Better Questions, Better Care: Reframing Research for Health Equity, with Dr. Tara Horrill

Dr. McGavock: [00:00:00] Today's podcast starts with a story, the story of a nurse working with a range of patients, some structurally oppressed, some not. Dr. Tara Horrill, during her career as a nurse, encountered something that should trouble us all. It was a patient from a remote First Nation community that arrived at a hospital with advanced cancer, a cancer that should've been caught earlier, prevented entirely.

Dr. McGavock: The gap between what could've happened with that patient and what actually did wasn't the result of bad doctors or careless patients, it was structural. But here's the harder question: How do we even know this? How do we even discover this? How do we understand the full scope of why patients can't access the care they need to prevent things that are preventable?

Dr. McGavock: The obvious answer, look at the data, count the barriers, measure the problems, misses something critical. Traditional research approaches are designed to be objective, empirical, methodological, [00:01:00] clean. They produce neat findings with statistical measures at the end. But health inequities aren't neat. They're contextual, they're historical, they're structural.

Dr. McGavock: It's lived in the body and in the community, and if your research methods are designed to strip away context and individual voice in the name of objectivity, you end up studying the problem in a way that actually mirrors the system that created it. So Dr. Horrill, as a curious academic, a curious nurse clinician scientist, describes the mismatch.

Dr. McGavock: Two mismatches, actually, working alongside each other. The first mismatch is an empirical one, how cancer services are not designed to match the lives of the people trying to access them, and the second mismatch that's equally important, the gap between how we've been trained to conduct research as neutral observers documenting objective facts, and what's actually required to understand and dismantle health inequities in the health systems where we work.

Dr. McGavock: You can't center patient voice and justice if your methods are designed to neutralize both. Through critical ethnography, sitting in clinics, listening to [00:02:00] nearly 30 people with lived experience of structural marginalization, and observing how systems actually work, Dr. Horrill and her team used research frameworks informed by social justice and critical theory to cut through that methodological mismatch.

Dr. McGavock: In this episode, Dr. Horrill shows us that the way you conduct research matters just as much as the questions you ask in research. That centering context, the voice, the lived experience of patients isn't a bias. It's essential to understanding what's actually happening in care and what justice requires.

Dr. McGavock: Today, on the Emerging Scholar Podcast, we're exploring how critical theory, justice-oriented research, and rigorous qualitative methods combine to create a different kind of knowledge, one that can actually serve the communities it was meant to help. Stay with us as we take a deep dive on this work. Tara, how are you?

Dr. Horrill: I'm well. How are you?

Dr. McGavock: Good. Thank you so much for making time. I know I reached out in the summer when this really, really great paper came across my desk, and I was like, "This is such great work. [00:03:00] I wonder where Dr. Horrill works. She's at the University of Manitoba. I think we could do this interview in person."

Dr. McGavock: So welcome to the studio.

Dr. Horrill: Yeah. Thanks so much for having me.

Dr. McGavock: This is so great to have you here. You and I talked a little bit earlier about your journey, but for our audience, maybe give us a sense of how you ended up here as a faculty member, and can I call you a clinician scientist?

Dr. Horrill: Well, I don't actually work clinically anymore.

Dr. Horrill: Mm-hmm. So I wouldn't consider myself a clinician scientist, but I can talk more later about how my previous clinical practice has impacted my research.

Dr. McGavock: All right. Yeah. So let's hear a little bit about that journey.

Dr. Horrill: Yeah, sure. So I finished my degree in nursing in 2005, and I started my career in the emergency room at the Grace Hospital.

Dr. Horrill: Worked there for a few years, and then I made the transition to outpatient oncology. So I worked as an oncology nurse for, I guess, close to a decade. Had a number of different roles there, and at one point, there was an opportunity to move into a research nurse role, so caring for patients on cancer clinical trials, and that was my first [00:04:00] foray into the research world, and it got me interested in what is research, why do we do research, how can it benefit our patients.

Dr. Horrill: And at the same time, I was working with a nurse who also did research, who had a PhD, who had a clinical practice, and I think she shoulder-tapped me and saw- Oh, nice ... potential for me to do something more. At that point is when I considered graduate studies, started a master of nursing, and actually, I'm not sure if that would've ever happened had that shoulder tap not happened, so I think that's something that's really important.

Dr. Horrill: So I started my master's in nursing, and it was like someone lit a match inside of me. I just fell in love with research. I loved that debate and exploration were encouraged and not discouraged. I loved learning. I love the academic setting, and so after a few years in the master's program, I transitioned directly into a PhD program and out of clinical practice completely.

Dr. Horrill: Finished my PhD in 2021 in the height of the [00:05:00] pandemic, which was an interesting experience, and then I did about an 18-month postdoc fellowship at the UBC in BC Cancer, and then in 2022, started my role here as a tenure-track assistant professor.

Dr. McGavock: What do you think when that mentor of yours tapped you on the shoulder?

Dr. McGavock: What did they see in you?

Dr. Horrill: That's a great question. I wish I would've asked that, but I think if I could hypothesize, it would be Having a curiosity and a growth mindset probably before I even knew what a growth mindset was. Having that innate curiosity, asking questions, wanting to know why things were the way they were, and probably being a hard worker

Dr. McGavock: Yeah,

Dr. Horrill: yeah. You're- So let's face it, graduate studies requires, you know, perseverance more than anything.

Dr. McGavock: Yeah. And she wasn't upset with all the questions you were asking about why-

Dr. Horrill: No ... why you

Dr. McGavock: were

Dr. Horrill: doing it? There were some people that were- Yeah ... upset by that, but she wasn't one of them.

Dr. McGavock: So I understand cancer settings, cancer hospitals are the optimal spot to do randomized controlled trials.

Dr. McGavock: Like- Mm ... almost every patient coming [00:06:00] in signs a consent form saying, "Yes, you can use my data in whatever way for part of research." Mm-hmm. A lot of platform trials, that kind of thing. But your work, you pivoted to the qualitative side. Mm-hmm. And was there like a, was there a patient experience? Was there a moment that triggered something in you to say, "My questions are deeper than just this therapeutic intervention-" Mm-hmm

Dr. McGavock: that you were involved in when you were a nurse?

Dr. Horrill: Yeah. That's a great question. I think there's a few different reasons that I moved away from the clinical trial type research and towards more qualitatively oriented research. The first, I think, is just the disciplinary orientation of nursing. We are often working one-on-one with patients, caregivers, families, and we hear their stories, and I think once you've been in clinical practice as a nurse for a while, you start to see how interconnected people's, you know, health and healthcare experiences are with their lives and the [00:07:00] context that they're in.

Dr. Horrill: You're trying to address many aspects of their health beyond just their physiological health, and I think that how we are able to a- address some of those aspects and, and learn more about the patient as a whole is through their stories, and hearing their stories and hearing more about their experiences.

Dr. Horrill: So I think I naturally gravitate to wanting to hear stories. Mm-hmm. So that's kind of one reason why I'm more drawn to qualitative research. Another element for me is the complexity of our healthcare system as well as people's healthcare experiences. There's a lot going on that we don't necessarily see or understand unless we ask those deeper questions.

Dr. Horrill: Mm-hmm. And, and qualitative approaches can help us do that. And I think the third reason is really rooted in the kinds of questions that I'm interested in. So you and I had just talked briefly earlier about how my work is really justice-oriented.

Dr. McGavock: Mm-hmm.

Dr. Horrill: That is a value that [00:08:00] I have personally held for a long time, and so I think it's natural that some of the research questions that I'm asking are coming out of that value.

Dr. Horrill: My program of research sort of sits, like if you picture a Venn diagram where health equity and cancer care services overlap. And so, um, I'm interested in questions around equitable access to care. How is care delivered in ways that either do or do not promote equity? How are people's care experiences rooted in issues of things like racism and discrimination and that sort of thing?

