2019-01-03 calendar... · 2019-01-03 6 canadian association of occupational therapists association...
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2019-01-03
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Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists1
CAOT Professional DevelopmentPractice Evidence Webinar
Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists
Informed consent in occupational therapy: How colonization and coercion impact
access for Indigenous Peoples
Presenters:
Janna MacLachlan, OT Reg. (Ont.), PhD Candidate
Lisa Boivin, PhD Student
University of Toronto
January 8, 2019
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists4Photo credit: Cathy McNeil
Lisa Boivin
Video
Lisa Boivin
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists7
Lisa Boivin
Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists8
Was consent
available in...
Residential schools?
Sixties Scoop?
Tuberculosis sanitoriums?
Forced relocation and expropriation
of lands?
Slaughter of sled dogs?
Sterilization of Indigenous
women?
Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists9
Lisa Boivin
Video
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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“Consent is a process that requires a dialogue between the person proposing the service and the person giving consent for that service or service plan.” (COTO, 2017, p.2)
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Lisa Boivin
Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists12
Acknowledging emotional responses to the topic
•Common to feel a range of emotions, e.g., anger, guilt, defensiveness, sadness•Be gentle with yourself•Focus on reflexivity, listening and openness•Moving past emotional responses opens space for working together
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Key concepts for exploring this topic• Informed consent
• Colonization
• Approaches to practice
– Cultural safety
– Cultural humility
– Critical reflexivity
• Power and privilege
• Worldviews: Indigenous and Western
• Self-determination
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Colonization
• Process that employs modes of control to manage a population and/or expropriate land, resources and people (Tuck & Yang, 2012)
• Purpose is to secure wealth and/or privilege and power for colonizers (Tuck & Yang, 2012)
• Often enacted through policies and laws
• Key determinant of health for Indigenous Peoples (Allan & Smylie, 2015)
• Not over
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Cultural safety
• Aims to decrease health inequities and social injustices (Beagan, 2016)
• Aims to support respectful, trusting and ethical relationships between client and clinician (Gerlach, 2018)
• Requires understanding of historical and ongoing impact of colonization on Indigenous Peoples (Gerlach, 2018)
• Draws attention to power relations (Beagan, 2016)
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Cultural safety
• Culturally unsafe practice includes “any actions that diminish, demean, or disempower the cultural identity and well-being of an individual” (NAHO, 2008, p. 4)
• Assessed by clients (Beagan, 2016)
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Cultural humility
• Aims to redress power imbalances between clients and clinicians
• Critical reflexivity/self-evaluation is key element
• “Difference” is not in the client, but within the relationship between client and clinician
(Hammell, 2013)
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Cultural humility
• Clinician aspires to embody:
– Humility
– Flexibility
– Openness
• Client is expert
• Reflect on power dynamics in client-clinician relationships
• Assessed by clients
(Beagan, 2016)
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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United Nations Declaration on the
Rights of Indigenous
Peoples (2007)
“free, prior and informed consent”
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Worldviews
• “ways of thinking that are formed in social life and function to direct humans in their behavior and life” (Sartini & Ahimsa-Putra, 2017, p. 267)
• Formed within societies• Shapes perceptions of the world around us, like
a “mental lens” (Hart, 2010)• Made up of beliefs, values and understandings
of the world around us
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Western/Eurocentric worldview
● Places itself at the centre of history and action ● Universalism (e.g., one right way)
○ Normal vs abnormal
● Hierarchical order (e.g., humans hold power over other life and inanimate objects)
● Linearity (e.g., a beginning and an end)● Centrality of the individual● Objectivity (e.g., knowledge comes from
science)(Norris, 2014)
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Inuit Qaujimajatuqangit
• Diverse knowledges and knowledge sources, including:
– Experiential
– Empirical
– Spiritual
• Knowledge is dynamic, adaptable, evolves to solve problems
– Oral traditions support this as texts privilege one version
• Knowledge production is relational, incorporating experience and innovation
• No universal truths, knowledge is context-dependent
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Inuit Qaujimajatuqangit
• Holism
• Humility
• Relationships, resourcefulness, respect
• Maintaining harmony
• Planning for the future
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Language
• Represents intellectual system and way of being (McGrath, 2011)
• Were no words in many Indigenous languages for disability and rehabilitation prior to colonization
• Currently almost no commonly used Indigenous language words for occupational therapist across the country
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists25Lisa Boivin
Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists26
Lisa Boivin
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Self-determination
• “Indigenous peoples have the right to self-determination. By virtue of that right they freely determine their political status and freely pursue their economic, social and cultural development.”
