Experiences and perspectives of thriving (or not) as Māori and Pacific allied health professionals

Despite widespread acknowledgement of the importance a diverse health workforce carries for addressing inequities in Māori and Pacific peoples’ health, there is an absence of research exploring how Māori and Pacific allied health professionals (AHPs) are enabled to thrive as health professionals. Māori and Pacific peoples are under-represented in our allied health workforce and may face unique stressors compared with their non-Māori, non-Pacific counterparts. Broader health and disability workforce research highlights that Māori and Pacific peoples experience cultural isolation, cultural safety concerns including racism or discrimination, and increased tensions of being Māori or Pacific in a Western-centric and biomedical-dominant health system.¹ These stressors pose potential challenges for all Māori and Pacific AHPs, but particularly those in their early years of practice when adjusting to new roles and organisational environments and systems.² While emphasis has been on increasing the number of Māori and Pacific health professionals in Aotearoa,^3–5 there is also equal responsibility to look beyond just “target numbers” and consider one’s ability to thrive within a given profession and specific work environment.⁶

Although there is increasing evidence highlighting consistent health system failures in addressing the needs of Māori and Pacific peoples more broadly,^7–10 the evidence base as it relates to allied health and thriving in the initial years of practice remains limited. Further, the experiences of Māori and Pacific AHPs, including what supports them to thrive in their roles, have not been investigated. As such, this research sought to explore, share and learn from the experiences of Māori and Pacific AHPs to understand their own perspectives on what enables and supports them to thrive as Indigenous practitioners within the health sector. It is expected that insights from this research will inform and guide actionable steps to develop culturally supportive and safe healthcare environments that embrace Māori and Pacific Indigenous AHP practices and values.

Methods

This was a qualitative study grounded in Māori and Pacific cultural frameworks,^11–14 drawing on the tenets of appreciative inquiry (AI). AI has alignment with the research intention of providing a positive, affirming and strengths-based approach to transformation, asking how things could be different rather than what’s wrong with them.^15,16 The research specifically drew on the Discovery and Dream steps of AI, bringing to life the experiences of Māori and Pacific AHPs working in an urban-based health organisation.

This research was instigated and led by the primary author, who is a Māori Samoan AHP. It was precipitated, at least in part, due to his personal experiences navigating a health career within non-Māori, non-Pacific working environments, and having spent time listening to colleagues sharing similar experiences. Co-authors include an experienced Pākehā qualitative health researcher with an interest in advancing the role of the allied health workforce in Aotearoa health systems, and a Māori health and allied health researcher of Ngāti T ū wharetoa descent. Ethics approval for this study was obtained from the Auckland University of Technology Ethics Committee (AUTEC Number 20/377) on 27 January 2021.

Sampling and recruitment

Māori and Pacific AHPs were eligible to take part if they were currently employed at the research locality (an urban publicly funded health organisation). Purposive sampling was used to capture a diversity of experiences, stories and knowledge of Māori and Pacific AHPs. This was to ensure participants possessed the adequate mix of political and cultural understanding to allow for robust and dynamic contributions to the research. Key sampling characteristics therefore included ethnicity, profession, work setting, gender, time since qualification, stage of career, stage of life and level of cultural knowledge.

Data collection

Consistent with Māori and Pacific research practices,^12,13 data were collected via a total of three in-person wānanga talanoa sessions with 11 Māori and/or Pacific AHPs. Two sessions consisted of five people each, while one person requested a one-to-one session due to an unforeseen scheduling clash. Length of wānanga talanoa sessions ranged from 60 to 80 minutes. The primary researcher, who as noted above is of both Māori and Pacific heritage and familiar with cultural practices, guided each session with appropriate cultural processes that reflected the unique mix of each group. Protocols included opening with karakia lotu (prayer); holding space and time for whanaungatanga; using Māori and Pacific languages/terminology; reflecting personal experiences; appropriately applying humour and challenge/provocation; and the sharing of kai (food). The outlined practices supported a culturally safe environment and gave participants the freedom to communicate verbally, physically, emotionally and spiritually. Each session followed a similar format, layered by cultural protocols and markers that ensured each session elicited its own unique feeling, different to the other but no less authentic, humbling or insightful.

