In 2010 the interCultural Online Health Network (iCON) at the University of British Columbia set out to explore problems faced by Indigenous peoples in British Columbia seeking health and wellness. Since then, iCON has been collaborating with health authorities and Indigenous communities across the province to support the integration of traditional medicine practices into Western primary care and acute care settings.

Providing culturally safe care for all Indigenous patients has been found to include:

• Ensuring all health care employees undertake cultural safety training.
• Fostering an understanding of Indigenous perspectives on health and wellness.
• Allocating time to build connections, relationships, and trust in the community.
• Supporting the integration of traditional practices through policy.

Context and background

The colonization of Indigenous peoples in Canada has adversely affected how the current Canadian health care system responds to the needs of Indigenous patients. Structural barriers, power imbalances, and the perseverance of stereotypes and racist attitudes all play a part.[1,2] One outcome of colonization is a lack of emphasis on traditional medicine and practices as important components of wellness for Indigenous peoples. Research and an environmental scan conducted by the First Nations Health Authority (FNHA) affirms the continued value of traditional medicine and practices within Indigenous communities.[1] Health policy frameworks and strategic documents, including the Truth and Reconciliation Commission report and the United Nations Declaration of the Rights of Indigenous Peoples (UNDRIP), highlight the need for improved services and support for Indigenous patients.[2-5] Specifically, UNDRIP article 24.1 states:

Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals and minerals. Indigenous individuals also have the right to access, without any discrimination, to all social and health services.[5]

In November 2019 British Columbia was the first province to legally implement UNDRIP. Bringing BC laws in line with UNDRIP is part of a major shift in provincial and local commitments to improve health access and outcomes for Indigenous patients. The Declaration of Commitment on Cultural Safety and Humility in Health Services was signed by the BC Ministry of Health and all BC’s health authorities in 2015[6] and by Doctors of BC in 2019.[7,8] The declaration commits health care professionals and organizations to culturally safe and appropriate practices and a process of mutual trust and respect when delivering services to Indigenous peoples. Specific health authority policies[9-14] and programs such as the San’yas Indigenous Cultural Safety Training Program[15] have been developed to support health care professionals. Nevertheless, medical trainees in Canada still receive limited education on the impacts of colonization and racism and little exposure to Indigenous traditional practices. This means that many newly trained health care providers are unable to provide culturally safe care.[16,17]

Supporting cultural safety

iCON[18] began developing educational tools to support cultural safety[19,20] in 2015. As part of a community-based initiative operated by Digital Emergency Medicine at UBC,[21] iCON explored how to partner with Indigenous community members to address specific health priorities and develop culturally relevant health resources. iCON then worked with Vancouver Coastal Health (VCH) to create A Coming Together of Health Systems, a video[22] featuring Indigenous traditional healers [Figure] and a discussion guide.[23] The aims of the video and guide were to:

• Increase understanding of the role of traditional healing and the work of traditional practitioners.
• Encourage the integration of traditional healing into the care of Indigenous patients.
• Support positive health care experiences through a culturally safe care framework.

Throughout the development of the video and accompanying discussion guide, feedback was sought from an advisory committee that had been formed in 2012. This committee was originally a tripartite collaboration between iCON, the VCH Aboriginal Health Strategic Initiative, and the former UBC Institute for Aboriginal Health. Members included traditional practitioners, Elders, and the project team.

With the committee’s help, stories and insights into traditional medicine were featured in the video. Traditional practices were described along with the experiences of individuals who have used traditional medicine in hospital settings. Key messages and learning objectives were summarized in the guide and included with reflection questions and additional resources.

The video and guide were piloted with health care professionals at Vancouver General Hospital and St. Paul’s Hospital to validate them, ensuring that the content was accessible and deepened understanding of traditional healing practices that patients might request in hospital settings.

The video and guide have now been disseminated through education sessions with health authorities, integrated into VCH cultural safety training, and presented at various conferences, including the 2016 Fourth Global Symposium on Health Systems Research and the BC Ministry of Health summit in 2017.[22-24] The video and guide are also now integrated into the UBC medical school undergraduate curriculum.

A Coming Together of Health Systems is not intended to be a definitive resource concerning traditional practitioners and healing services but a starting point for dialogue. Before medical professionals can be comfortable and confident providing culturally safe care, they must first recognize the value of offering dual services (traditional Indigenous and Western) in serving their patients, and must gain a more nuanced view of the nature of traditional healing practices. Watching the video and sharing experiences with a diverse group of stakeholders can produce attitude shifts and practice changes and have rich cultural impacts for both Indigenous and non-Indigenous British Columbians.

Community dialogue

To understand how the health care system can best integrate traditional healing into everyday practice, a community dialogue workshop was cohosted by iCON, VCH, Island Health, and FNHA on 15 March 2017. Elders, traditional practitioners, nurses, physicians, students, and Ministry of Health representatives were invited to Tsawout, located on the homelands of the W’SÁNEĆ peoples on the Saanich Peninsula, and asked to identify gaps and barriers in the system and to produce a list of recommendations.

The workshop began with more than 100 participants viewing the video. A storytelling session followed, with Elders and traditional practitioners sharing their experiences of seeking and/or delivering traditional wellness and healing. The candid and personal accounts created a sense of community that carried on throughout the workshop.

