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CANADIAN INDIGENOUS NURSES ASSOCIATION (CINA) ‘Collaborative Indigenous Partnership Framework: Supporting Our Unique Expertise - Indigenous Nursing Knowledge

Background It was envisioned by the CINA Board of Directors at their October, 2015 Strategic Planning Re-treat in Alberta, that the organization and its members were in need of a more formal articula-tion of how they will continue to collaborate with various partners in their work at the national, regional and local levels. This document was prepared to inform discussion among the CINA membership at the upcoming 2016 National Conference Pre-conference Session; “Developing a Collaborative Indigenous Partnership Framework: Supporting Our Unique Expertise: Indige-nous Nursing Knowledge”

Section #1 - A new era of Indigenous health partnership

As all of Canada enters into a new era of Reconciliation following the release of the long-await-ed final report of the Truth and Reconciliation Commission, ‘Honouring the Truth, Reconciling for the Future’(TRC), the challenge becomes how to effectively respond to the 94 ‘Calls to Ac-tion’ that have been set out by the Commission. The TRC report clearly lays out recommenda-tions for the ‘how-to’ applied level work. It is also important to note that the work of the Com-mission builds on the work of the United Declaration of the Permanent Forum of Indigenous Peoples (UNDRIP); a collective collaborative process that reflects the self-determining objec-tives of the world’s Indigenous peoples across all sectors of development.

For the Canadian Indigenous Nurses Association (CINA), the reconciliation path forward also builds on an Indigenous collective process. Namely, the 40 years of collaboration with our nurse members across the country. As we celebrate our organization’s anniversary year in 2016, we will continue to support our members in their work at the local, regional, national and international levels.

As we consider the TRC calls to action, we also reflect on our contribution as both an indepen-dent health professional organization, notably the longest standing Indigenous health associa-tion in Canada; and as a collaborator with numerous Indigenous health and leadership organi-zations, mainstream nursing organizations, educational institutions, federal-provincial- territor-ial governments and local Indigenous governments.

Section #2 - Indigenous health: a call for reform

2.1 Health status of Indigenous people

In terms of health status Canadians are amongst the healthiest in the world; in fact, according to the selected international Human Development Index (HDI) scores, Canada’s high develop-ment indicator of .937 ranks 8th in the world. However, there is significant disparity among the Aboriginal populations in Canada in that Indigenous communities ranked 33rd (.851) on that same HDI scale (Cooke et al., 2007). This disparities in the health of Aboriginal Peoples in re-lation to non-Aboriginal Canadians is a serious cause for concern. According to the United Na-tions Human Rights Council (2014), James Anaya, the UN Special Rapporteur on the Rights of Indigenous Peoples, highlighted a wide array of “devastating human rights violations” (p. 4) in

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Canada. He outlined many of the historical issues and stated that the poor health of Indige-nous peoples in Canada is “exacerbated by overcrowded housing, high population growth rates, high poverty rates, and the geographic remoteness of many communities, especially Inu-it communities in the north” (p. 10). 2.2 Call for reform of health policy/services at national and international levels. The efforts of First Nations, Inuit and Métis people in Canada to influence and enhance health care policy services and programs are reflected in various national level reports including the 1994 Royal Commission on Aboriginal Peoples (RCAP), The Blueprint on Aboriginal Health - Kelowna Accord and most recently, the Truth and Reconciliation Report (TRC). The in-ternational consultation process that Canada participated in for 20 years, resulting in the ‘Unit-ed Nations Declaration on the Rights of Indigenous People’(UNDRIP) is also a key informing document that has had considerable uptake among Indigenous leadership and academics.

While the evidence-base accumulated over the past 20+ years presents a strong rights-based case that calls for implementation of whole-of -government approaches in addressing the health and well-being needs for FNIM people, those in power have so far, been unsuccessful in achieving substantive or effective reform. Indigenous peoples have engaged in comprehensive consultation with various levels of government that clearly lays out what needs to be done. While there is now a few promising partnership models of Indigenous - led health governance in health care (i.e. the First Nations Health Authority in British Columbia), the uptake of recom-mendations by Indigenous leaders and community in various reports calling for a comprehen-sive, wholistic approach, is nominal, and remains in a siloed format led by government. This is supported in various monitored implementation progress reports (or lack thereof). For example, the Assembly of First Nations (AFN) released a 10-year report card on the implementation of the RCAP recommendations and issued a failing grade to the Government response. The print on the tri-partite signatories of the Kelowna Accord was barely dry when the government fell in 2004 and it was shelved by the newly formed Conservative government. The UNDRIP was not formally signed by Canada until 2010 -and when they did it was with the provisio that the Dec-laration was an ‘aspirational, non-binding document’.

The lack of action on calls for systemic reform has also been noticed by the international community. For example, the Special Rapporteur on the rights of indigenous peoples, James Anaya (2014), shone an international light on the health situation of Indigenous peoples in Canada describing it as a ‘national crisis’ and linking the existing Indian Act legislation that un-derpins racialized and paternalistic practices and policies stem from 19th century law that sought to eradicate the Indigenous peoples of Canadian society. Anaya advised the Federal Government of Canada “to arrive at a common understanding with indigenous peoples of ob-jectives and goals that are based on full respect for their constitutional, treaty and international-ly recognized rights.”

The initial response of both the government and the media response to the release of the TRC report perhaps holds promise for positive change. For example, Supreme Court Chief Justice Beverly McLaughlin’s affirmation of the term ‘genocide’ to frame the assimiliation policies of Canada towards Indigenous people and the immediate call by the newly elected Liberal gov-ernment for a national inquiry on missing and murdered Indigenous women signal that Indige-nous peoples’ voices on these and other matters are being supported in a meaningful way. Namely, that Indigenous peoples’ rights to development should be protected as called for by the Human Rights Council. This position has been upheld most recently in the landmark decision by the Supreme Court of Canada regarding the First Nations Child and Caring Society and the Assembly of First Nations legal challenge regarding the rights of First Nation children.