Data analysis

Data were analysed using reflexive thematic analysis following the six-step process outlined by Braun and Clarke.^17,18 Table 1 provides an overview of how these steps were applied in this research (see Table 1). While the steps reflect a somewhat linear process, it was more iterative and recursive in reality.

View Table 1–2.

Findings

Eleven Māori and Pacific AHPs took part in the wānanga talanoa, including physiotherapists (n=4), occupational therapists (n=2), dieticians (n=2), pharmacists (n=2) and one speech and language therapist. Length of professional service ranged from 5 months to 15 years. Although this research was specifically interested in the initial 2 years of practice, more experienced participants had the benefit of being able to step back and reflect on their experiences as a new graduate.

As noted in Table 1, three themes were constructed—valuing cultural intelligence; surviving, rather than thriving; it takes a village—which provide insight into the unique pressures Māori and Pacific AHPs faced in their first 2 years of practice. Each theme is discussed in more detail below. Pseudonyms are used to maintain privacy. Each pseudonym is a different Pacific language for numbers one to 11.

Valuing cultural intelligence

All participants agreed that a strong sense of identity or connection to culture helped guide and inform their clinical practice. Cultural identity was perceived as critical to who participants were as an AHP and they expressed being at their best when they felt enabled to bring their whole self into their role and draw on their innate ways of being in their practice.

“I will never stop being Māori, but I could stop being a physio. And so, I’m never not gonna walk in the room and not be Māori.” – Vitu

Participants perceived their sense of understanding and engaging with their own culture influenced how they cared for people from different cultures, including the value they placed on culture as a source for recovery.

“I think it’s influenced my understanding what culture means and how to kind of relate to someone and how to kind of make them feel like their culture is important. Making them feel empowered by their culture, making them feel like that matters.” – Nima

Participants were driven by a sense of responsibility, connection and commitment to the local community and a desire to have a positive impact.

“I’m here because I was born and raised here in [this community]. I’m here because I’m from here and because our people are here, and I don’t want our people to be here [in the hospital]. I want them out there, thriving. Being healthy. Making the right decisions. That’s why I’m here.” – Lua

Participants perceived their culture provided them with a unique skillset that could support engagement and outcome. Indeed, it was a resource routinely called upon by others in their work environment, with participants routinely sought out to be a translator or connector.

“It is a skill, lived experience is, and yeah … your skill in … your chance to be able to connect with other people so that they can engage the service to get a good outcome for them.” – Hongofulu

However, participants also acknowledged experiencing personal and professional tensions, as their cultural skillset in the workplace was valued in some spaces but not others, and at times was taken for granted. For example, on one hand being called upon to “double as an interpreter for our service” – Tolu, but then when “wanting to rep being Māori […] people telling me I’m not brown enough or I’m not, I don’t know the language, so what do I know.” – Ono.

Instead of feeling valued for “the fact that you can speak a different language, you can engage with these patients better than the rest of your colleagues” – Iwa, participants felt they were expected to take on the cultural load without acknowledgement: “Oh, you can do that too and so we’ll just take advantage of that” – Iwa. This was particularly challenging for new graduates who were still grappling with the usual challenges that come with the transition to an autonomous practitioner.

In summary, participants perceived that their sense of cultural identity was important to who they were as a practitioner, and it gave them a unique ability to relate to and connect with the communities they served. Their cultural intelligence was a significant resource routinely drawn upon by others in their organisation when it had practical utility for them. However, participants perceived there was a lack of systemic value attributed to this resource and limited understanding around the increased responsibilities and tensions inherently associated.

Surviving, rather than thriving

Participants struggled to respond to questions about thriving in the workplace, as their reality was “very much about surviving […] just getting through day-to-day or week-to-week” – Tasi. They felt hindered in their ability to thrive as Māori and Pacific AHPs due to the systemic barriers they faced. Their stories included examples of structural or institutional racism, personally mediated racism in the form of racial stereotyping and micro-aggressions, and internalised racism manifesting in the erosion of self-belief and confidence. This theme reflects the disadvantages, barriers and challenges participants experienced, on top of routine challenges that come with working in healthcare in the formative years of one’s career. Tasi reflected that thriving would be:

