Undergraduate Nursing Students' Experience of Northern Rural and Remote Indigenous Communities

Undergraduate nursing programs are moving towards a service learning model in teaching nursing student cultural awareness. In this article, we discuss the nursing student experience in a university elective which immerses students in rural and remote Indigenous communities resulting in cultural consciousness. This service learning experience that students encountered promoted growth in nursing praxis, and fostered positive curriculum growth and community partnerships between the College and the Indigenous communities in which they visited. Students gained cultural consciousness and increased awareness, which is beneficial in their future nursing careers as they grow into better culturally competent care providers. Also discussed is the history and background of these Indigenous communities, The Truth and Reconciliation Commission (TRC) and the First Nations Principles of OCAP (ownership, control, access and possession). These topics are discussed in detail throughout the student experience as they respond to nurses’ professional standards, development of cultural competency and integrating calls to action in truth and reconciliation.


Introduction
Recent literature provides evidence of the value of immersion in rural Indigenous communities in its ability to promote cultural awareness and cultural safety (Amerson & Livingston, 2014;Alexander-Ruff & Kinion, 2018). Integrating this kind of cultural learning is particularly valuable in nursing curriculums to enable cultural awareness and to educate culturally competent healthcare providers (Alexander-Ruff & Kinion, 2018; Canadian Association of Schools of Nursing (CASN, 2010). Bachelor of Science in Nursing (BScN) programs have begun to incorporate rural and remote experiences into their curricula in order to enhance experiential learning to promote success for young nurses to excel in these unique work settings (Bennett, Jones, Brown & Barlow, 2013) The purpose of this article is to disseminate the positive learning experiences and cultural consciousness, gained by undergraduate nursing students, as a result of the service learning experience via different teaching and learning models in rural and remote Indigenous communities. The context of a rural and remote nursing experience, in addition to reviewing the history and background of the communities visited is highlighted. The Truth and Reconciliation Commission (TRC) and the First Nations Principles of OCAP (ownership, control, access and possession) will be discussed in terms of its values to nursing education and to the nursing curriculum.

Experiential Learning Theory (ELT)
Two Models within ELT include Dewey's Model of experiential learning and Piaget's model of Learning and Cognitive development. Dewey's Model of experiential learning integrates experience with concepts, observations and actions and suggests a feedback process that transforms feelings and desires of the concrete experience into purposeful, direction-based actions (Kolb, 1984;Alexander-Ruff, 2016). Piaget's Model of Learning and Cognitive development encompasses the dimensions of experience and concepts, reflection and action through the process of development from infancy to adulthood where cognition moves from a concrete view of the world to an abstract constructivist view. He states that the learning process develops over cycles of interactions between individuals and their environment (Kolb, 1984;Alexander-Ruff, 2016). Therefore, ELT's overall approach demonstrates the power of amalgamating empirical and theoretical ideologies in teaching and learning (Kolb, 1984;Miettinen, 2000;Alexander-Ruff, 2016).
Consistent to these models, is the understanding that learning is a process and not an outcome. ELT addresses the concept of ideas, that ideas are not fixed, but rather are formed and reformed through experiences. It moves away from the traditional educational learning experience which has little environmental interactions and is largely limited to books, teachers and classrooms (Kolb, 1984;Alexander-Ruff, 2016). As such, nursing students are constantly learning as they interact with their environment which can have powerful influences on their values and beliefs.
Assignments required throughout the course included the completion of a learning plan and two critical reflections with the use of SMART goals (specific, measurable, attainable, relevant and time-bound) in order to meet professional nursing standards and the college nursing elective experience (College of Nurses of Ontario (CNO) 2018; CNO, 2019b). The learning plan was perused throughout the semester to ensure continuous competency. The required reflections from students are similar to the reflections that are mandated by the College of Nurses of Ontario's Quality Assurance program upon licensing (CNO, 2019a;CNO, 2019b). Each reflection was prompted by the course professor, and guided by the concepts and topics that were discussed during the experience. In these assignments, students had to critically reflect on their experience in tandem with evidence-based practice and with the support of scholarly literature.
Course content included an overview of population health, an introduction to community health assessment and epidemiological assessment, cultural competence, cultural responsiveness, cultural safety and culture shock. Other concepts discussed included shared leadership, empowerment, and capacity building. After completion of this course it was expected that students would be able to perform a community health assessment in a rural and remote health setting and apply principles of health promotion and population health, including determinants of health, throughout their service model experience.
This course allowed students to be exposed to culturally diverse environments in Canada with the purpose of exploring the influence of culture and geography on people's health. During this semester-long elective, nursing students spent a total of 10 days between two rural and remote Indigenous communities in Northern Ontario. This course provided students an unparalleled opportunity to explore rural and remote Indigenous Communities, unlike their previous clinical experiences in urban settings. The elective provided students with the opportunity to appreciate the lived experience of Indigenous people living within Northern Ontario.

