Effective and respectful interaction with Māori: How the regulators of health professionals are responding to the Health Practitioners Competence Assurance Amendment Act 2019
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It has been widely recognised that structural changes are required to address clear inequities in health and wellbeing outcomes within Aotearoa New Zealand and, in the context of Te Tiriti o Waitangi, specifically for Māori.[[1]] Indeed, this was a large part of the current Government’s motivation to restructure the health system and establish Te Aka Whai Ora – The Māori Health Authority, which, amongst other things, aims to enhance rangatiratanga over hauora Māori.
Legislative change is a clear mechanism for bringing about change and the Health Practitioners Competence Assurance Amendment Act 2019 (HPCA Amendment Act)[[2]] included expectations about how practitioners engage with Māori. An existing function of the responsible authorities (RAs) to set standards of clinical and cultural competence was extended with an explicit reference to competencies enabling “effective and respectful interaction with Māori” [[2]] (s37 (2)). In 2021, the NZMJ published an analysis of compliance with Te Tiriti o Waitangi in competency documents published by an RA[[3]] that found a lack of compliance with Te Tiriti o Waitangi. The analysis presented in this paper complements and extends upon that work by seeking to answer questions about the extent to which the RAs have responded to the amended requirement and function, three years after its enactment.
Practitioners, educators, researchers, policy makers, and professional leaders are engaged in work to ensure Te Tiriti o Waitangi and meaningful, respectful and empowering engagement with Māori is at the heart of developments across the health, wellbeing and disability support sectors.[[4]] For educators this includes considering the design and oversight of curricula;[[4,5]] how students experience curricula and are supported to move through it;[[6]] and by confronting the history and current practice regarding access and selection.[[7]] Workforce planning requires consideration beyond professional boundaries and a greater emphasis on serving the community,[[8]] particularly those who are inadequately served and, here in Aotearoa New Zealand, specifically Māori.
The original Act (HPCA Act)[[9]] outlined a list of functions of RAs, which included the clause: “to set standards of clinical competence, cultural competence, and ethical conduct to be observed by health practitioners of the profession” (s118 (i)).[[9]] Section 37 of the 2019 amendment to this Act[[2]] included an extension to this function with “cultural competence” being defined in relation to working with Māori. The function became: “to set standards of clinical competence, cultural competence (including competencies that will enable effective and respectful interaction with Māori), and ethical conduct to be observed by health practitioners of the profession” (s118 (i)).[[2]]
It is now three years since the amendments to the Act came into law. While there have been many distractions and pressures, including COVID-19, other changes required by the HPCA Amendment Act[[2]] have been made on the websites of the RAs, such as temporary scopes of practice and professional recognition,[[10]] not least to address issues of workforce surge capacity as has been necessary in the context of the COVID-19 pandemic, and other information has been updated. Ongoing reviews of generic competencies have also continued during this time, one example being the Dental Council of New Zealand | Te Kaunihera Tiaki Niho (Dental Council) updating competencies as recently as the end of 2021.[[11]] However, as researchers working in the area of health regulation,[[4,10]] from our reading of documents produced by the RAs, it appeared that they were not picking up this particular challenge.
The research
Against this background and in the context of previous research,[[4,10]] we wanted to answer the following questions:
1. Have the RAs updated the competence-related function to include reference to working with Māori?
2. If so, to what extent do RAs explain the functions outlined in the HPCA Amendment Act?
3. To what extent have RAs incorporated engaging with Māori into their professional competencies?
4. Are there any other indications in published information that RAs are responding to the expectation that they assure the competence of practitioners registered within them to enable effective and respectful interaction with Māori?
Method
We began by visiting the page on the Manutū Hauora | New Zealand Ministry of Health’s (2022) website that lists all of the RAs and provides internet links to their respective websites. On the RA websites we searched information and documents posted online. The first two questions (referring to the extended function) were investigated by searching for descriptions of the work of the RAs. This included checking for any navigation features such as tabs with relevant terms such as “functions”, “role”, “responsibilities”, “about us”, “what we do”, and “our work”. If this was unsuccessful, the same terms were entered into a search function (if it existed).
The third question (the extent to which engaging with Māori was incorporated into competencies) was investigated by exploring the RAs’ competency documents and statements. We interrogated what the documents were, when they were developed, and whether they had been updated since the original HPCA Act[[9]] was amended. The search terms we used within the documents were “Māori”, “Maori”, “Tiriti”, “Treaty”, “engage”, “interaction”, “respectful”, “effective” and “Waitangi”. All instances in which these terms were identified were carefully considered in relation to their context, which enabled a judgement to be made about the intention of the text.
Where there were multiple documents, we focussed on those with titles referencing cultural competence/competencies and cultural safety. Finally, the fourth question was addressed by means of notes we kept of any other indicators of engagement with the extended competency such as whether the terms “Te Tiriti o Waitangi” or “Treaty of Waitangi” were used, and the presentation of te reo Māori, including the use or absence of macrons.
Results
Three years following the legislative amendment to the function of RAs explicitly to include engaging with Māori as a cultural competency, it is clear that only a minority of them have fully responded to this requirement.
One of the functions of the RAs is to publish competencies for practitioners. There are a number of formats that are used such as a series of individual documents (clinical competencies, ethical standards, cultural competence) or a “live” site, which updates information and includes interactive features. The extent to which RAs have incorporated engaging with Māori into their professional competencies was explored by identifying and reading published text and is summarised in Table 1.
Eight of the RAs have updated competencies with reference to engaging with Māori; the remaining nine RAs do not appear to have updated their published information following the Amendment Act.[[2]]
In the process of undertaking this exploration of websites and published documents, we identified other issues that provided insights into how individual RAs appreciate the extended reference to cultural competence within the context of the amended Act, and of healthcare in Aotearoa New Zealand.
The Dieticians Board | Te Mana Mātanga Mātai Kai (Deiticians Board) and the New Zealand Psychologists Board | Te Poari Kaimāta Hinengaro o Aotearoa (Psychologists Board) use almost identical text to refer to Māori and “the Treaty”, with the Dietetics statement reading: “The Government affirms that Māori as Tangata Whenua hold a unique place in our country, and that the Treaty of Waitangi is the nation’s founding document” (page 6),[[30]] the only difference being the insertion of “te Tiriti o Waitangi” following “the Treaty of Waitangi” in the psychology statement (page 2).[[38]]
We also noticed the wide range of variation in the extent to which te reo Māori was used on web sites and within documents. All RAs incorporate some te reo into the information that is available online. The naming of the RA and the navigation tools such as tabs and headings commonly incorporate te reo Māori, and some refer to—and hopefully integrate—principles from Te Ao Māori into their thinking and work (see, for example, Te Poari o ngā Kaihaumanu o Aotearoa | The Psychotherapists Board of Aotearoa New Zealand [The Psychotherapists Board], 2022).[[39]] Some RAs also profile Te Tiriti o Waitangi as the first tab on their front page (Te Kaunihara Tapuhi o Aotearoa | Nursing Council of New Zealand and the Psychotherapists Board). RAs take different positions in affirming Te Tiriti o Waitangi and the place of Māori. Some indicate the Government has recognised Māori while most assert that the RA itself affords Māori the respect of being Indigenous.
In addition to the similarities between information published by the Dieticians and Psychologists Boards, noted above, the New Zealand Medical Radiation Technologists Board | Te Poari Ringa Hangarua Iraruke (Medical Radiation Technologists Board) and the Medical Sciences Council of New Zealand | Te Kaunihera a Pūtaiao Hauora Aotearoa (Medical Sciences Council) have what appear to be an identical website design. The very close similarities extend to published statements, including those referencing cultural competence. Thus, the following statement appears in publications by the Medical Radiation Technologists Board ( 2018)[[21]] and the Medical Sciences Council (2018)[[32]] with the only difference being the reference to the title of the board/council:
“The [Board/Council] acknowledges Te Tiriti o Waitangi as the founding document of Aotearoa New Zealand and the importance it has in informing legislation, policy and practice. As tangata whenua of Aotearoa New Zealand, Maori hold a unique position in our society and the Board acknowledges and respects the specific importance of health services for Maori” (page 3).[[21,32]]
View Tables 1–2.
