Indigenous Cultural Safety, Health Equity, & Anti-Discrimination Guide

"Looking Forward" is a piece that showcases important elements within Indigenous culture. These elements help highlight the College of Physiotherapists of Alberta looking into the future as equal partners with Indigenous people. In taking the time to understand the culture and walking hand in hand through the healing journey.

The main focal point is the Jingle Dress dancer wrapped in a blanket. The Jingle Dress dance is a healing dance amongst Indigenous peoples and represents the path one takes to heal from ailments or disease.

The blanket represents safety and warmth but more importantly, it represents Indigenous people taking back that culture that was lost or outlawed during residential schools.

The Tipi's represent the home. The place where we feel the most safe and a place where family can come together.

The Grandmothers and Grandfathers (Aurora Borealis), to Indigenous people the northern lights are actually our past ancestors still watching over us and dancing in the sky.

The final element of the piece is the way I made it look like it was going forward. From here, Indigenous people and any form of health care need to walk together "Looking Forward."

Scott Laboucan.

The terms cultural competence, cultural safety, and cultural humility have been used in relation to health service delivery for several years and are often used interchangeably. What do they mean?

What is health equity?

How can a physiotherapist embody anti-discrimination in their practice?

Why are cultural safety and health equity important?

Why is the College focused on this? Are these simply the latest buzz words or does the terminology signify a meaningful change in how health services are delivered? Why is it now time to act?

The purpose of this document is to address these questions and serve as a guide for the next steps in this journey.

Indigenous Cultural Safety & Humility

The College of Physiotherapists of Alberta acknowledges the distinct history and the unique relations between Indigenous Peoples and federal and provincial governments, established through Treaty and enshrined in the Canadian Constitution Act (1982).

Research has demonstrated that many Indigenous clients do not receive the care they deserve. Care that respects their identities and acknowledges the enduring harms of colonialism, Indian hospitals, the residential school system, and intergenerational trauma. Care that addresses existing health disparities and adverse health-system experiences.

Throughout this guidance document, we will share our learnings from sharing circles held on Treaty 6, 7, and 8 lands within Alberta in the spring of 2024 with Indigenous community members and physiotherapists, so that the lessons generously shared by participants can achieve greater effect on the physiotherapy community as a whole.

Health Equity and Anti-Discrimination

The College recognizes that none of us inhabits a single social identity. Some Indigenous clients experience discrimination and harm when accessing health services due to their other identities and the intersections between those identities.

In addition, the College recognizes that many non-Indigenous Canadians experience discrimination and harm when accessing health services due to their identities, culture, or individual characteristics, and the unique intersections between these factors.

The College’s recent focus on cultural sensitivity, cultural humility, cultural safety, and anti-discrimination in practice is a progression from longstanding professional expectations regarding client-centred care.

For decades the College has had client-centred care principles embedded in the Standards of Practice and Code of Ethical Conduct. These expectations have been grounded in key attitudes and behaviours that will be familiar to all registrants:

• Pay attention to the person in front of you.
• Treat them with respect.
• Value what they have to say.
• Understand what matters to them.
• Centre their needs, values, priorities, and objectives in the actions you take.
• Act with humility.
• Do not impose your will, values, needs, priorities, or what you think the client “ought to do” onto the person in front of you.

The College of Physiotherapists of Alberta was not the first organization to adopt or promote these ideas. The Canadian physiotherapy profession adopted client-centred care like all other health professions, and the principles have worked well to guide the actions of health professionals - up to a point. However, there is clear evidence that Indigenous people and members of historically marginalized communities and groups are consistently provided with care that is not client-centred. Countless research studies, reports, inquests, and public documents demonstrate the existence of health disparities and inequitable health outcomes among Indigenous people and communities, and among members of historically marginalized non-Indigenous communities and groups.

The In Plain Sight Report⁵ is a foundational document reporting on the investigation into the prevalence and nature of anti-Indigenous discrimination in the healthcare system in British Columbia. The report provides a thorough and startling account of the widespread experience of anti-Indigenous discrimination at the point of care. This discrimination negatively affects access to care, at times with disastrous results.

