A CONVERSATIONAL ANALYSIS OF COMMUNITY HEALTH NURSES AND SYSTEMS CHANGE IN FIRST NATIONS COMMUNITIES By Kathleen Lounsbury Bachelor of Science in Nursing (BSN), Trinity Western University, 2002 Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of MASTER OF SCIENCE IN NURSING in the FACULTY OF GRADUATE STUDIES TRINITY WESTERN UNIVERSITY January 2021 © Kathleen Lounsbury, 2021 1 Abstract Community-based health services for Indigenous communities are undergoing considerable change in Northern and Western Canada. This study aimed to explore the status of community health nurses’ (CHNs) leadership knowledge, levels of change agency and the leadership implications in changing Indigenous nursing contexts, which reflect the different paradigms of First Nations Health Authority and Health Canada models of care. Six stories (three CHNs and three Stakeholders) were framed with the Conversational Method espoused by Kovach (2010). Each conversation was situated within the image of the two contrasting health model “trees” alongside corresponding analogies to issues identified by the participants. The use of ceremony as a deep way of inculcating lessons learnt is offered. My journey from a linear approach to data analysis to an Indigenous one is threaded throughout this thesis, and the leadership implications and possible alliances for the individual nurse, nursing education and nursing policy are presented. Keywords: Indigenous Health, First Nations Health Authority, Nursing, Community health nursing, Leadership, Change agency, Cultural competency, Cultural safety. 2 Acknowledgements First and foremost, I would like to thank the Creator and His Son for the strength given me to complete this thesis. Next, I am forever grateful and raise my hands to my advisor and professor, Dr. Sheryl Reimer-Kirkham for your amazing guidance, mentorship, support, patience, and praise every step of the way during this adventure. This thesis would not have seen the light of day without you! I would also like to thank my supervisory committee, Dr. Evelyn Voyageur of North Island College (my Anise), and Dr. Barbara Astle, Trinity Western University’s Director MSN Program, for their continued wisdom, encouragement, and guidance throughout this process. Timing is important and their skillful ways of providing the mentorship needed was helpful in the direction this thesis took. Along with this, I want to acknowledge the Trinity Western University leadership for their understanding as I journeyed to complete this undertaking. To my noble participants, your gifts of story, your honesty and integrity helped me find a place to truly honour your words. The insights you shared will bring a ray of hope for change in future Indigenous healthcare delivery. Waxa. At this time, I would also like to thank my friends and family who directly and indirectly helped me in discussions and to think out loud, which awoke ideas and clarity that formed themes related to this thesis. The collective, living wisdom you have shared has deeply left its mark on this work. To my honourable parents and grandparents who are in the spirit world, your presence is indelibly felt throughout this work, your wisdom is echoed in the pages of this thesis. Finally, I want to thank my immediate family, my husband, Kendall whose gentle support means the world to me and my three sons, Kendrick, Kaleb, and Kyle who have watched me 3 work all these years, I hope this example will spur you all onto greater academic endeavors of your own. 4 Table of Contents Abstract ........................................................................................................................................... 2 Acknowledgements ......................................................................................................................... 3 Table of Contents ............................................................................................................................ 5 LIST OF TABLES ........................................................................................................................ 10 LIST OF FIGURES ...................................................................................................................... 11 CHAPTER ONE: INTRODUCTION .......................................................................................... 12 Background ................................................................................................................................... 13 My Introduction ........................................................................................................................ 14 Historical perspectives .............................................................................................................. 16 Definition of Terms....................................................................................................................... 18 Project Description........................................................................................................................ 20 Project Purpose and Objectives ................................................................................................ 20 Chapter Summary and Outline of Thesis ...................................................................................... 21 CHAPTER TWO: LITERATURE REVIEW .............................................................................. 22 Literature Review.......................................................................................................................... 22 Step One: Identification and Retrieval ...................................................................................... 22 Step Two: Extracting the Data and Encoding ........................................................................... 23 Step Three: Analyzing and Interpreting the Data ..................................................................... 24 Summary of Relevant Literature ................................................................................................... 24 Community Health Nursing in FN Communities ..................................................................... 26 Urgent need of Capacity ....................................................................................................... 27 Discussion of Theoretical Underpinnings ................................................................................. 28 Cultural Safety/Sensitivity .................................................................................................... 28 Indigenous Knowledges and Two-Eyed Seeing ....................................................................... 29 Complexity and Change Theories ......................................................................................... 30 CHAPTER THREE: RESEARCH METHODS ........................................................................... 34 Purpose and Research Questions .................................................................................................. 35 Research Design............................................................................................................................ 35 Qualitative Interviews ............................................................................................................... 35 Sampling Design ....................................................................................................................... 37 Sample Criteria ......................................................................................................................... 37 5 Inclusion Criteria .................................................................................................................. 37 Exclusion Criteria ................................................................................................................. 37 Access to Participants and Study Sites ..................................................................................... 37 Recruitment ............................................................................................................................... 38 Description of Sample............................................................................................................... 38 Interview Methodology ............................................................................................................. 39 Data Analysis ............................................................................................................................ 40 Indigenous Ethical Research Considerations ................................................................................ 41 Assumptions and Reflexivity ........................................................................................................ 43 Scientific Quality .......................................................................................................................... 44 Indigenous Methodology .......................................................................................................... 44 Qualitative Standards ................................................................................................................ 44 Summary of Chapter Three ........................................................................................................... 45 CHAPTER FOUR: FINDINGS ................................................................................................... 46 Grounding Image of a Tree with Roots, a Trunk, Branches, and Fruit ........................................ 47 Tree #1 as Indigenous Representation of the FNHA Model..................................................... 50 The Root System ................................................................................................................... 51 The Trunk and Bark .............................................................................................................. 52 The Tree Rings as SDH or Wellness Circle.......................................................................... 53 The Burls/Knots .................................................................................................................... 54 Branches ................................................................................................................................ 54 Tree #2 as Indigenous Representation of the Health Canada Model ........................................ 55 Learning about CHN Leadership from the Study Participants ..................................................... 57 Jess’s Viewpoints ...................................................................................................................... 58 Description of Identity .......................................................................................................... 58 Views on Community ........................................................................................................... 58 Nature of CHN role ............................................................................................................... 58 Conscientization is a Process ................................................................................................ 60 Gina’s Viewpoints .................................................................................................................... 60 Description of Identity .......................................................................................................... 60 Views on Community ........................................................................................................... 61 Nature of CHN role ............................................................................................................... 61 Skillset of CHN ..................................................................................................................... 62 Description of Nursing Leadership ....................................................................................... 62 6 Conscientization as a Process ............................................................................................... 63 Commentary on Two Nurses Immersed in the Health Canada Model ..................................... 63 Mercy’s Viewpoints .................................................................................................................. 64 Description of Identity .......................................................................................................... 64 Views on Community ........................................................................................................... 64 Conscientization as a Process ............................................................................................... 64 Description of Nursing Leadership ....................................................................................... 65 Nellie’s Viewpoints .................................................................................................................. 67 Description of Identity .......................................................................................................... 67 Nurses Need Knowledge Transfer ........................................................................................ 67 Nurses Need Self-Reflection................................................................................................. 68 Trauma-Informed Care as a form of Conscientization ......................................................... 68 Organizational Change, Chaos and Resilience ..................................................................... 69 Ed’s Viewpoints ........................................................................................................................ 70 Description of Identity .......................................................................................................... 70 Community Stakeholder’s view of Nursing ......................................................................... 70 Vision for CHNs in Community ........................................................................................... 70 Darlene’s Viewpoints................................................................................................................ 73 Description of Identity .......................................................................................................... 73 Nurses’ Role.......................................................................................................................... 73 Community in Change .......................................................................................................... 73 Leadership in Community..................................................................................................... 74 A Way Forward..................................................................................................................... 74 In Conversation ............................................................................................................................. 75 Ed, Nellie & Mercy in Conversation ........................................................................................ 75 Clearer Communication about the Partnership Agreements is needed to Address Systemic Racism................................................................................................................................... 76 CHNs in Relationship with Indigenous Communities .......................................................... 77 CHNs as Doing No Harm and being Passionate about Organizational Change to Redesign Health Programs for Health and Wellness Needs ................................................................. 78 Research as Ceremony .......................................................................................................... 79 Gina and Jess in Conversation with Nellie and Darlene ........................................................... 80 Vision-casting as to What Could Be ..................................................................................... 80 Research as Ceremony .......................................................................................................... 82 Darlene and Nellie in Conversation .......................................................................................... 83 7 Action! Play-calling to get the Ball down the Field ............................................................ 83 Research as Ceremony .......................................................................................................... 84 Kathleen and Ed ........................................................................................................................ 84 The Intricacies of a CHN working within a Band ................................................................ 84 The Eagle Flies above the Storm: Transcending the Challenges, Leading Toward Hope ... 86 Research as Ceremony .......................................................................................................... 87 Eyes of compassion............................................................................................................... 87 Chapter 4 Summary ...................................................................................................................... 88 CHAPTER FIVE: DISCUSSION ................................................................................................ 89 Bennis’ Leadership Theory ....................................................................................................... 90 Leadership involves Knowing Yourself ............................................................................... 91 Leadership involves Mastering Context ............................................................................... 92 Leadership involves Trust ..................................................................................................... 93 Leadership involves Systems Thinking ................................................................................ 94 Grossman and Valiga on Nursing Leadership .......................................................................... 95 Peter Northouse on Leadership, Theory, and Practice ............................................................. 97 Indigenous Leadership Theories ............................................................................................... 98 Indigenous Viewpoint of Feminism...................................................................................... 99 Indigenous Views on Learning to Lead .............................................................................. 100 Leadership as Collaboration and Interconnection............................................................... 102 Leadership as Healing and Perseverance for Resilience..................................................... 104 Chapter Summary ....................................................................................................................... 107 CHAPTER SIX: CONCLUSION AND IMPLICATIONS ....................................................... 108 Project Summary and Conclusions ............................................................................................. 108 Synopsis of Thesis ...................................................................................................................... 108 Conclusions ................................................................................................................................. 110 Limitations .................................................................................................................................. 110 Implications................................................................................................................................. 111 Implications for Health Systems Policy .................................................................................. 111 CHNs as Allies in Health Systems Policy .......................................................................... 111 The Role of Canadian Indigenous Nurses Association and Indigenous Nursing Leadership ............................................................................................................................................. 112 Implications for Community Health Nursing Leadership ...................................................... 112 Building CHN Capacity and Alliances ............................................................................... 112 Leadership Implications involve Mental Health for CHNs ................................................ 114 8 Implications for Nursing Education ........................................................................................ 114 Summary ..................................................................................................................................... 116 References ................................................................................................................................... 118 Appendix A: Interview Guide ..................................................................................................... 128 Proposed Interview Questions for CHNs ................................................................................ 128 Key Questions for Health Directors:....................................................................................... 129 Appendix B: Search Strategy ...................................................................................................... 130 Appendix C: Relevant Articles ................................................................................................... 131 9 LIST OF TABLES Table 1……………………………………………………………………………….31 Table 2……………………………………………………………………………….32 10 LIST OF FIGURES Figure 1……………………………………………………………………………….23 Figure 2……………………………………………………………………………….25 Figure 3……………………………………………………………………………….52 Figure 4……………………………………………………………………………….54 Figure 5……………………………………………………………………………….55 11 CHAPTER ONE: INTRODUCTION The First Nations (FN)1 of British Columbia have been experiencing a major paradigm shift in how their health care delivery services are managed with the implementation of the Tripartite Framework Agreement (TFA), that began in July 2013 (Nissen, Merrigan, & Kraft, 2005; Wardman, Clement, & Quantz, 2005). The First Nations Health Authority (FNHA) is a result of both the impetus of The Truth and Reconciliation Commission (TRC, 2015) and the Royal Commission on Aboriginal Peoples (RCAP, 1996) recommendations that the FN peoples be self-governing as the main pillar of how Canada can redress the inequities of the FN peoples and the rest of Canadians (Burrows, 2001). The TFA changed the deliverables that were previously handled by Health Canada to regional health centers, all operating under the newly formed FNHA. This agreement is based on the identified Seven Directives which were provided in the Consensus Papers of 2010 and 2011 and are as follows (First Nations Health, 2011): *Directive #1: Community-driven, nation-based * Directive #2: Increase First Nations decision-making and control * Directive #3: Improve services *Directive #4: Foster meaningful collaborations and partnership * Directive #5: Develop human and economic capacity * Directive #6: Be without prejudice to First Nations interests * Directive #7: Function at a high operational standard. In the context of the FNHA, Health Centre community health nurses (CHNs) provide a comprehensive range of nursing services to First Nation communities. Their practice is Please note the interchangeable use of “First Nations” and “Indigenous” in this thesis. First Nations is used when referring to the First Nations Health Authority (FNHA) and its services, resources, and policies. Please see Definition of Terms that follow in this chapter. 1 12 grounded in health promotion and disease prevention, aims to build the capacity of individual, family and community wellness. Health Centre CHNs work in partnership with the community to develop and implement relevant, culturally-centered interventions, providing services in clinic, home and community settings (from FNHA website). This thesis examined nursing leadership by community health nurses working with Indigenous communities who are faced with changes at the macro, meso, and micro levels of health operations in Northern and Western Canada. Background At the time of conducting this thesis, the political movement “Idle No More” (INM, 2012) among Indigenous people in Canada was taking hold and had grown worldwide, this was the largest civil rights movement in Canada since the 1960s. This movement is a call to action to investigate the embedded motivations of Canadian policies that influence all aspects of Indigenous peoples’ lives. The movement calls for change in how the Canadian Government handles Indigenous Rights and the health disparities between Indigenous peoples and the rest of Canadians. According to the Assembly of First Nations Fact Sheet, FN living conditions ranked 63rd on the United Nations Human Development Index, the rest of middle-class Canadians, ranked 6th in the world (Assembly of First Nations, Fact Sheet, p.1). With this in mind, and how historically governmental funding has proven to fall short in providing adequate access to healthcare delivery, past and current policies must change—and change fast—if the Indigenous peoples of Canada hope to attain an equitable place in society, as far as dealing with the real lack of attention to the Social Determinants of Health (SDH). Each piece of legislation that undermines the power of Indigenous people and their leadership to govern their people with the right resources sets a diminishing tone to the approach to solutions (Joseph, 2018). 