Implementing Indigenous-Specific Anti-Racism in Health Professionals’ Education: Pedagogical Principles from Educators’ Biographical Narratives

Abstract

Racism within healthcare systems remains a critical barrier to equitable care for Indigenous Peoples. Despite calls from the Truth and Reconciliation Commission of Canada to integrate anti-racist frameworks into health education, implementation remains limited. Understanding how educators integrate Indigenous-specific anti-racist pedagogy is essential for developing effective and sustainable teaching approaches. This study aimed to identify the pedagogical principles that educators implement when teaching Indigenous-specific anti-racism in health professionals’ education programs. Using biographical narrative methodology, we conducted 17 in-depth interviews between September 2023 and March 2024 with educators who met three criteria: (1) teaching in Canadian health professional programs, (2) explicit commitment to anti-racist approaches, and (3) focus on Indigenous health content. Analysis was validated through race-based focus groups (n = 8), individual follow-up interviews (n = 4), and written feedback (n = 5). Thematic analysis identified six interconnected pedagogical principles specifically designed for Indigenous-specific anti-racist education, grounded in educators’ lived experiences: (1) centering and privileging Indigenous knowledge, worldviews, and strategies; (2) adopting a relational approach to teaching and learning; (3) contextualizing content in relation to colonialism; (4) supporting transformational learning leading to action; (5) embracing discomfort and addressing resistance; and (6) incorporating accountability mechanisms. These principles collectively create safe and transformative learning environments that challenge systemic racism in healthcare education. Implementing Indigenous-specific anti-racist pedagogy requires a holistic, systemic approach that centers Indigenous knowledge, fosters relational learning, and embeds accountability. These principles provide a framework for educators and institutions committed to decolonizing health education and advancing health equity for Indigenous Peoples.

1. Introduction

Racism within the Canadian healthcare system remains a critical barrier to equitable healthcare access and the well-being of Indigenous Peoples [1]. Systemic racism, embedded within institutional structures, continues to contribute to significant health disparities that affect Indigenous communities disproportionately [2]. Research has established clear links between racial discrimination and adverse health outcomes, including hypertension, low birth weight, and preterm labor [2], while also highlighting racism’s broader impact on social determinants of health such as education, employment, and housing [3,4]. Indigenous individuals seeking healthcare frequently encounter systemic obstacles, including pervasive stereotypes and a lack of historically informed care [1,5,6]. These barriers perpetuate ongoing health inequities and underscore the urgent need for targeted strategies within health education to equip professionals with the critical skills required to address racism in their practice. The consequences of these systemic failures are profound, contributing to mistrust of healthcare systems, delayed care-seeking, and poorer health outcomes among Indigenous populations.

The Truth and Reconciliation Commission of Canada’s Calls to Action [7] explicitly emphasize the need for health professionals’ education to include comprehensive training on Indigenous-specific racism, cultural safety, and the colonial legacies embedded in healthcare systems. These calls recognize that addressing health inequities requires fundamental transformation in how health professionals are educated and prepared for practice. Anti-racist pedagogy offers a promising framework for this transformation, as it encourages learners and educators to critically examine and challenge racism at both individual and systemic levels [8]. Within the healthcare field, anti-racist pedagogy emphasizes the structural nature of racial inequities and the need for transformative learning to prepare future professionals to deliver culturally safe and equitable care [9]. Unlike traditional educational models that may inadvertently reinforce dominant power structures, anti-racist pedagogy explicitly names and confronts systems of oppression, positioning education as a tool for social justice and systemic change.

Despite the urgency of integrating anti-racist pedagogy, health profession education has historically relied on multicultural and cultural competence models to address issues of racism and discrimination [10]. However, mounting evidence indicates that these approaches fail to challenge power dynamics and do not effectively reduce the impacts of systemic racism in healthcare settings [11]. Multicultural frameworks often obscure the structural roots of inequities by focusing on cultural differences rather than addressing racism as a systemic issue [10,12,13,14,15]. In contrast, anti-racist pedagogy, grounded in critical perspectives, enables learners to critically analyze how colonialism and systemic racism shape health disparities and professional practices [8,16,17,18,19]. This approach shifts the focus from individual cultural awareness to systemic analysis and action, preparing health professionals to recognize and challenge the structural determinants of health inequities.

Educators play a central role in implementing anti-racist approaches in health education, yet studies suggest that many struggle with teaching about racism and structural inequities [20,21,22]. Some report hesitation or discomfort due to a lack of training, confidence, or institutional support. The transition to anti-racist teaching requires not only pedagogical adjustments but also personal reflection and an ongoing commitment to dismantling one’s own biases [20,23,24]. This highlights the critical need for resources, training, and institutional support to help educators integrate anti-racist pedagogy effectively [12,25]. Furthermore, the emotional labor involved in anti-racist teaching is substantial, particularly for Indigenous educators who may experience additional burden in addressing racism while navigating predominantly White institutional spaces. Non-Indigenous educators, meanwhile, must grapple with their own positionality and privilege while working to create meaningful change.

Despite growing recognition of the importance of anti-racist education, its application in health professions training remains limited, particularly in Indigenous health [26]. While the challenges educators face in integrating Indigenous-specific anti-racist content into curricula are increasingly well documented [12,24,25], less attention has been paid to a related but distinct question: what pedagogical principles educators mobilize and how they concretely integrate these principles into their teaching practice. A biographical narrative methodology makes it possible to foreground educators’ lived experiences and professional trajectories, acknowledging that Indigenous-specific anti-racist pedagogy extends beyond technical competencies and is deeply shaped by personal and relational processes. Educators’ engagements with colonial histories, privilege, systemic racism, and relationships with Indigenous communities influence how pedagogical commitments emerge, evolve, and are sustained. Attending to these life histories illuminates the experiential and relational foundations underpinning pedagogical choices within broader institutional contexts.

This study aimed to examine how educators who use an Indigenous-specific anti-racist pedagogical approach in courses or programs focused on Indigenous health enact this approach in their teaching practice through specific pedagogical principles. Specifically, we sought to answer the following research question: What Indigenous-specific anti-racist pedagogical principles do educators implement in health profession education? While existing literature addresses cultural safety and competence, this study uniquely examines how educators translate anti-racist commitments into concrete pedagogical practices through their biographical trajectories, offering an evidence-based framework that moves beyond conceptual discussions to actionable teaching principles. Rather than solely tracing the evolution of individual pedagogical approaches, this study sought to uncover the foundational principles guiding their work, emphasizing the ways in which Indigenous knowledge systems, relational accountability, and resistance to colonial structures informed their teaching.

2. Theoretical Underpinnings

This study is grounded in anti-racist pedagogy, informed by critical pedagogical theories, which encourages learners to examine and challenge structures of oppression and domination [9]. For the purposes of this study, we define pedagogy as encompassing both the content of teaching (what is taught) and the processes of teaching and learning (how it is taught), as well as the relationships between educators and learners [27]. Anti-racist pedagogy necessarily addresses all three dimensions: it requires transforming curriculum content to center marginalized knowledges, adopting teaching processes that challenge oppressive structures, and fostering relationships grounded in equity and accountability. This holistic understanding of pedagogy recognizes that meaningful anti-racist education cannot be achieved through content changes alone but requires fundamental shifts in how we teach and relate to students.

