Indigenous Māori nurses in Aotearoa are a critical part of the health workforce. They know their communities and are trusted. But rather than being valued, they are often silenced, rendered invisible, and oppressed, driven by unfilled rhetoric in the Māori nursing workforce and endemic racism within nursing that other colonized Indigenous nurses also experience. Despite inequities within the Māori nursing workforce and Māori health outcomes in general, nursing within Aotearoa, New Zealand has yet to meaningfully increase and value the role of Māori nurses. In this article, we discuss the history and impact of the concept of Kawa Whakaruruhau, a term to describe cultural safety. We also critique the rhetoric, racism, and reality of the Indigenous Māori nurses and discuss its significance as is relevant to the international Indigenous nursing workforce and minority nursing populations.
Key Words: Indigenous nursing, Indigenous, Aboriginal, Māori, nursing workforce, equity, racism, cultural safety.
COVID-19 has amplified the social and health inequities that Māori experience.Aotearoa New Zealand ('Aotearoa') is a small island country located in the South Pacific with a population of 4.97 million people, of which Māori (its indigenous peoples) comprise 16.5%. While other countries have been devastated by COVID-19 until recently, Aotearoa continued life relatively freely because we mobilized the 'team of 5 million' to contain relatively small outbreaks of COVID-19 with an elimination strategy. When writing this paper, it became apparent that COVID-19 will be endemic in our communities. To prevent COVID-19 from overwhelming Aotearoa's health system requires a national vaccination target of 90%. What has this to do with the Indigenous Māori nursing workforce? COVID-19 has amplified the social and health inequities that Māori experience.
...not until a notable lag in Māori vaccination rates was there a realization that the national vaccination strategy was not working for Māori...Early in the COVID-19 pandemic, Māori nurses, doctors and other Māori health and iwi (tribal) providers were mindful of the devastating outcomes for Māori of the 1918-19 Spanish Flu and the 2009 H1N1 Influenza pandemic. These events resulted in mortality rates seven and three times that of non-Māori, non-Pacific population groups (Summers, Baker, & Wilson, 2018; Wilson, Telfar Barnard, Summers, Shanks, & Baker, 2012). Healthcare providers urged the government and Ministry of Health to develop a Māori specific strategy to deliver timely services, like vaccinations, within Māori communities (McLeod, Blakely, Kvizhinadze, & Harris, 2014). Nevertheless, not until a notable lag in Māori vaccination rates was there a realization that the national vaccination strategy was not working for Māori, and that Māori health providers and communities needed resourcing to reach vaccine-hesitant Māori.
Māori nurses are a critical part of the health workforce because they know their communities and are trusted.Māori generally lack trust in the nation's health system and those who work within it. Most Māori prefer to encounter familiar Māori faces they trust when engaging with health services (Barton, 2018; Wepa & Wilson, 2020). Māori nurses are a critical part of the health workforce because they know their communities and are trusted. The COVID-19 pandemic highlights the silencing of, and resistance to the need for, Māori expertise and wisdom when working with Māori whānau (extended family networks) and communities. But this situation is not new.
Over the last three to four decades, increasing the proportion of the Indigenous Māori nursing workforce has been a priority in Aotearoa. In 1998, the Ministerial Taskforce on Nursing highlighted: "… the lack of Māori in the health-provider workforce is a barrier to meeting the health needs of Māori and affects the ability to improve health outcomes for Māori" (p.87). Unquestionably, Māori encounter health professionals (e.g., nurses) they do not trust and who display discriminatory and racist behaviors (Harris, Cormack, & Stanley, 2019; Mbuzi, Fulbrook, & Jessup, 2017; Wepa & Wilson, 2020). More recently, Whakamaua (the Māori Health Action Plan) indicated as a priority area the need to increase the Māori health and disability workforce (Ministry of Health, 2020). Despite substantive rhetoric over time about increasing the proportion of the Māori nursing workforce to reflect the Māori population (16.5%), progress has remained relatively static between 6 to 7.5% of the registered nursing workforce in Aotearoa (Nursing Council of New Zealand [NCNZ], 2019; 2020; Wilson, 2018). A recent review of the health and disability system reported that for Māori nurses, "… institutional racism inherent in the health system is to the detriment of Māori and to themselves as Māori nurses" (New Zealand Health & Disability System Review [HDSR], 2020, p.14).
