ABSTRACT:
The College of Physicians and Surgeons of British Columbia (CPSBC) created a new practice standard, Indigenous Cultural Safety, Cultural Humility and Anti-Racism, which was first published in February 2022. The new practice standard sets out a zero-tolerance approach to Indigenous-specific racism by establishing clear expectations for physicians and surgeons in BC. A comprehensive policy development process, spanning 18 months, was undertaken to develop this practice standard. Guided by Indigenous consultants, the process involved virtual discussion circles, surveys, and further engagement with various partners, including physicians, key health partners, and the public. A primary objective during the standard’s development was to amplify Indigenous voices and ensure the perspectives of Indigenous Peoples were front and center at all stages in the process. In this article, CPSBC offers insight into the practice standard development process and key learnings from the comprehensive engagement process involved.
Keywords:
Background
Among the responsibilities entrusted to the British Columbia (BC) health profession regulators is the duty to establish, review, and enforce standards of practice that enhance the quality of healthcare and mitigate instances of incompetence or unethical conduct among registered practitioners. For the College of Physicians and Surgeons of British Columbia (CPSBC), enforcement is largely guided through practice standards which reflect the minimum standard of professional behavior and ethical conduct on a specific topic or issue.
Though CPSBC has a practice standard, Access to Medical Care Without Discrimination,1which addresses racism and discrimination on a broader level, the standard’s lack of specificity regarding Indigenous issues and racism was insufficient in ensuring safe and accessible healthcare for Indigenous Peoples. Addressing racism and discrimination for all minority groups is important; however, Indigenous people face unique challenges as the First People of Canada.
Indigenous Peoples in Canada have been subjected to centuries of colonial policies that have disrupted their communities and access to services. To settle the country, dehumanizing stereotypes and harmful policies were used to rationalize the removal of Indigenous people from the land, undermine their decision-making, and disturb social order. Examples include the Indian Act,2 Indian Reserve System,3 Residential Schools,4 Indian Hospitals,5 the Sixties Scoop,6 and the continued overrepresentation of Indigenous Peoples in the prison and child welfare systems.7 The report In Plain Sight: Addressing Indigenous-specific Racism and Discrimination in BC Health Care,8 published in November 2020, showed the extent of Indigenous-specific racism in BC’s health-care system and underscored the importance of addressing inequities faced by Indigenous Peoples. In addition, a strong call to action has been shared in other reports, including Reclaiming Power and Place: The Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls,9 and the Truth and Reconciliation Commission of Canada: Calls to Action.10
Indigenous Peoples continue to experience disproportionately high rates of unsafe care and negative health outcomes. Encounters with stereotyping, dis-missive attitudes, and systemic bias can lead to delayed diagnoses, undertreatment, or misdiagnoses. Many Indigenous patients avoid seeking care altogether due to a deep-rooted lack of trust in the healthcare system, stemming from both historical and ongoing experiences of racism.
Recognizing the unique history and experiences of Indigenous Peoples in BC, CPSBC identified a pressing need to develop a new practice standard which specifically outlines expectations regarding Indigenous cultural safety, cultural humility, and anti-racism for physicians and surgeons licensed in BC.
Development process
The development process for the practice standard followed a six-phase approach, as outlined in Appendix A. This approach included (1) research and review, (2) establishing partnerships, (3) drafting core principles, (4) extensive engagement, (5) data analysis and revisions, and (6) launch and implementation. A description of the partners engaged throughout this process, and their contribution to the development of the practice standard, are outlined in Appendix B.
