Volume 44 Number 2

Introduction

In Aotearoa (New Zealand) health disparities and inequalities for Māori and Pacific populations are widely known and published.^1–3 These inequalities have been attributed to personal, social, economic and environmental factors such as access to employment, income, health, and educational opportunities, and for Māori the generational effect of colonisation.¹ As a consequence, this can lead to smoking, alcohol, and drug use; poor nutrition and living in overcrowded unhealthy homes.^1,2 In Aotearoa health disparities affect the young to old; 2013–2015 data for the 0 to 74 aged group indicated Māori and Pacific had higher rates of avoidable deaths and a lower life expectancy compared to non-Māori and non-Pacific people.¹ In addition, Māori have double the death rate from ischaemic heart disease, chronic lower respiratory diseases and all cancers combined.³

As healthcare professionals (HCPs) challenging racism and recognising cultural health inequities and how they have emerged, can empower us to practice in a culturally sensitive and safe way. In Aotearoa cultural safety is assessed or measured through clinical and cultural competencies developed by the profession’s governing body.^4,5 Like myself, Pākehā (white inhabitants of Aotearoa), or non-Māori, can find it challenging to evidence this within clinical practice.

Background

The signing of the Treaty of Waitangi (Te Tiriti O Waitangi) in Aotearoa in 1840 between the British Crown and Māori (indigenous peoples) is considered a founding document for Aotearoa to protect Māori culture and enable British governance.⁶ Though the Treaty interpretation varies between the Māori and English version it is considered a taonga (treasure) and is referenced widely in government documents.^6–8

Our Nursing Council defines culture as “Culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability”⁵. All nurses working in Aotearoa are required to meet the Nursing Council Code of Conduct and kawa whakaruruhau (cultural safety) standards.⁵ The Council reminds us that practicing and demonstrating culturally safe practice is based on the recipients’ experiences and not on the HCPs interpretation.⁵

In 2005 I was appointed as Wound Clinical Nurse Specialist. This newly developed role required the development of a service quality improvement plan. In accordance with the registered nurse competencies⁹ I included statements on the Treaty and kawa whakaruruhau but when the plan was presented to our Māori Health Manager, he asked how I would place this into practice. I requested his guidance, and he suggested I develop a ‘Cultural Focus Group’ with other health professionals to support and learn from our Māori health colleagues and develop whakawhanaungatanga (relationship building). With my manager’s support I developed the draft terms of reference that included the meeting location/s, day, time, frequency, quorum required, membership, chair, secretary roles and who the group is accountable to. In addition, it was documented that the group’s purpose is to share learnings, provide guidance, and improve cultural practices across primary and secondary care settings, while incorporating the Treaty of Waitangi Principles of partnership, participation, and protection.^6-8 The members’ responsibilities are to identify service inequalities for Māori and Pacific people to facilitate cultural awareness and safety, to address racism and encourage reflective practice and critical thinking in a supportive environment. Members are expected to communicate relevant learnings and information with their colleagues. The terms of reference were reviewed and approved by relevant managers and group members.

The first hui (meeting) was held in September 2005, in the hospital’s Māori Health Unit, and included our hospital’s Māori and Pasifika nursing teams, their clinical manager and an external Māori health provider known to me. This first meeting regarded the group purpose as important and the group decided to invite more external HCPs. Since then, membership has grown across primary and secondary sectors, including Māori and Pacific healthcare providers, kaiāwhina (non-regulated health and disability workers), cancer co-ordinators, podiatrists, social workers, prison nurses, educators, nurse practitioners, and clinical nurse specialists (e.g. sexual health, diabetes, colo-rectal). As secretary, I record the meeting minutes and circulate these with relevant information and resources to members to share with their teams and networks. Huis are held up to four times a year, for one to one-and-half hours; venues are changed with members hosting the events, which has enabled attendance and introduction of new members, nurturing whakawhanaungatanga (relationship building), and learning about the respective organisations.