Discussion
The original HPCA Act[[9]] was designed to protect the public and RAs are responsible for enacting the functions listed within it in the process of affording protection. The HPCA Amendment Act[[2]] added more detail to the function specific to competence. The definition of cultural competence was extended to include enabling “effective and respectful interaction with Māori” (s118 (i)).[[2]] Formally establishing this level of specificity provides a powerful mandate to ensure that students and practitioners in the health professions (and therefore serving the community in health, wellbeing, and disability contexts) are required to have the skills to engage with and support Māori. Addressing Māori health, wellbeing, and disability inequities[[44]] are imperative from a human rights perspective and on the basis of Te Tiriti o Waitangi, the founding document of Aotearoa New Zealand,[[4,45]] and responding to the extension of the requirement for cultural competence both imperative and courteous. With regard to understanding the position of Māori as tangata whenua, we note that some RAs refer to the Government as recognising Māori, a languaging that distances the particular RA from this recognition and suggests that they don’t recognise Māori as tangata whenua and/or only engage with this at a transactional level of compliance.
The results from this analysis of published information indicate that, three years following the enactment of the Amendment Act[[2]] there is, at best, an equivocal response to the extended cultural competence. The extent to which enabling “effective and respectful interaction with Māori” has been embedded into the work of the RAs can be seen in the extent to which they have updated their functions, competencies and related guidance to reflect the amendment. For instance, the Dental Council’s (2021)[[11]] statement on “Best practices” includes the phrase “respectful and trusting relationship” (page 3), some detail under the heading of “Māori culture competence standards” with regard to attitudes, awareness and knowledge, skills and practice, and the provision of a list of supporting resources. By contrast the New Zealand Chiropractic Board | Te Pōari Kaikorohiti o Aotearoa makes only passing references to engaging with Māori and “The Treaty” in the context of “understanding the needs of Maori” (page 5)[[29]] and “undertaking relevant CPD, where appropriate” (paragraph 4).[[28]]
The adoption of the reference to “Te Tiriti” rather than “the Treaty” and the utilisation of te reo Māori may also provide some insights into the level of engagement of individual RAs in relation to the extended cultural competence function and, more broadly, a bicultural perspective on health. Language conveys meaning; te reo Māori is an official language of Aotearoa New Zealand; and language and culture are inextricably connected. Being responsive to Māori (an absolute requirement under Te Tiriti o Waitangi) requires meaningful and genuine engagement. Our colonial history of preventing people speaking te reo[[47]] makes it even more critical that the first language of this country is afforded appropriate respect. In a similar vein, recognising Te Tiriti o Waitangi as distinct from “The Treaty” is also essential to appreciate the history and issues that have resulted in poor access to and outcomes from health, wellbeing and disability support services. This is closely connected to debates about the reference to principles of the Treaty[[48]] as distinct from the Articles of Te Tiriti (see, for instance, Berghan[[49]]). As the Waitangi Tribunal (2019) put it: “Contemporary thinking on Treaty principles has moved on significantly from the “three Ps” approach favoured in the health sector” (page 80), finding that “the Crown’s “three Ps” articulation of Treaty principles is outdated and needs to be reformed” (page 163).[[50]] In this context, we were surprised to see that not all RAs referenced Te Tiriti o Waitangi.
A number of RAs do not spell “Māori” with a macron, a very basic step in respecting te reo. There is also a variation between RAs in how they refer to this land mass and country as New Zealand, Aotearoa, Aotearoa New Zealand, or Aotearoa/New Zealand, all of which are referents that imply different understandings of the nation.
While specialist knowledge and expertise require experts, different disciplines and, ultimately, different RAs, other elements of practice, education and professional development may be more efficiently served within a more cohesive and synergistic model.[[4]] Cultural competence and engaging with Māori in the pursuit of fair and equitable health outcomes is arguably better served in a more joined-up or integrated rather than separate and separatist approach to competencies, the functions of RAs, and how educational curricula are developed, and students gain access to and engage within them.
The similarities between the websites and content published by some RAs suggests that information and resources may be shared to some degree. This in turn raises questions about the efficient use of resources and an emphasis on administrative or bureaucratic priorities rather than meaningful engagement with, and reflection of, professional practice and context. A further issue worth noting in this space is the titles of the RAs. The titles of the RAs and the emphases we identified within their websites suggest they are all seeking to balance the identity and profile of the RA itself, access for and engagement with the public, and the RA’s relationship with practitioners. Six RAs emphasise practitioners in their title (Dietitians Board, Medical Radiation Technologists Board, Psychologists Board, Psychotherapists Board, Optometrists and Dispensing Opticians Board of New Zealand | Te Poari a ngā kaimātau Whatu me ngā Kaiwhakaarato Mōhiti, and the Podiatrists Board of New Zealand). These titles imply that the RAs associate with the practitioners they register and suggest an organisational culture that emphasises practitioners (as distinct from the public or the practice/profession).
In summary, there is evidence that three years following the amendment to the HPCA Act[[2]] only two of the RAs appear to have amended their published information to expressly reflect the extension of the concept of cultural competence to refer to “respectful interaction with Māori”. While the majority of the RAs refer to “Te Tiriti o Waitangi”, five of them continue to refer to the “Treaty of Waitangi”. Other relevant insights include a high level of similarity between some of the RAs and a tendency towards administrative or bureaucratic information, which raises issues about the duplication of resources and presents opportunities to consolidate language, quality assurance information and competencies.
Conclusion
The complexity of the RAs’ websites, the variable emphases they present (regarding practitioners, the public, and themselves) along with the use of different terminology and navigation tools can cause confusion. Paradoxically, the shared design, content (text), and cross referencing between RAs suggests a considerable amount of interaction between them. This also raises questions about the need for individual authorities to be undertaking many tasks that could reasonably be consolidated and begs the question whether we need 17 (or more) individual health professional regulators to be consulting about professional, ethical and cultural competencies, a point that has been the subject of reviews of the HPCA Act.[[9]] The expertise and context of practice of each of the professions warrants a level of discipline-specific oversight. However, generic expectations of health professionals are fundamental and, apart from discipline-specific nuances, are not radically different between professions. Another clause in the Amendment Act[[2]] specifically relates to such working across professional boundaries, listing an RA function as “to liaise with other authorities appointed under this Act about matters of common interest” (s118 (j)).[[9]] This function was extended (in the Amendment Act)[[2]] to “promote and facilitate inter-disciplinary collaboration and co-operation in the delivery of health services” (s118 (ja)).[[9]] The amendment to this function of RAs underlines the expectation that they will facilitate collaboration and co-operation.
Working across professional boundaries has the potential to change and extend the workforce. Professional association and regulation tend towards insular silos. The COVID-19 pandemic has required rapid changes at national and local levels, with colleagues from across the regulated professions supporting one another. There have been opportunities to appreciate the similarities across professional boundaries, driven by the needs of the community being served. The protectionist culture of health professional regulators is widely understood,[[46]] and whilst it serves the purpose of maintaining expertise and professional identity it can also exclude radical and alternative practice, free and critical thinking, and informed dissent.
It is clear that three years following the amendment to the original HPCA Act,[[2,9]] defining “effective and respectful interaction with Māori” as a function of the RAs has not resulted in wholesale appreciation of this as a competence, its adoption, or change in practice. It is equally clear that some RAs have genuinely engaged and have a sound vision based on the need to address inequity. Others, however, have yet to engage fully. We suggest it is timely to reconsider consolidating key functions of the RAs to enable them to focus expertise on what sets them apart from one another and utilise administrative and leadership resource to bring about essential change across the sector as a whole for the improved health of Māori and of all New Zealanders.
Summary
Abstract
Aim
To ascertain the response of registered health professional regulators to the legislated requirement under the Health Practitioners Competence Assurance Amendment Act 2019 (HPCA Amendement Act) that practitioners are culturally competent and, specifically, enabling “effective and respectful interaction with Māori”.
Method
A document analysis of the extent to which the culturally competent requirement is indicated in information about professional competencies within publicly available information of the 17 responsible authorities (RAs) that govern health practitioners under the Health Practitioners Competence Assurance legislation.
Results
Three years after the amendment to the original Act (HPCA Act) requiring health professionals to be culturally competent specifically in relation to interacting with Māori, only four of the 17 RAs fully reference the amended requirement, and only two RAs link this specific cultural competence to the requirements of the amended Act (HPCA Amendment Act). The majority of the RAs have yet to integrate references to engaging with Māori in this way into their professional competencies.
Conclusion
Culturally competent practice is only meaningful once it is enacted by individual practitioners in their interactions with others. It is imperative for RAs to include the cultural competence requirement into their published information about professional competencies as this would signal to the profession, practitioners, and wider community that effective and respectful interaction with Māori is a fundamental expectation of all health practitioners in this country. Other issues identified during the analysis suggest an emphasis on administration and bureaucracy. This presents an opportunity for consolidating the practice of RAs including how key functions are expressed and promulgated.
