This article describes the experience of a pan-Canadian health organization that led a quality improvement collaborative focused on suicide prevention and life promotion with Indigenous communities in northern and remote regions of Canada. Working in partnership with a Guidance Group, it became clear that working in a relational way that is culturally safe and acknowledges "two-eyed seeing" helps to create an ethical space in which open dialogue and collaboration can occur. Relational work enabled the improvement teams in the Promoting Life Together Collaborative to co-develop life promotion activities within their communities. The primacy of building relationships is at the core of reconciliation with Indigenous peoples and is a key enabler of system transformation required to support the health and wellness of Indigenous communities across Canada.

Introduction: The Need for Indigenous Health Transformation

There is no single roadmap for how action should look, rather, it is engaging with a spirit of humility and collaboration that matters most. It requires that our actions acknowledge and account for the history, policies and processes that create power differentials and institutional discrimination that undermine equitable Indigenous health care. Acting ethically requires a commitment to accountable relationships. (Promoting Life Together Community Team Member, In Maar and the PLT Collaborative Guidance Group 2020: 35)

Racism and lack of cultural safety have exacerbated inequities in health that are mirrored in other facets of society. Numerous well-documented examples of systemic racism in the health system have come to light in recent years, highlighting significant quality and safety issues that have garnered national media attention and public outrage (Brian Sinclair Working Group 2017; Leyland et al. 2016; Turpel-Lafond and Johnson 2021). Our collective, overwhelming emotional response to detailed stories of the tragic deaths of Brian Sinclair and, more recently, Joyce Echaquan, leaves many things unsaid about the insidious nature of racism in the healthcare system, with many more everyday experiences well known to First Nations, Inuit and Métis peoples that are unrecorded and undocumented (Harding 2018; UBC 2020; Turpel-Lafond and Johnson 2021).

Addressing systemic racism and improving cultural safety requires system transformation that must be directed by First Nations, Inuit and Métis Peoples. Recent national dialogues and round tables led by the federal government have reinforced this sentiment that supports Indigenous health transformation by

transforming and expanding health systems to include practices that meet the unique needs of First Nations, Inuit and Métis Nation, including traditional approaches to health; [and] increasing Indigenous control and responsibility over the design, delivery and management of federally-funded health services. (Government of Canada 2021)

Other recommended actions include further training on cultural and patient safety, as well as mechanisms to hold systems and actors accountable (Government of Canada 2021). These actions require organizations and institutions to set "requirements for engaging people and communities with lived experiences of racism and other forms of discrimination, both in advisory capacities and as full partners, to work toward the ideals of reconciliation" (Browne et al. 2022: 223). Clearly, the key strategy in all these activities is meaningful and equitable collaboration with Indigenous peoples and organizations – a strategy that is based on equal and respectful relationships between First Nations, Inuit and/or Métis and non-Indigenous health system partners.

Over the past decade, Canada's policy directions have supported increased Indigenous control over health services in its health transformation initiatives (Hajdu 2022). However, it must be emphasized that if the goal of health transformation is to improve Indigenous health, it is Indigenous voices that must guide this process. Correspondingly, the Assembly of First Nations' Health Transformation Agenda underscores the need for a new era of reconciliation and collaboration that acknowledges governments and First Nations as full partners (Assembly of First Nations n.d.). The Truth and Reconciliation Commission's health-related Calls to Action echoes this assertion and calls for a process of acknowledging historic reasons for health and mental health disparities, dismantling jurisdictional barriers and developing health human resources capable of providing safe care (Truth and Reconciliation Commission of Canada 2015a). Sadly, Canada's past with Indigenous peoples is littered with ill-formed and often violent relationships, characterized by broken treaties and hostility toward Indigenous cultures, economies and worldviews (Angus 2015; Truth and Reconciliation Commission of Canada 2015b). The work of reconciliation cannot be advanced without an understanding of the truth and history of Indigenous peoples in Canada.

