Māori experiences and perspectives of hospital treatment in the context of acute care

The health system of Aotearoa New Zealand continues to deliver inequitable outcomes for Māori across a range of settings, notably in in-hospital care.¹ The quality of the in-hospital experiences of Māori patients and whānau is one determinant of equity. Care must be clinically competent but must also be culturally safe.^2,3 Cultural safety extends beyond cultural awareness and cultural sensitivity. Culturally safe care requires us to recognise and respect patients’ cultural identities, and emphasises critical consciousness, asking health professionals to reflect on their own cultural assumptions and biases.⁴

Research has highlighted the impacts of culturally unsafe care on Māori patients. In two separate studies, Harris and colleagues^5,6 reported how negative experiences of racism across a range of healthcare settings can lead to mistrust in health professionals and ultimately poorer health outcomes. Delayed or avoided care, cultural misunderstandings, lack of representation in the healthcare system and explicit biases towards Māori patients have been identified.^7–9 The legacy of colonisation and subsequent systemic biases continue to influence Māori health, and addressing this requires an intentional approach from healthcare institutions and health professionals.²

The Medical Council of New Zealand has recognised culturally safe care as a pathway to address long-standing inequities, and has made it a priority in the training of health professionals.¹⁰ Embedding cultural safety in organisations and at the point of care provides opportunities for systemic changes, further shaping staff training programmes.² Training should encourage health professionals to evaluate and challenge their personal and institutional biases, redress power imbalances and commit to transformative action.^10,11

The overarching aim for this study is to provide meaningful information to inform culturally safe training programmes for health professionals who work in hospital acute care settings. The goal is to provide culturally safe care and more equitable healthcare experiences for Māori in Aotearoa New Zealand. Our focus is to understand the experiences and perspectives of Māori patients and whānau on the care they receive when presenting to a hospital for urgent clinical care, and to use this as a starting point for the design of staff training interventions.

Our specific research questions are:

1. How do Māori experience healthcare in the context of clinical emergencies?
2. What are the perspectives of Māori concerning culturally safe care for Māori patients and their whānau in this context?

Methods

Ethics

This study was approved by the Auckland Health Research Ethics Committee (AH25184). All participants read the information sheet and signed a consent form.

Study design

Our research team comprised Māori and non-Māori researchers. Together, we undertook a qualitative interview-based study, embedding Kaupapa Māori (KM) approaches¹² and following Te Tiriti o Waitangi principles¹³ at every stage. Te Ao Māori and Māori world views guided our methodology for Māori-led research, and for engagement with Māori participants.

Recruitment

Whakawhanaungatanga and KM principles of ata (building respectful relationships) and kaupapa informed the recruitment process. An important first step in approaching our participants was identifying the kaupapa (shared vision/goal) and how that was to be translated for Māori. All interactions with participants were by the Māori researchers, from the initial contact through to follow-up interviews. Recruitment was limited to participants in Tamaki Makaurau Auckland.

We approached potential participants with whom we had established trusted relationships or connections through various community and professional networks using word-of-mouth, emails, texts and written notices. We sought Māori participants representing four different rōpū (groups) in the community: Group A, kaiako (educators); Group B, rangatahi (Māori youth) and wāhine Māori (women); Group C, kaumātua (elderly) support and carers; and Group D, gang (including gang-affiliated) and under-accessed community members. For those interested in participating we then established a time and place of their choosing for the kōrero (discussion or dialogue).

Information about the study and the process of informed consent was determined by the participants and influenced by factors including level of health literacy, capacity to attend in person, access to email, personal circumstances and wider whānau engagement. Manaakitanga, the process of sharing and hosting, created a collaborative pathway for a reciprocal relationship of knowledge flow between researcher and participant. The Māori interviewers used te reo (Māori language), tikanga (Māori protocols) and whanaungatanga (Māori customary engagement rituals) to facilitate the process.

