Visions Journal, 2016, 11 (4), p. 29
It's the first session in a therapeutic relationship. Susan, an Indigenous client, has just shared a story about her history, her experience at a residential school and what she has faced as part of a lifelong reality of colonial violence and racism. The practitioner interrupts and says, "That was in the past. You really need to move on. I will allow you to talk about it this session, but going forward, I don't want to hear anything else about the past."
This fictional anecdote reflects a common narrative about Indigenous people—that colonization is in the past and Indigenous people need to move on. This narrative and others are prevalent in the health care system, and Indigenous people experience harm on a regular basis as a result of them. For example, the idea that Indigenous people are 'stuck' in the past can lead to the stereotype that Indigenous people are unwilling or unable to 'get better.' This stereotype can foster prejudice, such as the feeling that treating Indigenous people is a 'waste of time,' which can result in discriminatory treatment, such as Indigenous people receiving a reduced quality of care. Being aware of how these narratives lead to stereotypes, and then to prejudice and discrimination—and harm—is an important step in fostering a safer and more effective health care system. This awareness is part of the journey towards increased cultural safety and increased equity in health and health care.
This article opens up a dialogue on the long-standing issue of Indigenous people experiencing harm while trying to access services—in health care, justice, child and family services and education. We argue that a cultural safety approach presents a promising way forward.
Why cultural safety?
What, exactly, is cultural safety? Why is cultural safety important in addressing the social inequities experienced by Indigenous people?
Most people are aware of the statistics that indicate significant health and social disparities between Indigenous and non-Indigenous people. For example, there are higher suicide rates in the Indigenous population, and Indigenous people tend to have poorer health than other Canadians.1 Indigenous youth don’t graduate from school at the same rate as non-Indigenous youth, and Indigenous children are five times more likely to be in foster care than other children.2 These realities are troubling—as they should be. But what is also important is the context in which these inequities occur, namely, the way social, historical, political and economic factors have shaped and continue to shape Indigenous peoples’ health. This context helps us answer questions such as “Why do Indigenous people have drastically different health and social outcomes?” and “Is there something wrong with the system?” Asking and answering these questions can help to disrupt narratives that blame Indigenous people for the failure to address their own health issues. How we understand these issues, and how we answer these questions, is critical to any action we take.
The concept of cultural safety can be used as a framework for examining and understanding these questions. Originating in New Zealand in the field of nursing education, cultural safety has become an influential perspective in developing better health care for Indigenous people. It differs from concepts such as cultural awareness and cultural sensitivity, cultural competency and cultural humility. The table below explains some of these differences.
Cultural safety considers the social and historical contexts of health and health care inequities and is not focused on understanding “Indigenous culture.” Many people come to the San’yas Indigenous Cultural Safety training program expecting to learn about the formal cultural ceremonies and practices of Indigenous people because they have been led to believe that this is the key to working with people who are culturally different from themselves. San’yas learners are often surprised to learn that a cultural safety approach to providing care is about paying attention to the roots of health and health care inequities, such as colonization.
Cultural safety differs from the following concepts
Cultural Awareness: An attitude that includes awareness about differences between cultures.3
Cultural Sensitivity: An attitude that recognizes the differences between cultures and that these differences are important to acknowledge in health care.3
Cultural Competency: An approach that focuses on practitioners’ attaining skills, knowledge, and attitudes to work in more effective and respectful ways with Indigenous patients and people of different cultures.4, 5
Cultural Humility: An approach to health care based on humble acknowledgement of oneself as a learner when it comes to understanding a person’s experience.
A life-long process of learning and being self-reflexive.6
Cultural Safety: An approach that considers how social and historical contexts, as well as structural and interpersonal power imbalances, shape health and health care experiences.
Practitioners are self- reflective/self-aware with regards to their position of power and the impact of this role in relation to patients.
"Safety" is defined by those who receive the service, not those who provide it.4, 5
A way forward: Cultural safety training
Actively practising cultural safety requires shifting the gaze away from Indigenous peoples’ cultural differences and practices towards one’s own beliefs, practices and histories—and how these impact Indigenous people. Cultural safety training helps practitioners see the impact of their own social, political and historical contexts on their practice. This is the heart of the matter: cultural safety involves developing an ongoing personal practice of critical self-reflection, paying attention to how social and historical contexts shape health and health care systems, and being honest about one’s own power and privilege, especially as these relate to Indigenous people.
