Health and Social Development, Faculty of (Okanagan)
Nursing, School of (Okanagan)
DSpace
UBCO
Froste, Amber Mercedes
Master of Science in Nursing - MSN
University of British Columbia
This research analyzes the integration of the Indigenous Patient Navigator (IPN) role within British Columbia's health systems, with a focus on Interior and Northern Health, guided by the Systematic Equity Action-Analysis framework. The study critically analyzes how integrating the IPN role aligns with organizational equity goals and, more broadly, explores how health systems can better advance equity in integrating Indigenous healthcare roles. Additionally, the study brings to light ways for health systems to align the IPN role integration with broader organizational equity objectives. The research employs a theoretical framework that grounds a systematic equity analysis in a philosophy where integrating Indigenous knowledge with critical Western frameworks challenges dominant worldviews and advances equity. This approach deepens the understanding of the research by considering two different worldviews to gain a clearer understanding of equity and how to integrate Indigenous healthcare roles equitably. The study analyzes the role integration of IPN using qualitative document content analysis, situated within an exploratory literature review. It seeks to identify promising practices and barriers to role integration, as well as similarities and differences in integration practices when compared to other special healthcare provider integration processes, such as the Participatory Evidence-based, Patient-focused, Process (PEPPA) and the PEPPA Plus frameworks for the Advanced Practice Nurse (Bryant-Lukosius & Discenco, 2004; Bryant-Lukosius et al., 2016). It aims to systematically explore coherence between stated intentions and the operationalization of role integration, with attention to factors that facilitate or hinder coherence. By examining how Interior and Northern Health operationalize equity goals through IPN role integration, this research generates actionable recommendations to enhance IPN role integration and align the way health systems integrate the IPN role with their equity goals and commitments. Overall, this work contributes to the broader understanding of how health systems can support reconciliation and advance equitable processes and practices that support health initiatives, such as integrating Indigenous healthcare roles that improve health outcomes for Indigenous populations.
THE INTEGRATION OF THE INDIGENOUS PATIENT NAVIGATOR ROLE IN BRITISH COLUMBIA HEALTH SYSTEMS: A SYSTEMATIC EQUITY ACTION-ANALYSIS by Amber Mercedes Froste, B.S.N. A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE COLLEGE OF GRADUATE STUDIES THE UNIVERSITY OF BRITISH COLUMBIA October 2025 © Amber Mercedes Froste, 2025 (Okanagan)ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis entitled: The Integration of the Indigenous Patient Navigator Role in British Columbia Health Systems: A Systematic Equity Action-Analysis submitted by Amber Mercedes Froste in partial fulfillment of the requirements of the degree of Master of Science in Nursing. Katrina Plamondon, School of Nursing, Faculty of Health and Social Development Supervisor Charlene Ronquillo, School of Nursing, Faculty of Health and Social Development Supervisory Committee Member Dennis Jasper, School of Nursing, Faculty of Health and Social Development Supervisory Committee Member Gabrielle Legault, Department of Community, Culture and Global Studies, Irving K. Barber Faculty of Arts and Social Sciences University Examiner Additional Committee Members include: Donna Mendel Supervisory Committee Member iii Abstract This research analyzes the integration of the Indigenous Patient Navigator (IPN) role within British Columbia's health systems, with a focus on Interior and Northern Health, guided by the Systematic Equity Action-Analysis framework. The study critically analyzes how integrating the IPN role aligns with organizational equity goals and, more broadly, explores how health systems can better advance equity in integrating Indigenous healthcare roles. Additionally, the study brings to light ways for health systems to align the IPN role integration with broader organizational equity objectives. The research employs a theoretical framework that grounds a systematic equity analysis in a philosophy where integrating Indigenous knowledge with critical Western frameworks challenges dominant worldviews and advances equity. This approach deepens the understanding of the research by considering two different worldviews to gain a clearer understanding of equity and how to integrate Indigenous healthcare roles equitably. The study analyzes the role integration of IPN using qualitative document content analysis, situated within an exploratory literature review. It seeks to identify promising practices and barriers to role integration, as well as similarities and differences in integration practices when compared to other special healthcare provider integration processes, such as the Participatory Evidence-based, Patient-focused, Process (PEPPA) and the PEPPA Plus frameworks for the Advanced Practice Nurse (Bryant-Lukosius & Discenco, 2004; Bryant-Lukosius et al., 2016). It aims to systematically explore coherence between stated intentions and the operationalization of role integration, with attention to factors that facilitate or hinder coherence. By examining how Interior and Northern Health operationalize equity goals through IPN role integration, this research generates actionable recommendations to enhance IPN role integration and align the way health systems integrate the IPN role with their equity goals and commitments. Overall, this work contributes to the broader understanding of how health systems can support reconciliation and advance equitable processes and practices that support health initiatives, such as integrating Indigenous healthcare roles that improve health outcomes for Indigenous populations. iv Lay Summary This equity research examines the Indigenous Patient Navigator (IPN) integration in two Health Systems, asking: How is the integration of the IPN role within Interior and Northern Health conducted, and is the process equitable and coherent with equity commitments and goals that the health systems claim to uphold and advance? Using Indigenous methodology, Critical Indigenous Theory, and Plamondon et al. (2023)'s Systematic Equity Action-Analysis (SEEA) framework, the study analyzes IPN integration documents alongside equity policies, strategies, and plans. The SEAA identifies promising practices and inhibitors to equitable integration through exploring worldview and coherence (Plamondon et al., 2023). A comparison with Bryant-Lukosius and Dicsenoâs (2004) Participatory, Evidence-based, Patient-focused Process (PEPPA) and Bryant-Lukosius et al. (2016) PEPPA Plus frameworks reveals similarities and differences in the integration of promising practices. IH and NH have made progress, but further improvements are possible. Using recommendations and an Indigenous framework can advance the equitable integration of IPNs. v Preface This thesis is original and unpublished work by Amber Mercedes Froste. The study and its writings reflect the author's research, perspectives, and interpretations. Dr. Katrina Plamondon provided ongoing guidance, feedback, and direction throughout the research and thesis writing process. Her support encompassed contributions to the study's purpose, methodology, structure, direction, and the application of a pre-existing theoretical framework on equity, as well as editing to support clarity and preparing the manuscript for final submission. The committee advisors of Dr. Charlene Ronquillo, Dennis Jasper, and Donna Mendal provided additional recommendations and feedback, including improvements for research and thesis understanding, scope, editing, and insights for further study. Lastly, Jennifer Thorne offered editing, structure, and formatting support that enhanced the thesis's organization, flow, and readability. In preparing parts of this thesis, ChatGPT, a generative AI tool, was used to confirm that the wording accurately reflected my original thoughts and intent. All AI outputs were reviewed by me and adapted to ensure they aligned with my perspectives and personal knowledge. I posed questions to Chat GPT, such as: Here is my original sentence: [I inserted a sentence]. I want to ensure I am sharing these thoughts accurately [I inserted my thoughts]. In plain language, can you describe what I am trying to say? When the AI provided information that did not align with my thoughts, perspectives, or insights, I revised and adapted my sentence wording to ensure that my improved sentence accurately reflected my intended thoughts. Grammarly, another AI-powered software, was also used to review the clear use of language and make sentence enhancements. This AI contributed to my writing and editing process by offering recommendations for improving spelling, grammar, clarity, and flow, identifying errors in spelling and grammar, and suggesting rewording, correct spelling, and punctuation improvements. vi Table of Contents Abstract ........................................................................................................................................................ iii Lay Summary ............................................................................................................................................... iv Preface .......................................................................................................................................................... v Table of Contents ......................................................................................................................................... vi List of Figures ............................................................................................................................................ xiii List of Tables .............................................................................................................................................. xiv Chapter One: Introduction ............................................................................................................................ 1 1.1. Background ............................................................................................................................... 3 1.1.1. The Indigenous healthcare landscape ................................................................................. 3 1.1.2. The role of the Indigenous Patient Navigator ..................................................................... 5 1.2. Research Overview .................................................................................................................... 8 1.2.1. Research problem ............................................................................................................... 8 1.2.2. Research purpose ................................................................................................................ 8 1.2.3. Research aims and objectives. .......................................................................................... 10 1.2.4. Significance ...................................................................................................................... 11 1.2.5. Scope and definitions of terms .......................................................................................... 11 1.2.6. Guiding philosophy, worldview, and theoretical framework. ........................................... 13 1.3. Positionality Statement ............................................................................................................ 14 1.3.1. Indigenous health system leader. ...................................................................................... 14 1.3.2. Indigenous healthcare provider. ........................................................................................ 14 vii 1.3.3. Indigenous person. ............................................................................................................ 15 1.4. Thesis Organization ................................................................................................................. 16 2. Chapter Two: Exploratory Review of Literature ..................................................................... 18 2.1. Participatory, Evidence-based, Patient-focused Process for Advanced Practice Nurse .......... 19 2.2. Systematic Equity Action-Analysis ......................................................................................... 19 2.3. Historical and Contextual Background ................................................................................... 19 2.3.1. Indigenous healthcare landscape. ...................................................................................... 20 2.3.1.1. Historical healthcare landscape for Indigenous peoples. ..................................... 20 2.3.1.2. Current Indigenous health system challenges. ..................................................... 25 2.4. Operationalizing health systems' commitments to reconciliation ........................................... 25 2.5. Literature Search: Indigenous Health Equity Policies, Strategies, and Plans and the IPN Role in Health Systems. ................................................................................................................... 27 2.5.1. Indigenous equity policies, strategies, and plans in health systems. ................................. 27 2.5.1.1. Search parameters and results. ............................................................................. 27 2.5.2. IPN Role in health systems. .............................................................................................. 29 2.5.2.1. Search parameters and results. ............................................................................. 29 2.6. Literature analysis ................................................................................................................... 30 2.6.1. Indigenous health equity policies, contexts, and frameworks. ......................................... 30 2.6.2. IPN Role in Health Systems ............................................................................................. 34 2.6.2.1. Patient, family, and community perspectives of the IPN. .................................... 34 2.6.2.2. Promising practices and barriers to IPN role integration. .................................... 37 2.6.2.3. Inclusion of pre-existing IPN roles. ..................................................................... 38 viii 2.6.2.4. Integrating the IPN role. ...................................................................................... 39 2.7. Limitations in the literature ..................................................................................................... 41 2.8. Conclusion ............................................................................................................................... 43 3. Chapter Three: Theoretical and Methodological Foundations ................................................ 45 3.1. Introduction ............................................................................................................................. 45 3.2. Philosophical Underpinnings .................................................................................................. 45 3.3. Worldview ............................................................................................................................... 47 3.4. Theoretical Frameworks .......................................................................................................... 49 3.4.1. Systematic equity action-analysis: A theoretically grounded approach to research. ......... 49 3.4.1.1. SEAA foundation. ................................................................................................ 49 3.4.1.2. SEAA dimensions. ............................................................................................... 50 3.4.1.3. SEAA practices. .................................................................................................. 53 3.4.1.4. Guiding dimensional questions. ........................................................................... 55 3.4.2. Participatory evidence-based patient-centred integration process for the advanced practice nurse. ................................................................................................................................. 57 3.5. Research Design ...................................................................................................................... 59 3.6. Research Methods ................................................................................................................... 61 3.6.1.1. IPN job descriptions............................................................................................. 61 3.6.1.2. Organizational charts, practice support documents, and IPN role integration resources. ............................................................................................................. 62 3.6.1.3. Health system equity policies, goals, commitments, and strategies. ................... 62 3.6.2. Data organization and analysis. ........................................................................................ 63 ix 3.7. Ethical Considerations ............................................................................................................. 66 3.8. Feasibility Considerations ....................................................................................................... 68 3.9. Knowledge Affirming Strategies ............................................................................................. 68 3.10. Areas for Future Growth ......................................................................................................... 70 3.11. Conclusion ............................................................................................................................... 71 4. Chapter Four: Findings ............................................................................................................ 72 4.1. Introduction ............................................................................................................................. 72 4.2. Overview of the Data .............................................................................................................. 72 4.2.1. IPN role integration resources .......................................................................................... 73 4.2.1.1. Job descriptions.................................................................................................... 73 4.2.1.2. Service delivery location lists. ............................................................................. 75 4.2.2. Equity informing policies and strategies ........................................................................... 77 4.2.2.1. Policies. ................................................................................................................ 78 4.2.2.1.1. IH AUD2100 Diversity Policy. ................................................................... 79 4.2.2.1.2. IH AU2200- Anti-racism Policy. ................................................................. 79 4.2.2.1.3. IH AD0200 Aboriginal Cultural Safety and Humility Policy. ..................... 81 4.2.3. Strategies and plans. ......................................................................................................... 82 4.2.3.1. Our Strategic Direction 2024-2027. ..................................................................... 82 4.2.3.2. 2022-2026 Indigenous Health and Wellness Strategy. ......................................... 83 4.2.3.3. Accessibility Plan. ............................................................................................... 85 4.3. Presentations of Findings ........................................................................................................ 87 x 4.3.1. IPN role integration: promising practices and inhibitors. ................................................. 87 4.3.1.1. Promising practices. ............................................................................................. 88 4.3.1.1.1. Commitments to diversity, human rights, and reconciliation. ..................... 89 4.3.1.1.2. Role holder knowledge of Indigenous histories, rights, and health disparities. .................................................................................................... 89 4.3.1.1.3. Supporting cultural safety and Indigenous healing practices. ..................... 90 4.3.1.1.4. Varied Indigenous-specific roles. ................................................................. 91 4.3.1.1.5. Patient- and family-centered care approach................................................. 91 4.3.1.1.6. Advocacy and system navigation services................................................... 91 4.3.1.2. Inhibitors. ............................................................................................................. 92 4.3.1.2.1. System governance and leadership. ............................................................. 94 4.3.1.2.2. Role Design and Infrastructure. ................................................................... 95 4.3.1.2.3. Indigenous engagement and partnership. .................................................... 96 4.3.1.2.4. Education and workforce development. ...................................................... 96 4.3.2. Comparing IPN role integration to evidence-based frameworks. ..................................... 97 4.3.2.1. Similarities. .......................................................................................................... 97 4.3.2.2. Differences. .......................................................................................................... 98 4.3.3. Worldview and power. .................................................................................................... 101 4.3.4. Worldview and language use. ......................................................................................... 102 4.3.4.1. Power and language use. .................................................................................... 103 4.3.4.1.1. Health system leadership and power-laden language. ............................... 104 4.3.4.1.2. The IPN and directive-compliance language. ............................................ 104 xi 4.3.4.1.3. Indigenous populations and deficiency-framing language. ....................... 105 4.3.5. IPN role integration alignment with health system equity goals and or commitments... 106 4.3.5.1. Health system equity commitments and goals. .................................................. 106 4.3.5.1.1. Alignment. ................................................................................................. 110 4.3.5.1.2. Weak Alignment. ....................................................................................... 111 4.3.5.1.3. Misalignment ............................................................................................. 116 4.4. Conclusion ............................................................................................................................. 117 5. Chapter Five: Discussion ....................................................................................................... 119 5.1. Opportunities for Improving Equitable Role Integration ...................................................... 119 5.2. Applying Critical Indigenous Theory .................................................................................... 125 5.2.1. Advancing equity: Integrating knowledge, critically assessing practice, and applying Indigenous worldviews in the IPN role integration. ....................................................... 125 5.2.1.1. Promising practices for IPN role integration. .................................................... 125 5.2.1.2. Literature-based inhibitors for IPN role integration. ......................................... 132 5.2.1.2.1. Lack of attentiveness to Indigenous worldviews. ...................................... 136 5.2.1.2.2. Absence of standardized integration frameworks and undue burden of systemic responsibilities. ........................................................................... 136 5.2.1.2.3. Role uncertainty, missing evaluation and monitoring mechanisms, and a lack of wage compensation for Indigenous expertise and knowledge. ...... 137 5.2.1.2.4. Lack of addressing the relational and cultural level of literature-informed inhibitors. ................................................................................................... 139 5.2.1.3. Indigenizing PEPPA and PEPPA Plus frameworks to advance equity. .............. 140 xii 5.2.1.4. Indigenizing job descriptions to advance equity. ............................................... 151 5.2.1.4.1. Foundation and influence of job descriptions. ........................................... 152 5.2.1.4.2. Impacts of role clarity and coherence deficiencies. ................................... 152 5.2.1.4.3. System-level opportunities for improvement. ........................................... 153 5.2.1.5. Advancing equity: Strengthening policies, strategies, and plans to translate goals and commitments into action. ............................................................................ 158 5.3. Implications ........................................................................................................................... 162 5.4. Limitations ............................................................................................................................ 164 5.5. Recommendations for Future Research ................................................................................. 166 5.6. Conclusion ............................................................................................................................. 167 6. Chapter Six: Conclusion ........................................................................................................ 169 7. References ............................................................................................................................. 172 xiii List of Figures Figure 1: Sequential Steps of IPN Role Integration ................................................................................. 645 Figure 2: Levels of Health System Functioning .................................................................................. 12122 Figure 3: Guidance for Developing Indigenous-Specific Healthcare Role Descriptions: Reframing Language and Alignment with Evidence-based Role Integration Frameworks ...................................... 1544 Figure 4: Decolonizing Health Systems: A Relational and Action-Oriented Framework Grounded in Indigenous Epistemologies ......................................................................Error! Bookmark not defined.69 xiv List of Tables Table 1: Core Research Topics and Key Search Terms .............................................................................. 28 Table 2: Literature Search Article Selection Parameters ............................ Error! Bookmark not defined. Table 3: Promising Practices in IH and NH IPN Role Integration ............. Error! Bookmark not defined. Table 4: Literature-informed Inhibitors in IH and NH Role Integration .................................................... 93 Table 5: PEPPA Framework Steps Identified in the IH and NH Role Integration ................................... 100 Table 6: IH Equity and Equity-Related Goals and Commitments ............Error! Bookmark not defined.7 Table 7: IH Actions to Advance Equity Goals and Commitments ............. Error! Bookmark not defined. Table 8: Indigenous Patient Navigator Integration versus Interior Healthâs Equity Commitments and Goals ........................................................................................................Error! Bookmark not defined.13 Table 9: Health System Implications Across Structural, Operational, Relational, and Cultural Levels ...................................................................................................................Error! Bookmark not defined.3 Table 10: IPN Role Integration Promising Practices Reflected in IH and NH IPN, and IPN-Similar Job Descriptions ...............................................................................................Error! Bookmark not defined.7 Table 11: Health System Literature-Based Inhibitors to the IPN Integration and Indigenous-Informed Recommendations ......................................................................................Error! Bookmark not defined.4 Table 12: Indigenization of the PEPPA Framework: Relational Integration Framework: Centering Indigenous Knowledge in the IPN Role ..................................................... Error! Bookmark not defined. xv List of Abbreviations Abbreviation Definition APN Advanced Practice Nurse BC British Columbia CC Care Coordinator CINHAL Cumulative Index to Nursing and Allied Health Literature CIT Critical Indigenous Theory CPHA Canadian Public Health Association CRNAC Crown-Indigenous Relations and Northern Affairs Canada DIAND Department of Indian Affairs and Northern Development DRIPA Declaration on the Rights of Indigenous Peoples FH Fraser Health FNHA First Nations Health Authority FNHA & BC OPHO First Nations Health Authority & BC Office of the Provincial Health Officer IHSA Indigenous Health Service Assistant ICC Indigenous Care Coordinator IH Interior Health IPS In Plain Sight MNBC Métis Nation British Columbia NCCIH National Collaborating Centre for Indigenous Health xvi Abbreviation Definition NH Northern Health NIMMWIG National Inquiry into Missing and Murdered Indigenous Women and Girls PEPPA Participatory Evidence-based Patient-focused Process for Advanced Practice Nursing PEPPA Plus Participatory Evidence-based Patient-focused Process for Advanced Practice Nursing PHAC Public Health Agency of Canada QDCA Qualitative Descriptive Content Analysis SEAA Systematic Equity Action-Analysis TRC of Canada Truth and Reconciliation Commission of Canada UBC University of British Columbia US United States VCH Vancouver Coastal Health 1 Chapter One: Introduction Health disparities are associated with variations in health outcomes among distinct and diverse populations (Public Health Agency of Canada [PHAC], 2018). In 2018, Canada's Chief Public Health Officer and Chief Medical Officer acknowledged the presence of health disparities in Canada, while emphasizing that mitigating these disparities remains a significant priority (PHAC, 2018). To monitor health disparities, the PHAC developed a Health Inequalities Data Tool, which systematically organizes health indicators by socio-demographic and economic groups (PHAC, 2018). One notable indicator, Indigeneity, which is inclusive of First Nations, Métis, and Inuit peoples (PHAC, 2018), serves as a key health indicator due to its close link to social, economic, and historical factors that increase health disparities (PHAC, 2018). Indigenous Peoples in Canada face distinct challenges of entrenched discrimination, limited access to culturally safe and relevant healthcare, and the enduring impacts of colonization, all of which adversely affect their overall health and well-being (Caron, 2020). As a result, Indigenous people in Canada experience worse health outcomes, including higher rates of acute and chronic illnesses, mental health challenges, and lower life expectancy (Caron, 2018). These systemic challenges, in conjunction with a higher prevalence of disease and infection, drive the considerable health disparities Indigenous people experience, both nationally and provincially in British Columbia (BC). In BC, Indigenous peoples also face significantly higher rates of both short-term and long-term health conditions (First Nation Health Authority & the BC Office of the Provincial Health Officer [FNHA & BC OPHO], 2024), resulting in a life expectancy that, on average, is seven years shorter than that of non-Indigenous populations (FNHA & BC OPHO, 2024). This startling reality is a direct result of the enduring and historical challenges that Indigenous peoples encounter when navigating health systems (FNHA & BC OPHO, 2024). As a result, Indigenous peoples access healthcare services at lower rates than their non-Indigenous population members, a behaviour which further exacerbates their unequal 2 health outcomes (Caron, 2020). Unfortunately, it is systemic barriers and experiences of cultural disconnection within BCâs health systems that frequently cause Indigenous Peoples to underuse health services. Among the more predominant barriers and cultural disconnections is the lack of culturally safe, accessible, and relevant care within BC's health systems (de Leeuw and Greenwood, 2019). In addition, Indigenous Peoples also experience systemic discrimination, racism, and a lack of cultural awareness, which discourages interaction with the system and results in worse health outcomes (Government of BC, 2020). The health systemâs shortcoming of integrating Indigenous cultural practices, values, and healing methodologies into services further alienates Indigenous populations, making them less likely to seek care when needed (Davies, 2022). This cultural disconnect and lack of culturally safe and relevant care not only exacerbates health inequities but also deepens mistrust between Indigenous peoples and the healthcare system, perpetuating a cycle of underutilization of services and ongoing health disparities (Davies, 2022). A key initiative to address the deficiency of cultural safety within health systems is the creation and integration of Indigenous-specific healthcare roles (Tremblay et al., 2023), such as Indigenous Patient Navigators (IPNs). The process by which these roles are integrated is vital to their success and effectiveness in advancing cultural safety in healthcare (Tremblay et al., 2023). Unfortunately, numerous challenges persist in integrating Indigenous-specific roles into health systems, such as role confusion, insufficient resources, and institutional resistance (Newham et al., 2016; Rankin et al., 2022; Schmidt et al., 2016). Despite recommendations to improve role integration, such as increasing role support, providing tailored training, and enhancing communication and collaboration, Indigenous-specific role integration continues to face significant barriers (Cochrane et al., 2014; Sedgewick, 2021; Schmidt et al., 2016). As a result, these roles often cannot fulfill their intended goals because they are not appropriately and effectively integrated into health systems. This research examines the integration of the IPN role within the Interior and Northern Health authorities in BC, using the Systematic Equity Action-Analysis (SEAA) framework. It critically assesses 3 how integrating the IPN role aligns with health system organizational equity goals and commitments and explores promising broader strategies for advancing equity in Indigenous healthcare role integration. The study highlights ways to align IPN integration more closely with equity objectives and incorporates Indigenous knowledge to challenge dominant worldviews and promote equity. Through document analysis and a literature review, the research explores the coherence between stated equity intentions and the operationalization of the IPN role, identifying promising practices and barriers. This study aims to generate recommendations to enhance IPN integration, advance equity in health systems, support reconciliation, and improve health outcomes for Indigenous populations. 1.1. Background 1.1.1. The Indigenous healthcare landscape The historical, ongoing, and pervasive marginalization of Indigenous peoples in Canada stems from the influence of Western Eurocentric colonial legislation and governing policies, which have systematically disrupted Indigenous healthcare systems and contributed to lasting health disparities (Guadagnolo et al., 2017). These legislatures/policies, rooted in colonial rationalism, capitalism, and imperial thought, prioritized assimilation, land dispossession, and cultural erasure through key legislation like the Indian Act (1985) and the Gradual Civilization Act (1857), all of which undermined Indigenous sovereignty and social structures (Belon et al., 2024; Raphael et al., 2022; Smith, 1999). These colonial frameworks established during colonial times negatively influenced health services for Indigenous Peoples. As a result, these frameworks shaped health systems that disregard and disconnect Indigenous patients from their cultural healing practices, thereby perpetuating systemic health outcome inequities (Caron, 2020). One profoundly harmful initiative formulated from historical Canadian colonial frameworks or legislation was the racially segregated Indian hospitals that existed from the 1920s through to the 1980s (Lux, 2016). Indian hospitals served to marginalize Indigenous peoples, segregate them from settler 4 populations, and shift healthcare responsibility outside of the mainstream healthcare system (Lux, 2016). Run in partnership between the Department of Indian Affairs (DIA) and missionary and religious groups, these hospitals provided inadequate and culturally insensitive care that resulted in worsened Indigenous health outcomes due to their underfunding, understaffing, and overcrowding (Indigenous and Northern Affairs Canada, 2011; Lux, 2016). Another intensely health-damaging initiative enacted through colonial legislation is the Canadian Indian Residential Schools of the late 1880s through to the 1990s (Milloy, 1999). These federally funded, religious-based schools, which spread across Canada, were formalized under Prime Minister John A. Macdonald as part of Canadaâs broader policy of assimilation (Milloy, 1999). By establishing and enforcing the residential schools, authorities forcibly removed Indigenous children from their families and communities (Milloy, 1999), subjecting them to rampant discrimination, racism, and physical, emotional, mental, and sexual abuse, including unethical medical experimentation where children were intentionally malnourished, deprived of basic care, or given inconsistent supplements without consent (McCallum, 2017). As a result of this legislatively enacted school system (Milloy, 1999) and segregated health facilities (Lux, 2016), and unethical health experimentation (McCallum, 2017), Indigenous Peoples experienced profound trauma that severely impacted their health and wellness- affecting not only those directly subjected to these systems but also the generations that followed (McCallum, 2017). This systemic, historical, and ongoing traumaâreferred to as intergenerational traumaâcontinues to contribute to the persistent Indigenous health disparities that persist today (McCallum, 2017). Unsurprisingly, government institutions and health systems have historicallyâand continue to fail to meet the health needs of Indigenous peoples (Caron, 2020; Davies, 2022). However, recent foundational documents and movements offer promising steps towards addressing these long-standing disproportionate Indigenous health disparities (Caron, 2020). Documents such as the Truth and Reconciliation Commission of Canada's Calls to Action (TRC of Canada) (2015), In Plain Sight (IPS) (2020), and the Reclaiming Power and Place: The Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls (2019) highlight systemic barriers faced by Indigenous people 5 while also providing recommendations and actions to improve Indigenous health outcomes. These documents stress the importance of increasing Indigenous representation in healthcare, enhancing cultural safety, and addressing discrimination (National Inquiry into Missing and Murdered Indigenous Women and Girls [MMIWG], 2019; Truth and Reconciliation Commission of Canada, 2015; Government of BC, 2020). In response, initiatives and frameworks such as the First Nation Health Transformation Agenda (2017) and the Transformative Change Accord: First Nations Health Plan (2006) build on these recommendations, reinforcing the need for transformative systemic change through the creation and implementation of initiatives and processes that improve health outcomes for Indigenous peoples. Together, these frameworks, recommendations, and initiatives demonstrate a growing commitment to advancing reconciliation- one that highlights the critical opportunity to integrate Indigenous knowledge and values into healthcare systems (Assembly of First Nations, 2017; BC Ministry of Health et al., 2006, Truth and Reconciliation Commission of Canada, 2015), as exemplified by initiatives like the creation and implementation of the IPN role. 1.1.2. The role of the Indigenous Patient Navigator The Government of BC commissioned the IPS (2020) report to investigate systemic racism and discrimination experienced by Indigenous Peoples interacting in BC's healthcare system. Recognizing mounting concerns and reports of unfair treatment, bias, and discrimination toward Indigenous Peoples in healthcare settings, the Government of BC developed the report as a means of addressing existing systemic issues (Government of BC, 2020). The IPS (2020) report uncovers and exposes systemic discriminatory practices within the BC health system, offering transformative, Indigenous-informed recommendations to enhance cultural safety, reduce racism, and create a more equitable healthcare environment for Indigenous Peoples (Government of BC, 2020). One crucial recommendation the IPS (2020) report offers is to increase the number of Indigenous healthcare workers as an initiative for enhancing cultural safety and addressing systemic racism in BCâs health system. The IPN role integration exemplifies this recommendation, as the aim of the role is to improve access, enhance cultural safety, and 6 address the systemic barriers Indigenous Peoples encounter with health systems (Boulton et al., 2022; Groot et al., 2024). The IPN role was first presented in North America, Australia, and New Zealand in the early 2000s to address the distinct healthcare challenges faced by Indigenous Peoples (Harjo et al., 2014). In the United States (US), the role was initially introduced within tribal health systems and the Indian Health Services, with the Indigenous community leaders playing a key role in advocating for its implementation (Harjo et al., 2014). The role focused on providing culturally appropriate support, improving access to and navigation of care, and enhancing trust in the health systems for Indigenous patients (Harjo et al., 2014). The roleâs impact included increased health system engagement and improved health outcomes for Indigenous patients who were often underserved and unsupported by health services (Harjo et al., 2014). In Canada, IPNs began providing health service support to First Nations communities in the late 1990s and early 2000s (Sheppard et al., 2019). These roles also focused on assisting Indigenous Peoples in accessing and navigating the health system by offering culturally relevant support aimed at improving Canadian Indigenous health outcomes (Sheppard et al., 2019). During this period, recommendations for integrating the IPN role emphasized the importance of adopting similar roles within other health entities to increase health service utilization and improve outcomes for Indigenous Peoples (Sheppard et al., 2019). Both in the US and Canada, the initial focus of the IPN role was on cancer screening, specifically created to address the higher rates of cancer diagnoses and limited healthcare access within Indigenous populations (Harjo et al., 2014; Sheppard et al., 2019). Over time, the scope of the IPN role expanded to address a broader range of health needs, reflecting a growing awareness of the distinct challenges Indigenous Peoples face (Sheppard et al., 2019). In Australia and New Zealand, roles such as the IPN also emerged in the early 2000s as an initiative to address the health needs and improve access to care for Aboriginal and Torres Strait Islander peoples and MÄori populations (Rankin et al., 2022). Health systems in Australia introduced the IPN role to address healthcare disparities experienced by Aboriginal and Torres Strait Islander communities (Rankin et al., 2022). These roles initially prioritized chronic disease management in addition to cancer 7 care (Katzenellenbogen et al., 2015; Sanjida et al., 2022), rather than concentrating solely on cancer screening. Similarly, New Zealand introduced IPNs to enhance healthcare access for MÄori communities, where the roles emphasized cultural safety as a way to reduce systemic service barriers (Stretton et al., 2022). Unique health system challenges within both countries shaped these roles, which delivered culturally tailored support to enhance health services and improve outcomes for Indigenous Peoples (Rankin et al., 2022). As the IPN role expanded across the US, Canada, Australia, and New Zealand, IPNs began working in a variety of healthcare settings, including primary care clinics, hospitals, mental health and addiction services, chronic disease management programs, and maternal and child health services (Hiscock et al., 2022). They became integral to community-based health programs, ensuring culturally safe care across a broader range of healthcare contexts and community locations (Hiscock et al., 2022). This expansion reflects growing recognition of the complex healthcare needs of Indigenous Peoples who present in a variety of health service settings globally (Rankin et al., 2022). Despite the documented impact of this role, an environmental scan of IPN programs in Ontario conducted by Hiscock et al. in 2022 concluded that there is a lack of guidance and strategic planning available for integrating IPNs into health systems, which limits the effectiveness and sustainability of the role (Hiscock et al., 2022). Recommendations stemming from their scan called for increased support and more purposeful integration of the IPNs into the health system as essential to realizing the goal of improving outcomes for Indigenous peoples (Hiscock et al., 2022). This recommendation aligns with other important lessons and insights emerging from research and evaluation of the integration of other specialized roles. Introduced in the early 2000s, Bryant-Lukosius and Dicenso (2004) created the Participatory Evidence-based Patient-focused Process (PEPPA) and, in 2016, the PEPPA Plus as frameworks for introducing Advanced Practice Nurses (APN) to healthcare settings, due to the APN role integration challenges related to role definition, acceptance, and full utilization of scope within the healthcare teams (Bryant-Lukosius et al., 2016). Similarly, integrating the IPN role faces comparable challenges. 8 Therefore, the success of the PEPPA and PEPPA Plus frameworks for the APN offers valuable insights into the importance of clear role definitions, comprehensive training, and strong institutional support to ensure the effective integration of IPNs. 1.2. Research Overview 1.2.1. Research problem The integration of the IPN role into healthcare systems presents challenges that limit its effectiveness in improving health outcomes for Indigenous populations (Rankin et al., 2022). Structural and operational barriers, including inconsistent implementation, lack of organizational alignment, and insufficient support, hinder the role's ability to function as intended (Isaacson et al., 2021; Klesynski et al., 2024; Yashadhana et al., 2020). Many healthcare organizations lack sufficient policies and standardized frameworks to guide the integration of IPNs, resulting in unclear role expectations, scope of practice, and levels of organizational support (Miyamoto et al., 2019; Rankin et al., 2022). Without formalized structures, IPNs struggle to navigate their responsibilities effectively, resulting in role ambiguity, burnout, and limited impact within health systems (Orr et al., 2022). Additionally, systemic inequities and the persistence of colonial healthcare models often marginalize Indigenous-led initiatives, further complicating the role's sustainability and impact (Caron, 2020). Addressing these challenges requires a critical analysis of how health systems integrate IPNs to ensure that they are meaningfully and effectively embedded into health system structures. 