Wâhkôtowin: a Nehiyaw Ethical Analysis of Anti-Indigenous Racism in Canadian Nursing

Submitted Feb 14th, 2021; Revised April 28th, 2021; Accepted May 5th, 2021 wâhkôtowin: A nehiyaw Ethical Analysis of Anti-Indigenous Racism in Canadian Nursing

Meghan Eaker, RN, MSc(A) University of Alberta

Cite As: Eaker, M. (2021). wâhkôtowin: A nehiyaw Ethical Analysis of Anti-Indigenous Racism in Canadian Nursing. Witness: The Canadian Journal of Critical Nursing Discourse, 3(1), pp. 31-44. https://doi.org/ 10.25071/2291-5796.93

Abstract: Indigenous Peoples in the settler state of Canada face racism on a daily basis, including in their interactions with nurses and the healthcare system. Canadian nursing consistently fails to recognize its role in continuing to perpetrate anti-Indigenous racism. Many nurses are not adequately taught about Indigenous history, settler colonialism, and anti-racism to be able to recognize anti-Indigenous racism against Indigenous clients and families in practice, let alone effectively address it. Considering the failure of current nursing ethics to adequately recognize and take a stand against anti-Indigenous racism, I propose using the nehiyaw (Cree) concept of wâhkôtowin as an ethical perspective that can help nurses tackle this pervasive problem.

Keywords: Anti-Indigenous racism, wâhkôtowin, nursing ethics, settler colonialism, anti- racism

Introduction Peoples in Canada is significantly shorter than for non-Indigenous Peoples Indigenous Peoples1 in Canada have (Tjepkema et al., 2019). The reasons for demonstrated incredible resilience in the these health disparities are complex, but face of the historic and continuing trauma they are clearly related to social inequities. they experience. While there is significant For instance, the average income for variation culturally and socially among the Indigenous men is 58% of that of non- many Indigenous groups in Canada, the Indigenous men, the unemployment rate health of First Nations, Métis, and Inuit has for Indigenous families is double that of been seriously and negatively affected by non-Indigenous Peoples, and Indigenous the historical and ongoing process of Peoples are four times more likely to live in colonization. Indigenous peoples face crowded housing conditions with food disproportionally high rates of infectious insecurity (Mikkonen & Raphael, 2010). and chronic disease, infant mortality, and As a graduate nursing student of mixed suicide (Mikkonen & Raphael, 2010). In nehiyaw2 (Cree) and European ancestry addition, the life expectancy for Indigenous who has pursued higher education to better

1 Indigenous Peoples in Canada refers to the 2 nêhiyawêwin (Cree language) words are not First Peoples of this land that include First capitalized according to my teachings. As Nations (status and non-status), Métis, and Lana Whiskeyjack and Kyle Napier explain, Inuit. this is done to acknowledge the fact that no Corresponding Author: Meghan Eaker. Email: [email protected] 31

