Two-Eyed Seeing as a strategic dichotomy for decolonial nursing knowledge development and practice.

The profession of nursing has recognized the need for contextual and relational frameworks to inform knowledge development. Two-Eyed Seeing is a framework developed by Mi'kmaw Elders to respectfully engage with Indigenous and non-Indigenous knowledges. Some scholars and practitioners, however, are concerned that Two-Eyed Seeing re-instantiates dichotomized notions regarding Western and Indigenous knowledges. As dichotomies and binaries are often viewed as polarizing devices for nursing knowledge development, this paper explores the local worldviews in which Two-Eyed Seeing emerged, proposing that the onto-epistemological and axiological 'roots' of the framework are antithetical to divisiveness, paradoxically asserting space for the dichotomy to stand. Two-Eyed Seeing, if understood as a relational, decolonial praxis, could fundamentally change the way nursing scholarship and practice operate by facilitating space for diverse knowledges, ways of being, doing and relating. In this paper, considerations for nursing scholarship and practice, as well as recommendations to support the uptake of Two-Eyed Seeing are explored. The authors assert that conceptual divisiveness, dichotomization and exclusion can be mitigated if nursing is informed by contextual knowledge, seeks to enact accountable partnerships with Indigenous knowledge holders, and holds the Mi'kmaq worldview upon which the concept developed in positive regard.

The social paediatrics initiative: a RICHER model of primary health care for at risk children and their families.

BACKGROUND: The Responsive Interdisciplinary Child-Community Health Education and Research (RICHER) initiative is an intersectoral and interdisciplinary community outreach primary health care (PHC) model. It is being undertaken in partnership with community based organizations in order to address identified gaps in the continuum of health services delivery for 'at risk' children and their families. As part of a larger study, this paper reports on whether the RICHER initiative is associated with increased: 1) access to health care for children and families with multiple forms of disadvantage and 2) patient-reported empowerment. This study provides the first examination of a model of delivering PHC, using a Social Paediatrics approach. METHODS: This was a mixed-methods study, using quantitative and qualitative approaches; it was undertaken in partnership with the community, both organizations and individual providers. Descriptive statistics, including logistic regression of patient survey data (n=86) and thematic analyses of patient interview data (n=7) were analyzed to examine the association between patient experiences with the RICHER initiative and parent-reported empowerment. RESULTS: Respondents found communication with the provider clear, that the provider explained any test results in a way they could understand, and that the provider was compassionate and respectful. Analysis of the survey and in-depth interview data provide evidence that interpersonal communication, particularly the provider's interpersonal style (e.g., being treated as an equal), was very important. Even after controlling for parents' education and ethnicity, the provider's interpersonal style remained positively associated with parent-reported empowerment (p<0.01). CONCLUSIONS: This model of PHC delivery is unique in its purposeful and required partnerships between health care providers and community members. This study provides beginning evidence that RICHER can better meet the health and health care needs of people, especially those who are vulnerable due to multiple intersecting social determinants of health. Positive interpersonal communication from providers can play a key role in facilitating situations where individuals have an opportunity to experience success in managing their and their family's health.

Engaging with communities to foster health: the experience of inner-city children and families with learning circles.

The authors briefly introduce a clinical outreach initiative that is innovative because of the types of partnerships that have been formed within an inner-city community context. The initiative was designed to foster access to primary health care and specialized services for children and families who are vulnerable because of their social and material circumstances.Through ongoing engagement and dialogue, the clinicians and the community have developed a number of points of engagement with the children and families.The authors use the case of Learning Circles to describe ways in which Indigenous knowledge and ways of being influenced the approaches taken to working with children and families. They reflect upon the ways in which this approach influenced community engagement and consider its potential for achieving health equity.

The RICHER social pediatrics model: fostering access and reducing inequities in children's health.

Considerable evidence shows that children and families who are vulnerable because of their social and material circumstances shoulder a disproportionate burden of disease and are more likely to face both social and structural challenges in accessing healthcare. Addressing these issues in children is particularly important as evidence has demonstrated that inequities in health are cumulative over the life course. In this article, the authors report on the RICHER (Responsive, Intersectoral-Interdisciplinary, Child-Community, Health, Education and Research) social pediatrics initiative, which was designed to foster timely access to healthcare across the spectrum from primary care to specialized services for a community of inner-city children who have disproportionately high rates of developmental vulnerability. Their research shows that the initiative has effectively "reformed" health services delivery to provide care in ways that are accessible and responsive to the needs of the population. RICHER is an intersectoral, interdisciplinary outreach initiative that delivers care through the formation of innovative partnerships. The authors share research results that demonstrate that the RICHER model of engagement with children and families not only effectively fosters access for families with multiple forms of disadvantage, but also improves outcomes by empowering parents of particularly vulnerable children to become more active participants in care.

Uptake of critical knowledge in nursing practice: lessons learned from a knowledge translation study.