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These notable events signal a shift in the relations between FNIM peoples and the State. As the work unfolds to both respond and implement the health-reform related recommendations of the TRC and other important reports, it is expected that Indigenous health professionals and organizations will be called upon to share their expertise. As the people of Canada enter into this new era of reconciliation, it is critical to engage in relationships with Indigenous peoples that honours their collective work done to date.

Section #3 - Indigenous health: a call for reform Aboriginal Nurses Association of Cana-da (CINA): 40 years of ‘unique expertise’

3.1 Historical Perspective

In the late 60’s and early 70’s Indigenous leaders in Canada began to formalize their political action in the search for true recognition of Treaty Rights, self-determination and sovereignty that led many advocacy groups to reclaim their indigenous lands and approaches to education, justice and health. As McCallum explains, it was in this context that a generation of nurses and thus, the ‘Registered Nurses of Canadian Indian Ancestry’ was born. This was a historically significant time in which Indigenous nurses found their collective voice within an emerging dis-course regarding Indigenous identity, language, and education and in turn began to influence nursing approaches to health promotion, prevention, treatment, and education.

The notion of ‘cross-cultural nursing’ that emerged in the 1980s resulted in Indigenous nurs-es bearing more than their fair share of the weight of the work of defining, teaching, and prac-ticing cross-cultural care, as a result of what Jean Goodwill called their “unique expertise.” During this time period, Indigenous nurses found for themselves a space in the nursing profes-sion as respected critics and providers of healthcare services to First Nations, Inuit and Métis people. They also developed an Indian nurse identity, which combined a strong belief in social and cultural responsibility with a professionalizing nursing ethic.

Throughout the 90’s the discourse on First Nations, Inuit and Metis health took hold under the auspice of cultural competency. Nursing institutions began exploring ways to be more open to cultural sensitivity and cultural awareness by focusing on the race of clients/patients and essentializing health care approaches. Although this was an important step, and action stem-ming from the work of Madeleine Leininger a nursing historian, the concepts of cultural safety were not well rooted.

CINA articulated their own version of an Indigenous nursing specialty; ‘Aboriginal Health Nursing’ (AHN) in 2001 with a process to embark on, “genuine search for a new way of nurs-ing and the challenges and benefits it presents for clients and populations born of social, phys-ical, economic, political, historical, and cultural realities which Aboriginal people want to be faithfully reflected in nursing care” (CINA, 2001, p.40). As an organization, CINA originally de-fined AHN as “the way in which nursing care is provided to Aboriginal clients; and also the way in which nursing interventions are targeted towards Aboriginal communities and popula-tions (i.e., community empowerment, etc.)” (Nowgesic, 1999). 3.2 Re-Connecting with Indigenous Nursing Knowledge

Today, it is acknowledged that the ‘unique expertise’ nurse members bring to various partner-ships is the Indigenous knowledge that we hold and how that knowledge is cultivated and harmonized in their practice. As described by various Indigenous scholars, Indigenous knowl-edge is the manifestation of human knowledge, heritage, and consciousness and is a means of

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ecological order (Battiste & Youngblood Henderson, 2000). Indigenous Knowledge covers a range of values and beliefs present in First Nations, Inuit, and Metis peoples’ ways of knowing and being. It includes knowledge stemming from the various, creation stories, traditional heal-ing approaches, language, traditional parenting, ceremonies, and spirituality.

Indigenous nurses in Canada have been combining their Western education with a firm ground-ing in their own languages, cultures, and healing traditions to shape the field of Indigenous-nursing knowledge and it is utilized to advance and shape the current context of nursing prac-tices. An Indigenous paradigm must begin with a common vision guided by the values and pri-orities of the community: “Aboriginal People must maintain the integrity of their traditional knowledge” (Dion Stout, Stout, and Rojas, 2001, p. 2). We have created our Indigenous perspective from our experiences situated in the traditions and customs of our people and shaped by our ancestors, land, and mental, emotional, physical, and spiritual rela-tionships with each other (Bill, 2012; Dion Stout & Downey, 2006; Struthers, 1999, 2003). It includes all generations and cycles in time and space for the manifestation of compassion and respect in the development of our self-understanding associated with identity formation, which is central to the creation of Indigenous knowledge.

3.3 CINA Organizational strengths and challenges

Over the generations, through its nurse members, CINA has contributed 40 years of experi-ence, and wisdom regarding Indigenous ways of knowing regarding health and well-be-ing and culturally safe nursing practice as reflected in our Mission Statement:.“The Aboriginal Nurses Association of Canada (CINA) is the longest standing Aboriginal health professional organization in Canada that is governed by a Board of Directors whose vision is to be “recognize as a vital expert resource in advancing the health of Aboriginal communities”, with an end view to improve the health of First Nation, Inuit, and Métis people, by supporting First Nation, Inuit and Métis Nurses and by promoting the development and practice of Aborig-inal Health Nursing. In advancing this mission, the CINA engages in activities related to re-cruitment and retention, Member support, consultation, research, education and policy direc-tives.”

CINA’s strength as an organization is realized through their membership. Indigenous nurses are called upon by many diverse groups to participate as both collaborators and leaders. Nurse members continue to bring their unique and diverse languages, cultures and healing traditions to their practice. Their role as stewards of Indigenous nursing knowledge (INK) informs the on-going development of local, regional and national Indigenous health policy services/programs.