“Not having to deal with little racist remarks, and even procedures or how things are done. So, not having to fight those kinds of things and not having to deal with those aggressions in the day-to-day.” – Tasi

Most participants were the only Māori or Pacific person in their teams. They spoke about not feeling culturally safe and frequently being put into culturally unsafe positions by seniors or colleagues. Tekau mā rua recalls:

“I was doing everything for anyone. I was like a PSA [Public Service Association] delegate, doing tikanga best practice for all the [health professionals] here […] There wasn’t anyone else to do it and I just didn’t, hadn’t learnt then how to say no, I guess […] it is hard to stand up when you’re a new grad.” – Tekau mā rua

Participants expressed a sense of weariness caused by the continued exposure to culturally unsafe spaces “because there’s only so many times one person can advocate for themselves” – Vitu. They also reflected on the absence of support for their cultural needs, compared to investment in their clinical and technical skills.

“I think my clinical skills and all that, they’re well taken care of, yes. But me as a person, me as a [mixed ethnicity] person, I ain’t getting that from nowhere.” – Tasi

This was perceived as a manifestation of institutional racism, which stifled participants’ ability to thrive at work, especially in their initial years of practice.

Tasi reflected that “If I’m stuck worrying about trying to push Māori stuff, basic stuff, then I’m not allowed to actually think creatively of how we can actually do this kind of stuff”, highlighting the cumulative impact this enduring pressure may have on one’s ability to be the kind of health professional they want to be, hindering the potential for their cultural resources to be fully realised.

“The lack of culturally safe spaces made it challenging to raise concerns; I’ve thought of many different ways I can try and bring it up, but I don’t have the confidence to bring it up. I don’t know how to, or whether or not it’s safe enough to bring it up.” – Nima

Nima’s reflections highlight the complexity that exists in trying to confront the unacknowledged tensions. Participants talked about the “extras” that come with being a Māori or Pacific AHP. Participants felt an ever-increasing burden, often tasked with fixing issues that were not their responsibility, and which should have been addressed by management and leadership.

“It’s hard because the burden that is placed on you culturally is massive, especially when you are like one or like, very few. Being the only one since 2017 has taxed me emotionally. It took me a long time to actually learn that it wasn’t my job to upskill or educate these people. That was a failure in the system.” – Iwa

There was an expectation that seniors would provide support, without protected time, structural supports or appropriate remuneration that recognised the extra responsibilities “[be]cause it’s expected” – Iwa, and “that puts the burden on us and leads to us burning out as well” – Tekau mā rua. This expectation and burden was not placed on their non-Māori, non-Pacific colleagues and demonstrates the inherently biased and culturally unsafe working environments at play. These environments contributed to some participants struggling with their identity as Māori or Pacific when they were embedded in a system that did not value what that offers.

“Like, I love being Māori, but sometimes I hate being Māori here. Here it’s shit to be Māori ’cause then you’re the point of call for everything and it’s a tick box for everyone else.” – Vitu

Participants suggested broader systemic issues impacted their ability to thrive because “[I] just feel like I’m trying to fit into a place that’s not made for me” – Ono. They described a predominance in approach, thought, feeling and attitude that resulted in them either having to fit in and conform or change the way they were in the workplace environment.

“When I was in a very Pākehā environment, I would try to act in that same way so that I’m accepted into that group and so that they will listen to me. […] It’s hard acting white, but it’s also … it’s harder being the different one in the room.” – Tasi

Participants spoke of a lack of organisational support for things Māori or Pacific and an organisational system that was not only difficult to navigate, but counter-productive and disempowering for them.

“You start to realise how the system is just not, that it’s not, it’s not supporting those values and aspirations that we have.” – Fa

In summary, thriving was an aspiration, but the lived reality of many participants was an overarching sense of survival. Their stories highlighted that unfair expectation was routinely placed on Māori and Pacific AHPs, which impacted how they felt in relation to themselves and how they felt perceived by colleagues. These stories reflect an organisational failing to provide a culturally supportive and uplifting environment in which Māori and Pacific AHPs can thrive.