Dr. Horrill: And so, you know, there are some types of research that lend themselves better to exploring those kinds of things. I think that in the space that I work in, you know, population-based studies using epidemiological methods, they're really important. They can give us an idea of what inequities exist, but they can't really tell us why they exist, and they can't really, you know, highlight areas where we might intervene to address those [00:09:00] inequities.

Dr. Horrill: Mm-hmm. And so I think that's what I'm really interested in. I'm, I'm trying to use qualitative methods to understand the why and the what next.

Dr. McGavock: Mm-hmm.

Dr. Horrill: If that makes sense.

Dr. McGavock: With a justice lens. Like I was reading a few o- your other papers, and justice comes up a lot.

Dr. Horrill: Mm-hmm.

Dr. McGavock: And systemic violence.

Dr. Horrill: Hmm.

Dr. McGavock: Like the way that you've written about the need to address equity.

Dr. McGavock: And I think one of the quotes that I pulled from w- your work was that health equities are both a product of and a reflection of unfair social, economic, and political arrangements.

Dr. Horrill: Mm-hmm.

Dr. McGavock: And so it's ultra complex.

Dr. Horrill: Mm-hmm.

Dr. McGavock: Right? And I think some people see research as... But you've really committed yourself to this.

Dr. Horrill: Well, I mean, I think I'm also a, a bit pragmatic. I've worked in the healthcare system. I know how complex it is, and I know that there's no way I'm going to change it. If there's even something small that, you know, I could contribute to-

Dr. McGavock: Mm-hmm ...

Dr. Horrill: I think that that's ultimately what I'm trying to do, but [00:10:00] I'm definitely not- Holding the illusion that I'm going to change the-

Dr. Horrill: healthcare system.

Dr. McGavock: But you know what? I bet you're an amazing clinician because you like people's stories, but more importantly, I think you see them as human.

Dr. Horrill: Mm-hmm.

Dr. McGavock: Right? And you see them battling through those things. And as someone who doesn't work in oncology, in one of the papers you wrote recently, it was just a surprise to me 'cause I see cancer as a random condition and-

Dr. Horrill: Right

Dr. McGavock: you know, it doesn't matter if you're the richest person in the city or the poorest person, it could hit you no matter what.

Dr. Horrill: Yeah.

Dr. McGavock: But at every level-

Dr. Horrill: Yeah ...

Dr. McGavock: of care, there's a gap.

Dr. Horrill: Yeah.

Dr. McGavock: Like-

Dr. Horrill: I have a colleague who I published probably the paper that you're citing. Yeah. He often will say, "We like to think about cancer as a deeply unfortunate thing that happens to unlucky people," and it is not.

Dr. Horrill: Various health and social inequities, s- social advantages or disadvantages, or social structures, you know, make some people more likely to develop cancer, more likely to be diagnosed at later stages with [00:11:00] cancer, more likely to die quicker of their cancer, more likely to, you know, not have their symptoms taken seriously.

Dr. Horrill: I mean, I could go on, but, uh- Right ... and it is very complex. Sometimes it's overwhelming in the complexity. Like, how do I study this in a way that shows that complexity, but then also how do we address it? Because the causes are so complex and so deeply rooted in things that are really difficult to change.

Dr. McGavock: Right. And studying that complexity is incredibly challenging.

Dr. Horrill: Mm-hmm.

Dr. McGavock: And so the paper that I'm referring to here, you published in the International Journal for Equity in Health in June this year, There's Just Such a Mismatch: A Qualitative Exploration of Health Systems, Organizational-Level Barriers of Accessing Care Services Among People Experiencing Structural Marginalization.

Dr. McGavock: Was this something that kept you up at night? Like, uh, coming at it as a clinician, and you're just like, "Oh, it's the same people who are- Yeah ... getting these inequities all the time, and it's the system that's screwing them over, [00:12:00] and I wanna understand what it's like from their perspective."

Dr. Horrill: What do you mean did it keep me up at night?

Dr. Horrill: Like, the problem?

Dr. McGavock: Like, the problem, right? Like, it seem- Like, this is a really... What I love about this paper too, you had a beautiful theoretical framework, right? Mm. It's grounded in your commitment to I'm gonna say justice, right? Mm-hmm. And, like, equity. But it just seems like it's more than just a question.

Dr. McGavock: It's something that you really care about. Yeah. Maybe because you saw this somewhere either working here or working in BC, and you're just like, "This has to change."

Dr. Horrill: Absolutely. My research questions are a direct result of my clinical experience. Was I as acutely aware as a clinician? No. I mean, diving into the literature and doing your own research, of course, has made me much more well-versed in what the problem is and, and why it exists.

Dr. Horrill: But, you know, when I started to think about my doctoral research, I, I looked at inequities in access to oncology care for indigenous peoples in Canada, and that was a direct result of a clinical experience that I had. At the time, I was working in the space of prostate cancer, a cancer that [00:13:00] we can detect fairly early.

Dr. Horrill: We have really good methods of treatment. Most people are diagnosed and treated and go on to live fairly long and healthy lives. Now, this man came to us from First Nations reserve, and he was diagnosed with a metastatic prostate cancer, which is, you know, not that common. Highly symptomatic, and I didn't have the language for what was going on, but it led me to investigate that further in my doctoral research.

Dr. Horrill: Now, that did not answer your question. Does it keep me up at night?

Dr. McGavock: No, no, but exactly that was what formed- Yeah ... the basis for this.

Dr. Horrill: Yeah,

Dr. McGavock: exactly. For th- For this study, and maybe your, your lab generally.

Dr. Horrill: It absolutely did. I think- There are other things that keep me up at night that are not research related.

Dr. Horrill: Hearing the patient or participant stories, sometimes they're patients, sometimes they're healthcare providers, sometimes they're family members, it is highly emotional for me. It can be really challenging to hear those stories and know that you may not be able to do anything to [00:14:00] change that person's experience or even to help them in the future.

Dr. Horrill: So yeah, at times they're deeply disturbing. During the data collection for the study that you referred to, we were collecting data in BC, and I remember one particular day where I'd been doing, I think it was focus groups, and the stories, they were just so disturbing, the experiences that some people had had, that I remember sitting on the seawall and just crying for a long time.

Dr. Horrill: There's some personal boundaries that I think you need to put around doing this kind of work and figuring out who your people are that you can connect with about the challenges of doing this work. But it also is continual motivation because these issues are widespread, and I think there's an opportunity to at least, if I can't make things better, at least hear those stories and share them.

Dr. McGavock: And share them. Mm-hmm. Exactly. And that is exactly going back to your first statement, population health, research health services research is critical in identifying that. The TRC calls to action have asked us, Call [00:15:00] 19, we've got to document those.

Dr. Horrill: Yeah.

Dr. McGavock: But it's the stories that drive us. Mm-hmm. Right?

Dr. McGavock: Hearing that story as a provider, as someone, and you're just like, "We got to share this."

Dr. Horrill: Mm-hmm.

Dr. McGavock: Yes. Like, this is what's going to make change happen. So in this journey that I'm describing for trainees, we talk about starting with a really good question, right? I never thought about this. This is a super complex study, and, and these are- Yeah

Dr. McGavock: complex issues, right? It's like systemic barriers, right? How do you narrow it down? Like- Oh my gosh ... how do you start with a question- Yeah ... that's like, okay, we, we gotta tackle something here. Yeah. We know it's complex. Like, w- where did you start narrowing down?

Dr. Horrill: In my PhD training, I had one professor that continually drove it into our heads regarding idea development and research proposal development.

Dr. Horrill: You need to think about what is the next logical question to ask. So for me, I did my doctoral research, and I was looking at equitable access to oncology care for First Nations people in Canada. One of the things that came out [00:16:00] of that research, I interviewed a range of actually oncology nurses across Canada, and we, uh, were often talking about, you know, the importance of culturally safe care and how when that is either present or absent, it has a huge impact on people's access.

Dr. Horrill: We like to think about access as actually, like, does a building exist, and are there healthcare providers in that building? Those things matter, but it goes beyond that.