Despite substantive rhetoric over time about increasing the proportion of the Māori nursing workforce to reflect the Māori population, progress has remained relatively static...Race and ethnicity are constructions used by 18th and 19th-century colonizers to oppress and dominate Indigenous peoples in countries they annexed (Zanchetta et al., 2021). Race is a construct used to classify and rank the value of human beings, and as Wilkerson (2020) explains, it sets the structural 'bones' of society. This hierarchical structuring of humanity has had devastating and detrimental impacts on colonized Indigenous peoples globally, such as those in Aotearoa, Australia, Canada, and the United States of America.
...colonization systematically dispossessed Māori of their land and language and severely reduced their populations through introduced infectious diseases and warfare. Despite Māori chiefs signing Te Tiriti o Waitangi (see Author Note below) in 1840 that affirmed their right to self-determination, equity, and cultural and spiritual wellbeing, colonization systematically dispossessed Māori of their land and language and severely reduced their populations through introduced infectious diseases and warfare. This has resulted in social and cultural disconnection and had detrimental impacts on the health and wellbeing of Māori (Moewaka Barnes & McCreanor, 2019). In this article we will critique the rhetoric, racism, and reality of the Indigenous Māori nursing workforce and discuss its relevance to other Indigenous and minority nursing populations. This article is about the silencing, invisibility, and oppression of Māori nurses, driven by unfilled rhetoric and endemic racism within nursing that other Indigenous nurses also experience (Brockie et al., 2021).
Author Note: Te Tiriti o Waitangi (Māori language version) and the Treaty of Waitangi (English version) is an agreement signed in 1840 with some, but not all, Māori chiefs and the British Crown representatives. The two versions differ in their meaning and intent. After being subjected to the articles of the Treaty of Waitangi, more recently, reference is being made to Te Tiriti o Waitangi and its articles: Kawanatanga (governorship); II Tino rangatiratanga (self-determination); III ÅŒritetanga (equity); and IV Wairuatanga (traditional and spiritual beliefs and practices). Te Tiriti o Waitangi lays out the relationship between Māori and the Crown (now the government of Aotearoa) in accordance with the articles.
Indigenous Nursing in Aotearoa
Such approaches enable culturally congruent delivery of mass public health strategies, mainly by known and trusted Māori healthcare providers. He kanohi i kitea (the seen or known face), and whakawhanaungatanga (the cultural imperative for establishing connections) are cultural concepts that highlight the importance of Māori and their whānau (extended family network) connecting with healthcare providers like Māori nurses (Wilson, Moloney, Parr, Aspinall, & Slark, 2021). Such approaches enable culturally congruent delivery of mass public health strategies, mainly by known and trusted Māori healthcare providers. Recently, increasing the COVID-19 vaccination rates among Māori reinforced the importance of culturally appropriate health service delivery, and highlighted the critical role of Māori nurses in improving equity in outcomes for Māori.
Enduring effects of colonization for Māori are evident in significant health outcome disparities...Enduring effects of colonization for Māori are evident in significant health outcome disparities apparent in their shortened life expectancy (by seven years), high rates of non-communicable diseases, avoidable hospitalizations, and amenable mortality than their non-Māori counterparts (Health Quality & Safety Commission [HQSC] New Zealand, 2019; Stats NZ, 2021). Recent reviews of health and disability services in Aotearoa reported significant failings for Māori (e.g., HDSR, 2020; Waitangi Tribunal, 2019), with an appraisal of the Māori health workforce concluding:
… work has often been piecemeal, has not been connected to any agreed national plan and there is no consistent information to support it. While some Māori workforce intake and student numbers are increasing, it is not at the pace or scale needed to drive real change (HDSR, 2020, p. 196).
The burden of disparities on Māori health and wellbeing is multi-faceted and driven by interpersonal and structural racism that influences the safety and quality of their healthcare and creates a significant barrier to accessing health services (HQSC, 2019). Expanding the Māori nursing workforce capacity and capability to meet the demands of Māori consumers of health services is recognized as one way to improve Māori health equity, a national priority for some time (Ministry of Health, 2014; 2020).
Historically, Māori fought for an autonomous health and nursing system because the one in place failed to meet their unique needsHistorically, Māori fought for an autonomous health and nursing system because the one in place failed to meet their unique needs (McKegg, 1992). At the turn of the 1900s, the Māori Health Nursing Scheme aimed to educate Māori women within hospitals to work with Māori. However, government and health officials hindered this scheme because of their inherent disinterest in improving health outcomes for Māori and their distrust in the capabilities of Māori women. Instead, it focused on assimilation through health legislation and practices. While supporters saw the Māori Health Nursing Scheme as a panacea to revive Māori as a 'dying race', barriers inhibited Māori women from succeeding amidst structural and institutional racism. This was buoyed by a disinterested government more intent on embedding assimilationist health legislation and practices (McKegg, 1992). Evident within the scheme was the nurturing of racism in nursing when Māori women attempted to embark on a nursing career, despite their cultural strengths for working with Māori. Instead of nurturing them, they encountered disdain, blatant racism, and were negatively judged without recognition of their value (McKegg, 1992).
