The Saskatchewan Health Authority [SHA] is built on the values of collaboration, respect, compassion, safety and accountability (SHA, 2019). These ideals haven’t been actualized when it comes to the SHA’s relationship with and treatment of First Nations and Métis people. The relationship between health services and First Nations and Métis peoples began at the time of Treaty negotiations. The spirit and intent of these negotiations were to be held in an ethical relationship between all the sovereign nations involved. This unity has historically been fundamentally broken between Health Services and First Nations and Métis peoples, who have endured trauma and injustices that continue to have impacts on their health and lives today. However, with the creation of a new provincial health authority in Saskatchewan, there is potential for unity to be built between Saskatchewan Health Authority and First Nations and Métis peoples. SHA’s ability to live out these values requires identifying, acknowledging and addressing the inequities embedded in the culture and delivery of health services. This framework seeks to present a pathway and vision for achieving unity through unlearning historical misconceptions, acknowledging and healing past injustices, rebuilding trust and forging authentic relationships.
“We add colour, dimension and life to each other, to all of life. No matter what colour, race or creed we are, we need each of us to create a beautiful existence and expression of the Whole.” (Beaucage, 2018).
Unity Model Theory of Change – Moving from linear models to the interconnectedness of the circle.
The Unity Model is fashioned around Life Circle Teachings (Papequash, Musqua), and reflects a non-linear understanding of the world that appreciates and respects the interrelatedness and interconnectedness of all things. It guides us to walk in balance with the natural world around us. It is in the natural world that we learn of disciplines necessary to maintain order required to ensure the unity of all living beings. The primary purpose is to promote balance and harmony within the circle of life. Change happens not as a result of a singular action or by a direct route but in a cyclic, holistic or circular manner – by interacting with rather than reacting to our environments. The growth and healing process is evolutionary deepening with every journey around the circle.
The inner circle holds the symbol of Kichi Mikwahp, meaning Great Lodge (Lee). The Lodge is representative of a woman as the Lifegiver. The poles extending upward symbolizes the woman’s hair and the many different pathways of understanding and being, each are individual and separate yet still being supported by the other poles with the rope (core values) that binds them all in unity. The flaps are a symbol of the woman with her arms outstretched in gratitude for the unity in life. Inside the Lodge is the sacred fire where the light comes from and is a symbol of the woman’s heart (Impey).
The Métis symbol provides insight into the creation of the Métis culture – one circle representing the European relations and one representing the First Nations relations co-mingling in unity to manifest as “Lii Michif” - the Métis (Letendre). This symbol teaches of the unity between different cultures and represents the ethical relationship between all peoples working in the Saskatchewan Health Authority to provide ethical and equitable health care services to Saskatchewan. To begin to reconcile the past and recreate ethical relationships in SHA we begin in the East and the second circle.
Symbolism and Movement within the Wheel
The wheel is divided into four quadrants symbolically identifying the power/medicine of the four directions (east, south, west, north) using four different colours - yellow, red, blue and white (First Nations and Métis Health, 2018). Yellow represents the east, physical, sunrise, birth, or spring. It is the spark that lights the fire. Red represents south, emotions, day, youth, or summer. It is the passion of a roaring fire. Blue represents the west, mental, dusk, adulthood, or autumn. It is the reflective heat of long burning embers. White represents the north, spirit, night, end of physical life and winter (Scott). It is purity – the result of a cleansing process of having journeyed through fire.
Movement in the wheel reflects a natural process. The wheel rotates clockwise around the centre circle beginning in the east and travelling to the south, west and north. The movement reflects the symbolic path of the seasons in the year, stages of life or path of the sun throughout a day. Each direction brings its unique gifts and wisdom and must be journeyed through in order to proceed to the next stage. Each pass through the circle deepens the knowledge and learning from the previous cycle. Energy in the wheel also begins in the centre and radiates out to the outer rings and then moves back again from the outer ring to the inner circle like a tide coming in and receding.
