Cultural Safety and!
Inuit Mental Health and Wellbeing
Allison Crawford, MD, FRCPC
Purpose of this module This module is an opportunity to question our underlying assumptions about “culture,� and to think about the ways that our ideas shape how we engage with people across groups and cultures, particularly in our work as healthcare providers. We will also think about the ways that healthcare itself is a culture, and how we can make it a culturally safe space for people to enter and engage with.
What is “culture”? •
Culture includes all of the socially transmitted aspects of a way of life, including values, knowledge, social behaviours and practices
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Culture is not biologically determined; it is constructed from social practices and beliefs.
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Culture is not static. The meaning of culture changes over time as society shifts its understandings of community and tradition.
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Culture produces forms of identity including race and ethnicity.
Race and ethnicity Race is a social marker of identity, usually of a group, and is often based on external appearances. Ethnicity refers to the ways in which groups identify themselves as historical peoples or communities.
Cultural biology and neuroscience Although culture is primarily socially determined or constructed, local biologies that reflect culturally mediated differences have been identified.! e.g., differences in medication response or metabolism These biological differences may reflect the impact of environment and/or social practices (such as child rearing) on the expression of genes, or the shaping of neurological and psychological processes such as cognition, emotion, memory and attention. These interactions are referred to as gene-environment interactions
REFLECTION What do you identify as your own culture(s)? How has this shaped your sense of yourself, or your identity?! What community group(s) do you belong to? ! Can others identify these differences in any way? How have you responded to the responses of other people to your cultural differences? If you have not experienced feeling “different� in any way, how do you think that has impacted your life?! How is healthcare a culture? Are there any ways that the healthcare culture in Nunavut differs from the healthcare culture you are used to? Take a moment to write brief answers to these questions in your journal.
Approaches to culture in healthcare These approaches represent a continuum of skills, with increasing degrees of self-reflection brought to bear on healthcare practice: Cultural awareness = the acknowledgement of difference
Cultural sensitivity = recognizing the importance of respecting difference e.g., diversity training
Cultural competence = the skills, knowledge and attitudes of healthcare providers
Examples of core competencies frameworks in healthcare
Indigenous Physicians Association of Canada and! The Association of Faculties of Medicine of Canada ! First Nations, Inuit, MĂŠtis health core competencies! http://www.afmc.ca/pdf/CoreCompetenciesEng.pdf
Aboriginal Nurses Association of Canada and ! Canadian Nurses Association! Cultural Competence and Cultural Safety in Nursing Education! http://www.anac.on.ca/Documents/Making%20It%20Happen%20Curriculum %20Project/FINALFRAMEWORK.pdf
What is cultural safety? Cultural safety goes beyond these three concepts, although cultural competence can provide a foundation for cultural safety. Cultural safety was developed by Maori healthcare providers in New Zealand, in response to recognizing the power imbalances in the healthcare system stemming from colonialism. It has led to a framework to improve the delivery of healthcare services to Indigenous peoples, in which:! Trust is established and maintained in the treatment relationship! Clients are treated with respect! Clients have their cultural location, values and preferences taken into account in the health service encounter
Cultural safety‌ Is a practice tool or framework, which requires ongoing ! self-reflection. Recognizes that health and illness are socially determined. Forms the basis for effective patient-centered care. Links knowledge and caring. Positions the general healthcare practitioner as a social advocate. Requires the involvement of individuals, families and communities.
Cultural Safety and Power • Colonialism resulted in power imbalances and the creation of hierarchies where one race was seen as superior to others • Neo-colonialism refers to colonial processes that remain part of the policies, laws and institutions that continue to influence the healthcare system and create disparities. • Even if individuals within the dominant culture are unaware of it, they benefit from their position of power. This power and privilege at the level of the individual, community, and society provides more opportunity and choice for some, at the expense of others who have less privilege, and fewer opportunities • “Othering” is the process by which people who are deemed “different” are excluded from certain social circles, while being given the message that they should strive to meet the norms of the dominant group
Central role of self-reflection in cultural safety “Cultural safety refers to a state whereby a provider embraces the skill of self-reflection as a means to advancing a therapeutic encounter with First Nations, Inuit, Métis peoples and other communities including but not limited to visible minorities, gay, lesbian, transgendered communities, and people living with ! challenges.”
from First Nations, Inuit, Métis Health Core Competencies, AFMC, http://www.afmc.ca/pdf/CoreCompetenciesEng.pdf
REFLECTION It can be uncomfortable to acknowledge our own social advantages and power, and the way this privilege works in everyday life. What is your social location? What intersections of race, class, education, religion, culture, gender contribute to your ‘location’? What privilege have you experienced in your life? Have you ever been made to feel “other”?
Take a moment to write brief answers to these questions in your journal.
