Applying critical leadership to advance 2SLGBTQIA+ health equity: A complex adaptive systems approach.

Health inequities are increasing in Canada and across the globe. They pose a substantial threat to the health and well-being of millions of people. Organizational leadership, if it is to effectively contribute to tackling these inequities, must become more systematically infused with competencies that address power and the structural determinants of health. Health equity contexts for 2SLGBTQIA+ (Two Spirit, Lesbian, Gay, Bisexual, Trans, Queer, Intersex, Asexual, and Plus) remain a neglected area of focus in organizational leadership. The goals of this article are to provide: (1) a concise description of critical perspectives and critical leadership studies, (2) describe the urgency of theoretical and applied leadership approaches that more fulsomely integrate critical perspectives, and (3) illustrate an integration of a Complex Adaptive Systems (CAS) approach to support critical perspectives in advancing health equity for 2SLGBTQIA+ people.

Historical and Continued Colonial Impacts on Heart Health of Indigenous Peoples in Canada: What's Reconciliation Got to Do With It?

Colonization and enforced genocidal strategies have collectively fractured and changed Indigenous people by attempting to erase and dismiss their voices and knowledge. Nearly a decade ago, we were reminded by Dr Ku Young of the cardiovascular health disparities, in evidence among Indigenous people in Canada. compared with White people. He went on to say that beyond a biomedical understanding of this health status is the ongoing impact of long-standing marginalization and oppression faced by Indigenous people. Limited attention has been afforded to advance our understanding of these colonial impacts on Indigenous people and their heart health. This article contributes to our collective understanding of Indigenous people and their cardiac health by covering the following topics: layers of foundational truths of relevance to healthcare contexts and Indigenous people; a critical reflection of Western (biomedical) perspectives concerning cardiac health among Indigenous people; and materials from 2 studies, funded by the Canadian Institutes of Health Research, in which Indigenous voices and experiences were privileged concerning the heart and caring for the heart. In the final section, 3 topics are offered as starting points for self-reflection and acts of reconciliation within healthcare practice, decision-making, and research: reflections on self and one's worldview; anti-racist healthcare practice; and 2-eyed seeing approaches to work within healthcare contexts. A common thread is the imperative for "un-silencing" Indigenous people's voices, experiences, and knowledge, which is a requirement if addressing the identified cardiovascular health disparities is truly a health priority.

La colonisation et les stratégies génocidaires mises en œuvre ont concouru à diviser et à transformer les peuples autochtones dans une tentative d'effacement et de rejet de leurs voix et de leurs connaissances. Il y a près d'une décennie, le Dr Ku Young nous a rappelé les disparités en matière de santé cardiovasculaire, mises en évidence chez les peuples autochtones du Canada comparativement aux blanches. Il a ensuite déclaré que, outre la dimension biomédicale de cette situation sanitaire, l'effet de la marginalisation et de l'oppression de longue date des peuples autochtones est en cause et qu'il continue de se faire sentir. Peu d'attention a été accordée à l'avancement de notre compréhension des effets de la colonisation sur les peuples autochtones et leur santé cardiaque. Le présent article contribue à notre compréhension collective des peuples autochtones et de leur santé cardiaque en abordant : les strates de vérités fondamentales importantes dans le contexte des soins de santé et pour les peuples autochtones; les points de vue occidentaux (biomédicaux) sur la santé cardiaque des peuples autochtones, sous l'angle d'une réflexion critique; les données de deux études, financées par les Instituts de recherche en santé du Canada, où les voix et le vécu des autochtones ont été privilégiés en matière de santé cardiaque et au regard de ce qu'elle implique. Dans la dernière partie de notre article, les trois thèmes suivants sont présentés comme autant de points de départ d'une autoréflexion et de gestes de réconciliation en matière de prestation de soins de santé, de prise de décision et de recherche : réflexion sur soi-même et sa vision du monde; prestation de soins de santé antiraciste; approche à double perspective des soins de santé. Il est impératif de briser le silence et de « laisser s'exprimer ¼ les voix, le vécu et les connaissances des peuples autochtones. Ce constat est un des fils conducteurs de notre analyse. Il faut agir en conséquence si tant est que l'élimination des disparités observées en matière de santé cardiovasculaire constitue vraiment une priorité sanitaire.

Differences in coronary artery disease complexity and associations with mortality and hospital admissions among First Nations and non-First Nations patients undergoing angiography: a comparative retrospective matched cohort study.