Non-Indigenous Canadians can experience discrimination due to their identity, culture, and individual characteristics. Comparable research into inequitable health outcomes of members of historically marginalized communities and groups exists. However, the In Plain Sight Report stands out due to its scope and scale, focusing specifically on discrimination towards Indigenous people and the resulting inequitable health outcomes experienced by Indigenous individuals and communities. Research demonstrates that the anti-Indigenous discrimination documented in the In Plain Sight Report is not limited to the British Columbia health system. For example, research into the triage practices in Alberta emergency rooms in 2022 revealed discriminatory practices towards Indigenous people seeking emergency care and inequitable outcomes between Indigenous and non-Indigenous individuals.⁶

Joyce Echaquan and Brian Sinclair come to mind as tangible examples of people who were not provided with client-centred care and who suffered severely as a result. The video posted by Joyce Echaquan shortly before her death makes the racism described in research clearly visible. Although these are two well-known, disturbing examples, the research demonstrates that their experiences of harm are not unique.

The report, research, and personal accounts provide compelling evidence that while health professionals may think we provide empathetic, client-centred care to all clients, Indigenous and non-Indigenous, that is not consistently what our clients experience.

Some readers may ask why we need to take specific action? Shouldn’t we treat all clients with empathy and respect? Why isn’t empathy enough to address these problems?

The answer is, “of course we should treat all clients with empathy and respect”. However, a universal approach to treating all clients with empathy and respect has been proven to be insufficient. Such an approach also ignores the client on the receiving end of physiotherapy services and the experiences they bring with them.

Research related to nursing practice when working with historically marginalized community members indicates that when a client has been subjected to bias, stigma, or discrimination during past health care interactions there is a power differential between the client and their current health care provider and the client may experience anticipatory distress, reducing the “therapeutic potential” of the clinical interaction.

Empathy alone therefore does not suffice to ensure trust and effective communication between nurse [physiotherapist] and patient when the latter is of a vulnerableª group.³

This finding was borne out in the comments made by participants in the sharing circles. Participants repeatedly highlighted that their past experiences of negative interactions had a significant effect on their sense of trust in the system and willingness or ability to seek care. Participants highlighted the way this mistrust represented a real and tangible barrier to access. One sharing circle participant powerfully reminded those present that “an Indigenous person has never had a day of comfort or feeling of safety and security within the health system.”

Although this is a strong statement from one sharing circle participant and may not reflect the experiences of every Indigenous person accessing healthcare in Alberta, research into the experiences of First Nations people when seeking emergency care supports the pervasiveness of the experience of unsafety. The research highlighted the experience of discrimination and anti-Indigenous racism within the health system, including how this relates to care disruptions, delays, and overall perceptions of safety. As stated by the authors “First Nations members have described how they cannot generally know whether a negative experience in the emergency department (such as a long wait) is related to racism or not, but that racism is always a stress-inducing possibility.”⁷

^{a. Since this reference was published in 2021, the term “vulnerable group” has been called into question, with many sources shifting away from the term. This quotation was used here due to its power, but we wish to highlight for readers the change in accepted terminology and fluidity of language.}

Health profession regulators exist to protect the public from unskilled practice by their registrants and to ensure that the public receives safe, high-quality, and effective health services. “The public” can be a vague and ill-defined concept. Who is the public? Which communities are included? What assumptions are made about the beliefs, values, and needs of “the public”? In fact, regulators have multiple “publics” to consider, including groups for whom stated performance expectations related to client-centred care have fallen short. This includes Indigenous Peoples and members of historically marginalized communities and groups.

When physiotherapy services are marked by discrimination and inequity, they are not safe, high quality, or effective.

When the actions or inactions of a regulated health professional consistently result in adverse or sub-standard outcomes for their clients, the health professional’s practice could justifiably be called into question, could be subject to regulatory review, and could be considered unskilled practice. The same can be said when the actions of a group of regulated health professionals consistently result in sub-standard outcomes or harm to clients belonging to identifiable communities or cultural groups.