5 Principles necessary for cultural safety (Ball, 2007) Cultural safety is an outcome that is defined by the recipient of service. It requires: Principles Protocols
Respect for cultural forms of engagement
Personal Knowledge
Understanding one’s own cultural identity and sharing information about oneself to create a sense of equity and trust
Process
Engaging in mutual learning, checking on the cultural safety of the service recipient
Positive Purpose
Ensuring the process yields the right outcome for the service recipient according to that recipient’s values, preferences and lifestyle
Partnerships
Promoting collaborative practice
Cultural Safety and Inuit Traditional Knowledge Applying the concept of cultural safety to Inuit Mental Healthcare requires: • establishing a connection between health-care professional and client, based on cultural safety. • believing that health is a holistic concept. • knowing that Inuit ways of thinking and being are important to the restoration of Inuit health. • recognizing that mental health is developed and is maintained through connectedness with family, community and the environment. • understanding how history may influence experience, including individual and community history. • accepting that different healing processes exist for different people, and respecting each other’s strengths and abilities in helping. ! Adapted from: http://www.naho.ca/documents/it/2009_Cultural_Safety_Knowledge_poster.pdf
Cultural Safety and Principles and Values of Inuit Qaujimajatuqangit (IQ)
Adapted from: http://inuitq.ca/learningresources/educatorsguide/Educators_Guide.htm
REFLECTION Read through the IQ principles and values on the previous page. ! Which value do you most closely relate to? Why? ! Which value feels the most unfamiliar, uncomfortable, or even at odds with your own value system? Why? Take a moment to write brief answers to these questions ! in your journal
Try the interactive movie ! The Inuit Qaujimajatuqanginnik Adventure at ! http://inuitq.ca/vle.html ! (you will have to register to log-in) The Shaman Teaches The Women Magic ! Jessie Oonark
Mental Health Resources Based on Traditional Inuit Knowledge Inuit Resilience! http://www.naho.ca/documents/it/2007_Inuit_Resilience_Book.pdf Ikajurniq BASIC COUNSELLING SKILLS: Inuit Voices, Modern Methods ! http://www.naho.ca/documents/it/2009_Ikajurniq_Counselling.pdf Suicide Prevention: Inuit Traditional Practices that Have Encouraged Resilience and Coping! http://www.naho.ca/documents/it/2006_Suicide_Prevention-Elders.pdf The Inuit Way: A Guide to Inuit Culture (revised edition), Pauktuutit Inuit Women of Canada, 2006! http://www.uqar.ca/files/boreas/inuitway_e.pdf Iceberg Healing Manual! http://www.healthykugluktuk.ca/book/The_Iceberg_Healing_Manual/
REFLECTION Can you think of ways that you can engage with and/ or incorporate traditional Inuit knowledge and values into your practice? Click on one of the traditional Inuit mental health resources on the previous page. ! Explore how it might be beneficial to your practice.! How does it challenge or even contradict your practice? Take a moment to write brief answers to these questions in your journal
REFLECTION: What would it mean to take a culturally safe approach in a health centre located in your Nunavut community?
What would it mean to take a culturally safe approach in a health centre located in a Nunavut community?
We Can‌
Principles Protocols
Respect for cultural forms of engagement
Personal Knowledge
Understanding one’s own cultural identity and sharing information about oneself to create a sense of equity and trust
Process
Engaging in mutual learning, checking on the cultural safety of the service recipient
Positive Purpose Ensuring the process yields the right outcome for the service recipient according to that recipient’s values, preferences and lifestyle Partnerships
Promoting collaborative practice
REFLECTION: What would cultural safety entail at higher policy levels in Nunavut?
What would cultural safety entail at higher policy levels?
We Can‌
Principles Protocols
Respect for cultural forms of engagement
Personal Knowledge
Understanding one’s own cultural identity and sharing information about oneself to create a sense of equity and trust
Process
Engaging in mutual learning, checking on the cultural safety of the service recipient
Positive Purpose
Ensuring the process yields the right outcome for the service recipient according to that recipient’s values, preferences and lifestyle
Partnerships Promoting collaborative practice
Arthur Kleinman's explanatory model of illness ! is designed to elicit the patient's perspective of illness 8 Questions to Understand Patient’s Explanatory Model of llness What do you call your illness? What name does it have? What do you think has caused the illness? Why and when did it start? What do you think the illness does? How does it work? How severe is it? Will it have a short or long course? What kind of treatment do you think the patient should receive? What are the most important results you hope she receives from this treatment? What are the chief problems the illness has caused? What do you fear most about the illness?
References and Further Reading
Additional Resources Avataq Cultural Institute, Nunavik website http://www.avataq.qc.ca/ Inuit Qaujisarvingat: The Inuit Knowledge Centre Website! http://www.inuitknowledge.ca