Indigenous social exclusion to inclusion: Case studies on Indigenous nursing leadership in four high income countries

Aims and objectives: This discursive paper provides a call to action from an inter national collective of Indigenous nurse academics from Australia, Canada, Aotearoa New Zealand and the USA, for nurses to be allies in supporting policies and resources necessary to equitably promote Indigenous health outcomes. Background: Indigenous Peoples with experiences of colonisation have poorer health compared to other groups, as health systems have failed to address their needs and preferences. Achieving health equity will require leadership from Indigenous nurses to develop and implement new systems of care delivery. However, little is known about how Indigenous nurses influence health systems as levers for change. Design: A Kaupapa Māori case study design. Methods: Using a Kaupapa Māori case study methodology, coupled with expert Indigenous nursing knowledge, we developed a consensus on key themes. Themes were derived from three questions posed across the four countries. Themes were collated to illustrate how Indigenous nurses have provided nursing leadership to re dress colonial injustices, contribute to models of care and enhance the Indigenous workforce. Results: These case studies highlight Indigenous nurses provide strong leadership to influence outcomes for Indigenous Peoples. Five strategies were noted across the four countries: (1) Indigenous nationhood and reconciliation as levers for change, (2) Indigenous nursing leadership, (3) Indigenous workforce strategies, (4) Development of culturally safe practice and Indigenous models of care and (5) Indigenous nurse activism. Conclusions: In light of 2020 declared International Year of the Nurse and Midwife , we assert Indigenous nurses’ work must be visible to support development of strategic approaches for improving health outcomes, including resources for workforce expan sion and for implementing new care models.


| INTRODUC TION AND BACKG ROUND
There are an estimated 476 million Indigenous Peoples worldwide in over 90 countries (The World Bank, 2020). Approximately seven million live within the high-income countries of Aotearoa New Zealand (NZ), Australia, Canada and the USA. These nations share similar colonial histories that were initiated 400-500 years ago in Canada and the USA and 200 years ago in Australia and NZ.
Although there are significant differences in time and space, the shared stories are similar and the lasting effects on the health status and economies of Indigenous People persist today Jackson Pulver et al., 2010; Moewaka Barnes & McCreanor, 2019). Indigenous Peoples make up about five per cent of the world's population but account for fifteen per cent of the world's extreme poor The World Bank, 2020) and are more likely to be alienated from their land and food resources , be victims of violence and murder (NZ Family Violence Death Review Committee, 2017;Power et al., 2020;United Nations, 2020), have their children removed illegally or without just cause (Amnesty International, 2020;Kapa-Kingi, 2019;Rouland et al., 2019), experience discrimination, stigma and racism (Cormack et al., 2018;Crengle et al., 2012;Harris et al., 2012;King et al., 2009) and be socially excluded (Dhir Kumar et al., 2020). These current and historical social conditions directly undermine Indigenous Peoples' self-determination and ability to care for themselves, their families and communities ).
Governments are attempting to resolve past injustices to Indigenous Peoples by 'recognizing and acknowledging past grievances, historical wrongs and injustices legitimates those whose political, spiritual and cultural practices have been brutally universalised into the values of their colonisers through processes of assimilation, integration or genocide' (Sullivan, 2016). This reconciliation is also about establishing and sustaining mutually respectful relationships The reconciliation process in Aotearoa (NZ) is state-led, statecontrolled and state-determined, with the Government acknowledging Treaty breaches. Recently a Treaty claim on healthcare services and outcomes (Wai2575) found Treaty breaches systematically provided poorer access to health care, poorer quality care and less choices in health care with poor governance and leadership for Māori (Waitangi Tribunal, 2019a). Māori are demanding constitutional reform to the Crown processes that they 'had no part in determining' to address the ongoing impacts of colonisation and ensuring that Treaty breaches are acted on and resources are provided for transformational change (Came & da Silva, 2011;Mutu, 2018).

On 13 February 2008, then Australian Prime Minister Kevin
Rudd offered an official Apology to Australia's Indigenous Peoples which is now commonly known as 'the apology'. The apology was prompted after inquiry that led to the Human Rights and Equal Opportunity Commission's creation of the Bringing Them Home Report (1997). It acknowledged the generations of forced removal of Indigenous Australians commonly referred to as the stolen generations. Aboriginal and Torres Strait Islander Peoples in Australia never ceded territory or sovereignty. No treaty was brokered.
Instead, the doctrine of Terra Nullius (land belonging to no one) was invoked (McMillan & Rigney, 2018). The Council for Aboriginal Reconciliation was established in 1991; however, this has not Relevance to clinical practice: Curating strategies to promote Indigenous nurse leaders around the world is essential for improving models of healthcare delivery and health outcomes for Indigenous Peoples.

