will have the group report using the flip charts. Slide overview (4-5  slides) Video Clips to illustrate what is meant by ‘effects’ (25 minutes): Marla Sokolowski of the Canadian Institute for Advanced Research explores how the hardships that some children face, including poverty, poor nutrition or neglect, can lead to biological changes that make them more susceptible to health problems - changes that they may then pass along to their own kids. http://ww3.tvo.org/video/192655/marla-sokolowski-biology-childhood-hardship   experienced. This will support capacity among service providers in engagement and retention of people who may have many ‘risk factors.’  11:45 a.m. – 12:30 p.m.  (Module #3: TVIC in Action) Large group Short slide presentation: Overview of the principles of TVIC as a reminder (handout laminated). (5 minutes)  Small groups (4-5 people in each) Mapping activity (large paper activity) (10 minutes): Participants will be asked to map out the key contact points that people go through when they access their services.  Large group Quick report back with the maps on the wall…  (5 minutes)  OVERVIEW In this module the participant will be invited to deepen their knowledge and build basic skills to support the application of trauma/violence-informed principles into practice.  This will include examination of key points in the service continuum with an emphasis on how TVIC can be used to support engagement during 	   86	  Time Activity  We will ask – at each of these points:  What has worked well from a TVIC perspective? What could be adjusted/added to emphasize TVIC more fully? Given the principles we have discussed, how could you shift that? (e.g., line ups at the door at Cool Aid)… (Think about experiences that people have had in other contexts – identify ways in which PHC (practices) might unintentionally open up a trauma reaction). (25 minutes)  In an informal way we will attend to signage, language, environmental impact etc.  Consider the service setting and practice and think about if there are there specific things that practitioners are already doing or could do to support engagement of people more fully?    intake and assessment.   Purpose a) By	  revisiting	  the	  TVIC	  principles,	  initially	  introduced	  in	  section	  one	  and	  examining	  how	  they	  have	  been	  integrated	  into	  programs	  and	  practice	  within	  a	  variety	  of	  service	  settings,	  participants	  will	  have	  an	  opportunity	  reflect	  on	  translating	  the	  principles	  into	  practice.	  	  b) To provide an opportunity for participants to consider how TVIC may be applied at the very first points of contact that people have with service providers and program environments.  c) To	  increase	  awareness	  of	  practitioner	  skills	  that	  can	  be	  developed	  to	  support	  and	  maintain	  safety	  for	  people	  who	  may	  have	  experienced	  trauma	  and	  who	  are	  accessing	  services.	    12:30 noon – 1:30 p.m. LUNCH  	   87	  Time Activity  1:30 – 3:00 p.m.  (Module #4: Organizational Culture)  Large group  Slides … We will use slides to present material re: organizational culture and a commitment to TVIC organizational culture as per the 10 commitments related to equity-informed approach or Bloom or another) (10 minutes) – We will note that we know the participants are committed to this BUT, there is a risk in thinking that they are already fully there…. when the participants look at how people are treated in the emergency or in other places it is easier to look at practitioners and practices in those settings rather than at their own organization so as we work through these slides we are going to ask them to do something very challenging… to move to the absolute ideal … to consider what it would mean to push their organization and their own practice to the ideal…  Small group • Participants will be asked to consider one or two of the items in the list of commitments (or other commitments based on previous discussions) and reflect on the following questions: a) Who are the most marginalized people and how do we get them exceptional care that brings them to a better place? Contrast exemplar – the guy on the street for 40 years who feels very unsafe (a tad crusty, perhaps a bit smelly, very quiet) or do you sit beside the 27 year old guy who is easy to be with …… b) What do you find challenging in enacting your commitment to equity in your practice? Where do you use your privilege to take the easy route?  c) Consider what role staff can play in this? d) List the types of organizational support that would be helpful in moving towards this goal? e) Consider the ways in which individuals can inspire and contribute to TVIC at the organizational level? (15 minutes) {Within the context of this discussion, participants will be asked to think about those things that work well in the organization, the language used with clients and the physical space} Large group OVERVIEW This	  module	  focuses	  on	  implementation	  of	  trauma/violence-­‐	  informed	  practice	  at	  the	  organizational	  level.	  	  Purpose a)	  To	  provide	  participants	  with	  the	  opportunity	  to	  reflect	  on	  trauma/violence-­‐	  informed	  practice	  as	  it	  might	  be	  implemented	  at	  the	  organizational	  level.	  b)	  To	  provide	  some	  practical	  examples	  of	  how	  TVIC	  is	  translated	  into	  practice	  at	  the	  organizational	  level.	  