Author Information
Acknowledgements
Correspondence
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Competing Interests
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Effective and respectful interaction with Māori: How the regulators of health professionals are responding to the Health Practitioners Competence Assurance Amendment Act 2019
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It has been widely recognised that structural changes are required to address clear inequities in health and wellbeing outcomes within Aotearoa New Zealand and, in the context of Te Tiriti o Waitangi, specifically for Māori.[[1]] Indeed, this was a large part of the current Government’s motivation to restructure the health system and establish Te Aka Whai Ora – The Māori Health Authority, which, amongst other things, aims to enhance rangatiratanga over hauora Māori.
Legislative change is a clear mechanism for bringing about change and the Health Practitioners Competence Assurance Amendment Act 2019 (HPCA Amendment Act)[[2]] included expectations about how practitioners engage with Māori. An existing function of the responsible authorities (RAs) to set standards of clinical and cultural competence was extended with an explicit reference to competencies enabling “effective and respectful interaction with Māori” [[2]] (s37 (2)). In 2021, the NZMJ published an analysis of compliance with Te Tiriti o Waitangi in competency documents published by an RA[[3]] that found a lack of compliance with Te Tiriti o Waitangi. The analysis presented in this paper complements and extends upon that work by seeking to answer questions about the extent to which the RAs have responded to the amended requirement and function, three years after its enactment.
Practitioners, educators, researchers, policy makers, and professional leaders are engaged in work to ensure Te Tiriti o Waitangi and meaningful, respectful and empowering engagement with Māori is at the heart of developments across the health, wellbeing and disability support sectors.[[4]] For educators this includes considering the design and oversight of curricula;[[4,5]] how students experience curricula and are supported to move through it;[[6]] and by confronting the history and current practice regarding access and selection.[[7]] Workforce planning requires consideration beyond professional boundaries and a greater emphasis on serving the community,[[8]] particularly those who are inadequately served and, here in Aotearoa New Zealand, specifically Māori.
The original Act (HPCA Act)[[9]] outlined a list of functions of RAs, which included the clause: “to set standards of clinical competence, cultural competence, and ethical conduct to be observed by health practitioners of the profession” (s118 (i)).[[9]] Section 37 of the 2019 amendment to this Act[[2]] included an extension to this function with “cultural competence” being defined in relation to working with Māori. The function became: “to set standards of clinical competence, cultural competence (including competencies that will enable effective and respectful interaction with Māori), and ethical conduct to be observed by health practitioners of the profession” (s118 (i)).[[2]]
It is now three years since the amendments to the Act came into law. While there have been many distractions and pressures, including COVID-19, other changes required by the HPCA Amendment Act[[2]] have been made on the websites of the RAs, such as temporary scopes of practice and professional recognition,[[10]] not least to address issues of workforce surge capacity as has been necessary in the context of the COVID-19 pandemic, and other information has been updated. Ongoing reviews of generic competencies have also continued during this time, one example being the Dental Council of New Zealand | Te Kaunihera Tiaki Niho (Dental Council) updating competencies as recently as the end of 2021.[[11]] However, as researchers working in the area of health regulation,[[4,10]] from our reading of documents produced by the RAs, it appeared that they were not picking up this particular challenge.
The research
Against this background and in the context of previous research,[[4,10]] we wanted to answer the following questions:
1. Have the RAs updated the competence-related function to include reference to working with Māori?
2. If so, to what extent do RAs explain the functions outlined in the HPCA Amendment Act?
3. To what extent have RAs incorporated engaging with Māori into their professional competencies?
4. Are there any other indications in published information that RAs are responding to the expectation that they assure the competence of practitioners registered within them to enable effective and respectful interaction with Māori?
Method
We began by visiting the page on the Manutū Hauora | New Zealand Ministry of Health’s (2022) website that lists all of the RAs and provides internet links to their respective websites. On the RA websites we searched information and documents posted online. The first two questions (referring to the extended function) were investigated by searching for descriptions of the work of the RAs. This included checking for any navigation features such as tabs with relevant terms such as “functions”, “role”, “responsibilities”, “about us”, “what we do”, and “our work”. If this was unsuccessful, the same terms were entered into a search function (if it existed).
The third question (the extent to which engaging with Māori was incorporated into competencies) was investigated by exploring the RAs’ competency documents and statements. We interrogated what the documents were, when they were developed, and whether they had been updated since the original HPCA Act[[9]] was amended. The search terms we used within the documents were “Māori”, “Maori”, “Tiriti”, “Treaty”, “engage”, “interaction”, “respectful”, “effective” and “Waitangi”. All instances in which these terms were identified were carefully considered in relation to their context, which enabled a judgement to be made about the intention of the text.
Where there were multiple documents, we focussed on those with titles referencing cultural competence/competencies and cultural safety. Finally, the fourth question was addressed by means of notes we kept of any other indicators of engagement with the extended competency such as whether the terms “Te Tiriti o Waitangi” or “Treaty of Waitangi” were used, and the presentation of te reo Māori, including the use or absence of macrons.
Results
Three years following the legislative amendment to the function of RAs explicitly to include engaging with Māori as a cultural competency, it is clear that only a minority of them have fully responded to this requirement.
One of the functions of the RAs is to publish competencies for practitioners. There are a number of formats that are used such as a series of individual documents (clinical competencies, ethical standards, cultural competence) or a “live” site, which updates information and includes interactive features. The extent to which RAs have incorporated engaging with Māori into their professional competencies was explored by identifying and reading published text and is summarised in Table 1.
Eight of the RAs have updated competencies with reference to engaging with Māori; the remaining nine RAs do not appear to have updated their published information following the Amendment Act.[[2]]
In the process of undertaking this exploration of websites and published documents, we identified other issues that provided insights into how individual RAs appreciate the extended reference to cultural competence within the context of the amended Act, and of healthcare in Aotearoa New Zealand.
The Dieticians Board | Te Mana Mātanga Mātai Kai (Deiticians Board) and the New Zealand Psychologists Board | Te Poari Kaimāta Hinengaro o Aotearoa (Psychologists Board) use almost identical text to refer to Māori and “the Treaty”, with the Dietetics statement reading: “The Government affirms that Māori as Tangata Whenua hold a unique place in our country, and that the Treaty of Waitangi is the nation’s founding document” (page 6),[[30]] the only difference being the insertion of “te Tiriti o Waitangi” following “the Treaty of Waitangi” in the psychology statement (page 2).[[38]]
We also noticed the wide range of variation in the extent to which te reo Māori was used on web sites and within documents. All RAs incorporate some te reo into the information that is available online. The naming of the RA and the navigation tools such as tabs and headings commonly incorporate te reo Māori, and some refer to—and hopefully integrate—principles from Te Ao Māori into their thinking and work (see, for example, Te Poari o ngā Kaihaumanu o Aotearoa | The Psychotherapists Board of Aotearoa New Zealand [The Psychotherapists Board], 2022).[[39]] Some RAs also profile Te Tiriti o Waitangi as the first tab on their front page (Te Kaunihara Tapuhi o Aotearoa | Nursing Council of New Zealand and the Psychotherapists Board). RAs take different positions in affirming Te Tiriti o Waitangi and the place of Māori. Some indicate the Government has recognised Māori while most assert that the RA itself affords Māori the respect of being Indigenous.
In addition to the similarities between information published by the Dieticians and Psychologists Boards, noted above, the New Zealand Medical Radiation Technologists Board | Te Poari Ringa Hangarua Iraruke (Medical Radiation Technologists Board) and the Medical Sciences Council of New Zealand | Te Kaunihera a Pūtaiao Hauora Aotearoa (Medical Sciences Council) have what appear to be an identical website design. The very close similarities extend to published statements, including those referencing cultural competence. Thus, the following statement appears in publications by the Medical Radiation Technologists Board ( 2018)[[21]] and the Medical Sciences Council (2018)[[32]] with the only difference being the reference to the title of the board/council:
“The [Board/Council] acknowledges Te Tiriti o Waitangi as the founding document of Aotearoa New Zealand and the importance it has in informing legislation, policy and practice. As tangata whenua of Aotearoa New Zealand, Maori hold a unique position in our society and the Board acknowledges and respects the specific importance of health services for Maori” (page 3).[[21,32]]
View Tables 1–2.
Discussion
The original HPCA Act[[9]] was designed to protect the public and RAs are responsible for enacting the functions listed within it in the process of affording protection. The HPCA Amendment Act[[2]] added more detail to the function specific to competence. The definition of cultural competence was extended to include enabling “effective and respectful interaction with Māori” (s118 (i)).[[2]] Formally establishing this level of specificity provides a powerful mandate to ensure that students and practitioners in the health professions (and therefore serving the community in health, wellbeing, and disability contexts) are required to have the skills to engage with and support Māori. Addressing Māori health, wellbeing, and disability inequities[[44]] are imperative from a human rights perspective and on the basis of Te Tiriti o Waitangi, the founding document of Aotearoa New Zealand,[[4,45]] and responding to the extension of the requirement for cultural competence both imperative and courteous. With regard to understanding the position of Māori as tangata whenua, we note that some RAs refer to the Government as recognising Māori, a languaging that distances the particular RA from this recognition and suggests that they don’t recognise Māori as tangata whenua and/or only engage with this at a transactional level of compliance.
