Five ways to get a grip on the need to include clinical placements in Indigenous settings.

Educational organizations that train medical professionals are intricately linked to the responsibility of creating culturally safe healthcare providers. However, prevailing inequities contribute to the continued oppression of Indigenous peoples, evidenced by inequitable access, treatment, and outcomes in the healthcare system. Despite an increasing awareness of how colonialist systems and the structures within them can contribute to health disparities, this awareness has not led to drastic improvements of health outcomes for Indigenous peoples. Many recently graduated health professionals will have likely encountered Indigenous peoples as a minority population within the larger, non-Indigenous context. Clinical placements in Indigenous settings may improve recruitment and retention of healthcare professionals in rural and remote settings, while helping educational institutions fulfill their social accountability missions. These placements may aid in the decolonization of care through reductions in bias and racism of medical professionals. Clinical placements in Indigenous settings may better prepare providers to navigate the dynamic challenges of the healthcare needs of Indigenous peoples safely and respectfully.

Introduction

Healthcare systems are responsible for cultivating more equitable and culturally safe environments; hence, the educational programs that shape the professionals that enter these systems are equally accountable. However, cultivating culturally safe providers can be a challenging task. Unlike the evaluation of medical competencies, practices of cultural safety and the somewhat invisible skills required for its effectiveness, are most appropriately assessed by patients.[1] Students graduating from medical school feel they lack the sufficient training and experience it takes to provide individualized, culturally safe care to Indigenous peoples.[2] Current literature supports an array of benefits from educational institutions implementing clinical placements in Indigenous settings. However, limited capacity for students, among other obstacles identified in the literature, continue to impede the organization and implementation of clinical placements in Indigenous settings.[3] Below are some of the common justifications for the lack of clinical placements, with accompanying responses on how we might perceive this challenge differently to advocate for these placements.

1. Coordination and convenience of rural placements

Clinical placements can require great organizational work, even more so in rural or remote areas. Chief components of facilitating clinical placements in Indigenous settings include emphasis on relationships and the ability to coordinate and adapt as needed.[4] Challenges do exist in recruitment and retention of healthcare students and providers in rural and remote areas. However, the challenge of arranging Indigenous placements for healthcare students is not a sufficient reason to cease efforts in creating these relationships or researching their benefits.[5] In previous studies, dental hygiene students perceived barriers to rural practice included being far removed from their home support and social systems, and preconceived notions about rural care.[6] Through their clinical placements, students uncovered their beliefs about these placements not being worthwhile were wrong.[6] Placements in Indigenous settings could allow students to be evaluated by Indigenous peoples and work to establish a true absence of racism in their clinical practice.[2] Studies have found a strong link between rural exposure in clinical placements and rural medical practice.[7] This could promote retention of healthcare providers in Indigenous communities and provide opportunities for growth in cultural awareness and safety.[8] These placements may allow students an opportunity to overcome their fear of offending Indigenous members by having the focus be centered around learning.[5] Additionally, these placements could create an authentic space for students to apply what they are learning[1] and improve the quality of the care Indigenous peoples receive. Current literature reveals the incorporation of Indigenous Elders as a component of primary care has demonstrated statistically significant reductions in suicidality, depression, and emergency department utilization by Indigenous patients.[9] These placements could help foster trust and relationship between Western educational institutions and Indigenous communities. In turn, this may reduce Indigenous peoples’ fear of accessing healthcare from Western organizations and professionals and decrease the likelihood of Indigenous people being retraumatized during their healthcare experience.[10]

2. Medical professionals working in Indigenous spaces

Challenges with recruitment and retention of healthcare professionals in Indigenous contexts has been suggested to be somewhat educationally derived, resulting from inadequately preparing health professional students to practice in Indigenous communities.[1][1] It has been argued the lack of health professionals working in Indigenous communities is, in part, due to the lack of opportunity for students to partner with Indigenous peoples during their clinical placements.[1][2] Canada’s Truth and Reconciliation Commission (TRC) Calls to Action includes No. 23, which “calls upon all levels of government to increase the number of Aboriginal professionals working in the health-care field, ensure the retention of Aboriginal health-care providers in Aboriginal communities and provide cultural competency training for all health-care professionals.”[1][3] Being in the physical presence of local members of the Indigenous community can provide a unique learning experience that could enable students to foster the skills required to work in a rural or remote environment and continue to apply those skills in the future, outside of the clinical context in front of them.[1][4] The development of desired characteristics like respectful and appropriate communication, culturally appropriate knowledge, and a positive attitude towards engaging with Indigenous people have been achieved through Indigenous clinical placements.[1][5] Providing the opportunity and targeting students that are interested in Indigenous health may help cultivate interest in pursuing careers in Indigenous settings.[3] This may provide more opportunity for student placement in the future, as challenges still exist in recruitment and retention of healthcare providers in rural and remote areas. However, it is plausible that those interested in Indigenous placements or culture, are the student practitioners that require it the least. Arguably, students with zero interest in Indigenous placement, or learning about culturally safe care are potentially a greater risk to Indigenous patients in their future practice. In either case, Indigenous placements may help uncover gaps in students’ culturally safe practices, which could aid in the development of educational strategies to combat them.[8]

