Graduate Studies, College of (Okanagan)
DSpace
UBCO
Mitchell, Vanessa
Master of Arts - MA
University of British Columbia
The purpose of this research project was to examine cultural safety from an Okanagan/Sqilxw perspective. Cultural safety is a term that originated in New Zealand with the Maori people in their need to address the health disparities and power imbalances within the institution of health. As cultural safety has become adapted in practice within the Interior Region, it became necessary to examine the concept closer with peoples of the Interior. As the Syilx (Okanagan) are one of the seven First Nations located in the Interior Region, and of which I am a member, this project was primarily conducted with Okanagan/Sqilxw members of the Okanagan Indian Band. The research was guided by participatory action research and Indigenous methodologies. The analytical framework was based on the enowkinwixw, which is an Okanagan/Sqilxw decision making process that undertakes serious issues of concern in the community. In order to ground this research in community, it was equally necessary that I abide by community ethics. Therefore, an Advisory Committee, formed solely of Okanagan Indian Band members, held my research and me accountable to community. Talking Circles was how community members were brought together to break down the terms culture and safety, and to discuss what cultural safety meant to them. In analyzing the contribution from community members, it is integral for Okanagan/Sqilxw to gain cultural confidence; that is, the confidence to voice one’s or people’s concerns and direction. Further, it is cultural safety that community and mainstream healthcare must strive for. Both are an investment in a lifelong journey into one’s self.
FROM THE MARGINS: CULTURAL SAFETY FROM AN OKANAGAN SQILXW PERSPECTIVE by Vanessa Mitchell B.A., The University of British Columbia Okanagan, 2008 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE COLLEGE OF GRADUATE STUDIES (Interdisciplinary Studies) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan Campus) March 2018 © Vanessa Mitchell, 2018 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis/dissertation entitled: From the Margins: Cultural Safety from an Okanagan/Sqilxw Perspective submitted by Vanessa Mitchell in partial fulfillment of the requirements of the degree of Master of Arts Dr. Rachelle Hole, School of Social Work, Faculty of Health and Social Development Supervisor Dr. Jeannette Armstrong, Community, Culture and Global Studies Faculty, Irving K. Barber School of Arts and Sciences Supervisory Committee Member Dr. Donna Kurtz, School of Nursing, Faculty of Health and Social Development Supervisory Committee Member Dr. Allison Hargreaves, Critical Studies, Faculty of Creative and Critical Studies University Examiner Click or tap here to enter text. External Examiner Additional Committee Members include: Dr. Peter Hutchinson, Canadian Partnership Against Cancer Supervisory Committee Member Click or tap here to enter text. Supervisory Committee Member March 21, 2018 iii Abstract The purpose of this research project was to examine cultural safety from an Okanagan/Sqilxw perspective. Cultural safety is a term that originated in New Zealand with the Maori people in their need to address the health disparities and power imbalances within the institution of health. As cultural safety has become adapted in practice within the Interior Region, it became necessary to examine the concept closer with peoples of the Interior. As the Syilx (Okanagan) are one of the seven First Nations located in the Interior Region, and of which I am a member, this project was primarily conducted with Okanagan/Sqilxw members of the Okanagan Indian Band. The research was guided by participatory action research and Indigenous methodologies. The analytical framework was based on the enowkinwixw, which is an Okanagan/Sqilxw decision making process that undertakes serious issues of concern in the community. In order to ground this research in community, it was equally necessary that I abide by community ethics. Therefore, an Advisory Committee, formed solely of Okanagan Indian Band members, held my research and me accountable to community. Talking Circles was how community members were brought together to break down the terms culture and safety, and to discuss what cultural safety meant to them. In analyzing the contribution from community members, it is integral for Okanagan/Sqilxw to gain cultural confidence; that is, the confidence to voice one’s or people’s concerns and direction. Further, it is cultural safety that community and mainstream healthcare must strive for. Both are an investment in a lifelong journey into one’s self. iv Lay Summary As cultural safety is a term that comes from New Zealand and the Maori people it is important to examine cultural safety from the Sqilxw people, the Indigenous peoples of the Okanagan, perspective in the Interior region of British Columbia, Canada. The research was guided by community participants and the findings were analyzed based on the enowkinwixw, a Sqilxw decision making process for dealing with serious community issues of concern. Sqilxw community members of the Okanagan Indian Band participated in Talking Circles to discuss what cultural safety means to them. The findings indicate that cultural safety is important in healthcare and that cultural confidence, which is the confidence to voice one’s or people’s concerns and direction, is integral to have when accessing healthcare for Sqilxw people. v Preface It is important to acknowledge that, in following with Participant Action Research and Indigenous Methodology, ethics approval for this research study was granted by the University of British Columbia Okanagan Behaviour Research Ethics Board Certificate #H15-00947, the Okanagan Indian Band leadership, and the Community Advisory Committee. vi Table of Contents Abstract .................................................................................................................................... iii Lay Summary ........................................................................................................................... iv Preface ....................................................................................................................................... v Table of Contents ..................................................................................................................... vi List of Tables ............................................................................................................................. x List of Figures .......................................................................................................................... xi Glossary .................................................................................................................................. xii Acknowledgements ............................................................................................................... xiv Dedication ............................................................................................................................... xv Chapter 1: Welcome to the Circle ............................................................................................ 1 1.1 Introduction to the Study .......................................................................................... 3 1.2 Research Question .................................................................................................. 4 1.3 Purpose of the Study ............................................................................................... 4 1.4 Rationale for the Study ............................................................................................ 5 1.5 Organization of this thesis by Chapters ...................................................................10 Chapter 2: Why Cultural Safety? ............................................................................................ 13 2.1 The Culture of Terminology .....................................................................................13 2.1.2 Culture .......................................................................................................13 2.1.3 Safety .........................................................................................................14 2.1.4 Cultural Blindness and Cultural Desire .......................................................15 2.1.5 Cultural Competency ..................................................................................16 2.1.6 Cultural Safety ............................................................................................16 2.2 What is Cultural Safety and what is Cultural Unsafety? ...........................................19 2.3 Summary ................................................................................................................21 Chapter 3: “It’s in the past, get over it!” Is it in the past? .................................................... 23 vii 3.1 Colonial Policies .....................................................................................................23 3.2 Colonization and Me: The Indian Woman ...............................................................24 3.3 The Journey of Self-Determination and Sovereignty ...............................................29 3.4 The Landscape .......................................................................................................30 3.4.1. British Columbia First Nations ......................................................................30 3.4.2. BC – Interior Region First Nations peoples ..................................................30 3.4.3. The Okanagan/ Sqilxw ..................................................................................31 Chapter 4: Methods................................................................................................................. 32 4.1 Applying an Okanagan/Sqilxw Lens to Methodology ................................................32 4.2 Indigenous Methods (IM) ........................................................................................33 4.3 Participatory Action Research (PAR) ......................................................................33 4.4 The 4Rs ..................................................................................................................34 4.5 Enowkinwixw ...........................................................................................................34 4.6 Maintaining Community Ethic ..................................................................................36 4.7 Participants and Recruitment ..................................................................................36 4.7.1 Permission ....................................................................................................36 4.7.2 Community Advisory Committee ...................................................................37 4.7.3 Community Participants ................................................................................39 4.7.4 Talking Circle ................................................................................................40 4.8 Protocol ..................................................................................................................42 4.8.1. Reporting Back ............................................................................................42 4.8.2. Traditional Knowledge..................................................................................42 4.8.3 Trauma and Loss ..........................................................................................43 4.9 Transcription Process .............................................................................................43 4.10 Data Analysis ..........................................................................................................44 4.11 Validity and Legitimacy ...........................................................................................45 viii 4.12 Self-Reflection ........................................................................................................45 Chapter 5: Wisdom within the Circle ..................................................................................... 47 5.1 Community Advisory Committee .............................................................................47 5.2 Community Participants ..........................................................................................60 5.2.1 Discussions of the Term ‘Culture/Cultural’ ..................................................62 5.2.2 Discussions of the Term ‘Safety’ ................................................................66 5.2.3 Discussions of the Term ‘Cultural Safety’ ...................................................67 5.2.4 Final Round ................................................................................................69 5.3 Enowkinwixw: Analytical Framework ........................................................................72 5.3.1 Tradition (skimxist) ........................................................................................73 5.3.2 Innovation (siya)............................................................................................74 5.3.3 Relationship (spitlem) ...................................................................................75 5.3.4 Action (ntixtiyx) .............................................................................................76 5.4 The Central Issue: Cultural Safety ..........................................................................77 5.5 Cultural Confidence ................................................................................................79 Chapter 6: Discussion ............................................................................................................ 82 6.1 Suggestions from the Findings for Healthcare Professionals ..................................82 6.2 Suggestions from the Findings for Community ........................................................85 6.3 Limitations ..............................................................................................................85 6.4 Implications for Future Research ............................................................................87 6.5 Self-Reflection ........................................................................................................88 References .............................................................................................................................. 89 Appendices ........................................................................................................................... 100 Appendix B: Advisory Committee – Consent Letter ............................................................. 101 Appendix C: Consent to Release Contact Information Form ............................................... 109 Appendix D: Community Member – Consent Letter ............................................................. 110 ix Appendix E: List of Local Resources ................................................................................... 116 Appendix F: Talking Circle Guide ........................................................................................ 117 Appendix G: Talking Circle - Presentation ........................................................................... 118 x List of Tables Table 1: Why Cultural Safety (Adapted from Ward, Branch, Fridkin, 2016, p.30) ......................19 Table 2: Culture and Safety.......................................................................................................52 Table 3: Community Definition of Safety ...................................................................................66 Table 4: Community Definition of Trust .....................................................................................66 Table 5: Siya/Innovation ............................................................................................................75 Table 6: Spitlem/Relationship ....................................................................................................76 Table 7: Ntyixtix/Innovation .......................................................................................................77 xi List of Figures Figure 1: Enowkinwixw Community ............................................................................................35 Figure 2: Power and Powerlessness .........................................................................................53 Figure 3: Cultural Safety in Balance ..........................................................................................72 Figure 4: Imbalance of Cultural Safety ......................................................................................73 Figure 5: Skimxist/Tradition .......................................................................................................74 Figure 6: Put the Coin Down .....................................................................................................78 Figure 7: Knowledge and Behaviour/Practice ............................................................................79 Figure 8: Cultural Confidence ....................................................................................................80 Figure 9: Imbalance ..................................................................................................................83 xii Glossary Aboriginal peoples: The Constitution Act (1982) recognizes Aboriginal peoples of Canada — Indian, Inuit, and Métis people. “These are three distinct peoples with unique heritages, languages, cultural practices and spiritual beliefs” (Government of Canada, 2016, para.3). Urban Aboriginal people: “refers primarily to First Nations, Inuit and Metis individuals currently residing in urban areas” (Government of Canada, 2016c, para.2). Indian: “Indian refers to a person, who, pursuant to the Indian Act, is registered as an Indian or is entitled to be registered as an Indian (Frideres and Gadacz, 2005, p. 25).  Status Indian: “An individual recognized by the federal government as being registered under the Indian Act is referred to as a Registered Indian (commonly referred to as a Status Indian)” (Government of Canada, 2017, para.2).  Non-Status Indian: “Commonly refers to people who identify themselves as Indians but who are not entitled to registration on the Indian Register pursuant to the Indian Act. Some may, however, be members of a First Nation band” (Government of Canada, 2012, para.2). First Nations: “Today, the term First Nations (a term not used by Aboriginal peoples outside Canada) has been used by a segment of Canada’s Indigenous population, and generally by status Indians as well as by the federal government” (Frideres and Gadacz, 2005, p. 20). Métis: “refers to a distinctive peoples who, in addition to their mixed ancestry, developed their own customs and recognizable group identity separate from their Indian or Inuit and European forbearers.” (Government of Canada, 2016b, para.7). xiii Indigenous Peoples: “It is a term that internationalizes the experiences, the issues and the struggles of some of the world’s colonized people. The final ‘s’ in Indigenous peoples has been argued for quite vigorously by Indigenous activists because of the right of peoples to self-determination. It is also used as a way of recognizing that there are real differences between different Indigenous peoples” (Smith, 2005, p.7). Okanagan: “Anglicized term referring to the Indigenous people of the Okanagan territory” (Cohen, 2010, p.xiv). Sqilxw: “The Okanagan term for the Indigenous people also commonly called the Okanagan whose territory is located in the southern interior of BC and north central Washington, literally translates as the dram in a spiral. Syilx is also used and refers to the people who speak Nsyilxcen, the Okanagan language” (Cohen, 2010, p.xiv). xiv Acknowledgements I acknowledge the ancestral, traditional, and unceded lands of the Okanagan/Sqilxw people. As a graduate student the journey is very much one of solitude, so to my supervisor, Dr. Rachelle Hole and my supervisory committee members, Dr. Jeannette Armstrong, Dr. Peter Hutchinson, and Dr. Donna Kurtz, I offer my gratitude for taking up the challenge in becoming my mentors and for their gentle encouragement and guidance as I navigated the world of academia. I acknowledge the funding support of the Okanagan Indian Band, UBC Okanagan, and New Relationship Trust. I raise my hands up to the Okanagan Indian Band leadership for allowing me to conduct my research in community and to the community members who joined me in this exploration of cultural safety from the margins: Fabian Alexis, Jonathon Alexis, Patsy Gregoire, Chris Marchand, Eric Mitchell, Guy Robbins, Jami Tonasket, and Marie Tonasket. I send many blessings to my parents, my partner, and our children for their encouragement, for their love, for their patience, for their understanding, and for their unshakeable belief in my ability to finish what I started. Lim limpt xv Dedication To my beautiful children, Thunder and Selena – who have endured my educational journey from upgrading to post-secondary – you are my inspiration, you are my strength, you are my courage, you are my dreams, you are my heart, and you are my future. 