CINA has traversed the ever-changing environment of Indigenous health infrastructure devel-opment and been responsive to a myriad of initiatives initiated by government and various non-Indigenous stakeholders at the national, regional and local levels. The organization’s work through its regional membership has established many organizational and community-based relationships. They are called upon to share their expertise from both an organizational policy perspective and their regional nurse members in a variety of initiatives, projects and reform processes. Partnership and collaboration processes are usually developed in a random way with various stakeholders identifying their priorities which while they may be in the realm of In-digenous health, usually lean towards the partner’s project priorities and goals. It is assumed that CINA will engage based on our organizational objectives and member profile. However, these processes are often problematic for both the organization and its members. For example:limited capacity to fully participate due to limited human resources at head office

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over-burden of nurse participants who already have full-time jobslimited ability to participate due to limited travel fundslack of support at the community level resulting in inability to participate

In addition, CINA as an organization experiences overarching sustainability challenges which results in again, a limited capacity to engage fully in a consultation process due to numerous competing demands for participation and operations/project obligations. Lack of ongoing sus-tainable resources underpin ongoing issues such as:

- limited capacity to maintain operations at high-level of excellence due to inadequate funding - lack of continuity from year to year due to high turnover of staff that is in turn related to project-based contractual staffing model- limited capacity to expand its work as a health professional organization: There are 7945 Aboriginal nurses in Canada. They make up 2.9% of the RN workforce. with 48% identifying as First Nations; 50.1% as Metis and 1.9% as Inuit.[Refn] CINA holds real potential to expand its work as a nurse member association if resources/capacity were enhance and protected limited capacity to maintain and enhance members services due to demand of project - based funding deliverables- limited capacity to strategically plan and implement a diversified funding model

The cycle of project-based funding, turnover of leadership staff and external focus of partner engagement continues to negatively impact the overall sustainability of CINAThese factors also contribute to the external perception lack of professionalism and inability to engage in a meaningful and sustainable way. Needless to say, this creates a crisis of credibility for the organization and more importantly perhaps, serious challenges in maintaining a high standard of membership support and services.

The need for a self-determining partnership modelIn addition to the over-burden of participation to external processes/initiatives and the sustain-ability challenges is perhaps, the more troubling situation of how many partnership processes fail to fully acknowledge and respect CINA’s self-determining aspirations and leadership.

In 2010, Canada endorsed the Declaration on the Rights of Indigenous Peoples and although they considered it to be a “non-legally binding aspirational document.” it is considered to be the way forward by Indigenous leaders because Canada has formally accepted the Declara-tion. (TRC-Final Report, 2015:242) By 2011, various groups were urging the federal government to implement it. A United Nations General Assembly at the World Conference on Indigenous Peoples in New York adopted an action-oriented “Outcome Document” to guide the implemen-tation of the Declaration. Member states from around the world committed, among other things, to consulting and co-operating with Indigenous people taking appropriate measures at the national level including legislative, policy, and administrative measure to implement the Declaration and promote awareness of it among all sectors of society. The call for commitment to cooperating with In-digenous peoples, ‘through their own representative institutions,to develop and implement na-tional action plans, strategies or other measures, where relevant, to achieve the ends of the Declaration” (2015,para.8) The TRC calls upon the private sector, civil society and academic institutions to take an active role in promoting and protecting the rights of Indigenous peoples. The TRC Commissioners note that the development of national action plans, strategies and other concrete measures will provide necessary structural and institutional frameworks for “en-suring that Indigenous people’s right to self-determination is realized around the globe”

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Section # 4 - Into the future: a reconciliation- based authentic partnership approach for CINA

The Truth and Reconciliation Commission’s describes ‘reconciliation’ as an ongoing process of establishing and maintaining respectful relationships at all levels of Canadian society. The TRC endorses the UNDRIP as the appropriate framework for reconciliation and advocates that studying the Declaration to identify its impacts on current government laws, policy and behav-ior would enable Canada to develop a holistic vision of reconciliation. One that embraces all aspects of the relationship between Indigenous and non-Indigenous Canadians.CINA believes in ‘authentic Indigenous partnerships’ with Indigenous rights-holders and non-Indigenous stakeholders that are inclusive of values grounded in diverse Indigenous philoso-phies that centre relationality, respect and reciprocity at the core of self-determination. This approach is in keeping with the United Nations’ recognition of “the urgent need to respect and promote the inherent rights of Indigenous peoples which derive from their political, economic and social structures and from their cultures, spiritual traditions, histories and philosophies.” [refn] 4.1 CINA Strategic Plan: how we will prioritize our work

CINA’s 2015-2016 Strategic Plan (SP) is inclusive of sustainable objectives that are in keeping with an Indigenous reclaimative and self-determining approach towards health and wellness. Goals and Objectives of the SP include the development of an Authentic Indigenous Partner-ship Strategy that identifies Indigenous relational values and protocols towards maintaining our established recognition as leaders in Indigenous health and Aboriginal Health nursing.

Secondly, that we would Identify collegial national, provincial, and local nursing partners that will maintain and advance ongoing nursing policy, research, practice and education goals including private sector partners that may yield funding sources that support Indigenous self-determination. It was determined that CINA would engage our members in the development of a collaborative framework that would articulate how we would engage with our partners.

As such, the focus of CINA’s work into the future will build on the many relationships that we have established and the new collaborations to come. Our approach will be in keeping with the spirit and intent of both the Declaration and one of reconciliation. We express this in a collabo-rative framework that aims to support and facilitate the partnership goals and aspirations of both CINA and our partners. The collaborative framework implementation protocol will ensure that CINA’s leadership and expertise is upheld in the spirit of an ‘Indigenous - ally’ relationship.

4.2 Collaborative Framework: how we will engage

CINA has honed our own process over the years both in multiple collaborations and project development processes, that is inclusive of an Indigenous worldview and cultural safety/com-petency concepts that also include internal mechanisms of approval. We endeavour to partner in a way that promotes the principle of ‘by and with’ Indigenous peoples and situates our part-ners as Indigenous ‘allies’. This is reflected in several association- level objectives. Most rele-vant to this aim are the following: 1. To work with communities, health professionals and government institutions on Aboriginal Health Nursing issues and practices within the Canadian Health system that address particular interest and concern in Aboriginal communities with a view to benefiting Aboriginal peoples of Canada by improving their health and well-being, physically, mentally, socially and spiritually.

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6. To facilitate and foster increased participation of Aboriginal Peoples’ involvement in deci-sion-making in the field of health care. (For full list of CINA’s objectives, see Appendix ~ XX)

While we have partnered with many diverse stakeholders, we endeavor to prioritize our part-nerships in alignment with the objectives of our strategic plan. Namely, member services and support, recruitment and retention, consultation, research, education, practice and policy. It is recognized that our unique expertise and stewardship of Indigenous Nursing Knowledge (INK) will inform our collaboration with other stakeholders and partners.