In this paper, we share what we have learned about respectful Indigenous/non-Indigenous relationship building using our experience of implementing a quality improvement collaborative focused on suicide prevention and life promotion in northern and remote regions across Canada. In what is known as the Promoting Life Together (PLT) Collaborative, a group of Indigenous and non-Indigenous organizations, Guidance Group members and coaches embarked on a two-year journey to learn how to foster effective collaborations to support life promotion in Indigenous communities and, in the process, moved toward health transformation (HEC 2022). The work of the PLT Collaborative highlights how prioritizing relationship building fosters the system transformation that is needed to meaningfully address systemic racism and improve cultural safety. Sharing our practice-based learning about the process of relationship building is not meant to provide a list of how-to instructions. Instead, we hope that readers will glean broad concepts to enact "two-eyed seeing" in the creation of a safe and ethical space for collaboration and come to understand the spirit that will help their journey on the path to reconciliation by centring Indigenous voices and worldviews. While we use the term Indigenous throughout this paper, we recognize that the teams that came forward in this collaborative worked predominantly in First Nations communities and that the Guidance Group members included First Nations and Métis partners. (See Appendix 1 here for a glossary of terms used in this paper.)

The Two Row Wampum belt: A traditional Indigenous approach to relationship development

We begin with a traditional Indigenous perspective on viable, ethical relationships between nations by retelling the events that unfolded at the beginning of the relationships between Indigenous people and newcomers to the part of Turtle Island (North America) known today as Canada. One of us (EC) has earned the privilege to share this story of the early relationships that unfolded between the Haudenosaunee people and Dutch newcomers in the year 1613:

The Two Row Wampum belt, the Gaswentha, tells the story of how the Haudenosaunee people have approached relationship agreements for peace and treaties with other nations since time immemorial. Understanding the teaching of the Gaswentha helps us to understand differences in the mindsets of how Indigenous people and the newcomers to Turtle Island have approached their relationship in the past.

The Haudenosaunee people understood creation and the life around them at the time that the newcomers arrived. They also understood that their ways were different from the ways of the newcomers. Although there were many commonalities, there were so many differences that there were in essence two minds and two worldviews. In order to create a good relationship that would respect these differences, they needed an agreement that would guide their relationship.

To do this, they used the Two Row Wampum [belt]. Its patterns can be interpreted to teach how to be in a respectful relationship with those we want to have peace with. There are deep and fundamental teachings within the two rows, but the basic interpretation from the Haudenosaunee perspective is this:

There are two purple rows on a white background. The one row of purple represents the newcomers in their ships and the other row is us in our canoes. We are all going down the river of life together. As we do this, it is important that we maintain our course and not pass into the path of the other. (See Figure 1.)

We have different ways, and it is important to respect the other's way and not to try to change the other. Each of us will live in equality and not try to change the other. Those in their ships had ways that were right for them. We in our canoes had ways that are right for us. Both are right.

We recognize that we have commonalities and basic needs that are the same. Those commonalities are the basis on which we form a good relationship as we build on the commonalties to form friendships.

Our thoughts were that we were equals, like brother and sister. But in the treaties that were written up, the newcomers referred to themselves as fathers and to Indigenous people as children. So with that perspective, they did not respect the differences and crossed over into our paths. This is the history that we refer to as colonization (HEC 2021h, 2021i).

This relationship and treaty of the Two Row Wampum happened more than 400 years ago. Yet the basic sentiment of newcomers deciding for Indigenous people in all facets of their lives – including what kind of healthcare system and services would be best for them, without creating space for the voice of Indigenous peoples, the individuals with lived experience and their families – is unfortunately still common practice. In the work of the PLT Collaborative, we reflected on the essence of the Two Row Wampum belt and its original intent that provides guidance for a better way forward together – where both are equal and work alongside each other in a relationship built on respect and trust.

Applying a contemporary two-eyed seeing approach to relationship development

The Canadian Foundation for Healthcare Improvement (CFHI) was a pan-Canadian health organization focused on healthcare improvement and system transformation. In 2020, CFHI amalgamated with the Canadian Patient Safety Institute to form Healthcare Excellence Canada (HEC). In 2017, CFHI hosted a meeting with the Canadian Northern and Remote Health Network (CNRHN), consisting of health leaders across northern provinces and territories, which identified a shared priority of suicide prevention in the north. CFHI worked together with CNRHN to develop a quality improvement learning collaborative to address this priority issue.

Knowing that partnerships with Indigenous organizations would be important to move this work forward, CFHI approached Thunderbird Partnership Foundation (https://thunderbirdpf.org/) and the First Peoples Wellness Circle (FPWC) (https://www.fpwc.ca/) to seek their collaboration in this work, setting them on a path to further build their relationships that has recently culminated in a three-party Commitment to Partnership agreement.