1 Chapter 1: Welcome to the Circle Welcome. I will begin by introducing myself twice. The first round of introduction is for the professional and academic setting, so I will share my name, title, organization and credentials. As a believer in education, I feel this first round of introduction is important to honour and acknowledge the time and investment one puts into oneself to be in their respective positions. So, for the first round, “Greetings, I am Vanessa Mitchell, Aboriginal Cultural Safety Educator, employee of Aboriginal Health, Interior Health, and holder of a Bachelor of Arts majoring in Indigenous Studies and a student in a Masters of Arts focusing on cultural safety.” To maintain the integrity of this story, a second round of introductions is equally necessary. In this round I share who I am, where I come from, and why I have chosen to enter the circle of cultural safety. My father describes the second introduction as a journey from the mind to the heart (E. Mitchell, personal communication, September 8, 2016). Introducing me in this way informs the reader, and my people who may read this, of where I belong and how I locate myself in this research. My name is Vanessa Mitchell, my parents are Chris Marchand and Eric Mitchell, and my brother is Samuel Mitchell. My maternal grandparents were the late Elizabeth (nee Fred) and Charlie Marchand. I also pay homage to my grandmother’s brother Edward Fred as he gifted my two children, Thunder and Selena Mitchell, and me with our Okanagan/Sqilxw names. The late Florence (nee Marchand) and Stanley Mitchell were my paternal grandparents. I am from the Okanagan Indian Band, which is one of the eight bands of the Okanagan Nation. I have family ties to the St’at’imc Nation through my great-grandfather, Sam Mitchell as he was from Xaxli’p (Fountain Indian Band). I was born on his eightieth birthday. My partner is from the Nlaka’pamux Nation and my four step-children are members of the St’at’imc Nation. That is a little bit of who I am and where I come from. Now, I will share why I have chosen to enter the circle of cultural 2 safety. This is important because when one enters a circle they are taking responsibility to actively participate, contribute their ideas and share their knowledge with those in the circle. In different meetings within the Okanagan territory, I have observed many Elders and Knowledge Keepers state, “The health of the people relies upon the health of the land.” Hearing those words over and over from people that were well-respected for their knowledge and whom I held the utmost respect for made it very clear to me that it was of no coincidence that Aboriginal people’s health is lower than that of all other British Columbians (Chappell & Penning, 2009; First Nations Health Council, 2011; Kurtz, D., Nyberg, J.C., Van Den Tillart, S & Mills, B., 2008). As I began my research, there was an overwhelming amount of research on Aboriginal people’s health disparities. While I think it is absolutely important to know and understand these disparities in order to identify gaps and propose ways to address the disparities, I wanted to broaden my understanding further as an Okanagan/Sqilxw woman with lived experience of many of the disparities often identified for Aboriginal women within health research. This exploration led me to look into the chaptikwl and ultimately the enowkinwixw. As a result, I was drawn to exploring cultural safety as situated in place here in the Okanagan territory. Doing so encouraged me to place myself and examine why, as an advocate for my family and community’s health and well-being, I stand strong, however, as a recipient of care in health, I am vulnerable, raw and exposed. So, my journey into cultural safety came from a need to further my understanding of the correlation between being a vulnerable recipient of care while still being a strong advocate. To do this work entailed me to bring together the wisdom of my community to see if this was common and to explore what other correlations existed. I did so by bringing together those who are knowledgeable in cultural safety, in health, and in community engagement to have dialogue with, as I myself am only just learning. So, the Community Advisory Committee members were sought out for their wisdom as well as for their 3 characteristics that they embodied that seemingly aligned with the enowkinwixw from my perspective. 1.1 Introduction to the Study The focus of this research is cultural safety, particularly cultural safety as informed by local Okanagan/Sqilxw knowledge and perspectives. Understanding this local perspective is important as it aligns with an Indigenous approach to knowledge, and it is worth exploring as there exists some uncertainty about the term cultural safety itself as well as the two words comprising the concept: “culture” and “safety.” The term culture is not an easy term to explore and, yet, it is a term often used in various circumstances. Battiste and Henderson (2000) successfully problematize the term as it is nested in the cloaks of colonialism. Other researchers (Douglas, 2013; Hendry, 2005) seemingly remain politically neutral and select a definition of culture that best suits their purpose. Due to the multitude of ways the term culture can be understood, the aim of this thesis was to look at the context and understanding of cultural safety as situated in the Okanagan. Rather than putting my own definition upon the term culture, I engaged community and listened to how Okanagan/Sqilxw defined culture and its impacts, be it positive or negative. For the second term, safety, although it does not seem to have the same complex connotations as the term culture, the process was the same. As such, this research aimed to meet the following two research objectives through community engagement and participatory processes that are informed by Indigenous methodologies: Research Objective#1: Break apart cultural safety as a term, to explore how it is situated within the Okanagan. 4 Research Objective#2: Identify guiding principles for culturally safe practice informed by Okanagan/Sqilxw ways of knowing and being. 1.2 Research Question What does cultural safety mean to you? This is the question that I posed to the Okanagan/Sqilxw community members who participated in this study. The overarching research question guiding this exploration was, “Informed by Indigenous methodologies (enowkinwixw) and participatory research practices, what is an Okanagan/Sqilxw understanding of cultural safety?” 1.3 Purpose of the Study In telling this story, it is important to acknowledge that the term cultural safety is rooted within the context of the Maori story in New Zealand. Although Canada and New Zealand do share vast similarities in the story of colonization, it is necessary to examine cultural safety from this place and from the Indigenous people’s perspective and lived experiences here in the Okanagan. As cultural safety may be very different from where it originated, an exploration of whether cultural safety is a concept that resonates and has application in this geography and landscape is to honour the distinct diversity that exists not only within Indigenous peoples globally, but within Aboriginal peoples locally as well. Therefore, to respect the territory, and as I am a member of the Okanagan Indian Band, this research takes place at “Nkmaplqs/Head of the Lake” in hopes to seek their community’s perspective (Cohen, 2010, p. xiv). If the community members who participate in this study conclude that cultural safety holds no relevance, then it is important to find out why not. However, if cultural safety has relevance to the people of this place, then it is beneficial to adopt cultural safety in health and it must be defined by the people in this place and in relation to their experience. After all, cultural safety is determined by the recipient of care (National Aboriginal Health Organization (NAHO), 2008), 5 and so it must be defined by that recipient and, in the context of this story, the recipients are Okanagan/Sqilxw. 1.4 Rationale for the Study To set the stage I need to first acknowledge that this thesis is intentionally written in a non-traditional academic format. As a result, the writing comes from a more personal perspective to honour the relationality of Indigenous Methodology (Wilson, 2008). The theory is that this study is relational, and it is a continuous process with no hard and fast, linear, concrete finish line or end, but rather a circular continuum (Archibald, 1997; Wilson, 2008). The works of Indigenous researchers (Archibald, 1997; Armstrong, 2009; Cohen, 2010; Wilson, 2008) have created a path for me as an Okanagan/Sqilxw researcher, in the infancy of learning, to follow in centering this study in Indigenous epistemology, particularly chaptikwl or story. The use of story provides a framework in which to tell the story and a medium in which to self-reflect in a safe way (Hargreaves & Page, 2013). What is contained within the act of storytelling is a relationship between story teller and listener, or rather the reader in the case of this thesis (Archibald, 1997). Hargreaves and Page (2013) assert that the power of stories is a place where common ground can be found as all people do it, and they are used as a way to explain, construct and understand the world around us as we engage with it. For this journey of reading through the thesis and the knowledge sharing, I call to the reader to move beyond the passive listener to the active, otherwise there is risk of missing meanings contained within (Archibald, 1997). I will explain this further by describing the role of the reader. I need to ask the reader to bring forward their wisdom to the journey of reading this thesis and shared knowledge. This is a call to the reader because too often I have witnessed in-person examples of Aboriginal peoples sharing their stories and the audience listening to their story is seemingly passively entertained, rather than listening as an active participant to a person’s 6 story. A person’s story in this context is speaking to a history or ‘her’stories, or a people’s story. When it comes to describing different roles the reader can take in engaging with story, I have identified it very simplistically into three stages: the child, the adolescent, and the adult. The role of the reader as child is simply to be entertained. Laugh when it is silly, cry when it is sad, and be fearful when the suspense is building. The role of the reader as adolescent is entertainment and the ability to glean a couple of life lessons from the story. Whereas, the role of the reader as an adult is more about practicing patience and pulling meaning from the story to the forefront (Archibald, 1997). It is from that place that I invite the reader (listener) of this story to engage in this thesis in the role of adult and bring their wisdom. It is in the role of the adult that the reader can immerse oneself into the story and do their storywork, which is to begin to think about it and reflect upon what the teachings are within the story (Archibald, 1997). To actively participate some questions to consider are: What are you hearing? What are you not? Why or why not? Where are you in this story? What wisdom can you bring to this story? The reader is invited to engage, be solution-oriented, and bring who they are and where they come from to this story. Now it is important to identify what story we are speaking of and, in doing so, I must situate the story to place and ground this research upon Okanagan/Sqilxw epistemology which can be found within the chaptikwl. The convention of [chaptikwl] is a method for humans to continuously learn, understand and be guided in ways to implement the life principles required to sustain a regenerative environmental ethos in their uniqueness as an aspect of nature itself. As expressed in the Syilx [Okanagan] language, they are a tmixw – life – force, themselves. (Armstrong, 2009, p.30) Chaptikwl are Okanagan/Sqilxw stories that explain the existence of the earth and all of its life forms (Vedan, 2002). Chaptikwl contain within them the natural laws that govern 7 Okanagan/Sqilxw people and it is the responsibility of the Okanagan/Sqilxw to pass this sacred knowledge to the new generations. Adrienne Vedan (2002) explains that the Okanagan/Sqilxw people’s worldview contains within it a deep understanding that ecology, language, origin, and beliefs are inseparable. The “accumulation of knowledge” is held within the chaptikwl and “things happen as a consequence, in relation to other things happening” (Armstrong, 2009, p.168; Vedan, 2002, p.4). In the chaptikwl, How Food Was Given, the community of Animal and Plant People gathered to prepare for the coming people. This chaptikwl holds within it teachings of coming together, collective decision-making processes (enowkinwixw), and planning for future generations (Vedan, 2002; Okanagan Nation Alliance, 2010b). As I ascribe to Indigenous Methodologies for this study, I must privilege the chaptikwl of How Food Was Given. By centering this research with the chaptikwl, I am inherently adhering to the four Rs – respect, relevance, reciprocity, and responsibility (Kirkness & Barnhardt, 1991). I have great respect for my people and it is an honour to engage with the knowledge encapsulated within the chaptikwl of How Food Was Given and to be able to bring it to the forefront of this research, as many far superior Okanagan/Sqilxw scholars have done before me. To ensure relevance, I am writing this thesis in an unconventional manner in the perspective of the academy in order to allow for this thesis to be accessible to “all facets of community” including those “who are not familiar with academic prose […and need to] know ‘what the hell I am talking about’” (Cohen, 2010, p. 159). For reciprocity, as a researcher participating in community engagement and actively learning, I am committed to sharing the outcomes of this research with my community and my nation. As an Okanagan/Sqilxw woman, I am taking my responsibility seriously by upholding the importance of community ethic above that of the university ethics. How I am doing so is by gathering the people via guidance of an Okanagan/Sqilxw Community Advisory Committee and participation of Okanagan Indian Band community members in Talking Circles. 8 This next section in italics, the chaptiwkl, How Food Was Given, which is a part of the published trilogy Kou Skelouwh/We Are The People. Interwoven throughout this section is my humble interpretation, as an Okanagan/Sqilxw woman learning of the chaptikwl in relation to the research question, “What is an Okanagan/Sqilxw understanding of cultural safety?” In the world before this world, before there were people, and before things were like they are now, everyone was alive and walking around like we do. All Creation talked about the coming changes to their world. They had been told that soon a new kind of people would be living on this earth. Even they, the Animal and Plant people would be changed. Now they had to decide how the People-To-Be would live and what they would eat (Okanagan Tribal Council (OTC), 2012, p.10). The four Chiefs of all Creation are: Black Bear, Chief for all creatures on the land. Spring Salmon, Chief for all creatures in the water, Bitter Root, Chief for things under the ground, Saskatoon Berry, Chief for things growing on land. They held many meetings and talked for a long time about what the People-To-Be would need to live. All of the Chiefs thought and thought (OTC, 2012, p.13). Now, it is time to gather the people for this research. To gather the people, I had to apply to UBCO ethics; however, my community’s ethical principles and values are integral in gathering the people. It is important for me to follow community ethics in this study. I know what it is I seek, but I must do it in a good way with community guidance. So, I approached four community members, to represent each of the characteristics of the Chiefs: Black Bear – tradition, Bitterroot – relationship, Saskatoon Berry – innovation, and Spring Salmon – action. I approached these four community members to become the Community Advisory Committee and provide their guidance and direction, and to assist me in gathering participants from the community: Eric Mitchell – tradition, Chris Marchand – relationship, Fabian Alexis – innovation, and Jami 9 Tonasket – action. These committee members were also asked to talk about cultural safety and to consider if cultural safety is important to this place. What can we give to the People-To-Be to eat that is already here on earth? They asked one another. There seems to be no answer (OTC, 2012, p.14). Now, it is time for the lighting of the fire. The Talking Circle for cultural safety has begun. A Talking Circle is about coming together in a respectful way to share your thoughts and ideas in a safe space free of judgment and interruption (Chilisa, 2012). The first rounds of the Talking Circle began with the stories of hurt, of cultural unsafety. The people needed to first share their stories of hurt and to speak from their heart of their lived experiences in relation to healthcare. As a researcher, I must listen with open ears to these stories in order to build trust and good relations. Finally, the three other Chiefs said to Bear, you are the oldest and wisest among us. You tell us what you are going to do. Bear said, since you have all placed your trust in me, I will have to do the best I can. He thought for a long time and finally said I will give myself, and all the animals that I am Chief over, to be food for the People-To-Be. Then he said to Salmon, what will you do? Salmon answered, you are indeed the wisest among us. I will also give myself and all the things that live in the water for food for the People-To-Be. Bitterroot, who was Chief of all the roots under the ground, said, I will do the same. Saskatoon Berry was last, she said, I will do the same. All the good things growing above the ground will be food for the People-To-Be. Chief Bear was happy because there would be enough food for the People-To-Be. Bear said, now, I will lay my life down to make these things happen (OTC, 2012, p.14-25). The time has come for ideas to emerge on what can be done to take action to improve healthcare. Multiple rounds occurred where the Community Advisory Committee and community 10 participants shared their innovation and creativity towards thinking about solutions and strategies. Because the great Chief Bear had given his life, all of Creation gathered and sang songs to bring him back to life. That was how they helped heal each other in that world. They all took turns singing, but Bear did not come back to life. Finally, it came to Fly. He sang, you laid your body down. You laid your life down. His song was powerful. Bear came back to life. Then Fly told the four Chiefs, when the People-To-Be are here and they take your body for food, they will sing this song. They will cry their thanks with this song. Then Bear spoke for all the Chiefs, from now on when the People-To-Be come, everything will have its own song. The People-To-Be will use these songs to help each other as you have helped me. This is how food was given to our people. That is how songs were given to our people. That is how giving and helping one another was and still is taught to our people. This is why we must respect even the smallest, weakest persons for what they can contribute. That is why we give thanks and honour to what is given to us (OTC, 2012, p.26-33). Relationship is integral within the chaptikwl. Each of the community participants from the advisory committee contributed their wisdom, or as the chaptikwl describes sang their songs, and invested their time to this research. In the spirit of good relationship building, I must take the time to introduce the research now that I have formally welcomed the reader to the circle. 1.5 Organization of this thesis by Chapters In Chapter One, the introduction, I present the research study focus. In centering this research in Indigenous Methodologies through the use of story and to provide context for the reader, I present the Okanagan/Sqilxw chaptikwl, How Food Was Given. In this chapter, I introduce the role of the reader and myself as writer. I present the research question that was the basis of 11 engaging in this research, including the purpose and rational of this study. I further position myself and this study within the chaptikwl, How Food Was Given. In Chapter Two, I begin by presenting some of the key concepts related to cultural safety. I further break down the words culture and safety separately to explore their contexts. Then, I present cultural safety by acknowledging the story of cultural safety through the work that the Maori people have done in New Zealand, which is where the concept originated. To contrast cultural safety, cultural unsafety is discussed to further identify the importance of these terms within this study. In line with the reasons behind how this thesis is written, this chapter does not contain within it a traditional literature review. Rather, this chapter identifies key concepts that exist to provide the reader with a basic understanding, similarly to the experience of the participants. The purpose for this approach is to center this research on the participants’ voices rather than that of the literature. In Chapter Three, I provide the historical context behind this story of cultural safety. I present the colonial history by situating my own story into the narrative. Permission has been granted by my family for the family stories shared in this chapter. I discuss a few of the present-day implications of colonialism upon Aboriginal people, self-determination and sovereignty. This chapter also situates the research to a people and a place. In Chapter Four, I discuss the approaches that were used in conducting this research; Participatory Action Research, Indigenous Methodology, 4R’s, and the enowkinwixw. This includes identifying how participants were selected and recruited, data collection and analysis, and ethical considerations adhered to in the study. In Chapter Five, I present the community advisory committee participants discussions and interweave my own voice throughout, in italics. This is followed by the community participants’ 12 sharing. In this section, I also present my interpretation of the findings through the lens of the analytical framework based in enowkinwixw. In Chapter Six, I conclude this thesis with suggestions for both healthcare providers and community. I speak to the limitations as well as the implications for future research. Finally, I close with a self-reflection of the study. 13 Chapter 2: Why Cultural Safety? In this chapter, it is important to determine key concepts as they relate to cultural safety. The first portion of this chapter focuses on unpacking why I chose ‘safety’ to accompany the term cultural, rather than ‘awareness,’ or ‘competency,’ or any other myriad of terms. This chapter also explores the parameters of cultural un-safety. By embracing the terms cultural safety and unsafety, I place the concept of cultural safety as a relationship between the health care provider (including the larger health system) and the recipient of care and, importantly, as a concept that is determined and assessed by the recipient of care (NAHO, 2008). As such, it becomes a term that is specific then to the recipient of care, and, in this case, that recipient of care is synonymous with being Okanagan/Sqilxw. As culturally safe practice is determined by Okanagan/Sqilxw, then I must bring the concept of sovereignty and self-determination to the forefront; however, these latter concepts will be discussed in Chapter Three. 2.1 The Culture of Terminology In undertaking this exploration of cultural safety, it is of benefit to acknowledge that there are many terms that are similar, for example cultural awareness, cultural sensitivity, cultural blindness, cultural desire, cultural humility, cultural competency, and cultural confidence. To begin, I explore the terms culture and safety. It is imperative to begin with these concepts prior to unpacking the meanings of cultural safety in the literature. Next, I discuss cultural blindness and cultural desire in relation to each other. This is followed by considering cultural humility, cultural competency and cultural confidence. Further, I explore cultural safety’s origins in New Zealand. Finally, I outline how I define cultural safety and cultural unsafety. 2.1.2 Culture Culture is an interesting term to discuss. There are many ways to define the word culture and what is clear is that “one size does not fit all” (Doutrich, Dekker, Spuck, & Hoeskel, 2014, p.16). 14 The very act of defining culture can be ambiguous and it becomes important to determine under what lens the term is being discussed: agricultural, esteemed arts, and/or beliefs and practices (De & Richardson, 2008). From an Indigenous perspective, Battiste (2000) critically examines the suppression of culture via cognitive imperialism. She speaks to how “culture remains elusive” and the transmitting of culture from an Indigenous context is often denied by educational institutes thereby “affirming the political and social status quo” (Battiste, 2000, p.196). This only serves to ignore the experience of Indigenous people in relation to the nation-state and the detrimental impacts of colonialism to Indigenous people’s identity. As such, health care providers need to be conscientious of the diversity of descriptions of culture and the way culture influences the people they serve (Kamrul, Malin & Ramsden, 2014). This is particularly important given that culture can affect perceptions of “health or illness […and] how health information is received, understood and acted upon” (Anderson, Scrimshaw, Fullilove, Fielding, Normand, & The Task Force on Community Preventative Services, 2003, p. 69 & 74). Finally, it is important to note that “culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability” (Nursing Council of New Zealand, 2011, p.7). 