The KAIROS Blanket Exercise: Engaging Indigenous ways of knowing to foster critical consciousness in medical education

Development and delivery of justice, equity, diversity, inclusion, and anti-oppression concepts in entry-level health professional education: A scoping review: BEME Guide No. 88

PURPOSE

Justice, equity, diversity, inclusion (JEDI), and anti-oppression (AO) concepts are necessary in healthcare settings to promote culturally safe and high-quality care; however, entry-level healthcare program curricula (EHPPC) may lack adequate integration and/or delivery of these concepts. The primary aim of this scoping review is to identify what guidelines, frameworks, and models (GFMs) are used, and how they are used, to develop and deliver JEDI, and AO concepts in mandatory EHPPC.

METHODS

A search of Ovid MEDLINE, Ovid EMBASE, and CINAHL was conducted for studies published in English from 2015 onwards that discuss what GFMs are included in mandatory EHPPC and how they guide the development and/or delivery of JEDI and/or AO concepts. Data from the included studies was collated into themes which were presented in tables and figures and described in narrative summaries.

RESULTS

Sixty-one studies from various healthcare programs including medicine, nursing, pharmacy, dentistry, and dietetics were included in this review. Data from the studies were organized into eight categories: GFMs, concepts, methods of evaluation, length and frequency of sessions, modes of delivery, learning activities, and training of curricular developers and facilitators.

CONCLUSIONS

GFMs are used in a variety of ways to integrate JEDI and/or AO concepts into health professional curriculum. Variability in the training of developers and facilitators of curricular concepts also exists. Future research is needed to determine if consistent or variable GFMs, as well as JEDI and/or AO developer and facilitator training, would be more effective for students' learning of these concepts.

Exploring medical students' experiences with indigenous patient care: a phenomenological study

BACKGROUND

Indigenous Peoples in Canada bear a disproportionate burden of disease and experience poorer health outcomes as compared to non-Indigenous populations within Canada; these conditions are said to be mediated and exacerbated by pervasive and uninterrupted anti-Indigenous racism. Third and fourth-year medical students at a Canadian medical school were asked to reflect on their experiences working with Indigenous patients in clinical settings, and how their preclinical Indigenous health curriculum impacted these experiences.

METHOD

Phenomenology was used, guided by Goffman's theory of social stigma. Eleven undergraduate medical students were recruited using purposeful sampling. Semi-structured phone interviews were conducted to gain an in-depth understanding of the participants' experiences. Interviews were recorded and transcribed verbatim. Data were analyzed using the four main processes for phenomenological analysis.

RESULTS

Four main themes emerged from students' descriptions of clinical experiences involving Indigenous patients: 1) students describe how their Indigenous patients encounter the health care system and their own lack of cultural sensitivity in this context; 2) racism was evident in students' clinical interactions with Indigenous patients, but students do not always perceive these biases nor the impact of this on patient care; 3) identifying the impact of racism on care is complicated by situational clinical encounters; and 4) practicality of preclinical Indigenous health education is desired by students to prepare them for working with Indigenous patients in the clinical setting.

CONCLUSIONS

In their clinical experiences, students witness racism against Indigenous peoples yet are unprepared to stand up against it. Findings highlight the importance of enhancing undergraduate medical training to allow students to better understand the unique experiences and perspectives of Indigenous patients. The results support the need for ongoing Indigenous health education, to foster culturally sensitive experiences while learning about Indigenous patients.

What Outcomes Are Associated with Learning About Colonialism and Its Impacts on Indigenous Peoples in Health Professional Programs? A Critical Integrative Review

Background

The Truth and Reconciliation Commission of Canada called upon health professional programs to teach about historical and on-going colonalism. Since these calls to action, there has been an increase in educational opportunities on the topic. Although it is generally assumed that learning about colonialism will reduce racism and improve allyship towards Indigenous Peoples, an evaluation of this assumption is needed.

Purpose

An integrated review of the literature was conducted to assess how participation in educational experiences is associated with learner outcomes and how they may vary according to course design considerations including the guiding framework, content foci, mode of delivery, activities, and duration.

Methods

Studies assessing outcomes of educational activities related to the legacy of colonialism identified in a previous scoping review, as well as any such studies published since then were included in the present study. Data synthesis was performed using content analysis of the results and discussions presented in the included papers.

