Braiding knowledges

Abstract

Objective

To evaluate the integration of Indigenous healing practices within an interprofessional team-based primary care clinic.

Design

Guided by the Two-Eyed Seeing and Eco-Normalization frameworks, a developmental evaluation was conducted from November 2023 to July 2024, and included surveys, semistructured interviews, and a facilitated sharing circle. Quantitative data were analyzed descriptively. Deductive content analysis—using the Eco-Normalization Framework and the Empathy Map analysis—was used for qualitative data analysis.

Setting

An interprofessional team-based primary care clinic in Winnipeg, Man, in Canada.

Participants

Indigenous and non-Indigenous patients (n=9) and health care providers (n=14).

Methods

An Indigenous Elder, Knowledge Keeper, and mental health counsellor were integrated into the study to embed Indigenous ways of knowing into care. Perspectives of patients and health care providers regarding the perceived value of integrating Indigenous ways of knowing and healing were explored.

Main findings

Nine themes emerged: valuing Indigenous ways of knowing and healing; culturally relevant, holistic care; incorporating Indigenous healing practices; whole-person care; collaboration within a team-based model; relationship building; barriers to health care access; lost traditional knowledge and continuation of intergenerational trauma; and centrality of emotional health. Patients and providers reported improved cultural safety, enhanced trust, and deeper engagement. Key facilitators included interdisciplinary collaboration, community partnerships, and integration of ceremony and land-based healing. Challenges included systemic barriers beyond the clinic and sustainability concerns.

Conclusion

Integrating Indigenous knowledge into team-based primary care can advance culturally safe, holistic, and equity-oriented health services. Structural transformation, sustainable funding, Indigenous governance, and embedding Indigenous ways of knowing into health professional education are critical for scaling and sustaining such models. Our findings support the Truth and Reconciliation Commission of Canada’s Calls to Action.

For more than 4 decades, shifts toward interdisciplinary, team-based models of care to improve population health and health equity have been a priority in Canada.¹ This included the Primary Health Care Transition fund from 2000 to 2006, which provided $800 million to provinces, territories, and health care system stakeholders to accelerate the development and implementation of new models of primary health care delivery.² However, despite these commitments to improved health care delivery, systemic inequities persist, with colonial structures contributing to disparities in access, quality, and health outcomes for communities who are marginalized, including Indigenous peoples.^3-5 Intergenerational trauma, including cultural suppression, family separation, and widespread abuse, has profoundly shaped health trajectories, manifesting in higher rates of illness among survivors and their descendants.^6-8

While Canada has made important strides toward reconciliation,⁹ a persistent gap remains in embedding Indigenous ways of knowing and healing into European-centric dominant health systems. Indigenous voices, as echoed in the Truth and Reconciliation Commission of Canada’s (TRC’s) Calls to Action for health⁶ and the United Nations Declaration on the Rights of Indigenous Peoples, call for a health system that honours both Western and Indigenous knowledge systems and supports culturally safe and responsive, holistic care.^10,11

Team-based care models have the potential to increase access to holistic and culturally safe care for Indigenous populations.^4,10,12 Understanding how team-based primary care can integrate Indigenous healing practices is crucial to building systems that are not only effective, but respectful and responsive to Indigenous worldviews.^13,14 In this study, we respond directly to the TRC’s Calls to Action by evaluating the integration of Indigenous ways of knowing and healing within an interprofessional, team-based primary care practice. We explored perspectives of patients and health care providers (HCPs) regarding the perceived value of integrating Indigenous ways of knowing and healing; and applied a user-centred design approach to understand the emotional and experiential dimensions of this innovation’s influence.

METHODS

Study design

This study was conducted as part of the Team Primary Care: Training for Transformation initiative (https://www.teamprimarycare.ca). A multimethod developmental evaluation^15-18 was applied from November 2023 to July 2024, and was guided by the Two-Eyed Seeing and Eco-Normalization frameworks.^17-21 Ethics approval was granted by the Human Research Ethics Board at the University of Manitoba and Shared Health Research and Innovation Manitoba. Reporting adhered to the Consolidated Criteria for Reporting Qualitative Research checklist (Appendix M, available from CFPlus^*).

