EXPLORING ULTURAL RE: THE D V LOPMENT OF ULTURALLY OMPETE T UR E PRA TITIO ER FOR BRIT! H OLUMBI FIR T NATION OMMU ITIE b Br an chultz , ni er ity fVi t ri a, 2 01 PR JE T BMITT D IN P RTIAL F LFILLM NT TH REQUIREM NT F R TH D RE MA ROF I E IN NUR ING (FAMILY N RSE PRA TITI NER) UNIV R ITY OF N RTH RN BRIT! H July 201 2 © Brya n hultz, 201 2 LUMBIA 111 AB TRACT b tiginal anadian ha hi t rica ll y uffi r d fr m bani r t h alth and h althcare. Ra ciali m col niali m , and culturali m continu to p rp tuate the barri er to healthcare that enabl e h alth di pariti bet e n ab ri ginal and n n-ab riginal anadi an . i recogniz d a a trat gy t am li rat th Nation popu lation . Mor r nur ffi ct f health inequiti ultural c mp etency that exi t for First practiti n r ar cun ntl y m rgin g a primary care provider for marginalized and und r r d popul ati on f ir t ati on in Briti h lumbia and are profe ionally required to provide culturall y c mp t nt and culturall y afe healthcare. This proj ect asks what culturally competent interv ntion can be u ed by nur e practiti ner to mitigate health dispariti experi enc d by Fir t Na ti n comrnuniti e in N rth ern Briti h Columbia, and fmd s that nur e practitioner mu t r lyon exp rt pinion , including th e view of First Nations patients and the profes ional standards. IV Table of Contents ABSTRACT iii LIST OF TABLE vi LIST OF FIGURES vii LIST OF ABBREVIATIONS viii INTRODUCTION 1 Chapter One 5 Canadian Aboriginal Identities 5 First Nations, Inuit, and Metis 5 Demographic Review of First Nations Populations in Northern British Columbia 6 Geographic Overview of First Nations Communities in Northern British Columbia 6 Chapter Two 9 What is C ultural Comp etency and C ultu ral afety? 9 Chapter Th ree 12 Government, Professi on al, and Stakeholder Commitm ents t o Cultural Comp et ency an d Safety 12 Provincial Agreements 13 Regional Health Authority 14 First Nations Stakeholders 15 Chapter Four 16 Health Dispariti es Experi ence d by First Nat ions of Northern British Columbia 16 v The Divide in Health Indices 16 Infant Mortality 17 Potential Years of Life Lost 18 Life Expectancy at Birth 19 Social Political Barriers to Health 19 Poverty 20 Education 21 Perceived Barriers to Healthcare by First Nations Peoples in Northern British Columbia 22 Chapter Five 27 Theoretical Discussion of the Role of Cultural Competence in the Practice of Nurse Practitioners 27 Theoretical Foundations of Cross -Cultural Nursing and Cultural Competency 27 The Heritage of Colonialism and Racialism as Explored through Critical Racial Theory 29 Critical Social Theory as an Underpinning for the Validity of CC in NP Practice 30 Chapter Six 32 Literature Review and Analysis 32 Meta-Analysis 33 Best Practice Guidelines 35 Implications for Practice 38 ChapterSeven 43 Conclusions and Recommendations 43 References 45 Vl LIST OF TABLE .. Yll LIST OF FIGURE Figur 1. Fir t Nati n Language Figure 2. Fir t Nation Figur 3. L inin g r' unrz (L ining r 2002) r up nununitie f fN rthe111 Briti h rth 111 Briti h Enabl r to Dis ov r ultur olumbia lumbia 7 8 ar Mod l 28 Vlll LI T OF ABBREVIATION B B Briti h olumbia lumbia Publi H alth fficer ciation lumbia ritical Race Theory at ty ry PYLL Potential Years of Life Lo t INT RVENIN F NUR IN DI PARITY: TH R L PRA TITI N R 1 INTRODUCTION anadian nur ing c ntinu it pr fe i nal pr gre i n during the p mng f th 2 1st century, attaining a 1 gi lat d rol for nur P ) in many 1 rovince . N ur practiti practiti on r provid primary car in a fa hi n that wa pr vi u ly d liv r d only by phy i ian . In Briti h olumbi a (B ) in 2005, th tlu·ough th Health Pr .D wn ct ( RN P r le wa I gi lati v lye tabli h d , 20 10). Th new h alth prac titi oner ro l wa envi ion d to pro id primary care to popul ati on under erved by the traditi nal phy iciandelivered primary care model (Burge Initiative, n.d.; ardn r & & Purkis 20 1O· ' Ke fe, 2003) . anadian Nur e Practiti ner ur e practiti on r provid car t underserved population in B , in new i1nmigrant cl inic , orphan d patient clinics, and in Fir t Na tion (FN) conununiti es (Burgess & Purki ). All healthcare professionals, including NPs, practice with cultural life-way or culturalisms that are informed by their heritage education and communi ty of origin. Culturalisms communicate value and meanings to pati ents and may includ e, but are not limited to, word use, meaning of health, social value , or gender relati onships (Leninger, 200 1). Nurse practitioner who practice in indi genous conm1unities provid e healthcar with culturalisms that may have a history of creating racist or coloni alist experience for indigenou pati ents (Hart-Wasekeesikaw, 2009a; Dhamoon, 2009; Wolfe, 20 10). The residual dynamics of raciali m and colonialism are prominent in the experience of the indi genous popul ation of anada (B PHO, 2009) . The term ' racialism ' d cribes the unintentional racist, cultural, and colonial structure that favo ur th dominant urocentric d mographic , while negati vely affecting FN peopl e (Fo rd & Airhihenbuwa, 20 10; Kafele, 2004; Wolfe, 201 0). ' olonialism ' i a clu ter f y temati c pro that ha be n u d in th pas t to F IN Dl P RITY : THE R L R INT RV IN a imilat anada ' indi gen u p pulati n int th pr cultur and p liti cal tru ctur H lm indi g nou b riginal H allh ur ntri ikaw, 2009a· rganiza ti n, 2002) . N ur id h alth ar t marginaliz d and ft n rem t p pul ati n practitioner wh pr rv1 ce ati nal i u ly pr d minant r wn 2 0 ; H art-W a k (Br wn , 200 7; R y & Perron 200 2 PRA anadi an r qUlr h uld be pr ializ d ultura l p in a mann r th at m id d b rc m th p pulati n , and h lp th culturali m (Hart-Wa ek mp t nci ikaw 2009a; f and trategi . H alth t th cultural n d f th f raciali m c 1 ni ali m, and p n n n tra, & an, 2007 ; orth ern B were h rald d by