4.3 Situating Indigenous Nursing Knowledge at the Centre’: Four Core Priority Areas of Collaboration

Our partners have acknowledged that Indigenous people are experiencing significant health disparity and inequity.

They seek to partner with Indigenous nurses as a doorway to Indigenous communities, The shift is not just acknowledging the cultural expertise.

Rather, its about Indigenous nurses as stewards of INK and how they centre INK within their practice.

Four priority areas of collaboration: education, research, policy and practice.

B.) Leadership and Allies: upholding and protecting the relationship

CINA organizational values are grounded in Indigenous philosophies that centers relationality, respect, reciprocity, and self-determination in a way that promotes the principle of ‘for and by’ Indigenous peoples. As such, CINA aspires to engage in collaborative processes with both Indigenous and non-Indigenous stakeholders situated as ‘allies’ that is inclusive of common goals and objectives and mutual benefit to each organization.

The UN Declaration calls for the development of effective ways of ensuring the participation of Indigenous peoples on issues that affect them. To accomplish this in the context of the work of CINA such a process requires that our partners understand our spiritual ties to our lands, our collective and individual rights and identities and our diverse worldviews, traditional, languages and cultures. Realizing our rights as Indigenous peoples and Indigenous nurses and upholding our right to participation and self-determination requires a rights -based approach.

A rights -based partnership then is captured in the phrase: “Nothing for us - without us” As such, implementation of a rights-based approach requires a willingness for nursing leader-ship organizations, policy makers, and educators/researchers to make room for Indigenous nurse leadership. They need to know the Indigenous people they are working with at the re-gional level; understand the structural barriers and challenges they encounter and co-create

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strategies and key features of an enabling environment for ensuring the full and effective partic-ipation of CINA and our nurse members.

A. NURSING PRACTICE In drawing on the work of Bourque Bearskin, (2014) research examining how indigenous knowledge manifests in the practice of our Indigenous nurses the four themes of practice, ed-ucation, research and policy were revealed in the experience of Indigenous nurses who have all be closely tied to the work of the Aboriginal Nurses Association of Canada. The articulation of the themes below are not comprehensive of the work of Indigenous nurses of Canada but were supported by the CINA Board of directors as areas that needed to be further explored as the foundation of Indigenous nurses contribution to nursing knowledge development. Nursing Practice

The professional role of nursing practice continues to evolve based on the settings and context where care is provided. Nonetheless, there continues to be concerns over the scope of prac-tice, development of standards, efficient clinical tools and knowledge to enhance patient out-comes when working with Indigenous people (Canadian Nurses Association, 2014; ). Indige-nous nurses hold the unique expertise of Indigenous nursing knowledge and its application to western nursing approaches (Bourque-Bearskin, 2014). However, they face many systemic bar-riers that prevent the harmonization of both bodies of knowledge/practice.

Proposed Partnership objectives: PRACTICE

I) identification of structural barriers and potential solutions

II) development of practice guidelines that move beyond cultural competency to include the utilization of Indigenous nursing knowledge

III) Connect with regulatory bodies (e.g. the Canadian Nurses Association)

IV) Incorporation of traditional healing in contemporary clinical practice, to ensure that we do not lose sight of Indigenous nursing knowledge

V) Value and understand the distinction between the parallel worldviews of Indigenous knowl-edge and Western knowledge in order to enhance practices

VI) Increased mentorship opportunities in order to enhance and build capacity

VII) Cultural safety is a starting point, and there should be an increased awareness for cultural safety, perhaps through a mandated course, or face to face training

VIII) Increased awareness of racism within health care

IX) Best practices should be used, as well as increased support for increased recruitment and retention of Indigenous students within Nursing education (from the undergraduate to doctoral level)

X) Increase in capacity and support for Indigenous researchers and experts who are bombard-ed by research requests

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B) EDUCATION

The education of nursing students is being called into question in almost every institution across Canada. The need to transform nursing approaches stems from concerns about sus-tainability and the reported poor delivery of health care services to Aboriginal peoples (CINA 2009; AFN, 2005; CASN, 2003; CNA, 2012; 2014, McBride & Gregory, 2005; McGibbon, & Etowa, 2009; Wasekeesikaw, 2003). CINA needs to support nurses to rethink how and what they teach about Indigenous nursing care.

Partnership objectives: EDUCATION

I) Identification of an optimal structure of nursing education inclusive of Indigenous knowledge systems in its design, implementation, and evaluation

II) Partner with other nursing educators throughout the country

III) Integrate and incorporate traditional medicine knowledge and Indigenous nursing knowl-edge within nursing programming in education

IV) Value the distinction between Indigenous knowledge and Western knowledge within educa-tion in order to enhance practices

V) Increase in mentorship and support within nursing education for Indigenous scholars and students in order to improve retention (from the undergraduate to the doctoral level)

VI) Increased cultural safety opportunities incorporated into nursing education programming, as well as increased awareness of racism in the healthcare system

VII) Address the lack of Inuk trainers, educators, and graduates

VII) The A.N.A.C should lead research in postcolonial perspectives in nursing education

IX) Increased research opportunities on racism within healthcare

C. POLICY

Policy development in nursing has not been widely supported. “Nursing leadership is about critical thinking, action, and advocacy” (CNA, 2012, p. 1) with a specific aim to advance nurs-ing policy. This management and leadership role requires that nurses be engaged with nation-al, provincial, and local community representatives and well informed on current trends such as the need to shift from I to we to develop a cultural intelligence that can be globally applied (Fitzgerald, 2002; Hanson, 2009; MacPhee, Chang, Le, & Spiri, 2013). Facilitating Indigenous nursing voices must be central to create change and informed on Indigeneity to develop cul-turally safe nursing services. This action will help to reduce the current disparities in access to health care services for Aboriginal populations (A.N.A.C 2014; Cameron et al., 2014).

