Voices from the Field

Welcome to Voices from the Field, a podcast series produced by the National Collaborating Centre for Indigenous Health (NCCIH), which focuses on innovative research and community-based initiatives promoting the health and well-being of First Nation, Inuit and Metis peoples in Canada.

Episode 27 – A medical student's journey – Part 2: Cultural safety and humility in practice

This episode was created as an adaptation from Arnold and Bogg’s textbook called Interpersonal Relationships, Professional Communication Skills for Canadian Nurses. Dr. Sheila Blackstock wrote a chapter called Engaging with Humility, Authentic Interpersonal Communication in Partnership with Indigenous People, and she oversaw the creation of this episode. In this episode, ways to practice in alignment with cultural safety and humility principles are discussed. These principles are somewhat specific to practicing in an Indigenous community or treating Indigenous patients, but ideas and themes are transferrable to all patients differing from the culture of one’s own.

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Bio

Kara Ruff is a Métis student, currently studying medicine through the University of British Columbia on the ancestral, traditional and unceded lands of the Sylix Okanagan Peoples at the Southern Medical Program in Kelowna, BC. She is entering her second year of medical school and has an interest in Indigenous and rural health care due to her familial ties and background of growing up in Campbell River on Vancouver Island. At the Southern Medical Program, she is the Indigenous Health Representative for her site and continues to advocate for improvement in culturally safe health care for Indigenous peoples in Canada.

The four-part mini-series, A Medical Student’s Journey in Learning about Indigenous Health, was developed with supervision and mentorship from Dr. Sheila Blackstock, a Gitxsan scholar and Academic Co-Lead for the NCCIH, and Dr. Viviane Josewski, a Research Associate with the NCCIH and Assistant Professor at the UNBC School of Nursing.

Transcript

Kara Ruff: Hello everyone and welcome to this episode of A Medical Student’s Journey in Learning about Indigenous Health, a mini-series within Voices from the Field. This episode will be on cultural safety and humility. My name is Kara Ruff, and I will be your host for this episode. I am of Métis descent on my father’s side, and on my mother’s side of mixed European origins. I am a member of Métis Nation BC, and I was born and raised in Campbell River, BC. I’m currently living as a guest on the traditional lands of the Syilx Okanagan Peoples in Kelowna, so I would like to thank them for allowing me to live, work, and play on their lands every day. For those of you who haven’t listened to previous episodes, I am a first-year medical student at the Southern Medical Program and the Indigenous Health Representative Junior for my class. This episode was created to outline what cultural safety and humility is and how to incorporate cultural safety and humility practice principles into your work as a health care provider. This episode was put together under the supervision of Dr. Sheila Blackstock who wrote a chapter in Arnold and Bogg’s textbook called Interpersonal Relationships, Professional Communication Skills for Canadian Nurses. The chapter was called Engaging with Humility, Authentic Interpersonal Communication in Partnership with Indigenous People. Dr. Viviane Josewski, another Associate Professor at the School of Nursing at UNBC co-supervised this episode, and I would like to thank both of them for their input.

One of the main reasons that I wanted to create these episodes is because I wanted to learn more on the subject of cultural safety and humility and how to improve my practice as a medical student. With writing these episodes, I realized how little I know with regard to this subject, and that I have a lot to learn as I progress throughout my career. Something that needs to be recognized is that practicing in a culturally safe manner and with humility is a process, and one needs to continually work to be reflecting and improving as part of that process. Reflexivity is a process where we consider the process of reflection and how the interpretation of the event in the reflection was achieved. Developing strategies for continuous self-examination allows you to become aware of your limits, become aware of biases that you have, and realize how your behaviour plays into organizational practices of a colonial system, allowing for recognition and change of those behaviours. I hope that this episode allows you to feel more equipped to engage in the process of practicing in a manner more aligned with cultural safety and humility. This episode will consist of knowledge translation as to what I learned through researching the subject, and under the guidance of my supervisors.