13 The impact of these policies and disparities is highlighted in Canada’s 2015 Truth and Reconciliation Commission (TRC). From 2008 to 2015, the Indian Residential Schools Settlement Agreement commissioners journeyed through the whole of Canada to record how the system of Indian Residential Schools (IRS) was a source of horrific cultural genocide to Canada’s Indigenous population. This Commission resulted in 94 Calls to Action by the government and all its subsidiaries, in all sectors of Indigenous life. Through this evolution of rediscovery of Indigenous sovereignty, voice, and placement, the Indigenous people all across Canada regrouped to form the political, social and spiritual will to redress these wrongs on a national and international stage. This has resulted in Canada being the birthplace and the progenitor of the Missing and Murdered Indigenous Women and Girls (MMIWG) movement (Drache, Fletcher, & Voss, 2016, p.34) (and subsequent Inquiry) that grew in influence to the United States. The United Nations Declaration of the Rights of Indigenous Peoples (UNDRIP) began as a working document between a Canadian (Haudenosaunee) chief and a New Zealand Maori chief to address how their people were being treated by the Crown in 1925. The result was the historical document that encompasses the rights of Indigenous peoples worldwide. The influence of these Commissions and Reports cannot be minimized; they provide a space to create solutions that are Indigenous-sanctioned structures to redress well documented wrongs that have affected all areas of Indigenous life (Woo, 2003). My Introduction As an Indigenous person, when presenting oneself, one’s work, or ideas, it is traditional that one introduces oneself. An introduction is really the beginning of the story and does many things: It locates who you are in the Kwak’wala speaking world from your community, your clan and your family and those rights, ranks, dances and stories associated with you; these are 14 your treasures. This process affirms you, values who you are and shows that belonging to a greater entity than just your individual self. “Hello, my Christian name is Kathleen ‘Wadhams’ Lounsbury, I am from the Kwakwaka’wakw peoples from the Northwest Coast of Vancouver Island in British Columbia. My given Kwak’wala name is T’lat’tla’yaligasis which is related to my traditional dance, the Lalulalal or Ghost Dance. My Uncle gave me that name as I was a “Spiritual one”. We are patrilineal, so I will talk about my father’s (Lloyd Wadhams Sr) side first. He was from the Ma’amtagila-Tlowitsis people of Turnour Island and my paternal grandmother is from Village Island, the Mamalilikala peoples. I am the eldest daughter of the eldest son of our Sisiulth clan. My mother (Virginia Robertson) was from the Dzawada’enuxw people of Kingcome Inlet who are the Wolf clan. We have lived in this territory since time immemorial and my Noxsola(wise ones) have given their knowledge freely since I was very young. Foundational to our ways is the law of giving away one’s wealth for the betterment of the community rather than accumulating it for posterity that is seen in dominant Canadian society. Our stories, myths, and legends of the power of spiritual transformation that has helped us to survive up until today, dovetails into the holistic viewpoint of understanding the personal stories written about in this thesis. This deepens my belief that the Creator and His Son have found ways to communicate with our people to understand how everything is interconnected and there is a reason for everything that happens, good or bad. These three treasures of generosity, transformation and interconnectedness shaped the conversations I had as part of this study. I am married and have three sons of my own who now benefit from all the gifts passed down to me by my family and community. Also framing how I engaged with the study conversations is my experience as a CHN in Indigenous communities in B.C. Waxa and Gilak’asla (Thank you and your welcome). 15 Historical perspectives For the last several years, many initiatives have been proposed that stem from the Royal Commission on Aboriginal Peoples (RCAP, 1996). This impetus for this report was a result of studies which identified health disparities between Indigenous people groups and the rest of Canadians. The colonial history between Indigenous peoples and the Government of Canada, embodied in the policies developed (e.g., the Indian Act) whereby the government subdued this people group, has led to a host of social and health inequities too numerous to mention here (See Figure 2). RCAP’s conclusions were heavily laced with recommendations for the emancipation of the Indigenous peoples from deepening colonialist rule. This Royal Commission has spurred the current governmental environment which advocates for a more self-governing model of healthcare delivery systems (Burrows, 2001). The British Columbia Tripartite Framework Agreement was signed about seven year ago, this was the culmination of work that began in 2005 with the Transformative Change Accord which states its purpose as, “to establish a new relationship based on mutual respect and recognition and develop 10-year plans to bridge the differences in socio-economic outcomes between First Nations and other British Columbians particularly in the areas of: education, housing, economic opportunities, and health” (Gallagher 2015, p. 256). When looking towards the future, it is important to review the foundations of our current practices and correct the thinking and inherent dysfunctional philosophies behind them. This moves us to where we are now, with the biggest query being: What initiatives are feasible that we can implement to stem the unwanted tide towards deteriorating health outcomes for this people group? As it is beyond the scope of this thesis to enlarge on the historical context of Indigenous health, it would however aide our understanding if we direct some attention to the RCAP recommendations for action in regard to First Nations self-governance. 16 In essence, the RCAP recommendations for self-governance are jurisdictional, which means that the effects will be felt communally. So when self-governance takes place, its affect includes local members and regions, which will manifest as increased FN governmental decisions “that affect individual citizens directly and obviously will, all of a sudden, be made locally, rather than by faceless, distant officials” (Diamond Consulting Group, p.4). The Transformative Change Accord was seconded by another document from the Office of the Prime Minister in November 2005, which addresses the movement toward a tripartite agreement; which meant that government would not be carried out at a great distance. Implementation will occur both through federal initiatives as well as through the development of plans at the level of each province and territory through tripartite negotiated agreements that respect the constitutional roles and responsibilities of governments. These initiatives and plans will be developed by parties working together and will identify priorities for action and investment. (Office of the Prime Minister, November, 2005) It would be remiss not to mention how the theory (and political movement) of postcolonialism sets the stage for this new era. New government is meant to give voice to the FN peoples of BC to restore power and authority for them to develop their own unique health care delivery systems for each FN community in BC. The development of the FNHA in BC is part of the movement of Indigenous peoples of BC to create a place where Indigenous worth is recognized and reflected in healthcare provision (Gallagher 2015, p. 256). The systems change that saw the implementation of the FNHA creates an urgent need to provide increased clarity in the CHNs’ roles and responsibilities. This thesis identifies an emergent shared vision of how role-clarity and an empowered voice can speak constructively to such changes (Vogel, 2011). 17 Definition of Terms 1. Aboriginal Peoples (Burrows, 2001; Clarke, 1997) include persons of Indian, Inuit or Métis descent regardless of where they reside and whether or not their names appear on an official register. The term “Aboriginal” fails to reflect the distinctions among First Nations, Inuit and Métis peoples, who have their own histories, cultures and languages, so an attempt has been made to limit use of the term in this policy to instances where a global term is appropriate. Indian peoples commonly identify themselves by distinct nation names such as Mi’kmaq, Dene or Haida, and as First Nations. In the international context, the term comparable to Aboriginal peoples is Indigenous peoples. 2. First Nations, Inuit and Métis lands – include Indian reserves, Métis settlements, and lands governed under a self-government agreement or an Inuit or First Nations land claim agreement. 3. Indigenous Peoples – Indigenous is a term used to encompass a variety of Aboriginal groups. It is most frequently used in an international, transnational, or global context. This term came into wide usage during the 1970s when Aboriginal groups organized transnationally and pushed for greater presence in the United Nations (UN). In the UN, “Indigenous” is used to refer broadly to peoples of long settlement and connection to specific lands who have been adversely affected by incursions by industrial economies, displacement, and settlement of their traditional territories by others. https://indigenousfoundations.arts.ubc.ca/terminology/#:~:text=%E2%80%9CFirst%20N ation%E2%80%9D%20is%20a%20term,not%20have%20a%20legal%20definition. 4. Change Agency (Caldwell, 2003). A change agent is defined as a person who leads change within the organization, by championing the change, and managing and planning 18 its implementation. The role can be official or voluntary; must be representative of the user population, understand the reasoning behind the change, and help to communicate the excitement, possibilities, and details of the change to others within the organization http://www.processexcellencenetwork.com/glossary/change-agent/ 5. Community Health Nurse Community health nursing practice describes the work of nurses who work in the community. Community health nurses partner with people where they live, work, learn, meet and play to promote health. (Community Health Nurses of Canada, 2009, Vision Statement) 6. Leadership The CNA describe leadership as the competent and engaged practice who provide exemplary care, think critically and independently inform their practice with evidence, delegate and take charge appropriately, advocate for patients and communities, insist on practicing towards their full and legal scope and push the boundaries of practice to innovative new levels (CNA Leadership Statement, 2009, p. 1). In their book The Leadership Challenge, James Kouzes and Barry Posner define leadership as "the art of mobilizing others to want to struggle for shared aspirations." (2012). In other words, a leader uses interpersonal skills (and change theory) to move stakeholders (community…lead lateral re: teams and vertical) and systems toward a shared aspiration. 19 Project Description Project Purpose and Objectives The purpose of this thesis was to explore the dynamics that influence the leadership capacities of CHNs in FN communities. Specific questions that guided this thesis were: 1. What is the state of knowledge (as portrayed in the scholarly and grey literature) in relation to CHN leadership in Indigenous communities, especially in the context of systems change (e.g., such as transition to the FNHA]? 2. What are the perspectives of CHNs in FN communities in regard to their leadership abilities, skills, and activities? Are there differences between Indigenous and nonIndigenous CHN perspectives? 3. What are the perspectives of key stakeholders in regard to the role of nursing leadership capacities in the FNHA? 4. What are the implications of these findings for the CHNs’ practice to enhance their leadership skills? To improve health service delivery in Indigenous communities? I conducted in-depth interviews with CHNs who work in the Indigenous context as well as other identified stakeholders to investigate how leadership skills are being identified and utilized and why CHNs need to be cognizant of their importance in aiding them in adapting to systems change. The study gives insight into how CHN leadership skills are identified and enacted, and how leadership skills could be strengthened via supportive actions (i.e., training, feedback loops), particularly in the context of changes in the delivery of Indigenous health. 20 Chapter Summary and Outline of Thesis In this chapter, I have introduced the central problem addressed by this study -- that of how CHNs and stakeholders interpret and enact nursing leadership in the Indigenous context. Canada’s colonial history, and contemporary governmental structures and policies that have resulted in Indigenous health disparities create an urgency for the examination of how the current structures of FNHA are enacting a more desired approach in which to deliver health (Gallagher, 2015 p. 255). In Chapter Two, I provide a summary of the literature informing the study. In Chapter Three, I present the Conversational Method (Kovach, 2010) employed, and describe the sample, the data collection and analysis. In Chapter Four, I present study findings, foregrounding the conversations with the study participants, myself as author, and my supervisory committee. In Chapter Five, I discuss these findings in the context of existing literature, and in the final Chapter Six, I provide implications of the study. 21 CHAPTER TWO: LITERATURE REVIEW In this chapter I present the literature review conducted in advance of the study. My goal was to provide a thematic synthesis where “knowledge of reality is mediated by our perceptions and beliefs”, as said by Polit and Beck (2012, p.667). I begin by describing the approach used to conduct the knowledge synthesis and follow with a summary of selected related literature and the theoretical framework guiding the study. Literature Review Step One: Identification and Retrieval My literature review (first conducted in 2016) involved the databases of CINAHL, PUBMED, Native Health Database, PsycINFO, EBSCO Host, and Google Scholar. Key search terms, CINAHL headings and MeSH terms included: Native American Indian, First Nations, Aboriginal, and Indigenous, AND, Leadership, AND Complexity Science AND Community Health Nurs* (truncated) to include variations of the word. I also added Complex Adaptive Systems and Leadership to this first search. Two independent searches yielded no results with a mix of First Nations AND Community Health Nurses AND Complexity Science. I also worked very closely with an Academic Librarian who was very helpful to bring attention to references as they came available. See Appendix A for Search Strategy. I completed a keyword search for First Nations Nursing and retrieved three articles that addressed current dynamics regarding nursing in FN communities in Canada. I also have a collection of articles that have been retrieved during my MSN studies which I have compiled for various assignments. The purpose of doing a knowledge synthesis is to create an ethically sound application of knowledge to improve the health of Indigenous Canadians and provide more effective health services (TCPS website). Pimiwatisin Aboriginal Journal of Community Health 22 was a source of several articles to give guidance as to how to frame the work from an Indigenous resilience lens rather than just gaps in knowledge on the part of the participants. See Appendix B for key articles. Step Two: Extracting the Data and Encoding During this step, I have reviewed my data (the articles identified in Step One), the themes of which I viewed as a pie. Each piece of pie represents a body of knowledge grouped together (See Figure 2). As I was unable to find even one article that encompasses all elements of my study, the strategy then looked like this. I started very broadly and worked my way down to assign each body of knowledge and graft it into my own study. There are four sections: Indigenous Knowledge; Community Health Nursing Knowledge (in the FN context); Leadership Knowledge; and Complex Adaptive Systems Awareness; and at the center, New Knowledge. I have in 2020 returned to review the state of evidence and there is little change. Figure 1 Data Extraction Strategy for Knowledge Synthesis 23 Step Three: Analyzing and Interpreting the Data In this step I was careful to choose the correct method of knowledge synthesis. This involves finding out how each relevant study is related to one another, (reciprocal, reputational or in line of argument in another direction completely) or being careful not to co-mingle data with interpretation. Of the three approaches mentioned by Polit and Beck (2020), synthesizing both types of data (quantitative and qualitative) and creating a metasummary was the synthesis method I chose for this thesis. Sandelowski and Barroso’s (2006) approach to metasynthesis follows a quasi-iterative approach to discover meta themes in the literature review and discover aggregate themes in the raw data. Summary of Relevant Literature As explained, in the early days of this study, there was a dearth of references to inform the study, in particular references on CHN leadership in Indigenous communities and how they socialize change. With the completion of the TRC and the launch of FNHA, there has been some academic examination of the new policies and how they have been received, including cultural safety as an approach that centres Indigenous individuals and communities. In this section, I summarize the theoretical and empirical knowledge that supported the study. The model represented in Figure 2 is my interpretation of the work of Loppie and Wien and how they see the determinants of health impact on First Nations people (Loppie & Wien, 2009). They state that “For First Nations, Inuit and, to a lesser extent Métis peoples, the colonial process has resulted in diminished self-determination and a lack of influence in policies that directly relate to Aboriginal individuals and communities” (p.2). What is interesting about their work is how they have positioned and separated into categories (i.e., proximal, intermediate, and distal) the types of impacts these determinants of health have impacted First Nations. 24 Figure 2 Health Inequities and Social Determinants of Heath in Indigenous Communities Colonialism Self Determination Racism Community Infrastructure Educational Systems Cultural continuity Health Care Systems Food Insecurity Physical Environment Education Employment and Income Life course: Child, Youth and adult Adequacy of public Health Holistic perspective of Health Health Behaviours SocioPolitical context It could be said that each section, all on its own, needs carefully thought-out plans and strategies on how to combat the downward spiral that happens when inequities build in a people group and all the compounding effects that lie therein. Interestingly, it is the distal determinants of health that have made most of the headlines regarding the INM Movement. Racism, colonial attitudes in the current legislative acts, and the fight for self-determination have made Indigenous peoples wake up and have a deep desire to keep fighting for their place in society. It will be 25 fascinating to see where all this leads; as Ronald Bayer (2007) and colleagues have noted in their book, Public Health Ethics: Theory, policy and practice, seismic changes occurred in public health policy due to the impact of the 60’s civil rights movement had on a generation. Community Health Nursing in FN Communities The new structure of the FNHA brings the decision-making (power, economic) about the development of community programs closer to home (Gallagher, 2016; Wilmot, 2018). The setup is the development of five regional centres where the identified FN bands will have access to funding (economic reconciliation) and decision-making for their programs and since the CHNs are the main persons who are delivering care in these communities, the CHNs’ abilities to communicate and have a strategic place in the planning of these programs create the necessity to examine which leadership skills and abilities the CHNs and other identified stakeholders perceive as vital to the thriving and success of this new initiative. In my preliminary search for articles that dealt with “Indigenous” and “First Nations” “Leadership” and “Nursing”, or “Community Health Nurses (CHNs)”, I retrieved about 40 results. When I added the terms adaptation, change, organizational change, results were zero. The next step was to do a search of grey literature and I received two articles that minimally spoke of notification of governmental or provincial policy change. Another result was more about recruitment and retention issues in Indigenous communities and was produced by First Nations Health Insurance Benefits (FNHIB) and the CHN Council. Preliminary searches reveal a gap in knowledge when one puts all three elements together and this study is a small start in the development of knowledge in this area. As the thesis moved along and I also expanded my ideas of what `knowledges” I needed to seek out; I found more writings by Indigenous authors which 26 provided more insight on how I organized my data. I used the Pimatisiwin Aboriginal Journal of Community Health to aid in including an Indigenous resilience lens to this work. Due to the well-documented urgent need of CHNs (McClymont Peace & Myers, 2012), where currently there is about a 40% vacancy nation-wide2, it becomes very evident that current information about this professional group and their identified leadership needs is required to better plan and inform current policy development. A major oversight in the FNHA’s development was the lack of Indigenous nurses’ voice at the early planning/negotiating tables and now that the implementation is happening, it is important to hone on how CHNs perceive their leadership skills enable them to carry out their duties in the midst of such transformative change. These answers highlight important knowledge transfer gaps in nursing education, the recruitment of and the hiring of CHNs working in Indigenous communities (Alexander et al., 2011; Boffa, King, McMullin, & Long, 2011; Young, 2003). Urgent need of Capacity Studies done by the Canadian Nurses Association (CNA) and the Community Health Nurses of Canada (CHNC), both national organizations, speak to the lack of information pertaining to Indigenous community health nursing in regard to leadership roles and responsibilities. (Gregory, Pijl-Zieber, Barsky, & Daniels, 2008; MacDonald & Schreiber, 2006). In addition, what makes this study valuable is that I address a very current issue in today’s CHN working landscape. 2 Although I was not able to find more recent statistics on the vacancy rate of CHNs in Indigenous communities, A 2018 Canadian Nurse article on Indigenous priorities cites the ongoing needs for healthcare personnel. 27 Discussion of Theoretical Underpinnings Cultural Safety/Sensitivity In our desire to understand embedded cultural leadership frameworks that CHNs approach their work, a central theoretical framework that I place within our learning context is the concept of cultural safety. Nurses who practice cultural safety are ones who intend to lessen the “cultural risk” for the people whom the health care system is set up for. Cultural safety requires the nurses’ reconsideration of the unequal power relations within and beyond health care and the historical and social processes that shape these relationships. Drawing on Maori scholar Ramsden (1993), Kirkham et al. (2002) defined cultural safety as “a process whereby people from one culture believe that they have been demeaned, diminished and disempowered by the actions and the delivery systems of people from another culture” (p.206). This concept has within it an intentioned focus on ingrained power relationships. An important lesson learnt from Kirkham et al.’s (2002) work is the notion of cultural safety as being very dynamic and it does not serve one to attach a static definition upon it (p.229). Since this earlier work, cultural safety has been widely studied and taken up (see, for instance, Brooks-Cleator, Phillipps, & Giles, 2018, for a scoping review). Culture is more than beliefs, practices and values and in 1996, RCAP proposed that postsecondary educational institutions, including nursing programs collaborate with Indigenous organizations (for example, such as Canadian Indigenous Nurses Association, (CINA) to examine how they could increase the amount of FN enrolling and graduating from their programs as well as increasing culturally appropriate material to prepare those students who will be providing healthcare services to this people group (HartWasekeesikaw, 2009, p.1). What postcolonial theorists bring to this discussion is their ongoing challenges and questionings of the cultural legacies of colonialism and imperialism by examining 28 the inherent relations of power and putting forth new ways in which to view other cultures (Kirkham et al., 2002, p.227). Indigenous Knowledges and Two-Eyed Seeing Bartlett, Marshall and Marshall’s (2012) work with Mi’kamaq Elders Albert and Murdena Marshall, Two-Eyed Seeing and Other Lessons Learned Within a Co-Learning Journey of Bringing Together Indigenous and Mainstream Knowledges discusses the importance of approaching learning as “we” and “us” and to be encouraged to use both Indigenous knowledge (one eye) and Western systems of knowledge (the other eye) to grow in academic strength in today’s world. Indigenous ways of knowing gives structure to the phenomenon of Indigenous knowledges that work or coincide with mainstream sciences knowledge that produces a unique lens in which to grapple with today’s issues at hand (Bartlett et al., 2012, p.339). As an Indigenous researcher who tried several times to work solely within the confines of thematic data analysis and other mainstream methods, I became quite frustrated and morose about my thesis and I would engage and disengage with the process as I struggled with something I could not really articulate. Framing my data as “stories” and not interviews released me to further find ways to engage with my participants. Stories made sense to me as a Kwakwaka’wakw person who learned at my Ni Noxsola (wise ones) knees as I grew up. Kovach (2017, chapter 9) in her chapter on Indigenous Methodologies states that Indigenous research “asks more”’, in relation to exploring identity, vulnerabilities, the desire for restitution, and being open to awakenings, so, to “re-story” the interpretation and presentation of knowledges given is an important part of Indigenous methodologies (pp. 215-218). Two-Eyed Seeing allows for the inclusion of innate Indigenous and Western constructs that are part and parcel of who I am and how I interact with my data (Wright, Gabel, Ballantyne, Jack, & Wahoush, 2019). Kovach’s Conversational Method 29 (2010, 2018) allowed for more flexibility and granted permission for me to be part of the data in how I listened to my participants and that this was not considered “outside my norms”. The conversation method means gathering knowledge through story as it flows from an Indigenous paradigm (p.124). She further clarifies the connections of this paradigmatic approach: In a paradigmatic approach to research, be it Indigenous or otherwise, methods ought to be congruent with the philosophical orientation identified in the research framework to show internal methodological consistency. If a researcher chooses to use an Indigenous methodological framework, the methods chosen should make sense from an Indigenous knowledges perspective. (Kovach, 2010, p.125) Leadership Theories Complexity and Change Theories Adaptation skills viewed through the lens of complexity theories such as chaos theory and quantum leadership theories provide a means where we can gain an understanding of how CHNs in the Indigenous context adapt to organization or systems change. What information we can extrapolate using these constructs will provide a very different knowledge base than if we were to view these changes from a more traditional or reductive viewpoint (Stackman, Henderson, & Bloch, 2006, p.78). Complexity Science is according to Burns (2001) “the study of living systems which include such diverse systems such as hospitals and communities of practice and complex adaptive systems.” Complexity science examines the unpredictable, disorderly, nonlinear, and uncontrollable ways that living systems behave. A complex adaptive system described by Burns (2001) is an individual agent or a group of agents whose behavior changes and evolves in complex ways that are not predictable. Viewing an organization through the lens of complexity 30 offers an alternative for successful leadership in the complex and chaotic healthcare world (Burns, p.475). Osborn and Hunt (2007) describe the main organizational metaphors of organizational life as those of a machine and military operation, whose organizations today demonstrate too little information flow, diversity and too much power differential (Hamel, 2004). This has led to the present state of health care status for Indigenous communities in Canada as described by the RCAP report of 1996 which was laden with health inequities that provide an impetus to create new systems of care that are meaningful and dynamic for the Indigenous communities identified. Leadership abilities and activities are then integral to the sustaining of this new system and require that the main health care delivery agents who provide the service, be equipped to move in the newly formed organism of the FNHA and its subsidiaries. It is my desire to ascertain which leadership abilities are most valued and utilized by these CHNs and other stakeholders, why or how they find these abilities enhance their capacity to adapt to systems change, and which change agency models they adhere to, if any. Table 1 below is adapted from the one found in Holland’s presentation at the 2008 Plexus Conference in Texas (Center for the Study of Healthcare Management, n.d.). Here he demonstrates the characteristic differences in two polarized systems of organizational leadership: The complex adaptive system and the traditional system. Table 1 Comparing Organizational System Characteristics Comparing of Organizational System Characteristics Complex Adaptive Systems Traditional Systems Are living systems Are adaptable, creative, unpredictable Are machines Predictable 31 Tap Creativity Control Behaviour Embrace complexity Find comfort in Control Evolve continuously Recycle Leadership abilities are valued according to which system an organization operates: Listed below (Table 2) is how they differentiate within each model of organizational understanding. Table 2 Leadership Attributes Adjusted for Organizational Systems Leadership Attributes Adjusted for Each Organizational System Complex Adaptive Systems Traditional Systems Open, responsive, catalytic Are controlling, mechanistic Offer Alternatives Repeat the past Are collaborative, co-participating Are in-charge Are connected Are Autonomous Are adaptable Are self-preserving Acknowledge paradoxes Resist Change, bury contradictions Are engaged, continuously emerging Are disengaged, nothing ever changes Value persons Value position and structures Shifting as processes unfold Hold formal positions Prune Rules Set Rules Help others Make decisions Are listeners Are knowers *Adapted from Dr. Holland’s lecture at the complexity conference Chapter Two Summary This study begins to address the urgent need for strong CHN leadership in Indigenous communities. A key component of identifying leadership needs is having a clear understanding of the issues that face the leadership. In the next chapter (Research Methods), I explain how I interviewed nurses who worked within the Indigenous context and discovered what are the issues, learning needs and/or strengths they identify as being critical to present a solutions-based 32 discourse to enable concrete critical thinking that will add to the current body of Indigenous nursing knowledge. 