understand these troubling disparities, it is Perhaps the most well-known and clear to me that the systemic anti- recognized form of racism is interpersonal Indigenous racism and ongoing racism (Allan & Smylie, 2015). Also colonization that contribute to inequitable known as relational racism, interpersonal health outcomes for Indigenous peoples are racism “refers to acts of racism that occurs not understood by the majority of nurses. In between people” (Allan & Smylie, 2015, p. this article, I seek to make plain the racist 5). Examples of this type of racism include foundations of the nursing profession and being called names, being ignored, to propose a nehiyaw (Cree) ethical receiving poor treatment, or being the perspective to challenge this racism. victim of various forms of violence on the basis of race (Allan & Smylie, 2015). Anti-Indigenous Systemic Racism While interpersonal racism may be the most visible form of racism, Waite and Due to the fact that racism is present in the Nardi (2019) emphasize that racism cannot social, economic, and political aspects of simply be viewed as a simple individual society that influence the social problem, because it is essentially a system determinants of health, systemic racism has of power. Thus, one cannot separate the been proposed as a meta-social determinant interpersonal from the whole of the system of health to help explain the health as interpersonal racism is a symptom of the inequities faced by many racialized groups larger problem of structural racism (Waite (Ramaswamy & Kelly, 2015). Racism can & Nardi, 2019). Waite and Nardi (2019) be defined as “a societal system [emphasis additionally argue that while “prejudice, added] in which actors are divided into bias, or discrimination based on ‘races’, with power unevenly distributed perceptions of skin color” are significant (or produced) based on these racial parts of racism, conceptualizing this as classifications” (Paradies, 2006, p. 145) racism’s full definition is “incomplete and and that creates “differential access to the misleading” (p.20). Therefore, goods, services, and opportunities of interpersonal racism cannot be addressed in society” (Ramaswamy & Kelly, 2015, p. isolation of institutional racism. 285). As with all other institutions, healthcare is While the nature of racism is a site in which racism is present. While fundamentally systemic, the terms both Indigenous nurses and Indigenous institutional, structural, and systemic clients experience the negative effects of racism are useful to highlight how racism is racism, this analysis focuses on the issue of embedded in society’s structures and anti-Indigenous racism directed at clients, institutions “that maintain and reproduce their families, and their communities; avoidable and unfair inequalities across recognizing that that all forms of anti- ethnic/racial groups” (Paradies et al., Indigenous racism are interconnected. A 2008). In addition, Kwame McKenzie recent inquiry into systemic discrimination (2017) stresses the fact that any lack of against Indigenous Peoples in Quebec action on the part of organizations to public services found that there is racism in address racially disparate outcomes is, in the healthcare system that results in fact, institutional racism. Simply put, significant negative health outcomes for institutional racism results in “inequitable Indigenous clients and sometimes even outcomes for different racialized groups” death (Viens, 2019). Specifically, (McKenzie, 2017, p. 5). discrimination and racism in interactions between health care providers and patients word or part of a word is more important than any other.

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actively discourages Indigenous clients is because the profession benefits from from seeking healthcare and negatively society’s unequal structure and is more affects their quality of care overall (Viens, interested in maintaining a likable, caring 2019). This is consistent with research that image than working towards achieving demonstrates that the health care of equity and justice. Indigenous Peoples in Canada is negatively impacted by “an unwelcoming As an Indigenous nurse who has witnessed environment, stereotyping and stigma, and countless instances of racism against practice informed by racism” (Wylie & Indigenous people in healthcare I think it is McConkey, 2019, p. 37). It was found that time that nursing examined its role in health care providers often blame perpetuating anti-Indigenous systemic Indigenous individuals for their state of racism. While nurses should be concerned health, ignore social determinants of with the deleterious effects of colonization health, and label Indigenous clients as and racism in all sectors of society on drug-seeking or alcoholics (Allan & Indigenous health, the presence of racism Smylie, 2015; Wylie & McConkey, 2019). in the healthcare sector and in nursing Negative outcomes for Indigenous people should be of the utmost concern. To included being denied care, having their address this issue and offer some potential medical issues go unbelieved, having their solutions, I will analyse the issue of anti- pain go untreated or undertreated, being Indigenous racism in nursing using the misunderstood, being demeaned, and nehiyaw principle of wâhkôtowin3. having delayed service (Allan & Smylie, 2015; Wylie & McConkey, 2019). wâhkôtowin

Considering the far-reaching impacts of wâhkôtowin is a foundational value of racism on the health of racialized peoples, nehiyaw natural law that is most often it is surprising that the subject has not been translated to English as kinship, yet the investigated more in the nursing or health concept means more than this simple care ethics literature. Indeed, the Canadian translation (Laboucan et al., 2009; Nurses Association’s (CNA, 2017) Code of Lindberg, 2020). nehiyaw epistemology is Ethics for Registered Nurses does not once based on the “accumulated knowledge of mention the word racism yet speaks about our ancestors” (Ermine, 1995, p. 104), the importance of the social determinants which is passed down through our Elders of health, social justice, and advocating for and oral traditions in the form of the eradication of health and social âcimowina (stories), âtayôhkewina (sacred inequities. Johnstone and Kanitsaki (2009) stories), ceremonies, songs, culture, and point out that the common practice in language (BearPaw Media and Education health care of avoiding the term racism in [BPME], 2016; Ermine, 2007; Ermine, favour of euphemisms does not stop racism 1995; Shirt et al., 2012). Elders in nehiyaw and, in fact, makes it harder to address. In communities are respected as irreplaceable The Unbearable Whiteness of Being (in sources of knowledge and “the guides of Nursing) Elayne Puzan explains how the our communities” (Ermine, 1995, p. 107). profession of nursing has yet to challenge As part of wâhkôtowin, the Elders teach us its whiteness, institutionalized as authority that everything in the universe is alive and and normalness, thereby perpetuating has ahcâhk (spirit) (BPME, 2009; systemic oppression. I argue that the reason Campbell, 2007; Lindberg, 2020). the nursing profession is unwilling to Therefore, we are related to and address racism or even admit that it exists interconnected with all of creation

3 nêhiyawêwin is an oral language, thus there wahkotowin, wahkohtowin, wâhkôhtowin, are many ways to spell wâhkôtowin: wahkootowin.

