Advancing health equity for Indigenous peoples in Canada: development of a patient complexity assessment framework.

BACKGROUND: Indigenous patients often present with complex health needs in clinical settings due to factors rooted in a legacy of colonization. Healthcare systems and providers are not equipped to identify the underlying causes nor enact solutions for this complexity. This study aimed to develop an Indigenous-centered patient complexity assessment framework for urban Indigenous patients in Canada. METHODS: A multi-phased approach was used which was initiated with a review of literature surrounding complexity, followed by interviews with Indigenous patients to embed their lived experiences of complexity, and concluded with a modified e-Delphi consensus building process with a panel of 14 healthcare experts within the field of Indigenous health to identify the domains and concepts contributing to health complexity for inclusion in an Indigenous-centered patient complexity assessment framework. This study details the final phase of the research. RESULTS: A total of 27 concepts spanning 9 domains, including those from biological, social, health literacy, psychological, functioning, healthcare access, adverse life experiences, resilience and culture, and healthcare violence domains were included in the final version of the Indigenous-centered patient complexity assessment framework. CONCLUSIONS: The proposed framework outlines critical components that indicate the presence of health complexity among Indigenous patients. The framework serves as a source of reference for healthcare providers to inform their delivery of care with Indigenous patients. This framework will advance scholarship in patient complexity assessment tools through the addition of domains not commonly seen, as well as extending the application of these tools to potentially mitigate racism experienced by underserved populations such as Indigenous peoples.

Access, Relationships, Quality and Safety (ARQS): a qualitative study to cocreate an Indigenous patient experience tool for virtual primary care.

BACKGROUND: Perspectives from Indigenous peoples and their primary care providers about the quality and impacts of virtual primary care for Indigenous patients are currently limited. This study engaged Indigenous patients and their primary care providers, resulting in four domains being established for an Indigenous patient experience tool for use in virtual primary care. In this paper, we explore the development and finalisation of the Access, Relationships, Quality and Safety (ARQS) tool. METHODS: We re-engaged five Indigenous patient participants who had been involved in the semistructured interviews that established the ARQS tool domains. Through cognitive interviews, we tested the tool statements, leading to modifications. To finalise the tool statements, an Indigenous advisory group was consulted. RESULTS: The ARQS tool statements were revised and finalised with twelve statements that reflect the experiences and perspectives of Indigenous patients. DISCUSSION: The ARQS tool statements assess the four domains that reflect high-quality virtual care for Indigenous patients. By centring Indigenous peoples and their lived experience with primary care at every stage in the tool's development, it captures Indigenous-centred understandings of high-quality virtual primary care and has validity for use in virtual primary care settings. CONCLUSION: The ARQS tool offers a promising way for Indigenous patients to provide feedback and for clinics to measure the quality and safety of virtual primary care practice on the provider and/or clinic level. This is important, as such feedback may help to promote improvements in virtual primary care delivery for Indigenous patients and more widely, may help advance Indigenous health equity.

Critically examining health complexity experienced by urban Indigenous peoples in Canada by exploring the factors that allow health complexity to persist: a qualitative study of Indigenous patients in Calgary, Alberta.

OBJECTIVES: This study aims to identify and critically examine the components of health complexity, and explore the factors that allow it to exist, among urban Indigenous peoples in Canada. DESIGN: Qualitative exploration with relational conversations. SETTING: Calgary, Alberta, Canada. PARTICIPANTS: A total of nine urban Indigenous patients were recruited from a multidisciplinary primary healthcare clinic that serves First Nations, Métis and Inuit peoples. Recruitment and data collection took place between September and November 2021. RESULTS: Thematic analysis revealed three main themes, namely: sources of health complexity, psychological responses to adversity, and resilience, strengths, and protective factors. Key sources of health complexity arose from material resource disparities and adverse interpersonal interactions within the healthcare environment, which manifest into psychological distress while strengths and resilience emerged as protective factors. CONCLUSION: The healthcare system remains inapt to address complexity among urban Indigenous peoples in Canada. Healthcare violence experienced by Indigenous peoples only further perpetuates health complexity. Future clinical tools to collect information about health complexity among urban Indigenous patients should include questions about the factors defined in this study.