The San'yas Indigenous Cultural Safety training program is an educational initiative launched by the Indigenous Health Program of the Provincial Health Services Authority (PHSA) in the province of BC. Formerly known as Indigenous Cultural Competency (ICC) training, the program has changed its name to reflect the notion of cultural safety, as well as the Indigenous concept of san'yas, which means "knowledgeable" in the Kwak'wala language. The San'yas program helps to address gaps in health between Indigenous and non-Indigenous people. It focuses on Indigenous people, as opposed to offering a more generalized diversity training, and provides organizations and practitioners (those in health care and those outside health care) with the knowledge, awareness and skills necessary to promote safe experiences for Indigenous people in the health care system, something that is certainly not standard today.7,8
To understand the lived experiences of many Indigenous people, we need to know the "colonial context," the historical and ongoing process of White European domination over Indigenous peoples and lands. This includes colonial policies such as the Indian Act and the legacy of the Residential School System, and the impact of these on Indigenous peoples' health and social lives. Because colonialism is always present but rarely talked about, this context has been called the "colonial elephant in the room."
In the San'yas Indigenous Cultural Safety program, thousands of participants have shared openly what they haven't been taught about history as it relates to Indigenous people. Although some changes to the BC public school curriculum are underway following the recent Truth and Reconciliation Commission,10 the topic of colonization and its legacies is still largely omitted from mainstream public education. For example, most Canadians learn at a young age that Canada was "discovered." Grade-school textbooks with images of European explorers finding "new lands," and of hard-working pioneer families struggling to make a life in a challenging environment all reflect a colonial settler narrative and identity that many Canadians still hold dear. You might well ask: Where are Indigenous people in all of this? Despite some efforts to teach about Indigenous peoples’ cultures in school, the omission of Indigenous perspectives of Canadian history effectively erases the colonial context from mainstream consciousness.
But even more deeply disturbing is what many Canadians have been taught about Indigenous people, not only in public school but also in mainstream literature and media. Indigenous people have been grossly misrepresented and are often portrayed as "inferior," "uncivilized," as "savages" and even as "not fully human."11 Although counter-narratives and self-representations by Indigenous people are beginning to emerge in various media, Indigenous people are still stereotyped everywhere in society, including the health care system.
The colonial elephant is a metaphor for the silence that exists around what we have been taught—and not taught—about the colonial context, and how the colonial context continues to impact Indigenous people in a range of social contexts. Not acknowledging the colonial elephant and its ongoing influence can make it difficult for practitioners to make informed and appropriate decisions concerning Indigenous people's health and health care. It also perpetuates denial of the ways that colonial ideology continues to shape our society today.
Thinking about cultural safety in practical terms
Remember the experiences of "Susan" at the beginning of this article, and consider the following questions from a cultural safety perspective:
What social or historical factors might have inhibited Susan's access to this care?
What might have been some of the trust issues that came up for her in the therapeutic context, and how might they have differed from those issues faced by non-Indigenous people?
What might it have been like for Susan, as an Indigenous person, to be told to "move on"?
What are some implications of being told that she was only "allowed" to talk about the past during that first session?
How likely is it that Susan will return for another session with this therapist, or even return for therapy at all?
Everyone in health care needs to ask questions like these in order to actively work towards cultural safety. We have a responsibility to do so, as professionals who follow a professional code of ethics and as moral individuals.
Putting cultural safety into action
Do something! Having good intentions is not enough. Take action to make change. Speak out against racism, ask questions of those with more understanding, find allies and create a support system for yourself that can help you advocate for culturally safe approaches.
Take responsibility for your own learning. Read, reflect and ask questions. Do not expect this learning to come from Indigenous people.
Take time for self-reflection. Be aware of your own assumptions and biases. Question everything you have ‘learned’ about Indigenous people and take steps to actively disrupt the stereotypes.
Commit to lifelong learning. Be prepared to be uncomfortable. Understanding colonialism and the legacy of racism is an ongoing and difficult task.
