In the summer of 2011 we participated in a project to look at the potential of artistic expression as a way for people to feel better and to articulate what is needed for their healing and well-being. 

The project, known in the community as Art Days, looked at the potential of artistic expression—everything from sketching, creative writing, music, mask-making, and painting—as a way for people to feel better, voice insights in innovative ways about their state of health, or articulate what is needed for their healing and well-being. 

The project, a partnership between the Nak’azdli Health Centre and the UNBC Northern Medical Program, offered us an opportunity to immerse ourselves in a northern First Nations community. For us, the project was a journey not only into examining the value of art creation on the health and well-being of Nak’azdli community members, but also one of self-exploration and reflection.

On one of our first visits to Fort St. James and Nak’azdli we visited the museum in town at the suggestion of a worker at the Nak’azdli Health Centre. We spent the afternoon learning about Carrier culture by running our hands through furs and savoring the smell of a restored salmon cache, and felt that this knowledge could be beneficial in helping us build relationships in the community. 

It wasn’t until later that we realized that these types of learning experiences are endorsed by leading authorities of health care; in their 2001 policy statement, the Society of Obstetricians and Gynaecologists of Canada (SOGC) encouraged health professionals to learn the appropriate names, demographics, and traditional geographic territories and language groups of the various Aboriginal groups in Canada.[1] 

Another afternoon, we learned about the medicine wheel from a local Carrier counselor. This proved to be time well invested into being physicians of tomorrow, better able to tackle the health inequities lived by Aboriginal peoples in British Columbia, given that the SOGC states “health professionals should appreciate holistic definitions of health as defined by Aboriginal peoples.”[2]

Despite having some background knowledge about Carrier culture, however, it wasn’t until the first Art Day that we really got a taste of the rich and diverse culture of the Nak’azdli, so different from our own. What happens when different cultures meet? How are our experiences relevant to future practice?

Reflections
It’s Friday morning. The supplies are bought, the agenda planned down to half-hour increments, and we’re on the road heading for Nak’azdli. We arrive early to check in at the Band office. The “day” is scheduled to begin at 11. At 11:00, no one has shown up yet. By 11:20, we’re getting a little worried. We hold tight until noon and slowly people start to trickle in. By 12:30, the maximum number we are able to accommodate have showed up and people are translating their feelings into various art forms.

Medical students are often thought to be of a similar character, the type of people who are accustomed to a schedule that does not permit much spontaneity or flexibility. Our days are similar to our Art Day agenda, planned in half-hour increments with tightly scheduled times for meals, exercise, and recreation. 

Following the rhythms of a community with everyday realities like berry picking in the morning, however, demanded a new understanding of time, and the perceived importance of things like research projects. Initially, it was difficult to appreciate how our value of a punctual start time differed from those in the community. But we let go of preconceived expectations, tucked away our agendas, and let the day unfold more naturally.

As students, each with our own in­dividual cultural experiences, we are concerned the idea of Art Days may be perceived differently than we in­tended. We know in the back of our minds that Art Days could be considered selfish: an opportunity for us to increase our experience working with Aboriginal communities and not actually giving anything substantial or sustainable to the Nak’azdli community.

In the words of Lucille Harms, a nurse in Kitamaat Village, “people come in and they think they can fix us.”[3] Our fear stemmed from this; what if that’s how the project is perceived—that we’re trying to “fix” something? As a result, we felt a bit vulnerable in our interactions: not wanting to overstep our boundaries and hoping that we empower rather than harm.

By the afternoon, things are in full swing. There is ongoing art creation and an impromptu guitar performance by a Nak’azdli Elder. Lunch is served and we all take a break to enjoy the meal catered by the local concession. The flow of people into the hall continues. Local construction workers on their break, unaware that an Art Day is even taking place, sit at a table and eat with us.

The casual nature of committing to several hours of art creation, seemingly on a whim, was surprising to us. Through our medical student lens, it is hard to imagine having a day with no plans and no preparation. People coming in and enjoying lunch with us, although welcome, was also unfamiliar. The communality of sharing food in the Kwah Community Hall made us realize that while we were participating in a community event, our perceptions of community were still not quite as communal as those in Nak’azdli. 