Dr. McGavock: Can I get in an Uber to get-

Dr. Horrill: That, but also- Yeah ... you know, what is the social space like? When I go into that clinic- Okay ... or the hospital, do I feel welcomed?

Dr. Horrill: Hm. Do I feel judged? Do I feel dismissed? Yeah. Those are access issues, too.

Dr. McGavock: Okay.

Dr. Horrill: Can providers deliver that culturally safe care where they're able to develop a, a bit of a trusting relationship? So the, the issue of culturally safe care came up in many of the interviews with nurses, and what was interesting is that not all of them, but a lot of them understood why that was important, and they really wanted to practice in culturally safe ways.

Dr. Horrill: Their environments, you know, there were certain structures in healthcare environments that prevented them [00:17:00] or limited their ability to do that. Mm. Like, a really simple example is the fact that our appointment slots are usually 10 minutes. If someone's coming in-

Dr. McGavock: Right ...

Dr. Horrill: and they have transportation issues, maybe they're coming from a reserve.

Dr. Horrill: Maybe there's complex issues around how their medications are funded. Maybe they can't afford some of the regular things that we would expect. Maybe they've experienced racism in every t- single healthcare experience they've ever had. Mm. And you only have 10 minutes. How can you possibly establish trust- Yeah

Dr. Horrill: and address some of those other things? You can't. Right. And so it was really interesting to hear that organizational context matters for equitable access to care. So that was the kind of one of the finishing points of my PhD, and when I went into my postdoc, I wanted to pick up on that idea. And so that's where the idea for the study that you're referencing came from.

Dr. Horrill: It was to look at what is it about the organizational context of a cancer care-

Dr. McGavock: Yeah ...

Dr. Horrill: health service delivery organization that either facilitates or hinders an [00:18:00] equity oriented approach to care, and that was the launching point for this study.

Dr. McGavock: So in season one, we talked about methodological coherence.

Dr. McGavock: Mm. And you, everything is so coherent. It was like- Ooh, that's great ... it was meant to be. So then you went from your question, and you put out a theoretical framework. Mm-hmm. All, any grad student that's ever worked in our institute is gonna laugh 'cause I bring up theoretical frameworks all the time. I'm like, "You always gotta put it up there."

Dr. McGavock: It doesn't matter, even if you're a basic scientist.

Dr. Horrill: You, you can't see me, but I'm clapping.

Dr. McGavock: I'm like, "Throw it up there." And you did it, like, you did such a good job. So let's go from, you went to a question- Yeah ... then your theoretical framework, and then- Mm-hmm ... we'll get into the methods, 'cause we are a, sort of a- Mm-hmm

Dr. McGavock: methods podcast trying to get into this. But let's talk about what a theoretical framework was for you- Mm-hmm ... knowing that, and we talked about this earlier, cancer is typically looked at as biology, biomedicine- ... physiology, right? Mm-hmm. It's all about numbers. Your perspective was way different than that.

Dr. McGavock: Mm-hmm,

Dr. Horrill: yeah. So- All research, I think you alu- alluded to this, but I'll pick up on it. All research contains assumptions. [00:19:00] All research is grounded in a theoretical perspective. Now, we don't always s- see that explicitly laid out, but, you know, your theoretical perspective really lays out explicitly what assumptions you're bringing to the research.

Dr. Horrill: And, you know, these should be reflected in your methodology and your methods. So the way I was trained is that you should be able to draw a clear line from your theory to your methods, and actually going even higher than theory to your epistemological-

Dr. McGavock: Mm-hmm.

Dr. Horrill: Yeah, Maria brought that up ... lens, I guess. Yeah.

Dr. Horrill: Yeah,

Dr. McGavock: yeah.

Dr. Horrill: So I think, you know, it's pretty rare to see this in clinical trials, to see it in epidemiological research, and it's influencing all aspects of the research. So I approach pretty much all my research through a critical theoretical perspective. Critical theory, it's really an umbrella term for a bunch of theories, but there's some commonalities across critical theories, and they will all be interested in how power is operating, often through unequal relationships, systems of oppression.

Dr. Horrill: But there'll be a common thread when [00:20:00] you're using a critical theoretical perspective to look at power. And then the other commonality is the assumption that context matters. So as it applies to my work, thinking about how health and healthcare systems are influenced by the context that we're in, so the political context, what's getting funded, what's not, not just research, but healthcare, historical context.

Dr. Horrill: We can dr- draw direct links between colonization and current health, social, cultural contexts, all of those things. So these assumptions influence the questions I'm asking, but also the way I'm gonna go about doing my research.

Dr. McGavock: And the type of patient is critical in that context. I think about my dad, who was treated at- Mm-hmm

Dr. McGavock: CancerCare, was living in a largely- Yeah ... Black neighborhood in Houston, and he's an older white guy. And I think about our friend who worked in CancerCare, who's indigenous-

Dr. Horrill: Mm-hmm ...

Dr. McGavock: who helped indigenous patients navigate and their- Yeah ... contexts. Those are two wildly different contexts.

Dr. Horrill: Yeah,

Dr. McGavock: absolutely. And that, that system is gonna operate wildly different- Yeah

Dr. McGavock: for both those. Yeah. You know?

Dr. Horrill: [00:21:00] Exactly.

Dr. McGavock: And so you describe that you have a theoretical perspective that's grounded in a critical theory. You draw out a nice figure. I also do that. We were talking about our colleague, Monica Sinclair. Mm-hmm. And her and I actually co-designed a nice one- Right ... that's, that's grounded in some indigenous structural determinants of health-

Dr. Horrill: Mm-hmm

Dr. McGavock: which I'll show you later. Yeah,

Dr. Horrill: I would love to see that.

Dr. McGavock: Then you line it up beautifully with two words that were super intimidating for me to read 'cause I hadn't heard about them, but it was another reason why I wanted to bring you in to walk us through it, critical ethnography and interpretive description.

Dr. Horrill: Uh-huh.

Dr. McGavock: Is that's your methodology, not your method?

Dr. Horrill: That's right.

Dr. McGavock: Okay. So your method was, and then I just skipped right to the methodology.

Dr. Horrill: That's okay. I would put methodology under a theoretical framework- Okay ... or a theoretical perspective. I think about methodology as your overarching strategy or your plan of action, and then your methods as the very concrete approaches that you're going to use.

Dr. Horrill: So do you want me to walk you through?

Dr. McGavock: Yeah.

Dr. Horrill: Yeah? Okay. Please, yeah.

Dr. McGavock: Sure. The methodology was?

Dr. Horrill: Yeah. I think in this, the study that, that you're referring to, we said that we used [00:22:00] a critical ethnographic approach.

Dr. McGavock: Mm-hmm.

Dr. Horrill: Like, ethnographic purists would probably not call this an ethnography, but it informed the methods decisions that we made.

Dr. Horrill: And so critical ethnography is a subtype of ethnography, and it's really investigating issues of justice and equity. The ultimate aim of a critical ethnography is to stimulate change of some sort, advance equity. It's very action-oriented, and I would say it probably could even be thought of as political.

Dr. Horrill: It's often got goals related to disrupting the status quo, bringing to light taken for granted assumptions, exploring power relationships, looking at systems of oppression. So you should be able to see the link here between critical- Yes ... theory and critical ethnography. The, the other thing I think that it brings to the table is that it helps to examine some of the processes that might be operating that are less visible, and maybe even that people aren't necessarily conscious of.

Dr. Horrill: So I can get into that more-

Dr. McGavock: Yeah ...

Dr. Horrill: if you'd like.

Dr. McGavock: Yeah.

Dr. Horrill: Yeah.

Dr. McGavock: Okay. Now, so let's [00:23:00] say we're a trainee and we're not familiar with critical ethnography- Mm-hmm ... and we choose a focus group methodology, let's say. Mm-hmm. But we don't align the critical theory with- Right ... a critical theory aligned method.

Dr. Horrill: Mm-hmm.

Dr. McGavock: Is that right?