33 CHAPTER THREE: RESEARCH METHODS In this chapter, I present the research methods. I employed the Indigenous research data collecting method known as the Conversational Method (Kovach, 2010) where oral storytelling is situated in the Indigenous context of community nursing. There is some wisdom in that we need to rethink how we can approach research in a more cultural way that makes sense to Indigenous scholars. Shawn Wilson’s (2008) work “Research is Ceremony: Indigenous Research Methods” underscores the need for Indigenous Knowledge to be experienced and written through an Indigenous perspective, and that what and how the Indigenous researcher internalizes the data is just as important as the data itself. Western approaches to take the researcher out of the process is antithesis to what and how Indigenous people know what we know, our ontology and how we think about what we know (epistemology). How can we dispassionately withdraw ourselves and wring out the very essence of what we see as pertinent to our interpretation of the data and then try to make sense out of the disjointed pieces left? Sieving data in such ways separated that rich data gathered in such a lush environment left the analysis wanting. Therefore, my data analysis was guided by the Conversational Method, with my interviews displayed as conversations and stories. In re-listening and examining my reflective notes I paid closer attention to the deeper “asks” of the interview as Kovach (2010) outlines in her work Doing Indigenous Methodologies. This approach helped to associate the holistic, interconnective understandings I had elicited from the conversations with my own traditional knowledges. Indigenous Knowledge is woven throughout the iterative process, incorporating the Two-Eyed Seeing philosophy, and straddling the two types of knowledge (Wright et al., 2019). 34 Purpose and Research Questions The purpose of this thesis was to explore the dynamics that influence the leadership capacities of CHNs in FN communities. Specific questions that guided this thesis were: 1. What is the state of knowledge (as portrayed in the scholarly and grey literature) in relation to CHN leadership in Indigenous communities, especially in the context of systems change (e.g., such as transition to the FNHA)? 2. What are the perspectives of CHNs in Indigenous communities regarding their leadership abilities, skills, and activities? Are there differences between Indigenous and nonIndigenous CHN perspectives? 3. What are the perspectives of key stakeholders regarding the role of nursing leadership capacities in the FNHA? 4. What are the implications of these findings for the CHNs’ practice to enhance their leadership skills? To improve health service delivery in Indigenous communities? Research Design To answer these research questions, I began with a knowledge synthesis (described in Chapter Two), followed by qualitative data collection via in-depth interviews (Keightley et al., 2011), and the Conversational Method (Kovach, 2010, 2018) approach to data collection. Qualitative Interviews What is qualitative research? Qualitative research, according to Streubert and Rinaldi Carpenter (2011), finds its foundations in a belief of multiple realities, a commitment to investigation that demonstrates the participants’ viewpoint and identifying an approach that is conducive to understanding the phenomenon of interest. This is not an exhaustive list, but it does give the reader a grasp of the approach upon which this type of inquiry is developed (p.20). 35 Qualitative research “seeks to arrive at an understanding of a particular phenomenon from the perspective of those experiencing the phenomenon” (p.23). Qualitative research or interpretive description as Thorne (2008) defines it as “an approach to new knowledge formations that straddles the chasm between objective neutrality and abject theorizing” (p.26). This type of research is a framework in which to engender a better understanding of the complex experiential clinical phenomena that occurs within nursing as well as other disciplines involved in applied health knowledge or questions from the field, such as I have (Thorne, 2008, p.27). An earlier work of Thorne, Reimer Kirkham, and O'Flynn-Magee (2004, p.2) also cautions the interviewer to layer multiple strategies within data collection of the interview to avoid a naïve overemphasis on interview data combined with a neglect of the material world that has led to research that does not offer comprehensive and contextualized interpretations of its central phenomena of interest”. With this in mind, I conducted semi-structured in-depth interviews with CHNs and Indigenous stakeholders, asking questions that drew out their lived experiences of leadership decisionmaking in the context of change (see Appendix B). These interviews were rich with contextual insight on which leadership skills were valued and utilized by these CHNs and community leaders. I employed an Indigenous research approach called the Conversational Method by Margret Kovach (2010) which helped frame each interview as a story that is located in the Indigenous context and includes a connection to Indigenous knowledges, celebrates the relational nature of the interview and identifies goals to motivate participants towards a decolonizing lens. Hearing stories with your mind, soul and heart is also how we make sense of what we hear and is part of the analysis process which is a very different approach than traditional research methods. 36 Sampling Design Sampling approaches vary across qualitative designs. I chose to start with a convenience and purposive approach. Thorne (2016) describes this as a “phenomenal” approach as I needed my participants to fit into a specified (and specialized) field of nursing. This type of sampling shows a “commitment to observing and interviewing people who have had an experience with a culture or a phenomenon” (Streubert, & Rinaldi Carpenter, 2011, p.29). Sample Criteria Inclusion Criteria Inclusion criteria included the following: (i) CHNs (Indigenous or Non-Indigenous) who work in an Indigenous context; (ii) other Indigenous stakeholders of Indigenous health such as health directors or chiefs; (iii) at least one year’s employment within the Indigenous community because this can give them time to be acclimatized and have the experience to speak to the phenomena of interest. Exclusion Criteria Exclusionary criteria were CHNs not working currently in the Indigenous context; and stakeholders under the age 19. I began with the exclusion criteria of those working outside the BC context due to my interest in addressing the coming proposed infrastructural changes, but because of some difficulty with recruitment, I extended recruitment to CHNs working outside of BC. Access to Participants and Study Sites Due to previous work experience and familial background, I was able to access leaders in Indigenous communities. Systems change is a very current topic and my background made it 37 possible to know what the current conversation flow was, and to easily find points of connection which facilitated rich conversation. Recruitment My recruitment strategy for participants was as follows. I connected with my main contact at the identified band offices via a letter of introduction. Next, I asked for volunteers for CHNs to participate in this study, but it was difficult to find CHNs in the all the various regions as I did not have strong connections there. I eventually used my connections with people I associated with in the past and through a colleague, was able to connect with the rest of my participants. For those closest geographically, I was able to conduct in-person interviews (two) and the rest of them (four) were done via the secure internet applications for meetings. Description of Sample I interviewed three CHNs and three key stakeholders (Indigenous and non-Indigenous) (n = 6) and kept an eye out for cultural differences or nuances. Five of the interviewees were women and one was male. The participants lived in different regions. Here are the characters whom you will meet in Chapter Four, and their unique contributions for which I am grateful: • Nellie: Indigenous FNHA champion and director, who communicated confidence in the organization’s 7 Directives, and emphasized the importance of addressing intergenerational trauma. • Ed: Indigenous senior community leader, who emphasized healthy systems with high operation standards, because of his distrust of governmental systems. • Darlene: non-Indigenous, PhD prepared leader who as a change agent is systems thinking, self-directed, and values teamwork. She has a grasp of both systems (FNHA and HC) and navigates between them. 38 • Mercy: non-Indigenous CHN who is very experienced and systems-critical; is articulate about her conscientization process and holds herself back as she does not want to be complicit in colonizing processes. • Gina: non-Indigenous CHN who practices in an Indigenous context with enthusiasm and openness to see work differently; constrained by the organization (Health Canada model) she works for; typifies the transient CHN flying in and out of communities. • Jess: non-Indigenous CHN who co-exists with the people she serves (i.e., lives in a northern community) and has a personal investment in their future. She has a desire to see change but has not learnt how to be a change agent. Interview Methodology After REB approval was obtained (May 2013), I contacted potential participants and set up an interview date with consent forms emailed for the interviews which were in-depth, one-onone and semi-structured. These conversations were conducted on site whenever possible (two interviews), if not a recorded telephone interview was the next choice of data collection (four were conducted this way via the Blue Jeans™ media network). The process was: (a) make appointments for interview and ask if there is a private place on site to conduct the interviews; (b) have consent forms signed and photocopied for interviewee; (c) reflexive journal notes reviewed prior to interview (assumptions, “going native”); (d) conduct interview (aware of rapport, non-verbal cues, position of recording device etc.) (See Appendix B Interview Guide); and (e) transcribe interviews. It was important to weave into my reflexive notes my own decision-making process to identify any unconscious prejudices that I might show, and to consider improvement for the successive interviews. Due to the highly political undertones occurring amongst this community, it was important to acknowledge its influence on the 39 information given. However, as time went by, I chose not to completely erase myself from the process and embraced a more authentic approach to allow for “going native” as those nuanced conversations were important to what information I gleaned from both my Indigenous and nonIndigenous participants. Data Analysis Thorne (2008) says that generating new constructions out of one’s data is “the most painfully difficult, yet essential element of an interpretive study” and that it behooves a person to “learn to see beyond the obvious” (p.256). Described in more detail in Chapter Four, my main access to the data was through listening to the recordings, more than 20 times, with deepened awareness of differing Indigenous motivations (struggle articulating the Indigenous leadership priorities, identifying meaningful interactions etc.) and taking detailed notes according to the motivation. I listened for the actual tone of a participant’s voice, their confidence, their struggle for words, surprise, or when they spoke articulately. I listened for what might be a new insight on their part, brought about by our conversation. For example, if there was a difficulty in describing leadership or an Indigenous health model, this became central to my analysis. I had intended to review the transcripts for recurring major themes and sub-themes, but this turned out not to fit with my Indigenous approach to data analysis. By using the conversation method, I was able to re-listen to the stories and apply an Indigenous construct of the tree to situate my participant in relation to how they place in the continuum of leadership role awareness, change agency readiness and critical consciousness of Indigenous ways of knowing. My own assumptions were carefully examined so that I was aware of myself as an instrumental tool in this process as I am of Indigenous descent. A burgeoning realisation that my Indigenous knowledge traditions were integral to how I collected and analyzed my data because 40 it dealt with Indigenous SDH issues which I was part of. I carefully journaled my own thoughts, concerns and opinions about the INM Movement and the TRC Calls to Action and how these phenomena influenced my own internal constructs about current change and that Indigenous “voice” was essential to informing any overarching policy transformations that serve the Indigenous population. Expected pattern of results and initial responses to coming changes, preparation modes, decision trees, adaptive evaluations, misgivings, and hopes were considered. Before and after each conversation it was essential to review my reflexive journal to identify possible gross biases and assumptions even from a Two-Eyed Seeing lens (Polit & Beck, 2020). Indigenous Ethical Research Considerations Endeavoring to conduct Indigenous research requires one to approach it with the utmost respect towards the Indigenous community, to have sensitivity to how your research is seen by the community, and how it will affect the community. Due to a troubled research past, many Indigenous communities view researchers and their ilk with a jaundiced and a wary eye. The First Nation Information Governance Committee (FNIGC) was formed to ensure that ethical standards be upheld when entities desire to conduct research within the FN context (National Aboriginal Health Organization, 2007, p.1). OCAP is a group of principles that guide researchers who desire to engage in research activities that involve FN safeguarding the FNs right to direct how research is carried out amongst their members (p.1-2). “O” stands for Ownership, refers to the relationship that the FNs have with their cultural knowledge, data, or information collectively and individually (p.4). “C” stands for Control and is about the FNs rights to maintain and regain their own information; they are tired of “being researched to death” with researchers not handling the data gathered from their communities with respect and dignity for those being researched. “A” signifies Access where the FNs assert their rights to have proper 41 access to their information, that they can control all aspects of data collection, interpretation, and dissemination. It is vital that FN communities be active participants and oversee that the proper respect is given to the entire process. And finally, “P” is for Possession. This refers to the stewardship of the information as should one party have the information and there is the potential for misuse. This is in place for protection of the FNs’ right to say who does what with the information or when there is a lack of trust between the research team and the FN community (p.3). Many times, the use of research regarding this people group has been used to stigmatize or stereotype them and they are cautious about who comes to do research amongst their community members. It was important to consult with (when there was one on site) a research committee for them to review my research proposal and scrutinize it as to whether it will be beneficial (monetary or otherwise) to proceed with my research. I first and foremost sent the band a letter of intent and a pdf copy of my proposal should they require it for approval for me to enter into their band office and interview their employee (p.6). Indigenous Research is a distinct form of Western research (Flicker & Worthington, 2012, p. 20). Now, although my research did entail whole communities, it remains my hope that in some way my research will be able to inform health policy being developed within the Indigenous community context. I inquired about the CHNs’ perceptions of their own skill set and this line of inquiry was one or two steps removed from the community, thus community consent was not an issue, since this study focused on their own perceptions of their leadership abilities and training needs. However, it was important to gain organizational consent as the anticipated participants are employed by an Indigenous organization and I did not want any harm to come to anyone, should the interviewee feel polarized by the situation. The importance of relationship building and trust with my participants was of vital importance and as such, it was my intention to target 42 recruitment to those Indigenous communities where I had connections or associated connections of trust (Flicker & Worthington, 2012, p.22). The ethics involved in this scholarly discussion and endeavor are manifold in how public health is affected. The ethics of healthcare allocation and its priorities are tied to this study and with the INM Movement taking center stage; this has been the larger public discourse. However, there is room for change in Canada as the gap between the Indigenous peoples and the rest of Canada continues to grow. Even undertaking this small study to find any slices of answers that are within this population and applying this knowledge to create stronger linkages towards health and equity will help. Each participant was provided an informed consent sheet to sign and given time to ask any pertinent questions prior to the interview in case they had any safety issues. Assumptions and Reflexivity The assumptions that I identified regarding my study were that there is an awareness of the CHNs’ anticipated expanded leadership role, as well as grasp of what the new governing body meant to these CHNs. These assumptions needed to be laid aside, along with my own beliefs about what the FNHA meant for these CHNs in the coming months and years. I was cognizant of myself as part of the setting, context and political landscape or social phenomenon (Polit & Beck, 2020). What was very clear to me from the outset was my own stake in this Indigenous environment, my own beliefs, and my hopes that this study might offer a ray of hope for a better future for this people group of which I am a part. I was careful to present the thesis in a way that was not exploitive or imposing to each participant by offering questions before the interview and gave time for them to ask any other questions. Throughout the study, I was very aware of my own vulnerability in bias and value judgements as the political climate is very volatile, and the stakes are very high. The historical background of this people group is coloured with a lot of 43 racism in the media right now that is very hurtful, but the marches and rallies repay with cultural pride and love of this land and country. Scientific Quality I applied the criteria or benchmarks for scientific quality in two ways: (i) in relation to the benchmarks of Indigenous methodology (Kovach, 2010), and (ii) qualitative standards for scientific quality. Indigenous Methodology Kovach, in her YouTube video entitled Margaret Kovach (December 11, 2018), discusses the benchmarks of Indigenous methodology as follows: • Protocol of Introduction. I situated myself with my kinship and relationship to my research in Chapter One, and in Chapter Four in the conversations. • Statement on Preparation. To prepare for the study, I spoke with many of our knowledge keepers (Noxsola,) Read many works of Indigenous scholars that have gone before me (Wilson, Voyageur, Kovach) Also my journey of Indigenous conscientiousness • Indigenous Epistemology and Theoretical Foundation. I have referenced Indigenous world philosophy throughout, especially Chapters 4 – 6 (Kenny & Fraser, 2014) • Reference to Ethics: REB and Dr. Evelyn Voyageur on Committee • Story as Inclusive to whole research work • Conceptual Framing that makes sense to Indigenous peoples and serves them • Plans for oral dissemination and reciprocity in sharing with the image of a tree. Qualitative Standards Regarding the scientific quality of this qualitative study, it offers “Good opportunities to assess the overall ‘goodness’ of the data” (Polit & Beck, 2012, p.225). It is my belief that we 44 had some inference quality and transferability with the selection of nurses who worked in each context of Indigenous community nursing whether it be in remote or very remote areas. What conclusions that we came to arises out of the data does inform practice in the areas of Indigenous leadership foci. Data saturation, a standard applied in traditional qualitative methods, is not an issue in the Conversational Method, as each story is viewed as unique and yet with wisdoms that are transferable to multiple settings. This study combined Indigenous knowledge systems, a literature knowledge synthesis component and qualitative iterative processes that found out what leadership skills are prized by nurses who work in this population concerning system change adaptation. A keen sifting through the data and strong attention to revealed nuances in the conversations and supporting literature generates descriptive information to inform nursing praxis (Polit & Beck, 2020). As described above, careful attention was given regarding my own position as a researcher in this process. A chronological journal that detailed my ongoing involvement with the plight of my Indigenous peoples helped with theoretical constructs that need re-examination. I like to think that this added richness to the end product and inform and impact any nurse who encounters my work. Summary of Chapter Three In this chapter I have presented the design of the study, as fitting to the topic of investigation. In the next chapter, I present the study findings. 