1. Research and Review
Before beginning the development process for the new practice standard, CPSBC staff engaged in a thorough review of the existing literature, resources and publications addressing Indigenous Peoples experiences in the health care system. These documents were reviewed in detail, so that the practice standard development process could be built on previous learnings. Documents reviewed included key reports such as the Indian Act,2 In Plain Sight: Addressing Indigenous-specific Racism and Discrimination in BC Health Care,8 Reclaiming Power and Place: The Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls,9 and the Truth and Reconciliation Commission of Canada: Calls to Action.10
2. Establishing Partnerships
Next, CPSBC engaged several key partners to collaborate in this work. First, CPSBC reached out to the First Nations Health Authority (FNHA), the health and wellness partner to over 200 diverse First Nations communities and citizens across BC.11 Engaging the FNHA was a critical step in ensuring that the practice standard would be grounded in the values and needs of Indigenous Peoples in BC.
CPSBC also engaged the British Columbia College of Nurses and Midwives (BCCNM) to see whether this project could be done as a joint initiative between the two colleges, to promote consistency and encourage a broader impact. BCCNM was interested in developing shared practice standard principles, and as such, a joint working group was established. BCCNM recently published their own learnings from the development of this practice standard, in the article Developing a Practice Standard to Address Indigenous-Specific Racism in Healthcare: A Case Study.12
As progress was made in shaping the practice standard principles, CPSBC and BCCNM (the colleges) recognized the importance of ensuring a culturally safe development process and partnered with two experienced First Nations consultants (the consultants). These consultants, with their deep understanding of Indigenous cultural practices, protocols, traditions, and perspectives, played a key leadership role within the working group and provided invaluable guidance and expertise throughout the standard development process.
An Elder and Indigenous Knowledge Kepper from the Musqueam Nation was also engaged to support this work. Engaging a Knowledge Keeper was essential to ensuring that Indigenous knowledge was respectfully and authentically integrated into the development of the standard, and their involvement provided valuable cultural insight while supporting meaningful dialogue amongst Indigenous partners.
3. Drafting Core Principles
Drawing on insights from the literature, CPSBC developed an initial set of core principles for the new practice standard. These principles helped define the key focus areas and were intended to serve as a starting point for exploring what requirements should be addressed in the practice standard. A critical step in refining these principles involved seeking feedback from the FNHA, whose input was instrumental in validating and strengthening the early draft. This engagement also underscored the importance of maintaining a collaborative approach with Indigenous partners throughout the development process. Following engagement with the FNHA, CPSBC met with BCCNM to gather additional feedback, further refine the core principles, and ensure alignment, and common understanding between the two colleges. These initial principles included: the need for physicians to acknowledge the inherent power imbalance in the provider-patient relationship; recognizing patients past trauma, beliefs, and values; understanding one’s own limitations in knowledge as it relates to culturally safe care; and formulating treatment plans in partnership with patients and their family members.
4. Extensive Engagement
Although the colleges had partnered to develop shared principles for their practice standards, it was determined that each would need to engage distinct partners to support the development of their respective practice standards. With guidance from the consultants, CPSBC engaged several key partners at various stages of the practice standard’s development process, including both the drafting and reviewing phases. Partners included the British Columbia Public Advisory Network (BC-PAN), Indigenous members of the public, Indigenous physicians, the public, physicians and surgeons in British Columbia and key health partners including both Indigenous and non-Indigenous focused organizations. These different partners were engaged through BC-PAN meetings, virtual discussion circles, surveys and direct invitations to provide feedback.
BC-PAN Meetings
The BC-PAN is a network of diverse public advisors who come together from across the province to discuss issues related to health care regulation. The network includes individuals with varied gender identities, abilities, ethnic backgrounds, and levels of experience engaging with the healthcare system. At the time of the engagement, the BC-PAN included four advisors who self-identified as being Indigenous. As part of the engagement initiative, the BC-PAN public advisors were asked to review the draft standard principles and provide their feedback on which principles were likely to be most important for patients who might experience discrimination, whether they thought any ideas were missing in the draft principles, and what advice they had for regulatory colleges or practitioners when implementing the principles.
