At the age of fourteen, Stephanie Vandevenne, a young Mi’Kmaq woman pregnant with her first child, became sick. When she sought care at a hospital, one of the physicians came in and looked at her and said, “you’re an absolute disgrace for society,” which hurt Vandevenne “very deep,” she recalled.
Not only did Vandevenne have all the stress of a teen pregnancy, she and her daughter were kicked out of her house and ended up going on welfare and using food banks. She said that after her daughter was born, the Ontario Children’s Aid Society representatives were at her apartment all the time, asking questions like “do you know how to clean your house?”
Vandevenne not only had to raise her child in extreme poverty, but herself as well. She explained that she felt “very hopeless, very worthless, that you’re not really even a part of society, that you’re just kind of on the outskirts.”
Fortunately, during that time, Vandevenne ended up with an “amazing social worker” who helped her pursue her dreams of being a nurse and be given the opportunity to help, guide and be a voice. “But not be a voice on behalf of people, but alongside people,” she said.
What Vandevenne endured is just one of the many experiences that the Indigenous community has faced within the Canadian healthcare system. These experiences not only deter Indigenous people from seeking care but it also affects their own self-perception.
There are many barriers that Indigenous people run into when they need healthcare and they continue to have hesitancy because of those challenges. Experts have proposed cultural-safety, trauma, and violence-informed care as models to improve healthcare access, but many practitioners lack expertise on how to address this problem.
Dion Simon, the Medicine Trail Program co-ordinator out of Mount Royal University in Calgary, provides and teaches cultural resources to students. Alongside instructors, he teaches workshops to provide Indigenous awareness teachings and delivers cultural direction for students in Calgary.
He suggests that the main barriers that Indigenous People face when seeking care are transportation, finances, childcare, and recent and/or personal experiences in the healthcare system.
Simon explained that struggles with the health care system and where a family lives could deter them from seeking care. “Some live in remote communities, some live on the street and don’t have a permanent address.”
Simon also suggested that the practices of the residential school systems and the resulting intergenerational trauma has created a perspective of the education and healthcare systems that may also be a factor.
“There’s still some practices of colonization assimilation that still do occur in the education and healthcare system towards Indigenous People,” he said.
However, Simon also mentioned that the healthcare system is opening up in some ways.
They are “taking into consideration the basic cultural, spiritual needs of Indigenous peoples and doing their best in their system to have those practices available and accessible in the healthcare system,” he said.
Even with the rising of awareness around Indigenous issues in society, Indigenous peoples in Canada are still disproportionately affected by systematic racism, and are continuously experiencing it in Canada’s healthcare system.
Cases like Joyce Echaquan, where an Atikamekw woman was mocked at Centre hospitalier régional de Lanaudière in Joliette, Que., in her hospital bed while trying to ask for care, is just one example of how dangerous racism is to Indigenous Peoples today.
On Sept. 28, 2020, Echaquan livestreamed her mistreatment from multiple healthcare workers and shortly after she died. The 37-year-old mother of seven went to the hospital for stomach pain and complained of being over-medicated. Instead of helping Echaquan, the nurses dismissed her calls for help and continued to mock her Indigenous identity.
The Quebec’s coroner launched an investigation into Echaquan’s death. A CBC article stated that “health-care workers who treated Echaquan the day she died testified they had assumed she had an addiction to medication and was suffering from withdrawal.”
Lawyer Jean-François Arteau argued that “the false assumption led them to pay less attention to her symptoms and to leave her unsupervised, ultimately leading to her death,” according to the article.
After the investigation, which sparked conversations about systematic racism in the Canadian healthcare system, the nurse and orderly (nurse-aid) involved were fired but no criminal charges were laid.
“A biomedical lens might ask, do we have services to treat people’s lung cancer? Whereas a post-colonial lens or an anti-racist lens might look at when people have lung cancer and come to the treatment center, are they experiencing racism and discrimination and stigma? Do they feel they’re judged and disrespected?tara Horrill
In order to create a safer space for Indigenous patients, the hospital will hire more Atikamekw employees and Guy Niquay, an Atikamekw from Manawan, will be taking on a new role as deputy CEO.
However, in most cases these incidents either go unreported or are not followed up on with any rigour.
Drawing from her own past experiences with the healthcare system, Vandevenne’s time as a nurse was not so different to when she sought care at 14. She dealt with many racist remarks that eventually led her to quit her job at an Ontario hospital.
She explained that her co-workers would make comments that made fun of Indigenous Peoples, assuming that they were all either on drugs or drunk. “It was constant,” Vandevenne recalled.
One specific time that stood out to Vandevenne was when several nurses were gathered together at the nursing station and were making guesses about the blood alcohol level of an Indigenous patient. “Oh, you know, so-and-so is coming, and let’s guess his alcohol level,” she said.
Not standing for that, Vandevenne went to her co-workers and said that they shouldn’t be making those comments because “it’s mean,” and when she walked away, she heard one more comment, “Oh, well, you know, she’s just another Indian and no wonder she’s saying that,” Vandevenne remembered.
