An Application of Two-Eyed Seeing to Community-Engaged Research With Indigenous Mothers

Abstract

The Two-Eyed Seeing framework advocates viewing the world with one eye grounded in Indigenous knowledges while the other eye is grounded in Westernized knowledges. Research funding bodies have recently advocated for its use in research with Indigenous peoples, yet its interpretation and application in the literature has been inconsistent. To contribute to its maturation as a framework, this article describes the application of Two-Eyed Seeing to a community-engaged study aimed at understanding how Indigenous mothers experience using health care to meet the health needs of their infants in Hamilton, Ontario, Canada. Two-Eyed Seeing was applied to the research while applying the four R’s as suggested by Kirkness and Barnhardt’s: relevance, respect, responsibility, and reciprocity. While providing practical applications of this framework to research with Indigenous mothers and infants in an urban off-reserve setting, this article also contributes an approach to data analysis that incorporates Indigenous and Western knowledges within interpretive description methodology.

Background

Two-Eyed Seeing has been described as an approach that values viewing the world using one eye grounded in Indigenous worldviews while the other eye is grounded in Western ones (Bartlett, Marshall, & Marshall, 2012). First described in 2004 by Mi’kmaq Elders Albert and Muerdena Marshall from Nova Scotia, Two-Eyed Seeing has since been advocated for use in research with Indigenous peoples by the Canadian Institutes for Health Research, the Natural Sciences and Engineering Research Council, and the Social Sciences and Humanities Research Council (Bartlett et al., 2012). Despite this, the literature is inconsistent in its interpretation and application of Two-Eyed Seeing to research, leaving researchers grappling to understand it (Wright, Gabel, Ballantyne, Jack, & Wahoush, 2019). In a recent integrative review on the use of Two-Eyed Seeing in the literature, authors advocated for thorough descriptions of the interpretation and application of Two-Eyed Seeing to research within the literature to contribute to its maturation as a framework (Wright, Gabel, et al., 2019). This article seeks to contribute to a growing body of literature that describes how Two-Eyed Seeing has been applied to research with Indigenous peoples (Cabrera, Beattie, Dwosh, & Illes, 2015; Carter, Lapum, Lavallée, Schindel Martin, & Restoule, 2017; Clark, 2014; Hunt et al., 2018; Mantyka-Pringle et al., 2017; Marsh, Cote-Meek, Young, Najavits, & Toulouse, 2016; Martin, Thompson, Ballard, & Linton, 2017; Rand, 2016; Peltier, 2018). Specifically, this article describes the application of the framework to a qualitative study with Indigenous mothers in Hamilton, Ontario, Canada, which aimed to understand their experiences of interacting with the health-care system while meeting the health needs of their infants (Wright, Jack, et al., 2019a, 2019b). A description of Two-Eyed Seeing and its use in the literature to date is first illustrated, followed by its application to the study. The challenges of its application to this study are also addressed to aid researchers in applying the framework to their work in future.

Definition and Application of Two-Eyed Seeing

Unethical research with Indigenous peoples has brought harm to Indigenous communities, primarily benefiting researchers rather than those “researched” and resulting in mistrust between Indigenous peoples and the academy (Assembly of First Nations, 2009; Schnarch, 2004). The Calls to Action resulting from the Truth and Reconciliation Commission of Canada urge researchers to conduct culturally safe research with rather than on Indigenous peoples (The Truth and Reconciliation Commission of Canada, 2015). In response, major research funders have advocated for the use of the Two-Eyed Seeing framework as an effective way for researchers to meet these ethical standards. Researchers of various disciplines have responded by applying Two-Eyed Seeing to their research, including those from education, geography, and social and health science disciplines; however, how they define and apply the framework to their research has varied considerably (Wright, Gabel, et al., 2019). Similarities in how the framework has been defined in the literature include an approach that (a) values both Indigenous and Western knowledges as having important contributions to knowledge and understanding, (b) encourages the blending and merging of Indigenous and Western knowledges, (c) is decolonizing, (d) is strengths based, (e) includes ethical and respectful coming together of people with differing perspectives, (f) results in significant impacts to the research design, and (g) requires reflexivity and flexibility on the part of the researcher (Wright, Gabel, et al., 2019). Evidence of its application to research has been characterized by researchers enacting some or all of the following: (a) authentic relationships between the researcher(s), community members, and participants; (b) mutual benefits from research processes and aims; (c) relational accountability in which the researcher is responsible for the well-being of those involved in the research; (d) involvement of the Indigenous community, including knowledge holders and Elders; (e) evidence of privileging Indigenous knowledges in the research design; and (f) a passive role for Western researchers. The literature describing Two-Eyed Seeing and its application to data analysis is vague and lacks sufficient detail to guide researchers in the approach. With this significant variation in the literature and in the absence of a defined approach to data analysis, it is essential that researchers thoroughly describe their interpretations of the framework and how they have applied it to their work to contribute to its development and maturation.