the Ind ian a t apell , V ham n, 2009; Kafel , 2004 · W olfe 20 10 ). Th c 1 niali t e p ri nee of 1876 . Thi legi lati on and it ub f th F of qu nt amendment have d fi n d th e ca retaker relati onship b twe n the FN communiti e and the Federa l cultural practic uch a the potl atch, deni ed ri ght f anadi an vernm ent outl awed anadi an citizen hip including th e right to vo te, and und ermined the political tru cture of th e FN through th e in ti tution of the Indian agent ( anadi an R oyal Commi ion on Abori ginal People , 1996; Mo & ardner- O 'Too le, 1987). The Indian agent a erted bureau cratic contro l over m any a p ect ofF community and individual affa ir in ord er a imilate its culture into ( anadi an Royal urocentric n rm mmission on Abori ginal Peop les, 1996. In 1879, the Davin R eport influenced the ini tia tion of the residential chool program by callin g for the civ ilization of FN through ducati on that eparated children fro m the influ nc communiti e (Keirn, 1998 ; Kinnayer, imp ceremome n, & uch a th p tl atch wer enforced in B of their fa mili and arg , 200 ). Law prohibiting cultural until 195 1 (Kclm, 199 ; Mo , & ardner- ' o le, I 87 .T h ri ght [ FN individual to v te wa n t r tor d until 196 7; the INT R IN IN DI PARITY: TH R la t r id ntial ch P pl E F UR 1 officiaJJy 1 ed in 19 6 ( anadian R yal & ,199 K lm, 1998 · K lm 2004; M Thi hi tory and th ngoing influenc ardn r- T mbl y of ir t ati n marginalized communiti and ndur d by indi g nou Talier, 200 ; ampbell, 2002· uantz, 2005). Individu al from und r erv d r ar m re lik ly t recommendation made by an boriginal f marginaliza ti n crea te impair d acce 2004; rowne Veen tra, 2009 · Wardman, 1 m nt & Imni IOn on 1 , 19 7). barri r t health ar that c ntribut t n tabl h alth di pariti anadian (A R PRA TITI k h alth care att nti n and compl y with P when they feel culturally und erstood, accepted, and upp011ed (Papp , 2005; Regi tered ur e rganization of ntario, 2007). Altem ately, if member of a community feel mi und er tood or culturally unkn wn by th e P, pati nt may be les likely to eek medical attention and edu ca ti n on i sue of health, and be ev n ]e likely to comply with medical in truction (Kingi, 2007) . Thi project a ks w hat culturally competent interventi ons can b u ed by Ps to mitiga te hea lth di parities ex perienced by FN communiti es in Northern BC . Cultural competency (CC) has become a prominent intervention trategy fo r N P to meet the needs of culturall y diverse or marginalized popul ation (CRNB , 20 11 ; Grote, 2008). The successful implementation of CC trategies may contribute to ameliorating the barrier to healthcare access, as a best practice ofNP providing primary health are erv1ces to FN populations (King, Smith, & Gracey, 2009; RNAO, 2007) . Professional organizations, government , and FN takeholder in B reco gni ze that healthcare professionals need to be responsive to the cultures of the population they erve, and tlm ne d to use . The culturall y di ver e population . organizati n have adopted to meet thi need for ullurally c mpetent care is fundamental in pr v nting INT RYE ING IN DI P RITY: TH R LE F NUR bani r that continu tor ult in poor r h alth outcom PRA TITI 4 R for FN p r on in B (Ad 1 n, lf 2005) . Thi qu ry b gin with a di cu JOn fth ba k gr und and onte t ~ r the importance of w ithin the conte t of d livering primary care to proJ t di cu : th id ntifica tion of indi gen u pe di paritie e peri enced by indig nou anadian in a ; and the cunent proD commun iti e . In thi regard, thi f anada and B ; h alth ; pr fe i nallit ratur d cribing th ing h althcar urr nt experi ence of erv ice ; the hi t ry f th r ti cal con tru ct of ional take-hold r and goverrun nt commitm ent to culturall y competent training fo r h althcare pro ider in BC . econdl y, a r v iew of published y t m atic review , m eta-analy e , and be t practi ce guideline for CC outcom es and intervention will be presented. F inall y, th e CC be t practi ces and outcom e evidence, a it appli es to N Ps who practice in FN communiti Northern BC, will be synthe i ed. of INT R NIN 5 R F IN DI P RITY: TH R hapter On e boriginal ld entiti e Canadian F ir t ation Inuit and Meti b ri gin al p pulati n within th e lit ratur and law : th being d ig nati n relati n hip [ cultural h f di f an ada ha b en at g n z d int thr e m ain ubgr up ati n , Inuit, nd M ' ti . Th it but ra th r pe pl gr up t th ear n t c n tru ed d , ripti n n1m nt [ [ anc imil ar t " b ing "' Urop a n" r " b in g cultur and nati naliti e . Th r [! r , ultural way may dif[i r in diffi r nt F anadi an fi deral g en1m ent id entifi e ian "', a it r fer t an aggr ga t pe pi e a ha ing m et purity, in relation hip t the pr - urop ean inh abita nt Many FN p eopl ar , or have been, re ident f [ a nada. h id ntity f '' b in g F " i The try and f di er e c mrnuniti e . m e level f ance tral men ca . f re er e or identify with a trib , band , or individual n ation . Fir t N ati on p r on ar furth er ateg ri zed a either tatu o r non- tatu . The differ nti ation i ba ed on the relati n hip that an indi idu al ha with the fed ral government. tatu FN individual ha v full treaty ri ght and th erefore h ave acce t federal ocial and health program a well a any treaty ri ght n goti a ted by th eir indi vidu al band o r nation . N n- tatu FN per ons may have no le cc urrence a nc tral purity but b cau e of hi t ri ca] uc h as la nd own er hip r c riminalized beha i r by an ance t r, th eir lai m to tatu ri ght m ay hav been e punged (And er o n, m yli e, 2006) . tatu N p opl e ar furth er de ig nated a nd er n, in lair, r ng l , ith r on-r er e r off-re erv , d p nding o n th eir primary re ide n e. h M ' ti hav h d a I ng hi t ri a] tru ggle for ffi ial recognit io n and land claim . In rec nt yea