1.2.2. Research purpose The purpose of this research is to critically assess how the integration of the IPN role into Interior Health (IH) and Northern Health (NH) aligns with health system equity goals and commitments, and to identify challenges and opportunities to improve the equitable integration of the role. Specifically, this research assesses the alignment between health system equity objectives and the integration of the IPN 9 role, focusing on the coherence between stated commitments and actual integration processes. The study focuses on IH and NH as they share key structural and operational similarities, making them ideal for comparative analysis (Canadian Public Health Association [CPHA], 2022). Both IH and NH serve vast, rural, and remote regions with significant Indigenous populations, where access to culturally appropriate healthcare remains a challenge (CPHA, 2022). Furthermore, both health authorities have equity goals and commitments that prioritize improving service for Indigenous Peoples, making it essential to assess how they are integrating the IPN role (IH, 2022; NH, 2025). This demographic selection of health authorities is also relevant due to my situatedness in the Interior of BC and my employment within IH, where I hold a position that focuses explicitly on improving health system services for Indigenous Peoples. Both my location and area of work offer valuable insights into the process, providing an insider's perspective on the integration of the IPN role. Including NH in this study allows for a broader understanding of the promising practices and barriers influencing IPN role implementation across different yet comparable health authorities, strengthening recommendations for improving role integration across BC's health authorities. This study does not include the remaining BC health authoritiesâVancouver Coastal Health (VCH), Island Health (VIHA), Fraser Health (FH), and the First Nations Health Authority (FNHA)âdue to key differences in geographic scope, population demographics, and health system structures (CPHA, 2022). The three health authorities â VCH, VIHA, and FH â primarily serve densely populated urban and suburban regions, where models for delivering services, resource allocation, and Indigenous-specific roles differ from those in IH and NH, which manage vast rural and remote areas (CPHA, 2022). While uniquely responsible for Indigenous health services in BC, FNHA operates independently from the regional health authorities and follows a distinct governance model centered on First Nations-led decision-making (CPHA, 2022). As a result, the FNHA does not have a direct function in integrating Indigenous-specific positions, such as IPNs, as it does not hire into these roles (FNHA, 2020). Instead, the FNHA focuses on guiding service delivery rather than role integration (FNHA, 2020). Subsequently, the 10 FNHA's responsibility for integrating Indigenous-specific roles, including navigators, differs from the integration processes within IH and NH, making it less comparable within the scope of this study. By concentrating on IH and NHâtwo comparable health authorities with vast regional geographies, relatively fewer large urban centres, and many First Nation communities that often face longer travel distances to access careâthis study offers a focused analysis of IPN role integration, framing these authorities as comparable contexts that have the potential to provide insights that resonate beyond these settings. 1.2.3. Research aims and objectives. Whereas the research problem focuses on the integration challenges of the IPN role within IH and NH, the research aim is to identify factors that facilitate or hinder the equitable integration of the IPN role and to provide recommendations for strengthening its implementation. This research also aims to examine how the operationalization of IPN integration can align more effectively with broader organizational equity goals, ensuring a relevant and sustainable approach to meeting the healthcare service needs of Indigenous Peoples. By examining key aspects related to integration processes, equity, and organizational alignment, this research aims to critically analyze the IPN role integration to identify opportunities for improvement while simultaneously providing a practical way to advance equity within IH and NH. To this end, the overarching research question guiding this study is: How is the integration of the IPN role within IH and NH conducted, and is the process equitable and coherent with equity commitments and goals that the health systems claim to uphold and advance? The research objectives are: 1. To identify the key promising practices and barriers influencing the integration of the IPN role within IH and NH systems. 2. To compare the integration of the IPN role with the integration processes of other specialist healthcare roles, such as the PEPPA and the PEPPA Plus for the APN, to identify similarities and differences. 11 3. To examine the worldview present in the integration of the IPN role in the IH and NH, and its influence on the integration process. 4. To examine alignment between articulated equity commitments and goals in IH and NH policies, strategies, plans, and processes related to the integration of the IPN role. Through these questions and the application of an equity perspective, the research will generate recommendations for improvement that will contribute to advancing equity within health systems while also supporting the effective integration of Indigenous-specific healthcare roles. 1.2.4. Significance The significance of this study lies in its potential to improve the integration of the IPN role within health systems, specifically IH and NH, in alignment with their equity policies. By critically evaluating the integration of IPN roles within these health authorities, the research will provide valuable insights into the barriers and promising practices of equitable integration. The findings will contribute to the development of actionable recommendations that not only enhance the IPN role's integration but also promote broader equity goals within healthcare systems. This work is essential because it helps address the historical and ongoing healthcare disparities faced by Indigenous populations, cultivating a more culturally safe, responsive, and inclusive healthcare environment. The research will support the advancement of reconciliation and improve health outcomes for Indigenous peoples by emphasizing the importance of effectively integrating Indigenous healthcare roles within health systems. 1.2.5. Scope and definitions of terms For this study, "Indigenous" refers to an expansive range of ethnic people, including but not limited to First Nations, Inuit, Métis, Aboriginal, Native American, Indian, Torres Strait Islander, Indigenous Australian, and Tribal peoples (United Nations Permanent Forum on Indigenous Issues, n.d.). This ethnic group reference acknowledges the rich global diversity of Indigenous identities, histories, and governance structures (United Nations Permanent Forum on Indigenous Issues, n.d.). Similarly, the term 12 "IPN" is used as an umbrella term to represent a variety of Indigenous-specific healthcare roles, such as Patient Navigator, Patient Advocate, Health Navigator, Cultural Liaison, and Care Coordinator. While these roles differ across organizations, they all aim to improve access to health services, support system navigation, enhance cultural safety, and coordinate services for Indigenous Peoples (Hiscock et al., 2022; Rankin et al., 2020). IPNs work across urban, rural, and remote settings, including both tertiary and community-based healthcare environments. They often support First Nations Peoples accessing care outside their home communities, or Indigenous Peoples accessing care in larger urban hospitals and community health centres (Hiscock et al., 2022; Rankin et al., 2022). This research examines the IPN role integration by IH and NH, assessing the alignment of implementation characteristics with organizational equity goals and broader commitments to Indigenous health equity. In this study, "integration" refers to the process of embedding the IPN role with health systems. For this studyâs literature review, âpromising practicesâ refers to facilitators of the IPN role integration, which are any strategies, approaches, or beneficial recommendations identified in the literature that effectively support successful integration. Conversely, "barriers" refers to systemic obstacles that hinder equity-based implementation. The concepts of âequity goals" and "commitments" refer to the formal policies, strategies, principles, and actions adopted by health systems to address and rectify health disparities experienced by marginalized populations (IH, 2022; NH, 2025). These equity goals and commitments prioritize fairness, inclusivity, and culturally safe care, aiming to reduce systemic barriers and improve health outcomes for Indigenous peoples (IH, 2022; NH, 2025). They also encompass broader commitments to reconciliation and self-determination, ensuring that Indigenous knowledge, practices, and perspectives are central in shaping Indigenous healthcare delivery and policies (IH, 2022; NH, 2025). Systematic Equity Action Analysis (SEAA) is a structured approach that supports analysis of systemic inequities, including identification of barriers, and reveals opportunities for aligning initiatives with broader equity goals and commitments (Plamondon et al., 2023). The framework draws upon critical theory and systems thinking to evaluate how policies, practices, and organizational structures either 13 promote or hinder health equity (Plamondon et al., 2023). This framework approach makes it a relevant choice for this research, which involves a comprehensive analysis of the integration of the IPN role at both structural and operational levels within health systems, focusing on the worldview and coherence elements of SEAAâcore elements of the equity-advancing framework (Plamondon et al., 2023) (described in more detail in Chapter 3). Additionally, using SEAA helps health systems align their operationalization processes and practices, such as the integration of the IPN role, with their equity policies and commitments (Plamondon et al., 2023), a complex task where blending of Western biomedical models and Indigenous worldviews is particularly challenging for health systems (Priest & Lockett, 2020). 1.2.6. Guiding philosophy, worldview, and theoretical framework. This research is grounded in Indigenous worldviews and the philosophy of interconnectedness, which stresses the importance of understanding the relational context (Wilson, 2019) that shapes whether a phenomenon thrives or struggles (Smith, 1999). By adopting a decolonial approach, this study examines systemic equity through a critical analysis of the impact of colonial power structures on the uptake and integration of Indigenous knowledges. This research focuses on how colonial constructs within health systems affect equity advancing initiatives, such as the integration of the IPN role. The insights provided will help identify the promising practices and barriers that influence how mainstream health systems either support or marginalize Indigenous-specific roles. Furthermore, guided by the SEAA, the evaluation will assess whether the IPN role aligns with the equity objectives outlined in IH and NH policies and evaluate the effectiveness of strategies for integration, sustainability, and role evaluation in supporting these objectives. Grounded in a philosophy of interconnectedness, an Indigenous worldview, and the SEAA theoretical framework, this study seeks to offer actionable recommendations for enhancing the equitable integration of the IPN role, thereby helping health systems fulfill their equity goals and commitments. 14 1.3. Positionality Statement 1.3.1. Indigenous health system leader. As an Indigenous health system leader within IH, my positionality is rooted in both my lived experiences and professional responsibilities. I possess firsthand lived experience, which I consistently apply to initiatives aimed at strengthening the integration and impact of the IPN roles I support. As a result of my leadership role, I can closely examine the unjust aspects of health systems and utilize my position to advocate for meaningful and positive changes. With a deep involvement in health system planning and policymaking, I am well-placed to navigate organizational complexities and drive initiatives that advance equity. I also acknowledge the complexities and challenges of existing within a Western healthcare system while simultaneously promoting Indigenous ways of knowing and healing in care services. This awareness enriches my approach, allowing me to challenge colonial system approaches while advocating for the integration of Indigenous knowledge within mainstream healthcare. Moreover, I am determined to ensure that Indigenous-specific health roles, such as the IPNs, are positioned not only as contributors but also as leaders in shaping healthcare policies that are responsive to the needs of Indigenous Peoples. Ultimately, my engagement with healthcare teams at various levels enables me to propose practical solutions, ensuring that recommendations for change are relevant, achievable, and meaningful. This positionality drives my passion for creating systemic transformation, from individual roles to organizational structures, in a way that is both respectful and empowering for Indigenous Peoples, families, communities, and populations. 1.3.2. Indigenous healthcare provider. As a Registered Nurse with Indigenous ancestry, my experience providing care within health systems gives me a deep understanding of the barriers and challenges Indigenous Peoples face. I have firsthand knowledge of the challenges Indigenous patients face in accessing culturally safe and equitable care, as well as the systemic issues that affect Indigenous healthcare workers. Both of these unique 15 experiences allow me to critically analyze the health system's shortcomings and approach the integration of Indigenous-specific healthcare roles from a place of empathy, understanding, and professional insight. My advocacy journey for culturally relevant, equitable, and decolonized healthcare practices strengthens my determination to improve the effectiveness of Indigenous healthcare roles, including the IPN. My unique professional experience enables me to offer culturally informed and strategically sound recommendations. By integrating my cultural knowledge with my professional expertise, I can adapt effectively to contribute to the decolonization of health systems and promote equitable and culturally safe integration practices for Indigenous-specific healthcare roles. 1.3.3. Indigenous person. As an Indigenous person, I possess a lived experience of navigating colonization and healing from its profound impacts.. My family has a long line of residential school attendees, and although I am the first generation not to attend, the intergenerational trauma of colonization profoundly shaped me. I grew up facing cultural erasure, separation from my community and homelands, and the reality that the reservation was not a safe place to exist or thriveâconditions created by assimilation policies. As a child, I experienced the âwhitewashingâ of my identity, carrying a deep sense of disconnection I could not yet name. Later, I began a personal journey of decolonization, driven by an intuitive need to reconnect with my culture and community. Through this journey, I came to understand the importance of being connected to my people and their teachings. Having lived through decolonization, I know firsthand the challenges of reclaiming identity and healing from imposed disconnection. These experiences strengthen my capacity to support others on similar paths and to help health systems move toward decolonizing practices that create space for Indigenous peoples to thrive. I intuitively perceive the world as a woven tapestry where all things are interconnected (Wilson, 2019). This understanding shapes my perspective on the importance of alignment and harmony in developing thriving systems and relationships. My blood memory, a knowledge source passed down by 16 my ancestors, allows me to draw from ancient wisdom that has guided the interactions of people, land, and spirit since time immemorial (Weber-Pillwax, 1999). This deep wealth of knowledge serves as a compass, offering valuable insights and guidance as I navigate both the challenges and opportunities in working toward decolonizing health systems. I believe that by honoring the wisdom embedded in these connections, I can advocate for and support the creation of healthcare systems that are not only responsive but also reflective of the needs and values of Indigenous peoples. My work is grounded in this worldview, where every action is considered in relation to how it can strengthen the web of connections between individuals, communities, and systems, ensuring that they thrive in a sustainable and culturally safe way. My positionality as an Indigenous health system leader, Registered Nurse, and person of distinct identity positions me to study the integration of the IPN role into health systems. My leadership and professional nursing experience enable me to critically examine the promising practices and barriers impacting the integration process. At the same time, my Indigenous personhood and lived experiences provide invaluable sources of knowledge and insights (Weber-Pillwax, 1999), both conceptualized by me and all my ancestors. With my combined perspectives and positional situatedness, I can approach this research with a holistic and informed lens, making me well-suited to explore this crucial topic. 1.4. Thesis Organization The following chapters will provide a structured analysis of the research problem, including an outline of the theoretical and empirical foundations necessary to assess the equitable integration of the IH and NH IPN roles. Chapter Two (Literature Review) will critically examine three key areas: (1) equity in health system policy, exploring theoretical frameworks and policy commitments related to equity; (2) challenges to the integration of Indigenous-specific roles in healthcare, identifying barriers at structural and operational levels linked to colonial health system structures; and (3) promising practices for role integration, highlighting models and frameworks that support the successful implementation of Indigenous-specific positions. Chapter Three (Methods) will detail the SEAA research design, including its qualitative approach, which utilizes content analysis guided by Critical Indigenous Theory (CIT). This 17 study will also outline the research philosophy, worldview, data sources, collection methods, and analytical techniques, ensuring a rigorous approach to understanding how health equity policies and organizational structures influence the integration of IPN roles. Together, these chapters will lay a foundation for assessing the alignment between IPN role integration and equity goals and commitments, and for generating informed recommendations to enhance health system policy, strategy, plans, and practices. Chapters Four to Six will present the research results, providing a comprehensive analysis of the collected data and offering insights into the integration of the IPN role within IH and NH health systems. Chapter Four will (Findings/Results) outline the research data, presenting the key outcomes without interpretation and providing a clear description of the observed evidence. Chapter Five (Discussion) will interpret the findings in relation to the research questions and the existing literature, highlighting key trends, contrasts, and implications for integrating IPN roles. Finally, Chapter Six (Conclusion) will summarize the study's key findings, discuss their broader implications for policy and practice, acknowledge the study's strengths and limitations, and propose possibilities for transforming health systems by advancing the equitable integration of the IPN role. Additionally, the study will conclude by providing recommendations to health system leadership on how to enhance the equitable integration of the IPN role within IH and NH, offering a comprehensive reflection on the role of health equity in the successful integration of Indigenous-specific healthcare positions. 18 2. Chapter Two: Exploratory Review of Literature Chapter Two presents the foundation for this research by describing key theoretical frameworks, defining relevant concepts, and providing a historical and contextual background. It begins with an overview of the Participatory Evidence-based, Patient-focused Process for Advanced Practice Nursing (PEPPA) and PEPPA Plus frameworks, which offer structured approaches to role integration and equity analysis in health systems. This chapter also explores the Systematic Equity-action Analysis (SEAA) framework, which serves as the theoretical foundation for this research. It assesses how health systems embed equity in their practices, particularly in Indigenous-specific roles such as the Indigenous Patient Navigator (IPN), and how these processes align with broader health equity goals and commitments. To deepen the analysis, this chapter also situates the PEPPA, PEPPA, and SEAA frameworks within the broader Indigenous healthcare landscape, grounding them in historical and contextual understandings. To build on this foundation, this study synthesizes existing research across three key areas: (1) Indigenous health equity policies, (2) the Indigenous Patient Navigator (IPN) role, and (3) promising practices and barriers for role integration. This synthesis enables a critical examination of the equity policy landscape shaping the IPN role and analyzes the systemic conditions within health systems that impact its integration. Finally, this chapter identifies shortcomings in the literature, identifying areas that require further investigation to advance understanding and inform future research. Chapter Two is structured as follows: first, an examination of the applicable theoretical and conceptual frameworks, which include the PEPPA, PEPPA Plus, and SEAA; second, a review of the historical and contextual background; third, an analysis of literature findings on the areas of (1) Indigenous equity policies and strategies and (2), the IPN role in health systems; and finally (3), limitations in the literature, before offering a conclusion to this chapter. 19 2.1. Participatory, Evidence-based, Patient-focused Process for Advanced Practice Nurse More than 16 countries worldwide successfully use the PEPPA and PEPPA Plus frameworks to support the integration of complex nursing roles (Bryant-Lukosius et al., 2016). These frameworks play a crucial role in integrating specialty nursing roles across various healthcare settings, including primary care, family practice, hospitals, long-term and home services, as well as transitional and outpatient care, to address the unmet needs of specific patient populations (Staples et al., 2020). To date, the use of the PEPPA and PEPPA Plus frameworks to support the integration of specialized Indigenous roles, such as the IPN, has not been explored. This chapter examines how the PEPPA and PEPPA Plus frameworks can support IPN integration, providing valuable insights into improving the integration process. 2.2. Systematic Equity Action-Analysis The SEAA framework, developed by Plamondon et al. (2023), is an emerging tool designed to translate equity research into actionable steps for leaders, teams, and communities. The SEAA provides a structured approach to identifying and addressing systemic inequities by examining power dynamics, worldview, coherence, and institutional accountability (Plamondon et al., 2023). By emphasizing the integration of multiple perspectives, including Indigenous worldviews, the SEAA provides a valuable framework for assessing equity in health systems (Plamondon et al., 2023). This research applies the SEAA to analyze the integration of the IPN role within British Columbiaâs (BCâs) health systems. Section 3.4.1., Systematic Equity-Action Analysis: A Theoretically Grounded Approach to Research provides a more detailed discussion of the framework. 2.3. Historical and Contextual Background A comprehensive understanding of the historical and contextual factors shaping the integration of the IPN role in BCâs health systems strengthens this study. Historical events have created enduring structures and practices within health systems, and recognizing their impact enables a deeper analysis of current 20 challenges and opportunities (Davies, 2022). Examining history reveals how health system assimilation policies and practices developed over time, exposing patterns that can inform future equitable approaches to health system transformation (Davies, 2022). Moreover, contextual factors, including cultural, political, social, and institutional elements, directly influence the design and implementation of health interventions (Davies, 2022). By analyzing the historical and contextual background of BCâs Indigenous healthcare landscape, this study identifies both effective practices and past harms, offering beneficial insights to improve health services for Indigenous Peoples. 2.3.1. Indigenous healthcare landscape. An "Indigenous healthcare landscape" refers to the distinct environment where Indigenous people access, experience, and receive healthcare (Greenwood et al., 2018). These landscapes include not only formal health services, such as hospitals, clinics, and healthcare providers, but also the social, cultural, and historical factors that influence health outcomes (Greenwood et al., 2018). As Greenwood, de Leeuw, and Lindsay (2018) argue, societyâs systems and the dominant ways of thinking within institutions influence these formal, social, and cultural factors, shaping how people experience healthcare. As perspectives shift toward reconciliation, there is a realization that BCâs Indigenous healthcare landscape, heavily dominated by Western Eurocentric worldviews, marginalizes Indigenous health and wellness views and perspectives (Caron, 2020; Smith, 1999). 2.3.1.1. Historical healthcare landscape for Indigenous peoples. Understanding the historical foundations of colonial legislation is essential for recognizing its lasting impact on Indigenous healthcare (Caron, 2020). Rooted in Western Eurocentric worldviewsâcharacterized by colonial rationalism, capitalism, and imperial thought (Caron, 2020)âthese legislations aimed to assimilate and subjugate Indigenous peoples, systematically disrupting their social, economic, and cultural lives (Wylie et al., 2019). For example, the Indian Act (RSC, 1985) is a Canadian federal act that governs Indigenous identity, rights, and lands, while also regulating band governance, reserve 21 management, access to federal programs, and, historically, education, health services, and cultural practices. Designed initially to enforce assimilation, cultural erasure, and control, the Indian Act (RSC, 1985) continues to undermine Indigenous rights and sovereignty (Davies, 2022), shaping health outcomes and perpetuating systemic inequities (Wylie et al., 2019) Colonial ideologies, embedded in historical Canadian legislation, persist in exerting a powerful influence on contemporary healthcare systems, reinforcing structural barriers and cultural insensitivity that contribute to ongoing Indigenous Peoples' poorer health outcomes (Caron, 2020). Acknowledging these historical legislations and their ongoing impact is crucial for transformative health system change, particularly change that addresses systemic inequities while centering Indigenous self-determination and culturally safe care (Wylie et al., 2019). Therefore, this portion of this study critically analyzes how Canadian legislation marginalizes Indigenous Peoples and shapes health systems that remain disconnected from their traditional ways of knowing and being in health and healing (Caron, 2020). By examining the impact of historical legislation on Indigenous Peoples and their health, this section of Chapter Two sets the stage for understanding how colonial worldviews continue to dominate BCâs health systems (Davies, 2022). In Canada, Western worldviews have historically driven the creation and enforcement of laws designed to assimilate and control Indigenous peoples (Caron, 2020). At both the federal and provincial levels, key government bodiesâsuch as the Department of Indian Affairs (established in 1755)âand legislation like the Gradual Civilization Act (1857), the Gradual Enfranchisement Act (1869), and the Indian Act (RSC. 1985) institutionalized themes of land dispossession, cultural erasure, and forced assimilation (Caron, 2019; Government of Canada, 2018; Crown-Indigenous Relations and Northern Affairs Canada [CRNAC], 2018). Through the service of the Department of Indian Affairs, these acts undermined Indigenous governance, sovereignty, and identity, embedding colonial control into every aspect of life, including healthcare (Caron, 2019; Government of Canada, CRNAC, 2018). Building on the previous examples, additional legislation, reports, and policiesâincluding the Indian Advancement Act (1884), amendments to the Indian Act (RSC. 1985), the Report on Industrial 22 Schools for Indians and Half-Breeds (Davin, 1879), Sir John A. Macdonald's Policy of Assimilation (Macdonald, 1883), and the White Paper (Canada. Department of Indian Affairs and Northern Development [Canada. DIAND], 1969)âfurther entrenched assimilation, cultural suppression, economic marginalization, and systemic inequities (Truth and Reconciliation Commission [TRC] of Canada, 2015a). The Western Eurocentric worldview underlying these legislative acts laid the groundwork for the ongoing marginalization of Indigenous peoples through dismantling their social, political, and cultural structures (Davies, 2022). These mechanisms of controlâsuch as imposing Indian status (Caron, 2020), creating reserves (Wylie et al., 2019), facilitating land dispossession (Davies, 2022), and enabling cultural genocide through residential schools (TRC of Canada, 2015a)- affected all of Canadaâs Indigenous Peoples in profound ways. First Nation Peoples, for example, were forcibly relocated onto reserves, often on poor-quality land, which restricted access to traditional territories, resources, and cultural practices (Caron, 2020). Additionally, the imposition of band councils under the Indian Act replaced traditional leadership structures, disrupting social and political systems and limiting self-determination (Caron, 2020; Wylie et al., 2019). Inuit Peoples experienced forced relocation from Port Harrison (now Inukjuak) to the High Arctic in the 1950s, resulting in service hardship and cultural dislocation (Guido, 2022). Métis Peoples also faced dispossession through the Manitoba Act (1870), which failed to deliver promised land, undermining their traditional livelihood and overall health. Collectively, these policies and practices influenced institutions, including healthcare systems, embedding colonial ideologies and structural inequities that continue to impact all of Canadaâs Indigenous Peoples today (Davies, 2022). As colonial Western Eurocentric governance took hold and assimilation-focused legislation was enacted, health-related acts, policies, and service delivery models were also introduced, marking the initial shaping of healthcare services for Indigenous Peoples (Caron, 2020; Lux, 2010). For instance, the establishment of racially segregated Indian hospitals, beginning in the 1920s, subjected Indigenous Peoples to substandard care and unethical medical practices, which not only worsened Indigenous health outcomes but also developed mistrust in health systems (Caron, 2020; Lux, 2010). 23 The division of jurisdiction between federal and provincial governments in Canada, established by the Constitution Act (1867), also contributes to Indigenous health disparities (Caron, 2020). Operating separately, federal programs (such as the First Nation and Inuit Health Branch) and provincial health systems result in fragmented and poorly coordinated services (Reading & Wien, 2009). This division of operation and responsibility forces Indigenous Peoples to navigate multiple, overlapping systems, resulting in a lack of services and shortcomings in care due to confusion over which level of government is responsible for funding and providing services (Greenwood et al., 2018). A prominent example of the harm caused by jurisdictional disputes is the 1999 case of Jordan River Anderson, an Indigenous child with chronic illness whose family wanted him to receive end-of-life care in his community (First Nation Child and Family Caring Society, n.d). However, Jordan died in a hospital after being denied home care due to government disagreements over who should pay for his health services when he was residing in his home community (First Nation Child and Family Caring Society, n.d). Similar jurisdictional confusion and disputes also affected Métis and Non-Status First Nations, who were not legally recognized under federal responsibilities until the Daniels Decision (Daniels v. Canada, 2016). Until those rulings, provinces and the federal government had disputed responsibility for their care for decades, resulting in shortcomings in health services that negatively impacted their health and well-being (McCarthy Tétrault LLP, n.d.). In the 1940s and 1950s, Canadian authorities forced Indigenous children into residential schools where they endured racism, discrimination, cultural erasure, and unethical treatment, including starvation levels of nutrition (Mosby, 2013). Between 1942 and 1946, under the direction of two physicians, the Department of Indian Affairs conducted government-sanctioned, highly unethical experiments where malnourished children were denied adequate nutrition (Mosby, 2013). Without parental consent, researchers manipulated the children's diets to study the effects of malnutrition (Mosby, 2013). These experiments worsened the childrenâs already fragile health, causing additional suffering and, in some cases, death (Mosby, 2013). Although researchers conducted this experimental study to improve the 24 health and nutrition of Canadian citizens through the development of the Canadian Food Guide, it inflicted profound harm on Indigenous children (Mosby, 2013). The traumatic impact of these government-supported medical research experiments endures (Lux, 2010; Lux, 2016). Beyond causing physical, emotional, mental, and psychosocial harm to the children, these practices increased mistrust among Indigenous Peoples toward health systems and medical research (Mosby, 2013). The experiments, conducted under the guise of research, violated fundamental ethical principles and human rights, including the requirement of informed consent and the protection of vulnerable populations (Mosby, 2013). This legacy of exploitation and abuse continues to fuel historical trauma and contributes to the ongoing health disparities of Indigenous Peoples (Lux, 2010; Lux, 2016). More recently, health practitioners and medical institutions have violated Indigenous human and health rights through forced or coerced sterilization, intentionally sterilizing individuals with a uterus to prevent them from having (or having more) Indigenous children (Leason, 2021). Alberta was the first province to pass a Sexual Sterilization Act in 1928, with BC following in 1933. Both acts were not repealed until 1972 and 1973, allowing for four decades of Indigenous healthcare abuse and human rights violations (Leason, 2021). Collectively, the mistrust created by these unethical acts of legislation persists across generations, further deterring Indigenous Peoples from healthcare systems and hindering efforts to address health inequities (Leason, 2021). Throughout Canada, including BC, health systems prioritize Western Eurocentric biomedical models over Indigenous health approaches and healing practices (Redvers et al., 2019). These imposed health system models fail to address the lasting impacts of colonization on Indigenous health (Redvers et al., 2019). The continued dominance of the Western Eurocentric worldview within provincial and federal health systems and legislation perpetuates systemic inequities and cultural insensitivity in healthcare services (Caron, 2020). Given the historical, societal, and political foundations that shaped early assimilated Canada, it is unsurprising that both past and present health systems continue to meet Indigenous health needs inadequately. 25 2.3.1.2. Current Indigenous health system challenges. This section examines the contemporary challenges within the Indigenous healthcare landscape, focusing on exclusionary practices that marginalize or omit Indigenous worldviews of health and wellness, and the emerging shifts driven by key reconciliation documents and frameworks. It explores current initiatives inspired by reconciliation frameworks that aim to address Indigenous health disparities, focusing on leadership, health, and wellness frameworks informed by Indigenous knowledge, as well as legislative acts that promote equity. Finally, it introduces the role of Indigenous-specific healthcare positions, such as the IPN, in advancing culturally safe and equitable care. The legacy of Indigenous health injustices, along with ongoing Indigenous-specific health system challenges, persists within the Indigenous healthcare landscape, as colonial biomedical worldviews continue to shape the foundation of Canada's healthcare systems (Caron, 2020). Indigenous peoples continue to experience systemic racism, discrimination, and cultural insensitivity, leading to healthcare mistreatment, mistrust, and reluctance or avoidance to seek care (Caron, 2020; Wylie et al., 2019). As a result, Indigenous peoples continue to experience disproportionately high rates of chronic diseases, mental health challenges, and lower life expectancy compared to non-Indigenous populations (First Nations Health Authority & Office of the Provincial Health Officer, 2024). 2.4. Operationalizing health systems' commitments to reconciliation The TRC of Canada (2105a) provides a national framework for addressing the historical and ongoing harms experienced by Indigenous Peoples. It documents the history and lasting impacts of the legislatively enforced assimilation and cultural genocide of Indigenous peoples in Canada, acknowledging the harm this caused (TRC of Canada, 2015a). It also promotes healing through 94 Calls to Action aimed at reconciliation for Indigenous and non-Indigenous Canadians (TRC of Canada, 2015a). Health systems across Canada are increasingly acknowledging their commitments to the TRC of Canada (2015a) Calls to Action, particularly those aimed at addressing the systemic inequities, racism, 26 and discrimination faced by Indigenous Peoples engaged in health services (First Nation Health Authority [FNHA], 2021). The TRC of Canada (2015a) calls on health system leaders to advance reconciliation by removing barriers and taking meaningful steps to enhance Indigenous Peoplesâ access to culturally safe care. Unfortunately, while health authorities frequently document reconciliation commitments in their policies, strategies, and plans, these efforts remain fragmented and varied across systems (Lavoie, 2018). Research consistently describes the harms of anti-Indigenous racism within health systems, where Indigenous Peoples experience inequities in care, ranging from neglect and stereotyping to outright discrimination and racism (Browne et al., 2015). In response, researchers recommend improving healthcare providersâ cultural competency and safety through education (National Collaborating Centre for Indigenous Health [NCCIH], 2013). While programs designed to teach and raise awareness of cultural competency and safety play a critical role in shifting individual behaviors and attitudes, they fail to address the systemic and operational factors that perpetuate cultural unsafety across the health system (Browne et al., 2016; NCCIH, 2013). As a result, educating healthcare workers at an individual level remains insufficient for achieving the whole-system transformation required to advance cultural safety in healthcare. To create transformative change, interventions can address the structural and operational factors embedded in health organizations (Browne et al., 2016). Addressing structural and operational factors includes implementing anti-racism policies, transforming organizational practices, and ensuring Indigenous governance in decision-making (Davies, 2022). By taking these actions, healthcare systems can provide culturally safe care while cultivating environments where Indigenous Peoples are respected and their voices actively inform healthcare service delivery (Davies, 2022). Together, these historical and contemporary factors demonstrate how colonial legacies continue to impact the Indigenous healthcare landscape in BC (Browne et al., 2016). Recognizing these influences drives the need for systemic reforms and the prioritization of culturally safe practices that integrate Indigenous knowledges and perspectives on health, wellness, and healing (Government of British Columbia, 2020). Building on this understanding, this study next examines present-day initiatives, 27 including Indigenous health equity policies, strategies, and plans, as well as Indigenous-specific healthcare roles, such as the IPNs, that aim to advance cultural safety and equitable healthcare outcomes for Indigenous Peoples (Rankin et al., 2022). 2.5. Literature Search: Indigenous Health Equity Policies, Strategies, and Plans and the IPN Role in Health Systems. The literature search for this study yielded a comprehensive collection of research on integrating the IPN role into health systems. The search identified articles that examine key factors influencing the integration of the IPN role within health systems and organizes them into two thematic areas for clarity. â¢ Area One: Indigenous Equity Policies, Strategies, and Plans in Health Systems. â¢ Area two: IPN role in health systems. Together, these areas provide the foundation for understanding the factors that influence the integration of IPN roles and their alignment with equity policies. This search and subsequent review support an examination of how health systems operationalize their health equity policies and commitments, assessing the extent to which key reconciliation recommendations translate into meaningful systemic change. By identifying areas of shortcomings between equity policy, strategy, and plan intentions and implementation, this research provides a critical analysis of the IPN role integration, promising practices, and barriers. The findings help guide the creation of practical ways to integrate IPNs into health systems more fairly and effectively. 2.5.1. Indigenous equity policies, strategies, and plans in health systems. 2.5.1.1. Search parameters and results. The studyâs literature search targeted research on Indigenous equity policies and strategies, focusing on how policies and/or strategies align with practices within health systems. The academic databases of Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE were 28 searched to identify relevant scholarly articles. Table 1 presents the core research topics and key search terms employed in this literature review. Table 1: Core Research Topics and Key Search Terms Core Research Topics Key Search Terms Indigenous Populations "Aboriginal," "First Nations," "Inuit," "Indian," "Native American," "Metis," "Torres Strait Islanders," "Indigenous Australian," "Tribal" Equity Policies or Strategies "Equity policy*," "Equity strategy*" Health Systems "Health system," "Health services," "Healthcare," Note. Search terms were selected based on relevance to equity and Indigenous healthcare systems in Canada, the USA, Australia, and New Zealand. The search followed specific inclusion criteria, such as publication date range, language, geographic focus, and a particular selection rationale that accounted for the final total number of relevant articles reviewed. Refer to Table 2. Table 2 Literature Search Article Selection Parameters Criteria Inclusion Details Publication Date 2014-2025 Language English Geographic Focus USA, Canada, Australia, New Zealand 29 Criteria Inclusion Details Rationale for Geographic Focus Shared impact of colonization on Indigenous health outcomes. Total Articles 49 articles for title and abstract review. Note. This table outlines the parameters used for selecting articles included in the study. Articles were excluded if they focused on concrete tools to enhance equity rather than overarching equity policies or strategies, or if they did not discuss coherence in the context of health systems and Indigenous equity. Articles related to COVID-19 vaccination were excluded unless they specifically addressed equity policy and coherence within health system equity, health policy, or equity policies. Of the 49 results initially identified, 19 articles advanced to full-text review. During the full-text review, three articles were excluded because they did not focus on coherence or Indigenous equity policy, strategies, or plans. In contrast, one article was added due to its relevance as a follow-up study because it also offered new findings related to Indigenous equity policies and strategies in health systems. Overall, this search strategy supported the inclusion of focused literature that directly informed Indigenous equity policies and strategies within health systems. 2.5.2. IPN Role in health systems. 2.5.2.1. Search parameters and results. Another structured literature search was conducted using the CINAHL and MEDLINE databases to identify peer-reviewed studies and academic dissertations that examine the role of IPNs and similarly described roles within healthcare systems. The search strategy incorporated Boolean search terms, including variations of Indigenous identity terms (e.g., Aboriginal, First Nations, Inuit, Native American, Métis, Torres Strait Islanders), combined with role-specific terms such as navigator, coordinator, or liaison. To ensure relevance and quality, inclusion criteria were applied, restricting the results to studies 30 with available abstracts published in English between 2014 and 2025, sourced from academic journals or dissertations. The geographical scope was once again limited to Canada, the United States, Australia, and New Zealand, as these countries share histories of colonization and systemic health inequities affecting Indigenous populations (Wispelwey et al., 2023). Additionally, these nations have implemented Indigenous-specific health policies and programs, including IPN roles or similar positions, making them relevant for explorative analysis. Regions with differing colonial healthcare structures or without comparable Indigenous-specific navigation roles were excluded due to variations in system organization and the presence or absence of such Indigenous-specific navigation roles. The initial search yielded 253 articles, which were screened based on titles and abstracts. Studies were excluded if they did not explicitly refer to an IPN or a role similar to that described within a health system. Following this, 31 articles underwent full-text review, with further exclusions applied to studies that did not specifically reference the IPN or a similarly described role within a health system or the role's capacity to impact Indigenous health patient outcomes. After these screening processes, a final selection of 29 articles met all criteria, forming the foundation for a focused examination of IPN roles within the health system impacted by colonization. 