Positioning of the Researcher

When undertaking qualitative research, and in line with Indigenous research methodologies, the researcher should thoughtfully disclose their worldviews and motivations of the research at hand (Kovach, 2009; Thorne, 2016). The researcher of this study (first author) is a non-Indigenous nurse practitioner of European descent. As such, she acknowledges her upbringing within what is considered Western or mainstream society and thus benefits from unearned privilege. Her nursing disciplinary lens motivates her passion for social justice and equitable access to health care for all. In this way, her nursing lens has also motivated her involvement in PhD studies to promote equitable access to care and improve health outcomes of Indigenous mothers and infants in her hometown, Hamilton, Ontario. The second author is a Métis scholar from Rivers, Manitoba, and brings a political science perspective and Métis knowledge to the research. The third author is First Nations (Mohawk) and brings her knowledge and lived experience as a mother, nurse, and member of a nearby First Nations community—Six Nations of the Grand River—to the research. The remaining author is of European descent, a nurse, and an established researcher and academic. She too acknowledges her unearned privilege as a member of mainstream society and of the academy. Together, and through this research, the authors sought to create an ethical space to collaborate as Western and Indigenous peoples, respecting each other’s knowledges and perspectives and working alongside the Indigenous community in Hamilton, Ontario, to improve the health of Indigenous mothers and infants (Ermine, 2007).

Application of Two-Eyed Seeing to Research With Indigenous Mothers

A detailed account of the methodology, which constitutes the first author’s doctoral research and aimed to understand how Indigenous mothers living off-reserve in urban Hamilton, Ontario, Canada, experience using health services to meet the health needs of their infants (less than 2 years of age), can be referred to elsewhere (Wright, Jack, et al., 2019b). However, a brief overview of the study methodology is described here to provide the context necessary to understand the following application of Two-Eyed Seeing. To begin, this study used interpretive description as described by Thorne (2016): a qualitative methodology that uses an applied health disciplinary lens—nursing in this case—to uncover patterns in experience and to present findings in such a way that clinicians can use the knowledge to benefit patients. As such, this study sought to understand how clinicians might adjust their care to improve how Indigenous mothers access and use health services to care for the health of their infants. Individual, semistructured interviews lasting approximately 1 hr in duration took place with 19 mothers as well as five primary care providers and seven providers of early childhood development programs to triangulate and provide additional contextual information concerning the mothers’ experiences. Interview questions, related to the health services mothers had used to meet their infants’ health needs and their experiences related to accessing and using these services, included: Can you share a story of a time when you needed to seek health care for your baby? and Can you tell me about your experience using that health service? among others. A discussion group with Indigenous mothers followed the initial data analysis to confirm findings and to fill theoretical gaps emerging in the analysis. All participant mothers were invited to attend and eight participated. Interpretation of the findings suggests that an approach that intersects culturally safe, trauma- and violence-informed, and family-centered approaches to care can promote positive health-care interactions and access to care for Indigenous mothers and infants in Hamilton, Ontario. The research was approved by three ethical review boards: the Hamilton Integrated Research Ethics Board, Mohawk College Research Ethics Board, and the McMaster University Family Medicine Program.

While Indigenous research methodologies were considered at the outset of this work (Kovach, 2009; Smith, 2012), it was concluded that a methodology consistent with a specific nation’s traditions, beliefs, and ways of knowing could not guide the study if the inclusion criteria were to allow for First Nations, Métis, and/or Inuit mothers to participate. These varying perspectives were valued, and thus, a specific Indigenous research methodology was not selected. In addition, the researcher does not have Indigenous lived experience, and thus, it was felt she could not appropriately conduct a study grounded in knowledges she did not have or intimately understand. The Two-Eyed Seeing framework was used instead, as it allowed for the respectful coming together of both Indigenous and Western knowledges and contributed to findings that bridged both worldviews.