During this time, Vandevenne didn’t even know her own Indigenous identity. She knew that she was Indigenous but didn’t know where she was from. “They made that comment, not even knowing I was Indigenous. They just saw my skin color, my hair and just made assumptions,” she said.
Tara Horrill, postdoctoral researcher at the University of British Columbia, suggests that there are repercussions for individual healthcare providers, but “at the same time, if we are only disciplining individual healthcare providers we are definitely failing to see the scope of the problem,” she explained.
“It’s systemic, and providers hold some responsibility, but so do organizations and systems.”
Horrill has been studying the subject of health equity within the healthcare system for around five years and suggests that some nurses have proposed models to improve health equity, but many practitioners lack guidance on how to implement those models in practice.
From her research, Horrill explains that nurses need to broaden their knowledge from not just looking through a biomedical lens but to also look at a postcolonial lens.
“A biomedical lens might ask, do we have services to treat people’s lung cancer? Whereas a post-colonial lens or an anti-racist lens might look at when people have lung cancer and come to the treatment center, are they experiencing racism and discrimination and stigma? Do they feel they’re judged and disrespected? Are they not able to access care because of those factors? The services might be there, but if people feel that they’re going to be treated so poorly, they’re not going to want to access those services,” she explained.
Horrill’s most recent study suggests that nurses need to start looking inward and thinking about what kind of attitudes they have about a certain group of people and how those attitudes impact the care they give.
“Because sometimes we don’t even realize the attitudes or the beliefs that we hold. Sometimes it takes dialogue and someone to facilitate that reflection to really start to think critically about this,” Horrill said.
Horrill explains that in a clinical setting, patients tend to feel like they don’t have a lot of power compared to healthcare professionals, and in order to shift the power dynamics, nurses and other healthcare providers need to prioritize the relationship with the patient.
“It’s really about the patient-provider relationship. Looking at how you interact with patients, are you creating space for them to feel safe and respected? Are you creating space for them to actually talk about the issues that really need to be addressed?”
For instance, Horrill turns to the example of a lung cancer patient. Instead of just asking them about their breathing and how their treatment is going, providers need to also make space for them to explain that they have been on social assistance and haven’t been able to have a meal in a couple days.
However, Horrill outlines that sometimes nurses are not able to build that trust or assist with other important issues because of the policies and ways the healthcare system is structured.
“The framework that I lay out is trying to address social determinants of health, like housing, food, and income so that people can access the care that they need. But if in practice, you’re only given a five minute appointment with a patient and your organization doesn’t employ a social worker. How are you realistically supposed to do that?” she said.
“So you can tell people how to practice and if their practice environments aren’t set up to support that kind of practice, it’s not going to happen.”
Horrill explains that even with the time barrier, building that relationship with your patient is essential.
“Thinking bigger beyond just the specific diagnosis of the patient and thinking about some of the other factors that may be impacting their health,” she said.
“[It’s about] some of the other things that they might be struggling with, and I hope it gets nurses thinking, or healthcare providers in general, about what’s underlying some of the inequities that we see. And is there a role for them to advocate within their organization or within the healthcare system for changes, or even broader? Is there a role for policy advocacy? And then thinking about ways that nurses or healthcare providers as citizens can start to dismantle systemic racism.”
One example that Horrill outlines is that it’s not just at an individual level that prevents patients from getting the care they need, but also at a systemic level.
“Lots of healthcare providers run up against the three strikes and you’re out policy, where if you miss three appointments for whatever that might be, then they’re not allowed to have that diagnostic, scan, biopsy or scope, or they’re not allowed to continue radiation treatment,” she said.
“It can be harmful because sometimes there are circumstances in play or in place, but they are limiting the patient’s ability to get there and it’s far outside of an individual patient’s control. There’s sort of this inflexibility within the healthcare system to accommodate individual patient needs that can be harmful.”
Which is why Horrill wants nurses to reflect on their own biases and take action when possible. “It’s definitely not a one size fits all framework, it’s an approach to start thinking about some of these issues and how you could address them.”
Mount Royal University’s nursing program addresses and teaches several Indigenous issues in Canada relating to health and how to address some of the stigmas that may happen within the Canadian healthcare system.
During the winter and spring semesters, Simon helps out with teaching these courses. He teaches nursing students in the winter the Indigenous issues related to health, spiritual, wellness and care, along with many of the stigmas and stereotypes. He also outlines how Indigenous Peoples may be a marginalized demography, and how the conditions of poverty affects the determinants of health.
In the spring, he then takes students to do community work. “They’ll visit specific agencies in the community, we’ll visit the Elbow River Healing Lodge, the Tsuut’ina Spirit Healing Lodge,” he said.
“It’s putting that theory into practice and those teachings into practice.”
Simon hopes the students learn to identify issues of racism in the healthcare system, as well as the ongoing suppressing systems that continue to occur so future nurses can begin looking at how those systems can be changed.
“[It’s] looking at how Indigenous Peoples could enter into a triage and sit down with a triage nurse and to have those human questions, not just what did you drink this morning? It’s asking those human needs, rather than assumptions being made,” he said.
“So it’s just the building of relationships and building the understanding of the needs of Indigenous Peoples.”