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including our “human and other than not received as much attention as it human relatives” (Wildcat as cited in deserves (Johnstone & Kanitsaki, 2010). Lindberg, 2020, p. 8), such as “trees, grass However, those who have addressed the and rocks” (Buhler et al., 2014, p. 185). issue show that classical principles of wâhkôtowin also teaches us that all our bioethics and other principles of Western relatives are equal: “no one is more ethics do indeed demonstrate that racism is important than the other, human, animal or wrong. For example, Johnstone and the natural world, and that we are on this Kanitsaki (2010) argue that racism is earth to help one another” (Buhler, 2014, p. wrong in healthcare, because it violates the 185). In this way, humans are bioethical principle of ‘do no harm.’ They interdependent with all of creation argue that the research has adequately (Friedland, 2016). As part of wâhkôtowin shown that racism is detrimental to the there are obligations to conduct ourselves receiving person’s well-being, which in proper ways that help us honour and results in a morally reprehensible harm to respect our relationships (Campbell, 2007; that person (Johnstone & Kanitsaki, 2010). Friedland, 2016; Lindberg, 2020). Another relevant principle of bioethics that kihcheyihta (respect), love, kindness, racism violates is that of justice (Danis et accountability, reciprocity, equality, and al., 2016). To uphold justice, there is “an responsibility are all values that help us obligation to promote health equity”, uphold our wâhkôtowin obligations and because “differences in health that are maintain healthy relationships (BPME, avoidable, unfair, and unjust represent 2009; Campbell, 2007; Johnson, 2017; inequitable health” (Danis et al., 2016, p. Lindberg, 2018). 5). In addition, Donahue (2008) outlines many proposed reasons for why racism is Ethical Analysis of Racism in Nursing wrong, including that it manifests injustice and malevolence (it makes people do bad Although racism is widely recognized as an things), and it violates the principles of afront to basic ethical principles such as equal respect, equal liberty, and equal justice and fairness, many famous ethicists dignity. Considering these arguments, we in history, such as Immanuel Kant, have are again faced with the question: If racism defended racism and even written lengthily is universally recognized as unethical, why on the subject of racial superiority and does it continue so pervasively? inferiority (Kant, as cited in Allais, 2016). For nurses, the presence of racism in our To analyse racism in the context of the practice is somewhat of a paradox, because relationship between Indigenous and non- if we accept the assumption that most Indigenous Peoples in Canada, one must nurses want to do the right thing and that consider the beginning of this relationship. they also believe that racism is wrong, then We must recognize that the settler state of why do so many instances of racism still Canada was founded on racism. If we do exist in healthcare? Racism is so deeply not recognize the foundational nature of entrenched and normalized in Western racism to the Canadian state, any attempt to society that it is often invisible to those address the issue in healthcare will be perpetrating it. Invisible racism in the futile. In the 1400s, the Doctrine of nursing context can manifest as making Discovery, founded on two papal bulls of decisions for Indigenous clients that are 1452 (Dum Diversas) and 1455 (Romanus ‘for their own good’ or ‘to protect them’ Pontifex), allowed European Christians the without meaningfully listening to the right to land occupied by Indigenous client, their family, and their community. Peoples because of what was believed to be their God-given racial superiority to those In the domains of philosophy and ethics, original inhabitants (Assembly of First the question of ‘why racism is wrong?’ has Nations [AFN], 2018; Vowel, 2016).