At the sharing circles, Indigenous clients told us of their experiences of both blatant and subtle discrimination when receiving health services, reinforcing the message found in research and key documents. Each day, physiotherapists work with Indigenous clients and with members of other historically marginalized communities and groups. It is this diverse public which is demanding that the status quo be upended, and that client-centred, culturally safe care be delivered to all clients, by clinicians who demonstrate respect and cultural humility.

Setting Expectations for Physiotherapy Practice

It is the business of regulators to establish a code of ethical conduct and standards of practice for their registrants, communicate about and facilitate registrant understanding of their professional expectations, and address matters of unskilled practice.

Existing standards of practice, codes of ethical conduct and the competency profile for physiotherapists in Canada all include expectations related to the importance of non-discriminatory actions, beneficence, client-centredness, and respect. However, given the consistent and reproducible inequitable health outcomes and harms experienced by Indigenous people and members of historically marginalized communities and groups, regulators have cause for concern that past guidance and the direction to treat all clients in a respectful, client-centred manner is inadequate.

Rather than continuing to speak generally about the principles of client-centred care such as valuing the client’s perspective and treating people with respect, the College’s perspective is that the time has come to recognize that some clients experience discrimination and inequity in Canadian health care settings, including physiotherapy practice settings.

Actions to address this reality must begin by first acknowledging that Indigenous people and members of historically marginalized communities and groups consistently do not receive client-centred care, despite the long-standing requirements of the Code of Ethical Conduct and Client-Centred Care Standards of Practice.

The College is working towards meaningful change by raising registrant awareness of these issues, generating resources, and employing other regulatory tools. Upending the status quo of health inequity will also require action by physiotherapists. It begins with developing self-awareness and knowledge. Physiotherapists need to invest time and energy towards enhancing the care that they provide by engaging in the work of self-reflection, learning and unlearning, and relationship building.

This section provides a starting point for action, however the appropriate next steps for each physiotherapist will depend upon the actions they have already taken. We begin with a review of general actions before addressing Indigenous-specific resources and actions.

Working with all Equity Seeking Clients

Reflective Practice

A physiotherapist should take the time to engage in self-reflection and develop self-awareness.

• Reflecting on their own identity, privileges, and biases.
• Reflecting on the stereotypes or assumptions they may hold about people who have other backgrounds and different lived experiences.
• Who were the physiotherapist’s ancestors and how were their ancestors’ lives impacted by major world events?
• What are some values and beliefs that are shared among family, friends, and the communities the physiotherapist belongs to?
• How does the physiotherapist’s culture and community membership affect the choices they make or the events in their life?
• How has the physiotherapist’s upbringing, formal and informal education, and socialization informed their attitudes and beliefs about people from backgrounds that differ from their own?
• Recognizing that all people inhabit more than one social identity and are more than their ancestry or culture, people can be at once privileged in some of their identities and disadvantaged in others. What privilege or power does the physiotherapist hold and how does that impact upon the physiotherapist’s daily life and interactions with others?

Education

There are three main areas of education for physiotherapists to pursue:

• Anti-discrimination,
• Cultures, communities, and lived experiences that differ from their own,
• Trauma and trauma-informed practice.

Physiotherapist must develop their knowledge and understanding of concepts related to anti-discrimination, such as:

• privilege, discrimination, and systems of oppression,
• social determinants of health,
• cultural safety and humility, and
• social justice.

Physiotherapists must take time to learn about people from cultures, communities, and lived experiences that differ from the physiotherapist’s own, paying particular attention to the communities that they provide physiotherapy services to. Learn about belief systems, ways of knowing, norms, and values common among members of a community.

Learning about different cultures and communities can take many forms:

• developing reciprocal relationships with community members and taking the time to listen to and learn from them, their stories, and their lived experiences.
• attending community events and festivals
• reading or viewing documentaries or other programming from credible sources which discuss aspects of a culture or community, historic events from the perspective of a person from another culture, or the lived experiences of members of communities other than the physiotherapist’s own.
• traveling and experiencing cultures firsthand (recognizing that cost can be a barrier).
• completing online courses to learn more about a community or cultural group, such as these ones from the University of Alberta and the Government of Canada.