K E Y W O R D S
education and leadership, Indigenous, inequity, minority, native, nursing, workforce What does this paper contribute to the wider global clinical community?
• These case studies demonstrate how Indigenous nurse leadership and models of health delivery can meet Indigenous and non-Indigenous community needs, currently not met by mainstream models of health care.
• Our vision is for an Indigenous nursing workforce that matches its population characteristics, has national and regional targets and aligned strategies for Indigenous workforce development and leadership with corresponding resources and political will. resulted in self-determination, reparation or equitable health outcomes (Collins & Thompson, 2018). A more recent, Indigenous led initiative called for a 'Makarrata Commission' (Yolngu word for treaty) to oversee 'a process of agreement-making' and 'truth-telling' during the establishment of a 'First Nations' voice in the constitution (Collins & Thompson, 2018).
In Canada, 2020 marks the five-year anniversary of the release of the Truth and Reconciliation Commission's Final Report.  (Collins et al., 2014).
In healthcare systems, Indigenous Peoples' needs are often silenced or invisible, with western health care failing to deliver accessible, high-quality, culturally relevant care (Jackson Pulver et al., 2010;Kurtz et al., 2014). Social exclusion consists of multidimensional processes driven by unequal power relationships across four dimensions -economic, political, social and cultural -and can deny individuals of security, dignity and the opportunity to lead a better life (Popay, et al., 2008). Additionally, the social determinants of health, the non-medical factors that influence health, and the systematic failure to meet Treaty obligations and to provide quality, culturally appropriate health care to Indigenous Peoples has resulted in persistently poor health outcomes (Jackson Pulver et al., 2010;Wilson et al., 2018). This is evidenced by Indigenous populations experiencing lower life expectancy, with noted life expectancy gaps at birth: 10 years in Australia; 7 years in New Zealand; 5.5 in Canada; 4.8 years in the USA . However, there are significant within-group differences, for instance between states and reservations. Peoples. However, given the nursing profession is based on a caring philosophy that aims to support 'human dignity, integrity, autonomy, altruism and social justice' (Fahrenwald et al., 2005), as an international group of Indigenous nurse academics from Australia, Canada, Aotearoa New Zealand and the USA, we argue that nursing has systematically failed Indigenous populations (West et al., 2010).  inequity for Indigenous Peoples will persist. Therefore, the purpose of this discursive paper is to highlight that in order to achieve health equity, we must curate and transform systems to support Indigenous Peoples that are shaped by Indigenous nurses and communities.

| ME THODS: C A S E S TUD IE S
The complexity of Indigenous worldviews requires an exploration beyond simple methodologies; hence a Kaupapa Māori case study design was used to highlight the work of Indigenous nurses in Aotearoa (NZ), Australia, Canada and the USA (Pihama et al., 2002).
Originating in Aotearoa, New Zealand, and rooted in Indigenous academics, Kaupapa Māori research is a philosophy, theory, methodology and practice of research for the benefit of Indigenous Peoples (Māori Health Committee, 2010;Smith, 2015). This methodology privileges and normalises Indigenous knowledge and looks for solutions to achieve the cultural aspirations of Indigenous communities, including self-determination (Haitana et al., 2020;Smith, 2013).
Various research methods can be employed in Kaupapa Māori research, with the chosen method tailored to address the specific research question and study design (Haitana et al., 2020). In this paper, a case study method was used to illustrate how each of the four countries have responded to Indigenous Peoples, and how Indigenous nurses can be instrumental in shaping change. A case study can be described as an 'intensive, systematic investigation of a single individual, group, community, or some other unit in which the researcher examines in-depth data relating to several variables' (Pihama et al., 2002).
We used collective expert Indigenous nursing knowledge and a collaborative decision-making methodology to develop a consensus on key themes (Heale & Twycross, 2018;Wilson et al., 2019).
Themes were derived from questions posed across the four coun- leadership, strategies and resourcing, it is unlikely that this target will be met (Chalmers, 2020).
The causes of Māori nursing workforce inequity are relatively complex and multifactorial (Wilson et al., 2011). Recruiting Māori into nursing careers is problematic with inaccessible pathways (Curtis et al., 2012) and absence of Māori nurse tutors and professors as mentors and role models (McAllister et al., 2019). Retaining Māori nurses in the workforce is also difficult, and the number is projected to continue declining. Reasons for leaving the workforce vary, but most agree it is often inherently due to issues related to their colonial history (ie experiences of systemic racism and cultural insensitivity) Such experiences often lead to Māori nurses being overworked and undervalued (Huria et al., 2014;Manchester, 2018).
There are significant pay inequities for Māori nurses, particularly working for Māori health providers with the government refusing to address pay parity for Māori nurses (Radio New Zealand, 2020). In 1990, New Zealand implemented cultural safety into practice largely influenced by Dr Irihapeti Ramsden, a Māori nurse, after witnessing unsafe cultural practice by nurses (Papps & Ramsden, 1996). While annual endorsements of culturally safe practice are required each year for nursing registration, there remain accounts of racist and unsafe behaviours towards Māori nurses and patients (Graham & Masters-Awatere, 2020;Huria et al., 2014). This year (2020) (Henly et al., 2006;Moss, 2015).  Organization, 2020) provides compelling evidence of the value of the nursing workforce and reports the nursing workforce is growing;