Population and recruitment

We recruited Indigenous and non-Indigenous patients and HCPs from a clinic using homogeneous purposive sampling.²² Patients were invited through posters posted throughout the clinic (the ballot box was located at the reception desk), a secure ballot system, or recommended by the Knowledge Keeper. HCPs were recruited through Team Primary Care meetings and email invitations.

Data collection

We used a repeated-measures process to gather multiple measurements of similar variables from patients and HCPs through surveys, interviews, and a facilitated sharing circle (Table 1).^4,14,21,23 All data were de-identified and stored on a password-protected laptop that only 1 study member (J.D.) could access.

Table 1.

Outline of data collection methods in chronological order

DATA COLLECTION METHOD	TIMELINE	DESCRIPTION OF DATA COLLECTED	PARTICIPANTS
Semistructured interviews with field notes*	Oct 2023 to Apr 2024	Care experiences and perceived impact of Indigenous services (Appendix E†)	Patients (n=6)
Survey 1‡	Nov 2023	Role, identity, and baseline experience working with Indigenous peoples (Appendix A)	HCPs (n=11)
Survey 2‡	Mar 2024	Reflections after participating in a land-based day—a day spent learning on the land through cultural and ecological activities guided by an Elder (Appendix B)	HCPs (n=13)
Survey 3‡	Apr 2024	Role, identity, and midpoint experience working with Indigenous peoples (Appendix C)	HCPs (n=14)
Facilitated sharing circle§	Jun 2024	A traditional Indigenous approach to relationship building and dialogue21 Began with a pipe ceremony and smudging led by the Knowledge Keeper, followed by a video introduction by an author (D.M.H.) Collected perspectives of integrating Indigenous ways of knowing into team-based primary care (Appendix G) A graphic artist visually captured participants’ contributions, which are described alongside the study evaluator’s (J.D.) reflection in the appendix (Appendices J and K)	HCPs (n=4) Patients (n=3)
Survey 4‡	Aug 2024	Final perspectives of those who missed the sharing circle (Appendix D)	HCPs (n=3)
Follow-up telephone interview with field notes*	Aug 2024	Final perspectives of those who attended the sharing circle to ensure patients had space to provide any insights they may have not been able to express during the sharing circle, either due to time or power dynamics of the sharing circle being conducted with both patients and HCPs (Appendix F)	Patients (n=3)

HCP—health care provider.

^*Conducted by the study evaluator (J.D.) with an average duration of 60 minutes. Participants were not recorded to promote a safe environment and participants received a $5 honorarium.

^†All appendices are available from CFPlus.

^‡Administered via SurveyMonkey by the study evaluator (J.D.).

^§Facilitated by 2 authors (K.M., M.B.) over 2.5 hours. Patients received a $40 honorarium.

Data analysis

Quantitative survey responses were analyzed using descriptive statistics in Microsoft Excel. Qualitative data, including sharing circle transcripts (transcribed via Trint software²⁴), field notes, and open-ended responses, were analyzed in Microsoft Word in 2 stages: first, through deductive content analysis using the Eco-Normalization Framework (ENF),²⁵ which explores interactions between innovations, people, and systems across 6 domains (Appendix H, available from CFPlus^*); and second, through an Empathy Map analysis²⁶ to surface underlying emotions, barriers to, and facilitators of innovation impact (Appendix I, available from CFPlus^*).

Initial coding was piloted by 3 researchers (J.D., S.G., Z.L.) before full coding proceeded in pairs (J.D., S.G.) with weekly alignment checks and consensus by a third researcher (Z.L.) if needed.

All participants were provided with a summary of findings and invited to offer feedback to ensure accuracy and integrity of interpretations.

