Cultural Safety and Humility Q&A

Q1: What is CSH and how does it apply to the practice of dietetics?

CSH stands for Cultural Safety and Humility.

Cultural safety is an outcome based on respectful engagement that recognizes and strives to address power imbalances inherent to health care relationships. It results in an environment free of racism and discrimination, where people feel safe and supported to access, receive, and make informed decisions about their health care.

Cultural humility involves educating health professionals on the history of the treatment of Indigenous peoples throughout Canadian history and facilitate self-reflection in understanding personal and systemic biases that may prevent Indigenous peoples from accessing health care. It aims to develop relationships based on reciprocal trust and listening, while acknowledging oneself as a learner when it comes to understanding another’s experience.

*Adapted from Cultural Safety and Humility (fnha.ca)

The principles of cultural safety and humility (CSH) align well with dietitians’ responsibility to practice ethically, safely, and competently.

Q2: I am reading the new Indigenous CSH (ICSH) and Anti-Racism Standard and feel that time constraints do not allow me to address/satisfy all of the core concepts. What approach should I take to ensure I am meeting the requirements of this new standard?

While the wording of the ICSH and Anti-Racism Standard is new for registrants, the concepts they embody are not new. The principles of ICSH and Anti-Racism align well with the CDBC Standards of Practice, both of which affirm dietitians’ responsibility to practice ethically, safely, and competently.

Registrants should take time to familiarize themselves with the new Standard’s Core Concepts and its Principles and reflect on how these apply to current practice when serving First Nations, Métis, and Inuit clients. Registrants may be at different places in their journey of reconciliation and will want to choose learning goals and activities that allows them to incorporate the standard into their practice over time.

Reconciliation is not a check box to be completed; it is expected to be a lifelong process of learning and practice, developed and applied by registrants throughout their careers.

Q3: I can’t find the ICSH and Anti-Racism Standard Core Concepts, nor their Principles in SkilSure when I am working on my CCP. How do I select and report on ICSH and Anti-Racism?

You are correct that the new ICSH Standards are not added directly into the CDBC Standards of Practice. This is similar to the way the CDBC Standards for Record Keeping and Marketing Standards aren’t included in the CDBC Standards of Practice. The ICSH and Anti-Racism Standard and Principles can be mapped to the CDBC Standards of Practice, as seen in Q4. It is these Standards of Practice and their Indicators, that have always formed the basis of the CCP.

Q4. For my CPP planning, I need help connecting the CDBC Standards to the new ICSH and Anti-racism Practice Standard, along with some guiding resources?
CDBC Standards of Practice ICSH & Anti-racism Standard

Example of Resources

(see Q10 below for more)

Standard 12. Quality services centered on client needs Principle 1. Self-reflective practice (it starts with me)

1. TVO – Why Do Indigenous Topics Cause Such Emotional Discomfort?

2. The Six Signature Traits of Inclusive Leadership

Standard 3. Continuing competence

Standard 13. Evidence-informed practice

Principle 2. Building knowledge through education

1. Celebrating Indigenous Peoples in Canada: Learning and Activity Guide

2. Island Health – Indigenous Health Cultural Safety Online Course

Standard 4. Ethical practice

Standard 9. Clear and respectful communication

Principle 3. Anti-racist practice (taking action)

1. The Pass System Documentary

2. Resilience BC Anti-Racism Network

3. Continuum on Becoming an Anti-Racist, Multicultural Institution

4. Toward the Science and Practice of Anti-Racism: Launching a National Campaign Against Racism

 

Standard 9. Clear and respectful communication

Standard 6. Informed consent

Standard 12. Quality services centered on client needs

Principle 4. Creating safe health care experiences

1. Dietitians of Canada Truth and Reconciliation

2. The Six Signature Traits of Inclusive Leadership

3. Nourish – Food Is Our Medicine Online Course

4. Traditional Foods and Indigenous Recipes in B.C.’s Public Institutions

Standard 9. Clear and respectful communication

Standard 12. Quality services centered on client needs

 

Standard 14. Critical thinking in the process of dietetic care

Principle 5. Person-led care (relational care)

