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Podcast - Voices from the Field 22 - A discussion of the importance of cultural safety in health care and how it can be achieved

July 2022

NCCIH Voices from the Field Podcast Series
NCCIH Voices from the Field Podcasts

Voices from the Field

Welcome to Voices from the Field, a podcast series produced by the National Collaborating Centre for Indigenous Health (NCCIH), which focuses on innovative research and community-based initiatives promoting the health and well-being of First Nation, Inuit and Metis peoples in Canada.

Episode 22 – A discussion of the importance of cultural safety in health care and how it can be achieved

In this episode we hear from Dr. Margo Greenwood, Academic Leader of the National Collaborating Centre for Indigenous Health at the University of Northern British Columbia and former Vice-President, Indigenous Health of the Northern Health Region. Dr. Greenwood discusses what a culturally safe health care system looks like and entails and explains how the work of the NCCIH supports cultural safety for First Nations, Inuit, and Métis peoples.

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Dr. Margo Greenwood, Academic Leader of the National Collaborating Centre for Indigenous Health, is an Indigenous scholar of Cree ancestry with years of experience focused on the health and well-being of Indigenous children, families and communities. She is a Professor in the Education program at the University of Northern British Columbia and was Vice President of Indigenous Health for the Northern Health Authority from 2013 to 2022. Dr. Greenwood has received numerous awards for her achievements in early childhood education and health policy, including the Queen's Jubilee medal (2002), BC Academic of the Year (2010), National Aboriginal Achievement Award for Education (2011.), and most recently, she was honoured to be appointed as an Officer of the Order of Canada (2021.)





Kelly Lerat: Welcome Dr. Greenwood and thank you for taking the time to be with us today, to share your work on cultural safety. So, we'll start with talking about, you know, why cultural safety is important. How does a culturally safe and responsive healthcare system improve the health of Indigenous people?

Dr. Margo Greenwood: I guess first of all a culturally safe and responsive health healthcare system would be accessed by First Nations, Inuit and Métis people and I mean that readily accessed. Right now, the reality is that many people won't engage with the healthcare system until very late in their illness, for example, because they have felt unsafe and responded to in that system.

And so a lot of people will wait till things are very serious before they access healthcare services. By then it's, you know, much more, perhaps complex treatment or stringent treatment, and, had they come earlier, it might've had a better outcome. Not saying that all outcomes are bad, but you know, if we had gone sooner, sometimes we can address things in a much quicker way.

I think it's really important because people, certainly in the province of British Columbia through the In Plain Sight Report, have come forward and really articulated and described some of the very negative experiences that they've had with the healthcare system and certainly have talked about racism, anti- Indigenous racism, within the system itself. Systems that are respectful of people that consider patient-centered care, trauma-informed care, are much better and much more responsive, I think, to First Nations, Inuit, and Métis people. Systems that think about Indigenous knowledge and Indigenous ways of healing and how those can work together with Western ways, I think, are a long ways down the road, to having, building those good relationships.

And that's, I think where we're trying to get to is to having positive relationships between the system and those that it serves. And I think all of these things, where we start to change how we interact with each other and how we experience the systems, begins to rebuild trust. I think that the system itself can be informed by Indigenous people that it serves itself and helps to support the kind of change that needs to happen.

Kelly Lerat: In your work, you have also described cultural safety as, at its core, being about ethical and respectful relationships. Can you describe what this means and what it looks like in practice?

Dr. Margo Greenwood: When I think about ethical and respectful relationships, so certainly I'm thinking really big picture to start with and that is sort of looking at the Indigenous / non-Indigenous relationships in this country, starting from the place that Canada is a colonial state and that the relationships between non-Indigenous and Indigenous people have not always been positive in this country. We have, and we acknowledge, the colonial reality and history … that we continue to live in. And I think that's really important because any of our individual, our collective, relationships are embedded and anchored in that colonial history.

When we know that and when we acknowledge that, then we know that we are not going to just assume trust underlies these relationships. And so when I think about the big picture, I think about those larger concepts of trust, because trust is absolutely fundamental to a one-on-one relationship or a country-to-country, nation-to-nation relationship.

So, I really think about that. So, for me when I think about ethical and respectful relationships, I think about those that are undergirded and anchored in trust. To get there, we have to listen to one another. We have to acknowledge that there are power differentials in current reality and we have to listen to one another.

I think that we have to seek solutions rather than blame. I think that there is lots to… lots to be concerned about, but I like to think that we look to the future for all of our children and that we look for solutions because we are all preparing for the future for our children and the generations to come.