This pedagogical approach not only seeks to reveal the mechanisms through which racism persists in healthcare education and practice but also promotes an engaged praxis aimed at social justice and systemic change [28,29]. Anti-racist pedagogy differs from multicultural education in its explicit focus on power, privilege, and systemic oppression. Rather than celebrating diversity without interrogating inequality, anti-racist approaches demand critical analysis of how racism operates at individual, institutional, and structural levels and require action to dismantle these systems [8].

In Indigenous-specific anti-racism, there is an understanding that our experiences and identities are shaped by the ongoing impacts of colonialism, which is embedded in both time and place. This approach acknowledges that anti-racist work must consider the historical and contemporary colonial structures that continue to shape Indigenous experiences, particularly within systems like healthcare and education. It is critical to distinguish Indigenous-specific anti-racism from broader anti-racist approaches or from the experiences of racialized peoples more generally. While Indigenous Peoples experience racism, their relationship to the Canadian state is fundamentally shaped by settler colonialism, ongoing dispossession of lands and resources, and the violation of inherent rights and sovereignty. Indigenous-specific anti-racism must therefore address not only racial discrimination but also the unique context of settler colonialism, treaty relationships, and the intergenerational impacts of genocidal policies designed to eliminate Indigenous Peoples, cultures, and governance systems. This differs from the experiences of racialized settlers, who while facing racism and marginalization within systems of white supremacy, do not face the same colonial project of erasure, dispossession, and denial of sovereignty. Our focus on Indigenous-specific anti-racism reflects this distinct historical and contemporary reality, recognizing that Indigenous Peoples’ experiences cannot be conflated with those of other racialized groups without erasing the specificity of settler colonialism.

By anchoring anti-racism in the specific time and place of colonial history and its present-day manifestations, Indigenous-specific anti-racism aims to disrupt colonial legacies and promote equity in a way that respects and uplifts Indigenous identities, histories, and sovereignties.

3. Methods

This study employed a biographical narrative methodology [30] to explore how educators engage with Indigenous-specific anti-racist pedagogy. Biographical narrative methodology was selected over other qualitative approaches (e.g., grounded theory, phenomenology) because it privileges educators’ lived experiences and developmental trajectories, which are central to understanding how anti-racist pedagogical practices evolve over time. This approach aligns with Indigenous research principles that value storytelling and relationality. It allowed for in-depth understanding of how educators navigate, integrate, and refine anti-racist teaching strategies within their professional development and practice. Biographical narrative methodology is particularly suited to capturing the complexity of educators’ journeys, including the critical incidents, relationships, and contextual factors that shape their pedagogical approaches.

We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [31] to ensure transparency and rigor in reporting. This study received ethical approval from the CERSES (2021-1266) on 12 November 2022.

3.1. Research Team Positionality

The research team consisted of Indigenous and settler scholars and practitioners, bringing a variety of perspectives shaped by their lived experiences, disciplinary knowledge, and commitments to decolonization and anti-racism in education. The involvement of Indigenous scholars and practitioners provided meaningful opportunities to center Indigenous perspectives, knowledge systems, and priorities. Together, the intersecting perspectives of Indigenous and settler team members strengthened the study’s grounding and analytical depth. This approach embodied principles of relational accountability and reciprocity that are fundamental to Indigenous research methodologies. Throughout the research process, team members engaged in ongoing reflexivity regarding their own positionality, biases, and assumptions. Regular debriefing sessions allowed the team to discuss challenges, tensions, and insights emerging from the data collection and analysis processes.

3.2. Participant Selection and Recruitment

Participants were selected based on three key criteria: (1) their role as educators in the initial or continuing education of health professionals; (2) their explicit commitment to an anti-racist pedagogical approach; and (3) their engagement with Indigenous health issues in their teaching. Educators’ explicit commitment to anti-racist approaches was established through multiple signals during screening: (1) self-identification in recruitment materials, (2) documented evidence such as course syllabi explicitly naming anti-racism or systemic racism, (3) publications or presentations on anti-racist pedagogy, or (4) institutional recognition for anti-racist teaching. During initial contact, potential participants described their understanding of anti-racism versus cultural competence to ensure conceptual alignment. Educators whose approaches were solely multicultural or culturally inclusive, without a critical anti-racist dimension, were not included in the study. This distinction was important for ensuring that participants had experience with pedagogies that explicitly name and address racism, rather than approaches that focus primarily on cultural awareness.

Recruitment was conducted through purposive and snowball sampling, beginning with professional networks of the research team and expanding through participant recommendations. Potential participants were invited via email with information about the study’s purpose, procedures, and ethical considerations. Recruitment continued until data saturation was reached, ensuring that no new substantial insights emerged from additional interviews. We determined saturation was reached when: (1) no new pedagogical principles emerged in the final three interviews, (2) existing principles were consistently reinforced across diverse participant profiles, and (3) the research team reached consensus that the conceptual framework was sufficiently robust.

Seventeen interviews were ultimately included in the analysis. One individual chose to withdraw after completing their interview for personal reasons; in accordance with ethical protocols, their decision was fully honored and all associated data were removed from the dataset before analysis. The remaining interviews provided sufficient depth and breadth to reach thematic saturation, as iterative narrative analysis showed no emergence of new pedagogical principles or substantively different meanings across later interviews.

3.3. Data Collection

Data collection occurred between September 2023 and March 2024 and involved two phases designed to capture both individual narratives and collective validation of emerging themes.

The first phase consisted of 17 in-depth individual virtual interviews lasting between 90 and 120 min. All interviews were conducted virtually via secure videoconferencing platforms (Zoom with end-to-end encryption) to accommodate participants’ geographic distribution across Canada and to provide flexibility in scheduling. Virtual interviews also allowed participants to engage from their own chosen spaces, which many noted contributed to their comfort in discussing sensitive topics related to racism and colonialism. Interviews were conducted in English or French, reflecting the bilingual nature of the Canadian context. These interviews explored educators’ conceptualization of anti-racist pedagogy, the defining moments in their professional journey, and the contextual factors influencing their teaching practices. Each interview was preceded by a socio-demographic questionnaire capturing information about participants’ professional roles, disciplines, years of teaching experience, and self-identified social locations. Interviews were facilitated by two research team members who, in most cases, had no prior relationship with the participant. This approach allowed for one team member to lead the interview while the other took detailed notes and could ask follow-up questions.

The interview guide was semi-structured to allow participants to narrate their experiences in depth while ensuring alignment with the study aim of examining how educators integrate Indigenous-specific anti-racist pedagogy into their teaching practice. The interview guide was pilot tested with two educators (one Indigenous, one non-Indigenous) who met the inclusion criteria but were not included in the final sample. Based on pilot feedback, we refined question wording to be more open-ended, added prompts to encourage storytelling about specific teaching moments, and adjusted the sequence to begin with educators’ personal journeys before discussing pedagogical practices. The guide continued to be refined iteratively throughout data collection as we identified emerging themes requiring deeper exploration in subsequent interviews. Questions invited participants to reflect on their understanding of anti-racist pedagogy and the pathways through which they came to adopt this approach. Participants were also asked to describe the pedagogical principles and strategies they implement in their teaching, the challenges they encounter and the supports that facilitate their work, and the institutional and social contexts in which their teaching takes place. Finally, interviews explored participants’ reflections on the perceived impacts of their teaching on learners and broader educational and health systems.