2.1.3 Safety The term safety does not seem to have quite the ramifications that the term culture has when it stands on its own. When considering healthcare, healthcare providers are well accustomed of the term safety as it determines ones overall competency and ability to practice (De & Richardson, 2008). What is of interest to note is that it was hard to find any discussion of the term safety on its own in relation to health. Most of the terms that paralleled that of safety in health were quality, ethics, and beneficence and were akin to “doing no harm” and/or for the “common good” (Dayer-Berenson, 2011, p.48). 15 2.1.4 Cultural Blindness and Cultural Desire These two terms are binary as they operate as opposite sides to a spectrum. Cross (2008) asserts cultural blindness to be commonly and mistakenly referred to as unbiased practice: where everyone is perceived as created equal and where colour and culture are rendered to have zero value. To practice in the realm of health with cultural blindness, where the recipients of care are at their most vulnerable because they are in need of help, is to exonerate the colonial history and its effects upon Aboriginal people and risk deeming it justified. Furthermore, cultural blindness is persistent in maintaining colonial systems of violence and oppression upon Aboriginal people. In comparison, Campinha-Bacote (2002) points to the idea of cultural desire. She describes that a health care professional whom is ready to critically examine the knowledge they have and the knowledge they are lacking in order to improve their practice is driven by an internal motivation she refers to as cultural desire (Campinha-Bacote, 2002). And, in relation to cultural blindness, she asserts that words are not enough, rather it requires putting the desire to action accompanied with a “genuine passion”, and “cultural humility” (Campinha-Bacote, 2002, p.183). Within the context of British Columbia, the First Nations Health Authority (2018) defines cultural humility as: …a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience. (para.7) 16 2.1.5 Cultural Competency Cultural competence is a “set of behaviours, attitudes, and policies” that supports agencies and its workers to effectively manage cross-cultural situations (Cross, 2008, n.p.). That said, Cross (2008) clarifies that while proficiency in competence may be achieved, it is considered a developmental process, a spectrum ranging from pre-competence to advanced competency. In pre-competence, there can be a gate-keeper. That is to say that although there is recognition and even acknowledgement that there may need to be changes made at a programs and services level, the gate-keeper solely decides what is and what is not possible for the organization to implement for the minority recipients of care (Cross, 2008). The gate-keeper of the organization still holds the power. Whereas, advanced competence opens the door and incorporates the recommended changes into practice and into all levels of the system itself (Cross, 2008). Arguably, this is problematic for as Brascoupé and Waters (2009) point out, determining the level of competence remains in the hands of the health care professional. Furthermore, cultural competence is talking only about building skill without needing to know the context of a person’s story (history, ‘her’story). Cultural competency, or skill development, is certainly important to the journey of cultural safety. What is integral to building competency is the understanding of the colonial narrative and how it is present in an encounter. Meaning that it is not enough to simply know about the colonial history, but rather it is crucial to connect the context of a person’s or a people’s story in relation to colonialism (Ward, Branch & Fridkin, 2016). After all, as Cheryl Ward asserts, “…we can never be truly competent in anyone’s culture but our own” (personal communication, January 30, 2018). 2.1.6 Cultural Safety The term cultural safety has been adopted by Aboriginal people and organizations within Canada in order to establish best practices and wellness (Brascoupé & Waters, 2009; Hole, 17 Evans, Berg, Bottorff, Dingwall, et al., 2015). However, the roots of this story begin in New Zealand and are deeply situated in the Maori people’s quest to challenge the extreme power differentials that exist in the colonial constructs of the institution of health (Papps & Ramsden, 1996; Wepa, 2005). This concept was not met without resistance and controversy (Papps & Ramsden, 1996). It was in 1988, that the term cultural safety was developed. There was a first-year nursing student who participated in the Hui Waimanawa gathering in honour of the tears caused by the legacy of colonization. This student posed the question: “[L]egal safety, ethical safety, safe practice/clinical base and a safe knowledge base were all very well to expect from graduate nurses, but what about cultural safety?” (Wepa, 2005, p.17). The late Dr. Irihapeti Ramsden’s doctoral work developed the foundation of cultural safety (Brascoupe & Waters, 2009; NAHO, 2006). Dr. Ramsden describes cultural safety in three steps. The initial two steps are knowledge that can only be learned internally because it is based on the providers’ learnings and exploration of self (Ramsden, 2002). The first step is cultural awareness, which is the understanding that there are cultural differences. Campinha- Bacote (2002) further asserts cultural awareness to be an examination of one’s own pre-judgments and biases that is necessary. The second step is cultural sensitivity, which is exploring one’s place of privilege and the potential effects of this privilege (De & Richardson, 2008). These two steps hold within them an opportunity to engage in deep self-reflection and questioning of existing prejudgments and biases as they arise. When observing personal prejudgments and biases, it is important to consider where these originated from and the potential for harm. Examining very simplistically a spectrum of prejudice that houses static perspectives of Aboriginal people illustrates how perilous self-reflection is to the journey of cultural safety. Exploring how Aboriginal men and women can be romanticized underscores this: for example, Aboriginal women can be referred to as the Indian Princess, and Aboriginal men can be 18 represented as the stoic Indian Warrior on Harlequin romance novel covers and the passionate lover of the heroine. These types of prejudgments and biases can be viewed as seemingly harmless; however, “romanticism makes possible a caricature of Indigenous identities” (Cannon & Sunseri, 2011, p.30). Other examples of prejudiced perspectives about Aboriginal people are the derogatory name-calling such as Drunken Indian or Squaw that are spat out at an Aboriginal person. The binary classification of these contrasting stereotypes of romanticism and sexism, particularly for Aboriginal women, is rooted in the patriarchal “virgin-whore dichotomy […and is…] “defined in terms of their relationship to or with European men” (Cannon & Sunseri, 2011, p.47). Critical reflection of how stereotypes such as these are founded and operate, and the impact these have upon Aboriginal people are integral parts of cultural awareness and sensitivity. And, cultural awareness and sensitivity (the initial steps) are a starting place towards cultural safety. It is in these two steps that a person has the opportunity to become aware of and reflect upon their prejudices and biases. In contrast, and moving on towards a deeper understanding of cultural safety, the relationship between the healthcare provider and recipient of care becomes primary and, centrally, it is the recipient of care who determines whether or not they have received culturally safe care (NAHO, 2006). Pilgrim, Tomasini, and Vassilev (2011) assert that to build a foundation of trust, a recipient of care must be well informed and empowered. Furthermore, in their interactions in healthcare, a recipient of care must feel they are visible to their healthcare providers and respected by these providers (Hole et al., 2015). Therefore, within the continuum of cultural safety there exists opportunity for healthcare providers to explore the power they hold and create change within their practice, programs, and/or services (De & Richardson, 2008). The following table illustrates the differences between the differing terminologies and highlights the distinction of cultural safety in how it places responsibility upon the healthcare provider to learn and asserts the ability to determine safety in the hands of the recipients of care. 19 Cultural Awareness An attitude that includes awareness about differences between cultures Cultural Sensitivity An attitude that recognizes the differences between cultures and that these differences are important to acknowledge in health care. Cultural Blindness The belief that color or culture make no difference and that we are all the same, so must be treated equally—regardless of race or culture. (Cross, 2018) Cultural Desire An internal motivation to examine the knowledge one has and the knowledge one lacks in order to improve one’s practice. (Campinha-Bacote, 2002) Cultural Competency An approach that focuses on practitioners attaining skills, knowledge, and attitudes to work in more effective and respectful ways with Indigenous patients and people of different cultures. Cultural Humility An approach to health care based on humble acknowledgement of oneself as a learner when it comes to understanding a person’s experience. A life-long process of learning and being self-reflective. Cultural Safety An approach that considers how social and historical contexts, as well as structural and interpersonal power imbalances, shape health and health care experiences. Practitioners are self-reflective/self-aware with regards to their position of power and the impact of this role in relation to patients. “Safety” is defined by those who receive the service, not those who provide it. Table 1: Why Cultural Safety (Adapted from Ward, Branch, Fridkin, 2016, p.30) 2.2 What is Cultural Safety and what is Cultural Unsafety? While there is literature on similar terms, such as cultural competency, the central focus of this proposed research is cultural safety. FNHA (2016) asserts, “Cultural safety means health care professionals adopt a humble, self-reflective clinical practice that positions them as respectful and curious partners when providing care, rather than as a figure of higher knowledge and authority” (p.3). NAHO (2008) states: Cultural safety refers to what is felt or experienced by a patient when a health care provider communicates with the patient in a respectful, inclusive way, empowers the patients in decision-making and builds a health care relationship where the patient and provider work together as a team to ensure maximum effectiveness of care. Culturally safe encounters require that healthcare providers treat patients with the understanding that not all individuals in a group act the same way or have the same beliefs. (p.19) 20 While Dr. Ramsden’s process is the foundation of cultural safety that I am working from, NAHO’s definition is the context that I am building from in this section. The last line in NAHO’s definition is significant as it acknowledges the unique diversity of people. This recognizes some of the vast diversity that Aboriginal people experience such as gender, ability, sexuality, age, and add to the list ways to self-identify, such as First Nation, Métis, Inuit, status, non-status, treaty, on reserve, urban, religious or spiritual, contemporary or traditional, or Okanagan/Sqilxw. It is essential to understand that there is individuality and variance within Aboriginal populations, and beliefs and values may differ person to person (De & Richardson, 2008). Kurtz et al. (2008) illustrate the impact of culturally unsafe services within colonial structures where patients experience structural violence, racism and discrimination. The Nursing Council of New Zealand (2011) defines cultural unsafety as “any action which diminishes, demeans or disempowers the cultural identity and well-being of an individual” (p.7). Upon reflecting about what an example of cultural unsafety might look like, I thought about when someone wants to learn only about a person’s formal rituals and practices without learning their story, their “his”story or “her”story. I came to this understanding, if someone only wants to learn the ceremony and practice of another person without getting to know them or their story, then that is shifting towards imperial voyeurism, which in turn is a form of cultural unsafety (Smith, 2005). The plight of perpetuating cultural unsafety is to follow the inclination to ignore the realities of the tensions that exist between Aboriginal and non-Aboriginal people. Instead, what is required to create cultural safety in healthcare is for healthcare providers to step into the circle, in other words meaningfully engage with recipients of care and speaking out when racism and discrimination occurs, and become an active part of the solution. When considering cultural safety, ethics must be a part of the conversation. Dr. Jeremy Etherington of Interior Health (2016) said it most eloquently, “Ethics is the discipline that examines who we ought to be and what we ought to do in light of who we say we are. Who we say we are is based on our values. 21 Almost every decision, action, and attitude of ours, personally and professionally, is based on values” (n.p.). Essentially, what a person believes personally is often reflected professionally. This aligns with FNHA’s definition of cultural safety and how knowing who you are through self-reflection is critical. Similarly, with cultural safety, the extent to which a person invests in self-inquiry and self-reflection will be present in an encounter and as a result will be embodied in the outcome of cultural safety and whether it is achieved or not. For this research, I opted to use cultural safety (unless otherwise specified) because it is defined from the point of view and experiences of the recipient of care: the recipient of care determines what is cultural safety and what is not. This speaks to self-determination and sovereignty, as well as Indigeneity, where the power is with the people. And in looking at health disparities the root of it all is colonization, which has strived to remove the power from the people. Therefore, the use of cultural safety acknowledges the original resistance to colonial practice by the Maori people of New Zealand, which is a resistance that the Okanagan/Sqilxw people are all too familiar. 2.3 Summary Vast power imbalances still exist due to the perpetuation of systemic discrimination that affects policy, in turn directly and/or indirectly impacting health and social service practices (Brascoupé & Waters, 2009; Hole et al., 2015). There continues to be barriers to receiving adequate services in the areas of prevention, intervention, and treatment, and this can be life threatening (Chappell & Penning, 2009; First Nations Health Council (FNHC), 2011; Kurtz et al., 2008). One cannot stress enough the importance of becoming educated on the social determinants of health to better understand how the gaps and inequities are intricately related to historical and contemporary colonialism of First Nations people, and how the delivery of information significantly impacts the effectiveness of practice (Rigby, Duffy, Manners, Latham, Lyons, et al., 22 2011; Downing & Kowal, 2011; Kurtz et al., 2008). The need to engage in initiatives that are culturally responsive has moved beyond necessary and has become mandatory (Campinha-Bacote, 2002). This dialogue is not a new one and has been taking place, as depicted in the age of some of the literature. For those who are new to the conversation, when considering where to begin the journey with cultural safety, a good starting place is to engage with the colonial narrative in Canada. 23 Chapter 3: “It’s in the past, get over it!” Is it in the past? For those who have not yet heard the story of colonization and ongoing impacts upon the Aboriginal peoples of Canada, it is important to illustrate the historical backdrop of colonization within Canada and how the effects continue to profoundly affect Aboriginal peoples today. In addition, learning the history is necessary in understanding and part of the journey essential to building, providing and living in culturally safe ways. Colonization has a vast world history and there are no peoples who have not been impacted (Daes, 2000). However, Indigenous peoples continue to represent the most marginalized in the world, economically, politically, and socially (United Nations, 2007; Wilmer, 1993). 3.1 Colonial Policies Policies exist that directly aim to eradicate Aboriginal people and impose on their livelihood in Canada. Furthermore, colonial policies illustrate how the interpretation of law can serve to create divides amongst Aboriginal people, particularly in the attempt to define the “politically undefined” within Section 35(1) (Walkem, 2003, p.197). The British North America Act of 1867 declares in Section 91(24) that Canada is “responsible for Indians and lands reserved for Indians” (Government of Canada, 2018, p.27). Over a century later, in the drafting of the 1982 Constitution Act of Canada, Section 35(1) states, “The existing Aboriginal and treaty rights of the Aboriginal peoples of Canada are hereby recognized and affirmed” (Government of Canada, 2018, p.63; Walkem & Bruce, 2003, p.11). Also, in the constitution, the term Aboriginal is defined as Indian, Inuit, and Métis (Government of Canada, 2018; Waddell, 2003). The Indian Act is explicit in determining whom the Act claims responsibility for and over, however, in contrast to the constitution, the term Aboriginal is seemingly left undefined as there is no Act or specific policy to provide clarity. This lack of definition only serves to further complicate process and skew accountability. These colonial created terminologies in these colonial policies create 24 grey areas which cause questions to arise such as, whose title and whose rights is the constitution referring to, the Indian, the Inuit or the Métis? Further confusion occurs, for example, if an Indian is claiming title and rights on another Indian nation’s territory, whose title and rights is protected? Or, if a person of Métis heritage is claiming title and rights on an Indian nation territory, then whose title and rights is protected? Or, if an Indian and Métis are claiming title and rights on Inuit territory, then whose title and rights is protected in this situation and who is it determined by? Is it federal or provincial jurisdiction? There are different rules for proving you are an Indian, or a Métis, or an Inuit, according to Canadian laws. These differences only serve to create division amongst Aboriginal people as they individually and collectively shoulder the “the burden of proof” (Tully, 2003, p. 286). To further this discussion and to gain a deeper insight into present day realities of colonial policies this next section is a personal narrative of the impacts of such policies. 3.2 Colonization and Me: The Indian Woman Virtually every Indigenous community carries the scars of generations of trauma due to genocide, colonial abuse, environmental degradation, residential boarding schools, and other dominating policies that have been inflicted on our nations and peoples. At its deepest level, this trauma is a spiritual problem which manifests itself in such symptoms as low self-esteem, high suicide rates, self-abuse through drugs and alcohol, spousal and child abuse, and other tragic difficulties… (Indigenous Law Institute, n.d, n.p.) I wanted to approach this section on colonization a little differently. I want to evoke thought and make it relevant to today, even for the reader who may be new to this conversation. In this exploration, I am adding my own personal narrative to the dialogue to illustrate the profound intergenerational effects of colonization. This section is meant to be provocative for the reader to consider the implicit and explicit issues that arise when considering intergenerational effects 25 within Indigenous families, communities, and nations. In order to get to a place where I can become self-determining I must acknowledge that I am colonized simply by nature of cause and effect. It is arguable to what extent I am colonized, however for the mere fact that there is a need for Indigenous peoples to decolonize implicitly acknowledges that I must be. While the desire for self-determination and sovereignty are beautiful goals, they are also precarious terms that require delicate balance to re-achieve because many nation-states do not want this to occur. Therefore, discussing the layers of colonial history that I have inherited as it is ongoing today is my intention in this section. To begin, I must first define the Indian Act, Indian Residential Schools and the Sixties Scoop. The Indian Act is a policy focused on assimilating strategies that govern the daily lives of Indian people. This Act is not incumbent upon non-status, Inuit or Métis people (Government of Canada, 2017). Although some amendments have been made to the Indian Act since its inception, there remains government power and control over every aspect of the lives of Indian people. Indian Residential Schools was a strategic part of assimilation and is referred to as cultural genocide by forcibly removing children from their families to “[disrupt and] prevent the transmission of cultural values and identity from one generation to the next” (Truth and Reconciliation Commission of Canada, 2015, p.1). The Sixties Scoop refers to another major forced removal of children into another system, the child welfare system (University of British Columbia Okanagan, 2009) When I consider this word colonization, I must consider my lived experience. My lived experience is a way that I can situate cultural safety to place. In the context of this study, place is Nkmaplqs/Head of the Lake, or in colonial terms the Okanagan Indian Band (OKIB) reservation (Cohen, 2010), of which I am member. In understanding my lived experience, I must begin with the Indian Act. The Indian Act is “a Canadian federal law that governs matters pertaining to Indian status, bands, and Indian reserves” (First Nations Studies Program (FNSP), 26 2009, n.p.). According to the Indian Act, I am a status Indian woman and I own a laminated Certificate of Status which contains my status number and states that I am a member of the Okanagan Indian Band through the registry number (Government of Canada, 2017). This Certificate of Status card expires every five years and, as a result, I must provide proof of who I am, as an Indian in the eyes of the government, in order to renew my membership status as an Indian woman. My children also have status as Indians; however, there is a limit to their status because their biological father whom I did not marry was identified on their birth certificates. Their biological father is the reason for their limit as he is considered a non-status Indian under the Indian Act. He is considered non-status because