2.6. Literature analysis 2.6.1. Indigenous health equity policies, contexts, and frameworks. The inclusion of literature studies that employ a range of research approaches enhances this literature review by providing a comprehensive understanding of existing scholarship. Reviewing articles with methodological diversity supports the synthesis of the broader context on Indigenous health equity, with a particular focus on equity policies, strategies, contexts, and frameworks that influence health outcomes for Indigenous peoples. The selected articles employ a variety of methodological approaches, including analytical commentaries and cohort studies, providing diverse insights into factors influencing Indigenous health 31 equity policies and strategies, as well as the integration of the IPN role into health systems. This methodological diversity also demonstrates how different analytical lenses, such as policy analysis, intersectional analysis, or surveillance approaches, help identify the numerous factors that impact the outcomes of Indigenous health equity policies and strategies, as well as the integration of the IPN role. Notably, five of the articles focus on Australia, where researchers link Indigenous health outcomes to equity and cultural attributes (Cohcrane et al., 2024; Kelly et al., 2021; Newham et al., 2016; Sanjida et al., 2022; Schmidt et al., 2016). Australia is a leader in incorporating cultural safety into its health systems, which has significantly contributed to improved equitable health outcomes for Indigenous Australians (Williams, 1999). It is not surprising that most research on health equity policy and strategies presented through the lens of cultural safety originates from Australia, given the country's leading role in discussing cultural safety as an aspect of health systems (Williams, 1999). Todic et al. (2022) conducted a literature synthesis using critical theory to analyze cultural change in health settings. Their review identified embedded structural, operational, relational, and cultural health inequities and barriers as key inhibitors to the successful implementation of equity policies and strategies in health systems (Todic et al., 2022). Todic et al. (2022) conclude that these inequities and barriers maintain systemic inequities and limit the transformative impact of equity initiatives. Fundamentally, their findings emphasize how interconnected health system levels impact the effectiveness of equity-driven policies and strategies (Todic et al., 2022). Achieving health equity requires initiatives, policies, strategies, and plans that effectively dismantle structural barriers that perpetuate disparities in access, quality of care, and outcomes (Bailey et al., 2017; Takenaka et al., 2024). Addressing the cultural, socioeconomic, and systemic factors that influence these disparities is crucial for creating sustainable, equity-driven reforms (Belon et al., 2024; Guadagnolo et al., 2017). These factors directly affect access to care and health outcomes, underscoring the need for policies and programs that cater to the unique needs of diverse populations (Cooke et al., 2017). Without addressing these determinants, health inequities will persist, limiting the effectiveness of reforms and reinforcing systemic disparities (Cooke et al., 2017). 32 A mixed-methods study involving policy analysis by Belon et al. (2024) and a critical policy analysis by Came et al. (2016) suggests that equity can be advanced through governance-supported systemic redesign and collaboration across sectors, when combined with sustained, multi-level interventions. Haitana et al. (2012) elaborate on this by emphasizing that embedding equity-focused governance, which includes Indigenous involvement, drives structural reform to dismantle barriers within health systems. Together, the recommendations from these three groups of researchers suggest that supporting Indigenous participation in health system planning and decision-making, as well as integrating equity-responsive interventions, can improve Indigenous health outcomes (Belon et al., 2024; Came et al., 2016; Haitana et al., 2022). Strategic policy framing, advocacy, and proportionate universalismâwhich allocates resources based on geographic needs (Fisher et al., 2022)âensure that equity-focused policies and strategies are practical and directed toward the health system areas with the most significant patient population needs (Baum et al., 2021; Burrage et al., 2024). Furthermore, sustainable funding, effective executive leadership, and data-driven decision-making are essential for optimizing resource allocation and implementing equity policies and strategies effectively (Agénor et al., 2021; Haitana et al., 2022; Lyle et al., 2017). These elements provide the financial stability, institutional commitment, and analytical insights necessary to address health disparities (Agénor et al., 2021; Lyle et al., 2017). Together, these interconnected strategies emphasize the importance of a culturally inclusive and well-supported approach to achieving health equity goals (Lyle et al., 2017; Uwuseba, 2025). Operational-level promising practices aim to enhance equitable healthcare delivery to Indigenous populations through culturally informed and context-specific services (Guadagnolo et al., 2017; Belon et al., 2024; Lyle et al., 2017; Fisher et al., 2021). Tailoring care to meet the unique needs of Indigenous communities, particularly in rural and remote areas, ensures equitable access (Cooke et al., 2017; Lyle et al., 2017). Continuous training in cultural competence and enhancing interdisciplinary collaboration creates a culturally safer environment where healthcare workers provide care that respects Indigenous Peoplesâ values and improves care effectiveness and patient engagement. (Lyle et al., 2017; Uwuseba, 33 2025). Collaboration within healthcare teams, investment in the Indigenous healthcare workforce, and evaluation of service models further improve care delivery (Burrage et al., 2024; Lyle et al., 2017; Uwuseba, 2025). Effective internal interdisciplinary communication strategies, resource allocation, and culturally tailored client interventions ensure that services are relevant and meet the equity needs of Indigenous people (Lyle et al., 2017; Uwuseba, 2025). Collectively, these operational promising practices enhance cultural safety, strengthen Indigenous workforce capacity, and tailor services to community needs, ultimately improving healthcare access and outcomes for Indigenous populations (Lyle et al., 2017; Burrage et al., 2024; Cooke et al., 2017). Two research studies on culturally responsive relationships and enhancing health equity in the Indigenous population stress the importance of relational-level promising practices in achieving equity policy and strategy goals (Cooke et al., 2013; Browne et al., 2016). These studies, which address the relational level of health systems, emphasize the need for active community involvement, ensuring that Indigenous Peoples, particularly those most affected by inequities, are meaningfully engaged in designing, integrating, and evaluating health services (Cooke et al., 2013; Browne et al., 2016). Additionally, investing in Indigenous leadership within health systems is crucial, as it drives culturally appropriate and equitable interventions (Burrage et al., 2024). Moreover, equitable partnerships between health systems and Indigenous communities promote inclusion, self-determination, and sustainable health improvements (Burrage et al., 2024; Haitana et al., 2022). By cultivating culturally appropriate care and addressing systemic inequities, these partnerships support long-term advancements in equity (Haitana et al., 2022). Priest & Lockett (2020) describe key cultural-level promising practices for achieving equity goals as involving embedding Indigenous values, practices, and worldviews into health systems. They argue that integrating Indigenous perspectives and practices promotes culturally relevant care, cultivates trust, and enhances the effectiveness of health interventions by aligning services with the unique needs and strengths of Indigenous populations (Priest & Lockett, 2020). In addition, tailoring services and health 34 system messaging to be culturally and linguistically appropriate further strengthens trust and engagement between diverse Indigenous communities and partnering organizations (Burrage et al., 2024). Understanding Indigenous health and wellness strengths and health service needs enables the development of culturally relevant equity strategies and interventions that improve both Indigenous health outcomes and community engagement (Burrage et al., 2024). Leveraging Indigenous-led organizations and community support further strengthens service delivery and promotes cultural safety, ensuring that healthcare aligns with Indigenous values and enhances the effectiveness of interventions (Cooke et al., 2017). By adapting strategies to local cultural and contextual needs, health systems can better address inequities and promote equitable outcomes for Indigenous Peoples (Lyle et al., 2017). In summary, the literature reviewed for this portion of the study indicates that research on equity policies and strategies in health systems identifies numerous promising practices that contribute to the operationalization of equity, subsequently improving Indigenous health outcomes (Belon et al., 2024; Cooke et al., 2017; Guadagnolo et al., 2017). The insights from this first part of the literature review emphasize the importance of identifying and leveraging effective practices that already show positive results (Came et al., 2016; Priest & Lockett, 2020). Promoting such working strategies is essential for advancing equity in healthcare and ensuring that future policy and strategy commitments are impactful (Baum et al., 2021; Fisher et al., 2022; Haitana et al., 2022). By focusing on proven approaches, health systems can drive meaningful, long-term improvements in equity and address persistent systemic inequities affecting marginalized populations (Lyle et al., 2017; Burrage et al., 2024). 2.6.2. IPN Role in Health Systems 2.6.2.1. Patient, family, and community perspectives of the IPN. To assess the integration and impact of the IPN role within healthcare systems, it is essential to consider the perspectives of Indigenous patients, families, communities, IPNs, and healthcare providers (Issacson et al., 2023; Orr et al., 2022). Understanding these viewpoints facilitates the evaluation of the 35 role's effectiveness and identifies areas for system improvement (Issacson et al., 2023; Orr et al., 2022). By exploring these various perspectives, the studies reveal both the successes and challenges of the role, providing insights into how patients, IPNs, and interprofessional healthcare teams perceive the role (Cochrane et al., 2024; Groot et al., 2024). Adopting a bottom-up perspective challenges colonial structures that often impose top-down decision-making, centering the voices of those directly impacted (Davies, 2022). This approach not only affirms lived experiences but also reimagines the role, facilitating new perspectives on its integration, alignment with equity policies (Priest & Lockett, 2020), and long-term sustainability in health systems (Burrage et al., 2024). Five U.S., one Canadian, and one Australian qualitative study explored patient perceptions of the IPN role and or programs, offering valuable insights into how patients, families, and community representatives experience and assess the role or program while disclosing key attributes that make IPNs effective (Grimes et al., 2017; Groot et al., 2024; Issacson et al., 2023; Kelly et al., 2022; Kleszynski et al., 2024; Morgan et al., 2025; Newham et al., 2016). The perception of the IPN role scope encompasses diverse responsibilities that extend beyond standard patient advocacy (Issacson et al., 2023). Patient perspectives showcase the IPN's essential role in bridging cultural gaps, promoting community and family involvement, and providing culturally competent support (Groot et al., 2024; Issacson et al., 2023). Patients emphasized the importance of IPNs in assisting with appointment management, facilitating communication, and integrating emotional and spiritual support, reinforcing the role's holistic and patient-centered approach (Grimes et al., 2017). Additionally, patients, families, and community representatives perceived IPNs as facilitators of culturally safe care (Kelly et al., 2022), supporting decision-making processes (Newham et al., 2016), overcoming bureaucratic hurdles (Kleszynski et al., 2024), and ensuring effective communication between patients and healthcare providers (Kelly et al., 2022). This part of this review of literature revealed that effective IPNs are distinguished by key attributes such as empathy (Kleszynski et al., 2024), cultural knowledge (Isaacson et al., 2023), lived experience within Indigenous communities (Kleszynski et al., 2024), and the ability to establish trust-based relationships (Morgan et al., 2024). Their humanistic approach, understanding of trauma impacts, 36 and capacity to support engagement with Indigenous communities significantly enhance their effectiveness (Kelly et al., 2022; Morgan et al., 2025). Patient evaluations of IPN roles and programs consistently reveal high satisfaction, emphasizing their success in overcoming care barriers, improving access to healthcare services and resources (Grimes et al., 2017), and enhancing patients' self-efficacy and resilience (Morgan et al., 2025). Collectively, these studies demonstrated that IPNs are regarded as a critical and beneficial component in improving Indigenous health outcomes and experiences within healthcare systems (Newham et al., 2016). Studies conducted in Australia and Canada offer valuable insights into the perspectives of IPNs and healthcare workers on collaboration (Cochrane et al., 2024; Orr et al., 2022; Schmidt et al., 2016; Sedgewick et al., 2021). These studies emphasize the importance of the IPN role in healthcare systems, underscoring the need to integrate Indigenous ways of being into patient care (Cochrane et al., 2024). A core function of the IPN role is creating culturally safe and therapeutic environments for Indigenous patients by enhancing trust with both the Indigenous patient and their communities (Cochrane et al., 2024). Additionally, IPNs facilitate inter-collaborative, culturally supportive approaches to service provision, ensuring that healthcare delivery aligns with Indigenous cultural values and needs (Cochrane et al., 2024; Sedgewick et al., 2021). Healthcare workers who collaborate with IPNs also consistently described several benefits. These include enhanced cultural competence, improved communication, and increased advocacy for Indigenous patients (Cochrane et al., 2024; Orr et al.,2022). Researchers recommend ongoing cultural safety training and education to strengthen these collaborative efforts, reduce biases, and create a more inclusive healthcare environment (Browne et al., 2016). One study by Schmidt et al. (2016) specifically focused on the enablers and barriers that impacted the success of the IPN role, particularly from the staff's perspective, revealing factors that facilitate or hinder effective role integration. Section. 4.3.1, Promising practices and inhibitors to the IPN role integration, further discusses this focus. Understanding these promising practices and barriers from the 37 literature is vital for informing future strategies and/or interventions that strengthen the roleâs effectiveness and sustainability within BCâs complex health systems. Overall, the literature emphasizes that the IPN role, alongside collaborative healthcare workers, plays a crucial role in integrating cultural knowledge and strengthening collaborative practices that contribute to improved health outcomes for Indigenous populations (Cochrane et al., 2024; Orr et al., 2022; Sedgewick et al., 2021). However, it also acknowledged the multifaceted challenges involved in ensuring the role's success and the broader integration of these programs within healthcare systems (Schmidt et al., 2016). Addressing these challenges through targeted strategies, adequate resources, and culturally informed processes is also vital in maximizing the IPN roleâs impact on equity and Indigenous health outcomes (Burrage et al., 2024; Cochrane et al., 2024; Schmidt et al., 2016). 2.6.2.2. Promising practices and barriers to IPN role integration. The literature search identified 17 studies that provided informative insights into the promising practices and inhibitors to the integration of IPN roles within health systems. Seven studies from Australia, the U.S., Canada, and a multi-country review examined existing IPN roles in health systems (Burhansstipanov et al., 2014a; Burhansstipanov et al., 2014b; Cheok et al., 2023; Hiscock et al., 2022; Karidakis, 2021; Mackean et al., 2020; Rankin et al., 2022). However, only six studies specifically focused on the integration of newly established IPN roles, with five from Australia and one from the U.S (Bernardes et al., 2018; Daws et al., 2014; Katzenellenbogen et al., 2015; McKenna et al., 2015; Miyamoto et al., 2019; Taylor et al., 2020). One Australian study evaluated the non-financial costs Indigenous patients face and offers IPN programming recommendations (Cummins et al., 2023). A Canadian study describes the IPN's role as a promising practice in improving Indigenous health outcomes, identifying both enablers and barriers to its effectiveness (Sanjida et al., 2022). Additionally, one Australian study examines IPNs within a broader system of Indigenous health support, providing further insights into integration challenges and best practices (Enuaraq et al., 2021). This section of literature 38 examines articles that offer a comprehensive understanding of the factors that shape the successful integration of the IPN role. 2.6.2.3. Inclusion of pre-existing IPN roles. Exploring the promising practices and inhibitors related to the integration of pre-existing IPN roles is essential for this research, which focuses on the challenges of effectively incorporating IPNs into health systems. Gaining an understanding of these factors provides valuable insights into the barriers and successes experienced in other health systems, which helps identify areas for improvement in the IPN integration process. By addressing whole-system health integration challenges, this study aims to strengthen the support structures necessary for IPNs to thrive, thereby enhancing care and improving equitable health outcomes for Indigenous Peoples. Seven key studies, two from the U.S., three from Australia, one from Canada, and one international, provide revealing insights into the integration of IPNs into health systems (Burhansstipanov et al., 2014a; Burhansstipanov et al., 2014b; Cheok et al., 2023; Hiscock et al., 2022; Karidakis, 2021; Mackean et al., 2020; Rankin et al., 2022). These studies identify several promising practices of successful IPN integration. For example, Burhansstipanov et al. (2014a) describe the benefits of refining and expanding IPN roles to support Indigenous patients throughout the continuum of care, from disease prevention to end-of-life services. Their follow-up study emphasizes the importance of comprehensive training for IPNs and strong engagement with local Indigenous communities to ensure effective implementation of their roles (Burhansstipanov et al., 2014b). Other research, such as that by Cheok et al. (2023), shows that regular collaboration between IPNs and healthcare professionals improves patient outcomes, including reducing the risk of self-discharge among Indigenous patients. Australian research by Karidakis et al. (2021) explains the value of IPNs as cultural brokers, utilizing their Indigenous worldviews to bridge the gap between Western biomedical perspectives and Indigenous knowledge. Finally, a multi-country scoping review by Rankin et 39 al. (2022) describes the importance of expanding IPN competencies in areas such as social service access, advocacy, outreach, and administrative navigation as best practices for successful integration. Conversely, several articles examining pre-existing IPN roles identify key inhibitors to successful integration within health systems. These inhibitors identified in the literature included a scarcity of IPNs (Schmidt et al., 2016), inconsistent role structures (Cochrane et al., 2024), insufficient specialized training (Burrage et al., 2024), and the lack of evaluation frameworks to measure the role's impact (Rankin et al., 2022). Systemic challenges, such as resource limitations (Hiscock et al., 2022), high workloads, and inconsistent professional development, further undermine the effectiveness of the role (Cochrane et al., 2024). To overcome these barriers, the literature suggests increasing the number of IPNs (Schmidt et al., 2016), standardizing training (Burrage et al., 2024) and embedding IPNs within multidisciplinary teams to enhance cultural safety and service effectiveness (Hiscock et al., 2022). Additionally, Australian research indicates that integrated collaborative care models, in which IPNs work effectively alongside other healthcare professionals, significantly strengthen Indigenous patient-centered care (Mackean et al., 2020). Together, these studies provided a comprehensive understanding of the factors that facilitate and inhibit the integration of IPNs into health systems. They underscore the need for structured support, systematic integration, and cultural responsiveness to ensure the effectiveness of pre-existing IPN roles in enhancing health outcomes for Indigenous patients. By identifying both promising practices and inhibitors, these studies offer valuable insights for optimizing IPN roles across diverse healthcare settings, thereby supporting the operationalization of equity and advancing Indigenous health equity. 2.6.2.4. Integrating the IPN role. Research on the integration of IPNs into health systems, primarily from Australia and one study from the U.S., provides valuable insights into key promising practices that support successful implementation (Bernardes et al., 2018; Daws et al., 2014; Katzenellenbogen et al., 2015; McKenna et al., 2015; Miyamoto et al., 2019; Taylor et al., 2020). A primary promising practice identified in an 40 Australian study is the importance of cultural competence and ongoing role evaluation (Bernardes et al., 2018). Continuous assessment of the IPN role and its integration ensures that IPNs effectively support Indigenous patients and adapt to evolving healthcare needs (Bernardes et al., 2018; Rankin et al., 2022). Similarly, enhancing collaboration between healthcare providers and IPNs enhances referrals and facilitates seamless integration into multidisciplinary teams (Daws et al., 2014). Another critical promising practice is the use of descriptive data on Indigenous patients' healthcare engagement, including access barriers, service utilization, and cultural safety considerations (Katzenellenbogen et al., 2015). Analyzing these factors enables health systems to tailor IPN services more effectively, thereby improving accessibility and responsiveness to the needs of Indigenous communities (Bernardes et al., 2018). Additionally, comprehensive training equips IPNs with the skills and knowledge needed for successful integration (McKenna et al., 2015). A single U.S. study highlights the value of adaptable service delivery models, enabling health systems to scale and replicate successful IPN programming across various service areas (Miyamoto et al., 2019). Strong executive leadership, initiative-taking employment strategies, and the establishment of dedicated IPN teams or units further reinforce effective integration (Taylor et al., 2020). Despite these promising practices, several inhibitors hinder the successful integration of the IPN role. Poor communication pathwaysâboth between Indigenous patients and IPNs and between IPNs and other healthcare teamsâcan disrupt care coordination and limit the effectiveness of the role (Bernardes et al., 2018). Additionally, a lack of cultural competence among healthcare workers and inadequate planning for collaboration and evaluation create further barriers to integration (Bernardes et al., 2018). The absence of strategic planning for team collaboration and failure to incorporate health system data related to Indigenous patient needs, such as access barriers and social determinants of health, further limits the IPN role's ability to address the unique health challenges Indigenous populations face (Daws et al., 2014; Katzenellenbogen et al., 2015). Resource constraints and insufficient training planning also undermine the sustainability of the role (McKenna et al., 2015). 41 Inflexible service delivery models that fail to consider the specific social determinants of health faced by Indigenous peoples pose significant barriers to IPN role integration (Miyamoto et al., 2019). These inflexible models do not adequately account for geographic isolation, cultural misunderstandings, and systemic inequities, making it difficult for IPNs to provide meaningful support (Hiscock et al., 2022). Additionally, a lack of organizational respect and inclusion for the IPN role negatively impacts job satisfaction and retention, leading to high turnover and reduced program effectiveness (Taylor et al., 2020). Yashadhana et al. (2020) provide further evidence of the importance of non-clinical patient navigation roles in improving access to care, particularly in Aboriginal eye health services. Their study emphasized that culturally tailored support services, community engagement, and outreach-based service provision models significantly enhance patient outcomes (Yashadhana et al., 2020). These findings align with the broader literature, which emphasizes the need for flexible, culturally responsive approaches in IPN integration (Miyamoto et al., 2019). This body of literature underscores the importance of cultural competence, collaboration, data-driven planning, and structured support systems in effectively integrating IPNs into health systems, while identifying barriers such as poor communication, insufficient resources, and rigid service models that continue to challenge successful integration (Cochrane et al., 2024; Bernardes et al., 2018; Schmidt et al., 2016). Understanding these promising practices and inhibitors provides a starting place for overcoming integration challenges. This knowledge is essential for evaluating current efforts, identifying shortcomings, and informing strategies to enhance the effectiveness and sustainability of the IPN role within health systems, such as IH and NH. 2.7. Limitations in the literature Despite the growing recognition of IPNs in health systems, research on their integration within Canadian healthcareâparticularly in BCâremains limited. Most studies on patient navigation roles stem from Australia and the United States, leaving a significant gap in understanding how IPNs function within 42 BC's regional health authorities, such as IH and NH. Additionally, there is a lack of research on how Canada's colonial history and systemic inequities influence the integration and effectiveness of these roles. A key deficiency in the literature lies in the absence of regionally relevant quantitative research on the role of IPN integration. Without such data, researchers cannot analyze cause-and-effect relationships or draw generalizable conclusions to guide the implementation of broader roles. Few studies examine how equity is considered or embedded in IPN integration. Although researchers recognize equity as a principle in Indigenous health, they rarely explore how the role's operation, including its training, practice, and system-wide implementation, reflects this principle. No existing framework analyzes whether IPN integration advances Indigenous equity in health outcomes compared to other health system roles, such as Advanced Practice Nurses (APNs). Furthermore, researchers have not applied the PEPPA and PEPPA Plus frameworks to the IPN role, leaving comparative analysis unclear. Studies have not fully explored the long-term sustainability or effectiveness of IPNs. Although some research identifies promising practices and barriers to role integration, there is a lack of research examining long-term outcomes, such as the impact of IPNs on patient health, system navigation, or Indigenous workforce retention. Researchers also investigate workforce sustainability minimally, leaving factors like job satisfaction, burnout, and career progression largely unexamined. Without this knowledge, researchers cannot determine whether the IPN role drives broader systemic change or remains a temporary, underfunded initiative (Schmidt et al., 2016). Another limitation is the absence of Indigenous methodologies and ways of knowing in existing research. Much of the literature relies on Western frameworks, with little engagement in Indigenous-led approaches to health navigation, governance, or relational care. This lack of Indigenous perspectives risks reinforcing colonial paradigms rather than creating community-driven solutions. Similarly, researchers have not sufficiently studied the structural and policy barriers affecting IPN integration. Few analyses explore how health authority policies, funding structures, and leadership decisions influence IPN sustainability or how systemic racism and institutional barriers impact their 43 effectiveness. The role of provincial and federal guidelines in either supporting or constraining IPN programs is also largely unexamined. Finally, there is a lack of research on how health authorities collect and utilize data related to Indigenous patient navigation, healthcare access, and health outcomes. Without culturally relevant data collection and reporting, it is difficult to assess the impact of IPNs or identify areas for improvement. Addressing these deficiencies is necessary to strengthen the integration of IPNs within BC health systems. By examining IH and NH through an equity-focused lens, this research contributes new insights into the promising practices and barriers that shape IPN integration. Utilizing Critical Indigenous Theory (CIT) and the SEAA framework, this study bridges these knowledge gaps and informs policy recommendations that enhance the effectiveness and sustainability of IPN roles in BC. 2.8. Conclusion The literature highlights structural and operational inequities that hinder the effective implementation of Indigenous equity policies and strategies within health systems. Addressing these systemic barriers requires governance-supported reforms, sustained multi-level interventions, and culturally inclusive approaches that integrate Indigenous leadership, community-driven decision-making, and equity-focused policy frameworks. Additionally, achieving equity within health system integration processes necessitates strategic policy framing, targeted resource allocation, and culturally informed service delivery. Sustainable funding, executive leadership, and data-driven decision-making remain essential for optimizing resource distribution and ensuring that health equity initiatives effectively address the unique needs of integrating Indigenous healthcare roles into health systems. This literature review examines the integration of the IPN role within health systems, with a focus on its development, key promising practices, barriers, and alignment with Indigenous health equity policies. The review identifies critical gaps, including a lack of regionally specific research, limitations of the application of equity-focused frameworks, and insufficient exploration of the long-term sustainability of the IPN role. Furthermore, the absence of Indigenous methodologies in existing studies reveals the 44 need for research that centers on Indigenous ways of knowing and governance structures. These limitations emphasize the need for further inquiry into how health authorities integrate the IPN role and whether current policies and practices support its effectiveness over time. By synthesizing existing literature, this chapter lays the groundwork for this study, demonstrating the need for a critical assessment of how BC health systems support or hinder the integration of IPN. The review provides insights that guide the research approach, ensuring that this research examines key areasâsuch as systemic barriers, workforce sustainability, and the implementation of equity-based rolesâthrough a critical and Indigenous-informed lens. The next chapter outlines the methodology used to explore the role integration of IPN and its coherence with health systems' equity goals and commitments. It explains how the PEPPA, PEPPA Plus, and SEAA frameworks support and guide the study. This approach generates new knowledge for the field and produces practical recommendations for strengthening the IPN role within BC health systems. It also provides actionable strategies to support health systems in advancing equity by aligning the operationalization of the IPN role with their broader equity goals and commitments. 45 3. Chapter Three: Theoretical and Methodological Foundations 3.1. Introduction As discussed in Chapter Two, existing literature showcases the potential of Indigenous Patient Navigators (IPN) to address systemic barriers and improve health outcomes for Indigenous people (Rankin et al., 2022). Building on this understanding, this chapter outlines the approach to exploring the integration of the IPNs in healthcare systems. It begins with an overview of philosophical stance and worldview, followed by a discussion of the chosen theoretical frameworks- Systematic Equity Action-Analysis (SEAA), Participatory Evidence-based Patient-focused Process for Advanced Practice Nursing (PEPPA), and PEPPA Plus. This chapter outlines the research design and methods, including data collection, organization, and analysis, as well as considerations of ethics and feasibility, and validation strategies. It concludes with a description of the study's limitations. 3.2. Philosophical Underpinnings This research is grounded in a philosophy that integrates Indigenous ways of knowing with critical approaches to Western frameworks, challenging dominant worldviews and promoting equity within health systems (Davies, 2022). My research perspective includes Indigenous values, beliefs, and priorities, recognizing their centrality in shaping policies and practices that impact Indigenous health and Indigenous healthcare roles (Caron, 2020; Wylie et al., 2019). By critically engaging with both Indigenous knowledge systems and Western biomedical frameworks, this approach uncovers and addresses colonial structures embedded within health governance, policy, service delivery, and internal practices that influence the integration of Indigenous-specific healthcare roles into health systems (Davies, 2022). Indigenous values and priorities in health system design emphasize relationality and relational accountability, holistic well-being, and self-determination (Dion Stout, 2012; Wilson, 2008). Equitable health systems must integrate Indigenous knowledge, respect traditional healing practices, and prioritize 46 culturally safe, trauma-informed care (Mitchell, 2018; Power Wiradjuri et al., 2022). Health systems must center Indigenous voices to ensure healthcare services reflect community needs and address systemic racism and inequity (Dion Stout, 2012). Achieving equity requires both setting clear goals and critically examining the worldviews that shape the health system while ensuring strong alignment between their commitments and the actions taken to fulfill them (Plamondon et al., 2023). By centering Indigenous perspectives and priorities, health systems can move beyond Western biomedical dominance, developing models that uphold Indigenous ways of knowledge and advance meaningful health equity that is responsive to the diverse needs of Indigenous people (Plamondon et al., 2023). This approach not only challenges existing power structures but also promotes a more inclusive, culturally safe, and equitable healthcare environment for all (Plamondon et al., 2023). My philosophical stance guides the research by ensuring that Indigenous perspectives and priorities are central to the analysis of health systems. It facilitates the integration of Indigenous ways of knowing by critically examining how these knowledge systems intersect with Western frameworks, health system designs, practices, and processes while identifying opportunities to advance equity within health systems. The research prioritizes relationality, fairness, and justice, ensuring that health system designs are not only culturally safe but also equity responsive. Incorporating these values allows the research to offer a more inclusive and equitable approach to integrating Indigenous-specific healthcare roles into health systems, thereby enhancing integration practices, advancing equity, and contributing to the decolonization of health systems. By focusing on Indigenous perspectives and priorities, the study embeds Indigenous knowledge and equity into every aspect of the analysis. It critically examines the impact of Western frameworks while advocating for culturally safe, equitable approaches that align equity goals with actionable strategies. The research examines the integration of the IPN role within an Indigenous-informed philosophy, ensuring it challenges dominant worldview frameworks to promote equity and diversity. It 47 also identifies both promising practices and barriers, while advocating for policy coherence to fully incorporate IPNs into health systems. 3.3. Worldview Worldview encompasses ways of thinking, perceiving, and interpreting the world, deeply rooted in cultural traditions and collective experiences (Crittenden, 2019). An Indigenous worldview is relational, process-oriented, and emphasizes the interconnectedness of all creation, as well as the cyclical nature of life without a defined beginning or end (Getty, 2010). While Indigenous worldviews often contrast with Western perspectives, which focus on linear rather than spatial conceptions (Crittenden, 2019), there are areas of overlap (Swidrovich, 2023). For example, both worldviews value knowledge sharing, though they differ in how knowledge is generated, applied, and shared (Datta & Starlight, 2024; Swidrovich, 2023). Furthermore, the Indigenous worldview sees reality and all things within it as relational rather than individualistic or compartmentalized (Duran & Duran, 1995; Wilson, 2001). While this contrasts with dominant Western perspectives, overlaps also exist in areas such as collaboration, accountability, and the value of knowledge as a guide for action (Datta & Starlight. In current practice, integrating Indigenous and Western frameworks shows promise in enhancing health system models and care delivery (Gould et al., 2023), particularly when there is intentional integration and leveraging of overlapping aspects of these worldviews. This research examines the challenges of integrating IPN roles within Interior Health (IH) and Northern Health (NH) from a lens that emphasizes interconnectedness and relationality. This perspective considers the opportunity to recognize and reflect on the challenges that exist within health systems while also striving for fairness and equality. It acknowledges that integrating Indigenous healthcare roles into these Western health system designs requires addressing both the existing tensions between worldviews and the desire to create more equitable practices (Wylie et al., 2019). By examining how the IPN role interacts with both Western worldviews and the colonial structures embedded in health system design, this study assesses how these systems facilitate or hinder the equitable integration of the IPN role. It explores 48 how these structuresâshaped by long-standing Western colonial biomedical modelsâeither support or impede the success of integrating the IPN role, recognizing the dynamics that influence this integration at both structural and operational levels within the health system. This research looks closely at how an Indigenous worldview responds to different situations, highlighting the importance of understanding the specific conditions in which health systems function (Dion Stout, 2012). This approach allows for a deeper understanding of how Indigenous worldviews can inform the interconnectedness of health policies and their real-world applications within health systems (Dion Stout, 2012). Health system equity policies are examined not as isolated commitments but as part of a broader web of relationships that formulate their practical impact (Haitana et al., 2022). These relationships reveal tensions between Western healthcare frameworks, Indigenous views of health and healing, and the aspirations for equity, which the historically colonial health systems struggle to reconcile (Wylie et al., 2019). This relational perspective enables me to evaluate how policies aimed at promoting equity interact with the institutional cultures and power dynamics within Western biomedical health systems (Davies, 2022). It reveals whether equity policies are genuinely integrated into health system practice or are superficial efforts that fail to address deep-rooted inequities (Plamondon et al., 2023). Ultimately, grounding the research in an Indigenous worldview of interconnectedness uncovers how the broader context of coloniality, historical trauma, and the ongoing tensions between Indigenous and Western worldviews in health systems influence the integration of the IPN role. This approach will identify the structural and operational factors that serve as promising practices or hinder the effectiveness of IPN role integration and provide actionable recommendations for health system leaders to embed equity-driven changes meaningfully. This research demonstrates how policy, practice, and system design interconnect, moving beyond surface-level reforms to provide insights for achieving systemic change that genuinely supports the equitable integration of the IPN role into health systems. 49 3.4. Theoretical Frameworks 3.4.1. Systematic equity action-analysis: A theoretically grounded approach to research. 3.4.1.1. SEAA foundation. An Indigenous philosophy and worldview prioritize the relationships and interconnections between all entities, emphasizing the interconnectedness of all things over the isolated existence of any single individual or thing (Ellington, 2019; Poitras Pratt & Gladue, 2022). SEAA aligns with this perspective by integrating Indigenous philosophies and worldviews in the pursuit of equity (Plamondon et al., 2023). Its multi-point nature and thoughtfulness provide a comprehensive understanding of different worldviews. It offers pathways to explore Indigenous perspectives in depth and extend these approaches to Western health systems or policy development (Plamondon et al., 2023). By beginning with an understanding of worldview, the choice to use SEAA (Plamondon et al., 2023) ensured that Indigenous knowledge systems are central to the process while also enabling the identification of dominant worldviews. This framework helps to understand how dominant worldviews influence equity and shape actions aimed at advancing it (Plamondon et al., 2023). By providing an analytical process focused on understanding how Indigenous ways of knowing inform an equity response (in this case, IPN integration), SEAA promotes a more inclusive and equitable approach to addressing systemic issues for diverse populations. Furthermore, this research employs the SEAA framework to systematically evaluate how equity is integrated into policies, structures, and practices within the relational worldview of an Indigenous paradigm (Plamondon et al., 2023). The SEAA framework aims to address inequities by identifying equity-defining contexts, analyzing systemic factors, developing actionable strategies, and evaluating outcomes (Plamondon et al., 2023). This research is an ideal choice because it combines a robust theoretical foundation with a relational approach that effectively integrates both Western and Indigenous perspectives (Plamondon et al., 2023), aligning with my Indigenous worldview and values. This approach enables a thorough examination of the worldview, coherence, potential, and accountability (Plamondon et 50 al., 2023) of equity visions within Interior and Northern Health systems, as well as the real-world impacts of their equity actions. The SEAA framework draws inspiration from Indigenous knowledge sources and beliefs, emphasizing the interconnectedness of all things, including knowledge and action (Plamondon et al., 2023). This alignment with an Indigenous worldview makes the framework particularly suitable for this study. SEAA recognizes that the distribution of resources, wealth, and power generates inequities, aligning with this studyâs philosophical stance that understanding whether something is thriving or struggling requires examining its relational connections to resources, wealth, and power (Plamondon et al., 2023). SEAA emphasizes that addressing power imbalances and inequities requires focusing on how power operates and interconnects within systems (Plamondon et al., 2023). Without this focus, it is challenging to identify the sources of these issues or find effective ways to promote equity (Plamondon et al., 2023). The overwhelming alignment between the foundations of SEAA and my philosophical stance and worldview is why SEAA became the most suitable theoretical framework for my research study. 3.4.1.2. SEAA dimensions. The SEAA framework incorporates four key dimensions: Worldview, Coherence, Potential, and Accountability (Plamondon et al., 2023). These dimensions interconnect with critically reflexive dialogue, agency, systems thinking, and humility, creating a more comprehensive approach to equity analysis within systems (Plamondon et al., 2023). Positioned within two dynamic, relational axesâcritically reflective dialogue and systems thinkingâand two practice-oriented axesâagency and humilityâthese intersecting principles actively guide both the research process and practice (Plamondon et al., 2023). Ultimately, grounding the research in an Indigenous worldview of interconnectedness uncovers how the broader context of coloniality, historical trauma, and the ongoing tensions between Indigenous and Western worldviews in health systems influence the integration of the IPN role (Plamondon et al., 2023; Browne et al., 2016). 