My name is Kethra Stewart, a First Nation Cree woman from Saddle Lake Cree Nation, Alberta, Treaty 6 Territory. I now live in the unceded territory of the Syilx people in the Okanagan, British Columbia. I’m a cellist, hand drummer, singer, triathlete, and mother. I recently earned my Master of Health Studies from Athabasca University, where my research focused on cultural safety and Indigenous peoples in what’s now called Canada. I noticed gaps in the literature, as cultural training was offered only to regulated health care professionals, excluding those in unregulated roles. To address this, I wrote a manuscript highlighting the need for cultural safety training when working with Indigenous communities and advocating for equal access for all health care professionals. I’m currently taking open learning prerequisite courses at Thompson Rivers University for the potential learning opportunity in the MD program at UBC. I plan to continue my research in Indigenous health while advocating for cultural safety training universally.

As a University of Saskatchewan (USask) graduate, Dr. Petrucka is proud to be a part of the College of Nursing and the School of Public Health. Throughout her career she positioned herself as a nurse scientist with a strong commitment to nursing research excellence and innovation. Petrucka’s program of research focuses on populations with potential (also known as marginalized or vulnerable) within the local and global context. This program variably includes novel/emergent methodologies, health related technologies, and engagement strategies. Over the last number of years, she has had the privilege of assembling a large cohort of researchers, graduate students, and undergraduate students who share interests, intents, and initiative to contribute to nursing science. Currently her research is focused on the area of Women’s Health – specifically in menstrual hygiene equity, as well as health care accessibility in developing contexts including Sub-Saharan Africa and Southeast Asia as well as amongst newcomer populations in Canada. Additionally, Dr. Petrucka is working in Global Health with a focus on improving awareness and access to public health and One Health innovations in Sub-Saharan Africa.

Abstract

This position paper outlines key arguments for implementing cultural safety training for unregulated healthcare professionals across Canada not registered with an organization or college. It highlights the necessary role of healthcare policymakers, organizations, and professionals working with Indigenous populations in advocating for mandatory cultural safety training. There is a gap in education and training regulations through the holistic health practitioner’s community who are transferring from other provinces and are not aware of cultural safety training when working within Indigenous populations. Health care members in organizations need more awareness through training and advocacy to promote equity for Indigenous people living in British Columbia. Cultural safety training is not widely known or accessible among all healthcare sectors. Healthcare workers who are without a healthcare organization and are unregulated professionals, not registered or recognized within an organization, cannot access cultural safety training without having to pay. The implications of the findings identify the gaps, barriers, and benefit that advocate for the advancement of cultural safety training. Implementing cultural safety training should be mandatory for all healthcare professionals, including those who are unregulated, to address health inequities and systemic racism and improve Indigenous healthcare. A call to action for ongoing community contribution and advocacy for funding and research is necessary to understand how cultural safety training is influencing positive changes for Indigenous people accessing healthcare.

Keywords: cultural safety training, Indigenous, health care professionals, Truth and Reconciliation, British Columbia, inequities, anti-racism

Acknowledgments

I would like to thank Sheridan Mahoney, Linda Hamm, Mackenzie Griffen, Dr. Petrucka and my classmates from the Master of Health Studies degree through Athabasca University who peer-reviewed my paper. These wonderful people took the time to suggest editing that were necessary for advancing my scholarly writing towards publishing with a reputable journal.

Positionality

As a health care practitioner and Master in Health Studies graduate, I am advocating for cultural safety training in non-regulated health care. As an adopted intergenerational Cree woman from Treaty 6 Territory, Saddle Lake Alberta, my key focus for this research is reducing inequities for Indigenous people’s health and promoting education. I am also bringing awareness to health care practitioners, who are unaware of the benefits and where to access resources for cultural safety training. I have included a recommendation and call to action for more accessibility in cultural safety training in the holistic and health care organizations who work with Indigenous populations and for more research to close the gaps.