...Māori were most likely to be channeled into enrolled nursing...rather than registered nursing...Fast forward to the 1970s and 1980s, Māori were most likely to be channeled into enrolled nursing (i.e., second-level nurses) rather than registered nursing because of the high likelihood they left secondary schooling without a qualification (Hylton, 2005). While some saw this as a steppingstone to registered nursing, the reality was that Māori were unable to advance beyond the position of second-level nurses (Hylton, 2005).
The 1988 Royal Commission on Social Policy report outlined the need to integrate Te Tiriti o Waitangi principles (partnership, participation, and protection) into all social and economic policies. Significant economic and health sector reforms during the 1980s and 1990s coincided with escalating Tiriti o Waitangi activism. It was a time when Māori protested the loss of their language, land, and cultural identity and increasing social and health disparities (Moewaka Barnes & McCreanor, 2019). During the late 1990s, considerable effort was undertaken to move Māori enrolled nurses into bridging programmes (i.e., to earn bachelor’s degrees) for registered nurses (Hylton, 2005). Grand narratives surrounding the dominant Western knowledge and culture in nursing were challenged, with calls for the political system to cater to a diverse range of realities (Richardson, 2010).
Kawa Whakaruruhau: Cultural Safety
The vision of this hui was to ensure cultural safety for Māori nursing students while undertaking nursing education...In 1988, the Hui (a gathering) Waimanawa, organized and facilitated by Māori nursing leader Dr Irihapeti Ramsden, focussed on the experiences of Māori nursing students. A first-year student attending the hui questioned the lack of emphasis on "cultural safety" amid the focus on physical, ethical, and legal safety within nursing curricula. The birth of Kawa Whakaruruhau (a term used to describe cultural safety, see Author Note below) was about Māori student nurses being culturally safe during their nursing education and for Māori to be culturally safe when accessing healthcare services. The vision of this hui was to ensure cultural safety for Māori nursing students while undertaking nursing education and to ensure others learnt how to care for Māori (their people) in culturally safe ways (Ramsden, 2002). Furthermore, Ramsden (1990) concluded, "As long as Māori people perceive the health service as alien and not meeting our needs in service, treatment, or attitude, it is culturally unsafe. A dangerous place to be" (p.3).
Author Note: Kawa Whakaruruhau refers to the shelter or protection afforded by customary protocols, which are often specific to different whānau (extended family networks), hapÅ« (constellations of whānau with common ancestors), and iwi (tribal nations). Kawa Whakaruruhau was the name Dr Irihapeti Ramsden's grandfather, Te Uri o Te Pani Manawatu Te Ra and confirmed by his peers, especially Hohua Tutengaehe (see Ramsden, 2002 for further information)
Ironically, instead of creating safety for Māori nurses and users of health services, cultural safety incited blatant racism across society.Cultural safety required nurses to undergo attitudinal shifts and understand the historical and social impacts Māori incurred (Papps & Ramsden, 1996). However, national social and political backlash resulted because nursing introduced cultural safety (that focused on Māori). This backlash led to a Parliamentary Education and Science Select Committee review of cultural safety in all nursing programmes (Papps & Ramsden, 1996). This led to renaming of Kawa Whakaruruhau as cultural safety with a broad focus inclusive of a diverse range of cultural groups, not just Māori. Ironically, instead of creating safety for Māori nurses and users of health services, cultural safety incited blatant racism across society.
The intention was not to create Māori language and customs experts but ensure that registered nurses were respectful of differences...Kawa Whakaruruhau, Cultural Safety in Nursing Education in Aotearoa (Ramsden, 1990) outlined the need for nurses to respond better to the cultural and spiritual needs of Māori. The report also outlined processes to support the cultural safety of Māori nursing students during their education and how to care for Māori in culturally safe ways. Ramsden refuted that Māori worldviews were simply a "perspective" that differed from others' realities. The intention was not to create Māori language and customs experts but ensure that registered nurses were respectful of differences and understood the drivers for Māori health disparities.
