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Empathy, dignity, and respect: The importance of cultural competency for First Nations, Inuit, and Métis people


I Introduction
II Why cultural competency is needed
III Developing cultural competency
IV Concluding comments
V Recommended resources

--submitted by Judy Irwin (senior writer) and Elaine Kachala (policy lead), Health Council of Canada

I Introduction

Most health care providers and policy-makers know there are significant health disparities between First Nations, Inuit, and Métis people and non-Indigenous Canadians. What they don’t know is that the attitudes and behaviour of health care providers may unwittingly contribute to this situation.

Indigenous people often feel uncomfortable, fearful, or powerless when they attempt to use the health care system because they don’t feel safe from stereotyping and racism, and because the culture of mainstream health care feels alienating and intimidating.  As a result, many Indigenous people avoid going for care, even when they are ill. And if they don’t feel safe visiting health care providers, they also miss the benefits of preventive care and early detection of disease. These are some of the reasons that Indigenous people are more likely to be diagnosed at a later stage of disease than non-Indigenous people, when treatment is more difficult or no longer possible. [1]

Research shows that Indigenous people are more likely to use health care services and follow treatment advice when they trust their health care providers. [2,3,4] In 2012, the Health Council of Canada held a series of meetings across Canada to ask health care providers, managers, and researchers about their efforts to create culturally competent care and culturally safe environments—places and providers that are welcoming, inclusive, and safe for Indigenous people.  

Our conclusion is that a cultural shift is needed in health care to ensure that First Nations, Inuit, and Métis people will feel welcome and safe. Health care providers need to learn about the diversity of First Nations, Inuit and Métis people, as well as the historical and social contexts that have shaped their health and well-being. Providers also need to be supported to learn new attitudes and behaviour. Health care organizations must develop policies and processes to ensure that cultural competency is valued and supported, and that racism is not tolerated. New programs are underway in some institutions, medical schools, health regions, and governments, but to be truly effective, individual health care providers must be prepared to change and ensure they deliver culturally competent care.

II Why cultural competency is needed

Until recently, most Canadians learned very little about Indigenous people in school, and what they did learn was typically the European perspective on the founding of Canada. They didn’t learn about the forced removal of Indigenous peoples from their traditional territories to make way for settlers, the prevalence of racism, the Indian Act, or the impact of residential schools, which were deliberately designed to separate children from their families and communities. Many children suffered physical, sexual, mental, and spiritual abuse in these facilities, with traumatic intergenerational effects on their lives and communities.

The legacy of this history includes persistent inequities in the determinants of health, health status, and health outcomes. [1] Indigenous people are more likely than other Canadians to live in poverty, which, in turn, is associated with other conditions that negatively affect health, such as inadequate housing, poor nutrition, obesity, and physical and emotional stress. [5,6,7] Another legacy of colonization and residential schools is significant mistrust of non-Indigenous people, institutions, and authority, which can include the health care system.

Health care providers don’t need to know all the details of someone’s culture, but they should have enough understanding of the history of colonization and resulting intergenerational trauma to understand how these factors may affect the lives and health of their Indigenous patients, and be willing to work actively to gain their trust.

III Developing cultural competency

Negative stereotypes about Indigenous people are deeply rooted in Canadian society, and much of what Indigenous people experience in the health care system is an extension of this systemic racism. In our sessions, participants shared many examples of the effects of damaging stereotypes, such as the stories of two Indigenous people (one suffering from a diabetic coma, another from an injury) who were not given proper care because health care providers assumed their symptoms were related to drug or alcohol abuse.

We also heard that the single most important factor in creating cultural safety was the attitude and behaviour of health care providers. Participants said that Indigenous people need to know that providers are interested in them as people; that they will be treated with empathy, dignity, and respect; and that they will be considered partners in their care.

Even the pace and style of Western health care—such as rushed appointments with impersonal providers—can feel like discrimination to Indigenous people. Health care providers can reduce misunderstandings by working with Indigenous communities to learn their concerns about local services, change practice styles, and ensure that all communication is clear and respectful.