3. Bridging clinical with the classroom

Designing for educational continuity can be challenging given its multifaceted nature.[1][6] Some essential elements for this involve the continuity of care, continuity of curriculum and continuity of supervision.[1][6] Unsurprisingly, within the classroom setting, educators often feel they have insufficient training to teach about Indigenous health.[17] Systemic barriers that act in and on educational institutions can restrict the development of comprehensive Indigenous health curricula.[18] Critics of the cultural competency model in medical education advocate for education above and beyond the beliefs that strictly learning about culture will foster competency, and that understanding culture will result in improved patient outcomes.[1][9] Predictably, most recently graduated health professionals will have likely encountered Indigenous peoples as a minority population within the larger, non-Indigenous context.[1][7] It has been argued how structural barriers that exist within traditional teaching modalities can impede the inclusion of genuine Indigenous clinical scenarios.[1] Evidence to demonstrate that we are sufficiently preparing learners to work with culturally safe practices with and in Indigenous communities is lacking.[1][7] Clinical placements in Indigenous settings can allow for cultural competency training in spaces that permit vulnerability and disclosure of cultural prejudice for the sake of learning and ultimately the reduction of cultural bias.[20] Students that have engaged in Indigenous clinical placements have been shown to gain detailed insights relevant to cultural competency and their training. These included deepened awareness of individual bias, increased awareness of everyday racism, and an enhanced understanding of health inequities related to Indigenous social determinants of health.[2][1]

Clinical placements in Indigenous settings may allow students to view culture in a way that transcends the classroom definition. Two-Eyed Seeing is a potential approach to consider for utilization in the classroom and in clinical placements. This perspective sees, values, and integrates the strengths of the Indigenous and Western worldviews equally.[2][2] Working immersed in Indigenous cultures may allow students to become more aware of the amassing impacts of colonization and intergenerational trauma.[5] Clinical placements in Indigenous settings can invite healthcare professionals to decolonize their care through reflection of how racism and discrimination permeate much of healthcare practice.[10] Individuals and the organizations in which they operate developing this awareness is crucial part of achieving culturally safe healthcare providers.

4.Bridging contrasting cultures

Our healthcare systems and biomedical perspectives are still largely founded in colonialist structures.[2][3] As a result, a significant barrier to the integration of Indigenous traditional medicine and Western biomedical practices include the incontrovertible differences in belief systems and approaches to health and wellbeing.[2][4] Particularly evident in Western Canada, our norms can sometimes dominate, and even undermine other minority cultures and their traditions.[20] When educating students about the many different cultural minorities, some medical institutions use the standard cultural competency model. In medical education, the utilization of this traditional approach to culture has been criticized. It has even been argued that the use of the phrase “cultural competency” may contribute to or worsen health disparity by magnifying a colonial gaze and upholding a power differential.[1][9] When cultural safety is conceptualized as “one-size-fits-all” it can overlook cultural strengths and diversity and perpetuate harmful stereotypes.[2][5] This practice contributes to health professionals feeling ambiguous about the true meaning of cultural safety.[1][7] Approaching culture this way may lack the comprehensive nature that is required to educate medical students about the powers that influence health disparities, or the skills required to combat them in practice.[2][6] While many factors impact health, the majority of these exist largely outside of the healthcare context.[2][7] As such, healthcare providers in Canada have been called to better their understanding and practices of providing culturally safe care to Indigenous peoples.[1][3] Although limited literature exists exploring the benefits of healthcare students in Indigenous clinical settings, Indigenous placements can offer students the opportunity to acknowledge that change is needed and possible, through authentic efforts of all participating stakeholders.[5] Despite evident obstacles, continued attempts to integrate Western and Indigenous medicinal approaches in Indigenous settings could help foster therapeutic relationships.[2][4] These placements could provide healthcare professionals an opportunity to move beyond a basic knowledge of Indigenous culture towards preparedness to navigate the dynamic challenges of the healthcare needs of Indigenous peoples safely and respectfully.[1][7]

5. Making this a priority

Health education institutions and individuals require training surrounding Indigenous culture in pursuit of acknowledging how culture influences the roles of health professionals and the patients they treat.[20] Some Indigenous health education practices still utilize a deficit approach that focuses on cross-cultural awareness, and the historical and social determinants of Indigenous health, rather than promoting positive interactions with Indigenous patients and communities.[1][5] Health professionals can cause Indigenous peoples to feel stigmatized when employing care that is deficit-based.[28] Some of the most valuable and culturally enriched learning occurs outside of the classroom setting[29] and these clinical placements may aid in creating environments more conducive to learning interprofessional collaboration.[30] When medical education programs actively partner with Indigenous settings for clinical placements, students are given valuable opportunities to grow in their culturally safe practices. For example, some leaders of Indigenous communities encourage working towards cultural humility over competency, as it is likely more pragmatic and attainable.[29] Cultural humility involves ongoing reflection and critique of individual biases and perceptions.[3][1] Placements in Indigenous settings could provide students with a deeper understanding of Indigenous values and beliefs, as well their own attitudes and orientation towards cultures outside their own.[5]

Conclusion

Systemic racism saturates many colonized countries, particularly within the healthcare system and inequities are evident in disease prevention, healthcare access, and treatment of Indigenous peoples.[5] Culturally irrelevant care can allow for oppression of Indigenous peoples that result in these severe health inequities.[3][2] Studies have demonstrated that students graduating from medical school feel they lack the sufficient training and experience it takes to provide individualized, culturally safe care to Indigenous peoples.[2] The education of health professionals can become a vector for imperialism, and continued oppression, when it fails to integrate the cultural beliefs and practices of the populations it is designed to serve.[17] Clinical placements in Indigenous settings allow students to uncover and acknowledge cultural differences and employ cultural humility. Through clinical placements students can gain experiential learning that combats racist perceptions and allows them to cultivate legitimate culturally safe practices.