c)	  To	  increase	  or	  strengthen	  awareness	  of	  vicarious	  trauma	  and	  it’s	  impacts,	  as	  well	  as	  to	  provide	  some	  strategies	  for	  managing	  the	  cumulative	  effects	  of	  jobs	  that	  include	  ‘emotional	  labor’	  (supporting	  recovery	  and	  healing	  for	  people	  working	  in	  PHC)	  and	  promoting	  wellness.	  d)	  To	  provide	  some	  basic	  examples	  of	  how	  supervision	  can	  support	  TVIC	  at	  both	  the	  practice	  and	  organizational	  levels.	  Not	  sure	  this	  is	  necessary	  but	  could	  be	  something	  incorporated	  into	  Session	  Four	  	   	   88	  Time Activity  Small group feedback (20 minutes).  Then participants will be asked to identify the ideal organizational culture to support TVIC in PHC.  a) How would the group develop the organization: brainstorm individual and collective actions toward a supportive culture (10 minutes) Slides (vicarious trauma) (5 minutes) Video Clip 	  Dr.	  Laurie	  Pearlman	  -­‐	  discussing	  strategies	  for	  managing	  vicarious	  trauma	  (5	  minutes)	  http://www.youtube.com/watch?v=wVDSdta0mbM&list=UUjY3NJMnT5Zc_VqtDWvdf0A	   Large group Participants will be asked to consider a) What strategies the organization might consider to ensure personal and organizational wellness? (20 minutes)  Preparation for next session (10 minutes)  Session	  Three:	  Linking	  Learning	  to	  Practice	  –	  Independent	  Ends	  in	  View:	  By	  the	  end	  of	  Session	  Three	  (Independent	  Learning)	  participants	  will	  be	  able	  to…	  1. Present	  a	  practice	  scenario	  and	  lessons	  learned	  related	  to	  TVIC	  (that	  they	  would	  like	  to	  share).	  	  Time Activity Independent exercise  o Participants will reflect on what they learned in Session Two and consider how TVIC may apply to real-life patients or clients they have worked with. o Each participant (or groups of participants who may wish to present a scenario together) will come to Session Four prepared to talk about an example from their practice where they have used, or might want to use, some of the principles and techniques learned in Section Two.   Session	  Four:	  Linking	  Learning	  to	  Practice	  –	  Face-­‐to-­‐face	  (2	  hours)	  Ends	  in	  View:	  By the end of Session Four participants will be able to… 1. Develop a personal action plan to enhance practice and the organization’s practices and policies toward universal trauma and violence informed care.  	   89	  2. Enact trauma-informed practice approaches in the care of individuals with varying trauma histories.   Time Activity  9:00 – 10:00 a.m. Overview of the day   Small groups Participants will be prepared to present a case scenario from practice (consideration across roles) for discussion (as per Session Three). The group members will: a) Identify specific actions to strengthen TVIC in practice as per this scenario. b) Consider the organizational features that need to be addressed to support their actions. c) Consider the structural factors that need to be addressed (all will be recorded on flip charts) (25 minutes)  Large group Participants will share commonalities across the group and what the group members learned from each other.  How for example, scheduling can feeling discriminatory for some (30 minutes)   Purpose To	  support	  people	  to	  reflect	  on	  specific	  goals	  that	  they	  can	  strive	  for	  to	  integrate	  TVIC	  conceptually	  and	  define	  some	  concrete	  actions	  to	  strengthen	  TVIC	  that	  they	  can	  take	  within	  their	  scope	  of	  practice.	  	   10:00 – 11:00 a.m.   Large	  group	  Participants	  will	  be	  given	  time	  to	  identify	  one	  or	  two	  strategies	  or	  skills	  related	  to	  each	  of	  the	  TVIC	  areas	  that	  they	  plan	  to	  continue;	  begin	  doing;	  learn	  more	  about	  or	  strengthen	  (as	  above).	  	  (10	  minutes)	  –	  give	  a	  paper	  handout	  –	  organizational	  …	  continue,	  begin,	  strengthen	  	  	  Participants	  will	  be	  asked	  to	  think	  about	  their	  goals	  both	  individual	  and	  organizationally	  and	  right	  them	  down	  on	  the	  handout	  (10	  minutes)	  	  Individual	  exercise	  	  Participants	  will	  be	  provided	  with	  the	  opportunity	  to	  share	  the	  organizational	  goals	  	  they	  want	  to	  work	  on	  and	  the	  support	  they	  hope	  for.	  They	  will	  be	  asked	  to	  write	  down	  personal	  /professional	  goals	  related	  to	  TVIC	  areas	  important	  to	  the	  organization,	  and	  next	  steps	  they	  wish	  to	  take.	  They	  will	  also	  consider	  areas	  of	  organizational	  support	  that	  may	  be	  necessary	  to	  implement	  the	  	   90	  plan.	  (30	  minutes)	  	  Write	  down	  your	  personal	  commitment	  as	  you	  move	  forward.	  	  Large	  group	  discussion	  of	  above	  (30	  minutes):	  You	  have	  heard	  ….You	  have	  your	  personal	  goals	  written	  –	  so	  now	  what	  are	  you	  going	  to	  do?	    Post Session Evaluation  Participants will be asked: o Would you like to have individual and/or organizational  follow-up?  o What types of supports do you envision now? o Working on a plan with the clinical leaders, what would it look like to pull meetings together?  o What does integration and tailoring look like? o What would be helpful in terms of moving forward with the $10,000? o What would the next step be in terms of your  goals?     	  

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