Shifting Power to Improve First Nation Peoples’ Access and Outcomes in Kidney Care

Related article, p 896In this internationally important systematic review1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar identified and given voice by a First Nation-led multidisciplinary group in Canada and amplified internationally in this issue of Kidney Medicine, readers are invited to engage with Indigenous peoples’ perspectives about Cultural Safety in kidney care. Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar posit 2 knowledge systems: the Eurocentric academic process and a process that centers on Indigenous peoples and storytelling.1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar The review identified 2,232 articles, of which 15 relevant articles addressed the research question on Cultural Safety within the context of Indigenous kidney health care. The review focused on research from New Zealand, Australia, Canada, and the United States, dating back to 2002, when Cultural Safety as a term was proposed by Ramsden2Ramsden I.M. Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu. [PhD thesis]. Victoria University of Wellington, 2002Google Scholar and gained academic acceptance.Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar introduce the academic knowledge system in the methodology of the paper, but first comes the story of Indigenous peoples lost, missing, and dying in care systems that fail them. Indigenous people seek access to health care as well as optimal health care interactions and outcomes, just as non-Indigenous people do. The reader is challenged to consider Cultural Safety in kidney care for Indigenous peoples, with a prompt to readers to recognize “triggered unease” as expected experiences when engaging “issues of racism.” Racism has persisted in health systems and continues to harm Indigenous peoples in Canada, the United States, New Zealand, and Australia.3Indigenous Strategic Framework 2018-2028The Royal Australasian College of Physicians.https://www.racp.edu.au/about/board-and-governance/governance-documents/indigenous-strategic-framework-2018-2028Google ScholarThis paper is a timely exploration of the depth and breadth of knowing of Cultural Safety, with its source material harvested from academic knowledge repositories. The 15 articles that Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar identified expose the differing assumptions of academic knowledge systems, in which academic repositories archive materials whose evidence ratings have been developed without the knowledge or values of Indigenous peoples. Nevertheless, this repository is used for purposes that fundamentally affect the nature of care provided to Indigenous peoples, including the teaching curricula of kidney health practitioners, designing health care systems, and accreditation of hospital practices.4Australian Commission on Safety and Quality in Health CareOverview: Improving Care for Aboriginal and Torres Strait Islander People. National Safety and Quality Health Service (NSQHS) Standards, Sydney, Australia2016Google Scholar In the area of kidney disease, the voices of Indigenous people have been largely absent from this repository, either as authors, researchers, or storytellers.Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar invite readers to reflect on sustained legacies of colonialism when considering the body of Cultural Safety in kidney care publications deposited in academic archives. Processes that intentionally make space (through shifting power) for Indigenous peoples’ self-determination in health care and those that promote improved health outcomes need research funding prioritization and the editorial commitment of assigning editors and journal reviewers to support research archiving. Utilization by editorial teams of research quality appraisal tools, which are designed by First Nations people,5Huria T. Palmer S.C. Pitama S. et al.Consolidated criteria for strengthening reporting of health research involving indigenous peoples: the CONSIDER statement.BMC Med Res Methodol. 2019; 19: 173Crossref PubMed Scopus (97) Google Scholar,6Harfield S. Pearson O. Morey K. et al.Assessing the quality of health research from an Indigenous perspective: the Aboriginal and Torres Strait Islander quality appraisal tool.BMC Med Res Methodol. 