Early conversations provided an important learning that well-intended initiatives often have paternalistic overtones that privilege Eurocentric worldviews. For example, the initial CNRHN work lacked Indigenous perspectives and used a deficit-based model to address one of the consequences of colonialism in Indigenous communities: high rates of suicides (HEC 2021c). However, the complex nature of the intergenerational harms of colonial policies requires a more comprehensive, strengths-based and life-affirming response. Many Indigenous worldviews imbue an intrinsic humility that recognizes that we cannot truly prevent individuals from attempting suicides. However, in taking a strengths-based approach, we can collaborate to create the circumstances that invite people to live and foster hope, purpose, meaning and belonging as described in the First Nations Mental Wellness Continuum Framework¹ (Assembly of First Nations et al. 2015). Some of CFHI's early conversations with First Nations and Métis partners were daunting, and it took courage to ask and resolve questions about this relationship; for example, how would respect for and protection of Indigenous knowledge be operationalized in written contracts with First Nations and Métis coaches (HEC 2021d, 2021e)?

Navigating these processes required a commitment to learning about the coming together of two worldviews. Mi'kmaw Elder Albert Marshall has developed the concept of two-eyed seeing as a framework for the process we applied in the work of this collaborative. Two-eyed seeing is "learning to see from one eye with the strengths of Indigenous knowledges and ways of knowing, and from the other eye with the strengths of Western knowledges and ways of knowing … and learning to use both these eyes together, for the benefit of all" (Institute for Integrative Science and Health n.d.). The engagement with TPF and FPWC led to the development of a Guidance Group (HEC 2022) to strengthen and maintain the Indigenous voices in leading this collaborative and facilitate a two-eyed seeing approach (Bartlett 2012). A paradigm shift was embraced by the Guidance Group, moving from suicide prevention to that of life promotion, which launched the PLT Collaborative (HEC 2021c). PLT teams, some that comprised Indigenous and mainstream health system partners, began to embrace Indigenous worldviews, allowing them to focus on culturally based life promotion activities grounded in Indigenous ways of being and knowing.

The PLT Collaborative

The PLT Collaborative was conceptualized as a co-designed learning approach involving mainstream health organizations and Indigenous community organizations across northern, rural and remote parts of Canada. Teams were supported by First Nations and Métis coaches to deliver an initiative that addressed suicide prevention using a holistic First Nations life promotion and community wellness approach (Assembly of First Nations et al. 2015; HEC 2021o). Over the course of this project, CFHI (now HEC) deliberately documented our journey using Indigenous storytelling, research and evaluation methods (HEC 2021l, 2022).

The PLT Collaborative brought together six teams from northern and remote regions (see Table 1 for list of teams, projects and partner organizations) from across Canada, with a key focus on the development of equitable partnerships between regional health organizations and Indigenous communities as they were developing and implementing life promotion initiatives. An early focus in the collaborative was to develop organizational readiness for relationship building; that is, to partner with Indigenous organizations in a culturally safe manner that in itself creates the conditions for health transformation.

To support teams on their learning journeys, the teams received in-person site visits as well as regular teleconferenced coaching sessions facilitated by First Nations and Métis coaches who were experienced knowledge keepers. These coaches mentored the group, enhancing their capacity for relationship and partnership building with Indigenous communities and organizations, aiming to create environments that were safe and spirit-centred through honouring cultural protocols (HEC 2021f). These experiential learning strategies with coaches also included webinars that focused on topics such as applying two-eyed seeing and cultural safety (HEC 2021g).

The heart of collaboration: The Guidance Group

The design, delivery and evaluation of the PLT Collaborative was guided by a Guidance Group that was supported by CFHI. This group of leaders in First Nations and Métis health and wellness, community engagement, suicide prevention and life promotion met regularly to guide all aspects of the collaborative, including mentoring CFHI staff, meeting teams where they were at on their own journeys, advising on curriculum development, planning and reporting requirements, timelines, evaluation and knowledge sharing activities.

Importantly, the Guidance Group included a broad range of perspectives, including an Algonquin spiritual advisor, First Nations and Métis mental health leaders, a youth representative (HEC 2021n) and an external evaluator, as well as representatives from national mental health organizations. Both Indigenous rights holders and their supporting organizations, as well as individuals with lived experience, are represented in the PLT Collaborative Guidance Group (see HEC 2022 for interviews with various Guidance Group members).