he is not registered with the federal government nor is he registered to a band which signed a treaty with the Crown (Frideres & Gadacz, 2005). The result is that my two children are considered subsection 6(1) (Frideres & Gadacz, 2005). This impacts their lives immensely because if they have children with a person considered non-status, non-band or a non-Indian, as defined by the Indian Act, then their children and grandchildren are at-risk of losing their status. This is regarded as the “second-generation cut-off” and has been argued by some as the government’s continued interest to “legislate out” Indian status altogether (Cannon & Sunseri, 2011, p.90 :FNSP, 2009, n.p.). My parents are both considered full status, as both of their parents held Indian status. How colonization situates itself within the lives of my parents is by legislative attacks upon children. I will begin with my father. He was born March 26, 1952, and he was forced to attend the Kamloops Indian Residential School. He spent six years at this institution. He was 6 years of age when he lost his mother and he was 13 years of age when he lost his father. My father used to say that he grew up with me. I did not understand what he meant until I became an adult and explored this thing called colonization in my undergraduate degree. What I came to understand as an adult-child was that he had to learn how to be a father for his experience at the Kamloops 27 Indian Residential School did not teach or model for him in any way how to be a loving and caring parent. My mother was born October 29, 1955. She did not attend residential school however, she was placed into foster care for five years during the sixties scoop era. The Sixties Scoop refers to “the mass removal of Aboriginal children from their families into the child welfare system, in most cases without the consent of their families or bands” (FNSP, 2009, n.p.). She lost her father at 17 years of age and her mother at 41 years of age. In a sense, she too grew up with me. When I look at colonization in relation to myself, I can see that I have spoken about justice via the Indian Act, education via the residential schools, child welfare via the Sixties Scoop, and I am just looking at the impacts of colonization in relation to my own sense of identity and belonging and see that it was built upon a very rocky foundation before I was even born into this world. Growing up I never had a sense of belonging and I recall wanting so strongly to be accepted by my own community and broader family yet felt like a complete outsider within. This rocky foundation impacts even the place where I call home. To be clear, where I call home is the OKIB reservation. I have heard the OKIB reservation referred to as the protectors of the northern Okanagan Nation boundary. I have also heard OKIB be denied as Okanagan from southern Okanagan Nation members. These references situate OKIB on the margins of the Okanagan Nation, whether it is depicted either positively or negatively, and has real consequences upon its membership, or at the very least it impacts me. To be even clearer, I refer to home as the Salmon River Round Lake (SRRL) area. To call SRRL home is to be living on the margins of the larger OKIB. It can be identified as geographically on the margins; however, as a member who calls SRRL area home and who has resided within the area most of her life, it has positive and negative connotations within OKIB as well. I have heard various positive and negative reasons as to how my family came to live in the SRRL area. I have also heard various positive and negative views of the SRRL area from members of the broader OKIB 28 community as well. The reason I am bringing these ways of viewing my home is to illustrate how the colonial narrative has compounded itself to this place; the place where this study takes place. If I delve deeper into my lived experience, I can recall stereotypes, discrimination, and racism. In grade school, I once had a teacher literally tape my mouth shut for talking too much. To be fair, a friend and I were talking and had repeatedly been told to stop talking. However, my friend who was non-Aboriginal did not get her mouth taped shut as I had in this scenario. Later in life, as any woman eventually has to do, I had to get my regular Pap smear. I was feeling very anxious and vulnerable for personal reasons and was not looking forward to it. My doctor looked at me, with what I felt was disgust, and said, “You’ve had sex haven’t you?” My anxiety increased exponentially as I felt I was being spoken down to and I responded feebly, “Yes.” He further insinuated that the tool that would be penetrating me as he conducted my Pap smear should not hurt or be a bother since I have already experienced the act of sex. I felt very confused as I did not see how the intimacy of sex and the annual Pap smear were in any way related. What is my point in sharing these stories? My point is simply that the macro-aggressions of colonization have become the micro-aggressions that do occur within the broader mainstream society and within Nations, communities, and families. All of these aggressions accumulate and only serve to decimate and minimize a peoples lived experiences. And, even if only for my own benefit, it is time to call it what it is and to put a stop to it by “examining, identifying, and interrupting” the colonial narrative (Cheryl Ward, personal communication, September 30, 2016). Furthermore, it is imperative to break down archaic ideologies of the “Indian” within the systems that hold power and come face to face with the lived realities of Aboriginal people living within Canada today (University of British Columbia Okanagan, Interior Health, Canadian Institute of Health Research, Okanagan Nation Alliance, 2007). 29 3.3 The Journey of Self-Determination and Sovereignty On the journey to self-determination and sovereignty, an inventory of strengths and weaknesses must occur as well as a critical self-reflection as to the extent one is colonized in order to begin to decolonize and seek indigeneity. Historically and presently, Indigenous people have been rendered invisible within society for nation-states want to protect their own perceived interests (Battiste, 2000; Morris, 1992). The impact of invisibility upon Indigenous people has had horrendous consequences. For example, Indigenous people’s health are the poorest compared to citizens in their respective nation-states (Brown, Carcoe, Lavoie, Smye, Wong, Krause, Tu, Godwin, Khan, & Fridkin, 2016; NAHO, 2008; UNDRIP, 2007). At the same time Indigenous people continue to become stronger and fight for their individual and collective rights. Wilmer (1993) identifies two key concepts commonly sought for within Indigenous community: sovereignty and self-determination. Mohawk (1992) describes “Indian sovereignty” as holding the power to make your own decisions in your life and to educate utilizing language, history, arts, and culture, all of which are the core elements that set Indigenous people apart as distinct (p.49). Wilmer (1993) asserts that self-determination frees “formerly colonized people” and gives choice in how to relate to nation-states and other such realms of politics (p.23). Self-determination and sovereignty is a way to dismantle the disease of colonialism (Daes, 2000). Indigenous peoples are continuing to exercise their inherent sovereign powers as they have not been relinquished because the nation-states colonialism has not been successful in eliminating, absorbing, assimilating or integrating Indigenous nations (Morris, 1992; Wilmer, 1993). However, it is integral to understand that the roots of colonization are well seeded in systems and institutions, such as healthcare and Indigenous peoples must continue to refute the “denial of Indigenous peoples’ self-determination [so that it does not become] the unfinished business of decolonization” for future generations to resolve (Wilmer, 1993, p.5). 30 This is important because Aboriginal peoples’ experiences of colonialism have resulted in a disregard for their histories, languages, customs, and knowledge which are often placed in the past as a way to justify colonial attitudes; attitudes that Aboriginal people need to “just get over it.” It is necessary to bring colonial attitudes to the forefront so that movement can be made away from learned misconceptions of culture to an understanding that Aboriginal people can and do evolve (Downing & Kowal, 2011, p.17). It is equally important to know the Aboriginal landscape of where one lives, works, and plays. 3.4 The Landscape 3.4.1. British Columbia First Nations In BC alone, there are 198 First Nations, which makes up about a third of the First Nations in Canada. There are eleven language families in Canada, and seven of them exist in BC comprising more than two thirds of Canada’s First Nations’ languages (Government of Canada, 2010a). It is vital to acknowledge this heterogeneity and, as such, recognize the diversity in people’s beliefs, customs, values and knowledge (De & Richardson, 2008). 3.4.2. BC – Interior Region First Nations peoples The interior of BC is home to Aboriginal peoples, who make up five percent of the provincial population (Kelly-Scott & Arriagada, 2016). Again, it is vital to acknowledge the diversity that exists, not only provincially, but also regionally. In the Interior, forty-two percent of the Aboriginal population lives on reservations in one of these seven nations: Syilx, St’at’imc, Nlaka’pamux, Tsilhqot’in, Dãkelh Dené, Secwepemc, and Ktunaxa (Interior Health, 2015-2019). The urban Aboriginal population is fifty-eight percent. This percentage may include local First Nations people and Aboriginal (Indian, Inuit, Métis) people from across Canada and the United States. 31 3.4.3. The Okanagan/ Sqilxw The Okanagan Nation has seven member communities that are in Canada and the eighth is in the United States: Upper Nicola Band, Okanagan Indian Band, Westbank First Nation, Penticton Indian Band, Osoyoos Indian Band, Lower Similkameen Indian Band, Upper Similkameen Indian Band, and the Colville Confederated Tribes (Okanagan Nation Alliance, 2010a). Of the seven that are in British Columbia, Canada, the Okanagan Nations’ population is 5,923 and 2,789 (47%) members reside on reserve (Okanagan Nation Alliance, 2010b). The Okanagan Indian Band population, where this study takes place, is just under 2,000 members with forty-three percent of the populace living on-reserve (Okanagan Indian Band Health Plan, 2014). 32 Chapter 4: Methods “I don’t think of myself as an expert, but no matter what issue is being decided, it’s my responsibility to stand up and ask…” (Armstrong, 2005a, p.14) My method is based upon my theory that cultural safety is relational and situated to place. And as discussed in chapter two, the term cultural safety originated in New Zealand and even though the history of colonialism is a commonality between New Zealand and Canada, there exists significant distinct uniqueness that must be considered. Therefore, I am conducting my research with a theoretical lens filtered through the Okanagan/Sqilxw chaptikwl, How Food Was Given. Within this chaptikwl are the foundational principles of the Okanagan/Sqilxw epistemology called the enowkinwixw. 4.1 Applying an Okanagan/Sqilxw Lens to Methodology In the journey of situating cultural safety in relation to place, as I am Okanagan/Sqilxw, the logical place for me to begin this study is here at the Okanagan Indian Band. Of equal importance, I was required to acknowledge that this research did not belong solely to the community as this research was also taking place within the context of the University of British Columbia Okanagan with its own standards, procedures and policies shaping the process in particular ways. Thus, as a believer in community and nation, I needed to navigate both the requirements of the academy and my own commitment to respecting the knowledge that belongs only with community and nation. Although I could easily have chosen to deepen my inquiry, I chose to engage in research that I believed would be permissible by community and nation, while meeting the standards of academia. This very act of balancing core beliefs and values in relation to the academic institution is not uncommon for Indigenous researchers (Smith, 2005). To explain further, although I need to comply with the university’s research ethics, as an Indigenous researcher, conducting research within her own community, it is 33 community ethics that supersedes any university requirements. This is critical as research does not have a good history within Aboriginal communities and Indigenous communities worldwide (Smith, 2005). As a result, this study was guided by Indigenous Methodologies (IM) and Participatory Action Research (PAR) to further explore the process of cultural safety with an Okanagan/Sqilxw lens. 4.2 Indigenous Methods (IM) Throughout this research, I chose to step away from the West’s or nation-states’ ways of conducting research by not merely creating space for Indigenous knowledge and ways of knowing; rather, this research actively and consciously centered entirely within Indigenous epistemologies (Chilisa, 2012; Smith, 2005). IM is defined as research centered within Indigenous ways of knowing that is done by and with Indigenous peoples (Chilisa, 2012; Evans, Hole, Berg, Hutchinson, & Sookraj, 2009; Kovach, 2009). In following IM principles this research was guided by an advisory committee consisting of community members knowledgeable in the areas of cultural safety, health, and community engagement. Conducting the research in this way created a safe space for community members to share their collective wisdom at the advisory and participant levels, thus centering Okanagan/Sqilxw ways of knowing throughout the research process (Cajax, Berman, Restoule & Ray, 2013; Smith, 2005). 4.3 Participatory Action Research (PAR) According to researchers (Evan et al., 2009; Fals Borda, 1987), PAR principles correlate well with IM as it acknowledges and respects the “people’s power” (p. 30). PAR is based in bringing to the forefront the local community that is often excluded, such as the Okanagan/Sqilxw people, and having them use their expertise in answering issues surrounding ownership, control and benefits of research, particularly when it is about them (Brydon-Miller, Kral, Maguire, Noffke, & Sabhlock, 2011). In employing both IM and PAR methodological frameworks simultaneously, 34 Okanagan/Sqilxw people were at the forefront of asserting their needs as defined by them, which is a core value in self-determination and indigeneity. 4.4 The 4Rs The four Rs – respect, relevance, reciprocity, responsibility – (Kirkness & Barnhardt, 1991) was the particular IM selected to uphold the integrity I wished to maintain. Kirkness and Barnhardt (1991) eloquently explain the necessity of colonial institutions to actively engage with Indigenous people in a relational way that “respects them for who they are, that is relevant to their view of the world, that offers reciprocity in their relationships with others, and that helps them exercise responsibility over their own lives” (p.1). Additionally, the 4Rs illustrate the academic pressures to conform that Indigenous student’s experience. Smith (2005) further speaks to the importance of respect and how it is synonymous with relationships. Relationships are an essential protocol in maintaining equilibrium with one another and with the land (Smith, 2005). To express these protocols – respect, relevance, reciprocity, responsibility – the 4Rs and enowkinwixw combined grounded this research. 4.5 Enowkinwixw The protocols of enowkinwixw are based on the recognition that in any circle of people there are different perspectives as a result of particular sensitivities, expertise and concerns and the recognition that diversity is necessary. Protocols are based on the idea that “community” as a whole unit actually functions like a living organism with different but vitally necessary parts. (Armstrong, 2009, p.189) The enowkinwixw was the analytical framework used to organize findings and examine what was shared. What is enowkinwixw? Researchers (Armstrong, 2009; Cohen, 2010) assert enowkinwixw to be an Okanagan/Sqilxw responsibility that undertakes serious issues of concern 35 in the community. The Okanagan Nation Alliance (2010b) further describes enowkinwixw as a cultural practice that gathers community around an issue(s) to surface differing perspectives and embrace the resulting dynamic tension in order to develop a collective “mind meld” or understanding in order to come to a solution and/or plan that has considered all views held by the community (p. 12). To be clear, the community is represented by the Four Food Chiefs: Siya – youth/innovation, Skimxist – elder/tradition, Spitlem – mother/relationship, Ntyxtix – father/action (ONA, 2010b). These quadrants represent “all facets of the community” (Cohen, 2010, p.114). Figure 1: Enowkinwixw Community Effectively, enowkinwixw shifts the gaze from a singular to a relational perspective within the research and grants me access necessary to further situate cultural safety relationally to an Okanagan/Sqilxw place. By identifying the Four Food Chiefs, the methodology guides one to examine the tensions that emerge when seeking to understand an Okanagan/Sqilxw account of cultural safety. To begin this process, it was important to ground the research within the Central Issue Skimxist/Elder: TRADITION Spitlem/Mother: RELATIONSHIP Siya/Youth: INNOVATION Ntyixtix/Father ACTION 36 analytical framework of the enowkinwixw. From this foundation, the findings were situated within their correlating quadrants as they relate to the central issue of cultural safety. 4.6 Maintaining Community Ethic As this research was conducted through an Okanagan/Sqilxw lens, the entire method was grounded in the chaptikwl, How Food Was Given. I needed the wisdom of Skimxist-tradition, Siya-innovation, Spitlem-relationship, and Ntyixtix-action, so they took the form of my Community Advisory Committee (CAC). The CAC guided the process of recruitment from beginning to end with lengthy discussions on who to include and why. The answer to why was found in the title of the thesis, “From the Margins.” The CAC sought to include those whose voices were not always heard from in community and so they gathered the people together to share their voices in the Talking Circle. To ensure life is brought into the words that are shared in the Talking Circle, I as the researcher needed to honour the peoples’ “giving and helping” by crying out my thanks and share the stories and the findings within this study with the people and leadership. 4.7 Participants and Recruitment 4.7.1 Permission One of the initial protocols of community ethic is to ask permission to engage in community research. This is also a requirement for university’s BREB. Following both community and academic protocols for research processes, I sought permission from the band’s leadership table, Chief and Council. I presented to leadership what I hoped to research, and why, and for what purpose. At this meeting with leadership, I fielded questions and committed to sharing the findings with the community, including sharing the final thesis with both the community and the Nation. Thankfully, following the presentation, the Okanagan Indian Band leadership granted 37 permission to conduct the research. I included an offer to present my proposal to their selected audience(s) (Government of Canada, 2015). 4.7.2 Community Advisory Committee As community ethics is a core belief and value of mine, my first engagement with community was to establish an Advisory Council consisting of members who were well versed in cultural safety, community engagement, and/or health. I approached four community members. I shared my research project with these four community members individually and I asked if they would be interested in participating either directly or in guiding me in recruitment of advisory. All four members chose to participate directly and they became my guides in navigating community ethics, protocols and process. Once established, the initial meeting was held that brought all of the Community Advisory Committee together for the first time. I connected with four community members and discussed the research and invited them to become a part of the Community Advisory Committee, from approval of ethics to analysis or to assist in recruiting an advisory from community in their stead. As there are four quadrants within enowkinwixw - youth, elder, mother, and father - my aim for the advisory was to represent the same. I provided them with an advisory package that contained details of the study and expectations of their role as advisory, researcher contact information, and a consent form that they were able to take home for their consideration. One role was to recommend and actively recruit potential participants. As such, I provided them with a participant package that contained details of the study, researcher contact information, and a permission to release contact information form for the advisory members to share with prospective participants that they recruited. The initial meeting of the Community Advisory Committee was to introduce the members, identify role of the members, and outline next steps. The Community Advisory Committee 38 established that it would be their responsibility to recruit participants for the Talking Circle. This responsibility met university requirements and community ethics as it allowed potential participants the space to speak freely without interference or influence from me as a researcher. To ensure the Community Advisory Committee recruited a cross section of community members, they went through the process of bringing forward names from each of the sub-communities of the Okanagan Indian Band. These sub-communities were identified as Duck Lake, Salmon River/Round Lake, Head of the Lake, Six Mile and Whiteman’s Creek. These sub-communities had been established in previous band-led community engagement and research, therefore, it needed to be followed in this research project. Advisory Committee members identified whom and where they were each going to approach community members to eliminate cross recruitment. The target recruitment number was ten; however, the list of potential participants was larger in recognition that some community members who were going to be approached may decline the invitation to participate in the research project. The required university project package, including consent forms, was provided to the members of the advisory. However, it was discovered that many discussions occurred during informal visits and to ensure consent was provided prior to me engaging directly with participants, in lieu of a signed consent form the participants whom agreed to participate contacted me instead as a way of announcing their consent verbally. This was followed up as soon as possible, within the participant’s availability, with an in-person visit reviewing the project package, including consent forms. This follow up in-person visit was an opportunity to introduce myself to the interested potential participant, provide more in-depth information of the project, and review the consent forms and ensure them that their participation remained their choice at all stages of the research, including during this in-person follow up visit. Although ten was the target number of community participants that were to be recruited, only nine community members consented and had forms completed in the timeline that the Community Advisory Committee agreed upon. 39 Once the nine signed consent forms had been received, preparation for the Talking Circle began. 