Partnership Objectives: POLICYAnti- racism, non-deficit approach to providing Diabetes - care; MB evaluated nationally; ca-pacity and - how we are approaching people and how we have to develop the relationship with them and where they are at.

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I) Integrating Indigenous world view.

II) Form partnerships with policymakers like provincial health ministries, regulatory bodies (e.g. the CNA), and other provincial leaders

III) Increased awareness of racism in health care

IV) Increased Inuk trainers, educators, and graduates

V) Increased research opportunities on racism within health care

III) Increased capacity and support for Indigenous experts and researchers

D.) RESEARCH

Indigenous health research has always been the central structure of support for the creation of Indigenous knowledge (Weber-Pillwax, 1999 p. 31). It has also been used extensively as a de-colonizing methodology to explain the relevance of research that is respectful of Indigenous peoples (Tuhiwai Smith, 2012) and to show how Indigenous research helps to develop theoreti-cal and conceptual tools for practice (Lavelle, 2009; Sam Ktunaxa, 2011; Wilson, 2008) Issues of ontological and epistemological differences are the main concerns that stem from the nar-row conceptualization of health and nursing to which we had all been acculturated.

Indigenous nurse scholars report that traditional Indigenous knowledge systems are open to other forms of medical knowledge and treatment, but Indigenous knowledge systems them-selves are not recognized or valued in current health practice.Indigenous knowledge also cannot be harmonized with health systems until we recognize that the specific ways of Indigenous being and doing are aligned with Indigenous ways of knowing. We also need to advance the work by Indigenous scholars and researchers to uphold and sup-port Indigenous research methodologies.

Partnership Objectives: RESEARCH

I) Co-host a process to explore and identify supportive mechanisms of harmonizing parallel knowledge systems

II) Lead research in postcolonial perspectives within nursing education

III) Increased research and research opportunities on racism within health care

IV) Adapt a national ethical framework for decision making around Indigenous nursing specific research

V) Increase support and capacity for Indigenous researchers

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4.4 Collaborative Framework - principles and protocols

4.4.1Guiding Principles and values: rights-based; relationality; reciprocity; standard of excel-lence; reconciliation; role of the ally (nursing and non-nursing); equity and respect

• Recognition of Indigenous Rights and self-determination; • Collaboration and partnership with Inuit, Métis and First Nations communities on the ap-

proach, implementation, and evaluation of any initiative

• Acknowledgment of historical and socio-economic experiences with practice, education, research, and policy

• Culturally appropriate health and wellness approaches implemented early in design process• Acknowledgement of holistic models of Indigenous health• Understanding of Indigenous diversity and its implications;• Incorporation of Indigenous ways of knowing, being and doing.

• Commitment to determining best practices or evidence-informed practice• Collection, interpretation and analysis of data/results, including disaggregated data within

Inuit, Métis and First Nations context• Preparation for appropriate community driven timelines, recognition of gatekeepers, and

leadership changes

• Support the recognition, preservation and promotion of First Nations, Inuit and Métis in their transmission of Traditional Knowledge, healing practices and medicine.

• Facilitate and promote research and develop relationships relating to First Nations, Inuit and Métis health and wellness that are grounded in First Nations, Inuit and Métis ethics and methodologies

• Support and promote First Nations, Inuit and Métis efforts to access relevant information regarding the opportunities and advantages of pursuing Traditional and Western based health related careers.

4.4.2 Implementation Mechanisms and Protocols

A.) Governance and Authority Mechanisms

CINA has developed formal strategic collaboration with multiple organizations across diverse sectors including Indigenous organizations at the provincial and national levels; national orga-nizations with diverse mandates related to health and social development; provincial organiza-tions and various Schools of Nursing across the country.

These collaborations have been expressed through various instruments such as ‘Memoran-dums of Understanding’ (MOU) and more recently, in the format of a Partnership Accord (PA). These mechanisms are typically used to articulate the governance and authority parameters of the relationship between two organizational partners and the scope of activities they will en-gage in.

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The following table identifies recent and existing examples of MOUs and PAs that CINA has engaged in.

OrganizationNature of PartnershipCanadian Institute of Health Research: Institute of Aboriginal Peoples’ Health The creation of linkages and establishing relationship networks between the two organizations to advance Indigenous health initiatives.Canadian Nurses FoundationDefines and describes opportunities between the two organizations to collaborate on: (i) ensur-ing the alignment of CNF’s fundraising efforts to increase support and capacity for Aboriginal nursing education and research; (ii) supporting initiatives fostering the value of increasing the capacity of Aboriginal nurses to meet the healthcare needs of their communities; and (iii) ex-ploring opportunities to collaborate further in increasing educational and research funding sup-port for Aboriginal nurses.Canadian Nurses AssociationIn the spirit of authentic Indigenous partnership, CINA and CNA endeavor to establish a struc-tural linkage with the development of a ‘Partnership Accord’. The CINA - CNA Partnership Ac-cord aspires to the self-determining principle of ‘for, with, and by’ Indigenous people, situates CNA as a professional ‘ally’ and aims to formally articulate a partnership that is in keeping with the mandate and structural boundaries of each organization. As such, CNA acknowledges CINA as the leading national voice regarding Indigenous health and well-being and culturally safe nursing practice and endeavors to consult and include CINA in all CNA activities, advoca-cy, and policy development pertaining to First Nations, Inuit and Métis health and/or nursing. Dalhousie UniversityTo collaborate with the CINA to develop strategies and initiatives intended to advance and im-prove Aboriginal health status. CINA has agreed to provide Dalhousie with the names of Abo-riginal nurses, who are members of A.N.A.C and who have agreed to provide mentorship to Aboriginal Nursing students at Dalhousie during academic years ending in 2018-2019. Dal-housie will communicate the availability of Aboriginal Nursing mentors to students of the School of Nursing and will provide the contact information of those mentors to Aboriginal stu-dents who express an interest in participating in a mentoring relationship. Forum Indigenous Implementation Research and Evaluation FIIRE Focused on national Indigenous knowledge network for the enhancement of IR/PHIR in In-digenous communities which will be known as the Forum for Indigenous Implementation Re-search and Evaluation (FIIRE). The FIIRE supports the development, piloting, evaluating and documentation of Indigenous implementation research and evaluation to enhance the uptake of Pathways population health interventions within Indigenous community contexts.Specifically, the parties will work together on: 1. the joint development, publication, and dis-semination of four national policy documents addressing key aspects of Indigenous implemen-tation research/population health intervention research. 2. An iterative evaluation of the FIIRE knowledge network First Nations Health Managers AssociationServes only as an instrument of acknowledgement and facilitation of the Parties’ collaborative and cooperative efforts toward mutually supported initiatives in the advancement and im-provement of First Nations’ health status in Canada. There is an agreement to receive and transfer to FNHMA members and CINA members, information on health human resources and First Nations health.