The most common stereotypes discussed by San’yas participants are that Indigenous people are "all drunk," "drug-seeking" and more likely to drink or use substances than other groups of people. The myth that Indigenous people have a genetic predisposition for alcohol intolerance or "addiction" is not supported by scientific literature.12 In fact, there is evidence that Indigenous people are more likely to abstain from alcohol or less frequently consume alcohol than non-Indigenous people.13,14 Despite these facts, such racist assumptions are frequently made in health care settings, and this has a direct impact on Indigenous people’s health and access to care.7
Where can I get cultural safety training?
For more information about the San’yas Indigenous Cultural Safety training program, visit our website: www.sanyas.ca.
About the author
Cheryl Ward (MSW, RSW, EdD candidate), Chelsey Branch (MEd, MA, PhD student) and Alycia Fridkin (MHSc, PhD)
Cheryl is Kwakwaka’wakw and a member of the ’Namgis First Nation. An educator and curriculum writer who has worked on several Indigenous cultural safety projects, Cheryl developed the San’yas Indigenous Cultural Safety training program at the Provincial Health Services Authority (PHSA), where she is currently the Interim Director of Indigenous Health and Provincial Lead for the San'yas program. Cheryl studies Indigenous-specific racism at Simon Fraser University
Chelsey is the Manager of the San'yas Indigenous Cultural Safety program at the PHSA. She is a White settler of Irish and English ancestry and her research interests are focused on non-Indigenous people's responses to Indigenous-specific racism in educational settings. Chelsey lives on the unceded territory of the Coast Salish peoples in Vancouver
Alycia is a Senior Policy Analyst in Indigenous Health at PHSA. She is a White colonial settler with Eastern European ancestry, living and working on unceded Coast Salish territory in Vancouver. Her academic research focuses on the meaningful involvement of Indigenous people in health policy decision-making
Chandler, M. & Lalonde, C. (2004). Transferring whose knowledge? Exchanging whose best practices? On knowing Indigenous knowledge and Aboriginal suicide. In J. White, P. Maxim, & D. Beavon (Eds.). Aboriginal policy research: Setting the agenda for change. Toronto: Thompson Educational Publishing.
Parkin, A. (2015). International report card on public education: Key facts on Canadian achievement and equity. Toronto: The Environics Institute.
Koptie, S. (2009). Irihapeti Ramsden: The public narrative on cultural safety. First Peoples’ Child & Family Review, 4(2): 30-34.
Anishnawbe Health Toronto. (2011). Aboriginal Cultural Safety Initiative. www.aht.ca/aboriginal-culture-safety
National Aboriginal Health Organization. (2009). Cultural competency and safety in First Nations, Inuit and Métis health care: Fact sheet. Ottawa: National Aboriginal Health Organization. www.naho.ca/documents/naho/english/factSheets/culturalCompetency.pdf
Tervalon, M. & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes. Journal of Health Care for the Poor and Underserved, 9(2): 117-125.
Allan, B. & Smylie, J. (2015). First peoples, second class treatment: The role of racism in the health and wellbeing of Indigenous peoples in Canada. Toronto: Wellesley Institute.
Health Council of Canada. (2012). Empathy, dignity and respect: Creating cultural safety for Aboriginal people. Ottawa: Health of Council of Canada.
Artwork copyright C. Ward (2013). The illustration was developed collaboratively with Sam Bradd for PhD comprehensive examinations at Simon Fraser University.
Sherlock, T. (2015, August 29). Major school curriculum changes coming to B.C. www.vancouversun.com/Major+school+curriculum+changes+coming/11325548/story.html?__lsa=f847-328a
LaRocque, E. (2010). When the Other is me: Native resistance discourse 1850-1990. Winnipeg: University of Manitoba Press.
CBC News. (2014, May 30). Aboriginal people and alcohol: Not a genetic predisposition. www.cbc.ca/news/aboriginal/aboriginal-people-and-alcohol-not-a-genetic-predisposition-1.2660167
First Nations Centre. (2005). First Nations Regional Longitudinal Health Survey (RHS) 2002/2003: Results for adults, youth and children living in First Nations communities. Ottawa: First Nations Centre at the National Aborginal Health Organization.
Cunningham, J., Solomon, T. & Muramoto, M. (2016). Alcohol use among Native Americans compared to whites: Examining the veracity of the “Native American elevated alcohol consumption” belief. Drug and Alcohol Dependence, 160: 65-75.