45 CHAPTER FOUR: FINDINGS The intent of this thesis was to critically examine the key factors that contribute to strong CHN leadership abilities in the face of change. Due to the paucity of literature regarding this phenomenon, especially in the current FN political climate, the results of this study add to the limited body of knowledge in this arena. In this chapter, the findings of the study are presented. I had six conversations (i.e., interviews); three were with CHNs and three were with stakeholders (a FN Chief, a manager, and an FNHA champion with close vested interests in the FNHA). Two of my participants were nursing in the Northern Canada/Indigenous context and the other four had varying degrees of engagement with the FNHA. All participants had over two years experience working in the Indigenous context. I start my introduction to the six participants by locating their stories in relation to the central image of the thesis analysis -- that of a tree which represents the health system (whether FNHA or Health Canada). To remind the reader of the participants introduced in Chapter Three: • Nellie: Key stakeholder, Indigenous • Ed: Key stakeholder, Indigenous • Darlene: Key stakeholder, non-Indigenous • Mercy: CHN, non-Indigenous • Gina: CHN, non-Indigenous • Jess: CHN, non-Indigenous Each conversation is then brought into expanded context by having the participants in conversation with each other, with myself (Kathleen), and my second reader (Voyageur). Since this thesis is in essence about community, it is important how we define this concept. In alignment with an Indigenous paper, I wish to “stand on the shoulders of one who has come 46 before me” and use his bedrock definition of community. This noted Cree scholar is Willie Ermine (2004) who co-wrote Ethics of Research Involving Indigenous Peoples produced by the Indigenous People’s Health Research Centre. He defines community as: a system of relationships within Indigenous societies in which the nature of personhood is identified. The system of relationships not only includes family but also extends to comprise human, ecological and spiritual origin. Community is the structure of support mechanisms that include the personal responsibility for the collective and the collective concern for individual existence. (Ermine, 2004, p.5). Grounding Image of a Tree with Roots, a Trunk, Branches, and Fruit As my analysis progressed, I arrived at a grounding image of a tree to illustrate the main features of an Indigenous health system and, in contrast, the Health Canada system. Each section of the tree has meaning and represents an Indigenous perspective, as opposed to boxes, matrices, or other thematic schema. The earlier analysis process involved a codebook, which stripped the meaning to the bare bones; that process of taking a phrase, isolating it, and matching it to another interview was very uncomfortable, as the phrase had lost its meaning. Next, I tried a type of matrix display (a grid) but it was too angular, too constrained, and did not reflect my understanding of the data. With the growth in recent academic examination of Indigenous ways of knowing and subsequent new boundaries, Indigenous scholars’ work provided the freedom to explore their research methodologies in ways that were more congruent to how they lived life, and the population they worked with -- this made for a truer, deeper, more thorough representation of the research question at hand (Kovach, 2018). Like the FNHA rejects a system that did not work (including the fruits and outcomes of the Health Canada system), similarly I rejected Western, linear patterns for this type of study. My final analysis and thesis report may 47 eventually resemble those linear approaches to some extent, but my process/approach required a more congruent lived experience and subsequent ideology/framework to analyse my data. The FNHA as a solution to bring better outcomes for BC’s Indigenous population is ground-breaking, outside the bounds of what would be allowed by the Indian Act, for example. Their process in creating a model of care that embraces the Indigeneity of its clientele and demands it to be part of the Canadian systems of care and forge a new body politic is revolutionary in its effect on the people it serves and the greater Canadian context (Gallagher 2015, Pp 259-261). The examination of the experience of CHNs working for FNHA/Indigenous context requires research approaches that align with Indigenous ways of knowing. The idiosyncrasy of valuing the organic, oral histories/storytelling where the listener should become part of the process is inverse of current research norms of interview analysis. To explicate this further, thematic analysis of syntax involves the excruciating process of stripping down words and phrases into the smallest, isolated units, and then reconstructing them into themes thus isolating the researcher, and labelling bias as an outcome to be avoided at all costs. This approach to thematic analysis was anathema to me. In using the conversation method, the data is not disembodied from each person, but rather we can wholly extrapolate the real issues from an Indigenous perspective. Kovach (2010) frames the Conversational Method as one that aligns with an Indigenous worldview that honours orality as a means of transmitting knowledge and upholds the relational, which is necessary to maintain a collectivist tradition (p.127). Kovach points to Stewart’s work on Native health, to further clarify this approach, “In her research on Native health, Stewart (2009) articulated the relational assumption underlying research methodology. She stated that from an Indigenous research perspective the relational is viewed as an aspect of methodology 48 whereas within Western constructs the relational is viewed as bias, and thus, outside methodology. For example, to understand Mercy I had to examine my own heart every time I listened to the story, to hear her story. When she said, “I live outside the universe [the boundaries of Health Canada that was doing harm, and the labelling that could come with being an agency nurse]”, she is talking about her own journey of self-realization, someone complicit in re-traumatizing of Indigenous people. Reflexively, I understood that she did not want to be liable. She did not want to be complicit in the maintenance of the healthcare gaps she observed and wanted to protect herself from being an active contributor through systemic multilevel racism. I perceived how she comprehends the intrinsic problems and where she could be positioned to bring about change. In that way, she becomes a centerpiece of the investigation, as a non-Indigenous person, which is remarkable. I have gained much from her conversation and her insights. She may not see herself as powerful, but I see her as powerful. In the [imagined and analytic] conversations she has with other participants (later in the chapter), she and the chief have a fruitful conversation about how things could be improved. They share a distrust of the system, though this does not have to be toxic (as when weaknesses are named and discussed with no efforts at resolution). Their lived experiences of its failure will provide an impetus for further kaizen (the continuous improvement of working practices). The contrasting systems of the FNHA and the Health Canada model are portrayed by two trees. The word for tree in my language is K’wax. The tree for many Indigenous cultures is viewed as the earth’s umbilicus, trees begin in the unseen and grow to be seen (Kimmer, 2013, p.268), and bear fruit. In the description that follows, I employ the analogy of the tree for a deeper analysis of the patterns made evident in the stories of my participants. By referencing the two trees, I could locate the context that profoundly shaped the experiences and views of each 49 participant spoke, as to the deep influencing structures (i.e., the roots), the values (i.e., the trunk), and the branches and the fruit (i.e., the outcomes of policies and approaches). I delved into the workings and meanings of trees and their significance for Indigenous knowledge; I was gaining deeper understanding of trees while opening spaces for Indigenous knowing. This exploration guided my interpretations of the conversations. Having this understanding sparked insights for me, as to where to locate each participant in a living way, to connect experiences, policies, and systems. Their stories then give life to the analogy, exhibiting what the trees produce. For example, I came to understand how Gina and Jess operate in the siloes of Health Canada, and had permission to be disengaged, based on the root system and structure of the Health Canada tree. In contrast, the FNHA tree would require engagement because everyone is “grafted in the vine” and in relationship. There is a degree to which I move between allegory, description, and interpretation. The trees have become encompassing in their explanatory framework for my data. The reader is invited to view the contrasting images of the trees (see Figures 3 and 4) frequently as they read this Chapter. Tree #1 as Indigenous Representation of the FNHA Model The first tree provides an illustrative example of the FNHA model of care. This natural structure aggregates deeper understanding of the issues that are intertwined in the tree and connects what is and what may be causing kyphosis (deformity of the tree) which then aids in identifying which branches need pruning. Each participant story lends itself to gauging the depth of their leadership knowledge, systems-thinking levels, and capacity for change. In applying the tree as illustration, their stories prompt analytic questions such as: Which of their actions are actively pollinating the tree? What seasons provide for faster growth? The idea of cross- pollinating the conversations of the participants can help isolate which part of the tree needs attention, to plan 50 for a more fertile environment in which to grow. Now as we move to examine the other parts of the tree—the branches as what has grown out of initiatives; the fruit as what have we produced; the rotten fruit as what did not work—as we understand the need to prune the tree. Suzanne Simard, in her work, Do Trees Talk To Each Other? theorizes that trees live in a community (forest) of trees with a “Mother” tree that is acutely aware of the needs of the trees around her and dispenses ways and means to get the nutrients to that tree. Tree reality is not the Darwinian model of “survival of the fittest” but rather they are working together so all can survive. So, in our case the FNHA exists as the “mother” tree that can nourish the sapling, or the near dead tree (Health Canada Model) to help clear pathways/ networks for resolution and healthy structures or healthy people as the end goal. This may address Mercy’s misgivings about “not being married to either model” because FNHA is built from the old system and sees the same bureaucratic processes but can have hope that the motivations that drive it are different, which will lead to better outcomes. The Root System The roots of all trees serve as anchors for the tree and therefore have a huge responsibility, a tree's roots are found in the first 6-18 inches directly beneath the ground where water and nutrients are found. Since oxygenation is vital to the tree’s health one must be careful to not put too much topsoil above the roots so as not to suffocate the tree. I portray the root system of each model of care tree indicative to demonstrate what it produced (i.e., for Tree #1 roots portray Indigenous history, teachings, healthy identity, cultural values, ceremonial practices/traditions, traditional governance). 51 Figure 3 Tree as Analogy of the FNHA The Trunk and Bark The bark of the tree is for the protection of the cambium that is just inside the outer tough ring that nourishes the tree. Most trees that are indigenous to BC have a “rough” exterior that 52 protects it from temperature extremes, UV radiation, insects, as well as fungal and bacterial agents of disease. However, the roughness can also act as a vehicle for certain insects to climb up and get at the cambium. In contrast, the tropical trees have smooth coverings which prohibits insects from climbing on the trees as mild year-round weather propagates numerous insects that would destroy the trees. (I am the Nursing Lorax: who speaks for the trees!) The Tree Rings as SDH or Wellness Circle The tree rings provide a snapshot of the past environment/fluctuations of growth. Here we use a tree ring composed of the SDH to identify which determinants we need to graft out and what elements need to be grafted in to create the desired tree. How do we replace a Western view of health to a more Indigenous form of wellness? Nellie spoke of how she would dovetail these elements: By embracing our values and our ceremonial practices, these things will provide meaning and guide our work”. SDH modeling is a Western construct and does not have meaning for most of Indigenous society. Darlene, when talking of her experience at the Gathering Wisdom conference said, “I was sitting in on the chiefs’ panel with the health officials. They were discussing the SDH for quite a while, and then when the Chiefs responded, they said, “we don’t care about SDH, we are in desperate need of nurses, that’s what we need to talk about!” So, there is a disconnect. Maybe if it was framed as motivations for health that were tied into Indigenous beliefs, they may have not lost their audience. So, for the FNHA tree, rather than applying the SDH, I apply the FN model of wellness (see Figure 4) that they have produced that governs how they write policy and prioritize programs. 53 Figure 4 The Tree Rings of Health Canada and FNHA3 for Social Determinants of Health The Burls/Knots The knots on a tree are formed in response to stress or injury (fungal infections); knots or “burls” are created as a last-ditch effort to save a tree's life from disease and acts like a protective scar. I have labelled these as barriers to the growth of the tree (Intergenerational trauma, systemic racism, willful ignorance, etc.). Proper pruning prevents these knots from forming (e.g., leadership growth places, trauma-informed care, SanYas4, accountability, structured system-wide plan for competencies for RNs Healthcare professionals). Branches A tree’s “crown” is that majestic system consisting of leaves and branches that start from a tree’s bud. It is in the bud that the future size of the tree exists. In each of my trees, I have given place for the accomplishments of each system, good and bad as told by my participants 3 With acknowledgements to Sam Brad for his 2018 First Nations Model of Wellness presented at Gathering Wisdom VII. https://drawingchange.com/gathering-wisdom-visuals-for-a-healthyfuture/. See also: https://i.pinimg.com/736x/68/c8/0d/68c80db32ff95b979072470d16e04a7d-social-determinants-of-health-first-nations.jpg 4 SanYas in a 10-12 hour online course. See: www.Sanyas.ca 54 and arranged the fruit at the end to exhibit my understanding of the health outcomes each system has produced. Nested in each tree, is the theoretical lens/belief systems which frames the whole system. Figure 5 Tree as Analogy of Health Canada Tree #2 as Indigenous Representation of the Health Canada Model My second tree depicts the Health Canada System model of care where the colonial roots of racism, the Indian Act policies (see Joseph and Turpel-Lafond report), IRS, colonialism, land dispossession and relocation (reserves), denied women status, assimilation/no voting; language 55 and culture loss) are in stark contrast to what the FNHA tree aspires to. Bob Joseph (2018), in his book, 21 Things You May Not Know About The Indian Act: Helping Canadians make Reconciliation with Indigenous Peoples A Reality describes the impact of IRS on the health of the students as “the schools were a breeding ground for disease….children suffering … severely impacted immune systems”. The history of how Indigenous Peoples were cared for by the governing body is honestly recounted by Dr. Turpel-Lafond in her report In Plain Sight (2020): Colonialism is a structured and comprehensive form of oppression that, in Canada, was justified through creating and perpetuating racist beliefs about the inherent genetic, cultural and intellectual inferiority of Indigenous peoples. These racist beliefs were entrenched through two pernicious propositions that gained structural, legal and policy form: first, that Indigenous peoples should be treated apart and separate, through a segregated health system imposed on them by a dominant regime; and second, that Indigenous peoples could be treated as objects of the health system for the purposes of research and experimentation. (Turpel-Lafond, 2020, p.12) So, the trunk and bark will illustrate these dark policies of our past, and the knots (poor access, culturally inappropriate care; lack of integration of traditional knowledge and disparate community priorities -- “imposition of Western ideas of wellness”) will portray the barriers that the CHNs/Stakeholders state they encounter while practicing in their Indigenous contexts. The branches (intergenerational trauma, trust issues, underfunding of programs) will demonstrate the far-reaching effects this has had on the people. And the fruit of such problems (mental health issues, substance abuse, chronic disease, loss of identity) will be displayed as rotting and falling off the tree. In contrast, where the decolonizing lens is nested in the FNHA tree, the decolonization lens rests with RN, not the system. The top down (rather than community driven) 56 mandate will be demonstrated by the direction of the words that describe the model. It is important for the CHNs to not only know the history of the experiences of the Indigenous people they serve, but they must also grasp the history of indignity and horror their governing body continues to represent to those people they serve. Working as CHN you are also vulnerable in this system (to the system, to each other, bullying, workload). The very name of “Land Corporation” speaks of a disconnected system built for Health Canada and service providers, it has no culturally relevant meaning other than it embodies those same systems that wounded them. The Health Canada Model is structured to be individualistic and cater to the individual; it reinforces the solo practitioner model (independent practice). If one was to take a look at Health Canada through a hierarchy of needs lens, the people in the system would be on the bottom rung of meeting basic needs and the self-actualization goals (understanding the need for a decolonizing lens that acknowledges the treasure of Indigenous ways of knowing and being) would be far away. The need for the nurse to exhibit an internal locus of control about how they conceptualize their practice in this context cannot be overstated. Being of an external locus of control does not make way for them to be held accountable to operate out of new forms of Indigenous knowledge paradigms. Nurses in this system may be the face of the monolith (Nursing station and not trusted by the community) but they tend to not see themselves this way as they are so removed from decision-making and do not make the connection that it is who/what they represent that may be the barrier. Learning about CHN Leadership from the Study Participants In this section, as a first analytic maneuver I describe the views of each participant (with a pseudonym), focusing on what can be gleaned about the main interest of the study--community 57 health nursing leadership. I include an overview of their setting, how they are mastering their context and role, and then evaluate their progress in conscientization of their future role. Jess’s Viewpoints Description of Identity Jess describes herself as French-Canadian, her land is in New Brunswick. She relates with the Indigenous peoples because of her emotional history of being displaced as a French Canadian (“in my history, we also lived rejection”). She has been living in her northern isolated community for 4 years and she describes the population as 50% non-Indigenous, with a large oil industry bringing in workers. When describing the community interaction, she uses the embedded colonial language of “land corporation”. Throughout our conversation there is a definite sense of fragmented governance systems, and no clear mandate; she was hard put to describe the local Indigenous body as something that gave direction to her practice. Views on Community Jess, in conversing about her experiences, feels part of the small community and senses they are more traditional, and states that she would like to see more FN involvement in teaching her how to ”be” in the community. She says one difference relates to dealing with families. She is used to dealing with one or two members but not the whole family, which she was not prepared for and had no prior experience in how to deal with a situation like that. She expounded on just being willing to listen and not take an authoritative stance when working through solutions. Nature of CHN role When talking about her nursing role, it moves along the lines of being very task-oriented rather than a systems level approach to her practice. Jess has had all the clinical/technical skills 58 covered in her remote nursing orientation, but only recently had cultural training that included the Indigenous historical context including the role of the RCMP in subjugating peoples. She did not know anything about IRS, TB hospitals and a host of other historical facts that could have aided her approach to nursing in her context. Without such education, as an individual practitioner, she is not able to provide trauma-informed care (TIC) (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005) and cannot connect what she is seeing in practice to her knowledge schema. When asked about her practice, it is very evident that she lacks a population health lens; rather she is task-oriented and not cognizant of the impact of her unexamined dominant views of health and wellness. As a result, she is ineffective in providing care for members of that population in a way that is consistent with the community’s cultural values. She misses this and discusses more clinical aspects instead. Regarding the questions about her perspective of nursing leadership, she framed it in the context of the immediate Health Centre teamwork and not the broader scope of systems-level cognizance. It is evident that without direction and vision from HC, or a FN governing body, the nurses will continue to be absent of a critical consciousness of the cultural ethos at play in different nursing situations. Jess does touch on an awareness that in her Health Centre -- only the clerk is of Indigenous descent and says, “I wish one day that we had FN workers, to empower people in the community, to share the same culture”. When asked about systems change/management she is very vague: “I am not too sure at the program level. We had regional meetings. A year ago, they decided to amalgamate, to provide “the care the same way everywhere”. Nothing is official yet.” “I am not sure”. From these statements and the lack of confidence in articulating her understanding of who the power players are and the direction of why they decided to “amalgamate”, Jess demonstrates that she does not see herself as a change agent, other than at the micro-level. Case in point, Jess shared 59 an example of a mother who was facing the possibility of her children being removed, so her team created a support system for her, with approval and funding from Whitehorse (proximity to decision-making). While it was commendable that the mother was supported in her community, Jess did not seem to have a more contextual understanding and systems-thinking that could impact change beyond this single case. Conscientization is a Process Jess has learnt she is a guide, not enforcing her beliefs on people and she also acknowledges that building trust is imperative. She says, “I’m conscious that they walk in my office, ‘oh, another white person’”. I try to build trust to work with them. “It took a long time for them to trust me.” She reveals that when invited, she does attend community events to build relationships. She attributes the length that she has lived in the community (4 years) and that she could not tell you when, but that somehow, their isolation struggles and all that went along with that became her struggles too. When talking about how she moves through change (other than clinical mandates) -- she does see the need to evolve, “I am an open-minded person”. She does clarify that to accept the changes, she needs to be informed of the “why” in the change so that she can help move things along. With this openness, Jess represents the potential for growth in leadership, systems-thinking, and advocacy. She has potential to advocate on a broader stage, especially if she were to work in a system that fosters change and community-led care. Gina’s Viewpoints Description of Identity Gina comes from a non-Indigenous background, but she has worked in the Indigenous context for several years and has some real investment in seeing things improve for the better. Enlargement of the scope of practice is marked as she talks about working in this context. She 60 also cites a lack of conflict resolution experience as something that detracted from her overall experience working in this setting. Views on Community Gina states that her health authority was adapted from the Health Canada model and when she started, she went through the community health nurse development program. She works for the Northwest Territories Health Services Authority and took an Introduction to Advanced Practice course. From our conversation, it became evident that nurses are not included in governance; the powers that be, when changing policy, did not include nurses in key meetings. When I asked her to elaborate more about this, she says, “there are disconnects” and she realizes she is not expected to work within the mandate of the Indigenous peoples she is serving. Gina says because the workload is great, she really does not have time to “see the big picture” and yet she wants to be part of “moving the needle” in giving more appropriate care to this population. She does not see herself as a change agent, as one to question the structure of care and analyze its weaknesses. There are few avenues for her to be a champion of the people she serves. Nature of CHN role Gina is a non-Indigenous nurse, working in an isolated northern Indigenous community for the last 3 years on a 6 week in and 6 weeks out rotation. She describes her practice as independent, with a large scope of practice, being typically 1 of 3 at the nursing Health Centre. The organization and herself do not articulate the CHN role as a leadership role, although she seemed intrigued by the idea. As our conversation moved to more explicit detail, she struggled in articulating her role with systems-thinking: her understanding is that Indigenous participation was framed as an interagency community meeting with one Indigenous person at the table to 61 represent the community needs, and this representation was inconsistent. Moreover, she inferred that this participation was for the sake of siloed service provision (e.g., her CHN practice), rather than to build community engagement as a way forward. She further explicates that “it would have been nice to keep those lines of communication open to understand what the community wants.” With this addendum, there is some awareness of what is lacking, and yet the system within which she is working (i.e., Tree #2, Health Canada) does not have a philosophy that can support community-driven, nation-based standards of care (such as that of FNHA, Tree #1) Skillset of CHN When called upon to expand on the hiring practices for the region she describes the governing body as being, “desperate for bodies -- do your references fit? Do you have some skills?” She goes on to observe that if there was a “hierarchy of needs” for the hiring of nurses in this context, the desperation levels would equal that of fulfilling “basic needs” as food, water, and shelter. The dominating emphasis is on clinical skills, apart from a population health lens, cultural knowledge, or leadership abilities. When talking about who she is in change, she sees herself as a flexible person, and when given a voice regarding upcoming changes, is able to be engaged with ownership and buy-in (in the context of system constraints). Description of Nursing Leadership Leadership is talked about in the nursing local context, not in the place of community empowerment. “If something goes down in the community, they (leadership) need to have your back .... Management