Dr. McGavock: Is that the right term to use?

Dr. Horrill: Sure.

Dr. McGavock: Right? And you just say, "I'm gonna pick this." Then what happens? Like that dis- when it's disjointed- Yeah ... like that, what, where, what's the problem then? I

Dr. Horrill: think ultimately you're not gonna be able to answer the question that you set out to.

Dr. McGavock: Boom.

Dr. Horrill: Right?

Dr. McGavock: Love it. Yeah.

Dr. Horrill: So in this study, you know, I talked about we were going in looking at organizational contexts of cancer care organizations and wanting to understand what facilitated or limited the provision of equity oriented cancer care.

Dr. Horrill: So if we just went and did focus groups- Mm ... we would've probably been able to glean something useful.

Dr. McGavock: Mm-hmm.

Dr. Horrill: But to focus groups, we added interviews as well as observations.

Dr. McGavock: Mm-hmm.

Dr. Horrill: And, you know, using those various methods, I think we were able to get at some of the challenges that were embedded in organizational [00:24:00] processes or contexts or even the way care teams were set up that individuals themselves may not have been able to comment on.

Dr. McGavock: Like, they couldn't feel they could comment on it, or they weren't aware of it?

Dr. Horrill: Not consciously aware- Okay ... necessarily.

Dr. McGavock: Also within that piece you had interpretive description. Right.

Dr. Horrill: Yeah.

Dr. McGavock: How do those two guys like dance together or-

Dr. Horrill: Yeah ... work together? That's a good question. Interpretive description is also a methodology.

Dr. Horrill: It's a qualitative methodology developed by Dr. Sally Thorne, absolutely brilliant nurse scholar, and it's really grounded in wanting to develop qualitative research findings that are relevant to applied research settings. So the idea here is that people who are interested in developing research findings that are applicable in a healthcare setting and have the potential to actually be taken up and have some sort of meaningful impact, rather than just doing research for the sake of doing research or developing theory or whatever.

Dr. Horrill: Like, there's an applied a ki- kind of thrust to that methodology. So I would say in terms [00:25:00] of how we used interpretive description, it was more applied in our analysis to push us towards thinking what is the application.

Dr. McGavock: Mm-hmm.

Dr. Horrill: Like, why does this matter?

Dr. McGavock: Mm-hmm.

Dr. Horrill: Although it, it can be thought of as a complete methodology in and of itself.

Dr. Horrill: I think one of the things I wanted to comment on is that qualitative methods, when I think about designing a qualitative study There is a lot of room for being flexible and for letting things... You know, you sort of s- set out with a bit of a plan, but you can draw on more than one methodology, and it can change as the study goes.

Dr. Horrill: And that doesn't mean that it's not rigorous, but you really do need to lay out and be explicit about those decisions and why they were made. My PhD supervisor just tell me all the time, "There's no right or wrong, it's just defensible or not defensible."

Dr. McGavock: Yeah. Well, and what I meant, you have triangulated different methods-

Dr. Horrill: Mm-hmm

Dr. McGavock: right? Yeah. So that it's... And I [00:26:00] guess the ethnography piece for me lies in the observational field notes.

Dr. Horrill: Yeah.

Dr. McGavock: Is that's the ethnographic piece.

Dr. Horrill: Mm-hmm.

Dr. McGavock: And then the critical piece, I guess, comes in how you examine what you're observing.

Dr. Horrill: Yeah.

Dr. McGavock: And then also the kinds of questions that you're asking of the data, even of the, the people who are participating in the interviews or the focus groups, right?

Dr. Horrill: For sure. Yeah, I think it comes through in how you're collecting data as well as how you're analyzing the data-

Dr. McGavock: Mm-hmm ...

Dr. Horrill: uh, in addition to why you ended up with this, you know, research question in the first place. I can give you really simple example that comes to mind in this study was, I did pretty much all of the observations myself, and one thing I noticed in the clinical settings, and I think it was maybe somebody commented in a focus group, quick comment about how there are still plexiglass dividers between when you go to check in for your appointment.

Dr. Horrill: Mm. And so between the staff member and the patient, and how you had [00:27:00] to wait in a lineup. And so I attended to that when I was observing. And if we weren't using a critical lens, may not have surfaced as really an issue. But when we looked at it through the lens of power dynamics and unequal relationships of power-

Dr. McGavock: Mm-hmm

Dr. Horrill: we were able to talk about how space is physically laid out can make people feel unwelcome and perpetuate that power dynamic, just from a piece of plexiglass and a sign that said, "We don't tolerate," the usual signage around

Dr. McGavock: violence. And this, this was a... Was this a leftover from COVID? Or was this- Yeah, probably.

Dr. McGavock: And then the observation that the experience that someone reflected to you- Mm-hmm ... in the focus group then catches your eye, so that when you're going in to do the observation-

Dr. Horrill: Right ...

Dr. McGavock: you're saying, "I'm looking at this through a critical lens."

Dr. Horrill: Yeah.

Dr. McGavock: Right? And- This might sound facetious, but you could look at this as, "Okay, well I've worked in this clinic, and I know why that [00:28:00] plexiglass is there."

Dr. McGavock: Mm-hmm. "And she's wrong."

Dr. Horrill: Yeah. Right? And I think coming to it as a clinician, even though I hadn't worked in that particular healthcare organization, there's always that narrative going on in my head of, you know, yes, I do know why that's there, but also, this other perspective is equally valid. Yes, I know it's there from COVID.

Dr. Horrill: Yes, I know there are population health reasons why it's there.

Dr. McGavock: Yeah.

Dr. Horrill: And both can be true at the same time.

Dr. McGavock: Yeah. Would you call that, like, double objectivity, right? It's like- ... some people are like, "Well, qualitative research is subjective, and we don't really know." But those two things are true. Like, those are- Mm-hmm

Dr. McGavock: two... I might... Like, some of people in work in my other space might call that a dialectic, right? Like-

Dr. Horrill: Mm-hmm ...

Dr. McGavock: the, the person behind the glass-

Dr. Horrill: Yeah ...

Dr. McGavock: on one side is saying, "Well, the glass is there for a reason."

Dr. Horrill: Yeah. "

Dr. McGavock: And you just have to deal with it."

Dr. Horrill: Yeah.

Dr. McGavock: And the person on the other side of the glass is like, "No, that's violent."

Dr. Horrill: Right.

Dr. McGavock: Right? Like, you're treating me other than.

Dr. Horrill: Yeah.

Dr. McGavock: And those two things are true.

Dr. Horrill: Exactly.

Dr. McGavock: Right? Yeah. So then [00:29:00] how does that roll out in each aspect of your methods or each aspect of your data analysis? Because you always have to hold those two kind of truths in there, right? Like, your equity lens-

Dr. Horrill: Mm-hmm

Dr. McGavock: right, and then what someone might push back against and say, "Actually..." Or how does that play out?

Dr. Horrill: Well, I'm not sure if I have an answer for that. I can say that it's extremely challenging to do this work because I think often it can be perceived not as critical, but as criticism-

Dr. McGavock: Right ...

Dr. Horrill: of individuals, of healthcare providers, of, you know, leaders who are making decisions- Mm-hmm

Dr. Horrill: of organizations. And-

Dr. McGavock: They

Dr. Horrill: take it

Dr. McGavock: personally.

Dr. Horrill: Yeah. Yeah. And it's not intended to be. Like, I think truly most people are not in the health professions to perpetuate racism. They're not going into it for that. But we work in a system that it's embedded in- Right ... and often you do end up perpetuating that.

Dr. Horrill: And so that's a, been a learning curve, I think. Probably one of the harder [00:30:00] things for me to learn how to navigate is that pushback when, you know, you maybe present your findings and, and it's received as criticism rather than as perhaps a launching point for considering how we might do things a little bit differently.

Dr. McGavock: Yeah.

Dr. Horrill: Yeah.

Dr. McGavock: Okay, so if I try to dig into the data analysis-

Dr. Horrill: Mm-hmm ...