In the second phase, participants were invited to review a written summary of the preliminary interpretations derived from their narratives, including the emerging pedagogical principles identified by the research team. Participants then reviewed and refined these interpretations through one of three modalities: race-based focus group discussions (two groups—one Indigenous and one white settler—each with 4 participants; 60 to 90 min), individual follow-up interviews (n = 4; 30 to 60 min), or written feedback (n = 5). These sessions enabled participants to validate, nuance, and deepen the analysis, ensuring that the interpretations accurately reflected their perspectives and experiences. They generated rich dialog about common challenges, strategies, and the emotional dimensions of this work. Race-based focus groups were designed to support psychological and cultural safety. The Indigenous focus group was facilitated by Indigenous members of the research team in accordance with Indigenous research protocols, while the white settler group was held separately to allow open discussion without placing additional burden on Indigenous participants. Facilitators established clear ground rules around respect, confidentiality, and the right to decline questions, and monitored group dynamics to ensure a safe and respectful environment. Sessions were held online to support participation across locations and allow participants to engage from spaces where they felt comfortable. All interviews and discussions were audio-recorded with participants’ consent, transcribed verbatim, anonymized, and managed using MAXQDA 24 software [32].

3.4. Data Analysis

Using Breton’s biographical narrative approach [30], analysis proceeded iteratively, with initial codes emerging from the data rather than from predetermined categories. The research team met regularly to discuss emerging patterns and refine the coding framework.

To honor participants’ diverse identities and positionalities while maintaining confidentiality, we categorized participants as: Indigenous Peoples (IP), who self-identify as First Nations, Inuit, or Métis; Racialized Settlers (RS), who identify as settlers with racialized identities; and White Settlers (WS), who identify as white settlers. Racialized settlers refers to individuals who experience inequities within a society structured by whiteness while also, as settlers, receiving some of the unearned advantages of living on Indigenous lands—although not to the same extent as white settlers. White settlers refers to individuals benefiting most consistently and comprehensively from systems that privilege whiteness and normalize Euro-Western worldviews as the societal default. Their racial and settler status affords them structural advantages, often rendered invisible through narratives of neutrality, meritocracy, and universality. We recognize the potential for oversimplification but adopt these terms to balance analytic clarity and participant confidentiality. Our use of “racialized” aligns with the Ontario Human Rights Commission’s framing of race as socially constructed, while acknowledging that this terminology does not fully capture the distinct and ongoing forms of racism targeting Indigenous Peoples. “Indigenous” refers to First Nations, Métis, and Inuit Peoples, whose unique histories and internationally recognized rights (e.g., UNDRIP) shape their experiences and positionalities. These categories reflect a commitment to Indigenous-specific anti-racism, which attends to place-based colonial histories and the unequal distribution of power and privilege within settler colonial systems.

Analysis proceeded through several iterative stages. Two team members independently coded a subset of transcripts to identify segments related to pedagogical strategies, principles, challenges, and contextual factors. The team then compared and refined these codes to develop a preliminary coding framework. When coding disagreements arose between the two coders, we employed a consensus-building approach: coders first discussed their interpretations independently, then brought unresolved disagreements to the full research team for deliberation. Final decisions prioritized interpretations that best honored participants’ narrative intentions and aligned with Indigenous research principles. This process was documented in analytic memos.

We balanced narrative coherence with thematic abstraction through a two-phase analytic approach. First, we maintained each participant’s narrative integrity by creating individual narrative summaries that preserved the chronological and relational flow of their stories. Second, we conducted cross-case thematic analysis to identify patterns across narratives. Throughout this process, we returned repeatedly to original transcripts to ensure that abstracted themes remained grounded in participants’ actual language and meaning-making. Finally, emerging themes were validated with participants during Phase 2, and their feedback was incorporated into the final analysis. When presenting findings, we intentionally include extended quotations to preserve participants’ voices alongside our thematic interpretations, allowing readers to assess the fit between data and interpretation.

Our research team’s diverse positionalities, including Indigenous and settlers members, racialized and white researchers, and varying disciplinary background, profoundly shaped analytic decisions. Indigenous team members challenged interpretations that risked reproducing colonial frameworks and ensured that Indigenous knowledge systems were centered rather than merely included. Settlers team members engaged in ongoing reflexivity about how their socialization and privilege might influence interpretation. We documented these discussions in analytic memos and used them to interrogate our assumptions. For example, Indigenous team members reframed what settlers members initially coded as ‘resistance’ to instead recognize it as ‘protective responses to colonial violence,’ fundamentally shifting the analysis.

Through this iterative and inductive process, conceptual categories were constructed to capture the explicit strategies, ethical commitments, and transformative pedagogical actions educators employed to disrupt systemic racism and foster Indigenous self-determination in health education. Thematic analysis highlighted how these principles were operationalized in practice, shedding light on the conditions that supported or hindered their implementation and offering insights into both personal transformations and institutional challenges.

3.5. Rigor and Trustworthiness

Several strategies were employed to enhance the rigor and trustworthiness of findings. Credibility was supported by member-checking during Phase 2 validation activities and by triangulating data across interviews, focus groups, and written feedback. Dependability was enhanced through detailed documentation of all research procedures and regular team debriefing sessions. Confirmability was reinforced by the research team’s reflexive journaling and the maintenance of a comprehensive audit trail. Finally, transferability was promoted through thick descriptions of participants, study contexts, and key findings, enabling readers to assess the relevance and applicability of the results to their own settings.

4. Results

Most participants identified as female (n = 15), with one participant identifying as trans and non-binary and one as genderqueer. We report gender diversity to honor participants’ self-identification and because intersectional identities shaped their pedagogical perspectives. In terms of race, participants identified as white (n = 9), Indigenous (n = 5), Black (n = 1), and Asian (n = 2). Ages ranged from 32 to 65 years, with a median of 48. Seven participants worked in academic settings, representing fields such as education, nursing, and social work. Educational backgrounds varied: ten held doctoral degrees, four held master’s degrees, and three held bachelor’s degrees. Participants were located across Canada, including British Columbia (n = 7), Manitoba (n = 1), Quebec (n = 3), Ontario (n = 4), New Brunswick (n = 1), and Nova Scotia (n = 1).

As described in Methods, participants are identified using positionality categories: Indigenous Peoples (IP), racialized settlers (RS), and white settlers (WS). While results are not presented in separate groupings, the analysis remained attentive to how Indigenous participants spoke from positionalities grounded in sovereignty, land, and ongoing colonial violence. Further disaggregation may be possible in future studies with larger or more balanced samples.

4.1. Principles for Implementing Indigenous-Specific Anti-Racism in Health Profession Education

The results of this study illustrate six key principles for implementing an Indigenous-specific anti-racist approach in health professionals’ education. These principles, derived from participant perspectives, aim at creating safe and transformative learning environments. Safety in learning environments was identified as essential for meaningful engagement, allowing learners to critically examine their biases and assumptions without fear of retribution or tokenization. A transformative learning environment is not only inclusive but also challenges dominant norms that perpetuate racial inequities.