1. Toward the Science and Practice of Anti-Racism: Launching a National Campaign Against Racism

2. BC Patient Safety and Quality Council – Cultural Safe Engagement (What Matters to You?)

Standard 9. Clear and respectful communication

Standard 12. Quality services centered on client needs

Principle 6. Strengths-based trauma-informed practice (looking below the surface) 1. CDBC Trauma Informed Practice Q&A
General Resources that encompass all 6 Principles

1. BCCNM Indigenous Cultural Safety, Cultural Humility, and Anti-racism

2. CPSBC Cultural Safety, Cultural Humility, and Anti-Racism Resources

3. Videos to support culturally safe care (developed by BCCNM and CPSBC)

4. Practice Standard Companion Guide (developed by BCCNM and CPSBC)

Q5: I need practical approaches for my learning journey. How do I understand the legacy of residential schools?
Q7: I am finding making a true SMART goal for Cultural Safety, Humility and Anti-Racism very difficult, since it is an interpersonal skill and difficult to measure. Is it ok to describe a learning outcome as a feeling (an increase in comfort, or confidence)?

You are encouraged to develop SMART goals in learning reports whenever feasible. The CDBC recognizes difficulty in developing truly measurable goals in Standards that promote interpersonal skill development, such as cultural safety.

“Measurable” can defined as being able to quantify the desired outcome to allow tracking of your progress in the context of goal setting.

Quantifiability of a goal means that it can be explicitly measured, such as % reduction in a waste audit, an improvement in blood glucose among clients, score on an exam, etc. These can easily be used to demonstrate that a goal has been achieved.

However, in the case of a cultural competence goal, outcome is often measured qualitatively, an outcome that is descriptive and conceptual. Examples of qualitative measures include communicating more effectively, learning to better adapt to change, working collaboratively with a team, etc. With intangible learning outcomes, you may consider tracking your goal internally. Some questions to ask yourself include:

  • Do I feel more comfortable about discussing the topic covered in my learning goal?
  • Have I gained a better understanding?
  • What has completing the learning report help me to achieve?

In both the qualitative and quantitative measures of goal achievement, the learning outcome description of the Professional Development Report (PDR) is very important, especially so in a qualitative goal. Here, you can use the space to truly reflect on how your intangible learning (goal achievement and thus meeting the Standard/Indicator combination) has affected your practice of dietetics in a positive way. These reflections are a powerful way in which to express advancement in professional practice and competency1.

 

1 Koshy et al (2017). International Journal of Surgery. Oncology. Reflective practice in health care and how to reflect effectively. Accessed June 29, 2021.

Q8: Can I get help in formulating a SMART goal with a qualitative measured outcome?

You may find the following framework1-4 helpful when developing goals for interpersonal skills:

Steps Questions to consider What part of the CCP is this?
1.    Provide context

· What does improvement in cultural competence mean to me?

· When and how do I need to practice cultural safety in my professional setting?

· Where am I in my cultural competence journey?

Self Assessment and Learning Goal

· Consider which Standard/Indicator combination best fits your learning needs.

· Start drafting a SMART learning goal in that section of the PDR.

2.    Determine desired outcome

· What aspect of cultural competence am I looking to improve?

· What am I looking to achieve?

· Where can I seek out education opportunities?

· Why is this important?

Portfolio and Learning Activities

· This may be reinforced and reassessed over time as a dietitian undertakes opportunities for learning in the desired area.

· Compile learning activities into a Professional Portfolio and seek additional learning in areas of interest/necessity.

· Record learning activities in that section of the PDR.

3.    Identify outcome measures

· How will I know I have achieved my goal?

· Are these outcomes (quantitative) measurable, or are they qualitative in measure (a change in perception/paradigm, a feeling of confidence/comfort in a new area, or a sense that your role has been positively impactful)?

Learning Goal

· This is where a dietitian reflects on the qualitative outcome of this goal.

· What was achieved?  Is there more learning that needs to be done?

· Finalize the SMART learning goal in that section of the PDR.

4.    Evaluate the outcome measures

· How will I evaluate my success measures?

· Did I learn more about the application of the Standard/Indicator in my practice?

Learning Outcome

· This is the last reflective stage of the PDR where a dietitian identifies how this learning and goal achievement has improved their practice of dietetics.

· Is there an additional goal for the next CCP cycle that could be developed from this learning?

For sample learning plans on cultural competence-based goals, please refer to Question 9.

1CDBC. SMART goal video.