History & Community Details
Rural areas are defined by having a population of at least 1,000 people and a population density of 400 people per square kilometer (Statistics Canada, 2017a; Statistics Canada 2017b). Northern Ontario Indigenous communities have been affected by residential schools, where legislation passed in 1870 with the intent to assimilate Indigenous children and strip them of their culture (Johnson, 2018;Union of Ontario Indians, 2013). Residential schools where Indigenous students were acculturated, are now commonly recognized as "cultural genocide" (Johnson, 2018). As a result, individuals in the communities visited are highly affected by the historical process of colonization, cultural genocide and intergenerational trauma experienced from these actions (Johnson, 2018;Hatala, Desjardins, & Bombay, 2016;Union of Ontario Indians, 2013). Common characteristics of Indigenous communities include poverty, unemployment, lower attainment in education level, poor housing and poor nutritional status (Hatala, Desjardins, & Bombay, 2016;Union of Ontario Indians, 2013). These factors contribute to, and manifest, the disparities experienced in the health and social attainment of Indigenous Diversity of Research in Health Journal / Revue de la Diversité de la Recherche en Santé Vol 5, No 1 peoples in these communities (Hatala, Desjardins, & Bombay, 2016;Union of Ontario Indians, 2013).

Prior to Community Visits
Prior to the experience students reviewed literature on colonial history, assimilation, treaty impacts, band structure relationships and organizations and commissions that influence Indigenous issues today. Students were given mandatory readings on Indigenous issues, history in Canada, and attended Indigenous guest speaker lectures. Initial classes were held in the college Tipi with a variety of guest speakers. These guest speakers were particularly valuable to answer student questions and to aid in teaching Indigenous culture and traditions, such as smudging and the importance and purpose of tobacco offerings. Students were introduced to elders at their home campus, were oriented to the Cree/Ojibwe language and traditions, and were provided with keywords to communicate. This allowed students the opportunity to facilitate engagement with the communities and Indigenous clients, by simply translating a few key words.
The Canadian Nurses Association (CNA) asserts that cultural competence enables cultural safety (CNA, 2018). Cultural safety is acknowledging differences in culture and respecting those differences, while having cultural competence through skills and knowledge of practitioners (CNA, 2018). In gaining cultural awareness, students realized the importance of individualized belief systems and maintained open-mindedness in the diversity of cultural beliefs across these communities. Exploring the various cultural values and beliefs was important to discuss prior to visiting the communities because this facilitated cultural safety and provided opportunities for students to deliver culturally appropriate care to individual clients.

During Community Visits
There were a few rural and remote service learning experiences, of varying lengths of duration, that students attended. Through these placements, students worked either in community or in acute health care settings. Debriefing after clinical days was facilitated by the course professor during non-clinical hours. These debriefing sessions were important as they facilitated learning. Hearing from other students' experiences and perspectives helped the group develop and gain insight on cultural awareness. Students also engaged in community functions, outside of clinical placement, such as sweat lodges, round dances and tamarack bird making. Oftentimes, outdoor activities would be completed in -40 degree Celsius temperatures, which provided students with an appreciation for the inclement weather to which the community members are accustomed.
In another excursion, nursing students provided educational sessions to school aged children on hand washing and adolescents on sexual health. Nursing students shared a lunch with community members, youth and elders in the community center, as they were recognizing Autism Awareness Day within the community. Students debriefed thereafter and wrote a reflective journal encompassing their overall experiences within this course.