Virtual Discussion Circles
Indigenous members of the public
Though a few of the BC-PAN public advisors self-identified as Indigenous, the colleges recognized the importance of further amplifying the voices of Indigenous members of the public. To do so, the colleges organized two virtual discussion circles with Indigenous members of the public from across BC. These virtual discussion circles included 10 participants and were facilitated by a consultant and Knowledge Keeper, to promote a safe and inclusive environment. Though 10 participants could never be representative of all the experiences of Indigenous members of the public, it was hoped that their in-depth feedback would provide valuable insights into key perspectives and issues. To complement this, a broader survey was conducted to engage a wider group of Indigenous community members, ensuring more diverse input and opportunities for involvement (described below). The Indigenous members of the public were asked to share their experiences facing racism in the health care system, as well as their perspectives and feedback on the draft standard principles. The experiences shared and feedback received during these sessions played a crucial role in the development of standards.
Indigenous physicians
Next, CPSBC engaged Indigenous physicians in a virtual discussion circle to gather in-depth and feedback on the draft standard and how to support its success in practice. The discussion circle involved 10 Indigenous physicians and was facilitated by an Indigenous physician, with support a Knowledge Keeper. The Indigenous physicians shared their experiences facing racism themselves, addressing racism for their patients, and engaging in challenging discussions regarding racism with their colleagues. This insight was instrumental for both the development of the practice standard as well as its accompanying resources.
Surveys
CPSBC shared surveys on two separate occasions throughout the engagement process, engaging both the public and physicians. Utilizing surveys was valuable in gathering broader feedback as any member of the public and any physician of CPSBC could share their thoughts and recommendations for the standard.
Survey Design
The survey used in this study was developed internally, with significant input from Indigenous advisors and the consultants to ensure cultural safety and relevance. The design process was guided by International Association for Public Participation (IAP2) principles of engagement best practices,13 which aimed to create a survey that was both accessible and respectful of Indigenous participants’ experiences and perspectives. In particular, the survey aimed to capture a comprehensive range of views regarding cultural safety, cultural humility, and anti-racism practices within healthcare systems. It was structured to allow for both qualitative and quantitative responses, ensuring that participants had the opportunity to provide detailed, narrative feedback alongside structured data.
Although the survey was not externally validated by a formalized process or standard tool, its development followed rigorous internal review to ensure that questions were clear, culturally appropriate, and aligned with the study’s objectives. Additionally, the survey content was reviewed by the consultants with expertise in cultural safety, ensuring that the language and concepts used were sensitive to the unique experiences of Indigenous peoples and reflected their perspectives accurately.
Survey Dissemination
Surveys were disseminated two separate times to gather broader feedback from the public and CPSBC physicians. Questions asked in the surveys included both multiple-choice questions as well as open-ended questions to ensure participants could express their feedback thoroughly. The public survey was shared through CPSBC’s social media platforms as well as through Health Quality BC’s Patient Voices Network—a community of patients, families, and caregivers working with health care partners to improve the healthcare system in BC. The physician survey was sent directly to all physicians and surgeons of CPSBC (n = ~15,000).
The first survey was made available from April to June 2021 and focused on gathering feedback on the initial draft principles. Feedback was gathered from 33 members of the public and 245 physicians (10 of whom self-identified as Indigenous).
During the second survey, CPSBC shared a more fulsome draft practice standard and sought feedback on the content, clarity, comprehensiveness, and layout. The second survey was made available from October to December 2021. A total of 21 members of the public (six of whom self-identified as being Indigenous) and 124 physicians (five of whom self-identified as being Indigenous) participated in the second survey.
Direct Invitations
CPSBC received feedback on the initial draft principles from several key health partners, including the FNHA, the College of Physicians and Surgeons of Alberta, Doctors of BC, Northern Health, Canadian Medical Protective Association, and the Section of Emergency Medicine. Active engagement with Indigenous health system partners, including health offices within health authorities, was prioritized as a next step in the process. The colleges sought feedback on the draft practice standard from partners such as the Indigenous Physicians Association of Canada, BC Ministry of Health— Indigenous Health Branch and Professional Regulation Branch, Métis Nation of BC, First Nations Health Council, BC Association of Aboriginal Friendship Centers, and health authority Indigenous health offices. Though not all the health partners the colleges reached out to responded to provide their input, CPSBC recognized the importance of providing the opportunity to do so.