r , M ' ti have ma e on id r bl e ga in in thi regard ia the , urt . , ide from INT R NIN IN DI PARITY: TH R L r cogniz d conununiti F R 6 PRA TITI N R in Manitoba, the M eti largely belong to an in i ibl popu lati n m te1m of aboriginal ri ght and d m graphic data coli cti n (Waldram, H rring & Y ung, rth W e t Territ ri 2006) . he Inuit f th arctic. In th tenit ri unavut and Nunavik inhabit , h alth program are managed by territ rial g vemm nt , rather than by th :D d ral goverrun nt (W aldram H rnng D emographi c Review of Fir t f Y ung, 2006). ation Population in North ern Briti h Columbi a A th focu of thi pr j ct i aboriginal communi tie an ada' P practice and p atient experi nc of hea lthcare in rth rn B , the term Fir t Na ti on (F ) i u ed to identify the ubj ect population. These peopl e are largely, but n t xclu ively, FN member . In ord er to streamline the discu ion the term wilt be u ed to refer to all indigen u p r on and communitie inN orthern BC , regardl e of their ac tu al racial or cultural origins (Briti sh Columbia Provincial Health Officer, 2009). According to the FN peopl e lived in 80 communities aero s anadian cen us, over 44,000 orthem BC in 200 1. Geographic Overvi ew of First N ations Communities in Northern B riti sh Columbi a Northern BC is populated by 14 language groups representing 37 different political entiti es and 80 cmrununitie (Figure l ). The majority of thi population of over 44,000 (> 80%) live in reserve communities. First Nation political entities ma y be self-de ignated as nations, band , or tribal council . Each political entity m ay represent a ingle community, multipl e communities, or the political cooperation of a group of nation or band (Figure 2) . For example, the arrier Sekani Trib al ouncil represent 11 conununiti es from two langua ge groups that have become politica lly aligned ( ani r ekani Family S 1 i es, n.d.). INTER NIN IN DI PARITY: TH R L R F 7 PRA TITI N R TIJlChOM / ·- ·- . Q ne- h h I 0 nno-UI . I I ' II ' . ! i / / I } Tslthqot'in ' Figure 1: First Na tions Language groups of Northern Brit ish Co1umbia. (Adapted from University of Bti ti sh olumbi a Museum of Antlu·opo1ogy, 2004) The FN of N orthern B have diverse cultures and ethni city, similar to the div r ity of cultural identity that can be found in kin-Tyee, N ee-Tahi Buhn, urope. The central N011hem B nati ons are the Takla, he latta, T s' il Kas Koh (Burns Lake), T l'azt'en. Nak'azdli. N adl eh, t llat' en, a ikuz, Lh .idli Tenne' h, Nazko . Lhatko D n , and Lh'oo k 'uz Dene. The coastal and w e tern nati n ar the Haida , H aisla, T sim hi an, it an, We t uwet' en. FNUR INDI P RITY: TH R L IN INT R PR a t, FN pe pl e b long t the Ni ga' a, ahltan Tlingit, and Daylu Den nation . T th T ekani, ault aux, W T ay K eh D n b rl y D g Ri ver Blu b rry Riv r, Halfway Riv r, Kw ada cha, Pr ph t Riv r, and Daylu - di ver ity of FN pe pl that ar tM pe ifi t TITI N R n nati n ( a bob ndung, 2007) . Thi may r quire that health prob nal d v lop cultural c mpetenci ach communi ty. Northern Communities F- or~ N<:lscn D e<~. 0 \ Q \_ 0 e 1ake 0 0 ~~~ ,~ 10,000 + persons 0 1000- 10.000 persons Figure 2: Fi rst Nations communiti es ofNmihern Briti sh Ta bobondung, 2007). First Nations Commu nity olumbia. (Adapted from INT -< R NIN INDI PARITY: TH R L F NUR 9 PRA TITI N R Chapter Two What is Cultural Comp etency and Cultural afety? thi pr j ct will review in th n c mpet nt and culturall y a£ car t of th concept can b pro£ ional bodi Regi tered ur e t chapt r, N P ar mandat d t pr vid e culturall y rthem B F communitie . Although the definition agu and may eem t b int rchang abJ (W lfe, 2009, , including th f Briti h ciati n ( olumbia ( RN B ) J arl y r quir and the 11 g of P t pr vid e culturall y safe care. At thi point, the e c ncept need t b clearl y diffe renti ated and their implicati ons to NP pra ti ce xplored. Cultural mpet nee ( ) i built on two et of know ledge . Fir t, cultural awarene th e kn ow ledge of one' own culture, in contra t to other culture (Grote, 2008) . Nur e practitioner can recognize that the cultural id enti ty and practice of other is equ all y valuable to their own, through the ability to identify the nature of culture and how di fferent cultures exist and coexist in relation with each other (Grote, 200 8), . Secondly, the knowledge of cultural sensitivity build s upon cultural awarene s, and is a gro unded reali zati on of the effect that one's own ex pres ion of culture may have in marginalizing patients that identify with a different culture. The N P' kn owledge of the historical interaction of a dominant or coloni al culture on other cultures i a form of cultural sensitivity (Kingi, 2007). ultural competency, in the contex t of Northern B , i a demonstrated awarenes of historical and contemporary forces that hav di mpow ered FN peopl es (Browne & T alier, 200 8; Campinha-Baco te, 1999) . Thi awar ne scan then be u d to r c gnize and decon tru t the heg m nies left in the wa k of co loniali m in hea lth are and miti gate the ong ing ffe t f racialism (B PH , 2009 ; Hart-Wa ek ikaw, 2009a). Nur e INT RVENINGINDI PARITY:TH R L OF UR 10 PRA TITI N R pra tition r ar culturally c mp tent wh nth y c mbine cultural n iti ity with a degr of fluency in th cultural norm of other . For example cultural flu ncy can be demon trated in learning th languag or traditional h aling n rm f c mmuniti ( ampinha-Bacote, 1999). ur e practiti n r can acqmr cultural und r tanding ab ut family and co mmunity attachment that ar tr ng pr dictor f elf-a d welln for indigen u peopl es (Hart- Wa ekee ikaw 2009a) . tat d diH r ntly, r lation hip are a ignificant dim en i n of indi genou health. For poli y-maker and healthcar pr vid r , thi knowl edge implie that family and community relati n hip need to be upp