Woman Warriors Newsletter

Cultural Safety in Health Care

A protest called ‘Justice for Joyce’ in Montreal, Saturday, October 3, 2020, where they demanded Justice for Joyce Echaquan and an end to all systemic racism. Joyce Echaquan was a 37-year-old Atikamekw woman who died on September 28, 2020 in the Centre hospitalier de Lanaudière in JolietteQuebec.

This research is the original, unpublished, independent work by the author, Shelley Wiart. The research outlined in this paper is covered by Ethics File number 23355, issued by the Athabasca University Research Ethics Board (AUREB) for the project “Digital Storytelling as an Indigenous Women’s Health Advocacy Tool: Empowering Indigenous Women to Frame Their Health Stories” on March 25, 2020. This research also received a Northwest Territories Scientific Research License number 16553, issued by the Aurora Research Institute on May 29, 2019. Any use of this publication must have prior permission from the author. All Women Warriors content is copyrighted. 

It has taken me a month to consider writing about Joyce Echaquan’s death because of the trauma and rage it brings up for me as a Métis woman and as an advocate for Indigenous women’s health. When I watched Joyce’s video of her last moments of life – being attacked and belittled by racist nurses  – I felt despair and outrage. I recalled all the participants of the Women Warriors program (2015-2018) that had come to me with racist stories about their own health care experiences. I also imagined my family members and friends on the hospital bed in pain – begging for an ounce of compassion – as they suffered and died alone. I am livid, as every single Indigenous person across Canada is right now, by the injustice of systemic racism and the lack of initiative on behalf of the government to enact cultural safety measures in our institutions. 

Joyce Echaquan’s death serves as a reminder of the urgency of cultural safety in health care. It motivates me to be a more vocal advocate for Indigenous women’s health and encourage Indigenous women to be vocal about their experiences of racism and discrimination within the health care system. Being action oriented is a key component of Indigenous health research so it is my responsiblity, as a Métis researcher, to share how I implemented cultural safety in my research and health care settings. 

The following is an excerpt from the cultural safety literature review that I conducted for my research paper, Digital Storytelling as an Indigenous Women’s Health Advocacy Tool: Empowering Indigenous Women to Frame Their Health Stories. Below the lit review is a real-life application of cultural safety in research after one of my digital storytelling co-creators contacted me regarding an uncomfortable interview with my settler research assistant. Further to that example, I provide a cultural safety proposal we submitted to the Alberta Health Services i4Launchpad competition, Building Relationship with Indigenous Communities: Physician Positionality and Self-Reflection through Digital Storytelling.

Building respectful relationships with Indigenous patients requires medical professional to receive education on cultural competency[1], relevancy[2], and humility[3]- all of which contribute to health care professionals ability to provide culturally safe care (Bourassa et al., 2020, p. 5). Bourassa et al. (2020) stated “a person is considered to encompass culturally safe practices if they are able to maintain a trusting and reciprocal working relationship with someone from another culture” (p. 4). Cultural safety (CS) is centered on “acknowledging and respecting patients’ attributes, such as their everyday activities, personal values, and life experiences, and on understanding the impact of the health-care providers’ culture on interactions with patients and his/her associated privilege as a health-care provider” (Brooks-Cleator, Phillipps & Giles, 2018, pp. 203-204). Moreover, the patients receiving care hold “the ability to define an interaction as culturally safe” and this definition can extend beyond the “individual provider-patient interactions” to examine systemic issues (Brooks-Cleator et al., 2018, p. 203). CS is a framework used to examine “relationships of power within organizational, structural and institutional conditions” which includes “colonial-based racism that is ingrained in the medical field” (Brooks-Cleator et al., 2018, p. 203; Bourassa et al.’s, 2020, p.5). Cultural safety is applied “through recognition of biases and critical self-reflection [that] diminishes the risk of unsafe care that result from cognitive errors or stereotypes” (Brooks-Cleator et al., 2018, p. 204). 

There exists a need for culturally safe and appropriate evidence and practices in health care systems that are relevant and applicable by systems users, such as Indigenous peoples, and by those who deliver health services (Jull et al., 2018, p.2). The literature on cultural safety training in Canada shows a focus on theory and training with unclear definitions of the actual concept of CS and limited discussion on its implementation (Brooks-Cleator et al., 2018, p. 204).  As well, the literature identifies how certain course designs may be “detrimental to cultural competency by providing only superficial knowledge or by contributing to the beliefs that Indigenous cultural competency training is a niche or irrelevant issue” (Berg et al., 2019, p. 128). Brooks-Cleator et al. (2018) identify six elements of culturally safe initiatives: “collaboration/partnership, power sharing, address the broader context of the patient’s life, safe environment, organizational and individual level self-reflection, and training for health care professionals” (p. 209). This digital storytelling research is directed at individual self-reflection on behalf of health care professionals that view the digital stories and as a form of CS training through a decolonized and strength-based lens approach to Indigenous health. The self-reflection of personal biases and examining of personal “attitudes, understandings and actions about Aboriginal people” is measured through the Audience Questionnaire on Indigenous Women’s Health Stories (Appendix I) (Brooks-Cleator et al., 2018, p. 210). 