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One Match Canadian Blood ServicesDescription The Society of Obstetricians and Gynaecologists of Canada Co-promotion of excellence in the practice of obstetrics and gynaecology and to advance the health of women through leadership, advocacy, collaboration, outreach and education.

University of AlbertaCo-creation of linkages between organizations may be of great benefit in jointly advancing agendas of common and mutual interest. In this instance, the mutual interest is in the overall improvement of the Aboriginal citizens and communities’ health status;Support students/faculty travel and participation at CINA conference. Research training activi-ties held at national conference.University of ManitobaCo-collaborate in good faith, either formally or informally, in the jointly determined initiatives and/or strategies intended engage in on-going dialogue and information exchange between the Parties assigned or re-sponsible officials;

have regular and formal communication between the Parties equivalent mandating body with respect to issues of common interest, shared objectives and updates on advancements;

the provision of reciprocated support and/or assistance in the advancement of common and/or agreed upon objectives where financially feasible; University of Ottawa collaborate in good faith, either formally or informally, in the jointly determined initiatives and/or strategies intended to advance the Objectives as noted above

engage in on-going dialogue between the Parties assigned or responsible officials; have regular and formal communication with respect to issues of common interest, shared ob-jectives and updates on advancements; and, provide support and/or assistance to each other in the advancement of common and/or agreed upon objectives where financially feasible. University of Saskatchewanpromote collaboration and leverage the strengths and resources of both parties in (a) improving the recruitment, retention and experience of the College of Nursing’s Aboriginal students; (b) jointly advocating for evidence-based strategies to strengthen the number of Aboriginal nurses in Saskatchewan and Canada; and (c) partnering on initiatives that will advance and improve the health status of First Nations, Métis and Inuit peoples in Saskatchewan and Canada.a) Seek to promote and facilitate mentorship between College of Nursing Aboriginal stu-dents and ANAC members. Foster and promote ANAC membership amongst College of Nursing students and alumni.c) Work to promote the sustainable and appropriate use of distributed or community-based learning to increase access to nursing education in Aboriginal communities.

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Jointly establish and sustain a Northern Nursing Education Network (NNEN).e) Collaborate on mutually relevant and beneficial initiatives that improve Aboriginal nurs-ing education and promote Aboriginal health equity, through student research assistantships and in-kind support.f) Work together to support continuing education initiatives related to cultural competency and Aboriginal determinants of health for practicing nurses in Saskatchewan and Canada.

B.) Leadership and Allies: upholding and protecting the relationship

CINA organizational values are grounded in Indigenous philosophies that centers relationality, respect, reciprocity, and self-determination in a way that promotes the principle of ‘for and by’ Indigenous peoples. As such, CINA aspires to engage in collaborative processes with both Indigenous and non-Indigenous stakeholders situated as ‘allies’ that is inclusive of common goals and objectives and mutual benefit to each organization.

The UN Declaration calls for the development of effective ways of ensuring the participation of Indigenous peoples on issues that affect them. To accomplish this in the context of the work of CINA such a process requires that our partners understand our spiritual ties to our lands, our collective and individual rights and identities and our diverse worldviews, traditional, languages and cultures. Realizing our rights as Indigenous peoples and Indigenous nurses and upholding our right to participation and self-determination requires a rights -based approach.

A rights -based partnership then is captured in the phrase: “Nothing for us - without us” As such, implementation of a rights-based approach requires a willingness for nursing leader-ship organizations, policy makers, and educators/researchers to make room for Indigenous nurse leadership. They need to know the Indigenous people they are working with at the re-gional level; understand the structural barriers and challenges they encounter and co-create strategies and key features of an enabling environment for ensuring the full and effective partic-ipation of CINA and our nurse members.

To uphold CINA leadership and maintain the collegial and self-determining integrity of the rela-tionship, our collaborative mechanisms will include a conflict resolution protocol.

C.) Capacity Building and Mentorship (to flesh this one out further) Responsibility to enhance the health care experience and nursing practice standards as de-scribed the organizational membershipinclusion of Indigenous nursing studentsresources to support inclusion of nurse members from diverse geographical locations in the work at the regional and national level

APPENDIX ~ CINA GOALS AND OBJECTIVES

The objectives of CINA serve to guide the membership and the Board of Directors. They were revised in 2010 to reflect new realities. They are:

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1. To work with communities, health professionals and government institutions on Aboriginal Health Nursing issues and practices within the Canadian Health system that address particular interest and concern in Aboriginal communities with a view to benefiting Aboriginal peoples of Canada by improving their health and well-being, physically, mentally, socially and spiritually.2. To engage and conduct research on Aboriginal Health Nursing and access to health care as related to Aboriginal Peoples.3. To consult with government, nonprofit and private organizations in developing programs for applied and scientific research designed to improve health and well-being in Aboriginal Peo-ples.4. To develop and encourage the teaching of courses in the educational system on Canadian Aboriginal health, Indigenous knowledge, culturally safety in nursing and the health care sys-tem and/or other educational resources and supports.5. To promote awareness in both Canadian and International Aboriginal and non-Aboriginal communities of the health needs of Canadian Aboriginal people.6. To facilitate and foster increased participation of Aboriginal Peoples’ involvement in deci-sion-making in the field of health care.7. To strengthen partnerships and develop resources supporting the recruitment and retention of more people of Aboriginal ancestry into nursing and other health sciences professions.8. To disseminate such information to all levels of community.