rted in h althcare ju t a health i piritual upported with infra tructure in the form fa chapel and staff (i.e., a pa tor) (Richmond, Ross, & Egeland, 2007). Further exampl e of cultural und r tanding D r P who serve FN communities were outlined in an orientation document created for health professionals by the Aboriginal Health Improvement ommit1ee of the Thomp on, Cariboo, Shuswap Health Service Delivery Area (2005) . The document lists action that would improve cultural understanding, such as: learning the indigenou langua ge, referring to traditional healing practices in care plan , supporting and attending cultural activitie , acces ing elders to act as guides for social protocol and tradition, acquiring know ledge of the seasonal activities, uch a hunting and gathering, and supporting traditional food in di tary teaching. The document offers further direction as to how health professionals may becom culturally competent in parti cular FN communities and, mor importantly, indicate the standard of , by which health profe ional s should be mea ured. ultural afety ( S), as a concept, aro in the 1980 out of a Maori tr aty with the New Z aland gov rnm nt that codifi d expectati ns for h althcare 1 ice that w r to b INTERVENING IN DI PARITY: TH R LE F NUR culturally appropriat £ r th indig n u p pulation (Hart-Wa 2007 ; Papp , 2005). pen n ultural a~ t f h alth car that wa kee ikaw , 2009a; Kingi, in it inc pti n wa intend d to upport a pati nl' f their cultural mpow ring, r p ctful and in lu i id ntity by D cu ing n the indig n u pati nt' percepti on (Kingi, 2007; 11 PRA TITI N R f cu ltura ll y appr priale car AH , 200 ). In practice, ameli rating a ti n P combin th c mp nent attitude , and poli i of eli nt (Grote 200 ; Papp , 2005) . f t pr vid by r c gnizing and that dimini h, di emp wer, r demean the culture ulturall y c mpetent P can upp rt the ofFN client by in tituting practice that recogniz , re pect, and participate in a culture f healing (Aboriginal Health Improvem ent ommitt e f th Thomp on, Service Delivery Area 2005; Peiri Br wn & ariboo, hu wap H ealth a , 2008). Nurse practitioner who practice both CC and share the r le of expert and, therefore, power with FN patients (Hmi-Wasekeesikaw, 2009a; Ri chardson & Williams, 2007; Wolfe, 2009). As indicated by Leininger (200 1) culturall y competent health practitioners apply a body of cultural knowledge to the clinica l relationship . In addition, Ps who practice in a culturally safe manner mu t rel y on FN clients as expert holding not only cultuTal knowledge but the m easure of whether their cultural id entity i supported by the clinical relationship (Hart-Wasekeesikaw, 2009a). This inver ion of the hegemony between expert and client enabl es NPs to be sensitive to inequities creat d by culturali sm, colonialism, or racialism (Browne & Varcoe, 2006 ; Haii-Wa ekeesikaw 2009a). IN INT R IN Dl P RITY: TI R R p 12 R TITI hapter Three Government Profe ional and ommitment to Th anadian iati n ur anadian nur e . Thi b d pr du e nur . h d f ultural ompetency and afety ) i th nati n ati n I pr fe i nal tand ard and e thi c fi r regi tcred r quire th e fi 11 w mg: thi Wh en pro iding are, nur d n t d i cri 111 in a te n th e ba i ethni city, ulture, politi cal and piritu al b li f: , ri ntati n ag , h alth tatu , pl ac oc io-e onomic tatu takeholder f a pe r n ra ce, cial or m arital tatu , g nd r, cx ual f ri gin , lifi ty l , m ntal r ph y ica l ability r r any th r attribute ( anadi an c iati n, 200 , p . ur e 17). Th p cific pr hibition again t di criminati on i ju ti ce, human right , equality, and faim obli gat upp rt d by affirmin g principl e of in th e practi ce of nur e . The N Ps to emplo y value of ju tice to advocate for fain1e ode f Ethi c quity, and the prom oti on of the public good for FN patient and the comn1uniti e in w hi ch th y li e. ultural comp et nee prom te ju ti ce in the prac ti ce o f N P by upp rting awarene r f th e hi t n al t and cultural dynami cs of ocial inequality and health di parity ( an adi an A s ociati n, 200 ; Regi tered Nur cia ti n of ntari , 2007; ur co tt , t rn , and r , R ag n, & M ath ew , 200 ). A N A (2004) p iti n tate m nt clea rl y tat r p n ibl e for acquirin g nd utili z ing edu ca ti n, g vernm nt, h lthcar in all a p that a ll do ma in of nur ing arc t of ar . he rgani za ti o n , nd r gul a t r bodi ::~Loaddre , cs wi th , uggcsted role INTER NIN OF NUR IN DI PARJTY: TH R 1 PRA TITI N R for pra titioner in pr moting cultw·ally comp t nt are. In ad cument utlining the c re compet ncie ofNP , the NA (2 0 I 0) tat that NP " will in c rp rate kn wl dg of div r ity and cultural aD ty and determinant f h alth in the a m nt di agn th rap eutic mana gem nt of li nt and in th e eva lu ati on of outco m s" (p . 17). the CN defin e un a[i cultural car a th body for nur dditi nall y, e practice whi h ar d m aning, disempowering, or dimini hing of a li nt' cultural li fe \ a The i and ll eg of Regi t r d in th Provine of B , pro id . lumbia ( RNB , 20 11 ), the lie nsing a irnilar stat m nt: The N P " inc rp rate know ledge of di er ity cultural afety and the determinant f health in a e m ent, diagnosi and therapeutic m anagem ent of the client and the eva luati n f outcome " (p. 9) . The RNB mandates N Ps to practice in F communitie in a manner th at id entifi e and affirms the culture need of patients. Provincial Agreements A memorandum of under tanding wa signed in 2006 between the Govenune nt of Canada, the Province of British Columbia, and British Columbian First Na tions stakehold er groups, with the following commitments: The Parti es seek to provide equitable access to health services that m eet the need of First Nations cmmnunities, and ensure that these ervice are culturally en itive . B. . and anada recognize