In 1992, cultural safety became a part of the state examination for all registered nurses in Aotearoa. Under the guidance of Dr Irihapeti Ramsden and other Māori nurses, the Nursing Council developed guidelines for integrating cultural safety into nursing education and practice. The term 'cultural' became central to defining cultural safety, moving away from Māori worldviews to broader manifestations of culture (Ramsden, 2002) – a deliberate action that soothed social and political criticism. In the process, the changes diluted the focus on addressing the cultural safety needs of Māori student nurses and Māori experiences of health services. This concern remains today because the measurement of cultural safety competence remains problematic (Heke, Wilson, & Came, 2018).
This concern remains today because the measurement of cultural safety competence remains problematicSuffice to say, racism and discrimination have been a feature in the working lives of Māori nurses, accompanied by rhetoric about the need to improve Māori health outcomes and increase the Māori nursing workforce. Following an initial outpouring of criticism in the media, cultural safety became established in nursing education and practice. However, the degree to which cultural safety has been taught, understood, and applied is variable and difficult to scrutinize. Despite Te Tiriti o Waitangi being fundamental to practicing cultural safety when working with Māori, the term Kawa Whakaruruhau is absent within nursing education standards (NCNZ, 2021a), relegated as a historical concept that led to the development of cultural safety. We argue that Kawa Whakaruruhau is critical to understanding the impact of ongoing historical and contemporary injustices that have created intergenerational realities detrimental to the wellbeing of Māori. Māori remain the most culturally at risk in Aotearoa.
Rhetoric in Māori Nursing Workforce
Part of this response is the recognition that the Māori health workforce reflects its community.Issues of racism and discrimination in healthcare have led the government to respond to improve healthcare delivery that better meets the needs of Māori and other minority groups (HQSC, 2019; Ministry of Heath, 2020). Part of this response is the recognition that the Māori health workforce reflects its community. The Ministry of Health (2019) recommends the creation of a Māori health workforce that matches both Māori health needs and population. Wilson (2018) reinforced this position describing the Māori nursing workforce as critical enablers and a major lever in addressing Māori health inequities. An over-represented Māori nursing workforce (more than 16.5% of the registered nursing populace) is likely necessary to reduce the inequitable burden of mortality and morbidity for Māori. Nonetheless, the Ministry of Health and the Nursing Council of New Zealand continue to identify retention of Māori within undergraduate nursing programs as a priority (Health Workforce New Zealand, 2016; NCNZ, 2015; 2019; 2020).
The relative inertia in growing the Māori nursing workforce reflects the lack of genuine planning and commitment... The relative inertia in growing the Māori nursing workforce reflects the lack of genuine planning and commitment by Aotearoa nursing leadership and the government to increase the Māori nursing workforce (Cook, 2009; Nana, Stokes, Molano, & Dixon, 2013; Nuku, 2015; Wilson, 2018). In the 1990s, Māori nurse academic Dr. Irihapeti Ramsden (2002) was a voracious promoter of Māori nurses but identified the paralysis within the predominately non-Māori nursing leadership, something that remains evident today. At the same time, nursing leaders within the practice and education sectors engage in rhetoric about improving outcomes for Māori nurses. However well-intended the rhetoric has been, lack of action and systemic racism within nursing are drivers for the racism that Māori nurses and Māori student nurses continue to encounter regularly (Barton & Wilson, 2021; Hunter & Cook, 2020; Wilson, 2017; Wilson, McKinney, & Rapata-Hanning, 2011). A general lack of political will has thrived and fueled the absence of a concerted national approach to enact targeted strategies to recruit Māori into nursing.
Drivers of Rhetoric
...Māori nurses have often been rendered silent and invisible in solving the issue of addressing Māori nursing workforce deficitsNursing leadership continues to avoid genuine engagement with Māori nurses to improve Māori health inequities, particularly regarding safety and quality of care. Aside from tokenistic appointments of often lone Māori members on committees, Māori nurses have often been rendered silent and invisible in solving the issue of addressing Māori nursing workforce deficits (Barton, 2018; NCNZ, 2017). Despite the Ministry of Health and the Nursing Council of New Zealand recognizing the need to increase the proportion of the Māori nursing workforce, there has not been any targeted intervention for either education or practice (Chalmers, 2020; Cook, 2009; Ministerial Taskforce on Nursing, 1998; Nana et al., 2013; Wilson, 2018).
Understanding barriers to increasing the Māori nursing workforce requires an examination of the inertia in the nursing leadership in Aotearoa. Wilson (2018) maintained, "… ongoing failure to increase the Mâori nursing workforce cannot be explained simply by individual-level factors and deficit explanations; it is symptomatic of serious ongoing structural and professional problems" (p. 2). Despite concerns raised about the divide between education (under the Tertiary Education Commission) and the employment of nurses for healthcare practice (under the Ministry of Health), there has been no resolution to connecting these two sectors. This divide creates a disconnect between the education and supply of Māori registered nurses for the practice environment that enables rhetoric and racism to thrive.