When learning about communities and cultural groups, physiotherapists seek to understand the perspective of a culture or community in a broad sense while remaining aware that each individual community member’s experience will reflect and be informed by the totality of their intersecting identities.3 Physiotherapists must be cautious to avoid perpetuating the assumption that there is a core set of static beliefs and values that are shared by all members of a community or cultural group or reinforcing stereotypes about the community or group in question.³

Having awareness of a community or cultural group’s history, belief systems and ways of knowing provides valuable background information but does not replace knowledge of the individual community member’s lived experiences, beliefs, and values.

Finally, physiotherapists need to develop their knowledge and skills related to trauma-informed practice, including:

• different sources of trauma,
• how trauma and adverse childhood experiences affect health outcomes,
• how a history of trauma may manifest in their client’s symptoms, and
• how to employ sensitive practice as a universal precaution and develop culturally safe, trauma-informed services, practice settings, and therapeutic relationships.

If a physiotherapist finds they are unsure about a client’s identity or have unanswered questions about a community or cultural group’s traditions and norms, there are many ways to find reliable information. Depending on the subject one could find answers online from reputable sources or from members of the client’s community. In some cases, it might be best to be honest and ask the client if there is something that they need from the physiotherapist to feel safe and respected when receiving care.

Some clients may be happy to take the time to educate the physiotherapist about their culture and beliefs and respect the fact that the physiotherapist took the time to ask them. However, it is also important to consider that some clients experience these questions as a burden. A physiotherapist should be careful about how they approach asking questions, be sensitive to the client’s needs and reactions (for example if they appear reluctant or uncomfortable during a discussion) and reflect on whether the physiotherapist needs the information to be able to provide culturally safe and appropriate care or if they are satisfying their curiosity. Conversations should be genuine and should employ communication best practices to create a safe space for the client to receive care.

Additional resources related to bias, privilege, and intersectionality can be found here.

A webinar about trauma-informed physiotherapy practice can be found here.

Relationship

Developing relationships includes developing relationships with the community at large, the individual client, and their family or support persons.

At the community level, developing relationships can be essential to the ability to deliver care to individuals within a given community. Physiotherapists should be aware of the different communities that compose the population that they serve. What communities or cultural groups are present? Has the physiotherapist ‘shown up’ to community events to meet with community members and leaders and to develop their awareness of the community’s customs and practices? Is the physiotherapist aware of significant religious, cultural or community events? How does the physiotherapist demonstrate their awareness through their actions?

Being open to new experiences and purposefully seeking out events and conversations with people from different communities, cultures, and lived experiences from one’s own can be rewarding and can increase cultural awareness. Volunteering with community organizations can be a way to learn about others and a way to give back to the community.

When it comes to developing therapeutic relationships with individual clients, the physiotherapist must inquire respectfully about the individual, their lived experiences, and reasons for seeking care. The physiotherapist must avoid making assumptions about the client based on the physiotherapist’s normative beliefs or the client’s visually identifiable characteristics. Making assumptions can lead to miscommunication, mistrust, and can adversely affect the therapeutic relationship.

With regards to the client’s support persons, physiotherapists must understand that although informed consent must be received from the client, concepts of family and the role of family or respected community members in health care decisions can differ based on the culture or community in question. Physiotherapists must not impose their own beliefs about the role of family and community members in health decisions onto others.

Reflective Practice

A physiotherapist should take the time to engage in self-reflection and develop self-awareness by reflecting on the stereotypes or assumptions they may hold about Indigenous people.

During the sharing circles, Indigenous participants highlighted common prejudices they face related to alcohol and drug use. They discussed how biases about drug use, prejudice about Indigenous people seeking medications, and inaccurate beliefs about Indigenous clients’ pain tolerance all contributed to negative health care experiences of those present. Participants also highlighted how biases about Indigenous women had led to direct and blatantly sexist and racist comments towards them.

Education

Physiotherapists must take time to learn about

• The history of colonialism and enduring effects of:

- Residential school system.

- Indian hospitals.

- The 60’s Scoop and ongoing concerns related to the child welfare system.

- The Indian Act.

- The intergenerational trauma resulting from colonialism.

• Indigenous worldview and health and wellness beliefs and practices

- Interconnectedness of physical, mental, emotional, and spiritual health and
the need for balance in all four areas (sometimes referred to as the medicine
wheel).