(United Nations, 2007, p. 4)
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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APPLICATION TO PRACTICE
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Interactions with health and social services
Indigenous Peoples often actively avoid accessing health care services because of:
• Systemic racism (Allan & Smylie, 2015)
• Lack of respect for Indigenous worldviews
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Parents who do not participate as expected in early childhood programs may be judged as non-compliant (Gerlach, 2018)
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Indigenous children represent 7% of child population but 48% of children in foster care (Turner, 2016)
3
In interactions with health care services, Indigenous mothers experience fear of judgement and threat of child apprehension (Denison, Varcoe& Browne, 2014)
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Common assumptions
Indigenous clients can and should trust the health care system.
The Western worldview is good and normal.
Evidence-based practice and best-practice guidelines are appropriate for use with Indigenous peoples.
The approach and values of occupational therapy services are beneficial for and wanted by Indigenous families.
Our bodies and actions are neutral.
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Are informed consent, cultural safety and self-determination possible?
• MMSE required for dementia medication funding
• Standardized developmental assessment• Need for complete assessment before loaning a
wheelchair• Not giving or receiving gifts from clients• Prioritization tools• FIM completion linked to service funding
Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists33
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists34
Documentation
• Is this “objective” or is it underpinned with cultural values and beliefs?
• What are the implications of this?
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Documentation• What if we tried to inject cultural humility into
our documentation?
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists34
Documentation
• Is this “objective” or is it underpinned with cultural values and beliefs?
• What are the implications of this?
Association canadienne des ergothérapeutesCanadian Association of Occupational Therapists35
Documentation• What if we tried to inject cultural humility into
our documentation?
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COTO Standards for consent (2017)
a. Scope and reason for the
referral;
b. Purpose and nature of the
service;
c. Expected benefits and
relevant risks of proceeding with
the service;
d. Likely consequences of not proceeding
with the service;
e. Expected outcomes of the
service(s);
f. Alternative courses of action;
g. The right of the client to withdraw
consent at any time during the
process;
h. Financial arrangements
regarding payment for the service;
and,
i. Legal authority of the OT for
conducting the service.
An OT will ensure the client has been given all the information a reasonable person in
the same circumstances would require in order to make a decision about the services
including:
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Code of Ethics
(COTO, 2011)
OTs are guided by two fundamental values:
• Respect
• Trust
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Implications of free and
informed consent
being inaccessible
• Blocks:
– Indigenous self-determination
– Human rights
– Culture (Northern Public Affairs, 2016)
• Clients in a vulnerable position, feel threatened
• Power differential between therapist and client is maintained
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Practice implications
• Texts written for broad audiences do not always account for a diversity of contexts and worldviews
• Standardization can be colonizing, blocks diverse ways of knowing
• Following mainstream (Western) practice can override:
– Client-centred practice values
– Opportunities for cultural safety
– Opportunities to practice trauma-informed and anti-oppressive practice
– And block access to free and informed consent
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Service could be perceived as:
• Gatekeeping
• Value-imposing
• Threatening (e.g., social services)
• Intrusive (e.g., needing to ask ++ questions before loaning a wheelchair)
• Exercise of power
• Judgemental
• Lack of choice
• Getting in the way of being human
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In other words…
• Epistemic violence
• Cultural imperialism
• Intellectual or medical colonialism
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Key take-home
message
The colonial context in which the interaction between Indigenous client and occupational therapist occurs impedes access to free and informed consent.
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Allyship
• “an active, consistent, and arduous practice of unlearning and re-evaluating, in which a person of privilege seeks to operate in solidarity with a marginalized group of people”
(The Anti-Oppression Network, n.d.)
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Allyship
“Allies are people who recognize the unearned privilege they receive from society’s patterns of injustice and take responsibility for changing these patterns.”
(Bishop, n.d.)
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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What can OTs do?
• Aspire to allyship
• Listen, ask, offer
• Practice cultural safety, critical reflexivity, cultural humility –find and share concrete approaches to this!
• Reflect on power and privilege in client interactions
• Face discomfort
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What can OTs do?
• Value diverse worldviews
• Consider representation within profession
• Build relationships
• Seek opportunities for reconciliation and learn what reconciliation means to the people you are working with
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What can OTs do?
• Consider who/what expertise is best suited to a context and concern (it might not be us!)
