In adapting your actions to your specific context it will be useful to organize your “taking stock” into a SOAR analysis identifying the unique Strengths, Opportunities, Aspirations and Results envisioned for your setting, allowing you to determine readiness, and set goals and priorities. Now that you have a committed group, the resources to get started and an idea of where you are starting, pull it all together into a plan.
To refine your planning and adapt actions to your context, build on the work you have done in Step 0: Taking Stock, to conduct an Equity Walk Through. Equity Walk Throughs are designed to prompt organizations, agencies, clinics, departments and whole organizations such as hospitals to consider how their settings might promote equity more effectively. It is designed to help administrators, leaders, and staff at all levels consider who is likely to feel welcome, and physically, culturally and emotionally safe and unsafe. Walk throughs can be conducted multiple times, and on a regular basis as changes are implemented. You may have done a Walk Through in the earlier steps. We suggest that staff do this on their own as an initial step, then with one another, and finally (and crucially) with people for whom they want to improve care.
We position Equity Walk Throughs as part of Step 3: Plan because to make Walk Throughs as effective as possible, it is important to have established working relationships, including with people with lived experience of inequities.
In EQUIP, we found in one setting that “walking through” with an Indigenous Elder led to staff feeling defensive, uncomfortable and angry, despite the fact that the Elder was only observing and saying how they felt in the setting without suggestion of criticism. “Walking through” with people with expertise in substance use health and TVIC, and with those with lived experience of stigma and discrimination will help identify strategies for improvement.
Specific actions you plan depend on your priorities. At a minimum you will want to plan:
1) Education: What is required and how should it be provided?
2) Opportunities for dialogue to support change: Who will be involved and how will they be facilitated?
Education is a necessary, but not sufficient, strategy for implementing equity-oriented care (EOC). Key goals of education are to ensure that everyone is aligned with respect to the three key dimensions of EOC and understands how inter-related they are in terms of how service users experience services and care. EQUIP has developed or contributed to a suite of educational tools, as follows. We encourage you to make these resources available to your staff, and ensure that leaders also participate:
Equipping for Equity Online Modules: the Equipping for Equity Online Modules are free on-line e-learning resources that include modules on each of the key dimensions and on strategies to “bring it all together”. A Certificate of Completion is available and recommended to demonstrate that people have engaged with the content.
Trauma- and violence informed care: the TVIC Foundations online e-learning curriculum is a free resource that has 7 sections, with embedded videos, case-based activities, a downloadable Notebook for reflection and links to key take-aways, and interactive quizzes throughout. A Certificate of Completion is available and recommended to demonstrate that people have engaged with the content.
Substance Use Health/Harm Reduction: The “Nexus Module” (coming soon!) gives service providers an opportunity to think about and learn more about how trauma, violence and chronic pain intersect with substance use, and how all of these issues are stigmatized. The module has 7 sections and includes videos and an interactive case study. A Certificate of Completion is available and recommended to demonstrate that people have engaged with the content.
In partnership with the Community Addictions Peer Support Association, Kílala Lelum Urban Indigenous Healing Cooperative and the Vancouver Community Action Team (a team leading responses to the drug toxicity crisis in Vancouver), EQUIP also created a brief animated video to educate on substance use stigma in health care. This brief video titled “Where Else Am I Supposed To Go?” can be used to better understand experiences of stigma and prompt dialogue on how to harness this understanding to reduce substance use stigma and improve interactions with people coming for care.
Anti-Indigenous Racism/Cultural Safety:
- EQUIP has partnered with the San’yas Anti-Racism Indigenous Cultural Safety Program, which is a fee-based, facilitated online educational program available in some Canadian provinces and has shown the potential for transformative learning among the staff in our research sites.
- A free online course called Indigenous Canada is available through the University of Alberta.
- The EQUIP “Equipping for Equity On-line Modules” include a short module on Cultural Safety and there are Essentials on Anti-Racism and Cultural Safety.