I am a nonregistered, nonregulated massage therapy “bodyworker” specialist in British Columbia, Canada, and an associate member of the Natural Health Practitioners of Canada (NHPC). I was granted permission to disclose this information from the NHPC head office in Edmonton, Alberta by email. I do not receive mandatory cultural safety training through the NHPC. I must seek out these resources because Alberta is not regulated and I live in B.C. (Government of British Columbia, 2024; NHPC, 2025).

I informed the NHPC educational manager and the CEO about the importance of cultural safety training and recommended a facilitator. This training is crucial for our 7,000 holistic practitioner members who work with First Nation, Metis, and Inuit clients across Canada. I work with Indigenous families and volunteer in partnership with the Ki-Low-Na Friendship Center and believe the cultural safety training will enhance my relationships with the Elders, staff, and community members. In this paper, I have included research gaps, barriers, and implications of racism. There are positive impacts being made through the Truth and Reconciliation of Commission in British Columbia for anti-racism, through cultural safety training and meeting the Calls to Action (NCTR, 2025). Indigenous relationships are improving within health care and cultural safety training is beneficial for intersecting education for health care practitioners while improving equity for Indigenous health across Canada. Cultural safety training is becoming more recognized and required for restoring relationships through reconciliation.

Introduction

This position paper rigorously outlines key arguments for implementing cultural safety training for all health care professionals and associated unregulated personnel working with Indigenous populations in British Columbia. Since publication of the 2020 In Plain Sight report, significant strides have been made in addressing health inequities with a commitment to implementing better health care for Indigenous people in British Columbia. (Turpel-Lafond, 2020). However, to achieve equity, collaboration within healthcare sectors, government officials and stakeholders in B.C. must address to the Calls to Action set by the Truth and Reconciliation Commission (NCTR, 2025). There are various socioeconomic factors influencing Indigenous people’s accessing safe and supportive healthcare services that are deeply entrenched in political contexts, particularly in health policy, structural racism, and colonization (Nguyen et al., 2020).

Recognizing disparities and working to address racism in Indigenous healthcare highlights the importance of ensuring healthcare professionals receive cultural safety training. There is a lack of ongoing evaluation and research of the potential benefits of cultural safety training, highlighting the need for further investigation and action. Additional measures are required to implement these recommendations to support the increase of educational incentives for educators, highlighting their potential impact on Indigenous people's health. Implementing cultural safety training should be mandatory for all healthcare professionals, including those who are unregulated, to address health inequities and systemic racism thereby potentially improving Indigenous healthcare.

Background

In British Columbia, Canada, there are 203 First Nations bands that represent 155,020 Indigenous people (James-Abra, 2023). The urgency in reducing inequities in each Indigenous community is a key focus of the public health care system for health promotion (Government of Canada, 2024; Turpel-Lafond, 2020). Cultural safety training is mandated for all regulated healthcare professionals in British Columbia, and important in creating a safe environment for Indigenous people accessing health care services (Interior Health, 2024). The benefits of this training for all health professionals ensures that respectful interactions are the norm, acknowledging and rectifying power disparities in the healthcare system (Blanchet et al., 2021). The efforts of the community are integral to making Indigenous people feel safe receiving medical care, free from racism and discrimination (FNHA, 2025).

Cultural safety training is a concept that goes beyond cultural competency, focusing on power disparities and the effects of colonialism on Indigenous healthcare (Blanchet et al., 2021). Unfortunately, it has been reported that the absence of cultural safety training for professionals who have not taken it, has led to frequent miscommunication, misunderstanding, and even mistreatment of Indigenous patients/clients from health care workers (Turpel-Lafond, 2020). This gap in training has led to detrimental unfortunate or unnecessary circumstances and even deaths and has a profound impact in Indigenous communities (Turpel-Lafond, 2020). The “In Plain Sight” report has highlighted the severe implications of systemic racism against Indigenous people in B.C. (Turpel-Lafond, 2020). Despite the ongoing efforts of organizations to address the Calls to Action set by the Truth and Reconciliation Commission, these efforts remain unmet (NCTR, 2025).