To adequately apply the Two-Eyed Seeing framework to the research, the four Rs of ethical Indigenous research as described by Kirkness and Barnhardt (1991) were applied, including relevance, respect, responsibility, and reciprocity. The four Rs were initially described as an approach to higher education that would encourage and empower Indigenous students (Kirkness & Barnhardt, 1991). Since then, they have been used as a standard of ethical considerations to empower engagement and collaboration in research with Indigenous peoples. Relevance is ensured when the research is in line with the values, beliefs, and priorities of the community engaging in the work. Respect is evident when the research is mutually empowering of Indigenous and Western perspectives. Responsibility means researchers privilege Indigenous voices, are decolonizing, and are supportive of Indigenous peoples’ rights to self-determination. Finally, reciprocity ensures that the research does not merely benefit the researcher through achieving academic recognition but mutually benefits the Indigenous community and contributes to their health and wellness. The application of Two-Eyed Seeing to the research is described in relation to this framework.

Relevance

To ensure the research was relevant to the priorities of the Indigenous community in Hamilton, the researcher began to engage with members of the community at the start of PhD studies. Staff at the local Indigenous Friendship Centre (IFC) and Aboriginal Health Access Centre, Indigenous researchers at McMaster University, and Indigenous Elders were approached to learn about the research priorities of the community and to seek opportunity for research collaborations. A Métis scholar and faculty member at McMaster University was invited to sit on the PhD supervisory committee along with three other non-Indigenous nurse academics. A First Nations nurse was asked to participate as a research assistant, though her intellectual contribution to the study was far beyond what is typical for such a position. As the researcher has expertise in maternal/child health as a neonatal nurse practitioner, community members were asked whether their research priorities fell within this area of focus. Several community members responded saying, “No one has ever asked about our babies” and, along with many other community members, affirmed that the community valued a deeper understanding of how to support the health and well-being of Indigenous mothers and infants. The research question was developed and approved by staff at the IFC, the supervisory committee, and the research assistant, and the study was developed with similar collaboration. The use of Two-Eyed Seeing as a guiding framework for the study was chosen to ensure the methodology was relevant to the Indigenous community. In this way, Two-Eyed Seeing also promoted demonstrating respect as action with the Indigenous community.

Respect

While a Western methodology—interpretive description—guided this study, Two-Eyed Seeing emphasized the importance of demonstrating respect for Indigenous knowledges and ways of knowing, which was evidenced by the selection of methods and data analysis procedure. First, interviews and a discussion group were selected as modes of data collection to honor the oral tradition that is important to Indigenous peoples (Kovach, 2009). The use of a sharing circle was initially considered, but not chosen because the Indigenous advisors involved in the study believed that not all participant mothers would relate to or practice the traditions and ceremonies associated with this type of gathering. Instead, the group conversation was called a “discussion group” to be inclusive of all First Nations, Métis, and Inuit mothers regardless of their cultural practices.

Second, the presence of the research assistant during interviews was offered to participant mothers on the recommendation of staff at the IFC who worked closely with many of the mothers. They believed the mothers would be more comfortable during the interview if given the opportunity to have an Indigenous individual present. While this choice was offered to all mothers, just one mother asked that the research assistant be present during the interview. The research assistant was also present during the discussion group.

Third, the offering of tobacco was initially considered for use as a sign of respect prior to the interview with mothers but was decided against as Indigenous advisors felt not all urban-dwelling Indigenous mothers had strong ties to Indigenous traditions and might not understand or appreciate its symbolic meaning. In addition, the participants would potentially be First Nations, Métis, and/or Inuit mothers, who did not all partake in the sharing of tobacco as a traditional custom. Instead, a cash honorarium was provided in appreciation of their time.