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Furthermore, Europeans did not recognize born of a racist dominant society (Waite & Indigenous forms of land use and laid claim Nardi, 2019). For example, nursing to the land based on the principle of Terra originally only accepted white women into Nullius, which is Latin for “land that the profession and actively challenged the belongs to no one” (Vowel, 2016, p. 236). entry of women of colour into the fold In this way, the Doctrine of Discovery and (Waite & Nardi, 2019). To this day, white Terra Nullius were used to morally justify middle-class women are grossly the dispossession, dehumanization, overrepresented in nursing while exploitation, and genocide of Indigenous minorities are underrepresented overall and Peoples in the interest of obtaining their occupy more often the lowest paid and less lands (AFN, 2018). prestigious nursing positions (Schroeder & Diangelo, 2010). In nursing and beyond, it In addition, it is important to acknowledge is true that “although individual whites may that settler colonialism sets not only the be ‘against’ racism, they still benefit from foundation for racism in settler states, but a system that privileges their group” also frames the past, present, and future of (Schroeder & Diangelo, 2010, p. 245). race relations (Bonds & Inwood, 2016). Nurses have a history of using their Since the goal of settler colonialism is the unacknowledged white privilege to gain permanent occupation of land previously power, authority, and legitimacy in occupied by Indigenous Peoples, it healthcare and thereby they “have a vested necessitates the eradication of Indigenous interest in upholding the status quo of people (Bonds & Inwood, 2016). existing social relations” (Hall & Fields, Furthermore, the racist logic of white 2013; Hassouneh, 2006, p. 259). supremacy is at the heart of settler colonialism, because it not only lowers the While profiting from systems of white moral standing of Indigenous peoples, but supremacy, nursing also has a tradition of also places whiteness at the top of the racial hiding this fact and endeavoring to remain systems of power, allowing whiteness to ‘innocent’ in its own eyes. In order to avoid dominate (Bonds & Inwood, 2016). Indeed, facing complicity with racism, nursing uses Bonds and Inwood (2016) explain that several strategies that must be overcome. “white supremacy is… a rationalization for First of all, nursing’s status as a group race” (p. 720). Therefore, it becomes clear oppressed by gender has been weaponized that part of the reason that racism is so to cast us solely as victims unable to difficult to eradicate is because it continues perpetrate harm against others (Hall & to be used as an effective tool in support of Fields, 2013; Waite & Nardi, 2019). This white supremacy, which keeps power and type of false argument has been challenged privilege in the hands of those who create by Audre Lorde (1984): and continue to benefit from racist systems. What woman here is so enamored Recognising nursing’s historic and of her own oppression that she ongoing vested interest in upholding white cannot see her heelprint upon supremacy helps to explain why nursing, as another woman's face? What a profession, is overwhelmingly complicit woman's terms of oppression have in racism. Owing to racism’s foundational become precious and necessary to nature, any person influenced by Western her as a ticket into the fold of the culture will not be able to escape righteous, away from the cold socialization into racist modes of being, winds of self-scrutiny? (p. 6) including nurses (Hall & Fields, 2013; Schroeder & Diangelo, 2010). Similarly, As Lorde notes, having a self-image of the nursing profession must realize that its being ‘righteous’ takes away the need to epistemological and structural roots are reflect on one’s actions as one has