Interview questions

The semi-structured interview focussed on participants’ experiences of acute hospital care. We started with a critical incident approach, asking about specific experiences, either positive or negative, and what could improve the experience for others. We explored perceptions of current processes in acute care hospital settings and how Māori needs or wishes fitted in with these processes.

Data collection

Participants were offered the choice of interview format, which could be online or in-person, individually or in a group. They were also offered the choice of audio- or video-recording the interview, or note-taking by the interviewer. Where participants requested note-taking, these notes were comprehensive, and read back to participants at multiple points during the interview for clarification and to confirm the interviewer’s understanding of what was said.

Data analysis

Recorded interviews were transcribed verbatim by two researchers. The combined transcripts and the written interview notes from all individuals and groups were de-identified and together formed the data for analysis.

The data were analysed iteratively, and recruitment continued until there was sufficient information to represent the views of Māori brought by the participants, with a cross-section of the diverse social groups.

Through the KM lens we used inductive thematic analysis as described by Braun and Clarke.¹⁴ One Māori researcher (ME) first read all the data and generated initial codes and themes, which were reviewed by the other Māori researchers. Coding was iterative, comparing new and initial codes and themes against the data. Initial themes were modified over the course of re-reading the data and refined in line with the KM lens. Preliminary coding and themes were presented to the whole research team for discussion. We then refined the themes and the sub-themes within Te Tiriti o Waitangi principles.

Follow-up meetings with participants

As we were accountable to the Māori participants, in order to uphold tino rangatiratanga (self-determination) we needed to ensure the participants’ stories were accurately reported and our interpretation and themes accurately reflected their views. Therefore, participants were invited to a follow-up meeting where their information and our interpretation were presented back to them for confirmation.

Researcher positionality statement

ME and SS identify as wāhine Māori with strong whānau intergenerational relationships. ME is a registered nurse and SS is a midwife. Both work within KM-driven spaces combining a scientific background and clinical practice within Western health systems with an Indigenous epistemology that supports Māori ways of knowing. ME is CEO of Iwi United Engaged Ltd. (IUE), an incorporated company committed to advancing Māori health and wellbeing through the development of culturally informed and relevant research. TIE has been involved in all aspects of Te Kōhanga Reo: from māmā awhi (peer support worker), kaiako (teacher) through to kaiwhakahaere (manager). JMW is an NZ European academic with a clinical background in anaesthesia. CC is a Brazilian general practitioner and academic working in the Waikato community. ML is a Māori doctor, academic and advocate for hauora Māori and equity.

Results

We interviewed the 17 participants individually or in groups (Table 1) between March and May 2023. All but one participant (in Group D: rōpū) participated in the follow-up interview. Interviews were audio-recorded for two individuals and for others written notes were taken, as requested by participants.

View Table 1–2.

The participants lived in the South Auckland suburbs of Ōtara, Manurewa and Papakura, and a small group lived in East Auckland. Several participants did not have a fixed abode.

Participant interviewees were allocated codes (e.g., Ha), which we used for direct quotations.

Interview duration was 45–60 minutes for individuals and up to 2 hours for groups. For Group D (gang and under-accessed community members) the researcher met the participants twice to complete the interview process due to the dynamics and day-to-day realities of this rōpū.

Thematic analysis

We developed four main themes and seven sub-themes, shown in Table 2.

Theme 1: manaakitanga me whanaungatanga

The lack of whanaungatanga in service interactions for patients

A lack of empathy and relationship-building was a pressing matter and a cause of distress for most participants when describing their experiences with the healthcare system. Participants described staff delaying assistance when requested by whānau members or patients, or not going beyond the bare minimum.

“When I was pregnant, I ended up in ED [emergency department] … they [took] me over to the maternity ward to check baby. We were left in the room, no blanket, minimal check in, and it just felt very uncaring.” (Ha)

The apparent absence of staff, and the consequent lack of patient reassurance, was a cause for anxiety, as participants felt they had been forgotten or “fallen off the list.” Many were unhappy with the communication from staff to patients and their whānau, feeling that doctors and nurses were minimising their issues.

