Nursing Leadership

Nursing Leadership 35(4) January 2023 : 68-84.doi:10.12927/cjnl.2023.27072
Special Focus On Nursing Retention

Pathways for Healthcare Organizations to Strengthen Indigenous Nurse Retention

Michelle Monkman and Jacqueline Limoges

Abstract

Call to Action #92 encourages corporations to apply the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) as an organizational framework and provides concrete strategies to guide policy and operational activities to increase Indigenous participation in the economy (Truth and Reconciliation Commission of Canada 2015b; UN 2007). Call to Action #92 and the UNDRIP are explored to provide strategies to decolonize mainstream healthcare organizations and promote workplace structures that assist Indigenous nurses in thriving in the work setting. The recommendations in this synthesis paper can be used by healthcare organizations to support Indigenous reconciliation in Canada.

Pathways for Healthcare Organizations to Strengthen Indigenous Nurse Retention

The Truth and Reconciliation Commission of Canada (2015a) outlines pathways to support Indigenous1 health and equity through 94 calls to action, asserting that all Canadians have a responsibility to enact the recommendations. “Call to Action #92” is the focus of this discussion as it outlines how institutions, such as those that make up the health system, can support Indigenous Peoples as full participants in the economy. Call to Action #92 encourages corporations to apply the United Nations Declaration on the Right of Indigenous Peoples (UNDRIP) as an organizational framework and provides concrete strategies to guide policy and operational activities (Truth and Reconciliation Commission of Canada 2015b). As healthcare institutions are large organizations that run like businesses, addressing Call to Action #92 and implementing UNDRIP can impact policies and procedures that drive corporate functions such as planning, leadership approaches and influencing organizational culture. Effective policies and procedures can increase and maintain Indigenous representation in the Canadian health workforce (as set out in “Call to Action #23”) (Truth and Reconciliation Commission of Canada 2015b). Indigenous representation in the health workforce will result in processes that are more responsive to the needs of Indigenous Peoples and, thus, assist in addressing inequities (Bourque Bearskin et al. 2020; Brockie et al. 2023; CNA and Aboriginal Nurses Association of Canada 2014; McCalman et al. 2019; Vukic et al. 2012). Enacting Call to Action #92 is particularly important, as efforts to address structural racism within institutions will advance human rights for Indigenous Peoples at individual, community and systemic levels (Stout et al. 2021). In turn, other calls to action that directly address healthcare, such as #18 to #24, can be further supported.

Indigenous nurses are gradually joining the health workforce in Canada, where numbers rose from 2.4% in 2011 to 3.0% in 2016 (University of Saskatchewan College of Nursing 2018). However, Indigenous nurses face problems in the work setting, such as racism, social exclusion and barriers to exercising self-determination and sovereignty when practising within mainstream healthcare settings (Bourque Bearskin et al. 2020; Brockie et al. 2023; CNA and Aboriginal Nurses Association of Canada 2014; Logan 2014; Stout et al. 2021; Vukic et al. 2012). Call to Action #92 and UNDRIP are explored in this synthesis paper to assist organizations in creating workplaces that can recruit and retain Indigenous nurses where they can thrive. A case study illustrating the achievements and lessons learned by a Canadian healthcare organization enacting Call to Action #92 is used to demonstrate targeted strategies and outcomes. Developing Indigenous-informed and equity-based initiatives is a powerful gesture of reconciliation (Bourque Bearskin et al. 2020; Brockie et al. 2023; Browne et al. 2016; Stout et al. 2021) and will signal commitment to Indigenous health equity.

Background

Colonization in Canada continues to have devastating impacts on Indigenous Peoples as they fall short in every measure of health as compared with their non-Indigenous counterparts (Allan and Smylie 2015; Bourque Bearskin et al. 2020; Brockie et al. 2023; MacDonald and Steenbeek 2015; McCalman et al. 2019; Reading 2018). Colonialism in the Canadian healthcare systems manifests as racism, social exclusion and restrictions to self-determination and sovereignty (Allan and Smylie 2015; Bourque Bearskin et al. 2020; Brockie et al. 2023; Browne et al. 2016; CNA and Aboriginal Nurses Association of Canada 2014; Dykhuizen et al. 2022; Vukic et al. 2012). When employed in mainstream healthcare contexts, Indigenous nurses “experience otherness”, that result in feelings of exclusion (Brockie et al. 2023; CNA and Aboriginal Nurses Association of Canada 2014; Vukic et al. 2012: 3), which are cited as a factor for Indigenous nurses' resignation from nursing positions (Stout et al. 2021; Vukic et al. 2012). Exclusion and power relations are evident when Indigenous Peoples' preferences for collective and wholistic approaches to health are sidelined by biomedical, individualistic and task-based approaches that dominate mainstream healthcare institutions (Benoit et al. 2019; McCalman et al. 2019; Richardson and Murphy 2018). With the lack of Indigenous representation in nursing and in leadership positions, racism and limits to self-determination continue uninterrupted and Indigenous Peoples continue to experience implicit and explicit discrimination (Allan and Smylie 2015; Bourque Bearskin et al. 2020; Brockie et al. 2023; CNA and Aboriginal Nurses Association of Canada 2014; McCalman et al. 2019; Vukic et al. 2012).