Reading the Framework
The Centre Circle
The Framework begins in the centre circle with Unity. This is the goal or vision of the Strategy. Unity is the fire at the centre of the circle that must be nurtured (given air and fuel) in order to burn and provides heat or gifts that radiate from the centre of the framework outward. Unity is a vision that calls for healthy relationships and true interconnectedness between all people, where everyone is working for the betterment of the whole.
The Second Circle
The second ring of the model represents milestones on the journey of the individual and the system from self-awareness to cultural safety. This circle is divided into quadrants that are stationary meaning you begin in the east quadrant (self-awareness) and journey through the south (sensitivity), west (cultural self-awareness) and north (cultural safety) building on the learning from each direction.
Self-awareness begins with learning our history beginning with the spirit and intent of Treaty negotiations and examining one’s own values, beliefs and biases developed from that history. Through this process we can identify how the spirit and intent of Treaties has been violated (historical traumas and inequities) resulting in racism in health services.
In this quadrant we begin to acknowledge the impact past behaviours have had on our health system. We feel the pain suffered by those affected by the historical traumas and inequities. We also acknowledge that the health system has been developed into a culture based on privilege and societal standing thereby fracturing unity.
With cultural self-awareness we begin to understand why the culture we work in does not allow for equity. When we connect our emotion with this understanding it has the potential to motivate us to reconcile the past and work towards redeveloping our workplace culture. It provides opportunities for all SHA staff to understand how their cultural values, beliefs and biases interact with other cultures in the workplace.
Knowing the truth about our history, acknowledging the pain of past traumas and inequities, combined with sensitivity and understanding, allows the opportunity to move from discrimination to cultural responsiveness to cultural integration. When all staff can make a commitment to work towards unity in the workplace then we will have cultural safety in SHA.
The Third Circle
The third circle of the framework contains the four areas in which action is needed in order to achieve Unity. These recommended actions come out of a 2010 Environmental Scan completed by the National Collaborating Centre for the Determinants of Health [NCCDH] (NCCDH, 2013). This circle is intended to rotate around the model’s core. While we will start in the east, with the building of broader and deeper partnerships we understand that we will move through these areas at varying times and ways, in each of our four directions. As with the other components of the wheel each area is not meant to be understood in isolation from the others but to be considered as important aspects for strengthening and reinforcing change. Partnerships, for instance, will be necessary in developing policies and interventions as will knowledge be important to shaping partnerships. The color of this circle is green symbolizing growth needed in the four action areas. Each area must be addressed if a holistic and sustainable vision of Unity is to be achieved.
Partnerships and relationships with genuine listening and commitment to act on issues that are identified are essential to the achievement of Unity. Achieving Unity requires changing the way we deliver health services to be more responsive to the needs of First Nations and Métis people and also to recognize that addressing health includes working collaboratively to address needs outside the health care system. Meaningful partnerships will help illuminate the pathways to change and to build the holistic support required to make change sustainable. Within these partnerships the leadership of First Nations and Métis people and the strengthening of the voice of their lived experience is vital if we are to achieve change that accurately reflects the desires and perspectives of First Nations and Métis people.
Racism has become embedded in societal norms and policies within institutions and ingrained in the way we deliver health services and treat First Nations and Métis people. Reviewing and analyzing regulations, policies and practices within Health Services is essential to illuminating the inequities that exist. This would include policies affecting the treatment of employees and patients such as anti-discrimination and personal respect policies. It would also include policies that affect the way we deliver services which have typically catered to the cultural norms of non-indigenous people and the needs of middle and upper income people; an income bracket in which indigenous people are underrepresented. Addressing policy inequities for indigenous people also means that health needs to support and participate in policy change and advocacy with other partners for improvements in health determinants outside health care services. The inequitable burden of illness faced by First Nations and Métis people can only be properly redressed through changing factors such as discriminatory employment practices, inequitable access to education and housing. Unity includes incorporating the needs and perspectives of all people within policies and addressing the discriminatory practices and policies that perpetuate current inequities.
