Doctor of Philosophy in Nursing (PhD) 
First Nations health and healing
Seabird Island Band
Alongside consistent reporting on health inequities affecting Indigenous peoples in Canada, Indigenous people have been routinely excluded from health policy decision-making. This pattern of exclusion perpetuates health policy decisions that are often ineffective at addressing the root causes of persistent health inequities. Despite Indigenous peoples’ repeated calls to be meaningfully involved, and the emergence of health policy initiatives that include Indigenous peoples, the influence of neoliberalism and neocolonialism in the Canadian policy sphere continues to undermine self-determination and limit Indigenous peoples’ involvement in health policy processes. Those advocating for Indigenous health equity are left wrestling with the question: What constitutes, and what can foster, meaningful involvement in the contemporary health policy climate? This exploratory qualitative research aims to provide a window of insight into this urgent social justice question by exploring the perspectives of twenty leaders and decision-makers in First Nations health and other areas of health policy, with a view to understanding what constitutes meaningful involvement of First Nations peoples in health policy decision-making in BC and Canada. A critical analysis of these data reveals that meaningful involvement is often experienced as a paradox where Indigenous people are excluded via processes of inclusion, and that fostering meaningful involvement requires attuning to the underlying power dynamics inherent in policymaking and taking action to decolonize and transform the policy system itself. Based on this analysis, I articulate a new conceptualization of and framework for meaningful involvement, which is rooted in seven key elements: Recognizing and Representing Indigenous Peoples; Interrupting and Re-imagining Relationships; Preparing Agreements; Practicing Protocols; Leveraging Power; Exerting Community Authority; and Shifting Social Structures. This dissertation concludes with a discussion on the significance and implications of these findings and strategic directions and recommendations for meaningfully involving urban First Nations people in health policy decision-making in BC and beyond.
Improving the health of Indigenous children and fostering health equity requires a radical shift beyond prevailing health care approaches. Early child development (ECD) and intervention programs are increasingly recognized for their potential in promoting children’s health and well-being, and appear to be ideally positioned to play a vital role in fostering child health equity. Currently, there is a lack of research on early intervention (EI) programs in the context of Indigenous families and children in Canada. The purpose of this qualitative study was to generate knowledge on how an urban-based EI home-visiting program for Indigenous families and children in BC, known as the Aboriginal Infant Development Program (AIDP), influences families and children’s health and well-being, and is responsive to health and social inequities affecting families and children experiencing social disadvantages. This inquiry was informed by critical theoretical perspectives and undertaken in collaboration with the AIDP. Ethnographic methods of data collection were used to obtain the perspectives of: Indigenous caregivers (n=10) and Elders involved in AIDPs (n=4), AIDP workers (n=18), and administrative leaders of organizations that hosted AIDPs (n=3). Findings demonstrate: (a) a relational perspective of ECD that emphasizes how family well-being and children’s health equity are inextricably connected, and shaped by intersecting structural inequities; (b) how AIDP workers influence family well-being and foster child health equity by: (i) contextually tailoring their programs for female-led single-parent families in urban contexts, and (ii) reframing the EI process so that it is responsive to women’s agency and self-identified priorities, which are frequently centered on accessing determinants of health and navigating the health care and child welfare systems; (c) how locating AIDPs in multi-service organizational hubs enhances a relational orientation to EI, and (d) how AIDP workers traverse a contested ECD landscape and an increasingly complex relationship with the child welfare system. This knowledge will be used to inform and enhance AIDP practices, policies, and education. These findings are applicable to a broad range of ECD and health care disciplines, including occupational therapists, and EI programs that serve Indigenous and non-Indigenous children who live with social disadvantages that stem from structural inequities.
This dissertation explored the experiences of health and healthcare reported by members of an urban First Nations community who had arthritis and the ways in which arthritis health services were aligned (or not aligned) with these experiences. Using a community-based, participatory design, grounded in decolonizing methodologies and ethnographic methods, this study had two research fields that related to the research questions. Study activities in one research field included intensive immersion in a First Nations community over a period of three years, and interviews with 24 community members. In the second field, which included three arthritis services settings, study activities involved approximately 100 hours of immersion and interviews with 30 healthcare professionals. The analysis of community-based data revealed that experiences of ongoing arthritis/pain and social suffering were inextricably linked to and underpinned by the social and historical context of life in the community. Most, but not all, community participants were reluctant users of health services, largely related to prior negative experiences utilizing health services. The organization and delivery of arthritis health services, shaped by dominant healthcare discourses, were not well aligned with the experiences of First Nations peoples with arthritis; rationing and biomedical discourses limited the ability of the system to be responsive to social contexts, and culturalist and self-management discourses served to deflect healthcare professionals’ attention away from the role that social and material life conditions played in shaping the experiences of First Nations individuals living with arthritis. Amongst arthritis health services leaders and professionals there was a sincere desire to provide effective, quality care to all people with arthritis. Creating more opportunities for social/critical knowledge to be present in health services settings could go a long way towards improving the alignment of arthritis services with arthritis experiences of First Nations peoples.