This article is based on a knowledge translation (KT) study of the transition of patients from hospital to home. It focuses on the lessons learned about the challenges of translating research-derived critical knowledge in practice settings. The authors situate the article in current discourses about KT; discuss their understanding of the nature of critical knowledge; and present themes from their body of research, which comprises the knowledge that was translated. The findings have the potential to guide future KT research that focuses on the uptake of critical knowledge in nursing practice.

Inequities in health and healthcare viewed through the ethical lens of critical social justice: contextual knowledge for the global priorities ahead.

The authors use the backdrop of the Healthy People 2010 initiative to contribute to a discussion encompassing social justice from local to national to global contexts. Drawing on findings from their programs of research, they explore the concept of critical social justice as a powerful ethical lens through which to view inequities in health and in healthcare access. They examine the kind of knowledge needed to move toward the ideal of social justice and point to strategies for engaging in dialogue about knowledge and actions to promote more equitable health and healthcare from local to global levels.

Critical inquiry and knowledge translation: exploring compatibilities and tensions.

Knowledge translation has been widely taken up as an innovative process to facilitate the uptake of research-derived knowledge into health care services. Drawing on a recent research project, we engage in a philosophic examination of how knowledge translation might serve as vehicle for the transfer of critically oriented knowledge regarding social justice, health inequities, and cultural safety into clinical practice. Through an explication of what might be considered disparate traditions (those of critical inquiry and knowledge translation), we identify compatibilities and discrepancies both within the critical tradition, and between critical inquiry and knowledge translation. The ontological and epistemological origins of the knowledge to be translated carry implications for the synthesis and translation phases of knowledge translation. In our case, the studies we synthesized were informed by various critical perspectives and hence we needed to reconcile differences that exist within the critical tradition. A review of the history of critical inquiry served to articulate the nature of these differences while identifying common purposes around which to strategically coalesce. Other challenges arise when knowledge translation and critical inquiry are brought together. Critique is one of the hallmark methods of critical inquiry and, yet, the engagement required for knowledge translation between researchers and health care administrators, practitioners, and other stakeholders makes an antagonistic stance of critique problematic. While knowledge translation offers expanded views of evidence and the complex processes of knowledge exchange, we have been alerted to the continual pull toward epistemologies and methods reminiscent of the positivist paradigm by their instrumental views of knowledge and assumptions of objectivity and political neutrality. These types of tensions have been productive for us as a research team in prompting a critical reconceptualization of knowledge translation.

Cultural safety and the challenges of translating critically oriented knowledge in practice.

Cultural safety is a relatively new concept that has emerged in the New Zealand nursing context and is being taken up in various ways in Canadian health care discourses. Our research team has been exploring the relevance of cultural safety in the Canadian context, most recently in relation to a knowledge-translation study conducted with nurses practising in a large tertiary hospital. We were drawn to using cultural safety because we conceptualized it as being compatible with critical theoretical perspectives that foster a focus on power imbalances and inequitable social relationships in health care; the interrelated problems of culturalism and racialization; and a commitment to social justice as central to the social mandate of nursing. Engaging in this knowledge-translation study has provided new perspectives on the complexities, ambiguities and tensions that need to be considered when using the concept of cultural safety to draw attention to racialization, culturalism, and health and health care inequities. The philosophic analysis discussed in this paper represents an epistemological grounding for the concept of cultural safety that links directly to particular moral ends with social justice implications. Although cultural safety is a concept that we have firmly positioned within the paradigm of critical inquiry, ambiguities associated with the notions of 'culture', 'safety', and 'cultural safety' need to be anticipated and addressed if they are to be effectively used to draw attention to critical social justice issues in practice settings. Using cultural safety in practice settings to draw attention to and prompt critical reflection on politicized knowledge, therefore, brings an added layer of complexity. To address these complexities, we propose that what may be required to effectively use cultural safety in the knowledge-translation process is a 'social justice curriculum for practice' that would foster a philosophical stance of critical inquiry at both the individual and institutional levels.

Understanding marginalization as a social determinant of health

Population-based studies have drawn attention to the associations between social and material disadvantage and poor mental and physical health over the life course, thereby contributing to inequalities in health. More recently, research in Britain has demonstrated that the effects of such disadvantage are cumulative through childhood and has shown that ethnic minorities are at particular risk. This study gathered data form persons at risk, specifically first-generation migrant teenaged girls and their mothers, in Britain and Canada, and identified marginalization as a central feature of their relationships with others. Bourdieu's theoretical perspective is drawn on to examine the processes that contribute to marginalization and the conditions of broader society that sustain and reproduce them. It was the participant's experience that their potencial goes unrecognized, their oportunities to develop new relationships curtailed and possibilities to acquire new competences were eclipsed by others' assumptions about them. The authors illustrate the social processes that contribute to the creation of tensions between seeking to belong and being assigned to the margins and consider their attendant influences on health. Taking direction from Bordieu they illustrate ways in which discourses of marginalization practices associated with them can be interrupted, and in so doing work towards redressing processes that create a context for health inequalities (AU)

Re-thinking the complexities of 'culture': what might we learn from Bourdieu?

