Table 4 Recommendations for ED Best Practices (Department Level)

Recommendations for Delivery of Emergency Care for First Nations Patients

For Providers

• Treat each patient as a unique individual for purposes of diagnosis and shared decision making.

• Conduct complete investigations at each ED visit.

• Learn about and reflect on stereotypes and biases, and self-correct during care encounters.

• Learn about history of colonialism and contemporary realities of First Nations – including locally.

• Recognize that:

- Resources outside ED are not always the same for First Nations patients as non-First Nations patients (e.g., primary care, transport).

- First Nations patients often have past negative experiences with healthcare.

- Communications styles and behavioral expectations vary cross-culturally.

- Stereotypes can be activated by your words and actions regardless of your intent.

• Modify approach and care plan accordingly.

• Be very cautious about reporting a family to Children’s Services or calling police, given stereotyping and adverse consequences in child welfare and criminal justice systems.

For Departments

• Take for granted that racism impacts health and healthcare.

• Work to build formal relationships with First Nations communities. These could serve to:

- familiarize providers with the realities that First Nations patients face and the resources that are available to them.

- enable the ED to understand and work to address the expectations of the community/community health services for emergency care.

- facilitate inclusion of First Nations members in department committees and governance.

• Ensure providers have resources necessary to offer equity-oriented care for all patients and presenting complaints.

• Develop training on local resources, services and funding sources available for First Nations patients.

• Create standard discharge pathways for First Nations patients that involve:

- sensitively enquiring whether the patients’ living environment is suitable to healing, and involving social supports where it is not,

- considering patient access to transport home following the ED visit, and providing support where needed (e.g. assistance calling friends/family for transport, a safe place to wait until transport arrives, taxi vouchers)

- considering patient access to transportation when developing plans for follow-up and ongoing care, and providing related supports (e.g. asking specialists to schedule follow up at times and places patients feel they can attend, accessing health system resources like inter-facility transport),

- follow up communication with the next provider,

- follow up communication with Health Clinics in First Nations communities,

- enquiring whether patients require physician letters (e.g., for time away from work, medical reimbursement or other services),

- involving Health System Navigators or Indigenous Health Liaisons in discharge and follow up planning.

• Advocate within the healthcare system for resource allocation and quality improvement efforts for First Nations care - within and outside ED.

For Emergency Care Systems

• Create safe and well-moderated ED specific training to help providers identify prevalent stereotypes of First Nations patients and develop anti-racism skills. This training should involve First Nations educators and professionals, and address specific problematic ideas:

- that colonialism happened only in the past.

- that history is not relevant to the present.

- that stereotypes about First Nations peoples are rooted in reality.

- that encounters with particular patients can be used to draw conclusions about the social group the patient is perceived to belong to.

- that generalizations about social groups can be applied in the diagnoses and medical treatment of particular patients.

• Promote education on racism and colonialism, and not only First Nations languages, English dialects, communication styles and behavioural norms.

• Create standard forms, planning documents, information resources and other tools to facilitate the above.

• Provide departments with resources necessary to offer contextually tailored care and address patient barriers to continuity of care (e.g., transport and other resources).

• Ensure appropriate processes for reporting and restorative follow up of racist behaviour that ensure anonymity of the reporting party.

• Recognize First Nations’ sovereignty by ensuring that First Nations governments are robustly involved in decision making about the resources, goals and form of the emergency care system in keeping with the United Nations Declarations of the Rights of Indigenous Peoples.