Experiences in health care among patients are influenced by the knowledge base and worldviews of health practitioners. Indigenous patients are more likely to experience higher number of racist encounters when accessing healthcare and social services (1–7), which in many ways has been exacerbated during the COVID-19 pandemic (8). The Truth and Reconciliation Commission (9) calls upon all health care organizations to provide mandatory cultural safety training to their health professionals to reduce racism, discrimination, and harm to Indigenous peoples when they seek care. The need to learn how to better serve Indigenous patients is also upheld in the Ontario Ministry of Health and Long-Term Care guideline, Relationships with Indigenous Communities Guidelines, (10), where they recommend that health professionals learn about local Indigenous peoples and build true and authentic relationships with Indigenous peoples, communities and organizations with the goal of improving relations and reducing racism and microaggressions reported by Indigenous peoples who access healthcare in the province. Hiscock et al. (11) argue that Indigenous patient navigators would assist Indigenous patients with navigating the healthcare system as well as being a knowledge broker between health professionals and Indigenous peoples. The need to ensure cultural safety in accessing health care services is paramount; and yet, it is unclear how and if these trainings have been provided and what accountability mechanisms exist to ensure that staff participate meaningfully and incorporate the information into their daily health care practice. We provide a detailed account of how a tailored evaluation tool for health practitioners was developed to assess staff performance and measure accountability.
Cultural Safety
Cultural safety can be viewed on a continuum that moves from cultural awareness to cultural sensitivity to cultural competency and ending with cultural safety. Cultural awareness refers to the acknowledgement of cultural differences (12). Cultural sensitivity is respecting these cultural differences (12). Cultural competency refers to a set of skills required to work in cross-cultural settings and can include a services provider’s knowledge of and attitudes towards their clients (12, 13). Unlike cultural competency, which is defined by the service provider, cultural safety is defined by the client and requires that a service provider self-reflects about power imbalances and harmful biases they may hold (14). Cultural safety, within the context of healthcare delivery, requires healthcare providers to consider the broader social, political, and historical difference contexts of patients including the consequences of racism and discrimination (12). Cultural safety is inherently reflexive as a practice, requiring the health care provider to not only operate with a sufficient level of cultural competency towards their patients, but also to identify and understand their own sets of values and norms and how a healthcare provider’s cultural context might influence how their patient received healthcare service (12).
Unlike cultural awareness training, it is not sufficient to simply provide staff with an overview of what cultural safety is and expect that health care providers can now integrate the content into their practice. Cultural safety is a journey which healthcare providers must choose to accept and feel personally committed to developing, as well as being held accountable by their accreditation bodies and employers. In addition to mandating the completion of cultural safety trainings, workplaces can also incentivize the integration of cultural safety into healthcare practice by including it into the organization’s performance management evaluations (14) and requiring competency in cultural safety to qualify for promotions.
What do we mean by Accountability?
Each person is accountable for and to different peoples, organizations, and bodies based on the context the person is situated within. In the context of cultural safety, organizations are often held accountable to foster environments that prioritize the worldviews, values, and needs of Indigenous communities, delivering healthcare equitably, and incorporating regular reviews of staff (9, 14–16). Within healthcare, accountability may involve staff and organizational evaluations to ensure processes and goals are being attained; these are commonly published in annual reports to enhance transparency and public knowledge (17). Accountability measures are increasingly important as they assist in monitoring staff for culturally safe, appropriate, and patient-centred care. Within the contexts of Indigenous health and wellness, the idea of accountability is related to targeting the impacts of colonialism, including the mistrust of institutions, particularly the healthcare system and governments (18).