This action area represents tracking and reporting on our progress as well as supporting change through knowledge exchange and transfer to assist us in developing interventions to support the vision of Unity. In order for change to be possible we need to understand and monitor where racism and inequitable treatment of First Nations and Métis people is occurring. Often high level epidemiological indicators aren’t sensitive enough to be able to track the complex and subtle ways that racial inequities are manifesting themselves. Intentional development of tracking mechanisms, appropriate and contextualized indicators as well as conscious capturing of learnings along the way are needed to accurately monitor and course correct. Equally important in achieving readiness for change is the sharing of best practices and learning within SHA and from others who are leaders in effectively addressing racism and racial inequities.
Interventions is an action area that represents modifying and orienting health interventions and services to reduce inequities experienced by First Nations and Métis People. In order to achieve more culturally responsive and culturally safe health services supportive leadership structures, staff capacity for addressing inequities, adequate resourcing of services and accountability measures need to be in place. Organizational readiness for change will require building capacity within leadership to embed racial equity into strategic planning, quality improvement initiatives and decision-making and building capacity in staff to understand and deliver accessible and culturally safe services. Recruiting and retaining First Nations and Métis staff at all levels of the organization will help support and reinforce culturally safe care and embed the vision of Unity in SHA.
The Outer Circle
SHA values have been strategically located on the outer circle of the wheel. The vision of Unity at the Centre of the framework will ripple outwards to the outer circle and enhance and strengthen these values and these values will flow inwards to fortify and support the work and Vision of Unity. These values, also on a wheel, do not work in isolation but collectively to reinforce and strengthen each other and the other rings of the wheel in all the four directions. The color of this circle is light purple symbolizing the healing needed to achieve Unity.
These values include:
- Respect: Be kind. Honour diversity with dignity and empathy. Value each person as an individual.
- Compassion: Be caring. Practice empathy. Listen actively to understand each other’s experiences.
- Collaboration: Be better together. Include and acknowledge the contributions of employees, physicians, patient, families and partners.
- Accountability: Be responsible. Own each action and decision. Be transparent and have the courage to speak up.
- Safety: Be aware. Commit to physical, psychological, social, cultural and environmental safety. Every day. For everyone (SHA, 2019).
The Vision of Unity can strengthen and make these values more robust as these values will also help us to actualize the Vision of Unity. Cultural safety is an essential and often unrecognized aspect of achieving safety. The experience and treatment of First Nations and Métis people is central to accountability and often not consciously built into accountability mechanisms. Respecting First Nations and Métis people requires acknowledging and addressing the gaps in their treatment and access to services and recognizing the central role they play in leading the change that needs to happen. Collaboration will be supported by strengthening the inclusion of First Nations and Métis voices typically lacking in decision making and the building of strategic direction. Compassion calls us to empathize with the suffering First Nations and Métis people have experienced as a result of historical and current inequities in health services and to act to change these injustices.
First Nations and Metis Health (2018). Knowledge keeper’s forum. Wanuskewin, Saskatchewan.
Impey, Isabelle, Nehiyaw Kisetew, Cumberland House, Saskatchewan.
Lee, Mary, Nehiyaw Kisetew, Pelican Lake First Nation, Saskatchewan.
Letendre, A. dit’ Batoche oral history. Saskatoon, Saskatchewan.
Papequash, Campbell, Anishinabe Kistew, Key First Nation, Saskatchewan
Musqua, Danny, Anishinabe Kistew, Keeseekoose First Nation, Saskatchewan
National Collaborating Centre for National Collaborating Centre for Determinants of Health (2013). Let’s Talk: Public Health Roles for Improving Health Equity. Retrieved from: http://nccdh.ca/resources/entry/lets-talk-public-health-roles
Scott, Albert, Nakawe Kiteyak. Kinistin First Nation, Saskatchewan.
SHA (2019). Business Plan:2019-20.