Truth and Reconciliation Commission (TRC) and Ownership, Control, Access and Possession (OCAP)
A goal of the Truth and Reconciliation Commission (TRC) is to have a historical account of residential schools to help individuals heal and to encourage reconciliation between Indigenous and non-Indigenous (Truth and Reconciliation Commission of Canada, 2015a). The TRC's efforts are geared towards achieving restorative justice in order to address the historical wrongdoings of the Canadian Federal Government (Truth and Reconciliation Commission of Canada, 2015a). This article and delivery of this elective aim to respond to the TRC's Calls to action for educators and healthcare providers.
It is crucial to incorporate these Calls to Action into nursing education, as the new generation of healthcare providers are preparing to enter the workforce (Truth and Reconciliation Commission of Canada, 2015a). By informing students on the TRC, they become better equipped to be agents of change in order to promote and respond to these calls to action. Awareness of the funding gaps and implications that might affect Indigenous children provide insight into the health disparities that exist (Truth and Reconciliation Commission of Canada, 2015b). Nurses are able to advocate for social justice and equity, and engage in political action to close the educational and employment gaps between Indigenous and non-Indigenous Canadians (Truth and Reconciliation Commission of Canada, 2015b). Furthermore, we must acknowledge and understand the power differentials in health services and take actions to reduce inequities through the educational processes (CNA, 2018).
First Nations Information Governance Centre (2014) created the tenets of "OCAP -Ownership, Control, Access and Possession" to reflect First Nation commitments to use and share information in a way that brings benefit to the community while minimizing harm. Although this course did not conduct research, faculty endeavoured to create a respectful learning environment for students while fostering support for the community within its activities. In recognizing that OCAP is a political response to the role of knowledge production in perpetuating colonial relations, nursing students exercised care when speaking about the traditional teachings and culture that they learned so that they respected Indigenous history and values. In summary, the TRC and OCAP served as guides, for students to see the change that needs to occur in order to achieve reconciliation and to bring issues to light so that they may advocate for Indigenous health and wellness in regards to future nursing practice.

Social Determinants of Health
Similar to the approach utilized by Alexander-Ruff (2016), reflection was part of the student's final assignment. It was through this exercise that nursing students were able to see how Indigenous peoples' health has been affected by colonial history through the appropriation of Indigenous lands and culture (Greenwood, de Leeuw, & Lindsay, 2018). Today, Indigenous Diversity of Research in Health Journal / Revue de la Diversité de la Recherche en Santé Vol 5, No 1 peoples are challenged by the lifetime effect of discriminatory policies, residential schools, health inequities, racism, chronic disease, and other social determinants of health (Bryant, Raphael, Schrecker & Labonte, 2010;Greenwood, de Leeuw, & Lindsay, 2018;Kaspar, 2014;Loppie, Reading & de Leeuw, 2014). Through this experience, students were able to learn how the federally funded healthcare system contributes to ill health and problems in accessing quality healthcare services for Indigenous peoples living in rural and remote areas. Students found that peoples in these communities were less able to make healthy choices due to broader oppressive social and economic factors. The most common determinants affecting the communities, as discussed by students, were food and water insecurity, geographical isolation and access to healthcare.
Food and water insecurity within the communities makes it difficult to engage in healthy eating. Food prices for everyday items in the local grocery store were double to triple that of the nearest urban centre. Students reflected on the connection that the lack of access to healthy foods and the inability to afford healthy foods, are antecedents to ill health with consequences such as, diabetes, heart disease and hypertension (Ontario Federation of Indigenous Friendship Centers, 2016). Students were also able to witness how one community has made attempts to address the high cost of food. For example, there is a weekly farmer's market in which fresh produce is brought to the community by train. It was important for students to note the resilience and initiative found in these communities to increase access to healthy foods for its residents.
Geographic isolation further impacts the health of Northerners. In Northern Ontario, geographical isolation is linked to shorter life expectancies, increased suicide rates, heart disease, respiratory diseases, and residents are less likely to seek medical attention (Health Quality Ontario, 2017). These rural and remote and coastal communities experience geographical isolation. Access to communities with medical services is restricted. Transportation to these communities are challenged by the changing seasons, rural remoteness and geographical isolation. These challenges are magnified by the lack of a stable mode of transportation and therefore the safety of these modes varies with the season. Barriers such as these put stress on an individual's health and decrease the quality and access of health care provided to community members.
Individuals in the North are less likely to have a regular primary healthcare provider and are less likely to have regular access to any health care provider which has been identified as a key indicator in a person's health (Health Quality Ontario, 2017). This was witnessed by students when community members presented to a pop-up health promotion booth, where many individuals presented with severe hypertension and hyperglycemia. From conversations with these individuals, many lacked health professional oversight for the management of their chronic conditions. This puts them at further risk of further complications such as heart attack, stroke, neuropathy and retinopathy (Bril, Breiner, Perkins & Zochodne, 2018).
Although social determinants and colonial history negatively affects the health of Indigenous peoples, the communities showed strengths in their commitments and programming.
Diversity of Research in Health Journal / Revue de la Diversité de la Recherche en Santé Vol 5, No 1 In reflecting, students commented on the efforts that the communities made towards selfdetermination and for their economic, social and cultural development. For example, some communities coordinated events that students witnessed such as naloxone training, a ceremonial feast and round dance, as well as organized fresh produce markets. Through discussions with community members, it was evident to students that the community strongly cherished their cultural values and traditions who described dedication to self-determination and regaining their cultural traditions. Furthermore, students were impressed to see the incorporation of both traditional and westernized medicine within these programs. These programs increase community pride as members demonstrated their Indigenous beliefs and values to students which include commitments to land, culture and traditions.