Dr. McGavock: I, I haven't prepped you for this- Okay ... so it's, this is... So in the data analysis, right, if, if I am reading a transcript, right? Mm-hmm. And I am just reading it verbatim, and then I'm saying, "This is what the person said," and I grab a quote that I think is important, right?

Dr. Horrill: Okay.

Dr. McGavock: That's just me looking at it. But now if I'm looking at this through a critical lens or through an equitable lens- Mm-hmm ... what are some of the things that I'm looking for as I'm coding or observing the system through that critical lens- Yeah ... through that equity lens? When you're analyzing the data and thinking about that methodological coherence- Mm-hmm

Dr. McGavock: you have to look at that. So do you have an example that kind of rings out- Um- ... to you when you've read something and you're like, "Oh, I know what they're talking about"? Here's the problem

Dr. Horrill: with my papers, is once they're published, I [00:31:00] actually forget what I wrote. Despite spending so much time on them. Yeah. I can tell you that I think, in general, the things that I'm often doing You know, qualitative, your data set can end up being quite large and quite overwhelming.

Dr. Horrill: So for this study, we had 60 participants in total, and that was a mix of individual interviews and focus groups, and then about 40-plus hours of observational field notes, as well as different documents that we collected. And sometimes it's hard to know where to start. And so the thing that I'm doing often is returning to my research question because you can go in any one of 100 different directions with your analysis, but continually going, "So what are we asking?

Dr. Horrill: What are we trying to understand?" That's often what I'm returning to. I'm also often asking, like, how is power operating here? What's going on that somebody might say something, but what's going on underneath what they're saying? Right. Why did they have that experience? So it's digging [00:32:00] deeper than what they're just saying necessarily.

Dr. McGavock: And that's also probably part of the running the focus group. If someone says something, then you're also digging a little bit deeper to be like, "Can you explain that a little bit further?"

Dr. Horrill: I mean, I think that's actually easier in individual interviews, but, like, sometimes you have to make pragmatic decisions.

Dr. Horrill: And in this case, we were running focus groups with patient participants, and these are folks that, you know, I, I use the concept of structural marginalization, but very practically, they're experiencing extreme poverty, unstable housing, sometimes living on the street or in a tent or on a couch. You know, using substances and experiencing a lot of substance use stigma.

Dr. Horrill: So to plan and conduct individual interviews, like, it was a method o- it, it was a methods decision that we made as a team that this would be a bit more logistically feasible.

Dr. McGavock: Right.

Dr. Horrill: Yeah.

Dr. McGavock: Okay. So then maybe we'll just turn to the-

Dr. Horrill: Mm ...

Dr. McGavock: kind of beautiful summary results- Mm-hmm ... which not enough people do. Is to create that...

Dr. McGavock: So the, the overarching theme [00:33:00] is there's just a mis- mismatch, right? Mm-hmm. So that first theme is service delivery mismatches.

Dr. Horrill: Mm-hmm.

Dr. McGavock: And this, I think, is the heart and soul of really good qualitative research- Mm-hmm ... is that you're taking all this information- Mm-hmm ... right? And you're not counting quotes.

Dr. McGavock: You're not counting words. You're like, "You know what they're talking about. I need this." They're just seeing my cancer.

Dr. Horrill: Mm-hmm.

Dr. McGavock: And w- what they're doing- Or

Dr. Horrill: they're just seeing the fact that somewhere on my chart it's written that I use substances. Oh. Or they're just seeing that I'm coming in and

Dr. McGavock: they're- Undressed, yeah.

Dr. Horrill: Yeah, exactly.

Dr. McGavock: Right. So theme one just comes out, service delivery mismatches. Cancer services do not account for social needs.

Dr. Horrill: Mm-hmm.

Dr. McGavock: How do you confirm that theme? Do you go back to the participants or is that a discussion with your colleagues?

Dr. Horrill: That's a great question. And actually, I don't tend to do that at the end, and the reason why is because a robust qualitative analysis, you're developing your themes across a large data [00:34:00] set, so an individual might not actually recognize their own experiences in your theme.

Dr. McGavock: Right.

Dr. Horrill: That does not mean that it's not true or doesn't exist, it's just you're drawing from your entire data set to develop that. So I wouldn't say that we do, like, member checking in the way that it- Yeah ... was originally described in qualitative research. As far as our analysis, you know, it was a team approach.

Dr. Horrill: What we did do was when we had developed-- We were pretty far into our analysis. We went back and we held, we called them engagement sessions, I think.

Dr. McGavock: Oh,

Dr. Horrill: yeah. And we held three with community members, so again, people experiencing structural marginalization, and we held three with healthcare providers. And for the community member sessions, we presented these themes through the use of photos and images.

Dr. McGavock: Awesome.

Dr. Horrill: And we had discussions, like, "Does this resonate with you? Does this make sense?"

Dr. McGavock: Yeah.

Dr. Horrill: So it wasn't like, "Is this theme correct and have you experienced this?" It was, like, more of a general conversation.

Dr. McGavock: [00:35:00] Right.

Dr. Horrill: And then we did something similar with healthcare providers. I think it was a bit more text-based versus image-based.

Dr. Horrill: And then in those sessions we actually also talked about, which is not published yet, the so what piece. Like, here's all the challenges, what would we recommend cancer care organizations to do-

Dr. McGavock: Nice ...

Dr. Horrill: to be an environment that supports an equity-oriented approach to care?

Dr. McGavock: Nice. I'm gonna circle back to this, but the way that you do that, you also talk about in other papers, like reducing that power and privilege.

Dr. McGavock: As an equity part of research, right? When you're presenting pictures back to your participants- Right ... I'm sure it's in a place that they consider safe, or they feel comfortable. Right.

Dr. Horrill: Exactly, yeah. We actually-

Dr. McGavock: There's gonna be food involved

Dr. Horrill: Exactly, yeah. Right? We had those- You're done ... sessions in the community, in a couple different places.

Dr. Horrill: We had a community center. We h- used, like, a boardroom of a primary health s- care center. I can't remember if we had a third location. But yeah, we provided a full hot meal, soup, sandwich, drink, dessert, that kind of thing. We offered a cash honorarium. People did not have to sign up. They could just [00:36:00] literally show up.

Dr. Horrill: Yeah. So it was as, as low barrier as possible.

Dr. McGavock: And there were more of the participants than the scientists.

Dr. Horrill: Oh, by far.

Dr. McGavock: Right?

Dr. Horrill: I think there was maybe two or three of us, and we were very conscious of that, making sure that we weren't overwhelming the group.

Dr. McGavock: Yeah.

Dr. Horrill: The other thing we did for the community, uh, member sessions was that we provided, like, an arts-based activity to do.

Dr. Horrill: So if they didn't feel like they wanted to look us in the eye or contribute verbally, they could work on a little art activity to hopefully make people feel a little bit more comfortable, give them something to do with their hands, that kind of thing.

Dr. McGavock: We have people doing that at all of our research conferences now-

Dr. Horrill: Mm-hmm

Dr. McGavock: uh, just to support people who are there who may not feel comfortable in that space.

Dr. Horrill: Mm-hmm. Yep.

Dr. McGavock: Um, we'll figure out how we'll do this, but I just wanna go through those themes a little bit. And for me as a non-qualitative, but someone who respects and admires qualitative work, I think this is the gold. Mm.

Dr. McGavock: Like, when you have said- Yeah ... "Here's the themes," and I think it's science and art combined, and I think that's just something you don't see in the [00:37:00] quantitative, right? Uh, sorry if that was, like, offensive

Dr. Horrill: or anything, but- No, it's not offensive at all ... I think it's amazing. I was just gonna say, I actually can't take credit for this-

Dr. McGavock: Okay

Dr. Horrill: particular diagram. I've been working with the Centre for Healthcare Innovation- Oh, yeah ... at the University of Manitoba. Nice. And so they did this one, and they developed three infographics for us. They're now working on a final report, and they do beautiful work. Yes. So this is not my creation.

