Table 3. Personal Factors as Sources or Reasons for Practice of Power by the Regional Office Managers^a .

	Supporting Implementation	Constraining Implementation
Sources underpinning the exercise of power (the how question)	Value judgment “It is the right thing to do”(Program Assistant). “We accommodate as long as safety is not compromised; standard of care is not sacrificed”(Regulation and Licensing Officer). Intrinsic motivation linked to indigeneity “I am Indigenous. That’s my driving force”(Program Assistant). “We have Indigenous wisdom and technology that could be integrated in health programs”(Regulation and Licensing Officer). Knowledge and skills relevant to tasks (cultural competence) from training, education, experience Planning Officer: social science educational background, previous work in Indigenous areas; Training Specialist A: IP Focal Person in previous work; LHSS Chief: previous medical work in Indigenous area; Program Assistant: previous work in Indigenous development field; Regulation and Licensing Officer: previous employment in the NCIP.	An attitude of low regard for what is Indigenous “Why did we imbibe Western culture so easily? Because of our colonial history. It degraded the Indigenous peoples’ spirit. ‘IP’ is associated with ‘superstition, backward, substandard.’ They got our psyche. Nobody wants to be seen as backward”(Provincial Health Officer). “There is doubt in ‘traditional medicine’ compared to the scientific data written in our books”(Training Specialist B). Lack of knowledge and skills on Indigenous health and culture/cultural competence Lack of awareness on Indigenous culture and issues “We lack awareness on Indigenous peoples’ issues”(Planning Officer).
Reasons why power was exercised in these ways (the triggers for exercising power)	Alignment of personal values with policy “I’m proud to be IP so my principle is you cannot say you are IP if it doesn’t show in your actions and work”(Training Specialist A). Personal commitment and motivation “I look for that (culture-sensitivity) because I’m Indigenous”(Licensing Officer).	Lack of commitment Unclear concept or limited understanding of what Indigenous health is “On Indigenous health, if your assumption is that because we are all Indigenous, that’s just the coverage of your services. It doesn’t tell about the quality or culture-sensitivity. We lack a deeper understanding of what culture sensitive means for our Indigenous peoples’ services”(LHSS Chief). Unclear about the need for ‘Indigenous Peoples health’ in the region “Our weak regard for our Indigenous health locally may be unintentional because we are the majority here in our region. Maybe if we are the minority, we would be more conscious of it”(Planning Officer). Limited skills for local Indigenous Peoples health “In our transcultural nursing, we learned about other countries’ culture like Mexico’s but not ours. We were groomed for the NCLEX”(Training Specialist B). “There’s no Indigenous Peoples health in our educational curriculum”(Planning Officer). Lack of guidance and incentives Indigenous Peoples Health is seen as an additional task/workload “Everybody’s overloaded with many programs. Personally I want to see the integration of Indigenous health in the programs. But I see the workload as a barrier”(Training Specialist). Indigenous health activities in Individual performance target not institutionalized and sustained. Policy not clear about instances when Indigenous culture may be in conflict with DOH standards/other policies.

Abbreviations: DOH, Department of Health; LHSS, Local Health System Section; NCIP, National Commission on Indigenous Peoples, NCLEX nursing examination to practice in USA.

^aCategories adapted from Gilson et al. ²⁶