The results from this analysis of published information indicate that, three years following the enactment of the Amendment Act[[2]] there is, at best, an equivocal response to the extended cultural competence. The extent to which enabling “effective and respectful interaction with Māori” has been embedded into the work of the RAs can be seen in the extent to which they have updated their functions, competencies and related guidance to reflect the amendment. For instance, the Dental Council’s (2021)[[11]] statement on “Best practices” includes the phrase “respectful and trusting relationship” (page 3), some detail under the heading of “Māori culture competence standards” with regard to attitudes, awareness and knowledge, skills and practice, and the provision of a list of supporting resources. By contrast the New Zealand Chiropractic Board | Te Pōari Kaikorohiti o Aotearoa makes only passing references to engaging with Māori and “The Treaty” in the context of “understanding the needs of Maori” (page 5)[[29]] and “undertaking relevant CPD, where appropriate” (paragraph 4).[[28]]
The adoption of the reference to “Te Tiriti” rather than “the Treaty” and the utilisation of te reo Māori may also provide some insights into the level of engagement of individual RAs in relation to the extended cultural competence function and, more broadly, a bicultural perspective on health. Language conveys meaning; te reo Māori is an official language of Aotearoa New Zealand; and language and culture are inextricably connected. Being responsive to Māori (an absolute requirement under Te Tiriti o Waitangi) requires meaningful and genuine engagement. Our colonial history of preventing people speaking te reo[[47]] makes it even more critical that the first language of this country is afforded appropriate respect. In a similar vein, recognising Te Tiriti o Waitangi as distinct from “The Treaty” is also essential to appreciate the history and issues that have resulted in poor access to and outcomes from health, wellbeing and disability support services. This is closely connected to debates about the reference to principles of the Treaty[[48]] as distinct from the Articles of Te Tiriti (see, for instance, Berghan[[49]]). As the Waitangi Tribunal (2019) put it: “Contemporary thinking on Treaty principles has moved on significantly from the “three Ps” approach favoured in the health sector” (page 80), finding that “the Crown’s “three Ps” articulation of Treaty principles is outdated and needs to be reformed” (page 163).[[50]] In this context, we were surprised to see that not all RAs referenced Te Tiriti o Waitangi.
A number of RAs do not spell “Māori” with a macron, a very basic step in respecting te reo. There is also a variation between RAs in how they refer to this land mass and country as New Zealand, Aotearoa, Aotearoa New Zealand, or Aotearoa/New Zealand, all of which are referents that imply different understandings of the nation.
While specialist knowledge and expertise require experts, different disciplines and, ultimately, different RAs, other elements of practice, education and professional development may be more efficiently served within a more cohesive and synergistic model.[[4]] Cultural competence and engaging with Māori in the pursuit of fair and equitable health outcomes is arguably better served in a more joined-up or integrated rather than separate and separatist approach to competencies, the functions of RAs, and how educational curricula are developed, and students gain access to and engage within them.
The similarities between the websites and content published by some RAs suggests that information and resources may be shared to some degree. This in turn raises questions about the efficient use of resources and an emphasis on administrative or bureaucratic priorities rather than meaningful engagement with, and reflection of, professional practice and context. A further issue worth noting in this space is the titles of the RAs. The titles of the RAs and the emphases we identified within their websites suggest they are all seeking to balance the identity and profile of the RA itself, access for and engagement with the public, and the RA’s relationship with practitioners. Six RAs emphasise practitioners in their title (Dietitians Board, Medical Radiation Technologists Board, Psychologists Board, Psychotherapists Board, Optometrists and Dispensing Opticians Board of New Zealand | Te Poari a ngā kaimātau Whatu me ngā Kaiwhakaarato Mōhiti, and the Podiatrists Board of New Zealand). These titles imply that the RAs associate with the practitioners they register and suggest an organisational culture that emphasises practitioners (as distinct from the public or the practice/profession).
In summary, there is evidence that three years following the amendment to the HPCA Act[[2]] only two of the RAs appear to have amended their published information to expressly reflect the extension of the concept of cultural competence to refer to “respectful interaction with Māori”. While the majority of the RAs refer to “Te Tiriti o Waitangi”, five of them continue to refer to the “Treaty of Waitangi”. Other relevant insights include a high level of similarity between some of the RAs and a tendency towards administrative or bureaucratic information, which raises issues about the duplication of resources and presents opportunities to consolidate language, quality assurance information and competencies.
Conclusion
The complexity of the RAs’ websites, the variable emphases they present (regarding practitioners, the public, and themselves) along with the use of different terminology and navigation tools can cause confusion. Paradoxically, the shared design, content (text), and cross referencing between RAs suggests a considerable amount of interaction between them. This also raises questions about the need for individual authorities to be undertaking many tasks that could reasonably be consolidated and begs the question whether we need 17 (or more) individual health professional regulators to be consulting about professional, ethical and cultural competencies, a point that has been the subject of reviews of the HPCA Act.[[9]] The expertise and context of practice of each of the professions warrants a level of discipline-specific oversight. However, generic expectations of health professionals are fundamental and, apart from discipline-specific nuances, are not radically different between professions. Another clause in the Amendment Act[[2]] specifically relates to such working across professional boundaries, listing an RA function as “to liaise with other authorities appointed under this Act about matters of common interest” (s118 (j)).[[9]] This function was extended (in the Amendment Act)[[2]] to “promote and facilitate inter-disciplinary collaboration and co-operation in the delivery of health services” (s118 (ja)).[[9]] The amendment to this function of RAs underlines the expectation that they will facilitate collaboration and co-operation.
Working across professional boundaries has the potential to change and extend the workforce. Professional association and regulation tend towards insular silos. The COVID-19 pandemic has required rapid changes at national and local levels, with colleagues from across the regulated professions supporting one another. There have been opportunities to appreciate the similarities across professional boundaries, driven by the needs of the community being served. The protectionist culture of health professional regulators is widely understood,[[46]] and whilst it serves the purpose of maintaining expertise and professional identity it can also exclude radical and alternative practice, free and critical thinking, and informed dissent.
It is clear that three years following the amendment to the original HPCA Act,[[2,9]] defining “effective and respectful interaction with Māori” as a function of the RAs has not resulted in wholesale appreciation of this as a competence, its adoption, or change in practice. It is equally clear that some RAs have genuinely engaged and have a sound vision based on the need to address inequity. Others, however, have yet to engage fully. We suggest it is timely to reconsider consolidating key functions of the RAs to enable them to focus expertise on what sets them apart from one another and utilise administrative and leadership resource to bring about essential change across the sector as a whole for the improved health of Māori and of all New Zealanders.
Summary
Abstract
Aim
To ascertain the response of registered health professional regulators to the legislated requirement under the Health Practitioners Competence Assurance Amendment Act 2019 (HPCA Amendement Act) that practitioners are culturally competent and, specifically, enabling “effective and respectful interaction with Māori”.
Method
A document analysis of the extent to which the culturally competent requirement is indicated in information about professional competencies within publicly available information of the 17 responsible authorities (RAs) that govern health practitioners under the Health Practitioners Competence Assurance legislation.
Results
Three years after the amendment to the original Act (HPCA Act) requiring health professionals to be culturally competent specifically in relation to interacting with Māori, only four of the 17 RAs fully reference the amended requirement, and only two RAs link this specific cultural competence to the requirements of the amended Act (HPCA Amendment Act). The majority of the RAs have yet to integrate references to engaging with Māori in this way into their professional competencies.
Conclusion
Culturally competent practice is only meaningful once it is enacted by individual practitioners in their interactions with others. It is imperative for RAs to include the cultural competence requirement into their published information about professional competencies as this would signal to the profession, practitioners, and wider community that effective and respectful interaction with Māori is a fundamental expectation of all health practitioners in this country. Other issues identified during the analysis suggest an emphasis on administration and bureaucracy. This presents an opportunity for consolidating the practice of RAs including how key functions are expressed and promulgated.