There seemed to be an unspoken message we only slowly became aware of: food is available to all and no one in this group of people seems more privileged than the next. There was a sense that each person has a role in the community, and that role is crucial to the whole. By eating and sharing food in Nak’azdli, we came to fundamentally understand what Dr David Beaulieu, a northern physician, writes: “that kind of awareness is the heart of community.”[3]

Cultural immersion
Art Days, which involved working in partnership with a First Nations community, spending time on a reserve, and experiencing a meeting of cultures offered the opportunity for “cultural immersion,”[4] an alternative ap­proach to didactic lecturing in teaching and learning. 

Cultural im­mersion places a learner in different contexts of culture and language. It creates new spaces for us to critically examine our own cultural identity as well as those of a different culture. Our approach to cultural immersion was to be reflexive in situations that challenged our values or beliefs. By examining the dichotomies that arose over things as seemingly simple as a start time, we were able to develop an appreciation for perspectives of a culture different from our own. 

Knowledge about any group or population is a necessary prerequisite to culturally informed service delivery. As Rothman suggests and as we experienced, a meaningful way to acquire this knowledge is through cultural immersion in a population.[5] Morgan and Reel argue that cultural immersion is not only meaningful, but that the experiential learning that cultural immersion provides results in heightened attainment of cultural competence.[6]

Cultural competence and safety
As medical students and future physicians, we are aware of the concept of cultural competence, defined as “the attitudes, knowledge, and skills of practitioners necessary to become ef­fective health care providers to patients from diverse backgrounds.”[7] How­ever, we may not be aware of its limitations. For example, cultural com­petency engenders the belief that cer­tain groups of people have the same, shared cultural meanings. 

Such an assumption can lead to dangerous generalizations. As Kleinman and Ben­son highlight, culture is not static and “cultural processes frequently differ within the same ethnic or social group because of differences in age cohort, gender, political association, class, religion, ethnicity, and even personality.”[8]

Another limitation of cultural com­petency is that it is focused and measured solely on the knowledge of the practitioner, who comes from a biomedical culture, among others.[8,9] To each interaction, medical students bring with them their own culture and often unconsciously “perceive others through the filter of [their] cultural upbringing.”[7] 

Privileging of biomedical culture in our curricula and in the frameworks of our future professions is described by Richardson and Wil­liams as ethnocentric: the patient’s culture is always viewed as foreign. Richardson and Williams challenge health care professionals to consider the patient’s culture as the norm and health care culture as foreign.[9] This shifts the power of bicultural interactions into the hands of the patient, ensuring a safer experience for those seeking care.

The shortcomings of cultural competence are addressed by the concept of cultural safety. With roots in the New Zealand nursing field,[10] the concept of cultural safety is more layered. It can be thought of as either an ex­tension of cultural competence or as a paradigm shift.[11] 

Starting with an awareness of the existence of other cultures, cultural safety further re­quires recognizing that one’s own cultural identity may impact an interaction, as well as allowing a safe inter­action to be defined by the pa­tient.[4,9] Culturally safe care is providing care congruent with the knowledge that cultural values of a patient are different from one’s own. 

The issue of cultural safety has moved beyond New Zealand and be­gun to permeate other health professional curricula in Canada. Smye and colleagues[12] feel the use of cultural safety in Canada is essential “in relation to First Nations health care,” particularly because First Nations, along with Inuit and Metis people, make up a growing part of Canada’s population.[13] 

Canadian medical schools, in­cluding the University of Manitoba,[14] have taken steps to recognize cultural safety as a key component of becoming a physician by integrating it into the role of a communicator within the widely utilized CanMEDS framework.[15]

For future practice
Having a background understanding of other cultures gained by visiting museums and learning about traditional definitions of health has merit. Above all, however, we must be cognizant that cultural differences exist. We must be attuned to the fact that ethnic identity may or may not matter to someone’s sense of self.[8] 

Richardson and Williams warn that biomedical culture deems it appropriate to “identify a key set of cultural parameters… within which generalizations are the norm.”[9] The assumption that all pa­tients loosely associated with a culture will share similar beliefs and characteristics is culturally unsafe.[9] This is where the distinction between cultural competence and cultural safety is made, and cultural competence is found wanting. 

