Bridging the Divide through Cultural Competency

In an occasional blog feature, CFHI staff and invited guests explore key topics in healthcare improvement. This month, writer Laura Eggertson discusses topics that impact Indigenous health and a vision for reconciliation.

Cultural CompetencyAt times, the divide between mainstream Canadian society and Indigenous Canadians seems too wide to bridge – especially for those, like Carol Philbin Jolette, who work in the healthcare field.

A year ago, Philbin Jolette began her job at Ontario’s North East Local Health Integration Network as the senior advisor for the western James Bay coast. As she works with First Nations communities, their funding partners and the Weeneeybayko Area Health Authority to improve the way healthcare is delivered, Philbin Jolette sees first-hand the devastating effects of the health disparities Indigenous Canadians face.

From suicide and the intergenerational trauma that feeds it, to accidental deaths and injuries, to chronic illnesses such as diabetes and infectious diseases including tuberculosis, Philbin Jolette knows that Indigenous Canadians are affected at rates many times the average for non-Indigenous Canadians.

The health inequities are evident. What is less clear for health care organizations is how best to respond to the Truth and Reconciliation Commissions Calls to Action. One critical call, which the Commission issued a year ago, was to build cultural competency. That call is what brought Philbin Jolette to the cultural competency workshop that the Canadian Foundation for Healthcare Improvement (CFHI) regularly offers.

“As a non-Indigenous Canadian, I felt a strong need to understand the divide between Indigenous cultures and mainstream society,” says Philbin Jolette, a social worker by background. “I believe we need to continuously increase our cultural competencies in order to understand Indigenous issues from the historical context, so that we can build positive, respectful relations and partnerships with the Indigenous cultures.”

On May 11, 2016, Philbin Jolette was one of about 25 healthcare leaders from across Canada who attended the one-day workshop, which preceded the Northern and Remote Collaboration’s third annual Roundtable on Indigenous health and suicide prevention, held in Saskatoon.

Instructor Rose LeMay, director of Northern and Indigenous Health for CFHI, deepened participants’ understanding of the common elements of Indigenous culture around the world, provided background about First Nations, Métis and Inuit peoples, and addressed the ways that intergenerational trauma and racism contribute to negative health outcomes. LeMay, who is a member of the Tlingit First Nation from Taku River, BC, also took participants on a journey through Canada’s history of colonization and systemic racism, framing both as patient safety issues.

The journey was not always a comfortable one, as LeMay acknowledged – deliberately so. Adults learn better when they are uncomfortable, she stressed.

“We’re going to talk about racism – possibly more today than you have ever talked about it,” she told the group. “Canada tends not to see itself as a racist country. But proportionately more Indigenous are in jail in Canada than blacks in the United States …. So we definitely have a problem. And part of the problem is that we don’t talk about it.”

Throughout the day-long course, the group did discuss racism, both individual and systemic. In one exercise, small groups of the healthcare leaders related their own experiences of either experiencing or witnessing racism, and brainstormed around ways to challenge it. LeMay also led a discussion about the importance of being an ally. It is critical that First Nations, Inuit and Metis people in Canada not confront racism and injustice alone, she emphasized.

“There are going to be some programs and policy shifts that need you as an ally,” she told the non-Indigenous leaders in the room. “It’s a delicate position, though, because you can’t take over their (Indigenous) voice.”

The value of having a non-Indigenous ally was brought home to Lori Lafontaine, a member of the Kitigan Zibi Anishinabeg First Nation in Quebec, a few years ago when she worked as a social worker on a multidisciplinary health team in Ottawa. One day, a nurse colleague began to complain about the parenting skills of her First Nations’ clients.

“I don’t understand why ‘they’ can’t just supervise their children,’’ the nurse began.

For Lafontaine, the nurse’s words were an immediate red flag. They implied the kind of a negative judgment that has resulted in decades of bad child welfare practice in Canada. As the nurse continued her tirade, Lafontaine, tensed and uncomfortable, tried to summon the right words to object.

Before she could muster them, another non-Indigenous nurse stepped in. “I don’t agree with you at all,” she said.

By entering the conversation and indicating her disagreement, the second nurse changed the tone and created a safer space for Lafontaine, now the senior advisor, Indigenous, for the Mental Health Commission of Canada.

By intervening without escalating the situation, the second nurse also shifted the responsibility from Lafontaine of defending her community - and by extension, herself. It is a role LeMay urged everyone in the room to play.

“We all have a role and an opportunity to do something,” LeMay said. “I hope that in your organization, in your networks, that Indigenous are not left to deal with racism by ourselves.”

Those discussions around how to be an effective ally stayed with many of the participants at the workshop.

The training, which began and ended with a blessing by Saskatchewan elder Florence Allen, also included discussions about what competency means, how organizations can manifest it, and how competency relates to reconciliation.

“Cultural competence is very much how you interact with others,” LeMay said. “It’s about the values you bring and your openness to learning from others.”

LeMay, who developed the course and has taught it 60 times to more than 2200 participants, hopes that through a train-the-trainer model, CFHI will be able to offer it to even more organizations and their staff. The historical portion of the workshop, which discusses not only the legacy of residential schools but the impacts of repeated trauma, is particularly surprising to many participants, she notes, because they realize what they were not taught in school about Canada’s history.

“I really liked the historical timeline,” said Sheila Gordon-Payne, practice lead for Northern Health in British Columbia. “Now I want to pull up the Indian Act and read it.” History matters, in part because the impacts of colonization and residential schools are so pervasive that “when any Indigenous go into an emergency room, we should assume some concurrent trauma,” said LeMay.

“But not all Indigenous are traumatized,” she added. Part of cultural competency is adopting a strengths-based approach to treating and working with Indigenous people – and that means finding the balance between trauma-informed practice and resilience-based treatment. It was an approach that resonated with many of the participants at the training.

By the time the workshop was over, Philbin Jolette felt less overwhelmed and better prepared to continue her work with First Nations communities such as Attawapiskat, where she has recently travelled to try to help the community build its own capacity to respond to the suicidal ideation and suicide attempts of many members. She better understands the impact of historical/intergenerational trauma, she says.

Since the course, Philbin Jolette has reminded herself every day of the saying “Start by doing what's necessary; then do what's possible; and suddenly you are doing the impossible."

“I find it keeps me focused on what really needs to get done today to improve my relationship with First Nation communities. Sometimes it’s as simple as sitting with elders to hear their stories – and that’s O.K.,” Philbin Jolette says.