Author Information
Acknowledgements
Correspondence
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Competing Interests
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Effective and respectful interaction with Māori: How the regulators of health professionals are responding to the Health Practitioners Competence Assurance Amendment Act 2019
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It has been widely recognised that structural changes are required to address clear inequities in health and wellbeing outcomes within Aotearoa New Zealand and, in the context of Te Tiriti o Waitangi, specifically for Māori.[[1]] Indeed, this was a large part of the current Government’s motivation to restructure the health system and establish Te Aka Whai Ora – The Māori Health Authority, which, amongst other things, aims to enhance rangatiratanga over hauora Māori.
Legislative change is a clear mechanism for bringing about change and the Health Practitioners Competence Assurance Amendment Act 2019 (HPCA Amendment Act)[[2]] included expectations about how practitioners engage with Māori. An existing function of the responsible authorities (RAs) to set standards of clinical and cultural competence was extended with an explicit reference to competencies enabling “effective and respectful interaction with Māori” [[2]] (s37 (2)). In 2021, the NZMJ published an analysis of compliance with Te Tiriti o Waitangi in competency documents published by an RA[[3]] that found a lack of compliance with Te Tiriti o Waitangi. The analysis presented in this paper complements and extends upon that work by seeking to answer questions about the extent to which the RAs have responded to the amended requirement and function, three years after its enactment.
Practitioners, educators, researchers, policy makers, and professional leaders are engaged in work to ensure Te Tiriti o Waitangi and meaningful, respectful and empowering engagement with Māori is at the heart of developments across the health, wellbeing and disability support sectors.[[4]] For educators this includes considering the design and oversight of curricula;[[4,5]] how students experience curricula and are supported to move through it;[[6]] and by confronting the history and current practice regarding access and selection.[[7]] Workforce planning requires consideration beyond professional boundaries and a greater emphasis on serving the community,[[8]] particularly those who are inadequately served and, here in Aotearoa New Zealand, specifically Māori.
The original Act (HPCA Act)[[9]] outlined a list of functions of RAs, which included the clause: “to set standards of clinical competence, cultural competence, and ethical conduct to be observed by health practitioners of the profession” (s118 (i)).[[9]] Section 37 of the 2019 amendment to this Act[[2]] included an extension to this function with “cultural competence” being defined in relation to working with Māori. The function became: “to set standards of clinical competence, cultural competence (including competencies that will enable effective and respectful interaction with Māori), and ethical conduct to be observed by health practitioners of the profession” (s118 (i)).[[2]]
It is now three years since the amendments to the Act came into law. While there have been many distractions and pressures, including COVID-19, other changes required by the HPCA Amendment Act[[2]] have been made on the websites of the RAs, such as temporary scopes of practice and professional recognition,[[10]] not least to address issues of workforce surge capacity as has been necessary in the context of the COVID-19 pandemic, and other information has been updated. Ongoing reviews of generic competencies have also continued during this time, one example being the Dental Council of New Zealand | Te Kaunihera Tiaki Niho (Dental Council) updating competencies as recently as the end of 2021.[[11]] However, as researchers working in the area of health regulation,[[4,10]] from our reading of documents produced by the RAs, it appeared that they were not picking up this particular challenge.
The research
Against this background and in the context of previous research,[[4,10]] we wanted to answer the following questions:
1. Have the RAs updated the competence-related function to include reference to working with Māori?
2. If so, to what extent do RAs explain the functions outlined in the HPCA Amendment Act?
3. To what extent have RAs incorporated engaging with Māori into their professional competencies?
4. Are there any other indications in published information that RAs are responding to the expectation that they assure the competence of practitioners registered within them to enable effective and respectful interaction with Māori?
Method
We began by visiting the page on the Manutū Hauora | New Zealand Ministry of Health’s (2022) website that lists all of the RAs and provides internet links to their respective websites. On the RA websites we searched information and documents posted online. The first two questions (referring to the extended function) were investigated by searching for descriptions of the work of the RAs. This included checking for any navigation features such as tabs with relevant terms such as “functions”, “role”, “responsibilities”, “about us”, “what we do”, and “our work”. If this was unsuccessful, the same terms were entered into a search function (if it existed).
The third question (the extent to which engaging with Māori was incorporated into competencies) was investigated by exploring the RAs’ competency documents and statements. We interrogated what the documents were, when they were developed, and whether they had been updated since the original HPCA Act[[9]] was amended. The search terms we used within the documents were “Māori”, “Maori”, “Tiriti”, “Treaty”, “engage”, “interaction”, “respectful”, “effective” and “Waitangi”. All instances in which these terms were identified were carefully considered in relation to their context, which enabled a judgement to be made about the intention of the text.
Where there were multiple documents, we focussed on those with titles referencing cultural competence/competencies and cultural safety. Finally, the fourth question was addressed by means of notes we kept of any other indicators of engagement with the extended competency such as whether the terms “Te Tiriti o Waitangi” or “Treaty of Waitangi” were used, and the presentation of te reo Māori, including the use or absence of macrons.
Results
Three years following the legislative amendment to the function of RAs explicitly to include engaging with Māori as a cultural competency, it is clear that only a minority of them have fully responded to this requirement.
One of the functions of the RAs is to publish competencies for practitioners. There are a number of formats that are used such as a series of individual documents (clinical competencies, ethical standards, cultural competence) or a “live” site, which updates information and includes interactive features. The extent to which RAs have incorporated engaging with Māori into their professional competencies was explored by identifying and reading published text and is summarised in Table 1.
Eight of the RAs have updated competencies with reference to engaging with Māori; the remaining nine RAs do not appear to have updated their published information following the Amendment Act.[[2]]
In the process of undertaking this exploration of websites and published documents, we identified other issues that provided insights into how individual RAs appreciate the extended reference to cultural competence within the context of the amended Act, and of healthcare in Aotearoa New Zealand.
The Dieticians Board | Te Mana Mātanga Mātai Kai (Deiticians Board) and the New Zealand Psychologists Board | Te Poari Kaimāta Hinengaro o Aotearoa (Psychologists Board) use almost identical text to refer to Māori and “the Treaty”, with the Dietetics statement reading: “The Government affirms that Māori as Tangata Whenua hold a unique place in our country, and that the Treaty of Waitangi is the nation’s founding document” (page 6),[[30]] the only difference being the insertion of “te Tiriti o Waitangi” following “the Treaty of Waitangi” in the psychology statement (page 2).[[38]]
We also noticed the wide range of variation in the extent to which te reo Māori was used on web sites and within documents. All RAs incorporate some te reo into the information that is available online. The naming of the RA and the navigation tools such as tabs and headings commonly incorporate te reo Māori, and some refer to—and hopefully integrate—principles from Te Ao Māori into their thinking and work (see, for example, Te Poari o ngā Kaihaumanu o Aotearoa | The Psychotherapists Board of Aotearoa New Zealand [The Psychotherapists Board], 2022).[[39]] Some RAs also profile Te Tiriti o Waitangi as the first tab on their front page (Te Kaunihara Tapuhi o Aotearoa | Nursing Council of New Zealand and the Psychotherapists Board). RAs take different positions in affirming Te Tiriti o Waitangi and the place of Māori. Some indicate the Government has recognised Māori while most assert that the RA itself affords Māori the respect of being Indigenous.
In addition to the similarities between information published by the Dieticians and Psychologists Boards, noted above, the New Zealand Medical Radiation Technologists Board | Te Poari Ringa Hangarua Iraruke (Medical Radiation Technologists Board) and the Medical Sciences Council of New Zealand | Te Kaunihera a Pūtaiao Hauora Aotearoa (Medical Sciences Council) have what appear to be an identical website design. The very close similarities extend to published statements, including those referencing cultural competence. Thus, the following statement appears in publications by the Medical Radiation Technologists Board ( 2018)[[21]] and the Medical Sciences Council (2018)[[32]] with the only difference being the reference to the title of the board/council:
“The [Board/Council] acknowledges Te Tiriti o Waitangi as the founding document of Aotearoa New Zealand and the importance it has in informing legislation, policy and practice. As tangata whenua of Aotearoa New Zealand, Maori hold a unique position in our society and the Board acknowledges and respects the specific importance of health services for Maori” (page 3).[[21,32]]
View Tables 1–2.
Discussion
The original HPCA Act[[9]] was designed to protect the public and RAs are responsible for enacting the functions listed within it in the process of affording protection. The HPCA Amendment Act[[2]] added more detail to the function specific to competence. The definition of cultural competence was extended to include enabling “effective and respectful interaction with Māori” (s118 (i)).[[2]] Formally establishing this level of specificity provides a powerful mandate to ensure that students and practitioners in the health professions (and therefore serving the community in health, wellbeing, and disability contexts) are required to have the skills to engage with and support Māori. Addressing Māori health, wellbeing, and disability inequities[[44]] are imperative from a human rights perspective and on the basis of Te Tiriti o Waitangi, the founding document of Aotearoa New Zealand,[[4,45]] and responding to the extension of the requirement for cultural competence both imperative and courteous. With regard to understanding the position of Māori as tangata whenua, we note that some RAs refer to the Government as recognising Māori, a languaging that distances the particular RA from this recognition and suggests that they don’t recognise Māori as tangata whenua and/or only engage with this at a transactional level of compliance.