These ongoing colonial structures also directly impact Indigenous Peoples seeking healthcare. For instance, they will delay accessing healthcare for fear of discrimination, and when they do access care, the care is of lower quality when compared with the care received by most other Canadians (Allan and Smylie 2015; Stout et al. 2021). Indigenous nurses who witness patients experiencing these harms and colonial structures are also impacted (Stout et al. 2021; Joy-Correll et al. 2022; Vukic et al. 2012). Cumulatively, these exclusionary practices reinforce the status quo of colonialism, deficit-based discourses and healthcare systems that fail to meet the needs of Indigenous Peoples as patients, and nurses as employees, ultimately impeding reconciliation (Allan and Smylie 2015; Bourque Bearskin et al. 2020; Brockie et al. 2023; Browne et al. 2016; CNA and Aboriginal Nurses Association of Canada 2014; Symenuk et al. 2020; Vukic et al. 2012).

There are growing calls for anti-Indigenous racism, culturally safe healthcare and overall decolonization of healthcare systems (Allan and Smylie 2015; Richardson and Murphy 2018; Stout et al. 2021; Vukic et al. 2012). Indigenous nurses are uniquely positioned to lead decolonization processes and to address Indigenous health inequities. With adequate policy and structural supports, Indigenous nurses can help identify colonial structures within healthcare and implement decolonizing approaches to care (Bourque Bearskin et al. 2020; Brockie et al. 2023; CNA and Aboriginal Nurses Association of Canada 2014; Stout et al. 2021; Vukic et al. 2012). Their worldview enables them to deliver culturally safe care and to contribute to public health policy that supports caring for Indigenous Peoples (Bourque Bearskin et al. 2020; Brockie et al. 2023; CNA and Aboriginal Nurses Association of Canada 2014; McCalman et al. 2019; Vukic et al. 2012). Therefore, increasing and retaining Indigenous representation in the Canadian health workforce is one of the recommendations (Call to Action #23) made by the Truth and Reconciliation Commission of Canada (2015b). Pathways outlined in Call to Action #92 can impact corporate structures that enhance representation of Indigenous nurses, which can help drive Call to Action #23.

Call to Action #92 recommends that the UNDRIP be applied as an organizational framework in Canada's corporate sector (Truth and Reconciliation Commission of Canada 2015b). The UNDRIP was created in response to the growing awareness of ongoing global Indigenous oppression and resulting inequities (UN 2007). Adopted into the Canadian Constitution in 2021 (Government of Canada 2022), the UNDRIP incorporates existing global human rights legislation and proposes a charter of recommendations that are minimum standards for countries to reconcile the ongoing damage from colonial-based policies and processes (UN 2007). UNDRIP is rooted in self-determination and sovereignty, which are achieved when Indigenous Peoples freely exercise and express political, social and cultural practices and have the ability to apply a decolonizing lens to processes and policies (Bauder and Mueller 2021; Bourque Bearskin et al. 2020). Addressing Call to Action #92 and applying the UNDRIP framework in healthcare settings can create organizational and corporate conditions that help dismantle colonial structures. Policies, organizational conditions and workplace supports that specifically incorporate UNDRIP can assist Indigenous nurses in promoting health, reconciling western biomedical and Indigenous worldviews and lead to anti-Indigenous racism initiatives within mainstream healthcare systems. Enacting Call to Action #92 and UNDRIP can promote the full participation of Indigenous nurses in the nursing workforce. Recruiting and retaining Indigenous nurses can help to address the nursing shortage, bolster Indigenous-inclusive work environments (Joy-Correll et al. 2022; Vukic et al. 2012) and promote culturally safer care for patients. The actionable items outlined in Call to Action #92 (Truth and Reconciliation Commission of Canada 2015b) can guide healthcare leaders to create work environments where Indigenous nurses can thrive (Box 1).