is in another community two-hours away”. Gina places leadership (positional) in context of the team dynamic and nursing hierarchies (when a bullying problem surfaced, she faced the challenge of working with a remote manager and felt her inexperience did her some harm). Northern nurses are a “cog in the wheel” (lack systems thinking) so it is hard 62 for them to piece together the concept of leadership in the broader context. She does however show potential to expand her definitions of leadership by her statement of “Wondering if the system was imposing Western ideas of health and wellness” in contrast to Indigenous views which are “grounded in the language of the community”. She also said that maybe “leadership is assumed” because there is no focused training about it. Conscientization as a Process Gina talks about being impacted by an elder’s story that created an awareness of the contrast in Western and Indigenous worldviews, this had her asking about who sets priorities. History can shape practice. She had very little training about Indigenous world views from her employer but they did use a case study called Esther Story (for cultural context) that could open to discussions of the SDH, but is still relatively individualistic in its reach, and aimed at care for the individual more so than care for the community. This initiative may have come from the TRC and this was the employer’s response: Esther’s story provided some anchoring but seemed hypothetical. Something that would have a more enduring response would have been to find those stories amongst those communities. Commentary on Two Nurses Immersed in the Health Canada Model These first two non-Indigenous CHNs are committed to their clinical practice but are not fully embedded in a community. There is not a sense of “walking together” with Indigenous communities. Missing were echoes of cultural engagement and traces of deeper understanding. From such a vantage point, they had some awareness, and operated from a posture of technical skill, but lacked the cultural capital that would bred a deeper curiosity about Indigenous knowledge. Marcia Anderson-DeCoteau (2016) frames this as reflective of structural (social) 63 epistemic racism, with an undergirding assumption of the centrality, normality, and superiority of Western dominant ways of knowing. Mercy’s Viewpoints Description of Identity Mercy who is non-Indigenous, currently works in an Indigenous community on the West Coast of BC as a home and community care nurse along with case management. She graduated nearly 20 years ago and describes herself as an interagency nurse who “lives outside the universe”, she has extensive experience working in nursing stations as a “remote” nurse, including agency nursing in two different provinces, as well as had experience in a developing nation for a year with a non-governmental organization (NGO). She was remote certified (Health Canada) 2011 and worked in a remote coastal community for two years. Views on Community Mercy enjoys the independent nature of her work and feels that she works well with “one-to-one” communication rather than being a leader in charge. She is committed to working with this population: her years of varied Indigenous experience are testament to that. Conscientization as a Process While working in this developing country, Mercy observed sovereignty issues, food security issues with the Indigenous peoples. When describing the differences of how the SDH impacts the health of Indigenous peoples, she states that the SDH are worse among the Indigenous peoples here in Canada than in this other developing country. Mercy’s narrative is about decolonizing herself as she works within a racist country, Mercy has an earnest desire to improve herself, never forgetting the lessons learnt from her lived experience working in a foreign context. She explains, “I was raised in a red-neck community, I’ve had to undo a lot of 64 learning to not be a complicit part of Health Canada's mandate to systematically maintain the status quo.” Mercy’s reflections of being a product of a systemically racist Canada are similar to the stories of a White community health nurse in a remote coastal community decades earlier (Harold, 1996). As for leadership, she finds it difficult in the current system laced with institutional racism, so she distances herself from the system. She points out that there is much woundedness in the system (“gaping wound”) and herself and if one is not careful, “soul damage” can happen if you feel you are making things worse, putting yourself at risk, that you are complicit. She was not conversant of the seven directives of the FNHA, despite being an employee. Description of Nursing Leadership Mercy’s story is more about leading herself than leading a community or team; because she can see the whole system, she could “call the plays” (clear view from her higher vantage point, like Darlene, Nellie, and Ed). When asked about how she engages with the FNHA, she describes herself as being “system-critical of where power is housed and distributed” and that is why she lives “outside the universe”. Says she does better with one-on-one and works as an “autonomous being”. She is very interested in FNHA's cultural competency piece and has “wheeled and dealed” to get what education she could because as an agency nurse she is “under no one’s umbrella”. She takes what training she can get when she can get it. She does see some promise as she has attended some info sessions with FNHA that she knows would never have happened under Health Canada. If HC had run those events, it would have been “garland” with no real deep meaningful change. So, there is some shifting taking place. Mercy told me two experiences with the FNHA in its early days, that left her ambivalent and without buy-in. Her first experience with the FNHA in a snowy, dicey situation was one that 65 was punitive, where they made pharmacy decisions based on the current bad weather conditions and the FNHA RN was just full of complaints. Mercy’s second experience of being brought into a remote community to mediate in the health clinic: I have tons of anecdotes. I was asked to switch contracts from where I was in a remote community. They drove me over “Freedom Road” (a remote road with a set of switchbacks down into Bella Coola) in an ambulance, then I caught a boat or plane and was dropped in Klemtu. Because there was a new nurse, who just finished mentorship for remote nursing, left in a similar position where she was acting NIC because something happened. The 2 nurses were not getting along. A bullying situation. You know. We see it too much. Older nurse being a bully. Not the kindest. I was brought in as an agency nurse to put out a fire, 1.5 weeks. Not to mediate. Give the younger nurse a break. Settle things down with another body there. Again – agency nurses not familiar with systems from FNHA perspective. Using me in a strange way to deal with problems. I do not know what the outcome was. I do not think the younger one stayed with FNHA. This was in the early days of FNHA. From a Human Resources perspective, at that time it seemed like FNHA was moving under the Health Canada model in “imposing” in their ad hoc decision-making where she was a body parachuted in to address a problem. What Mercy’s story gives is a viewpoint from a micro and macro level understanding of how the two systems of care are evolving, and she can see the strengths and weaknesses of both. She is also rich in her understanding of applying a decolonizing lens to her situations. 66 Nellie’s Viewpoints Description of Identity As a key stakeholder, Nellie, an Indigenous woman and a regional director/manager for FNHA, had been involved with the early founding of the authority, also during the process of creating the tripartite agreement (between the federal, provincial governments with the new health authority). Nellie has worked for the FNHA for over 10 years and has had multiple roles working this organization from its inception to where it stands as of this recording. In this way, she carries much of the FNHA corporate history and is now involved in establishing collaborative partnerships and alliances for the FNHA. Being heavily invested, she is a champion for the stated values of the organization and identified three main achievements of the FNHA as: a) high levels of community engagement; b) bringing decision-making closer to home; and c) having Indigenous ways of knowing inform policies being developed at regional levels. Nurses Need Knowledge Transfer When speaking of capacity building with new nursing staff who come into the “region”, Nellie identifies the need to look for opportunities for in-depth orientation of FNHA priorities and shared values. She iterates that nurses need “knowledge transfer” to know where our shared values come from, to “fully embrace the seven directives that guide our work.” There are a lot of words that they are expected to know and need to recite, but with space for reflective work on where those values come, nurses will be better positioned to fully embrace the values which they in turn can reflect in all that they do. 67 Nurses Need Self-Reflection Nellie was a strong proponent for cultural safety and cultural humility because they prompt self-reflection to understand one’s personal biases, for both Indigenous and nonIndigenous nurses. Such understanding of one’s own personal history/lived experience will impact one’s interactions with others and how one comes across when providing services to others. A lack of such deeper self-understanding may result in the community putting up walls. Conversely, CHNs’ deepened self-awareness will lead to trauma-informed care (TIC). Trauma-Informed Care as a form of Conscientization From Nellie, we learn how important it is to tie meaning to nursing practice by providing services in a culturally appropriate way, as to not to re-traumatize clients and communities. CHNs who engage with the community, with personal investment being cognizant of traditional knowledges, will be an asset to a community. She holds up the standard for CHNs, reminding CHNs of what communities would want from CHNs. She told a poignant story about her mother who is in care: They were having a family interdisciplinary meeting to discuss her mother’s “noncompliance” with the regimen where the lead nurse exasperatedly said, “Well, why don’t we just tell her this is the way it has to be” and I said, “Hold on, she already has fear of authority and if you approach her in that authoritarian way she will shut down, she won’t respond to that approach” Nellie then talked of how nurses need to learn about providing Trauma-Informed Care, being aware that the paternalistic approaches to treating Indigenous clientele harm rather than heal; she emphasized that CHNs need to be aware of several different trauma-informed cues that clients may exhibit (such as medication “non-compliance”) and adjust your practice. A related issue she 68 felt was that the “system” itself does not lend itself to give time for nurses to build that relational care approach, because of the “pressing need for care” that overwhelms the system. Organizational Change, Chaos and Resilience When asked about how the system changes are going (i.e., the transition to FNHA), Nellie concedes that there are echoes of the old system in that they are fighting a top-down model and wanting it community-based where the local issues are what drives the meetings with the top brass. In one instance, it did not go as planned and they had to adjust and shore up the team morale. She tells the story: I planned to present community-based plans for the region that would support innovation, but the agenda was derailed the morning of the meeting by the FNHA leaders. At the last minute, the question was changed on us, and we did not have a choice. This was not ideal and had implications for staff morale and community optics. But we roll with it. Further expanding on leading her team’s adjustment to change, she says she has been called, “round” because she has learned how to adjust herself to fast-moving changes by “rolling with it”. This example highlights her resilience even amid chaos. When asked about which barriers she faces in her work, Nellie identifies the need for shared data in the partnership work that she is now involved in. It is important for funding to know which services Indigenous people are using and where. The other barrier is that agreements may exist between organizations (what she refers to as “upper partnership work”), but the shared values need to be felt at the front line. For example, every Health Authority in BC has made commitments to Cultural Safety/humility, but these may not be enacted on the front lines. This gap is now echoed in the new report regarding systemic racism experienced by Indigenous peoples in BC (In Plain Sight, 2020). 69 Ed’s Viewpoints Description of Identity Ed is an Indigenous community leader and at the time of the interview, was serving his 5th year as the elected Chief, but also spent close to 18 years as a chief councillor who has had many opportunities to see how governmental policies have played out in his community. Having been on the receiving end of bad governmental policies, he is keenly aware of actions in the FNHA that mimic the old way of doing things. Community Stakeholder’s view of Nursing As someone who oversees the hiring of executive nursing personnel, he understands the need for nurses to have experience in managing people and communicating to senior band council officials. Even with the said “self-governance health model of the FNHA, the Canadian governmental thumb is still on the scale and the FNHA is still seen as a government agency”. Ed’s observation points to the continued shadow of historic colonizing systems. The process of the implementation was very coercive and thereby resulted in a residue of distrust. His experience was this: They came in and basically said this is what we want to do, and I asked myself; Is this really the new relationship you want with us? It seemed like the same old thing.” Overall, his interview had a spirit of distrust. Ed also brings to the table a viewpoint of fiscal planning in relation to a community’s population growth. He explained that they were experiencing shortfalls in funding because there had not been a correct estimate as to the number of births. Vision for CHNs in Community Ed says that it is imperative for the CHN to take a step back and reorient themselves to reservation life by learning how funding (or underfunding) structures work. This may be 70 evidenced in run-down housing with a need for repairs because of black mold or a host of other issues. It should be understood that these houses are owned by the government, not the people living in the houses. CHNs may feel a sense of “culture shock” when they visit their clients’ homes and be prone to judging their worthiness based on what they see as “laziness or carelessness” in an unkempt home. Ed says, “we would rather you have some empathy for the sense of powerlessness revealed in such living conditions”. Bob Joseph, in his book, 21 Things You Didn’t Know About the Indian Act: Helping Canadians make reconciliation with Indigenous People A Reality, points out that “Reserves were created as a place of confinement until they [Indigenous people] became civilized. Once they learned habits of industry and thrift, they could then be released” (Joseph, date, p.24). So those displacement policies are echoed here. Ed suggests cultural sensitivity training is needed to offset the “culture shock” these professionals feel when they are doing home visits. He describes CHNs as being “shy or hesitant to go to their homes”. He understood their hesitancy as reflective of many in today’s Canadian society who have no context of how governmental policies of disenfranchisement, underfunding and the forming of reserves have had an impact on quality of life for Indigenous communities. He was clear that nurses would need to acquaint themselves to the governing structure on a reserve, including knowledge about access to housing, food, employment, and education, all of which are housed in band office. With the shift from Federal (in Ottawa) to local FNHA funding, changes were being felt at the point of service in harsh ways. Ed tells of an experience with a local pharmacist who had an attitude of a gatekeeper and had a “pay to say” mindset: He went in to fill his prescriptions as he normally would, except this time the pharmacist took him to a back room and proceeded to tell him what was covered and what wasn’t, or if it was covered, a generic one will be provided 71 because “he as a taxpayer, was paying for the subsidizing of their prescriptions. He left feeling terrible and wondered if other members of his community were being treated in the same manner. Ed described a similar experience from the elders regarding their prescriptions: They commented that they used to get the “real thing” but now received “knock offs” (this expression of a lower grade) which would communicate an “Indigenous people are inferior” attitude of the dominant society. The discrepancies between the quality of supplies available to the rest of the Canadian populace compared to what we see on the reserves are stark. For example, the lower quality dressings available, and higher levels of diabetic amputations in Indigenous communities (related to not using the better dressings, and healing times is mentioned by Anderson-DeCoteau (2016). As the elected Chief in his community, Ed oversaw those who handled the health portfolio. It is his job to hire community health directors who in turn engage with FNHA regarding priorities and needs on the ground and communicate changes designed by that organization. It is his desire that the FNHA build capacity with these health directors, that they be trained with a population health and trauma-informed lens. His interview gives insight into how important the stance of the CHN is, to present confidence, to show respect at the house. Additional questions stemming from his interview relate to the cultural safety training of CHNs: What influences their level of comfort during home visits? What self-knowledge do they have? Do they see themselves as leaders capable of influencing service delivery, rather than just doing a task? At the Chief and Council meetings, the community would blame the Chief for a bad nurse. Going forward, based on Ed’s interview, one can conclude that the leadership of a CHN is made possible by their critical consciousness and awareness of structural factors (such as fiscal 72 shortfalls, systemic racism as illustrated in gatekeeper mentalities). Without this sensibility, the community and community leaders will not respect the CHN, which further feeds into the general sense of distrust and high turnover of CHNs. Darlene’s Viewpoints Description of Identity Darlene works in a well-positioned Indigenous community that has focused on building capacity for many years. She is a non-Indigenous PhD-prepared nurse manager, and a long-term employee in the community. Nurses’ Role Darlene has worked in both systems and can see strengths and weaknesses of each. She portrays the HC model as follows: the community leaders had found a way to navigate it well, to work the system in a way that was fluid and beneficial to their nursing site. They knew who their contacts were, which were stable, and had built good relationships with those on the HC team which lent itself to good relationships with the local health authority, such that they were clear about pathways for resourcing. Nurses had had professional training on cultural safety and community engagement. The community had established a partnership with a local college to deliver LPN education, as an avenue to build community capacity. Community in Change Darlene was excited about the new system, though it was not that different from what they had already achieved. She welcomes the strides FNHA has made in mental health focus, especially the mental health of staff which was a gap in the HC model. She would like to see more of what is promised in the “inverted triangle” of the community-driven, nation-based model, where they would have a more fluid way of communicating with the powers that be as to 73 their identified priorities and needs. She was eager to see action, stating “there has been enough reflection and now it is time for action”. Leadership in Community When questioned about her desired hiring criteria for CHNs, she characterizes them to be a) a self-starter; b) an independent practitioner; c) one who works well within a team; and d) if possible, of Indigenous descent. Darlene further expands that “fit” and trust issues are urgent. Fit includes being a self-starter, independent practice, team motivator, someone who brings positive energy to a team (knowing not to be overwhelmed and not to bring negativity even when the system and SDH are overwhelming). These relate to capacity-building to make FNHA what it needs to be. Systems-thinking people are willing to address grappling in the hiring process. “You actually need someone, but there is a trade off. We took who came, and that did not work out for us”. Darlene also addresses the scarcity of Indigenous RN-prepared nurses and retention issues. In these ways, Darlene helps us understand that a CHN brings much more than clinical skills and that there are personal and professional qualities that are very important to the fit of a CHN to an Indigenous community. A Way Forward Darlene puts staff mental health as part of the substructure for capacity building to address underlying issues: “Autonomy cannot happen until there is more mental health in communities” and this requires that we move past dialogue and discussion of the past 10 years, and into action. She posits that trust can be a barrier to healthcare due to historical trauma. Thus there is a need for continuity of care, which she acknowledges as an ongoing issue within her context of practice. Her views for leadership for CHNs involve a broad view of health. She says “… our view of health is very broad. I am all about the SDH. A no-brainer. I have heard 74 dialogue at the Gathering Wisdoms whether SDH should be included in FNHA purview. I heard the chiefs say, ‘why focus on SDH when we should have enough nurses and doctors.’” With Darlene’s systems thinking and clarity about the contribution of the CHN role, she recognizes this as short-sighted. In listening to Darlene, I was struck by her ability to tease out strategic systems thinking from managerialist thinking. The disconnect may also have stemmed from the panelists’ proposal of a Western construct (SDH), rather than the FNHA (n.d.) Model of Wellness as touchpoint (Gallagher 2015, p. 255). There could have been more buy-in from the chiefs if they were presented with an Indigenous construct they were familiar with, whereby they could link the SDH directly to their need for nursing staff. In Conversation The second analytic maneuver I undertook was to have the participants converse with each other, in dyads, triads, and a quadrad. I also brought them in conversation with the supervisory committee. This approach is in line with Kovach’s (2010) Conversational Method and “the oral storytelling tradition congruent with an Indigenous paradigm” (p.124). While these conversations are hypothetical, my deep listening to participants’ stories and views allows me to draw deeper insights through these conversations, akin to being in a sharing circle. This has allowed integration across the interviews. In keeping with Indigenous method, I suggest an Indigenous ceremony in response to each conversation. Ed, Nellie & Mercy in Conversation I formed this triad because of several linkages in each of their stories, and how they could work together for greater understanding of the deep issues at play. Their identities—Ed and Nellie as Indigenous, and Mercy as non-Indigenous—shape the conversation. Mercy describes herself as being a beneficiary of the state policies that have at the same time disenfranchised 75 Nellie and Ed. Embedded in this discussion are the years of familiarity with both systems by these three participants. The conversation would cover the strengths and weaknesses they identified in each system, and how they could work to build trust as they close those gaps and journey through self discovery of how their constraints can give way to great leadership capacity, once they find the keys to opening up deep dialogue to heal and move forward. Clearer Communication about the Partnership Agreements is needed to Address Systemic Racism Gaps in services result because a frontline service provider (in Ed’s case, this was the pharmacist) may not be “getting the message” about how they are to provide healthcare to Indigenous communities. Nellie and Ed can talk through Ed’s experience with the pharmacist. Nellie can add her experience of how partnership agreements were built and must be communicated to all service providers at the frontline. As the FNHA was being established, Nellie helped to draft partnership agreements with all of the governing bodies (BC Ministry of Health, Health Authorities, Health Canada) and the professional bodies (e.g., College of Surgeons & Physicians, College of Pharmacists of British Columbia, College of Nurses and Midwives). These agreements include how healthcare professionals are to be trained with information and reflection about how to provide proper, culturally sensitive care to Indigenous populations. As a result, Nellie is conversant with what is in the agreements, and what their expectations are. She will tell Ed that pharmacists cannot be gatekeepers, which is an expression of systemic racism through blocking access to services. They can talk about their shared experience of the “pay to say” attitude, which is present in much of Canadian society, that infers that the non-Indigenous taxpayer would have freedom to say what they wish to an Indigenous person, because paying taxes gives them license to provide a lower grade of quality (e.g., a 76 generic drug rather than a name brand) and communicate this as a cost-saving priority. This knowledge that Nellie shares with Ed could strengthen his advocacy voice. As it stands, he is frustrated because, if this type of interaction and service happens to him (without regard for his office and position in the community), he anticipates even deeper offences for others in his community. With this knowledge he can step into advocacy for his community and in this way redress the systemic racism that is visible when a pharmacist becomes a “gatekeeper” as to which drug would be dispensed. CHNs in Relationship with Indigenous Communities For Ed and Mercy, I would want Ed to help Mercy understand how her stance of hesitancy can look to the home community she works in. He could help her understand how she could work to not enforce the longstanding hurtful practices deemed the “status quo” by non-Indigenous service providers. Mercy has been referred to by Indigenous community members as a “mercenary” because of her transitory practice of taking short contracts, and she agrees with this reference. She herself uses