Engaging with pa­tients in order to recognize how they perceive their own cultural identity, re­flexively acknowledging how one’s own culture is influencing interactions, and routinely empowering pa­tients to evaluate what matters most to them in the experience of illness and treatment is paramount and culturally safe health care.[8,9]

Art Days, or similar community-based projects, highlight the importance of cultural safety and the benefits of cultural immersion for medical students. This heightened awareness about the need to provide culturally safe care can be carried from community to clinical settings. Safe multi­cultural interactions are essential in establishing trust and are, ultimately, “the first step in the healing process.”[11] By establishing a culturally safe relationship to facilitate healing, there is great potential to promote more positive health outcomes.

Acknowledgments
Thank you to the project supervisor, Dr Sarah de Leeuw, assistant professor of the UNBC Northern Medical Program. Thank you to the staff at the Nak’azdli Health Centre and the Nak’azdli community.

References

1.    Smylie J. SOGC Policy Statement: A guide for health professionals working with Aboriginal peoples. J Obstet Gynae­col Can 2001;23:54-68.
2.    Smylie J. SOGC Policy Statement: A guide for health professionals working with Aboriginal peoples. J Obstet Gynae­col Can 2000;22:1056-1061.
3.    de Leeuw S, Swanky T. Front lines: Portraits of caregivers in northern British Columbia. Smithers: Creekstone Press Ltd.; 2011.
4.    Crampton P, Dowell A, Parkin C, et al. Combating the effects of racism through a cultural immersion medical education program. Acad Med 2003;78:595-598.
5.    Rothman J. Cultural competence in pro­cess and practice: Building bridges. Boston: Allyn & Bacon; 2008.
6.    Morgan L, Reel S. Developing cultural competence in rural nursing. Online J Rural Nursing Health Care 2003;3:28-37.
7.    University of Ottawa Faculty of Medicine. Cultural Awareness and Sensitivity. 2011. Accessed 25 July 2011. www.med.uottawa.ca/sim/data/Cultural_Awareness_e.htm.  [11]
8.    Kleinman A, Benson P. Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS Med 2006;310. Accessed 21 July 2011. www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030294 [12].
9.    Richardson S, Williams T. Why is cultural safety essential in health care? Med Law 2007;26:699-707.
10.    Ramsden I. Cultural safety. Nurs N Z 1990;8311:18-19.
11.    Brascoupe S, Waters C. Cultural safety: Exploring the applicability of the concept of cultural safety to Aboriginal health and community wellness. J Aboriginal Health 2009;52:6-41.
12.    Smye V, Josewski V, Kendall E. Cultural safety: An overview. A report for the Cultural Safety Subcommittee, First Na­tions, Inuit and Metis Advisory Committee Mental Health Commission of Canada. 2010:i-28. 
13.    Statistics Canada. Aboriginal peoples in Canada in 2006: Inuit, Metis and First Nations, 2006 Census. 2006. Accessed 2 August 2011. http://www42.statcan.gc.ca/smr08/2010/smr08_145_2010-eng.htm [13].
14.    University of Manitoba, Faculty of Medicine Undergraduate Medical Education. UGME Mission & Objectives. 2011. Accessed 27 July 2011. http://umanitoba.ca/faculties/medicine/education/undergraduate/ugme_miss... [14].
15.    Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 Frame­work. accessed 27 July 2011. http://rcpsc.medical.org/canmeds/CanMEDS2005/index.php [15].

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Ms Klopp is in the University of British Columbia Medical Class of 2013. Ms Nakanishi is in the UBC Medical Class of 2014. Both are in the Northern Medical Program.