RESULTS

A total of 9 patients and 14 HCPs participated in this study. No participants withdrew from the study (Table 1).²¹

Overview of health care providers

Most HCPs identified their role as clinicians in both surveys 1 and 3 (n=8 and n=9). Three HCPs self-identified as Indigenous in both surveys. At the start of the innovation, 6 HCPs identified as settlers; at mid-point, 9 did. In survey 1, 73% of HCPs reported extensive experience working with Indigenous patients, while 1 HCP reported limited experience. By survey 3, all but 1 HCP (93%) indicated their comfort level working with Indigenous peoples had improved since the beginning of the innovation (no baseline data were collected for this measure) (Table 2).

Table 2.

Health care provider characteristics and experience working with Indigenous peoples: Survey 1 (November 2023) was the start of innovation implementation. Survey 3 (April 2024) was midway through innovation implementation. N=14.

CHARACTERISTICS	SURVEY 1, n (%), n=11	SURVEY 3, n (%), n=14
HCP role
• Clinician	8 (73)	9 (64)
• Other	2 (18)	3 (21)
• No Response	1 (9)	2 (14)
Self-identity*
• Indigenous	3 (27)	3 (21)
• Settler	6 (54)	9 (64)
• Canadian born	5 (45)	10 (71)
• Non-Canadian born	2 (18)	2 (14)
Experience working with Indigenous peoples
• Lots of experience	8 (73)	NA†
• Feel comfortable	5 (45)	NA†
• Less experience	1 (9)	NA†
Improvement in comfort level working with Indigenous peoples
• Yes	NA†	13 (93)
• No	NA†	1 (7)

HCP—health care provider, NA—not applicable.

^*Respondents were allowed to choose more than 1 option.

^†Question was not asked in the survey.

Participants’ perspectives and experiences

Analysis of qualitative data generated 9 key themes that reflected participants’ experiences with the integration of Indigenous ways of knowing and healing practices. Table 3 provides a detailed mapping of each theme to the ENF, supported by illustrative quotes and frequency of occurrence across the data set. Additional exemplary quotes are found in Appendix L, available from CFPlus.^*

Table 3.

Generated themes from patients and health care providers about their experiences

THEMES AND ENF DOMAINS (NO. OF TIMES CODED)	EXEMPLARY QUOTATIONS*
Valuing Indigenous ways of knowing, healing practices, and intergenerational healing (35 codes: GA & S, GA & P, I & S, S & P, P & I)	I was actually valued if I was an Indigenous person.... It’s been really amazing as an Indigenous person to start seeing the things that I feel in my heart, my spirit, are incorporated into our clinic. And I think if I can feel like I belong more in this space then our patients are going to feel like they belong more in [this] space (SC-S258)
Culturally relevant and holistic care is better care (21 codes: GA & I, GA & S, GA & P, I & S, S & P, P & I)	This complementary approach has made my need for follow-up visits decrease while facilitating improved access to care for my patients. I am so nervous to go back to providing care without these culturally appropriate care supports in place. I feel the care my patients will receive will be of lower quality (S4, anonymous HCP)
Incorporating Indigenous ways of knowing and practices (15 codes: GA & I, GA & S, GA & P, I & S, P & I)	I find the actual incorporation in a meaningful way challenging, it helps me address the needs of my patients in a way that actually meets their needs in a much better way thus requiring less face-to-face time or visits to address their needs. That said, it is challenging for me to adjust my approach to be in line with Indigenous ways of knowing in order to accomplish this (and I am still learning and only attempting to do this) (S4, anonymous HCP)
Whole-person care as a systemic goal (14 codes: GA & I, GA & S, GA & P, I & S, S & P, P & I)	It’s not just about siloing, Indigenous wellness in this thing, but it’s about everybody’s wellness. It’s about reining in how we do things and how we function from day to day (SC-S258)
Collaboration and support within a team-based model (12 codes: GA & P, GA & S, I & S, S & P, P & I)	And to have the [Knowledge Keeper] and [mental health counsellor] here to support our patients. And it just again, it just helps to recognize, you know who they are. And tightens that relationship too between the important person as well because they see that I recognize that these things that I cannot provide but I have colleagues that do, trusted colleagues, people who I know will be providing good care in the same way (SC-S297)
Relationship-building between health care providers and patients (11 codes: GA & I, GA & P, I & S, P & I)	Different people need different things and we’re all so different. And you know, working within a team, we have different people that, like I said, offered their various gifts (SC-S297)
Barriers to accessing health care for Indigenous peoples (10 codes: GA & S, GA & P, I & S, S & P)	Yes, it gave me perspective on specific ways that racism is perpetuated in the health care system and led me to explore how those same issues play out in my area of practice (S2-S411)
Loss of traditional knowledge and cultural practice; continuation of intergenerational trauma (9 codes: GA & I, GA & S, GA & P, I & S, S & P)	I never grew up with these traditional ways. There were some things, some influences that I did have, but it was not talked about because it was against the law, too (SC-S265)
Mental and emotional health being central to overall health (9 codes: GA & S, GA & P, I & S, S & P, P & I)	That mental health piece I had to unload. I had to talk about it. I had to, you know, this is my reality, and this is what I am experiencing and connecting. It’s affecting my health. Right? And if my health is affected, then my children, who’s going to look after my daughters? (SC-P336)