51 Recognizing different worldviews helps to better understand the forces shaping systems and their outcomes, and it also encourages the examination of underlying assumptions regarding the functioning of the world and how inequities are perceived and interpreted (Plamondon et al., 2023). Exploring worldview is essential for this research, as it helps uncover the foundational beliefs that drive actions within health systems, particularly in relation to equity (Davies, 2022). This understanding is crucial for identifying systemic barriers and advancing equity within health systems (Davies, 2022). Ensuring the meaningful integration of Indigenous worldviews into health system planning and policy will move beyond superficial changes, driving long-term, transformative equity. Exploring worldviews is crucial for this research, as it enables a deeper understanding of the forces shaping health systems and their outcomes (Plamondon et al., 2023). By identifying both dominant and marginalized worldviews, this dimension uncovers the assumptions and perspectives that drive actions within health systems (Plamondon et al., 2023). Recognizing these different worldviews encourages critical reflection on the foundational beliefs that shape health policies and practices, particularly in terms of equity (Plamondon et al., 2023). It also provides a framework for examining how inequities are understood and interpreted, which is essential for identifying systemic barriers and advancing equity within health systems (Plamondon et al., 2023). Integrating this understanding allows health systems to meaningfully incorporate Indigenous worldviews into planning and policy, moving beyond superficial changes to supporting long-term, transformative equity (Caron, 2020; Davies, 2022). Coherence addresses the alignment of policies, practices, and structures with equity goals, ensuring they work together harmoniously rather than in conflict (Plamondon et al., 2023). It provides a foundation for meaningful, systemic change by aligning efforts toward equity (Plamondon et al., 2023). Examining how equity goals align with the operationalization of the IPN role is essential for this research, as it clarifies whether existing systems, policies, and practices achieve the intended equity outcomes. Examining how well the integration of the IPN role reflects these goals helps identify shortcomings, inconsistencies, and areas where intentions fall short. This examination provides insights into how health systems can better support the integration of the IPN role, ensuring that processes are 52 equitable, culturally safe, and effective. By analyzing this process, equity goals move beyond aspiration, translating into meaningful, systemic change within health systems primarily shaped by dominant Western worldviews (Caron, 2020; Plamondon et al., 2023). Potential emphasizes the capacity of individuals, communities, and systems to drive change, revealing opportunities for growth and ensuring that marginalized groups thrive and exercise agency (Plamondon et al., 2023). This dimension supports a vision of equity that moves past incremental or transactional adjustments, striving for transformative change (Plamondon et al., 2023). This research explores the concept of potential, identifying opportunities for growth and transformation that may not be apparent to individuals, teams, leaders, or systems (Plamondon et al., 2023). This approach allows for the discovery of innovative strategies and solutions that drive meaningful change within health systems (Plamondon et al., 2023). Lastly, by highlighting potential, this research inspires health system leaders to recognize and invest in the strengths and capabilities of IPNs, leading to effective and sustainable integration practices that advance equity (Cochrane et al., 2024; Plamondon et al., 2023) Accountability, on the other hand, underscores the responsibility of individuals, institutions, and, in this research, health systems to honor their equity commitments (Plamondon et al., 2023). It stresses the importance of transparent evaluation and feedback loops to ensure that efforts toward equity are grounded in measurable actions and lead to tangible improvements (Plamondon et al., 2023). Exploring accountability in this research provides valuable realizations into how IH and NH health systems can honor their equity commitments and promote transparency and continuous improvement (Came et al., 2016; Priest & Lockett et al., 2020). By focusing on accountability, this research reveals incoherence between stated equity goals and actual practices (Plamondon et al., 2023), offering insights into how health systems can enhance the integration of Indigenous-specific healthcare roles. This emphasis on accountability enables health systems to take concrete steps toward genuine equity advancement, cultivating more inclusive and equitable healthcare environments for Indigenous populations (Plamondon et al., 2023). 53 3.4.1.3. SEAA practices. This section describes the four key practices of the SEAA frameworkâCritically Reflective Dialogue, Systems Thinking, Agency, and Humility (Plamondon et al., 2023). These key practices are applied in this study to analyze the integration of IPNs within health systems. Exploring these practices demonstrates how the SEAA framework guides the research and identifies actionable strategies to advance equity in healthcare (Plamondon et al., 2023). Critically reflective dialogue is a thoughtful and open exchange of ideas in which participants explore, examine, and question their personal beliefs, assumptions, and experiences (Plamondon et al., 2023). This process enhances a deeper understanding and challenges existing viewpoints, promoting personal growth and transformation (Plamondon et al., 2023). Critically reflective dialogue is a key component of the SEAA framework because it encourages deeper self-awareness and critical engagement with the systems in which individuals, groups, and leaders operate (Plamondon et al., 2023). Encouraging individuals to question their assumptions and reflect on their experiences helps identify biases and power imbalances within the systems of study (Plamondon et al., 2023). This process is crucial for promoting equity and decolonization, as it enables the examination of how personal and collective experiences shape decision-making and systemic outcomes (Plamondon et al., 2023). Through this practice in dialogue, the SEAA framework supports the assessment and addressing of the complexities involved in integrating the IPN role and achieving health system equity (Plamondon et al., 2023). Systems thinking, in practice, analyzes complex systems by examining the interrelationships and interactions between components, focusing on connections that shape the system rather than isolated parts (Plamondon et al., 2023). Systems thinking offers a broader and interconnected perspective on how various dimensions interact within larger, dynamic systems (Plamondon et al., 2023). In the research, systems thinking is used to analyze the complex interactions between worldview, equity policies or commitments, role integration practices, and the structural and operational levels within health systems 54 (Plamondon et al., 2023). This approach helps identify how these elements collectively influence the integration of IPNs. Practicing systems thinking is crucial for exploring health systems because it provides a comprehensive understanding of the systemic barriers and promising practices related to equity (Plamondon et al., 2023). By considering all the various dimensions of health systems and integration practices, systems thinking helps to identify how these elements interact and influence equity outcomes (Plamondon et al., 2023). Through systems thinking, this research aims to develop more effective and sustainable integration practices that support health systems in advancing equity within their Indigenous healthcare roles (Plamondon et al., 2023). The axes of agency and humility also guide the research by ensuring that the content is approached with sensitivity and openness (Plamondon et al., 2023). Agency emphasizes the importance of identifying and understanding the capacity for change within systems, policies, and practices (Plamondon et al., 2023). Staff, teams, departments, leaders, and partners explore their agency by actively engaging in self-reflection, seeking diverse perspectives, and taking intentional actions to promote equity (Plamondon et al., 2023). Personal agency exploration is key because it empowers individuals and groups to drive meaningful change within health systems, ensuring that equity commitments are translated into tangible improvements in practices and outcomes, particularly through diverse role integration (Plamondon et al., 2023). The practice of humility in research, particularly when exploring equity and integrating diverse healthcare roles, involves recognizing the limits of one's knowledge, being open to learning from others, and critically reflecting on one's positionality, biases, and assumptions (Wadell, 2017). Practicing humility requires individuals to engage in deep listening, remain open to being challenged (Wadell, 2017), and maintain self-awareness (Wadell, 2017), particularly when working within systems shaped by colonial histories and power imbalances (Bögel et al., 2021). Humility emphasizes openness to learning while respecting Indigenous worldviews and diverse perspectives (Bögel et al., 2021). This research applies humility by acknowledging the analysisâs limitations and actively remaining receptive to new 55 insights. Practicing humility ensures that the research stays grounded in an understanding of systems, structures, and policies, allowing for a thorough and respectful analysis of the data (Plamondon et al., 2023). This approach strengthens the study's findings by uncovering insights that advance systemic equity and meaningful change (Plamondon et al., 2023). The SEAA begins with identifying an object or set of analyses as situated in a particular set of structures and contexts (Plamondon et al., 2023). For this research, the object of analysis is the integration of the IPN role, situated within the colonial contexts that shape the Interior and NH systems. The SEAA guides navigating each of the four dimensions of analysis (worldview, coherence, potential, and accountability) and applying the four practices (critically reflective dialogue, systems thinking, agency, and humility) through a process of gathering, describing, engaging, and responding. To manage the scope of this master's research, this thesis focuses on gathering, explaining, and engaging. Responding will evolve and flow from this work, with emphasis on respect, relevance, reciprocity, responsibility, and relationships (Wilson, 2019). These guiding principles, known as the Four Rs, form the foundation of Indigenous research methodologies, ensuring that the research process remains grounded in ethical and relational considerations (Wilson, 2019). 3.4.1.4. Guiding dimensional questions. Using the SEAA framework, I developed guiding questions related to the four dimensionsâworldview, coherence, potential, and accountabilityâbecause these dimensions help explore the key factors influencing the integration of the IPN role into IH and NH, particularly in relation to equity (Plamondon et al., 2023). These guiding questions enable me to critically analyze how health systems' practices align with their equity commitments and whether they adequately address power imbalances, cultural safety, and systemic barriers (Plamondon et al., 2023) for the IPN role integration. By developing these questions, I gain clarity and focus, ensuring a comprehensive and meaningful analysis of health system integration practices (Plamondon et al., 2023). Below are guiding questions for each dimension that guide the study: 56 4) Worldview: a) How do the Indigenous worldviews and knowledge systems embedded in the IPN role challenge or align with Western healthcare frameworks in IH or HN? b) In what ways do IH and NH consider the cultural perspectives and experiences of Indigenous patients in their integration of the IPN role? c) How do IH and NH's policies and practices reflect an understanding of interconnectedness and relational accountability from an Indigenous perspective? d) What barriers or promising practices exist in the health systems' adoption of an Indigenous worldview within healthcare practices, particularly concerning the IPN role? 5) Coherence: a) How consistent are IH and NH's policies and practices with their stated equity commitments, specifically in terms of integrating the IPN role? b) In what ways do IH and NH integration practices reflect coherence between equity policy statements and culturally diverse healthcare role integration practices? c) How do IH and NH ensure alignment between the integration of IPNs and other healthcare roles in the pursuit of equity? d) What are the discrepancies or shortcomings that exist in how IH and NH apply equity goals, particularly concerning the IPN role? 6) Potential: a) How do IH and NH recognize and support the potential of the IPN role to contribute to meaningful change in the delivery of culturally safe and equitable care? b) What opportunities exist within the IH and NH to expand the IPN role and better address equity for Indigenous populations? c) In what ways can the IH and NH enhance the capacity of IPNs to create systemic change in healthcare delivery and policy? 57 d) What challenges or barriers may limit the potential of the IPN's role in transforming healthcare services for Indigenous people? 7) Accountability: a) How do IH and NH measure and assess the effectiveness of the IPN's role in advancing health equity for Indigenous patients? b) What mechanisms are in place to make IH and NH accountable for the successful integration and operation of the IPN role? c) How do IH and NH provide IPNs with the resources, support, and authority necessary to fulfill their roles in advancing equity? d) In what ways do IH and NH leadership engage in self-reflection and critique to ensure that their practices and directives are accountable to the needs and rights of Indigenous populations? These guiding questions will help me systematically evaluate each dimension and determine how effectively IH and NH are integrating the IPN role to advance equity for Indigenous peoples. Ultimately, the use of the SEAA framework guides this analysis of how IH and NH integrate the IPN role and reflect their equity worldviews, statements, and visions in the operationalization of integration practices (Plamondon et al., 2023). This study examines equity goals, objectives, strategies, and organizational statements from IH and NH to understand how they conceptualize at both structural and operational levels (Plamondon et al., 2023). This approach directly supports the pursuit of research objectives, which focus on understanding the integration challenges of the IPN role within IH and NH. It also identifies factors that facilitate or hinder the equitable integration of the IPN role and provides recommendations to IH and NH leadership for future IPN role integration. 3.4.2. Participatory evidence-based patient-centred integration process for the advanced practice nurse. The PEPPA and PEPPA Plus frameworks are systematic approaches that guide the integration and evaluation of specialized healthcare roles into health systems, such as Advanced Practice Nurses (APNs) 58 (Bryant-Lukosius et al., 2016). These frameworks emphasize a participatory and evidence-based process that centers on patient needs and aims to improve health outcomes (Bryant-Lukosius et al., 2016). These frameworks provide a structured methodology for assessing role integration, identifying promising practices and barriers, and developing strategies to optimize the use of specialized roles within healthcare systems (Bryant-Lukosius et al., 2016). The PEPPA framework includes steps such as identifying patient needs, defining the role, developing a plan for role implementation, and evaluating the outcomes (Bryant-Lukosius et al., 2004). PEPPA Plus builds on this by incorporating elements such as stakeholder engagement, continuous feedback loops, and a focus on sustainability and scalability (Bryant-Lukosius et al., 2016). By utilizing these frameworks, the study leverages their structured approach to assess how health systems align with equity goals and improve health outcomes for Indigenous populations. Using these frameworks facilitates the identification of best practices and areas for improvement (Bryant-Lukosius et al., 2016), thereby contributing to the advancement of equity within health systems. Multiple systematic reviews demonstrate that the PEPPA frameworks effectively improve healthcare delivery and patient outcomes by enhancing role integration processes (Bryant-Lukosius et al., 2016). By comparing the PEPPA and PEPPA Plus frameworks with the integration and evaluation of the IPN role in IH and NH, this study provides valuable insights into the processes that support or hinder current integration practices. Given the evidence in the literature on the usefulness of these frameworks for integrating and evaluating the APN role (Bryant-Lukosius et al., 2016), comparing them with the IH and NH integration and assessment of their IPN role can reveal processes that both support and hinder current integration practices. Therefore, this study assesses the IPN role integration process using the knowledge-informed standards of the PEPPA and PEPPA Plus frameworks to identify promising practices and areas for improvement in advancing equity within health systems. This approach helps ensure that the research remains grounded in an understanding of systems, structures, and practices, allowing for a thorough and respectful analysis. 59 3.5. Research Design This research adopts a Qualitative Descriptive Content Analysis (QDCA) approach to systematically interpret qualitative data and uncover the social, cultural, and systemic factors influencing the equitable integration of the IPN role within health systems (Vaismoradi et al., 2023). This method effectively explores complex and nuanced experiences, perspectives, and practices, with a particular focus on equity and power dynamics (Vaismoradi et al., 2023). By emphasizing qualitative descriptions of health authority content, QDCA facilitates a thorough examination of how Indigenous-specific healthcare roles are integrated into Western health system designs, revealing insights that may otherwise remain hidden. A collection of resources from various sources, including materials that provide insights into the IPN role integration process, policy documents, and texts related to equityâsuch as health system policies and strategiesâguides the analysis of the coherence between IPN role integration and IH and NH equity commitments. These sources provide a comprehensive understanding of the integration of the IPN role, highlighting the challenges and opportunities involved, and examining how equity considerations influence the process. By critically engaging with these materials, the research assesses whether current policies and strategies effectively support the meaningful integration of IPNs within health systems. The analysis begins with a thorough review of the data to gain a deeper understanding of its context. This step is crucial for ensuring an in-depth understanding of the data, enabling accurate interpretation, meaningful coding, and the identification of key themes that shape the analysis (Belotto, 2018). Thematic coding of the data involves grouping meaningful units into emerging themes related to IPN role integration and equity, allowing for the identification of patterns, challenges, and opportunities that shape the effectiveness of the role within health systems (Belotto, 2018) This process focuses on identifying patterns and issues that reflect Indigenous perspectives and priorities, such as cultural safety in healthcare, systemic barriers, and key factors that support integration. After coding, the analysis 60 synthesizes the data into a clear and concise summary that examines how equity goals align with the design and implementation of health systems. One of the strengths of QDCA is its flexibility and adaptability (Vaismoradi et al., 2023). This method accommodates diverse data sources and adapts to the specific needs of the research, which is essential for capturing a range of Indigenous perspectives and experiences (Vaismoradi et al., 2023). The study adopts a methodology that supports the representation and respect for the voices of Indigenous worldviews throughout the analysis process (Vaismoradi et al., 2023). This design suits the study of the integration of the IPN role because it enables a deep exploration of the systemic and structural factors that influence integration. By focusing on policy documents, reports, and other relevant textual materials, this approach provides a comprehensive understanding of framing the IPN role within health systems and assesses the operationalization of equity goals. The qualitative document content analysis (QDCA) method is also well-suited for examining power dynamics and equity in the integration process (Bowen, 2009). It identifies systemic barriers and challenges while uncovering opportunities to align the IPN role with Indigenous values and practices. This design ensures the analysis is sensitive to Indigenous worldviews and prioritizes equity considerations. QDCA's flexibility accommodates diverse data sources (Vaismoradi et al., 2023), enabling the study to capture the multifaceted nature of integrating the IPN role. The systematic coding process organizes data into meaningful units, supporting a clear and transparent analysis of how the IPN role aligns with organizational equity policies. Moreover, the iterative nature of QDCA supports a reflexive analysis process, enabling the study to adapt to emerging findings (Vaismoradi et al., 2023). This approach ensures the research stays grounded in the broader context of health systems and Indigenous equity needs, making QDCA an effective method for exploring the integration of the IPN role. The use of QDCA will help identify actionable insights that can lead to improvements in the integration of the IPN role, contribute to the decolonization of healthcare systems, and promote culturally safe and equitable practices in healthcare delivery. By critically examining the data through this design, 61 the research aims to offer recommendations that support systemic change and enhance equity for Indigenous peoples within the healthcare system. 3.6. Research Methods My study systematically collected and analyzed resources related to the IPN role within IH and NH. Data collection focused on IPN integration resources and health system equity policies, goals, and strategies. Following data collection, resources were organized and analyzed using comparative tables and thematic coding. The order of presentation mirrors this process, moving from data sources and collection methods to organization and analysis. To gather data on health system IPN role integration, documents such as job descriptions, organizational charts, and practice support documents related to the IPN role were compiled. A targeted Google search was conducted using keywords such as "Indigenous Patient Navigator," focusing on official Indigenous Health IH) and National Health NH) authority sources. 3.6.1.1. IPN job descriptions. To capture job description resources for the IPN role from IH and NH, the official career websites of IH Careers and NH Careers serve as primary sources. These platforms frequently post roles such as IPN, Indigenous Health Liaison, and Cultural Safety Facilitator (IH, n.d.; NH, n.d.b). Commercial job posting sites, such as Indeed, LinkedIn Jobs, Glassdoor, BC Jobs, and WorkBC, help locate Indigenous-specific positions across the province from various sources, including health authorities, Indigenous organizations, and government agencies. Searching keywords like "Indigenous Health," "Indigenous Patient Navigator," or "Cultural Safety" refines the results. However, for the most up-to-date and detailed job descriptions, the IH and NH career websites remain the primary sources, as they directly reflect open positions within the health authorities. To ensure data relevance and accuracy, this study excludes job descriptions and documents that are unrelated to the IPN role. It also excludes documents from unofficial or non-authoritative sources, as 62 well as postings that do not specifically mention roles and responsibilities, such as those of the IPN role. The analysis also excludes outdated materials or those that do not coincide with current IPN integration practices within IH and NH. 3.6.1.2. Organizational charts, practice support documents, and IPN role integration resources. To capture relevant organizational charts, practice support documents, and IPN role integration resources, searches of official health authority websites of IH and NH using terms such as "Indigenous Patient Navigator," "Indigenous Health," "Indigenous Cultural Safety," "Indigenous healthcare role," "Indigenous role," and "role integration" to locate health system sources. Searches of the Provincial Health Service Authority (PHSA) SHOP site, using the same terms to find IPN role integration resources not available on the IH and NH public-facing websites, support a broader range of materials for analysis. Exclusion criteria include documents unrelated to the IPN role, outdated materials, or those from unofficial sources. 3.6.1.3. Health system equity policies, goals, commitments, and strategies. The collection of resources related to health system equity policies, goals, commitments, and strategies within IH and NH focuses on key documents, including strategic plans, equity frameworks, and policy documents. These resources specifically address Indigenous health equity, cultural safety, and anti-Indigenous racism. This approach ensures that the materials collected are directly relevant to improving health outcomes for Indigenous populations. Understanding these policies and commitments is essential to examining current practices and their impact on Indigenous healthcare (Fisher et al., 2021). Search for official publications on the health authority websites by using search terms such as "equity goals," "health system strategies," and "Indigenous health initiatives." This targeted approach helps identify key documents such as strategic planning reports, diversity and inclusion policies, and equity assessments. These documents are essential for understanding how IH and NH address Indigenous 63 health and equity, providing insight into ongoing efforts to improve health outcomes for Indigenous populations through comprehensive, system-wide strategies. Exclusion criteria for this data collection include any documents that do not specifically address health equity within the context of Indigenous health or that focus on broader equity topics unrelated to healthcare delivery or Indigenous-specific health services. The analysis excludes outdated documents or those lacking actionable strategies that are not aligned with current health system practices or commitments within IH and NH. Additionally, it excludes resources from unofficial sources or those not directly related to health system equity, thereby enhancing the relevance and credibility of the data. 3.6.2. Data organization and analysis. The resource organization followed a structured process, utilizing data and comparison tables to produce comparative data analysis. These tables facilitated the organization, review, and comparison of findings, ensuring the effective management of resources and data. First, a comparative table examines the alignment between IH and NH IPN role integration and advanced practice integration resources, allowing for a comparison of how IH and NH integrate their IPN roles in relation to the best practice integration outlined by PEPPA and PEPPA Plus. Second, the process of identifying themes involves analyzing how IPN role integration aligns with IH and NH policy and strategy commitments by examining relevant data tables. The review also examines integration resources for the APN role to assess their relevance to the IPN role integration. The themes emerging from these analyses are organized into structured tables, highlighting key patterns in role alignment and system integration. These thematic tables serve as a foundation for further interpretation, ensuring a systematic approach to understanding the coherence of IPN integration within health system policies and frameworks. The analysis of data and organization into tables, and then the comparison of data tables, proceeds as follows: â¢ Step One: Develop data lists, organized into the following groups: 64 â¢ IPN or IPN-similar job descriptions and operational support for IPN role integration in IH and NH resources. â¢ Promising practices- defined as those identified in the literature and consistent with existing scholarly research and found in IH and NHâs IPN role integration, â¢ Literature-informed inhibitors- defined as promising practices identified in the literature that are absent in the IH and NH IPN role integration. â¢ PEPPA and PEPPA Plus framework steps and stages. â¢ Equity Policies, Indigenous Health Strategies, and Equity-related Plans in IH and NH. â¢ Step Two: Compare lists I, II, and III to create Table 3, "Promising Practices in IH and NH IPN Role Integration," and Table 4, "Literature-informed Inhibitors in IH and NH IPN Role Integration," which provide insights into the literature-supported IPN role integration's promising practices and inhibitors. â¢ Step Three: Compare Lists I and IV to create Table 5, "PEPPA Framework Steps Identified in the IH and NH IPN Role Integration," which provides insights into which steps and stages of the framework are present in the IH and NH IPN role integration. Step Three: Compare lists I and V to examine how the IPN role integration in IH and NH aligns with their equity policies, strategies, and Indigenous health policies. This comparison resulted in the creation of Section 4.3.5, IPN Role Integration Alignment with Health System Equity Goals and Commitments. This step reveals findings related to how IH and NH operationalize their equity goals within the IPN role integration practices. Figure 1 visually represents the steps taken for an extensive analysis of the data. This analysis compares literature findings and applies the SEAA framework to gain deeper insights and draw meaningful conclusions about the role of IPN integration within IH and NH health systems, focusing on how integration practices align with system equity goals and commitments presented in Chapter Four, Findings. 65 Figure 1 Sequential Steps of the IPN Role Integration Note. This figure provides a visual representation of the ordered steps taken to organize, compare, and analyze data sources to assess the IPN role integration in IH and NH. The review systematically organizes and codes IPN role integration practice documents to identify key themes related to equity in the role. Both inductive and deductive coding methods are employed to uncover patterns within the data (Braun & Clarke, 2016). Inductive coding allows for the emergence of new, unanticipated themes related to the integration process (Braun & Clarke, 2016). In contrast, deductive coding helps to confirm existing theoretical concepts and anticipated frameworks in the data (Braun & Clarke, 2016), such as equity goals, cultural safety, and role clarity. This combination of coding methods enables a nuanced analysis of the challenges and opportunities associated with integrating the IPN role within health systems, thereby advancing alignment with health system equity goals. To organize and support the coding process, NVivo, a qualitative data analysis software, streamlines the coding process and manages the data (Edward-Jones, 2014). NVivo provides a platform 66 for categorizing and visualizing emerging themes and patterns, allowing for a more structured and systematic approach to data analysis (Edward-Jones, 2014). Using NVivo's capabilities for thematic coding refines and validates the key themes related to IPN role integration, ensuring consistency across the data (Edward-Jones, 2014). The software also facilitates the identification of connections between themes, helping to uncover both the overarching and subtle relationships within the data, which is essential for a comprehensive analysis (Edward-Jones, 2014). Elements of SEAA guide this thematic coding, providing a map for assessing alignment between the integration of the IPN role and equity goals and practices. By mapping the findings through the SEAA framework, the analysis examines how policies, organizational structures, and support systems either promote or hinder the equitable integration of the IPN role. This framework provides a structured approach to critically assess how systemic factors (Plamondon et al., 2023), including organizational culture and health policy, impact the success of IPN role integration, identifying both promising practices and inhibitors. This analytical process reveals a rich understanding of how equity operates in integrating the IPN role and its implications for health system equity reform. 3.7. Ethical Considerations This study did not involve direct engagement with live participants or the use of human health data, which significantly reduces the risk of ethical concerns typically associated with research involving people (Stommel & Rijk, 2021). As the research relied on secondary data sources such as equity policy statements, IPN job descriptions, organizational charts, and practice documents, there was no direct interaction with individuals or collection of personal health information. The study also adheres to the principle of integrity by ensuring that all data collection and analysis are conducted with transparency, objectivity, and accuracy (Kretser et al., 2019). The use of secondary data aligns with ethical research practices, properly acknowledging the sources from which the data is obtained and applying appropriate analytical methods to draw conclusions in ways that support the integrity of research (Kretser et al., 2019). There was no need to obtain ethical approval from a research ethics board. 67 Although the study does not require research ethics review and approval, it involved two core ethical considerations. Cultural sensitivity is integral to the study, especially given the focus on Indigenous healthcare roles in Western health systems (Lie-A-Ling et al., 2023). While the study does not directly engage Indigenous healthcare workers, the research methods, interpretation of findings, and recommendations are designed to be culturally respectful and aligned with the values and principles of relationality and relational accountability within Indigenous research paradigms (Ling-A-Ling et al., 2023; Wilson, 2008). This approach is essential because cultivating cultural respect and alignment with the values and principles of relationality and relational accountability within Indigenous research paradigms promotes a more ethical, inclusive, and culturally appropriate approach to research (Ling-A-Ling et al., 2023; Wilson, 2008). Grounding the study in these principles honors Indigenous knowledge systems, strengthens the relevance and applicability of the findings (Ling-A-Ling et al., 2023; Wilson, 2008), and contributes to a more equitable integration of the IPN role in health systems. While this study did not involve direct engagement with Indigenous individuals, it adheres to the principles of OCAP (Ownership, Control, Access, and Possession) by centering Indigenous worldviews, self-determination, and governance in the creation and use of the findings and recommendations. Although I work within a regional health authority, I will not unilaterally share this information with health systems for their independent use. Instead, as an Indigenous researcher, healthcare provider, and health system leader, I prioritize supporting Indigenous Nations by offering the knowledge and insights gained to the Nations first, allowing them to decide if and how to use it in dialogue with health systems regarding the integration of IPN roles. I commit to supporting the dissemination or application of these recommendations only with Indigenous oversight, control, and consent, respecting the authority of Indigenous Nations to determine the appropriate next steps. By honouring these principles, this approach preserves control over the data. It ensures the responsible and ethical use of its findings in alignment with the values of the Indigenous Peoples and communities impacted by the research (First Nations Information Governance Centre, n.d.). 68 3.8. Feasibility Considerations This research requires no financial consideration, as all resources are publicly available online at no cost. 3.9. Knowledge Affirming Strategies Incorporating critically reflective dialogue with supervisory and advisory committee members, checking enhances the credibility and trustworthiness of the study by ensuring that the research process and findings are critically and rigorously reviewed and validated by experienced scholars in the field of health systems, role integration practices, equity policy, and Indigenous studies (Lee & Murray, 2015). This form of checking provides a critical layer of oversight, allowing for constructive feedback, the identification of potential biases, and recommendations for refining the analysis (Lee & Murray, 2015). By engaging these experts throughout the study, I ensure that the research aligns with academic and ethical standards while also ensuring that the interpretation of data and the conclusions are robust and well-supported (Lee & Murray, 2015). This process not only strengthens the reliability of the findings but also reinforces the study's commitment to transparency and rigor (Lee & Murray, 2015). The second process employed to ensure study rigor is reflexivity maintained through journaling and by asking the key reflexive questions outlined below: 1. Did the research design align with the overall objectives of the study? 2. How did the use of my chosen philosophy, worldview, or theoretical framework inform the research study? 3. Are there any additional methodological improvements you would make for future studies on this topic? 4. What were the significant challenges faced during data collection or analysis? 5. Were there any challenges in identifying and categorizing themes related to equitable integration of the IPN role and coherence between Equity policy statements and IPN role integration? 6. Was the coding process consistent and aligned with the research framework? 7. Were there any challenges or limitations in applying the SEAA framework? 69 8. How well did the findings address the research questions? 9. Did the analysis reveal new insights into the integration of IPNs and systemic inequities in health systems? 10. How did the study's findings relate to existing literature on IPN integration? 11. What are the practical implications of the research findings for the integration of IPNs in health systems? 12. How can health authorities apply the recommendation? 13. How can the findings be used to advocate for policy changes or new practices within the IH Authority or other health systems? 14. Did any unforeseen biases or assumptions emerge during the research process? How can future studies account for these biases? 15. How did your personal and cultural perspective influence the research process, particularly in your interpretation of data? 16. Which areas could researchers explore further? 17. How can this research be expanded or replicated in other regions or healthcare settings? Reflexivity plays a critical role in ensuring rigor and trustworthiness in this research by actively engaging with personal biases, assumptions, and perspectives throughout the study (Palaganas et al., 2017). Through journaling and consistently asking reflexive questions, awareness is maintained of how the chosen philosophy, worldview, and theoretical framework shape the research process. This reflective practice allows for an examination of whether the research design aligns with the study's objectives. It also helps identify any potential biases or limitations that may arise in the data collection and analysis phases (Palaganas et al., 2017). By acknowledging and addressing these factors, the study maintains transparency and grounds interpretations of the findings in a self-aware and critical approach (Palaganas et al., 2017). The use of reflexivity supports the ongoing improvement of the research process by encouraging regular self-assessment (Palaganas et al., 2017). Questions such as whether the coding process aligns with 70 the research framework or if new insights have emerged create opportunities to revisit the data, refine interpretations, and make necessary adjustments (Palaganas et al., 2017). Reflexive inquiry helps maintain alignment with the overall research goals and ensures the analysis remains consistent with the established theoretical framework (Palaganas et al., 2017). This process contributes to the rigor of the study by ensuring the findings are both credible and meaningful, providing a solid foundation for making well-informed recommendations. The processes of supervisory and advisory committee member checking, along with reflexivity, ensure that the research maintains high rigor and trustworthiness (Lee & Murray, 2015; Palaganas et al., 2017). By continuously engaging with the data, reflecting on perspectives, and seeking feedback from knowledgeable colleagues, the credibility of the findings is strengthened (Lee & Murray, 2015; Palaganas et al., 2017). These practices help address potential biases, ensure consistency, and refine the approach as needed, supporting the integrity and reliability of the research outcomes. 3.10. Areas for Future Growth This research has several inherent limitations. First, the study focuses specifically on integrating the IPN role within the IH and NH systems. This geographic scope may limit the generalizability of the findings to other regions or health systems with different healthcare structures, priorities, or community needs. The experiences and challenges within Interior and NH may not fully reflect those in other parts of British Columbia or across Canada, where health system integration processes, resources, and Indigenous health priorities may differ. Another limitation is related to access to specific resources. Due to the health system's practice of not making all its guiding resources publicly available, it is challenging to obtain a comprehensive range of data from IH and NH. Confidentiality, internal organizational requirements, and access barriers to specific resources restrict the analysis, affecting its completeness. This limitation may prevent the inclusion of all relevant data, both publicly available and not, that could offer more profound insights into their IPN health system integration process. 71 Moreover, while the SEAA framework is valuable for assessing equity, it may not fully capture all dimensions of cultural safety or the complex, nuanced dynamics of Indigenous healthcare role integration. Cultural safety, which emphasizes the importance of power dynamics and Indigenous worldviews, might require more specific, in-depth frameworks to be fully understood and addressed. Lastly, relying primarily on publicly available online resources also limits the diversity of perspectives and insights available for analysis. These resources might not always reflect the latest developments in the field or capture a truly comprehensive understanding of the IPN role's integration. It is essential to consider these limitations when interpreting the findings, as they may impact the depth and applicability of the study's conclusions. 3.11. Conclusion This chapter outlines the research approach and methodology used to explore the integration and operationalization of equity considerations in the IPN role within the IH and NH systems. By prioritizing Indigenous knowledge and worldviews alongside Western frameworks, this methodology seeks to challenge dominant paradigms and promote a more equitable healthcare system. The use of the SEAA framework and the PEPPA Plus integration model enables a detailed examination of the factors influencing IPN role integration while also highlighting the systemic inequities and power imbalances that may hinder progress. The approach strengthens an inclusive environment for critically analyzing and decolonizing health systems, ensuring that Indigenous perspectives play a vital role in shaping healthcare policies and practices. This chapter has provided a comprehensive foundation for understanding the research process, and the following chapters will build on these methodological principles to draw meaningful conclusions about the IPN's role and its alignment with health system equity goals. 72 4. Chapter Four: Findings 4.1. Introduction Chapter Four presents an analysis of the data sources associated with Interior Health (IH) and Northern Health (NH), which provide information on the integration of the IPN role, as well as health system commitments and goals related to advancing equity within their respective health systems. It articulates findings that are congruent with the four research objectives found in Section 1.2.3, Research Aims and Objectives: 1. To identify the key promising practices and barriers influencing the integration of the IPN role within IH and Northern Health (NH) health systems. 2. To compare the integration of the IPN role with that of other specialist healthcare roles, such as the Advanced Practice Nurse (APN), to identify similarities and differences. 3. To examine the worldview present in the integration of the IPN role and its influence on the integration process. 4. To examine the alignment between IH and NH equity commitments and goals and the integration of the IPN role, assessing the coherence between stated commitments and integration processes. The analytical framework provided by the Participatory Evidence-based Patient-focused Process for Advanced Practice Nursing (PEPPA) and PEPPA Plus models strengthens the investigation of the first two objectives. Subsequently, the examination of the other two objectives relies on the aspects of worldview and coherence within the SEA framework for analysis (Plamondon et al., 2023). Chapter Four includes three sections: an overview of the data, interpretations of the findings, and a conclusion that prepares the stage for the discussion of the findings in Chapter Five. 4.2. Overview of the Data The dataset is divided into two distinct categories to enable a targeted analysis: the first is associated with Research Objectives One and Two, while the second pertains to Objectives Three through Five. The initial category, as shown in Section 4.2.1 IPN Role Integration Resources, supports the 73 examination of Objectives One and Two, and includes job descriptions and service delivery location lists that demonstrate how IH and NH integrate the IPN role into their respective health systems. The search for publicly available organizational charts, practice support documents, and other integration resources related to the IPN role in IH and NH found no additional data sources beyond job descriptions and service location lists; therefore, this research could not analyze any further materials. The second category, Equity-Informing Policies, Strategies, and Plans, includes equity or equity-related policies, strategies, and plans that inform or guide organizational goals and commitments to equity. Since neither IH nor NH provides specific, publicly available equity policies or strategies, the analysis relies on broader equity-related documents. These include diversity, anti-racism, and Aboriginal cultural safety and humility policies, as well as strategic priorities outlined in organizational plans and an equity-related plan. These sources guide the examination of alignment and coherence between organizational equity goals or commitments and the actions taken to achieve or advance them. 4.2.1. IPN role integration resources This section of the study provides an opportunity to examine how IH and NH operationalize the IPN role in practice, particularly in the absence of formal integration frameworks. Job descriptions and service delivery listings offer insight into the practical structure, distribution, and expectations associated with the role. These documents provide a basis for identifying integration-promising practices and barriers, while also highlighting the underlying worldviews that shape integration. Their use supports a structured application of the SEA framework's worldview dimension, revealing how dominant assumptions, values, and power dynamics influence role integration within IH and NH. 4.2.1.1. Job descriptions. Publicly available job postings from the IH and NH career websites provide three relevant IPN job positions and descriptions: the IPN (IH, n.d.b), Indigenous Care Coordinator (ICC) (NH, n.d.a), and Indigenous Health Service Assistant (HISA) (NH, n.d.b). Each IPN or IPN-related role job description posting contains details such as the job title, team placement and dynamics, role summary, shift schedule, 74 and service delivery site (IH, n.d.b; NH, n.d.a; NH, n.d.b). They also outline essential aspects, such as expectations for multidisciplinary team collaboration, supervisory or support mechanisms, salary ranges, qualifications, and educational requirements (IH, n.d.b; NH, n.d.a; NH, n.d.b). The job descriptions for IH and NH demonstrate a clear commitment to hiring Indigenous candidates, supporting reconciliation efforts, and promoting workforce diversity (IH, n.d.b; NH, n.d.a; NH, n.d.b). Both health systems emphasize increasing Indigenous representation in their workforce, reflecting reconciliation frameworks that prioritize the recruitment of Indigenous-identifying individuals (IH, n.d.b; NH, n.d.a; NH, n.d.b). According to IHâs Careers website, IH intentionally aligns its hiring practices with the Truth and Reconciliation Commission, the Declaration on the Rights of Indigenous Peoples Act, and the BC Human Rights Code (IH, n.d.b). In contrast, the NH Careers website emphasizes developing diversity by building a workforce that more closely reflects the community it serves (NH, n.d.a; NH, n.d.b). Consistent with these commitments, the job descriptions highlight the importance of candidates having lived Indigenous experience and a deep understanding of Indigenous histories, health needs, services, cultural practices, and community-led Indigenous health initiatives (IH, n.d.b; NH, n.d.a; NH, n.d.b). A significant distinction between the IH and NH job descriptions lies in how each health system situates the IPN or IPN-similar role within its organizational structures. IH emphasizes the IPN's integration within an interdisciplinary team, stating that the role operates under the supervision of an operations manager (IH, n.d.b). This mechanism of supervision represents a structured, team-based approach to service delivery, aligning the role with formal clinical leadership (IH, n.d.b). In comparison, NH describes its IPN-related roles as operating under general supervision, with a less formal linkage to NH's Indigenous Health Department, rather than direct operational leadership (NH, n.d.a; NH, n.d.b). NH's health supervision approach suggests greater autonomy for their IPN-like positionsâbut also implies less integration into interdisciplinary teams (NH, n.d.a; NH, n.d.b). Additionally, IH explicitly indicates the role of the IPN is to provide services in âaccordance with the established visions and values of the organizationâ while working âunder the direction of the Manager or 75 Directorâ (IH, n.d.b, p.1). In contrast, NH does not specify that its IPN-related roles must align with any set of system-wide values, visions, or strategic principles. The organization describes the management approach as âgeneral supervisionâ (NH, n.d.a) or âunder the direction of the Team Leadâ (N.d.b, p.1). Coincidentally, NH presents a less rigid approach that appears flexible in how the role is guided and functions within its health system. These distinctions highlight how each health authority situates its IPN or IPN-related functions within its health system: IH emphasizes alignment with overarching organization-defined values supervised by upper leadership whereas NH adopts a more autonomous structure with flexible, culturally informed oversight facilitated by âcollaboration with [â¦] First Nation communities and Metisâ and supported in more of a team approach (n.d.a, p.1). 