5. Data Analysis and Revisions
Data analysis was carried out by the policy team at CPSBC, in close collaboration and consultation with the policy team at BCCNM. The analysis process was iterative and took place at multiple stages throughout the development of the practice standard, allowing insights from earlier phases to inform subsequent engagement and policy work.
Initial analysis followed the first survey and the series of virtual discussion circles. Using a collaborative and thematic approach, the policy team reviewed and coded responses to identify patterns, emerging priorities, and shared experiences. Through this process, six core concepts were identified:
1. Self-reflective practice
2. Building knowledge through education
3. Anti-racist practice
4. Creating safe health care experiences
5. Person-led care
6. Strengths-based and trauma-informed practice
These core concepts provided the conceptual foundation for organizing the principles outlined in the practice standard. They were refined and validated through ongoing feedback gathered in the second survey and from input provided by Indigenous partners and key health partners, further detailed in Appendix C.
6. Launch and Implementation
Following the engagement process, and after a comprehensive review of the feedback received, CPSBC finalized its practice standard. The final draft was brought to CPSBC’s Patient Relations, Practice Standards and Ethics committee for review and comment. It was then presented to the Board and granted approval on February 25, 2022. The Indigenous Cultural Safety, Cultural Humility and Anti-racism practice standard14 was subsequently published to CPSBC’s website and shared widely through an extensive communications effort.
Working collaboratively with Indigenous partners, the colleges also developed several learning resources to assist physicians and surgeons on their learning journey. These resources encompass a range of valuable tools, including a curated list of external learning resources that physicians can utilize to acquire the necessary knowledge to understand and implement the standard effectively.15Frequently Asked Questions (FAQs) have also been created to provide further clarity and guidance on key aspects of the standard.16 Additionally, a series of seven short videos, each lasting three to four minutes, were developed to offer a concise overview of the core concepts encapsulated within the standard.16
Subsequently, CPSBC undertook a critical review of its complaints process to identify opportunities to make it safer and more accessible to Indigenous Peoples. This critical review was done by the Castlemain Group, which specializes in research, engagement and collaboration with Indigenous people, communities and organizations. The review identified several key themes that highlight the current gaps in CPSBC’s complaints process: accessibility, cultural safety, formal versus soft complaints, communication, resolution and accountability, self-identification, and data collection. The Castlemain Group presented CPSBC with concrete recommendations to address these key themes, which have been fully endorsed by the Board. CPSBC is currently implementing these recommendations.
Learnings
Several themes emerged from CPSBC’s engagement process, which reflect key learnings from a health regulator’s perspective regarding the practice standard’s development process. These learnings are outlined below.
Physicians exist on a wide spectrum regarding their current knowledge on Indigenous cultural safety, cultural humility and anti-racism
It was found that physicians exist on a wide spectrum of knowledge and understanding when it comes to Indigenous cultural safety and humility, particularly evidenced by the feedback shared in the open-ended survey responses. While some physicians acknowledged the importance of the new practice standard and shared gratitude for this work, others questioned the need for a standard to specifically address the needs of Indigenous patients and dismissed the fact that systemic racism exists. CPSBC heard from several physicians that they felt this topic was ‘political’ and a topic that should not be addressed by a practice standard, while others described feeling blamed or targeted by the standard. This feedback demonstrated a large variability regarding levels of awareness, education and understanding regarding Indigenous Peoples, their care needs, and the barriers they may face when accessing health care.