According to participants, creating such environments requires moving beyond performative allyship to actively dismantling structures that marginalize Indigenous perspectives. The six principles emphasize: (1) centering and privileging Indigenous knowledge and worldviews; (2) adopting a relational approach to teaching and learning; (3) contextualizing content in relation to colonialism; (4) supporting transformational learning leading to action; (5) embracing discomfort and addressing resistance; and (6) incorporating accountability mechanisms. These interconnected principles collectively foster systemic change in educational and healthcare institutions. The six pedagogical principles are deeply interconnected and mutually reinforcing rather than discrete or sequential steps. For example, centering Indigenous knowledge (Principle 1) requires relational approaches (Principle 2) and colonial contextualization (Principle 3), while embracing discomfort (Principle 5) enables transformational learning (Principle 4). Participants emphasized that these principles work synergistically to create conditions for anti-racist learning; implementing them in isolation diminishes their transformative potential. We present them separately for clarity, but readers should understand them as an integrated pedagogical ecosystem. Treating these principles as a checklist to be checked off risks superficial implementation that fails to challenge fundamental power structures. Meaningful anti-racist education requires comprehensive transformation of curriculum, pedagogy, relationships, and institutional structures—a systemic approach that recognizes the interdependence of these principles.

4.1.1. Centering and Privileging Indigenous Knowledge, Worldviews, and Strategies

Participants highlighted the necessity of centering and privileging Indigenous knowledge systems, worldviews, and strategies within health professionals education, moving beyond multicultural integration to fundamentally restructure curricula and pedagogical approaches. This principle requires actively dismantling the dominance of Western/white worldviews and repositioning Indigenous knowledge systems as equally valid and valuable—indeed, as essential—frameworks for understanding health, healing, and professional practice. This includes acknowledging Indigenous ways of knowing, which emphasize the interconnectedness of physical, emotional, mental, and spiritual health. One participant underscored this holistic approach, stating:

“Indigenous people utilize a more holistic approach, not only in education, but in health. And so, I feel our teachings are more balanced, and they include your emotional and your spiritual development” (IP8).

This participant expanded on the importance of spirituality in learning, explaining:

“Our spiritual development is practiced on a daily basis from when we wake up in the morning, till the time we go to sleep. And even during our sleep period, we call that our—we learn as we travel and journey in our dreams” (IP8).

The integration of Indigenous methodologies, such as storytelling, land-based activities, and ceremony, was also identified as central to grounding students in Indigenous worldviews. One educator described structuring their course as a guided journey:

“We talk about how we’re gonna journey in the first two weeks and what the focus will be in the second two weeks, and the last two weeks. Often, I use different little things like TED Talks so that they can start to listen to peers talking. I layer in a lot of Indigenous, Black, and Asian scholars into the literature” (IP1).

As part of centering and privileging Indigenous knowledge, worldviews, and strategies, participants indicated that decentering whiteness is critical to meaningful anti-racist education. Participants emphasized that whiteness has historically been positioned as the normative framework within healthcare and education, marginalizing Indigenous knowledge. Operating from a white supremacy stance in healthcare and education causes significant and multifaceted harms to Indigenous Peoples and communities. These harms include epistemic violence—the systematic devaluation and erasure of Indigenous knowledge systems and ways of knowing; exclusion from decision-making processes and leadership positions; ongoing trauma through the reproduction of colonial practices and attitudes; and the perpetuation of health inequities through care that fails to address root causes of illness. White supremacy normalizes Western biomedical frameworks as the only legitimate form of knowledge, rendering Indigenous healing practices invisible or illegitimate. This ideological dominance translates into material consequences: misdiagnosis, inappropriate treatment, lack of culturally safe care, and continued mistrust of healthcare systems.

One participant explicitly addressed this issue:

“That’s why, in class, […] I want to talk to students about whiteness. I want to address white supremacy. I want to address racism” (RP16).

Another participant reflected on their own teaching struggles, stating:

“Anti-racist pedagogy is not just to teach white people how to not be racist, but everything that I’m doing has not to center whiteness, and we need to decenter whiteness. That’s the whole thing. But that’s the struggle that I’m having” (WP2).

As participants emphasized, decentering whiteness is not merely an intellectual exercise but a necessary step toward dismantling the structures that actively harm Indigenous Peoples. It requires recognizing that Western knowledge has been imposed through colonial violence and continues to operate as a tool of oppression when positioned as superior or universal.

Participants further highlighted that decentering whiteness requires exposing students to multiple epistemologies. As one participant put it:

“I always found it useful, and this was very relevant in helping us being able to draw on different ways of knowing and understanding the world and not just quantitative and all those things which we die for in health” (RP15).

Another elaborated:

“I revise my syllabus every year, and that is really pushing for epistemic justice. If I reflect on my education all the years here in high school, in university, graduate studies, PhD and all that stuff, what we have been taught is always the Western worldview, framed in a way that is superior” (RP16).

Participants emphasized the importance of co-teaching models in which Indigenous and settler educators work together, noting that such partnerships bring multiple knowledge systems into the classroom and strengthen anti-racist pedagogy. Participants stressed that meaningful centering of Indigenous knowledge requires direct engagement with Indigenous scholars, Elders, and community members. Co-teaching, in particular, was identified as an effective strategy for ensuring that Indigenous perspectives are authentically represented. One educator described their co-teaching experience:

“I have a co-teacher, which I’ve never had before, so it’s just amazing on so many levels of having a second person at the front of the room with you. But to be able to teach from two standpoints, so from my standpoint as a white woman and a white nurse and white educator and her as an Indigenous woman” (WP2).

“My role is to echo what the Indigenous person is saying and amplify their voice and then call out Whiteness and systemic racism in a way that sometimes the Indigenous facilitator could be pathologized or labeled for doing so” (WP5).

Another participant underscored the value of inviting Indigenous guest speakers:

“There are students who always, always tell me that when they have guest speakers from First Nations or Inuit communities, it really has a great impact on their understanding of things” (WP14).

Flexibility in citation and assessment practices further supported this pedagogical shift, with participants encouraging the use of non-traditional sources, including Elders and oral histories. As one participant noted:

“Allowing students to use resources that they have, being a little flexible about the [American Psychology Association] stuff, but also saying you have to learn this, but looking at sources of wisdom—could you bring Elders in as a citation?” (IP13).

4.1.2. Adopting a Relational Approach to Teaching and Learning

A relational approach to education, as described by participants, shifts away from hierarchical teaching models and fosters reciprocal relationships between educators and students. This model supports open dialogue and values students’ lived experiences. Learner-centered and strengths-based approaches were seen as essential in engaging students meaningfully and ensuring that educational spaces recognize and respect diverse backgrounds and lived experiences.

“That one of the most important things we do, and one of the hardest and riskiest things we do as faculty is invite the lives of our students into the classroom. Cause to truly work in a relational way, you have to think about that piece” (IP1).

“With the students, it’s really about an invitation to come into relationship. I sit in circle with the students, we talk together, we have small group work that we allow whatever level of vulnerability is comfortable or not. I do a lot of storytelling myself, not necessarily about me, but about the complexities of relationships that I have witnessed as a nurse” (IP11).

Participants stressed the need to adapt teaching approaches to meet the needs of diverse student populations. This includes recognizing that Indigenous students may bring different perspectives and lived experiences that enrich learning:

“I believe—and this is what I-I tell people now colonization hurts our people because if you look at the curriculum, the Canadian curriculum, it’s teaching you how to be a good European and you need to fit into that box. And most of our people don’t fit into that box. They need to be who they are and that needs to be nurtured […] And I said, ‘Your identity is a gift’” (IP8).

“If you don’t do anything else in your classroom, name, where you grew up, where your ancestors came from, and what your relationship is to the land. Not just the land acknowledgment. That’s important, but name who you are. It creates a very important level of trust within a classroom to say, ‘I’m being vulnerable enough to share this, and this is where I’m coming from’” (RP17).

