Note: this Standard comes into effect on January 31, 2022
A self-assessment tool for this standard is available here.
A PDF version of this Standard is available here
Acknowledgments
He mihi tēnei ki ngā mema katoa o te Poari hei tautoko mai tēnei mahi. Ara, te mahi hei kimihia he ara hou ta mātau kaimahi. He mihi hoki ki a Dr. Irihapeti Ramsden te kaiarahi o tenei kaupapa ,Te Kawa whakaruruhau. Kei te mihi hoki ki te rōpu hei wanangatia tēnei purongo, hei tuhi ta rātau whakaaro, hei whakaoti pai ai tēnei taonga. Ko Maarama Davis (Ngāi Taiwhakaea hapū o Ngāti Awa) tera, rātau ko Dr Te Kani Kingi (Ngāi Pukeko hapū o Ngāti Awa), Dr Ben Darlow, Tammi Wilson Uluinayau (Te Rarawa me Ngāi Tahu ngā iwi), Ulima Tofi (Ngāi Te Aweawe me Ngati Kaipoho ngā hapū o Rongowhaata), Witana Petley (Pirirakau me te whānau a Tuwhakairiora ngā hapū o Ngāi Te Rangi me Ngāti Porou).
Greetings and thank you to all the physiotherapists and stakeholders who contributed to the development of this Standard. Acknowledging Dr Irihapeti Ramsden whom lead the development and establishment of Te Kawa whakaruruhau. The Board specifically acknowledges the efforts of the working group that was established to undertake this mahi. A group that was led by Maarama Davis and with the support of Dr Te Kani Kingi, Dr Ben Darlow, Tammi Wilson Uluinayau, Ulima Tofi and Witana Petley.
Introduction
Physiotherapists in Aotearoa practise within a culturally diverse environment. They are required to be culturally competent when engaging with ngā kiritaki hauora (patient/client/health consumer), whose cultures may differ from their own, their colleagues and other health professionals from diverse backgrounds.
The culture of ngā kiritaki hauora affect the way they understand health, well-being and illness, the choices regarding health, how health care services are accessed and the responses to interventions.
The Board’s Cultural competence standard requires a broad view of culture, and includes, without limitation: age, gender, sexual orientation, race, socio-economic status (including occupation), religion, ethnicity, organisational culture, and mental, physical and neurocognitive diversity.
The Board continually strives towards building and maintaining authentic relationships between physiotherapists and ngā kiritaki hauora. Having an understanding of Te Tiriti o Waitangi which upholds the relationship of mutual benefit between Māori and Tauiwi (non-Māori), is key to this relationship.
He kawa whakaruruhau ā matatau Māori: Māori cultural safety and competence standard places particular emphasis on tangata whenua (Māori) and our unique Treaty relationship. This Standard is determined by the Board and is a required competence of all physiotherapists under section 118(i) of the Health Practitioners Competence Assurance Act 2003 (HPCAA).
Te Tiriti o Waitangi and Treaty of Waitangi
The Board acknowledges both Te Tiriti o Waitangi (Māori text), and Treaty of Waitangi are founding documents of Aotearoa; and, which informs legislation, policy and practice with the aim to improve health equity between Māori and Tauiwi.
The Board actively prioritises the ongoing obligations under Te Tiriti o Waitangi and the Treaty of Waitangi, in improving health equity and improving outcomes. Acknowledging this is an ongoing and evolving journey.
Under article 1 concepts of Kāwangatanga (Governance) and Mana Motuhake (self-determination).
Under article 2 to enable Māori to exercise authority over their health and wellbeing.
Under article 3 to have equal rights access and achieve equitable health outcomes for all.
Ritenga Māori declaration in ways that enable Māori to live, thrive and flourish as Māori.
The five principles highlighted in WAI 2575 provide a tangible view to honour Te Tiriti o Waitangi.
These principles are:
Tino rangatiratanga: provides for Māori self-determination and mana motuhake in design, delivery, and monitoring of health and disability services.
Equity: achieving equitable health outcomes for Māori.
Active protection: acting to the fullest extent practicable to achieve equitable health outcomes.
Options: ensuring that Kaupapa Māori health services are available and properly resourced, and that all health and disability services are provided in a culturally appropriate way that supports the expression of hauora Māori models of care.
Partnership: working in partnership with Māori to co-design the governance, design, delivery, and monitoring of health and disability services.
The Board values incorporating and utilising the different Māori models of health and Māori led approaches to providing assessment, treatment and care which best suit the needs and expectations of ngā kiritaki hauora Māori.
To practise effectively in Aotearoa, a physiotherapist must understand the relevance Te Tiriti o Waitangi and the Treaty of Waitangi and be able to demonstrate contemporary application, while promoting equitable opportunity for positive health outcomes within the wider context of hauora Māori (Māori health).
Māori cultural safety was initially promoted as a means of recognising and respecting the cultural values and identity of patients who identify as Māori; a concept further developed to create a platform for engagement and by extension a framework for improved health outcomes.