APPENDIX ~ X CINA Representation on External Committees (Updated January 2016) 1. CINA Representation on External CommitteesCommitteeCINA RepresentativeCanadian National Working Group on HIV & AIDS (CNAWGHA)Michele Parent Canadian Nurses Association Aboriginal Health Nursing Advisory GroupBernice Downey, Canadian Nurses Association Canadian Network of Nursing Specialties (2 ANAC reps)Lisa Bourque BearskinLucy BarneyCanadian Pediatrics Society First Nations, Inuit and Métis Health CommitteeCheyenne Mary.Canadian Pediatrics Society International Meeting on Indigenous Child Health (IMICH)Planning CommitteeCheyenne MaryInternational Centre for Infectious Diseases, National Collaborating Centre for Infectious Dis-eases Advisory BoardJoanne CookPublic Health Agency Family- Centred Maternity and Newborn Care National Guidelines (FCMNC) Oversight CommitteeDelia McDonaldDebbie GrisdaleFamily Violence Public Health Association of CanadaLisa Bourque Bearskin/Kevin BarlowPartnership Engagement Knowledge Exchange: NWAC Angie Letendre & Ada RobertsPartnership Engagement Knowledge Exchange: Manitoba ChiefCaroline Chartrand & Lisa Bourque Bearskin Forum Indigenous Implementation Research and Evaluation (FIIRE)

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Lisa Bourque Bearskin/Angie Letendre

APPENDIX ~ X Demographic Profile of Canadian Aboriginal Registered Nurses *Based on the 2011 National Household Survey [Refn] There are 7945 Aboriginal nurses in Canada. They make up 2.9% of the RN workforce.48% are First Nations. 50.1% are Metis. 1.9% are Inuit.Overall in Canada, 60.8% the Aboriginal population identified as First Nations, 32.3% of as Metis, and 4.2% as Inuit. Aboriginal people make up 4.3% of the Canadian population.

The territories had the highest percentage of Aboriginal nurses, with Nunavut at 24.2%, NWT at 23.7% and Yukon at 11.1%. Amongst the provinces, Manitoba and Saskatchewan had the highest proportions, at 7.2% and 6.1% respectively, while Quebec had the lowest at 1.0%. Ontario had the largest number of Aboriginal RNs at 1195. 77% of Aboriginal health professionals are RNs. Aboriginal health professionals include physi-cians, dentists, veterinarians, pharmacists, OTs, optometrists, chiropractors, speech patholo-gists, dieticians, nutritionists, physiotherapists, audiologists, and registered nurses etc, of which there are 10,260 total identifying as Aboriginal, and of which 7945 nurses.

In the broader Canadian public, 59% of all health professionals are RNs (562,930 of which 332,680 nurses). 6.0% of Aboriginal RNs are male (480 vs 7465). 7.3% of all Canadian RNs are male (24,295 vs 308,385).

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Aboriginal RNs are younger than the average Canadian nurse.

APPENDIX ~ X LIST OF ORGANIZATIONS THAT CINA HAS DEVELOPED STRATEGIC COLLABORATION WITH

CINA has developed formal strategic collaboration with various organizations across diverse sectors including Indigenous organizations at the provincial and national levels; national orga-nizations with diverse mandates related to health and social development; provincial organiza-tions and various Schools of Nursing across the country.

Indigenous Organizations:Assembly of First NationsAboriginal Caucus on Family ViolenceFirst Nations Health Commission First Nations Health Managers Association of Canada Indigenous Physicians Association of CanadaNative Women’s Association of CanadaNational Aboriginal Health NetworkNational Aboriginal Health Organization National Collaborating Center for Aboriginal Health National OrganizationsCanadian Council on Children and YouthCanadian Council on Social DevelopmentCanadian Diabetes AssociationCanadian Institute on Child HealthCanadian Federation of Nurses UnionCanadian Nurses Association (PA)Canadian Nursing Student Association

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Canadian Pediatric SocietyCanadian Public Health AssociationCanadian Society for Circumpolar HealthJoint National Committee on Aboriginal AIDS Education Prevention Provincial/Regional OrganizationsEconomic Development for Canadian Aboriginal WomenHearings on Mental Health and AIDSHearings on New Reproductive TechnologiesJoint Advisory Committee on HIV/AIDSNative Nurses Entry Program (Lakehead University)Provincial and Territory Registered Nurses Association Red Cross Blood ServiceSociety of Obstetricians and Gynaecologists

Schools of NursingDalhousie UniversityThompson Review UniversityUniversity of AlbertaUniversity of ManitobaUniversity of OttawaUniversity of Saskatchewan

APPENDIX ~ XX LITERATURE REVIEW (IN PROGRESS)

The focus of this literature review is to identify and support collaborative Indigenous partner-ship frameworks, situated in Indigenous Knowledge. The significance a identifying and dissem-inating collaborative research that reflects the self-determining objectives of the world's indige-nous people across all sectors of development have the potential to foster increased participa-tion of Aboriginal People's involvement in decision-making in the field of health care. As well as facilitate and promote research and development of relationships relating to First Nations, Inuit and Métis health and wellness that are grounded in First Nations, Inuit and Métis ethics and methodologies. Questions that guided this review included: how does the application of this knowledge contribute to or influence the ways in which nursing services are/can be delivered to First Nations, Inuit, and Métis populations? How does the application of indigenious knowl-edge change the way we practice nursing? And what does this work have to do with the de-velopment of nursing in practice and as a discipline?