4.2.1.2. Service delivery location lists. Searching the IH and NH official websites for IPN service delivery location lists reveals two publicly accessible lists from the IH and NH. IH designates eleven IPN roles across a range of specialized health areas, which encompass four in hospitals, one in a standard hospital, two in urgent and primary care centers, one in a community health center, and three in mental health and substance use services (IH, 2025b). Furthermore, IH places nine IPNs in the urban regions of Kelowna, Cranbrook, Penticton, Kamloops, Williams Lake, Vernon, and Castlegar, British Columbia (BC) (IH, 2025b). The last two IPN roles deliver services from the rural areas of Ashcroft and Creston, BC (IH, 2025b). At every service delivery location, only a single IPN position exists operating from each site (IH, 2025b), which does not appear to correlate with the size or demographics of Indigenous populations in the area or surrounding communities. The online investigation into the service delivery particulars of the NH Indigenous Patient Liaison Program uncovers a variety of publicly available resources that delineate the roles of IPN-similar roles throughout the Northern Region. The Indigenous Patient Liaison Program established by NH delineates five categories of positions analogous to IPNs: sixteen Indigenous Health Service Assistants (IHSAs), eight ICCs, two Indigenous Patient Liaisons, one Indigenous Care Engagement Advisor, and 76 two roles lacking specified titles (NH, 2025). In total, 25 of these positions function within hospital environments, while four provide services from integrated hospital and health centre facilities (NH, 2025). Seven of these roles, which bear similarity to IPNs, cater to urban or regional areas, including Prince George, Fort St. John, Dawson Creek, Prince Rupert, Quesnel, and Terrace, BC (NH, 2025). The remaining eight positions assist Indigenous patients in rural and remote communities, including Burns Lake, Chetwynd, Haida Gwaii, Hazelton, Kitimat, Masset, Fort St. James, and Smithers, BC (NH, 2025). In contrast to IH, NH consolidates multiple IPN-like positions within a single service delivery location (NH, 2025). For instance, in hospital settings, Prince George accommodates seven roles, Fort St. John comprises four, while both Prince Rupert and Hazelton each host three, and Quesnel similarly encompasses three (NH, 2025). Hazelton is the only health service delivery location in a rural setting that contains multiple IPN-similar positions providing care (NH, 2025). Conversely, Burns Lake, Chetwynd, Haida Gwaii, Dawson Creek, Kitimat, Masset, Fort St. James, Smithers, and Terrace each support a single IPN-related role that delivers services (NH, 2025). The structure and function of NH's Indigenous Patient Liaison Worker Program offer insight into the health system's approach to Indigenous-specific healthcare roles. The program describes the aim of IPN-similar positions as one that bridges Indigenous communities with NH providers by integrating both Western and traditional medical practices (NH, 2025). NH's IPN-similar roles also collaborate with on-site healthcare personnel, leadership, and the Patient Care Quality Office to address the needs of Indigenous patients (NH, 2025). Their responsibilities include navigating patient feedback pathways, resolving concerns in real-time, supporting care and discharge planning, explaining diagnoses and treatments, coordinating patient travel, and facilitating culturally grounded conflict resolution processes such as talking circles (NH, 2025). In contrast, IH does not provide detailed information about service delivery methods within its IPN service delivery location list. Instead, IH hosts a separate webpage that outlines general role functions and describes how IPNs support Indigenous patients across different care settings. 77 IH offers a detailed description of the IPN role service delivery approach on its designated webpage, Indigenous Patient Navigator (IH, 2025b). Within this online resource, IH describes the goal of the role as improving access and ensuring that Indigenous patients understand the health system process, as well as ensuring that healthcare staff are aware of patients' unique cultural needs (IH, 2025b). The responsibilities of the IPN role include aiding Indigenous patients and their families by enhancing communication with healthcare providers, facilitating care planning and discharge processes, and advocating for culturally respectful care (IH, 2025b). More specifically, IH explains that IPNs collaborate with healthcare teams to promote and or support access to culturally safe practices (IH, 2025b). Finally, unlike NH, which uses five distinct title roles with similar functions, IH refers to all Indigenous supportive positions uniformly as âIPNâ (IH, 2025b), indicating a more cohesive approach to Indigenous patient support roles. 4.2.2. Equity informing policies and strategies The second collection of data sources comprises policies, strategic documents, and plans that articulate health system commitments and goals related to advancing equity. Searching the IH and NH websites for specific equity policies, strategies, and plans yields no results. Consequently, this study analyzes only publicly available documents that reference themes such as anti-racism, cultural safety, diversity, equity, and access. These documents correspond with the fourth research objective, which aims to investigate the coherence between IPN role integration and each health authority's broader equity-related commitments and goals, as shown in Table 3. This study analyzed IH online resources to examine the coherence of equity. Consequently, the assessment of the coherence dimension within the SEA framework relies solely on IH documents, as there are no pertinent public online data sources from NH that provide equity or equity-related policies or strategies. This absence of information sources constrains any assessment of how NH fulfills equity commitments or integrates the role of the IPN within the framework. As a result, Section 4.2.2.1 analyzes 78 three equity-oriented IH policies that illustrate how IH is dedicated to and establishes objectives for equity-related principles, including diversity, anti-racism, and Indigenous cultural safety. 4.2.2.1. Policies. Understanding equity-related conceptsâsuch as cultural safety, anti-racism, and diversityâenables health systems to prevent and address inequities, even without formal equity policies (University of British Columbia [UBC] Learning Circle, 2021). By examining cultural safety, anti-racism, and diversity policies, this study assesses how IH incorporates elements of equity into its existing health system design, providing valuable insights into its overall commitment and goals for equity. This approach ensures that the analysis remains relevant to the research objectives while acknowledging the absence of explicit equity policies. This analysis organizes IH's administrative policies along a continuum of equity considerations, reflecting varying levels of focus on preventing, recognizing, and responding to inequity (UBC Learning Circle, 2021). At one end of the continuum, preventive policies guide responsibilities and expected conduct to stop inequities from occurring (UBC Learning Circle, 2021). IH's (2019) diversity policy serves as an example in this category. The next category includes anti-racism policies that help identify characteristics of inequity and recognize inequity experiences, such as racism (UBC Learning Circle, 2021). At the other end of the equity-policy continuum, policies address the root causes of inequity, such as cultural unsafety (UBC Learning Circle, 2021). IHâs (2021a) Aboriginal Cultural Safety and Humility policy represents the final example on the equity-policy continuum, outlining responsibilities and providing guidance to address conditions that create inequities or function as mechanisms to advance equity (UBC Learning Circle, 2021). The next component of this policy section provides a more in-depth examination of IH's three administrative equity-related policies. 79 4.2.2.1.1. IH AUD2100 Diversity Policy. IH's (2019) AUD2100 Diversity Policy articulates the organization's dedication to âpromoting a culture of inclusiveness and participation in decision-makingâ (p.2) and to âfoster a working environment supportive of diversity (p.2) as a âpermanent organizational priorityâ (p.2). It characterizes diversity as âan array identities, abilities, backgrounds, cultures, skills, perspectives, and experiences âthat âshapes values, attitudes, expectations, perceptions of self and others an in-turn impacts behaviors in the workplaceâ (IH, 2019, p.1). The policy stresses the importance of âthe unique contribution to the organizations, clients, customers, and our communities by all individualsâ (IH, 2019, p.1). IH strengthens this objective, stating that âIH will work towards [â¦] ensuring employment and Human Resource strategies, policies, and procedures are consistent with [their] policyâ (IH, 2019, p.2). As part of IHâs equity goals and commitments, the health system also aims to create proactive workforce âknows the value of diversityâ and its capacity to â[enhance] organizational efficiency and effectiveness through the inclusion of diverse perspectives and point of view (IH, 2019, p.1) These initiatives strive to promote equity within the concept of inclusion which the define as âthe fair, equitable, supportive, welcoming and respectful treatment of allâ (IH, 2019, p.1). By embedding these commitments into organizational structures and processes, the IH (2019) AU2100 Diversity Policy functions as a mechanism for â[addressing] the needs of present and future employees from a full Diversity (sic) of communitiesâ (IH, 2019, p.2). 4.2.2.1.2. IH AU2200- Anti-racism Policy. IH's (2021b) AU2200 Anti-Racism Policy establishes the organization's commitment and goal âto eliminate racism in Interior Health workplaces and healthcareâ settings along with â[eliminating] harms and [â¦] negative experiences resulting out of race-based discrimination at individual and systemic levels (p.1). The policy defines Anti-Aboriginal racism as the âsystems of power that advantage and privilege some peoples and disadvantage Aboriginal peopleâ (IH, 2021b, p.2) It further defines Anti-Aboriginal 80 racism as âbeliefs about the superiority of non-Aboriginal people over Aboriginal people including intelligence, abilities, appearance, culture and other attributes that justify higher statusâ (IH, 2021b, p.2). As a response, the policy outlines that all staff and clients â[have] the right to work and receive health-related care and services in an environment that is anti-racist and values diversity, inclusion, and equityâ (IH, 2021b, p. 1) Lastly, IH proactively identifies, âidentifying, removing and eliminating systemic racism in addition to individual racism and anti-Aboriginal racismâ (IH, 2021, p.1) The authority is âcommitted to consistently applying [the] policy across the organization and utilizing [the] policy as an anti-racist lens through which other IH policies are developed, reviewed, and revisedâ (IH, 2021b, p.4). The IH (2021b) AU2200 Anti-racism Policy outlines the process and the responsibilities of managers and/or supervisors for reporting incidents of racism and commits IH to investigating complaints and taking corrective action where necessary. Some of the management responsibilities include âensuring that all breaches of this Policy are promptly and effectively investigated, and action that is appropriate based on the investigation resultsâ (IH, 2021b, p.5). By clearly naming racism and outlining responsibilities for identifying and responding to it, the policy appears to be a tool for recognizing inequity across the organization (IH, 2021b). The IH (2021b) AU200 Anti-racism Policy also serves as a system-level response aimed at identifying and addressing the practices, behaviors, and structures that perpetuate racial inequities in healthcare settings. The policy purpose statements exemplify this function by declaring that the policy aims to âaddress the unequal power dynamic affecting Racialized groups and the structures that sustain itâ and âidentify, remove, and eliminate barriers created by systemic racismâ (IH, 2021b, p. 1). The policy adopts an initiative-taking approach, addressing not only current incidents but also establishing long-term actions to prevent and reduce the recurrence of racism within the organization, thereby contributing to sustainable equity practices over time (IH, 2021b). For example, the policy mandates âorganizing anti-racism education, training, and professional development opportunities for staffâ and by having leadership â[implement] and properly [apply] this Policy within their respective portfolios of responsibilityâ (IH, 2021b, p.5). 81 4.2.2.1.3. IH AD0200 Aboriginal Cultural Safety and Humility Policy. IH's (2021a) AD0200 Aboriginal Cultural Safety and Humility Policy establishes a foundational framework for delivering culturally safe care across its health system. IH indicates that the policy was created âspecifically in recognition of the legacies of colonization and the history of policies [â¦] directed at oppressing Aboriginal populationsâ (IH, 2021a, p.1). The policy also describes cultural safety as âa health care approach that considers how social and historical contexts, as well as structural and interpersonal power imbalance, shape health and healthcare experiencesâ (IH, 2021a, p.1). The policy emphasizes cultural humility as an âin-depth examination of a providerâs assumptions, beliefs and privilege embedded in their own understanding and practiceâ (IH, 2021a, p.1) Moreover, the policy discloses that âIH is committed to Cultural Safe care, as defined by Interior region Aboriginal peoplesâ and that â[health] services are expected to be accessible, of high quality, relevant, culturally safe, and provided in a culturally competent mannerâ (IH, 2021a, p.1) The policy further discloses that âIH is committed to embedding this policy throughout the organization to address and decrease health inequities through meaningful engagement with Aboriginal Partnersâ (IH, 2021a, p.3). To operationalize the IH (2021a) AD0200 Cultural Safety and Humility Policy, IH outlines procedures that direct the health staff to enhance cultural safety within its system by: (1) promoting organizational Aboriginal cultural safety, (2) promoting staff cultural safety, (3) providing culturally competent health and wellness services, and (4) upholding rights to traditional medicines (IH, 2021a, pp. 4â7). The policy instructs staff to strengthen their cultural competence through ârelevant, mandatory education that builds cultural awareness and deepens understanding of the unique history of the Aboriginal populationâ (IH, 2021a, p. 5). However, the policy does not specify the type of training required or explain how staff could complete these education requirements. IH also describes collaboration with Indigenous partners, organizations, and communities as a step toward implementing the policy (IH, 2021a, p. 4). Yet, it provides no clear direction on how to conduct this engagement. To support Indigenous rights to traditional medicines and ceremonies in care, 82 the policy instructs staff to follow cultural protocols (IH, 2021a). It directs the organization to develop site-specific procedures to enable patients and Indigenous staff to support cultural practices (IH, 2021a). However, the policy omits critical information, including where to find organizational or community cultural protocols and their existence. Lastly, the policy does not provide staff and patients with information on accessing funding or resources for acquiring traditional medicines. Ambiguity of information leaves staff and patients unclear about who is responsible for providing traditional medication and whether the health authority or the patient will cover the costs. 4.2.3. Strategies and plans. Key strategic documents from IH inform the organizationâs approach to advancing equity. Our Strategic Direction 2024â2027 and the Accessibility Plan 2024â2027 together articulate IHâs commitments, strategic priorities, and specific actions aimed at achieving and promoting equity within the health system (IH, n.d.a; IH, 2022; IH, 2024). Reviewing these documents provides essential context for understanding how IH translates its stated equity goals into practical efforts to operationalize and advance equity within its organization. 4.2.3.1. Our Strategic Direction 2024-2027. This research identified one publicly accessible IH strategic document, IH's (2024) Our Strategic Direction 2024â2027. It outlines IH's health system vision, mission, values, and priorities that guide its efforts in enhancing health and wellness across the BC Interior (IH, 2024). Two of the health authorities' strategic priorities in this strategy include âadvancing equity and accessâ and âadvancing Indigenous health and wellnessâ (IH, 2024, âOur Strategic Prioritiesâ). Both these priorities focus on âbuilding capacity and shared understanding across IHâ (IH, 2024, âAdvancing Equity and Accessâ). To fulfill IHâs strategic commitment to âadvancing equity and access,â IH declares it will â[focus on] building capacity and shared understandingâ of equity throughout the organization (IH, 2024, âAdvancing Equity and Accessâ). IH also aims to achieve this equity goal by âusing data to reveal and 83 address inequitiesâ and âchanging how [IH] delivers services, [â¦] including for Indigenous rural and remote communitiesâ (IH, 2024, âAdvancing Equity and Accessâ). Lastly, within IHâs 2024-2027 Strategic Direction, IH outlines its advancing equity and access goals by committing to â[acting] on the many factors that influence population health and health equityâ (IH, 2024, âAdvancing Equity and Access). However, IH does not provide descriptions of what it considers these factors to be. 4.2.3.2. 2022-2026 Indigenous Health and Wellness Strategy. IH identifies advancing Indigenous health and wellness as a key strategic priority in its Our Strategic Direction 2024-2027 (IH, 2024). Central to this priority is the continued implementation of the Indigenous Health and Wellness Strategy 2022-2026, which aims to deliver quality, culturally safe, and effective health services to Indigenous peoples and families across the Interior region (IH, 2022). Analyzing Our Strategic Direction 2024â2027 and the Indigenous Health and Wellness Strategy 2022â2026 reveals the depth and direction of the health authorityâs efforts to advance equity. While Our Strategic Direction 2024-2027 outlines broad organizational goals, the Indigenous Health and Wellness Strategy provided detailed guidance on addressing systemic inequities affecting Indigenous Peoples through four areas that â[move IH] forward with accountabilityâ (IH, 2022, p. 19). To achieve the strategyâs âoverall goal [of improving] health and wellness outcomes and health equity for Indigenous Peoplesâ focus is placed on: 1) a âcommitment to cultural safety and humilityâ, 2) âstrengthening partnership and shared decision makingâ, 3) âhealth and equity through shared accountabilityâ, and 4) âperson, family, and community wellnessâ (IH, 2022, p. 19). Developed in collaboration with First Nations, Métis Nation British Columbia (MNBC), and IH leaders, the strategy is grounded in key frameworks including the Truth and Reconciliation Commission (TRC) of Canada, the Declaration on the Rights of Indigenous Peoples Act (DRIPA), and the In Plain Sight (IPS) report (IH, 2022). The IHâs (2022) Indigenous Health and Wellness Strategy 2022-2026 also emphasizes health equity as âan important focus,â stressing that many initiatives contribute to this goal, including 84 âaddressing racism, involving Indigenous Partners in service planning, supporting shared decision making, and integrating traditional [â¦] healing practicesâ (p.20). Central to this emphasis is the concept of âhealth equity through shared accountability,â which guides cooperative efforts to enhance Indigenous health and wellness outcomes through Nation-informed and prioritized initiatives (IH, 2022, p. 30). To advance the IH (2022) Indigenous Health and Wellness Strategy 2022-2026 initiatives, IH pledged to âdevelop a data governance framework with Nation Partners to enhance information and reportingâ and to âensure appropriate, culturally safe, and meaningful use of Indigenous self-identification dataâ (IH, 2022, p.30). The framework aims to âincrease visibility of and access to relevant, timely, and appropriate Indigenous health data to inform population health and service delivery planningâ (IH, 2022, p.29). In 2023, IH released the Interior Health Research Data Management Strategy to operationalize one of its commitments made in IHâs (2022) Indigenous Health and Wellness Strategy 2022-2026. This data management strategy outlines a collaborative approach to data governance with Interior Indigenous Partners (IH, 2023). The initiative aims to support ârespectful access to Indigenous health data to inform population health and service planningâ (IH, 2022). At the time of this study, IH had not released additional resources describing the initiativeâs progress or how Interior Indigenous Partners have benefited from the data management framework. Finally, The IH (2022) Indigenous Health and Wellness Strategy 2022-2026 further specifies that indicators âdetermined by Indigenous Partners, [are] to measure progress towards health equity and guide IH in organizational accountability (p. 30) Operational goals of include â[enhancing] the Indigenous Patient voice in quality improvement workâ, â [utilizing] a quality improvement approach to reviewing select IH programs and services prioritized by Indigenous Partners, [enhancing] primary and community care resourcesâ, â[supporting] Elders to remain close to homeâ, and â[improving] discharge planning and transitionâ (IH, 2022, p.32). Of the four initiatives, publicly available information only documents progress in improving âdischarge planning and transitionsâ (IH, 2022, p.32). In 2024, IH released the Indigenous Discharge Toolkit: Thompson Cariboo (2024) to operationalize that last of these 85 commitments within the Thompson Cariboo region. How the toolkit is benefiting discharge and transitions for Indigenous Peoples in this area is not available or being shared. At the time of this study, IH had not released or made publicly available any additional resources or evidence demonstrating progress on the other initiatives. 4.2.3.3. Accessibility Plan. Given IH's strategic emphasis on advancing equity and access, it is essential to evaluate the organizationâs Accessibility Plan 2024-2027 (IH, n.d.a). This plan outlines how IH envisions addressing obstacles within its systems, environments, and services, â[serving] as a roadmap, [to guide IH] through the practical steps necessary to improve equity and access for [â¦] the people [it serves] (IH, n.d.a, p. 3). It underscores IH's dedication to eliminating physical, attitudinal, and systemic barriers to care, deepening our understanding of how the organization translates its commitments into concrete actions (IH, n.d.a). Therefore, including the IH (n.d.a) Accessibility Plan 2024-2027 in this policy analysis allows for a more thorough assessment of how IH weaves equity into its frameworks and aligns its policy initiatives with these aims. IHâs (n.d.a) Accessibility Plan 2024-2027 articulates the organizationâs commitment to promoting accessibility and equity by creating an inclusive environment âwhere everyone, regardless of their abilities, can participate fully and equallyâ (p. 7). The plan also âemphasizes respect, accessibility, equity, and person- and family-centered care for all individualsâ (IH, n.d.a., p. 7) IH proposes achieving these accessibility goals âby actioning the objectives set out in the planâ which include: 1) [cultivating] a workforce that reflects the diversity of the population [it] serves, 2) [creating] a welcoming and inclusive environment for persons with disabilities, and 3) [creating] physical and psychological environments to enable participation for everyone.â (IH, n.d.a., p. 12). The plan outlines a three-year action strategy, detailing each action alongside success indicators, the relevant focus area, and the year for implementation (IH, n.d.a.). 86 The plan categorizes its objectives into the four focus areas: 1) employment and staff, 2) community engagement and service delivery, 3) built environment, and 4) information and communication (IH, n.d.a., p. 12-13). Specific actions under these objectives include: â[creating] an employment equity policy and programâ, â[implementing] training [â¦] to reduce ableism and promote [â¦] awareness and understanding of supporting persons with disabilitiesâ, â[implementing] an accommodation request procedure [â¦] to support employment equityâ, â[creating] mechanisms to engage with communities and recipients of care to [â¦] garner feedback on [the] planâ, â[conducting an] accessibility audit of [â¦] buildings, sites, and services, and â[establishing] a presence for inclusion and accessibility on IHâs websiteâ (IH, n.d.a., p. 13-17). Collectively, these objectives reflect IHâs efforts to advance equity by making accessibility a structural priority in the pursuit of a more inclusive and representative health system (IH, n.d.a). Ultimately, IH outlines its commitment to accessibility and equity in the Accessibility Plan 2024-2027, accompanied by a three-year action plan (IH, n.d.a). While the plan provides a dedicated email address for âcommunity members, recipients of care, and staffâ to âsubmit their feedback and suggestions via a confidential email address of accessibility@interiorhealth.ca (IH, n.d.a., p. 18). IH has not published evidence detailing how the plan is being implemented, with no public updates or progress reports available on the accessibility objectives of the plan. The previous sections outlined the data sources used to examine how IH and NH integrate the IPN role, alongside their stated equity commitments and goals. These sources included job descriptions, service delivery locations, publicly accessible policies, strategic documents, and plans that reflect each organizationâs approach to advancing equity. The following section provides an examination of the IPN integration, comparing it to the existing literature and utilizing the PEPPA, PEPPA Plus, and SEA Frameworks. 87 4.3. Presentations of Findings Analyzing the data regarding the integration of the IPN role within IH and NH yields essential insights into how these health systems incorporate their Indigenous-specific healthcare roles and the extent to which their integration practices align with their declared objectives for promoting health equity. By employing the PEPPA and PEPPA Plus Frameworks in conjunction with the Systematic Equity Action-Analysis (SEAA) Framework, this interpretation critically analyzes the elements influencing the role integration and the extent to which equity policy commitments correspond with that process. It explores factors that facilitate or hinder effective role integration and compares this process with the integration of another specialized health system role- the APN. It also examines how differing worldviews affect IPN integration and considers how the integration of the IPN role aligns with the operationalization of equity within health systems. 4.3.1. IPN role integration: promising practices and inhibitors. Due to the absence of publicly accessible integration guides or practice documents detailing how IH and NH incorporate the IPN role into their health systems, this analysis focuses solely on the available sources of IPN job descriptions and service delivery location lists. This analysis draws on relevant literature to evaluate the extent to which these sources reflect effective integration by identifying key factors that support the successful implementation of the IPN role within health systems. When elements from IH or NH data align with literature-based enablers, they function as active, promising practices in the integration process. Their involvement increases the likelihood of successfully integrating, maintaining, and sustaining the IPN role over time. This approach provides a systematic understanding of how IH and NH facilitate IPN role integration and the degree to which their practices align with evidence-informed strategies. 88 4.3.1.1. Promising practices. Drawing from existing literature, this analysis examines the extent to which IPN role integration in IH and NH aligns with established promising practices of successful role implementation. Identified strengths reveal where IH and NH approaches reflect evidence-based recommendations for integrating IPN roles. Table 3 presents the promising practices of IPN integration observed across both health authorities. A detailed discussion follows, exploring each promising practice in-depth and illustrating how these elements contribute to the effective integration and long-term sustainability of the IPN role. Table 3 Promising Practices in IH and NH IPN Role Integration Theme Promising Practices System Governance and Leadership Commitment to diversity and reconciliation Knowledge of Indigenous histories and rights Organizational commitments to Indigenous health equity Role Design and Infrastructure Variation in Indigenous-specific roles Cultural safety and Indigenous healing support Indigenous Engagement and Partnership Patient- and family-centered care Education and Workforce Development Advocacy and system navigation 89 Note. This table presents promising practices of IPN role integration within IH and NH, identifying where elements from the literature aligned with the content in job descriptions and service delivery location lists. 4.3.1.1.1. Commitments to diversity, human rights, and reconciliation. Health system commitments to diversity, human rights, and reconciliation serve as foundational structural practices that promote the integration of IPN within IH and NH (Davies, 2022). A review of selected policy documents shows that both authorities explicitly declare their support for these commitments. For instance, IH discloses its commitment to the TRC of Canada (2015a) Calls to Action, the DRIPA, and the BC Human Rights Code, displaying an official acknowledgment of Indigenous rights and obligations within healthcare (IH Careers, n.d.). Similarly, NH emphasizes diversity and inclusion within its organizational values, reinforcing its commitment to culturally safe and equitable service delivery (NH Careers, n.d.). These documented commitments not only reflect institutional support for Indigenous-specific roles but also align with the literature, which identifies such commitments as critical for embedding equity within health systems and advancing Indigenous health priorities (Tremblay et al., 2023). By linking IPN roles to these broader frameworks, IH and NH strengthen the legitimacy and necessity of Indigenous-specific positions as integral components of system-level change. 4.3.1.1.2. Role holder knowledge of Indigenous histories, rights, and health disparities. Expanding on these organizational commitments, literature and organizational data highlight that a strong understanding of Indigenous histories, rights, and health disparities is another key promising practice (Lux, 2010). Both IH and NH disclose, particularly in their job postings, a preference for candidates with knowledge of colonizationâs ongoing effects, systemic racism, and Indigenous rights (IH Careers, n.d.; NH Careers, n.d.). This emphasis directly complements their institutional commitments and aligns with research underscoring the importance of cultural and historical knowledge within Indigenous-90 specific roles (de Leeuw & Greenwood, 2019; Harjo et al., 2024). Such expertise enables IPNs not only to challenge systemic barriers but also to advocate for culturally safe care and build trust with Indigenous patientsâfactors essential to improving health outcomes and advancing equity (Groot et al., 2024; Tremblay et al., 2023; Rankin et al., 2024). Embedding staff with this expertise into healthcare teams further strengthens the sustainable implementation of the IPN role by ensuring that care practices reflect Indigenous worldviews and lived experiences (Caron, 2020). Research supports that culturally informed perspectives enhance both cultural safety and responsiveness, developing trust and engagement between patients and providers (Government of BC, 2019; Isaacson et al., 2023). By demonstrating this promising practice through recruitment strategies that prioritize knowledgeable hires, IH and NH actively support systemic change toward more equitable access to and outcomes in healthcare. 4.3.1.1.3. Supporting cultural safety and Indigenous healing practices. Organizational data from IH and NH show support for Indigenous health navigation through the employment of multiple Indigenous-specific roles. NH, for example, includes positions such as ICC and IHSA alongside the IPN role (NH Careers, n.d.). These varied roles focus on navigation, coordination, and advocacy, forming a complementary network that enhances Indigenous patient care (NH Careers, n.d.). The literature consistently describes the presence of diverse Indigenous-specific positions as a promising practice for effective role integration, improving cultural safety, and strengthening advocacy and communication between patients and providers (Tremblay et al., 2023). IH and NHâs use of multiple Indigenous-specific roles aligns with these evidence-based strategies, contributing to more holistic and culturally responsive health systems (Cochrane et al., 2024). 91 4.3.1.1.4. Varied Indigenous-specific roles. NHâs integration of diverse Indigenous-specific roles contrasts with IH, where the IPN role remains the sole Indigenous-specific title in use (IH Careers, n.d.). The literature emphasizes that integrating multiple Indigenous-specific roles strengthens the organizational capacity to provide culturally responsive care and improve outcomes (Tremblay et al., 2023). NHâs approach reflects a promising structural practice that supports the sustainability and effectiveness of the IPN role. 4.3.1.1.5. Patient- and family-centered care approach. Both IH and NH emphasize care models that extend beyond the individual patient to include the involvement of families and visitors. IPN role descriptions outline responsibilities spanning patient intake, discharge, and transitions to Indigenous health services or community supports. This approach aligns with Indigenous perspectives on wellness, which emphasize relational aspects of care involving family, community, land, and spirit (FNHA, n.d.). Supporting this approach, Isaacson et al. (2023) describe in their qualitative study of Great Plains American Indians how patient and family needs throughout the cancer journey are central to engagement and treatment adherence. 4.3.1.1.6. Advocacy and system navigation services. Advocacy remains a central function of the IPN role, essential for ensuring Indigenous patientsâ needs and preferences receive recognition within the health system (Newham et al., 2016). Both IH and NH organizational data describe advocacy as a fundamental IPN responsibility, encompassing the promotion of culturally safe care, service coordination, and removal of barriers (IH, n.d.b; NH, n.d.a). This emphasis on advocacy in both organizational data and role descriptions aligns strongly with the literature, which links advocacy to improved health outcomes and reduced disparities (Mackean et al., 2020). 92 System navigationâsuch as providing referrals, facilitating program enrolment, and coordinating appointmentsâconstitutes another core IPN function. Literature shows that navigation improves access to timely care, including critical screenings and treatments (Groot et al., 2024; Kleszynski et al., 2024). IH and NH data confirm these activities as fundamental to IPN roles, reinforcing their importance in role integration and utilization. Effective communication also supports IPN integration (Cochrane et al., 2024). Facilitating clear, jargon-free dialogue and employing visual aids improves patient understanding and engagement in care decisions (Cochrane et al., 2024; Orr et al., 2022). Literature describes respectful communication as a means of strengthening relationships between patients and providers (Newham et al., 2016; Enuaraq et al., 2021). IH and NH recognize communication support as core to the IPN role, further supporting successful integration (IH, 2025a; NH, n.d.a; NH, n.d.b). Together, these promising practices illustrate how IH and NH embed evidence-based practices that advance culturally safe, equity-oriented healthcare systems through IPN role integration. The promising practices summarized in Table 3 reflect foundational strengths in organizational commitments, knowledge integration, role design, and patient engagement. While these promising practices establish promising conditions, challenges remain. The following section examines structural and organizational inhibitors that impede the full integration of the IPN role within IH and NH, identifying key barriers supported by organizational data and literature. 4.3.1.2. Inhibitors. Document analysis identified multiple inhibitors embedded in organizational structures, policies, and implementation processes. For example, neither IH nor NH provided clear, system-level role expectations for IPNs despite literature emphasizing the importance of standardized frameworks (Hiscock et al., 2022) and role clarity for effective integration (McKenna et al., 2025). These inconsistencies in role definition and implementation demonstrate a lack of system-wide coordination, which hinders the full integration of the IPN role across health authorities. The following paragraphs outline specific barriers 93 identified in IH and NH that limit the integration process, including fragmented role governance, inconsistent organizational support, and misalignment with equity-based practices (Hiscock et al., 2022; Schmidt et al., 2016; Cochrane et al., 2024; McKenna et al., 2015). Comparing current practices in IH and NH to promising practices identified in the literature reveals several key themes that explain barriers to IPN role integration. Refer to Table 4 for a concise overview of the barrier themes. Table 4 Literature-informed Inhibitors in IH and NH Role Theme Inhibitors System Governance and Leadership Minimal Indigenous leadership in healthcare governance structures Lack of clear responsibility assignment to specific positions for cultural safety Role integration process not aligned with Indigenous health equity goals No evaluation and monitoring mechanisms Role Design and Infrastructure No role definition, including unclear scope and responsibilities of the IPN No foundational and guiding principles No compensation for specialized knowledge Indigenous Engagement and Partnership Lack of inclusivity of Indigenous communities in integration processes No stakeholder engagement 94 Theme Inhibitors Education and Workforce Development Lack of clear IPN educational responsibilities No culturally tailored training for IPNs Note. This table presents grouped inhibitors to IPN role integration, based on document analysis of IH and NH integration resources. The âinhibitorsâ column indicates integration activities or occurrences within IH and NH integration processes that correspond with barriers described in the literature on IPN role integration. 4.3.1.2.1. System governance and leadership. Governance and leadership challenges hinder the integration of IPN within IH and NH (Cochrane et al., 2024; Schmidt et al., 2016). One major inhibitor is the limited presence of Indigenous-identifying leadership at the executive and operational levels (Bernardes et al., 2017). The literature emphasizes the importance of Indigenous leadership in guiding culturally safe health system transformation and ensuring Indigenous perspectives shape service delivery (Bernardes et al., 2017). Without such leadership, IH and NH lack the organizational insight necessary to fully support the IPN role and respond to the needs of Indigenous communities (Bernardes et al., 2017). Another barrier involves misallocating responsibility for cultural safety. Both IH and NH primarily assign cultural safety to the IPN, despite research emphasizing that organizations as a whole must uphold cultural safety (Caron, 2020; Tremblay et al., 2023). This framing risks overburdening IPNs while allowing the broader system to avoid accountability (Mashford-Pringle et al., 2023). Further, the literature identifies the promotion of Indigenous health equity as a central goal of the IPN role (Rankin et al., 2022). IH and NH instead position the role as a support function for the health system to demonstrate Indigenous health equity rather than to improve health outcomes for Indigenous patients (Mackean et al., 95 2020; Newham et al., 2016). This misalignment undermines the transformative intent of the role. Compounding these issues is the lack of evaluation and monitoring systems (Schmidt et al., 2016). Without precise mechanisms to assess the impact of the role, IH and NH cannot ensure that the IPN role is meeting its intended objectives or adapting to changing needs (Schmidt et al., 2016). The absence of measurement and feedback impedes ongoing improvement and limits transparency and accountability (Pratt-Chapman et al., 2021). 4.3.1.2.2. Role Design and Infrastructure. Poorly defined role design continues to restrict the effective integration of IPNs (Rankin et al., 2022). The literature emphasizes the need for clearly defined roles to support practice and reduce confusion (Rankin et al., 2022). In IH and NH, organizational documents indicate that the IPN role lacks consistency in definition, purpose, scope, and titles, resulting in operational inefficiencies and reduced clarity (IH, n.d.b; NH, n.d.a; NH, n.d.b). IH and NH also fail to ground the IPN role in foundational Indigenous principles such as relational accountability, decolonization, and interconnectedness (Hart-Wasekeesikaw, 2009; Wilson, 2019). These principles critically shape culturally appropriate care models, yet current integration efforts fail to incorporate them (Hart-Wasekeesikaw, 2009; Wilson, 2019). Without embedding these values, the role risks becoming tokenistic rather than transformative (Hart-Wasekeesikaw, 2009; Wilson, 2019). Both health authorities also undercompensate IPNs despite the specialized knowledge the role demands (Mackean et al., 2020). IPNs bring expertise in Indigenous cultures, histories, and health disparities (Mackean et al., 2020), yet IH and NH do not provide wage remuneration that reflects this complexity. This lack of competitive pay undermines recruitment and retention, potentially discouraging qualified candidates from applying (Mackean et al., 2020). 96 4.3.1.2.3. Indigenous engagement and partnership. Both IH and NH fail to engage effectively with Indigenous communities during the integration of the IPN role (Browne et al., 2016; Cooke et al., 2013). While literature highlights stakeholder engagement as critical to shaping relevant and culturally safe Indigenous health roles (National Collaborating Centre for Indigenous Health [NCCIH], 2019), IH and NH do not provide evidence of formalized or consistent engagement strategies during role development and implementation. The absence of structured processes to engage Indigenous stakeholdersâincluding Elders and Knowledge Keepersâcompromises the IPN roleâs alignment with community needs and values (Tonkin et al., 2018). Without such partnerships, the role cannot fully reflect or respond to the lived realities and expectations of Indigenous patients and communities (Kelly et al., 2022). 4.3.1.2.4. Education and workforce development. Capacity and training limitations significantly reduce the effectiveness of the IPN role (Hiscock et al., 2022). Although expectations of the IPNs for educating both Indigenous patients and healthcare teamsâespecially in larger facilitiesâorganizational documents lack clear indications of this educational responsibility (IH, n.d.b; NH, n.d.a). This deficiency poses challenges because culturally tailored education plays a crucial role in driving systemic change (Quiñones et al., 2015). The literature indicates that IPNs serve as educators not only within healthcare settings (Mackean et al., 2020) but also in Indigenous communities (Burhansstipanov et al., 2014b). However, IH and NH have not fully articulated or supported this responsibility in their role descriptions. Furthermore, culturally specific training for IPNs remains insufficient (Hiscock et al., 2022). While clinical and medical training form a necessary foundation, research emphasizes the importance of knowledge about Indigenous worldviews, traditional healing practices, and community-specific approaches for the IPN (Hart-Wasekeesikaw, 2009). IH and NH do not provide this specialized training, 97 limiting IPNsâ ability to deliver culturally responsive care and effectively address Indigenous health disparities (Orr et al., 2022). 