4.7.3 Community Participants With respect to the principle of “Concern for Welfare” (Government of Canada, 2015), I worked specifically within the OKIB. The best effort was made by the advisory committee to recruit two participants (male, female) from the five sub-communities of the OKIB: SRRL, Duck Lake, Head of the Lake, Six Mile, and Whiteman’s Creek. Potential participants received a package that contained details of the study, the researcher’s contact information, and a consent form that they were able to take home for their consideration. Once identified by the advisory members, I followed up within one week in-person, via telephone or email and confirmed expressions of interest. And, in cases where a form was not signed and submitted to me prior to the follow up, the advisory members ensured the potential participant called me as this provided their permission for a follow up, where I would then re-confirm their permission and have them sign. In the end, although ten had confirmed their participation only four actually attended the Talking Circle scheduled for community participants. Follow up phone calls occurred leading up to, and including the day of, the Talking Circle. Two confirmed community participants sent their regrets as they had been asked the day prior to speak at a local college on the same day. They were open to participating at a later date. The third community participant called two days before to confirm that the format was to be held in a Talking Circle. The third participant had confessed that, although I had indeed identified that participation for this project was to be in a Talking Circle format, they actually get severe anxiety in Talking Circles and as a result withdrew their consent. It is important to respect that not everyone is mentally, emotionally, spiritually, and physically ready to step into the circle and take on the responsibility to share their thoughts and ideas freely. Further, when conducting research, it is paramount that researchers understand that, as a result of colonization, Aboriginal communities faces complexities, including mental 40 health, which can create barriers. A fourth participant who had consented shared that they had competing priorities and chose not to participate and withdrew. The fifth and final participant had not arrived nor notified of any changes to participating, so I called them, and they sent regrets as they were not feeling well and their ride was not available. In the end, there were four community participants who attended the Talking Circle. There was discussion regarding involving the three community members that had not fully withdrawn their consent in this study, however the advisory committee reminded me that in community engagement ten may be the goal, but that may not be the result. In addition, I wanted to respect the timeline that the advisory committee had provided me as far as their active participation in the process. Although there were only four participants, the participant criteria as presented in the research proposal were still met. There were two males and two females and the participants were from the different sub-communities within the larger Okanagan Indian Band (i.e. Head of the Lake, Six Mile, and Lake Country). When the Community Advisory Committee members were included in ensuring same, representation from Salmon River Round Lake, Six Mile and off-reserve were included. The rationale for continuing with only four participants in the Talking Circle was guided by the practical realities of community engagement and grounded in an Indigenous teaching that my father had been taught and shared with me. The teaching was that for anything that gathers people together “those who are in the circle are those who are meant to be here” (Eric Mitchell, personal communication, 2015). 4.7.4 Talking Circle Talking Circles are common practice to many Indigenous peoples and they are a sacred place for members of a community to come together (Chilisa, 2012; Kurtz, 2013; Wilson, 2008). There is also protocols inherent when entering a circle that is not often spoken of in the literature and a key one is responsibility. In entering a circle there is a responsibility to create safety for one 41 another, to share in the dialogue, to participate in decisions and solutions, and in any follow up and/or action that may need to occur as a result. The first step for the Community Advisory Committee was to develop the Talking Circle guide, including the questions. The next priority was to facilitate a practice Talking Circle through with the Community Advisory Committee to address any issues that may arise. Although this was viewed as a test run, the Community Advisory Committee wanted to actively participate in the Talking Circle to provide their contribution to the research and findings. Then, after the community participants had their Talking Circle, the Community Advisory Committee was to attend the follow up presentation to voice their concern and/or their support of the findings. Upon receiving consent of participants, I scheduled two Talking Circles to address both objectives, respectively. The Talking Circle for the Community Advisory Committee agreed that the OKIB Health Centre was a quiet, safe, and accessible place to meet. The Talking Circles were held Friday, March 11, 2016 and Monday, March 14, 2016. The team required two dates because their first date of Saturday, March 5th had to be postponed due to a death in the community. To ensure the Community Advisory Committee’s Talking Circle occurred prior to the community’s Talking Circle, the team chose a couple of evenings. The Talking Circle for community was held Saturday, March 19, 2016 at the Head of the Lake Hall. The Talking Circles were recorded using a digital recording device and notes on flipcharts. Throughout the community engagement portion, I documented my ideas, thoughts, and reflections on the process and data analysis: keeping an audit trail of the research and methods as it unfolded. To address the principle of “Respect for Persons” (Government of Canada, 2015), at each meeting and/or Talking Circle, I regularly informed participants that their participation and knowledge shared in the study was entirely voluntary and that they could withdraw at any time with no consequences. 42 Finally, I attended to a commitment to “Justice” throughout the research process (Government of Canada, 2015). The aim of this research was to not be confidential. The reason for this was to be proactive in effectively reducing and striving to eliminate any imbalances of power, misappropriation, and/or devaluing of community knowledge and/or misrepresentations. 4.8 Protocol 4.8.1. Reporting Back With respect to my commitment to the “4Rs” (Kirkness & Barnhardt, 1991), I invited all participants, including the advisory committee, to a community presentation on April 27, 2016, where I reported back the summary of findings from the community engagement. All feedback provided by research participants, including the advisory committee, has been incorporated into the summary that was presented. I invited the advisory committee to participate in the analysis. However, they chose to not participate in the analysis portion. Finally, I also presented the summary of findings to the Okanagan Indian Band leadership at one of their regularly scheduled Chief and Council meetings February 26, 2018. Lastly, an electronic and hard copy of this thesis was shared with the Okanagan Indian Band and the Okanagan Nation Alliance to support their initiatives in cultural safety. 4.8.2. Traditional Knowledge In working with my community and nation, one key ethical consideration was the importance of addressing and respecting the subject of traditional knowledge. To ensure that participants understood the overarching purpose of this research was to produce my Master’s thesis, I communicated to all participants their full autonomy over what they shared, and if there was any traditional knowledge they chose not to include in the data analysis, I would remove it upon request. However, no information was requested to be removed. 43 4.8.3 Trauma and Loss One of the most significant, and often overlooked, community ethics is for a researcher to be conscientious of trauma and loss. Individuals are connected to family, family is connected to community, and the community is interconnected with the Nation and/or neighbouring Nations with their extended family kinship systems. Therefore, to ensure the participants’ needs were met, I was flexible and rescheduled due to any unforeseen tragedies or loss in the participant’s family, community and/or Nation. The advisory committee’s Talking Circle did have to be rescheduled due to a passing of a community member. As a result, due to the advisory committee members conflicting schedules, two – 2.5 hour – Talking Circles were conducted. 4.9 Transcription Process A record of each community AC meeting and Talking Circles were obtained. The AC meetings were simply recorded using a digital recorder and the Talking Circles had the additional use of flip charts. As I wanted to familiarize myself further into the discussions captured in the recordings for the purposes of analysis, I transcribed. The process of transcribing entailed two parts, the CAC and the community. I initially focused on the CAC recordings and began with an initial listen to their recordings in full to hear the CAC’s words, silences, and the way they interacted with one another. As the CAC had meetings prior to their Talking Circle, I began transcribing the CAC meetings first. As the CAC’s Talking Circle needed to be rescheduled, due to a loss in the community, they decided to meet over two days for two and half hours each. They wanted to be able to participate and conduct a practice run simultaneously; this was done in order to not make the community reschedule their Talking Circle while ensuring that the CAC Talking Circle would run smoothly. Therefore, the CAC had two Talking Circle recordings for transcribing. Once I completed the CAC, I began transcribing the community participants Talking Circle. 44 The CAC and community were invited to continue their participation further in conducting the data analysis. Both groups felt their participation in the Talking Circle was what they felt most comfortable with, so long as I followed up with the presentation on the summary of findings. Therefore, I conducted the data analysis in full. I listened to the recording while I read the transcriptions and began formatting the findings portion of my thesis as an active dialogue containing each speaker’s voice in the order they presented themselves in. As this way of formatting unfolded, I began weaving my voice into their dialogue. It was as though the role of my voice was to narrate to the reader questions to consider from their sharing in relation to the research. 4.10 Data Analysis The data analysis began with listening to the stories that were recorded and re-living the experience of the Talking Circle all over again. Re-living the experience allowed me to be an observer of and deep listener at the Talking Circle, where once I was a participant. I began to thread my own reflective responses throughout the summarized narratives of the participants who made up the Advisory Committee. Once I completed this process, I read through the narratives looking for the four key aspects of the enowkinwixw: tradition, relationship, innovation, and action. Then I went through the narrative and wrote down the emerging themes of the central issue being discussed, cultural safety, onto flipcharts that eventually littered my living room walls in order to visually look for linkages. The two key themes that arose for cultural safety were knowledge and behaviour/practice. For the community participants it was a bit different as I had chosen to not thread my own reflective responses as I had with the advisory committee members. Instead, I wrote the words culture, safety and cultural safety on three different flip charts and sorted through the narrative 45 to list all that was relevant to the corresponding word in order to visually look for linkages and tensions. 4.11 Validity and Legitimacy In fall of 2017, I was invited by the Provincial Health Services Authority (PHSA) Indigenous Cultural Safety (ICS) team to participate as part of my Interior Health position in their Indigenous Cultural Safety Intervention in Vancouver, British Columbia (BC). The topic of validity was discussed at length. It was during this discussion that Tara Nault, Métis, Director, Office of Aboriginal Health, BC Ministry of Health stated, “Our peoples’ stories are our validation, those stories that are told from those very lives that we are trying to support” (personal communication from Tara Nault, Sept 30, 2017). In discussing story further, Thomas King declares that “the truth about stories is that that’s all we are” (as cited in deLeeuw, 2014). And, Cohen (2010) states as a matter of fact, “The Okanagan are the people of the stories. Our knowledge, survival, and cultural practices have been maintained through story” (p.5). Cohen (2010) asserts, “Okanagan knowledge, values and ways are also valid academic knowledge” (p. 26). In looking to the wisdom of Indigenous and Okanagan/Sqilxw peoples like those whom have already been mentioned, my research is guided by the chaptikwl, How Food Was Given, and the “legitimacy of Okanagan knowledge taken for granted” (Cohen, 2010, p.40). 4.12 Self-Reflection As an Okanagan/Sqilxw woman, this research journey is a troubling path filled with unknown, unexpected, unanticipated and jarring barriers and challenges to overcome. Self-doubt and questioning have crossed my mind and heart many times. As an Indigenous student, the expectation is greater to be transparent in answering the eight key questions; (1) what research do we want done, (2) whom is it for, (3) what difference will it make, (4) who will carry it out, (5) 46 how do we want the research done, (6) how will we know it is worthwhile, (7) who will own the research, (8) who will benefit? (Denzin, Lincoln & Smith, 2008, p.9). The initial challenge that I found myself confronted by was realizing academia is really about understanding how to cunningly formulate and articulate information as evidence to prove why it is important for the academy to respect the research. In writing this thesis, I am conscientious that as an Okanagan/Sqilxw student I must appreciate the delicate “two-culture tightrope I am walking at my own high stake risks” (NAHO, 2005, p.18). For if I am to lose my footing or my way, I risk forfeiting my commitment to community ethics. Then comes learning the research nomenclature necessary to define to the higher education system in a simplistic, layman, handholding language just how my research, based upon an Indigenous worldview, is relevant to the institute of academe. In comparison, I did not have to be so academically descriptive in community because much of what I said and did not say was simply “taken for granted” (Cohen, 2010, p.40). Interestingly, in the realm of the academy where Indigenous attrition and retention can be commonly low due to supposed poor achievement, in choosing to write in a non-traditional, non-academic way I risk being perceived as problematic because I can potentially be labeled as a student who has not adopted and integrated well (Kirkness & Barnhardt, 1991). Mine is not an uncommon story. Smith (2005) describes the lived realities of Indigenous communities and the consequences of same, along with the accompanying colonial dehumanizing that can occurs. She cautions the risks of simply acquiescing and declares, “[T]o resist is to retrench in the margins, retrieve what we were and remake ourselves” (Smith, 2005, p.4). It is with these words that I work through self-doubt and hold onto the inspiration that “the past, our stories local and global, the present, our communities, practices, languages, and social practices – all may be spaces of marginalization, but they have also become spaces of resistance and hope” (Smith, 2005, p.4). 47 Chapter 5: Wisdom within the Circle “Whatever comes to my mind and my heart, I will share with you.” ~ Elder Patsy Gregoire Chapter five begins with the advisory committee’s stories and understandings about cultural safety. In line with IM, in part one; I privilege their voices to center this study in Okanagan/Sqilxw community. I added my reflections in italics to present my reflections, understanding and questions in order to be a part of the dialogue, share what learnings have occurred through the process, and to showcase how we have grown stronger (Cohen, 2010). Part two, of this chapter, presents the dialogue of the community participants and their perception of the term cultural safety as one term and broken apart as two terms “culture” and “safety”. This way of formatting this chapter is important and purposeful in privileging the community member’s knowledge and honouring their talk (Kovach, 2009, p.99). Part three presents the themes of their sharing based on the analytical framework using the enowkinwixw process. 5.1 Community Advisory Committee Talking Circle with Advisory Committee: Pre-trial run of Talking Circle with Advisory Committee, review of the power point, and then into their active participation with the question, “What does cultural safety mean to you?” Eric Mitchell points out that “understanding what cultural safety is defined as is different than putting it to action and understanding you have voice.” He describes this to mean that “for people who have never had a voice before, there’s a journey that’s made emotionally and intellectually and spiritually that we have to understand, yes we do have a voice.” He shares that “understanding you have voice is the big move here.” Mitchell tells a story about his own experience of realizing his own voice. Mitchell had an issue with his knee and his family 48 physician prescribed him to take ibuprofen and if that did not help him, then to come back in for a cortisone shot. In this instance, Mitchell refused this prescription. He saw that it would not heal it, but rather just numb it. In that moment, Mitchell realized that this was not what he wanted; however, this was all that his family physician could offer him, so he went to alternative medicine and found healing. It made him wonder how many other people do that: tell the physician what you want and to even know what you want or need in that moment. In Mitchell’s sharing he is identifying his realization of his own voice, similarly to that of Fly singing his song. Chris Marchand illustrated the importance of understanding each term, cultural and safety, separately by sharing a personal story. She shared that she feels like health professionals do not know her, except her name, her age, her band member. She further described that “culturally, women aren’t safe. It doesn’t matter what culture you come from.” In her experiences, most health providers are men and in her observation most female nurses do not seem like they have a safe place either. She recounted a recent experience with a doctor. In this one office, there was one particular doctor that she never wanted to see again; however, at her next visit, he was the doctor working that day. In this particular encounter, she described that the doctor yelled at her and informed her that she was not describing her ailment very well and in order for him to help her she would have to be clearer. She was at odds and did not know what to do. Marchand felt caught between a rock and a hard place because all she knew was that she was having spasms and she was in pain; yet, this doctor was yelling at her, “Well, you can see spasms, so show me!” She tried sharing with him what she was experiencing and what she had been previously prescribed and that it did not work to stop the spasms. She described how “with his voice [he] was overpowering [her] and overwhelming [her].” Even when they continued to the front office the doctor was still carrying on loudly and at this point was no longer acknowledging her presence but rather chose to focus on her husband instead Marchand 49 stated, “I’ve never been hollered at like that before, ever. And, so I didn’t feel safe, in the end I did not feel safe.” What is important to note is that no one was stepping in to call the doctor on the unprofessional behaviour that he was conducting. And, the doctor placed the onus on her as the recipient of care to communicate in a way he could understand. He was not asking her questions of any sort other than demanding that she show him. Basically, this was another way of asking her to prove it, as if he did not believe her description. In this scenario although health care providers are supposed to be well-versed and competent in the ability to provide safe care, one can come to question where was this doctor’s compliance to his own standards of ethics to do no harm (Dayer-Berenson, 2011)? In another experience, however, Marchand shares a culturally safe encounter with a nurse in the emergency department. Both Marchand and Mitchell taught Aboriginal health and cultural safety modules to third year nursing students at UBCO. This scenario holds relevance because the nurse she encountered was a previous student. This nurse had checked her chart and recognized her name. He introduced himself as a previous student of hers and acknowledged her as his teacher. She felt that he slowed right down to her pace by sitting down, looking at her and asking her, “How are you doing?” She felt like he knew her because he had participated in the class and because he sat down with her human to human and had a conversation. She felt he was ready, willing, and able to make her feel comfortable and safe. He also asked her if she had any questions. He “talked to the patient, not just the orders on the thing there what they’re supposed to do, made a difference.” In this encounter she felt culturally safe and even today she is trying to figure out how to roll that experience up into a definition of cultural safety. In this experience what is important to highlight is how this way of practice aligns with FNHA’s (2016) definition of cultural safety, “Cultural safety means health care professionals adopt a 50 humble, self-reflective clinical practice that positions them as respectful and curious partners when providing care, rather than as a figure of higher knowledge and authority” (p.3). For healthcare professionals this is a valuable example of how to put cultural safety to practice. In her sharing of these two contrasting examples of her own experiences with the health care system, she also reflected on her process for teaching cultural safety at UBCO. She described that she has angry parts and sad parts within her and that she has to put those parts of her aside in order to put herself forward to create a safe place for everyone, the students and herself. She explained that you have to step out of where you are at and think about everybody else in order to teach cultural safety. “‘Cuz you know if somebody comes in and they’re angry, do you feel safe? I don’t. You know, it makes a difference, right?” In Marchand’s reflection of teaching, it almost is a descriptor of what health professionals need to consider doing in order to practice culturally safe care: engage in personal self-reflection about their own biases, beliefs, and personal location. I