With regard to data analysis, the developers of Two-Eyed Seeing propose that a process of weaving and merging of both Indigenous and Western perspectives should occur (Bartlett et al., 2012). How to enact this, however, is not clearly described. Rather, the developers suggest four “big pictures” of how Indigenous and Western perspectives of ontology, epistemology, methodology, and knowledge objectives differ from one another and advise that these differences must be considered during analysis to create a new understanding that will benefit others (Institute for Integrative Science & Health, 2013). First, Indigenous ontology is described as interconnective, animated, and balanced, while Western ontology is made up of parts and wholes. Wilson (2008) describes Indigenous ontology as one’s relationship to reality, rather than reality as a phenomenon external to the individual. It is not surprising then that Indigenous epistemologies are relational and reciprocal in nature while Western science values hypothesis building and testing, data collection and analysis, and construction of theory (Institute for Integrative Science & Health, 2013). Third, Indigenous methodologies promote patterns and relationships between love, the land, and life, while Western methodologies seek to break down patterns into their parts for the purpose of constructing models and theories. Finally, Indigenous knowledge is living and promotes interconnectedness, while Western knowledge seeks to understand, predict, and/or control. Consideration of these differences was paramount during data analysis and necessitated a collaborative approach with the First Nations research assistant to fully incorporate her Indigenous ontology and epistemology. In as much as the first author sought to understand and relate to these worldviews, she does not have Indigenous lived experience and thus cannot fully comprehend how the participant mothers related to and interpreted their experiences. The data analysis that was completed would not have been possible without the research assistant’s perspectives, who challenged the researcher’s assumptions of what was being seen in the data. Because of her lived experience and First Nations worldview, the research assistant recognized belief patterns in the language of the mothers that were otherwise not apparent to the researcher and explained their relationships to language, land, traditions, and ceremonies and how these impacted the health of Indigenous infants and families.

In determining how to conduct data analysis process in this study, suggestions from interpretive description were applied, including the use of broad-based coding strategies, until the researcher and research assistant were fully familiar with the data (Thorne, 2000, 2016). Coding strategies included those described by Saldana (2016) to assist the researcher and research assistant in thoughtfully considering the data, its concepts, and patterns. Structural coding provided an initial inventory of the content of the data and allowed further analysis by descriptive coding, which was used to describe the data in broad categories. Values coding was used to code data that reflected the values (preferences, likes and dislikes, facilitators, and barriers to care) of the participants based on their beliefs and worldviews. Values coding was particularly important in this research as the researchers sought to identify attributes of health care and health providers that Indigenous mothers felt was important to the care of their infants. Some examples of positive attributes of health providers that facilitated access to care included effective communication and nonjudgmental and respectful care (Wright, Jack, et al., 2019b). Later in analysis, concept coding assisted to ascribe meaning to the descriptive and values codes, and pattern coding was used to find themes among the codes and to develop the thematic summary (Saldana, 2016).

Despite using Western coding strategies for data analysis, Two-Eyed Seeing was influential throughout the process, emphasizing a respectful and collaborative effort between researcher and research assistant to engage both Indigenous and Western knowledges and perspectives. Both the researcher and research assistant completed the initial phases of analysis separately and then came together many times to compare perspectives and to learn from each other. During these meetings, the four “big pictures” (Institute for Integrative Science & Health, 2013) were constantly at play, through the researcher’s (Western) and research assistant’s (Indigenous First Nations) knowledges and worldviews, which they both innately and purposefully contributed to the analysis. The Indigenous knowledge held by the research assistant was instrumental in illuminating cultural nuances in the data relating to the impact of residential schools on family dynamics, local traditions, meaning and values, slang, and politics that arose from the mothers’ stories. The thematic summary resulting from the findings sought to bridge both worldviews in such a way that the mothers’ stories, values, and perspectives were conveyed to health providers to influence clinical practice and benefit Indigenous mothers and infants. The process of data analysis, while designed to respect Indigenous knowledges and worldviews, also reflected the researcher’s responsibility to the Indigenous community and participant mothers as it created a space for Indigenous women’s voices to be heard among other mainstream perspectives that historically have been the dominant voice in health care.

