Exploring culturally respectful care in Aboriginal communities
Dr. Pammla Petrucka, RN, PhD, College of Nursing, University of Saskatchewan
Dr. Sandra Bassendowski, RN, EdD, College of Nursing, University of Saskatchewan
This project established a research and knowledge translation (KT) network between two Aboriginal communities, a health region and three tertiary educational institutions in Saskatchewan. The resulting coalition aimed to identify aspects of culturally respectful care that could ultimately be used to develop appropriate health care delivery systems and health professions educational programs for Aboriginal peoples. Relationship building between the coalition members took longer than originally anticipated, but resulted in important mutual learnings about Aboriginal ways of knowing, healing, and culture and has prepared the coalition to embark on a new phase of collaborative research.
Indigenous peoples in Canada generally experience significantly lower health status than the rest of the Canadian population. They have differentially and increasingly been impacted by non-medical factors, such as socioeconomic status, education level, geography and cultural identity, leading to significant inequities in, and barriers to, achieving the health of individuals and communities.1 Although the issue of health and health care for Aboriginal groups has been increasingly present on the national stage, these inequities persist.
This project, which established a research and KT network between non-traditional partners, was based on the belief that all people entering the health care system deserve to receive equitable and effective treatment in a culturally appropriate and respectful manner. For Indigenous peoples, culturally respectful environments acknowledge and, as appropriate, incorporate Indigenous knowledge. Examples of culturally respectful care include being inclusive of cultural health beliefs and practices in negotiating treatment options, and promoting a truly collaborative and mutual involvement of the health system and the community.
Our goal was to determine whether we could identify aspects of culturally respectful care that could ultimately be used to develop appropriate health care delivery systems and health professions educational programs for Aboriginal peoples. The project involved a coalition between two Aboriginal communities, the Regina Qu'Appelle Health Region (RQHR) in Saskatchewan, and three tertiary educational institutions. One Aboriginal community was a rural, non-treaty environment; the other, an urban, Métis community. Both were located within the RQHR. The three educational institutions, the First Nations University of Canada, the Saskatchewan Institute of Applied Science and Technology and the University of Saskatchewan, are all directly involved in the delivery of the Nursing Education Program of Saskatchewan, as well as a variety of other health services education programs which have involved the two Aboriginal communities.
The KT initiative
From its inception, the coalition emphasized the importance of relationship building for research, dissemination, and knowledge translation. We viewed KT according to the CIHR definition,2 with an extra layer of understanding that recognized and adopted culturally appropriate and competent approaches.3-5 We selected a community-based research method to build links between theory, practice, and policy.6,7 We continually sought to relate research learnings to practice and policy applications and, of greatest importance, strove to be equally responsive to empirical and non-empirical evidence.
Early attempts to gain entry into the communities resulted in poorly constructed research strategies and general resistance from participants.
The coalition was initiated in late 2002, when three members of the research team recruited other colleagues and community members to formalize and submit a proposal to the Prairie Women's Health Centre of Excellence, which was supporting teams to prepare future funding proposals through seed grants.
The initial project phase aimed to identify appropriate ways to undertake research with Aboriginal communities. This preliminary relationship building and research planning allowed for team members to recognize and respect the equality of all voices in the process. Through the involvement of elders and Aboriginal community members, the group grew in its openness to the diversity of Aboriginal communities and knowledge. Awareness and agreement building strategies included community newsletters, stories/storytelling, workshops and sharing circles.
Each stage of involvement in the project was based on a negotiated and transparent approach to create a research environment that acknowledged and, as appropriate, incorporated Indigenous knowledge.
It was during this phase that the need for an Aboriginal advisory committee was identified. Early attempts to gain entry into the communities resulted in poorly constructed research strategies and general resistance from participants, who indicated that we were not including them or embracing Aboriginal knowledge in a respectful and meaningful way. This committee included individuals of varying educational, occupational, and community backgrounds (including both Métis and First Nations representatives), and provided direction and advice on general matters, such as potential partnering communities and strategies for building relationships. The committee also offered direction on specifics such as research methodology and appropriate KT strategies.
For the Aboriginal community partners, each stage of involvement in the project was based on a negotiated and transparent approach to create a research environment that acknowledged and, as appropriate, incorporated Indigenous knowledge. The inclusion of Aboriginal elders in advisory, facilitative, and interpretative roles was critical to achieving such an approach. Undergraduate and graduate Aboriginal students were also involved at all stages of the research process.