think that is worth exploring because, if the responsibility to teach and role model cultural safety is solely on the shoulders of Aboriginal people, what are the impacts and consequences to Aboriginal people, and why does it rest solely on the shoulders of Aboriginal people? Fabian Alexis stated that cultural safety is not unlike ethno-sensitivity. He further made clear that local First Nations people have ways of knowing, being and practicing, and cultural safety requires that there be an acknowledgement that there is First Nations culture and people that exist here. He further underscored that practices that are opposite of cultural safety is an ethical issue, particularly when a health professional knows about cultural safety but is not willing to practice it because they may be stuck in their own ways. He explained that when health professionals are not willing to acknowledge or be sensitive to the Aboriginal people they are 51 caring for, this is when it becomes an unsafe environment and where things can go sideways: this is when a recipient of care does not receive or experience good care. Alexis brings forth the point that it is important to consider our personal and professional ethics. Similarly, to practice culturally safe care is to incorporate best practices and for some that may require moving from viewing Aboriginal peoples as a societal problem that needs to be dealt with to elevating an understanding and an appreciation of the experiences from an Aboriginal person’s perspective and lived realities (Hole et al., 2015). Therefore, any resistance must ignite self-reflection at the very least by asking a few questions such as, what is this resistance to cultural safety really about? Is it in the common good to consider lowering quality of care with a particular population? And, how is this non-compliance in alignment with beneficence? Jami Tonasket calls for the need for there to be an understanding of the diversity of cultures within our community, within our nation, and across the country. She spoke to the need to respect the difference of the culture and to respect the diversity of beliefs, spirituality, and ways of being within the Okanagan community. She strongly advocated for the need to respect this diversity even if you do not agree with it. She further stated, “Everybody has a right to safety and to be treated in a good way and have access to equitable services”. Tonasket also pointed out, “Not everybody has that ability to have that voice to articulate what it is that they need, and they need support.” And for some the inability to communicate may be due to past traumas that they have experienced, and they do not feel safe. Therefore, we must be supportive of others when we see they may be in need, not just in health but even in the common day to day interactions. Putting cultural safety to action is “communicating, and educating, and talking about cultural safety and how that applies to each of us individually, to empower ourselves, to have voice, and to be strong and to also be supportive of others when we see they may be in need.” 52 This point further illustrates that people are all different, so it is important to establish a way to work with each individual (De & Richardson, 2008). Tonasket’s sharing illustrates the need for voice, which connects to Mitchell’s previous sharing of same, and voice speaks so strongly to the chaptikwl, How Food Was Given, and the character of Fly. Fly’s ability to sing his song helped the People-To-Be, much in the same way it is important for Okanagan/Sqilxw to realize they have a voice, to find their voice and to use their voice to advocate for their self, their families, and their community and for future generations. In his next sharing in the Talking Circle, Mitchell shared his list used in separating the terms cultural safety to simply culture and safety as follows: My culture has…  A distrust of non-Indians  Little or no knowledge of medical terms  History of negative experiences  Has had no voice  Asks, am I allowed to speak or guide you? Under safety, concerning safety the questions are:  Am I physically and emotionally safe?  Do I feel confident to share my understanding of my medical concerns?  Will I have a positive or a negative experience? Table 2: Culture and Safety Mitchell shared that there is a space in between asking these questions or considering these realities and putting cultural safety to action. He goes on to consider what non-Aboriginal people might say in their lists. For example, my culture has a preconceived notion of Indians, or I have little or no knowledge of Indian people, or maybe all that is known are the negative experiences with Indians from what I see in movies, on TV, or what I hear in the news. Mitchell further explained that if a non-Aboriginal is in the medical field, “one of the things that they think they know is our health disparities.” Gravely Mitchell stated, “And if that’s all they know about us, that’s nothing.” He further added that non-Aboriginal people in the medical field “have not given us a voice and they don’t believe that you’re the expert. They believe that they’re the expert.” He sees the necessity for service providers to go through a reflection of their own biases and of 53 who they are. Mitchell observed that many non-Aboriginal people often do not know what white privilege is because it does not affect them negatively to have that white privilege; so how would they understand what it is? He sees that non-Aboriginal people have a learning curve as well, because “until they learn things like that, they don’t even know they have a negative effect on us.” His conclusion is that learning is necessary from both Aboriginal and non-Aboriginal people. He shares an exercise that he learned from one of his teachers as he was being trained to become a facilitator of Life Skills. This exercise shows two sides of the same coin. Figure 2: Power and Powerlessness Mitchell tells that this spinning coin can refer to racism, inequalities, discrimination, etc. One person can feel powerlessness and in order to feel powerful they need to say something negative to the other person, and, so on and so forth. Mitchell shared, “If you don’t learn beyond that, you don’t learn how to quit that coin spinning.” He emphasized that a healing journey, emotionally, physically, intellectually, and spiritually, is necessary in order to come to a place where, when encountered with the spinning coin, you can say, “Put that coin down and let’s talk. You don’t need to feel powerful over me and I don’t need to be feeling power over you.” Mitchell stated that the ability to stop comes from understanding that the spinning coin is simply a game that you have the choice to engage in or not. He goes on to explain that although “I can have my list and they can have their list […] the way we put that down, put that aside, is [by] understanding each other more.” That is what these cultural safety sessions are about: “Giving Power Powerlessness 54 knowledge to both sides, about both sides.” He went on to share, “If we can understand who that doctor is, where they came from, what their training is, then we can appreciate.” Mitchell shared a personal story about his view of western medicine. He acknowledges that he does not hold the western medicine too high. He almost alluded to a danger of doing so. He explained that there are some things that western medicine can do that are awesome, such as stints, or fixing broken bones, or amputating a leg. However, he also sees that western medicine is more of an illness model and, as a result, is not good at prevention. In his own healing journey, he has come to know that when he encounters health professionals there are certain things he needs to know, such as, what the doctor has to offer. Mitchell knows that he will consider the help the doctor of western medicine can prescribe, but he may not follow it if he does not agree with it or feel that it is sufficient. Eric provided the example of his knee. The doctor could only prescribe ibuprofen and if it worsened the next option was a cortisone shot. Mitchell considered these options and decided he would go elsewhere seeking a healthier alternative for himself. For Mitchell this is a recipient of care’s right to do. Mitchell advises to “use them as a tool in your own health; they’re not the experts of your life.” Mitchell concluded by stating, “Cultural safety is about true or total acceptance of each other, I for them and them for me.” In reflecting on the list piece, I find that this speaks to the ongoing and inherited divisiveness between Aboriginal and non-Aboriginal people. Mitchell’s example of lists illustrates the active things that we do to maintain our division, or objection, or resistance, to relationship building and/or best practices, such as cultural safety. He also speaks to how to break down barriers simply by putting the coin down and learning together about each other. To do so would be to have genuine passion and cultural humility in your personhood (Campinha-Bacote, 2002. 55 Marchand added to the discussion by saying, “We need to get rid of those pre-conceived notions of one another and that’s 500 years of all of that. It’s not going to happen overnight. Preconceived notions need to be changed but how, when, and where? As Marchand pondered this very question she wrote down, “self-reflection, self-reflection, self-reflection! And opportunities to practice.” In her processing, Marchand described opportunities to practice cultural safety as the very fact of us, the Advisory Committee, coming together. She goes on to explain, “We don’t sit together, none of us, right? And talk about our life, our experiences, our ideas and notions of others, and we need to.” She depicts the importance of practicing cultural safety by coming together because and she describes, “Not only do we need to change the pre-conceived ideas of them out there, of us. We need to change that within our community, of one another.” In reflecting on Marchand’ words, she illustrates Campinha-Bacote’s (2002) assertions clearly by stating that examining our internal baggage, such as our pre-judgments and biases, is necessary in culturally safe care. Marchand’s discourse extends beyond just speaking to mainstream (external) health care that is outside community and she speaks to how it is just as integral that culturally safe practice is within community (internally) as well. Marchand goes on to reflect further about preconceived notions by sharing about her years of work at the local university in the realm of cultural safety. Originally, she wanted to host the trainings by bringing spirituality into their work, but she was told by her ancestors to hold off as the university and the students are not ready for this part of us. Then, she thought of bringing prayer to their work, but there were complaints from students that felt she was trying to convert students. Whereas, in Marchand’s teachings a healing circle begins and ends with a prayer in order to take care of those within the circle, to ensure everyone’s safety, and to create a safe space. It was in the institution of education teaching cultural safety where the beginning of her deep journey of becoming culturally aware began in relation to non-Aboriginal people. The first 56 step was recognizing the diversity of the class. The next step was to role model humility, by not thinking or acting better than anyone else. It was a balance within your ‘self’. Marchand explained her process of teaching cultural safety in the university as an opportunity of, “me looking at me,” by asking herself these questions, “Who am I? What are my beliefs? Where do I come from? And how do I do this in a good way?” In asking these questions, one of the answers that came to her was “voice”. This class was an opportunity for her to voice and in doing so everybody else was going to have a voice, too. Marchand went on to describe that the first two modules was purposeful in that students were not granted space to speak because they did not know ‘us’ as Okanagan people, many even had preconceived notions of ‘us’, the majority of them negative, but they did not know ‘us’. Marchand told of how the class was held in a circle and in the first module not one student would sit by them, her and Mitchell. In fact, there were often several seats empty on either side of her and Mitchell and she wondered why. Throughout the semester Marchand asked herself, “I wonder why? I wonder why?” She continued her story and said that by the second module students did begin to sit by them in the circle. Marchand asked herself, “So, who has trust and who doesn’t? How deep does that pre-conceived idea go?” In her learning and listening, some of the students did share that they had negative experiences with Aboriginal people before. In Marchand’s observing, she became aware that the majority have “never even sat beside any Indian and they wouldn’t dare sit beside an Indian.” Marchand concluded by acknowledging that in this work of cultural safety, “we have to, and have had to, make the first move to help them get past those pre-conceived ideas of us.” ‘We’ means us as First Nations people and ‘them’ as in non-First Nations people. By her and Mitchell making the first move in that class, students and teachers now acknowledge Marchand and Mitchell by saying hello when they see them at the university or outside of the university. Marchand recognized that with that “little bit of trust, little bit of knowledge of one another shared” a difference was made. She goes on to illustrate 57 the necessity of creating opportunities to practice and the detriment of not creating opportunities. Marchand states, “If there’s no opportunities, it’s not going to happen.” However, Marchand is optimistic that if there are opportunities “and with those opportunities accepted, then the doors will open. Doors will open.” And she demonstrates that by opening the doors, as she did in her own journey, then we can become culturally aware to move into cultural safety. In relation to cultural safety, we have to know our history and we must acknowledge our history within Canada has deeply seeded and deeply entrenched preconceived notions of Aboriginal people that have been passed down the generations (Morris, 1992). And are we going to continue to “the passing of the colonial torch” or are we going to interrupt it (Harjit Mann, personal communication, April 16, 2017)? Alexis speaks to what it takes to achieve cultural safety. He believes that what goes hand in hand and side by side with cultural safety is cultural confidence. He begins by illustrating that cultural safety begins when a healthcare provider is truly responsive and attentive to a recipient of care along with the recognition that the recipient of care is often vulnerable. Alexis points out that it is important to cultural safety to break down barriers by no longer reinforcing the binary ‘us and them’ and by addressing the negativity found within stereotypes and prejudices. He wonders if healthcare providers know about our humour and our laughter for that is a good side of our people. He relays the value of an ‘ease of communication’. He explains what he means by an ease of communication as when you have no fear of being put down, of being laughed at, or of going away mad. Alexis further clarifies, when you have reached an ease of communication that is when a healthcare provider makes you feel comfortable, is when you feel confident that they are not going to hurt you. He shares that there are healthcare providers who can do that. So, begins the dialogue of the cultural confidence that our people need to feel in order for cultural safety to be achieved when practiced. 58 What Alexis illustrates here is that the structural violence, racism and discrimination that has existed has made it challenging for Aboriginal people to have confidence that healthcare providers will do no harm (Kurtz et al., 2008: Dayer-Berenson, 2011). He also speaks to cultural confidence, which I see very much speaks to a lost Fly whom has forgotten their song. Tonasket recounts her journey of establishing cultural confidence. She discloses that it took her many years to understand within herself that it is OK to say no and to ask for an alternative. She shares that cultural confidence is an understanding of where you are at emotionally, intellectually, spiritually, and physically. It is important to have the awareness to know what it is you need to feel culturally confident so that you can bring it forward and verbalize it in a good way for yourself and/or for your family. She reminds us that we are educated to take what healthcare professionals have to offer you and it took her a long time to realize that she had a voice and that she had rights. She realized she did not have to be “allowed” to say no and to tell the doctor that she did not want them to be a part of her team of doctors because it was within her rights. And to build cultural confidence, it is critical to have the opportunity to have conversations with your family and to identify advocates. It is our culture to be supportive and reach out to family and to community when they are in the hospital and/or in emergency. When a family or community member is in the hospital there will be a large number of people from community who will arrive to offer support. Tonasket affirms that “the relationships we have is a big part of our culture.” She further asserts that “within our culture we all have our roles and we know what our roles are” and because of our teachings it is OK for us to “do what comes natural to us, what’s been a part of our culture always.” Tonasket firmly declares that no one has the right to tell us different “and if anybody questions that well we’ll just tell ’em where to go.” Tonasket’s words speak to the heart of the chaptikwl, How Food Was Given, in how in relation to cultural safety it is us, the Okanagan/Sqilxw people who are the Fly. And there are those that are lost, those that are in need of support and those that have found their voice, their song. And, 59 it is those who have found their voice who need to support those that are lost or have not quite gained their voice yet, and to keep singing. Marchand continues sharing her story/experience and reflects about a time when she explained with university students that the impact of a death in the community can affect the whole entire Nation and how hearing that was an eye opener for many of the students. Tonasket adds that in her work with the local school district she depicted that a death in the community impacts families and in turn impacts the attendance of students at various schools. And the details such as who it was and how it happened impacts how relatives are doing. Therefore, creating relationships with community is paramount to understanding what is happening to the students, to the youth. These final thoughts tie in eloquently with the words of an Indigenous woman and leader in cultural safety education, “…we can never be truly competent in any one’s culture but our own” (Cheryl Ward, personal communication, January 30, 2017). Creating relationships is integral to building understanding and developing culturally safe practices. 60 5.2 Community Participants I welcomed the community participants to the Talking Circle and thanked them for answering the invitation. Following the welcoming, space was provided for the community participants, Jonathon Alexis, Marie Tonasket, Patsy Gregoire, and Guy Robbins, to introduce themselves to one another. As two of the last names are the same as in the previous section, for ease of distinguishing difference and for consistency, first names will be used. Each participant shared where they lived and who their family is and stated that they were there to help and support me in my pursuance of education. Elder Patsy expressed, “Whatever comes to my mind and my heart I will share with you”. Guy shared that because he did not grow up connected to his culture learning about “what cultural safety is… past, present, and where the future of cultural safety is going” is a valuable take away for him as he wants to share with and teach his boys. I introduced myself, my connection to the Okanagan and St’at’imc people, and how I got into the work of cultural safety. After the introductions, I presented a short power point of the history of cultural safety and its origins in the home of the Maori people, New Zealand. The presentation was viewed as important by the Community Advisory Committee to ensure that the community member participants had an understanding of the origins and definitions of cultural safety prior to answering what cultural safety means to them. Once the presentation was completed, the participants discussed what was shared and the following questions arose: Is it just New Zealand or did Australia pick it up because they treat their Aborigine’s very badly? Is this a movement happening across Canada to other provinces to bring awareness of cultural safety? What is the role of the Aboriginal Cultural Safety Educator in Interior Health (IH) and who is served by this position (i.e.: nations, bands, school districts)? IH is planning a new building and they have brought in an Aboriginal representative from the ONA for their advice. This would be a good role for the Aboriginal Cultural Safety Educator. However, when IH is asking for 61 consultation they have to mean it otherwise it is a waste of time and causes hurt feelings. Is cultural safety already established across Canada for other people because there are so many nationalities/immigrants/minorities? Will they become a part of cultural safety or is it for just Aboriginal people? Are there other people working on cultural safety? Overall, it was felt that this topic of cultural safety is very broad and a good start. Although, it was considered to be backwards in the sense that cultural safety should be taught in the schools and then put into practice. It was felt to be of benefit to understand the process and to have the explanation of cultural safety because there are professionals who may use the term cultural safety but have never had it explained to them so that they are able to fully understand it. Marie viewed cultural safety as a “heavy word with a lot of implications.” Once all participants felt they had shared all that they wanted to and were ready to move on, the next discussion really looked at the term cultural safety by breaking them apart into culture and safety. The first term discussed by the community participants was culture/cultural. I asked them “What do they think of when they hear the word culture or cultural?” Have you had any difficulty with the use of the word culture? Lastly, they were asked if they were comfortable with the word culture. After lengthy discussions of the first term, participants were asked to consider how they define safety and to elaborate on how one acquires personal safety and how one gains trust. To end the Talking Circle there was a summary of the day and the final question, “What does cultural safety mean to you?” From the dialogue came another question to elaborate on: “What does cultural safety mean and where does that apply?” Once it began to quiet in the room, and the researcher observed that the energy of the participants was lowering; a break was taken so that the community participants could have the opportunity to review the flip charts that were posted around the hall. Returning to the Circle, the researcher stated, “[S]adly our people have had culturally unsafe experiences and it