Cultural Experiences
People in Northern rural and remote Indigenous communities may have poorer health status; however, sociologists argue that they have a greater sense of community and often value self-sufficiency, self-reliance, independence and stoicism (Lightfoot et al., 2008). The service learning experience in these communities allowed for students to experience a glimpse of this sense of community and provided an opportunity to develop their own sense of cultural awareness. For example, students were privileged to attend an Indigenous Memorial Round Dance at the local community center. For this celebration, community members gathered to dine, perform traditional drumming, and to mourn and heal from the losses of their loved ones.
The student group was awestruck with the beautiful sense of community and the amazing traditional drumming and singing. The ceremony began with a bear fat blueberry blend, one of the traditional ways to open a passage for loved one's ancestral spirits to join the celebration. During the ceremony, children were encouraged to play, as this was one of the ways that showed that loved ones' spirits were present. Throughout the evening community members gestured invitation by grasping students' hands to participate in the round dance. Embracing the lived experiences of smudging, participating in a round dance and learning about cultural ideas, values and traditions cannot be replicated in the classroom.
One of the goals of this immersion experience was to embrace all cultures, values and beliefs. Thus, in addition to the Indigenous traditions, students also attended church as many community members also practice Christianity. In an effort to show respect, nursing students offered tobacco ties when receiving teachings from community members and elders. Tobacco is important to some Indigenous cultures (2017, Canadian Lung association), as it is one of the four sacred medicines. Tobacco is offered when seeking the help and advice of an Elder, Healer or medicine person. For example, when receiving teachings on tamarack bird making, students presented the elders with tobacco ties to honour the Indigenous traditions and acknowledge the value of their knowledge and teachings to the class. Moreover, students also made attempts to speak and reply in Cree whenever an opportunity existed. Attempting to converse in Cree is a simple way that nursing students can promote therapeutic relationships with Indigenous peoples, Diversity of Research in Health Journal / Revue de la Diversité de la Recherche en Santé Vol 5, No 1 and move towards reconciliation by implementing language recognition, preservation and revitalization (Galley, Gessner, Herbert, Thompson, Williams, 2016).
Other Indigenous experiences included educational health teachings to youths on proper hand washing techniques as well as providing sexual health education regarding puberty and expected body changes to the adolescent age group. Students realized the importance of incorporating Indigenous traditional knowledge (i.e. the Seven Grandfather teachings) within their health teaching sessions because of their heightened cultural awareness and dedication to respect and reconciliation. This experience was valuable for students, as the children were engaging in the provided teachings and openly asked questions about the content. This was evidenced by some of the adolescents having discussions with nursing students about Indigenous culture involving sexuality, gender, and spiritual identity.