...the lack of a national strategy and robust evidence, despite calls from Māori nursing leadership, makes it is difficult to understand the problems affecting Māori. The Nursing Council is the independent regulatory authority registering nurses and setting the standards for the education of registered nurses. While their primary statutory focus is on maintaining public safety, they do not regularly monitor performance of nursing schools for recruitment, retention, and success of Māori. Underperformance, and resistance by nursing schools to provide a national dataset and metrics to track recruitment, retention, and success of Māori nursing students, remain an issue. Thus, the lack of a national strategy and robust evidence, despite calls from Māori nursing leadership, makes it is difficult to understand the problems affecting Māori. Consequently, the environment lacks transparency regarding Māori student retention and success (Barton & Wilson, 2021; Cook, 2009). The ongoing rhetoric about Māori nurses signals that significant structural racism is rooted in the leadership, policy, education, and practice levels in Aotearoa.
Racism Within Nursing
For most Māori nurses, experiencing such behaviors takes a toll on their resilience and mental and spiritual wellbeing, with many leaving nursingThe experiences of racism and discrimination are all too familiar for Māori nurses working at all levels of the national health system and within education. Māori nurses report ongoing discrimination and marginalization in their work environments, creating additional pressures when caring for Māori in a health system (Hunter & Cook, 2020; Huria, Cuddy, Lacey, & Pitama, 2014; Wilson & Barton, 2011). Reports of discrimination and marginalization range from microaggressions that Māori nurses face daily; to active denial of opportunities to progress professionally and educationally; to being reported for transgressing professional boundaries when engaging with Māori whānau in culturally appropriate ways; to higher workloads imposed because they have dual clinical and cultural competence; to encountering active racism (Barton & Wilson, 2021; Huria et al., 2014; Wilson, 2017; Wilson & Baker, 2012). For most Māori nurses, experiencing such behaviors takes a toll on their resilience and mental and spiritual wellbeing, with many leaving nursing (Huria et al., 2014; Wilson & Baker, 2012).
...as only 7.5% of nurses are Māori, the likelihood of selecting or voting Māori is low despite the priorities of increasing the Māori nursing workforce and improving Māori health equity.Mechanisms for representation on the Nursing Council of New Zealand highlight how structural racism exists in nursing leadership. The legislation deems members are either appointed by the Minister of Health or voted in by nurses themselves. However, as only 7.5% of nurses are Māori, the likelihood of selecting or voting Māori is low despite the priorities of increasing the Māori nursing workforce and improving Māori health equity. Until this year, Māori nurses have consistently been under-represented in nursing's regulatory body. Māori nurses have actively lobbied for equitable representation on the Nursing Council through the Minister of Health's appointments. Consequently, the Minister appointed two Māori nurses (NCNZ, 2021b). Furthermore, outside of the context of the Nursing Council, there is a tendency for nurse leaders to invite sole Māori nurses onto committees as a Māori representative regardless of Māori nurses pleading for more robust Māori representation. Such strategies marginalize single Māori nurse representatives, often rendering them voiceless and invisible but ticking the box for representation on a committee.
An example of structural and interpersonal racism is the continued low proportion of nurse educators (i.e., fewer than 3% of Māori nurse educators) in undergraduate nursing programs across Aotearoa (NCNZ, 2020). Research with Māori students indicates that having Māori nursing role models and having their cultural identity affirmed is essential for their success. Nursing education leadership has done little to rectify this situation (Barton & Wilson, 2021; Wilson et al., 2011). In addition to structural issues, interpersonal racism and discrimination experienced by Māori nurse educators are ongoing problems affecting the recruitment and retention of Māori into education roles in undergraduate nursing schools (Barton & Wilson, 2021). Recent moves to standardize and strengthen nursing program curricula and improve Māori responsiveness across 15 nursing schools have met with resistance from nursing education leadership.
The lack of urgency in addressing incidents of overt interpersonal racism occurring within nursing practice and education environments reflects the lack of commitment and apathy of non-Māori to address this problem.Māori nurse educators routinely encounter racism and discrimination while carrying out their roles, maintained by structural racism designed to prevail within nursing education programs (Barton & Wilson, 2021). While some racism experienced by Māori nurse educators is overt, the inaction of managers when racism occurs ensures its continuance. The lack of urgency in addressing incidents of overt interpersonal racism occurring within nursing practice and education environments reflects the lack of commitment and apathy of non-Māori to address this problem. There is a lack of awareness amongst many non-Māori nurse educators of their responsibilities to deliver content related to cultural safety, specifically Te Tiriti o Waitangi and Kawa Whakaruruhau. Māori nurse educators currently carry the burden of both colleagues and non-Māori students' journeys in unpacking their identities; what this means to be a nurse in Aotearoa; and addressing push-back from these students (Barton & Wilson, 2021).