Interactive and dialogic approaches, such as small-group discussions, case studies, and problem-based learning, were viewed as essential for encouraging critical reflection on systemic racism in healthcare. As one participant explained, “We are the facilitators to find creative ways to actually engage them in dialogue” (RP16). Another emphasized the collective work required to examine relationships to land and colonial histories:

“So all of a sudden we had to figure out who we were in relationship to Indigenous people and in relationship to the land. And we did that collectively. Once the safety in the room was created, we could start naming the stereotypes that exist about Indigenous people and how they show up in ourselves and in the service that we were providing” (WP5).

Acknowledging and incorporating students’ lived experiences also emerged as a key strategy, often through reflective journals, storytelling, and flexible assignment options. One educator noted:

“And that’s where you have to build in the choice for assignments too, because you have to figure out how can you get to the individual, and what they need. The collective and the individual” (IP1).

Participants also stressed the importance of flexibility and relational approaches in fostering meaningful engagement with anti-racism education:

“We come from a very oral tradition. When students would really, really struggle with writing… I said, ‘We could do a poster or what do you want to do? Do you want to do a presentation to me?’” (IP13).

Yet, participants also recognized the structural tensions embedded in assessment, particularly when students must disclose aspects of their identity to instructors in positions of power:

“You know, these people are having to submit assignments about their identities to a white educator. And I then have the power to grade them on it. There are so many problems in those structures, so I resist only in naming these things to students” (WP2).

Flexibility in teaching methods, including the use of visual aids, simulations, and role-playing exercises, was similarly seen as important for supporting diverse learning needs and fostering an inclusive environment. As one participant described:

“I don’t like lecturing some groups but then also being very aware. I used to circle a lot, but to be aware of who’s in the classroom. Even in Indigenous health, it’s not just Indigenous people in the classroom. There’s that intersection of identity. There are other equity-deserving groups, and it’s very visible. You spend time at the beginning of your class talking about, so how are we going to work together? What are the major principles?” (IP13).

Another highlighted the importance of openness and relational engagement:

“Maintaining that sense of openness and being non-judgmental, and really being able to actively listen to folks and draw people out of their shells and support people in their own reflection” (RP15).

Collectively, these strategies point to pedagogical approaches that honor students’ lived experiences and foster learning environments conducive to meaningful and transformative educational experiences.

4.1.3. Contextualizing Content and Strategies in Relation to Colonialism

Participants emphasized that education on anti-racism in healthcare must be deeply contextualized within the history of colonialism. Understanding how colonial policies shape current health inequities is fundamental to decolonizing healthcare education.

• Acknowledging That the Past Informs the Present

Participants noted that many health inequities experienced by Indigenous populations are rooted in historical and ongoing colonialism. Teaching must therefore explore these connections rather than treating health disparities as isolated issues. As one participant stated:

“So tying it back to the current and past and ongoing colonialization, um, ensuring that the framing of everything is on the systems of harm and there isn’t a pathologizing. We’re focused on Indigenous ways of knowing and being, or—and there’s like that beautiful reframe, constantly reframing it away from pathologizing Indigenous people’s culture” (WP5).

The colonial project in Canada was explicitly designed to achieve the assimilation, displacement, and elimination of Indigenous Peoples. Policies such as the Indian Act, residential schools, the Sixties Scoop, and forced sterilization were not isolated historical events but rather systematic efforts to destroy Indigenous cultures, families, and governance systems [1]. These policies were underpinned by ideologies of white supremacy and cultural superiority that positioned Indigenous Peoples as inferior, savage, and in need of civilization. Critically, these same ideologies continue to operate in contemporary healthcare systems [1,7].

The goals and methods of colonization—surveillance, control, assimilation, and paternalism—directly inform current healthcare practices. For example, the medical system’s historical role in residential schools, where physicians participated in nutritional experiments and denied care to sick children, established patterns of medical violence that persist today. The forced sterilization of Indigenous women, which continued into the 1970s and has been documented in recent years, reflects ongoing assumptions about Indigenous women’s bodies and reproductive autonomy. Child welfare systems, which continue to apprehend Indigenous children at disproportionate rates, echo residential school policies of family separation.

In healthcare encounters, Indigenous patients frequently experience stereotyping (assumptions about substance use, non-compliance, pain tolerance), dismissal of their concerns, lack of informed consent, and care that ignores cultural protocols and healing practices. These are not isolated incidents of individual bias but rather manifestations of colonial ideologies embedded in institutional structures, professional training, and systemic policies. As participants explained, understanding this historical context is essential for students to recognize that health inequities are not the result of Indigenous Peoples’ behaviors or cultures but rather the predictable outcomes of ongoing colonial violence.

Teaching the past as informing the present requires making these connections explicit: showing students how residential school trauma manifests in mistrust of institutions; how the Indian Act’s control over status and membership affects access to services; how land dispossession relates to food insecurity and chronic disease; and how the systematic devaluation of Indigenous knowledge undermines holistic approaches to health and healing. Without this contextualization, students may inadvertently perpetuate deficit-based narratives that blame Indigenous communities for health disparities while failing to recognize the structural violence that produces these inequities.

Teaching the history of colonial policies (e.g., residential schools, the Indian Act, forced sterilization) can help students understand contemporary health inequities. One participant described their approach:

“To add the theoretical and the historical context, to really understand what marginalization is, what assimilation is, what the current context is for Indigenous communities in terms of health, in terms of access, in terms of taking charge of their health situation with what is offered to them by the government, whether it’s national or whatever. And that’s really how I shaped the training here at the university.” (WP10).

Findings indicate that inequities should not be attributed solely to individual behaviors but rather examined within broader systemic and structural contexts. Participants emphasized that health disparities result from intersecting forms of oppression, including systemic racism, colonialism, and economic marginalization. One participant described the need to move beyond a symptom-based model in healthcare education:

“It was around holism and they said, we keep being taught about holistic nursing, but we can’t practice it. The system is symptom management. That’s another key thing I would say. Holism is really important in a lot of cultures. A lot of cultures have a very holistic understanding of a person, but our system is managed by symptoms only. That’s a tension as well” (IP13).

Another participant spoke about the necessity of bringing in structural critiques:

“A good anti-racist approach needs to engage with the notions of whiteness and white supremacy and not just leave them to the wayside. I think a big one is action-oriented, being able to support some movements, and what action looks like will be different for all of us. If it’s someone who is a researcher, action will look very different about how do you rethink how you engage in your research” (RP15).

Analyzing real-world examples of systemic inequities though structural case studies allows students to explore the root causes of racism in healthcare. As one participant noted:

“If we’re gonna change something in a white organization, we need to figure out how to do it in a way that people are gonna listen” (WP7).

Visiting Indigenous communities or engaging with Indigenous-led health organizations can offer first-hand insights into the lived realities of colonialism’s ongoing impacts. One participant described the importance of concrete examples and active learning:

“I try to bring it back to reality: What does that mean for you in practice? You know, in concrete terms. I also give them a lot of examples from practice.” (WP3).

By embedding these approaches, educators can create learning environments that acknowledge colonial histories, center structural analyses, and support meaningful engagement with anti-racist healthcare education.

4.1.4. Supporting Transformational Learning Leading to Action

Participants emphasized that learning must be action-oriented, ensuring that students not only understand anti-racism but also integrate it into their professional practice, thereby fostering a transformative shift from awareness to sustained changes in clinical judgment, professional accountability, and everyday decision-making. As one participant noted:

“Because I think the anti-racism work tends to remain theoretical until we have opportunity to apply it. That application piece needs to be grounded in reality” (IP11).