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permanently become good and moral. domination as a just social order (Allais, Nursing’s cherished persona as the caring, 2016; Seawright, 2014). To avoid having to ethical woman is a moral tool used to make treat ‘othered’ humans with principles of the false claim that nurses have achieved equal respect, these theorists and settler morality and thus can legitimately act in a societies simply dehumanize certain morally passive way because they are groups and accept the proposition that already ‘good’ (Johnstone & Kanitsaki, some classes of human are less than (Allais, 2010). Nurses and other professionals have 2016; Seawright, 2014). Considering the become adept at self-deception in which failure of classical Western philosophy to they can ignore that they “trade off self- eradicate racism or indeed even denounce interest with ethical principles” and that it, it becomes clear that a new approach is they “falsely believe that they have not needed. engaged in or promoted racism or racialised practices in health care when in Ethical approaches such as feminist ethics fact they have” (Johnstone & Kanitsaki, and relational ethics have been created in 2010, p. 493). Indeed, I would argue that response to criticisms about classical what Martin Luther King Jr. said in 1963 Western ethics and these frameworks are about white moderates is true for white useful in finding new ways to approach nurses in the context of anti-Indigenous nursing ethics (Austin et al., 2003; racism as well: Liaschenko, 1993). However, considering the fact that racism also occurs on an I have almost reached the epistemological level with the regrettable conclusion that the delegitimization of Indigenous ways of Negro’s great stumbling block in knowing, a step in anti-racist nursing his stride toward freedom is… the would be to embrace Indigenous ethics white moderate, who is more regardless of the presence of non- devoted to “order” than to justice; Indigenous critical ethical traditions (Allan who prefers a negative peace & Smylie, 2015). Therefore, I answer which is the absence of tension to Seawright’s (2014) “call for epistemic a positive peace which is the resistance” (p. 570) by using the nehiyaw presence of justice. (King, as cited concept of wâhkôtowin. As we have seen, in Hassouneh, 2006, pp. 259-260) dehumanization is a key mode of racism in Western epistemology. In contrast, the To understand why so many nurses are beauty of wâhkôtowin is that it teaches that capable of accepting racism in exchange everything in the universe is alive and in for an unjust social order with its uneasy relationship with one another, and one must façade of ‘peace,’ we must delve deep into be respectful to all relations (BPME, 2009; the roots of Western epistemology. Campbell, 2007; Lindberg, 2020). Thus, Seawright (2014) explains that Western the moral loophole of dehumanization to settler epistemologies are founded on legitimize treating others as lesser beings “racialized, anthropocentric, and does not exist as there is no concept of capitalistic understandings” (p. 554). ‘lesser beings.’ Additionally, when Within Western epistemologies exist focusing on the tenets of wâhkôtowin, “epistemic and moral limitations” racism is wrong because in a relationship (Seawright, 2014, p. 558) that lead to all entities have an obligation to treat one viewing the world fundamentally in a another reciprocally with respect hierarchical fashion with white males at the (Lindberg, 2020). Elder Isaac Chamakese top of the social structure. Indeed, the teaches that “we have to love each other inherent hierarchical nature of Western and greet each other every day” (as cited in epistemology made it possible for theorists BPME, 2009) as part of wâhkôtowin. like Kant and Locke to legitimize Remembering our interdependence and

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interconnection can help us honour and and Reconciliation Commission of Canada respect those with whom we share relations (TRC): Calls to Action outline the need to (Campbell, 2007; Johnson, 2017). respect and allow Indigenous traditional knowledge in healthcare:

22. We call upon those who can effect change within the Canadian Working Towards the Elimination of health-care system to recognize the Racism value of Aboriginal healing practices and use them in the No matter how unachievable the goal of treatment of Aboriginal patients in eliminating racism may seem at times, any collaboration with Aboriginal work towards this objective is morally healers and Elders where requested necessary and worthwhile. As Schroeder by Aboriginal patients. (TRC, and Diangelo (2010) state, “to not address 2015, p. 3) racism is to actively collude with racism” (p. 245). Therefore, there are many actions Additionally, acknowledging the nurses can take in the struggle against importance of relationships using racism. The first step is to shine a light and wâhkôtowin suggests another avenue to reveal the racism and white supremacy pursue positive relations between hidden in plain sight in our society and Indigenous and non-Indigenous Peoples: institutions. Instead of relying on simple treaty relationships. While not all cultural notions of difference as theories Indigenous peoples have signed treaties, in that mask the underlying systemic nature of some areas, using Treaty principles as a discrimination leading to health inequity, guide can be helpful in navigating the nurses need to expose racism and talk about complex relationship between Indigenous the problem openly (Hall & Fields, 2013; and non-Indigenous peoples. Oda and Hassouneh, 2006; Puzan, 2003; Schroeder Rameka (2012) explain how adhering to & Diangelo, 2010). If nurses do not first the principles of the treaty of Te Tiriti O recognize the root of the problem, they Waitangi (1840), such as ensuring that cannot conceivably self-reflect on their Māori have “all the rights and privileges of motivations and learn to act in a way not British subjects” (p. 108) and that their self- influenced by racism (Hall & Fields, 2013). determination is respected, can lead to As long as whiteness remains invisible, it positive health outcomes for Māori. In the remains indestructible (Waite & Nardi, nehiyaw context, Elder Fred Campiou 2019). describes how, when the newcomers came, we, the nehiyaw people shook hands with However, while simply identifying and them and agreed to live in peace and talking about racism is a good first step, it harmony. Our ancestors conducted is not enough. Action needs to be taken to ceremonies and lifted the pipe to honour challenge it. Considering the concept of the new relationship between our peoples. wâhkôtowin, several methods to counteract In this way, “we have a wâhkôtowin with racism are relevant and supported by the the Moniyaw4, a relationship” (Campiou, literature. First, although culture is not the as cited in BPME, 2009) that comes with root problem in racial health inequities, the obligations on both sides to treat each other treatment of different ways of knowing as with respect. inferior (epistemic racism) is wrong and can be addressed in healthcare. The Truth