It is important to advocate for cultural safety training to stakeholders in health policy, to ensure accessibility for all healthcare professions, particularly unregulated professions (Interior Health, 2024; Jewell & Mosby, 2023; TRC, 2015). There is a pressing need for increased funding and comprehensive research into the benefits of cultural safety training and education respecting potential impact Indigenous people for better health outcomes.

Methods

The positional paper outlines information from scholarly articles, published reports, grey literature, government websites. The information was searched and conducted through Google Scholar, PubMed, and through the Athabasca University (AU) library databases. The Boolean operators are OR, AND, under “cultural safety training” Indigenous Peoples of Canada” through the AU library. Search words through the database CINAHL plus with text, “Cultural awareness,” “cultural sensitivity,” “train,” “educate,” “learn,” “develop,” “trauma-informed,” “intervention,” “recommendations,” “Indigenous partnerships.” Cultural safety training approaches to Indigenous people health care, anti-racism, inequities, research, strategies, and recommendations. This process yielded inclusion of journals of eleven peer-reviewed studies dating 2012-2025. Articles excluded did pertain to cultural safety in health care or Indigenous people. Peer-reviewed articles include mixed methods, integrative, quantitative, and qualitative, policy reports, scoping reviews, two-eyed seeing approaches and narrative reviews. The included websites were from government, businesses, organizations, and grey literature.

Results

Cultural Safety Training is Mandated for All Registered Health Care Providers in B.C.

The regulated professions in B.C. include registered massage therapists, acupuncturists, chiropractors, Chinese medicine and naturopathic physicians and they receive cultural safety training through the college (CCHP-BC, 2025). Nurses, physicians, and other regulated health care professionals receive mandatory training through the Interior Health of B.C. in accordance with the Truth and Reconciliation of Commissions (TRC) Calls to Action under Section 23 (Interior Health, 2024; TRC, 2015). Section 23 states in the Calls to Action (2015), states that “the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, Indigenous teachings and practices, and the history and legacy of residential schools are just a few of the topics surrounding Aboriginal health issues that we urge Canadian medical and nursing schools to mandate all students take” (p. 3).

By including cultural safety training and being mandated, the outcomes for health care workers will be that they are proficient in understanding intercultural competency, conflict resolution, human rights, and anti-racism (Gallagher et al., 2019; TRC, 2015). Health care professionals have free access to online modular learning for cultural safety training through their professional work businesses such as San’yas Anti-Racism Indigenous Cultural Safety Training Program, or First Nations Health Authority (FNHA, 2025; San’yas, 2025). The CCHP-BC (2024) does provide cultural safety training for all health care practitioners who are regulated and registered through the College. It is unclear as to why regulated health care professionals have access to free training while non-regulated health care providers do not.

Unregulated Health Care Practitioners Across Canada

In B.C., massage therapy is a regulated profession (Government of British Columbia, 2024). Health care professionals registered in Alberta who reside outside of their regulatory provinces are not regulated (NHPC, 2018). Health care practitioners who are not affiliated with the CCHP-BC must seek cultural safety training outside of their affiliated organizations (NHPC, 2018). There are over 7,000 holistic healthcare practitioners across Canada with the Natural Health Practitioners of Canada (NHPC, 2018). NHPC (2018) is an organization which has members in several heath care professions, and they must complete twenty mandatory credits, as part of membership requirements in education every two years. To date NHPC (2018) does not have cultural safety training available however, membership does include advancing practitioner’s credentials through continuing education.

Therefore, advocating for more cultural safety training initiatives and funding for anti-racism education when collaborating with Indigenous clients is needed for unregulated health care professions across Canada. Holistic health practitioners, workers, and members of NHPC, can look for private facilitators who do cultural workshops or educational modules online cultural safety training for a fee (PowerEd, 2025).