Another participant highlighted the importance of relational learning in this process:

“So when I think of the anti-racist work, I’m always thinking about us as human beings continually growing, developing, changing. And that’s the focus, the content is there to support” (IP1).

Participants highlighted that transformational learning requires students to critically reflect on their biases and social positioning. Self-reflection was seen as essential for fostering long-term commitment to anti-racist practice:

“I dare to hope that what I provide through my teaching helps fuel their reflection and allows them to continue it… Because what I see is that people sometimes hold very fixed assumptions, and some of them are even mistaken.” (IP4).

“If you give people things to read on theories and stuff like that… some people get bored halfway through. What I often do is I try to get them to do exercises where they identify like who are you? What do you know about yourself? What do you believe in? What do you believe about people?” (IP13).

Participants emphasized the value of reflective practice as a means of deepening students’ engagement with critical incidents involving racism in healthcare. Encouraging learners to examine their emotions, experiences, and assumptions was described as essential for fostering meaningful insight and professional growth.

“Much more reflective assessments. When I assign work, it’s very much about reflection. I ask students to pay attention to their emotions and their lived experiences, and to translate that directly into their practice” (WP3).

Participants highlighted the use of role-playing and simulation exercises as an effective way to help students practice responding to racism in clinical situations. These scenarios were designed to provoke discomfort and prompt learners to consider appropriate actions, as one participant noted: The study found that students must be equipped with concrete skills and strategies to apply anti-racism principles in real-world healthcare settings:

“My approach is always… Western systems like to penalize people for behaving bad, whereas our approach is more restorative. Helping people to get back into their rightful place, however which-which way we present that. So that’s my approach to racism” (IP8).

“I think it’s experience, too, and I think it’s putting that experience in the classroom. That’s how I would teach it. It’s actually having students talk about experiences or helping create experiences for them that they get to navigate and think about” (IP13).

Participants highlighted the use of role-playing and simulation exercises as an effective way to help students practice responding to racism in clinical situations. These scenarios were designed to provoke discomfort and prompt learners to consider appropriate actions.

To illustrate how educators translate transformational learning principles into concrete pedagogical practices, Table 1 presents examples of action-oriented assignments and assessment strategies designed to foster critical reflection, accountability, and practical engagement with anti-racist practice. These examples represent concrete teaching practices described by participants and illustrate how each principle manifests in practice. They are not prescriptive checklists but rather demonstrate the diversity of ways educators enact these principles across different contexts and disciplines.

Table 1. Examples of Action-Oriented Assignments and Assessment Strategies for Anti-Racist Learning.

Assignment Type	Description	Skills Developed	Assessment Considerations
Critical incident analysis	Students analyze a clinical encounter involving racism, identifying systemic factors and alternative responses	Critical reflection; structural analysis; application of anti-racist frameworks	Assess depth of analysis, recognition of power dynamics, and actionable strategies rather than “correct” answers
Community-based project	Students partner with Indigenous organizations to address identified health needs	Relationship-building; cultural humility; collaborative practice; application of Indigenous methodologies	Co-assessment with community partners; emphasis on process and relationship rather than only outcomes
Reflective portfolio	Ongoing documentation of learning journey, including evolving understanding of racism and personal positionality	Self-awareness; reflexivity; integration of theory and practice; identification of growth areas	Assess honesty and depth of reflection, evidence of growth over time, and connections to practice
Role-play/simulation	Students practice responding to racism in clinical settings	Communication skills; intervention strategies; emotional regulation; advocacy	Assess appropriateness of responses, demonstration of anti-racist principles, and ability to navigate complexity
Policy analysis	Students examine healthcare policies through anti-racist and decolonial lenses	Structural analysis; policy literacy; identification of systemic barriers; proposal of alternatives	Assess sophistication of analysis, recognition of colonial underpinnings, and feasibility of recommendations
Alternative formats	Oral presentations, artwork, video, community presentations	Cultural responsiveness; diverse ways of knowing and expressing; creativity	Flexibility in assessment criteria; recognition of diverse strengths; consultation with Indigenous advisors on appropriateness

4.1.5. Embracing Discomfort and Addressing Resistance

Participants recognized that discussions on racism often generate discomfort. However, they stressed that discomfort is necessary for growth and must be navigated carefully. As one participant noted:

“This is great, this is a great sign. If people are getting uncomfortable, tensions are surfacing, you are on the right track. This is good. This is supposed to happen” (WP7).

Establishing early on that discomfort is a natural and necessary component of learning was also critical. As one participant explained, “I like having those uncomfortable discussions; not to shock, but to open up dialogue so we can improve things and find solutions” (WP10).

A key finding was that racism must be explicitly named and addressed rather than diluted through culturalist frameworks. Participants emphasized that racial inequities in healthcare stem from systemic racism, not cultural differences. One participant stressed the importance of avoiding the trap of over-culturalizing or essentializing identities, saying:

“To be careful not to fall into the trap of over-culturalizing or essentializing identities and cultures.” (WP3).

Preparing for resistance was seen as essential, with some educators using pre-course surveys to gauge students’ perspectives and adapt their approaches accordingly. A participant also underscored that meaningful change requires a broader organizational commitment rather than relying on a single individual or department, stating:

“I really believe it has to be the whole institution in—by—in every aspect of it. I think that’s where it falls apart. They-they say, ‘Oh, she’s in charge of EDI so go and talk to her.’ Or, ‘Go and talk to her because she, you know, we hired her to-to do that.’ It-it can’t be one individual. It can’t be one department. It has to be the whole institution involved in that priority. Like all of Canada needs to be involved in it” (IP8).

• Fostering Educator Reflexivity and Humility

Participants emphasized several strategies to help educators navigate the challenges associated with anti-racist teaching. Sustained mentorship and professional development for educators emerged as another key strategy, given the emotional burden and potential burnout associated with this work. One participant noted the importance of relational support:

“Strong sustained relationships, supporting each other because, in this work, it can be so, um, defeating, even soul-destroying” (WP6).

Participants noted that educators who model humility and openness to learning help create spaces where students feel safe engaging in difficult conversations. Educators must engage in their own reflexive work to navigate difficult discussions effectively. A participant emphasized the importance of pushing through discomfort:

“We’re doing the work and that’s great. We need everybody to be able to join. I feel that there are probably a good amount of faculty members and educators who… are very scared of saying or doing the wrong things when it comes to anti-racism. My advice would be to get over that fear in whichever way you can. Magic is getting out of our comfort zone. That’s where the magic happens with everything” (RP17).

4.1.6. Incorporating Accountability Mechanisms

Participants emphasized that accountability is necessary for ensuring that anti-racist education leads to meaningful change. Accountability was understood as operating at both individual and institutional levels, requiring educators to enact anti-racist principles in their teaching while holding institutions responsible for sustaining these practices through structures, policies, and curricula. As one participant put it:

“It is about doing the work and doing it with accountability” (WP5).

This sentiment reflects the deep importance of holding both individuals and institutions accountable for the actions they take in the realm of anti-racist education. Another participant also highlighted the emotional impact of this work:

“I have created an opportunity for students to really express themselves, and so when I read some of the things that students say, I have to close the book and walk away, and then come back because it is very hurtful. It’s tough to have that cross-racial lines vulnerability” (IP11).