Indigenous Mentorship for the Health Sciences: An Appraisal of a Contemporary Model by Indigenous Stakeholders.

Construct: In 2021, Murry et al. put forward a model of Indigenous mentorship within the health sciences based on the behaviors of Indigenous mentors toward their Indigenous mentees. This study explored mentees' endorsements and/or criticisms of the IM model and how IM constructs and behaviors described in the model benefited them. Background: Models of Indigenous mentorship have been developed previously yet have not yet been empirically examined, restricting our ability to measure or make claims as to their consequences, correlates, and antecedents. Approach: Interviews with six Indigenous mentees asked about their: 1) resonance with the model, 2) stories related to mentors' behaviors, 3) perceived benefits of their mentors' behaviors on their journey, and 4) components they felt were missing from the model. Data were analyzed using qualitative content analysis. Findings: Overall, the model resonated with participants. Mentees told stories about mentors engaging in the IM constructs practicing relationalism most frequently, followed by fostering Indigenous identity development, utilizing a mentee-centered focus, and imbuing criticality, advocacy, and abiding by Indigenous ethics. Benefits included improved career and work attitudes, motivation, and overall well-being, engaging in helping behaviors, and enhanced criticality. Recommendations to expand the model included incorporating: 1) additional mentor behaviors (e.g., transference of traditional knowledge), 2) higher-order dimensions (e.g., the impact of the institution), 3) specific mentee characteristics (e.g., age and gender), and 4) additional types of mentoring relationships (e.g., peer, multiple mentors). Conclusions: This study showed that Murry et al.'s model resonated with primary stakeholders (i.e., Indigenous mentees), that Indigenous mentorship behaviors have perceived consequences that are important for adjustment, and ways the model is limited or mis-specified. This information can inform mentor practices, selection and support, and program evaluation.

Readiness to Practice in Health Care: An Empirical Definition Based on a Content Analysis of the Literature.

BACKGROUND: Health care services require practitioners to be ready to practice (R2P), but evidence shows new graduates vary in R2P. Unfortunately, there is a lack of clarity about what R2P entails. METHOD: A content analysis of the empirical literature (Gaur & Kumar, 2018) was used to quantify the elements and higher-order categories of R2P. RESULTS: Across 108 articles, professional development activities, communication, previous experience, confidence, clinical skills, patient-centered care, integration of knowledge, teamwork, competency, management, and interpersonal skills were used to define R2P at least 25% of the time. We identified seven domains of R2P: clinical experience, social experiences, professional development experiences, personal attributes, cognitive aspects, onboarding experiences, and educational experiences. CONCLUSION: Our study empirically defined what is associated with health professionals who were perceived as or perceived themselves as R2P in health care. Our results inform training, preparation, research, and the transition from medical training to the workplace. [J Contin Educ Nurs. 2023;54(7):302-312.].

Access, relationships, quality and safety (ARQS): a qualitative study to develop an Indigenous-centred understanding of virtual care quality.

BACKGROUND: Among Indigenous peoples in Canada, access to high-quality healthcare remains an important determinant of health. The shift to virtual and remote-based approaches, expedited during the COVID-19 pandemic, influenced the ways in which individuals accessed care and the quality of care received. This study sought to determine which elements are required for effective and sustainable virtual care approaches for delivery of primary care to Indigenous patients and develop quality indicators grounded in Indigenous community and experience. We share a conceptual framework to understand how Indigenous patients access and define high-quality virtual care, grounded in Indigenous patient experiences and worldviews. METHODS: Using principles of patient-oriented research, we grounded this work in social justice and participatory action research. We sought to gain an in-depth understanding of the Indigenous experiences of virtual care and specifically of primary care. This was developed through semistructured interviews with Indigenous patients and Indigenous virtual primary care providers. RESULTS: Thirteen participants were interviewed between 5 August 2021 and 25 October 2021. Using Framework Analysis, we constructed four domains including access, relationships, quality and safety as being primary facets of defining high-quality Indigenous virtual primary care. DISCUSSION: The results presented here indicate that the shift to virtual care, largely seen in response to the COVID-19 pandemic, does not compromise quality of care, nor does it lead to negative patient experiences. Optimal care is possible in virtual settings for some care needs and types of appointments and has the potential to decrease barriers to access and improve patient experiences of safety and quality while facilitating patient/provider relationships. CONCLUSION: In summary, high-quality Indigenous virtual care benefits from attention to patients' experiences of access, relationships, safety and quality with their service providers and healthcare teams.

