Cultural Safety Module 3: Peoples Experiences of  Colonization in Relation to Health Care




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Experiences of Health and Health Care

Aboriginal peoples' experiences of the health care system are varied. Although the latter part of this module focuses on positive experiences of healing, unfortunately, many Aboriginal people relate experiences of shame, marginalization, and fear. Trust is rarely part of healing relationships in the current system. Survivors of residential school and/or Indian hospitals speak of being re-traumatized by medical procedures because it reminds them of the intimidating environment of these places where nothing was explained to them and they were mistreated or experimented on. Module 1 describes these experiences.

Joan Morris relates examples of fear and the importance of trust in the clips found below.


Click to watch video clips/read text transcripts.

Joan Morris, Coughing Elder
Joan Morris,
Coughing Elder

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  vertical line   Joan Morris, Sensitive to Elders
Joan Morris,
Sensitive to Elders

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Then, Roger John describes how having an Aboriginal nurse in the community built trust and a feeling of safety.

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Roger John, Positive Presence
Roger John,
Positive Presence

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  vertical line   Roger John, Safe in Hospital
Roger John,
Safe in Hospital

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The ideas of cultural safety remind us that people have histories and, within those histories, there may be experiences that are embedded with fears. Think about your power as a health professional and how you may be involved in the re-traumatization of Aboriginal peoples.

Nurses who internalize their dominance believe, and enact their beliefs, that there is only one way the world can be. These nurses take for granted that whatever is dictated by the culture of Western medicine or nursing is the one right way.

This internalized dominance and taken-for-granted power are apparent in the all-too-common failure of health professionals to explain anything to people they are treating. Roger describes this experience in the "Childhood X-rays" clip.

Nurses who include the concept of cultural safety in their practices are aware of internalized dominance and taken-for-granted power. However, rather than use them negatively, they work to transform them into constructive opportunities.

 

Roger John, Childhood X-rays
Roger John,
Childhood X-rays

[Text Transcript]


  

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Using Power Constructively

As nurses, we can greatly influence people's health care experiences. We can do this by learning to use our personal and our professional power to positively shape their experiences of health and health care and to create supportive healing environments.

We have the power to create open, non-judgmental, and respectful relationships with people. We can be sensitive to the experience of individuals by taking time to come to know each of them and their unique context and to understand the meaning they attribute to their experience.

We can use our power to advocate for a partnership model of health care relationships whereby health care providers and clients/patients work together to determine their health care needs and the best way to meet these.

We can work with people in ways that promote autonomy and self-determination, rather than dependency, to create healing relationships that focus on building strengths and increasing choice for individuals, groups, and communities accessing health care through our workplaces.

Finally, we can use our power to question authoritarian organizational policies, rules, and practices that are based on only one view of health and healing, that create restrictive practice environments for nurses (such as inflexible hospital visiting policies), and that promote top-down patterns of decision-making.

Take a moment now to complete Activity 1, Using Power Constructively.  

Canales (2000),1 wrote about what she calls "inclusionary othering," the process of transforming power in health care settings from exclusive to inclusive. Instead of judging others in ways that exclude them from the mainstream, inclusionary othering advocates that we connect through difference in order to respect and embrace it. In your powerful position as a nurse, you have the capacity to do this.

Health care administrators are beginning to create a more inclusive system by offering health care professionals continuing education in cultural sensitivity and cultural competence. Review the Introduction to this module for clarification between cultural awareness, cultural sensitivity, and cultural competence.

Are there opportunities in your workplace to engage in conversations about cultural sensitivity? Cultural competence? Reflect on any differences you have noticed between cultural sensitivity and cultural safety.

Gaining awareness of cultural sensitivity is a good start to the process of making health care settings more inclusive, but it does not go far enough. It does not require enough self-reflection on the part of health care professionals; its focus on others may, in fact, continue to perpetuate stereotypes.



Leona Smith, Talking About Cultural Sensitivity
Leona Smith,
Talking About Cultural Sensitivity

[Text Transcript]


 

The language of cultural safety is not yet widespread in the workplace. However, you have an opportunity to make a difference if you practise in a culturally safe way. By doing so, you will have a better understanding of the multiple situations that lead to patients feeling vulnerable, based on their experiences of racism.

Leona Smith, a Ucwalmicw nurse, is a perfect example of a health care professional who uses her power to change the system.

  

Understanding how history may influence experience, but not assuming that it has, will help you develop a relationship with your patients. The current health care system tends to demand that all people, regardless of their multiple difference, conform to one system, one set of rules.

When we become distanced from one another, we may relate to our patients only as personal health numbers. In the clip below, Sheila Dick reflects on being number 114 in residential school, how it felt to be "objectified," and how this experience has stayed with her to the present day. A personal health number can remind Aboriginal people of their residential school experiences, causing them to relive their trauma.

Click to watch video clips/read text transcripts.

Sheila Dick, On Being a Number
Sheila Dick,
On Being a Number

[Text Transcript]


Establishing a connection with your clients based on cultural safety will go far to interrupt traumatic experiences like those described below by Sheila.

Click to watch video clips/read text transcripts.

Sheila Dick, On Hospital Lab Technician
Sheila Dick,
On Hospital Lab Technician

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  vertical line   Sheila Dick, On Dentistry
Sheila Dick,
On Dentistry

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Take a few minutes here for some private reflection.  



The following clip includes a good example of how a nurse transformed her power in a positive way.