Māori cultural safety has been integrated as a Standard under section118(i) of the HPCAA to assist with protecting the health and safety of members of the public by enabling physiotherapists to engage in effective and respectful interaction with Māori, and to contribute to improving and attaining Māori health outcomes and health equity in Aotearoa.
Background
Within this Standard, Māori cultural safety centres on the experience of ngā kiritaki hauora Māori, their whānau and community.
Māori cultural competence, on the other hand, places emphasis on the practitioner or organisation to integrate Māori cultural and clinical elements within their practice or deliverables.
Physiotherapists in Aotearoa must be able to engage effectively with people whose cultural realities are different to their own. Effective engagement with ngā kiritaki hauora Māori requires a working knowledge of holistic Māori models of health and the other social and environmental determinants which influence the health and well-being of Māori and communities. This includes an understanding of the concepts of wairuatanga, whenua, whānau, whakawhānaungatanga, tikanga and te reo, and how these can shape ngā kiritaki hauora Māori perspectives and interactions.
Māori cultural safety is an opportunity to apply these concepts in all physiotherapy settings in ways which match the diverse cultural realities of ngā kiritaki hauora Māori. Integration of concepts and approaches that improve Māori experience of health care is also likely to improve all ngā kiritaki hauora experiences.
Reflecting on and improving one’s own practice to ensure equitable outcomes and demonstrating life-long learning is a key component of Māori cultural safety and cultural competence.
Māori culturally safe physiotherapists contribute to improving health outcomes for ngā kiritaki hauora Māori through:
- understanding own cultural identity, expression, unconscious bias and values held can influence and impact on the effectiveness with ngā kiritaki hauora Māori interactions and outcomes
- acknowledging that cultural differences and perspectives can impact on timely access to physiotherapy and care services
- acknowledging that Māori are both individual and diverse with cultural perspectives that are often influenced by their rohe (geographical location) and iwi (tribe) affiliations
- responding to diverse communication styles and needs of ngā kiritaki hauora Māori, other providers and colleagues when gathering information
- developing assessment, treatment and delivery plans that are focused on improving health outcomes; and empowering ngā kiritaki hauora Māori and their whānau to better manage their health and wellbeing.
Māori culturally competent physiotherapists contribute to improved and equitable outcomes for ngā kiritaki hauora and all those working in the health sector through:
- understanding the culture of the organisation/institution where they work
- acknowledging and respecting there are a variety of Māori integrated models of care
- awareness of institutional culture and its impacts on ngā kiritaki hauora Māori outcomes
- awareness of institutional and system barriers or enablers that effect equality and equity.
1. Awareness of own culture and understanding how culture impacts and affects ngā kiritaki hauora Māori
To work successfully with Māori, physiotherapists must be able to reflect on their own background and experiences (develop insight and knowledge of themselves) and the impact this may have on their own decisions and opinions. This may include:
- awareness and acknowledgement of one’s own limitations of cultural knowledge, an openness to ongoing learning, and a capacity and willingness to ask questions and continuously engage in self-reflection
- understanding interactions with individuals, whānau or organisation/institution
- accessing and providing physiotherapy and health care services that can support Māori to achieve optimal wellbeing
- respect that Māori definitions of health and Māori models of health may include domains that extend beyond physical or medical diagnoses
- acknowledgement of the cultural diversity within and between Māori
- respect that ngā kiritaki hauora (patient/client/health consumer), including Māori, may identify with multiple cultures that make the individual who they are.
Appreciating this complexity is critical to ngā kiritaki hauora engagement and outcomes
To work effectively with Māori, a physiotherapist must demonstrate a range of skills, including:
- an appreciation of own cultural values and beliefs held and how these may impact on interactions with ngā kiritaki hauora Māori, colleagues and staff which may be different cultural values and beliefs from their own
- a responsibility to challenge cultural biases where they have, or will have, a negative impact on Māori health outcomes
- respond appropriately when asked to modify one’s approach to provide culturally appropriate care by ngā kiritaki hauora Māori.
2. Application of Māori cultural safety skills and knowledge in practice
Ngā kiritaki hauora Māori
To work effectively a physiotherapist must demonstrate appropriate skills, including:
- an ability to engage with ngā kiritaki hauora Māori; to speak, observe, and respond accordingly in ways which are respectful and builds rapport. This may require sharing appropriate information about themselves and asking questions about the person that may not at first be relevant to their specific health concern. For example:
- sharing where they are from and providing an opportunity for ngā kiritaki hauora Māori to explain where they are from
- asking how their day was and other topical issues that may assist with building rapport
- asking whether ngā kiritaki hauora Māori would like their whānau, family or others to be present or involved in the assessment or treatment process
- reflecting on ngā kiritaki hauora Māori world view and identifying how Māori culture might inform the physiotherapist-ngā kiritaki hauora relationship
- identifying actions (conduct), which may be appropriate (or inappropriate)
- consider ngā kiritaki hauora Māori cultural beliefs, values, practices and social rules in developing a relevant treatment plan
- working cooperatively with ngā kiritaki hauora Māori individuals, whānau and organisations
- working with other healthcare professionals to provide integrated, culturally safe and competent care for Māori.