Practicing accountability can take different forms, but a key priority is ensuring the voices of Indigenous Peoples lead the way of defining what is culturally safe care, and that healthcare organizations and authorities are held accountable for delivering such care (19). Some Indigenous Peoples regard accountability as a responsibility for the safety and wellbeing of individuals and community informed by collective values, community health and well-being, harm prevention, and dismantling of power imbalance in structures and organizations (20). Indigenous communities see accountability as individual, familial, community, nation and all in creation, therefore health professionals must examine their accountability for culturally safe practice to Indigenous person(s) and community(s) as well as to the general public as a responsible provider and human being (21–23). In the Royal Commission on Aboriginal People (RCAP) report (24), accountability was a key theme and guiding principle throughout, expressing that there is an important accountability to Indigenous peoples with all related to their well-being (p. 655). Subsequently, the Truth and Reconciliation Commission (TRC) of Canada’s 57th Call to Action recommended the provision of education on Indigenous rights, law, and residential schools, alongside skills-based training in cultural competency and anti-racism among federal, provincial, territorial, and municipal public servants (9). As stated in the TRC’s Final Report (25), accountability in this context goes beyond an apology and rather, must encompass mutual respect and meaningful dialogue that aims for coexistence (p. 217–218). Extending these statements, non-Indigenous organizations, like public health units with non-Indigenous leadership, must be held accountable for providing adequate and appropriate cultural safety training and then determining if the skills gained are being used and the impact of culturally safe staff on the wellbeing of Indigenous peoples. In our project, accountability takes on different forms and relationships. Figure 1 describes the relationships and power dynamics involved in using the staff evaluation tool. Drawing upon Wilson (26), relationality and relational accountability exist within the same realm and manifest through our physical practices, methodologies, and ethics.
The motivation to be held accountable should shift from one rooted in colonial, patriarchal ideas to one that embraces Indigenous peoples, worldviews, and cultures which is centred on optimizing community health. Accountability, in this way, is one of relationship and invites public health staff to engage in relational accountability with the Indigenous communities and Nations whom they serve (19, 26). Health professionals who embody personal and professional accountability for integrating the skills of cultural safety also assist Indigenous peoples, communities and Nations to heal from colonial violence while uplifting and being allies for the return to self-determination and governance for Indigenous individuals, families, communities and Nations (5); it is through embodying and valuing Indigenous peoples, worldviews, and knowledges that decentres and decolonizes hierarchy in favour of true and authentic relationships who subscribe to the 7 Grandfather teachings of love, respect, humility, bravery, truth, honesty and wisdom.
Cultural safety is often understood from a theoretical perspective through the Transtheoretical Model of Behaviour Change, also known as Stages of Change (
15,
27,
28). Although this is a model created by Western scholars, it is fitting and relevant to the epistemologies and worldviews of the target audience of cultural safety training, often being non-Indigenous peoples (
28). According to the Transtheoretical Model of Behavior Change, people must move through six stages to obtain change: precontemplation, contemplation, preparation, action, maintenance, and termination (
29,
30). Individuals go through this process in a cyclical manner as it may take many attempts to achieve change (
31). In the context of cultural safety and our project, precontemplation may not be as related as the broader non-Indigenous community is aware that cultural safety is needed and individuals are ready to take action to improve health and wellbeing (
10,
28). Individuals must contemplate the change to be made, even if it is mandated, then determine the course of action, and start the action. They may or may not enter a relapse stage before they require some re-learning and reinforcement of the knowledge that helps to change their behaviour or using the Social Norms theory (
32,
33), they are confronted by the perceived norms (i.e., it’s okay to say/do microaggressions or racist remarks/behaviours) rather than reflecting the actual norm in society which shows more harmony and social justice. The misperception between these concepts is a space of discomfort that Indigenous cultural safety brings about before a person can self-reflect toward personal change. Operationalizing accountability through the development of tools ensures the delivery of person-centred care by staff who may unintentionally or intentionally harm, or who hold power in the patient-provider relationship (
22). In collaboration with a public health unit in Ontario, we developed the Indigenous Cultural Safety Evaluation Checklist (ICSEC) to assess the performance of staff after the completion of an online Indigenous cultural safety education course. The objective is to provide a tangible tool for public health management to incentivize the implementation of cultural safety in staff’s professional practice and evaluate the program’s uptake. The results of the evaluation can support each organization and accreditation body (i.e., physicians’ college) in determining the implications (e.g., administrative, financial, social) of implementing Indigenous cultural safety training.