BACKGROUND: First Nations people are more likely than the general population to experience long-term adverse health outcomes after coronary angiography. Our aim was to quantify the extent of coronary artery disease among First Nations and non-First Nations patients undergoing angiography to investigate differences in coronary artery disease and related health disparities. METHODS: We conducted a retrospective matched cohort study to compare health outcomes of First Nations and non-First Nations adult patients (> 18 yr) who underwent index angiography between Apr. 1, 2008, and Mar. 31, 2012, in Manitoba, Canada. The SYNTAX Score was used to measure and compare severity of coronary artery disease between groups. Primary outcomes of all-cause and cardiovascular mortality were compared between groups using Cox proportional hazard models adjusted by SYNTAX Score results and weighted by the inverse probability of being First Nations. Secondary outcomes included all-cause and cardiovascular-related hospital admissions. RESULTS: The cohort consisted of 277 matched pairs of First Nations and non-First Nations patients undergoing angiography; the average age of patients was 56.0 (standard deviation 11.7) years. The median SYNTAX Score results and patient distributions across categories in the matched paired cohort groups were not significantly different. Although proportionally First Nations patients showed worse health outcomes, mortality risks were similar in the weighted sample, even after controlling for revascularization and SYNTAX Score results. Secondary outcomes showed that adjusted risks for hospital admission for acute myocardial infarction (adjusted hazard ratio [HR] 3.03, 95% confidence interval [CI] 1.40-6.55) and for congestive heart failure (adjusted HR 3.84, 95% CI 1.37-10.78) were significantly higher among First Nations patients in the weighted sample. INTERPRETATION: The extent of coronary artery disease among matched cohort groups of First Nations and non-First Nations patients appears similar, and controlling for baseline sociodemographic characteristics, coronary artery disease risk factors and SYNTAX Score results explained higher mortality risk and most hospital admissions among First Nations patients. Although there is a need to decrease risk factors for coronary artery disease among First Nations populations, addressing individuals' behaviour without considering root causes underlying risk factors for coronary artery disease will fail to decrease health outcome disparities among First Nations patients undergoing angiography.

Cardiovascular Medication Use and Long-Term Outcomes of First Nations and Non-First Nations Patients Following Diagnostic Angiography: A Retrospective Cohort Study.

Background In Canada, First Nations (FN) people are at greater risk of mortality than the general population following index angiography. This disparity has not been investigated while considering guideline-recommended cardiovascular medication use. Methods and Results Retrospective analysis of administrative health data investigated patterns of medication dispensation during the first year after index angiography among patients in Manitoba, Canada. Medication possession ratios (MPRs) reflecting the percentage of days in which medications were supplied were calculated separately for ß-blockers, angiotensin-converting enzyme inhibitors, statins, and antiplatelets (clopidogrel). Patients were assigned to 1 of 4 categories: (1) not dispensed (0% MPR), (2) low (1-39% MPR), (3) intermediate (40-79% MPR), (4) high (≥80% MPR). Cox regression models that adjusted for MPR categories were used to explore the association between FN patients and both 5-year all-cause mortality and cardiovascular mortality. FN patients were less likely to have an intermediate MPR (odds ratio: 0.75; 95% CI, 0.57-0.99) or a high MPR (odds ratio: 0.64; 95% CI, 0.50-0.81) for statin medications than non-FN patients. FN patients also had higher adjusted risks of all-cause and cardiovascular mortality than non-FN patients (hazard ratio, all-cause: 1.54 [95% CI, 1.25-1.89]; cardiovascular: 1.62 [95% CI, 1.16-2.25]). Conclusions FN status was independently associated with intermediate and high MPRs for statins during the first year following index angiography among patients with known ischemic heart disease. Differences in MPR categories did not explain the disparity in all-cause and cardiovascular mortality between the 2 populations. Reduction of cardiovascular disparities may be best addressed using primary prevention strategies that include decolonizing policies and practices.

Truth and reconciliation: Healthcare organizational leadership.

Health leaders in organizational governance have a key role in enacting the Truth and Reconciliation Commission's Calls to Action. This discussion highlights historical and contemporary truths that can underpin action for addressing colonial impacts on Indigenous (First Nations, Metis, and Inuit) health outcomes and healthcare. Emphasis is on white settler roles and responsibilities, where health-related Calls provide a blueprint for health reconciliation leadership. There is broad agreement of the necessity to acknowledge and address key cornerstones of decolonization at individual, intermediary, and organizational stages: racism, white settler power and privilege, and cultural safety. Already existing leadership roles, responsibilities, and inter-organizational networks can form a solid foundation for health leaders to bring the Calls to the table-alongside First Nations, Metis, and Inuit peoples, in meetings, forums, and conferences and in lobbying efforts to influence the structural, systemic shape, and direction of healthcare in Canada.

Health Outcome and Follow-up Care Differences Between First Nation and Non-First Nation Coronary Angiogram Patients: A Retrospective Cohort Study.