terms such as “gig”, “contract”, and “show”, all language of being an observer rather than being known and knit into a community. At the same time, Mercy is well aware of the need for equity in health services to address the SDH, which are so devastatingly lacking in the communities she works in. And yet, her choice is to “not be married to any organization” and to work for a private agency, rather than Health Canada, as a way to distance herself and not be complicit in Health Canada’s “status quo”. She sees CHNs as fighting a colonized system, but removes herself somewhat, not seeing how she can directly challenge the status quo of this hegemonic system. Ed can help her see how she can ensure her safety, even as she engages with Indigenous community members. He can help her to see how to be a more impactful nurse who steps into relationship as a route toward leadership. His wisdom as a 77 community leader will imbue self-confidence in her, to transform the hesitancy to courage. If she were to ask him, “how do you see nurses in your community? Do they simply provide the service, or are they a part of the community?” He would reply, “this is more than a service because your work is so personal, it is someone’s home, you cannot be detached. You are on our land, and we are doing our part in opening our lives. In response, you need to want to be known by the community, to understand our context and lives, much more than just doing tasks. Cultural safety training will allow you to see from the Indigenous perspective regarding what your work should look like”. CHNs as Doing No Harm and being Passionate about Organizational Change to Redesign Health Programs for Health and Wellness Needs Although Nellie (as an “inee”) and Mercy (as an “outee”) both have lived experience in Indigenous health, they would benefit from listening to each other. Nellie is a champion of the FNHA, and Mercy is a skeptic about the FNHA. Their conversation would be animated! Both have been in the trenches, so to speak – Nellie as trying to create something from the ground up with a community-driven, nation-based mandate to redress historical issues (i.e., to interrupt the historical, intergenerational trauma of racism at systemic and individual levels). Mercy has also been in the trenches, and has seen firsthand the dichotomous, paradoxical impacts of the SDH in two different Indigenous contexts; comparing a developing (in the Global South) to a developed country that has Indigenous peoples in Canada worse off. This lived knowledge speaks to her desire to do good. She has seen governmental policies doing harm rather than good and has become jaded. For Mercy, her biggest issue is with organizations and where power is housed. She could talk with Nellie about her fears of power housed in the wrong place. Nellie will say, “utilize the FNHA’s values and see where they line up in your heart, and in your practice. I 78 think the FNHA values could provide powerful meaning to your work that would result in a very different experience from the Health Canada model.'' Nellie explains that the power is housed locally so we can do the right thing for our people, this is a change that a nurse like herself, can fully appreciate. Their common ground is desire for organizational change. Nellie has invested much in the FNHA, and equally Mercy has given her time and energy to build a nursing practice to be helpful to people she serves. Both are passionate about doing no further harm. Mercy tells Nellie: “I had a situation whereas an interagency nurse, I was called upon by the FNHA to use my experience to diffuse a situation (mediate) where bullying was involved.” She tells Nellie this, to emphasize the need to grow, support, and protect their nurses better, so the FNHA organization “does no harm” to their nurses. This commitment becomes a two-way street, in that nurses “do no harm” to the communities they serve. Nellie tells Mercy that being a part of FNHA can be congruent with her desires to do no harm. Mercy is watchful. It would behoove Nellie to recruit her, pull her in, and it would be great to have her passion for FNHA rub off on Mercy, to start taking on the FNHA tenets. The 7 directives could inspire Mercy (even as she is currently working in a FNHA contract). Could the FNHA provide safety for Mercy’s practice? I think so, she has fashioned her practice to be on “the outside of the universe”, but as Ed has just explained, this is not a helpful place from which to influence change and bring better health outcomes. Research as Ceremony These three participants, sitting down together, might do a ceremony for Mercy, to wash away and address her hurt. An Indigenous perspective would be to have a ceremony -- digetaht - where something has happened in a group and there is a need to “make things right” to address her woundedness and move forward. 79 Gina and Jess in Conversation with Nellie and Darlene Vision-casting as to What Could Be Considering Gina and Jess (both non-Indigenous nurses) are in the neophyte stages of Indigenous-led healthcare consciousness, it would be great to have these two converse first with Nellie (Indigenous stakeholder) to vision-cast how to move forward in their growth as nurse leaders and change agents. Nellie’s strength of holding historical knowledge of FNHA’s founding will help Jess and Gina find hope and discover pathways in how to convey more engagement to their practice. This would address the cultural dissonance that they experience and bring it to an end. She can resource and mentor them, as they address their model of care’s shortcomings. Her directions about self-reflection about their beliefs and value systems to see if they align with Indigenous values could move them forward on a decolonizing path. She would point them to resources such as the TRC report as a guiding document, CINA, and the FNHA philosophy to provide added meaning to their work and guide their growth in leadership abilities. Nellie can also demonstrate how to move beyond tokenism (e.g., in having a community representative or an Indigenous staff person) and move forward for real community engagement that results in real change. In these ways, Nellie helps them to see what the aspirations and purposes of decolonization and reconciliation entail, such that they are no longer content with the current state of the system in which they work; neither are they content with their own practice. In essence, she is breaking them out of the stagnation of the HC model, to be internally motivated to not only “move the needle” but to contribute to social reconciliation and system transformation. The job for Gina and Jess is large, but they have some mandate from the TRC Calls to Action, with a road somewhat paved for them as to how they can contribute to 80 reconciliation with the people they serve. As individual nurses, they have a contribution to reconciliation, the Calls to Action are also for them individually. Darlene (non-Indigenous stakeholder) in the conversation is clear about the importance of the right “fit, teamwork, and independence of practice”. Both Gina and Jess resonate with this, as they are living their expanded scope of practice everyday, and well know that their work is much more than a nurse filling a need “for a body”. They themselves were hired on their ability to “do the job” when the employer was “desperate for a body”. They see how influential Darlene is, as a non-Indigenous nurse, in providing leadership, not to speak on behalf of or to represent an Indigenous view, but to advocate for systems that best support Indigenous health. Darlene and Nellie both help Gina and Jess to understand the crucial relevance of the roots of the trees -Indigenous knowledge and the trauma of the colonial system. The Health Canada model of sending in nurses, without acknowledgement of the roots of the system, is to the detriment of the leadership practice of CHNs (both Gina and Jess had worked for years before receiving cultural knowledge and cultural safety training). The disconnect to the community, without a schema of how they are integrated into a community, is not their fault, it is the system in which they are working. Jess has an advantage over Gina as she is living in the community and has more investment in that way. Nellie might help her capitalize on her location in the community, so that she takes on an Indigenous philosophy in pursuing leadership. Jess and Gina face system barriers in the process of change, which Nellie can help them to see and navigate. They both need to take on systems thinking as leaders, to move beyond the immediate clinical skills they are so capable of. They need the vision and understanding of change (perhaps by going through a crucible), to develop the influence they need from being a team member to being someone who 81 has followers. The leadership they report to, and the leadership in their immediate contexts, have not given them the vocabulary or the vision of Indigenous health. They were lacking in a grounding understanding of a community lens and the Indigenous peoples they cared for (e.g., how to the local Dene identify themselves as to more specific affiliation). How could they be working and living in the community and not know more about the community? It could be that Health Canada does not value this type of knowledge for nurses who come and go. Jess is perhaps further along with this viewpoint, in that she says, “we [referring to non-Indigenous people in the community] are fighting the same battles”. Gina spoke about building trust with another white person but did not reflect on how to build trust with Indigenous community members. She appreciated the story of Esther taught by her employer, but more as a hypothetical story, without equivalent stories from the community in which she worked. Back to Ermine’s (2019) definition of community, Gina and Jess would benefit from hearing from Nellie about community engagement as one of the fruits of FNHA, as they are just beginning to own their health leadership style, solve their own problems. Jess could ask Nellie about the tailored program they created for the young mom in her community, and what might she have done to make it even better: Nellie would begin with the importance of TIC training, and a course such as SanYas, to expand her thinking, along with anecdotes from her context about what they did and what it took to effect change at the local and regional level. This could serve as a local gathering of wisdom to help inform others, to create something specific and effective and end with an invitation to the next FNHA Gathering Wisdom event. Research as Ceremony In this conversation with Jess and Gina, Darlene and Nellie, there is an extent to which “I am the wrong colour” is the elephant in the room. This assumption can be immobilizing in its 82 effect to move CHNs to engage in discussions of what can be done differently. Nellie might provide an initiation ceremony, to “knight” them with permission to move forward in their roles in Indigenous communities. We want them grafted in the vine of Indigenous community. Darlene and Nellie in Conversation Action! Play-calling to get the Ball down the Field As key stakeholders, both Darlene (non-Indigenous) and Nellie (Indigenous) are in positions of leadership and influence in their communities. Using the analogy of football, they could move the ball down the field, as they have vision, strategies, experience to get the plays going. These two are deep systems-level thinkers and change-agents. Discussions of systems strengths and weaknesses would be very informative. Nellie may help Darlene in her system navigation issues, and Darlene may help inform Nellie of getting resources for mental health advancement in the system. They have a deep understanding of both systems (trees) and Darlene knows about workarounds to make even the Health Canada system work. Access to healthcare was not the same issue, given they were not as remote and isolated geographically and because they were well aware of how to navigate a system (both upstream and downstream). For Darlene, she has much to say about Health Canada and who to go to; they had fewer decisionmakers they had to approach with their “asks”. Now, her issue is what she perceives as a revolving door at the FNHA, with multiple contacts. She could help Nellie with her capacity building mandate by sharing the broad vision of health in Darlene’s (“everything is health”) -this would be helpful for Nellie to reimagine how she can merge and strengthen programs in a streamlined fashion. In this way, there is a mutual exchange between Nellie and Darlene. They are both role models (“the tip of the spear”) because they have equally embraced their leadership responsibility and know how to maximize their impact. As they move through 83 change, they are not afraid of the chaos and are able to evaluate quickly and accurately, to mitigate things that might arise from the change. When Nellie’s community-planned event did not go as planned, she was able to move her team through it by utilizing a “quick huddle” to keep team morale up. Again, with their anecdotes they can help with understanding the gaps in the system. Darlene’s observation about the new opportunities for mental health as a key development in capacity building can be helpful to Nellie. The community she works in has built a lot of capacity over the years, and this is new terrain for FNHA. With merging workforce programs and a local university, Darlene’s site has adopted the policy that everything we do is health. Research as Ceremony I would “mantle” Darlene and Nellie in a commissioning ceremony of sorts, in how they can water the tree. I recognize them as movers and shakers who are not in survival mode (not at the bottom of hierarchy of needs) but in actualization for their communities. These two have the vision to fine-tune things to make them work well, in their communities and influence beyond at a broader level. Kathleen and Ed The Intricacies of a CHN working within a Band Kathleen (Indigenous researcher) picks up a conversation with Ed’s (Indigenous key stakeholder) comment about nurses going to homes. Nurses tend to work in the “monolith of the nursing station”, in Mercy’s words, but CHNs need to move into the community. Kathleen’s own experience can offer an example of a CHN stepping into an expanded role to challenge the common, implicit message that nurses’ services are provided from health clinics, and to 84 encompass attention to housing5 as a SDH into the CHN role. My experience as CHN in an Indigenous site after a family all came down with breathing and lung issues. So, being new, I checked my textbook about conducting a housing survey and I did find black mold at the back of the kitchen pipes and elsewhere in the home. I wrote a report to the Housing Department for repairs and moved the family until this could be dealt with. I came in with background knowledge of how the Canadian Mortgage and Housing Corporation (CMHC) works in Indigenous communities, which is notorious for limited designated monies for housing repairs on band land (money by headcount, even when there is a shortfall that has not been addressed: growth). FNHA also has the same way of funding programs--through plans for block transfers of funds. Ed and I would discuss how echoes of the Indian Act are still embedded in the new structure of the FNHA which we see as setting the Indigenous people up for failure. There needs to be a plan B and a safety net that allows time for each community to build capacity to take on new forms of self-governance. We would discuss how nurses need to understand the bigger picture and power structures at play. Ed's resource as a community leader and knowledge of the Douglas Agreement that allowed some families to own land but provided no service road which would allow them to develop it according to today’s standards. Those service roads are subject to government jurisdiction and they cut off a potential access road that could expand the community’s safety. Right now, they only have one way into the community; if disaster struck, they would be trapped. This conversation provides an example of economic and structural reconciliation that is required. Community Surveys by health professionals may carry some weight to get the Government to change these policies. Housing as a SDH takes on particular nuances in Indigenous contexts. For example, housing may be “band housing” meaning it is not individually owned, and therefore a family cannot easily build another wing. Often housing is a, multi-family home. 5 85 The Eagle Flies above the Storm: Transcending the Challenges, Leading Toward Hope My experience working with band councils has been extensive and I share Ed’s frustration with broken promises of government agencies then and now. My goal is to encourage Ed. I would point just how far we have come from (give the examples of Gina and Jess) and emphasize the hope I feel from the success stories that are accumulating within the FNHA, and the improved outcomes. I would encourage him to bring forward concerns for funding shortages, perhaps with a team at the Gathering of Wisdom, to speak into planning. His disappointment at the implementation stage would be acknowledged (“did not know what we were signing on”, “went so fast, we did not know what we were doing”, “so much change so fast”, “communication between FNHA and the Band was broken”, “they downloaded on to us and we were not even prepared”) -- as well as his experience that “nothing the government has done was ever good for us”. I would point out that there are ways in which to give feedback to the FNHA and look for pathways of resolution where they are committed to doing a better job. Ed carries the burden of caring for his community, especially keeping his community economically solvent. He could look outward, to find other successful bands (e.g., Native American Corporations that have done well) to have hope and exemplars of what could work. Back then, everything was new, he had little in the way of a point of reference, which made him reluctant to change his distrustful stance. At the end of these conversations, I would acknowledge where things did not go well, and that the human inclination is to draw back. But we cannot give up so it is better to go after it again, to find other examples as to what could be done better. He is in a place of wisdom, if he could learn from other places, and speak into failures to generate encouragement and hope. 86 Research as Ceremony With aging, value in the community increases. Ed’s father was an elected chief for many years (not a hereditary chief/lineage): an Honouring ceremony for what he has contributed (e.g., a Headdress Ceremony), to encourage him as someone who will use his experience in a mentoring role. Evelyn & Mercy in Conversation Eyes of compassion I would love to have Evelyn (Indigenous researcher) and Mercy (non-Indigenous CHN) have a heart-to-heart. Evelyn’s comments on how having a strong identity made a crucial difference to her practice. Mercy’s deep desire to “do no harm” will be helped by her engagement with Evelyn. Evelyn spoke to us about the importance of having a strong identity. Evelyn would embrace Mercy, and give her some guidance about her fears, in a deep way (as an elder with wisdom). Her guidance would be well received, because of Mercy’s heart to not do harm. The starting point into their conversation might be their shared insights into the very challenging circumstances in which Indigenous communities lived in the north. Evelyn had to seek education about her people, to understand the destitution. Let us embrace this nurse, to strengthen her. Envision Mercy’s identity as to who she really is, not as “in the outer part of the universe”, but rather being in community as a CHN. Research as Ceremony For these two, I would have a healing circle, Mercy’s penchant to ‘sit back’ does not serve her going forward, so it would be important to address her hesitation to engage with the mandate that makes sense to her. Having access to a No’xolla would enrich her practice and help 87 give motivation that gives space for understanding and reengagement and reflecting on the trauma she has experienced. With the ending of the ceremony, a medicine pouch could be given. Chapter 4 Summary In this chapter I have gone over each story and have listened for those needs that are important for growing as a nurse/stakeholder and that theoretically placed my participants in quadrads, triads and dyads to help glean more from their lived experiences and how they can give to someone else during this journey of self knowledge. Research is a ceremony and data is viewed as a gift; and so in accordance to Indigenous protocol, I state which ceremony I would engage to affirm their gift to this process. Ceremony is given to us so we can “remember to remember” and as each story told is considered a gift and is medicine, so we wish to be true to the saying by Shawn Wilson (2008): “Research is ceremony”. 88 CHAPTER FIVE: DISCUSSION Indigenous research involves orating, telling the story in an Indigenous way. As Indigenous research, we cannot escape the spiritual aspects of personhood, to honour what they have given. I was listening to Margaret Kovach (2018), to see who she is: She stated something quite profound, “the data is a gift”; and that we as investigators should treat it as such. She also highlights the need to be cognizant of the orality of your work and its dissemination, that this should reflect your Indigenous heritage. Research means to serve, and reciprocity is embedded in it. The trees are there, visibly, but there is also a large degree of the unseen with a tree (e.g., the roots). One can see the top of a tree, but what is hidden affects the whole tree. To do research, we gave hidden parts prominence (what is unseen). Some background knowledge about trees is that they live in community too and have ways and means to communicate underground with each other as referenced before, through nourishing one another and it each tree community there is a “mother” tree that sees that all trees in community get what nourishment/oxygen that they need. In the same way, our conversations nourished each other, there were things unseen in play that our conversations gave visibility to. It is very important how we “Harvest” such knowledge. I would like to insert here the Indigenous view of the Noble Harvest as described by Robin Kimmerer (2013) in Braiding Sweetgrass: Indigenous Wisdom, Scientific Knowledge, and the Teaching of Plants. He is teaching a group of neophyte Harvesters on how to treat the tree. He points out the waste on the ground, “You’ve missed what is most important, that tree has honoured you with its life, you owe that tree respect so let’s sort through the debris and use it all.” He says that the tree is a good teacher and makes the connection the work of being human is about finding balance and that when Harvesting from the tree, one need only take what you 89 need and use it well (p.147-148). Each conversation is my harvest. I do not wish to take more than what I need, but to put things in balance as I discuss what I learned. I have chosen to explain my work in the image of two trees in conversation with each other. The discussion chapter considers how the findings answer the research questions, and how the findings can be situated or located within existing literature. I begin by drawing on three leadership books, commonly referenced by nursing leadership courses. These are books I used in my graduate studies: Bennis (2009); Grossman and Valiga (2020); and Northouse (2016). I attempted to use these leadership theories to interpret the findings presented in Chapter 4. Yet, I found these Eurocentric theories limited in the extent to which they honour Indigenous ways of being and knowing. In the latter part of this chapter, I draw more specifically on Indigenous leadership theories that help to interpret the findings of this study, for a deeper understanding of CHNs as leaders. The sequence of the chapter, then, represents this evolution of my analysis and thinking. Bennis’ Leadership Theory Warren Bennis, in his 2009 book On Becoming a Leader, argues that leadership involves knowing yourself, knowing your world, mastering context, moving through chaos, and forging a future. He posits that the need for leaders is great and we must master our own context to solve our own problems (Bennis, 2009, p.7). He illustrates the difference between a manager and leader in that managers surrender to their context and leaders master their context. He outlines several different behavioural and mental approaches that vary in each style of leadership. Understanding which one you fall into helps to place you on the continuum of leadership growth. Each of these have their importance in one’s journey to having the ability to move in and out of 90 different situations while keeping your sanity intact. For CHNs this is the basic starting point on a journey of self discovery. Leadership involves Knowing Yourself Bennis discusses the difference between the “once-born” leaders and the “twice-born” leaders: the once-born leaders are products of good circumstances and transition from family to independence in society quite easily but the twice-born suffers greatly as they grow up and thereby develop a vibrant inner life, are charismatic, have inner direction and self-invention (p.46-47). I would like to say that the twice-born leader would be more consistent with most Indigenous peoples as they have more to overcome than the rest of the Canadian populace as evidenced by the SDH that many scholars have written about. For CHNs in the Indigenous context, circumstances beyond their control bring about a crisis to become more than they ever thought possible. Bennis argues that no one can teach you to become yourself, express yourself, except you. Indigenous ways of being take a different approach, whereas a leader learns to be a leader in communion with her environment, family connections and community. Her identity is wrapped up in her interconnectedness to those around her. Now what of the nurse? How strong is she/he in her/his identity? Knowing one’s identity improves your nursing (as exemplified by Dr. Voyageur’s narrative). Mercy is experiencing the tension of knowing oneself and protecting oneself which was articulated in identifying things she did not like in either systems of care she encountered. I think of Gina and Jess who are grappling with the big picture; they go into a big situation (e.g., SDH, isolation, poverty) and are overwhelmed with just the tasks needed to be done and subconsciously decide to not address the bigger picture. It is in the shared struggle with that community that they can come to deeper self-knowledge as they derive greater meaning from their work. They then will begin to tackle questions of, what lens should I be viewing my 91 practice? How do I fit? And how do I help? This moves them forward to mastering the Indigenous context. Leadership involves Mastering Context To further expand on these four competencies involved in mastering context that Bennis lays out: (1) become self-expressive; (2) listen