Box 1. Actionable items in Call to Action #92
  1. Commit to meaningful consultation, building respectful relationships and obtaining the free, prior, and informed consent of Indigenous peoples before proceeding with economic development projects.
  2. Ensure that Aboriginal peoples have equitable access to jobs, training, and education opportunities in the corporate sector and that Aboriginal communities gain long-term sustainable benefits from economic development projects.
  3. Provide education for management and staff on the history of Aboriginal peoples, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, Indigenous law and Aboriginal-Crown relations. This will require skills-based training in intercultural competency, conflict resolution, human rights, and antiracism.


Source: Truth and Reconciliation Commission of Canada (2015b: 10).

 

Strategies to Enact Call to Action #92

Implementing the actionable items in Call to Action #92 (Box 1) will require strategies that decolonize healthcare and address systemic racism. The following four proposed, intersecting strategies can generate compounding benefits for the recruitment and retention of Indigenous nurses and ultimately advance Indigenous health equity:

  • Identifying and challenging deficit-based discourse is crucial to changing mindsets and addressing Indigenous-specific racism.
  • New approaches to collaboration and engagement will ultimately lead to new models of healthcare delivery that include the perspectives of Indigenous nurses and communities.
  • Incorporating Indigenous worldviews into policies, education and leadership guide effective change.
  • Education to support cultural safety will provide the necessary foundation for healthcare providers to support Indigenous health equity.

Identify and Challenge Deficit-Based Discourse

Structural racism and social exclusion of Indigenous Peoples have perpetuated deficit-based discourses that create harms and impede reconciliation (Allan and Smylie 2015; Bourque Bearskin et al. 2020; Brockie et al. 2023; Browne et al. 2016; Dykhuizen et al. 2022). When unconscious bias and deficit-based mindsets are not contested or redressed, and when they are left to manifest within relationships with co-workers, Indigenous nurses are negatively impacted (Stout et al. 2021; Joy-Correll et al. 2022; Vukic et al. 2012). Furthermore, when Indigenous nurses see racism and ongoing colonialism impact Indigenous patients and when they witness lower quality of care and health outcomes for Indigenous Peoples, this exacerbates the situation for them (Allan and Smylie 2015; Benoit et al. 2019; Bourque Bearskin et al. 2020; Vukic et al. 2012). Efforts to name and shift the deficit-based discourses of Indigenous Peoples are needed to interrupt structural racism and promote Indigenous equity (Allan and Smylie 2015; Bourque Bearskin et al. 2020; Browne et al. 2016; CNA and Aboriginal Nurses Association of Canada 2014; Stout et al. 2021). Reflexive questions such as the examples posed below can propel individuals to consider their own implicit biases and create a sense of urgency for the need to shift the deficit-based discourses imposed upon Indigenous Peoples:

  • Have I ever been afraid to access healthcare for fear of experiencing discrimination or receiving a lower standard of care because of my race?
  • Is my life expectancy reduced because of my ethnicity?
  • How do deficit-based ideas enter into my practice and impact the ways I care for Indigenous Peoples?

Healthcare organizations and healthcare providers must take care to ensure that they respect the diversity and distinctness between Indigenous Peoples, communities and nations in Canada (Bourque Bearskin et al. 2020; Browne et al. 2016; CNA and Aboriginal Nurses Association of Canada 2014; Richardson and Murphy 2018).

New Approaches to Indigenous Collaboration and Engagement

The relationships between healthcare and Indigenous Peoples are complex and continue to be negatively impacted by the ongoing consequences of government-imposed assimilation-based policies such as the Indian Act and residential schools (MacDonald and Steenbeek 2015; Stout et al. 2021). Nurses' particular involvement in colonial harms has recently been explored, demonstrating the need for the nursing profession to understand their past and current roles in colonizing practices (Symenuk et al. 2020). Although there are Indigenous-led health systems (CNA and Aboriginal Nurses Association of Canada 2014; Government of Canada 2021), Indigenous Peoples will always need to access mainstream health services, and these services need to be oriented to address health disparity, equity and wellness (Allan and Smylie 2015; Benoit et al. 2019; Dykhuizen et al. 2022; Stout et al. 2021; Vukic et al. 2012). Therefore, healthcare organizations seeking to offer relevant health services and address Indigenous inequities require support through diverse partnerships with Indigenous communities and nurses (Bourque Bearskin et al. 2020; Brockie et al. 2023; Browne et al. 2016; McCalman et al. 2019).