Organisation/institution/interprofessional (Māori cultural competence)
To work effectively a physiotherapist must:
- observe, listen, and consider how the health provider organisation/institution operates
- whether Māori culture and world views are demonstrated in co-design or leadership (governance/operationally) or should they be
- whether Māori representation is expressed at decision/governance levels and if not, why not and how this could be achieved
- how Māori perspectives and input are considered and reflected in organisational policies, procedures, training and deliverables
- whether Māori cultural audits are undertaken and what actions are considered
- consider whether Māori culture and world view is an integral part of how the organisation/institution operates
- have an awareness of organisational capacity to understand Māori cultural competence and its potential impact on delivery of services to Māori
- where institutional racism is identified by the physiotherapist, they must articulate this to the appropriate peer or senior in the organisation and seek action to remediate.
3. Ongoing reflection
Self/ngā kiritaki hauora Māori care/organisation/institution
Successful reflection results in better health outcomes for ngā kiritaki hauora Māori, being able to influence and contribute to improved organisational responsiveness to Māori health needs, behaviours and health advancement.
A physiotherapist must:
- continually self-reflect about their own culture, unconscious bias, pre-formed attitudes and behaviours towards others
- question what Māori cultural safety means to self and an ability to navigate through the process of looking listening and responding differently
- continually reflect on the outcome for ngā kiritaki hauora Māori and their experience (how it went for them) and respond differently
- understand the implications of Te Tiriti o Waitangi and The Treaty of Waitangi for physiotherapists and their roles in upholding the right to equal accessibility and equity to health care for Māori
- be able to demonstrate self-awareness and self-reflection skills within the context of the institutional culture and its impacts on ngā kiritaki hauora Māori outcomes
- be able to describe institutional and system barriers (racism) or enablers that affect equality and equity
- demonstrate knowledge and strategies and skills that could be used to navigate institutional and system barriers (racism) or enablers
- continually reflect about one’s practice to promote equitable outcomes and demonstrate lifelong learnings in Māori cultural safety and competence.
Practitioner Guidance
This section explains how physiotherapists may demonstrate their cultural safety and competence to interact effectively and respectfully with health consumers who identify as Māori (ngā kiritaki hauora Māori) and identifies some resources. A PDF version of this tool is available here.
The key competencies and enabling competencies can be viewed and demonstrated in one reflective or conversation depending on the context of the engagement with ngā kiritaki hauora.
Ways of developing key competencies
Be open to ask ngā kiritaki hauora Māori, in terms of reciprocity with generosity that focuses to maintain strength relationships.
Ensure appropriate acknowledgement and having the awareness to avoid exploitation of overusing resources.
Connect with local Iwi leaders and/or DHB Kaumatua and Kuia to create ongoing and sustainable engagement, establish links with Māori health providers.
Glossary of terms
For the purpose of this Standard, the Physiotherapy Board has defined the following key terms:
Appropriate peer or senior in organisation:
A colleague that one feels safe with having open and honest discussions and provides support and guidance on what actions may be taken
Cultural competence:
Being aware of cultural diversity and the physiotherapist has self-awareness, attitudes, skills and knowledge to provide appropriate services
Cultural Safety:
Focusing on ngā kiritaki hauora experience to define and improve physiotherapy services provided. The physiotherapist reflects on their own world view of culture and understanding how that impacts and affects ngā kiritaki hauora
Culture:
May include, but not be limited to age, gender, sexual orientation, race, socio-economic status (including occupation), religion, ethnicity and organisation, as well as physical or mental or other impairments
Institutional racism:
Institutional racism is a pattern of differential access to material resources, cultural capital, social legitimation and political power that disadvantages one group while advantaging another. Power can be exercised through the entrenchment of institutions, the creation of legislation, framing of policy, decision-making, agenda setting, withholding information, prioritisation and imposing worldviews
Kāwangatanga:
Governance Governing
Kawa whakaruruhau:
Cultural safety
Ngā kiritaki hauora:
Person that uses health care services (patient, client, or consumer)
Matatau:
Competence
Mana motuhake:
Enabling the right for Māori to be Māori (Māori self-determination); to exercise their authority over their lives, and to live on Māori terms and according to Māori philosophies, values and practices including tikanga Māori
Reo:
Language
Wairuatanga:
Distinctive to Māori spirituality and identity
Whakawhānaungatanga:
Attaining and making connections or relationships
Whānau:
This is generally described as a collective of people connected through a common ancestor (whakapapa) or as the result of a common purpose (kaupapa)
Whakapapa and kaupapa are not mutually exclusive. Whakapapa whānau will regularly pursue kaupapa or goals. Kaupapa whānau may or may not have whakapapa connections. Whakapapa whānau and kaupapa whānau are social constructs, and as such can be located along a continuum depending on the function and intent
Whenua:
Relationship with and connection to the land of birth.