Firstly, I’d like to outline what cultural safety and cultural humility are as concepts. There are so many terms that have been tossed around over the years, and currently, there is a move away from “cultural competency” as it insinuates that you can become “competent” in the cultures of others. The First Nations Health Authority (FNHA) in BC defines cultural safety as: “an outcome based on respectful engagement that recognizes and strives to address power imbalances inherent in the health care system. It results in an environment free of racism and discrimination, where people feel safe when receiving health care.” The First Nations Health Authority then defines cultural humility as: “a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience.” I thought it was so important to create these podcast episodes after first year as I feel engaging with these principles early on in one’s career can facilitate healthy habits of reflection and practicing in a culturally safe way. It is important for medical students to begin to uncover the biases that we have learned at this point in our lives about the healthcare system, race, Indigeneity, and culture to understand how our behaviour is perpetuating a colonial system. Medical students are learners, we are learning every day, so to remind ourselves that all patients’ experiences are different, to learn to unlearn our biases, and to learn to acknowledge the power imbalances while we are so new to the system seems of the utmost importance.

Although there is a push away from cultural competency, health care workers should educate themselves on how health and wellness is viewed from an Indigenous lens. People in the health care field should recognize that the way health care is conducted currently is a colonial practice, and different cultures’ view health in different ways. A physician practicing in Watson Lake, the traditional lands of the Kaska Nation, said “The current form of health care is a colonial practice; we took it and monopolized health care and the way that it is delivered. We need to allow this community to provide input on their health care spaces and how they want their health care to be delivered.” I’d never considered how deeply the roots of colonization are in every system in Canada. The healthcare system may have looked completely different had the Western European culture not monopolized it. Indigenous knowledge is diverse and varies locally, but I’ll highlight here the fundamentally relational view of health common to many Indigenous groups.

Health is viewed with a more holistic perspective as depicted by the Indigenous medicine wheel, that has origins in Ojibwa teachings. On the First Nations Health Authority website, the wheel is described as follows: The Centre circle represents individual human beings with the idea that wellness starts with individuals claiming responsibility for their own health and wellness. The second circle moving outwards represents the importance of the mental, emotional, spiritual, and physical aspects of a healthy life. There is an emphasis that these aspects be balanced and that they are all tended to together to create a holistic level of wellness. The third circle moving outwards represents the overarching values that support and uphold wellness: respect, wisdom, responsibility and relationships. The Fourth circle moving outwards depicts the people that surround us and the places from which we come from. Land, community, family and Nations are all critical components of our healthy experiences as human beings. The fifth circle depicts the social, environmental, cultural, and economic determinants of health and well-being, recognizing that health is not merely biological. The outer circle shows people holding hands to represent togetherness and the FNHA vision of strong children, families, Elders and people in communities. Although, this is a general principle as to how health is viewed by Indigenous people, do not make assumptions and be sure to ask your patient how they view their health and wellness and create a wellness plan moving forward with them sharing an equal partnership.

It was found that person-centered approaches with cultural awareness of nurse and physician providers were a key factor in improving Indigenous patients with diabetes health outcomes. Another key factor in improving health outcomes for Indigenous Peoples is allowing self-determination through the reclamation of land and the environment Nations inhabited prior to colonization. Author’s Richmond and Ross identified Six Critical Indigenous Determinants of Health as follows: balance (of the mental, physical, emotional, and spiritual aspects of health), life control, education, material resources, social resources, and environmental and cultural connections. Colonization has caused Indigenous Peoples to face inequities in access to all of these critical Indigenous determinants of health, and that is why providing care in accordance with cultural safety and humility practices is so important.

In her chapter, Dr. Sheila Blackstock highlights the concept of the 4 R’s by Kirkness and Barnhardt. The 4 R‘s of respect, reciprocity, responsibility, and relevance can be used as guiding principles in culturally safe care for Indigenous Peoples. Respect can be conveyed through the demonstration of an understanding and value of cultural knowledge, traditions, and activities specific to each Indigenous community. Ways to develop that understanding will be discussed in a moment when I discuss protocols and relevance. Respect must also be highlighted through an understanding that every individual within a community or culture is different, and you should never make assumptions about a patient’s culture. Presencing is a process that occurs between the health care provider and the patient that is based on paying deliberate attention to the patient’s shared experience of humanity and recognizing and respecting that every individual differs. The Truth and Reconciliation Calls to Action highlight that “reconciliation is about establishing and maintaining a mutually respectful relationship between Aboriginal and non-Aboriginal peoples in this country.” Health care providers have an opportunity to learn how to enact allyship by providing culturally safe care to Indigenous Peoples. This includes examining systemic barriers to culturally safe care that exist within the healthcare system, addressing behaviours and actions of racism or stereotyping if they are witnessed, and authentically engaging in activities with Indigenous Peoples to honour their culture.