can be interesting to envision what culturally safe experiences would look like.” The researcher then offered a final round for the community 62 participants to share any last thoughts, words, comments, about what cultural safety means for them. 5.2.1 Discussions of the Term ‘Culture/Cultural’ The group had great variation in their responses to the word culture. It was stated by Patsy that culture included your whole lifestyle in everyday life meaning the way you live and the beliefs you hold. Guy responded with, “[T]he history of our people” and how there can be an attraction to Okanagan/Sqilxw culture, history, land, and the practical ways of preserving culture from non-Aboriginal people locally and globally. Jonathan approached the term culture from a total biological lens and answered, “I think of bacterial culture and from that I mean just an environment where things grow, total environment.” Marie brought into the conversation the concept of family and how understanding family norms help in knowing why you do things the way you do. Patsy added the aspect of rituals around death as well as the value of language and the history that is held in language. The conversation then brought forth the question, “Is there any difficulty with the word culture/cultural?” The participants described scenarios in their everyday lives when they experienced non-Aboriginal people being, what one participant described as, scared of the word culture. Another participant shared that they felt a sense of awkwardness from non-Aboriginal people when they had put forth a need or desire for culture; while another participant shared a time when they had perceived that non-Aboriginal people get seemingly intimidated or visibly uncomfortable when they brought their cultural medicines to the work place. One participant shared their frustration when they felt their culture was viewed as an inconvenience and described how this created conflict, pressure, and misinterpretations. Guy revealed his own experience of being questioned by both Aboriginal and non-Aboriginal people about how he as an Okanagan/Sqilxw man can be in business and still preserve his 63 culture. Patsy indicated that non-Aboriginal people are still trying to assimilate us Okanagan/Sqilxw into their world and goes on to state matter of fact, “We are not the same no matter what [they] do.” Marie added that it feels as though at times she has to apologize for being Aboriginal, even on her own reserve. She shares a personal example of when she had asked for a circle to be held in her work place as a way of resolving a stemming conflict and she was denied by a non-Aboriginal colleague who stated it was not an appropriate course of action as it was not a “cultural issue.” Marie professed that it made her feel as though her culture was unimportant, and her experience was minimized. She further explained that there is importance to understanding that “culture is not a onetime experience but rather it is how we live every day and it is a comfort to us.” Patsy advocated for the circle and how “we want people to be sensitive.” She used the example of a circle that she held for students that she worked with when she was employed in a local school district. Patsy told us how her students gained such a sense of belonging and how the students would tell her just how much they looked forward to that circle time. Guy spoke of the need to have his medicines with him so that he can maintain balance and create safety for himself in his work while he is away from his family and home. Jonathan asserted that people can tend to misinterpret the word culture with being authentic. Jonathan compares it to the word medicine and how, culturally, it is valued in a holistic sense. However, when you take the word medicine outside of the cultural context it means something totally different. For example, if a doctor says medicine, it is a pharmacy product and it is there to treat only a symptom. Jonathan provides another example of how culture is at conflict with big business who just wants to take the trees from the forest with no regard to anything else. Marie described how the word culture creates pressure within the work place by sharing an experience when she worked with a majority of non-Aboriginal colleagues and how, as the only Aboriginal employee, she felt as though she was expected to be the expert for all Aboriginal 64 people. Marie revealed that culture can be a double-edged sword in work because you want to make a difference and you have experience but mainstream questions your loyalty if you do not succumb to the pressures. She tells of her frustration at times when she is asked to teach about her culture in completely inappropriate situations. In those situations, she is there in her professional realm and not a cultural capacity. Marie speaks to how it can be an invasion of privacy because there is an expectation that she shares her innermost beliefs and values with a complete stranger. She goes on to explain that, at times, it is no one’s business and it is not her responsibility to teach her culture to non-Aboriginal people whenever she is asked. Considering there was a great discussion regarding some of the challenges that can come with the word culture the discussion then progressed to, “Are we comfortable with the word culture/cultural?” Everyone was comfortable with the word culture on a personal level, but not everyone felt the same way when considering the word culture outside of family and community. Patsy asserted her comfort with the word culture and how “it has so many parts to it.” Guy also conveyed sentiments of comfort with the word culture and speaks to how it is strong and powerful word that brings with it a sense of pride and purpose and he sees that as “motivating to preserve our culture by holding on to the past.” Jonathan emphasized how culture can work in different ways. He provided an example of when the ruling power wants land: they want the land, but when First Nations, whose land it rightfully is, “wants a fair share of the pie,” the ruling culture denies their cultural claim. Marie added that there is a “misinterpretation of what culture is” and how “[the] mainstream is defining it and we are not defining it as much as we need to.” Jon cautions that the ruling power limits how culture can be defined. He provided the example of lakefront property: the ruling powers only value lands off reserve and if we as Okanagan/Sqilxw ask for fair value of our lands on reserve, then suddenly there is a double standard and we are asking for way too much. Guy encouraged putting culture in land by growing something or bringing in local Aboriginal artisans, so long as it signifies that it is Okanagan/Sqilxw land. Marie 65 declared, “We don’t do our political claiming as we should.” She added that a flag is needed to show that this is Okanagan/Sqilxw territory. She shared how at the local tourist stop, O’Keefe Ranch has information that tells about the settlers in the area, but what is missing is the local history of the Okanagan/Sqilxw people. Marie also expresses the internal need to value Okanagan/Sqilxw people and to validate Okanagan/Sqilxw culture. She demonstrates the need by stating that Okanagan/Sqilxw do not seem to be valued for the knowledge that they hold in their own community, such as here at OKIB, so they have to go to another community to be valued or validated. It seems in OKIB only Aboriginal people who are from somewhere else are valued and treated with respect for their knowledge. To create change she recommended that every spring there be a recognition because “we have some amazing people” in our community that we do not often hear about or celebrate. Both Marie and Guy agreed that there needs to be a word in the Okanagan/Sqilxw language that captures “living in two worlds.” Marie affirms that, “We don’t ever forget where we came from and we need to look after that, but there’s a reality that we have to live in two worlds and there needs to be a word that captures that, that honours our uniqueness in striving to be progressive and also striving to maintain who we are and honor that.” 66 5.2.2 Discussions of the Term ‘Safety’ Once the group agreed they had exhausted their thoughts on the word culture the discussion moved to the second term safety and answering the question, “How do we define safety?”  Preservation of what we see/what exists/physical, and what we have to find out amongst ourselves  Comfort level, based on that you’re either participating or not, you’re in or you’re out  Personal feelings of safety of not having a fear that you can walk into a Doctor’s office or health centre and not be afraid to bring out what you have to say, that goes with your environment, safety of your environment that you go into  There’s got to be a trust between you and the other person  And with that a consistent, you have to believe every time there’s going to be a consistent response Table 3: Community Definition of Safety This brief discussion as followed by the question, “How does one acquire personal safety and how does one gain trust?”  Through personal interaction with the person that you are going to see or the hospital/institution and being aware of what goes on in that institution so that you know before you go and have the trust/awareness  Self-explanatory – have respect and courtesy with people  Be less like a factory, step back and treat people like they’re people Table 4: Community Definition of Trust Very quickly the discussion broadened to how access to safety is an issue. Patsy told a story of a woman in labor in Merritt who could not access service in her community because there was no doctor on duty and as a result had to travel all the way to Vernon. Marie spoke to healthcare being in a state of crisis with shortages of healthcare providers, such as doctors. She stressed, “…you get desperate people in a desperate situation, so how much safety is going on there?” She added, “You’re working with people that are pressured and they’re probably not feeling safe. How much safety can they offer to us? If they’re not supported, how much generosity can they give when they’re pressured?” Jonathan spoke of the difficulty to find a doctor or a dentist for community members. Jonathan notes that statistics show Aboriginal communities have high 67 rates of poverty and yet healthcare providers “expect impoverished people to be able to pay” for their own care up front and deal with Department of Indian Affairs (DIA) paperwork. Jonathan explains that DIA’s system is slow and the healthcare benefits are so low that even if there is coverage, it is not fully covered, and the difference still needs to be paid. He explained that not everyone can afford it. He illustrates the propensity of placing all the blame for the problems of an imposed colonial policy squarely on the shoulders of Aboriginal recipients of care as utterly unjust. 5.2.3 Discussions of the Term ‘Cultural Safety’ When considering cultural safety, the participants had to first share their thoughts on cultural unsafety by telling of their own personal experiences or by thinking about cultural safety on a larger scale. For example, Jonathan conveyed the difficulty in answering what cultural safety means to Okanagan/Sqilxw people because our community is so large and equally diverse. Jonathan further asserted that the Okanagan Valley is “a very racist, monochromatic culture…with some very, very ingrained racial stereotypes and very deep-rooted biases” that the broader community does not acknowledge. Marie affirmed that “racism is accumulating” and “when you’re vulnerable and…in pain” accessing healthcare can be intimidating when faced with attitudes that “you’re less than.” Patsy recalled her personal experience of going to an eye doctor and being unheeded to the point where she viewed him as incompetent and no longer wanted his services because she felt “he had no idea what I was talking about or how he could help me.” Participants then began to consider cultural safety, and what does that mean and where does that apply? In this discussion, they spoke of how cultural safety is not only required in mainstream healthcare services, but also within community programs and services on reserve. Culturally safe care in mainstream health care services occurs when, as Patsy described, an 68 elder is brought in to have time with someone that has a mental health diagnosis and the elder is able to bring forward a different perspective. She also made reference to when non-Aboriginal people tell community that residential schools are in the past so “get over it.” Patsy declared that for culturally safe care we must “talk about history, but we don’t talk about the implications of today and we need to.” She recognizes that it is also important to be aware of the practices within healthcare and the positions, rather than just going in and doing as you are told. She speaks about when her own mother was at the end of life. At that time, her mother lived in Summerland and Patsy wanted her closer. Patsy reached out to the local Aboriginal Patient Navigator and did not receive any help, so she contacted a community healthcare provider for help. She shared the frustration she felt when the provider simply said, “I don’t know” and “I don’t do that.” Patsy shared that “when a person is in that state of mind and in that place [of worry, concern, feeling alone] and your workers at your own community health centre cannot help you, it’s awful and very frustrating.” Marie added that not only did the provider not have the information; they did not offer a sympathetic ear either. As a result of Patsy’s sharing, the definition of culturally safe care included being sensitive to the needs and situation, particularly at end of life, and to work to reduce barriers to information by opening pathways to a solution versus creating barriers by simply responding with a resounding “no”. As well, culturally safe care in community requires a good relationship and supports. Patsy acknowledged that, The health out there is changing, the shortage and everything. And we have to adjust ourselves to that. Years ago, we used to have one doctor to look after our whole family and now everyone has their own doctor. Things change and evolve. Evolve or de-evolve. Adjust and accept those changes. Marie defined cultural safety as a process and not a destination and emphasized the need to have respect for the process. She further expressed that cultural safety is situational and the definition can change. In Marie’s sharing, she also spoke to the need to be supported within the 69 band when receiving culturally unsafe care in community. She proposed that an immediate resolution process be put in place because “if you cannot feel safe on your own reserve within your own services and not have support by your own people, you are really left on your own.” Marie recalled a time when she was in excruciating pain and the healthcare provider assumed she drank every day and minimized the pain she was experiencing. She said it was an unkind system and in order to be a culturally safe experience it would need to be free of assumptions, and, instead, be empathetic and caring. Guy stated that cultural safety is needed “not just outside of our community but within first.” He spoke about how within his own family disagreements and animosity exists from long time ago and how that is harmful to our family systems. He strives to not take old grudges on and he said, “I’m not going to utilize your anger towards my judgment of a person.” Guy feels that a cultural safety workshop could benefit the community on a larger scale and could provide further clarity on the broader community’s perspective of cultural safety. 5.2.4 Final Round The day began to wind down, so there was a final round for each participant to share their last thoughts on what cultural safety means to them. This following are direct quotes from each participant. Marie Cultural safety, it should be just there. It should be a way of living. There should be a process of education that goes through all the disciplines because when you are marginalized you don’t have the power to stand up for yourself and to expect better treatment and puts you farther away from the resources that you need. And, it has to start with us. Because if we don’t know it as an individual, as a community member, as a community employee, then how can we ever 70 hold that to the standards in town? We should be poised to learn from it: our mistakes, culturally unsafe moment in care. Culture, we have such beautiful teachings, but we don’t follow them. We assign blame instead –with everything that happens there’s a lesson. We don’t do that because we’re a new order of business [colonial band]. We need to push back and remind where all those good teachings/lessons came from – respect, hearing, acknowledging, honoring ourselves… we’re moving forward/progressing, but we still have the opportunity to hold our relationship to the land in esteem. We’re not so infiltrated by outside influences […] we need to define our standards. Pasty More awareness, more teachings, back to my family, community, helping others to be aware to understand and make allowances for the people out there so that we can stop becoming a victim. Instead, building a pride and self-esteem [in our young people] to be able to walk proud in the outside world and to be able to deal with things out there. Our safety net is our treed-in reserve, but we have to show our young people, there’s a whole world out there for they’re the ones that our going to go out and face that world. And, we have to give them all the support and knowledge that we’ve lived through. [Elders] give them our knowledge and our strength so they can be stronger people. [Elders/youth] Guy Cultural safety wasn’t a term that I had heard of prior to you and I speaking. I didn’t know what my purpose would be, but I came in open-minded to this. What it means inside/outside the community. Today has planted the seed to think more about cultural safety and what can I do to contribute to my community, my boys – starting a ripple effect of cultural safety awareness so that I can take this to my dad and ask him the question, take this to elders and ask them the question, so I can get more knowledge to understand, what is it going to take for us to continue 71 teaching our community about cultural safety and how can we protect it for the future? Letting our next generation know what we need for the future. We need our own doctors, lawyers, entrepreneurs, protectors. Do our next generation know what we actually need as community to maintain our lands, knowledge, and our stand? I’m walking away with a mountain full of knowledge. Jonathan In BC, in Canada, it’s going to be a lot different than New Zealand to implement it. New Zealand, you have a very small population that’s not growing with immigration like here in Canada, the Okanagan. Everybody’s trying to chomp at the same ear of corn and, because of that, it’s going to need a lot of diligence and consistent reinforcing of it. Otherwise, because we’re such a growing population, it will just get ignored and thrown away – marginalized…one of the things we do have is half of our community doesn’t live on reserve. How do we protect them? Can we protect them? How do we even reach out to them? Most of them are starting to become disconnected with us and so how do we protect them? Especially the Okanagan is becoming how Kamloops used to be. There are many other nations coming here. How do we protect our people while respecting a number of other people [nations] too? We’ll have to have some sensitivity ourselves and work with the other communities to know what their concerns are with us: diabetes, heart problems, etc. To expand to people that are coming in, we don’t know what their stories are, we need to incorporate that, if we help them would be beneficial because of numbers. Instead of separating Okanagan, Carrier, etc. …instead we could be Natives asking respect and that would carry a lot more weight rather than individuals asking. That would be some of our challenges in establishing cultural safety. 