Racism leads First Nations patients to leave emergency departments without completing care, study finds

First Nations patients face anti-Indigenous stereotypes and language, U of A researchers say.


Anti-Indigenous racism is leading First Nations patients in Alberta to leave emergency departments without receiving treatment more often than non-First Nations patients, according to new research published today in the Canadian Medical Association Journal

The study was co-led by Lea Bill, a registered nurse and the director of The Alberta First Nations Information Governance Centre and Patrick McLane, adjunct associate professor of emergency medicine at the University of Alberta, and was supported by seven Alberta First Nations and funded by the Canadian Institutes of Health Research

“There are multiple factors that influence the decision to leave the emergency department without being seen,” says Bill.

“Some of these include how First Nations people are treated while waiting to be seen, such as minimizing and dismissing the urgency of presenting symptoms, and the use of inappropriate language directed at them while in the emergency department.” Bill says some patients report feeling unsafe.

The team used a mixed quantitative and qualitative approach to investigate the reasons behind previous study results that showed more First Nations patients than non-First Nations patients leave emergency departments without completing care (6.7 per cent versus 3.6 per cent.)

“We knew that First Nations people were leaving more, so what this paper does is really dig into why,” explains McLane.

“We asked whether it could be anything else that would explain the differences, such as different hospital types or being more rural.This paper suggests that, no, the thing that is making the difference appears to be First Nations identity.”

The researchers analyzed records from nearly 12 million emergency department visits between 2012 and 2017, and shared the results through sharing circles, focus groups and telephone interviews with First Nations patients, health directors and emergency care providers. The researchers also conducted a quantitative analysis to control for factors such as ultimate diagnosis, geography and patient demographics other than First Nations status, and found none explained the difference in outcomes. 

“It matters if care isn’t completed,” says McLane. “Some of those people who left might have needed to be admitted to hospital for ongoing treatment or might have needed a referral to a specialist.”

The researchers report that about one in 20 people who left the emergency department early and returned within three days were then admitted to hospital. 

Relationships, education and process changes are key

The patients and providers who gave perspectives on why patients leave before completing care noted factors such as long wait times, poor communication and perceptions that the emergency department could not or would not address patient needs. 

Other reasons for leaving were specific to First Nations patients. Participants described providers relying on anti-Indigenous stereotypes and language, as well as feeling that they were being made to wait longer than non-First Nations patients who seemed to be in less urgent need of care. 

“This doctor didn’t even know me,” said one patient. “First thing he asked me was how much have you had to drink? What? I got up and walked out.”

The new findings aligned with the team’s previous publication of interviews with health-care providers, who reported that First Nations patients are "exposed to disrespect through tone and body language, experience overt racism, and may be neglected or not taken seriously.”

The First Nations partners have expressed a need for more First Nations-led health-care services and facilities to ensure quality care for First Nations members. 

Since 2023, the group has been working on an anti-racism intervention to ensure patients across Alberta receive equitable and dignified care. The University of Alberta and Alberta First Nations Information Governance Centre are working with the Blackfoot Confederacy Tribal Council, Stoney Nakoda Tsuut’ina Tribal Council, Bigstone Health Commission, Maskwacis Health Services, Paul First Nation Health Services, Yellowhead Tribal Council, and Kee Tas Kee Now Tribal Council. The project is funded by a $1.75-million grant from the CIHR.

McLane says the intervention will be tailored to local circumstances but — in general — building relationships, education and establishing new processes will be key to addressing the problem. 

“We think simulation education will be valuable, so not just lectures or reviewing materials but practising how you would have a conversation with a colleague who’s expressing a racist stereotype or how you would retain a patient in care if they feel they’re being discriminated against and are intent on leaving,” McLane says.

“I see a lot of desire among providers to address this anti-Indigenous racism.”