Public health nurses (PHNs) have a long history of supporting the health of families living with social and material disadvantages. Professional nursing organizations, researchers and theorists emphasize that consideration of the social determinants of health and efforts to address health inequities are critical components of nursing’s mandate. Literature emphasizes that nurses’ practices are shaped by personal, organizational and ideological factors that influence their assumptions about, and understanding of their role with, vulnerable families. Literature also highlights the need for PHNs to engage in critical reflection about their personal assumptions regarding their clients in order to provide care that is socially just. The purpose of this qualitative study is to explore the range of understandings and assumptions PHNs may hold about families living with social and material disadvantages, how PHNs understand their work with these families and the ways in which PHNs reflect on their assumptions and nursing practice. The specific research questions are: What is the range of assumptions that PHNs have in relation to families living with social and material disadvantages? How do PHNs understand their work with families living with disadvantages? How do PHNs describe engagement in self-reflection regarding their assumptions about clients living with disadvantages and how does this impact the PHNs’ nursing practice? What can be learned from the perspective of expert PHNs on the ways that nurses can work effectively with families living with social and material disadvantages? What recommendations can be generated to help support PHNs working with families living with social and material disadvantages? A qualitative exploratory research design was used to address these research objectives. Six, experienced PHNs participated in interviews with the researcher. The findings are organized around five main themes: (i) understanding clients’ context and engaging with individuals and families, (ii) building trusting relationships, (iii) PHNs are one agent, among many, that may influence change, (iv) recognizing the significance of small increments of change, (v) PHNs’ practice has a primary focus on mothers and children. PHNs valued opportunities to engage in self-reflection, but identified barriers to this practice. Recommendations are suggested in domains of education, organizations, PHNs’ practice and research.
This study explores the effectiveness of the traditional First Nations practice of storytelling as a tool in improving Community Health Nurse (CHN) continuing education, regarding tuberculosis (TB) programming in First Nations communities. The first part of this study involves a critical analysis of literature regarding the evolution of Canada’s First Nations policies and health care, and the use of storytelling as a learning tool in Western and First Nations contexts. Informed by critical social justice as a theoretical lens, and decolonising perspectives in health care, the analysis of the literature focuses on (a) shifting factors and societal values shaping the evolution of health care policy and regimes in First Nations health, and (b) the use of storytelling as an educational tool for CHNs working in First Nations communities. The analysis indicates that generations of inequities have resulted in First Nations mistrust of the Western health care system and a widening gap between the health status of First Nations and that of the broader Canadian population. The analysis also reveals that storytelling is an essential component of traditional First Nations education. Finally, the literature shows that there is increasing recognition by current health care policy makers that narrowing the gap in health outcomes requires that First Nations health care programming reflects First Nations input and community needs. The second part of this study evaluates the use of storytelling in CHN TB continuing education. TB continuing education sessions for CHNs included first person accounts by First Nations Elders, as part of the TB Tapestries Project, after which 70 CHNs were invited to provide written feedback. Thematic analysis of this feedback reveals increased appreciation for First Nations traditional storytelling as an important tool in provision of First Nations health care; recognition of the effectiveness of storytelling compared to other teaching methods; and a desire to change future TB programming by including storytelling. Based on the analysis of literature and CHN responses to the TB continuing education sessions, the primary recommendation of this study is to incorporate storytelling into TB education sessions for CHNs and broader health care programming for First Nations communities.
Background: Advance care planning (ACP) is a process for patients and families to engage in discussions around future wishes for health care. It offers a means to increase dialogue about end of life care and has the potential to improve patient outcomes. Despite the benefits demonstrated in literature, there are still many challenges to ACP implementation. This thesis investigated why ACP is so difficult to implement by reflecting on the following stakeholders: patients and families of older adults and individuals living with chronic illnesses, health care providers, and health care organizations. Particular examples are drawn from the context in British Columbia, Canada.Methods: A purposeful search strategy modifying the rapid evidence assessment approach was used to synthesize the literature. Research studies, summary reports, and policy documents were used to build a balanced picture of perspectives for policy makers. Bryant’s (2009) Policy Change Model and critical theoretical perspectives shaped this analysis and highlighted the complexities and ideologies behind public, professional, and organizational sentiment. Findings: The analysis of literature on patient and provider perspectives shows the biomedical dominance in health care culture and the disinclination to discuss end of life issues. A shift is needed where recognition and prioritization of ACP implementation is supported by leaders in health organizations. Organization-wide multi-component ACP efforts combined with goals of care documentation have been shown to be most successful in improving patient outcomes, but organizational commitment to development of processes and policies is necessary. There is opportunity for nursing leadership and research to move ACP efforts forward in organizations. Conclusion: The analysis presented in this thesis maps evidence for policy makers, stakeholders, and nursing leaders interested in promoting strategic ACP implementation and future ACP research. Process and policy changes are needed to support public and provider engagement.