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Applications to Practice

The content and guidance on this webpage were created in partnership with a cultural safety consultant, along with Elders of the Syilx/Okanagan Nation.

Introduction

Cultural humility is a life-long process of self-reflection and self-critique. It is foundational to achieving a culturally safe environment. While western models of medicine typically begin with an examination of the patient, cultural humility begins with an in-depth examination of the provider’s assumptions, beliefs and privilege embedded in their own understanding and practice, as well as the goals of the patient/provider relationship. Undertaking cultural humility allows for Indigenous voices to be front and centre and promotes patient-provider relationships based on respect, open and effective dialogue and mutual decision-making.

Cultural safety: A culturally safe environment can only be defined by the Indigenous person receiving care. … [It] is experienced as respectful, safe and allows meaningful communication and service. It is a physically, socially, emotionally and spiritually safe environment, without challenge, ignorance or denial of an individual’s identity. To be culturally safe requires positive anti-racism stances, tools and approaches and the continuous practice of cultural humility.

Indigenous specific racism: The unique nature of stereotyping, bias and prejudice about Indigenous peoples in Canada that is rooted in the history of settler colonialism. It is the ongoing race-based discrimination, negative stereotyping, and injustice experienced by Indigenous peoples in Canada that perpetuates power imbalances, systemic discrimination and inequitable outcomes stemming from the colonial policies and practice.

In Plain Sight, full report, page 8

Colonialism and its negative effects on Indigenous communities are distinct from other forms of discrimination. Indigenous peoples are the first peoples of Canada and were subjected to colonizers’ dehumanizing stereotypes and harmful policies. The In Plain Sight report reminds us that some health care practitioners continue to perpetuate stereotypes born from colonization.

Cultural humility is meant to be a lifelong journey that can elevate professional practice. The learnings from Indigenous cultural safety and humility span across every patient encounter and are not limited solely to Indigenous peoples; cultural safety and humility principles are transferrable to anyone you are working with. CMTBC asks that RMTs adopt into their practice the principles and applications below – titled “Humility in Practice” – and regularly review this framework to reflect on how their practice evolves.

Humility in Practice

Principles & Applications to RMT practice

In the journey to embed cultural safety and humility within massage therapy practice, there is work to be done before an RMT enters the treatment space, when the RMT enters the space and provides massage therapy, and after the treatment is complete.

The treatment space refers to the experience of receiving care from an RMT; it is influenced by a therapist’s demeanour and by the practice environment itself.

The principles and applications to practice (below) suggest a way to “walk with humility” in practice.

Beginning

The Before Work: groundwork for safe, effective, and ethical care before touch occurs

Principles: self-awareness, motivation, signaling safety, reverence and respect for persons and for touch

When you reflect on the historical timeline, consider the impact of systemic racism on an Indigenous person’s ability (or desire) to trust.

Self-awareness and self-reflection are foundational to cultural humility. Being self-aware within the therapeutic relationship means to understand one’s own biases and assumptions while tracking patients’ comfort levels through observation or gentle questioning. RMTs should never assume that their own comfort level with massage therapy is shared by patients.

When patients seek massage therapy, they expect it to benefit them. The RMT from whom they seek care has an opportunity to earn and deepen trust in the profession and the work. Ongoing self-awareness about one’s biases is nurtured by taking a moment to be neutral, calm, and helpful before joining a patient. Bring your best professional self to the patient; leave your personal cares, concerns, or worries outside the treatment room.

A culturally safe treatment space welcomes every person and can signal safety; for example, through nature, art, sound, and most importantly, through the RMT’s demeanour and presence. Elders have shared that signals can be viewed as “the medicine in the room”.

Cultural safety and humility are integral parts of the “before work”, which happens before touch occurs. RMTs are asked to consider (or reconsider) what motivates them to be an RMT, to tap into a desire to help, and to remember that most people do not share RMTs’ ease and high comfort levels with touch. Reverence and respect both for the persons touched and for the impact of touch is key.

Middle

Treatment Space: each patient is your only patient

Principles: humility, questions, empowerment, trust, patient-centred care

When entering the treatment space, consider “each patient is your only patient”. During treatment, the therapeutic relationship is strengthened by listening and attending with all senses. Your patient brings all aspects of themselves: physical, intellectual, emotional, and spiritual, including their ancestors, their history, and their culture.