- Smudging (the purpose of smudging, and a basic understanding of what is
involved).

• Cultural beliefs and practices which can be understood by:

- attending community events and festivals.

- participating in discussions or sharing circles.

- completing online courses to learn more about a community or cultural
group, such as this one from the University of Alberta.

When learning about Indigenous Peoples, physiotherapists need to be thoughtful about their approach. In some instances, learning can occur at the pan-Indigenous level, for example when seeking to understand intergenerational trauma and the lasting effects of Residential Schools, Indian Hospitals and the 60’s scoop. However, physiotherapists should also seek out learning specific to the distinct First Nation, Inuit, or Metis communities that they serve. Indigenous people do not all share the same language, culture, customs, practices, and beliefs.

Physiotherapists must have both general knowledge and knowledge that is as specific to their context and population served as possible.

Again, physiotherapists must be aware that each individual community member’s experience will reflect and be informed by the totality of their experiences and intersecting identities. Sharing circle participants cautioned that having an identifier, such as being “status” or being a recognized member of a community, does not necessarily mean that an individual is connected to culture. Physiotherapist participants were cautioned to avoid assuming that because someone is old, they are connected to culture. Some older Indigenous clients are not connected to culture, and some members of younger generations are actively reclaiming their culture.

Relationship

Developing relationships includes developing relationships with the community at large, the individual client, and their family or support persons.

Developing relationships with Indigenous people and communities takes time.

Sharing circle participants highlighted the importance of reciprocity in Indigenous culture and when engaging with Indigenous clients. This begins with how the physiotherapist introduces themselves and asks questions of the Indigenous client. When introducing themselves, sharing circle participants encouraged physiotherapists to tell their clients a little bit about themselves:

• Who are you?

- Your name.

- Where you are from.

- Who your family is.

- How you came to be on this land.

- What is your connection to this land?

This approach reflects the way that Indigenous people traditionally introduce themselves, as was evident in the sharing circles. It is up to the physiotherapist to determine how much personal information they wish to share with their clients, however, this type of intentional disclosure, designed to build connection and relationship with the Indigenous client, falls well within the parameters set by the College regarding the maintenance of professional boundaries.

It is also essential to disclose both your name and your professional designation to Indigenous clients. During the sharing circles, participants provided examples of situations where that did not occur, with negative effects on the therapeutic relationship and client trust. With regards to the client’s support persons, although consent must be obtained from the client, physiotherapists must understand that for Indigenous people, concepts of family and the role of different family members and respected community members in health care decision-making can differ significantly from Eurocentric attitudes and approaches. Generally, Indigenous people’s concept of family is much broader than the nuclear family recognized by European settlers.

At the community level, physiotherapists need to take the time learn from Elders and Indigenous community members, by listening to their stories and lived experiences. Developing relationships with community leaders and Elders can be essential to the ability to deliver care to individuals within a given community. Has the physiotherapist sought to develop relationships by requesting meetings with Indigenous leaders or asking for assistance from Elders and Knowledge Keepers? Has the physiotherapist followed appropriate protocol when seeking assistance?

"The System"

One of the recurring themes that was identified through the sharing circles was that of the system and the barriers that exist in the health system which can negatively affect the delivery of culturally sensitive and safe care to Indigenous clients. Examples and suggestions brought forward by sharing circle participants included:

• Physical space design and considerations

- Do not block the door to the treatment room.

- Are there designated spaces where an Indigenous client can smudge before treatment?

- How do you make those spaces available and communicate their availability to your clients?

• Policies re: family members accompanying clients

- Are family members allowed to accompany clients? How many family members are permitted into the treatment area?

- How can space use and client bookings be adjusted so that the client can bring the family members they need with them to feel safe and comfortable in the physiotherapy environment.

• Communication needs and appointment time allocations

- More time may be needed to build trust and allow the client to tell their story.

- Indigenous clients may have health literacy gaps related to intergenerational trauma and family disruption.

- Physiotherapists need to take extra time and care in explaining what they are doing and why.

- Physiotherapists may wish to consider adjusting existing appointment time blocks and booking practices when working with Indigenous clients to enable this communication.