Modelling relational practice in the Guidance Group

The group connected regularly through teleconference, virtual meetings and in-person gatherings. Their relational practice included beginning gatherings with an opening prayer or with a ceremony. Spending time together in ceremony was significant to honouring cultural protocols and provided experiential learning for all participants. Such spirit-centred practices enabled members to be emotionally and psychologically present and mindful, embrace an openness to Indigenous worldviews, enhance readiness and co-create culturally safe spaces. It allowed all members to learn, embrace discomfort that sometimes came with learning together and share their vulnerability.

Time was also set aside at the beginning of meetings for each member to speak and share within their comfort zone so that members could get to know each other or reconnect. Dedicating time and space to work in a relational way helped to build trust and understanding. Emphasis was placed on self-reflection and a respectful process that focused on "how" we do things together instead of predetermined meeting outcomes. This way of relational work through a Guidance Group was also modelled when working with the PLT teams as many Guidance Group members also acted as their coaches.

Relationship Building at the Core of Health Transformation

Fostering relationships was an ongoing process that pervaded all aspects of the PLT Collaborative, with a focus on building and nurturing trust-based relationships that could handle discomfort and thrive while we addressed and confronted difficult topics in Indigenous–settler relations. In the following sections, we outline aspects of the PLT Collaborative that supported relationship development, both within the Guidance Group and within PLT Collaborative teams.

Guiding principles

The story of the Two Row Wampum belt and the divergent interpretation by the Haudenosaunee people and Dutch settlers, as well as the early misunderstandings of the needs of the Indigenous and non-Indigenous collaborators, served as a reminder of how easily plans can be misinterpreted across cultures and different language systems. The Guidance Group, therefore, created seven principles to guide the transformative and reconciliatory approach to this work (see Box 1). These principles were foundational to the collaborative and served to ground the work as they reflected on the spirit of these principles in decision making, and their essence could be applied to workplans, implementation and evaluation. These principles also guided the PLT Collaborative teams to work in new and different ways and to develop their capacity to make meaningful systemic change.

A mentor model to support learning in action

The extensive lived experiences and strong community connectedness of many in the Guidance Group positioned these members to serve as coaches to the teams. Their insights and experiences brought a two-eyed seeing approach that allowed PLT teams to understand both the Indigenous and Western knowledges and perspectives. With the realization that relationship building and readiness would be foundational to the work of PLT Collaborative teams, the role of coaches intensified. Supportive coaching was offered during multiple 1–2 day site visits with PLT Collaborative teams and in community; this was augmented with regular coaching calls (1–2 hours in duration) throughout the 20 months of the collaborative. In some cases, coaches met with non-Indigenous staff on PLT Collaborative teams who requested further understanding of cultural practices, such as how to offer tobacco to an Elder. Practices that reflect reconciliation such as how to offer a meaningful and authentic land acknowledgement or how these staff can conduct themselves respectfully in Indigenous communities and with their mainstream partner organizations were also integrated into PLT teams through opportunities for experiential learning (HEC 2021f).

Coaches invited interested team members to ceremonies and offered teachings (HEC 2021j). They discussed unconscious bias and how one might break down cycles of poor relationships with Indigenous communities. The coaches also provided opportunities for team members to ask questions of people with lived experience in a safe space, without risking ruining relationships or losing face. Their mentoring ability made it possible to work through the struggles of individuals and teams on their learning journeys, regardless of the stage of learning or prior experience of each of the team members. Such extended "hands-on" mentoring resulted in an increased readiness and confidence of many individuals within PLT Collaborative teams to develop and sustain relationships between Indigenous and non-Indigenous partners, gain trust of community partners and show willingness to engage in the ongoing development of life promoting activities in the community. This type of relational work that was fostered within the PLT teams working with Indigenous communities mirrors the type of relational work embraced by the Guidance Group as together they designed, implemented and evaluated this learning collaborative.

Creating ethical space

One of the guiding principles was to respect the voice of Indigenous peoples in guiding the collaborative and the work of the PLT Collaborative teams, which required the creation of ethical space for meaningful communication that would lead to mutual understanding (Ermine 2007). The term ethical space has been applied by the Cree scholar Willie Ermine (2007) to denote a "cooperative spirit between Indigenous peoples and Western institutions" (p. 194) to create new currents of thought that flow in different directions and replace the archaic ways of interaction. The ethical space became important as the Guidance Group needed a sense of safety, wholeness and peacefulness as they made sense of the work of the PLT Collaborative, deliberating development of teams as documented in workplans and reports (HEC 2021b) and, eventually, began to make meaning of their collective experiences through evaluation activities (HEC 2021l).