BACKGROUND: First Nations (FN) people experience high rates of ischemic heart disease (IHD) morbidity and mortality. Increasing access to angiography may lead to improved outcomes. We compared various outcomes and follow-up care post-index angiography between FN and non-FN patients. METHODS: All index angiography patients in Manitoba were identified between April 1, 2000 and March 31, 2009 and categorized into acute myocardial infarction (AMI) or non-AMI groups based on whether their angiogram occurred within 7 days of an AMI. Cox proportional hazard models estimated associations between FN status and outcomes related to mortality, subsequent hospitalizations, revascularizations, and physician visits. RESULTS: Cardiovascular mortality was higher among FN patients in the non-AMI group (hazard ratio [HR] = 1.50, 95% confidence interval [CI], 1.17-1.94) and in the AMI group (HR = 1.57, 95% CI, 1.05-2.35). FN patients were also more likely to have a subsequent hospitalization for AMI (HR = 2.26, 95% CI, 1.79-2.85) in the non-AMI group. FN patients in the non-AMI group were less likely to receive percutaneous coronary intervention (HR = 0.85, 95% CI, 0.73-0.99) and more likely to undergo coronary artery bypass graft (HR = 1.26, 95% CI, 1.10-1.45). FN patients in both groups were less likely to visit a cardiologist/cardiac surgeon, internal medicine specialist, or family physician within 3 months and 1 year of angiography. CONCLUSIONS: Cardiovascular health and follow-up care outcomes of FN and non-FN patients who undergo angiography are not the same. Addressing Indigenous determinants of health are necessary to improve cardiovascular outcomes.

Index coronary angiography use in Manitoba, Canada: a population-level descriptive analysis of First Nations and non-First Nations recipients.

OBJECTIVES: To investigate recipient characteristics and rates of index angiography among First Nations (FN) and non-FN populations in Manitoba, Canada. SETTING: Population-based, secondary analysis of provincial administrative health data. PARTICIPANTS: All adults 18 years or older who received an index angiogram between 2000/2001 and 2008/2009. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Descriptive statistics for age, sex, income quintile by rural and urban residency and Charlson Comorbidity Index for FN and non-FN recipients. (2) Annual index angiogram rates for FN and non-FN populations and among those rates of 'urgent' angiograms based on acute myocardial infarction (AMI)-related hospitalisations during the previous 7 days. (3) Proportions of people who did not receive an angiogram in the 20 years preceding an ischaemic heart disease (IHD) diagnosis or a cardiovascular death; stratified by age (<65 or ≥65 years old). RESULTS: FN recipients were younger (56.3vs63.8 years; p<0.0001) and had higher Charlson Comorbidity scores (1.32vs0.78; p<0.001). During all years examined, index angiography rates were lower among FN people (2.67vs3.33 per 1000 population per year; p<0.001) with no notable temporal trends. Among the index angiogram recipients, a higher proportion was associated with an AMI-related hospitalisation in the FN group (28.8%vs25.0%; p<0.01) and in both groups rates significantly increased over time. FN people who died from cardiovascular disease or were older (65+years old) diagnosed with IHD were more likely to have received an angiogram in the preceding 20-30 years (17.8%vs12.5%; p<0.01 and 50.9%vs49.5%; p<0.03, respectively). FN people diagnosed with IHD who were under the age of 65 were less likely to have received an angiogram (47.8%vs53.1%; p<0.01) CONCLUSIONS: Index angiogram use differences are suggested between FN and non-FN populations, which may contribute to reported IHD disparities. Investigating factors driving these rates will determine any association between ethnicity and angiography services.

Toward decolonizing nursing: the colonization of nursing and strategies for increasing the counter-narrative.

Although there are notable exceptions, examination of nursing's participation in colonizing processes and practices has not taken hold in nursing's consciousness or political agenda. Critical analyses, based on the examination of politics and power of the structural determinants of health, continue to be marginalized in the profession. The goals of this discussion article are to underscore the urgent need to further articulate postcolonial theory in nursing and to contribute to nursing knowledge about paths to work toward decolonizing the profession. The authors begin with a description of unifying themes in postcolonial theory, with an emphasis on colonized subjectivities and imperialism; the application of a critical social science perspective, including postcolonial feminist theory; and the project of working toward decolonization. Processes involved in the colonization of nursing are described in detail, including colonization of nursing's intellectual development and the white privilege and racism that sustain colonizing thinking and action in nursing. The authors conclude with strategies to increase the counter-narrative to continued colonization, with a focus on critical social justice, human rights and the structural determinants of health.

