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Nurse Practitioners: Delivering culturally safe care makes all the difference


As health authorities in British Columbia work to close the gap on the significant health disparities that exist between Indigenous and non-Indigenous people, new Indigenous led primary care centres that embody culturally safe care are leading the way. In the Vancouver Coastal region eight clinics have formed the First Nations and Aboriginal Primary Care Network. There are now four on reserve primary care clinics, Squamish Nation's Yúustway Health Services, Tsleil-Waututh Nation's Helping House. Primary Care Clinic, Musqueam Indian Band Primary Care Clinic, Tla'amin Health and four urban medical clinics at Urban Native Youth Association, Vancouver Native Health Society, Lu'ma Medical Clinic and Kilala Lelum Health Centre. 

What sets these Indigenous led clinics apart from others is the intentional focus on holistic health care -caring not only for the body but the mind, spirit as well as emotional well-being and encompassing Indigenous culture, beliefs and spirituality. At Lu'ma every part of this approach is included in the design elements from the colours on the walls, to the art and traditional medicines that are available to patients in the waiting room. There are specialized talking rooms with low lighting and cedar walls and benches with cushions that make it warmer and less clinical. Patients refer to it glowingly as 'in your face Indigenous'.

These Indigenous Primary care clinics provide much more than primary care services to their clients. It’s a team based approach to health and wellness with a range of other health programs and services for the clients. Lu’ma has two traditional Elders/Healers that share cultural knowledge and teachings and engage patients in practices, ceremonies, and holistic ways of healing from trauma. If requested they will sit in the medical appointment with the patient. The clinic also has women’s and children’s drumming circles and men’s and women’s talking circles so people can attend these to create community. They host events like health promotion for women’s health and the team has organized traditional medicine making workshops so people can make salves. Brunch and bingo events have been hosted for the Elders to provide more of a social event.

Every part of Lu’ma has been designed to create trust with patients. Walking in the door patients are greeted by the friendly medical office assistants who also get to know patients and their children. Patients may come to see the physician or NP for medical care but can then also see an Elder and social worker (social navigator) who can help them access resources and complete forms for services and attend a drumming circle all in one place.

The Musqueam Primary Care Clinic collaborates closely with the Musqueam health department that includes many more services such as a Chronic Disease Management and Injury Prevention through Community Health Nurses and Community Health Representatives (CHRs), Home and Community Care, Mental Wellness and Substance Use Services, navigation and advocacy. Within these teams the Nurse Practitioner role is well suited. There is a Nurse Practitioner working at each of these clinics serving the Indigenous population. I spoke to three of them to find out what is making the difference for patients at these clinics.

Nurse Practitioner Role 

The role of the nurse practitioner is uniquely positioned to provide patient-centered care to remove power imbalances and create an environment to support and empower Indigenous people. This creates partnership and knowledge sharing in the patient-provider relationship. 

NPs are registered nurses with experience and advanced master’s level nursing education. They integrate holistic nursing experience with the authority and autonomy to diagnose and treat acute and chronic conditions with a focus on health promotion, disease prevention, community development, relationship building and the impact of social determinants of health. 

Sarah began working at Lu’ma medical clinic full time in December 2017. Laura is also full time at Lu’ma and also provides relief coverage for Musqueam and Tsleil-Waututh clinics. Karen is the NP at Musqueam and has been full time since February 2017.

Relationship Building 

When Sarah started at Lu’ma she had no patients. Through recruiting people living in the Lu’ma housing then through word of mouth and referrals from other Indigenous organizations her caseload exploded. She now has over 400 patients with a wait list of four to five months. Patients come from all over metro Vancouver, and across Western Canada with more than 130 nations represented.

This surge in patients is similar at the on reserve clinic in Musqueam First Nation where Karen is the main practitioner. The Musqueam Primary Care Clinic has a room in the Elder’s centre and but they hope to have their own new space soon where they will have two exam rooms so there is more space for another nurse or counselor. They now have about 600 registered patients of the more than 1300 nation members who live on reserve.

Many of the patients coming to see them haven’t had medical care in years. Patients have stories about being mistreated or ignored at a clinic or hospital and some have avoided institutions altogether because of their past experiences with Residential schools. Karen explains, “For some people they just don’t like leaving the reserve. For some people they had really bad experiences with the health care system thirty or forty years ago where they didn’t feel safe with their care providers and they never went back.” 

Sarah says, “But I still hear stories that happened yesterday at a local emergency room. The patient is 70 and the first question he was asked is, ‘How much do you drink?’ He said, ‘I haven’t had a drink in 40 years.’ This is the kind of care we’re trying to change.”