Dr. McGavock: Yeah. A shout-out to SPOR Networks- Mm-hmm

Dr. McGavock: and our Centre for Healthcare Innovation is amazing.

Dr. Horrill: Yeah.

Dr. McGavock: Our leadership is amazing. Mm-hmm. We're very fortunate. I'll talk about something that a friend of mine told me who does a lot of these himself.

Dr. Horrill: Hmm.

Dr. McGavock: But your other themes that came out, number one, or number two was competing priorities. So discourses of efficiency are in tension with patient-centered, and what you also called culturally safe care.

Dr. Horrill: Mm-hmm. So I touched on that a little bit when I was talking about my dissertation research, right? Mm-hmm. Where, you know, individual providers may want to use certain strategies to approach their care delivery in a certain way. But there may be formal [00:38:00] policies or there may be things that are operating more at the level of discourse where it's like an unwritten rule that structure their work in certain ways.

Dr. Horrill: And so one of the things that we see in healthcare is this constant push towards efficiency. I think I talk about it in this paper. It's been referred to by others as lean oncology. You know, the lean movement- Yeah ... or the McDonaldization of oncology care. Oh,

Dr. McGavock: wow.

Dr. Horrill: And this idea that, you know, we need to see as many patients as possible, as quickly as possible, as cheaply as possible.

Dr. McGavock: Mm-hmm.

Dr. Horrill: Now, again, I understand there's reasons for that. Mm-hmm. Healthcare resources are limited. We're, you know, in this, a health human resource crisis right now in Canada, so that makes sense, and we're not pointing out that there isn't reasons for that, but it has impacts- Right ... and it has specific impacts on people's care experiences and on health equity.

Dr. McGavock: Yeah, disproportionate. Mm-hmm. Like, the impact is- Yeah ... not the same for every patient.

Dr. Horrill: Precisely.

Dr. McGavock: And from a clinical or from a critical lens- [00:39:00] It's in your commercials, it's on your posters. We're a patient-centered place, but you have the power to dictate how long that session's gonna be.

Dr. Horrill: Mm-hmm.

Dr. McGavock: Right? And so you as a system say, "It's 10 minutes, and I don't care who you are.

Dr. McGavock: I don't care- That's right ... what your cultural beliefs are, but too bad." That would be my lay interpretation of how you brought the cl- Yeah ... critical piece there. Theme number three were uneasy spaces. Mm-hmm. So physical spaces for cancer care matter.

Dr. Horrill: Yeah. I allude to this as well with the plexiglass. But other things that came up that make people feel unwelcome or make them feel like just a number are, you know, the very clinical feeling of outpatient care, where it maybe looks and smells like a hospital.

Dr. Horrill: But one thing that might not be immediately obvious that came up in our research was around this idea that people experiencing structural marginalization often have some experience in their life of institutionalization. So maybe it's the foster system, maybe it's the criminal justice system, maybe they are residential school survivors- Yeah

Dr. Horrill: you know, a number of [00:40:00] things. Yeah. And it's not even that outpatient or inpatient oncology settings look like any of those things, but they feel like those things. Right. And so people start to feel and interpret their experiences as discriminatory or racist or stigmatized.

Dr. McGavock: And then theme four, so just going back to that too, I think talking about some of the work we're doing is around trails in the city, and one of our indigenous community leader just said, like, "I don't see myself here."

Dr. Horrill: Mm-hmm. "

Dr. McGavock: I don't see myself anywhere in this space."

Dr. Horrill: Exactly.

Dr. McGavock: Right?

Dr. Horrill: And that did come up. Like, can you put indigenous artwork on the walls? Can you, like, just make this look anything but like it looks like?

Dr. McGavock: So an inter-

Dr. Horrill: Can you add plants? Can you- Yes ... make it smell like cedar or pine? And, and not all of these things are possible, but could we at least think about the potential for that?

Dr. McGavock: Right. And everyone would love it, right? But it'll matter more to the people that need it.

Dr. Horrill: Exactly.

Dr. McGavock: And that is what is the big thing.

Dr. Horrill: Yeah.

Dr. McGavock: And ironic- Aspect of where we [00:41:00] work. We have a hotel adjacent to our hospital-

Dr. Horrill: Mm-hmm ...

Dr. McGavock: which connects to the Cancer Care Institute. And if you go into that hotel, they have pictures of all parts of Manitoba.

Dr. McGavock: So if you came here from a Dene community in the north, you will see yourself somewhere in that hotel.

Dr. Horrill: Hmm.

Dr. McGavock: And you get out of the elevator-

Dr. Horrill: Mm-hmm ...

Dr. McGavock: and then you go into the hospital, and you're like, "Oh, my God. There's nothing." Right? Mm-hmm. It's insane. The hotel got it.

Dr. Horrill: And it seems like it's low-hanging fruit.

Dr. Horrill: It's low-hanging

Dr. McGavock: fruit. This is something we

Dr. Horrill: can actually do.

Dr. McGavock: Then the last theme were incompatible experiences.

Dr. Horrill: Mm-hmm.

Dr. McGavock: So e- experiences of stigma and discrimination are making it challenging for people to access care.

Dr. Horrill: Mm-hmm.

Dr. McGavock: And I think we don't think about that in terms of access, right?

Dr. Horrill: Right. Yeah, and I've touched on that a couple times already, that access is not simply having a building or having, you know, exam room or having a provider, but that people's experiences actually really matter.

Dr. Horrill: And we heard about this a lot in this study and others that I've done, that, you know, that interaction with their healthcare provider can make or break their cancer experience. And for some people, [00:42:00] they will not come back for their cancer treatment. I actually had one healthcare provider in this study say almost these exact words.

Dr. Horrill: She worked with people experiencing extreme mental health challenges layered onto poverty and housing challenges, and she said, "Some of my patients would rather die than get care for their cancer."

Dr. McGavock: Yeah.

Dr. Horrill: Which really says something.

Dr. McGavock: That's crazy. Yeah. And That leads into, you talk about social justice as a framework for like oncology research.

Dr. McGavock: So what kinds of system organizational level changes could be changed with these stories? And I always see it as a, a three-pronged approach, right? If I'm a leader, if I'm a, a big policy decision-maker, I wanna see efficacy, like this is gonna make a difference- Mm-hmm ... in terms of something.

Dr. Horrill: Right.

Dr. McGavock: I wanna see money.

Dr. McGavock: I wanna see cost savings.

Dr. Horrill: Yeah.

Dr. McGavock: But what I think really flips the switch are the sto- Mm-hmm ... the personalization-

Dr. Horrill: Yeah ...

Dr. McGavock: of what's happening here. [00:43:00] So is there something within this paper that if we were fortunate enough to be able to sit down with our health minister and say, "We gotta change cancer care organization or oncology care in this province based on this research," what are some of those justice things that come out at you first?

Dr. Horrill: Where to start? Oh. What's- That's a loaded question.

Dr. McGavock: What's the low-hanging fruit to start with?

Dr. Horrill: Well, I mean, like we talked about changing the look of spaces to make them feel a little bit more welcoming. I think one of the directions that I would like to see this go, in the first theme there, you know, you mentioned about oncology services not being able to take into account social needs, and that's an area that I'm planning on exploring a little bit more.

Dr. Horrill: I think that there are ways that when we know about social needs, we can slightly adapt how our care is delivered. It doesn't mean that we're fixing that social need, but at least that we're tailoring our care a little bit more to make sure the person, despite [00:44:00] the social need, can still have access to care.

Dr. Horrill: If we could do a better job of caring for the whole person, including some of those social needs, from a entire health system perspective, we could probably also be more efficient and see cost savings. Yeah. So I'll have to dream up a hypothetical example, but if in an intake assessment we learned that someone is living in quite extreme poverty or living unhoused or whatever, and making some attempts at supporting that person and addressing some of those needs for the time being, that might prevent a number of emergency room visits for, you know, any number of complications related to cancer treatment.