It takes a village

Participants shared a view that having appropriate mentors, supervisors and support people around them, and going into the right team setting and environment, played a role in promoting positive experiences. Tolu reflected on positive mentorship from a senior Pacific colleague, which he attributed to their similar value system and shared cultural understanding:

“She wanted me to be my own clinician, and she created that safety net for me. I felt confident enough to go off, because she trusted my clinical reasoning.” – Tolu

Others similarly spoke about the importance of culturally aligned leadership that allowed them “to practice in more a holistic and probably a Māori-centric way” – Tasi.

There were also examples highlighting the role of non-Māori, non-Pacific leaders in creating safe and supportive working environments.

“The manager in this role, although she’s European, she is a lot more open to understanding who I am. So, in that sense I feel comfortable enough to share my family, my situation, what I believe in, what I don’t believe in with her … I feel really safe in this job, because I know that if I do challenge the status quo I have support behind me.” – Lua

A key characteristic of positive support was taking the time to get to know and understand who they were as a person and “believing, people believing in me. I think that’s probably where I am my best” – Tasi. This helped to build self-confidence and instilled a sense of belief in themselves.

“Having the right person to be there and to listen and to understand. And not to make excuses for what I was saying, but to guide me in a way that’s gonna be productive. And then that’s when it turned around, and it took me probably two or three years as well to fully be confident in myself and to be able to stand up and advocate for myself.” – Fa

New AHPs shared how the right kind of support also served to mitigate self-doubt, which is common with new graduates and is compounded in marginalised groups like Māori and Pacific peoples due to prevailing attitudes and systems.

“I find myself second-guessing a lot of my capability and if I’m meant to be here, like if I’m smart enough. And just also feeling like I can’t do much independently.” – Ono

Allies—non-Māori, non-Pacific colleagues—also contributed as part of the broader village. Participants described this support manifesting in several ways and reflected that it could include both conscious and unconscious behaviours.

“Finding allyship as a big thing. So, I have a colleague who’s doing the reo Māori course at, like in the hospital, and having her do that meant that I wouldn’t get asked for Māori translations. But she is then promoting te reo Māori, which like even in it’s, like that’s her 1%, but it’s 1% off me. And that is, that to me like it means support that she probably doesn’t even know she’s giving me.” – Vitu

Allyship also encompassed the efforts of colleagues to understand them better as a Māori or Pacific person, not just a homogenous AHP.

“Being surrounded by colleagues who make the effort to understand who I am as a Samoan who lives in [local suburb].” – Lua

For others, it was as simple as having their non-Māori, non-Pacific colleagues offering words of support and encouragement. This indicated a recognition of the extra load Māori and Pacific AHPs carry.

A common thread was the notion of giving back, which is grounded in important Māori and Pacific values of manaakitanga and reciprocity. All participants spoke of someone who believed in them at some stage, and the importance of passing that on to the next person.

“If people didn’t care about me and if people didn’t take time to spend with me in those first years, it would’ve been a bit different. And I think, I’ve had a lot of people who’ve invested time into me, and energy. And so, I try as best I can, I know I can do better, but I try to return that by doing it with other people.” – Tasi

In summary, participants reflected that it took a collective effort to create an enabling environment in which Māori and Pacific AHPs could flourish. Being surrounded by people who took time to understand them and who invited them to bring the whole of themselves into the work environment instilled a sense of belief and confidence in themselves as Māori and Pacific AHPs. This created the context for a virtuous cycle, where they were enabled to provide support to the next generation of Māori and Pacific AHPs.

Discussion

The findings of this research make visible the views and experiences of Māori and Pacific AHPs. The three themes highlight the struggle between aspiration and reality, commitment and disillusionment for Māori and Pacific AHPs navigating work in a hospital setting in their first 2 years of practice. The findings highlight an interesting juxtaposition for Māori and Pacific AHPs. On one hand, their shared experience of growing up as Māori and Pacific in Aotearoa and their shared cultural identity is a strength that uniquely positions them to connect with, understand and attend to the needs of people from such communities. On the other hand, they are embedded within a system that often functions in ways that are inconsistent (or indeed conflict) with their personal and cultural values, and where they are subject to the cumulative effects of institutional racism, reducing their capacity to bring the whole of themselves into their role as AHPs. Despite this, AHPs who took part in this research identified key experiences, moments or interactions that provide insights into how things could be different. Our findings champion the collective strengths of Māori and Pacific AHPs and offer solutions for positive change in the contexts in which they work.