A Conceptual Framework of Organizational Capacity for Public Health Equity Action (OC-PHEA).

The Canadian public health sector's foundational values of social justice and equity, and its mandate to promote population health, make it ideally situated to take a strong lead in addressing persistent and unacceptable inequities in health between socially disadvantaged, marginalized or excluded groups and the general population. There is currently much attention paid to improving understanding of pathways to health equity and development of effective population health interventions to reduce health inequities. Strengthening the capacity of the public health sector to develop, implement and sustain equity-focused population health initiatives - including readiness to engage in a social justice-based equity framework for public health - is an equally essential area that has received less attention. Unfortunately, there is evidence that current capacity of the Canadian public health sector to address inequities is highly variable. The first step in developing a sustained approach to improving capacity for health equity action is the identification of what this type of capacity entails. This paper outlines a Conceptual Framework of Organizational Capacity for Public Health Equity Action (OC-PHEA), grounded in the experience of Canadian public health equity champions, that can guide research, dialogue, reflection and action on public health capacity development to achieve health equity goals.

Racism and cardiovascular disease: implications for nursing.

The social determinants of health (SDH) are recognized as a prominent influence on health outcomes across the lifespan. Racism is identified as a key SDH. In this article, the authors describe the concept of racism as an SDH, its impact in discriminatory actions and inactions, and the implications for cardiovascular nurses. Although research in Canada on the links among racism, stress, and cardiovascular disease is limited, there is growing evidence about the stress of racism and its long-term impact on cardiovascular health. The authors discuss how cardiovascular nursing could be enhanced through an understanding of racism-related stress, and race-based differences in cardiovascular care. The authors conclude with strategies for action to address this nursing concern.

Addressing the determinants of child mental health: intersectionality as a guide to primary health care renewal.

Primary health care (PHC) renewal was designed explicitly to attend to the multidimensional factors impacting on health, including the social determinants of health. These determinants are central considerations in the development of integrated, cross-sectoral, and multi-jurisdictional policies such as those that inform models of shared mental health care for children. However, there are complex theoretical challenges in translating these multidimensional issues into policy. One of these is the rarely discussed interrelationships among the social determinants of health and identities such as race, gender, age, sexuality, and social class within the added confluence of geographic contexts. An intersectionality lens is used to examine the complex interrelationships among the factors affecting child mental health and the associated policy challenges surrounding PHC renewal. The authors argue that an understanding of the intersections of social determinants of health, identity, and geography is pivotal in guiding policy-makers as they address child mental health inequities using a PHC renewal agenda.

An institutional ethnography of nurses' stress.

There are three main conceptualizations of nurses' stress: occupational stress, moral distress, and traumatization (compassion fatigue, secondary traumatic stress, vicarious trauma). Although we have learned a great deal from these fields, some of them lack important contextual aspects of nurses' practice, such as the gendered nature of the workforce and the nature of the work, including bodily caring. The purpose of this study was to reformulate the nature of stress in nursing, with attention to important contextual aspects of nurses' practice. Smith's sociological frame of institutional ethnography was used to explicate the social organization of nurses' stress. Data collection methods included in-depth interviews, participant observation, and focus groups with pediatric intensive care nurses. Data analysis focused on the social organization of nurses' stress, including negotiating power-based hierarchies and articulating the patient to the system. The article concludes with recommendations for addressing nurses' stress through a more critical and contextual analysis.

Health-care access as a social determinant of health.

The social determinants of health (SDH) are recognized as important indicators of health and well-being. Health-care services (primary, secondary, tertiary care) have not until recently been considered an SDH. Inequities in access to health care are changing this view. These inequities include barriers faced by certain population groups at point of care, such as the lack of cultural competence of health-care providers. The authors show how a social justice perspective can help nurses understand how to link inequities in access to poorer health outcomes, and they call on nurses to break the cycle of oppression that contributes to these inequities.

Interpretive pedagogy in action: design and delivery of a violence and health workshop for baccalaureate nursing students.

This article presents the planning and implementation of a Violence and Health Immersion Workshop for undergraduate nursing students. Given the enormous personal and economic costs of violence, the central importance of addressing violence issues in nursing curricula is emphasized. The application of three key interpretive pedagogical strategies is described: choosing critical social science as a conceptual framework for the workshop; placing specific emphasis on the decentering of content; and creating space for learners to explore this difficult issue. Formative and summative evaluations of the workshop indicated that the majority of students found the workshop to be helpful in providing the opportunity to examine and shift their own values, attitudes, and beliefs regarding violence and health. Recommendations for future research include the need for increased knowledge regarding barriers to the implementation of interpretive pedagogies, and for greater insight regarding the process of attending to differences in the participants and the facilitators.