ENF—Eco-Normalization Framework, GA—grand aspiration, HCP—health care provider, I—innovation, P—people doing the work, S—system, SC—sharing circle.

^*Quotations are from HCPs (ie, system) and patients (ie, people doing the work) from the recorded SC, land-based day survey 2 (S2), and survey 4 (S4), anonymously; interviews and the SC follow-up telephone calls were not recorded so verbatim quotations are unavailable.

Valuing Indigenous ways of knowing, healing practices, and intergenerational healing. HCPs described integrating Two-Eyed Seeing into their care practices and expressed commitment to the TRC’s Calls to Action.⁶ Patients emphasized the value of having space for conversations beyond physical health, focusing on empowerment and holistic wellness.

Culturally relevant and holistic care is better care. HCPs felt better equipped to provide culturally safe and preventive care. Patients reported stronger connections with themselves and providers and described the clinic as a safe and supportive environment.

Incorporating Indigenous ways of knowing and practices. Patients reported feeling connected to their identity and supported beyond conventional medical models. HCPs described the integration as a natural extension of their daily work.

Whole-person care as a systemic goal. HCPs described moving beyond a biomedical approach to support patients holistically—physically, mentally, emotionally, and spiritually. Patients expressed appreciation for being seen and treated as a whole person.

Collaboration and support within a team-based model. HCPs noted improvements in team cohesion and described a clinic culture that was inclusive and respectful.

Building relationships between HCPs and patients. Participants highlighted how time, intention, and open dialogue created opportunities for healing and enhanced care quality.

Barriers to accessing health care for Indigenous peoples. Both HCPs and patients identified ongoing systemic barriers, such as limited availability of culturally appropriate services. HCPs expressed empathy and acknowledged the need for structural change to advance reconciliation.

Loss of traditional knowledge and cultural practice; continuation of intergenerational trauma. Patients shared how colonial histories, including residential schools, disrupted cultural continuity and identity. They emphasized that Western biomedical care alone is insufficient to meet their needs and called for the integration of traditional knowledge in healing.

Mental and emotional health as central to overall well-being. The innovation’s emphasis on holistic care was seen as critical to patient healing, moving beyond physical symptoms to address core dimensions of health.

Emotional and experiential dimensions of innovation

Our Empathy Map analysis illuminated the underlying emotions, attitudes, barriers, and facilitators shaping the innovation’s impact on both HCPs and patients. The Visual Empathy Map, available from CFPlus,^* provides a summary of the empathy maps for both HCPs and patients.

Hear. Most HCPs reported hearing frequent discussions about health disparities faced by Indigenous populations, alongside narratives that emphasized the importance of community engagement and the integration of Western and Indigenous knowledge systems. Patients recalled hearing the Knowledge Keeper’s guidance and messages that reinforced the importance of self-care and cultural reconnection.

See. HCPs noted visible expressions of racism, the realities of remote community health care, and the impact of witnessing Indigenous patients share personal stories and reclaim their cultural identities. They also observed Indigenous staff members meeting patients where they were—honouring their priorities and pace of care. Patients described seeing culturally affirming practices, including smudging ceremonies, advocacy for Indigenous wellness, and the creation of safe spaces. They also recognized the effects of “perimeteritis,” described as “all the access to care is in that perimeter and you are out of the perimeter.” Mental health also emerged as a visually and emotionally salient aspect of care.