2College of Dietitians of Ontario. SMART goal webinar. https://www.collegeofdietitians.org/resources/quality-assurance/self-directed-learning-tool/sdltool-webinar-smart-goals.aspx, accessed June 30, 2021.

3Eileen Azzara (2016). SMART goal examples for developing leadership competencies. SMART Goal Examples for Developing Leadership Competencies (linkedin.com), accessed June 21, 2021.

4McGill University (n.d.). Smart goals and intrinsic motivation. https://www.mcgill.ca/engineering/files/engineering/smart_goals_and_intrinsic_motivation.pdf; accessed on May 14, 2021.

Q9: Do you have examples of SMART learning goals and learning outcomes specific to Indigenous cultural safety, humility and anti-racism?

We would like to share three sample learning reports related to cultural humility and safety for Indigenous populations. The purpose of the sample learning reports is to clarify how the SMART learning goal model may be adapted for qualitative outcomes for interpersonal skill development and provide inspiration to registrants. You may choose how you would like to develop your learning reports as long as that they comply with the CCP guidelines. To learn about tips on writing SMART goals for interpersonal skills, please refer to Q8.

The learning activities section of the learning reports below has not been included. These opportunities can be specific to geographical region, time of year, and community/workplace engagement and can become easily outdated. For more information and to access examples of resources for your learning needs, please see Q10 below.

Note that the letters S-M-A-R-T have been included so sections of the learning report can be identified.

Example 1 (ICSH and Anti-Racism Standard Core Concept 6, Principle 6.3)

Standard 12: A dietitian provides quality professional services that reflect the unique needs, goals, values, and circumstances of the client.

Indicator 1: Provide quality professional services respecting the client’s ancestry, nationality, ethnic background, religion, age, gender, social and marital status, sexual orientation, political beliefs or physical or mental ability.

Learning Goal: My aim is to improve my cultural competence (R) within this 1-year CCP cycle (T) to ensure inclusion of Indigenous members of my community (A) such that they can receive care that is consistently culturally safe. I would like to feel more confident (M) about plans of care that (1) reflect unique perspectives of this population and (2) address systemic barriers which have often caused poor outcomes in this population (S).

 Learning Activities:

To access examples of resources for your learning needs, please see Q10 below.

 Learning Outcome: My learning this CCP cycle has been tied to an acknowledgement and understanding of the systemic racism that pervades our healthcare system. I was able to work within my interdisciplinary team to plan for improved culturally safe care and to revise (1) our language used in internal policies and on our website, and (2) in my documentation, to avoid colonialist wording and phrasing, providing a more inclusive and welcoming experience for all.

 

Example 2 (ICSH and Anti-Racism Standard Core Concept 4, Principle 4.1)

Standard 4: A dietitian acts ethically in their professional interactions and while providing professional services.

Indicator 3: Demonstrate inclusion, honesty, and fairness.

Learning Goal: This year (T), I would like to learn how to provide meaningful land acknowledgements (S) at the outset of all meetings and webinars/seminars (A) that truly reflect my desire to be an ally and meaningfully contribute to reconciliation by demonstrating gratitude and humility (M) while avoiding the perpetuation of colonization’s damaging effects (R).

Learning Activities:

To access examples of resources for your learning needs, please see Q10 below.

Learning Outcome: I feel I have gained knowledge and understanding that translate well into practical tips on how to approach a land acknowledgement, such that it has maximum impact and sincerity. I gained an appreciation for the need to take time to develop such an acknowledgment, by providing thoughtful and reflective practices to the process, recognizing that it is an important truth and reconciliation action to respect and honour the Indigenous peoples who have been on this land for centuries.

Example 3 (ICSH and Anti-Racism Standard Core Concept 5, Principle 5.4)

Standard 9: Clear, respectful, and culturally sensitive communication.

Indicator 3: Demonstrate cultural competence.

Learning Goal: By mid-way through this CCP cycle (T), I would like to read about sources of power imbalances that exist in healthcare between healthcare practitioners and Indigenous clients in BC (A), and their impact on safe care delivery (S, R) with the aim of being able to name and discuss (M) sources of power imbalances and impact on care of Indigenous clients with my team.