The Reality
Racism is a recognized determinant of health that, when experienced, increases the likelihood of poor health outcomes (Harris et al., 2019). In Aotearoa, Māori, Pacific, and Asian populations all self-report higher rates of racism as recipients of healthcare than European and other groups. Racism impacts accessing and engaging effectively with health services and receiving safe, quality care (Harris et al., 2019; Rumball-Smith, Sarfti, Hider, & Blakely, 2013). Māori report experiences of a health system that alienates them from their culture, implies blame for their health status, and suggests noncompliance, prompting distrust and avoidance of health services to protect against these experiences (Graham & Masters-Awatere, 2020; Mbuzi et al., 2017; Wilson & Barton, 2011). Māori are also vulnerable to additional and intersecting forms of discrimination associated with gender, socio-economic status, and age (Cormack, Harris, & Stanley, 2020). Cormack et al. described racism as a pervasive experience for Indigenous peoples within colonized countries. Ensuring that Māori worldviews are integrated within health systems and influence the practice of health professionals are potential ways to reorient the current healthcare experiences for Māori (Graham & Masters-Awatere, 2020; Wilson & Barton, 2011).
Māori are also vulnerable to additional and intersecting forms of discrimination associated with gender, socio-economic status, and ageAs the largest health professional group, nurses can play a pivotal role in improving Māori health equity. Cultural safety is a compulsory component of undergraduate nursing programs. Once graduated, all nurses must demonstrate clinical and cultural competence under the Health Practitioners Competence Assurance Act 2003 and (Amendment) Act 2019 (Health Quality & Safety Commission [HQSC], 2021; NCNZ, 2011). As previously mentioned, Kawa Whakaruruhau originally placed the determination of nurses being culturally safe on Māori and their whānau 31 years ago, which nurses have yet to resolve. But iterations of cultural safety over time and shifting cultural safety to nurses being inward-looking, whereby nurses determine if a nurse is culturally safe, leads to ongoing debate regarding the place of Māori and their whānau.
There have been calls to review cultural safety in nursing education, and its measurement Nurses are required to provide evidence of their cultural competence. However, the process is flawed, with inconsistencies and inadequate mechanisms for measurement, possibly influenced by the social and political criticism with the introduction of cultural safety and simply just needing to tick the box to demonstrate compliance. There have been calls to review cultural safety in nursing education, and its measurement (Barton, 2018; Heke et al., 2018; Roberts, 2020).
The Nursing Council sets the foundation for cultural responsiveness and inclusivity through its regulation and education activities. In te ao Māori (Māori worldview), a kaitiaki (a custodian or guardian) is associated with caring for others, similar to nursing practice. Māori nurses consider the Nursing Council as the kaitiaki of cultural safety, a concept borne from Indigenous nurses. Internationally recognized, cultural safety is a theoretical concept that informs nursing education and practice in Aotearoa so that nurses deliver culturally respectful care. Despite the introduction of cultural safety, and theoretically having a culturally competent nursing workforce, Māori patients and nurses continue to face discrimination and racism in education, healthcare, and work settings. However, given the reality that Māori nurses experience and the inequity of Māori health outcomes, the kaitiaki status of the Nursing Council's guardianship of cultural safety is questionable.
...an expectation exists that Māori nurses resolve dissatisfaction and disharmony with Māori whānau not in their direct careMāori nurses are not immune to the effects of racism, particularly those who work within publicly funded health services (Hunter & Cook, 2020). The profession of nursing’s dominant discourse drives a need to be task-focused within a biomedical model of care that is resistant to different cultural priorities with more relational approaches. Such discourse leads to Māori nurses over-compensating and apologizing to Māori whānau for care that does not uphold the mana (status and spiritual authority) of Māori patients. Moreover, an expectation exists that Māori nurses resolve dissatisfaction and disharmony with Māori whānau not in their direct care (Wilson & Baker, 2012).
Additionally, Māori nurses are expected to address systems and processes that perpetuate structural racism, categorized as ‘Māori business.’ This expectation places responsibility for racially based cultural and structural change within nursing firmly at the feet of Māori nurses. Fitting Māori within health services, rather than changing the health services and nursing practices to better align with cultural needs of Māori, is intensified by a continual drive to improve Māori health outcomes without changing the root cause of Māori health inequities.