We need to be flexible when we listen to one another, we need to accommodate new ideas, new ways of doing things. I think that's, for me, when I think about building those kinds of respectful relationships, those are some elements that certainly come to my mind. I'm also reminded about the Truth and Reconciliation Commission. One of my colleagues and friend always says to me, ‘truth first Margo’. I said, ‘you're absolutely right’. There can be no peace and harmony without justice. Justice begins with truth. Honesty will start there too. And, trust will start there. So, I think about that from, I guess, multiple perspectives.

Kelly Lerat: So, in your work, you've also discussed that, you know, a multilevel approach is required to create change at a structural, systemic, and service delivery level. Can you describe this model and how it can be used to integrate cultural safety into the health systems?

Dr. Margo Greenwood: This is deeply, deeply complex. It's not new ideas. It's old realities that we continue, I think, as generations that we continue to work at. It's almost like peeling the proverbial onion, you just keep peeling back a layer, then you get another layer, then you peel back some more.

And so, I think about that and I think about the complexity. And so, I try to always find my way through that in whatever context I'm working in, and in this particular case, I was working in a health authority. So, I got to see firsthand how some of these ideas and concepts are being realized at the practice level.

And so that really led to my model that I think is deceptively simple. I think, and at the heart, it's certainly based on an ecological model. So, at the heart of it is individuals and practices and those individual relationships we just talked about. How can we talk to one another? How can we be in relationship in a good way?

And then the next level, next level outward, would be our systems. So what system are we, are we in? So, in my particular case, obviously the health care system and so I think about, so what are the policies that guide the health care system and how do those enable good practice? Because really, it's that point of care that real change, healing, wellness happens.

And so, I'm always thinking, how does the system then support that good practice and support those individuals that we're serving – in this particular case First Nations, Inuit and Métis peoples, and then the structures are like the big legislative pieces that guide the policies or the Healthcare Act that governs and guides the delivery of healthcare in the province of British Columbia.

So, let's go back to our inner circle. When I think about practices, I think about the people that are actually engaged in the relationships, and I think about healthcare professionals and allied healthcare professionals as well. What is it that I can do to support them to be the very best practitioner they can be?

So perhaps that's some education. So, for example, where I worked, I developed a 20-hour education course on cultural safety and anti-Indigenous racism to support practitioners to be the very best they can be with First Nations, Inuit and Métis peoples. We also afforded learning opportunities with the communities. So how can we facilitate those engagements and those relationships with First Nations, Inuit and Métis communities so that people can learn about who it is that they are serving in their particular geographic locale. That's really important because we all know the diversity of Indigenous peoples in Canada.

It's really important for practitioners to know who you said that I'm serving and what do I need to know about them so I can serve them better and more appropriately. I think those are pieces where we supported healthcare practitioners and professionals to be in relationship in a good way. And of course, most fundamental to all of that is self-reflection. How is… how are my own biases, how are my own assumptions, influencing how I practice and how I think about what it is that I'm doing. I think for those that we're serving, we need to support them as well. We need to have Indigenous patient liaison workers to walk the journey with them, that when they come into our facilities, people see themselves and feel welcomed, and that there are people there that are welcoming them into the system and that they're not just leaving them at the door, but they see them throughout their journey in the facilities. So, I think about things like that at the point of care and practice level. And so, then I think about what are the activities I need to do to support that kind of relationship. At the systems level, it's really important to be looking at the policies, the guidelines, the practice guidelines, the policies— this is where you're into accreditation standards and all of those things.

So, within those systems, you may be working at developing standards that are at an accreditation level, which is a bit different than the health system itself, where you deliver. But how do we influence those? And, I've just been a part of developing health standards for it around cultural safety in the Province of British Columbia, so that's been really exciting work. So that's part of a system, that's part of the healthcare system. Another part of that is the policies that we see in each health authority that guide the practice within the health authority itself, and so how do we ensure that First Nations, Inuit, and Métis peoples are being engaged in, being involved in, the development of those pieces of policy?

So, we actually developed a policy system assessment tool to guide people in the development of policy and in the review of existing ones. So, there was another way that we could begin to create the kind of system change that we want to see. So, it's not just at the practice level that we need to see system change that's going to enable those good culturally safe practices, but the policies themselves are also culturally safe and respectful of First Nations, Inuit, and Métis people.

And then I guess an example of the big structural change, absolutely, is healthcare legislation in the Province of British Columbia. In British Columbia, we have enshrined in legislation the UN Declaration of the Rights of Indigenous People. That framework, the declaration, shows us how to implement and gives us guideposts. The Province of British Columbia and all systems ministries within the province are committed to including and using the declaration in their practice and in their legislation. So that's huge when we think about it and that is a way - because cultural safety to me, in a lot of ways, is about being in respectful relationship with one another.