2020; 20: 79Crossref PubMed Scopus (63) Google Scholar can systematically promote the epistemic publication value of research produced from and by First Nation communities. Important power shifts and process shifts are occurring in international journals, such as Kidney Medicine, to amplify Indigenous peoples’ knowledge.The kidney health writing collaboration of Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar was First Nation-led and multidisciplinary. Through this lens, readers are invited to witness the profound cultural strength of Indigenous peoples. These were revealed in the clustered identification of Cultural Safety concepts of relationality, engagement, and health care self-determination. These profound strengths occur among systemic issues (barriers and access) that are an ongoing legacy of colonialism and resonate with Australian experiences among Indigenous peoples as health care users.Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar advocate that Cultural Safety in kidney care within Indigenous communities requires further understanding and delineation. We agree but also provide an Australian example of Indigenous leadership in transforming kidney care. Australian processes that enable access to specialized kidney treatments, specifically to kidney transplantation, have only recently invited engagement of Aboriginal and Torres Strait Islander people.7Barrett E. Salem L. Wilson S. O'Neill C. Davis K. Bagnulo S. Chronic kidney disease in an Aboriginal population: A nurse practitioner-led approach to management.Aust J Rural Health. 2015; 23: 318-321Crossref Scopus (14) Google Scholar,8Hughes J.T. Dembski L. Kerrigan V. Majoni S.W. Lawton P.D. Cass A. Gathering perspectives - finding solutions for chronic and end stage kidney disease.Nephrology (Carlton). 2018; 23: 5-13Crossref Scopus (16) Google Scholar In early 2019, the Transplant Society of Australia and New Zealand secured federal government funding to establish a National Indigenous Kidney Transplant Taskforce, the first in more than 50 years of Australian transplantation. This Taskforce was formed to improve Aboriginal and Torres Strait Islander peoples’ access to kidney transplantation, recognizing the inequity of being a minoritized population (3% of the Australian population), with a 4-5 times higher incidence of end-stage kidney disease than other Australians, yet with lower access to kidney transplantation.9Khanal N. Lawton P.D. Cass A. McDonald S.P. Disparity of access to kidney transplantation by Indigenous and non-Indigenous Australians.Med J Aust. 2018; 209: 261-266Crossref PubMed Scopus (24) Google Scholar The Taskforce champions, who were Indigenous and non-Indigenous clinicians and transplantation leaders, met with the federal Minister of Indigenous Health, Hon Ken Wyatt AM, MP, in the preceding year, and all parties supported the Aboriginal and Torres Strait Islander peoples’ self-determination for equitable kidney transplant care8Hughes J.T. Dembski L. Kerrigan V. Majoni S.W. Lawton P.D. Cass A. Gathering perspectives - finding solutions for chronic and end stage kidney disease.Nephrology (Carlton). 2018; 23: 5-13Crossref Scopus (16) Google Scholar and recognized that systemic cultural bias contributed to lower access to transplantation.10Improving Access to and Outcomes of Kidney Transplantation for Aboriginal and Torres Strait Islander People in Australia: Performance Report. The Transplantation Society of Australia and New Zealand (TSANZ).https://www.anzdata.org.au/wp-content/uploads/2019/07/TSANZ-Performance-Report-Improving-Indigenous-Transplant-Outcomes-Final-edited-1.pdfGoogle Scholar This work has been shared in community meetings, conferences, and a recent publication.11D’Antoine M. Owen K. McDonald S. National Indigenous Kidney Transplantation Taskforce (NIKTT): an update.Transplant Journal of Australasia. 2021; 30: 5-6Google ScholarWith 3 years of funding (2019-2022), the Taskforce includes 25 members from the Aboriginal Community Controlled Health Sector, primary and tertiary health care, transplant units and medical, nursing and allied health professionals, and patient leaders. We committed to 4 principal activities:11D’Antoine M. Owen K. McDonald S. National Indigenous Kidney Transplantation Taskforce (NIKTT): an update.Transplant Journal of Australasia. 2021; 30: 5-6Google Scholar (1) convening an Aboriginal and Torres Strait Islander Consumer community network; (2) defining data variables and data capture to define barriers to access transplant workup; (3) Access and Equity Sponsorships, which provisioned $1 million across 7 pilot projects to support regionally defined initiatives to improving access to transplant waitlisting, and which privileged community-led and or community-health care partnerships; and (4) a review of Cultural Bias initiatives in Australian renal units. For this activity, the Taskforce commissioned the Lowitja Institute to review the depth of publications describing Cultural Bias initiatives in kidney transplantation in Aboriginal and Torres Strait Islander peoples in Australia.12Kelly J. Schwartzkopff K. O’Donnell K. Dent P. Owen K. Cultural bias initiatives to improve kidney transplantation among Aboriginal and Torres Strait Islander people−a scoping review.Nephrology. 