Think and feel. HCPs characterized the innovation as essential, fostering personal and professional growth, reconnecting with land-based healing traditions, and enriching their capacity for holistic care. They expressed a sense of renewed purpose in aligning care with patients’ cultural and spiritual values. Patients described feelings of gratitude, recognition, and support. They emphasized the innovation helped them feel seen as whole people. Despite ongoing challenges with access, patients saw the innovation as affirming their identities and essential for well-being.

Say and do. HCPs articulated a desire to shift conventional practices, advocate for Indigenous leadership and resources, and reported feeling affirmed by their participation in the innovation. They described forming deeper connections with patients. Patients shared a mix of grief and resilience, often questioning systemic neglect while also expressing a willingness to accept support in any form available. Their actions reflected determination to engage with culturally meaningful care when it was offered.

Challenges and obstacles. HCPs highlighted resource constraints and the sustainability of the innovation as major concerns. Despite challenges, HCPs emphasized that team cohesion and a shared vision were critical to advancing high-quality care. Patients noted that systemic gaps remain and expressed concern culturally relevant care could be easily dismissed or deprioritized. They stressed the need for continued effort to decolonize health care delivery and protect Indigenous healing practices.

Facilitators and successes. HCPs cited the integration of Indigenous and biomedical knowledge systems as a foundational strength, along with the collaborative nature of interdisciplinary practice. Embedding Indigenous practices into routine care was seen as a sign of successful cultural transformation. Patients reported a greater sense of self-understanding and confidence in their health. They recognized the innovation’s success required a collective, team-based effort, reinforcing the value of interprofessional collaboration in advancing culturally safe care.

DISCUSSION

This developmental evaluation demonstrates how integrating Indigenous ways of knowing and healing practices into an interprofessional primary care clinic can foster culturally safe, holistic, and responsive care.

Valuing Indigenous knowledge was a foundational element. Both HCPs and patients acknowledged the importance of Indigenous epistemologies—particularly oral traditions, land-based knowledge, and spirituality—as critical to understanding and delivering meaningful care. These findings reflect growing literature emphasizing the need to decolonize health care systems by integrating Indigenous perspectives.¹²

Culturally relevant and holistic care was viewed as superior to standard biomedical models. The innovation deliberately addressed physical, emotional, mental, and spiritual dimensions of health, with participants frequently describing care as “whole person.” This is consistent with a scoping review of Indigenous primary health care models that emphasized comprehensive, culturally secure, and community-informed care as hallmarks of success.¹² Patients reported improved trust, fewer missed appointments, and greater personal reflection on health, while HCPs felt more confident in addressing social and historical determinants of health.¹²

Incorporating Indigenous healing practices—including smudging, talking circles, land-based activities, and visits with Elders—was seen as an essential part of wellness by both patients and providers. HCPs noted how these ceremonies facilitated patient engagement, trust, and emotional healing. Previous studies have similarly found that embedded Indigenous-led healing programs increase mental health resilience and cultural pride.^8,21 Our study builds on this evidence by demonstrating how such integration can be operationalized in an interprofessional primary care clinic.

The emphasis on whole-person care as a systemic goal was evident throughout. Providers made efforts to address structural determinants alongside biomedical issues, which was valued by patients, as acknowledgment of their intergenerational trauma was vital to healing. Browne et al²⁷ argue that equity-oriented health care must attend to patients’ structural vulnerabilities and histories of colonization. Our results support this, showing how teams who intentionally link clinical and social care can better support Indigenous well-being.