Dr. Horrill: So you'd be saving money and time there alone. Mm-hmm. They might be able to be managed more effectively in the community and not have it to make their way to tertiary care. So I think, you know, part of the problem is that our healthcare system is incredibly siloed. Yep. And things are coming from different [00:45:00] budgets and different line items.

Dr. Horrill: I don't actually know how that all works 'cause I don't work in that area, but I know that it's very siloed. And, you know, the cancer care organizations will be thinking about their own budgets versus the healthcare system as a whole. So I don't know how to address that problem, but I think that we need to be thinking more in that way.

Dr. McGavock: Right. Yeah. Like, anytime you have any interaction with the system, at one point, and cancer care is one of those places, we're gonna give you wraparound care for other aspects. Did you know you have access to this?

Dr. Horrill: Precisely.

Dr. McGavock: Did you know that we can help you with that?

Dr. Horrill: Yeah.

Dr. McGavock: It's not the job of the social worker.

Dr. McGavock: We're not gonna send you down the hall and remake another appointment. We're gonna deal with it right here.

Dr. Horrill: Yeah. That speaks to whole other issues around interdisciplinary team-based care and who does what. I think that we could think about efficiency different in that way too. I know that in some of the oncology settings, they're very physician-dominated, and there aren't some of those other pieces, whereas in other settings they'll have very robust nur- nursing services, except [00:46:00] the types of work that the nurse is doing is not necessarily meant To complement the physician services, it's almost replicating it, and so I think we need to think differently too about how we're approaching team-based care.

Dr. McGavock: People often wanna just stay in their role. They wanna stay, like, there's silos in the hospital- Mm-hmm ... but then there's silos within each clinic team, and you're just like, "That's not my job."

Dr. Horrill: Yeah.

Dr. McGavock: And I totally agree that it should be more wraparound. Yeah. So thinking about the trainees that are listening or residents who are trying to get into this space, sounds like you had some amazing mentorship.

Dr. McGavock: Like, someone- Mm ... tapped you on the shoulder. Your PhD advisor- Mm-hmm ... did an amazing job. Can we give a shout-out to that person?

Dr. Horrill: Absolutely. It's Dr. Annette Schultz. She's in the College of Nursing.

Dr. McGavock: Oh, right on.

Dr. Horrill: Yeah, fantastic mentor.

Dr. McGavock: Fantastic human.

Dr. Horrill: And I've told her she can retire, she can move away, but she will always be my mentor.

Dr. McGavock: Nice. So find yourself a good mentor.

Dr. Horrill: I also was co-supervised in my postdoc by Dr. Annette Browne from UBC-

Dr. McGavock: Mm-hmm ...

Dr. Horrill: and Dr. Kelli Stajduhar from the University of Victoria, also fantastic human beings and mentors.

Dr. McGavock: Okay. Yeah. So we're gonna put [00:47:00] links to their labs- Yeah, yeah ... in, in this. And then so what would you advise, other than finding a good mentor, for a trainee, like, thinking about this, listening to this, and saying, "You know what?

Dr. McGavock: That's exactly the kind of research I wanna do"?

Dr. Horrill: I think one of the things that I have observed is that sometimes folks without qualitative training will assume that a qualitative study is simple, with very limited training and perhaps no mentorship or no expert on their team. And I think that is a false assumption, but also it's a disservice to qualitative research, but to your participants, you know, they're giving you the gift of their story, and you have a responsibility to use that wisely.

Dr. Horrill: Uh, so I think enlist someone who is an expert. There is a huge role for collaboration. I have collaborators that are experts in epidemiol- epidemiological research, and so I, I don't really [00:48:00] know how to design a study like that. I haven't made up questions, and so that's why we collaborate. We don't have to be experts in everything.

Dr. McGavock: How do you learn how to do really good focus group discussions and-

Dr. Horrill: Well ...

Dr. McGavock: also thinking about populations that you may be working with that won't feel comfortable coming into that space? Mm-hmm. Like, practice obviously is something,

Dr. Horrill: but- Yeah, I think there's a few things. First of all, like, again, the mentorship in that has been Absolutely critical.

Dr. Horrill: The people that I listed off all have done extensive work with various structurally marginalized populations and have been in it for 30 years. And so they have been instrumental in guiding every decision. How are we gonna approach this? How are we going to advertise it? How are we gonna offer honorariums?

Dr. Horrill: What kind of food? What kind of questions are we gonna ask? Mm-hmm. Like, all of those things I've been very much influenced by my mentors. You know, honestly, there's some trial and error involved, too. Like, yes, I've had fantastic mentorship, and then when you go into a focus group or an interview, you don't always get it right.

Dr. Horrill: Reviewing that [00:49:00] transcript and making the notes of what you might do differently and just sort of humbly recognizing that I'm always learning, so I'm always hoping to get better. And then I think the other thing is anyone who's working in the equity space, this takes a lot of personal work. There's a lot of reflection, a critical self-reflection.

Dr. Horrill: There's a lot of reading. There's a lot of thinking about power, oppression, those kinds of things, and a lot of humility in recognizing that I bring a lot of privilege into the research, and so there's a huge element of personal work. I think it's interesting that, you know, health equity has become this sort of buzzy topic.

Dr. McGavock: Yeah.

Dr. Horrill: And we see people jumping on the bandwagon without really have- having done a lot of that personal work, which it's glaringly obvious to me. There's a scholar in the US, Elle Lett, who wrote a brilliant paper on health equity tourism.

Dr. McGavock: Yep.

Dr. Horrill: And this idea that people are just kind of jumping into the space without being fully [00:50:00] prepared, trained, doing the reflective work, and that's dangerous.

Dr. McGavock: Mm-hmm. It's an unintended consequence or maybe, you know, you could have expected it. But when- as soon as you tie dollars to equity-

Dr. Horrill: Mm-hmm ...

Dr. McGavock: or you tie dollars to, like, indigenous patient engagement- Mm-hmm ... you're gonna have a flood of people going in there- Right ... who haven't done that kind of work. This is a tough question, but what was your moment of self-reflection or something that you did that you're like, "Oh my God."

Dr. McGavock: Oh. Yeah.

Dr. Horrill: I, I remember the moment.

Dr. McGavock: I have a distinct one too. I would love to hear yours. What was that?

Dr. Horrill: So I was in my first year of my PhD, and my supervisor, Dr. Schultz, also hired me as an RA and gave me quite a bit of freedom in my RA work, and I had this idea for a grant, and she was very supportive of me writing it.

Dr. Horrill: What we wanted to do was look at First Nations people in Manitoba, cancer incidence, stage diagnosis, mortality, and compare it to all other Manitobans. And as I was kind of starting to engage in this work, she had me read large chunks of the [00:51:00] TRC report. And I remember sitting in my office as an RA and just having this realization of all that I did not know about my own country's history- Yeah

Dr. Horrill: and just sobbing, uh, because I had been so ignorant and also at the atrocities. So that was a really impactful moment for me of realizing my privilege.

Dr. McGavock: Mine was actually flying to Garden Hill First Nation and being alone for the first time, and I was supposed to meet with the ADI worker there, Larry Wood.

Dr. McGavock: And I say this all the time, and it's hard. I choke up almost every time. But, like, the harms that we do to First Nations people in our country In stark contrast, the amount of love that I got when I walked- Right ... off that plane is just... It's, it just- It's humbling ... magnifies how disgusted I am with how our country has treated indigenous people.

Dr. McGavock: Mm-hmm. It's just like they've shown nothing but love, in my experience. And so yeah, and then reading, right, doing the deep dives on the history of Canada. And then also, like, people asking me [00:52:00] questions like, "What are things that you were taught that you thought are true that are not grounded in equity?" And if you pull yourself up by your bootstraps, you're gonna make it.

Dr. McGavock: If you just work hard enough... No, that is not true in this society.

Dr. Horrill: Right.

Dr. McGavock: If you're a 20-year-old white guy from a middle-class income or higher, yes. But if you're anyone else-

Dr. Horrill: Mm ...