4.3.2. Comparing IPN role integration to evidence-based frameworks. The PEPPA and PEPPA Plus frameworks serve as tools to analyze how IH and NH integrate the IPN role. Using these integration frameworks enables a clear comparison of how IH and NH integrate the IPN role, along with best practices for APN role development, implementation, and evaluation. These integration frameworks help interpret the findings in a way that connects integration processes to established standards or approaches, enabling an assessment of how closely the integration of IH and NH's IPN role aligns with established best practices for specialized healthcare roles. Overall, this illustrates where IH and NH adhere to best practices outlined in the PEPPA and PEPPA Plus frameworks, and where their approaches to integrating the IPN role differ. 4.3.2.1. Similarities. IH and NH take some actions to support the integration of the IPN role, which aligns with the structured implementation and evaluation steps and stages described in the PEPPA and PEPPA Plus frameworks. Framing the findings within both frameworks enables the assessment of how each health authority applies evidence-informed practices that strengthen the IPNâs integration and evaluation. The analysis draws on available IH and NH data sourcesâspecifically, IPN job descriptions and service delivery location listsâto identify areas of similarity and to determine which steps of the PEPPA and PEPPA Plus frameworks current integration practices for the IPN role reflect. Analysis of IH and NH IPN job descriptions and service delivery location lists indicates that integration efforts correspond primarily to step one of the PEPPA framework and partially to stage one of the PEPPA Plus framework. Evidence of early-stage elements is present in IH and NHâs IPN or IPN-similar job descriptions, which identify the rolesâ patient target populations, describe models of care, and 98 include initial role planning (IH, 2025a; NH, n.d.a; NH, n.d.b). However, there is no straightforward evidence in the IH and NHâs data sources of progress beyond these initial steps or stages. Table 5 showcases the similarities between the best practice recommendations for APN role integration and the current IPN role integration practices in IH and NH. Although the initial step of the PEPPA framework for role development and implementation is present in IH and NH IPN data sources, publicly available documents from both health authorities do not show evidence of later integration stepsâsuch as systematic role evaluation, stakeholder engagement, or organizational readiness (Bryant-Lukosius, 2004). These missing steps suggest that IH and NH have established foundational elements, but they have yet to document or develop more advanced integration steps. Table 5 illustrates the PEPPA Framework steps involved in integrating the IH and NH roles. 4.3.2.2. Differences. The integration of the IPN role within IH and NH shows key differences when compared to the steps and stages outlined in the PEPPA framework and PEPPA Plus frameworks. These differences manifest as missing steps and stages in the frameworks for health system integration processes. Publicly available information from both health authorities provides no evidence of action on the PEPPA framework Steps Two through Nine, which encompass stakeholder identification and engagement, needs assessment, priority setting, role definition based on identified needs, structured implementation planning, Stakeholder engagement builds trust, secures buy-in, and gathers diverse perspectives that inform role design and integration priorities (Bryant-Lukosius & DiCenso, 2004). Similarly, needs assessment identifies service delivery challenges and clarifies how the IPN role can effectively address these issues (Bryant-Lukosius & DiCenso, 2004). The publicly accessible IH and NH IPN integration sources do not show evidence of these foundational activities. Additionally, they do not explicitly demonstrate priority setting and role definition, as organizations establish clear goals and expectations for the IPN role based on gathered data and 99 stakeholder input (Bryant-Lukosius & DiCenso, 2004). Without this clarity, the role risks being vaguely defined and inconsistently implemented across care settings (Bryant-Lukosius & DiCenso, 2004). The PEPPA framework also stresses the importance of structured implementation planning, which includes identifying necessary resources, aligning policies, and establishing evaluation processes to ensure effective role adoption and ongoing improvement (Bryant-Lukosius & DiCenso, 2004). IH and NH provide no public evidence of engaging in systematic planning or outlining processes to evaluate and refine the IPN role. The lack of visible documentation or formal strategies for these later stages reflects a significant departure from the comprehensive best practices advocated by the PEPPA framework. No publicly accessible IH and NH documents reveal key aspects of the PEPPA Plus framework, indicating that the integration of the IPN role in these health systems diverges from best practice guidelines. In the introduction stage, the PEPPA Plus framework emphasizes identifying the role needs of patients, families, healthcare teams, and the broader health system (Bryant-Lukosius et al., 2016). It also emphasizes the importance of promoting role clarity among stakeholders to support the development of competencies and clearly defined scopes of practice (Bryant-Lukosius et al., 2016). However, publicly available IH and NH information shows no evidence of stakeholder engagement or needs assessment, both of which are essential for aligning the IPN role with actual needs and securing stakeholder support. During the implementation stage, the PEPPA Plus framework advises organizations to ensure that they have in place appropriate professional standards, education, organizational policies, funding, and resources to support the role (Bryant-Lukosius et al., 2016). For example, the framework outlines the importance of aligning job descriptions with professional competencies and ensuring access to targeted education and sustainable funding to promote effective role implementation (Bryant-Lukosius et al., 2016). This alignment helps ensure that the role functions as intended and receives consistent organizational support across care settings (Bryant-Lukosius et al., 2016). However, the data analyzed from IH and NH do not indicate that either health system has undertaken these critical implementation activities to support the IPN role and understanding.100 Table 5. PEPPA Framework Steps Identified in the IH and NH Role Integration Step PEPPA Framework Application of the PEPPA Framework Step in Action: Description Interior Health Northern Health 1 Define the patient population (Bryant-Lukosius, 2004) â Identifies Indigenous patients and families â Identifies Indigenous patients and families Describe the model of care: How the patient enters the health care system (Bryant-Lukosius, 2004) â Describes acute or community health facility as the setting of service provision (IH, n.d.b) â Describes acute or community health facility as the setting of service provision (NH, n.d.a; NH, n.d.b) How the patient interacts with health care providers and services (Bryant-Lukosius, 2004) â Describes supportive, promotional, advocacy-based, and consultative interactions (IH, n.d.b) â Describes respectful, communicative, engaging, enabling, supportive, service-based, provisional, and incorporative interactions NH, n.d.a; NH, n.d.b) Describe the patient continuum of care (Bryant-Lukosius, 2004) â Describes the care continuum as throughout the patient care journey (IH, n.d.b) â Describes continuum of care as throughout patient engagement with acute or primary care services and from admission to discharge NH, n.d.a; NH, n.d.b) Note. This table summarizes Step One of the PEPPA framework. It illustrates the similarities between how IH and NH integrate their IPN roles and the best practices for role development and implementation recommended by the PEPPA framework 101 The analysis of IH and NH data reveals no evidence that either health authority addresses the Long-Term Sustainability stage of the PEPPA Plus framework in their IPN role integration. Publicly available documents do not show mechanisms for ongoing evaluation of the IPN roleâs impact on Indigenous patients or the broader health system. Neither IH nor NH describes processes to optimize the role based on outcomes or changing health system priorities (Bryant-Lukosius et al., 2016). Additionally, both health authorities lack formal plans to assess and adapt the IPN role to ensure it continues to meet the evolving needs of Indigenous patients and families (Bryant-Lukosius et al., 2016). This absence identifies a significant missing integration process for sustaining the IPN role, which consequently risks role underperformance and limited longevity within IH and NH (Bryant-Lukosius et al., 2016). The analysis reveals that the integration of the IPN role within IH and NH diverges significantly from the comprehensive, evidence-based processes outlined in the PEPPA and PEPPA Plus frameworks (Bryant-Lukosius et al., 2004; Bryant-Lukosius et al., 2016). This lack of similar action for integration suggests that IH and NH do not currently employ a systematic or collaborative approach necessary for an effective and sustainable IPN role. The preceding analysis reveals significant differences in the IPN role integration processes of IH and NH compared to established best practice frameworks. To deepen understanding of these findings, the upcoming section applies the SEAA framework to examine how dominant worldviews and power dynamics further influence the integration of the IPN role within these health authorities. This analysis examines the language and structures that reveal whose perspectives shape the process. It assesses how these perspectives align withâor contradictâthe equity commitments stated in IH and NH policies and practices. 4.3.3. Worldview and power. The SEA framework guides the examination of how IH and NH incorporate equity advancement into the integration of the IPN role within their health systems. Advancing equity necessitates a critical understanding of how dominant worldviews and unequal power distributions shape systems and practices 102 (Plamondon et al., 2023). These dynamics drive inequities and identifying them enables the dismantling of barriers to equitable outcomes (Plamondon et al., 2023). By applying the worldview element of the SEAA framework, this study analyzes the IPN role integration process to reveal the dominant worldviews and power structures embedded in the integration practices of IH and NH that impact the equitable integration of the IPN role. (Plamondon et al., 2023). Focusing on the SEAA framework element of worldview, the study will investigate the following research objective: 1. To examine the worldview present in the integration of the IPN role and its influence on the integration process. 4.3.4. Worldview and language use. Personal worldviews provide the lens through which individuals, groups, or systems perceive and comprehend the world around them (Dilthey, 1989). Worldview influences the health system design, delivery, and evaluation of care, reflecting core principles about health, illness (Dion Stout, 2012), as well as the hierarchy of individuals within the system (Mazurek Melnyk, 2013). Language plays a crucial role in conveying and reinforcing the worldviews and the structures of power they sustain (Matikeeva, 2022). Health systems use words and phrases that reflect dominant worldviews to indicate the underlying values, beliefs, assumptions, approaches to action, and priorities embedded in their system design (Matikeeva, 2022). Matikeeva (2022) states that language actively expresses and reinforces worldviews. An examination of the language use of IH and NHâs IPN job descriptions expresses the dominant worldview that shapes their health system designs, including how they integrate the IPN role. By utilizing these job descriptions as data sources, this study illustrates how language reinforces the dominance of one worldview over others within their health system (Matikeeva, 2022). IH and NH job descriptions use language that reflects a Western biomedical, Eurocentric worldview. Terms such as client, patient, clinical, primary care, and acute emphasize a focus on medical 103 care and treatment, consistent with biomedical health system paradigms (Smith, 2010; Wilson, 2008). Additionally, words like workforce, providers, team, professional roles, organizational structure, and collaboration highlight professional roles and organizational aspects typical of Western healthcare ideologies (Pol & Thomas, 1992). Phrases including best practice, evidence-based, accredited, and systems approach demonstrate adherence to standardized protocols and measurable outcomes, reinforcing a scientific, outcome-driven approach (Pol & Thomas, 1992). This language pattern reveals a structured, hierarchical system that prioritizes clinical effectiveness, organizational control, and efficient healthcare deliveryâhallmarks of a Western biomedical Eurocentric health system design (Kelkar, 2021). These terms and themes also impact how IH and NH integrate their IPN roles, situating these Indigenous-specific healthcare roles within system designs that centre scientific evidence and organizational efficiency. 4.3.4.1. Power and language use. The worldview element of the SEA framework guides the examination of IH and NH IPN job descriptions by showing the worldview that dominates the integration processes. It also identifies integration key actors and assesses the power dynamics of their relationships (Plamondon et al., 2023). This analysis categorizes language into three key themes: (1) power-laden, (2) directive-compliance, and (3) framing deficiency. The following critically reflective and systems-thinking questions guide the equity analysis of worldview within the IH and NH IPN role integration: â¢ What language is used to describe the varying levels of authority among key players in the health system? â¢ How does this inform whether Western or Indigenous worldviews dominated the health system designs of IH and NH? 104 4.3.4.1.1. Health system leadership and power-laden language. Indigenous health equity remains a critical concern within BCâs health systems (Sehgal et al., 2025). Despite efforts to improve care for Indigenous populations, the integration of IPN roles reveals persistent challenges rooted in underlying worldviews. Analyzing job descriptions from IH and NH uncovers a consistent use of power-laden language that reflects a Western biomedical worldview. This worldview constructs a hierarchical and centralized health system design, reinforcing existing authority structures and influencing how Indigenous roles are positioned within these organizations (Kelkar, 2021). Addressing barriers and advancing more equitable healthcare systems requires understanding this dominant worldview (Kelkar, 2021). Power-laden language in IH and NH job descriptions reinforces hierarchical authority within the health system (Ojha, 2021). Verbs such as establishes, invites, assigns, offers, covers, and delivers, along with nouns like consideration, internal equity review, preference, values, and fully accredited, appear frequently throughout the data (IH, n.d.b; NH, n.d.a; NH, n.d.b). These word choices frame the health system as the central agent of actionâleading, controlling, and directing the integration processâwhile positioning leadership as the source of authority (IH, n.d.b; NH, n.d.a; NH, n.d.b). Phrases such as "is directly relevant," "we also want," and "provides exceptional health services" further reflect this directive tone (IH, n.d.b; NH, n.d.a; NH, n.d.b). This language constructs the system and its leadership as dominant decision-makers, guiding role integration through centralized institutional control (Hadem, 2022). It reflects a Western biomedical worldview that concentrates decision-making power within formal hierarchical organizational structures (Ojha, 2021). 4.3.4.1.2. The IPN and directive-compliance language. Directive-compliance language in IH and NH job descriptions positions the IPN as a role that functions under institutional authority rather than shaping or challenging it (Langevoort, 2017). Verbs and directive phrases such as supporting, providing, ensuring, assigned, works, acts as a, assists, at 105 [managerâs] request, attending, as required, maintains, shall adhere to, are responsible to, under the direction of, working directly as a member of, reporting, as well as terms like in accordance with, in alignment with, demonstrated, using, commitment to excellence, and dedicated staff, appear frequently across job postings (IH, n.d.b; NH, n.d.a; NH, n.d.b). These verbs describe the expectations of IPN under the direction of others, signaling actions that sustain existing health system frameworks rather than transform them (Kuang & Bicchieri, 2024). This language reflects an expectation that the IPN fulfill supportive tasks directed by a higher authority within the organization, rather than act autonomously or engage in systemic change (Kuang & Bicchieri, 2024; Langevoort, 2017). By emphasizing compliance over leadership, this framing reinforces the IPNâs subordinate position within a hierarchical structure and aligns with a Western biomedical worldview that centers on control and institutional authority (Langevoort, 2017). 4.3.4.1.3. Indigenous populations and deficiency-framing language. The language used to describe Indigenous patient populations in IPN role integration documents reflects a deficit-oriented framing that positions Indigenous individuals and families as dependent on institutional support (Neeley, 2024). Verbs such as supporting, providing services to, works with, problem-solving for, and counsels portray Indigenous people as passive recipients of care rather than active participants in decision-making (IH, n.d.b; NH, n.d.a; NH, n.d.b). Nouns like positive relationship between Indigenous individuals/families and healthcare providers, impacting, needs of, and First Nation, Métis, and Inuit care needs reinforce narratives centered on unmet needs and institutional responsibility (IH Careers, n.d.; NH Careers, n.d.). Phrases such as supporting positive relationships, problem-solving for Indigenous individuals and families, providing services to Indigenous, Métis, and Inuit individuals, and monitoring of needs (IH Careers, n.d.; NH Careers) further highlight this dynamic of external intervention and oversight (Neeley, 2024). This language sustains a power imbalance where the health system leads, controls, and directs care, aligning with a Western biomedical worldview that centers institutional authority and minimizes Indigenous agency (Ojha, 2021). 106 This analysis reveals how the dominance of a Western worldview influences the choice of language used in IH and NH's IPN integration resources. The specific word choices reflect and reinforce hierarchical power structures (Ojha, 2021), particularly in how the health system describes itself, its leadership, and its expectations of workers (Langevoort, 2017). At the same time, the language used to refer to Indigenous patients constructs them as passive recipients of care, often framed through deficit-based and compliance-oriented terms (Neeley, 2024). Together, these linguistic patterns reveal how Western health systems maintain authority and marginalize Indigenous worldviews by positioning Indigenous peoples as deficient and the IPN role as a subordinate role (Ojha, 2021). These findings signify the need for critical reflection on how language shapes healthcare processes, policies, strategies, frameworks, and practicesâand how it can either reinforce or disrupt structural inequities in care delivery involving Indigenous Peoples. 4.3.5. IPN role integration alignment with health system equity goals and or commitments. Researchers can critically analyze the integration of the IPN role to determine how well IH and NH practices align with their health systemsâ existing equity commitments and goals. Guided by the coherence element of the SEAA framework, this research examines the alignment between IH and NH equity commitments and goals, as well as the integration of the IPN role. It assesses how well the stated commitments correspond with actual integration processes. This lens enables researchers to evaluate not only the presence of equity language in policy and planning documents but also how Indigenous and non-Indigenous IH and NH communities operationalize these commitments through IPN integration (Plamondon et al., 2023). 4.3.5.1. Health system equity commitments and goals. The SEA framework offers a structured, multimodal approach to evaluating how equity is embedded and advanced within health systems (Plamondon et al., 2023). It provides a lens to assess the 107 extent to which IHâs stated equity goals align with its operational practices related to integrating the IPN role. The analysis examines the coherence between IHâs commitments, and the actions undertaken to advance equity through the integration of the IPN role. To support this assessment, an analysis of IHâs strategic priorities first identifies its equity goals and the corresponding actions proposed to advance equity. The study examines the proposed actions within the IPN role integration process to determine their presence and application. IHâs (2024) Our Strategic Direction 2024â2027 strategic priority explicitly commits to advancing equity and access (IH, 2024). To fulfill this commitment, IH outlines targeted actions, including modifying service delivery to enhance equity and access, particularly for Indigenous, rural, and remote communities, and addressing the factors that impact equity (IH, 2024). These strategic priorities emphasize a comprehensive approach to advancing equity throughout the organization. The analysis assesses whether the integration of the IPN role encompasses proposed actions, including capacity building, enhancing shared understanding, leveraging data, transforming service delivery, and addressing equity-influencing factors (IH, 2024). To assess how IH operationalizes its commitments to equity, this section presents an overview of the organizationâs stated goals, followed by the corresponding actions designed to advance these goals. Table 6 H Equity and Equity-Related Goals and Commitments Interior Health Data Source Equity and or Equity-Related Goals and Commitments AU2100- Diversity Policy Encourage a diverse, inclusive, and respectful workforce 108 Note. This table articulates IHâs equity and equity-related goals and commitments as outlined in IH's key policies and strategies. The goals emphasize IHâs commitment to advancing equity, increasing diversity, eliminating racism, promoting cultural safety, strengthening Indigenous partnerships, and improving equitable access to health services (IH, n.d.a; IH, 2022; IH, 2024). They form the foundational principles guiding IHâs equity-focused initiatives. Following this, the upcoming list outlines the specific actions IH proposes to employ to achieve equity goals and commitments. Interior Health Data Source Equity and or Equity-Related Goals and Commitments AU2200- Anti-Racism Policy Eliminate racism through active anti-racism efforts Address racism with accountability AD0200- Aboriginal Cultural Safety & Humility Policy Provide culturally safe, competent care and services Ensure safe, discrimination-free workplaces Support access to traditional medicines and healing Embed cultural safety in policies and practices Indigenous Health and Wellness Strategy Partner with Aboriginal communities Our Strategic Direction 2024-2027 Advance equity and access by transforming service delivery 109 Table 7 IH Actions to Advance Equity Goals and Commitments Interior Health Data Source Actions to Achieve their Equity Goals and Commitments Indigenous Health and Wellness Strategy âHealth equity through shared accountability. We will: Develop a data governance framework with Nation Partners to enhance information and reporting [â¦]. Utilize a quality improvement approach to reviewing select IH programs and services [â¦]. Enhance the Indigenous patient voice [â¦]. Enhance primary and community care resources. Support Elders to remain close to home. Improve discharge planning and transition in care. Advance digital health initiatives to increase access to servicesâ (IH, 2022, p.22). Our Strategic Direction 2024-2027 âBuild capacity and shared understanding [â¦] and using data to reveal health inequities. Changing how we deliver services to improve equity and access, [â¦]. Acting upon the many factors that influence [â¦] and health equityâ (IH, 2024, Advancing Equity and Access). Accessibility Plan 2024-2027 Establish accessibility committees and plans to remove and prevent barriers (IH, n.d.a). Create feedback tools to report barriers and suggest improvements (IH, 2024). AD0200- Aboriginal Cultural Safety & Humility Ensure culturally safe workplaces, care, and physical environments (IH, 2021a) âSupport Aboriginal Staff to access Cultural Practices and traditional medicines where possible 110 Interior Health Data Source Actions to Achieve their Equity Goals and Commitments and appropriate, in their work environmentâ (IH, 2021a, p. 4). âSupport staff to participate in [â¦] that promote Aboriginal Cultural Safety, including education, resources, and/or community engagement, based on availability and applicability and managerial support for cultural safetyâ (IH, 2021a, p. 4). â [â¦] investigate and address anti-Aboriginal racism and actively engage in Anti-Racism practicesâ (IH, 2021a, p. 4). AU2200- Anti-racism Actively engage in anti-racism efforts addressing anti-Indigenous racism (IH, 2021a). Support recognition, reporting, and response to racism; prohibit retaliation against reporters (IH, 2021a). Note. This table outlines the specific actions IH indicates it is taking, or will take, to implement its equity goals and commitments across key strategies, plans, and policies. The actions listed collectively illustrate how IH translates its equity commitments into operational practice to advance equity within its health system. Integration of the IPN role demonstrates how IHâs organizational actions reflectâor fall short ofâits stated equity policy goals and commitments. Document analysis reveals areas of alignment, such as efforts to build capacity and improve access, alongside shortcomings in accountability, evaluation, and clarity of implementation. The findings below describe how the integration of the IPN role aligns and misaligns with IHâs equity intentions. 4.3.5.1.1. Alignment. The integration of the IPN role into IHâs health system aligns with some organizational commitments outlined in its equity and equity-related policy goals. For example, IHâs AU2100 Diversity Policy commits to âthe inclusion of diverse perspectives and points of viewâ (IH, 2019). IH demonstrates this 111 commitment in their IPN hiring practices, which gives âpreferential consideration and/or hiring [..] to qualified applicants who self-identify as Indigenousâ (IH, n.d.b, p. 1). This practice supports the inclusion of Indigenous Peoplesâ diverse perspectives and points of view within the IPN integration. Further alignment is evident with IHâs Our Strategic Direction 2024-2027, which sets the goal of âadvancing equity and accessâ by âchanging how [IH] deliver services to improve equity and accessâ (IH, 2024, âOur Strategic Priorities). Similarly, the IHâs Accessibility Plan emphasizes a similar goal by committing âto changing how [IH] deliver services to improve equity and accessâ (IH, n.d.a., p.7). The IPN role itself transforms service delivery by introducing an Indigenous-specific positionâhistorically absentâdesigned to support culturally safe care and guide patients through the health system. These examples reflect tangible steps that IH is taking to achieve its equity or equity-related commitments and goals in its process for integrating IPNs into its health systems. Refer to Table 8 for demonstrations on how IH shows coherence between its IPN role integration and its equity and equity-related goals and commitments. 4.3.5.1.2. Weak Alignment. Some areas of IPN integration demonstrate precise alignment or misalignment with IHâs equity commitments and goals. In contrast, other areas reveal vagueness due to a lack of clarity, direction, or detail in key documents. Vagueness, omissions, or silences occur when policies, strategies, or plans make broad statementsâor say nothing at allâomitting the specific processes, resources, and responsibilities required to operationalize commitments (McConnell & Hart, 2019). One example of this is IHâs statement that âsystemic racism exists in the workplace and healthcareâ (IH, 2021b, p.1). This generalized wording does not explicitly acknowledge that systemic racism occurs within IHâs workplaces or services. By framing the issue broadly, the organization distances itself from the problem, effectively minimizing its sense of responsibility to address racism internally. Unfortunately, this approach makes the operationalization of addressing Indigenous-specific racism less likely to occur or be successful. 112 While the IHâs (2021) AU2200 Anti-Racism Policy outlines procedures for reporting experiences of racism, it offers limited detail on how reports are investigated or acted upon. This combination of vague statements and omissions produces a âreport itâ approach without clarifying the subsequent steps. Consequently, even when reporting mechanisms exist, the lack of operational guidance and follow-up limits meaningful action. In IPN role integration, this performative statement signals a commitment without providing the direction needed to ensure its implementation. As a result, the health system offers no concrete support to IPNs in addressing racism, limiting their ability to carry out key functions, such as reducing incidents of racism and cultural unsafety experienced by Indigenous Peoples. These omissions and vagueness in IHâs Anti-racism policy undermine the successful integration of the IPN role and the broader equity advancement goals of the health system. The IPN integration process reveals a misalignment with the health systemâs stated equity goals and commitments. While these goals emphasize advancing equity, the actual efforts within the IPN integration often fall short of fully realizing these commitments. Furthermore, there is a disconnect between the equity-advancing actions taken and the recognition or addressing of the underlying root causes of inequity (Plamondon et al., 2023). This section examines these misalignments to identify inconsistencies between the health systemâs equity intentions and the practical actions taken to advance equity, highlighting the need for stronger alignment to achieve meaningful equity outcomes (Plamondon et al., 2023). The analysis focused on how IH has integrated the IPN role into its health system, using IHâs stated equity and equity-related goals, commitments, and focused actions as the basis for comparison. A review of IHâs publicly available data sources did not identify evidence that the integration of the IPN role included actions explicitly aligned with several key commitments. These include eliminating racism through active anti-racism efforts, embedding cultural safety into policies and practices, fostering an inclusive and respectful workforce, and ensuring safe, discrimination-free workplaces (IH, n.d.a; IH, 2022; IH, 2024). 113 Table 8 Indigenous Patient Navigator Integration versus Interior Healthâs Equity Commitments and Goals Equity Commitment and or Goal Evidence of Alignment Evidence of Misalignment Alignment Rating âChange how [IH] delivers services to improve equity and accessâ( IH, n.d.a., p. 7). The IPN role is a relatively new approach to service delivery aimed at reducing barriers to health services and promoting equity. Alignment âTo develop a workforce that knows the value of diversity, appreciates the unique contributions to the organizations, clients, customers, [â¦] through the inclusion of diverse perspectives and points of viewâ (IH, AU2100 Diversity Policy, p. 1) IPN job descriptions prioritize hiring Indigenous applicants to support inclusion of Indigenous perspectives and points of view in their workforce (IH, n.d.b., p. 1). There is no evidence to indicate that within the IPN role integration, there are efforts to promote a workforce that values diversity and/or recognizes the unique contributions that diversity brings to the organization, its clients, and/or customers. Partial Alignment âAdvance equity and access [by] focusing on: 1. Building capacity and shared understanding, and using data to reveal health inequities 2. Change how [they] deliver services 3. Act upon the many factors that influence population health and IH job descriptions describe the IPN role as a position that changes service delivery to âensure the provision of care is culturally safe and client-centeredâ. Under âWhat you will work on,â the job description outlines the roleâs capacity to â[promote] safe, inclusive, respectful, No evidence indicates how IH is building shared understanding, or how it is using data to reveal health inequities. There is also no evidence on how IH identifies and then acts upon the many factors that influence population health and health equity. Partial Alignment 114 Equity Commitment and or Goal Evidence of Alignment Evidence of Misalignment Alignment Rating health equityâ (IH, 2024, âAdvancing Equity and Accessâ). and productive access to care for Indigenous individuals.â (IH, n.d., p.1). âTo eliminate racism in Interior Health workplaces and health care. Define the differences between racism, systemic racism, and anti-Aboriginal racism. Address unequal power dynamics [â¦] and the structures that sustain it. Identify, remove, and eliminate barriers created by systemic racism.â âEliminate harms and eliminate negative experiences resulting from race-based discrimination at individual and systemic levels created by systemic Racism (IH, n.d.b., p.1). Outline responsibilities and procedures to respond to Racism (IH, 2021b, p.2). There is no evidence of anti-racism strategies within the IPN role integration. Integration resources do not outline responsibilities and procedures for responding to Racism. There is no evidence of approaches to how the IPN, or others working with the IPN, can identify, report, and/or address racism. There is no evidence of efforts to address unequal power dynamics or dismantle systemic racism and the structures that sustain it. No evidence of redistributing power, resources, or decision-making. There is no evidence to show how to identify harms and eliminate those harms that result from race-based discrimination at any level of the health system. Misalignment âCreate racial equity throughout IHâ (IH, 2021b, p. 2) There is no evidence of practices or actions that ensure fair and just outcomes for racialized groups in the area of health. Misalignment 115 Equity Commitment and or Goal Evidence of Alignment Evidence of Misalignment Alignment Rating There is no evidence of intentional designs to remove racial disparities and achieve fair and just outcomes across racial groups in the area of health. Embedding Cultural Safety into policies and practices There is no evidence of any policies and or practices that embed cultural safety within the IPN integration. Integration resources do not provide information regarding cultural safety training or education for the IPN or their coworkers. Misalignment Community engagement and collaboration The sources provide no descriptions of how Indigenous community input, partnership, or collaboration informs the IPN role. Misalignment Note. This table compares IH's equity commitments and goals with its integration of the IPN role, revealing where IH meets, partially meets, or does not meet its stated equity commitments and goals as outlined in its equity or equity-relevant policies, strategies, and plans, or other key documents. 116 The analysis found no documentation indicating that the IPN role integration process incorporated strategies to raise organizational awareness of social, historical, and power dynamics or to embed these perspectives in policy development (IH, 2022). Nor was there evidence of integration actions related to investigating complaints of cultural unsafety, addressing anti-Indigenous racism, or establishing accountability mechanisms for racism in the workplace (IH, 2022). Additionally, no references were found to suggest the IPN integration process supported staff participation in cultural safety education, facilitated Indigenous community engagement, or involved collaboration with Indigenous partners in planning and evaluation (IH, 2022). The review also did not identify efforts within the integration process to build internal capacity or shared understanding of equity, use data to identify health inequities, or implement tools to report and address accessibility barriers (IH,2024). These findings indicate limited transparency in how IHâs commitments to equity and anti-racism are reflected in the integration of the IPN role. A comparable analysis could not be conducted for NH, as no publicly available documents outlining NHâs equity or equity-related goals or commitments were identified. 4.3.5.1.3. Misalignment The analysis identified a degree of misalignment between IHâs stated equity and equity-related commitments and the documented actions associated with the integration of the IPN role. While IH commits to eliminating racism, embedding cultural safety, supporting inclusive workplaces, and increasing organizational awareness of power dynamics, the materials reviewed did not reflect these goals in the IPN role integration. The data did not indicate that actions tied to these commitments were embedded into the integration process. As a result, the integration of the IPN role showed limited alignment with the broader structural changes IH has committed to. This misalignment identifies the absence of documented efforts connecting the IPN role to specific equity-advancing actions. Plamondon et al. (2023) caution that bold equity statements without accompanying systemic change risk reinforcing existing inequities under the appearance of progress. 117 The analysis uncovered a disconnect between IHâs suggested measures to promote equity and the fundamental causes of inequity highlighted in the literature (Plamondon et al., 2023). Plamondon et al. (2023) assert that inequities are mainly perpetuated through the imbalanced distribution of resources, wealth, and power. Although IH presents a variety of initiatives aimed at enhancing equityâsuch as raising organizational awareness of social and historical contexts, engaging in anti-racism initiatives, promoting cultural safety education, and leveraging data to pinpoint inequities (IH, n.d.a; IH,2022; IH, 2024)âthese initiatives fail to directly tackle or assess how power, resources, or wealth are allocated within the health system or concerning the integration of the IPN role. The analysis did not find evidence that the integration process incorporated strategies focused on redistributing decision-making power, earmarking funding specifically for the IPN role, or guaranteeing equitable representation of Indigenous perspectives in structural or policy-level decisions. Consequently, the coherence between IHâs proposed equity measures and the evidence-based root causes of inequity remain limited concerning the integration of the IPN role. 4.4. Conclusion Chapter Four presents the analytical content derived from IH and NH data sources regarding the integration of the IPN role and each health authority's equity commitments and goals. It reports findings connected to the research objectives, including key promising practices and inhibitors of the IPN role integration, similarities and differences compared to the PEPPA and PEPPA Plus frameworks for the APN role integration, and considerations of worldview and power, as well as alignment and misalignment between stated equity intentions and operational practices. The findings reveal both coherence and disconnect between health system equity goals and commitments, and the actions intended to achieve them within the IPN role integration. Chapter Four findings provide the basis for Chapter Five, where the study analyzes the results through the SEA framework and relevant literature to interpret their significance and explore implications for advancing equitable IPN role integration and systems change. Chapter Five also provides an in-depth 118 discussion of these findings, analyzing their implications and examining the structural, operational, relational, and cultural levels of health systems to produce recommendations that could influence the equitable integration of the IPN role within IH and NH. 119 5. Chapter Five: Discussion The first four chapters provide background and present the results of the analysis on integrating the Interior Health (IH) and Northern Health (NH) IPN roles, as well as their alignment with health system equity commitments and goals. Building on this foundation, this chapter presents the results of a systematic analysis comparing the integration of the IPN role in IH and NH with the Participatory Evidence-based Patient-focused Process for Advanced Practice Nursing (PEPPA) and PEPPA Plus frameworks for the Advanced Practice Nurse (APN), seeking similarities and differences within the frameworks and health system processes. Additionally, the analysis examines how prevailing worldviews and dominance-supporting language influence practices and assesses the extent to which the integration of these roles aligns with stated equity goals and commitments. Finally, this chapter concludes with a presentation of the research's interpretation and significance in the context of inequities and the spirit of promoting equity, along with descriptions of the studyâs limitations and recommendations for future research. 5.1. Opportunities for Improving Equitable Role Integration This analysis finds that IH and NH adopt an approach to integrating the IPN role that largely misaligns with the APN integration frameworks described by Bryant-Lukosius and Dicenso (2004) and Bryant-Lukosius et al. (2016), sharing only minimal similarities. This misalignment indicates that both health authorities need a more comprehensive, context-specific process for integrating IPN roles. For the PEPPA framework, this research finds the main similarity between how IH and NH integrate their IPN role and the recommended steps of the PEPPA framework is that both health systems define a target patient population and describe a model of care, elements identified by Bryant-Lukosius & Dicenso (2004) as steps one and two of their integration process. However, the analysis identifies several key steps missing from how IH and NH integrate the IPN role compared to the PEPPA framework. The study finds that IH and NH omit several key steps, including engaging stakeholders, determining the need for new models of care, identifying priority problems and goals to improve the model, defining the new model, 120 and planning implementation (Bryant-Lukosius & Dicenso, 2004). These steps correspond to steps three through nine of the PEPPA framework (Bryant-Lukosius & Dicenso, 2004). Similar shortcomings appear when comparing IH and NH integration practices with the PEPPA Plus framework. Specifically, the three stages of the frameworkâIntroduction, Implementation, and Long-Term Sustainability (Bryant-Lukosius et al., 2016)âare absent from the IPN role integration processes in both health authorities. The elements missing from IH and NH IPN role integration practices, as outlined in the PEPPA (Bryant-Lukosius and Dicenso, 2004) and PEPPA Plus frameworks (Bryant-Lukosius et al., 2016), reveal key differences between recommended best-practice integration and current practices in IH and NH. Indigenous scholar Davies's (2022) research on the impacts of Settler colonialism on health interventions targeting Indigenous Canadians indicates that the legacy of colonialism and paternalistic models of care continues to shape health systems, contributing to the ongoing discrimination and domination of Indigenous Peoples through entrenched power relations. This analysis reveals the dominance of a similar colonial or Western biomedical worldview, as suggested by the hallmark utilization of power-laden language (Fairclough, 2013) to characterize the health system and leadership comprehensively, as well as directive-compliance indicators for the IPN, alongside deficiency-framing references concerning Indigenous patients and families. Findings show that IH implements the role in ways that conflict with equity goals more than they align with them. It is worth noting again that the analysis of the coherence between the equity goals of NH is not attainable for this study due to the absence of publicly accessible data sources that delineate equity or equity-related commitments. Therefore, this study bases its interpretations of the findings regarding equity coherence alignment and equity policies, strategies, and plans solely on the analysis of IH data. Evaluating the research results in the context of existing knowledge reveals how the new data align with previous findings in the literature. The analysis comparing IPN role integration with the APN processes outlined in the PEPPA and PEPPA Plus frameworks reveals practices that could strengthen IPN integration and promote a more equity-oriented approach. Undoubtedly, empirical and anecdotal evidence suggest the IPN role helps reduce health disparities (Pratt-Chapman et al., 2021). Efforts to redress these 121 inequities are a pressing requirement in the current landscape of Indigenous healthcare and a pivotal recommendation within modern Indigenous reconciliation frameworks. Social and structural determinants of health, as well as the underlying conditions that shape power and resource distribution within health systems, determine equity (Plamondon & Shahram, 2024). Given the critical importance of IPNs in reducing Indigenous health disparities (Pratt-Chapman et al., 2021), the approaches and practices of health systems in integrating the IPN role serve as a determinant of equity. The results of this study provide specific, practical recommendations and pathways forward for a more meaningful and equitable integration of IPNs in health system settings. Lastly, this chapter builds on a comparative analysis by examining how the study's findings can inform the multiple levels of health system functioning, as depicted in Figure 2, which includes structural, operational, relational, and cultural aspects. The study integrates concepts from two complementary health system frameworks: Singer et al.'s (2020) integration model and Leslie, Fadaak, and Pinto's (2023) meso-level integration study. Singer et al. (2020) provide two of the health system levels: structural and functional (which I refer to as operational). Meanwhile, Leslie et al. (2023) contribute the remaining two levels: relational and cultural. Combining insights from both models, the analysis identifies four interrelated levels â structural, operational (Singer et al., 2020), relational, and cultural (Leslie et al., 2023) â to examine the conditions that support or constrain the integration of Indigenous-specific roles. Each level reflects distinctive characteristics, responsibilities, decisions, and relationships within health systems (Singer et al., 2020; Leslie et al., 2023). By synthesizing these systemic levels from both frameworks, the analysis constructs a more comprehensive framework for interpreting the findings in the context of Indigenous equityâfocused integration. Considering these distinct levels supports a nuanced interpretation of the findings, revealing how the integration of promising practices and barriers is distributed across the system and highlighting specific points for action to promote a more effective and equitable integration of Indigenous-specific roles. 