The good news is that cultural competency can be developed in most caring providers, described by one participant as “the right kind of people, not just people with the right credentials.” Most providers are well intentioned, but they may not be aware that their lack of cultural competency is causing a problem. They may not realize that they are the reason someone does not follow a treatment protocol or return for appointments. Becoming culturally competent requires training and education, self-reflection, and the courage to change behaviour.

Health care providers who are culturally competent take a holistic approach to care—one that considers physical, emotional, mental and spiritual wellness—and consider how the circumstances of patients’ lives may be affecting their health. They ask questions about what their patients need and are willing to advocate for it, such as a request to have a traditional ceremony or involve a traditional healer in care. Culturally competent providers also know that Indigenous communities are very different from one another, with a wide range of beliefs, cultural practices, and languages, and not all Indigenous people are interested in following traditional ways.

IV Concluding comments

Although a number of research and government reports have discussed the need for increased cultural competency in health care, [1,8,9] this issue is not widely known or understood in the health care field. However, this is beginning to change.

Cultural competency and cultural safety are becoming top-of-mind topics across the country in many governments, health regions, and hospitals. The result is a growing number of initiatives such as cultural competency training programs and patient navigators specifically for Indigenous people. More than 30 of these innovative programs, as well as the issues discussed in this article, are presented in the Health Council’s 2012 report, Empathy, dignity, and respect: Creating cultural safety for Aboriginal people in urban health care.

We encourage readers to ask their organizations and local health regions what is underway in their areas, to take cultural competency training programs, and to build relationships with the Indigenous communities and people they serve.

V Recommended resources

The National Aboriginal Health Organization provides a practical guide to help people at all levels of the health care system understand and implement culturally competent practices. Cultural competency and safety: A guide for health care administrators, providers and educators is available at

The Indigenous Physicians Association of Canada (IPAC) and the Royal College of Physicians and Surgeons of Canada (RCPSC) have developed a curriculum for medical residents which is being implemented in a number of medical schools. The curriculum is a useful resource for any health care provider. Promoting culturally safe care for First Nations, Inuit, and Métis patients is available at

BC’s Indigenous Cultural Competency Training, a facilitated online program, provides fundamental information and encourages self-reflection about Indigenous people, the history of colonization, cultural biases, and the importance of culturally safe health care. The program, developed and operated by the Provincial Health Services Authority in BC, serves as a foundation for additional cultural competency training about local communities. There is fee for out-of-province participants.


1. National Collaborating Centre for Indigenous Health (NCCAH). (2011).  Access to health services as a social determinant of First Nations, Inuit, and Métis health. Prince George, BC: NCCAH.

2. Indigenous Physicians Association of Canada (IPAC) and the Royal College of Physicians and Surgeons of Canada (RCPSC). (2009). Promoting culturally safe care for First Nations, Inuit, and Métis patients. A core curriculum for residents and physicians. Winnipeg, MB & Ottawa, ON: IPAC-RCPSC Core Curriculum Development Working Group.

3. National Indigenous Health Organization (NAH0). (2008). Cultural competency and safety: A guide for health care administrators, providers and educators. Ottawa, ON: NAHO.

4. Indigenous Physicians Association of Canada (IPAC) and the Royal College of Physicians and Surgeons of Canada (RCPSC). (2009). Cultural safety in practice: A curriculum for family medicine residents and physicians. Winnipeg, MB & Ottawa, ON: IPAC-RCPSC Family Medicine Curriculum Development Working Group. Retrieved from

5. Reading, C. & Wien, F. (2009). Health inequalities and social determinants of Indigenous peoples’ health. Prince George, BC: National Collaborating Centre for Indigenous Health.

6. Reading, J. (2009). A life course approach to the social determinants of health for Indigenous Peoples. Ottawa, ON: Senate Sub-Committee on Population Health.

7. National Collaborating Centre on Indigenous Health (NCCAH). (2009–2010). Poverty as a social determinant of First Nations, Inuit, and Métis Health. Prince George, BC: NCCAH.

8. Royal Commission on Indigenous Peoples. (1996). People to people, nation to nation: Highlights from the report of the Royal Commission on Indigenous Peoples. Ottawa, ON: Royal Commission on Indigenous Peoples.

9. Commission on the Future of Health Care in Canada. (2002). Building on values: The future of health care in Canada. Ottawa, ON: Commission on the Future of Health Care in Canada.