that First Nati ons n ed to be partner in the de ign and delivery of health programs and services fo r First Na tion (First Nation H ealth Plan, 2006, ect. 3.l (c)). INT R pr IN F IN DI P RITY: TH R Th m m randum cl arly mmit b th th nt t the pr i ion [ ulturall in ial g nu11 R p 14 an dian il d ral g n iti upp rting a an .5 milli n B car . hi tripartite agr m nt in th 2007 annual r p rt b th B Publi Health In lud d in th r p rt nllTI nt and th ffic r ( PH , 200 . mmitm nt t impl m nting th agre m nt by i nal . The fundin g wa t b mad e a ailabl e initiati [ era thr e-year peri d t adapt health e1 mmuniti e and indi idual . Regional Health The uthority 011hern Hea lth uthority ( H ), whi ch crve th e par ely p pul ated n rth ern half ofB , ha well-de el ped vi i n, mi i n, and alu e tatem nt t guid e the devel pment of cultural h alth initi ati e . Th n f th excell ence in rural h althcar . p cifica ll y th m1 the health of communiti , r lation hip , and all peopl m HA i t b a mode l of t build and trength en orthem B . More v r, the HA li t the follo wing va lu e : a commitm nt to imp roving the health of all peopl e of 011h rn B through a pirit of co ll aboration, trengthening conununitie , ac ountabl deci ion- making, h nesty, integrity, a culture f re p ct, learning, innovation, and ontinuou impr vement. The overall long-term goal ofthi initi ati ve i to ori nt and equip per onn 1 to deli ver qu ality ervic H to peopl ofN011hem B , including indigen u individual , familie , and co mmuniti e , and other culturall y different hea lth 'con umer ' (Mu el, 2006; Northern Hea lth uthority, 2007). INTERVENIN IN DI PARITY: TH R LE F R 15 PRA TITI N R First Nations takeholder Th A embl y f Fir t Nati n (2004) cl arl y r gniz d bani r to primary h althcar in an a ti n plan fl r not d to be p peciall y u c ptibl t culturall y inappr priat pro id er . The mbl y f ir t a cept inflexible pr gram r pr ati n al n t d that ace id r that did n t m r en h mg pl wer til h althcar rv1ce requir d FN to t th ir cultural ne d . Am ng th e u gge ted oluti n in the d cum nt wer particip at ry input int hea lthca r erv1ce provi ion and th training of culturall y appr priat h alth erv1ce pr vid er . In the statem nt , the g v ming b di that fund healthcare ervices and th e H ealth Care Authority for Northern B mad a c mmi tm nt t th pr vi i n of culturall y comp etent healthcare. In additi on, the C and th RNB have r cognized the imp rtant r I culturally competent care to m eet the need of FN communi tie . La tly the f ati onal Assetnbly of First Nations recognized the role that culturall y competent training can pl ay in improving the healthcare provision to FN. INTER NIN IN D I PARITY: TH R E R F 1 PRA TITI N R Chapter Four Health Disparities Experienced by Fir t Nation s of Northern Briti h Columbia Th f rth m B ar ethnicall and culturally di er to pro id g n raJ tat m nt with r gard t cultur . which mak it difficult ev rth Ie , the health di pari tie xper1enc d by the indig nou p ople ar much more hom g n ou . H alth di pariti e of experienced by the 11hem B ar in th area of xperience, health indice , and determinant of h alth, which eparate th m from the greater Bmnet, Huang, hin, & Cagn y, 2007· P iri NP practicing in FN communiti of the health di pariti m Brown, & rth m B ana dian population (Fi her, a , 2008). It is important for the to have an und er tanding of the magnitude . Thi und er tanding then provides directi n to the practi ce of Ps by highlighting the profe ional imperative to utilize culturally compet nt interventions to reduce health disparities. The Divid e in Health Indices This overview of the indigenous indice of health uses data from: Census Canada, variou researcher , and the Vital Statistics Agency of British olumbia, a rep rt d by the BCPHO. The data sets for review were identified in a report by the B PHO (2007) a benchmark indices that indicated the ma gnitude of the h alth di sparity experienced by FN Briti h olumbians. Th hea lth indice includ e infant mot1ality, life ex pe tancie at birth, potential year f life lo t, and a few notabl e di ea The sourc generated from the f orne of the data wa the en u pr va len e rates . anadian £ dera l govemm nt. The indi anada data are populated nationall and th re[i re ma y not INT R NING IN DI P RITY : TH R LE F UR 17 PRA TITI N R ifi p pula ti n f N orthen1 B . The data ha be n criticiz d hi t ricall y fi r und er-r p rting h alth di pariti xperienced by FN accurat ly r pr ent th di pariti c01nmuniti f th mall r ( mylie, And r on, Ratima, on th h alth data t rengle, in po t olonial countrie And r n (2006) compared vari ou countri p Ander n 2006 , p. 1 ). In th ir report m yli , And er n, R atima rengle and and noted that th data coll ected in anada fo r FN i ue wa impair d by a co nflict of intere t, ince fi deral rganizati ns w re reporting on the effi cacy of th ir own health program . Thi cti ti ci m c uld al provincial tati tic where th b generalized to arn e confli ct f int r t may ex i t. Youn g (2003) found that re earch on health i ue exp ri need by anadian aboriginal wa lackin g in many area of morbidity and mortality. Infant Mortality Infant m ortality is a trong indicator of the effi ctivene s of health ystems ( mylie et al. , 2006). This health indicator states the number of death in the first year of life per 1,000 births (BCPHO 2009). Adelson (2005 ) noted that in 1999, Canadi ans a a whole experi enced an infant mortality of 5.5 per 1,000 , while the rate wa 8 death per 1,000 fo r FN live births. Thus, from a national perspective, a FN infant in 1999 would have been nearly 30% more likely to die before it fi rst birthday, comp ared to other Canadian infant ( anadian In titute for Health Informati on, 2004). In B , a stud y that tracked infant mortality