Responsibility

Embarking on research with Indigenous peoples necessitates a decolonizing approach, to challenge and break down power imbalances that exist in society and to give voice to those who resist these forces (Kovach, 2009; Smith, 2012). Taking a decolonizing approach, this research aimed to create a space for Indigenous women to be heard by policy makers and health providers who currently control the access and provision of health services. In doing so, the findings also recognized the important work that Indigenous organizations in Hamilton, Ontario, were already doing to meet the needs of their community, through providing care that effectively addresses a wide range of social determinants—contextual factors known to greatly influence health outcomes (Wright, Jack, et al., 2019b). Similarly, knowledge dissemination strategies of this research aim to privilege Indigenous mothers’ and Indigenous health providers’ voices using excerpts from interviews, despite publishing pressures to write as succinctly as possible.

The resiliency of mothers is purposefully made clear through the analysis of the data and presentations of the results (Wright, Jack, et al., 2019a, 2019b). During any presentations and publications of these findings, examples of how mothers continue to fight against mainstream views of parenting and amid political structures and racist policies that make these efforts truly difficult will be illustrated (The Truth and Reconciliation Commission of Canada, 2012). One important example of this resiliency was evident from the experiences of many participant mothers whose parenting skills were challenged by child protection services. Despite feeling judged and discriminated against, these mothers did not give up, but rather worked tirelessly and passionately to satisfy the requirements necessary to continue or resume the independent care of their children. By emphasizing the strengths of Indigenous mothers in this research, the study aims to abolish the negative stereotypes of Indigenous mothers perpetuated by mainstream society and government policy. In doing so, this research seeks to recognize the impact of colonization and Western dominance on the health behaviors and outcomes of Indigenous peoples as an important contextual factor influencing health and well-being.

Rather than to encourage the further assimilation of Indigenous peoples, the data analysis took a decolonizing approach, and the results are organized using cultural safety, trauma- and violence-informed care, and family-centered care approaches which align with the Calls to Action outlined by the Truth and Reconciliation Commission of Canada (The Truth and Reconciliation Commission of Canada, 2015). Calls to Action demanding that health policy support health providers to become educated on the historical, political, and social contexts influencing the lives of Indigenous peoples were reinforced by the experiences of participant mothers. Acquiring this knowledge should result in transformative change, in which negative stereotypes are abolished, health providers become allies and advocates of marginalized groups, and health care is reshaped in ways that positively impact the health of Indigenous peoples.

Despite the best intentions of the researcher, frictions exist between the academy and the goals of community-engaged research. First, the researcher undertook the research as part of her PhD studies and, as such, obtained a degree following its completion. The research assistant, though fully engaged in the design, implementation, and dissemination of the research, did not gain similar recognition. Neither did the community members nor participant mothers, who were instrumental in their contributions to the work. The Métis scholar who sat on the supervisory committee, however, will receive academic recognition through advising a graduate student and publications (such as this one) that follow, as will the research assistant and other non-Indigenous academic advisors who also participated on the committee. As a result, it was extremely important for the research to be reciprocal in all possible ways, so that the community members involved in the work would also benefit from the research, if not in the same ways as the researcher and the supervisory committee.

Reciprocity

Although the aim of the research was to uncover knowledge to influence clinical practice and benefit Indigenous mothers and infants, the research process was also designed with reciprocity as a priority.

Participant mothers

First, the study sought to ensure that mothers benefited through their participation in the research. While the direct impact of sharing their stories may not have immediate effect, mothers were informed while collecting study consent that their experiences would be shared with health providers in the city with the aim of improving future care. The researchers also prioritized adequate compensation for their time. Mothers were offered refreshments of their choice and a cash honorarium during data collection, as a sign of respect and appreciation. The honorarium consisted of a fair hourly wage, as required of employers in Ontario, to adequately compensate the mothers for their time. By providing cash rather than gift cards, mothers were afforded the choice to spend the money as they felt appropriate. A discussion group was conducted to bring together the participant mothers to discuss the initial findings, but also to provide an opportunity for socializing and building relationships and to promote health and healing. The researcher and research assistant provided a meal and a communal craft for mothers at the beginning of the discussion group, which helped to further strengthen the relationships and trust within the group, allowing for other group members to meet new friends, share stories, and care for one another (Marsh et al., 2016). The remaining craft supplies, bus vouchers, and food were donated to the IFC as a contribution to their important community programming.

