3 cultural safety

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”?

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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.

Jamasie Pitseolak

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, Meﾌ》is 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 provides more opportunity and choice for some, at the expense of others who have less privilege • “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

Cultural Safety and Power • Social locations reflect the many groups that an individual may belong to, such as social class, religion, sexual orientation, age, etc.

• It is very important, however, not to assume that you know the social location of anyone. Cultural safety involves BOTH recognizing the impact of social location, and remaining open to understanding the social location of others without making assumptions.

Ravens Entwined, Kenojuak Ashevak, 2004

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

References and Further Reading 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 Avataq Cultural Institute, Nunavik website http://www.avataq.qc.ca/ First Nations, Inuit, Métis Health Core Competencies (AFMC) http://www.afmc.ca/pdf/CoreCompetenciesEng.pdf Inuit Qaujisarvingat: The Inuit Knowledge Centre Website! http://www.inuitknowledge.ca National Aboriginal Health Organization (NAHO)!

NAHO article on cultural safety http://www.naho.ca/jah/english/jah05_02/V5_I2_Cultural_01.pdf University of Victoria – Cultural Safety Modules! http://web2.uvcs.uvic.ca/courses/csafety/mod1/