“Some people come in with a cold to meet you and you’ll treat that. The next time they come in they’ll tell you all this stuff that they didn’t mention in their first visit. There’s this testing the waters and it takes some time to build the trust.”

A Different Approach to Care

Building caregiver trust with patients begins upon intake. Laura says, “We have a very comprehensive intake process that covers social and medical history. Patients like it because they feel heard. We’ll make a list of things they want to address and slowly work through it over time.”

Another major way these clinics are providing care differently is that all of the appointments are a half hour. Because many of the patients haven’t had care in years, people come in with complex needs and there may be 6 – 10 things to address in one appointment such as medical exams, writing prescriptions, making referrals and follow up.

Karen: “With this amount of time, there is also time to talk about other aspects of their life. Sitting down with someone to understand their barriers, their struggles, or their challenges to following a care plan is important. If someone is struggling just to get food on the table, they are not necessarily going to be concerned about lifestyle changes. Or if they're struggling with anxiety, depression or trauma history, you just have to meet people where they are at and deal with that first.” 

Sarah: “Having a half hour appointment you can do a lot more health promotion and education because when people have, for example, a polyp in their colon – they don’t know what that is. If you can tell them what that is and how it affects them then they’re going to follow up. In some cases no one has ever explained this to them and they’ve had the condition for twenty years.”

Karen: “I have one patient Elder that is very medically complex. It took a good six to nine months to build up a good rapport and therapeutic relationship to the point of earning her trust and helping her to feel safe before I could address her medical issues.”

Laura is the newest member of the care team at Lu’ma. She says, “Most rewarding is helping people break down their fear of accessing care and creating that safe space so that people feel that they can go to medical appointments and to see specialists and don't have to feel scrutinized or judged.” Laura worked with one patient for six months to help her with her fears so the patient could go see a specialist.

Cultural Safety Awareness 

All of the NPs have taken the Indigenous Cultural Safety training delivered by the Aboriginal Health team. As Sarah says, "Having an understanding of the history in Canada and context and how that ties into chronic pain, mental health trauma is most important. You can’t work in this area without that knowledge.”

Karen: “We focus on people’s wellness. We’ll ask how their spirit is. Do they have an Elder they can go to for support, what their traditional beliefs are or what are some of the things they do to keep well? It goes beyond the Western idea of health and medicine.” 

Sarah: “Often if people are depressed or anxious – they’re not going to exercise every day or make behavior changes so mental health must be addressed first. Put it into the context and it totally changes the approach you’re going to take.”

Both at Lu’ma and the Musqueam clinic the NPs will use the rest of the team to address their patients’ needs. Karen says, “If someone has a high level of trauma and are unable to follow a care plan, we try to identify along with them what need needs to be met in order for them to be able to look at their health. What other resources or supports do we need to bring in? What other team do we need to mobilize to assist this person?”

“We try to advocate for patients as much as we can. We collaborate with the closest community health centre or get on the phone if someone is in the hospital or attending a specialist clinic out of the hospitals. We utilize the rest of the team here to use everyone’s expertise to help this person.” 

Sarah: “We had a patient who was in Saskatchewan and had a medical crisis. He was extremely fearful of hospitals because of all the negative experiences he’s had getting care. He called the clinic and the physician took the call in one of the healing rooms the patient had been in when he was at the clinic. One of our Elders did a smudge with him while he was on the speaker phone. Then he was able to go into the hospital and he felt that we were kind of here for him even from afar. It just seemed to help having somewhere that he could go back to for support.”

This is a unique opportunity for these three NPs being at the forefront to help change the kind of care being delivered to Indigenous people. All three NPs spoke about how much they appreciate working in these clinics and being part of the effort to build respectful caregiver relationships with Indigenous patients.

Karen sums the experience so far, “I really thrive with building these long term relationships with people. For me that’s something I value. It is such an honour and privilege to work in Aboriginal health to see the tremendous strength and tremendous resiliency is just amazing.”

This is the beginning of a journey in health care to heal the broken relationship with Indigenous people. We are making progress, but to create culturally safe care in all health services is going to take time. It requires a new partnership with Indigenous people built on respectful relationships and teamwork. This is reconciliation in action. It begins when an Indigenous person receives health care without fear of prejudice. Within these eight new Indigenous led primary care clinics, that kind of care is standard and is making all the difference.

SOURCE: Nurse Practitioners: Delivering culturally safe care makes all the difference ( )
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