4 White people, in nehiyawewin

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Another way that wâhkôtowin can be used clients (Allan & Smylie, 2015; FitzGerald to counteract racism in nursing practice is & Hurst, 2017; Wylie & McConkey, 2019). through offering a different perspective. As When healthcare professionals have previously mentioned, wâhkôtowin holds implicit biases against certain groups it all entities of creation as deserving of interferes with their ability to form a respect and that “no one is more important positive therapeutic relationship due to than the other, human, animal or the natural “negative emotional tone, more clinician world” (Buhler et al., 2014, p. 185). dominance…[and] less patient-centered Teaching this value to nurses and nursing care” (Danis et al., 2016, p. 6). Implicit students could have positive effects, biases also negatively affect treatment considering that, in social psychology, the recommendations; for example, racialized concept of the human-animal divide has patients have been shown to receive less been found to have serious implications for pain medication than their white human discrimination and prejudice counterparts (Allan & Smylie, 2015; (Costello & Hodson, 2014). For example, it FitzGerald & Hurst, 2017; Hall & Fields, was found that having research participants 2013; Johnstone & Kanitsaki, 2010). read stories that likened animals to humans made the participants more compassionate Due to the unconscious nature of implicit towards immigrants that became biases, solutions to address them are ‘rehumanized’ through this new difficult to find, yet research suggests some perspective (Costello & Hodson, 2014). possibilities. Many of the promising While anti-Indigenous racism and other proposed solutions are in keeping with forms of racism such as anti-Black and values embedded in wâhkôtowin. First of anti-Asian racism operate and manifest in all, healthcare providers who are aware of distinct ways, they are all related. Nurses their implicit biases have been shown to have a responsibility to address all forms of take a conscious effort to be less racism and discrimination, and what is discriminatory in their treatment of learned in the struggle for equity and racialized patients (Allan & Smylie, 2015). justice for Black and Racialized Peoples Another promising intervention is can inform Indigenous anti-racist work and ‘perspective taking.’ Nurses who were vice versa. asked to imagine themselves in the place of their racialized patients were shown to One of the ways in which racial bias provide them with equal levels of pain escapes attention in healthcare is that it has treatment, while nurses that did not been shown to operate on a subconscious participate in the ‘perspective taking’ level, making it that much more difficult to exercise gave significantly more pain address. Implicit biases are the unconscious medication to white patients, attitudes one holds about certain groups of demonstrating their pro-white bias in people that affect one’s thoughts and action (Allan & Smylie, 2015). actions (Allan & Smylie, 2015). These biases can be positive or negative; for Other solutions for countering provider example, research in healthcare has shown implicit biases include focusing on that healthcare providers regularly communication skills training for demonstrate measurable pro-white implicit healthcare professionals to enable them to biases and anti-Black and anti-Latino better model positive non-verbal biases (Allan & Smylie, 2015). Evidence behaviours towards racialized patients and shows that even when healthcare providers to better read those patients’ non-verbal demonstrate no explicit racial biases, their cues (Hagiwara et al., 2019; Levine & unconscious biases influence clinical Ambady, 2013). Such training could decision-making in ways that result in include exercises such as ‘counter- negative outcomes for their racialized stereotypic imaging’ which aims to change