Education and Funding Implementation

The First Nations Health Authority (FNHA, 2025) is an independent provincial government since 2013. FNHA is an Indigenous-led government responsible for implementing health programs in partnership with the B.C. First Nations (Government of Canada, 2024). This self-governing organization offers cultural safety training to all staff and health care workers in the Interior Health of B.C. (FNHA, 2025; Interior Health, 2025). This training, which provides healthcare providers with an understanding of the Indigenous perspective of their culture, past occurrences with the government, not only fosters more compassion towards the Indigenous population but also promotes personal growth and professional development (FNHA, 2025). Understanding leads to better patient healthcare treatment and equity and includes anti-racism prevention controls and protection of Indigenous people’s health care rights (Gallagher et al., 2019). The urgent need for implementing cultural safety training for health care professionals is a key strategy in addressing health inequities and systemic racism in healthcare. There is a pressing need for increased education funding and the allocation of resources for training and evaluation in Indigenous healthcare in Canada. The Government of Canada (2023), has made a significant commitment, investing a substantial $2 billion over 10 years through a new Indigenous Health Equity Fund. This investment is designed to ensure access to quality and culturally safe healthcare services, aligning with the priorities of Indigenous partners (Government of Canada, 2023). The funding provided by the Government of Canada (2023) is needed for enhancing supportive education and training services, while ensuring the implementation of cultural safety training (Interior Health, 2024). Collaboration can be achieved by fostering relationships between healthcare professionals and Indigenous communities, which is vital for advancing our journey toward health equity in an ethical manner. Cultural safety training will occur in all health sectors, including unregulated employees, who will be provided with the necessary resources and support to participate. Social action and awareness training will be promoted as per the Truth and Reconciliation Report (2015).

Systemic Racism and Cultural Safety Training

First, concerning Indigenous health care overseen by the First Nations Health Authority (2025), a call for action is needed to allocate increased services for cultural safety training awareness. The establishment of inclusive relationships with Indigenous people approaches to cultural safety training strategies are not plainly important, but a matter of empathy and understanding towards equity (CIHI, 2021; FNHA, 2025; TRC, 2015).

Second, the healthcare profession has a historical context that has led to ongoing systemic racism for people who identify as First Nations, Métis or Inuit, a context that demands immediate action and change (CIHI, 2021). In the In Plain Sight report, the prevalence of racism is apparent among healthcare workers toward Indigenous people. A follow up evaluation of cultural safety training practices is needed and evaluation in meeting the Call-to-Action #23 (Jewell & Crosby, 2023; TRC, 2015).

Third, countless unregulated healthcare professionals in B.C. lack access to essential cultural safety training. Healthcare professionals, equipped with cultural safety training, are part of a collaborative effort to understand and address the social determinants that affect health promotion for Indigenous peoples (Webb et al., 2023). This understanding, rooted in the critical points resulting from colonialism on multiple levels, is key to meeting Indigenous people's unmet healthcare needs and shaping how healthcare services are accessed, funded, and delivered (NCCIH, 2021).

In ongoing research, Indigenous communities and health sectors are at the forefront of shaping their health care, working in tandem with front-line health professionals to integrate their cultural and Indigenous worldviews, traditional knowledge, and practices (Allen, 2020; FNHA, 2025; Martin, 2012).

This collaborative integration of cultural safety training is not important, but it makes these professionals an integral part of improving knowledge of colonialism to improve better health outcomes for Indigenous people (Webb et al., 2023).

Addressing Racism and Indigenous Methodologies: Two-Eyed Seeing

The reality is that healthcare professionals remain uninformed about Indigenous people, their history and their health and their critical importance in health care. Two-eyed seeing is understanding Western and Indigenous spiritual views towards a person's holistic care (Martin, 2012). Using a two-eyed seeing approach in research and in education can utilize the strengths of each domain to deliver intersecting modalities and learning for both Indigenous and non-Indigenous learners (Wright et al., 2019). Understanding how colonialism has impacted Indigenous people in the health care system can greatly shift attitudes and biases of discrimination.

According to the In Plain Sight report, an investigation went under review in British Columbia in 2019 in the hospitals after there were allegations that healthcare staff were discriminating against Indigenous people with a game called "The Price is Right,"(Turpel-Lafond, 2020). This game is where staff would guess Indigenous patient's blood alcohol levels when they came into the emergency (Turpel-Lafond, 2020). The investigation uncovered the presence of racism, discrimination and stigma from staff and Indigenous patients through ethnographic and mixed studies (Turpel-Lafond, 2020). Furthermore, following this investigation, twenty-four recommendations in the In Plain Sight report discussed strategies for reducing anti-racism and advancing Indigenous peoples' health (Turpel-Lafond, 2020).