“The response I got was that I was just an anxious young mum.” (Aa)

“[My] son ended up in ED for… self-harming. Felt like [the] doctor wasn’t understanding my concerns as a mother and just kept pushing for me to take him home and it would be all good.” (Ha)

Participants reported belligerent treatment from individual staff members. One described the nurses as “snooty” and another commented that the “nurses were very professionally kind, but doctors were dicks.” Participants reported disheartening interactions with staff, which dissuaded them from seeking further help in the Western healthcare system. One participant described how she sought Rongoā Māori, traditional Māori healing and medicinal practices, to help with problems that the Aotearoa New Zealand healthcare system was not addressing.

“I don’t like the hospital or health system. I usually just fix myself up unless it’s surgery… I don’t feel like I’m taken seriously [and] I feel shy when I can’t answer their complicated questions and I have no knowledge of the system… [I] keep getting the feeling of ‘just another waste of time’.” (Ke)

When asked where they would see Māori needs or wishes fit within the processes of clinical settings, one participant responded:

“I think the processes should start in the beginning and run all the way through for Māori to be able to trust the healthcare system. ‘Cos we don’t trust—I don’t trust—the healthcare system.” (Ee)

Improvements through whanaungatanga

Long waiting times was one of the most talked about issues in the ED setting. Participants would often cite this as an opportunity for better communication and whanaungatanga from hospital staff. They suggested staff check in on the patients, keep them informed of how long their wait was likely to be and offer refreshments to those in the waiting room as well. Further, staff could take the initiative to establish whakawhanaungatanga with patients.

“Staff should also initiate the offer for support—[it] is even bigger than responding to a request for support.” (Ho)

However, participants said staff would walk in, complete their task and walk out, with no attempt to build rapport with patients.

Participants emphasised the importance of a positive patient–provider relationship, reflective of the values within Te Ao Māori. They considered this relationship an important aspect of wairua (spiritual wellbeing) within the healthcare system, to ensure that, as one participant put it, the “patient–clinician relationship is culturally competent and culturally safe.” Participants suggested the environment would feel more welcoming and caring if staff tried to build that relationship—for example, if staff properly introduced themselves, or if the same few nurses were assigned to a patient to increase familiarity.

Participants also recognised the extreme demands that staff were under, which could perpetuate negative interactions between staff and patients. They felt that while more staff were required to support patients’ needs, staff could potentially benefit from whakawhanaungatanga with other staff members to ease their burden, and doing so would create better conditions for everyone.

Ngā takiwā puaroa: improving accessibility for Māori whānau

Our participants talked about the importance of spaces within the hospital. While there were designated whānau rooms, participants talked of the need for appropriate spaces beyond these designated rooms. Participants provided their views about these different spaces in the following examples. The whānau room of an ED was often too small to accommodate the whānau of multiple patients, and patient rooms had insufficient space for whānau to visit. The ED waiting room should allow for more confidentiality and privacy when discussing health issues. If the police could keep their “patients” (i.e., recently arrested and unwell people) in separate areas it would avoid other patients’ feelings of being in a dangerous situation. Participants also wanted clean hospital rooms for whānau and patients. One described mould in their room, and blood on their sheets and on the floor from a previous patient.

One participant described her experience of hospital admission for a miscarriage and offered examples of what sacred spaces for shared grieving could be like, spaces that acknowledged the spiritual aspects of illness and loss.

“For Māori, as wāhine Māori, having an area for women for this experience of a miscarriage, there is strength in being in a familiar place with other women, not around [random] dementia patients or a non-gynae space, where general public are experiencing the very personal, wāhine-specific trauma, and observing what’s happening, when they aren’t necessarily welcome to that experience. This looks at options, and providing this option is important for all wāhine, Māori and non-Māori.” (Oo)

“There should be a whānau room for the conversation with everyone over the death. This is a critical kōrero within the whānau and requires a space which honours the death of a loved one in the whānau. Open spaces and shared rooms are not appropriate for this process.” (Oo)

Another participant talked of the concept of an ārai, or veil at the door, which staff would cross when entering a patient’s room.