Research exploring Māori and Pacific AHPs’ experiences at work has been limited. Even research in the broader Māori and Pacific health workforce is surprisingly limited, focussing primarily on their participation in the health and disability workforce with strategies predominantly generated for tertiary health education providers.^7,19 Nonetheless, our findings do resonate with research that has been undertaken. Wilson et al. (2022) provided a powerful overview of the working lives of Māori nurses, which they argue has been characterised by racism, discrimination and marginalisation, perpetuated by Māori nurses being excluded from, or silenced in, forums seeking to address Māori nursing workforce deficits.²⁰ Research in health adjacent roles similarly reflect that Māori and Pacific members of health advisory groups feel isolated, under-valued, experience frustration with not being taken seriously and express overall discomfort with meeting processes and environments.²¹ Furthermore, Māori scientists have reported operating across two worlds, with their “cultural double-shift” having detrimental effects on career progression and leading to burnout and stress.²² Our findings highlight that these challenges persist for Māori and Pacific AHPs, signalling a failure to address these systemic issues. Hence, taking a strengths-based approach and offering a way forward has been a key priority in our research process.

Drawing on the “Sea of Islands” to support Māori and Pacific AHPs to thrive at work

In his seminal 1995 offering, Pacific academic Epeli Hauʻofa rallied for a conscious shift in the way people perceived the Pacific. He presented the prevailing discourse of the Pacific Islands as tiny, underdeveloped, dependent states.²³ Hauʻofa put forward the “Sea of Islands” concept as an alternative narrative, whereby the sea was not something that separated, but rather connected the islands. From this perspective, the sea is viewed as supporting connection to the wealth of language, culture and resources across the moana, providing communities with a strengthened sense of pride and collective relationality. The “Sea of Islands” concept resonated with the findings, reinforcing the Māori and Pacific AHPs’ values and sense of responsibility to community, interconnectedness, reciprocity and belonging. It also provides a framework to prompt non-Māori, non-Pacific colleagues to consider what connects us, and what systemic and structural barriers hinder those connections. When participants’ ancestors voyaged across the vast ocean, they were not bound by borders and restrictions, but rather by their own understanding, awareness of and connection with the environment. As present-day voyagers, a “Sea of Islands” lens reminds us, regardless of their background, that AHPs have a shared desire to contribute to improving the lives of those around them, clients and colleagues alike. Collectively, AHPs possess abundant resources with a richness of culture, language, relationships, reciprocity and interdependence grounded in service and purpose.

How do we create the context for our “Sea of Islands” to flourish?

Our findings offer a range of opportunities for individuals, leaders and organisations to realise the aspirations of the “Sea of Islands”. Consistent with the tenets of AI used in this research, which includes envisaging a possible future, an underpinning aspiration was to document what participants felt they needed to be at their best at work. As such, during wānanga talanoa participants provided practical ideas and strategies they believed would support them as Māori and Pacific AHPs to shift from surviving to thriving at work. Table 2 provides an overview of key recommendations generated through that kōrero. As noted in Table 1, while these recommendations were initially constructed as a fourth theme, Being at our best, we have opted to include them in this final section as they represent a pathway forward.

The recommendations align with and draw on contemporary understandings of cultural safety, arguing for the critical role of structures and organisations in creating culturally safe environments and the importance of reflexivity on power relationships in health interactions.²⁴ This conceptualisation of cultural safety extends to and invites organisations to address systemic issues and power structures to achieve equity within the workforce and working environment. To that end, Table 2 is formatted to serve as a reflection and planning tool for individuals, teams and organisations to engage reflexively and identify opportunities for change. Māori and Pacific AHPs may consider using it as a tool to examine structural supports available when considering employment opportunities.

Conclusion

Our findings highlight that providing opportunities for cultural development, recognition of cultural knowledge/intelligence and culturally safe and enriching work environments are key ingredients to enabling Māori and Pacific AHPs to thrive at work. This supports previous work highlighting the importance of being able to be Māori or Pacific in the workplace.^7,8,19,25,26 For Māori and Pacific AHPs to thrive at work, they must be able to practice as their Indigenous selves. To enable this, there must be an organisational shift in what knowledge and skills are valued and how they are recognised.