Organizational structures that ensure collaboration and engagement with Indigenous communities during the planning, delivery and evaluation of Indigenous-led and mainstream health services are crucial (Allan and Smylie 2015; Bourque Bearskin et al. 2020; Browne et al. 2016; Richardson and Murphy 2018). Acting upon Call to Action #92 and implementing UNDRIP can provide the infrastructure and supports for Indigenous nurses to lead these collaborations in healthcare organizations. The full commitment of all organizational staff, including management and leadership, is needed as new approaches to interacting with Indigenous Peoples, nations and communities will unfold when self-determination and sovereignty become the focus (Bourque Bearskin et al. 2020; Brockie et al. 2023; Browne et al. 2016; McCalman et al. 2019).

For example, before engaging with Indigenous communities, trust must be established (Bourque Bearskin et al. 2020; Browne et al. 2016; McCalman et al. 2019). Ensuring effective and meaningful engagement that is inclusive of consent and consultation will increase trust among Indigenous patients, nurses and communities and result in reciprocal relationships that will help to meet Call to Action #92a (Box 1) and advance reconciliation. For example, before implementing new health services or revising existing programs, consultation with Indigenous Peoples will ensure that these services and programs promote access to care and build upon the strengths of Indigenous communities and existing community programs. Another strategy to facilitate effective relationships with Indigenous Peoples is to apply Indigenous methodologies when engaging with Indigenous communities (Hart 2010; Kovach 2009; Wilson 2008). The 4Rs (Kirkness and Barnhardt 1991) were initially introduced to guide the relationship between educational institutions and First Nations' learners to increase academic success. These 4Rs – namely, respect, relevance, reciprocity and responsibility – can be applied as guiding principles when interacting and collaborating with Indigenous Peoples. As connections to the community are established, healthcare organizations can benefit from the synergies of existing Indigenous staff and community knowledge to create effective programs that are culturally safer.

Incorporating Indigenous Worldviews into Policies, Education and Leadership

Effective policies and opportunities aligned with Call to Action #92b (Box 1) can support equitable access to various roles within healthcare. Decolonizing all levels of healthcare organizations will bring balance to dominant practices embedded in Canadian mainstream healthcare systems to promote Indigenous self-determination and sovereignty (Bourque Bearskin et al. 2020; Brockie et al. 2023; CNA and Aboriginal Nurses Association of Canada 2014). Incorporating Indigenous ways of knowing and knowledge into all processes and policies to establish Indigenous-led health programs will create openings and opportunities. This will also support inclusion and equity while also enhancing mainstream healthcare processes that benefit Indigenous nurses and patients (Brockie et al. 2023; Doria et al. 2021; Joy-Correll et al. 2022; McCalman et al. 2019; Richardson and Murphy 2018). For example, healthcare organizations can use co-development approaches to indigenize health education to ensure relevancy to the intended audience while promoting environments where Indigenous Peoples can feel some sense of belonging (CNA and Aboriginal Nurses Association of Canada 2014; Ragoonaden and Mueller 2017).

A strategy for creating inclusive work environments and promoting culturally safer care is Etuaptmumk, or “Two-Eyed Seeing”. This concept was developed by Mi'kmaw Elder Albert Marshall and supports the inclusion of Indigenous worldviews into healthcare settings (Bartlett et al. 2012; Bourque Bearskin et al. 2020; CNA and Aboriginal Nurses Association of Canada 2014). Etuaptmumk, or Two-Eyed Seeing, is where the healthcare provider intentionally acknowledges and places equal value on the strengths apparent in both western and Indigenous knowledges and ways of knowing, and then interweaves the strengths of each paradigm into the delivery of care (Bartlett et al. 2012; Bourque Bearskin et al. 2020). Indigenous nurses routinely integrate westernized and Indigenous worldviews into their practice (Bourque Bearskin et al. 2020; CNA and Aboriginal Nurses Association of Canada 2014). However, through Indigenous consultation and education, non-Indigenous healthcare professionals can learn to apply a Two-Eyed Seeing approach that will demonstrate respect and reciprocity and enhance care to Indigenous clients and families (Bartlett et al. 2012; Bourque Bearskin et al. 2020; CNA and Aboriginal Nurses Association of Canada 2014). Promoting Indigenous perspectives will create inclusive work environments where Indigenous nurses feel respected and valued. Strengthening engagement with Indigenous Peoples and nurses will aid in workforce retention, ultimately assisting healthcare organizations in meeting Call to Action #92b.

