Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training.

BACKGROUND: Health care routinely fails Indigenous peoples and anti-Indigenous racism is common in clinical encounters. Clinical training programs aimed to enhance Indigenous cultural safety (ICS) rely on learner reported impact assessment even though clinician self-assessment is poorly correlated with observational or patient outcome reporting. We aimed to compare the clinical impacts of intensive and brief ICS training to control, and to assess the feasibility of ICS training evaluation tools, including unannounced Indigenous standardized patient (UISP) visits. METHOD: Using a prospective parallel group three-arm randomized controlled trial design and masked standardized patients, we compared the clinical impacts of the intensive interactive, professionally facilitated, 8- to10-h Sanyas ICS training; a brief 1-h anti-bias training adapted to address anti-Indigenous bias; and control continuing medical education time-attention matched to the intensive training. Participants included 58 non-Indigenous staff physicians, resident physicians and nurse practitioners from family practice clinics, and one emergency department across four teaching hospitals in Toronto, Canada. Main outcome measures were the quality of care provided during UISP visits including adjusted odds that clinician would be recommended by the UISP to a friend or family member; mean item scores on patient experience of care measure; and clinical practice guideline adherence for NSAID renewal and pain assessment. RESULTS: Clinicians in the intensive or brief ICS groups had higher adjusted odds of being highly recommended to friends and family by standardized patients (OR 6.88, 95% CI 1.17 to 40.45 and OR 7.78, 95% CI 1.05 to 58.03, respectively). Adjusted mean item patient experience scores were 46% (95% CI 12% to 80%) and 40% (95% CI 2% to 78%) higher for clinicians enrolled in the intensive and brief training programs, respectively, compared to control. Small sample size precluded detection of training impacts on clinical practice guideline adherence; 100% of UISP visits were undetected by participating clinicians. CONCLUSIONS: Patient-oriented evaluation design and tools including UISPs were demonstrated as feasible and effective. Results show potential impact of cultural safety training on patient recommendation of clinician and improved patient experience. A larger trial to further ascertain impact on clinical practice is needed. TRIAL REGISTRATION: Clinicaltrials.org NCT05890144. Retrospectively registered on June 5, 2023.

Patient racism toward nurses in a divided society: The case of Jews and Arabs in Israel.

AIM: This study examines whether racism exists among Jewish and Arab patients in Israel, as reflected in patient preference for receiving treatment from a nurse with the same ethnic background. BACKGROUND: We examine the relationship between racism and the level of trust in a nurse from a different ethnic group than the patient, as well as the preferred level of social distance, in the context of ongoing conflicts between the Jewish majority and the Arab minority in Israel. METHODS: A cross-sectional study was conducted using a unique study questionnaire that asked 534 Jewish and 478 Arab respondents to express their preference for an Arab and a Jewish nurse. RESULTS: Among both the Jews and the Arabs, there is a similar tendency of racism toward nurses of the dissimilar ethnic group. This racism was also prevalent among participants who live in a mixed environment or those who studied or are studying and worked or work in a mixed environment. As the trust in nursing staff members from the other group increases, the level of racism decreases. The greater the social distance the participants felt from the members of the other group, the more racist the attitudes they expressed. CONCLUSIONS: Both Jews and Arabs preferred to be treated by nurses of their own ethnic group. In contrast to the contact hypothesis theory, participants who live in a mixed environment did not express fewer racist preferences. We conclude with some useful practical suggestions aimed at decreasing racism in health care. CLINICAL RELEVANCE: Findings imply that prospective patients prefer to receive nursing care from nurses of their own ethnic group and trust these nurses more than they trust nurses of different ethnic group.

Health ethics and Indigenous ethnocide.

In colonial societies such as Canada the implications of colonialism and ethnocide (or cultural genocide) for ethical decision-making are ill-understood yet have profound implications in health ethics and other spheres. They combine to shape racism in health care in ways, sometimes obvious, more often subtle, that are inadequately understood and often wholly unnoticed. Along with overt experiences of interpersonal racism, Indigenous people with health care needs are confronted by systemic racism in the shaping of institutional structures, hospital policies and in resource allocation decisions. Above all, racism is a function of state law - of the unilateral imposition of the settler society law on Indigenous communities. Indeed, the laws, including health laws, are social determinants of the ill-health of Indigenous peoples. This article describes the problem of Indigenous ethnocide and explores its ethical implications. It thereby problematizes the role of law in health ethics.

Is Trust Enough? Anti-Black Racism and the Perception of Black Vaccine "Hesitancy".

In this article, I offer a preliminary exploration of the heavy lifting that the word "trust" is doing in questions about Black distrust of medicine and what, if anything, comes from it. I also offer an account of why questions like, "Why don't Black people trust vaccines?" are not only the wrong questions to ask but also insulting, and I go on to provide a Black feminist analysis of racial injustice in medicine-an analysis that does not center a notion of trust. I begin by arguing that implicit in these questions is a pathologizing of Black people-the idea that there is something wrong with Black people rather than something wrong with the conditions within which Black people exist. The sense that there is something wrong with Black people both further disadvantages them and ignores the role that health care institutions have played and continue to play in fostering a climate of distrust. I show that even attempts to explain distrust fail to adequately capture the harms committed against Black people, even if such efforts gesture at institutional responsibility. I sketch out what is important about trust but also briefly discuss why trust may not be the answer to the problems that Black people face in health care encounters.