The results from this analysis of published information indicate that, three years following the enactment of the Amendment Act[[2]] there is, at best, an equivocal response to the extended cultural competence. The extent to which enabling “effective and respectful interaction with Māori” has been embedded into the work of the RAs can be seen in the extent to which they have updated their functions, competencies and related guidance to reflect the amendment. For instance, the Dental Council’s (2021)[[11]] statement on “Best practices” includes the phrase “respectful and trusting relationship” (page 3), some detail under the heading of “Māori culture competence standards” with regard to attitudes, awareness and knowledge, skills and practice, and the provision of a list of supporting resources. By contrast the New Zealand Chiropractic Board | Te Pōari Kaikorohiti o Aotearoa makes only passing references to engaging with Māori and “The Treaty” in the context of “understanding the needs of Maori” (page 5)[[29]] and “undertaking relevant CPD, where appropriate” (paragraph 4).[[28]]
The adoption of the reference to “Te Tiriti” rather than “the Treaty” and the utilisation of te reo Māori may also provide some insights into the level of engagement of individual RAs in relation to the extended cultural competence function and, more broadly, a bicultural perspective on health. Language conveys meaning; te reo Māori is an official language of Aotearoa New Zealand; and language and culture are inextricably connected. Being responsive to Māori (an absolute requirement under Te Tiriti o Waitangi) requires meaningful and genuine engagement. Our colonial history of preventing people speaking te reo[[47]] makes it even more critical that the first language of this country is afforded appropriate respect. In a similar vein, recognising Te Tiriti o Waitangi as distinct from “The Treaty” is also essential to appreciate the history and issues that have resulted in poor access to and outcomes from health, wellbeing and disability support services. This is closely connected to debates about the reference to principles of the Treaty[[48]] as distinct from the Articles of Te Tiriti (see, for instance, Berghan[[49]]). As the Waitangi Tribunal (2019) put it: “Contemporary thinking on Treaty principles has moved on significantly from the “three Ps” approach favoured in the health sector” (page 80), finding that “the Crown’s “three Ps” articulation of Treaty principles is outdated and needs to be reformed” (page 163).[[50]] In this context, we were surprised to see that not all RAs referenced Te Tiriti o Waitangi.
A number of RAs do not spell “Māori” with a macron, a very basic step in respecting te reo. There is also a variation between RAs in how they refer to this land mass and country as New Zealand, Aotearoa, Aotearoa New Zealand, or Aotearoa/New Zealand, all of which are referents that imply different understandings of the nation.
While specialist knowledge and expertise require experts, different disciplines and, ultimately, different RAs, other elements of practice, education and professional development may be more efficiently served within a more cohesive and synergistic model.[[4]] Cultural competence and engaging with Māori in the pursuit of fair and equitable health outcomes is arguably better served in a more joined-up or integrated rather than separate and separatist approach to competencies, the functions of RAs, and how educational curricula are developed, and students gain access to and engage within them.
The similarities between the websites and content published by some RAs suggests that information and resources may be shared to some degree. This in turn raises questions about the efficient use of resources and an emphasis on administrative or bureaucratic priorities rather than meaningful engagement with, and reflection of, professional practice and context. A further issue worth noting in this space is the titles of the RAs. The titles of the RAs and the emphases we identified within their websites suggest they are all seeking to balance the identity and profile of the RA itself, access for and engagement with the public, and the RA’s relationship with practitioners. Six RAs emphasise practitioners in their title (Dietitians Board, Medical Radiation Technologists Board, Psychologists Board, Psychotherapists Board, Optometrists and Dispensing Opticians Board of New Zealand | Te Poari a ngā kaimātau Whatu me ngā Kaiwhakaarato Mōhiti, and the Podiatrists Board of New Zealand). These titles imply that the RAs associate with the practitioners they register and suggest an organisational culture that emphasises practitioners (as distinct from the public or the practice/profession).
In summary, there is evidence that three years following the amendment to the HPCA Act[[2]] only two of the RAs appear to have amended their published information to expressly reflect the extension of the concept of cultural competence to refer to “respectful interaction with Māori”. While the majority of the RAs refer to “Te Tiriti o Waitangi”, five of them continue to refer to the “Treaty of Waitangi”. Other relevant insights include a high level of similarity between some of the RAs and a tendency towards administrative or bureaucratic information, which raises issues about the duplication of resources and presents opportunities to consolidate language, quality assurance information and competencies.
Conclusion
The complexity of the RAs’ websites, the variable emphases they present (regarding practitioners, the public, and themselves) along with the use of different terminology and navigation tools can cause confusion. Paradoxically, the shared design, content (text), and cross referencing between RAs suggests a considerable amount of interaction between them. This also raises questions about the need for individual authorities to be undertaking many tasks that could reasonably be consolidated and begs the question whether we need 17 (or more) individual health professional regulators to be consulting about professional, ethical and cultural competencies, a point that has been the subject of reviews of the HPCA Act.[[9]] The expertise and context of practice of each of the professions warrants a level of discipline-specific oversight. However, generic expectations of health professionals are fundamental and, apart from discipline-specific nuances, are not radically different between professions. Another clause in the Amendment Act[[2]] specifically relates to such working across professional boundaries, listing an RA function as “to liaise with other authorities appointed under this Act about matters of common interest” (s118 (j)).[[9]] This function was extended (in the Amendment Act)[[2]] to “promote and facilitate inter-disciplinary collaboration and co-operation in the delivery of health services” (s118 (ja)).[[9]] The amendment to this function of RAs underlines the expectation that they will facilitate collaboration and co-operation.
Working across professional boundaries has the potential to change and extend the workforce. Professional association and regulation tend towards insular silos. The COVID-19 pandemic has required rapid changes at national and local levels, with colleagues from across the regulated professions supporting one another. There have been opportunities to appreciate the similarities across professional boundaries, driven by the needs of the community being served. The protectionist culture of health professional regulators is widely understood,[[46]] and whilst it serves the purpose of maintaining expertise and professional identity it can also exclude radical and alternative practice, free and critical thinking, and informed dissent.
It is clear that three years following the amendment to the original HPCA Act,[[2,9]] defining “effective and respectful interaction with Māori” as a function of the RAs has not resulted in wholesale appreciation of this as a competence, its adoption, or change in practice. It is equally clear that some RAs have genuinely engaged and have a sound vision based on the need to address inequity. Others, however, have yet to engage fully. We suggest it is timely to reconsider consolidating key functions of the RAs to enable them to focus expertise on what sets them apart from one another and utilise administrative and leadership resource to bring about essential change across the sector as a whole for the improved health of Māori and of all New Zealanders.
Summary
Abstract
Aim
To ascertain the response of registered health professional regulators to the legislated requirement under the Health Practitioners Competence Assurance Amendment Act 2019 (HPCA Amendement Act) that practitioners are culturally competent and, specifically, enabling “effective and respectful interaction with Māori”.
Method
A document analysis of the extent to which the culturally competent requirement is indicated in information about professional competencies within publicly available information of the 17 responsible authorities (RAs) that govern health practitioners under the Health Practitioners Competence Assurance legislation.
Results
Three years after the amendment to the original Act (HPCA Act) requiring health professionals to be culturally competent specifically in relation to interacting with Māori, only four of the 17 RAs fully reference the amended requirement, and only two RAs link this specific cultural competence to the requirements of the amended Act (HPCA Amendment Act). The majority of the RAs have yet to integrate references to engaging with Māori in this way into their professional competencies.
Conclusion
Culturally competent practice is only meaningful once it is enacted by individual practitioners in their interactions with others. It is imperative for RAs to include the cultural competence requirement into their published information about professional competencies as this would signal to the profession, practitioners, and wider community that effective and respectful interaction with Māori is a fundamental expectation of all health practitioners in this country. Other issues identified during the analysis suggest an emphasis on administration and bureaucracy. This presents an opportunity for consolidating the practice of RAs including how key functions are expressed and promulgated.
Author Information
Acknowledgements
Correspondence
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Competing Interests
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Effective and respectful interaction with Māori: How the regulators of health professionals are responding to the Health Practitioners Competence Assurance Amendment Act 2019
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It has been widely recognised that structural changes are required to address clear inequities in health and wellbeing outcomes within Aotearoa New Zealand and, in the context of Te Tiriti o Waitangi, specifically for Māori.[[1]] Indeed, this was a large part of the current Government’s motivation to restructure the health system and establish Te Aka Whai Ora – The Māori Health Authority, which, amongst other things, aims to enhance rangatiratanga over hauora Māori.