Curriculum Growth and Community Partnerships
The community networking required to ensure the success of the program delivery was critical. The College staff contacted community health organizations in the communities visited, including both acute and non-acute settings. Key Indigenous community members were also contacted to help facilitate the non-clinical experiences that occurred in the community. Relationships and partnerships within each community have developed over the five years of offering this course. These types of reciprocal relationships can lead to sustainable projects that simultaneously benefit the community and the nursing education (Taylor, Pruitt and Fasolino: 2017). Reciprocity and support for the exchange of knowledge, cultural respect and awareness through community engagement and participation has grown to allow students with these learning opportunities.
One of the ways that the nursing faculty engages in fostering these relationships is by integrating community suggestions and experiences in the nursing curriculum. Examples of the program development include the newly developed Indigenous cultural elective offered in the first year of the BScN program called "working with an Indigenous Reality". Additionally, the nursing faculty organizes Indigenous guest speakers to share traditional knowledge to all nursing students in every year of the program. Other activities and teaching incorporated into the nursing content delivery include: the KAIROS (2019) "Blanket Exercise '', Grandfather Teachings, the Medicine Wheel and its application in healthcare, traditional medicines, and ceremonies. Faculty have also shown growth in cultural awareness and are incorporating Indigenous teachings into the curriculum rather being an afterthought. As stated by Harrowing et al. "faculty members and curriculum designers are encouraged to integrate threads of culture and cultural safety throughout the nursing program to stimulate, challenge and support students' understanding over the course of the entire undergraduate journey" (2012, p.500).
Diversity of Research in Health Journal / Revue de la Diversité de la Recherche en Santé Vol 5, No 1 A study performed by Oosman et al. (2019), revealed that community engagement and practicums that are based on strong community relationships contribute to the success of community-based learning experience for physical therapy (PT) students engaged in a Metis community. Similar to our nursing elective, Oosman and colleagues utilized reflective practice and required students ensure cultural immersions readiness. (Oosman et al., 2019). They too, support the importance of these elements in order to ensure cultural safety in these Indigenous communities, and suggest that this approach allow students to practice in reconciliation (Oosman, et al., 2019).
As a result of this elective, students demonstrated increased interest in achieving placements in Indigenous agencies and healthcare settings. Students also had the opportunity to share their lived experiences, formally and informally, to family members, peers, nursing faculty, the Northern College Board of Governors, Health Science Advisory Committee, and Indigenous Educational Conference. This promoted positive ideas of Indigenous culture by educating others to support Indigenous peoples and move towards reconciliation. Kolb (1984) describes learning as a continuous process where knowledge is transformed by experience and thus influences the way a person thinks and behaves. Through implementation of this experiential learning process into the nursing curriculum, nursing students are able to combine concrete nursing knowledge learned in the classroom with real life experiences to move towards an abstract constructivist view (Kolb, 1984;Alexander-Ruff, 2016). As a result, the experiences that nursing students had in these rural and remote areas were supported with what Kolb (1984) predicted; a change in beliefs of Indigenous peoples and actions to support their new learned knowledge. This was demonstrated by students' discussion in their second reflective journal on the social determinants of health from both the theoretical and experiential points of view.The service learning model has provided a unique learning opportunity for students within the elective course. The theoretical-based coursework and preparatory research that was conducted prior to the experience, and attuned student's focus to the individual issues and needs of the communities. This model also allowed students to practice the application of nursing science in acute and community settings. During cultural activities, students gained a sense of cultural engagement and cultural safety in a safe, immersive learning environment. Students were able to experience nursing praxis, by appreciating the chronicity of Indigenous peoples' health in the clinical setting. Students gained a greater understanding of colonial history, the social determinants of health, and their lived experience in a rural and remote setting. These experiences provided students the opportunity to exercise compassion and advocacy for this vulnerable population's health disparities. Embedding reflections in the course further developed the student's critical thinking skills that are required to consider the various factors that shape the health of Indigenous peoples in these communities, and required students to further consider how these factors can be addressed in future nursing practice. Therefore, the service learning model allowed students to be flexible with the classroom and theoretical based learning, which consolidated the learning into personal and professional growth and development. This reflexivity nurtured students' skills and confidence in their nursing practice in rural and remote Indigenous community settings (Johns, 1995). Harrowing, Gregory, O'Sullivan, Lee and Doolittle (2012), conducted a critical analysis of an undergraduate student's cultural immersion experience similar to ours. The overall findings of their analysis were that students entered the immersion experience with an essentialist understanding of culture and gradually experienced an epistemic movement towards a constructivist point of view (Harrowing et al, 2012). Similar to the Harrowing et al (2012) study, our nursing student cohort also experienced a paradigm shift from essentialist point of view to constructivist point of view in our nursing reflections. Students moved away from previous assumptions and the rigid checklist of attributes that certain cultures exhibit, and developed a deeper understanding based on the cultural experiences and personal reflections.