In this paper we continue an ongoing dialogue that has as its goal the critical appraisal of theoretical perspectives on culture and health, in an effort to move forward scholarship on culture and health. We draw upon a programme of scholarship to explicate theoretical tensions and challenges that are manifest in the discourses on culture and health and to explore the possibilities Bourdieu's theoretical perspective offers for reconciling them. That is, we hope to demonstrate the need to move beyond descriptions 'of' culture to an understanding of cultures as dynamic, and to show ways cultural practices create contexts that have the potential to foster or impede health. In our early research, largely undertaken in Canada's multicultural context, we sought to make visible the ways in which culture shaped conceptions of health and influenced health practices of immigrant groups. In recent years this focus has expanded to include populations that reflect the cultural and social diversity of our region. From the outset we attempted to move towards a conception of culture as negotiated, unifying, transformative and dynamic. While this position continues to hold appeal we are continually reminded that, despite our leanings towards constructivism, there is salience to the notion of culture as having enduring elements. It is this tension between the view of culture as embodied and enduring and culture as constructed and dynamic that we seek to examine. We explore whether Bourdieu's theoretical perspective offers promise for reconciling these apparently competing views. Using exemplars from our research we share insights that Bourdieu's work has offered to our analyses, thereby enabling us to move towards a view of culture that holds in tension these apparently contradictory positions of culture as both essence (albeit unstable, negotiated) and constructed.

Health as a socially mediated process: theoretical and practice imperatives emerging from research on health inequalities.

Population-based studies on health disparities provide compelling evidence that inequities in health status over the life course accrue from social conditions. Our knowledge of how such conditions exert their effect on health, however, is limited. An examination of explanations for health disparities shows that a theoretical perspective that enables the exploration of the links between broader social processes (macro) and experience (micro) would offer valuable insights for practice. This article introduces a theoretical perspective informed by Bourdieu and Smith that has been used to undertake such an analysis and that opens up possibilities for new practice forums and foci.

Parents' perspectives on decision making after antenatal diagnosis of congenital heart disease.

OBJECTIVE: To discover and describe how prospective parents make decisions when they learn of their baby's congenital heart disease (CHD) during pregnancy, and to provide professionals with direction for their interactions with these families. DESIGN AND METHOD: Qualitative analysis informed by symbolic interactionism. SETTING: A tertiary care women's health center that provided referral services for a province with a population of 4 million. PARTICIPANTS: Mothers and fathers of 19 babies with antenatally diagnosed CHD participated in interviews during pregnancy and after the birth of their baby. Thirty-four interviews were analyzed for common themes and distinguishing characteristics of antenatal decision making. RESULTS: Parents approached their antenatal decisions regarding further testing and continuation of the pregnancy as their first parenting decisions. They made their decisions with differing degrees of apparent ease or deliberation, and some parents more readily sought the opinion of professionals. The offered opinions offended some parents, even though the professionals may have intended the information as descriptive of options, not suggestive of a particular decision. CONCLUSION: Although advances in technology have enabled diagnosis of CHD antenatally, health care professionals, including nurses, must elicit each parent's particular perspective, be cognizant of their professional influence, and actively support parents from the time of the antenatal diagnosis.

Healthcare restructuring with a view to equity and efficiency: reflections on unintended consequences.

This paper is developed from a research study that examined the hospitalization and helpseeking experiences of diverse ethnocultural populations in the era of healthcare restraint. Interview data were gathered from 60 patients while hospitalized and after their discharge home. Fifty-six healthcare professionals, the majority of whom were nurses caring for these patients while they were in hospital, were also interviewed. The data gathered in this study provides evidence to illustrate how restructuring associated with fiscal restraint designed to enhance efficiencies while ensuring the provision of medically necessary services, has had unintended consequences for some groups of patients and for nurses. These consequences have created a context for inequities in care delivery for those most vulnerable. In this paper we trace the ways in which the changed context of care delivery has exerted its effects on both nurses and patients and illustrate how each has sought to bridge gaps created when organizational supports are lacking. Our study data offer insight into the complexities of the practice setting and difficulties that arise when resources cannot be mobilized to match patients' needs. Our analysis examines how tensions between ideologies of efficiency and accessibility are navigated at the front lines, and draws attention to unintended consequences of the current policy context.

Rethinking cultural safety while waiting to do fieldwork: methodological implications for nursing research.

The concept of culture has been widely applied as an explanatory concept within health care, often within a framework representing culture as a fixed, reified entity, with cultural groups existing in a binary sense vis-;-vis mainstream culture. However, if our scholarship is to generate knowledge that addresses longstanding patterns of inclusion and exclusion along lines such as race, ethnicity, class, and gender, interpretive frames are needed that account for culture as embedded in fields of power relations; as mediated by social forces such as economics, politics, and historical patterns of oppression and colonization; and as being constantly renegotiated. In this article we trace a series of theoretical explorations, centered on the concept of cultural safety, with corresponding methodological implications, engaged in during preparation for an intensive period of fieldwork to study the hospitalization and help-seeking experiences of diverse ethnocultural populations.