The hui agenda includes opening and closing with a karakia (prayer) and/or waiata (song). This has improved our use and pronunciation of te reo Māori (Māori language) with guest speakers or members sharing their learning from attended seminars or conferences. Each member shares a report of their current work, practice advancements, successes, and practice needs. In addition, relevant educational huis, health screening and promotion clinics, cultural initiatives, government documents and research are shared via the Māori Health and Pacific Health Review, these on-line free publications provide extracts of Māori and Indigenous health research from Aotearoa and internationally that identify health disparities and initiatives that raise group discussion and learning.^10,11 Members have introduced cultural models of care, such as the Dr Mason Durie’s Te Whare Tapa Whā Māori Mental Health and Wellbeing model.¹² This model of care presents the concept of a four-side whare (house) with the whenua (land) forming the foundation. The four-dimensions represent the tinana (body), wairua (spirit), whānau (extended family network) and hinengaro (mind) that must be in equilibrium to maintain the person’s and whānau’s wellbeing.¹² I have applied this model of care when working with Māori, and non- Māori, to aid holistic assessment and develop therapeutic patient and whānau relationships.

The group provides an excellent forum to share resources, debrief, brainstorm, and troubleshoot in a safe and supportive environment. This has cemented close relationships and social connections between members. This is especially important when tragic or celebratory events have occurred with members showing aroha (love, compassion) and manaakitanga (kindness, generosity, caring for others). A noteworthy example is when Sandra Vaeluaga Borland was named Member of the New Zealand Order of Merit in the Queen’s Birthday Honours for her services to the Pasifika community and to nursing.¹³ Over the years members have also assisted colleagues clinically, assisting at community days and clinics to reach underprivileged people and providing services such as cervical screening and diabetes education. Another initiative is assisting our Pasifika nurses by promoting and contributing to the annual Christmas food drives for families in need.

The group effect is far outreaching with new members being welcomed onto the group often from word-of-mouth. This is especially important for HCPs working in challenging or isolating roles such as our prison nurses, and the formation of new roles over the years, such as our Cancer Coordinator who has connected with our Māori and Pacifica nurse teams to reduce barriers to access timely cancer support and treatments.

In 1987 the Māori Language Act declared te reo Māori to be an official language of Aotearoa.¹⁴ Using te reo Māori every day is a way we can show our support, to connect, grow and protect this beautiful language. I use te reo Māori in my greetings with colleagues and patients, email correspondence and when answering my personal and work phone. From this simple act others have been encouraged to use te reo Māori. Encouragingly, group members have also introduced morning karakia and waiata into their work environments encouraging HCP connections and further use of te reo Māori.

Member comments:

“The group provides a place of safety to learn, discuss and care for our professional colleagues within this group.” Rachel

‘Ma te whiritahi, ka whakatutuki ai nga pumanawa a tangata’ (Together weaving the realisation of potential). Charleen

“The word ‘safe’ reflects what the Group means to me.” Nadine

“A safe environment to build authentic relationships that support each other and share knowledge that enhances our professional practice.” Sandy

“I work in isolation, so the contacts I have developed have been invaluable to promote my service and grow my support network.” Sue

Conclusion

As HCPs we can work individually and collectively to address health inequalities, racism, discrimination, and meet our cultural competencies in creative ways. Many HCPs are time-poor but the importance of whakawhanaungatanga (building relationships) using face-to-face huis should not be underestimated to enhance our growth, improve our resilience and cultural awareness collectively. On reflection, my early intentions of including cultural elements into my quality plan was “lip service” and lacked actions to provide culturally appropriate outcomes, I will be forever grateful for being challenged to develop the Cultural Focus Group. The group, now running for 19 years, is an accomplishment and testament to its importance to members. Personally, for me the group has enhanced my cultural understanding, empathy, and growth, and facilitated strong collegial bonds that challenge me to improve my practice in a culturally sensitive and responsive way. Take up the wero (challenge) and consider what small changes you can perform to acknowledge your indigenous people and facilitate cultural relationships and awareness in your work environments.

Mahitahi (Collaboration)

E hara taku toa
i te toa takitahi,
he toa takitini

My strength is not as an individual, but as a collective.¹⁵

Acknowledgements

My amazing and courageous ‘Cultural Focus Group’ colleagues who continue to inspire and guide me.

Conflict of Interest

The author declares no conflict of interest.

Funding

The author received no funding for this study.

Author(s)

Mandy Pagan
MHealSc (Distn) PGDip Wound Care RN
Wound Clinical Nurse Specialist, Health New Zealand, Te Whatu Ora, Southern District

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