Results

A review of 15 papers identified a backfire effect that was only evident among the studies that included a delayed post-evaluation timeframe. In two educational experiences, it was found that learners were more likely to express unfavourable attitudes towards Indigenous Peoples post-training. These educational opportunities were designed using a cultural safety framework and followed a similar course delivery (e.g., viewing of vodcasts, use of case studies) and provided similar content (historical policies, Indigenous cultural beliefs and practices).

Conclusions

The findings should be interpreted with caution but point to plausible implications related to the backfire effect of educational opportunities on learners' attitudes towards Indigenous Peoples post-training.

Racial biases in clinical practice and medical education: a scoping review

INTRODUCTION

Health inequalities represent a major challenge in contemporary medicine, with some attributed to racial biases. Recently, in the United States, a call to combat discrimination in the field of health has resonated, particularly in the context of the COVID-19 crisis, in which minorities have been disproportionately affected. These calls echo recommendations from the Institute of Medicine dating back to 2001, urging the fight against inequalities in access to health care. In France, inequalities based on presumed origin persist, yet medical education on these issues is virtually nonexistent.

MATERIALS AND METHODS

We conducted a scoping review literature review in accordance with the JBI recommendations for scoping review writing and applied the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist to explore existing conceptual and educational data on racial biases in medicine. The inclusion criteria were interventional studies or evaluations of existing educational programs in medical training addressing the fight against racial biases in clinical settings published in French or English between 2003 and 2023. Six databases were systematically consulted.

RESULTS

Out of 748 initial studies, 28 were included in our study. The median number of participants in the studies was low, interventions were diverse, and participants were generally well received, most of whom were self-selected. No study has evaluated the clinical impact of these interventions. The highlighted concepts included levels of racism, cultural competence, cultural humility, and critical race theory.

DISCUSSION

The authors most frequently referred to institutionalized racism, demonstrating the systemic nature of these issues. At an individual level, implicit and unconscious biases were most often emphasized. It appears that the concept of "race" is a sociopolitical construct without supporting biological determinants. Humility is central to this field of study, as it encourages questioning of individual or collective medical practices. In France, the context, including the prohibition of ethnic statistics, may hinder the objectification of discrimination. Immersion and virtual patient scenarios emerged as potential solutions for evaluating the clinical impact of interventions. A more horizontal medical pedagogy seems better suited to teach these sensitive issues.

A narrative inquiry into non-Indigenous medical educators and leaders participation in reconciliatory work

INTRODUCTION

Globally, medical schools are operationalising policies and programming to address Indigenous health inequities. Although progress has been made, challenges persist. In Canada, where this research is conducted, Indigenous representation within medical schools remains low, leaving a small number of Indigenous advocates leading unprecedented levels of equity-related work, often with insufficient resources. The change needed within medical education cannot fall solely on the shoulders of Indigenous Peoples; non-Indigenous Peoples must also be involved. This work aims to better understand the pathways of those engaged in this work, with careful consideration given to the facilitators and barriers to ongoing engagement.

METHODS

Data collection and analysis were informed by narrative inquiry, a methodology that relies on storytelling to uncover nuance and prompt reflection. In this paper, we focus on interview data collected from Canadian non-Indigenous medical educators and leaders (n = 10). Participants represented different career stages, (early to late career) and occupied a mix of clinical, administrative and education roles.

RESULTS

Although each participant's entry into reconciliatory work was unique, we identified common drivers actuating their engagement. Oftentimes their participation was tied to administrative work or propelled by experiences within their roles that forced them to confront the systemic inequalities borne by Indigenous Peoples in both academic and healthcare settings. Some admitted to struggling with understanding their appropriate role in Indigenous reconciliation; their participation often proceeded without firm support.

CONCLUSION

Medical schools have an obligation to ensure their faculty, including non-Indigenous Peoples, are equipped to fulfil social accountability mandates regarding Indigenous health. Our findings generate a better understanding of the tensions inherent in this equity work. We urge others to reflect on their role in Indigenous reconciliation, or else medical schools risk generating a false sense of individual and institutional progress.

