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. Inuit clients are often faced with healthcare providers who might not recognize, acknowledge and address some of the barriers they face to managing their health. When we, as healthcare providers, are trained and supported, we are better able to bridge barriers such as language, social challenges, and institutional racism and to recognize and develop the necessary advocacy skills to work collaboratively with Inuit clients, communities and other members of interdisciplinary teams to achieve better health outcomes, together. At the same time, Inuit peoples have shown great resiliency in dealing with these challenges and have a rich body of knowledge and traditions to share. Traditional knowledge and ways of healing continue to be facilitated through elders and community helpers who constitute a significant Inuit health provider system.

What is “culture”? Culture includes all of the socially transmitted aspects of a way of life, including values, knowledge, social behaviours and practices Culture is not biologically determined; it is constructed from social practices and beliefs. Culture is not static. The meaning of culture changes over time as society shifts its understandings of community and tradition. 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, Métis 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%20Proj ect/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 Self-reflection in this case is underpinned by an understanding of power differentials. For First Nations, Inuit and Métis communities this power imbalance is unequal and can be seen as a residual element of colonization and act as a barrier to facilitating the health and healing for First Nations, Inuit and Métis citizens of Canada.

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) IQ principles represent the cornerstone of Inuit thinking and beliefs. Knowledge of these central principles can help the healthcare provider to reflect on the client’s possible perspectives. However, we also need to keep in mind that what is culturally relevant for one individual may differ from others. Again, a cultural safety lens reminds us that it is the client who decides if they feel culturally safe, and what that means. A simple way of gauging this might be to ask, “Does what I am saying or explaining fit with what you believe?” Adapted from: http://inuitq.ca/learningresources/educatorsguide/Educators_Guide.htm

The Shaman Teaches The Women Magic Jessie Oonark 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/ Cultural safety does not mean becoming an expert in Inuit culture, or trying to become a “traditional” practitioner. It means bringing the best practices and evidence that you can offer, while being open to other perspectives, world views and approaches.

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? Principles We Can… 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

What would cultural safety entail at higher policy levels in Nunavut? REFLECTION: What would cultural safety entail at higher policy levels in Nunavut?

What would cultural safety entail at higher policy levels? Principles We Can… 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/FIN ALFRAMEWORK.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/