In the In Plain Sight report, Recommendations 19-21 discuss revamping the San'yas online training program and implementing cultural safety training to be accessible and universal to all healthcare workers in B.C. (Turpel-Lafond, 2020). These changes are essential to ensure that unregulated health care practitioners can receive cultural safety training. With ongoing cultural safety training, evaluation and follow-up, healthcare practitioners can understand the benefits of cultural care for Indigenous people's health (Martin, 2012; Turpel-Lafond, 2020). However, it is important to note that these benefits can be further enhanced through collaboration with local Indigenous Elders and communities, improving relationships and health outcomes through two-eyed seeing approaches (Barudin, 2021; Turpel-Lafond, 2020; Wright et al., 2019). It is imperative to strengthen the relationships between federal and provincial governments to involve communities in providing and accessing health care services (Government of Canada, 2024). This approach is fundamental for the self-determination of Indigenous peoples (Government of Canada, 2024). Furthermore, creating awareness and fostering dialogue through education and advocacy on this important topic is essential (Lapointe et al., 2014). As outlined by the Government of Canada (2024), this approach to building and transforming healthcare is a testament to the empowerment of Indigenous communities, ensuring their unique needs are met and celebrated.

Limitations

Progress has been made in the TRC (2015), but the Call to Action 23 remains unmet (NCTR, 2025). Hence, to achieve this collaboration within healthcare sectors, government officials and stakeholders in B.C. must be upheld due to the Calls to Action (NCTR, 2025). Improving equity demonstrates the government's commitment to reconciliation and implementing better health care for Indigenous people in B.C. (Turpel-Lafond, 2020).

Cultural safety training is not mandated among all healthcare professionals and is not regulated with ongoing evaluation and research of how it benefits Indigenous people's health (Turpel-Lafond, 2020). However, since identifying the challenges of the inequities, the government is continuing to reduce racism by implementing the recommendations from the In Plain Sight report and Calls to Action in Indigenous healthcare (Interior Health, 2024; NCTR, 2025; TRC, 2015; Turpel-Lafond, 2020). Cultural safety training reduces the power differentials and improves communication between health care professionals and Indigenous people (Webb et al., 2023). Cultural safety training and awareness remove barriers by understanding the effects of colonialism, which can improve systemic racism and discrimination that have been toward Indigenous people (Webb et al., 2023). Healthcare professionals play a crucial role in advocating for more educators and increased education incentives for health care providers to receive cultural safety training (Turpel-Lafond, 2020). Therefore, increased cultural safety training will benefit Indigenous people's health (NCTR, 2025). Understanding the barriers of accessibility to health care services can lead to the solutions to inform project plans for research platforms, and advocate for evaluation for health care workers who have taken the cultural safety training. Active support from healthcare leaders at NHPC and advocating for cultural safety training for unregulated healthcare sectors, are essential steps toward meaningful change for anti-racism for when collaborating with Indigenous people. The government's active support for changing health care systems with reducing anti-racism is clearly stated throughout this paper (Turpel-Lafond, 2020).

Conclusion

This position statement paper demonstrates that cultural safety knowledge is not widely known among all healthcare provider groups. It is necessary to advance workplace equity and take active measures to address racism against Indigenous communities (Nguyen et al., 2020). As demonstrated throughout this paper, cultural safety training aims to strengthen healthcare practitioners' knowledge of cultural differences and raise awareness of one's biases (Webb et al., 2023). The progress of integrating cultural safety training is slow though the In Plain Sight report supports the ongoing action and initiative to enhance healthcare practices for professionals working with Indigenous populations (Turpel-Lafond, 2020). Research has shown that cultural safety training leads to improved healthcare and better interactions with Indigenous peoples, helping to reduce racism and discrimination (Interior Health, 2024; Webb et al., 2023). Recommending further research and a follow-up of the progress made for cultural safety training of healthcare professionals needs to be implemented.

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