Learning resources must accompany the practice standard to ensure its success
Due to the large number of physicians requiring further education on Indigenous cultural safety, cultural humility, and anti-racism, as well as the frequent request for learning resources in the open-ended survey responses, it became clear that learning resources would be vital for the standard’s success. The need for creating learning resources to accompany the practice standard was also a key theme in the virtual discussion circles held with Indigenous physicians and member of the public. Key health partners who provided feedback to CPSBC also shared that the gap in education and training may cause confusion and fear among physicians who would like to improve their education and feel obligated to do so to meet the standard but lack the necessary support.
Amplify Indigenous voices but do not place the burden of work on Indigenous People
A resounding message received throughout the engagement process from Indigenous partners and leaders was that although Indigenous voices need to guide this work, it is not the responsibility of Indigenous people to solve the issues at hand. Recognizing the importance of creating an environment which amplifies Indigenous voices, while being careful not to off-load the burden of work onto Indigenous partners, was identified as critical to the development process. This learning was identified by CPSBC as a foundational principle in shaping how engagement with Indigenous partners is approached, ensuring that responsibility for addressing systemic inequities remains with the institutions that created them.
Indigenous People are not homogenous: What works for one person may not work for another
Another key theme from the survey data and discussions was that Indigenous people are not a homogenous group, and therefore, a one-size-fits-all practice standard will not ensure culturally safe care. The diverse cultures, traditions, and experiences within Indigenous communities in BC contribute to significant variability in terms of what constitutes culturally safe care for individuals. As such, what may work for one person might not work for another. Recognizing this variability was crucial in developing a practice standard that embraces and accommodates the unique needs and preferences of all Indigenous Peoples.
Barriers to implementing the standard must continue to be identified and addressed
Continued efforts are necessary to identify and address barriers to the successful implementation of the practice standard. One barrier to implementation identified by physicians was that of reporting colleagues. It was highlighted that reporting can be difficult, particularly for those without positions of power or leadership as there is a fear of retribution. Reporting the behaviour of other health professionals shifts the burden onto individuals who are likely in a vulnerable position. Physicians identified that training on how to constructively address racism and/or report a colleague would be helpful.
Another significant barrier discussed was time constraints, and the challenges of facilitating in-depth conversations with patients in addition to existing practice demands. Members of the public expressed concern about how physicians can deliver person-led care without having more time to spend with patients. Some physicians indicated that the fee-for-service payment model does not support the needs of Indigenous patients and that the Medical Services Plan (MSP) fee schedule should include “listening.” Acknowledging and addressing these barriers is an important part of supporting physicians in understanding the standard and applying it in their practice.
The complaints process is not currently culturally safe
Another key theme from the data was that the CPSBC’s complaints process is not seen as culturally safe for Indigenous patients. Regulators need to grasp the reasons behind the apparent lack of significant complaint numbers related to Indigenous-specific racism, by understanding the historical context of Indigenous experiences within the healthcare system and with other regulatory bodies and institutions. Indigenous individuals have frequently faced dismissal and marginalization, leading to a hesitancy in engaging with regulatory bodies to voice their concerns. It is important to note that the absence of formal complaints does not negate the existence of inappropriate care. This calls for a comprehensive understanding of these dynamics to ensure a culturally sensitive and accessible complaints process is available for Indigenous patients so that the practice standard can be enforced.
The development of the new practice standard is only the beginning
Lastly, it was communicated by Indigenous Peoples and leaders that the introduction of the new practice standard marks only the beginning of a long journey ahead towards the provision of culturally safe and anti-racist care for Indigenous patients. Recognizing the dynamic nature of healthcare and the need for continuous improvement, ongoing revisions will be necessary to the standard over time as insight into its implementation and impact are uncovered. Recurring evaluations of the practice standard, to assess awareness and effectiveness will be necessary to assess its success.