“I mean going into a patient’s room, whanaungatanga is a given! Perhaps all nurses need some of that cultural competency [and] even the doctors. People’s feelings matter—patient or whānau.” (Ka)

The participants articulated the desire for Māori frameworks of health and wellbeing within the healthcare system—more familiar faces, and familiar language, incorporating Te Ao Māori. They proposed that “the foundation of the healthcare system in Aotearoa should be based upon Kaupapa Māori frameworks.”

Theme 2: issues in cultural safety

Lack of staff cultural safety

A prevalent issue for participants was the lack of cultural safety of healthcare professionals. Aside from the physical components of care, participants wanted staff to consider the “mental, emotional, social and spiritual” elements of health. The participants described a disconnect with health professionals, whose approach to health and wellbeing was not perceived as holistic and whānau-centred.

Reflecting on their admission to the ED, one participant noted:

“[It] would’ve been a lot better if they actually incorporated a holistic approach of Te Whare Tapa Whā framework… I reckon that should be banged within the staff.” (Ee)

Participants also reported cultural insensitivity and belligerence of younger staff and trainee doctors:

“Cultural competency, like some of those young doctors, need a rude awakening. I think cultural competency wouldn’t go astray. I know [there’s] time and things, but I think it’s important.” (Ko)

“Should be part of their training, and if it is already, maybe they need better training, like their bedside manner, right?” (Ki)

The double-edged sword of being Māori

One participant felt she was being discriminated against and treated as “just another Māori” and others felt their problems were minimised because they were Māori. Another participant said that not all Māori patients wanted to be treated differently because they were Māori, and healthcare professionals should recognise that not all Māori were the same. A participant shared their story of admission to hospital with their first presentation of asthma:

“The doctors in ED assumed that I was just one of those Māori that don’t listen, don’t take my asthma medication. It wasn’t until I was preparing to get discharged, one of the nurses was asking me if I knew how to use the inhalers. Which I didn’t because I had never been diagnosed with asthma previously. She read through the notes and the handover that they received was that I don’t use my medication effectively which is how I ended up in ED.” (Ku)

On the other hand, participants wanted to be given the option of including cultural needs into their treatment plan or not. This was captured in a conversation between two participants:

“I guess if cultural needs are what people need, then that’s cool and that’s great. It’s a bit like that kaumātua [Māori elders] thing right, someone ticked the box saying they are Māori and so this kaumātua turned up and then we were like ‘umm, okay’, it was nice to chat and all but like.” (Ki)

“It’s also that thing right, like do you need to have that? I mean like for us it was a bit of a hōhā [some annoyance or hassle], but for you maybe, it would have been better. But you had the opposite, you didn’t have the option.” (Ko)

Another participant found the assumption that they would want cultural support distressing when in hospital:

“[The] bad side of [the] experience was waking up surrounded by kaumātua and kuia [elderly women] —I thought I had died or was gonna die; I was shocked to have so many unknown Māori around me in a hospital setting. This was a bad experience because no one asked if I wanted cultural support, it was just assumed because my information said ‘Māori’.” (Oo)

As one participant said about these assumptions, the only way to meet a Māori patient’s needs is when “the patient physically stipulates [their] needs or wishes.”

Theme 3: tino rangatiratanga

This theme was about trust, power sharing, effective communication and empowering patients and their whānau to be active participants in their care.