Digital storytelling as a form of cultural safety training is culturally relevant for Indigenous peoples because the methodology of storytelling aligns with oral traditions (Smith, 1999; Kovach, 2009). The most important aspect of this research has been the formation of empathetic connections between health care providers and Indigenous women’s stories of cultural genocide such as the forced removal of Indigenous children to residential schools, and how it manifested in Indigenous peoples’ physical, spiritual, mental and emotional health. Berg et al., (2019) stated, “post colonialism as a theoretical approach enables healthcare providers to better understand the ongoing role of colonialism in producing health inequities” (p. 128).  Indigenous women’s health stories are post-colonial accounts, and therefore, function as a form of reconciliation in healthcare. These stories assist medical professionals in understanding their own positionalities and reflect on the ways they may disrupt the systemic racism embedded in our institutions (Brooks-Cleator et al., 2018; Berg et al., 2019). 

Next week I will share the health care provider’s feedback from our Government of the Northwest Territories cultural safety training last November in Yellowknife, NT. I will share my insights on the responses and my vision for future cultural safety training in the North. 

References 

Berg, K., McLane, P., Eshkakogan, N., Mantha, J., Lee, T., Crowshoe, C., & Phillips, A. (2019). Perspectives on Indigenous cultural competency and safety in Canadian hospital emergency departments: A scoping review. International Emergency Nursing. https://doi.org/10.1016/j.ienj.2019.01.004. 

Bourassa, C., Billan, J., Starblanket, D., Anderson, S., Legare, M., Hagel, M. C., … McKenna,     B. (2020). Ethical research engagement with Indigenous communities. Journal of Rehabilitation and Assistive Technologies Engineering. https://doi.org/10.1177/2055668320922706.

Brooks-Cleator, L., Phillipps, B., & Giles, A. (2018). Culturally Safe Health Initiatives for Indigenous Peoples in Canada: A Scoping Review. The Canadian Journal of Nursing Research = Revue Canadienne de Recherche En Sciences Infirmieres, 50(4), 202–213. https://doi.org/10.1177/0844562118770334.

Jull, J., Morton-Ninomiya, M., Compton, I., & Picard, A. (2018). Fostering the conduct of ethical            and equitable research practices: the imperative for integrated knowledge translation in research conducted by and with indigenous community members. Research Involvement and Engagement, 4(1), 1–9. https://doi.org/10.1186/s40900-018-0131-1. 

Kovach, M. (2009). Indigenous methodologies: Characteristics, conversations and contexts. Toronto: University of Toronto Press.

Smith, L.T. (1999). Decolonizing methodologies research and Indigenous peoples. London, UK and New York, NY: Zed Books and Dunedin, NZ: University of Otago Press.


[1]Defined as a process of individuals gaining information, skills, and respect for cultures with the intention of effectively working with individuals of that culture (Brooks-Cleator et al., 2018, p. 203).
[2]Defined as determining if programs and services aptly include relevant aspects of values, traditions, beliefs, and practices (Bourassa et al., 2020, p. 5). 
[3]Defined in relation to safety involves internal self-reflection of personal bias while being able to humble yourself immersing or understanding the cultures of other people (Bourassa et al., 2020, p. 5).

Cultural Safety in Ethical Re-search*

I did my best to protect my co-creators from colonial violence and I took full responsibility for any issues the storytellers had with our re-search. For example, one of the storytellers called me after her interview with my research assistant and told me she felt uncomfortable with her lack of introduction, and intrusive interview style. I told my co-creator I would take responsibility for my re-search assistant’s behaviour by asking her to self-reflect on why her behaviour was considered insulting to the storyteller. Her reflections, provided below, demonstrated her understanding that her position of power and lack of introduction were problematic for the storyteller.

The most important learnings I gained from this process came from my first storytelling interview. Even though certain parts were uncomfortable, I’m happy that it was my first interview, as I learned a lot from it and was able to apply those learnings to interviews with the other co-creators. When I read the transcript from the first interview, I feel uncomfortable with the way that I come across . . . I was very concerned with trying to ask the questions on the interview guide to make sure that we were ‘covering’ the topics that I thought Shelley might want to write about. I think I made 2 mistakes in the process: first, I didn’t share my own background, how I came to be involved in these interviews, and the fact that I had already viewed all of the digital stories. This was exacerbated by the fact that I was just an impersonal voice on the other side of the phone and we were unable to see each other’s faces or our physical cues. Even though I know that it is important, in accordance with Indigenous research protocols, to situate myself and build relationship through introduction, I got nervous and I forgot to do so. This is not a mistake that I will make again, as it seems to set the tone of “I’m the researcher, and you are the one being researched”.