Results of the KT experience
The KT experience resulted in mutual learnings, the development of trust-based relationships, and new research directions. Although the team initially expected to be embarking directly on the main research questions—identifying aspects of culturally respectful care that could be used to develop appropriate health care service delivery systems and health professions education programs—we encountered many unanticipated issues associated with seeking information from the Aboriginal community about Aboriginal ways of knowing, healing and culture. We decided we needed more time for exploration and development in this critical area and pursued additional funding support. In the spring of 2003, the coalition received funding from an Indigenous Peoples Health Research Centre Partnership/Network Developmental Grant.
To date, the project has allowed us to draw out the preferred approaches of each Aboriginal community on the future directions for culturally respectful care and its relationship to health professions educational programs. While there were considerable differences between the two Aboriginal communities, the analysis of data from workshops and sharing circles revealed common themes relating to health, knowledge and spirituality in a holistic framework.
We have also measured the success of our KT activities by the intent of both Aboriginal communities to maintain and expand their relationships with the coalition. The coalition has also moved forward with research proposals on different areas of interest—one considering community building, the other articulating Aboriginal pathways to healthy living to inform how health services can be delivered in a culturally competent way.
Gaining community trust
At the early stages of the project, Aboriginal community buy-in and trust were extremely low and these relationships required a large investment in time and commitment to affirm and build. Initially, the academic arm of the coalition entered the communities with research questions and approaches that were rooted in theory and experience in non-Aboriginal contexts. This yielded resounding criticism and rejection by the communities, which expressed feelings of under-involvement and disrespect. Rather than continuing with the researchers' agenda, the coalition had to reframe the project to adopt a more appropriate community agenda. The process also challenged the research team to be more inclusive of non-traditional partners at all stages of the project, and resulted in the formation of the Aboriginal advisory committee.
The advisory committee also helped us address the highly sensitive issue of consent—both at the community and individual level. They advised us of the sensitivities in Aboriginal communities around consent as "giving something away," and through their guidance, we were able to reconstruct consent as "having control over what happens to their knowledge."
The partnering Aboriginal communities identified the development of research understanding and capacity as a priority. This focus was critical to informing and influencing policy processes by these communities, leading to buy-in and sustainability. For KT to be successful, the community of interest must see its relevance and utility.
Recognizing the diversity of Aboriginal communities
The two partnering communities had different needs and expectations of the projects. The urban community was more intent on community building and participation; the rural community on cultural competence in health care. However, as the project progressed, we were also able to share mutual findings between the two communities and identify areas of similarity.
We quickly identified the need for a community champion as a link for knowledge translation in the Aboriginal communities. The elders, particularly through the Aboriginal advisory committee, were critical in mediating between the researchers and the communities and establishing credibility for the process.
Time and time constraints were major barriers in this process. The cycle for research funding creates an often unrealistic timeline for building trust, understanding, and mutuality in learnings and sharing in Aboriginal communities. A significant investment in time is required to be considered credible and collaborative in these environments: our coalition required at least two years to establish this foundation before we could consider entering the collaborative research phase.
Conclusions and implications
This is a continuing project, with the coalition now focusing on the learnings from the first phase of the project. The project has also expanded, bringing on new partners and collaborators outside of health care and post-secondary education, with new perspectives and contributions.
Our experience strongly indicates that there must be a cognizance of the cultural aspects to KT, which extend beyond just the Aboriginal context. In the current health care, health education, and health research environments, research teams cannot neglect or under-value multicultural aspects. This has major implications for the time frame for KT activities, the preferred KT strategies and appropriate dissemination of KT learnings. There are currently only limited tools for developing culturally appropriate KT strategies, and this creates a need for skills development, additional time and negotiation in the KT process.
1 Romanow, R. J. 2002. Building on values: the future of health care in Canada. Saskatoon: Commission on the Future of Health Care in Canada.
2 Canadian Institutes of Health Research. 2004. Overview of knowledge translation.
3 Purnell, L. D., and B. J. Paulanka. 2003. Transcultural health care: A culturally competent approach. Philadelphia: FA Davis.
4 Canadian Nurses Association. 2003. Promoting culturally competent care. Position statement.
5 Dreher, M., and N. MacNaughton. 2002. Cultural competence in nursing: Foundation or fallacy? Nurs Outlook 50:181-86.
6 Stoecker, R. 2003. Community-based research: From practice to theory and back again. Mich J Comm Service Learning 9 (2): 35-46.
7 Strand, K. 2000. Community-based research as pedagogy. Mich J Comm Service Learning 7:85-96.
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