Legislative change is a clear mechanism for bringing about change and the Health Practitioners Competence Assurance Amendment Act 2019 (HPCA Amendment Act)[[2]] included expectations about how practitioners engage with Māori. An existing function of the responsible authorities (RAs) to set standards of clinical and cultural competence was extended with an explicit reference to competencies enabling “effective and respectful interaction with Māori” [[2]] (s37 (2)). In 2021, the NZMJ published an analysis of compliance with Te Tiriti o Waitangi in competency documents published by an RA[[3]] that found a lack of compliance with Te Tiriti o Waitangi. The analysis presented in this paper complements and extends upon that work by seeking to answer questions about the extent to which the RAs have responded to the amended requirement and function, three years after its enactment.
Practitioners, educators, researchers, policy makers, and professional leaders are engaged in work to ensure Te Tiriti o Waitangi and meaningful, respectful and empowering engagement with Māori is at the heart of developments across the health, wellbeing and disability support sectors.[[4]] For educators this includes considering the design and oversight of curricula;[[4,5]] how students experience curricula and are supported to move through it;[[6]] and by confronting the history and current practice regarding access and selection.[[7]] Workforce planning requires consideration beyond professional boundaries and a greater emphasis on serving the community,[[8]] particularly those who are inadequately served and, here in Aotearoa New Zealand, specifically Māori.
The original Act (HPCA Act)[[9]] outlined a list of functions of RAs, which included the clause: “to set standards of clinical competence, cultural competence, and ethical conduct to be observed by health practitioners of the profession” (s118 (i)).[[9]] Section 37 of the 2019 amendment to this Act[[2]] included an extension to this function with “cultural competence” being defined in relation to working with Māori. The function became: “to set standards of clinical competence, cultural competence (including competencies that will enable effective and respectful interaction with Māori), and ethical conduct to be observed by health practitioners of the profession” (s118 (i)).[[2]]
It is now three years since the amendments to the Act came into law. While there have been many distractions and pressures, including COVID-19, other changes required by the HPCA Amendment Act[[2]] have been made on the websites of the RAs, such as temporary scopes of practice and professional recognition,[[10]] not least to address issues of workforce surge capacity as has been necessary in the context of the COVID-19 pandemic, and other information has been updated. Ongoing reviews of generic competencies have also continued during this time, one example being the Dental Council of New Zealand | Te Kaunihera Tiaki Niho (Dental Council) updating competencies as recently as the end of 2021.[[11]] However, as researchers working in the area of health regulation,[[4,10]] from our reading of documents produced by the RAs, it appeared that they were not picking up this particular challenge.
The research
Against this background and in the context of previous research,[[4,10]] we wanted to answer the following questions:
1. Have the RAs updated the competence-related function to include reference to working with Māori?
2. If so, to what extent do RAs explain the functions outlined in the HPCA Amendment Act?
3. To what extent have RAs incorporated engaging with Māori into their professional competencies?
4. Are there any other indications in published information that RAs are responding to the expectation that they assure the competence of practitioners registered within them to enable effective and respectful interaction with Māori?
Method
We began by visiting the page on the Manutū Hauora | New Zealand Ministry of Health’s (2022) website that lists all of the RAs and provides internet links to their respective websites. On the RA websites we searched information and documents posted online. The first two questions (referring to the extended function) were investigated by searching for descriptions of the work of the RAs. This included checking for any navigation features such as tabs with relevant terms such as “functions”, “role”, “responsibilities”, “about us”, “what we do”, and “our work”. If this was unsuccessful, the same terms were entered into a search function (if it existed).
The third question (the extent to which engaging with Māori was incorporated into competencies) was investigated by exploring the RAs’ competency documents and statements. We interrogated what the documents were, when they were developed, and whether they had been updated since the original HPCA Act[[9]] was amended. The search terms we used within the documents were “Māori”, “Maori”, “Tiriti”, “Treaty”, “engage”, “interaction”, “respectful”, “effective” and “Waitangi”. All instances in which these terms were identified were carefully considered in relation to their context, which enabled a judgement to be made about the intention of the text.
Where there were multiple documents, we focussed on those with titles referencing cultural competence/competencies and cultural safety. Finally, the fourth question was addressed by means of notes we kept of any other indicators of engagement with the extended competency such as whether the terms “Te Tiriti o Waitangi” or “Treaty of Waitangi” were used, and the presentation of te reo Māori, including the use or absence of macrons.
Results
Three years following the legislative amendment to the function of RAs explicitly to include engaging with Māori as a cultural competency, it is clear that only a minority of them have fully responded to this requirement.
One of the functions of the RAs is to publish competencies for practitioners. There are a number of formats that are used such as a series of individual documents (clinical competencies, ethical standards, cultural competence) or a “live” site, which updates information and includes interactive features. The extent to which RAs have incorporated engaging with Māori into their professional competencies was explored by identifying and reading published text and is summarised in Table 1.
Eight of the RAs have updated competencies with reference to engaging with Māori; the remaining nine RAs do not appear to have updated their published information following the Amendment Act.[[2]]
In the process of undertaking this exploration of websites and published documents, we identified other issues that provided insights into how individual RAs appreciate the extended reference to cultural competence within the context of the amended Act, and of healthcare in Aotearoa New Zealand.
The Dieticians Board | Te Mana Mātanga Mātai Kai (Deiticians Board) and the New Zealand Psychologists Board | Te Poari Kaimāta Hinengaro o Aotearoa (Psychologists Board) use almost identical text to refer to Māori and “the Treaty”, with the Dietetics statement reading: “The Government affirms that Māori as Tangata Whenua hold a unique place in our country, and that the Treaty of Waitangi is the nation’s founding document” (page 6),[[30]] the only difference being the insertion of “te Tiriti o Waitangi” following “the Treaty of Waitangi” in the psychology statement (page 2).[[38]]
We also noticed the wide range of variation in the extent to which te reo Māori was used on web sites and within documents. All RAs incorporate some te reo into the information that is available online. The naming of the RA and the navigation tools such as tabs and headings commonly incorporate te reo Māori, and some refer to—and hopefully integrate—principles from Te Ao Māori into their thinking and work (see, for example, Te Poari o ngā Kaihaumanu o Aotearoa | The Psychotherapists Board of Aotearoa New Zealand [The Psychotherapists Board], 2022).[[39]] Some RAs also profile Te Tiriti o Waitangi as the first tab on their front page (Te Kaunihara Tapuhi o Aotearoa | Nursing Council of New Zealand and the Psychotherapists Board). RAs take different positions in affirming Te Tiriti o Waitangi and the place of Māori. Some indicate the Government has recognised Māori while most assert that the RA itself affords Māori the respect of being Indigenous.
In addition to the similarities between information published by the Dieticians and Psychologists Boards, noted above, the New Zealand Medical Radiation Technologists Board | Te Poari Ringa Hangarua Iraruke (Medical Radiation Technologists Board) and the Medical Sciences Council of New Zealand | Te Kaunihera a Pūtaiao Hauora Aotearoa (Medical Sciences Council) have what appear to be an identical website design. The very close similarities extend to published statements, including those referencing cultural competence. Thus, the following statement appears in publications by the Medical Radiation Technologists Board ( 2018)[[21]] and the Medical Sciences Council (2018)[[32]] with the only difference being the reference to the title of the board/council:
“The [Board/Council] acknowledges Te Tiriti o Waitangi as the founding document of Aotearoa New Zealand and the importance it has in informing legislation, policy and practice. As tangata whenua of Aotearoa New Zealand, Maori hold a unique position in our society and the Board acknowledges and respects the specific importance of health services for Maori” (page 3).[[21,32]]
View Tables 1–2.
Discussion
The original HPCA Act[[9]] was designed to protect the public and RAs are responsible for enacting the functions listed within it in the process of affording protection. The HPCA Amendment Act[[2]] added more detail to the function specific to competence. The definition of cultural competence was extended to include enabling “effective and respectful interaction with Māori” (s118 (i)).[[2]] Formally establishing this level of specificity provides a powerful mandate to ensure that students and practitioners in the health professions (and therefore serving the community in health, wellbeing, and disability contexts) are required to have the skills to engage with and support Māori. Addressing Māori health, wellbeing, and disability inequities[[44]] are imperative from a human rights perspective and on the basis of Te Tiriti o Waitangi, the founding document of Aotearoa New Zealand,[[4,45]] and responding to the extension of the requirement for cultural competence both imperative and courteous. With regard to understanding the position of Māori as tangata whenua, we note that some RAs refer to the Government as recognising Māori, a languaging that distances the particular RA from this recognition and suggests that they don’t recognise Māori as tangata whenua and/or only engage with this at a transactional level of compliance.