Fundamentally, Kawa Whakaruruhau is about Māori reclaiming power as recipients of nursing care. That cultural safety has been a requirement for nurses' education and competence for over three decades is of concern as Māori patients, nurses, and educators continue to face dominant cultural belief systems that override respecting difference. Additionally, neoliberal funding models that drive health service delivery in Aotearoa individualize and compartmentalize care which disregards Māori holistic and relational understandings of hauora (wellbeing) (Waitangi Tribunal, 2019). Fundamentally, Kawa Whakaruruhau is about Māori reclaiming power as recipients of nursing care. However, the climate of interpersonal and structural racism is enabling nurses to unravel the korowai (cloak) of cultural safety that Indigenous nurses across the world have celebrated. Papps and Ramsden (1996) provide a useful reminder that "nurses cannot provide quality patient focused care if they have unconscious negative attitudes towards patients [and nurses] who are different from them" (p. 496). Māori are entitled to receive care that meets and respects their cultural needs, delivered by nurses who are like them. Non-Māori nurses need to address their own racial and cultural biases for this to happen.
The Reality for Indigenous Māori Nurses
Māori are motivated to become nurses for many reasons but primarily to improve healthcare delivery and outcomes for Māori. Still, most significantly, many aspire to be nurses, having witnessed or experienced the different treatment and care Māori receive in the healthcare system in Aotearoa (Chittick, Manhire, & Roberts, 2019; Foxall, 2013; Wilson & Barton, 2011; Wilson et al., 2011). Lack of culturally responsive care significantly contributes to the negative experiences Māori encounter when accessing healthcare (Wepa & Wilson, 2020). Māori and their whānau continue to be marginalized within the health system, believing that the hospital environment is not conducive to healing (Wilson & Barton, 2010). Nevertheless, it is Māori nurses who are more likely to sustain the cultural context in healthcare for Māori whānau and contribute to equitable access (Baker, 2009; Baker & Levy, 2013; Barton & Wilson, 2008; Hunter, 2019; Hunter & Cook, 2020; Huria et al., 2014; Simon, 2006; Wilson, 2018).
They often resolve the tensions that arise from assisting whānau in navigating conflicting worldviews while balancing their cultural and clinical practice...Māori nurses continually mediate the cultural expectations of patients and families and the requirements associated with their nursing roles. Wilson and Baker (2012) suggested that Māori nurses are ultimately the 'guardians of spiritual wellbeing' for Māori under their care. They often resolve the tensions that arise from assisting whānau in navigating conflicting worldviews while balancing their cultural and clinical practice by "bridging the two worlds" (Wilson & Baker, 2012, p. 2). Simon (2006) also explained Māori nurses provide effective and empathetic healthcare because these are Māori cultural concepts such as aroha (empathy, compassion, love) and manaakitanga (obligation to take care of others) that influence how they practice. For instance, this may include awareness of their cultural identity and the inclusion of mātauranga Māori (Māori ways of knowing).
Just as significant as the responsibility to provide culturally competent care, Māori nurses are observers of the reality of cultural safety in practice. The contributions of interpersonal and institutional racism significantly influence Mâori health outcomes and inequities when compared to non-Māori. For example, Māori are twice as likely as non-Māori to experience discrimination in healthcare and are three times more likely to experience unfair treatment based on ethnicity (Harris et al., 2012; Ministry of Health, 2015). Māori nurses experience racism within their education and work environments (Barton & Wilson, 2021; Chittick et al., 2019; Foxall, 2013; Hunter & Cook, 2020; Huria et al., 2014; Wepa, 2003). There is no doubt that racism in the workplace contributes to the difficulty in retaining Māori nurses, who frequently experience interpersonal and structural forms of racism within their workplaces.
There is no doubt that racism in the workplace contributes to the difficulty in retaining Māori nurses...The dual competency Māori nurses bring to their practice is often under-valued, although often used, by non-Māori. But with dual competency comes the notion of a double-cultural shift that Haar and Martin (2021) explain occurs when cultural factors impose “… additional role pressures leading to high role conflict and ultimately causing frustration, exhaustion and turnover” (p.18). Demands placed on Māori nurses contribute to ongoing stress and burnout, eventually leading to loss of job satisfaction while increasing the desire to leave. Consequently, this imposed “emotional labor,” an intangible burden often carried by Indigenous nurses, requires them to modify the sense of outrage and distress they feel while continuing to be professional (Hunter & Cook, 2020). The extra responsibilities of culturally competent and safe care usually include caring for Maori patients with often complex needs.