Upholding mana: mana to enhance practice

Participants often described feeling belittled, not being treated with respect and dignity, or receiving lower-quality care than non-Māori patients. They reported a lack of mana-enhancing relationships—noting the absence of respect, empowerment and upholding of personal dignity. For example, a relative was left to “sit in their own shit” for over 35 minutes because the nurses were not fast enough to respond to him needing to use the restroom, and were non-responsive to the participant’s request for assistance. Another participant’s mātua (parents) both suffered from incontinence. His father’s bed mattress was on the floor in the hospital:

“He would cry to me that he just wanted to go to the toilet… he was in his early 80s—the lack of dignity by wetting himself at this age!” (Ka)

This participant also recalled their interactions with staff members:

“You’re made to feel dumb, which really deflates someone quite quickly, especially when they are already double-guessing themselves. You’re afraid to say too much in the beginning. I was just trying to get answers and [was] basically told ‘I am the doctor, and this is what I say, and this is what we will do.’ So, what can you do but play along?” (Ka)

Empowerment through effective communication

Participants desired more effective communication from staff to promote understanding of their health needs, processes and management plans. Participants described a fear of not understanding the language, and a lack of effort from doctors and nurses to engage with them in conversations to better understand what was happening with their health, and what needed to be done after their discharge. They suggested that health literacy of Māori patients needed to be strengthened, but staff “don’t try and explain in normal terms.” Participants could attribute this shortcoming to lack of time, or perceive it as racism:

 “Māori are often swept under the rug. Get them in. Get them out. But if you’re from the wealthy side and you’re white? Different story. You get treated so well.” (Ee)

Participants talked of “hinengaro” (“discussing the process of what the nursing team are doing to ensure that the patient understands”), which extended to the patient’s whānau. Hinengaro also applied to nurses and doctors listening and being receptive to the patients’ needs.

Participants called for empowerment of Māori patients and whānau through better communication.

“Why I was having to be admitted to hospital, how long I possibly [had] to stay for, why they were taking my bloods as I had no clue.” (Me)

Participants described a desire to be able to make informed decisions about their own or their whānau members’ care, which, when lacking, could compromise their own or their relatives’ care.

“There have been many instances where patients are not fully informed or do not fully understand treatment/diagnosis. To improve this, patient safety should be of importance ensuring that every patient and whānau are informed of critical information regarding treatments instead of just administrating treatments. Also ensuring that patients and whānau are fully informed regarding diagnosis and have effective support, be that from MDTs [multidisciplinary teams] or whānau, to ensure that all aspect of their Te Whare Tapa Whā are being met.” (Me)

Participants suggested effective communication from healthcare professionals would enable Māori and whānau to understand their health issues and to work as partners in their care.

“Empower the whānau coming through the service. Regardless of age, ethnicity, gender—all people deserve to have their mana maintained during their time with you. Work together with the whānau present to come to a solution that addresses the concerns.” (Aa)

Theme 4: positive experiences from patients

Some participants reported positive hospital experiences, feeling that they were in a safe environment or were being given sufficient information and regular updates by staff about their sick relatives. They provided examples of Māori cultural support integrated into their care through Māori support workers or kaumātua to talk to while in hospital if requested. They also gave examples of Māori cultural practices (e.g. waiata/Māori songs) within the healthcare environment.

“[O]ne time we went to Auckland Hospital and… the Māori team did a little sing-song thing in the outside area—you know, where people wander around. They were singing songs, you know, like with mum and dad; they were singing songs from [their] era, and it was something nice and it passed the time nicely… And then the man came and spoke to mum and dad about the old days.” (Ki)

Discussion

Our study brings the voices of Māori to the fore. Māori values and ways of thinking about health should be normal values in healthcare, but our participants tell a different story. These values were often missing from the experiences reported here. Māori participants highlighted the importance of trusting relationships, of empowerment through communication, of time and spaces and of the role of whānau in the provision of appropriate and culturally safe care. Through sharing their personal experiences, they identified specific elements of their interactions with the hospital system that could be amenable to change through clinical and managerial staff training and reconfiguring existing power structures, practices, spaces and processes. Whole of system change will be needed to address the issues identified here that compromise cultural safety for Māori patients and whānau and the ability of healthcare professionals and patients to build trusting relationships. The five Tiriti o Waitangi principles recommended by the Waitangi Tribunal¹³ and referenced by the Ministry of Health¹⁵ assist in viewing our findings through a Māori and equity lens: active protection, tino rangatiratanga, equity, partnership and options.