2020; 25: 78Google Scholar Consistent with Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar, there is a critical need for Indigenous peoples to self-determine Culturally Safe Kidney Care as well as a critical need for research documentation that supports Indigenous academic, clinical, and methodological leadership and authorship.In conclusion, Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar entreat us in their systematic review, advocating for shifting power differentials so that all people (health providers and Indigenous recipients of health care) feel safe and respected in the health care system. There is a critical need to improve Cultural Safety in all health care interactions and for Indigenous peoples’ kidney care. Creating a body of knowledge within the academic repositories is crucial – we look forward to the day when systematic reviews can find hundreds, not a dozen, reports supporting programs that address these issues. Indigenous peoples’ self-determination in improved kidney health outcomes is critical; engagement, involvement and leadership in research, and design and service improvement of health care systems will be required to ensure that kidney health care is fit for this purpose. Related article, p 896 Related article, p 896 Related article, p 896 In this internationally important systematic review1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar identified and given voice by a First Nation-led multidisciplinary group in Canada and amplified internationally in this issue of Kidney Medicine, readers are invited to engage with Indigenous peoples’ perspectives about Cultural Safety in kidney care. Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar posit 2 knowledge systems: the Eurocentric academic process and a process that centers on Indigenous peoples and storytelling.1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar The review identified 2,232 articles, of which 15 relevant articles addressed the research question on Cultural Safety within the context of Indigenous kidney health care. The review focused on research from New Zealand, Australia, Canada, and the United States, dating back to 2002, when Cultural Safety as a term was proposed by Ramsden2Ramsden I.M. Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu. [PhD thesis]. Victoria University of Wellington, 2002Google Scholar and gained academic acceptance. Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar introduce the academic knowledge system in the methodology of the paper, but first comes the story of Indigenous peoples lost, missing, and dying in care systems that fail them. Indigenous people seek access to health care as well as optimal health care interactions and outcomes, just as non-Indigenous people do. The reader is challenged to consider Cultural Safety in kidney care for Indigenous peoples, with a prompt to readers to recognize “triggered unease” as expected experiences when engaging “issues of racism.” Racism has persisted in health systems and continues to harm Indigenous peoples in Canada, the United States, New Zealand, and Australia.3Indigenous Strategic Framework 2018-2028The Royal Australasian College of Physicians.https://www.racp.edu.au/about/board-and-governance/governance-documents/indigenous-strategic-framework-2018-2028Google Scholar This paper is a timely exploration of the depth and breadth of knowing of Cultural Safety, with its source material harvested from academic knowledge repositories. The 15 articles that Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar identified expose the differing assumptions of academic knowledge systems, in which academic repositories archive materials whose evidence ratings have been developed without the knowledge or values of Indigenous peoples. Nevertheless, this repository is used for purposes that fundamentally affect the nature of care provided to Indigenous peoples, including the teaching curricula of kidney health practitioners, designing health care systems, and accreditation of hospital practices.4Australian Commission on Safety and Quality in Health CareOverview: Improving Care for Aboriginal and Torres Strait Islander People. National Safety and Quality Health Service (NSQHS) Standards, Sydney, Australia2016Google Scholar In the area of kidney disease, the voices of Indigenous people have been largely absent from this repository, either as authors, researchers, or storytellers. Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar invite readers to reflect on sustained legacies of colonialism when considering the body of Cultural Safety in kidney care publications deposited in academic archives. Processes that intentionally make space (through shifting power) for Indigenous peoples’ self-determination in health care and those that promote improved health outcomes need research funding prioritization and the editorial commitment of assigning editors and journal reviewers to support research archiving. Utilization by editorial teams of research quality appraisal tools, which are designed by First Nations people,5Huria T. Palmer S.C. Pitama S. et al.Consolidated criteria for strengthening reporting of health research involving indigenous peoples: the CONSIDER statement.BMC Med Res Methodol. 2019; 19: 173Crossref PubMed Scopus (97) Google Scholar,6Harfield S. Pearson O. Morey K. et al.Assessing the quality of health research from an Indigenous perspective: the Aboriginal and Torres Strait Islander quality appraisal tool.BMC Med Res Methodol. 2020; 20: 79Crossref PubMed Scopus (63) Google Scholar can systematically promote the epistemic publication value of research produced from and by First Nation communities. Important power shifts and process shifts are occurring in international journals, such as Kidney Medicine, to amplify Indigenous peoples’ knowledge. The kidney health writing collaboration of Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar was First Nation-led and multidisciplinary. Through this lens, readers are invited to witness the profound cultural strength of Indigenous peoples. These were revealed in the clustered identification of Cultural Safety concepts of relationality, engagement, and health care self-determination. These profound strengths occur among systemic issues (barriers and access) that are an ongoing legacy of colonialism and resonate with Australian experiences among Indigenous peoples as health care users. Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar advocate that Cultural Safety in kidney care within Indigenous communities requires further understanding and delineation. We agree but also provide an Australian example of Indigenous leadership in transforming kidney care. Australian processes that enable access to specialized kidney treatments, specifically to kidney transplantation, have only recently invited engagement of Aboriginal and Torres Strait Islander people.7Barrett E. Salem L. Wilson S. O'Neill C. Davis K. Bagnulo S. Chronic kidney disease in an Aboriginal population: A nurse practitioner-led approach to management.Aust J Rural Health. 2015; 23: 318-321Crossref Scopus (14) Google Scholar,8Hughes J.T. Dembski L. Kerrigan V. Majoni S.W. Lawton P.D. Cass A. Gathering perspectives - finding solutions for chronic and end stage kidney disease.Nephrology (Carlton). 2018; 23: 5-13Crossref Scopus (16) Google Scholar In early 2019, the Transplant Society of Australia and New Zealand secured federal government funding to establish a National Indigenous Kidney Transplant Taskforce, the first in more than 50 years of Australian transplantation. This Taskforce was formed to improve Aboriginal and Torres Strait Islander peoples’ access to kidney transplantation, recognizing the inequity of being a minoritized population (3% of the Australian population), with a 4-5 times higher incidence of end-stage kidney disease than other Australians, yet with lower access to kidney transplantation.9Khanal N. Lawton P.D. Cass A. McDonald S.P. Disparity of access to kidney transplantation by Indigenous and non-Indigenous Australians.Med J Aust. 2018; 209: 261-266Crossref PubMed Scopus (24) Google Scholar The Taskforce champions, who were Indigenous and non-Indigenous clinicians and transplantation leaders, met with the federal Minister of Indigenous Health, Hon Ken Wyatt AM, MP, in the preceding year, and all parties supported the Aboriginal and Torres Strait Islander peoples’ self-determination for equitable kidney transplant care8Hughes J.T. Dembski L. Kerrigan V. Majoni S.W. Lawton P.D. Cass A. Gathering perspectives - finding solutions for chronic and end stage kidney disease.Nephrology (Carlton). 2018; 23: 5-13Crossref Scopus (16) Google Scholar and recognized that systemic cultural bias contributed to lower access to transplantation.10Improving Access to and Outcomes of Kidney Transplantation for Aboriginal and Torres Strait Islander People in Australia: Performance Report. The Transplantation Society of Australia and New Zealand (TSANZ).https://www.anzdata.org.au/wp-content/uploads/2019/07/TSANZ-Performance-Report-Improving-Indigenous-Transplant-Outcomes-Final-edited-1.pdfGoogle Scholar This work has been shared in community meetings, conferences, and a recent publication.11D’Antoine M. Owen K. McDonald S. National Indigenous Kidney Transplantation Taskforce (NIKTT): an update.Transplant Journal of Australasia. 