WHAT HAVE WE LEARNED FROM THE SAN’YAS DATA? MAPPING THE HARMS OF ANTI-INDIGENOUS RACISM IN THE BRITISH COLUMBIA HEALTH CARE SYSTEM GLOSSARY Anti-Racism Think Tank March 12, 2019 1 Prepared by: San’yas: Indigenous Cultural Safety Training Program Indigenous Health, Provincial Health Services Authority Suite 201-601 West Broadway, Vancouver, BC V5Z 4C2 Unceded Homelands of the Musqueam, Squamish, and Tsleil-Waututh Nations March 2019 For questions, please contact: Cheryl Ward, Executive Director, cward-02@phsa.ca or Jane Collins, Provincial Lead, jane.collins@phsa.ca 2 WHERE DID THE DATA COME FROM? PURPOSE OF THE GLOSSARY The purpose of this glossary is to support discussions among partners who are working in different ways to address racism and disrupt harm to Indigenous people in the health care system. This has been prepared for the Anti-Racism Think Tank convened by Provincial Health Services Authority (PHSA) Indigenous Health. BACKGROUND METHODS This glossary has been created from a recent analysis of the San’yas Indigenous Cultural Safety (ICS) Training Program’s participant data. Participants are people who are working across the health care system in British Columbia and have taken the San’yas Core ICS Health, Mental Health, or Foundations training. A search of San’yas participant responses was done using specific keywords to focus the search on PHSA service areas which are also sites where harm has been documented in the literature. Keywords used were: cancer, mental health, addiction, surgery, pregnant, ambulance, and triage. The keyword search generated 1,120 entries that were reviewed by an Indigenous and a nonIndigenous researcher who identified 252 entries that included examples of harm to Indigenous people. The researchers used a collaborative, iterative, and consensus-based approach to thematic analysis. This approach generated eight categories of harm, and three layers (interpersonal, organizational, and systemic) of anti-Indigenous racism with sub-themes in each. Conceptually, the sub-themes are the mechanisms that operate at each level, underlying and driving the harms. An iceberg visual (p. 7) is used to show what is happening at multiple levels that contribute to harm. Note that the layers of anti-Indigenous racism are complex and inter-related. This means that mechanisms at each level can work independently or together to produce harm. A brief description of the eight categories of harm and the three layers of anti-Indigenous racism are presented in this glossary. CONTENT WARNING This glossary contains explicit examples of harms that are occurring to Indigenous peoples as a result of anti-Indigenous racism in the health care system in British Columbia. Many people are unaware of how colonization has harmed Indigenous peoples, or how the harms continue today. These examples may be difficult and emotionally challenging to read. For Indigenous people with lived experience, the examples may be familiar, and reading them can be difficult. If you find the material challenging please take breaks, talk to someone you trust. San’yas program Elders Gerry Oleman and Lillian Howard are here today to support you. For non-Indigenous people, the examples may be discomforting and we ask that during today’s Anti-Indigenous Think Tank that you sit with this discomfort and remain engaged in the discussions. Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Cheryl Ward cward-02@phsa.ca or Jane Collins jane.collins@phsa.ca 3 WHAT ARE THE HARMS? Since 2009, the San’yas program has documented thousands of examples of harm. In this analysis of a subsection of the data, we examined hundreds of real-life examples of people in health services doing harm, witnessing harm, or anticipating harm based on harmful beliefs and behaviours. We reached consensus on eight categories of harm. Each category of harm is defined with support from a quote below. The definitions reflect what was reported in the San’yas data and align with the peer-reviewed literature. HARM LEGEND DEATH When life ends prematurely. “The consequences to dismissive incomplete assessments (at any point in an emergency encounter) have resulted in severe and sometimes deadly consequences for patients. I have seen this happen in a straight line of dismissive ambulance crew, dismissive triage nurse, dismissive physician; leading to patient death from an inter-cranial event. I learned of three of these cases in mortality and morbidity rounds and each involved an Indigenous male with long standing alcohol abuse disorder. It is well established that individuals with long standing alcoholism are at greater risk to sustain an inter-cranial hemorrhage from head trauma and thus raises the uncomfortable question as to why these cases happen when all the risk factors are there and indicate the need for an urgent head CT.” PROLONGED PAIN AND SUFFERING When any sort of pain or suffering that could be interrupted or stopped , is not. “An Indigenous teenager had fallen off his skateboard and broke his collar bone. The ambulance attendant wheeled him into the waiting room where he sat for literally hours. In those hours not one clinical staff member came to see him. My wife and I got him blankets, water, and offered coffee. We asked the nurse on duty if they could give him anything for his pain as he was visibly shaking and the response was “we will get to him when we get to him.” The White person I was with who was sitting