to inner voice; (3) learn from right mentors; (4) give yourself over to a guiding vision (let go of your reticence, have buy-in to the system you are within). Nurses, as they grow in their knowledge of Indigenous health and hear the wisdom from their communities of what wellness means to them, will be better equipped to master their contexts. Gina identifies that she may have missed this in her evaluation of what exactly is happening on her site, saying, “We may have once again brought our Western ideas of healthcare and wellness into our practice…” She acknowledges a lack of awareness of how her community defines wellness. She also identifies that her own Health Authority “didn’t really lend itself to that.” Most of the nurse participants spoke of bullying and lateral violence between team members, with little space for finding the right mentors and trying to express their concerns. Mercy, Gina, and Jess all spoke about how decision-making was very far away and that there was a disconnect from the community to real power. Mercy addresses this very well when she speaks of her lens of “where power is housed” and how it can affect their ability to master their context. What was evident was at time their ability to “work around the system” to make a difference in some situations (i.e., Jess: a program for a young mom with ETOH addiction to help her keep her family intact). FNHA’s Directive One is that the healthcare delivery be community-driven and nation-based, I feel that this is a policy that, if correctly applied, could help alleviate the issues expressed by these CHNs. 92 Leadership involves Trust In many ways, Bennis makes a case for trusting yourself. He emphasizes those leaders who are “more interested in personal growth, in which one is less concerned with specific skills than with self-understanding and the transformation of values and attitude”. They see the gap of what he or she is and what they could be (Bennis, 2009, p.53). If our CHNs and stakeholders are shown this gap and trust that there is a way to fill it, they then embrace the idea opening themselves to ideas and other motivations to improve themselves. Bennis then moves us to the next level of trust: Trusting the people. Because of past historical traumas and new traumas for the CHNs who nurse in these isolated contexts, trusting your people is important. Many of my participants' stories involved the heartbreak of broken trust on many levels (between team members, between them band members, between band and governing bodies etc.). They state many times that this then compromises their ability to do their best before the community. This is where resilience has a place. Bennis lays out a table of identified conflicts and their connected leadership characteristics that counter them. So, for instance, bind trust vs suspicion = hope, initiative vs imitation = purpose, you get the idea (p. 113). Leadership requires the ability to identify your conflicts and find space for resolution. These are in the stories of not giving up, learning to “roll with it” as Nellie describes when faced with setbacks. Hardiness was how this was framed in my nursing education from a professor (Dr. Julia Emblen). There is a need to understand the historical context that they are serving in: The community is trusting that those who are serving their communities are cognizant of what has taken place historically, so they will not be on the defensive on how their surroundings make them look to outsiders. Often this comes about through training (leadership training, cultural safety training). Many of my participants said they needed additional training about Indigenous history – they did not 93 understand what they were seeing in their nursing practice, and once they did, they were able to be more effective. Trust was also Ed and FNHA’s issue and how it can be dismantled easily if processes and honoring is not part of the deal. It behooves the FNHA to follow through on each directive, especially number seven: To function at a high operational standard, and for them to improve their communication with the Chief and Council, by addressing issues and not ignoring them when they come up repeatedly in the meetings. Bennis (2009) states it like this, “Wisdom usually follows illusion, delusion and disillusion…. once you have learned to reflect on your experiences until the resolution of your conflicts arise from within you then you begin to develop your own perspectives.” (p.114). Leadership involves Systems Thinking When I began this thesis, seeing communities contending with the chaos of systems change and how it was being poorly played out in the FNHA’s implementation with the nursing profession taking the brunt of the displeasure of the communities motivated me to explore how CHNs were being prepared for the role they had to fulfill. Did they have the leadership “chops” to remain stable throughout this process? I was curious to see just how much depth they had in systems thinking. Did they understand the crucial role they had to portray in creating a system that was to be the opposite of what they were used to? Were they able to make the paradigm shifts that would cause them to re-evaluate their approaches to their practices? Did they know the difference between transformational and transactional leadership? Were they willing to investigate how the “unseen” was impacting their practices? Bennis says, “People who cannot reinvent themselves must be content with borrowed postures, second-hand ideas and fitting in instead of standing out” (2009, p 1). 94 Systems thinking and being able to “give yourself over to a guiding vision” involves processes of trust as we laid out in earlier portions of this thesis. Included in this is the amount of “uptake” the employees have in the vision of the relevant system. Have these CHNs explored the vision that FNHA adheres to? And if not that, their regional authorities vision statement regarding working within the Indigenous context? What did become evident throughout my participants’ stories was that there was a disconnect between the organizational structure’s vision and frontline employees: They were unable to articulate the vision of the organizational bodies for which they were employed. This creates a divergence in what really happens in communities as the continued status quo that Mercy describes and hopes she is not complicit in and wants to avoid. Understanding how their work is anchored and threaded in the hopes and dreams of the communities/people they serve is pivotal in giving themselves “over to a guiding vision”. That leadership is shared is something CHNs understand because teamwork is important. Darlene, when asked about what she looks for when hiring for her site stated, “Do they know the importance of the team? Can they work well within a team? Can they motivate within a team?” And all the other CHN participants, when asked what leadership meant to them, spoke of the localized leadership, which is important for sharing the load/magnitude of the tasks set before them; what I found missing was their ability to transcend their local context of their leadership purview to that of seeing the existing larger structures in which they were practicing and finding ways and means to initiate change in policies and priorities. Grossman and Valiga on Nursing Leadership Sheila Grossman and Theresa Valiga, in their book The New Leadership Challenge: Creating the future of nursing (2017), explore the elusive elements of true leadership and say that the phenomenon of Leadership is something that cannot concretely be outlined in step-by95 step order (p.ix). They also state that in different situations nurses are leaders and/or followers at other times. Furthermore, “engaged followers are critical to the success of any organization.” (p.vii, emphasis mine). The authors in chapter two discuss the nature of leadership and for nurse leaders to examine their philosophy of work state this, “Regarding their conception of work, leaders work to develop new approaches for long standing problems, …. they are not satisfied with the status quo … take risks, challenge sacred cows and existing assumptions and ask, “why not”? In contrast, managers act to limit choice and not rock the boat. Their instinct is survival. (p. 20). So how do we move nurses from such limiting beliefs? If we can add deep meaning to their work and show them how to yoke their internal beliefs to aspects of a leadership and change agency lens/ purview, we can demonstrate to nurses to show how integral they are to see changes in the system. Fidelity to a belief system and to have honouring be part of the building up of their practice can motivate CHNs to delve into their internal resources like never before. Grossman and Valiga discuss how vision help to harness the dreaming of possibilities of what can be is a hallmark of leadership (p.21, emphasis mine). Grossman and Valiga (2017) highlight the differences of leadership between a management lens and dynamic leadership approaches, who create excitement from their work, who do not accept the status quo and challenge those “sacred cows” rather than tasks that must be accomplished (p.28). When asked about leadership Gina’s responses verbalized her role within an immediate system of her team not at the macro level system. Grossman and Valiga also distinguish leadership versus management in how one situates oneself in the journey of selfknowledge, either through personnel (managerial approach) paradigms or personal (leadership) paradigms (p.21). 96 Peter Northouse on Leadership, Theory, and Practice Peter G. Northouse in his book, Leadership: Theory and Practice (2016), describes leadership as having several components/ phenomena tied to it: a) leadership is a process; b) leadership involves influence; c) leadership occurs in groups; and d) leadership involves common goals. So leadership is a process that tells a story between a leader and a follower that is a two-way street (as transformational leadership) and not just going one way. This conceptualization fits within an Indigenous way of being, more so than transactional leadership does, which only goes one-way; leader to follower (Northouse, 2016, p.2-7). Another interesting thought that Northouse expresses is that leadership and power are confluent with one another because of the resulting influence that emerges in the relationship whether that comes from reward power, legitimate (positional) power, coercive power or reverent powers, so one is very concerned with how a leader uses their power. I like how he delineates how different managerial power is used in an organization to produce order and consistency, and leadership power produces change and movement (p.14). Of the different approaches to leadership that Northouse highlights (i.e., Trait approach, skills approach, behavioural approach, and situational approach) the Situational Leadership approach is one that I see that would work well in this context. This style of leadership gives room for emergent leaders to be groomed for more leadership capacity down the road (p.99). When asked about how they cope with, or identify barriers, each of my participants answered at different places on a continuum of leadership knowledge and experience. This approach asks the leader to pay very close attention to their followers, so they can mine leadership potential from them and use context in creating capacity that allows them to flourish. 97 Indigenous Leadership Theories Throughout this thesis I have struggled to pin down a leadership theory or model that was congruent with an Indigenous worldview. Reading canonical leadership theories brought some ideological relief, however further efforts brought me to the work of Carolyn Kenny and Tina N. Fraser called Living Indigenous Leadership (2014) which was like a breath of fresh air. They frame this struggle as “walking between worlds” since this is the reality we now live in with a more global consciousness in everyday life. They start off by positing leadership as something unbound and yet embodied in the lived experiences of those living authentic and aesthetic Indigenous leadership (p.9). The authors direct us to Amanda Sinclair’s work, Leadership for the Disillusioned (2007), that orientates leadership to be in harmony with their senses and coherent with their belief systems. Sinclair describes a leadership ideology that can “Liberate us from confining and oppressive conditions-- imposed by structures, others or ourselves. Rather than (leadership) being used as a means to compel compliance and conformity, to dominate or prescribe, leadership can invite us to imagine, initiate and contest.” These concepts help to bridge the Indigenous leadership theories that guide our work. Kenny and Fraser (2014) emphasize that interconnectedness to the earth and those around us is the start of leadership, we begin to understand leadership in our relationship with the land, this earth. We allow the laws of our natural environment to inform us on how to peacefully exist on mother earth, this includes our spiritual relationship to the earth (p.6). They state it this way, “To maintain this sense of coherence, we can accept the earth as our first embodied concept of leadership. As we follow earth, we respond to guidance of the processes expressed in our home place.” They expand on this further by stating, “We mirror the patterns, the textures, colour, sounds and processes of the earth as embodied beings…. without you, we wouldn't be here” 98 (p.9). These authors identify Narrative Leadership models in the shared/collaborative Indigenous context of how we gain knowledge, then use that knowledge to properly persuade those in our communities to live better lives. Narrative Leadership is relational and collaborative which is affirming to our historical context; we were not of the “elected” leadership roots, leadership was passed down through generations in oral storytelling, consensus, and accountability to a circle of Elders. Leadership is non-hierarchical. Men had the public leadership roles, but women held the circles of accountability (p.6). In my own experience, there are times when women do go up front in the bighouse, it is during the “mourning songs”, the noble matriarchs are chosen to represent the deaths in those clans. We as women are not diminished; each role is important and seen as essential in governing ourselves. Leadership is viewed in terms of the influence of generations; my mother, my grandmother, my great-grandmother, the stories carried on, they inoculated their worldview of what leadership is with each example they chose to share with us. The timing of the stories is also important, that is the wisdom of the grandmothers, our Adas. Kenny and Fraser (2014) situate leadership as a consciousness that grows out of a cycle of one’s lived experiences, the ability to reflect on those experiences and then direct oneself in the most appropriate way. The mental/emotional maturity to do these things aid in one's ability to be someone who can persuade and influence a community (p.62). Indigenous Viewpoint of Feminism It would be remiss of me to not include the topic of feminism in leadership as we have interviewed several women in this study. In the back of my mind, I knew that to do scholarly work, I needed to address this issue but was unsure how to do so in a way that honoured an Indigenous worldview. Kenny and Fraser’s work (2014) quite eloquently portrays this in a way 99 that coincides with my cosmovision as I too, am hesitant to fully embrace a feministic paradigm that is born of the dominant society’s historical past and not authentic to my community reality. They state it this way, “native women do not want to be bound by dominant theories that limit their capacity to function in the community in their own ways and informed by their own values''. And their conclusion is something I agree with, “Strong native communities with strong traditional values have no need for feminism” (p.11). In relation to my findings, in the formation of the FNHA nurses were not at the table, unintentionally creating barriers for nurses to have buy-in into the new structure and many decided to leave. Of the many nurses who chose to continue in the Federal system, pay scale and retirement benefits were motivations to stay because those things were not clearly addressed in the new system. With nursing as a gendered and often underestimated profession, CHNs are caught up in systems of power. The question remains as to how nurses in this structure, as the backbone of the structure, find their voice. In this way, feminist theory with its attention to social relations of power, does carry some relevance. Indigenous Views on Learning to Lead Included in Kenny and Fraser’s volume is a chapter by Anna Young Leon’s work called, Elders’ Teachings on Leadership where she starts off by stating, “Strong Indigenous leadership is developed by empowering people to reclaim cultural values through the investigation of local, living genealogies, oral histories and praxis. They should be allowed to do so within an environment that supports self-determined change” (p.48). They also state Indigenous leadership includes “knowing and sharing your history by introducing yourself, your family and your nation when you begin speaking” (p.48). Her work on the Longhouse Leadership Program at UBC focuses on the four Rs of leadership: Respect, responsibility, reverence, and relationship. The 100 leadership program was established in 2000 to help supplement training because academic training offered to students was insufficient in providing the leadership training required to work in Indigenous contexts. She further explains that Elders are integral to the development of Indigenous leaders because of their combined expertise and wisdom, those elders who are strongly related to understanding cultural protocols are chosen by their communities as leaders. They teach one how to create meaning out of history, to connect the past to present context and indicate safe directions to pursue so that the people’s history can be sustained and advanced. Elders also emphasize living a life that is respectful, wholesome, and spiritual to affect/influence for seven generations (p.51). Very early in Kenny and Fraser’s book, they identify a foundational belief concerning each member of the Indigenous community, “it is a timehonoured belief among Indigenous peoples that each person is born with innate strengths that can assist with the overall betterment of the community” (p.ix). In Indigenous leadership, the authors point out, role-modeling and mentoring is integral to finding one’s leadership voice whereas contemporary scholarly thoughts move toward individuality (as illustrated by Bennis’ leadership theory). You are your own best teacher; you decide when you become a leader. This is shown in the contrasts between Nellie’s experience of being closely connected to her mom and traditional values, imbibing leadership values and wisdom from those closest to her, compared to Mercy, Jess and Gina where they struggle to find a voice and place of belonging due to being unaware of the opportunities to learn from the community. The value of imbuing a strong identity/belonging is integral to Indigenous communities and the honoured authority of Elders cannot be emphasized enough. Hours are spent at the knee of our knowledge keepers and listening; learning about the power of persuasion in community; holistic, and that leadership is not a separate “task” or “thing” you do; a way of 101 being, a knowing. How are you being known? In the nursing context do nurses know how Indigenous people view trust? Many times, it is in the willingness of the nurse to be known to the people and the people open to be known by the nurse. Other keys of knownness are related to Indigenous knowing, of how we are in our own context, how we work together, how we govern ourselves, our approaches to healing and medicine. “Knowing on whose shoulders we are standing” (p.97) underscores the need to know your own history and your place in history. If the nurse understands oneself and how to apply wisdom in practice, so learning to lead involves learning how to be known to yourself, to your clients, to your superiors and to your team. Leadership as Collaboration and Interconnection To further expand on how leadership encompasses knowing yourself, your history, how you are known to others, and knowing whose shoulders you are standing on, and understand that your actions will have an impact on those who follow you, so that journey begins at home. Kouzes and Posner, in The Leadership Challenge (2017), discuss something close to an Indigenous perspective in their chapter on clarifying values, writing a tribute to yourself, writing a credo (how you see yourself tied to your organization), and talking in your credo language. This is a concrete example that can also reside in an Indigenous context because this process honours the past and gives connecting links on how to bring it into your future. Likewise, in Kerry and Fraser’s work (2014), Chapter Six includes the story of Rachel Guiterres, a member of the Tamhumaran Mexican Tribe. She describes leadership processes in a unique way: “Like my ancestors, I experience the world through multiple paradigms that require me to shift seamlessly between the gifts of leadership passed on from generation to generation. These gifts include an eagle eye; the ability to move from a micro to macro perspective with ease, a seventh generation thinking; a multi-generational framework for making decisions, and a pachamama heart; the 102 know-how to consider the physical and metaphorical ecosystem when making choices and determining actions” (p.97). She understands the need for a collaborative past to work in the collaborative present through moments of true dynamic connection that leave lasting impacts and impressions on others. The sharing of the sacred is important, that aesthetic leadership concerned with sensory knowledge and felt meanings associated with leadership phenomena (p. 104). If CHNs open themselves up to such understandings and key insights from the people they serve, much can be accomplished in the arena of bringing a sacred connectedness to their service. When Gina was invited to participate in the Feeding of the Fire Ceremony, instead of viewing it as an “honoured” novel experience, she may well have better helped herself by spending time with the elders who led those ceremonies and understood what it meant for them to do such ceremonies in front of her. Feeding of the Fire Ceremonies have deep meaning of respectful reciprocity, in particular the Dene’s spiritual and natural relationship with the animal kingdom and the need for the right kinds of foods. If she could take this learning and understanding when serving her community, it would allow her more “knowingness access” to really make a difference in her practice. The FNHA has what is called “The Gathering of Wisdom” conferences and invites health practitioners to participate and observe how regions gather information, experiences and find meaning ways forward towards healthier Indigenous communities. It is interesting to see the response from the College of Pharmacists of BC who have written about what they learned from attending this forum and it does address Ed’s issues/experiences he had with his pharmacy. (See https://www.bcpharmacists.org/readlinks/fnha-gathering-wisdom-forum-what-we-heard) 103 Leadership as Healing and Perseverance for Resilience As stated earlier, one grows as a leader by one’s environment of belief systems and knowledge of self and the culture it is bred upon. In doing so, it creates an environment for one to “bounce back” or be resilient. For this author, it was taught by my grandmother that the (elkwa) blood in our veins echo our ancestors and since it was our parents who gave us our bodies, so they (our bodies) do not completely belong to ourselves, rather, we must consider them as we figure out how best to use our bodies to live. This is the primary way the word “respect” and the idea of leadership was introduced into our lives; that when we see our elders, we know that they carried the blood and walked on earth before us and therefore are to be revered; their knowledge, their ways, should be held in high esteem, as we see ourselves as part of generations. I remember cutting myself peeling potatoes with my maternal grandfather, he deliberately nicked himself and then put our two fingers together and said, “See, the same blood.” He then spat on our wounds, wrapped them in softened cedar and hugged me and we carried on. This experience was a lesson in healing that involved connection, addressing a problem, and moving forward. The world of Traditional Indigenous Medicine (TIM) is something that one growing up in traditional ways takes as a natural way of being rather than an anomaly. Attempts made to integrate Western approaches to healing and TIM is a daunting task for experts in both fields due to the diverse beliefs systems attached to either model. For instance, TIM’s approach to illness is more likely to be viewed as a message that something is out of balance and one is then challenged to learn to bring about balance once again. They take into consideration not only biological processes but spiritual processes too. In opposition, the Western approach is that 104 something biological needs to be overcome. How do we teach others the reverence Indigenous cultures have for both the practical and spiritual worlds? Any CHN in an Indigenous community needs to have a respect for the place of traditional wisdom, which is “a compilation of worldview, based on lived experience” (Hart, 2010, p. 2). Our “wise ones” (called the Ni No’xolla in my language) have not only acquired a wealth of knowledge and experience, but they are also emulated by the community, because we know their actions mirror what is to be sustained in all areas of life. Traditional practices are genuine, spiritual, exhibited in ceremony, as interrelated parts of a greater whole; they help bring balance to community members. Leadership takes on layers of complexity as we struggle to take on Western and traditional knowledges. For instance, when I started my nursing education, my grandmother and other wise ones began teaching me about proper ways to approach elders when asking about their medicines, ask about what traditional medicines they are taking along with what their doctor has given them and be alert in the hospital for certain amulets they have brought with them because they have more faith in that then what is being done in hospital. Albert Marshall, (Sesatu’k Etuaptmunk) an Elder from Nova Scotia who was the originator of the “Two-Eyed Seeing approach, states, “Two-Eyed Seeing, means that Indigenous knowledge and Western science are considered complementary knowledge forms; when integrated, these knowledge forms can advance the health and well-being of Indigenous people. Marshall asserts that “Two-Eyed Seeing” is the need to learn (from one eye) the strengths of Indigenous traditional knowledge and from the other eye, the strengths of Western scientific knowledge. Learning to use both eyes together will benefit both Western and Indigenous peoples’ health and lives (Harder, Astle, Grypma & Voyageur, 2018, p.24). 