Promoting Indigenous nurses into formal leadership positions and providing training and support so that they can succeed in their roles provide strong signals of commitment for changes (Brockie et al. 2023; CNA and Aboriginal Nurses Association of Canada 2014; McCalman et al. 2019; Richardson and Murphy 2018; Vukic et al. 2012). Strong Indigenous leadership will create work environments that are inclusive and representative of the nursing workforce demographics. Indigenous nurses and organizations will benefit from Indigenous leadership. (Brockie et al. 2023; CNA and Aboriginal Nurses Association of Canada 2014; Vukic et al. 2012). By seeing Indigenous nurse representatives in formal leadership roles, existing Indigenous nurses within the organization will feel safer in voicing their unique perspectives, inevitably supporting self-determination. Healthcare organizations can be guided by Indigenous nurse leaders to enact Call to Action #92 and to bridge western and Indigenous worldviews resulting in systems that are more responsive to both Indigenous culture and community needs (Bourque Bearskin et al. 2020; Brockie et al. 2023; CNA and Aboriginal Nurses Association of Canada 2014; McCalman et al. 2019; Vukic et al. 2012). The 4Rs approach to consultation and education (Hart 2010; Kovach 2009; Wilson 2008) and strengths-based approaches can guide leadership action to challenge the status quo and shift away from dominant, deficit-based, biomedical approaches that are traditionally used to serve Indigenous populations (Bourque Bearskin et al. 2020; Brockie et al. 2023; Browne et al. 2016).

Education to Support Cultural Safety

Call to Action #92c emphasizes the need for education related to colonization and Indigenous rights and governance, and asserts the need for skills-based training in “intercultural competency, conflict resolution, human rights and anti-racism” (Truth and Reconciliation Commission of Canada 2015b: 10). Article 24 of the UNDRIP (UN 2007) declared that Indigenous Peoples have the right to accessible, culturally safe healthcare services; to freely exercise traditional approaches to health; and to enjoy the “highest attainable standard of physical and mental health” (p. 18). Addressing the existing inequities in the Indigenous social determinants of health (Reading 2018) is necessary to fulfill the requirements of Article 24 of the UNDRIP (UN 2007). The Indigenous social determinants of health extend beyond the factors that influence the health of the dominant culture and include colonialism, racism, social exclusion and lack of self-determination (Reading 2018). Allan and Smylie (2015) asserted that Indigenous health cannot be understood or addressed if the historical and ongoing impacts of colonization are not considered within the delivery of care. Therefore, education and skills-based training can include the Indigenous determinants of health, cultural safety and the implementation of UNDRIP. Education that explains how eligible First Nations and Inuit people access healthcare services covered by Indigenous Services Canada in addition to mainstream healthcare (Government of Canada 2021) and how to navigate multiple systems can promote accessibility. Understanding the factors that drive disparities in Indigenous health can assist in determining an appropriate, equity-oriented intervention (Browne et al. 2016; Richardson and Murphy 2018).

Ongoing education is necessary so that healthcare providers can continually strengthen their ability to promote cultural safety (Bourque Bearskin et al. 2020; CNA and Aboriginal Nurses Association of Canada 2014; Doria et al. 2021; Joy-Correll et al. 2022; McCalman et al. 2019). Cultural safety is an outcome to care that balances power within the therapeutic relationship by empowering the client to be the sole evaluator as to whether culturally safety is achieved (Northern Health Indigenous Health n.d.; Poitras et al. 2022; Ward et al. 2016). Therefore, cultural safety is not an intervention that can be applied by healthcare providers but instead is achieved through the application of relevant approaches when caring for and interacting with Indigenous Peoples (Bourque Bearskin et al. 2020; Browne et al. 2016; Poitras et al. 2022). Organizations striving to promote culturally safe environments should include Indigenous cultural safety training and an evaluative process to ensure accountability, sustainability and critical praxis within the existing workforce and structures of the organization (Northern Health 2020; Northern Health Indigenous Health n.d.). Indigenous cultural safety training is a specific recommendation made in Call to Action #92c (Box 1) and has been cited as a “way forward” in advancing Indigenous health (Ward et al. 2016: 29). Indigenous cultural safety training strives to address Indigenous stereotypes, prompt self-reflection and minimize power imbalances present in therapeutic healthcare interactions and other social processes (Browne et al. 2016; Northern Health 2020; Ward et al. 2016).