A literature review of 7 relevant articles published between 2005 to 2014 identified the impor-tance of collaborative partnership frameworks situated in indigenous knowledge within re-search when implementing health services, programs, policy, ect. I utilized CINHAL, MEDLINE, and PUBMED databases, using key words such as “collaborative framework”, “Indigenous Health”, “Indigenous Research”. This preliminary search yielded limited results, in which I re-viewed 7 articles relevant to the focus of this literature review. A common theme identified be-tween each article was the importance of collaboration, consultation and engagement within the indigenous community in implementing any framework or research to address the dynam-ics of colonization present in the indigenous population. Adequate and appropriate Indigenous community engagement and participation has emerged as imperative in improving indigenous health outcomes, with key documents such as United Nations Declaration on the Rights of In-digenous Peoples (UNDRIP) supporting this approach. Being emphasised that the use of in-

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digenous framework would enable development of a “whole-system” capacity to achieve an indigenously grounded, controlled and driven view of health and well being through methods and process that are consistent with the ideologies of indigenous people. It was highly recom-mended that a partnership approach looking to communities to set mutual priorities will indeed improve responsiveness and relevance of health programs and services. Ultimately it was not-ed the need to challenge non-indigenous nurses to understand the larger dimensions con-tributing the health comes in indigenous communities.

However, through this analysis it can be concluded that literature in regards to the topic is greatly limited. A gap exists in the lack of resources on how to properly implement collabora-tive framework in indigenous communities. As well as, there is a lack of Indigenous researchers implementing collaborative frameworks. Further research can be conducted on the health out-comes of implementing collaborative Indigenous frameworks situated in Indigenous communi-ties.

APPENDIX ~ XX HEALTH STATUS OF INDIGENOUS PEOPLES IN CANADA

In Canada, Indigenous peoples are the fastest growing population in the country, totalling 1.4 million; they represent almost 4.3% of Canada’s population, and 61% self-identify as First Na-tions, 32.3% as Métis, and 4.2% as Inuit (Statistics Canada, 2013). Romanow (2002) reported that Canada has more than 605 different First Nations communities, each with its own unique history, language, traditions, and ceremonies; however, it is important to note that some people prefer to identify themselves as part of their linguistic group (e.g., Cree, Blackfoot, Dene, or Chipewyan), whereas other people would refer to themselves according to their community of origin (e.g., Blood Tribe or Beaver Lake Cree Nation) or Treaty area. These population statistics offer just a glimpse into the cultural diversity of the Indigenous populations across Canada, yet they lack any significant cultural or traditional descriptions that do not in fact show Indigenous peoples’ strength, resilience, or diversity. Statistics Canada (2013) estimated that if the overall Aboriginal population continues to grow at this same rate, it will triple the non-Aboriginal popu-lation by 2018.In terms of health status Canadians are amongst the healthiest in the world; in fact, according to the selected international Human Development Index (HDI) scores, Canada’s high develop-ment indicator of .937 ranks 8th in the world. However, there is significant disparity among the Aboriginal populations in Canada in that Indigenous communities ranked 33rd (.851) on that same HDI scale (Cooke et al., 2007). This disparities in the health of Aboriginal Peoples in re-lation to non-Aboriginal Canadians is a serious cause for concern. According to the United Na-tions Human Rights Council (2014), James Anaya, the UN Special Rapporteur on the Rights of Indigenous Peoples, highlighted a wide array of “devastating human rights violations” (p. 4) in Canada. He outlined many of the historical issues and stated that the poor health of Indige-nous peoples in Canada is “exacerbated by overcrowded housing, high population growth rates, high poverty rates, and the geographic remoteness of many communities, especially Inu-it communities in the north” (p. 10).King, Smith, and Gracey (2009) emphasized that the underlying causes of poor health are linked to the socioeconomic deficits related to colonization, globalization, migration, and loss of language and culture, which are intensified by the displacement of Indigenous people from the land, disconnection from their identity, and the devolution of self-determination over the last 100 years. In recognition of the historical and intergenerational trauma, the Canadian Insti-

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tutes of Health Research–Institute of Aboriginal People’s Health [CIHR–IAPH] suggested that healthy public policy framed from a social-determinants health perspective holds the greatest potential to improve the health and well-being of Aboriginal people in Canada. The 2009-2014 strategic directions for health research call for actions that create “Pathways to Health Equity for Aboriginal Peoples” (CIHR–IAPH, 2013b).Similarly, the Canadian Community Health Survey (Statistics Canada, 2013b) revealed that First Nations, Inuit, and Métis people (who were living off reserve) reported that their perceived health status was poorer than that of non-Aboriginal peoples. It is very evident that Aboriginal peoples are rapidly acquiring lifestyle diseases such as Type 2 diabetes, heart disease, and mental health illnesses. These diseases have been clearly associated with colonialism, poverty, malnutrition, overcrowding, and environmental contamination, coupled with inadequate clinical care (CNA, 2012; Health Council of Canada, 2012b, 2013; King, 2010; Gracey & King, 2009; UN, 2014). Loppie-Reading and Wien (2009) also reported that the strongest predictors of Indigenous health inequities are the social determinants of health, which are viewed from a holistic per-spective that includes the past, present, and future. These authors categorized the social de-terminants of health for Indigenous people as distal, intermediate, and proximal determinants. In addition, the cultural, linguistic, and social differences have played a significant role in health equity and these differences include location (urban, rural, or remote), gender, age, employ-ment, resources, level of political autonomy, recognition of Treaty rights and the complex gov-ernance structure involved in delivering health care services to First Nations, Inuit, and Métis communities that makes access to health care more complicated (Adelson (2005) . Thus, the promotion of health in Aboriginal communities requires action related not only to treating dis-eases and addressing culture, but also to the inequities that continue to exist in Aboriginal health (CINA, 2009b; UN, 2014). These inequities heavily influence individual health behaviours by creating social conflict, hostility, insecurity, and violence across gender and race (Valaskakis, Dion Stout, & Guimond, 2009). In response to these growing disparities, the WHO (2011) sug-gested that the social mandate to address the determinants of health lies in an approach aimed at capacity building, collaboration, participatory governance, and measurement strategies that all sectors of society must adopt (Health Disparities Task Group, 2004; Mikkonen, & Raphael, 2010).

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