Collaboration and support within a team-based model was also a prominent theme. HCPs described the process of shared learning, co-reflection, and interdisciplinary trust as instrumental to high-quality care. Similar conclusions have been drawn in studies of Aboriginal Medical Services in Australia and First Nations–led clinics in British Columbia, where shared governance and interprofessional teamwork enhanced cultural safety and service responsiveness.^12,27

Relationship-building between patients and providers emerged as a critical driver of success. Many patients entered the clinic with deep skepticism due to previous experiences of racism and neglect. However, sustained, culturally affirming relationships with HCPs—especially those who were Indigenous or who visibly respected Indigenous traditions (ie, allies)—allowed patients to feel seen and supported. These findings resonate with research that emphasized trust and belonging are prerequisites for Indigenous engagement in institutional settings.^14,21

Despite the innovation’s strengths, barriers to health care access persisted. Participants highlighted challenges, including limited appointment availability, lack of transportation, and subtle forms (ie, institutional or cultural norms and historical biases that lead to inequities in accessing care and health outcomes) of systemic racism beyond the clinic’s walls. These barriers are well-documented in Indigenous health literature and reinforce the need for broader system reforms.^4,27

Participants also described the loss of traditional knowledge and intergenerational trauma as persistent undercurrents affecting health. Providers were mindful of these histories and attempted to foster reclamation through ceremony, education, and culturally rooted counselling. Wilk et al⁷ found survivors of residential schools and their descendants carry substantially higher burdens of chronic disease and mental illness, underscoring the importance of trauma-informed, culturally grounded care.

Finally, spiritual, mental, and emotional health were positioned as central health priorities. The innovation created space for patients to discuss grief, identity loss, and resilience, often through traditional healing mechanisms and ceremonies. Providers expressed gratitude for having the tools to address spiritual and emotional wellness beyond pharmacotherapy. This supports findings from studies of Indigenous mental health programs that emphasize cultural identity and reconnection as essential therapeutic tools.^21,27 Importantly, the co-presence of mental health counsellors and Elders created layered, complementary support that many patients found healing.

Strengths and limitations

First, while the study was conducted at a single urban clinic, the richness of contextual detail enhances the transferability of findings to similar interprofessional and culturally integrated primary care settings. Second, although the sample size was modest, it was consistent with the principle of information power²⁸ to generate meaningful insights given the study’s focused aim, strong dialogue quality, and applied theoretical frameworks. Third, patient interviews were not audiorecorded to prioritize psychological safety. The lack of recording may have resulted in a loss of tone, message, and language, as well as an increased reliance on the study evaluator’s (J.D.) interpretation of the interview. To ensure accountability and limit bias, the study evaluator (J.D.) kept a detailed log of interview notes that were used during analysis. This approach may have affected data completeness, though detailed field notes were used to capture narratives. Fourth, sex and gender were not considered in this study, as we did not feel this information would add or detract from the study, so these data were not collected. Finally, given the close relationships between some participants and members of the research team, there is a possibility of social desirability bias. However, this embeddedness also facilitated trust, which is essential for eliciting candid accounts in Indigenous health research.

Implications for policy and practice

To advance reconciliation in primary care, health systems should prioritize the TRC’s Calls to Action 18 to 24.⁶ This includes formally recognizing and funding Indigenous healing practices, ensuring Indigenous cultural responsiveness and safety is embedded in health professions education and reinforced by accrediting bodies, and embedding Indigenous-led care models within mainstream health services. As reinforced by our findings, sustainability of these innovations beyond the research study is a challenge. Our study showed that integrating Indigenous ways of healing and knowing into routine clinical practice was beneficial for patient experiences and health. However, if this innovation and subsequent positive impacts cannot be sustained, it may lead to a waste of resources, poor patient experiences, and increasing the gap in care for populations who are marginalized.

Sustainability is influenced by factors including funding, workforce availability, adaptability of the innovation, and partnerships.²⁹ Establishing governance partnerships with Indigenous communities including Elders, Knowledge Keepers, and dedicated staff is essential to sustain these investments.

Conclusion

This study contributes to the growing body of evidence that Indigenous-led, culturally safe, team-based care fosters better health. Our findings are transferable to team-based models of care in addition to primary care settings (eg, hospitals, communities, home care) and aim to provide person-centred care through integrating Indigenous ways of knowing and healing as part of clinical practice. By valuing Indigenous ways of knowing and fostering respectful relationships, health systems can move meaningfully toward equity and reconciliation.