This leads me to my second mistake in this interview: I prioritized staying true to the interview prompts, even when (upon reviewing the transcript I can now see) there were some signs that they were causing tension. Due to my position as a researcher from settler background, and my failure to open up and share details about myself in the beginning, I can understand why these very personal questions would seem imposing and potentially judgement-laden. These questions likely would have been received completely differently had Shelley posed them, as there was a pre-existing relationship there and mutual trust. Moving forward, I was much more conscious of this and tried to be much more gentle, flexible, and conversational in the way that I posed questions.

Like healthcare providers, researchers are often blind to the ways that they may perpetuate power differentials in their interactions and in their work, and this was a very real risk in this interview. In an attempt to encourage the storyteller to be as detailed as possible in her answers, I posed questions as if I hadn’t seen her digital story. My logic was that I didn’t want her to gloss over details that she figured were already apparent in her story. In reality, I had viewed all the stories and was quite enthusiastic about their potential impact, which is one of the reasons why I think Shelley asked me to conduct these interviews. By failing to communicate my relationship to the research and my own background and intentions, I missed a major opportunity to set a positive and respectful tone. I am happy that the storyteller was assertive enough to nip this in the bud and give me constructive feedback that strengthened the interviews going forward.

[*]A term coined by Indigenous academic, Absolon (2011) to reflect the concept of research through as Indigenous paradigm of “rewriting” and “rerighting” our own stories and positions in history (p. 27).

September, 2019 I was invited to present at the Internal Medicine Retreat for residents. Two of our digital storytelling co-creators, Sheryl & Tanya connected via Facetime to speak with the residents. Following that experience I thought about ways that physicians could be more self-reflective in their approach with Indigenous patients.

Building Relationship with Indigenous Communities: Physician Positionality and Self-Reflection through Digital Storytelling

This past September myself, Megan Sampson, Research Associate at the Cumming School of Medicine UCalgary, and Rachel Ward, UCalgary Medical student submitted this proposal for the i4Launchpad Pitch created by Alberta Health Services. I thought a great way to start off doctor-patient virtual relationships in a good way would be for physicians to do their own digital story with personal details and self-reflections that the patient could view prior to the clinical encounter. This pitch was not accepted for i4Launchpad Summit, but I believe it is an idea worth exploring with the uptake of virtual health care due to the pandemic.

What is the problem? (300 characters max)
Clinical encounters are often unsafe for Indigenous people/communities. Covid-19 poses a physical risk if they visit a clinic. Once there, they may experience a lack of attention to cultural safety on the part of care providers. Virtual healthcare is one solution for the former problem; however, its impersonal nature increases risk of the latter.
 
What is your idea? (300 characters max) 
Digital storytelling by healthcare providers working in Indigenous communities, as a tool for introducing themselves/their services in a culturally relevant way. Digital stories are 3-5 minute virtual narratives, serving as a medium for relationship building and allowing patients to screen their service provider prior to their clinical encounter.
 
What makes your idea innovative? (300 characters max)
Pitch lead Shelley Wiart has used Indigenous Digital Storytelling (DS) with Indigenous women as a research method and pedagogical tool, but DS also has untapped potential to help decolonize healthcare encounters in a time of reliance on virtual care. Cultural values can be acknowledged and enacted on a contemporary platform to improve quality of care.
 
What is the impact of your idea? (300 characters max)
These digital stories will encourage healthcare providers to self-reflect, position themselves, and begin the process of relationship building in the Indigenous communities they work in. This can result in improved cultural safety, and in more empathetic and human relationships between care providers and patients.
 
At what stage is your idea or project (pick one)
Concept Development (early stage)
 
Why do you want to share your idea/project on this platform? (200 characters max)
The emphasis on innovative/actionable projects with a social impact focus make it a good fit.  Pitching to this audience will allow us to gain valuable feedback to inform applications for operational/evaluation funds in the near future.

Upcoming Speaking Engagements & Conferences

October/November: AbSPORU Virtual Institute 2020, to be held online from October 13th to November 20th, 2020. You can view my recorded presentation here, Decolonizing Health Care: Indigenous Digital Storytelling as Pedagogical Tool for Cultural Safety in Health Care Settings. 

November 17th: Canadian Science Policy Conference (CSPC) November 16th-20th, 2020. Our panel, Covid-19 and Global Indigenous Health Inequity: A Holistic Life Cycles Approach to Systems Change is scheduled for Tuesday, November 17th 12:30–2:00 pm MST. Please view our panel on the CSPC program.