72 5.3 Enowkinwixw: Analytical Framework This section utilizes the enowkinwixw as the analytical framework overlaying the findings in order to observe and identify what it is that is causing imbalance or conflict (Armstrong, 2010a). Firstly, the tensions that exist with the term culture, as identified by participants, will be shared in order to illustrate how conflicting perceptions may cause harm. Then, tradition will be described and discussed, and innovation will follow as they are on opposing sides of the circle. Following this, relationship will be considered, with action to outline the implications of the research beyond the scope of the study based upon the findings. Lastly, the learnings surrounding cultural safety will be shared. Figure 3: Cultural Safety in Balance In approaching the analysis of this study informed by enowkinwixw, Dr. Jeannette Armstrong (2009) speaks about the protocol of the enowkinwixw and how “in any circle of people there are different perspectives as a result of particular sensitivities, expertise and concerns and the recognition that diversity is necessary” (p. 189). By looking at cultural safety through these protocols of the enowkinwixw and the four quadrants, it is clear that the ideal state of cultural safety would be a balance of tradition, relationship, innovation and action. And where cultural Cultural Safety Skimxist Elder TRADITION Spitlem Mother RELATIONSHIP Siya Youth INNOVATION Ntyixtix Father ACTION 73 safety in community or in healthcare “actually functions as a living organism with different but vitally necessary parts” (Armstrong, 2009, p.189). In the findings of the research and in applying the enowkinwixw in the analysis, it was glaringly obvious that there existed an imbalance of cultural safety in relation to healthcare. The imbalance lies in that healthcare values innovation and action, seemingly over that of tradition and relationship, as depicted in the image below. Figure 4: Imbalance of Cultural Safety 5.3.1 Tradition (skimxist) This quadrant is referred to as the Elder voice wherein what is prominent is Mother Earth and traditional practices (Armstrong, 2009). Tradition is not necessarily of the past, rather best practices, that can direct and guide the present and future if you allow. The culture of Aboriginal people is grounded in tradition (Indigenous ways of knowing) and what becomes clear is that if non-Aboriginal people do not see Indigenous ways of knowing as a gift that can benefit the world, then it is difficult to begin to build a relationship based upon, what Mitchell refers to as, “true and total acceptance”. This diagram below highlighting participants’ responses to the term culture emphasizes the dichotomy that exists when acceptance is not a part of the outcome. Participants’ sharing depicts how the term culture, when viewed from their own lens, is about pride, purpose, and belonging. Whereas, when they consider the term Cultural Safety TRADITION RELATION-SHIP INNOVATION ACTION 74 culture, in relation to mainstream, it becomes a double-edged sword where, on one hand, it can become an invasion of privacy when non-Aboriginal people want to know everything and, on the other hand, loyalty is questioned when culture is brought into mainstream uninvited. Figure 5: Skimxist/Tradition 5.3.2 Innovation (siya) This quadrant reflects the Youth voice wherein advocacy and change are the driving force (Armstrong, 2009). In this study what has been identified for advocacy is Indigenous strengths and finding the holism within seemingly differing worlds (Cohen, 2010). Further, to address the change component of innovation, this study has identified cultural confidence. In examining innovation, I must recognize and acknowledge that this aspect of the enowkinwixw is necessary to any dialogue about cultural safety, as it is a calling or “yearning for change that will bring a better future” (Armstrong, 2005, p.15). The table below is what community participants perceived as missing from the healthcare system: respect for strength Indigenous concepts of family have for Aboriginal people in care. In addition, community members who participated spoke of the need for healthcare systems to be scared intimidated questioned imperial voyeurism & entertainment inconvenient conflict awkward medicine - symptom uncomfortable "authenticity" "validation" Culture history land language environment where things grow power motivation strength medicine - holistic pride purpose belonging teachings diversity life 75 balanced. Where there is recognition by Aboriginal recipients of care of the limitation of healthcare in their holistic wellness and where healthcare providers acknowledge and create space for traditional practices and medicines that some of their Aboriginal recipients of care may adhere to. Table 5: Siya/Innovation 5.3.3 Relationship (spitlem) To consider relationships, it is necessary to identify who the people are that are being spoken about in relation to cultural safety. In this research and the conversations that community held, the people spoken about were acknowledged two-fold: (1) non-Aboriginal professionals, particularly in healthcare although education, and (2) non-Aboriginal and Aboriginal professionals working in community, with a focus mainly on healthcare. How respectful and reciprocal relations with non-Aboriginal and Aboriginal professionals are established will have significant impact upon Okanagan/Sqilxw individuals, families, and communities, so it is crucial Indigenous strength Accept and work with Indigenous concepts of family Family is culture Family roles are important Relationship is culture Balance Recognition of limitation of health system Recognition of traditional practice and medicine and other alternatives 76 that it happens in a good way. The first column entitled “Aboriginal and non-Aboriginal” in the table below depicts what the community participants describe as important for healthcare providers to integrate into their practice in order to improve care outcomes when working with Aboriginal recipients of care. The second column speaks to principles of cultural safety that community participants spoke of loud and clear in their Talking Circles. These guiding principles for cultural safety are necessary to integrate into mainstream and community healthcare systems. Table 6: Spitlem/Relationship 5.3.4 Action (ntixtiyx) Action is exploring what needs to be built, developed and implemented to move forward with cultural safety successfully both in community (internal) and in mainstream health care (external). The community participants voiced the need to have resolution processes that incorporate Aboriginal culture, such as Talking Circles that is an outlet for Aboriginal people to Aboriginal and non-Aboriginal Practice Humility Allow Humour Identify pre-conceived notions and establish whether or not they are still working for you Engage in self-reflection See the gifts in one another Create space to learn about one another Break down "us and them" mentality Healthcare and Community Recognize fair, sameness, and equality is not the same as equity Acknowledge power and privilege of healthcare providers Recognize diversity within Aboriginal peoples Realize family has a significant role in health Safety for all - recipients of care and providers Aboriginal spirituallity is a must for those who practice 77 report when they are, as Marie states, “receiving culturally unsafe care” in both community and in mainstream healthcare. Alexis spoke of when a healthcare provider knows about cultural safety but is not willing to practice that it becomes an ethical issue. Therefore, the need to consider a human resource strategy that outlines ethical accountability of the healthcare provider to Aboriginal recipients of care. And to become a part of the fabric of a healthcare system, performance evaluations include principles of cultural safety for both contactors and employees be conducted. The outcome is that a cultural safety strategy is containing both the conflict resolution process and the human resource strategy, as a start in taking action. Table 7: Ntyixtix/Innovation 5.4 The Central Issue: Cultural Safety In seeking cultural safety there must be a mutual desire to “put the coin down.” Where Okanagan/Sqilxw people have space to share about their knowledge and where non-Aboriginal people have space to share about their knowledge. In the realm of healthcare that would be defined as recipients of care and healthcare providers. Cultural Safety Strategy Human Resource Strategy Performance evaluations Ethics Contracts/ contractors Conflict Resolution Process Talking Circles 78 There can be risks if this is ever too one-sided. It could be argued that this has already been a one-sided affair where the sole focus is only on western knowledge. Western knowledge is not holistic and so does not see the entire recipient of care. Western knowledge tends to only see the health disparities of a recipient of care, their deficit. Western knowledge seemingly believes that health care providers are the expert, yet providers often have no relationship or knowledge of Aboriginal people in the region or area where they work. The risks are that one-sided affairs have a negative effect on Aboriginal people and it becomes an ethical issue that causes harm and becomes culturally unsafe. In the context of this research, it has been identified where we are speaking of, who is being spoken to, what the ideas are, and what needs to be developed in relation to cultural safety for Okanagan/Sqilxw people. Now, it is time to speak to the two central themes that came out from the community participants’ Talking Circle about cultural safety: these were the interconnected ideas of knowledge and behaviour/practice (see image to follow). Put the Coin Down Okanagan/Sqilxw Knowledge Western Knowledge Figure 6: Put the Coin Down 79 The participant’s spoke of the importance of healthcare providers to self-reflect upon their own lists, as Mitchell described, as well as have the knowledge of the history and present-day realities of Aboriginal people. For some healthcare providers, knowledge may be a process of discovering and unpacking stereotypes, bias, and pre-judgments of Aboriginal people that they may be holding that may impact their behaviour towards Aboriginal people and ultimately their practice. The outside circle is behaviour or practice. What is listed in behaviour/practice are what participants voiced as ways healthcare providers can be proactive in becoming and/or maintaining culturally safe care to their Aboriginal recipients of care. 5.5 Cultural Confidence In this study, the need for cultural safety within the local Aboriginal community was prominent amongst the participants. The central theme for Okanagan/Sqilxw participants was cultural Knowledge • History of Aboriginal people • Present day - our whole lifestyle, the way we live and our beliefs • rituals - particularly around death • self-reflect on potential • fear of Aboriginal people • feelings of awkwardness of cultural practices • feelings of being inconvenienced by cultural practices Behaviour/Practice • humility • balance self • be vulnerable and open • provide an ease of communication • make the first move to show humanity • share space • trust • share of self and allow others to share with you • eradicate binary of "us" and "them" • eradicate concept of being the expert and determining recipients of care as simply passive • build recipient of care confidence in you and in their own voice cultural safety knowledge behaviour/practice Figure 7: Knowledge and Behaviour/Practice 80 confidence. Cultural confidence is not a new concept in the literature; however, it typically has centred on the self-efficacy of the healthcare provider as used in the literature (Mesler, 2017; Muzumdar, Holiday-Goodman, Black & Powers, 2010; Singleton, 2017). Cultural confidence in the present research vastly differed: rather than focusing on the cultural confidence of a healthcare provider, participants in this study emphasized the importance of cultural confidence for and centred on the Aboriginal individual, family, and community. Cultural confidence in this context was described as having a voice, believing in your voice, and using your voice. The roots of Aboriginal people being silence and not allowed to speak from colonization and, unfortunately, Aboriginal communities have their own pre-conceived notions of one another that need to be healed. Healing in this way can assist in nurturing cultural confidence within an individual, family, and ultimately the community. Figure 8: Cultural Confidence The participants shared valuable ways to build cultural confidence within oneself and within families in order to build relations with one another where community can sit together and visit and begin to undo pre-conceived ideas of one another. Cultural confidence is a goal that “puts Cultural Confidence ~VOICE~ Have rights Can say NO Advocate Raise our Flag Value our people Validate our culture Support each other 81 the coin down” on marginalizing or oppressing one another and elevates community, including sharing knowledge with those who may not know their role in community. And, in the realm of health, cultural confidence is recognizing that while there can be respect for healthcare providers and their teachings, they are not the experts in an individual’s life, but rather they are a tool in achieving good health. 82 Chapter 6: Discussion “I wonder why? I wonder why?” ~ Chris Marchand This research focused on eight community members, who identify as Okanagan/Sqilxw people, sharing their personal perceptions of cultural safety. Their stories are not meant to be representative of all Okanagan/Sqilxw people, but rather to shed light upon their experiences for consideration in the conversation of cultural safety here in this place. And, although this is not designed with the intent to speak on behalf of all Aboriginal people, the experiences shared within this research may resonate with readers who identify as Aboriginal. I believe that this research offers actionable and accessible ways to increase knowledge and build culturally safe practice for professionals working with Okanagan/Sqilxw people, families, and communities. In this section, I outline suggestions from the findings, implications of the method, and limitations and implications for future research. The research asked, “What does cultural safety mean to you?” The larger impetus guiding this study was, “Informed by Indigenous methodologies and participatory research practices, what is an Okanagan/Sqilxw understanding of cultural safety?” All of the community members, who comprised of the advisory committee and the community participants, began with sharing their culturally unsafe experiences before moving into dialogue about cultural safety. Ultimately, there were four key concepts identified: knowledge; behaviour/practice; mainstream healthcare professionals; and community healthcare professionals. 6.1 Suggestions from the Findings for Healthcare Professionals Providing culturally safe care is becoming a prominent discourse for health professionals. Looking through the lens of the enowkinwixw, the colonial institution of health holds value in 83 innovation (siya) and action (ntyixtix). Where the systemic barriers and cultural unsafety occur is in the devaluing of tradition (skimxist) as a thing of the past and grossly inhibiting time for building truly meaningful relationships (spitlem) with recipients of care. What is interesting to note is that throughout this research, participants spoke of the need for creating opportunity to take the time to listen to each other’s story in order to build good relations. Research participants also spoke of the need for healthcare professionals to understand their traditions and the importance of family ties, stories, and spaces for ceremony in healthcare facilities. Therefore, cultural safety is perceived to be out of balance by the participants, as demonstrated by the differing size of the four quadrants in image below, which can also be viewed as an illustration of how cultural unsafety can occur. Therefore, healthcare providers need to re-balance their services in order to increase culturally safe practice at individual and systemic levels by acknowledging the importance of tradition (skimxist) and relationship (spitlem) and incorporating same to align with that of innovation (siya), and action (ntyixtix). Figure 9: Imbalance In order to build relationships, systems must create space for stories of hurt to be heard. It is important to persevere through the stories of hurt shared without the need to defend or resist Cultural Safety TRADITION RELATION-SHIP INNOVATION ACTION 84 what is being said. It may even seem as though there are no answers or solutions provided, but it is important to be open and to listen, for building meaningful relationships takes time as outlined by participants in the findings. And, if it is the first time Aboriginal people have been given the space to share about healthcare experiences, there may be many meetings to be had and stories told to process the gravity of what is needed for good healthcare from an Aboriginal perspective. The concept of culture was discussed at length by participants. In cultural safety it is important to not minimize Aboriginal people to a cultural experience to be consumed and subsumed for voyeuristic pleasure or curiosity. It is important to recognize that for Aboriginal people culture can be a “double-edged sword”. The sharing of culture needs to be determined by an Aboriginal person and the healthcare provider needs not learn all about culture but rather provide service that takes into account the cultural needs of their Aboriginal recipients of care (Nursing Council of New Zealand, 2011). Otherwise, there is risk of being perceived as a voyeur of culture and maintaining the colonial othering, which is culturally unsafe. A significant component of cultural safety is self-reflection as one of the participants, Chris Marchand, highlighted. This is delicate work as self-reflection requires one to identify strengths as well as weaknesses, particularly in a relationship. In examining who has been leading the dialogue in cultural safety, it has seemingly been Indigenous peoples - from the Maori peoples in New Zealand, to Aboriginal peoples in Canada, and to the Okanagan/Sqilxw people in the Okanagan. Throughout the research the participants voiced the need to create space and opportunity to promote cultural safety: to do the work; to know/examine pre-conceived notions, biases, and stereotypes. In listening to the participants stories, it is hard to deny the vulnerability and openness that is displayed. What is also distinct is the work that Indigenous peoples have done to create a safe space for non-Aboriginal people to engage in dialogue. Whereas, in many of the examples shared by participants, the effort has seemingly not been equally reciprocated 85 by non-Aboriginal people, including students and healthcare providers. One of the participants, Chris Marchand, eloquently questioned, “So, who has trust and who doesn’t?” Cultural safety is about relationships and Aboriginal people are already engaged in the dialogue. A thought to consider is that in healthcare, providers often speak of recipients of care who do not actively engage in their own care as being non-compliant. In choosing to not actively engage in culturally safe practice, could a healthcare provider be seen as non-compliant as well? 6.2 Suggestions from the Findings for Community The findings of this study provide insight into OKIB community members’ perspectives on why cultural safety is important within the local Aboriginal community. The main concept that was brought forward was that of voice. In exploring voice, it was determined that OKIB leadership needs to be on board with cultural safety and implementing culturally safe care into practice at all levels. Education in our own community needs to occur in order to increase understanding of cultural safety and its importance and to gauge community readiness. It was identified in this study that cultural unsafety, or harms, is not readily tracked; therefore, there is a need to develop a community cultural safety strategy that includes a human resource strategy and a process for conflict resolution. 6.3 Limitations In the following section, I will discuss what some might argue to be limitations in research. That said, the following possible limitations are also concomitantly and arguably strengths of this research in terms of its design and commitment to the 4R’s and Okanagan/Sqilxw knowledge. One of the limitations to this research was that the number of OKIB community participants was low. However, I did not take that as a limitation. One of the teachings that my father has learned that he has shared with me and that I have heard often in community is that “those who are 86 meant to be here are” (E. Mitchell, personal communication, December 2013). What I have come to understand is that this means it is no accident who is present and who is not. Those who are present are who is intended to contribute. When I think of this, I recall the words of Dr. Jeannette Armstrong (2009), “For the Syilx the concept of community, as well as extended family, is analogous to a living person with brains, muscles, heart and spirit which is perceived as the body of community ― awakening each time they gather” (p.189). Furthermore, the small numbers increased the opportunity for in-depth conversations to occur within the circle and provided participants space to deepen their discussions which in turn offered greater insight to the findings. A second limitation (and strength) was that this study was centered in Okanagan/Sqilxw knowledge. As a result, there is less likelihood that this can be generalized beyond the scope of the research. I do not take this to be limiting as it was never intended to speak for all Indigenous peoples, Aboriginal peoples, or even Okanagan/Sqilxw peoples. In this research, cultural safety was examined from an Okanagan/Sqilxw perspective within one of the member bands within the Okanagan Nation. When considering that since time immemorial the community chief represented the “will of the people” and a tribal chief represented “the laws of the whole […] at the nation level” this does hold relevance to not only the community but the Nation (Okanagan Tribal Council, 1993, p.8). For fundamentally, it is individuals who create the family, families who create the community, and communities who create the Nation we live in (Armstrong, 2009). Therefore, it is the people who live in community who in turn inform the Nation and it is the Nation leadership that considers the health and well-being of all in their territory. In addition, although it was centred in Okanagan/Sqilxw ways of knowing and being, Indigenous peoples could use similar principles and conduct research with their traditional teachings found within their chaptikwl, oral histories. 87 A third limitation is that this thesis is situated to place, here in the traditional territory of the Okanagan/Sqilxw peoples. Situating this research to place strengthens the learnings as it prioritizes local Indigenous ways of knowing and adds value to same, which is a completely transferable approach. Furthermore, this study complements other research findings that were conducted within the broader North Okanagan. 6.4 Implications for Future Research In order to increase cultural safety there is a need to find balance, as discussed in the findings. To further the research, it would be great to engage with the healthcare providers and ask them the same questions that were asked in this research. Then bring both the community members who participated in this research and the healthcare providers and report back the findings. Following this, there would be a collaborative discussion to identify ways to achieve balance within the healthcare system in order to define what cultural safety means, to both healthcare providers and Aboriginal community here in this place in order to ultimately increase cultural safety. A question arose from this study for future exploration. In this study I was looking at cultural safety through the analytical lens of the enowkinwixw and what it meant to Okanagan/Sqilxw people. One of the central findings in this study was that of cultural confidence. In the literature, cultural confidence is centred in healthcare, on providers and students in the realm of healthcare, whereas the findings of this study centred cultural confidence in community and the importance of voice. Therefore, it would be interesting to unpack cultural confidence further and to explore cultural confidence in relation to cultural safety. For example, what is the relationship between healthcare providers and Aboriginal community as recipients of care, and their respective levels of cultural confidence? What raises their level of cultural confidence and what lowers same? How is cultural safety impacted? This would contribute valuable insights into how 88 cultural safety can be achieved, which is a central question to healthcare providers as well as systems, such as sites and the larger health authority. 6.5 Self-Reflection For me it was important to centre the analytical framework in enowkinwixw for two reasons: it allowed me to get acquainted with chaptikwl and in Okanagan/Sqilxw ways of knowing and being. It would be difficult to gain access to enowkinwixw without first looking to the chaptikwl as they go hand and glove together. I acknowledge that as a non-language speaker, I am limited in my scope of understanding as I am reading translated versions of the chaptikwl. However, I as an Okanagan/Sqilxw woman, I will continue to look to the Okanagan/Sqilxw traditions and stories as I know that they are strong and can still provide teachings to learners like me. In closing, in the beginning I was looking within myself to examine the correlation between being a vulnerable recipient of care accessing healthcare services while being a strong advocate for my family, community and Nation. What I came to find is that standing up for my family, community and Nation comes easy to me. It is when I have to stand up for myself where the challenge lies. Jami shares how sometimes those who have the inability to have voice can be due to past traumas. While I self-reflect regularly, it is equally important for me to heal those parts of me that have felt unsafe. Throughout this research I became aware of some of those parts that I had not acknowledged or remembered for some time. In addition, Eric speaks to the journey one takes of understanding emotionally, physically, spiritually and intellectually that they have a voice. 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Thesis/Dissertation
eng
Interdisciplinary Studies
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
From the margins : cultural safety from an Okanagan/Sqilxw perspective
Text