And we have to address issues of justice. Some people in this country – First Nations, Inuit, and Métis people – have not always had the privilege of having their voice. I see this as an opportunity to open those doors and to bring those voices in and to realize they have a right, through the UN Declaration, have a legal right to those voices, and I think as systems we need to adjust accordingly to ensure that that is a part of our sort of normed reality. So, we're asking for system change, big time, and we're asking for societal change.

Kelly Lerat: So, thank you for taking us through that very, you know, complex work that needs to go into the different changes and the levels of change that need to go into implementing cultural safety. How is the National Collaborating Centre for Indigenous Health supporting the working culturally?

Dr. Margo Greenwood: Well, it's really exciting. I mean, the National Collaborating Center is 17 years old. In those days, we didn't really have the words “cultural safety” but we certainly knew what racism was and we certainly knew power differentials. And so, one of the things that has always guided the Centre, which I have been so committed to and all of us have at the Centre, is to privileging Indigenous voices. That to me was a huge step in just opening the door and making sure that the voices of First Nations, Inuit, and Métis peoples were heard, and we could do that as a Centre. We could engage with community. We could engage with Indigenous scholars, Indigenous groups, to help us to develop the tools that were meaningful and relevant to them. That was another guiding principle. These principles were given to us by an advisory committee that we brought together representing First Nations, Inuit, and Métis peoples from coast to coast to coast. So, we sat together and we talked about what is it that we really needed to have in place to guide our work?

I cannot tell you how many times I've reached back to these guiding principles. So privileging voice is meaningful and relevant on every project we do. Is there a reason that we're doing this? Is this going to support and better the lives or potentially better the lives of First Nations, Inuit, and Métis people.

So for 17 years, we've been doing that. But more recently, we've been able to develop repositories. So right now, we have a nationally and provincially funded repository on cultural safety and anti-Indigenous racism, which is very, very exciting. Sad that it came about and how it came about – it was in response to deaths of our people within the healthcare system. And, but really important for all of us to have access to these resources, to the best thinking about how is it that we find our way on this journey to being in respectful relationships with each other and to achieving the peace and harmony that I think we all strive for and we all aspire to in this country. And I think, you know, having these resources are really important. There are other things that we do too. I mean, we certainly have lots of media resources and videos that are great, that have just showcased powerful messages and images that I think are useful to folks.

We've done some books. We're on our third textbook, if you will, on the determinants of health and Indigenous people in this country, and I think it's been a seminal text. So, we've done a lot of work in this area and part of the reason we’ve stayed with…, is it resonates so well with holistic health. I know that when I go in community, people know what I mean when I say holistic health and determinants of health – looking at all the things [that] impact our lives allows us then to look at all of those different elements that do impact our lives.

And so, it's been really important to have that, as comprehensive a look at the health and well-being of First Nations, Inuit, and Métis peoples as possible. We also… another piece of work that we do is we convene people in national gatherings to have national conversations. I remember when the social determinants of health first came out, we held a meeting, we held four annual national gatherings where we began with, “so what is social determinants of health and how does that impact First Nations, Inuit, and Métis people in Canada?” So, we've done a lot of work by just coming together to have the conversations, to support one another, to network with each other and to come out with amazing ideas that only a collective, I think, can do when they get together and you get all of these brilliant minds in one room, it's so exciting. So that's just some of the ways that I think the Collaborating Centre has contributed to the health and well-being and, in particular, to cultural safety in this country today.

Kelly Lerat: Where do you see future work is needed in creating culturally safe healthcare for Indigenous people?

Dr. Margo Greenwood: Well, I think we have to continue down the same path. I think we have a window of opportunity here and I hope that window continues for a very long time, so it becomes the norm. We have to continue to face the truth. I think we have to continue to have the hard conversations and that we have to, together, find those solutions.

I never lose sight of the concept of peace and harmony and balance in our lives, our old teachings for many Indigenous places, and I always have them at the forefront of my mind. Even when it gets really hard, sometimes I think the visions of our ancestors and of our collectives sustain us and build on the resilience that we have had to have over the last 500 years. And so, I celebrate our people in their resilience and their ability to find their way to that much more positive place. It won't be without a struggle, but I am confident in all of us to find that place or change.

Kelly Lerat: And thank you so much, Dr. Greenwood, for your time today and sharing with us your knowledge or experience and expertise with us. So, thank you very much.

To hear more podcasts in this series, head to the Voices from the Field on the National Collaborating Centre for Indigenous Health, Music on this podcast is by Blue Dot Sessions. It appears under a creative commons license. Learn more at


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