Dr. McGavock: that's not true. So yeah, a deep dive if you're into this, and we are gonna have a couple of episodes on critical perspectives- Mm

Dr. McGavock: critical indigenous perspective. We're trying to get, yeah, some of the experts in here- Mm ... to just say, like, "This is how this came about." And so as we look... I'm looking at your website right now, Reach. Mm-hmm. And doing this kind of work, where is your lab going? What are some of the things you're doing if a trainee's interested and was loving what- Mm-hmm

Dr. McGavock: we were just talking about?

Dr. Horrill: Yeah, I think if you have any interest in health s- in sort of the intersection of health services and health equity, probably what we're doing would be of interest. What- where I'm trying to go with my research is I've done a number of scoping reviews over the past few years, and that exposes you to just, like, a huge range of research, [00:53:00] right, in all of the reviewing.

Dr. Horrill: What I've gotten very frustrated with is that there are thousands and thousands of studies describing what the problems are, and very, very few that have moved into the space of, "What are we going to do about this?"

Dr. McGavock: Right.

Dr. Horrill: And so that's where I'm trying to move my program of research, is into the more co-development of interventions and, and pilot testing those and maybe scaling them up.

Dr. Horrill: So that's the space. In terms of what to expect, I try to place a high priority on a more relational approach to, to my lab. Being together and learning from each other is really important. We do prioritize being together physically on site at the same time, and I'll be the first to say that I think I've probably learned as much from my staff and trainees as they've learned from me.

Dr. Horrill: So I guess that's a little bit of what you could expect.

Dr. McGavock: Nice. And then probably some incredible skills in qualitative inquiry.

Dr. Horrill: We'll see. Research skills. It's a, it's a hard thing to, to teach and to, to train in, and it's so incredibly time and resource consuming.

Dr. McGavock: Mm-hmm.

Dr. Horrill: Uh, I have yet to [00:54:00] figure out how to do this in an awesome way.

Dr. McGavock: Well, you had good mentors- True ... and usually that's a sign that you're a really good mentor yourself, so.

Dr. Horrill: Cool.

Dr. McGavock: Thank you very much for that. Thanks for helping us- Thank you ... do a deep dive into this and give us another really important perspective on what qualitative inquiry is, how it can be done, and then its implications for social justice, which I think is super important.

Dr. Horrill: Thanks so much for having me.

Dr. McGavock: Good luck with everything you're doing, and hopefully we'll cross paths in the hallway at some point soon. So in today's episode, we talked about two mismatches, and they're inseparable. The first, the mismatch between cancer care services who are designed for a patient that doesn't exist, leaving those with the fewest resources to face impossible choices.

Dr. McGavock: But that's only visible if you use research methods that actually capture the complexity and lived experience of those individuals. And that's where the second mismatch comes in: the mismatch between traditional empirical quantitative research approaches and what justice actually requires. And here's what matters.

Dr. McGavock: Dr. Horrill didn't use methods that [00:55:00] pretended to be neutral observers documenting objective facts. She used critical ethnography informed by social justice frameworks. Specifically, because those approaches allow you to ask different questions, deeper questions, important questions. Not questions like, "How many barriers exist?"

Dr. McGavock: Or, "How are barriers built into the design of systems?" Not, "What do patients need to know to change?" But rather, "What would it take for us to redesign the systems that treat these patients from the ground up to increase equity, justice, and the health of the patients we're here to serve?" Those aren't just different questions.

Dr. McGavock: They're questions that center the people most affected by their condition and point towards genuine transformation of a healthcare system. This gets at something fundamental about emerging scholarship in health justice. You can't separate the methodology from the mission. If your goal is to serve justice for structurally marginalized patients, you can't use research methods designed to strip away context, voice, and relationship.

Dr. McGavock: You need frameworks, critical theory, participatory approaches, interpretive methods that [00:56:00] actually honor the knowledge of the communities you're working with Honor the knowledge of the patients that you're working with. The rigor isn't compromised by this. It's deepened because you're actually understanding what's happening, not a flattened version of it.

Dr. McGavock: Dr. Horrill's work reminds me that methodology is not neutral. The tools we choose to use to research social injustices, healthcare injustices, are either gonna reinforce it or they're gonna challenge it. When she sat in those clinics and listened to what was happening, when she centered the voices of people navigating impossible systems with the lives that they're living with, when she asked structural questions instead of individual ones, they weren't soft choices.

Dr. McGavock: They were rigorous, intentional, methodologically grounded choices made in the service of justice. And the knowledge they generated, the specific contextual human understanding of what the mismatch actually looks like and what fixing it requires, that knowledge can only come from that approach. This is the work of the emerging scholar, not just documenting what's wrong, but using frameworks and methods specifically designed to understand injustices in [00:57:00] ways that serve people the most affected by it.

Dr. McGavock: Not settling for clean research questions that miss the messiness of actual human suffering, but staying in that complexity with rigor and care until you can see what transformation actually looks like. I can't thank Dr. Horrill enough for this conversation. If you're an emerging scholar that wants to engage more deeply in justice research, more deeply in the critical lens, you should take a look at her work.

Dr. McGavock: Head to our show notes where you'll find links to her recent research on health systems and organizational barriers to cancer care, her foundational work on access to cancer services among indigenous people, and the critical theoretical frameworks, decolonial theory, structural analysis, intersectional approaches that shape how Dr.

Dr. McGavock: Horrill asks her questions. You'll also find information about critical ethnography and justice-oriented research methodologies that bridge knowledge to action in a meaningful way for structurally marginalized patients. This has been The Emerging Scholar podcast. I'm Jon McGavock. Thank you for listening.

Dr. McGavock: And if you enjoyed this episode, you are gonna love our next episode. We are turning the page into [00:58:00] how to communicate your science and how to communicate with the public in a meaningful way using social media. Again, we're interviewing a colleague of mine from the University of Manitoba, Dr. Michael Narvey, also known as NICU Musings, whose social media platform is there to teach the general public about fascinating stories in medicine, important decisions they need to make about the care of their children, and very importantly, how to dismantle health information that's emerging from health influencers that's not grounded in truth.

Dr. McGavock: Look forward to seeing you next week. This is Jon McGavock, and this is The Emerging Scholar podcast. The Emerging Scholar Podcast was recorded in the UMFM studios located at the University of Manitoba in Winnipeg, Manitoba, Canada. This is Treaty 1 territory, the original homeland of the Anishinaabe, the Ininew, and on the national homeland of the Red River Métis.

Dr. McGavock: Manitoba is also homeland to the Anishininew, the Dakota Oyate, and the Dene peoples. We acknowledge that our water is sourced from Shoal Lake 40 First Nation. As a settler [00:59:00] scientist working in health research, I acknowledge TRC Call to Action number 18, that health inequities between Indigenous and non-Indigenous people are the direct result of colonization.

Dr. McGavock: Winnipeg is the center for reconciliation in Canada, and where we are speaking from today is at the crossroads of Canada's history and Canada's future. We are three kilometers away from one of the most sacred meeting grounds for Indigenous people on the plains and within Turtle Island. We are also several kilometers away from one of the last residential schools in the province.

Dr. McGavock: We are working collectively on reconcili-action with youth, elders, and community leaders to heal from the trauma of colonization, past and present, honor the original treaties, and create a Canada that addresses and eliminates the inequities and injustices of the past and present to create a future for Indigenous children to live and thrive.

Dr. McGavock: On behalf of the team at the Emerging Scholar Podcast, we wanna thank Osani Balkaran for the great production for our opening and [01:00:00] closing themes. We also wanna thank UMFM 101.5, especially our executive producer, Jared McKetiak, for technical assistance and production on this project. We also wanna thank all of our guests for the discussion and the insight that they've provided.

Dr. McGavock: Once again, thank you for listening. Be sure to subscribe to the Emerging Scholar Podcast on Apple Podcasts, Spotify, and umfm.com.