Exploring the implicit meanings of 'cultural diversity': a critical conceptual analysis of commonly used approaches in medical education

Existing approaches to cultural diversity in medical education may be implicitly based on different conceptualisations of culture. Research has demonstrated that such interpretations matter to practices and people concerned. We therefore sought to identify the different conceptualisations espoused by these approaches and investigated their implications for education. We critically reviewed 52 articles from eight top medical education journals and subjected these to a conceptual analysis. Via open coding, we looked for references to approaches, their objectives, implicit notions of culture, and to implementation practices. We iteratively developed themes from the collected findings. We identified several approaches to cultural diversity teaching that used four different ways to conceptualise cultural diversity: culture as 'fixed patient characteristic', as 'multiple fixed characteristics', as 'dynamic outcome impacting social interactions', and as 'power dynamics'. We discussed the assumptions underlying these different notions, and reflected upon limitations and implications for educational practice. The notion of 'cultural diversity' challenges learners' communication skills, touches upon inherent inequalities and impacts how the field constructs knowledge. This study adds insights into how inherent inequalities in biomedical knowledge construction are rooted in methodological, ontological, and epistemological principles. Although these insights carry laborious implications for educational implementation, educators can learn from first initiatives, such as: standardly include information on patients' multiple identities and lived experiences in case descriptions, stimulate more reflection on teachers' and students' own values and hierarchical position, acknowledge Western epistemological hegemony, explicitly include literature from diverse sources, and monitor diversity-integrated topics in the curriculum.

Towards abundant intelligences: Considerations for Indigenous perspectives in adopting artificial intelligence technology

Artificial Intelligence (AI) applications in healthcare are evolving rapidly. The integration of AI into the Canadian healthcare system has demonstrated significant potential for enhancing the efficiency of care and improving patient outcomes. However, as this transformative technology continues to advance, it is crucial to take into account the unique perspectives and requirements of Indigenous Peoples in Canada. This article delves into the political, ethical, and practical considerations associated with introducing AI into Indigenous healthcare, emphasizing the paramount importance of equity and inclusion, which are rooted in the Two-Eyed AI framework. It also underscores the significance of co-creating AI technology in collaboration with Indigenous communities and multidisciplinary development teams. To illustrate these principles, this article spotlights an international AI epistemology-focused working group example. Healthcare professionals who engage with AI, whether it be through research, management, development, or leadership are implicated with this contemporary paradigm shift in decolonizing novel AI technology.

A scoping review of frameworks utilized in the design and evaluation of courses in health professional programs to address the role of historical and ongoing colonialism in the health outcomes of Indigenous Peoples

Indigenous education curriculum has been implemented in health professional programs as a potential solution to addressing commonly held false beliefs, as well as negative social attitudes and behaviours. As such it is important to map and analyze the current literature on educational initiatives that teach about historical and ongoing colonialism as a determinant of health to identify commonly used theoretical frameworks and outcomes assessed, as well as the intended and unintended short- and long-term outcomes on health professional learner's beliefs, attitudes and behaviours. This scoping review follows the framework by (Peters et al., JBI Evidence Synthesis 18:2119-2126, 2020). Six databases (MEDLINE, CINAHL, PsychInfo, Sociological Abstracts, ERIC, and ProQuest Dissertations and Theses) were searched with grey literature included through hand-searching of Indigenous journals and citation searching for papers published up until 2022 based on an established search criterion. Two reviewers independently screened articles. In total, 2731 records were identified and screened; full text was assessed for 72 articles; 14 articles were identified as meeting all the inclusion criteria and included in the final review. Commonly- used theoretical frameworks were transformative learning and cultural safety, with a variety of evaluation tools used and post-intervention outcomes measured across the studies (e.g., knowledge, beliefs, attitudes, behaviour and general learner feedback). Indigenous education interventions require longitudinal evaluation studies to address shortcomings in the design and evaluation of outcomes associated with teaching about colonialism as a structural determinant of health. It is critical that we identify and monitor the intended and unintended consequences of such curriculum as we look to develop solutions to changing health professional learners' false beliefs and attitudes, in hopes to inform their future care practices.

Navigating the burden of proof and responsibility: A narrative inquiry into Indigenous medical learners' experiences

INTRODUCTION

Many medical schools have well-established admission pathways and programming to support Indigenous medical workforce development. Ideally, these efforts should contribute to attracting highly qualified Indigenous applicants which, in turn, may improve accessible, quality care for Indigenous people. However, it is difficult to evolve and tailor these approaches without a situated understanding of Indigenous learners' experiences. In this paper, we focus on the Canadian context, sharing Indigenous learners' stories about their journey towards and throughout medical training.