Propelled by the Pandemic: Responses and Shifts in Primary Healthcare Models for Indigenous Peoples.

The COVID-19 pandemic posed a significant risk to the health and well-being of First Nations and Métis communities in Alberta. Communities' self-determined and integrated responses with embedded cultural supports - in collaboration with governments, organizations and providers - were key to minimizing morbidity and mortality. Maintaining and building these relationships in the continued pandemic response, broadening approaches to healthcare delivery and continuing to include culture will support attainment of the Indigenous primary healthcare model while addressing logistical challenges in transforming and sustaining healthcare systems in the background of ongoing inequities in the social determinants of health.

Indigenous Mentorship in the Health Sciences: Actions and Approaches of Mentors.

Phenomenon: Indigenous and non-Indigenous scholars have called for mentorship as a viable approach to supporting the retention and professional development of Indigenous students in the health sciences. In the context of Canadian reconciliation efforts with Indigenous Peoples, we developed an Indigenous mentorship model that details behavioral themes that are distinct or unique from non-Indigenous mentorship.Approach: We used Flanagan's Critical Incidents Technique to derive mentorship behaviors from the literature, and focus groups with Indigenous faculty in the health sciences associated with the AIM-HI network funded by the Canadian Institutes of Health Research. Identified behaviors were analyzed using Lincoln and Guba's Cutting-and-Sorting technique.Findings: Confirming and extending research on mainstream mentorship, we identified behavioral themes for 1) basic mentoring interactions, 2) psychosocial support, 3) professional support, 4) academic support, and 5) job-specific support. Unique behavioral themes for Indigenous mentors included 1) utilizing a mentee-centered approach, 2) advocating on behalf of their mentees and encouraging them to advocate for themselves, 3) imbuing criticality, 4) teaching relationalism, 5) following traditional cultural protocols, and 6) fostering Indigenous identity.Insights: Mentorship involves interactive behaviors that support the academic, occupational, and psychosocial needs of the mentee. Indigenous mentees experience these needs differently than non-Indigenous mentees, as evidenced by mentor behaviors that are unique to Indigenous mentor and mentee dyads. Despite serving similar functions, mentorship varies across cultures in its approach, assumptions, and content. Mentorship programs designed for Indigenous participants should consider how standard models might fail to support their needs.

The Indigenous primary health care and policy research network: Guiding innovation within primary health care with Indigenous peoples in Alberta.

In 2015, the Truth and Reconciliation Commission of Canada released its Final Report with 94 Calls to Action, several of which called upon the health care sector to reform based on the principles of reconciliation. In the province of Alberta, Canada, numerous initiatives have arisen to address the health legacy Calls to Action, yet there is no formal mechanism to connect them all. As such, these initiatives have resulted in limited improvements overall. Recognizing the need for clear leadership, responsibility, and dedicated funding, stakeholders from across Alberta were convened in the Spring of 2019 for two full-day roundtable meetings to provide direction for a proposed Canadian Institutes of Health Research Network Environment for Indigenous Health Research that focused on primary health care and policy research. The findings from these roundtable meetings were synthesized and integrated into the foundational principles of the Indigenous Primary Health Care and Policy Research (IPHCPR) Network. The IPHCPR Network has envisioned a renewed and transformed primary health care system to achieve Indigenous health equity, aligned with principles and health legacy Calls to Action advocated by the Truth and Reconciliation Commission of Canada.