Sheila relates how her mother's treatment in the ICU was very trying. Assumptions were made about her mother and her family because they were Aboriginal. Her family was labelled as a bother and this was very hurtful. However, one nurse used her power to connect with the family rather than focus on Sheila's mother's illness. Her efforts made Sheila's mother more comfortable and her family less stressed. Sheila's mother died the next morning.

As Roger John describes,

... When a person is passing to the other side is a very emotional time for families, all families. Aboriginal families try to create a space of love, comfort and safety for the person who is dying, even if they are unconscious, because that helps to make the transition easier.2
 

Sheila Dick, Mother in Hospital Experience
Sheila Dick,
Mother in Hospital Experience

[Text Transcript]


  

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Focus on Mental Health

Aboriginal peoples' experiences with mental health services require special mention because of the powerful influence of colonization and current forms of colonialism on their mental health. It is now clear that the dominant mental health issues in Aboriginal communities are social in nature. It is also clear that mainstream mental health programs and services are ineffective and, in some cases, harmful to Aboriginal individuals.

As health care providers, we must be mindful that we are bearers of culturally derived attitudes. Knowing this allows us to carefully examine our views and to question how health care structures may be impacting our practice.

Rapid Cultural Change, Oppression, and Intergenerational Trauma

Aboriginal peoples experience a high incidence of mental health problems, such as depression, suicide, family violence, and substance abuse. The source of these problems reflects their unique experiences of colonization.

Smye and Browne3 and van Uchelen4 have linked mental health and social problems in Aboriginal communities to the social and cultural disruption and historical trauma that Aboriginal peoples have lived with since contact. As discussed in Module 1, the loss of traditional lands and the gradual erosion of language and cultural traditions have harmed the cultural identity of many Aboriginal people. A tragic legacy of colonization is the continuous passing of unresolved deep-seated emotions such as grief and chronic sadness to successive generations.

Also, associated conditions such as poverty, unemployment, lack of appropriate housing, and dependency on social assistance have helped to create and maintain a social and economic environment conducive to the development of mental health problems.

Mainstream Health Care Services

Many Aboriginal peoples perceive existing mental health programs and services as inaccessible or culturally unsafe. For people living in rural and remote locations, access to specialized services and supports, particularly those for people with serious and persistent conditions such as schizophrenia, is especially difficult.

The current mental health care system is fragmented, offering services across a wide variety of contexts, including hospitals, community clinics, and specialist practitioners. These services tend to operate independently in "silos," which deal with isolated aspects of health.

Aboriginal peoples also face the additional problem of who (the federal or provincial government) is responsible for providing them with mental health services. This makes it difficult to coordinate planning and delivery of health care and results in a "patchwork" of programs, services, and providers.

The inflexibility of the system, compounded by racism and ethnocentrism restricts Aboriginal peoples' access to culturally safe programs and services. Current mental health policy and planning are based on a Western medical and illness care model, which focuses on pathology and emphasizes diagnosis and treatment of symptoms by specialized practitioners. No consideration is given to either Aboriginal traditional knowledge or healing practices.

Gwen Campbell McArthur, an Aboriginal mental health nurse, believes that mainstream counsellors try to shape behaviours in ways that conflict with Aboriginal beliefs. This serves to further alienate people from their communities and traditions.5

Existing approaches are based on assessment, questioning, examination, and testing. Medical treatments include medications, admissions to hospitals, and individualistic psychotherapies. In addition to being a poor fit culturally, these approaches do not address the social problems influencing mental health. Refer back to the discussions on intersectionality in Module 2 to see how these multiple factors may influence lives of Aboriginal people.

As discussed in Module 2: Peoples' Experiences of Oppression, in Western health care systems, lack of access to health care is often seen as a "cultural" problem, that is, the problem resides with Aboriginal people rather than with the health care provider or the service, which is a good example of racialization. In reality, many Aboriginal people report being treated differently than non-Aboriginal people and, as a result, they do not use health services. Recall some of Sheila and Joan's stories of the impacts of racial stereotyping on their health care experiences.

Possibilities for Improving Mental Health Care

What would mental health services look like if they were influenced by traditional and contemporary Aboriginal understandings of health, illness, and healing? Although there is no single Aboriginal framework on health, several common themes are found in Aboriginal world views and languages.

These include believing that health is a holistic concept related to harmony and balance; that Aboriginal ways of thinking and being are important in the restoration of health; and that mental health develops and is maintained through connectedness with family, community, and the environment.

Community-based efforts at reclaiming traditional practices and building cultural pride have been supportive of mental health. Of particular importance are efforts to reclaim ancestral lands to obtain self-governance.

Ideally, culturally safe services would be rooted in a deep awareness of the forces of colonial oppression, be community developed and based, integrate all dimensions of health, build on Indigenous knowledge and existing strengths, and utilize a blend of traditional and contemporary healing practices.

Gwen Campbell McArthur stresses the importance of learning about the many healing traditions of Aboriginal peoples. Traditional healing practices vary greatly and ceremonies may include daily smudges, prayers before and after healing circles, sweat lodges, dancing, drumming, participation in community gatherings, family ceremonies, and other community-specific activities. She uses her knowledge of the nature and importance of animal guides, such as the Eagle and its spiritual significance, as an integral part of her counselling practices.

Gwen believes that mental health practitioners need to consider how traditional Aboriginal healing ceremonies and practices could be intermingled with Western therapeutic techniques to improve mental health services for Aboriginal peoples. Mental health settings must become much more flexible if they are to incorporate traditional healing practices.6

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