aero s 19 years fo und an intere ting trend in health di sparity. On-reserve FN babies ex perienced a grea ter declin in infant mortality, compared to FN babi e in urban areas. The number are clear, with urban FN p ople exp ri encing an infant mortality rate of 7 .2, and their n n-FN urban neighbour having an infant m rtality rate o f le s than 2.5 p r 1,000 liv bitih ( rohli h, Ro , & Ri hmond , INTERV NINO IN DI P RITY: TH R L 2006). B twe n 2000 and 2004, the B PH FN R 18 PRA TITION R rep 11 d a provinc -wid aggr gate infant mortality rat of 8.6 for tatu FN and 3.7 :D r th r r ident (B PH , 2007) . Thi gr ater than two-fold in r a in infant m rtality for FN re id ent fB may b appreciated again t the ba kgr und f ri ing di parity in the race-ba d infant m 11ality gap ince 1 97 (B PH , 2007). In th 2007 interim r p rt by th B PH (20 7) th gap wa n t d to have grown by 23% in the 5 y ar preceding 2004 with -year aggr ga te infant m rtality rat reported t be 7.3 (1997 to 2001), which in r a d t 8.6 (2000 to 2004) , whil the rat fir n n-FN Briti h olumbian remained at 3. 7 during the arne period . Potential Years of L ife L ost Potential yea rs of life lo t (PYLL) i an indicator ba ed on mean life exp ctancy at birth for a population that i corTected for actual year liv d per 1,000 individual (World Health Organization, 2007) . In 1999, non-aboriginal male lost 62.5 y ar of life per 1,000 individuals, while tatu s FN mal e lot 158 .3 years of life (Mar1en , and er on, & Jebam ani , 2005) . This is a greater than two-fold increase (disparity) in te1ms of years of life lost for this group of aboriginal males, compared to the greater Canadian population of male . In BC , even thou gh overall PYLL is les , the magnitude of the disparity is similar. In 2006, PYLL for all causes for Status FN was 97.0, compared to 41.5 for other British Columbian (BCPHO, 2009) . The B PHO (2007) offers insight into the hea lth disparity e perienced by FN, u ing the PYLL to understand the burden of individual di seas in the popul ation. The effect of suicide and motor vehicle accident is tlu·ee times greater in the FN population, which lead to a PYLL of 12, as compared to le than :D ur for other British human immun defi ciency viru is nearl y even tim olumb ians. Th burden of great r in th FN population than in th IN RV g n ral B IN p pulati n 4 .7 and 0.7 r ti thr ugh 2004 (B PH , p. 1 ). Diab t Briti h FN R IN Dl P RITY: TH R whi h ha a 40% high r pre al n great r than that f th r riti h Th B PH f 2.1 year , which i 2.5 tim e ha a PY tati tic that track th numb r [ d ath fr m di a e i t that w uld b rea nabl e pect d t prevent d ath . Th tati ti c de cribe a p pul ati nth t ha failed t r cei c full acce ort f barri er. In 2 06, tatu F di a e f 1.5 per 10 0 t health are du t me p ri n d a m rtality rate fr m m di ca lly tr atabl e th r Briti h (0.3 death per 10,000). Thi rat fl r tatu PH , p. ll . 20 9) c mpil for whi h m dical tr atm nt d aggr gat ly [! r th y ar 2000 ly) e pr PH , ha . 4 al lumbian ( 19 PRA TI I N R lumbian e p ri need a rate that wa 500% l wer tati tic capture the effect that barri r to healthcar hav in increa ing the m rtality rate fi r tatu F in B (B PH ,) . Life Expectancy at Birth In B , the B PH (2 009 p. xxix) rep rted an aggregate life exp ctancy for all tatu FN, from 2002 to 2006, f 74.9, a compared t 0.7 for oth er Briti h olumbi an during that ame period . The aggregate life expectancy at bi11h for female tatu F (2002 to 2006) wa 77 .0, compared to 83 .0 for other Briti h olumbian female . The arne index [I r FN male wa 73.0, whil e the rate wa 7 .4 for other Briti h olumbi an male . he r ult indi cated that the FN men experi need a 5.4 y ar p nalty and FN wo men had a 6 yea r penalty (B PH , 2009, p. 108). o ial Political Barriers to Health The barri er t hea lthca rc e peri nc d by FN p en ompa ing dct rrninant f h alth . pi c ar often r th bj ccti e and ubj ti t d in the -vid nc wi ll be u, d IN R IN pi ring th margin lizing h r in fp ar nt n n e f rty, la k f du ati n, and ra iali m will b n d pl r d a they f cultur and th und erlying h alth ur e pra titi ner n d t unci r tand that th pati ntp r pti n fh alth ar an imp rtant targ t f th r clueing h alth eli pariti mmuniti e . hi i e p m g1v n that culturall c mp tent kill are primaril y out ing h al th ar . h pe pl in a t [! r under tanding adaptati n 20 PRA TITI N R R IN D I P RITY: T I R m in h althcar pr b ing d (King id r , in rei r t inte1 enti n aimed at ially r I va nt t th eli u i n f nc rned with crea ting behavi raJ liminat barri r [! r th min rity popul ati n n tra, 2 0 ). mith, Poverty Po rty i a foundational detenninant f hea lth that r at with poor r population p rb rmance, a captured by th ab eli adva ntage , rrelat d e h alth indi ce . Th eli advantage of i alation, poor h u ing, lack of adequ ate ewer y tern , poor wat r qu ality, and th impact of dom tic viol ence ar all ve tige of poverty experienc d by on-re erve F population (Bun1 , Bruce, & Marli, 2007; NAHO, 2002; Noel & Larocque, 2009). The 'e socioeconomic c ndition are well doc urn nted by the anadi an media and are part of the c mmon kn wledge of anadian . P verty compound the ef[i ct of chroni c eli a e , uch 'Ne il, & Ma Kinnon, 2007), and i a Type II Diabete ( am pbell , 2002; Marten , Martin , signifi cantly correlat cl with po r hea lth (8 PH , 2009) . B tat (2009) publi heel e onomic data for ea h Hea lth 2006 cen u . Although n h u h lei inc m lata i a ail ab le, the eli parity f p verty e p ri en eel by N c mmuniti rc crve h me in th NH . uth rity, ba, eel on the m oth r mctri indi ate er n -third ( 6.1°o) of on- wcr in need of majo r r p ir , ' Om par d to 9.0° o for non-F INT R NING IN Dl PARITY: TH R LE hom nr . rve h m in the F NUR HA were mor lik ly to hav cr wding f more