Accessing Oncology Care Among Indigenous Peoples: A Cultural Safety/Trauma-Violence Informed Care Perspective

Background: Once virtually unheard of, cancer is now a leading cause of death among Indigenous peoples in Canada, and cancer disparities continue to widen between Indigenous peoples and other Canadians.¹ For example, Indigenous women are significantly more likely than non-Indigenous women to be diagnosed with late-stage breast cancer, and, although breast cancer mortality has decreased among non-Indigenous women, it has increased among Indigenous women.² Research on cancer disparities in this population has primarily been epidemiological in nature, focusing on the role of ‘culture’, and known cancer risk factors.^3–5 Meanwhile, Canadian nurse scholars have studied the role of equitable access to healthcare in widening health disparities between Indigenous and non-Indigenous populations.^6,7 These scholars have demonstrated that although access to healthcare is mediated by a range of factors (service location, provider availability, policies, social determinants of health), the nature of the patient-provider relationships is an essential component and necessary prerequisite for equitable access to high quality, patient-centered care.^6–8 However, despite this excellent work on patient-provider relationships and their impact on access to healthcare, scholars examining issues of access to oncology care among Indigenous peoples have yet to explore the role of patient-provider relationships as a factor in equitable healthcare access. We do not yet understand the impact of nurse-patient relationships on improving access to oncology care among Indigenous peoples, nor have the perspectives of nurses, who provide the bulk of clinical patient care, been explored. Finally, few studies explore the linkages between individual perspectives (whether they be patient, family, or healthcare provider perspectives) and structural factors that shape healthcare systems, health disparities, and individual cancer experiences. This study will address these research gaps.

Purpose & Specific Aims: To generate knowledge on the role of nurses in shaping access to high quality oncology care for Indigenous peoples. Specific aims include: a) to identify how nurses understand barriers and facilitators to accessing oncology care for Indigenous peoples; b) to explore how nurses understand their role in shaping access to oncology care for Indigenous peoples; and c) to identify nursing strategies to improve access to oncology care for Indigenous peoples.

Theoretical & Conceptual Frameworks: A postcolonial theoretical perspective along with cultural safety and trauma/violence-informed care perspectives will guide this study. The weaving of these three theoretical perspectives to investigate access to healthcare is informed by the work of Browne and colleagues.⁷ In this proposed study, these perspectives are applied to the oncology care context, and focused on the role of individual healthcare providers. Postcolonial theory positions race, culture, colonialism and power as central organizing concepts for critical analysis. Cultural safety and trauma violence-informed care frameworks draw on these concepts and apply them to the healthcare context. A cultural safety framework draws attention to unequal power relationships, and the nature of healthcare relationships as an essential component to accessing quality patient-centered cancer care, while also illuminating the impact of social and structural determinants of health on access to cancer care.^9–11 Trauma/violence-informed care (TVIC) is an approach that explicitly recognizes the impacts of multiple forms of trauma and violence in an individual’s life.^12,13 TVIC assumes that those who are disadvantaged by systemic inequities experience different forms of violence that have ongoing traumatic impacts.¹⁴ This is particularly relevant in the context of colonial Indigenous relationships in Canada. Evidence suggests that healthcare encounters can trigger traumatic responses among trauma survivors, and experiencing or anticipating such responses can prevent trauma survivors from accessing care.¹³

Methodology & Design: To address the research objectives, an embedded sequential, multi-method qualitative research design informed by interpretive description and critical discourse analysis will be used. In phase 1, an online survey using Qualtrics® software will collect demographic data, and qualitative data in the form of open-ended questions (n=100) to address the specific aims. Questionnaire data will be exported directly from Qualtrics® to Excel® (for demographic data) or NVIVO® (for qualitative data). Interested participants will be recruited into phase 2 for individual in-depth, semi-structured follow-up interviews (n=30). Interviews will be digitally recorded and transcribed verbatim, and exported to NVIVO® for analysis.

Participants will be recruited from oncology settings, including provincial, regional and rural cancer clinics throughout Manitoba and Saskatchewan, two central Canadian provinces with large Indigenous populations. Nurses with a minimum of one year of oncology nursing experience will be recruited to participate using convenience, purposive, and snowball sampling.

An interpretive descriptive approach was selected to facilitate the collection of nursing narratives around accessing to cancer care, and is highly relevant to explore what the barriers are to accessing cancer care for Indigenous peoples, and how, from nurses perspectives, access to cancer care can improved. However, as an approach, it lacks an explicitly critical lens or a strong theoretical grounding. For these reasons, critical discourse analysis methodology will be used to inform an interpretive descriptive approach. The addition of CDA builds upon interpretive description to further explore how and why is it that nurses understand these particular issues as barriers to accessing cancer care, and how specific discourses influence nursing practice in ways that may limit access to cancer care among Indigenous peoples. CDA facilitates analyses of power, discourse and social inequality at both the micro and macro levels¹⁵, enabling a more nuanced and contextualized analysis linking the broader institutional, social, political and historical contexts to healthcare systems, nursing practice (collectively and individually), and access to cancer care among Indigenous peoples in Canada. Rigor will be enhanced by reflective and analytic memos documenting decisions made by the researchers, triangulation of multiple data sources (questionnaire and interview), and confirming preliminary research findings with consenting participants.¹⁶

Rationale & Significance: Nurse-patient relationships are rarely considered a barrier to equitable healthcare access. This novel approach to understanding the influence of nurse-patient relationships on access to cancer care begins to disrupt our limited understanding of barriers to access, particularly among marginalized populations, while promoting the agency of oncology nurses to improve access to cancer care.