The next R, reciprocity, indicates that there is mutual benefit from an interaction. Reciprocity can first be conveyed through protocols and introducing yourself correctly, which I will highlight how to do when I discuss those in a moment. Reciprocity can also be conveyed by having policies that welcome Indigenous patients’ family members, support persons, translators, or Indigenous Patient Navigators, and creating safe places in health care buildings for those people to gather or perform cultural practices. Reciprocity can also be conveyed by hosting appreciation gatherings for Elders in the Community or meeting with community members to discuss what is needed to better care for those within the community.

The third R, responsibility, represents the responsibility we all have as individuals in a colonial country to actively participate in conversations around reconciliation and Indigenous activities. As I mentioned before, we all have a responsibility to enact allyship and advocate for decolonizing the healthcare system to better serve our Indigenous patients.

The last R, relevance, refers to respect underlying our learning of local Indigenous protocols, enactment of cultural safety and humility practices, and all of the other ways we conduct ourselves as an ally. Your actions must be relevant to the community you are practicing in and there are ways to facilitate gaining knowledge of the protocols. Dr. Blackstock outlines that “a protocol is a sequence of culturally appropriate behaviours that acknowledge the traditional ways of knowing and being inherent and expected in respected interactions with Indigenous Peoples”. Before going to a community, you can use the BC Assembly of First Nations interactive map to find out about the geographical area, treaties, local language spoken, chief and councillors, and be directed to other relevant resources.

To receive some guidance on the local protocols of the area surrounding language, traditions, or ceremonies you could approach the band office, who may put you in contact with a local representative, Elder, or Knowledge Keeper. They may guide you on how to respectfully engage, starting with situating yourself authentically, acknowledging territory, and possibly advising you on a gift to present that is meaningful to the Indigenous community. Dr. Blackstock outlines situating self authentically as introducing yourself, sharing your family lineage and the Indigenous community that you come from in your traditional language. You then translate what you said into English and explain the meaning to demonstrate transparency of who you are, where you came from, and your culture. It also demonstrates respect acknowledging whose land you are on and that you are a guest. Over time spent in the community, and under the guidance of the Elders and Knowledge Keepers, you may learn some of the local language. There is an app that you can download onto your phone called First Voices to learn general greetings and practice them with local community members. The most important aspect of engaging with protocols is doing so with interest, demonstrating respect and humility, indicating what you do not know, and humbly asking for guidance from people within the community.

To finish up, I’m going to discuss some other aspects of providing culturally safe care and acting with humility. As I was researching this topic, many resources kept discussing not adopting pan-Aboriginal approaches to care. This concept refers to an amalgamation of “all Aboriginal cultures into a single melting pot,” contributing to an erasure of cultural aspects of identity specific to varying Indigenous individuals. As highlighted above, all First Nations, Métis, and Inuit communities are different, and the ways individuals identify with their indigeneity vary, so do not make cultural assumptions based on the way someone appears. This is also important when it comes to providing care to Indigenous individuals who are “white-passing”, and an article about caring for Métis individuals highlights the vast differences in appearance that Métis peoples have, which also extends to other Indigenous groups as well. If you make a mistake in assuming someone's cultural identity, make sure to reflect on the biases you had when you saw your patient so such assumptions you had are not repeated in the future.

It is of critical importance to take time with your patients, create space, and discuss a health care plan with your Indigenous patients as partners in the interaction. Individual patients have unique needs, and in a colonial healthcare system as a non-Indigenous practitioner with your own cultural values, beliefs, and attitudes, you don’t know what you don’t know, so you must make space for questions and open dialogue to occur. Body language, tone, and speed of the interaction are all non-verbal cues to create a safe space and establish a trusting relationship with your Indigenous patients. Be very aware of the power imbalances as a health care provider and work to make others feel they have control of their health care and can have their needs met. Additions to your clinic to make Indigenous people feel more culturally safe include some Indigenous decor, visible policies encouraging patients to discuss traditional medicines or spiritual beliefs, and having staff educated on cultural safety and humility principles, as well as in resources to be able to offer to Indigenous patients.

I only was able to cover a few of the most pertinent concepts in regard to providing care in alignment with cultural safety and humility principles, and I encourage you to visit the website of the National Collaborating Centre for Indigenous Health to learn more on this subject. Thank you so much for taking the time to listen to this episode and I hope you found it informative!

To hear more NCCIH podcasts, head to podcast section of the NCCIH website. Music on this podcast is by Blue Dot Sessions. It appears under a creative commons license. Learn more at www.sessions.blue.

Download the transcript (PDF)