This quote underscores the emotional labor involved in confronting and addressing racism in educational settings.

While educators play a crucial role, participants stressed that institutions must also take responsibility for sustaining anti-racist educational practices. One participant shared, “If you’re a facilitator working on this on your own, you need—You want to hold yourself accountable” (WP6), underscoring the necessity for both individual and institutional accountability. Another participant reflected on the institutional responsibility in ensuring anti-racism learning is ongoing:

“But we know indigenous anti-racism learning is lifelong. It’s certainly not one course. That’s why we had the scaffold layered learning journey” (WP5).

Furthermore, the need for institutions to acknowledge the broader societal impacts of their actions was emphasized:

“It’s not even that they don’t like them, they just don’t understand or they don’t like poverty. They don’t like disadvantage. They don’t like any of that, and so it’s just so messy. I try to understand that and I have a very strong network of indigenous people that I connect with” (IP11).

This points to the broader context in which educational institutions must engage to address systemic inequities.

Accountability mechanisms must be in place to assess the impact of anti-racist education and address gaps. One participant shared their experience, saying:

“I would advise to like really have ways of being able to get critical feedback… build in those pathways of accountability and feedback and criticism” (WP9).

Another participant echoed this, adding:

“Having relationships with Black, Indigenous, and racialized people… needs to be structures of accountability” (WP9),

reinforcing the idea that accountability should involve active collaboration and continuous feedback from diverse perspectives. Another participant shared a more reflective perspective on institutional accountability:

“I would say that this work was always done under the radar, we just did it” (IP13).

This highlights the often informal, yet deeply impactful, ways that individuals within institutions work towards accountability and racial justice.

Participants described several mechanisms to strengthen accountability in anti-racist teaching. Regular student feedback was regarded as essential for evaluating the effectiveness of pedagogical strategies, with one participant noting:

“You get regular feedback and that has always been helpful… evaluations from participants which I always find is useful” (RP15).

Peer review processes further supported educator growth by creating opportunities for mutual learning and reflection; as the same participant explained:

“If I was doing something with a colleague, then I would always want like, have a debrief for that person to say, ‘Okay, what did we plan on doing? What worked well?’” (RP15).

Mentorship also emerged as a critical component for faculty development, particularly in supporting sustained self-reflection and interrogating one’s positionality. One educator emphasized this ongoing work, stating:

“It’s an ongoing daily self-reflection on commitment to learning… what does the humble stance look like for a white person” (WP12).

This highlights the ongoing process of self-awareness and commitment to growth in anti-racist work. Together, these strategies illustrate how systems of feedback, peer support, and mentorship can foster deeper accountability and continuous growth in anti-racist pedagogy. To further contextualize these findings, Table 2 presents a framework for institutional accountability in anti-racist health education.

Table 2. Framework for Institutional Accountability in Anti-Racist Health Education.

Level	Accountability Mechanisms	Indicators of Success	Challenges
Individual Educator	Self-reflection; peer feedback; student evaluations; mentorship relationships	Demonstrated growth in pedagogical approaches; positive student feedback; ongoing professional development; integration of feedback	Emotional labor; time constraints; lack of expertise; fear of making mistakes
Program/Department	Curriculum audits; community advisory boards; program evaluation; equity data collection	Representation of Indigenous faculty; integration of anti-racist content across curriculum; student learning outcomes; graduate practice patterns	Resistance from faculty; resource limitations; competing priorities; lack of institutional support
Institution	Equity policies; Indigenous leadership in governance; funding allocation; public reporting	Indigenous representation in leadership; dedicated resources for anti-racist education; transparent equity data; partnerships with Indigenous communities	Institutional inertia; superficial commitment; lack of accountability structures; competing interests
Community	Partnerships with Indigenous organizations; community advisory roles; reciprocal agreements; impact assessments	Community satisfaction with partnerships; tangible benefits to Indigenous communities; respectful engagement processes; Indigenous leadership in research and education	Power imbalances; extractive relationships; lack of follow-through; inadequate compensation for community contributions

5. Discussion

The results of this study highlight the need for a holistic, systemic approach to integrating Indigenous-specific anti-racism into health professionals’ education. Participants emphasized that true transformation requires centering and privileging Indigenous knowledge, fostering relational and strengths-based learning, contextualizing content in colonial history, supporting action-oriented education, addressing resistance, and embedding accountability mechanisms. By implementing these principles, health education institutions can contribute to systemic change, ultimately fostering culturally safe and equitable healthcare environments.

5.1. Key Findings

This study identified six interconnected pedagogical principles that educators employ when teaching Indigenous-specific anti-racism in health profession education. These principles represent a comprehensive framework that moves beyond superficial diversity initiatives toward substantive transformation of educational practices and institutional cultures.

The first principle, centering and privileging Indigenous knowledge, worldviews, and strategies, challenges the epistemological dominance of Western biomedical frameworks in health education. Participants emphasized that meaningful transformation requires more than tokenistic inclusion of Indigenous content; it demands fundamental restructuring of curricula to center Indigenous ways of knowing and actively dismantle the supremacy of Western epistemologies. This finding aligns with scholarship on epistemic justice [33] and decolonizing methodologies [34], which argue that true equity requires recognizing multiple knowledge systems as equally valid and valuable.

The second principle, adopting a relational approach, reflects Indigenous pedagogical traditions that prioritize relationship-building, reciprocity, and collective learning [35]. This stands in contrast to individualistic, hierarchical models that dominate Western education. Participants described how relational approaches create the safety and trust necessary for students to engage authentically with difficult content about racism and colonialism. This finding resonates with research on culturally responsive pedagogy [36] and the importance of relational accountability in Indigenous contexts [37].

The third principle, contextualizing content in relation to colonialism, addresses a critical gap in much health education, which often treats Indigenous health disparities as isolated problems rather than outcomes of ongoing colonial violence. Participants emphasized the necessity of teaching the historical and contemporary mechanisms through which colonialism produces health inequities, explicitly linking colonial policies and ideologies to current healthcare practices and Indigenous-specific discrimination. This structural analysis is essential for moving beyond victim-blaming narratives that pathologize Indigenous communities [38].

The fourth principle, supporting transformational learning leading to action, reflects participants’ commitment to education as a tool for social change rather than mere knowledge transmission. This aligns with Freirean pedagogy [28] and transformative learning theory [39], which emphasize the role of critical consciousness and praxis in education. Participants stressed that learning about racism must translate into changed professional practices and advocacy for systemic change.

The fifth principle, embracing discomfort and addressing resistance, acknowledges the emotional and psychological challenges inherent in anti-racist education. Participants recognized that discussions of racism, privilege, and complicity often generate defensive reactions, particularly among White students and those from dominant groups. However, they emphasized that discomfort is a necessary part of transformational learning and must be skillfully navigated rather than avoided. This finding aligns with research on White fragility [40] and the pedagogical strategies needed to work through resistance [41].

The sixth principle, incorporating accountability mechanisms, addresses the sustainability of anti-racist education. Participants emphasized that individual educator efforts are insufficient without institutional commitment and structural support. Accountability must operate at multiple levels: educators to students, students to communities, institutions to educators, and institutions to Indigenous Peoples. This finding highlights the need for systemic change rather than relying solely on individual champions of anti-racist education.

