Table 3 Experiences in virtual care for first nations communities

Indigenous cultural safety was an essential component in the primary care case study. Elders and older adults living in the First Nations communities served by the primary care organization were identified as experiencing important challenges with virtual care, especially if they were not fluent in English. Members of the First Nations communities participating in the case study described themselves as being a part of a very visual culture. In this sense, visual culture refers to the importance of seeing as a way of knowing the world, and through visions and dreams, represents connection to the spiritual realm. Members of this community described themselves as visual learners, for whom knowledge is acquired through real-life, practical, and hands-on experiences. Beyond the importance of a visual culture, care was not understood by participants in the First Nations community as “transactional”, but rather as relational. Care and healing were understood to occur through co-presence, not through the exchange of diagnoses and advice. Connected to these understandings, in-person care was valued for its visual and relational presence because of the energy people bring to one another when they interact. Energy helps with the healing process, but with the rapid onset and widespread implementation of virtual care, First Nations communities had to adapt to offering their energies in a new and different way.

The rapid switch to virtual care as a result of the pandemic was interpreted by some members of the communities involved to mean that the delivery of health care services had halted, and providers did not want to see them. These beliefs were reinforced by the lived experiences of community members who had experienced health care racism and had been recipients of substandard care from a health care system that has historically refused to treat them. Community clinics had closed in March 2020, during the first wave of the COVID-19 pandemic, and due to the lack of effective communication about the switch to virtualized services, many patients did not realize there were alternative care options available for them. As a result, many issues that could have been resolved virtually went unaddressed and some patients were described to experience poorer health.

Initially, there was no plan in place to build the self-efficacy of First Nations communities to engage with virtual care in ways that reflect their culture. In order to implement such a large-scale change, the primary care organization required a more fulsome and repetitive communication strategy to inform clients about the switch to virtual care and increase awareness about the available digital health options being provided. In response to feedback from community members, the primary care organization spent a lot of time engaging with community members and leaders of the neighbouring First Nations communities. In general, the organization took its direction from the community leadership when it came to service provision, which now included virtual care. Having incorporated initial feedback about the challenges of virtual care, the organization sought out additional feedback and adapted their services to align with the needs and wishes of communities. An important example was that health care providers began conducting virtual visits from community clinics located in First Nations communities in order to demonstrate their commitment to being present in communities. The clinics were not necessarily open for community members to access, but the physical presence of providers in their local communities reflected the understanding by the organization of the cultural significance of having providers in close proximity to their clients.