Student Growth in Nursing Praxis
In reviewing reflections, it became evident that content was initially centered around the student having feelings of shame and guilt. These feelings stemmed from realization of the unequal treatment and discrimination experienced by Indigenous peoples, as a result of the harsh living conditions historically inflicted by the Canadian government. Students discussed that they felt more should be done to support Indigenous peoples and felt remorse that they did not know more about the experiences of Indigenous Peoples. Furthermore, students considered their role in reconciliation and discussed avenues in which they could support Indigenous peoples as a future professional in the field of nursing. Interestingly in the second reflection, following the rural experience, the content was more focused on the strength and resilience of Indigenous peoples despite historical contexts and their lived trauma. Rather than discussing "how we can help Indigenous peoples", the reflection discussed "how Indigenous peoples can be self-empowered", and how nurses can be supportive in this endeavour. Students pondered ways in which their future selves can interact and support individuals and communities, as a result of this experience.
Growth exhibited in these reflections are demonstrated in the thick and rich descriptions of the interactions the students experienced with community members, clients, Elders, Guest Speakers, and the environment. This student described strong emotions while attending an Indigenous guest speaker who was delivering messaging about the importance of cultural identity. Students felt empowered to find ways to support social justice and Indigenous initiatives that promote reconciliation, both personally and professionally in their nursing practice. The reflections evolved from simple reflections about feelings, to further description of important concepts and inquiry in the second reflection.
Diversity of Research in Health Journal / Revue de la Diversité de la Recherche en Santé Vol 5, No 1 Students in their self-reflection and critical analysis also demonstrated increased selfperceived knowledge, self-awareness, and comfort with their skills related to cultural competency. Research with other similar cultural immersions experiences have yielded similar impacts for students (Gavin Knecht et al., 2019). This heightened awareness, exposure, and practice within these settings have supported student growth and provided a better sense of cultural awareness, advocacy and safety in our own urban communities. For example, something as simple as saying "Wachay", a general greeting in the Cree language, to Indigenous Cree patients has had a powerful effect in developing mutual trust and respect in the hospital setting. Presence in the community, however, allowed students the opportunity to learn cultural nuances and equipped them to enhance therapeutic relationships with their patients, especially those who find themselves outside of their rural and remote Indigenous community . Through this experience students have come to value and appreciate the unique sense of humour that many community members possess. Despite the oppression and intergenerational trauma that the community has experienced, students were able to see the strengths and positivity that individuals within the visited communities uphold.

Conclusion
Integrating this unique experiential learning opportunity has provided undergraduate nursing students with a better understanding of cultural consciousness particularly in Indigenous cultures. As demonstrated through assigned reflections, students better able to comprehend the many components that influence health particularly for those living in rural and remote areas. The experiential learning approach allowed students to gain cultural consciousness which they were able to carry forward in their future therapeutic nurse-patient relationships. Furthermore, the mutual relationships made at the personal level and at the college level have initiated steps towards truth and reconciliation and the empowerment of Indigenous peoples in their health. As outlined in the TRC, we are called to establish treaty relationships based on mutual recognition, respect and responsibility and to carry these forward into the future (Truth and Reconciliation Commission of Canada, 2015b). This immersion experience has provided students the opportunity to initiate and develop this type of relationship, recognize its importance, and carry it forward with them throughout their careers as nurses therefore improving healthcare delivery for Indigenous peoples. The nursing curriculum fulfills part of this mission and vision by offering this unique elective experience and integrating Indigenous health teachings throughout their curriculum. In the future, it would be beneficial to recruit Indigenous professors and mentors at the College and for this particular elective as it provides unique insights and enables learning of cultural competency.