• Cancellation fees

- Sharing circle participants highlighted the many barriers they faced to being able to attend a physiotherapy appointment as scheduled, including transportation and family care responsibilities, which can differ from those encountered by non-Indigenous clients.

- Participants highlighted the additional burden that cancellation and late fees add to clients who are already faced with barriers and inequitable socio-economic status, and how these fees affect access to care.

- Sharing circle participants suggested developing ‘drop-in’ appointment times or waiving late fees as potential ways to address this issue.

Developing equity, cultural sensitivity, and cultural humility is an ongoing process. Regardless of their starting point, physiotherapists are encouraged to continue their learning journeys according to their prior learning and learning needs.

Having a practice that is culturally safe and equitable means that a physiotherapist accepts the notion of cultural humility and is willing to continue to learn about people and how their practice intersects with a person’s culture and lived experiences.

Ultimately, the physiotherapist’s willingness to continue to learn creates positive therapeutic relationships and a culturally safe environment for the client.

Why now?

Some registrants may ask why the College is focused on Indigenous cultural safety and anti-discrimination now. The answer is that discrimination and related health inequities have gone on for far too long. Too many people have experienced harm and suffering due to bias and discriminatory policies and practices in the health system. As awareness grows, there are increasing demands for action.

Faced with the evidence and calls for change, the College is employing the regulatory tools available to contribute to efforts to address discrimination and rectify inequitable health outcomes.

It has been said that Indigenous Peoples plan their actions with the next 7-generations in mind. The College is not accustomed to thinking in a 7-generation mindset, however, we know that improvement will take concerted effort and above all things, time.

There is much to be done to build the collective knowledge and skills of the physiotherapy profession, including that of physiotherapy regulators. During a recent conversation with Indigenous community members, the College heard very clearly that “not asking, or not even trying is a bigger insult than making a mistake or doing things ‘wrong’.” We were advised to be humble and vulnerable and to risk making an error, rather than using fear of making a mistake as an excuse for inaction. We are embracing risk-taking, and a ‘learn as we lead’ mentality as we undertake a journey to advance anti-discrimination, health equity, and Indigenous cultural safety in physiotherapy care. We invite all physiotherapists to do the same.

The time to move is now. 

This section highlights key terminology used in this document. Some terms, such as cultural sensitivity, cultural competence, and cultural humility are often used together and sometimes used interchangeably or imprecisely by physiotherapists and other health care professionals. Other terms, such as health equity and anti-discrimination may or may not be familiar to physiotherapists.

Anti-discrimination is a mindset based on conscious efforts and actions to provide equitable opportunities for all people on an individual and systemic level. It is also a form of action against discrimination, and the systemic racism towards and oppression of historically marginalized communities and groups.¹

Cultural competence, cultural sensitivity, and cultural humility are terms that are often used together and sometimes used interchangeably.

Cultural competence is an older term, often used in discussions about treating clients from diverse backgrounds. However, cultures are ever-shifting, and many people argue that to be truly ‘competent’ in a culture, one must be a member of that culture. Beyond that, the individuals who identify as members of a culture or community are still individuals with a range of identities, characteristics, and lived experiences that the physiotherapist must also attend to,² meaning that each person’s experience and embodiment of culture will differ.

Recently the term, and the idea of being ‘culturally competent’ has been questioned as it can imply that a person has achieved an end state; the “competent” person who has checked a box and has nothing further to learn or understand about a culture or community.

While a physiotherapist may attain competence in the performance of a physiotherapy technique, it is doubtful that they can truly become “competent” in another person’s culture.

For these reasons, the College avoids the term “cultural competence.”

This is different from someone having the competencies to work with clients from backgrounds that differ from the physiotherapist’s own. These competencies can include communication, sensitive practice, and trauma-informed practice skills; awareness of cultural practices of different communities and groups; and attitudes of respect and humility.