Case Study: The First Nations, Inuit and Métis Program

The following case study describes concrete strategies to illustrate how one healthcare organization is addressing Call to Action #92. Formally known as Saint Elizabeth Health Care, SE Health is a not-for-profit, home health organization in Canada and was established in 1908 with four visiting nurses caring for underserved and at-risk populations in Toronto, ON (SE Health 2022). SE Health's commitment to their values and vision led to the establishment of the First Nations, Inuit and Métis Program in the early 2000s. The establishment of the First Nations, Inuit and Métis Program provides a corporate structure and policies specifically aimed at enhancing opportunities for Indigenous nurses to contribute to the design and delivery of Indigenous health initiatives. The mission of the SE First Nations, Inuit and Métis Program (2023) is Working Together for Indigenous Health. The SE First Nations, Inuit and Métis Program (2023) is guided by the principles of the 4Rs and relationship to foster effective and respectful Indigenous collaboration and engagement as outlined in Call to Action #92. The SE First Nations, Inuit and Métis Program team works virtually and is spread out all through Canada.

SE Health recognized the value in situating Indigenous nurses into leadership roles and enhancing Indigenous representation in the workforce. The First Nations, Inuit and Métis director is a First Nations nurse with an extensive work history that includes employment at all levels of government and has worked in many rural, remote and isolated Indigenous communities. In collaboration with the program lead (MM), the director guides a team that is committed to acting upon the Truth and Reconciliation's Calls to Action (SE First Nations, Inuit and Métis Program 2023). The SE First Nations, Inuit and Métis team has 19 full-time staff comprising 12 nurses, seven of whom are Indigenous. This equates to 58.3% of Indigenous nurse representation and exceeds the national average of 3% (University of Saskatchewan College of Nursing 2018). Having a high rate of Indigenous nurse representation allows the First Nations, Inuit and Métis Program team to effectively engage and collaborate with Indigenous individuals, families, communities and organizations in all aspects of service delivery. These corporate structures demonstrate a positive regard for Indigenous nurses, challenge the deficit-based discourse and assist SE Health to advance the calls to action.

Designing Services through Collaboration and Engagement

The First Nations, Inuit and Métis Program team uses a co-development approach with Indigenous organizations and communities to design innovative and culturally responsive health solutions and services to their identified needs (SE First Nations, Inuit and Métis Program 2023). These health solutions and services address access to care and align with existing programs and models of care to build upon community strengths (SE First Nations, Inuit and Métis Program 2023). For example, to provide high-quality, equitable and culturally safe palliative and end-of-life (PEOL) care for Ontario First Nations, the First Nations, Inuit and Métis Program led the development of Community Voices (First Nations, Inuit and Métis Program 2022). Community Voices is a report that outlines strategies and recommendations to help address the long-standing inequities and gaps in PEOL care for Ontario First Nations (First Nations, Inuit and Métis Program 2022). Funding for the report was provided by Indigenous Services Canada. In the spirit of reciprocity, SE Health provided additional supports to develop the framework by permitting the SE First Nations, Inuit and Métis team to leverage SE Health's PEOL advanced care consultants and provided additional funding through the Saint Elizabeth Foundation.

To ensure that the strategies and recommendations made within Community Voices were Indigenous informed, the First Nations, Inuit and Métis Program team facilitated in-depth collaboration and engagement with community-based healthcare providers involved in the delivery of PEOL care in Ontario First Nations (First Nations, Inuit and Métis Program 2022). In utilizing a strengths-based approach and challenging deficit-based discourses, surveys were used to identify wise practices occurring in communities. This approach highlighted that despite limited resources, Ontario First Nations had always found ways to creatively address gaps and to facilitate some PEOL care (First Nations, Inuit and Métis Program 2022). Prior to the finalization of Community Voices, all participants were invited to review and provide feedback on the report to ensure authenticity and reciprocity in the data collection and analysis process (First Nations, Inuit and Métis Program 2022). This example demonstrates consultation, use of strengths-based approaches and Indigenous nurse representation to create health service solutions for PEOL care that are innovative, accessible and culturally safe.