than one p rson to a b droom than were non-FN h m (5 .6% and 0. %, r p ctiv ly). Th averag incom fl r FN p r n 25-34 year ofag , li m g n r figurer e to 23,15 fl r tho than twic th 21 PRA TITI N R 5-5 4 year rv in the fag H , wa $ 16,203 ; thi n-FN p r on ean1ed more am unt ( 35, 64 D r 25- 4 year ld · and 4 , 1 fl r 5-54 year ld ). Unemployment i al o e n a c ntributing t p verty n re erve (Ander n et al., 2006) . ln May 200 , 33.1% of th FN per n li ing n re erve were unemployed, in contra t t 7.1% of non-FN per on in the H (B tat , 2009). Education In a discu ion paper prepar d fl r th A mbly of Fir t Nation (Reading, Km etic, & Gideon, 2007), poor acce s to quality education was noted a a barrier to healthcare. Individuals in Inuit and FN communiti e regularly find that adult illiteracy and limited English fluency impede their effmis to receive and understand health teaching. Writt n instruction for medication, di et, and self-care are not available in the indigenous langu age that many FN peopl e speak. For older adult who do not speak English or French, the language barriers separating them from healthcare providers i exacerbated by the lo of bilingual speakers, resulting in commuruti e in which access to translator for healthcare visits is increasingly diffi cult (Rosenberg, Wil on, Abonyi, Wi ebe, & Beach, 2008) . Higher edu cational level are also po itively a ciated with health indice uch a life expectancy; edu ca tion i al o linked to higher incomes, decrea ing levels of poverty, and the effect of chroni c di ease. Th B PHO (2009) state that hi gh chool graduate benefit from nearly a 10-year increa e in life e pectancy. In the 2005/2006 choo l year, onl 50.9° o INT RVENING IN DI P RITY: TH R L FN R 22 PRA TITI N R ofFN tu dent graduat d from high chool, a compar d t 78.4% f oth r British olum bian (B PH ). Perceived Barriers to H ealthcare by Fir t Nation Peopl es in Northern Briti h Columbia Th h alth erv1c uroc ntri that are offered to oloni al ocial tructur p r n in B ar de end ed from that pre i u ly nacted racially bia d policie (Ad elson, 2005 ; Hart-W a ekee ikaw 200 a; Kafele, 2004; Peiri , Brown, & a , 200 8) . The mo t glaring raciall y bia ed poli y that captured th e attenti on of anadi an medi a and in pired an apol gy from the Prime Mini ter of anada wa the re id ential chool . The chool were mo tl y admini trated by churche w ith the ex pre a imi lation of anada ' indi ge nous populati on intenti on of cultural ati onal A b ri gin a l Hea lth rga ni zati on, 2002) . In their health plan for abori ginal , the NHA (2007) recognized that coloni za ti on wa a system atic process that devastated the communitie and culture of the F ofN rth em BC (Hm1-Wa ekeesikaw, 2009a) . Although m any of the ovet1 raciall y biased and colonial policies have been hed, postcolonial healthcare i still Em·ocentric (Lancillotti, 2008) . H ealthcare is d livered in ways that meet the needs of the dominant culture and that are often blind to the cultura l need of the indigenous people of Canada (Browne, 2009) . V ickers (2008) and H art-Wa ekee ikaw (2009b) recognized the effect of the status qu o post-col nial racialism in nur ing cuiTicula . Vickers found that nursing edu cation was largely blind to the coloni al cultura li m that pervade nursing theory. ·w olfe (2009) de cri di cours d raciali m in nursing th ory and edu cational a the dominati on of urocentric values of health that requir d non-dominant culture to n goti ate -D r 1 gitimi za ti on . F r ampl e, -; uro ntric nur in g th ori d rib INT RYE IN IN DI PARITY : TH R LE OF R PRA TITI R 23 health a belonging to th individual, wherea , many FN communitie id ntify health in r lation to th xtend d family (Boutain, 2005). Thu , one i nly healthy whil in relati n hip with ne' famil . The r ult i a y tem that ech e the marginalizin g efD ct of previou time when colonial and raci t policie wer openly accepted (Ka[! 1 2004 ). Kelln (2004) identifi ed that ev n wh n people ha e elf-governed healthcar , uch a th N i ga' a, it r quir d an ong ing tru ggl again t the c 1 nial nature of We tern healthcare y tem and the ur c ntri health profe i nal that operat d within those y tern . K l1n coined the t rm, · m di cal c loniali m ', to de cribe the dynami c between Westem.ized healthcar and traditional healing. The medical model of healthcare which informs NP practi ce to a greater degree than it doe other nur e (Di cen o & B ryant-Luko iu , 20 10), i con trued b y Holmes, Roy, and Perron (2008) to have are idual colonial influence. In the context of FN healthcare, the biomedical approach to health remain in Eurocentric opposition to traditional modaliti es of healing, such as the topical use of pl ant products to promote healing (Hart- Wasekee ikaw , 2009b). Ford and Airhihenbuwa (2010), in a study of race as a detem1inant of health, ugge t that racialism is ubiquitous in healthcare system s. Anderson et aL (2006) summarily define colonial structures in healthcare as all those structures that are not refl ective of the cultural ways of indigenou peoples. In tills light, nearly all healthcare, including the primary care role ofNPs, can be een as being imposed on FN communiti s by government that are nearly indi cernible from the colonial tructure that pr ceded them. In the NHA, the Haz lton Memorial Hospital that provide h althcare e1 it aan peopl e , is still owned and op rated by th e United hurch of anada (United to the burch INT R IN OF IN DI PARITY: TH R UR 24 PRA TITI N R of anada, 2009). Thi organizati n wa one th M thodi t church which d liv red 1ru ionary h alth ervic to the co tal indig n us pe pl col nial tru cture of church tru tur till xi t in the am phy ical pr viding g vernm nt a th y did in the 19 0 . Thew rk f outreach clinic in th fB . In Haz It n , th