• Consult practice guides (e.g., Gerlach, 2018; CAOT, 2018)
• Seek and value local knowledge and contextually relevant practice information (e.g., child development knowledge written by Inuit Elders)
• Resist, advocate with
– Document injustices
– Raise injustices with managers, those in power
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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ReferencesAllan, B. & Smylie, J. (2015). First Peoples, second class treatment: The role of racism in the
health and well-being of Indigenous peoples in Canada. Toronto, ON: the Wellesley Institute.
Beagan, B. L. (2016). Approaches to culture and diversity: A critical synthesis of occupational therapy literature, Canadian Journal of Occupational Therapy, 82(5), 272–282.
Bishop, A. (n.d.). Becoming an Ally. Retrieved from http://www.becominganally.ca/Becoming_an_Ally/Home.html
Boivin L. Image-based storytelling: a visual narrative of my family's story. 2018 09/17; 2019/1;190(37):E1112+.
Boivin L. Searching for Answers in the Garden of Bioethics. Ars Medica. 2015;11(1).
Canadian Association of Occupational Therapists. (2018). CAOT Position Statement: Occupational therapy and Indigenous peoples. Author: Ottawa, ON.
College of Occupational Therapists of Ontario. (2017). Standards for Consent. Author: Toronto, ON.
Crawford A. Dene and Western medicine meet in image-based storytelling. 2018 09/10; 2018/12;190(36):E1085+
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References
Denison, J., Varcoe, C., & Browne, A. J. (2014). Aboriginal women’s experiences of accessing health care when state apprehension of children is being threatened. Journal of Advanced Nursing, 70(5), 1105–1116.
Gerlach, A. (2018). Exploring Socially-Responsive Approaches to Children's Rehabilitation with Indigenous Communities, Families and Children. National Collaborating Centre for Aboriginal Health: Prince George, BC.
Hammell, K. R. W. (2013). Occupation, well-being, and culture: Theory and cultural humility. Canadian Journal of Occupational Therapy, 80(4), 224–234.
Hart, M. A. (2010). Indigenous worldviews, knowledge, and research: The development of an Indigenous research paradigm. Journal of Indigenous Voices in Social Work, 1(1), 1–16.
McGrath, J. T. (2011). Isumaksaqsiurutigijakka : Conversations with Aupilaarjuk Towards a Theory of Inuktitut Knowledge Renewal. Carleton University.
National Aboriginal Health Organization. (2008). Cultural Competency and Safety: A Guide for Health Care Administrators, Providers and Educators. Author: Ottawa, ON.
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ReferencesNorris, H. (2014). Colonialism and the rupturing of Indigenous worldviews of impairment
and relational interdependence: A beginning dialogue towards reclamation and social transformation. Critical Disability Discourse/Discours Critiques dans le Champ du Handicap 6, 53-79.
Northern Public Affairs. (2016). Volume 4 Issue 2: The Right to Free, Prior & Informed Consent. Retrieved from http://www.northernpublicaffairs.ca/index/volume-4-issue-2/
Sartini, S., & Ahimsa-Putra, H. S. (2017). Preliminary study on worldviews. Humaniora, 29(3), 265-277.
The Anti-Oppression Network. (n.d.). Allyship. Retrieved from https://theantioppressionnetwork.com/allyship/
Tuck, E., & Yang, K. W. (2012). Decolonization is not a metaphor. Decolonization: Indigeneity, Education, & Society, 1(1), 1–40.
Turner, A. (2016). Living arrangements of Aboriginal children aged 14 and under. Ottawa, ON: Statistics Canada.
United Nations. (2007). United Nations Declaration on the Rights of Indigenous Peoples. Retrieved from http://www.un.org/esa/socdev/unpfii/en/drip.html
MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.
2019-01-03
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Acknowledgements
Janna MacLachlan
Canadian Occupational Therapy Foundation
Northern Scientific Training Program
Lisa Boivin
University of Toronto Fellowship - Rehabilitation Science Institute
Banff Centre for Arts and Creativity
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Questions?
Janna MacLachlan, OT Reg. (Ont.)
Lisa Boivin
THANK YOU - Mahsi Cho
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MacLachlan, J., & Boivin, L. (2019, January 8). Informed consent in occupational therapy: How colonization and coercion impact access for Indigenous Peoples. In CAOT Practice Evidence Webinars series. Retrieved from http://www.caot.ca/site/pt/resources/odwebinars?nav=sidebar
These webinar materials are copyrighted to the presenters and may not be distributed or shared without the express permission of the presenters.