122 Figure 2 Levels of Health System Functioning Note. This figure illustrates and describes the structural, operational, relational, and cultural levels that influence the functioning of a health system. Adapted from Singer et al. (2020) and Leslie et al. (2023), health system integration frameworks. Table 9 outlines key implications of this study across four levels of the health system: structural, operational, relational, and cultural. Within each of the structural, operational, relational, and cultural levels, the table identifies specific areas of focus and corresponding actions that support systemic equity transformation. Together, these implications provide health system leaders and practitioners with clear guidance on how to embed Indigenous perspectives, strengthen the integration of Indigenous-specific roles, such as IPNs, and create culturally safer, more accountable, and equity-focused care environments. 123 Table 9 Health System Implications Across Structural, Operational, Relational, and Cultural Levels Level Focus Area Key Implications Structural Policies, governance, funding, accountability â¢ Reform equity policies and governance frameworks to embed collective responsibility for Indigenous health equity across all departments and leadership levelsânot just Indigenous-specific roles or programs. â¢ Restructure funding models to provide sustained, core funding for IPN roles, embedding them as essential rather than short-term or externally funded. â¢ Establish system-wide accountability mechanisms, including oversight by Indigenous partners. â¢ Align organizational strategies with commitments to decolonization, role integration, and Indigenous self-determination. Operational Processes, role clarity, Implementation, practices â¢ Revise job descriptions, onboarding, and reporting for IPNs to reflect relational, advocacy, and cultural bridging functionsânot just clinical support roles. â¢ Ensure cross-departmental coordination to integrate IPNs across care pathways, particularly in crisis response, transitions, and discharge planning. â¢ Develop implementation tools that distribute responsibility for IPN support across teams and management. â¢ Integrate IPNs into interdisciplinary care teams and workflows to avoid peripheral positioning. Relational Relationships, power-sharing, trust, engagement â¢ Foster shared responsibility for building trust with Indigenous patients and communities, beyond relying solely on IPNs. â¢ Promote power-sharing so IPNs can co-lead initiatives and address systemic issues without fear of tokenization. â¢ Invest in leadership development and mentorship for IPNs and Indigenous staff to build confidence and relational accountability. 124 Level Focus Area Key Implications Structural Policies, governance, funding, accountability â¢ Reform equity policies and governance frameworks to embed collective responsibility for Indigenous health equity across all departments and leadership levelsânot just Indigenous-specific roles or programs. â¢ Restructure funding models to provide sustained, core funding for IPN roles, embedding them as essential rather than short-term or externally funded. â¢ Establish system-wide accountability mechanisms, including oversight by Indigenous partners. â¢ Align organizational strategies with commitments to decolonization, role integration, and Indigenous self-determination. â¢ Model ethical, reciprocal engagement with Indigenous partners and knowledge holders. Cultural Values, norms, worldviews, epistemologies â¢ Challenge dominant biomedical paradigms by validating Indigenous worldviews as equal and essential to the design of holistic care and services. â¢ Support cultural continuity by embedding local Indigenous knowledge, language, and protocols in care environments and frameworks. â¢ Promote decolonizing, strength-based, and relational language in communications, policies, and tools. â¢ Normalize cultural humility through reflective practice, education, and institutional storytelling grounded in local histories and traditions. Note. This table summarizes the key implications for integrating the IPN role across four levels of the health system: structural, operational, relational, and cultural. The organization of implications reflects areas for action that support systemic transformation and advance Indigenous health equity in the Interior and Northern Health regions. 125 5.2. Applying Critical Indigenous Theory The transition from presenting findings to interpreting them prompts the application of Critical Indigenous Theory (CIT), which centers on Indigenous philosophies, worldviews, and principles, exposes Western dominance and power relations, while introducing a relational practice committed to decolonization (Denzin et al., 2008). Applying CIT moves this study to move beyond a descriptive account of how health systems operationalize IPN role by showcasing how integration documents, such as IPN job descriptions, perpetuate power distributions in ways that might otherwise remain unnoticed (Denzin et al., 2008). In this study, CIT also brings forward relationality and collective responsibility as lenses that not only reveal insightful and promising practices but also provide relevant strategies for addressing current barriers to role integration and equity advancement. For example, CIT examines how health systems apply promising practices across different levels and identifies the actors responsible for implementing them. This approach of critical analysis reveals opportunities to reframe responsibility through Indigenous concepts of collectivism and shared accountability. In this way, CIT enables a critique of colonial constructs while privileging Indigenous knowledge (Denzin et al., 2008) as a foundation for integrating the meaningful IPN role. This approach helps health systems in meeting their equity goals and commitments while generating insights into systemic barriers and relational practices necessary to advance equity through IPN role integration. Ultimately, insights gained from applying CIT provide health systems and their leadership with strategies that are culturally grounded, equity-oriented, and responsive to the needs of Indigenous patients, staff, and communities. 5.2.1. Advancing equity: Integrating knowledge, critically assessing practice, and applying Indigenous worldviews in the IPN role integration. 5.2.1.1. Promising practices for IPN role integration. Promising practices currently supporting the integration of IPN roles within IH and NH align with recommendations from the literature on the successful implementation of other specialized roles, such as 126 the APN. Promising practices for integrating the IPN role exist within both health systems and emerge across the four health system levelsâstructural, operational (Singer et al., 2020), relational, and cultural (Leslie et al., 2023). The study finds that promising practices already exist within IH and NH, indicating a positive starting point for integrating the IPN role. This section identifies and analyzes these practices in terms of their occurrence within IH and NH, as well as who holds responsibility for implementing or supporting them. In doing so, the analysis addresses the research objective of identifying current practices that strengthen the integration of IH and NH IPN roles. This study identifies several promising practices that support the integration of the IPN role within IH and NH, including organizational commitments to promote diversity (Vukic et al., 2012), enhance human resources (Pratt-Chapman et al., 2021), and advance reconciliation (Caron, 2020); varied IPN roles (Rankin et al.,2022); patient and family centre care approach (Groot et al., 2024); advocacy (Orr et al., 2022); role-holder knowledge of Indigenous histories, rights, and health disparities (Rankin et al., 2022); and support cultural safety (Tremblay et al., 2023) and Indigenous healing practices (Davies, 2022). These promising practices map to the four distinct health system levels â structural, operational, relational, and cultural â wherein each level involves different responsibilities and accountabilities. Figure 2 visually represents the four-level health system framework, which contextualizes the nature and focus of each level. Table 10 lists the currently practiced promising practices found within IH and NH. By organizing promising practices according to the system level to which they belong and the actors responsible for them, the analysis demonstrates the value of understanding where practices fit and how health systems assign responsibility for acting on them. Research findings reveal that IH and NH have several promising practices supporting the integration of IPN roles, all of which align with promising practices identified in the literature by Caron (2020), Hiscock et al. (2022), Issacson et al. (2023), Mackean et al. (2020), Morgan et al. (2025), and Sanjida et al. (2022). To further interpret these findings, the analysis critically examines the promising practices at the health system level where they functionâstructural, operational (Singer et al., 2020), relational, or cultural (Leslie et al., 2023)âand identifies the actors responsible for supporting or enacting 127 them. The analysis also indicates the level within IH and NH where each promising practice occurs. Understanding the health system level at which each promising practice operates, as well as who is accountable for its enactment, provides opportunities to gain insights into the successful and equitable integration of IPN roles within health systems. (See Table 10 for a visual display of these relationships.) Table 10 IPN Role Integration Promising Practices Reflected in IH and NH IPN, and IPN-Similar Job Descriptions Promising Practice Responsible Party Health System Level Guiding Worldview and or Philosophy Principles Organizational Commitments to Diversity, Human Rights, and Reconciliation Health System Leadership Structural Western Biomedical Varied IPN-roles Health System Leadership/Program Management and Leads Operational Western Biomedical System Navigation IPN Operational Western Biomedical Patient and Family Centred Care Advocacy IPN IPN Relational Relational Indigenous Indigenous Role Holder Knowledge of Indigenous Histories, Rights, and Health Disparities IPN Cultural Indigenous Supporting Cultural Safety and Indigenous Healing Practice IPN Cultural Indigenous 128 Note. This table presents promising practices identified in IH's IPN (IH, n.d.a), NH's Indigenous Care Coordinator (NH, n.d.a), and Indigenous Health Service Assistant (NH, n.d.b) job descriptions, mapped to the health system level at which each operates (structural, operational (Singer et al., 2020), relational, or cultural (Leslie et al., 2023)). It also describes the promising practices' guiding worldviewâthe underlying knowledge system, values, or assumptions that influence how the literature-based promising practices are understood and applied, indicating whether it reflects a Western biomedical or an Indigenous perspective. Finally, the table identifies the responsible parties involved in integrating promising practices. IH and NH consistently place promising practices at what Singer et al. (2020) describe as the structural and operational levels of the health system, where health system leadership often enacts and controls them. This distribution of responsibility is not randomâit reflects the influence of a dominant Western biomedical worldview. Leadership typically assumes responsibility for these promising practices, located at the structural and operational levels, as they align with the familiar Western biomedical worldview's values, approaches, and beliefs. For instance, Cabestan (2008) explains that principles like individual rights, legalism, and democratic governance are deeply rooted in Western traditions. These principles align closely with the structural and operational levels of health systems, a point noted by Mulumba et al. (2021) as being frequently emphasized within leadership and governance structures. Plsek and Wilson (2001) expand on Cabestan's (2008) assertions by indicating that health system leaders often seek to optimize performance by narrowly defining tasks to individuals or separate groups working in isolation. The explanations by Cabestan (2008) and Plesk and Wilson (2001), together with the responsibility distribution pattern identified in this study, become more apparent when examining how health system leaders assign specific IPN integration promising practices across health system levels, and which stakeholders hold oversight responsibilities. Table 10 illustrates how IH and NH leadership actively shape the integration of IPN roles by retaining responsibility for key promising practices situated at the structural and operational levels of the health system. For example, in IH and NH IPN or IPN-similar job descriptions, health system leadership includes statements of organizational commitments to diversity, human rights, and reconciliation (IH, 129 n.d.b; NH, n.d.a; NH, n.d.b). These commitments reflect promising practices that align with what Singer et al. (2020) describe as the structural level of health systems. Legal frameworks that emphasize individual rights and formal compliance shape these commitments, reflecting a Western worldview that privileges codified law, as Cabestan (2008) observes. Leadership and program management oversee the development of various IPN roles at the operational level- a level Singer et al. (2020) describe as involving managing day-to-day activities and staff supervision. IH's IPN and NH's job descriptions reflect this by identifying the supervision of the IPN role by a manager or director (IH, n.d.a), a senior position (NH, n.d.b), or a team lead (NH, n.d.a). Positioning healthcare roles within predefined structures and hierarchies aligns with Western notions of what Plsek and Wilson (2021) describe as individualistic and compartmentalized. Treatment of the IPN role in ways that mirror these characteristics makes it what Plsek and Wilson (2001) describe as defined, separated, and embedded within existing traditional management approaches and organizational hierarchies. This health system approach stands in contrast to the community-based contexts that Davies (2022) stresses as more beneficial. Assigning IPNs the responsibility of system navigation, as shown in IH's IPN (IH, n.d.b), NH's Indigenous Care Coordinator (CC) (NH, n.d.a), and Indigenous Health Service Assistant (HISA) (NH, n.d.b) job descriptions, perpetuates the Western assumption that Vukic et al. (2012) see as health systems believing they do not need to undergo fundamental change. By expecting Indigenous or diverse individuals to learn how to navigate current systems, this approach also does what Vukic et al. (2012) describe as supporting the current system to stay as is. Additionally, this implies what Vukic et al. (2012) suggest: that it is the responsibility of Indigenous or diverse people using the system to change, rather than the system itself needing to change. These examples, highlighted in blue in Table 9, demonstrate how system leadership gravitates toward taking responsibility for the promising practices that reflect their familiar governance logics and worldview alignment, while sidelining more relational and cultural level promising practice responsibilities primarily to the Indigenous role. In contrast, when promising practices fall within the relational and cultural levels, responsibility is more often delegated to the IPN role. This delegation may be intentional, as these levels are more 130 challenging to define, measure, or operationalize within the Western biomedical paradigm (CITE). The four IPN role integration promising practices, highlighted in orange in Table 9, closely align with Indigenous worldviews, as described by Wilson (2008), which emphasize a relational, cultural, and holistic understanding of health. Vukic et al. (2012) note that health systems often place the primary burden of advancing relational and cultural change on the IPN, rather than sharing responsibilities across all levels of the health system. This pattern of assigned responsibility and the holders of the burden of advancement is apparent in the following examples, where I describe how the IPN holds responsibility for the four relational and cultural promising practices outlined in Table 9. IH and NH assign responsibility for relational and culturally promising practices to the IPN, which includes patient and family-centred care, advocacy, role holder knowledge of Indigenous histories, rights, and health disparities, and supporting cultural safety and Indigenous healing practices. These IPN role promising practice responsibilities reflect a closer alignment with Indigenous worldviews that center on relationality, cultural continuityâa concept Auger (2016) describes as intergenerational cultural connectedness maintained throughout generationsâand collective well-being, as described by Ife et al. (2023). As Vukic et al. (2012) explain, it is essential not to place all the burden of responsibility for relational and cultural advancement solely on the IPN. However, allowing IPNs to lead in these domains represents a positive step, demonstrating inclusion and respect for Indigenous values in health system role integration practices. The promising practices highlighted in the orange-shaded area of Table 10 draw on Indigenous principles that emphasize community inclusiveness, interrelatedness, and respect for Indigenous ways of knowing and being (Ife et al., 2023). For example, the IPN role integration in IH and NH currently includes practices such as: patient and their family approach; advocacy; IPN role holders' knowledge of Indigenous culture and traditions, unique history and rights, health care needs, cultural protocol, traditions, ideologies and disparities; and support for cultural safety and Indigenous healing practices (IH, n.d.b; NH, n.d.a; NH, n.d.b). These facilitating practices of both health systems demonstrate that positioning IPNs with responsibility for upholding the relational and cultural dimensions of integration is 131 a clear strength of their integration practices, as it reflects the importance and respect for Indigenous values and principles. However, while these promising practices embody Indigenous values and principles, they often remain in Western-structured health systems. The embedding of Indigenous values and principles within a predominantly Western framework complicates the integration of roles (Ife et al., 2023), such as the IPN role, and limits the role's transformative potential. Assigning the IPN responsibility for relational and cultural health systemâlevel promising practices represents a positive step. However, Ife et al. (2023) argue that health systems must implement broader systemic changes and distribute responsibility more widely to achieve sustained, meaningful transformation that aligns with Indigenous ways of knowing and being Notably, IH and NH do not incorporate promising practices that assign responsibility to Indigenous patients, families, or community representatives â a promising approach that Kleszynski et al. (2024) advocate for in the development of patient navigation programs, due to their potential to strengthen IPN role integration. This absence reveals a distinct shortcoming, as Indigenous Peoples, guided by an Indigenous worldview, view health systems and communities as interconnected rather than separate, as described by Lyle et al. (2017). Moreover, Turner et al. (2022) explain that Indigenous communities possess extensive knowledge and relational strength, which this disconnect overlooks. When involved, Indigenous Peoples make meaningful contributions at all levels of the health system where IPN role integration takes place, as Lyle et al. (2017) suggest. However, the current IH and NH integration approaches position them as external or missing from the system's approach, leaving little or no opportunity for Indigenous Peoples to provide input or contribute. This exclusionary approach aligns well with Western frameworks that position institutions as central (Davies, 2022) and Indigenous Peoples and communities as peripheral, thereby excluding them from the integration process (Pratt-Chapman et al., 2021). The division of responsibility is not coincidentalâit reflects how each system operates from within its worldview and how those worldviews influence health system accountability approaches. For 132 example, health systems assign IPNs responsibility for relational and cultural health systemâlevel promising practices. However, they do not distribute this responsibility equally among all integration stakeholders involved in the IPN role. As Vukic et al. (2012) describe, Indigenous health professionals often bear the burden of advancing cultural understanding within health systems that fail to share this responsibility. In the case of the IPN, this uneven distribution of responsibility and accountability means that no one beyond the person in the role is held accountable for honouring Indigenous relational and cultural principles. As a result, the system perpetuates division, and as Plamondon et al. (2023) explain, it avoids any shared responsibilities. To strengthen IPN integration and enhance the implementation of current promising practices in health systems at all levels, key participants in IPN role integration could adopt a more balanced and collaborative approach, as stated by Tremblay et al. (2023). For example, applying a guiding Indigenous worldview and principles, such as relationality, reciprocity, and collective well-being (Wilson, 2008), allows health systems to address existing systemic barriers and actively integrate promising practices in a meaningful and effective manner. This approach to operationalizing the IPN role ensures that integration efforts move beyond procedural tasks (Plamondon et al., 2023) and actively embed culturally relevant values that strengthen relationships, encourage respect, and promote shared responsibility. By harmonizing responsibilities across all system levels and actorsâand intentionally interweaving Western and Indigenous worldviewsâthe health system can move toward a more holistic, collaborative, and culturally responsive model of integration, as described by Came et al. (2016). 5.2.1.2. Literature-based inhibitors for IPN role integration. Analysis of IPN role integration in IH and NH also shows that minimal consideration of key recommendations identified through research in other parts of Canada, New Zealand, Australia, and the USA undermines the potential and impact of IPN role integration. Australian research has identified literature-based inhibitors to IPN integration, including the absence of key Indigenous leadership, which Bernardes et al. (2017) consider imperative for incorporating Indigenous perspectives into service 133 delivery development. Another four-country study, analyzing information from Canada, the USA, Australia, and New Zealand, describes an additional literature-based inhibitor as the absence of a standardized integration framework (Boulton et al., 2014). This literature-based inhibitor, as explained by Boulton et al. (2014), is crucial for integrating culturally responsive health services. Furthermore, Rankin et al. (2022), in their study of IPNs in Canada, the USA, Australia, and New Zealand, reveal that insufficient role clarity is another literature-based inhibitor, which, when present, produces difficulties in integrating the role into existing health systems. Next, Hiscock et al. (2022) note that limited monitoring and evaluation of existing IPN programs prevent a clear understanding of their impact on Indigenous Peoples and fail to signal when changes are needed to improve these services. Lastly, a lack of funding and IPN-tailored training, also described by Rankin et al. (2022), poses as a literature-based inhibitor and, when missing, challenges the success of role integration efforts. To support reduced brevity and to avoid repeating content discussed in Section 4.3.1.2 on IPN role inhibitors, Table 11 summarizes additional literature-based inhibitors under the column heading âIPN Role Integration Inhibitor". When literature-based inhibitors appear in IH and NH IPN role integration practices, they act as barriers that hinder the operationalization of these roles. As shown in Table 11, this study categorizes the literature-based inhibitors once more across structural, operational (Singer et al., 2020), relational, and cultural levels (Leslie et al., 2023) of the health system. It also provides examples of how to address the literature-based inhibitors by applying Indigenous worldviews, as illustrated under the column heading "Recommended Change Based on Indigenous Worldview." Table 11 provides a focused understanding of the location of literature-based inhibitors across the various levels of the health system. It also exemplifies how to enable transformative change in the IPN role integration by applying an Indigenous worldview and specific Indigenous values and principles, listed under the heading "Guiding Indigenous Worldview and or Philosophy Principles." Table 11 presents the IPN role integration literature-based inhibitors identified in this study, along with examples of how health systems can address these barriers. 134 Table 11 Health System Literature-Based Inhibitors to the IPN Integration and Indigenous-Informed Recommendations Health System Level IPN Role Integration Inhibitor Recommended Change Based on Indigenous Worldview Guiding Indigenous Worldview and or Philosophy Principles Structural Lack of leadership in Indigenous healthcare Establish Indigenous-led leadership structures in health services Respect, Responsibility, Self-determination, Community leadership Lack of IPN role definition and clarity Co-develop role clarity through Indigenous-informed frameworks Relationality, Collective responsibility, Accountability, Respect Operational Lack of evaluation and monitoring Implement accountability structures informed by Indigenous relational evaluation Accountability, Reciprocity, Balance Lack of compensation for specialized knowledge Equitably compensate IPNs to reflect the value of Indigenous knowledge systems. Respect, Responsibility, Recognition, Collective identity IPN holds the cultural safety educational provision responsibilities Distribute cultural education provision responsibilities across the system, not solely to IPNs Reciprocity, Shared accountability, Collective responsibility, Balance Large workload distributed to one or a small number of IPNs, e.g., having only one IPN role Balance expectations with capacity and support; avoid overburdening IPNs. Balance, Collective care, Responsibility, Respect 135 Health System Level IPN Role Integration Inhibitor Recommended Change Based on Indigenous Worldview Guiding Indigenous Worldview and or Philosophy Principles working in large acute facilities Integrate teams of IPNs versus a single role Relational Lack of stakeholder engagement and partnership Form authentic relationships with Indigenous communities in governance and decision-making Relationality, Respect, Community leadership Misappropriated responsibility for ensuring cultural safety Frame cultural safety as a collective system responsibility Responsibility, Shared Accountability, Respect, Interconnectedness Lack of alignment with Indigenous health equity goals Ensure health equity goals are co-created and aligned with community visions Collective Identity, Cultural continuity, Respect, Responsibility Inclusivity of Indigenous communities Integrate Indigenous communities in all stages of decision-making Relationality, Respect, Community Leadership Cultural Lack of culturally tailored training for IPN Support IPNs with role-specific, culturally grounded training Cultural continuity, Collective responsibility, Respect Lack of health system-wide responsibility for cultural safety Position cultural safety as an organizational priority, not an individual task, and link importance to Cultural Safety and Humility Policies Shared Accountability, Collective Responsibility, Cultural continuity, Respect 136 Note. This table organizes literature-based inhibitors to the integration of the IPN role within IH and NH at the health system level. The second column identifies gaps drawn from literature and practice. The third column presents actionable recommendations grounded in Indigenous worldviews. The fourth column reflects guiding Indigenous principles and values informed by Indigenous scholars and knowledge holders (Wilson, 2008; Denzin et al., 2008). 5.2.1.2.1. Lack of attentiveness to Indigenous worldviews. IH's IPN and NH's Indigenous Care Coordinator (ICC) and HISA job descriptions reflect a lack of attention to Indigenous knowledge systems and guiding principles (IH, n.d.b; NH, n.d.b; NH, n.d.c). These documents fail to honor Indigenous worldviews, which emphasize cultural rootedness, connectedness, and collective identityâvalues identified as critical determinants of health and wellness by Ife et al. (2013). Instead, the IPN role integration efforts reflect Western, hierarchical models of management. For example, the job descriptions for IH and NH state that the IPN "works under the direction of the Manager or Director" (IH, n.d.b) or "reports to [organizational] community administrator or manager" (NH, n.d.b). This structural alignment with Western hierarchies marginalizes Indigenous leadership philosophies and limits the potential for what Came et al. (2016) describe as cultivating authentic, appropriate, and relevant Indigenous-informed role integration. 5.2.1.2.2. Absence of standardized integration frameworks and undue burden of systemic responsibilities. In their study on the integration of Nurse Practitioners (NPs) in Quebec primary care settings, Chouinard et al. (2017) found that the absence of standardized integration frameworks results in responsibilities being disproportionately placed on the NPs themselves, without adequate systemic support. The analysis identifies similarities in how IH and NH integrate IPN roles. In both cases, the absence of standardized integration frameworks allows key systemic responsibilitiesâsuch as improving cultural safety and reducing Indigenous-specific racism, which Vukic et al. (2012) highlightâto fall disproportionately on the Indigenous-specific role, without sufficient systemic support. In addition, 137 Newham et al. (2016), in their study on barriers and enablers to implementing a quality improvement program in primary healthcare services, call for careful attention to reporting structures and integration strategies that protect Indigenous-specific positions from bearing the weight of systemic racism. Vukic et al. (2012) echo this concern by explaining how other Indigenous-specific positions, like nurses, are often made responsible for reporting to and navigating within systems that perpetuate racism and cultural unsafety. The analysis also identifies a disconnect between the promising practices outlined in the literature and the current approach to the IPN role. This finding supports the recommendation that IH and NH reassess their reporting mechanisms and integration strategies. Adopting a multi-stakeholder responsibility for creating an integration framework prevents IH and NH from leaving the IPN to self-navigate barriers such as role ambiguity (Payne et al., 2017), team misalignment (Vukic et al., 2012), and system-level incoordination (Pratt-Chapman et al., 2021), which Chouinard et al. (2017) explain leads to increased stress and dissatisfaction for the role holder, something the health authorities could benefit from avoiding. 5.2.1.2.3. Role uncertainty, missing evaluation and monitoring mechanisms, and a lack of wage compensation for Indigenous expertise and knowledge. Other literature-based inhibitors identified in the IH and NH IPN role integration practices include the absence of role clarity (Rankin et al., 2022), inequitable compensation (Vukick et al., 2012), and the lack of evaluation and monitoring mechanisms (Bernardes et al., 2017). The vague and unclear language used in IH's IPN job description (under the heading "will work on") and NH's Indigenous CC and HISA job descriptions (under "skills and abilities") creates confusion for applicants, role holders, and leadership about the role's purpose, scope, and responsibilities (IH, n.d.b; NH, n.d.a; NH, n.d.b). As Ducey (2002) and Krasna et al. (2023) note, this ambiguity contributes to uncertainty among multidisciplinary teams regarding the roles' function and expectations for service provision. To reduce confusion and ensure clarity, IH and NH could revise the job descriptions for the IPN role to include 138 explicit language and sections that outline the core responsibilities, expectations, and scope of practice, as explained by Krasna et al. (2023). Additionally, analysis of salary ranges for IH and NH's IPN and IPN-similar job descriptions reveals wage compensation comparable to that of non-Indigenous Patient Navigators, CCs, and Health Service Assistants. Both IH and NH offer hourly wages for the IPN role, ranging from "$34.08 to $52.61", depending on the posting, with compensation tied to a "diploma or degree in Social Work or a related health field" (IH, n.d.b; NH, n.d.a; NH, n.d.b). However, this wage does not account for the additional qualifications emphasized in job postings, such as "lived experience with Indigenous populations, and in-depth knowledge of Indigenous cultures, care needs, and organizations" (IH, n.d.b; NH, n.d.a; NH, n.d.b). While added expertise reflects a specialized and culturally grounded skill set, compensation remains equivalent to that of non-Indigenous-specific navigator roles, which require only academic credentials. For instance, Patient Care Coordinators at NH earn "$49.20 to $63.47 "per hour with a nursing degree (NH, n.d.c), whereas IPN rolesârequiring both similar academic training and cultural expertiseâoffer a lower wage range, a practice Cidro et al. (2024) reveal as a structural inequity in compensation practices. Lastly, this analysis of the IPN role integration data sources revealed no evidence of monitoring and evaluation mechanisms, which, when present, Pratt-Chapman et al. (2021) describe as crucial in determining role effectiveness, improving services, and demonstrating impact. This type of literature-based inhibitor plays a role in IH and NH IPN role integration, such that there is no means to identify and act on interventions to alleviate systemic obstacles (Pratt-Chapman et al., 2021). Moreover, and more importantly, without comprehensive approaches that evaluate and monitor the IPN role â one that includes shared responsibilities between the health system and Indigenous Peoples â there is a risk that these functions will not occur or fall solely to IH and NH leadership. Such leadership, as explained by Cabestan (2009), typically operates within a Western biomedical paradigm that lacks an understanding of Indigenous worldviews, values, and principles. As a result, the lack of shared, culturally informed monitoring and evaluation structures not only limits opportunities for continued improvement (Hiscock et 139 al., 2022) but also reinforces systemic imbalances that undermine the integrity, sustainability, and effectiveness of the IPN role. Unfortunately, this lack of relevant monitoring and evaluation contrasts with a U.S. study on patient navigation programs, which found that programs with structured evaluation and monitoring protocols are more effective in demonstrating their value and achieving long-term stability (Pratt-Chapman et al., 2021). 5.2.1.2.4. Lack of addressing the relational and cultural level of literature-informed inhibitors. IH and NH IPN role integration efforts lack evidence of actions addressing literature-based inhibitors related to the relational and cultural levels within health systems, which widens the disconnect between health system strategies and Indigenous approaches. These literature-based inhibitors or shortfalls in the IH and NH IPN role integration include insufficient culturally tailored training for IPNs (Rankin et al., 2022), limited inclusion of Indigenous communities in decision-making (Burhansstipanov et al., 2014), and a narrow framing of responsibilities, such as cultural safety and system navigation, to the responsibility of individual staffâsuch as the IPNârather than the system as a whole (Vukic et al., 2012). While Western biomedical systems tend to isolate responsibility (Popescu & Gulay, 2019), Indigenous worldviews emphasize relational accountability and respect (Wilson, 2008). Tremblay et al. (2023), in their cross-nation study spanning Australia, Canada, the U.S., and New Zealand, found that respecting Indigenous cultural identities and worldviews helps address healthcare racism and discrimination. Tremblay et al. (2023) further emphasize that health systems must cultivate respect for diverse worldviews to ensure culturally safe and relevant care, a requirement central to the IPN role. Despite the existence of Indigenous-specific positions, this study's findings suggest that IH and NH integration strategies continue to be shaped by dominant Western perspectives. Addressing this dominance of Western perspectives requires health systems to meaningfully embed Indigenous worldviews and actively challenge prevailing paradigms (Plamondon et al., 2023) at every level. Doing so 140 supports an approach to IPN role integration that is more equitable, relationally accountable, and culturally groundedâone strengthened by promising practices and informed by common, literature-based relational and cultural inhibitors. 5.2.1.3. Indigenizing PEPPA and PEPPA Plus frameworks to advance equity. The PEPPA and PEPPA Plus frameworks exist as recognized models for integrating specialized healthcare roles, valued for their structured, evidence-informed approach, implementation, and evaluation (Boman et al., 2021). Their comprehensive, modular, and sequential design supports sustainable role integration, making them promising frameworks (Boman et al., 2021) for embedding the IPN role within health systems. However, rooted in Western biomedical and clinical paradigms, these frameworks do not fully reflect the values, worldviews, and priorities inherent to the IPN role. To enhance their relevance and effectiveness, health systems can adapt and expand these frameworks beyond their Western foundations (Pratt-Chapman et al., 2021). Indigenizing the PEPPA and PEPPA Plus frameworks through the integration of Indigenous worldviews and principles offers a culturally grounded approach to IPN role integration, one that is both culturally relevant and equity oriented. A culturally relevant and equity-driven approach aligns with the findings of Miyamoto et al. (2019), whose study on a culture-based, family-centered health system navigation intervention for Native Hawaiians highlights how culturally rooted models enhance both relevance and impact for Indigenous Peoples engaged in health services. Adapting existing specialized role integration frameworks in this way supports processes that are not only culturally appropriate but also actively advance equity in the integration of the IPN role. Colonial care models that disregard Indigenous knowledge, health values, and priorities undermine the effectiveness of health services aimed at improving Indigenous health disparities (Davis, 2022). Conversely, care models tailored to Indigenous values improve awareness, understanding, and usability of health system services among Indigenous communities (Burhansstipanov et al., 2014). Therefore, integrating Indigenous and Western frameworksârather than relying solely on biomedical 141 Table 12 Indigenization of the PEPPA Framework: Relational Integration Framework: Centering Indigenous Knowledge in the IPN Role PEPPA Step and Description Applied Indigenous Worldview and or Philosophical Principle(s) Adapted Indigenize PEPPA Framework Step Transformation in Integration Practice â¢ Define patient population and describe current model of care Self-determination Relationality Collective responsibility Respect for Indigenous knowledge sources Holism Engage with Indigenous Peoples to identify a community-defined patient population and co-describe a holistic and relational model of care. Shift from a system-defined to an Indigenous Peoples-defined patient population. Shift from a clinical interventionalist provider-driven model of care to a relational, holistic model of care. â¢ Identify stakeholders and recruit participants Self-determination Relationality Collective responsibility Engage with Indigenous Peoples to identify community and health system stakeholders and invite these stakeholders to partner in collaborative engagement. Transition from system-identified stakeholder selection and participant recruitment to Indigenous Peoplesâdetermined stakeholders with invitations for collaborative engagement. 142 PEPPA Step and Description Applied Indigenous Worldview and or Philosophical Principle(s) Adapted Indigenize PEPPA Framework Step Transformation in Integration Practice Respect for Indigenous knowledge sources â¢ Determine need for a new model of care Relationality Collective responsibility Respect for Indigenous knowledge sources Partner with Indigenous Peoples to identify the need for a new, relational, holistic model of care. Assess whether varied communities can meet role needs through diverse models of care. Shift from system-determined need for a new model of care to Indigenous-Peoples' self-determination for a new relational, holistic model of care. â¢ Identify priority problems and goals to improve model of care Self-determination Relationality Strength-based and restorative framing Collective responsibility Partner with Indigenous People in recognizing key areas for improvement. Partner with Indigenous Peoples to create an enhanced, relational, holistic model of care. Shift from deficit-framing to a partnered recognition of identifying key areas for improvement. Shift from system-defined goals and need for improvement in the model of care to Indigenous Peoples-identified goals for an enhanced relational, holistic model of care. 143 PEPPA Step and Description Applied Indigenous Worldview and or Philosophical Principle(s) Adapted Indigenize PEPPA Framework Step Transformation in Integration Practice â¢ Define new model of care and APN role â¢ Stakeholders' consensus about the 'fit' between goals, new model of care, and APN role Self-determination Relationality Respect for Indigenous knowledge sources Collective responsibility Reciprocity Partner with Indigenous and System Stakeholders for a dialogue on the coherence between Indigenous-identified goals, the relational, holistic model of care, and the role of the IPN Shift from a system-defined model of care shaped through rational deliberation and consensus about the 'fit' between goals, the care model, and the IPN role, to a partnered approach that centres Indigenous Peoples' self-determined, holistic, and relational model of care, ensuring dialogue about the coherence between Indigenous-identified goals, the model of care, and the IPN role. â¢ Plan implementation strategies â¢ Identify outcomes, outline evaluation, plan, and collect baseline data â¢ Identify role promising practices and barriers (stakeholders' awareness of role; APN education; Self-determination Relationality Respect for Indigenous knowledge sources Collective responsibility Co-partner with Indigenous Peoples to bring the work into being Co-determine with Indigenous Peoples' Indigenous goals, processes to reflect, co-plan, and collect early insights Shift from a technical, top-down, linear approach of implementation to a collaborative journey to move the work forward. Shift from an emphasis on measurement, objectivity, and linear, technical, top-down processes that separate data from being and relating, toward a 144 PEPPA Step and Description Applied Indigenous Worldview and or Philosophical Principle(s) Adapted Indigenize PEPPA Framework Step Transformation in Integration Practice administrative support and resources; regulatory mechanisms, policies, and procedures Dialogue rooted in ethical relationships Reciprocity Co-determine promising practices and areas of improvement (Partners' mutual understanding of role, IPN ways of knowing, relational support, and resources, guiding principles, shared protocols, community agreements, IPN ways of doing process rooted in partnership and Indigenous-identified goals that reflects a relational way of setting goals, observing, and reflecting on progress, and gathering early insights. Shift from categorization and objectivity, and an emphasis on institutional, technical, top-down, linear approaches that separate roles from relational contexts, toward shared determinations of promising practices and areas for improvement that include partner understanding of the IPN role, IPN learning rooted in Indigenous ways of knowing and doing, and program observations and guidance grounded in relationship, culture, and Indigenous-practices. 145 PEPPA Step and Description Applied Indigenous Worldview and or Philosophical Principle(s) Adapted Indigenize PEPPA Framework Step Transformation in Integration Practice â¢ Initiate the APN role implementation plan o Begin role development and implementation o Develop APN role policies and protocols o Provide education, resources, and support Relationality Inclusivity Community-based approach Self-determination Reciprocity Initiate role co-development and implementation, inclusive of: 1. Relationship-building and community guidance. 2. Collective responsibility where the health system and Indigenous Peoples work together. 3. Monitoring and evaluation measures 4. Regular communication amongst stakeholders 5. Initiation of the role in Indigenous protocols and or ceremony Shift from a health system-driven biomedical implementation plan to a partnered approach rooted in relationality, reciprocity, inclusivity, and Indigenous ways of knowing and doing. Ensure principles of collective responsibility are upheld and understood by all. 146 PEPPA Step and Description Applied Indigenous Worldview and or Philosophical Principle(s) Adapted Indigenize PEPPA Framework Step Transformation in Integration Practice Co-develop policies and protocols with Indigenous Partners that: â¢ Are rooted in Indigenous ways of knowing and being â¢ Prioritize equity, cultural safety, and Indigenous self-determination as foundational to the role â¢ Embed Indigenous governance and leadership, with meaningful decision-making authority â¢ Shape protocols and practice guidance documents through Indigenous-led processes that support the meeting of the distinct needs, strengths, and expectations of Indigenous Partners Co-provide education, resources, and support by: 147 PEPPA Step and Description Applied Indigenous Worldview and or Philosophical Principle(s) Adapted Indigenize PEPPA Framework Step Transformation in Integration Practice 1. Accessible and consistently available to the IPN at regular intervals, such as a community of practice 2. Grounded in Indigenous knowledge systems, collective well-being, land-based healing, and cultural practices 3. Offered to all stakeholders, including leadership, management, and interdisciplinary teams, to build shared responsibility and understanding 4. Designed to reflect and respond to Indigenous priorities, with tools and supports that uphold cultural safety and community-identified needs. 148 PEPPA Step and Description Applied Indigenous Worldview and or Philosophical Principle(s) Adapted Indigenize PEPPA Framework Step Transformation in Integration Practice â¢ Evaluate APN role and new model of care Community-based approach Relational accountability Respect Relationality Engage with Indigenous Partners to guide evaluation using community-defined priorities and indicators. Evaluate the role and model of care in ways that uphold relational accountability. Ensure opportunities for Indigenous Partners to voice beliefs regarding the role and its impact. Include evaluation approaches that are culturally appropriate and grounded in Indigenous knowledge systems. Shift from Western, health systemâdriven evaluation methods toward community-led, relational approaches that uphold Indigenous principles of respect, relationality, and relational accountability. Center the evaluation of the role and model of care in community-defined priorities and indicators of success. Ensure evaluation practices reflect a commitment to collective responsibility and reciprocal relationships with Indigenous partners. 