Participants were divided into small groups for breakout sessions. Each group included a mix of health care professionals and community members to ensure a range of perspectives, expertise, and experiences were represented. In these sessions, participants were invited to share their views on ways to provide better access to traditional medicine within the BC health care system and how to harmonize Indigenous and Western approaches. Guiding questions were provided:

• In what ways can access to traditional practitioners be improved in your work setting at the clinical/practice level?
• How should we start thinking about shifting and changing health care system settings to better incorporate traditional medicine?
• What type of policy needs to be in place to facilitate and enable the changes discussed?

Perspectives and proposed actions

The post-workshop evaluation surveys that were completed by 59 participants showed how perspectives were changed: 93% felt the workshop helped them better understand traditional healing and the role of traditional practitioners; 89% agreed they would use the information from the workshop to better facilitate access to traditional practitioners; and 81% agreed they would make a change to improve the BC health care system to better incorporate traditional medicine.

Participant recommendations gathered from the breakout sessions were analyzed and grouped according to whether the actions proposed could be taken at the individual, advocacy, community, or health care system level.

Individual actions

All health care employees, including administrative staff, should engage in cultural safety training as part of an ongoing learning journey that helps individuals to:

• Practise humility and self-reflection in words, actions, and work activities.
• Integrate learning into their work.
• Increase knowledge of resources already in place at hospitals (e.g., how to access traditional practitioners).
• Continue the dialogue and share with colleagues (e.g., start conversations at staff meetings).
• Respond to the patient’s need in the moment (e.g., ask “What do you need/want?” or “Are there any resources outside the ones we are providing that might help you?”).

Advocacy actions

Advocacy for traditional healers and practitioners should include actions that encourage individuals, community-based organizations, and policymakers to:

• Respect the use of Indigenous language and worldviews as integral to the healing process.
• Promote a better understanding of the value of culturally safe care and the different perspectives Indigenous patients may have on health and wellness.
• Shift the definition and understanding of “health” to incorporate mental and spiritual health.
• Address misconceptions and mistrust through education about traditional healing and its value.
• Recognize and embrace the power of story­telling to create a space for shared understanding and self-reflection and to build community resiliency.
• Avoid tokenism.

Community actions

Community-based organizations should engage with others to:

• Include more policymakers in future workshops and dialogue.
• Build experiential learning and training opportunities for health care professionals, trainees, and medical students.
• Increase involvement of community advocates, patient voices, and Aboriginal liaison nurses.
• Codevelop protocols led by traditional practitioners in partnership with health authorities.
• Develop a directory for contacting traditional practitioners.
• Use a Plan-Do-Study-Act model for quality improvement to increase access to traditional practitioners in work settings.
• Allocate time to build connections, develop relationships, and increase trust with traditional practitioners and community leaders.
• Create space for authentic discussions and meaningful relationships.

Health care system actions

Policymakers should engage with others to:

• Acknowledge the spiritual side of well-being in policy.
• Incorporate healing rooms into the health system.
• Make cultural safety training mandatory (e.g., San’yas Indigenous Cultural Safety Training).
• Navigate and translate policy at the local level.
• Incorporate appropriate language in new policy mandates (e.g., avoid inappropriate terms such as “our Indigenous people,” which implies ownership).
• Develop protocols and policy for accessing traditional practitioners.
• Adapt funding models to incorporate traditional practitioners, Aboriginal liaison nurses, and Elders-in-residence.

Feedback welcomed

iCON, FNHA, and the province’s health authority partners remain committed to collaborative, inclusive dialogue that helps participants reach a greater understanding of barriers, challenges, and experiences in accessing culturally safe care.

The iCON team continues to cohost discussions that provide an opportunity for Indigenous peoples to share insights and guidance on forging a pathway to culturally safe care and that engages administrators, decision-makers, and policymakers in transforming the health care system to better serve all British Columbians.

We welcome feedback from readers about their own experiences with traditional healing practices and any efforts made to improve access to culturally safe health care for Indigenous patients in BC.

Competing interests

UBC Digital Emergency Medicine has received funding from the BC Ministry of Health to organize these events.

Acknowledgments

We would like to acknowledge that the activities discussed in this issue of the BCMJ took place on the traditional unceded homelands of the xʷməθkwəy̓əm (Musqueam), Skwxwú7mesh (Squamish), and Səl̓ílwətaʔ/Selilwitulh (Tsleil-Waututh) First Nations, and on the land of the W̱SÁNEĆ (Pauquachin, Tsartlip, Tsawout, Tseycum) peoples. We would like to say a special thank you to all of the participants, event organizers, and panel speakers at the inaugural 2017 workshop for their invaluable contributions. Thank you also to Allison Boothe and Susan Powell for their invaluable support. Finally, thank you to the BC Ministry of Health Patients as Partners Initiative for making this work possible.

This article has been peer reviewed.

Ms Hyman was a project coordinator in Digital Emergency Medicine at the University of British Columbia when this article was written. Ms Stacy was a research coordinator in Digital Emergency Medicine in the eHealth Strategy Office at UBC when this article was written. Ms Atkinson was a researcher in Digital Emergency Medicine at UBC when this article was written. Dr Novak Lauscher is associate lead, research, in Digital Emergency Medicine at UBC. Mr Rabeneck is the Coast Salish community engagement coordinator with the First Nations Health Authority. Elder Oleman is a member of the St’at’imc Nation and has been involved as a change agent for First Nations communities and agencies. Ms Cooper is interim director of Aboriginal Health at Island Health. Dr Young is a research facilitator and knowledge translator with Island Health. Ms Kellman is an Aboriginal nurse practice leader at Providence Health Care. Dr Ho is a practising emergency medicine physician at Vancouver General Hospital. He is also a professor in the Department of Emergency Medicine at UBC and lead, Digital Emergency Medicine.