right in front of the youngster was regularly seen and provided with updates even though her condition was far less painful or critical.” MEDICAL COMPLICATIONS When a condition worsens or a new condition emerges. “I was once asked to perform a cognitive assessment on an Indigenous client in the inpatient rehab unit I was helping out on. When I reviewed his chart, there were violence alerts throughout due to one incident where he had threatened the life of a nurse at Emergency. He went on to explain that his initial interaction with the nurse in Emergency was of anger because he was sent home by her without a diagnosis. He explained he continued to have symptoms of vertigo and was found on the floor by his family 3 hours after he was sent home from ER. Of course, the ambulance was called and he absolutely had an acute episode of a stroke. He explained the initial nurse in ER never took his vitals or anything, she just sent him home. Unfortunately, he continued to have the violence alert on his medical chart.” Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 4 WHAT ARE THE HARMS? FAMILY AND/OR COMMUNITY DISRUPTION When an individual is removed, separated, or isolated from their family and/or community supports. “Currently, a lot of pregnant mothers need to move to higher levels of care to deliver babies. This is distressing for all patients, but particularly for Indigenous communities given their strong family ties and emphasis of community. When patients move to larger towns/cities to deliver babies, often their loved ones are not able to come with them for the whole duration due to financial or personal barriers. Separating pregnant mothers from their families creates a greater sense of isolation and increases risk of peri/post-partum depression.” RELUCTANCE TO, DELAY IN, OR REFUSAL TO ACCESS CARE When an individual is reluctant to, refuses to, or waits until it is critically necessary to access health services. “I was with a young woman who let her illness go on so long because of the discrimination she faced the previous times coming to hospital. She discussed the racial slurs she had experienced. I am learning, through this teaching, that I did not do everything I could have, but she eloquently articulated how her care had been impacted due to her race.” LOSS OF AUTONOMY When an individual is denied the ability to make decisions about their own body or treatment; the use of coercion, threats, and/or force to persuade someone to participate in a treatment or service. “A young infant became seriously ill and was eventually diagnosed with a condition that would require an organ transplant, with a guarded prognosis even then. After much discussion with their families and community, the parents made the agonizing decision to provide palliative care for the infant rather than putting him through questionable surgery in a city several provinces away from their home. The specialist who had determined that a transplant was needed was unhappy with their decision and decided that they were guilty of negligence. He set in motion the process to apprehend this baby, stating that they were unfit parents who believed that traditional medicine would heal their son. The parents were forced to go to another province to avoid the apprehension, then spent the few months remaining to them, fighting a court battle to be able to remain with him and care for him medically and spiritually. At the same time, a patient of mine of European heritage had a baby with a similar prognosis. They were allowed to make the decision to palliate with little opposition and much support from the local medical community. The difference in treatment that these two families received was incomprehensible to me at that time but something I have seen too frequently since.” Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 5 WHAT ARE THE HARMS? EMOTIONAL, PSYCHOLOGICAL, AND SPIRITUAL When an individual experiences distress as a result of emotional, psychological, and/or spiritual harm. Spiritual harm includes the undermining, obstruction, or misappropriation of Indigenous worldviews, values, beliefs, or practices. “An Aboriginal woman came in as a trauma who required extensive surgery that lasted most of the night. As we were giving her a post-op bath (thinking she was still under anaesthetic) a racist remark was made at her bedside as we were busily doing our tasks at hand (she was on a ventilator and had a breathing tube in place). When I looked up into her eyes a few moments after the remarks were made, she had tears in her eyes. I was mortified and it was too late. The damage of those words said at her bedside was done.” WIDE-REACHING OR UNDEFINED When the specific harms of a reported action or behaviour either: a) are not documented, but have an undeniable impact on the health and wellbeing of Indigenous patients, or b) reach across multiple domains of harm. “Working with nurses and doctors and various administrators I had to endure multiple negative comments about one remote community: ‘Oh that community is the dog’s breakfast!’ (from a senior rep in health); ‘Nobody wants to work in that community! It isn't safe!’ ‘There are too many addicts nobody can work there alone!’ This in turn made it extremely difficult to recruit new providers to a community that desperately needed and wanted them and the accusations and stereotypes were unfounded and based on an incident that occurred nearly 30 years ago." Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 6 WHAT IS HAPPENING? Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 7 WHAT IS HAPPENING? Interpersonal Racism INTERPERSONAL RACISM When an individual holds and expresses negative thoughts, beliefs, or actions about an Indigenous person or people (e.g. providers to patients, helpline operators to community members, nonIndigenous staff to Indigenous staff). This type of racism is the most visible and is placed at the tip of the iceberg. STEREOTYPING Viewing or judging an Indigenous person based on generalizations that are made about their group. TREATING AS “UNWORTHY” Dismissing, guilting, shaming, treating as undeserving of receiving care or serious consideration. “One time I remember a lady coming in, quite nauseated and vomiting, and someone said ‘must be drunk again.’ In fact, the lady had not been drinking, and rarely drank. She had cancer and her chemotherapy was making her very ill. I never hear these comments for a White person, and although we do have intoxicated people puke in the ER sometimes, very rarely is it a person who identifies as Indigenous.” INSULTING AND RIDICULING Disrespectful, contemptuous, or scornful words or actions. Includes mockery and joking. CRIMINALIZING AND/OR PATHOLOGIZING Assuming that an individual or family is violent, dangerous, or incapable. “Through a friend, I was made aware of an incident where a young Métis woman visited a hospital for a routine pregnancy check-up. The nurse read in her medical record that she was Métis, and saw a notation from years before about a child welfare issue, long since resolved. This made her immediately call in child welfare. My friend was present in the hospital during this situation and she witnessed the distress of the pregnant woman and her interrogation at the hands of people who misunderstood her.” NOT BELIEVING PATIENT Expressing mistrust, doubt, or disbelief about a patient’s circumstances, symptoms, or experiences. “One young [First Nations] mother came in with abdominal pain. Nothing on x-ray (but we did not have ultrasound or CT scan) and the nurse who I took over for said “I didn’t go in there often because every time I did she wanted pain medication and she doesn’t look [like she’s] in pain.” This comment made me so angry – to be denied of pain medication when in pain is awful. It turned out she was full of cancer when they finally transporter to higher level of care and she died soon after.” Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 8 WHAT IS HAPPENING? Interpersonal Racism MICROAGGRESSIONS Day-to-day remarks, questions, or actions that while largely unintentional are disrespectful, prejudiced, or insulting. PREMATURE DISCHARGE A patient is discharged from care before they are medically stable and/or before they have received a proper diagnosis, necessary testing, adequate treatment, or appropriate referrals. “Recently in [city] an Indigenous woman was asked to leave the ER without treatment after she had been brought in by ambulance after being hit by a truck. She has multiple fractures. When she was in a wheelchair trying to take cover under the overhang of the hospital, she was asked by security to leave the property. This later became a national scandal when the family when to the media with the story. She is known as a street person with opioid addiction so I felt that stereotyping, prejudice and discrimination played a huge part in this incident.” INAPPROPRIATE REFERRAL A patient is sent to a health care provider or service that is inappropriate for their needs. MISDIAGNOSIS An incorrect diagnosis of an illness or condition. SUBSTANDARD CARE Care that does not meet professional standards or requirements set out by hospitals, organizations, or other regulating bodies in health care. “A young Indigenous woman presented to ER with a presumed miscarriage. I was working as an RN there at the time. She was very difficult to engage and it was difficult to get an accurate history. Several other Indigenous youths accompanied her. There were "rolled eyes" from colleagues about the number of people with her, as well as comments about how I should be enforcing the unwritten rule of two visitors at a time. During her ER visit, this woman was experiencing episodes of significant abdominal pain. I felt that she was ignored by the physician and made to wait longer than necessary. I really struggled to get the physician's attention over approximately 4-5 hrs. I documented every single time I approached the physician requesting a reassessment. She was eventually sent home with the advice to return to the hospital the next day for an ultrasound. I felt very uncomfortable sending her home. Several weeks later it came to my attention that an incident report had been filed. This woman had not been having a miscarriage, she had been in active labour! When she presented for the ultrasound she was found to be in labour with a baby at 35 weeks gestation. The incident report was for failure to refer the client to social work because of alcohol use during pregnancy! The physician had done not one single iota of charting or documentation on this woman. The only information was what I had documented. As far as I am concerned, this woman was completely misdiagnosed and mismanaged.” Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 9 WHAT IS HAPPENING? Interpersonal Racism DELAY IN OR DENIAL OF CARE When a patient does not get treatment in a timely manner, or is denied treatment altogether. This can include delays in initial appointment or follow-up. “There was an older First Nations man brought in [to the ER], lethargic and unable to speak, who had been found on the street. Everyone from the ambulance crew through to the ER doctor made the same conclusion, that he was heavily intoxicated, and so he was parked in the back corner of the ER to sober up. A few hours later I found his lab tests showing that he had no alcohol in his system, much to everyone’s surprise, and it was eventually determined that he had experienced a stroke.” CULTURALLY INAPPROPRIATE CARE, RECOMMENDATION, OR ACTION When proposed or actual care does not consider the diversity or cultures of Indigenous peoples. This is often the result of a one-size-fits-all model imposed without sensitivity that such an approach might harm the patient. “I always remember this First Nations Elder, who I became somewhat attached to during his hospital stay. I arrived to do "rounds" one morning when I was told that he was in the process of "signing himself out of hospital". He required heart surgery and had significant coronary disease. I went to talk with him. His family was present who were explaining to him that he needed to stay. He was of sound mind. To make a long discussion short he was leaving the hospital because he was not allowed to also use his traditional medicines. He had a mason jar of mixed natural roots and plants that he was taking which he believed was helping with his coronary disease. After much discussion, he did stay in hospital and eventually had his surgery. The family, patient and myself along with help from pharmacy and input from the First Nations Liaison determined that in fact his medicine would be beneficial and certainly not harmful to him. If any other individual asked to take a supplement it would have been discussed. It bothered me that this Elder's needs/requests were dismissed and ignored. In fact, his medicine was actually removed from his bedside and put on display like it was a crazy idea for him to be wanting to take this supplement. I felt sad that this happened and that professional people felt that his beliefs were un-valued.” DIFFERENTIAL TREATMENT Indigenous patients being treated differently than non-Indigenous patients in the same or similar circumstances. (THREAT OF) MEDICAL VIOLENCE Acted or attempted use of medical force that causes injury to the patient. “Unfortunately, I have had heard many negative things said in my career but one that was especially horrible and still sticks with me many years later was when an Indigenous client was pregnant with her 5th child and a co-worker stated, "God when are they going to sterilize her already? Great, another kid we are going to have to support". I think what bothered me the most about this was not only what she said but that I let her say it.” Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 10 WHAT IS HAPPENING? Organizational Racism ORGANIZATIONAL RACISM Anti-Indigenous racism that manifests in organizational policies, practices, and workplace culture that consistently penalize, disadvantage, or otherwise harm Indigenous people. These workplace standards, norms, or regulations are harmful on their own, and are placed in the middle of the iceberg because they encourage and enable racism at the interpersonal level by creating an environment where individual actions are taught, encouraged, or mandated. CRIMINALIZING AND/OR PATHOLOGIZING Organizational policies or practices that reflect the assumption that an individual or family is violent, dangerous, or incapable (e.g. automatic referrals to child protection services; violence alerts that follow people through the system). INAPPROPRIATE REFERRALS Referral pathways that are considered the “standard” but do not take Indigenous contexts into account. “I was asked to meet a gentleman over the weekend and assess his needs. He presented with significant mobility issues and I needed to assess his psychosocial needs. The nurse had yet to check in on him and medically assess him. She was very abrupt and abrasive when discussing him, which caught me off guard. After meeting him I went to update her and was informed that she requested a chemical dependency worker to assess him as well given his previous history of alcohol. She reported it was an automatic referral even though his presenting issues were related to mobility. I was quite upset by this blatant disregard of the situation and "adherence" to the rules. Adherence to instituted policies aren't always necessary or appropriate especially if they are sensitive issues.” GROOMING OF STAFF The teaching or transmitting of biased beliefs and practices to fellow staff (e.g. teaching of students and new staff by leaders or other people in positions of power who have the responsibility to train and mentor within the organization). “As a nursing student I had the opportunity to work in a small rural hospital that was surrounded by First Nations Reserve. At the time there was an increased number of Aboriginal children admitted to the hospital. One of the staff told me that this was common at that time of year because there was a big event that people attended and the families used the hospital as a daycare so they could attend the event. I wish I had asked more questions and I know an older more experienced nurse would (I hadn’t yet found my confidence or voice as a nurse or even as an adult at the time). The children were diagnosed with an illness and were being treated medically so I don’t understand why this comment was made.” Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 11 WHAT IS HAPPENING? Organizational Racism ACCEPTANCE OR NORMALIZATION OF SUBSTANDARD CARE Processes and practices that create an environment where it is normative, regular, and acceptable to provide substandard care to Indigenous patients (e.g. documentation of harms with no consequence or follow-up; institutional protection for people who have expressed anti-Indigenous racism or provided inadequate care; culture of dismissing or ignoring Indigenous patients is the norm). “I have spent more than a decade working in the local Emergency Department and have seen many examples of stereotyping and discrimination towards Indigenous People. I was on shift when an Indigenous lady came in with slurred speech and an altered gait and was put on a stretcher in the ambulance bay (away from nursing line of sight) because the triage nurse assumed she was just drunk, despite no charted history of substance abuse. It turned out that this poor woman had had a stroke and had significant delay in being provided care because of the triage assessment. The Emergency Room Physician on shift started an incident report because of it and has pushed for retraining of the ER triage nurses (which has gone nowhere because the nurses’ union fought against the retraining and "discrimination" of the triage nurses). The whole situation was upsetting and absurd.” CULTURALLY INAPPROPRIATE AND HARMFUL POLICIES, PRACTICES, AND SERVICES When policies, practices, and services are presumed to be universal but are not designed with the needs, values, or circumstances of Indigenous patients or families in mind. This compromises the effectiveness, relevance, and benefit of health care (e.g. visitor limitations; preventing families or communities from participating in decision-making processes; mental health programs that do not take the worldviews of Indigenous peoples into account). “Some Indigenous patients were upset one night. One of the Elders were in the hospital actively dying. The rule of only two people visiting at a time was at that time enforced, regardless of circumstance. The extended family wanted to be present, to do their ceremonial rituals. They were upset that this was not going to be permitted. This was a big violation to them. This was handled by a few of us nurses, under cloak of night shift, moving the patient, after discussion with the spokesperson. The family were so very appreciative. The administration not so much at first: ‘If you do for one, you do for all.’” INDIGENOUS PEOPLES NOT MEANINGFULLY ENGAGED IN POLICY OR DECISION-MAKING The exclusion, lack of representation, or lack of collaboration with Indigenous peoples, organizations, or communities around issues that impact Indigenous health and wellbeing (e.g. reluctance to work with community-based organizations or services; tokenizing Indigenous representation or input; Indigenous leaders not invited to the table). “I can think of many examples of Indigenous stereotyping in working with groups related to service planning. I’ve seen how the common stereotype of Indigenous people being late and slow in responding negatively impact engagement with Indigenous partners, as people weren’t as willing to try to engage with certain groups because they assumed there would be challenges and it would slow their work. This impacts the design of services and future outcomes for Indigenous patients if their voices and ideas aren’t represented in the service.” Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 12 WHAT IS HAPPENING? Organizational Racism DIFFERENTIAL IMPACTS OF HEALTH CARE GAPS AND SYSTEMS ISSUES ON INDIGENOUS PEOPLES When wide-reaching health systems gaps impact all patients, but have a distinct and more pronounced impact on Indigenous peoples because of bias or broader social issues that amplify the effect [e.g. travel policies that do not take the additional needs and contexts of Indigenous peoples into account; gaps in continuity in care (moving between providers, having to repeat stories) present more barriers for more Indigenous patients resulting in higher loss-to-follow-up and other harms]. “There was a significant problem around discharging patients that had travelled 2.5 hours by ambulance to hospital, sometimes in their pajamas with no purse or wallet. Many people were stranded by this lack of policy and planning, and Aboriginal people in particular were in a jam as they had no money to catch a bus home, or did not have access to a car or friend with a car to make a 5 hour round trip to pick them up and take them home.” Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 13 WHAT IS HAPPENING? Systemic Racism SYSTEMIC RACISM Values and beliefs that maintain and reproduce anti-Indigenous racism, including ideas that Indigenous peoples and knowledge systems are inferior, conquered, and uncivilized, and settlerimposed systems are superior, inevitable and ideal. These values and beliefs inform wider public policies, practices and processes (e.g. funding decisions) that influence and maintain anti-Indigenous racism at organizational and interpersonal levels. Systemic racism is often the most difficult to conceptualize and recognize, so it is placed at the bottom (the deepest level) of the iceberg. LACK OF RESOURCES AND HEALTH COVERAGE COMPLEXITIES When chronic underfunding and jurisdictional complexities result in a) limited or no access to healthcare services in communities and b) the lack of adequate, clear, and comprehensive health care coverage for all Indigenous peoples (e.g. communities lacking trained health care providers and health programs; mandatory evacuation policy for pregnant people; people being forced to leave communities to access lifesaving treatment; inadequate health care benefits to meet needs; exclusion of culturally specific or appropriate care from coverage). “Working in a small community hospital there were fly in reserves that were serviced by our hospital. The more remote and smaller areas some did not have any trained medical staff such as a nurse or a doctor on site. They would have staff with no medical education on call in case of an emergency. The lack of medical staff shows this community that they are not worthy of medical treatment. If [the community] could have trained medical staff on site or on call then people would be properly assessed on site. They would get proper treatment or life saving measures from a nurse right away instead of waiting to speak to a nurse over the phone at our hospital. The nurse would be able to get medical orders from a physician over the phone while they wait for an air ambulance if required. This would save a person’s life in a medical emergency.” INEQUITIES CREATED AND PERPETUATED BY OTHER INSTITUTIONS THAT IMPACT THE SOCIAL DETERMINANTS OF HEALTH When the impacts of poverty, inadequate housing, food insecurity, and the other determinants of health are compounded by and felt within the healthcare system. “A First Nation's man was discharged from hospital after a surgery without consideration given to his living situation. He did not have cooking facilities or a bed. He told me he slept on a mattress which was on the floor and he had no way to do his laundry. He had a new colostomy which he was learning to master and it would sometimes pop off so it was difficult to keep bedding clean. I advocated that more time was needed in the hospital for the man to recover from the surgery and master the colostomy and pointed out that he would not be able to manage okay at home due to his living environment. I spoke to the surgeon about my concerns and the man was discharged home anyway. The dominant culture was totally at play here focusing on efficiency in the institution as well as individualism and self-sufficiency expecting the patient to manage on his own.” Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 14 WHAT IS HAPPENING? Systemic Racism VALUES, BELIEFS, AND WORLDVIEWS Indigenous peoples and knowledge systems are seen as inferior, conquered and uncivilized; settlerimposed systems are seen as superior, inevitable, and ideal. “Very recently I was requested to provide a presentation to the Board Members of one Indigenous community on a relatively new nurse-led home visiting program. As a health authority and provincially, this program has been implemented as its curriculum is evidence-based, with proven positive, long-term health outcomes for mother and child over their life course in multiple countries throughout the world that this program has been implemented in. The implementation of this program in one specific Aboriginal community had created some anger, frustration and "hard feelings" between the Board Members, Health Director and Elders versus the health authority as they saw this program as a duplication of service to a similar Maternal Child Program they already offer to the pregnant moms in their community and was insulted that the health authority thought their Band Community Health Nurses were not doing a ‘good enough job’ so felt compelled to implement this provincial nurse-led home visiting program utilizing health authority trained public health nurses.” “The priority for me is to see each client as an individual and to treat them within the framework that best supports their cultural safety. The other day I had a patient who was first raped at age five. She became pregnant and had a hysterectomy, without consent by age 12. She had a harsh, protected demeanour. Trust does not come easily to her. I realized that every time I wanted to do a portion of the exam, I would have to empower her to own it. I would only do it if she said she wanted me to. I would describe each part and the reason I wanted to do it. If she declined, I did not argue. I did not take her approach personally. When next I saw her, it was on her terms. She refused to have a follow up, but let me see her eye. She told me it was better. She has been to the unit every day since to chat, even though she has a new prosthetic leg. I don’t think she comes to see me, but she is not avoiding me and answers my greetings with a smile. Building trust is what it is about. And equality in health care is important. But at times, if someone has been injured, culturally safe care is care that goes beyond the normal. Maybe understanding helps me to not stereotype and to accept that she has to do what is necessary for her to feel safe. It is complex.” Anti-Racism Think Tank March 12, 2019 Not for distribution or copying; for permission to use please contact Jane Collins at: jane.collins@phsa.ca 15 Anti-Racism Think Tank March 12, 2019 PHSA \s . Indigenous Health Health ?3 Servuces Authority Province-wide solutions. Better health.