149 PEPPA Step and Description Applied Indigenous Worldview and or Philosophical Principle(s) Adapted Indigenize PEPPA Framework Step Transformation in Integration Practice â¢ Long-term monitoring of the APN role and model of care Relationality Inclusivity Accountability Responsibility Community-based approach Ensure ongoing, Partner-guided monitoring of the role and model of care remains aligned with Indigenous priorities. Use a culturally rooted monitoring and evaluation approach. Continuously observe and adapt the role and model of care to meet the diverse and distinct needs of Indigenous Partners. Shift from institutional, system-centered monitoring toward a community-rooted approach grounded in relationality, inclusivity, and ongoing accountability to Indigenous partners. Ensure that reciprocal relationships, collective responsibility, and Indigenous-defined markers of success guide the long-term reflection and adaptation of the role and the model of care. Uphold community leadership and presence throughout the monitoring process to ensure it remains responsive, respectful, and relevant. Note. This table adapts the PEPPA Framework developed by Bryant-Lukosius and DiCenso (2004). Applied Indigenous Worldview and/or Philosophical Principle(s) outlines the Indigenous values guiding each step. Adapted Indigenized PEPPA Framework Step reflects how each step has been re-envisioned in partnership with Indigenous Peoples. Transformation in Integration Practice highlights the key shifts from conventional approaches toward Indigenous-informed, relational ways of working. 150 modelsâenables health systems to develop what Davies (2022) refers to as a more inclusive and community-driven model of health service provision. Incorporating Indigenous perspectives into existing modelsâsuch as adapting the PEPPA framework in Table 12ârepresents a necessary step for advancing equity in health systems and improving health outcomes for Indigenous Peoples (Dover & Belon, 2019). Table 12 illustrates an approach that integrates a clinical biomedical model with Indigenous worldviews and processes, ensuring intentional and inclusive stakeholder engagement to address systemic and cultural barriers across all levels of the healthcare system. By creating a space similar to Ermine's (2008) ethical space of engagement, multiple knowledge systems can coexist and inform one another, an approach also supported by the British Columbia (BC) Office of Improving Health Outcomes for Indigenous Peoples (Dover & Belon, 2019). Table 12 illustrates an approach that integrates a clinical biomedical model with Indigenous worldviews and processes, ensuring intentional and inclusive stakeholder engagement to address systemic and cultural barriers across all levels of the healthcare system. By creating a space similar to Ermine's (2008) ethical space of engagement, multiple knowledge systems can coexist and inform one another, an approach also supported by the British Columbia (BC) Office of the Provincial Health Officer and the First Nation Health Authority (2018), in their report, "Indigenous Health and Well-being: Final Update," outlined a vision for holistic, culturally appropriate, and equitable Indigenous healthcare integration. To achieve transformative change within health systems, advancing equity in the integration of the IPN is essential for improving Indigenous health outcomes. In BC's current healthcare landscape, IH and NH can explore adapting frameworks, as exemplified in Table 12. While this study did not conduct an adaptation of the PEPPA Plus framework, Table 12 serves as a starting point for others to tailor the framework to their specific contexts in a meaningful way. The current integration of the IPN role within IH and NH does not align closely with the comprehensive, participatory PEPPA and PEPPA Plus frameworks. Bryant-Lukosius and Dicenso (2006) emphasize that these frameworks provide a structured approach to role development, implementation, and 151 evaluation. To date, IH and NH implement only the early steps, Steps One and Two, of the PEPPA framework. The limited actioning of Steps Three to Nine of the PEPPA framework (Bryant-Lukosius & Dicenso, 2004) and Stages One to Three of the PEPPA Plus framework (Bryant-Lukosius et al., 2016) highlights the need for IH and NH to move beyond initial steps and adopt the full processes that Bryant-Lukosius and Dicenso (2004) and Bryant-Lukosius et al. (2016) identify as essential for achieving successful sustained role integration. 5.2.1.4. Indigenizing job descriptions to advance equity. Kransa et al. (2023) view job descriptions as foundational resources for integrating new roles into health systems, as they shape perceptions, define responsibilities, and align roles within organizations. In IH and NH, job descriptions could move beyond primarily serving recruitment to deliver many of the additional benefits that the authors Kransa et al. (2023) indicate. Applying Critical Indigenous Theory (CIT) to the IH and NH job descriptions can strengthen recruitment and integration effectiveness because CIT centres Indigenous worldviews, values, and relational ways of knowing (Denzin et al., 2008). This approach also helps ensure that the language of the IPN job description resonates with Indigenous candidates and communities, thereby enhancing cultural relevance. By challenging the dominant Western assumptions embedded in current IH and NH job descriptions, CIT actively promotes cultural safety, inclusivity, and equity (Denzin et al., 2008). These principles attract Indigenous candidates (Browne et al., 2016) and support the integration of sustainable roles (Browne et al., 2015). Moreover, as Denzin et al. (2008) emphasize, CIT provides a vital lens for examining how systems reflect a dominant Western worldview while simultaneously marginalizing Indigenous knowledge systemsâa dynamic that this analysis indicates is present in IH and NH. Using a CIT-informed analysis approach, this study reveals how the use of language in job descriptions perpetuates colonial hierarchies and power imbalances in the integration of Indigenous-specific healthcare roles. 152 5.2.1.4.1. Foundation and influence of job descriptions. To deconstruct colonial paradigms, health systems can adopt a restorative approach (Denzin et al., 2008), as described by Plamondon et al. (2023) as one that disrupts and redistributes power. In this research, I employ a CIT-informed approach to analyze the language used in IH and NH's IPN and IPN-similar role job descriptions, following Denzin et al. (2008), in order to dismantle culturally unsafe power distribution practices. CIT helps reveal how hierarchical and biomedical norms conflict with Indigenous values of relational accountability, cultural continuity, and collective responsibility, as Moreton-Robinson (2008) explains. Indigenizing these documents provides a way to identify and correct language that reinforces hierarchical imbalances among IH and NH leadership, IPNs, and the Indigenous patients, families, and communities they serve, an example of the kind of power dynamics that Fairclough (2013) refers to in an analysis of how power is reflected and reinforced through language. Reforming IPN job descriptions through this lens is both necessary and overdue, offering a pathway to support more equitable and culturally safe integration of Indigenous-specific healthcare roles. 5.2.1.4.2. Impacts of role clarity and coherence deficiencies. Improving the structure and clarity of Indigenous-specific healthcare job descriptions, such as those for the IPN role, can benefit role integration. Insufficient role clarity contributes to significant integration challenges, including ambiguity, a lack of understanding of role contributions, and an under-recognition of the IPN's value (Rankin, 2022). Research by Payne et al. (207) indicates that role uncertainty causes confusion and conflict regarding responsibilities. Saxena et al. (2018) emphasize that this issue is also prevalent in other roles, as well as in leadership and interdisciplinary teams, contributing to unmet clinical needs for patients. Proulx et al. (2015) further argue that clarifying and streamlining job descriptions strengthens role integration by ensuring that the position is understood, strategically supported, and operationalized across the health system. Taken together, the research findings of these authors reinforce the opportunity to improve the IH and NH IPN job descriptions as a critical next step necessary for enhancing the clarity and coherence of the roles. 153 5.2.1.4.3. System-level opportunities for improvement. IH and NH may benefit from revising their IPN and IPN-similar job descriptions to improve consistency, organization, and clarity around role responsibilities. The IH and NH IPN and IPN-similar role job descriptions vary in structure, tone, and level of detail, resulting in what Rankin et al. (2022) describe as confusion that limits shared understanding of the role across health systems. Without consistency in role clarity, misunderstandings about a role's scope and function persist (Payne et al., 2017). Furthermore, studies on nursing teams emphasize the importance of clear role definitions, which reduce confusion, scope ambiguity, and challenges in integration (Brault et al., 2014). Currently, job descriptions in IH and NH reflect a pervasive Western biomedical worldview, which often sidelines the cultural, relational, and community-informed foundations of the roleâan approach that Denzin et al. (2008) critique in their discussion of colonial research and institutional practices. Applying a CIT lens can help realign these job descriptions with Indigenous values and perspectives. This approach promotes equity by ensuring job descriptions offer clarity, cultural relevance, and respect for Indigenous knowledge and labour in the healthcare system. IH and NH can revise their job descriptions in several ways to address operational and cultural oversights and more closely align with Indigenous worldviews. Such revisions could also challenge the power dynamics that reinforce dominant Western biomedical perspectives. In doing so, they may help advance principles of diversity, equity, and cultural safety, principles emphasized broadly in health system equity work by Plamondon et al. (2023), and reflected in the legal mandates and performance targets that the Ministry of Health Sets for these authorities (BC Ministry of Health, 2020). The following section illustrates how a CIT lens can guide the assessment, deconstruction, and reframing of job description language to support more equitable, culturally grounded role integration, setting up IH and NH to resolve any inconsistencies and misalignments between their stated equity goals and their IPN role integration. Alongside reframing the language used in IPN job descriptions, IH and NH can align these documents with the steps and stages of the Indigenized PEPPA and PEPPA Plus frameworks. Doing so could ground the role in relevant, actionable practices often referenced when 154 developing, implementing, and sustaining roles across the health system. Figure 3 provides a job description template that supports both reframing of language and alignment with PEPPA and PEPPA Plus steps and stages. Figure 3 Guidance for Developing Indigenous-Specific Healthcare Role Descriptions: Reframing Language and Alignment with Evidence-based Role Integration Frameworks Job Title: For example, Indigenous Patient Navigator, Indigenous Care Coordinator, Indigenous Health Service Assistant. Refer to the Role of the Indigenous Patient Navigator: A Scoping Review by Rankin et al., 2022. Employment Equity and Commitment to Indigenous Recruitment: An example statement to use could be: In alignment with [organization name] 's commitment to reconciliation and equity, preference is given to qualified candidates who self-identify as Indigenous (First Nations, Métis, or Inuit). We encourage applicants to self-identify in their applications voluntarily. * Avoid framing Indigenous hiring through the lens of health authority diversity commitments, as this centers organizational goals rather than the deeper purpose of the role. It is recommended that Indigenous-specific hiring be grounded in the obligations outlined by reconciliation frameworks, including the Truth and Reconciliation Commission's Calls to Action, the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), and other Indigenous rights commitments. These frameworks recognize Indigenous Peoples as rights holdersânot simply as under-represented groupsâand call for meaningful inclusion, self-determination, and systemic change. Guiding Visions and Values: 155 Critically reflect on and resist alignment with solely relying on health system visions and values when they fall short of meeting the needs of Indigenous Peoples or fail to offer culturally relevant approaches to healthcare provision. Wherever possible, centre Indigenous worldviews, philosophies, and guiding principles to guide practice and decision-making. Job Summary: Provide an overarching description of the role. Include description of key aspects listed below and refer to PEPPA Step(s) 1-6 and PEPPA Plus Stage: Introduction (a,b) for guidance. Role: 1. Purpose: This is the primary objective of the role and what the role aims to accomplish. 2. Scope: This is the boundaries or breadth of the role. 3. Target Population: A Specific group of people, and any unique characteristics, to whom the role provides services. 4. Model of Care: Design of services, including how individuals interact with the role and services over a continuum of care. Sample Job Summary: The Indigenous Patient Navigator is a vital facilitator of connections between Indigenous individuals, families, and communities and the healthcare system. Using an approach rooted in Indigenous knowledge systems and a relational model of care, the IPN cultivates culturally safer, respectful, and trusting relationships to enhance equity, access, and navigation across the individual and family's care journey. This role empowers and guides Indigenous Peoples in overcoming health system barriers, advocates for their rights and needs, and partners in collaboration with care teams to promote equitable, culturally relevant, and responsive services. Commitments: Frequently referred to as responsibilities, duties, and or tasks. Refer to PEPPA steps 3-9 and the section on the Role of Profession and Role Community, as well as the PEPPA Plus stages: 156 Introduction (points 1 and 2), Implementation (points 2 and 3), and Long-term Sustainability (points 1 and 2) for guidance. *Add as many commitments as agreed upon by all stakeholders. Job descriptions should include key role commitments, such as education provision, training, partnership and engagement, monitoring, knowledge sharing, and evaluation, to support comprehensive implementation of the role. Work Environment & Conditions: The working environment and conditions, including both tangible and intangible factors. It is the physical, operational, relational, and cultural contexts. Refer to PEPPA steps 7 and PEPPA Plus stage Implementation (points 1 and 3) for guidance. Key aspects can include: â¢ Physical environment and its characteristics: For example, health service settings, Indigenous community settings, and/or a combination of both. â¢ Work Schedule and Hours: Full-time, part-time, shift work, flexible hours, On-call, or travel requirements. â¢ Workload and Pace: Volume of patients, number of engaged communities or Indigenous organizational wellness representatives, Elders, Cultural Leaders, Knowledge Keepers. â¢ Cultural Environment: Indigenous worldview-informed ways of being and doing, including concepts of relationality, equity, diversity, collective responsibility, partnership, responsibility, reciprocity, and respect. â¢ Relational and Team Dynamics: Partnership and collaboration with a) Indigenous individuals, families, communities, and other community representatives, b) interdisciplinary teams, and c) Indigenous role holistic and cultural wellness supports, and/or d) Indigenous team and colleagues. *Link to health system policies such as Anti-Aboriginal Racism, Cultural Safety and Humility, Diversity, Safe Workplace Environment, etc. â¢ Resources and Supports: Access to supplies, technology, and/or tools; training and development opportunities; transportation; and other relevant resources. Include both health system resources and Indigenous community resources (ex., Indigenous created wellness frameworks, Elders, Knowledge Keepers, Cultural Advisors, etc.). Guidance & Direction: Often referred to as leadership, supervision, and or management. Refer to PEPPA, step 7 (points 1 and 2), and PEPPA Plus Implementation stage (point 1), for guidance. Ensure connection to Indigenous leaders and or departmental teams. Compensation & Benefits: Indigenous-specific healthcare roles involve specialized care that draws on personal Indigenous knowledge, understandings, and lived experiences. Health systems should 157 appropriately compensate applicants for their Indigenous expertise, honoring both their professional contributions and cultural knowledge. *There is a lack of understanding and attention to Indigenous knowledge compensation; however, applying the principles outlined in Topp et al.'s (2021) article "Unique knowledge, unique skills, unique role: Aboriginal and Torres Strait Islander health workers in Queensland, Australia" promotes understanding and drives meaningful change. Educational and Career Advancing Opportunities: Access to training, mentorship, and learning pathways that support growth and advancement within the health system. Consider providing funding for the training listed in the section below. Educational Background and Experiential Qualifications: â¢ Academic institutions often define what constitutes education, which can overlook or exclude Indigenous knowledge sources. A more inclusive understanding recognizes that learning can include academic training in combination with Indigenous-led education and or training. For example, the Saint Elizabeth Health Care Indigenous Patient Navigator Program (Canada-wide with virtual options) and the Nicola Valley Institute of Technology programs include the Aboriginal Community & Health Development Certificate, Indigenous Holistic Wellness and Addictions Advanced Diploma, Indigenous Support Worker Training Micro-Credential, and the following courses: INST-341, IHMS-120. â¢ Experience: Lived experience offers valuable knowledge and expertise, particularly when shaped by cultural and relational learning through Indigenous ways of knowing, being, and doing. Such experience may come from living within Indigenous communities or through meaningful engagement with Indigenous Peoples, communities, or Nations. Alignment with Health System Policies and Protocols: For example, Diversity, Anti-racism, Cultural Safety and Humility, Safe Work Environments, or other relevant policies, strategies, frameworks, Agreements, or other practice guidance and protocol resources. Alignment with the Indigenous community led to the creation of resources. For example, policies, protocols, strategies, frameworks, or practice guidance or protocol resources. Alignment with legislation: For example: 158 â¢ United Nations Declaration on the Rights of Indigenous Peoples Act (2007), â¢ BC Declaration on the Rights of Indigenous Peoples Act (2019) â¢ Human Rights Code Amendment Act (Bill 18) â¢ Anti-Racism Act (Bill 23) Alignment with Reconciliation Frameworks: For example: â¢ Truth and Reconciliation Commission of Canada (TRC of Canada) Final Report (2015) â¢ In Plain Sight Report (2020) â¢ Royal Commission on Aboriginal Peoples (RCAP) Final Report (1996) â¢ Missing and Murdered Indigenous Women and Girls (MMIWG) Final Report (2019) â¢ BC Tripartite First Nations Health Plan (2013) Applying Critical Indigenous Theory Lens & Systematic Equity-Action Analysis Framework Guiding Principles: â¢ Examine the presence of a worldview and how the use of language strengthens current power allocation among stakeholders and participants â¢ Ground description creation in Indigenous worldviews, philosophies, and principles. â¢ Shift from a biomedical clinical care model to an Indigenous-enriched relational model of care. Note. This IPN job description development guidance document draws on Indigenous knowledge, evidence-based frameworks such as PEPPA (Bryant-Lukosius & Dicenso, 2004) and PEPPA Plus (Bryant-Lukosius et al., 2016), as well as Indigenous scholarship on Indigenous Patient Navigators by Rankin et al. (2022). It aligns with legislative mandates and reconciliation frameworks while centering Indigenous worldviews, rights, and responsibilities. In the figure, italics indicate guidance statements, bold text shows recommended language, and regular font presents additional suggestions or considerations for developing IPN role job descriptions. 5.2.1.5. Advancing equity: Strengthening policies, strategies, and plans to translate goals and commitments into action. Together, this analysis and the insights it generated offer three recommendations that illustrate what decolonizing health systems involves. For clarity, the following summarizes recommendations proposed in Sections (5.2.1.1 to 5.2.1.4). 159 1. Conduct a literature-informed assessment of the IPN integration processes to identify promising practices and barriers. Utilize this knowledge to develop a shared responsibility approach across all levels of the healthcare system, promoting a coordinated and effective response. (See Table 3 and Table 4). 2. Critically assess IPN role job descriptions to identify patterns of language that reinforce privilege or contribute to systemic disadvantages. Use findings to support the Indigenization of job descriptions as illustrated in Figure 3. 3. Apply an Indigenous lens to existing research-based specialty role integration frameworks, such as PEPPA and PEPPA Plus, to develop an Indigenized evidence-based integration model. (See Table 11). Figure 4 below presents a synthesized integration of the studyâs three recommendations into a single, Indigenous-informed and pragmatic framework that supports alignment between organizational operations and behaviors, such as those in IH and NH's IPN role integration, with equity goals and commitments. Figure 4 presents a synthesized framework that integrates the three recommendations of this study into a single, Indigenous-informed, action-oriented model. This framework can guide health systems in aligning their practices, such as the integration of IH and NH IPN roles, with stated equity goals and commitments. A key feature of the framework is its incorporation of transformative pedagogies, which draw on Indigenous epistemologies and worldviews to reshape the ways learning, knowing, and doing occur within health systems. By employing approaches that emphasize relationality and respect for Indigenous ways of knowing and doing, health systems can advance equity, promote cultural continuity, and make meaningful progress toward decolonization. This relational, action-oriented framework provides a process-focused approach to applying CIT to health system elements, guided by the worldviews, philosophies, principles, and knowledge that constitute Indigenous ways of knowing and being. Health systems can apply it to a wide variety of things that present opportunities for honouring and integrating Indigenous ways of knowing and being, including 160 policies, strategies, plans, frameworks, and job descriptions, to support systemic equity transformation. As a result of this research and the insights gained, I developed a framework using CIT to promote the use of specific actions, such as reframing language, engaging ethically, redistributing power and resources, and prioritizing cultural continuity. These actions work in unity to challenge pervasive worldviews, embed relational practices, and promote transformative pedagogies, encouraging health systems to move beyond symbolic gestures and toward decolonization and equity advancement. The framework enables health authorities to critically assess how existing operations contribute to or exacerbate inequities, while offering an approach to translating equity commitments into whole-system-level transformation. Figure 4 Decolonizing Health Systems: A Relational and Action-Oriented Framework Grounded in Indigenous Epistemologies Note. This relational, action-oriented framework utilizes Critical Indigenous Theory to transform key aspects of the health system, including policies, strategies, and plans. Grounded in Indigenous epistemologies, it promotes reframing language, ethical engagement, power redistribution, and cultural continuity. Together, these actions 161 expose and shift power structures, cultivate relational practices, and advance transformative pedagogies, enabling health systems to enact their commitments to decolonization and critically examine their impact on equity. At the heart of my framework lies an epistemological foundation rooted in Indigenous worldviews, philosophies, knowledge systems, and principles that guide transformative change in the health system. When applied, these interwoven elements can demonstrate how Indigenous perspectives can inform system design, service provision, interpersonal interactions, and actions aimed at advancing Indigenous equity. My frameworkâs foundation includes four core actions: Reforming Language, Participating in Ethical Spaces of Engagement, Redistributing Power and Resources, and prioritizing cultural continuity. These actions are visually represented by directional arrows that point to transformative goals, emphasizing their dynamic and interconnected nature. Each action provides a process to disrupt colonial patterns and embed Indigenous values into everyday health system practices, offering a clear route to translating equity goals into systemic change. Using my created framework drives equity-focused transformation by advancing four core goals: exposing and disrupting power structures, embracing relational practices, applying critical transformative pedagogy, and achieving cultural continuity. These goals directly confront long-standing colonial health system patterns, where the hierarchy of power structures marginalizes Indigenous leadership, transactional relationships undermine trust, and systems often reject or devalue Indigenous practices. To expose and disrupt disproportionate allocation of power (Denzin et al., 2008), my framework guides health systems in challenging hierarchical models and redistributing authority in ways that support Indigenous self-determination. It encourages systems to embrace relational practices by prioritizing trust, mutual respect, accountability, and shared responsibility (Wilson, 2008). By applying a CIT perspective, system actors can actively reflect on their roles in maintaining oppressive structures and take conscious steps toward systemic change (Plamondon et al., 2023). Ultimately, my framework promotes cultural continuity by integrating Indigenous worldviews and practices into health systems, ensuring sustained change that endures across generations while respecting Indigenous beliefs, values, and perceptions of health and wellness. 162 Indigenous principles, values, and beliefs form the foundational "guiding ways of being" that underpin my framework, reminding users to conduct their work in an ethical manner. These teachingsâcentered on respect, responsibility, relationality, and humilityâare not optional but essential for grounding action. By prioritizing these values, my framework encourages users to embody Indigenous ways of being rather than treating equity work as a technical checklist. Consequently, the framework promotes not only changes in health system actions but also supports profound transformations rooted in Indigenous knowledge. Together, my framework's foundation, core actions, goals, and values address the root causes of inequity, rather than merely treating symptoms, and positions health systems as enablers of Indigenous wellness rather than barriers. By integrating these key insights, my framework advances beyond theory to offer an innovative, forward-thinking approach for change that aligns with Indigenous knowledge systems and equity commitments. It serves as both a tool and a call to action, urging health systems to honor their equity commitments through intentional, culturally grounded, and structurally embedded change. My framework directly addresses the research problem by providing a structured approach to overcoming challenges in integrating the IPN role. It also supports the study's purpose by providing a process to assess and enhance the equity and coherence of IPN integration within IH and NH, aligning their IPN operationalization with their stated equity goals and commitments. 5.3. Implications The implications of this study center on advancing equity within health systems, both in integrating the IPN role and in meeting broader organizational equity commitments and goals. Three key areas emerge. First, the study identifies promising practices and barriers that influence the integration of IPN roles across various health system levels, highlighting the importance of collective responsibility rather than individual burden. Second, the study demonstrates how language influences perceptions, reinforces dominating worldviews, and can either sustain inequities or act as a lever for change. Third, it emphasizes the significance of Indigenous pedagogies in guiding equity-driven practices and bridging 163 knowledge and action through embedding Indigenous worldviews into health system operations. Together, these implications call for structural, operational, relational, and cultural shifts that move health systems beyond symbolic inclusion toward a meaningful transformation of equity rooted in Indigenous knowledge sources. This study demonstrates that the structural levels of health systems could begin by reforming policies, governance, funding models, and system designs to develop collective responsibility and accountability for equity. Health systems leaders could move beyond relying on a dominant biomedical worldview (Keklar, 2021) that currently shapes the integration of Indigenous roles. Instead, they could incorporate diverse ways of knowing and being, making space for Indigenous worldviews and practices within the system's core structures and approaches (Groot et al., 2024). By doing this, health systems can provide equitable, culturally safe role integration that will enable them to respond by offering services that meet the health needs of Indigenous Peoples (Groot et al., 2024). Operationally, these findings suggest that health system leaders can proactively reassess how they define, support, and integrate the IPN role into daily operations and service delivery. Specifically, leaders can revise IPN job descriptions to emphasize relational responsibilities, advocacy, navigation, and cultural bridging. They could align onboarding and reporting structures with equity goals and ensure IPNs are fully embedded in interdisciplinary care teams and decision-making processes to dismantle siloes (Rankin et al., 2022). Implementing these operational changes can enable IPNs to perform effectively, enhance collaboration, and improve cultural safety and patient- and family-centered care for Indigenous populations (Rankin et al., 2022). These implications highlight the importance of health systems considering concrete steps to translate equity commitments into meaningful and sustainable improvements that advance Indigenous health equity. The relational implications of the findings highlight an additional area for health systems to establish shared responsibility and accountability in developing and sustaining trust with Indigenous Peoples (Gonzalez and Clark, 2016). Establishing shared responsibility involves moving beyond reliance on the IPN as the sole means of relational connection between communities and care (Guadagnolo et al., 164 2017). Health systems can respond by supporting collective responsibility through co-led planning processes, providing mentorship (Lester-Tsetsakos, 2022), and culturally grounded support for Indigenous staff (Rankin et al., 2022), as well as modeling ethical, reciprocal engagement with Indigenous partners (Guadagnolo et al., 2017). Embracing these relational approaches distributes responsibility more equitably, strengthens authentic relationships, and contributes to a system culture rooted in mutual respect and trust. These shifts present a vital opportunity to dismantle ongoing and historical barriers, ensuring that Indigenous perspectives and voices are not only included but also meaningfully embedded in health system decision-making. Lastly, culturally, health systems can consider shifting dominant Western worldview norms by validating and including Indigenous knowledge systems (Denzin et al., 2008) and embedding cultural continuity into care environments (Auger, 2016). Validating and Indigenous knowledge inclusivity systems requires adopting language and values that prioritize relational accountability over biomedical authority (Rankin et al., 2022), ensuring that Indigenous worldviews are central to the design and delivery of care. Such cultural shifts avoid superficial or symbolic inclusion (Vukic et al., 2012) and develop genuine systemic transformations that honor Indigenous identities and ways of being. By embracing these changes, health systems can avoid the characteristics of tokenism and strive closer to their goal of creating environments that truly support Indigenous health equity and well-being (IH, 2022). 5.4. Limitations Considering the limitations of this study and their impact on applicability is essential. Methodologically, the analysis relied on publicly available documents, such as IPN job postings, health authority strategies, and online equity-related resources. Internal organizational data would have provided more detailed insight into IPN role integration, such as internal evaluations, onboarding processes, or implementation tools. A lack of additional informative organizational data limits the ability to capture the full scope of system practices and may impact the reliability of the analysis. The findings rely solely on formal documents, as researchers did not conduct interviews or engage directly with IPNs or decision- 165 makers, which could also limit the study's credibility (Mays and Pop, 2000). Future studies could strengthen both credibility and comprehensiveness by expanding the methodological scope beyond a document analysis. Furthermore, the availability of resources from IH primarily directs this study, since the analysis found no equity-specific policies, strategies, or plans for NH. This limitation restricts the opportunity to compare regional approaches and may narrow the depth of analysis. Future studies analyzing the role of IPN in the integration of health systems' equity could seek to access internal organizational data to continue building on the findings of this study. Theoretically, while the study is grounded in CIT, this lens may not fully account for the operational or clinical dimensions that influence IPN integration within complex health systems. Practically, time and resource constraints limited the ability to pursue internal documents or engage with Indigenous partners and health authority leaders for validation. The findings primarily reflect the policy and integration context within IH and NH, limiting their generalizability to other authorities. While the findings reflect the IH and NH contexts, they may not generalize to other authorities; however, generalizability is not necessarily appropriate given the diverse needs and unique circumstances of Indigenous Peoples and their communities, which require tailored approaches rather than one-size-fits-all solutions (Burrage et al., 2024), making the concept of transferability relevant. Transferability is the extent to which insights from one context may inform another, provided that similarities exist (Korstjens & Moser, 2017). In this study, specific principles and learnings, such as exposing and disrupting power, collective responsibility, and utilizing Indigenous pedagogies, could be transferable to other health systems (Korstjens & Moser, 2017). Although some insights and recommendations from this study are not universally applicable, they can still guide reflections in other settings when adapted collaboratively with local Indigenous Partners to address contextual differences. Lastly, these limitations reveal the opportunity for health authorities to make more internal resources publicly available to support transparency and accountability in the integration of Indigenous-specific roles such as the IPN. Addressing these challenges through further research and greater 166 organizational openness can strengthen the integration and effectiveness of Indigenous roles across diverse health systems. 5.5. Recommendations for Future Research This study highlights several priority areas where future research can strengthen the integration of IPNs and advance health system equity. Future research could engage directly with IPNs, Indigenous clients, families, communities, and health system staff across IH and NH to better understand the lived experiences of those working in and impacted by these roles (Lester-Tsetsakos, 2022). Such studies can deepen understanding of the relational nature of IPN work, the systemic and cultural barriers IPNs face, and the supports required for long-term success. Including perspectives from both Indigenous and non-Indigenous staff can also clarify how the IPN role is understood and supported across distinct parts of the system (Rankin et al., 2022). Second, comparative research between IH, NH, and other BC health authorities could reveal essential similarities and differences in the integration of IPN. Examining how each health authority approaches funding, onboarding, role clarity, and alignment with equity goals would help identify both promising practices and shared challenges. These insights could inform more consistent and culturally safer approaches to integrating IPNs across the province. Third, future research could also examine how leadership, governance, and accountability influence the effectiveness of IPN roles. Key areas include the inclusion of Indigenous voices in processes, decision-making, and leadership, as well as the sharing of responsibilities for equity across departments, and the mechanisms used to track progress on equity commitments over time. Investigating these structures can support a shift from symbolic inclusion to meaningful, systemic change (Vukic et al., 2012). Fourth, future research could examine how organizational language and discourse influence the positioning and perception of IPN roles. Documents such as job descriptions, policies, and internal communications shape expectations and can either enable or limit the effectiveness of the role. Research 167 in this area could assess how language reflects underlying power dynamics and explore whether it supports a strengths-based, relational approach that aligns with Indigenous worldviews and values. Longitudinal research is crucial for evaluating the long-term effects of IPN integration on outcomes, including access to care, cultural safety, service coordination, and overall wellness for Indigenous clients. Tracking these impacts over time can generate critical evidence to support sustained investment in IPN roles. Such research can also guide continuous improvements in system practices and inform how IH and NH implement equity commitments in a lasting and measurable way. 5.6. Conclusion This study demonstrates the systemic changes needed to integrate IPN roles more equitably within IH and NH. The findings show that both health systems privilege dominant Western biomedical models over Indigenous-informed approaches and place disproportionate relational and cultural integration responsibilities on the individual IPN. Current role operationalization overlooks the importance of collective responsibility in addressing and/or strengthening the structural, operational, relational, and cultural practices that shape role success across all levels of the health system. The research emphasizes that language use is important and that there is a need for improved language use that shifts power, respects, and includes Indigenous knowledge in ways that make everyone involved in the system accountable. In response to the biomedical model dominance, lack of Indigenous-informed processes and collective responsibility, the study identifies key promising practices and inhibitors, points to the importance of language use that maintains power and/or need for power redistribution, the validation and inclusion of Indigenous knowledge systems and models, and collective accountability across the system. These insights also highlight how Indigenous worldviews remain inconsistently present in role integration and how this influences both practice and policy coherence. By comparing the integration of IPNs with other specialist roles, such as the APN, the analysis underscores the unique equity-related challenges and opportunities facing Indigenous-specific roles. 168 The developed recommendations and framework in this study synthesize these findings and offer a values-based, action-oriented approach to help health systems align their operations with their stated equity commitments. Through this approach, the research directly examines whether IH and NH are integrating the IPN role equitability and in alignment with the goals they commit to. The closing chapter concludes by summarizing the study's key contribution and its potential to address current challenges in IPN role integration, highlighting how these findings directly respond to the central research question. It also provides a summary of health system approaches that promote a more equitable integration of the IPN role. 169 6. Chapter Six: Conclusion Health systems increasingly introduce Indigenous-specific healthcare positions, such as the Indigenous Patient Navigator (IPN), to advance equity, enhance cultural safety, and improve health outcomes for Indigenous peoples (Rankin et al., 2022). This intervention creates an opportunity for practical insights, evidence-informed recommendations, and processes to support the equitable integration of these roles. By applying the Systematic Equity-Action Analysis (SEAA) alongside Critical Indigenous Theory (CIT), this study examines how Interior Health (IH) and Northern Health (NH) integrate the IPN role. The findings make primary contributions across three domainsâconceptual, empirical, and practicalâwhich together address the central research question: How is the integration of the IPN role within IH and NH carried out equitably, and are these processes coherent with their stated equity goals and commitments? Conceptually, the study reveals new ways of understanding the role of IPN integration by demonstrating that successful integration requires attention to both promising practices and barriers across all levels of the health systemâstructural, operational, cultural, and relationalâand effective coordination through collective responsibility among all stakeholders. Organizations can share responsibilities equitably to prevent overburdening certain actors and limiting others to specific system levels. Table 9 operationalizes these insights by synthesizing literature-based IPN role integration as reflected in IH and NH IPN and IPN-like job descriptions. In contrast, Table 10 highlights health system inhibitors and pairs them with Indigenous-informed recommendations. Taken together, these contributions show that intentionally designing IPN integration through Indigenous-informed, collectively responsible processes can transform health systems and advance health equity. The study also Indigenized existing frameworks (PEPPA and PEPPA Plus) by embedding Indigenous epistemologies, relational approaches, and reflexive practices, ensuring integration processes are culturally safe, equity-driven, and responsive to Indigenous priorities. Building on these insights, I developed a relational, action-oriented framework to guide the integration of IPN. This Indigenous- 170 informed framework (Figure 4: Decolonizing Health Systems: A Relational and Action-Oriented Framework) provides health systems with a pathway to advance their organizational equity goals through a decolonial approach that challenges the Western-dominated worldview and centers on Indigenous knowledge and perspectives. Empirically, the study documents how IPN integration occurs within IH, rather than NH, due to the lack of available documents for analysis, and identifies levels of coherence between stated system equity goals and commitments and actual practices, as shown in Table 6: IH Equity and Equity-Related Goals and Commitments. This table illustrates how IHâs stated equity and equity-related goals and commitments, as outlined in its relevant policies, strategies, and plans, serve as a reference point for assessing the alignment of IPN integration with organizational intentions. Evaluating the alignment of the IPN role with health system equity goals and commitments determines whether the role actively advances these objectives. The analysis also underscores the central role of language in shaping perceptions, relationships, and institutional norms, as illustrated in Figure 3: Guidance for Developing Indigenous-Specific Healthcare Role Descriptions: Reframing Language and Alignment with Evidence-Based Role Integration Frameworks. This guidance shows that language does more than describe; it actively constructs realities within health systems by signaling values, priorities, and power dynamics (Ojha, 2021). Shifting language toward relational, equity-informed, and Indigenous-centered terminology shapes how roles function, guides their implementation, and affects their reception across all organizational levels. Language in job descriptions, policies, and communications shapes perceptions, sets expectations, and directly influences the effectiveness of IPN roles. In this way, language becomes a critical lever for advancing equitable role integration. Practically, the study translates these insights into actionable recommendations and a framework for health systems. Key recommendations and the framework include: 1. Applying collective responsibility across all system levels when implementing IPN integration, ensuring equitable distribution of responsibilities. 171 2. Indigenizing existing frameworks to integrate both Indigenous and Western worldviews in ways that maintain balance and cultural safety. 3. Reframing language and role descriptions to redistribute power, emphasize partnership, and support shared accountability among stakeholders. 4. Operationalizing the Decolonizing Health Systems framework to embed culturally safe, equity-driven, and sustainable practices across structural, operational, relational, and cultural dimensions. This study demonstrates that the equitable integration of the IPN role within IH and NH requires more than creating Indigenous-specific positions; it demands intentional, Indigenous-informed processes that operate across structural, operational, relational, and cultural levels of the health system. When guided by Indigenous epistemologies, collective responsibility, and equity-driven practices, the IPN acts as a transformative agent, advancing systemic equity for Indigenous Peoples. The findings show that current integration practices are not yet fully coherent with IH and NHâs stated equity goals and commitments, underscoring the need for coordinated attention to power dynamics, role definition, and relational accountability. 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Thesis/Dissertation
eng
Nursing
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Plamondon, Katrina
The integration of the Indigenous patient navigator role in British Columbia health systems : a systematic equity action-analysis
Text