| Summary of case studies
however, this growth is not equitable.

| DISCUSS ION
The aim of this paper was to highlight case studies to demonstrate how Indigenous nurses can progress and influence Indigenous health First, all Indigenous Peoples require acknowledgment of Indigenous nationhood and reconciliation as a foundation for addressing health inequity. Health systems will not change unless inequity is exposed and there is political will and action to change it. Second, the creation of Indigenous leadership is essential, and non-Indigenous nurses cannot lead and support the development of Indigenous strategies (although allies are required) in academic institutions, clinical or policy settings. Examples of Indigenous nursing leadership has had immeasurable ripples across the health systems from bedside cultural safety practice to influencing governmental policies. Third, the development of national, regional and service workforce development strategies to actively recruit and maintain Indigenous nurses into the profession is required. Without purposeful strategic direction, leadership and resourcing, the Indigenous nursing profession will not grow. The fourth theme is the development of non-racist and self-determined models of care led by Indigenous community needs. To do this, there must be recognition that mainstream models of care that are consistently under-delivering and underperforming for Indigenous Peoples be replaced by holistic Indigenous models of care that are frequently led by Indigenous nurses, Indigenous community workers and Indigenous doctors. The fifth and final common thread in these case studies is nurse activism. Indigenous nurses who see broken systems are standing up for their communities to make a difference, in often very hostile environments. These strategies will now be discussed.
We have described reconciliation and Treaty processes as a strategy to redress colonial injustices as levers to facilitate system-level changes in health care. Reconciliation is a significant lever to hold governments and policymakers to account for colonial health systems that have generationally harmed and marginalised Indigenous Peoples, although with varying success. Such 'one-size-fits-all' approaches disregard collectivist Indigenous cultural systems, and while convenient, dismisses promoting health equity needs of Indigenous Peoples (Mitchell & Wilson, 2019;Wilson et al., 2018 knowledge and understanding positions us well to respond to and meet the health aspirations and needs of Indigenous Peoples (Mitchell & Wilson, 2019;Wilson et al., 2018). In addition, ethnic concordance in patient-healthcare provider relationships has been highlighted as an important lever for improving health outcomes (Mitchell & Wilson, 2019;West et al., 2011

| RELE VAN CE TO CLINI C AL PR AC TI CE
Developing a strategy to enhance Indigenous nurse leaders from Aotearoa New Zealand, Australia, Canada and the USA will contribute to innovative Indigenous models of care and increase the Indigenous workforce to improve outcomes for Indigenous Peoples.

ACK N OWLED G EM ENTS
The term 'Indigenous' commonly refers to Aboriginal Peoples globally (National Aboriginal Health Organization, 2003), regardless of borders, constitutional or legal definitions and is in keeping with Indigenous rights movements (Frideres & Ludwin, 2014). Indigenous Peoples is a global term encompassing all Indigenous People.
Aotearoa New Zealand: Māori. Australia: Aboriginal. Canada: First Nations, Inuit, and Metis. US: Native American is a national term inclusive of American Indian and Alaska Native.

CO N FLI C T O F I NTE R E S T
The authors declare no potential conflicts of interest with respect to the research, authorship, or publication of this work.