5.2. Comparison with Existing Literature

The findings of this study both confirm and extend existing literature on anti-racist pedagogy in health education. Previous research has documented the limitations of multicultural and cultural competence approaches [10,11,12,13,14], and our findings reinforce these critiques. Participants explicitly distinguished their anti-racist approaches from cultural competence models, emphasizing the need to address power, privilege, and systemic oppression rather than focusing solely on cultural differences.

Our findings align with emerging scholarship on critical approaches to health profession education [16,17,18,19,42], which calls for explicit attention to structural determinants of health inequities and the role of healthcare systems in perpetuating harm. However, this study extends this literature by providing detailed insights into how educators operationalize these principles in practice, including specific strategies, challenges, and contextual factors that shape their work.

The emphasis on Indigenous knowledge systems and decolonizing pedagogies in our findings contributes to a growing body of literature on Indigenous health education [43,44,45]. While previous studies have articulated the importance of Indigenous perspectives, our research provides concrete examples of how educators center and privilege Indigenous worldviews, methodologies, and community partnerships into their teaching. The principle of decentering whiteness and addressing the harms of white supremacy, in particular, represents an important contribution to discussions of how to dismantle epistemic colonialism in health education.

Our findings also contribute to understanding the emotional and relational dimensions of anti-racist teaching. Participants’ descriptions of navigating discomfort, modeling vulnerability, and engaging in ongoing reflexivity highlight the personal and interpersonal skills required for this work. This complements research on the hidden curriculum [46] and the importance of educator positionality [47] in shaping learning environments.

5.3. Theoretical Implications

This study’s findings have several important theoretical implications. First, they support a constructivist understanding of learning that emphasizes the active construction of knowledge through experience and critical reflection [27,28]. Participants described how their own pedagogical approaches evolved through transformative experiences, ongoing learning, and engagement with Indigenous communities and scholarship. This suggests that supporting educators in developing anti-racist pedagogies requires attention to their own learning journeys, not just provision of technical skills or resources.

Second, the findings highlight the importance of experiential and transformative learning theories [30,39] for understanding how anti-racist education can lead to changed consciousness and practice. Participants emphasized that intellectual understanding of racism is insufficient; students must engage emotionally, reflect on their own positionality and complicity, and practice new ways of being in relationship with Indigenous Peoples and communities. This requires pedagogical approaches that integrate cognitive, affective, and behavioral dimensions of learning. Such approaches align with anti-racist pedagogy by intentionally disrupting dominant, depoliticized forms of knowledge transmission and by foregrounding reflexivity, relational accountability, and action as core educational outcomes rather than optional add-ons.

Third, the interconnected nature of the six principles suggests that Indigenous-specific anti-racist pedagogy must be understood as a holistic, integrated approach rather than a set of discrete techniques. The principles reinforce and depend on one another—for example, centering Indigenous knowledge requires relational approaches to build the trust necessary for authentic engagement; contextualizing content in colonialism creates the foundation for understanding why transformation is needed; and accountability mechanisms ensure that the discomfort of learning translates into sustained change rather than performative allyship. Treating these principles as a checklist to be checked off risks superficial implementation that fails to challenge fundamental power structures. This has implications for faculty development and curriculum design, suggesting the need for comprehensive rather than piecemeal approaches to integrating anti-racist education.

5.4. Implications for Practice

The findings emphasize that integrating Indigenous-specific anti-racist pedagogy demands ongoing personal and relational commitments. Educators need to commit to continuous learning, actively engaging with Indigenous scholarship, communities, and reflecting on their own positionality. Establishing genuine, reciprocal relationships with Indigenous scholars, Elders, and community partners is crucial, as is demonstrating vulnerability and reflexivity to create safe and supportive learning environments. Participants highlighted the importance of using diverse pedagogical methods—such as storytelling, land-based learning, simulation, and reflective activities—to connect theory with practical application and to support diverse learners. Educators should also expect discomfort and resistance, and develop the skills necessary to facilitate challenging conversations constructively, ensuring that learning results in tangible actions students can implement in their professional practice.

The findings highlight that educators cannot bear the sole responsibility for anti-racist teaching; institutional frameworks must meaningfully support these efforts. This includes providing resources such as dedicated time, funding, and professional development, and integrating Indigenous-specific anti-racism throughout curricula rather than restricting it to isolated courses. Institutions should prioritize Indigenous leadership in curriculum development, governance, and decision-making, while establishing accountability mechanisms, such as community advisory bodies and regular program assessments, to track progress. Changing institutional culture is essential, requiring a review of policies and practices to ensure they align with principles of equity and decolonization. Finally, recognizing the emotional labor involved, especially for Indigenous educators, institutions must invest in comprehensive supports, including mentorship, peer networks, and well-being resources.

5.5. Strengths and Limitations

This study has several important strengths. The biographical narrative methodology allowed for rich, detailed exploration of educators’ experiences and the contextual factors shaping their pedagogical approaches. The inclusion of Indigenous and non-Indigenous researchers on the team, along with validation activities involving participants, enhanced the credibility and cultural appropriateness of the research. The diversity of participants across disciplines, institutions, and social locations strengthened the transferability of findings.

While our findings offer valuable insights into Indigenous-specific anti-racist pedagogy, several factors limit transferability. First, our sample reflects a concentration of nursing and social work educators, with limited representation from medicine, pharmacy, and other health disciplines; pedagogical principles may manifest differently across professional cultures. Second, participants were primarily located in Ontario, Quebec, and British Columbia, potentially reflecting regional variations in Indigenous-settler relations and institutional contexts. Third, all participants self-selected based on their commitment to anti-racist teaching, representing educators already engaged in this work rather than those beginning this journey. Fourth, the study captured educators’ perspectives on their own practices but did not include direct observation of teaching or assessment of student outcomes. Fifth, while we included both Indigenous and non-Indigenous participants, the specific challenges and strategies may differ based on educators’ social locations. Finally, the study focused on initial and continuing education of health professionals; the applicability of these principles to other educational contexts (e.g., K-12 education, other professional programs) remains to be explored.

5.6. Directions for Future Research

This study suggests several promising directions for future research, including exploring how Indigenous-specific anti-racist pedagogical principles can be effectively applied across various institutional settings and the factors that promote or impede their adoption. Long-term outcome studies are necessary to evaluate impacts on student learning, professional practice, and ultimately health outcomes for Indigenous Peoples, alongside research that identifies effective strategies to support educator development through mentorship, communities of practice, and institutional scaffolding. Future work should focus on student perspectives to understand how anti-racist pedagogy influences their learning, identities, and commitments to equity, while institutional-level research is needed to identify structural conditions and change processes that sustain anti-racist education. Comparative and cross-national studies could reveal how different colonial and educational contexts affect implementation, and intersectional analyses are crucial for understanding how pedagogy can address racism, sexism, homophobia, ableism, classism, and other interconnected forms of oppression.

6. Conclusions

This study provides valuable insights into the pedagogical principles that educators employ when teaching Indigenous-specific anti-racism in health profession education. The six principles identified, centering and privileging Indigenous knowledge, adopting relational approaches, contextualizing content in relation to colonialism, supporting transformational learning, embracing discomfort, and incorporating accountability, offer a comprehensive framework for transforming health education. By centering and privileging Indigenous perspectives, challenging systemic racism and white supremacy, and fostering critical consciousness, these principles have the potential to contribute to meaningful change in healthcare education and practice. However, realizing this potential requires sustained commitment from individual educators, institutional leaders, and the broader health professions community. The path toward reconciliation and health equity demands nothing less than fundamental transformation of how we educate future health professionals.