Physicians and Healers Educating Towards Culturally Safe Health Care for Urban Indigenous Peoples INIHKD October 7th, 2014 D. Behn Smith on behalf of P&H team

Introductions Territorial acknowledgment Our Elders - Roberta Price & Doris Paul Our team

Project Context Coast Salish territory Vancouver Native Health Society UBC Aboriginal FP residency site

What we hoped to learn.... What are the impacts of working with an Aboriginal Elder on culturally safe practice? How does a FP resident’s sense of confidence in culturally safe practice shift?

What we hoped to learn... What are the strengths, weaknesses and lessons learned from having an Elder provide longitudinal mentorship to Family Practice Residents?

Study Design Qualitative description Five interviews (2 Elders, 1 resident, 2 preceptors) Nine Elder-lead case conference minutes Three researchers coded and performed thematic analysis

Strengths Nawtsamaat Shqwualuwun Learner openness, reflexivity and assimilation Elder openness, generosity and spiritual wisdom Physician openness and humility Safe spaces and relationship

Learner openness, reflexivity, assimilation “Part of what makes it [developing culturally safe care] happen is their willingness to learn, their openness and their respect.” (Elder) “After each of the meetings that we have – there is a huge amount of reflection that goes on for me and really drives me to reflect upon what can I do better to be providing culturally safe care, to be better for my patients. That’s been really important in my learning process.” (Resident) “And just becoming more comfortable and confident about asking patients both where they are from and if they identify with any traditional beliefs or if they participate in ceremony or anything like that. I definitely do that more often than I did previously.” (Resident)

Physician openness and humility “We as clinicians have felt that that we provide culturally safe and competent care but it's not until we've actually had Elders here and witnessed how they work, how they expect to work, and how they expect to be treated that we’re getting a better sense of what that really means.” (Physician) “I think one of the strengths is that it's clearly better for the residents to learn about cultural practices from the elders than it is from us” (Physician) “We have had several occasions that having an elder on site when somebody has been in some form of crisis has been incredibly powerful. I’ve witnessed this a couple of times and it’s been humbling for me to see this happen in the context of a medical clinic” (Physician) “I think one of the strengths is that it's clearly better for the residents to learn about cultural practices from the elders than it is from us” (Physician)

Elder openness, generosity & spiritual wisdom “I think too that the understanding and the teachings of the Elders will be that we don’t say things directly, we don’t say things in bullet point form. We say things as we’ve been taught from our Elders through stories” (Elder) “So my experience with the training has been a good one. It has made me want to share my culture and my teachings with them as a First Nations in a good way. It has been a good experience.” (Elder) “Residents can gain an appreciation into the workings of a spiritual practice of healing (gratitude, forgiveness, trust, faith, prayer, love)” (observation from rounds discussion on co-managed patients)

Safe spaces foster good relationships “I think in many Indigenous communities knowledge is spread by spoken words, so many of these lessons that you learn along the way, its information that you couldn’t just read in a book, it needs to be taught, you need to understand the context while you are leaning it. That makes this invaluable.” (Resident) “I think the biggest thing is just having the ability to develop a relationship with the Elders so that I feel comfortable asking questions and seeking their guidance.” (Resident) “The ability to present complicated or difficult situations to Doris and Roberta has been helpful in that it’s a safe way that I can ask a question. And get some guidance with people that I have become comfortable asking questions with.” (Resident) “There is a huge gap in in bringing some very ill people into care and making them feel safe here. If the elders can help to close that gap in terms of relationship building, that is a valuable piece of the picture.” (Physician)

Navigating tension filled spaces Respect Time Place

Tension filled spaces Respect “What I really love about this model is that the physicians … even offering to pray and bless the food. It is spreading. They’re willing to participate in the blessing of the food or the table or opening with a prayer. Those are strengths.” (Elder) “To have those discussions that we end up starting and end up stopping mid- way. Where we feel cut off, we feel disrespected; we feel our voice is not being listened to – by that time frame. 1 hour.” (Elder) “It would be more beneficial for the trainees to have some time to work 1:1 with all of the Elders or with one of the Elders and receive those cultural teachings. Before we even start working in relationship and in partnership with patients. “ (Elder)

Tension filled spaces Place “The residents are participating in the dialogue around culture. It would be great for them to have a chance to actually participate in the culture itself – via ceremony, a nature walk in the Squamish Valley. Etc.” (Elder)

Tension filled spaces Time “Hard to get patients to understand that they are on a 1-hour timeline… when they get started and they are heartbroken and they are crying – and in our culture we don’t shut them down and say ok an hour is up, I have to let them go until they cry where they can’t cry no more.” (Elder) “I wish the timing (of a meeting) be addressed – that we come together and to meld both of our ways would be to have 1 time/month for the Elders just to be on Elders time.” (Elder)

Tensions filled spaces Resources Lack of sustainability Grant chasing ?FNHA advocacy

What we are learning Nawtsamaat Shqwualuwun Bring service and teaching into culture Long-term supportive relationships between residents / elders / preceptors is beneficial Careful planning and respectful listening helps navigate challenges

Miigwetch Hay Hay Huy tseep q’u Masi Cho Merci Thank you