Attending to the following will help ensure that education forms an authentic foundation for action and change:
- Time is appropriately allocated for all team members to participate in education activities
- Educational activities are framed as ongoing vs. one-time initiatives
- All staff and leadership engage with all aspects of the educational content – this can be staged according to the priorities you identified in Phase 1; but at minimum all staff should review the “Essentials” material for each key dimension at the outset of your change process, and complete more in-depth education on a schedule that is feasible for your setting. The “Essentials” materials offer 5-10 key points “any service provider should know” about each of 6 concepts, including the key dimensions:
- Equity-Oriented Health Care
- Trauma- and Violence-Informed Care
- Anti-Racism & Cultural Safety
- Chronic Pain
- Substance Use Health
- Substance Use Stigma and Discrimination
They take about 10 minutes to review, and are accompanied by 1-2 minute videos of people with lived experience of the various forms of inequity and experience of promoting equity.
In the EQUIP primary care study we provided mandatory education on Indigenous cultural safety and anti-racism and trauma- and violence-informed care, and this training was impactful for many. However, across all 4 sites staff found that team discussions of the “so what” for their practice, and having data about their own clients made the education meaningful and relevant to their work. During a series of discussions held over time, it was clear that there were tensions related to staff members’ increasing awareness of how common and harmful systemic and interpersonal racism are, and their own role and responsibility in countering it. Supplementing these discussions with data showing how your own clients and staff are affected is the most impactful approach. As you approach Step 5: Monitoring and Reporting, look for opportunities to share data with staff. The anti-racism online courses linked above can support this learning process and the EQUIP Equity Essential on Anti-Racism/Cultural Safety is a brief resource, which can provide a shared foundation for team members to build upon.
Some staff saw their own practice as deeply transformed by the TVIC and cultural safety component of the EQUIP intervention, which had a focus on strategies that could be used to counteract racism and discrimination in relation to Indigenous peoples, and offered insight into how these processes shape health and health care experiences for other groups experiencing racialization, stigma and varying forms of discrimination. For others, the training provoked defensiveness and discomfort reflecting what they described as an internal struggle related to the emphasis on acknowledging historical trauma as integral to reconciliation. Throughout, work to anticipate the diversity of responses to the work and anticipate the types of pushback you will encounter so you can be prepared to work with diverse perspectives.
Similarly, the TVIC training we provided was seen as important and as we have described elsewhere, the interprofessional discussions were most impactful, especially when they were supplemented by data from the clinics themselves showing the levels of trauma symptoms and depressive symptoms experienced by many of the patients and service users.
As suggested above, new educational content is best taken-up when people can discuss what they learned and start to see the opportunities for how it can influence policies and practices in your setting. Consider having members of your Equity Committee and/or Working Group(s) lead facilitated sessions with groups of staff, which are ideally interprofessional and include both leadership/management and direct service staff: multiple perspectives are crucial to ensure a vital and productive discussion that generates a range of strategies. Facilitators must ensure the emotional and cultural safety of all present, recognizing power imbalances among different staff groups, and between staff and leadership. If it’s feasible and can be done with appropriate remuneration and support, involving service users is also recommended.
Using the momentum from these educational integration discussions, create ongoing mechanisms for interprofessional dialogue, including ways for staff to share ideas large and small, in ways that are safe and practical. Strategies can include staff presentations specific to site-implemented equity strategies during existing meetings; new equity-specific gatherings; anonymous suggestions, ‘tips of the day’ displayed on monitors, etc.
In May 2022, St. Paul’s Hospital Emergency built on their work with EQUIP to bring staff together to discuss how the Equipping for Equity online modules might be useful for designing a more effective and equity-oriented approach to preventing and responding to violence and aggression in the Emergency Department. Doing so made the modules highly relevant to the staff because it was linked to an issue that they were deeply concerned about.
Learning about equity-oriented care is best done in meaningful conversations, supported by local data (see Step 5), of how to enact equity as part of broader system changes in your setting, and the development of policies to support this new way of working.