Learning Activities:

To access examples of resources for your learning needs, please see Q10 below

Learning Outcome: Learning about the power imbalances in healthcare and how Indigenous populations are affected allowed me to gain a better understanding of the challenges Indigenous Peoples face. This learning helped me strengthen my understanding of the importance of cultural safety and what it entails in healthcare. Providing a culturally safe environment in a healthcare setting involves integrating cultural humility and competency into practice, and having cultural awareness is not enough. I am now better able to recognize my own privilege and will work on establishing trust and rapport with my Indigenous clients, so this power imbalance is not felt as much. I realize that I am only in the beginning stages of gaining cultural competence, and I am inspired to further improve my cultural competence as an individual and a team member, keeping the “learner” perspective in mind.

Q10: I am interested in learning more about CSH and Indigenous-specific racism. Can you recommend some resources to start with?

The CDBC acknowledges that the following resources are not exhaustive and are provided as a starting point. Registrants may find that this information can be complemented by additional resources on trauma-informed practice and decolonizing the dietetics profession.

General Cultural Safety & Humility Resources:

BC Patient Safety & Quality Council. Cultural Safety & Humility

BCCNM and CPSBC – Practice Standard Companion Guide

BCCNM and CPSBCVideos to support culturally safe care

CDBC – Trauma Informed Practice Q&A

CPSBC – Cultural Safety, Cultural Humility, and Anti-Racism Resources

Dietitians of Canada Truth and Reconciliation

First Nations Health Authority

Len Pierre Consulting – Transformative Territory Acknowledgment Guide

Ministry of Indigenous Relations and Reconciliation – Province of British Columbia (gov.bc.ca)

NCCIH – National Collaborating Centre for Indigenous Health. Resources relevant to the health of Canada’s Indigenous peoples

TVO – Why Do Indigenous Topics Cause Such Emotional Discomfort?

UBC Dietetics Program Decolonizing Dietetics Reading List

 

Nutrition-specific Cultural Safety & Humility Resources:

BC Patient Safety and Quality Council – Sharing Care Concerns: Improving the Patient Feedback Process for Indigenous Patients and Families

BC Patient Safety and Quality Council – Cultural Safe Engagement (What Matters to You?)

CBC – The dark history of Canada’s Food Guide: How experiments on Indigenous children shaped nutrition policy

CBC – Traditional foods give boost to First Nations battling diabetes

CDBC – Indigenous Racism and Colonialism in Dietetics in BC and Canada

Dietitians of Canada – Webinar Truth, reconciliation, and food

Government of BC – Traditional Foods and Indigenous Recipes in B.C.’s Public Institutions

Kelty Eating Disorders Trauma-Informed Nutrition

 

Resources to learn about the Residential School System:

Indian Residential School History & Dialogue Centre

Indian Residential School Survivors Society

Truth and Reconciliation Commission of Canada. Residential Schools of Canada

UBC Indigenous Foundations – The Residential School System

 

Indigenous Anti-Racism Resources:

Continuum on Becoming an Anti-Racist, Multicultural Institution

In Plain Sight Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care

Resilience BC Anti-Racism Network

 

Cultural Safety & Humility Webinars, Videos, & Documentaries:

CBC First Hand: 10 Indigenous Films to Celebrate International Day of the World’s Indigenous Peoples

Circling Together for Wellness: A Virtual Gathering Upholding Indigenous Knowledge

Lament For Confederation by Chief Dan George

National Indigenous Cultural Safety Learning Series. ICS Collaborative – PHSA

The Pass System Documentary

 

Cultural Safety & Humility Courses:

Island Health – Indigenous Health Cultural Safety Online Course

Nourish – Food Is Our Medicine Online Course

San’yas Indigenous Cultural Safety Training

University of Alberta – Indigenous Canada Online Courses

University of British Columbia – Reconciliation Through Indigenous Education

 

Books to Learn More About Cultural Humility & Safety:

Métis Nation British Columbia. 2021. Kaa-wiichitoyaahk: We Take Care of Each Other. Métis Perspectives on Cultural Wellness

Amazon Canada – Highway of Tears

 

For the development of education materials or presentations:

Writing Guide for Indigenous Content – Province of British Columbia (gov.bc.ca)

Terminology in Indigenous content – Province of British Columbia (gov.bc.ca)

Why Aboriginal Engagement isn’t Stakeholder Engagement (ictinc.ca)

Indigenous-Peoples-A-Guide-to-Terminology.pdf (ictinc.ca)

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