METHODS

The conceptual underpinnings of narrative inquiry and key principles from Indigenous methodologies were drawn upon throughout both data collection and analysis. Participants were Indigenous learners (medical students and residents) and a recently graduated physician (n = 5) from one Canadian medical school. Both spoken (formal recorded interviews) and visual (photographs) texts were used to make meaning of participants' experiences.

RESULTS

Participants' experiences during medical training showed a striking resemblance at three points in their transition to, and progression through, medical education: preparing for and applying to medical school, completing undergraduate medical training and determining specialty choice. Participants' stories revealed a tug-of-war between their identities as an Indigenous person and as a medical trainee, with these tensions sometimes compromising their perceived sense of belonging within both Indigenous and academic circles, creating, at times, a heavy burden to shoulder.

CONCLUSION

Meaningful representation of Indigenous people in the medical workforce is about more than training additional health care providers; it requires understanding Indigenous learners and recently graduated physicians' experiences as they enter and navigate the medical profession. By amplifying their voices, we stand to gain a more holistic representation of the factors that contribute to and potentially impede the recruitment and retention of Indigenous people into the medical profession.

Beliefs around the causes of inequities and intergroup attitudes among health professional students before and after a course related to Indigenous Peoples and colonialism

BACKGROUND

Addressing the Truth and Reconciliation Calls to Action on including anti-racism and cultural competency education is acknowledged within many health professional programs. However, little is known about the effects of a course related to Indigenous Peoples and colonialism on learners' beliefs about the causes of inequities and intergroup attitudes.

METHODS

A total of 335 learners across three course cohorts (in 2019, 2020, 2022) of health professional programs (e.g., Dentistry/Dental Hygiene, Medicine, Nursing, and Pharmacy) at a Canadian university completed a survey prior to and 3 months following an educational intervention. The survey assessed gender, age, cultural identity, political ideology, and health professional program along with learners' causal beliefs, blaming attitudes, support for social action and perceived professional responsibility to address inequities. Pre-post changes were assessed using mixed measures (Cohort x Time of measurement) analyses of variance, and demographic predictors of change were determined using multiple regression analyses. Pearson correlations were conducted to assess the relationship between the main outcome variables.

RESULTS

Only one cohort of learners reported change following the intervention, indicating greater awareness of the effects of historical aspects of colonialism on Indigenous Peoples inequities, but unexpectedly, expressed stronger blaming attitudes and less support for government social action and policy at the end of the course. When controlling for demographic variables, the strongest predictors of blaming attitudes towards Indigenous Peoples and lower support for government action were gender and health professional program. There was a negative correlation between historical factors and blaming attitudes suggesting that learners who were less willing to recognize the role of historical factors on health inequities were more likely to express blaming attitudes. Further, stronger support for government action or policies to address such inequities was associated with greater recognition of the causal effects of historical factors, and learners were less likely to express blaming attitudes.

CONCLUSION

The findings with respect to blaming attitudes and lower support for government social action and policies suggested that educational interventions can have unexpected negative effects. As such, implementation of content to address the Truth and Reconciliation Commissions Calls to Action should be accompanied by rigorous research and evaluation that explore how attitudes are transformed across the health professional education journey to monitor intended and unintended effects.

Reflexive Practice as an Approach to Improve Healthcare Delivery for Indigenous Peoples: A Systematic Critical Synthesis and Exploration of the Cultural Safety Education Literature

Cultural safety is increasingly being taught in tertiary programmes of study for health professionals. Reflexivity is a key skill required to engage in culturally safe practice, however, there is currently limited literature examining how reflexivity is taught or assessed within cultural safety curricula. A systematic review of the literature up until November 2021 was conducted, examining educational interventions which aimed to produce culturally safe learners. Studies were limited to those with a focus on Indigenous health and delivered in Australia, Aotearoa New Zealand, Canada, and the United States. A total of 46 documents describing 43 different educational interventions were identified. We found that definitions and conceptualisations of reflexivity varied considerably, resulting in a lack of conceptual clarity. Reflexive catalysts were the primary pedagogical approaches used, where objects, people, or Indigenous pedagogies provided a counterpoint to learners’ knowledges and experiences. Information regarding assessment methods was limited but indicates that the focus of existing programmes has been on changes in learner knowledge and attitudes rather than the ability to engage in reflexivity. The results demonstrate a need for greater conceptual clarity regarding reflexivity as it relates to cultural safety, and to develop methods of assessment that focus on process rather than outcomes.