Research assistant

Engaging the research assistant prior to defining the research question or designing the research process was also an act of respect and reciprocity to the Indigenous community, as it allowed the research assistant to participate in the entire research process. In doing so, the research assistant gained research capacity—particularly skills in developing a research protocol, interviewing, and data analysis—that she now brings to her own PhD and future research with her community. In addition, the research assistant has been acknowledged in publications and has participated in presentations of the findings to the Hamilton and academic communities, which contributes to her own academic record and assists her in gaining future employment in academia. The researcher made a consistent and conscious effort throughout the research to ensure the research assistant did not feel inferior to the researcher but on the same level, working in partnership with and equally important to the research process. They both continue to mentor and support each other in their own research efforts even after this project has concluded. Finally, the efforts of the Indigenous community, particularly the IFC, are acknowledged in all dissemination activities. Staff from the IFC involved with the study have also acquired research skills, through confirming research findings, participating in the discussion group, and involving in recruitment strategies.

Community

Two-Eyed Seeing continues to influence future knowledge translation efforts, as these are community-led and consist of more than the usual presentations of the findings to the academic community through publications and presentations at conferences. The researcher continues to work with the Indigenous community in Hamilton, including some of the participant mothers, to disseminate the findings in ways identified as effective and necessary by the community itself. Finally, although this research project has concluded, the researcher’s responsibility to reciprocity does not end; the researcher remains committed to fostering research knowledge and skills in the Indigenous community to promote Indigenous researchers and self-governance. This commitment is reflected in future collaborations already underway with the community, collaborative funding applications, and community-engaged knowledge translation projects aimed to be completed within the coming years.

Challenges Encountered in Applying Two-Eyed Seeing to Research

The application of Two-Eyed Seeing to this research was not without challenges, and several are outlined here. First, engaging and building relationships with an Indigenous community takes humility, perseverance, and time (Hall, Dell, Fornssler, Hopkins, & Mushquash, 2015). For 2 years prior to embarking on the research, the researcher engaged with members of the Indigenous community in Hamilton, participating in community events and attending Indigenous conferences to familiarize herself with Indigenous knowledges and methodologies and to network with Indigenous researchers, as well as meeting with community members to build authentic, trusting relationships, and demonstrate sincerity (Whiting, Cavers, Bassendowski, & Petrucka, 2018). Similarly, recruitment of participant mothers required that the researcher and research assistant be familiar with the mothers, which was facilitated through their participation in mother/baby classes and community events at the IFC to gain trust and build relationships that enabled mothers to feel comfortable engaging in the research and sharing their stories. At the same time, numerous attempts to engage Elders throughout the research process were unsuccessful, as the Elders approached did not have time to be involved despite affirming the importance of the research. Elders are presently committed to activities related to the Truth and Reconciliation Commission recommendations and are engaged in numerous research and community endeavors, and student research funding is not always adequate to compensate Elders for their time. Instead, other members of the Indigenous community and participant mothers were invited to contribute their knowledge and wisdom to the research. In future, funding from granting agencies will be requested to specifically support the adequate monetary compensation of Elders and other community members for their contributions to the research. Finally, as the researcher was a novice, interpreting the limited and, at times, vague literature concerning the application of Two-Eyed Seeing to data analysis was challenging, especially as her research skills were still developing and her training stemmed primarily from Western approaches to research. In consultation with the supervisory committee and the research assistant, the approach to data analysis was developed which emphasized the influence and contribution of Indigenous knowledges to interpretations of the data and presentation of the findings.

Conclusions

This article describes the interpretation and application of Two-Eyed Seeing to a community-engaged, qualitative research study that aimed to understand Indigenous mothers’ experiences of accessing and using health-care services to meet the health needs of their infants in Hamilton, Ontario. The thorough description as provided here is necessary to contribute to the growing body of literature concerning the application of Two-Eyed Seeing and to assist its maturation as a framework for research with Indigenous peoples. In particular, the approach to data analysis described herein is an important contribution as to how one might incorporate Indigenous and Western perspectives in this process. It is the position of the authors that the application of Two-Eyed Seeing to research with Indigenous peoples is all encompassing, necessitating an approach to research that addresses relevance, respect, responsibility, and reciprocity (Kirkness & Barnhardt, 1991). Researchers using Two-Eyed Seeing should endeavor to describe their interpretations and applications of the framework to research with Indigenous peoples to contribute to its maturation in the literature and assist others in applying it to their work.