Simon believes that the healthcare system is opening up because there are big changes that are being made to support Indigenous patients. So doctors and nurses can see with two eyes, one from a Western viewpoint and also through an Indigenous perspective.
“So we’re looking at those practices to be considered through the nurses that we work with, and that they may see the importance of it,” he said.
Simon experienced this change in the healthcare system first hand when his uncle passed away in February, 2020.
When his uncle was at the Peter Lougheed Hospital in Calgary, 13 family members were welcomed into the room at the same time, including sisters, children, grandchildren, nieces and nephews.
“And what was really, really good was a nurse came in and said, can I get anyone, anything here? Is there anything I can get for anyone, a pillow, a bottle of water, anything for anyone?” he explained.
“That is the traditional way and that was really, really beautiful. We know we saw that the hospital, the staff, were speaking a traditional language to the family, but that was a traditional language seeing that everyone was there. And, if anyone needed anything rather than just numbering the numbers in the room. And that was really beautiful to see. So I take my hat off to the hospital there.”
Although the Canadian healthcare system is changing, some Indigenous-led agencies are taking control of their own health structures.
The Southwest Ontario Aboriginal Health Access Centre (SOAHAC) has been working with the Indigenous Primary Health Care Council and five hospitals on the Pathways to Care Improving Indigenous Outcomes Project. It’s funded by the Public Health Agency of Canada to foster cultural safety for Indigenous Peoples in the healthcare system.
The program provides Indigenous cultural safety training to healthcare providers, across participating hospitals and implements organizational plans to promote and strengthen cultural safety for Indigenous patients.
Based on community partnerships with hospitals, SOAHAC currently has five main sites in Ontario: Owen Sound, Wellington Waterloo, London, Windsor, and Muncey. Most recently SOAHAC has opened a space in Newbury, Ont. in the Four Counties Health Services hospital.
The team has worked over the last seven months co-designing educational content that provides insight, advice and guidance from an advisory committee and an Indigenous circle, according to the most recent report.
The training includes a reflection on the social and structural determinants of Indigenous health, in-depth learning about biases and stereotypes that negatively impact patients, creating an ability to intervene when something happens, and an exploration of examples that hospitals can use to improve their inclusiveness and accessibility for Indigenous Peoples.
Since Vandevenne left her position as a nurse, she found a place to work that’s more than culturally safe. She is the director of quality and accountability at SOAHAC.
Vandevenne explained that people feel more included, welcomed and interested in learning, in the space that SOAHAC opened in one hospital.
For instance, on Sept. 30, Orange Shirt and Truth and Reconciliation Day, SOAHAC held a ceremony where hospital employees could come and engage with Indigenous culture and learn.
“Many practitioners asked me a lot of questions and they’re very curious and they wanted to learn,” she said.
“So when you have that welcoming space within the hospital it helps build those relationships and that trust, not only between the hospital and SOAHAC, but with people coming into the hospital period. They’re going to feel safer.”
Vandevenne shared a story about a woman who had come into the centre with her family and children to see a nurse practitioner. “I said to her, ’How are you liking our new space? How do you feel when you’re here?’ And she said, ‘I feel a lot more comfortable coming to this hospital now, and I never used to, and it’s just more accessible for me as well.’”
Vandevenne believes that SOAHAC is trying to build those connections and relationships within Ontario to help people feel more at ease when seeking care.
She explains that because they are a patient-centered agency they differ from typical primary care by creating relationships with each patient.
“For example, we provide longer appointment times. In a typical primary care setting, people are booked in like every 10, 15 minutes, [but we book] 45 minutes, an hour” for each patient, she said.
“It’s just very different, and it’s not just the medical pieces. It’s ‘what else do you need today? Do you need to go for a smudge before you leave? Do you want to talk to our social worker?’” she explained.
SOAHAC also has a lot of programs such as how to create a drum and online smudging (an Indigenous ceremony practice for purifying or cleansing the soul of negative thoughts of a person or place). Vandevenne explains that it is holistic and is geared around each single person and their family and their community.
“And so the work that we do too is not just centred around the client or the patient, but it’s centered around their family because family is extremely important. [It is also] centered around their community that they live in as well,” she said.
“We are always making space so that when someone comes in for an appointment, they can bring as many people as they want. And even during COVID a lot of primary care organizations basically shut down and you were lucky to get a phone call with your doctor. But SOAHAC was open during the whole pandemic to make sure that we were caring for people.”
The Canadian healthcare system is changing and many Indigneous people are taking it into their own hands, however there is still much to be done as it is still affecting Indigenous patients today.
“[It’s about] providing that extra love and care and attention to Indigenous Peoples because that’s been a component that has not been present for the last hundred years,” Simon said.
“We haven’t had that care and that love. Like my father, my parents, they were residential school survivors, and I have not once in my years have ever received a hug from my mother and from my father that was so genuine as a loving child. And I know that they never received that from their parents as well, but to have that ongoing love and care and support is important because we’ve been drifting away from it for so long,” he said.
“We don’t have that intimate connection with care providers. But when we see a care provider, it’s everything that they demonstrate, care and support, but to bring that in, to invite that in with Indigenous people, means everything to them.”