Cultural sensitivity is the physiotherapist’s ability to recognize and be responsive to the client’s attitudes, feelings, or circumstances arising from their identity, individual characteristics, and lived experiences. Being culturally sensitive involves setting aside the physiotherapist’s own beliefs and assumptions about what is “normal” and the presumption that the client’s identity, lived experiences, values and beliefs align with the physiotherapist’s own normative beliefs.²

Being culturally sensitive also implies that the physiotherapist recognizes that social determinants of health and the failure of health care providers to be culturally sensitive can lead to health inequities including, higher rates of illness, lower rates of health care access, and negative health outcomes for clients.3 Culturally sensitive providers acknowledge these inequities and accurately identify the systemic factors that result in the observed outcomes.

Cultural humility is an attitude of self-reflection and self-awareness of one’s own culture, characteristics, and inherent biases paired with a lifelong commitment and willingness to invest the time and energy to learn from clients about their culture and lived experiences, respecting the client’s own expertise when it comes to “the social and cultural context of their lives”.^2,3

While cultural competence implies a finite endpoint, cultural humility refers to a continuous approach to learning and self-reflection that leads to person-centred physiotherapy care.²

Cultural safety is a hallmark of a positive therapeutic relationship. When cultural humility and cultural sensitivity are evident within a therapeutic relationship, the result is culturally safe care. It is the combination of respectful inquiry about the client’s lived experiences, values and perspectives and application of that knowledge into practice that results in care that matches the client’s values, culture, and beliefs and creates culturally safe care.³ A physiotherapist who has increased cultural sensitivity and humility will be at a lower risk for actions that may be harmful or perceived as inappropriate or unsafe by the client or the client’s family, and be better prepared to correct their actions or address their mistakes when they occur.

While striving to deliver culturally safe care, physiotherapists must understand that it is the client who determines if the care they received was culturally safe and if they can trust the physiotherapist and the practice setting.

Health equity “means that all people have fair access to, and can act on, opportunities to reach their full health potential and are not disadvantaged by social, economic and environmental conditions, including socially constructed factors such as race, gender, sexuality, religion and social status. Achieving health equity requires acknowledging that some people have unequal starting places, and different strategies and resources are needed to correct the imbalance and make health possible. Health equity is achieved when disparities in health status between groups due to social and structural factors are reduced or eliminated.”⁴

Indigenous Peoples is the term used to refer to all Inuit, and First Nations and Metis Peoples. An approach or initiative is considered pan-Indigenous when it groups together and generalizes the experiences of members of all three groups, thereby obscuring the important distinctions that can exist between the three groups in relation to history, culture, language, specific rights, priorities and interests. A distinctions-based approach is generally preferred. This approach acknowledges and respects the unique cultures, histories, rights, laws, and governments of each group.

1. College of Physiotherapists of Alberta. Draft Standards of Practice
2. Lekas HM, Pahl K, Fuller Lewis C. Rethinking Cultural Competence: Shifting to Cultural Humility. Health Services Insights 2020; 13:1-4.
3. Burton CW, Nolasco K, Holmes D. Queering Nursing Curricula: Understanding and Increasing Attention to LGBTQIA+ Health Needs. Journal of Professional Nursing 2021; 37:101-107
4. National Collaborating Centre for Determinants of Health. Glossary. Available at https://nccdh.ca/learn/glossary/ Accessed February 23, 2024.
5. Turpel-Lafond M.E. In Plain Sight: Addressing Indigenous-specific Racism and Discrimination in B.C Health Care. Addressing Racism Review Data Report, British Columbia. Available at https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Full-Report-2020.pdf Accessed January 19, 2024.
6. McLane P, Barnabe C, Mackey L, Rittenbach K, Holroyd B, Bird A, Healy B, Janvier K, Louis E, Rosychuk R. First Nations Status and Emergency Department Triage Scores in Alberta: A Retrospective Cohort Study. CMAJ 2022 January 17;194:E37-45.
7. McLane P, Bill L, Healy B, Barnabe C, Big Plume T, Bird A, Colquhoun A, Holroyd BR, Janvier K, Louis E, Rittenbach K, Curtin KD, Fitzpatrick KM, Mackey L, MacLean D, Rosychuk RJ. Leaving Emergency Departments Without Completing Treatment Among First Nations and Non-First Nations Patients in Alberta: A Mixed Methods Study. CMAJ 2024 April 22;196:E510-23.