cla tc communiti P in thi c tnmunity i intend d to pr vide that n ighb ur Haz lt n. a umpti n, a FN p r on might i w th new P rol a a m r s a rea nable x tension of the urviVmg colonial healthcare infra tru ctur Th t rtiary ho pi tal of the of orthen1 Briti h H in Prince olumbia [ HNB ] i e rg (central B ), niversity Ho pita] ituated in the middle of the traditional Sekani Fir t Nation teni tory. In 200 1, 9% of th re ident of Prince them elve as aboriginal (Coo k & Daniele, 2006). From per arrier eorge identified nal ob ervation, however, the Carrier culture i not significantly repre en ted in the art, language, or architecture of the ho pital that serves them . FN individual who are acce ing healthcare in Northern BC wo uld find themselves entering building that either echo the colonial experiences of the pa tor are mute to the present existence of their culture. N Ps need to be en iti ve to the barrier that may exist in the infrastructure when providing healthcare, which m ay repre ent a la ck of cultural safety for their FN patients. In exploring the expe1iences of FN women with healthcare in BC, Browne and Fiske (2001) identified three recurrent them e . The women who were interview d poke about their experiences of raci m , di crimination, and m arginaliza tion. ln another B tudy, more than 80% of a sample gr up f FN persons reported avoiding acces ing health are er ice due to a fear of racism (Wardman, lement, & Qu antz, 2005). The an1e numb r ofr pond nt rep rt d feeling very unco mfortabl e in B h alth facilitie (Wardman, I m nt, & Quantz, INT R NIN IN DI P RITY: THE R L F NUR 25 PRA TITI NER n FN women in B 2005). Brown (2007) tudi d the di c ur betw em rg ncy healthcar . In the tudy, theme f cultura li m and raciali m w r pr val nt in th v1 w e pr d by th nur . Browne rec mm nd d that r begin app lying a criti al approach to healthcar for FN w m n. uilfl yle, Kell y, and Pierre-Han en u gge t that heaJthcare profe i nal and in titutions t m a ure th prej udic mu t b gin d veloping t archer and nur e n ed to plore the manner in which ra ciali m may be influ ncing th nur ing carer c iv d by F (200 ) u ed m re dir ct langu ag t and nur e providing of car provid er that create baJTi r to anadian Anoth r tudy, de cribing di spariti e in health erv1c , examined anadian neonatal int nsive care units. The author found that abori ginal neonate were given fewer treatments, medications, life support, and nutrition, c mpared to non-abori ginal pati ent (Reime, Tu, & Lee, 2007). The author u gge ted that more re earch wa n eeded to explore the relationship between ethnicity and denial or refu al of treatment. This evidence of h ea lthcare di parity does not describe a causal relation hip between raciali sm and health outco mes. eve1ihele it suggests that FN patients encounter greater barrier to healthcare, suggesting that difference in race and culture between hea lthcare provider and patients ma y act a a detenninant of health . Data collected by the NHA (2006) from FN focu gro ups id entifi ed a number of themes with regards to healthcare staff. In particular, the staff lacked cultural awaren ss or ensitivity, did not support relationship- or tru t-buiJd ing, cau ed experience of raci m and di scrimination, used tereotyp e , were not responsive to language barrier , elicited f ar in the interaction with healthcare staff, reinforced the effects of coloniza tion, and had int raction that wer affected by the hi stori cal m mory of ra ism , leading to disempowerm nt or the INT RVENIN INDI PARITY:TH R L taking away of aboriginal v i H alth Auth rity, 2006). FN R PRA TI IN R 26 fr m th m dical d ci i n-making (Mu ell, 2006; Northetn INT RV IN IN Dl P RITY : TH R R PRA TI I R 27 hapter Five Theoretical Di cu ion of the Role of ultural ompetence in the Practice of ur e Practitioners Theoretical Foundation of In th 19 0 , Leining r th e ry L ining r, 2002). B ro - ultural ur in g and r te ab ut th rl ap b tw e mm g r' ompetency n anthr p logy and nur ing 1 6 , th e re ult wa the concept f cultura ll y c ngru nt car , which led t the publi hing f the th furth r lu ida t d her tran ultural ry f tran c ultural nur ing in 197 0. In 199 1, e ining r ultural nur ing th ry in cultur car diver ity a nd uni ver ality. o rk firm I e ntre nched th imp rtanc f culture a a dim e n i n f nur ing, noting that culturall y- ba ed ca re i fund a m nta l to pr m ting health a nd und er tandin g w ellne . L ininger furth r rec gniz d th at p cia li zed kill and k.now ledg w re n c ary work w ith patient fro m di ffere nt c ulture . T hi area f nur ing tud y ha become kn wn a tran c ultural nur ing. The primary focu s of tra n cultural nursing i th e prov i i n of c ultura ll y co ngru nt care, w hi ch require nur e to appl y cultural know! dge rega rdin g a p a ti nt in a mann er that deliver ca re to m eet the pati ent' ho li ti c need (Leininger, I 97 ). In L inin ger ' unn e m del (2006), th e ho li ti c ca re need of p ati nt are influ enc d by the ir world iew, cu ltu ral and oc ial structure , environm ental conte t, life way , kin hip , pirituality, edu ca tion, and pattern r practi ce f r ceiving ca re (Fi gure 3 ). Tran cultu ra l nur c mp et nt care thro ugh pre erva ti on, ac p ro id cu lt ural! mm oda ti n, or re tru turing of ei th r the expecta ti ns of th pa ti nt o r th deli very of care. T h r ult [ th . e a ' lion. ' u ld id all be th e a a il ability o f ultura ll co ngru ent a re th a t uppo rt th e pati en t' , holi . ti h ~alth need . INT RV IN IN D I P RITY: TH F R L R .. PRA T IT I N R 2 • lll"ia l '-, tructure l>imcn,inns l ( ullurul \ atu ..... B .. u. r. / .. -. '"'"""" I· .u--t'''"' • l'nlihn tl& I t · l( I t 1u t ur-. - .. I "''runmt•nl.ll ( u nl <' I I Ml!!Uolf!t' S, I lhllllhl'lllt' • H.dlf!luu• & l' hll•.... •phl