The ethical spaces took many forms. Ethical space was established by adopting a relational meeting style where the group made space for ceremonial openings, attending ceremonies (HEC 2021a) and "check-ins" with each other at the beginning of meetings and used learning circle dialogue (Nabigon et al. 1999) to describe the progress of the PLT Collaborative (Maar and the PLT Collaborative Guidance Group 2020). Within the ethical space, topics were given the time they required instead of the time they were allotted on the agenda. The groups were prepared to stay for as long as it took to work through issues and come to consensus on how to move forward (HEC 2021m).

The coaches often supported the creation of ethical space together with CFHI staff, grounded by the words of the Elder and spiritual advisor. Creating an ethical space allowed the Guidance Group and PLT Collaborative teams to deal with their discomfort with difficult conversations in a good way. Difficult conversations included operationalizing respect for Indigenous voices (e.g., facilitating payment for Indigenous Elders in a respectful way) and culture (e.g., establishing accommodating protocols for smudging and ceremonial practices) and addressing unconscious bias (e.g., creating more flexible reporting mechanisms, performance measures and deadlines) and experiences of microaggressions and racism. Within the PLT Collaborative teams that consisted of Indigenous and non-Indigenous partners, ethical space allowed difficult conversations to emerge – an openness for dialogue and an opportunity to reflect on what was heard, in essence, offered a different way of being and doing together, which is at the heart of system transformation.

As the formal collaborative program came to a close, the concept of an ethical space was also essential in the creation of a knowledge translation strategy. Early on, the Guidance Group realized the importance of transmitting the learnings of the PLT Collaborative and honouring the authentic voice. They recognized that Indigenous teachings and knowledge were woven throughout the PLT Collaborative into the coaching, the webinars and the work of the teams themselves. The co-creation of a knowledge sharing protocol helped to delineate what would be appropriate to share and in what format. A protocol was needed to acknowledge the difference in knowledge translation expectations commonly found in mainstream quality improvement and evaluation approaches that may be inconsistent with Indigenous worldviews. The strength of relationships formed already within the Guidance Group and maintaining ethical space allowed for the co-creation of a knowledge sharing protocol (HEC 2021k) that guides the sharing of many knowledge products, including webinars, audiovisual materials and written materials (including this paper) (Maar and the PLT Collaborative Guidance Group 2021).

By grounding the work of the PLT Collaborative in guiding principles and by creating experiential learning conditions through a mentorship model, the PLT teams were enabled to begin work in a way that prioritized relationship building and the creation of a safe and ethical space in which to work together on life promotion activities. For many teams, this work has started them on a path to build community wellness together and has formed a foundation of ongoing transformational activities that are rooted in community and culture (Maar and the PLT Collaborative Guidance Group 2020). As a pan-Canadian health organization, the PLT Collaborative – developed and implemented together with a Guidance Group – has set us on a path that is rooted in building and sustaining equitable relationships with First Nations partners and seeking to expand our relationships with Métis and Inuit partners to advance the work of truth and reconciliation and that of health system transformation.

Conclusion: The Paradigm Shift toward Health Transformation

Developing the capacity for relationship building between Indigenous and non-Indigenous health organizations and communities is an important part of reconciling a troubled history in Canada and to support transformative change that will improve the health and wellness of Indigenous peoples. We were inspired to share the story of the PLT Collaborative to highlight the significance of relationship building as the foundation to creating space for Indigenous voices to shape the services and programs that address their health needs. The PLT Collaborative represents a collective learning journey that supported Indigenous and non-Indigenous teams to work in relational ways. Our story also illustrates that relationship building is at the core of health transformation. Through relationship building, the PLT Collaborative is also a story of paradigm shifts that enabled health system improvement in ways that move toward reconciliation and recognizes the trauma of Indigenous peoples as a result of colonization. Our approach is not new; it has been shared by Indigenous peoples on Turtle Island for hundreds of years (Figure 2).

Our story paints a picture of health transformation that will challenge all readers to view their relationship development via the Two Row Wampum belt as "we travel the river of life in peace with each other as equals. This agreement shall stand for as long as the grass shall grow, as long as the rivers flow and as long as the sun shines" (Blanchard 1980: 124).

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