The results from this analysis of published information indicate that, three years following the enactment of the Amendment Act[[2]] there is, at best, an equivocal response to the extended cultural competence. The extent to which enabling “effective and respectful interaction with Māori” has been embedded into the work of the RAs can be seen in the extent to which they have updated their functions, competencies and related guidance to reflect the amendment. For instance, the Dental Council’s (2021)[[11]] statement on “Best practices” includes the phrase “respectful and trusting relationship” (page 3), some detail under the heading of “Māori culture competence standards” with regard to attitudes, awareness and knowledge, skills and practice, and the provision of a list of supporting resources. By contrast the New Zealand Chiropractic Board | Te Pōari Kaikorohiti o Aotearoa makes only passing references to engaging with Māori and “The Treaty” in the context of “understanding the needs of Maori” (page 5)[[29]] and “undertaking relevant CPD, where appropriate” (paragraph 4).[[28]]
The adoption of the reference to “Te Tiriti” rather than “the Treaty” and the utilisation of te reo Māori may also provide some insights into the level of engagement of individual RAs in relation to the extended cultural competence function and, more broadly, a bicultural perspective on health. Language conveys meaning; te reo Māori is an official language of Aotearoa New Zealand; and language and culture are inextricably connected. Being responsive to Māori (an absolute requirement under Te Tiriti o Waitangi) requires meaningful and genuine engagement. Our colonial history of preventing people speaking te reo[[47]] makes it even more critical that the first language of this country is afforded appropriate respect. In a similar vein, recognising Te Tiriti o Waitangi as distinct from “The Treaty” is also essential to appreciate the history and issues that have resulted in poor access to and outcomes from health, wellbeing and disability support services. This is closely connected to debates about the reference to principles of the Treaty[[48]] as distinct from the Articles of Te Tiriti (see, for instance, Berghan[[49]]). As the Waitangi Tribunal (2019) put it: “Contemporary thinking on Treaty principles has moved on significantly from the “three Ps” approach favoured in the health sector” (page 80), finding that “the Crown’s “three Ps” articulation of Treaty principles is outdated and needs to be reformed” (page 163).[[50]] In this context, we were surprised to see that not all RAs referenced Te Tiriti o Waitangi.
A number of RAs do not spell “Māori” with a macron, a very basic step in respecting te reo. There is also a variation between RAs in how they refer to this land mass and country as New Zealand, Aotearoa, Aotearoa New Zealand, or Aotearoa/New Zealand, all of which are referents that imply different understandings of the nation.
While specialist knowledge and expertise require experts, different disciplines and, ultimately, different RAs, other elements of practice, education and professional development may be more efficiently served within a more cohesive and synergistic model.[[4]] Cultural competence and engaging with Māori in the pursuit of fair and equitable health outcomes is arguably better served in a more joined-up or integrated rather than separate and separatist approach to competencies, the functions of RAs, and how educational curricula are developed, and students gain access to and engage within them.
The similarities between the websites and content published by some RAs suggests that information and resources may be shared to some degree. This in turn raises questions about the efficient use of resources and an emphasis on administrative or bureaucratic priorities rather than meaningful engagement with, and reflection of, professional practice and context. A further issue worth noting in this space is the titles of the RAs. The titles of the RAs and the emphases we identified within their websites suggest they are all seeking to balance the identity and profile of the RA itself, access for and engagement with the public, and the RA’s relationship with practitioners. Six RAs emphasise practitioners in their title (Dietitians Board, Medical Radiation Technologists Board, Psychologists Board, Psychotherapists Board, Optometrists and Dispensing Opticians Board of New Zealand | Te Poari a ngā kaimātau Whatu me ngā Kaiwhakaarato Mōhiti, and the Podiatrists Board of New Zealand). These titles imply that the RAs associate with the practitioners they register and suggest an organisational culture that emphasises practitioners (as distinct from the public or the practice/profession).
In summary, there is evidence that three years following the amendment to the HPCA Act[[2]] only two of the RAs appear to have amended their published information to expressly reflect the extension of the concept of cultural competence to refer to “respectful interaction with Māori”. While the majority of the RAs refer to “Te Tiriti o Waitangi”, five of them continue to refer to the “Treaty of Waitangi”. Other relevant insights include a high level of similarity between some of the RAs and a tendency towards administrative or bureaucratic information, which raises issues about the duplication of resources and presents opportunities to consolidate language, quality assurance information and competencies.
Conclusion
The complexity of the RAs’ websites, the variable emphases they present (regarding practitioners, the public, and themselves) along with the use of different terminology and navigation tools can cause confusion. Paradoxically, the shared design, content (text), and cross referencing between RAs suggests a considerable amount of interaction between them. This also raises questions about the need for individual authorities to be undertaking many tasks that could reasonably be consolidated and begs the question whether we need 17 (or more) individual health professional regulators to be consulting about professional, ethical and cultural competencies, a point that has been the subject of reviews of the HPCA Act.[[9]] The expertise and context of practice of each of the professions warrants a level of discipline-specific oversight. However, generic expectations of health professionals are fundamental and, apart from discipline-specific nuances, are not radically different between professions. Another clause in the Amendment Act[[2]] specifically relates to such working across professional boundaries, listing an RA function as “to liaise with other authorities appointed under this Act about matters of common interest” (s118 (j)).[[9]] This function was extended (in the Amendment Act)[[2]] to “promote and facilitate inter-disciplinary collaboration and co-operation in the delivery of health services” (s118 (ja)).[[9]] The amendment to this function of RAs underlines the expectation that they will facilitate collaboration and co-operation.
Working across professional boundaries has the potential to change and extend the workforce. Professional association and regulation tend towards insular silos. The COVID-19 pandemic has required rapid changes at national and local levels, with colleagues from across the regulated professions supporting one another. There have been opportunities to appreciate the similarities across professional boundaries, driven by the needs of the community being served. The protectionist culture of health professional regulators is widely understood,[[46]] and whilst it serves the purpose of maintaining expertise and professional identity it can also exclude radical and alternative practice, free and critical thinking, and informed dissent.
It is clear that three years following the amendment to the original HPCA Act,[[2,9]] defining “effective and respectful interaction with Māori” as a function of the RAs has not resulted in wholesale appreciation of this as a competence, its adoption, or change in practice. It is equally clear that some RAs have genuinely engaged and have a sound vision based on the need to address inequity. Others, however, have yet to engage fully. We suggest it is timely to reconsider consolidating key functions of the RAs to enable them to focus expertise on what sets them apart from one another and utilise administrative and leadership resource to bring about essential change across the sector as a whole for the improved health of Māori and of all New Zealanders.
Summary
Abstract
Aim
To ascertain the response of registered health professional regulators to the legislated requirement under the Health Practitioners Competence Assurance Amendment Act 2019 (HPCA Amendement Act) that practitioners are culturally competent and, specifically, enabling “effective and respectful interaction with Māori”.
Method
A document analysis of the extent to which the culturally competent requirement is indicated in information about professional competencies within publicly available information of the 17 responsible authorities (RAs) that govern health practitioners under the Health Practitioners Competence Assurance legislation.
Results
Three years after the amendment to the original Act (HPCA Act) requiring health professionals to be culturally competent specifically in relation to interacting with Māori, only four of the 17 RAs fully reference the amended requirement, and only two RAs link this specific cultural competence to the requirements of the amended Act (HPCA Amendment Act). The majority of the RAs have yet to integrate references to engaging with Māori in this way into their professional competencies.
Conclusion
Culturally competent practice is only meaningful once it is enacted by individual practitioners in their interactions with others. It is imperative for RAs to include the cultural competence requirement into their published information about professional competencies as this would signal to the profession, practitioners, and wider community that effective and respectful interaction with Māori is a fundamental expectation of all health practitioners in this country. Other issues identified during the analysis suggest an emphasis on administration and bureaucracy. This presents an opportunity for consolidating the practice of RAs including how key functions are expressed and promulgated.
Author Information
Acknowledgements
Correspondence
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Competing Interests
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Effective and respectful interaction with Māori: How the regulators of health professionals are responding to the Health Practitioners Competence Assurance Amendment Act 2019
It has been widely recognised that structural changes are required to address clear inequities in health and wellbeing outcomes within Aotearoa New Zealand and, in the context of Te Tiriti o Waitangi, specifically for Māori.
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