Incorporating Indigenous Worldviews into Policies, Education and Leadership

To support healthcare providers and organizations serving Indigenous Peoples to meet Call to Action #92b, SE Health created accessible vocational and professional development courses. Through the support of the Saint Elizabeth Foundation, the SE First Nations, Inuit and Métis Program team offers 18 online and free professional development courses to enhance skills required to meet Indigenous-specific health needs (SE First Nations, Inuit and Métis Program 2023). To date, more than 6,000 healthcare providers from over 700 First Nations, Inuit and Métis communities and organizations have participated in the online professional development courses (SE First Nations, Inuit and Métis Program 2023). SE Health's online courses address a critical gap in the provision of culturally safe, accessible, continuing education for healthcare providers working in rural, remote and isolated communities (CNA and Aboriginal Nurses Association of Canada 2014).

In addition to online learning, SE Health offers in-person professional development courses and entry-level vocational programs, including the Community Health Representative (CHR) course (SE First Nations, Inuit and Métis Program n.d.). The CHR role is a crucial link between healthcare providers and community members, and educating for this role strengthens capacity within communities. Most vocational programs and in-person professional development sessions are led by Indigenous nurses who have lived and worked in Indigenous communities. A safe environment is promoted when Indigenous learners interact with Indigenous instructors (CNA and Aboriginal Nurses Association of Canada 2014; Doria et al. 2021; Ragoonaden and Mueller 2017). If non-Indigenous instructors deliver education, content is always supplemented and verified by Indigenous instructors demonstrating the value placed on the contributions of Indigenous nurses. The Two-Eyed Seeing approach is used in these programs to ensure that Indigenous ontology and epistemology are privileged and to promote harmony between diverse worldviews. Finally, the SE First Nations, Inuit and Métis Program team recognized that Indigenous learners enrolled in the entry-level vocational programs often have competing life priorities that can negatively impact their attainment of higher education (Bourque Bearskin et al. 2020; CNA and Aboriginal Nurses Association of Canada 2014; Vukic et al. 2012). Therefore, proactive strategies such as offering computers and in-depth orientation to technology are included in all programs. All vocational programs and professional development courses use a combination of online and in-person learning to promote accessible education.

Education to Promote Cultural Safety

SE Health is addressing Call to Action #92c by providing education to all staff “on the history of Aboriginal peoples, including the history and legacy of residential schools, the UNDRIP, Treaties and Aboriginal rights, Indigenous law, and Aboriginal–Crown relations” (Truth and Reconciliation Commission of Canada 2015b: 10). SE Health's executive leadership supported the First Nations, Inuit and Métis Program team to develop an accessible online Indigenous cultural safety course to ensure that all staff have the necessary foundation to support Indigenous health equity. In addition to the education recommended in Call to Action #92c, the course outlines approaches to care that support cultural safety and the Indigenous social determinants of health and provides tips on how to be an ally to Indigenous Peoples. As of December 2022, 232 individuals logged into the course, completing 111 hours of learning. The First Nations, Inuit and Métis Program team is examining how Northern Health's “Cultural Safety and System Change: An Assessment Tool” (Northern Health 2020) can be utilized in the organization as an evaluative framework. In response to evaluation feedback, additional content was recently added to the course that strengthens learner reflexivity as it relates to implicit bias and social positioning. This additional content is further assisting in challenging deficit-based discourses. The First Nations, Inuit and Métis Program team is in the process of releasing their Indigenous cultural safety course on their website to ensure open access across the country.

Case Discussion

The case study illustrates strategies that can be used by other healthcare organizations to create organizational structures that enhance the work environments for Indigenous nurses, which, in turn, promote the health of Indigenous Peoples. In acting upon Call to Action #92, SE Health disassembles socio-political structures that maintain the deficits in the Indigenous social determinants of health by creating pathways to reconciliation in the work setting. Through the creation of the First Nations, Inuit and Métis Program, SE Health offers a platform that elevates the voices of Indigenous nurses and allows them to respond to Indigenous inequities in healthcare in a meaningful way. In relying upon Indigenous nurses to lead projects and infuse their knowledge into education and project work, the SE Health First Nations, Inuit and Métis Program places Indigenous nurses in the role of expert and leader, which results in feelings of value and self-determination to align with the UNDRIP. SE Health's dedication to promoting culturally safer work environments creates a sense of belonging, safety and respect for Indigenous nurses. All of these actions result in the promotion of sovereignty and self-determination for the Indigenous nurses, creating deep intrinsic motivation and a strong sense of purpose related to employment. These strategies contribute to Indigenous retention and their full participation in the workforce.