2021; 30: 5-6Google Scholar With 3 years of funding (2019-2022), the Taskforce includes 25 members from the Aboriginal Community Controlled Health Sector, primary and tertiary health care, transplant units and medical, nursing and allied health professionals, and patient leaders. We committed to 4 principal activities:11D’Antoine M. Owen K. McDonald S. National Indigenous Kidney Transplantation Taskforce (NIKTT): an update.Transplant Journal of Australasia. 2021; 30: 5-6Google Scholar (1) convening an Aboriginal and Torres Strait Islander Consumer community network; (2) defining data variables and data capture to define barriers to access transplant workup; (3) Access and Equity Sponsorships, which provisioned $1 million across 7 pilot projects to support regionally defined initiatives to improving access to transplant waitlisting, and which privileged community-led and or community-health care partnerships; and (4) a review of Cultural Bias initiatives in Australian renal units. For this activity, the Taskforce commissioned the Lowitja Institute to review the depth of publications describing Cultural Bias initiatives in kidney transplantation in Aboriginal and Torres Strait Islander peoples in Australia.12Kelly J. Schwartzkopff K. O’Donnell K. Dent P. Owen K. Cultural bias initiatives to improve kidney transplantation among Aboriginal and Torres Strait Islander people−a scoping review.Nephrology. 2020; 25: 78Google Scholar Consistent with Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar, there is a critical need for Indigenous peoples to self-determine Culturally Safe Kidney Care as well as a critical need for research documentation that supports Indigenous academic, clinical, and methodological leadership and authorship. In conclusion, Smith et al1Smith M. Silva e Silva V. Schick-Makaroff K. et al.Furthering cultural safety in kidney care within indigenous communities: a systematic and narrative review.Kidney Med. 2021; 3: 895-903Abstract Full Text Full Text PDF Scopus (1) Google Scholar entreat us in their systematic review, advocating for shifting power differentials so that all people (health providers and Indigenous recipients of health care) feel safe and respected in the health care system. There is a critical need to improve Cultural Safety in all health care interactions and for Indigenous peoples’ kidney care. Creating a body of knowledge within the academic repositories is crucial – we look forward to the day when systematic reviews can find hundreds, not a dozen, reports supporting programs that address these issues. Indigenous peoples’ self-determination in improved kidney health outcomes is critical; engagement, involvement and leadership in research, and design and service improvement of health care systems will be required to ensure that kidney health care is fit for this purpose. Jaqui T. Hughes, BMed, PhD, Kelli J. Owen, MA, and Stephen P. McDonald, MBBS, PhD. Dr Hughes holds research funding from the National Health and Medical Research Council (NHMRC, fellowship number 1174758). Dr McDonald holds research funding from the NHMRC (Investigator Grant 1173941), Baxter Healthcare (Investigator-initiated grants), and the South Australia Hospital Research Foundation. The authors declare that they have no relevant financial interests. Dr Hughes is a Torres Strait Islander woman (Wagadagam tribe), a nephrologist and clinician researcher, mentor, and Indigenous Health Systems Innovator based on Larrakia Country (Darwin, Northern Territory, Australia). Ms Owen is a mother, sister, daughter, aunty, and proud First Nations community member (Kaurna, Narungga & Ngarrindjeri), and an activist and a teacher, who lives on Ngarrindjeri Country and works across Kaurna Country. Received October 13, 2021 in response to an invitation from the journal. Direct editorial input from the Editor-in-Chief. Accepted in revised form October 26, 2021. Furthering Cultural Safety in Kidney Care Within Indigenous Communities: A Systematic and Narrative ReviewKidney MedicineVol. 3Issue 6PreviewCultural Safety is being prioritized within health care around the world. As a concept, Cultural Safety centers upon power relations between health providers and indigenous recipients of care, ensuring that all people feel safe and respected in the health care system. In this article, we explored the breadth of the literature regarding Cultural Safety within the context of indigenous kidney health care. Full-Text PDF Open Access

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