Discussion
The Indigenous Cultural Safety, Cultural Humility and Anti-racism practice standard was published by CPSBC on February 25, 2022, alongside the accompanying resources, to set out clear expectations for how physicians are to provide culturally safe and anti-racist care for Indigenous patients. The 18-month development process for this standard and its accompanying resource was a rigorous and important journey that led to a robust standard and heightened awareness and understanding for college staff, key partners and physicians.
CPSBC’s practice standard sets out clear expectations for over 15,000 physicians and surgeons. Additionally, since the publication of its practice standard, other BC health regulators have adopted all or part of the standard’s content, expanding the standard’s reach and impact. Now, more than 80,000 BC health professionals can reference clear expectations set out in practice standards to eliminate Indigenous-specific racism and foster culturally safe care in their practice.
While the development process outlined for this practice standard may not perfectly align with every regulatory context, sharing insights, findings, and key lessons learned aims to offer valuable guidance for healthcare leaders, regulators, and policymakers engaged in this critical work. Furthermore, CPSBC acknowledges the importance of ongoing evaluation of the practice standard to ensure it is successful in achieving its intended purpose. Evaluation efforts will be held regularly by CPSBC, and results will be shared in a future article.
Furthermore, since the launch of this practice standard, CPSBC has been actively addressing the shortcomings identified in a critical review of its formal complaints process, with a focus on improving accessibility and cultural safety for Indigenous Peoples. The review, conducted by the Castlemain Group—an organization with expertise in Indigenous engagement—highlighted key areas for improvement, including accessibility, cultural safety, the distinction between formal and informal complaints, communication, resolution and accountability, and self-identification and data collection. Guided by an implementation plan, CPSBC has begun operationalizing the review’s recommendations to ensure the complaints process is more responsive, respectful, and inclusive.
Recognizing that meaningful change requires sustained effort, CPSBC remains committed to dismantling harmful systems and structures within its processes.
Limitations
This study has several limitations. First, the response rate to both physician surveys was low, which may limit the generalizability of findings. However, this is consistent with similar surveys conducted among health professionals and the insights obtained were consistent with qualitative data gathered during discussion circles, enhancing the validity of the identified themes. Second, participation was voluntary, raising the possibility of selection bias, as those most engaged with the issue may have been more likely to respond. Future research could aim to include a broader cross-section of practitioners through targeted outreach.
Supplemental Material
Practice Standard Development Process
Key Partners Contributing to the Standard’s Development
Core Concepts in the Practice Standard
Footnotes
Open Access: © 2026 The Authors. Published by the Journal of Medical Regulation. This is an Open Access article under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC, https://creativecommons.org/licenses/by-nc/4.0/), which permits use and distribution in any medium, provided the original work is properly cited, and the use is noncommercial.
Funding/support: N/A
About the Authors: Kelly Newton-Mari, RN, MSN, MPH, is a Policy and Engagement Lead, College of Physicians and Surgeons of British Columbia, Vancouver, BC, Canada. Susan Prins, MEd, is Director, Communications and Public Affairs, College of Physicians and Surgeons of British Columbia, Vancouver, BC, Canada. Hope Moir, RN, MPH, is a Policy Analyst, College of Physicians and Surgeons of British Columbia, Vancouver, BC, Canada. Heidi Oetter, MD, is a Medical Contractor, Registrar’s Office, College of Physicians and Surgeons of British Columbia, Vancouver, BC, Canada.
Author contributions: KNM: Co-led the project, served as primary author for the manuscript (wrote first draft). SP: Co-led and supervised the project and provided critical revisions of the manuscript. HM: Assisted with literature review and helped prepare the manuscript. HO: Co-led and supervised the project and provided critical revisions of the manuscript.
Other disclosures: N/A
Acknowledgements: The authors would like to acknowledge the Indigenous partners engaged in this work, including the consultants, Knowledge Keeper, registrants, and members of the public. Without your collaboration, leadership and insights, this work would not have been possible.
- Received January 30, 2024.
- Revision received August 6, 2025.
- Accepted September 10, 2025.
References
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