Nurturing humility can be challenging, particularly for a health care practitioner who has dedicated time and resources to developing their knowledge and skills. Humbling oneself is not about discrediting your accomplishment; it is about recognizing that each patient you encounter comes with their own lived/living experiences. Humility, patience, and time are required to learn their story and how you can best help as a health care practitioner.

Within the context of Indigenous cultural safety, Indigenous peoples have too often experienced “about them, without them” practices, including health professionals who moved forward with little or no concern for sharing information and establishing consent. As a result, much harm has occurred for Indigenous peoples throughout the continuum of health care. It is therefore critical that RMTs seek to obtain consent with great care, ideally throughout the intake process, so that they obtain full and informed consent.

One way to place the consent discussion within the framework of cultural safety is this: after completing intake and negotiating consent for the treatment plan, ask for questions, and then pause. Rest in the pause, patiently allowing questions to arise. After questions have been addressed, or a comfortable silence has passed, ask, “Shall we proceed?” 

Allow for either response, free of judgement: yes or no.

Throughout the treatment, maintain and hold safe, non-judgmental space, including opportunities for a patient to signal stop. The “stop” does not always carry pain or judgement; sometimes “stop” can be translated as “I need a moment”. Empower patients to practice self-care by welcoming questions and offering breaks (e.g., a drink of water). Be mindful that information is power; share with the patient any information you learn about their body, that falls within your scope of practice.

Consider appropriate home care and recommended changes to activities of daily living. Do your recommendations make sense in the context of care? Will they address the patient’s goals, for example to improve function? Do you know if they are able to safely perform the home care you recommend? This is an opportunity to gently learn about community or household support – or possible lack thereof – of the patient’s home health care needs. Take time in the treatment setting to co-create a useful home care plan with and for the patient. Request consent to discuss options for follow-up care, including the next appointment if appropriate. Provide opportunities for the patient to ask questions.

End

Reflections: focused attention by RMT

Principles: self-care, self-reflection, connection

Cultural safety and humility require focused self-reflection. After leaving the treatment space, the RMT remains mentally present with the patient as they consider the treatment provided and next steps for care.

RMTs should reflect on the following:

  • During treatment, were you fully present with the patient or did you let your mind wander?
  • Were you working together with the patient, with them and for them?
  • When and how will you follow-up to check if massage therapy was useful? (e.g., did the patient’s function improve? Did the patient notice an effect, whether positive or negative?)
  • How will you ask the patient if they wish to continue with the treatment plan?

Take time to reflect on cultural safety and humility in the context of care, and shift to your own self-care. Take a moment to re-ground yourself as you prepare for the next patient or for the end of your clinical day.

Definitions

Indigenous-specific racism

The unique nature of stereotyping, bias and prejudice about Indigenous peoples in Canada that is rooted in the history of settler colonialism. It is the ongoing race-based discrimination, negative stereotyping, and injustice experienced by Indigenous peoples in Canada that perpetuates power imbalances, systemic discrimination and inequitable outcomes stemming from the colonial policies and practice.

In Plain Sight full report

Full and informed consent

is defined in CMTBC’s Consent Standard of Practice and the Health Care (Consent) and Care Facility (Admission) Act.

Intergenerational trauma

… describes experiences rooted in multigenerational, cumulative, and chronic trauma, injustices, and oppression. The effects of trauma can reverberate through individuals, families, communities and entire populations, resulting in a legacy of physical, psychological, and economic disparities that persist across generations.

Aboriginal Peoples and Historic Trauma: The process of intergenerational transmission

Reconciliation

To the [Truth and Reconciliation] Commission, reconciliation is about establishing and maintaining a mutually respectful relationship between Aboriginal and non-Aboriginal peoples in this country. In order for that to happen, there has to be awareness of the past, acknowledgement of the harm that has been inflicted, atonement for the causes, and action to change behaviour.”

Honouring the Truth, Reconciling for the Future – Summary of the Final Report of the Truth and Reconciliation Commission of Canada (pages 6-7)

Patient-centred care

Patient-centred care means the RMT is dedicated to professional excellence in responsible care and serving the best interests of the patient at all times. This enables the patient to make informed choices about their treatment and/or options.

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