Conclusion

Implementing Call to Action #92 can strengthen Indigenous representation in the economy through employment and culturally safe work interactions. These outcomes can improve the recruitment and retention of Indigenous nurses, which can lead to health benefits for Indigenous Peoples. Identifying and challenging deficit-based discourses, establishing new approaches to collaboration and engagement, incorporating Indigenous worldviews in leadership and education to support cultural safety can result in healthcare organizations that meet the unique needs of Indigenous Peoples (Truth and Reconciliation Commission of Canada 2015b; UN 2007). The case study demonstrates that it is possible to implement Call to Action #92 within healthcare and reinforces the benefits that can be achieved by decolonizing workplaces so that Indigenous nurses can thrive. Increasing Indigenous nurse representation through recruitment and retention and promoting self-determination and sovereignty will assist mainstream healthcare organizations in developing Indigenous-informed and equity-based initiatives. Enacting Call to Action #92 signals organizational commitment to equity, diversity and inclusion of all staff, patients, families and communities and is a powerful gesture for reconciliation (Box 2).


Box 2. Summary of strategies to align workplace structures with Call to Action #92
  • Engage in reflective practice to challenge biases, stereotypes and deficit-based discourses.
  • Respect the diversity and distinctness of Indigenous Peoples, communities and nations.
  • Consider how historical and contemporary colonization continues to impact the health of Indigenous Peoples.
  • Consider how existing colonial-based health systems influence the relationship between health systems and Indigenous Peoples.
  • Use strengths-based approaches when engaging with Indigenous Peoples to celebrate capabilities.
  • Engage in collaboration and engagement characterized by consultation and consent with Indigenous communities, nurses and patients.
  • Support Indigenous nurses to lead initiatives aimed at improving health services for Indigenous Peoples.
  • Use Indigenous methods when engaging with Indigenous Peoples, such as the 4Rs.
  • Incorporate Indigenous ways of knowing and knowledge into all organizational processes and policies.
  • Promote the sovereignty and selfdetermination of Indigenous nurses.
  • Promote healthcare approaches that are inclusive of Indigenous worldviews, such as Two-Eyed Seeing.
  • Ensure institutional policies and processes reflect commitments to the calls to action.
  • Promote and support Indigenous nurses to positions of formal and informal nursing leadership to build capacity and role modelling.
  • Implement Indigenous cultural safety training.
  • Evaluate strategies to ensure that they are achieving their desired outcomes.

4Rs = respect, relevance, reciprocity and responsibility. Source: Truth and Reconciliation Commission of Canada 2015b.

 

Relevance to Nurse Leaders

Nurse leaders can advocate and promote workplace structures that align with Call to Action #92 (Truth and Reconciliation Commission of Canada 2015b). Enacting the strategies outlined in this synthesis paper will assist in propelling Indigenous health equity and promote reconciliation in the workplace.

Position Statement

The first author is a First Nations woman from Kinosao Sipi Cree Nation and has been a registered nurse since 2004. The first author has spent her career serving Indigenous populations in both First Nations communities and urban healthcare systems. The first author is a proud member of the SE Health, First Nations, Inuit and Métis Program team since early 2018. The second author is an ally who provided guidance in writing this paper.

Funding

Funding for open access fees has been provided by the Athabasca University (GRSF) Publications Fund.

Correspondence may be directed to: Michelle Monkman. Michelle can be reached by e-mail at michelle_monkman@hotmail.com.

About the Author(s)

Michelle Monkman, RN, MN, Faculty of Health Disciplines, Athabasca University, Athabasca, AB, Program Lead, SE Health, First Nations, Inuit & Métis Program, Winnipeg, MB

Jacqueline Limoges, PhD, RN, Chair, Ontario Cancer Research Ethics Board, Associate Professor, Athabasca University, Athabasca, AB

Correspondence may be directed to: Michelle Monkman. Michelle can be reached by e-mail at michelle_monkman@hotmail.com.

References

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Footnotes

1. The term Indigenous is used throughout the article to describe First Nations, Inuit and Métis people in Canada, unless otherwise specified. The term Aboriginal is the language used by the Truth and Reconciliation Commission of Canada and will only be used in direct quotations to accurately reflect this doctrine.

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