International Indigenous Nursing Workforce
Māori nurses’ experiences are reflective of their Indigenous counterparts in Australia, Canada, and the United States of America. Māori nurses’ experiences are reflective of their Indigenous counterparts in Australia, Canada, and the United States of America. Racism and other factors contribute to the retention of Indigenous nursing students in education programs (Martin & Kipling, 2006). It is common for Indigenous nurses to be exposed to racism in its subtle and more explicit forms at individual and system levels, such as tokenistic representation, leaving them as outsiders, or a reticence to declare their Indigenous identity (Vukic, Jesty, Matthews, & Etowa, 2012), or using silence to respond to ongoing racism. While there is little in the literature that reports Indigenous nurses' experiences, the international literature about Black, Indigenous and People of Colour (BIPoC) populations critiques the need to address the role of white dominance that perpetuates racism within nursing. The ongoing racism within nursing, and the subsequent inaction by nursing leadership despite the need to address inequities for Indigenous nurses, are indicators of deeply entrenched racism within nursing systems and structures. Nurse leaders have a role in creating the space for advancing Indigenous nurses (Barton & Wilson, 2021; Vukic et al., 2012).
Zanchetta et al. (2021) claim that the ideology of race-inclusivity and equality for all citizens within nursing is problematic and is to the detriment of the realities and experiences of minority groups. Furthermore, they stress,
Being 'blind' to race negates the realities of these individuals and gives society license to ignore the issues and silence any challenges brought by minority racial groups or labels confronters as being militant, exaggerating and self-victimizing. This cycle leads to the pressure on minorities to suffer in silence and gives racism an environment to proliferate and continue unmitigated (p.474).
Bell (2021) also urges the need for anti-racist and anti-oppressive initiatives that address "… internalized white supremacist ideology and persistent racial [white] privilege …" (p.9). It is time that nurse leaders within positions of influence globally examine the issues of racism that is a blight on nurses and their potential.
Concluding Comments: Going Forward
It is the structural racism supported by interpersonal racism that enables the oppression of Māori nurses. The Indigenous Māori nurses’ experience of improving the cultural safety and quality of care for Māori whānau provides an excellent exemplar of the silencing, invisibility, and oppression of Māori nurses, driven by unfilled rhetoric and endemic racism within nursing. Being the eternal ‘squeaky wheel’ has done little to change the embedded structural racism that sits within the nursing leadership of Aotearoa. It is the structural racism supported by interpersonal racism that enables the oppression of Māori nurses. Instead, it places additional demands on them because of the cultural strengths they bring to their practice as Māori first and nurses second. The nursing profession must be accountable for its role in the perpetuation of Māori health inequities, similar to those of other colonized Indigenous peoples. It is time to stop the rhetoric and begin action because Indigenous wellbeing matters.
Authors
Denise Wilson, PhD, RN, FCNA(NZ), FAAN, FRSNZ
Email: denise.wilson@aut.ac.nz
ORCID ID: 0000-0001-9942-3561
Denise Wilson (Ngāti Tahinga ki Tainui) is a registered nurse and Professor in Māori health at Auckland University of Technology in Auckland, New Zealand. Her work focuses on improving Māori health experiences and outcomes, Māori workforce development, family violence and cultural issues related to nursing.
Pipi Barton, MPhil, RN
Email: pbarton@northtec.ac.nz
ORCID ID: 0000-0003-4226-0196
Pipi Barton (Ngati Hikairo ki Kāwhia) is a registered nurse, having previously worked as a mental health nurse in various settings. She is currently a Senior Nurse Lecturer on the Bachelor of Nursing program at Northtec in Whangarei, Northland, New Zealand. She is a Doctor of Philosophy candidate, examining factors that have led to the static Maori nursing workforce over the last 40 years.
Zoë Tipa, PhD, RN
Email: zoe.tipa@aut.ac.nz
ORCID ID: 0000-0003-4366-9997
Dr Zoë Tipa (Kai Tahu, Kahungunu) is a registered nurse with 20 years of experience in primary healthcare, Māori health and well child/tamariki ora nursing. She is the chair of Wharangi Ruamano – Māori Nurse Educators in Aotearoa. Zoë is a senior lecturer in nursing at Auckland University of Technology with a focus on Māori health, Te Tiriti o Waitangi and cultural safety. Her research is centered on developing the cultural responsiveness of health professionals and services in their work with Māori.
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