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stereotypes by exposing healthcare to represent Indigenous land prior to professionals to stories or people that contact (Baldasaro et al., 2014). A script is challenge commonly held stereotypes used to show the various points in history (Devine et al., 2012; Levine & Ambady, including decimation by illnesses, 2013). In addition, social science has Residential Schools, and the Indian Act shown that the ability to recognize (Baldasaro et al., 2014). The activity emotions from facial expression on people finishes with the participants (standing in from another race improves with practice place of Indigenous Peoples) now standing (Levine & Ambady, 2013). Therefore, it is on very small sections of blankets that have conceivable that nurses could be trained to been folded into tiny areas—a visual better read and perhaps interact more representation of how Europeans took authentically with racialized patients. almost all the land for themselves Several more implicit bias-reducing (Baldasaro et al., 2014). Baldasaro, training strategies have been proposed, Maldonado and Baltes (2014) explain that including stereotype replacement the lesson this activity teaches, with its (recognizing responses based on emotional, narrative, and experiential stereotypes and replacing them with components, is “keenly remembered” (p. unbiased responses), individuation 223) by participants. (thinking of someone as an individual who is not defined by stereotypes of their Finally, while all the aforementioned group), and increasing opportunities for strategies to combat racism and implicit contact between groups (Devine et al., bias are worthwhile, it is still crucial to 2012). Studies on such interventions found remember that racism is a systemic issue that long-lasting reductions in the implicit and there is need for structural change to biases held by participants were moderated truly resolve it. Unfortunately, there is very by increased concern about discrimination little literature about how to effectively in society (Devine et al., 2012). In other address anti-Indigenous systemic racism in words, teaching people to care about health care (Allan & Smylie, 2015). Some injustice was the most important part of the promising, individual-level, clinical intervention. strategies to specifically improve Indigenous health equity, like “inequity- Another intervention that could be used to responsive care, culturally safe care, teach nurses about both the relationship trauma- and violence-informed care, and between settlers and Indigenous Peoples in contextually tailored care” (Browne et al., Canada and how to have more compassion 2016, p. 1), require that clinicians practice for Indigenous Peoples would be the Kairos in explicit consideration of the ways that Blanket Exercise (Kairos Canada, 2016). systemic racism affects health. Cultural As an Indigenous concept, wâhkôtowin is safety, in particular, is a leading concept in often learned and taught though stories in Indigenous health equity that was Cree culture (Shirt et al., 2012), and I developed by Irihapeti Ramsden, a Maori would argue that it can also be taught nurse (Browne et al., 2016). Cultural safety through the modern narrative and emphasizes the presence of power experiential learning-based Blanket dynamics in healthcare and encourages Exercise. The Blanket Exercise was self-reflection about these power developed by Kairos, a Canadian Interfaith imbalances, learning about racism and group, to interactively teach settlers about social injustice, and empowering patients the historical treatment of Indigenous in healthcare encounters (Bailey et al., Peoples (Baldasaro et al., 2014). In the 2017; Browne et al., 2016). exercise, participants imagine themselves in the place of Indigenous Peoples and start Additionally, nurses who are able to by standing on blankets spread on the floor recognize systemic racism, can challenge it

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through advocacy. Bailey et al. (2017) systems), speaking up when witnessing stress the importance of “place-based, racist interactions, and advocating for multisector, equity-oriented initiatives… systemic change to address institutional [and] advocating for policy reform” (p. racism. Indeed, there is a need for more 1459) in tackling health inequity. This nursing literature, research, and action on could include advocating for Indigenous addressing systemic racism. Finally, by self-determination in healthcare, embracing the Cree principle of supporting Indigenous-led health wâhkôtowin, both to analyze the ethical initiatives, and ensuring that policies align problem of racism, and to provide potential with principles outlined in the United solutions to address it, a new perspective in Nations Declaration on the Rights of nursing ethics, which takes a stance against Indigenous Peoples (UNDRIP), the Royal epistemological racism, is herein provided. Commission on Aboriginal Peoples (RCAP), and the Truth and Reconciliation Conflict of interest statement Commission (TRC) (Allan & Smylie, 2015). Real world examples of political The author has no conflict of interest to advocacy for Indigenous health equity report. include Jordan’s Principle and the #aHand2Hold campaign (Allan & Smylie, Ethical permission 2015; Tirmizey, 2021). These initiatives, which depend upon the leadership of Dr. No ethical permissions were required for Cindy Blackstock (Social Worker) and Dr. this work as there were no human Samir Shaheen-Hussain (Physician) participants. respectively, challenge racist policies that harm Indigenous children by using Funding strategies that encourage care and compassion (Blackstock, 2016; Tirmizey, The author received no financial support 2021). In this way, wâhkôtowin can be associated with the authorship and used as a guiding principle to reimagine publication of this article. how we practice nursing.

Conclusion

Through an exploration of the moral implications of the history and foundations of racism in nursing and society, and an analysis of racism with wâhkôtowin, we realize that anti-Indigenous racism is an issue of great ethical importance to nurses in Canada. Anti-Indigenous racism is wrong; it is unjust and harmful, it violates principles of equal dignity, and it precludes the possibility of a good relationship between Indigenous and non-Indigenous Peoples. Nurses have a moral obligation to counteract the pervasive racism in healthcare, and they can do so by taking personal steps of education and self- reflection to override implicit biases, learning to recognize and identify racism (in one’s own behaviours, in others, and in

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