Building Cultural Safety and Providing CARE for First Nations Clients in Pharmacy Practice

By Patricia Chang, PharmD student & Tiana Tilli, BScH, PharmD, RPh, ACPR

Stereotyping and racism towards First Nations Peoples are long-standing and systemic across British Columbia’s health care system. The In Plain Sight report from 2020 found that only 27 per cent of Indigenous individuals felt their needs were taken seriously when accessing health care in B.C.¹ Pharmacy is not immune to these issues, as highlighted in the spotlight feature at the beginning of this article. First Nations Peoples in B.C. continue to share heartbreaking examples of culturally unsafe care and barriers to accessing medications when seeking pharmacy services. Despite Plan W covering eligible over-the-counter (OTC) medications, with a pharmacist recommendation or prescription, a survey from November 2023 showed that 74 per cent of Indigenous clients were made to pay out-of-pocket by community pharmacies.^2,3

While on the surface this may appear to be a medication coverage issue, it’s often deeply rooted in discrimination and related to how the issue is addressed by the pharmacy team. Unsafe interactions create and uphold barriers of mistrust between First Nations Peoples and the health care system. Pharmacists inherently hold a position of power as the health care expert compared to clients seeking care. We must consider the privilege this imparts and learn how to build and maintain trust with First Nations Peoples. Trust is the foundation of authentic pharmacist-client relationships and is instrumental in reconciliation.

While cultural safety has not historically been included in pharmacy curricula, resources are now available to help pharmacists on their learning journeys. The University of British Columbia’s Faculty of Pharmaceutical Sciences have developed two courses, with the First Nations Health Authority (FNHA) and with guidance and teachings from a First Nations advisory group and a pharmacy advisory group, on Building Cultural Safety and Humility for First Nations Clients into Pharmacy Practice. The FNHA has also developed a B.C. Cultural Safety and Humility Standard documentary. The College of Pharmacists of British Columbia has released an Indigenous Cultural Safety, Humility and Anti-Racism Standard of Practice to emphasize that cultural safety and humility are vital for the provision of fair and equitable health services where individuals feel safe and respected.⁴ Core concepts and principles include: (1) self-reflective practice, (2) building knowledge through education, (3) anti-racist practices, (4) creating safe health care experiences, (5) person-led care, and (6) strengths-based and trauma-informed practice.⁴

Each pharmacist must take responsibility for educating themselves on anti-racist approaches and providing the level of care that First Nations clients deserve. While learning, unlearning, and re-learning take time, in this article are some small steps derived from the two courses mentioned above that you can implement in your practice.

A foundation of trust between a client and their pharmacist can promote open dialogue around client preferences, authentic collaboration, and promote clients as decision-makers in their health and wellness journeys.

To help with cultivating relationships built on trust, pharmacists can adopt the “CARE” framework (being Considerate, Aware, Respectful, and Empowering) when engaging with clients.

Artwork by Evelyn Alec

Considerate

We can communicate and provide better care when we understand clients. Here are some tips to consider:

• Listen and learn from them and take time to do your own learning about local communities. Acknowledge the land you’re on (native-land.ca).
• Read local First Nations’ websites to learn about their history and traditions.
• Participate where appropriate by attending public cultural events and workshops or by supporting local Indigenous artists and businesses.
• Create a welcoming pharmacy environment by displaying biographies of pharmacy team members.

Aware

Being informed about personal and intergenerational trauma inflicted on First Nations Peoples can help to prevent triggering a trauma-response and in having compassion if this occurs (e.g., a client’s reaction seems intense). Here are some tips to consider:

• Consider trauma and violence experienced without the client having to disclose their personal history. For example, consider the forced and coerced sterilization of Indigenous individuals in Canada before engaging about birth control.⁵
• Always offer private counselling areas to clients to prevent others from overhearing conversations and to emphasize clients’ safety and control.

Respectful

Treat the whole person rather than strictly a prevailing ailment. Approach with dignity and reciprocity. Here are some tips to consider:

• Place value on Indigenous ways of knowing as well as Traditional Wellness if that’s the client’s choice.
• Be mindful that each client is unique and each community is diverse.
• If you make a mistake, acknowledge it, offer a genuine and specific apology, and take actions to prevent it in the future.
• Avoid stigmatizing phrases including “powwow”, “spirit animal”, and “savage”.
• Do not profile clients, including stereotyping individuals as “drug-seeking” or “drinkers”. When clinically relevant, first ask “do you take recreational drugs” then follow-up with “how often?” only if the first response is affirmative.
   

Empowering

Provide clients with the information needed to make informed decisions and be their own wellness champion. Explain health conditions and benefits of taking medications in a way where clients know what is happening, feel equipped on the steps to take, and know their options. Ensure consistent communication on upcoming pharmacy closures, holidays, and staff shortages.

In addition to employing the CARE framework to cultivate relationships, pharmacists should proactively help reduce barriers to clients accessing medications. Otherwise, clients may leave without the medication and information they need for their wellness and may be less likely to attempt to access health care in the future. Providing good CARE means knowing how to navigate coverage issues and helping people access eligible covered products and services.
 

Pharmacist OTC Recommendations: 

Eligible OTC medications have 100 per cent of eligible costs covered by Plan W without a prescription following a pharmacist’s recommendation and documentation of a First Nations client’s need using the Plan W OTC Recommendation Form.² If a client shares with you that their coverage includes OTC items, listen without judgement and accept this information. Approach with curiosity and take the time to investigate coverage options rather than responding with doubt. An article entitled Ensuring First Nations Plan W Clients Receive Coverage For OTC Medications from the February 2024 issue of The Tablet describes additional ways to improve access.⁶ This includes stocking specific brands of OTC products and placing signs next to common items eligible for coverage through Plan W.⁶ Another way to improve access is to proactively set up your pharmacy dispensing system to bill Plan W OTCs and ensure all pharmacy team members are familiar with the processes.
 

Special Authority: 

Sometimes a medication may not be a regular benefit through Plan W, but coverage can be accessed via Special Authority for that specific medication or a similar alternative.⁷ For example, while liraglutide is listed as a non-benefit on the PharmaCare Formulary, semaglutide is eligible for coverage through Special Authority for blood glucose lowering effects.⁷ Pharmacists can increase access by proactively determining therapeutic alternatives and presenting them for clients to choose from if desired. This includes explaining the reasoning behind recommending the alternatives and how they align with the client’s goals and prescriber’s initial prescription. When a pharmacy client would like to pursue coverage through Special Authority, pharmacists can be proactive by prefilling the Special Authority request form or eForm and providing it to the client and/or prescriber. Pharmacists may also submit Special Authority requests for clients in certain situations, such as when prescribing for minor ailments or contraception and adapting a prescription.⁸

Remember, any dollar amount owing when processing a prescription or OTC medication for a client with Plan W coverage should prompt further action to assess coverage options if the client would prefer a fully covered product.

Learning, Unlearning and Relearning

The journey towards creating a culturally safe and accessible health care system for First Nations Peoples begins with each of us. The two courses within Building Cultural Safety and Humility for First Nations Clients into Pharmacy Practice contain a combination of Canadian history, pharmacy-specific practical examples, and activities for pharmacists at varying places in their learning journeys. Each course takes approximately two hours, can be completed in multiple sittings, and is available at no cost.

We hope these courses, and the exerts from the courses covered within this article, help to strengthen your relationships with the First Nations clients who are entrusting you with their health care.

Building Cultural Safety and Humility for First Nations Clients into Pharmacy Practice — Education for Pharmacy Team Members Now Available