Active protection

The data speak to a lack of trust, and failure to uphold the principle of active protection. Māori participants perceived that they were not getting the same treatment as non-Māori in health services. They felt that being Māori influenced the quality of care they received, the amount of time staff spent with them explaining their diagnosis and care and the time they were left waiting for help. Participants understood that hospital staff were time-poor and wait times for everyone were long, but they felt that better communication and being able to trust that doctors and nurses cared about them would make this more acceptable. Māori perceptions of unequal treatment will contribute to negative experiences, self-discharge and avoidance of Western healthcare institutions.

Tino rangatiratanga

Central to participants’ positive experiences was mana motuhake, acknowledging their separate identity, independence, self-determination and control, such that they felt that they could be Māori in this space, and this linked to feeling safe. One participant described the “veil at the door,” acknowledging Māori ways of entering another’s space, or in this case, their hospital room. In addition, Māori ways of thinking about space were not acknowledged; for example, the importance of appropriate spaces for wāhine Māori, spaces for grieving and spaces for whānau. This supports the value of involving Māori partners in co-design of hospital buildings or refurbishments.

Equity and options

Whakawhanaungatanga and building rapport were critical in forming trusting relationships between hospital staff, Māori patients and whānau. Within the existing healthcare system there was insufficient time or importance assigned to building trusting relationships. Absence of trust contributed to perceptions of unequal treatment compared to non-Māori across experiences of waiting, being kept informed and time spent by hospital staff providing information and explanations they could understand.

Partnership

Trust could be built through small acts, such as health professionals properly introducing themselves, explaining what they were doing, why they had been called away or may be delayed, and letting patients and whānau know that they matter. Māori patients may be more accepting of waiting or “the bad stuff that happens” in hospital if there was time to build a relationship, and if they trusted the hospital staff were looking after them. Participants were concerned about upholding mana, “working with rather than on,” in a partnership. Not being told or not understanding what is going on leads to loss of agency or mana, a perceived lack of respect and disempowerment as a partner in achieving health goals.

Our findings add to the existing body of research on Māori experiences of healthcare in Aotearoa New Zealand. A recent systematic review of Māori experiences of hospital care identified only seven such studies, each with variable focusses and methods.¹⁶ The review identified many barriers to the care of Māori patients resulting from the design and delivery of services, and interpersonal and institutional racism. Proposed interventions focussed on building cultural safety. The authors of the review called for strategies promoting access to care for Māori and cultural safety training for the workforce. ¹⁶ Our study confirms these findings and adds new empirical data to the small existing body of research. Adhering to the ideals of KM methodologies, we were able to gather authentic experiences of Māori from diverse backgrounds, including from those who are often unheard. The experiences and perspectives offered by our participants provide a practical starting point for incorporating cultural safety into health professionals’ training programmes.

Limitations and strengths

Our findings represent rich stories from a small geographical area of Aotearoa New Zealand and may not be the same for other regions. We acknowledge the potential for researcher bias from note-taking rather than recording interviews and have described the steps we took to mitigate this bias. However, a strength of our study was our KM approach, which has, we believe, allowed our Māori participants to speak freely and participate fully in the collection and interpretation of the information in this study. Future research could explore the perceived value by Māori of training interventions or space redesign to incorporate the lessons learnt from our participants.

Conclusion

Māori participants highlighted the importance of time, spaces, trust, cultural safety and understanding the role whānau play in the provision of safe and appropriate in-hospital care. Building positive relationships with staff influenced how safe Māori patients and whānau felt. Culturally safe practices and working in partnership with patients and their whānau were seen as central to achieving the best outcomes. In addressing our aims, this study provides very clear examples for health professionals on appropriate (and inappropriate) ways of engaging with Māori patients and whānau, which could be explicitly included and assessed in staff training programmes. At a structural level, our results support the co-design of healthcare environments and services with and by Māori. Prioritising cultural safety is a key factor in redirecting processes in the acute care setting to build trusting relationships with and improve outcomes for Māori.