105 These kinds of Two-Eyed Seeing bridges are needed at the point-of care, and within systems of care ( Forbes, Ritchie, Walker, & Young 2020, para 18) One can see evidence of the effects of the Partnership Accords that Nellie felt would be beneficial to frontline workers if the top leadership had buy-in. The pharmacist governing body wrote about what they learned from the Gathering Wisdom Conference this past year (Oct. 26th, 2020) on community feedback and culturally safe practices. Their section on how we know we have received culturally safe care: ● When you feel respected and heard by the health care provider: ● Having the value of traditional medicines recognized ● Cultural rooms in hospitals, patient navigators ● When the conversation is easy and happy ● When you feel comfortable with the care of your doctor. The importance of addressing culturally safe care and Indigenous-specific racism is central in Turpel-Lafond’s commissioned Report “In Plain Sight” released on November 30, 2020 by the Government of British Columbia. Recommendations from this landmark report will be referenced in Chapter Six. In conclusion, I would like to point to a great quote the authors (citation) give on p.164: “Leadership is the ability to balance traditional culture with strategies to navigate the uncertainty and complexity of our times, to bring forth the resilient nature of all of us”. Indigenous leadership theory can re-lens CHNs’ work for meaningful purpose and help them open up to seek opportunities to gain wisdom from those they serve, so they are able to provide culturally safe care that extends beyond tending to the next task in front of them. 106 Chapter Summary This chapter looks at contemporary leadership theories and Indigenous leadership theories and knowledges. I link lessons to be learnt by the participants, and highlight some initiatives directed by the FNHA that have impacted governing bodies to work for a better future with culturally safe practices. This demonstrates that organizational change, albeit gradual, is coming and we can be optimistic of a brighter future in healthcare in BC. 107 CHAPTER SIX: CONCLUSION AND IMPLICATIONS In this chapter, I summarize the study findings and conclusions, present study limitations, and discuss possible implications arising from the study. Project Summary and Conclusions The purpose of this thesis was to explore the dynamics that influence the leadership capacities of CHNs in FN communities. Specific questions that guided this thesis were: 1. What is the state of knowledge (as portrayed in the scholarly and grey literature) in relation to CHN leadership in Indigenous communities, especially in the context of systems change (e.g., such as transition to the FNHA)? (presented in Chapter 2) 2. What are the perspectives of CHNs in Indigenous communities regarding their leadership abilities, skills, and activities? Are there differences between Indigenous and non-Indigenous CHN perspectives? (presented in Chapter 4) 3. What are the perspectives of key stakeholders regarding the role of nursing leadership capacities in the FNHA? (presented in Chapter 4) 4. What are the implications of these findings for the CHNs’ practice to enhance their leadership skills and to improve health service delivery in Indigenous communities? (presented in Chapters 5/6) Synopsis of Thesis This study aimed to investigate the status of CHNs leadership knowledge, levels of change agency and the leadership implications in a changing Indigenous nursing context that examines the different paradigms between the First Nations Health Authority and the Health Canada Models of care. Framing each of the six stories (three CHNs and three stakeholders) through Conversation Method (Kovach, 2010, 2018) with a decolonizing, Two-Eyed Seeing 108 lens, aids in being true to the stories in their contexts while allowing one to capture nuances instinctive to an Indigenous cosmology that would otherwise be missed or omitted by a linear methodology. The FNHA’s changing environment has increased CHNs awareness for change due to the different values the organization espouses. It requires them to shift paradigms of valuing Indigenous knowledges and creating new ways of being in the Indigenous context. CHNs must move from a task-oriented focus to embracing a change agency stance. One cannot be willfully ignorant of past abuses and trauma perpetrated by governmental and church institutions. A decolonizing lens is embedded within the FNHA model through multiple policy endeavors, but decolonizing intent for those working in the HC model involves individuals challenging institutionalized dogma when they step up with new ideas for leadership and advocacy. One disappointment was not having the opportunity to interview an Indigenous nurse in this study, however, the Indigenous paradigmatic approach to my analysis allows insight to the Indigenous perspective. In addition, two Indigenous stakeholders also brought this perspective, as well as me and supervisory committee member Dr. Evelyn Voyageur. I began this thesis with a literature review to examine the state of knowledge about CHN leadership in Indigenous communities and how they adapt to organizational change. I reviewed the historical timeline of how we came to have an FNHA, and as there was a dearth of information, I added articles and books as they became available. After several attempts at linear approaches to data analysis, I used the Conversational Method (Kovach, 2010) in identifying meanings that influence leadership practice. I used the image of a tree and the natural aspects of how a tree works to locate my participants’ contexts. This allegory helps to clarify the 109 comparison between the two models of care while highlighting the essential differences in values. After analyzing the data, several implications for leadership change emerged. For the stakeholders, building capacity with mental health and wellness being a convector that ventilates growth, having culturally sensitive training for all CHNs, structural training to embed TIC and “buy-in” emerged as being tributary growing a healthy community. For the CHNs, implications for leadership could be placed in two different settings: One being immersed in an FNHA context and the other in a Health Canada context of nursing. For each context, self awareness, mental health, and an expanded view of leadership was needed to adapt to systems change as well as having a working knowledge of colonial histories including IRS and other oppressive governmental policies infiltrated with Indigenous-specific racism, and the TRC’s Calls to Action. Conclusions The following conclusions based on study findings and interpretations are offered: CHNs, despite their altruism, lack fundamental knowledge that could empower them as leaders. Such knowledge unleashes them from socially bound ideologies that constrain models of care and effective leadership. Systems change in both FNHA and HC models of care is needed to support CHNs in moving from potential to actual leadership. With this new knowledge and systems support, CHNs can draw into Indigenous communities to engage and capacitate their identified wellness priorities. Limitations Before exploring the implications of this study, the limitations need to be considered. This was a very small study (six participants) with no Indigenous CHN interview. I did not get 110 to have interviews from each regional hub of the FNHA. The dearth of literature regarding the subject of CHN Leadership in the Indigenous context of organizational change was challenging, as articles became available, I included them. This study was to add to a limited body of knowledge on what leadership deficits are experience amid a paradigm shift to include Indigenous knowledge in the nursing Indigenous community context. Implications Despite these limitations, the study does offer implications for policy, leadership, practice, and education. The implications presented here are not meant to be all encompassing, but rather point to directions and possibilities. Implications for Health Systems Policy CHNs as Allies in Health Systems Policy In the HC model (Tree), the policy needs to address the dissonance between the nurse and the community; this requires a mandate for the nurse to understand the community in their historical and immediate context (nurses carry forward this dissonance, even in a FNHA context, acting like a HC nurse as per Ed’s observations). The “fly-by-night” nurse is antithesis to Indigenous philosophy as known ness is considered a two-way street. The ongoing battle to not reintroduce a “brown bureaucracy” within the FNHA practices will diminish as Indigenous leaders/communities find their voice. Nellie states that “you could hear a pin drop” when they were first asked what they wanted for their community, because they had never been asked before and found the new paradigm uncomfortable. Unfortunately, the CHNs were not strongly integrated at the start up of FNHA. As an illustration of this, the nurses’ role was nearly invisible on the organization’s website; there was little in the way of a nursing “manifesto” that could engage a nurse. The nurse needs to make meaningful linkages between TRC and their 111 work to have impact. The Partnership agreement accord (i.e., between the nursing regulatory body BCCNM and FNHA) exists but its message has not made its way “down to the frontline nurse” for more clarity and direction on what culturally safe care should look like for the nurse and the clients. Stronger communication of the vision is needed--the passion and championing of Nellie is not yet in the language of the nurses or stakeholders. The Role of Canadian Indigenous Nurses Association and Indigenous Nursing Leadership CHNs could be supported by of Canadian Indigenous Nurses Association (CINA) and strong Indigenous nursing leadership, to inform their practice, and provide mentorship because stable capacity-building & mentorship is missing in both structures. The need for bridges like CINA and online Indigenous Community Journals like Pimiwatsin (Aboriginal Journal with themed resilience at its core) can help with the contextual underpinning of their nursing practice. It is important to tap into the motivations of why nurses choose to practice in an Indigenous context (e.g., opportunity, monetary gain, guilt, or curiosity). Once the impetus is known, be it guilt or something else, such awareness can lead to internal change and resilient pathways: Turning guilt into conviction is a better pathway and can be the impetus for change; guilt only looks at the past but conviction is future-focused and enhances one’s practice. The perceived “mercenary” can position themselves to serve with insightful magnanimity, thereby skillfully demonstrating fealty to their community. Organizations such as CINA and FNHA lend themselves to a more engaged and authentic practice. Implications for Community Health Nursing Leadership Building CHN Capacity and Alliances Strong and direct communication is imperative for informing nurses. Mercy tells of being rushed into a remote village to mediate between an experienced nurse and a junior nurse 112 without much clarity about what she was to accomplish as an agency nurse; this was not a good look for the FNHA in its early days. The need for “fit” when hiring a nurse is key; we must move past finding a body to fill a vacancy (as in the assumption that any nurse will do). The short-sightedness of simply filling positions leads to less retention and a residue of bad feelings on both sides. As the profession of nursing builds capacity for Indigenous nursing, nurses, whether Indigenous or non-Indigenous, need to see their practice as “our” work that is couched in terms of a formed alliance to tackle the issues together in culturally appropriate ways, not as one being the helper and the helped. Being non-Indigenous or White is not a reason to have one’s hands tied. This alliance requires the need for distinct, targeted, and pervasive cultural professional development (e.g., SanYas as starting point) that includes responsible accountability for those who break faith with the “covenanted” work (e.g., Nursing Ethics board, and partnership accord commitments that have some “teeth” to them). Also needed is an accountability from the community’s end to protect those going into their communities; wrong is not just one-sided. Circles of Accountability is an Indigenous governance structure that is as healing as it is corrective. This accountability is not to create a punitive environment but for communities to have an instrument to set right things that go wrong. The use of strong illustrative models (like this study’s tree models that connect the dots as to the SDH akin to the rings of the tree, the roots of racism, and how these impact care) helps integrate Indigenous models of understanding, to know where to place things. Living structures (such a birds, wolves, marine creatures, seasons) are used everyday to teach life lessons as reminders of what was taught by those in authority. Building capacity by the CHN requires decolonization of self (through the process of conscientization), and the guidance from the community on what culturally safe care feels like 113 and what the community cues are that demonstrate the CHN is being grafted into the community (e.g., invitation to sacred events, elders share medicinal knowledge, honoured with a name). Leadership Implications involve Mental Health for CHNs Nursing leadership in the Indigenous contexts needs to address the “elephant in the room” that CHNs need a pathway to get help in the moment when they feel unsafe. SDH impact both community and nurses. Nurses become impacted by community trauma (including physical threats to themselves) which results in their woundedness and trauma. To tend to the mental health of CHNs is capacity building. Not knowing or being prepared for the differences in the SDH of the Indigenous context is doing a disservice to new CHNs or current CHNs. Avenues to receiving mental health help need to be secured for the staff. Mercy states her own experiences with violence and community trauma and the failures of the greater structures in not having a clear path to disassemble created more hesitancy to engage in the new structure. Darlene identifies that the path forward for capacity building lies in creating a strong mental health program for the community members to move past crisis/demoralizing events and on to creating a solid future/outcome for themselves. Coping strategies need to be studied for their effectiveness within their immediate context. CHNs need space to be reflexive of their experiences and different impacts of working in communities with higher incidences of violence and disease processes that could affect their activities of daily living. This guidance and support encourage hope and endurance to “stay the course” and grow with the community in their desired goals for the future. Implications for Nursing Education Which educational approaches are best practice when teaching about the historical, economical, and political history of Indigenous peoples? How should one Indigenize nursing 114 curricula that can bring transformative change to the health care systems in Canada? There are new competencies by BCCNM (effective December 31, 2020) that outline the start of what should be taught to nursing students (RCAP, TRC, INM, MMIWG, TIC) but how this is taught is key. Indigenous health curriculum needs to be framed through a resilience lens and not as deficits. Also, important to teaching nursing students about the Indigenous context are how basic operational structures work on reserves throughout Canada (i.e., the local band in relation to provincial and federal level policies). The Two-Eyed Seeing approach has both Western knowledges and Indigenous knowledges being complementary to each other. Harder et al. in their article A “Two-Eyed Seeing” Approach to Indigenizing Nursing Curricula (2018) state that “They recommend using “Two-Eyed Seeing” approach in curricula to heighten student nurses’ knowledge relating to Indigenous people and to clarify understandings about the realities and diversities among Indigenous people to provide individualized health-care” (p.24). So, it is important to highlight the significance of spirituality to an Indigenous worldview; one does not just take into consideration the physical world, the spiritual world is dove-tailed into lived experiences of this population too (Drawson, Toombs, & Mushquash, 2017, p.1). Nurses cannot neglect this aspect of life in the Indigenous context; for instance, it is not enough to just take the medicine, one should believe in the medicine. Understanding the spiritual concepts behind the medicine is important too. Bartlett et al., in their (2012) article, Two-Eyed Seeing and other lessons learned within a co-learning journey of bringing together Indigenous and mainstream knowledges and ways of knowing, state that such knowledges need to be validated by Elders and knowledge keepers to ensure that it is true and not made up. Also important is learning to weave between the two knowledge systems and move amongst them as circumstances dictate because the strength in one may complement the weakness in the other. Lack of preparedness for 115 practice in Indigenous contexts has led to high nursing turnover and vacancies in this population (Harder et al., 2018, p.23). Mercy, when speaking about vacancies, iterates that nurses do not understand the structure in which they work, and the learning curve may be too steep. They have not been taught to see the underlying forces at play which they can end up clashing with, even in a clash between a junior nurse (new FNHA nurse) and an experienced nurse as she shared about how the younger nurse was ill equipped to deal with the situation and decided not to stay. In the spirit of Two-Eyed Seeing, both views of illness and wellness need to be contrasted and explained clearly, with references to frameworks such as a medicine wheel and the FNHA Model of Wellness (Gallagher 2015 p.256). Summary For the Indigenous people, our founding document of Canada is not the Constitution but the traditional beaded Wampum belt used to mark agreements between peoples. Referred to as a “man-made river”, the Wampum belt tells the story of the promises as they, the Indigenous people, understood them to be. The belt symbolizes two canoes traveling on a river that do not interfere with each other, representing an agreement of non-interference and a shared responsibility for the land that we are living on. Despite this historical agreement, we are far from that ideal and historical texts reveal a story that does not include an Indigenous worldview. The consequent intergenerational trauma has tinted the vast landscape of the Canadian with a dark picture of disparate health outcomes that demand attention. The current socio-political climate has given way for change in how we do health with the Indigenous population. Grassroots movements like Idle No More and the TRC demonstrate our desire to move past White fragility (Diangelo, 2018; Frey, 2019, para 8) and guilt, to empowering (not about re-opening scars that have not healed) this population in strong self-governance. We need true reconciliation (in the analogy of the scar, antibiotic healing is needed) to not keep tripping over 116 woundedness; we need genuine partnership and a real sense of community, to be knit together with the greater Canadian populace (not us vs them). The FNHA, though not perfect, does give us a platform where we can launch a more authentic voice to a brighter future than that of the past (HC model). Each story highlights the colonial past and a tentative hope for the future. We have gained insights and concrete ideas on how we can move nursing leadership forward with a jaundiced eye on the past, to not repeat its mistakes. Indigenous knowledges need to be honoured and dovetailed with Western ones allowing for true relationship between the two ideologies; they do not have to be contrasted but be bonded to attest the new knowledges that will spring for such a joint venture. 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Which of these skills would you say you use most when faced with changes or the challenges of change? B. What words would you use to describe your feelings about change/changes? C. (Excited, apprehensive, questioning, dread) D. How do you feel you cope amidst change, (prompts, Stimulated, fearful, challenged? E. What is your understanding of the proposed changes coming in regards to FN Health? F. Do you see your role changing because of these changes? G. What do you think will be the biggest change for you or your community and do you feel you are adequately prepared for these changes? (Prompts: programs you are excited about improving, glad that to dialogue with community members about what is important to them?) Key questions for Chiefs: A. At this time, what skill set are you using that you find most valuable each time you are involved in the FNHA meetings? B. What key characteristics demonstrated by the FNHA leadership are the most important to you and why? (i.e., vision-casting, delegating, creating alliances). C. What strategies of knowledge synthesis (there is probably a better way of saying this!) are you and your team employing to get a handle of all the information being given to you? (Do they have an in-build team or have they hired consultants?) D. Regarding surveying the capacity levels your own community, what identified areas are priorities for you? E. Regarding your health department, have they communicated to you what information is important to them? 128 Key Questions for Health Directors: A. Looking ahead, what key traits would you be recruiting your nurses for? B. Given the changing climate of healthcare delivery in the FN Communities right now, if you direct one question to the FNHA that would help your team’s understanding of this process, what would it be? C. How do you feel that the Aboriginal Nurses Association (ANA) and/or other nursing bodies could be of help to you right now in this process? What supports/alliances do they have access to that could inform this transition process for you and/or your team? D. From your perception, what will be the key benefit of having a “Regional Hub” as opposed to the previous Health Canada Model? Key questions for Aboriginal Nurses Association: Dr. Evelyn Voyageur and for the BCNU Aboriginal Liaison Coordinator: Tania Dyck A. For you, what is the central element of the Tripartite Framework Agreement that (TPA) carries the most significance for you? B. How do you situate the ANA/BCNU in this TPA process? Have you been invited to be a part of helping to inform key priorities for Aboriginal Nursing/BCNU? If so, what have you identified as important? C. What is the most frequent issue that is discussed by the ANA/BCNU about this process? D. What leadership processes best facilitate community growth (from a nursing perspective). How do nurses get positioned amid transition? Nurses (and Health Directors) must facilitate the community-driven directive (yet Chiefs are making decisions, etc.). E. Data Analysis procedures: Coded-themes, Key words: Chaos theory, quantum leadership theory, transformational leadership, transactional leadership, inclusive team processes, capacity-building, collaboration, strategic alliances, congruency of stated aims and current process. F. What is the history of your organization? What was it like before? What is it like now? G. How did you become involved (including discussion of interviewee’s initial experience)? H. What elements or practices are of value to you? I. What is the glue that holds your organization together and what do you do to protect and perpetuate your organization? J. What do you see as the opportunities for and threats to your organization in the future? 129 Appendix B: Search Strategy Month Databases Key Words Output CINAHL Leadership Approximately 6 MEsH Headings Nursing possible articles Native Health Native American And database Quantum Leadership Searched November 6th, 2012 Google scholar Keywords Subject November 21st, 2012 CINAHL Leadership and Nurs Approximately 5 PubMed Native Am and FN possible articles Medline Combined Google Scholar Organizational University of Sask. psychology McMaster Quantum Leadership Complexity Science Aboriginal (excl, Australia, aborigine) November 30th, 2012 CINAHL Change Agency Subject Headings Change Theory And 6 good articles Native American Organizational Change December 1st, 2012 “” NA Research, incl FN 3 articles. Aboriginal 130 Appendix C: Relevant Articles Title: Nursing leadership and health sector reform Authors: Borthwick, C. Galbally, R Research design: An opinion article Subject: Can nurses help empower others when they are not particularly good at empowering themselves? What will the role of the nurse be in creating the information flows that will guide people toward health? Nursing's long history of adaptation to an unsettled and negotiated status may mean that it is better fitted to make this adaptation than other more confident disciplines Key points: Nursing must equip itself with skills in advocacy and political action to influence the direction the system will take. Title: Canadian Nurses Association National Expert Opinion: Community Health Nurses Brief Research design: National Position statement on Aboriginal Community Nursing Subject: Creating a System for (Community) Health If we are serious about improving the health of all Canadians we must shift our voice and share power and responsibility differently. Key points: Political voice, Public Health Policy, Aboriginal context Title: Leadership to reduce health disparities: a model for nursing leadership in American Indian communities: Authors: Keltner, B. Kelley, F. J. Smith, D. Research design: A model for nursing leadership in Native American communities is proposed and a case study that illustrates how culturally diverse leadership in a public health setting can maximize results is presented. Subject: Model for nursing leadership Key points: Community Health Nursing, Health Care Delivery, Leadership, Medically Underserved, Native Americans, Cultural Diversity Title: Role conflict, role ambiguity, and job satisfaction in nurse executives Authors: Theresa Tarrant; Carolyn E. Sabo Research design: Descriptive Research, Descriptive Statistics Subject: Job Satisfaction, Nurse Administrators, Role Conflict, Role Stress, Stress, Occupational 131 Key points Results indicated that the respondents had low to moderate amounts of role ambiguity, high levels of job satisfaction, low levels of depression, a negative relationship between role conflict and role ambiguity and job satisfaction, and a positive relationship between role conflict and depression. Furthermore, although levels of role conflict are decreasing, levels of role ambiguity are increasing. Title: BC First Nations to run own health system Author: Vogel Research design: An opinion piece Subject: Readiness of FN peoples Key points: A way forward. 132