Te Umanga Whakaora Accelerated Māori Occupational Therapy Workforce Development

Transcription

1 - Te Umanga Whakaora Accelerated Māori Occupational Therapy Workforce Development

2 Te Umanga Whakaora Accelerated Māori Occupational Therapy Workforce Development Te Umanga Whakaora is one te reo Māori translation for occupational therapists, meaning resourceful, helpful and supportive, to enhance wellbeing 1. We have used the image of He Kupenga, the fishing net, identified by the reference group as the desired framework. The net depicts the weaving together of multiple concepts to form a tool that provides sustenance and resources. How to make and use the net requires the passing of knowledge from one generation to another. This is all situated in the world view where the environment is us and we are the environment, recognising the close relationship occupational therapists have with holistic care and the physical environment. TRM/06/01 ISBN: July, 2009 This document is available on the website of Te Rau Matatini Te Rau Matatini, PO Box 5731, Wellington, New Zealand 1 Professor Taiarahia Black (2009).

3 Foreword Whānau ora is essential to the quality of life in our communities. The greatest challenge ahead of us all, is how to ensure whānau, hapū and iwi are supported in a way which enhances their potential to develop and advance. Such a foundation is vital to our collective futures, particularly in the context of recession. Within the health sector, the profession of occupational therapy is at the front-line cutting edge of health services in supporting tangata whaiora in enjoying full participation in their communities. This framework, Te Umanga Whakaora, invests in a workforce plan for occupational therapy, to enable the profession to be resourceful, helpful and supportive, to enhance wellbeing. Te Umanga Whakaora is a workforce development strategy for the occupational therapy profession and Māori occupational therapists. It is designed to increase the cultural, clinical and technical capacity and competency of the workforce. This plan is situated in the health context and seeks to support the growth of the workforce, best practice and responsiveness to Māori as well as more broadly across the health sector. Te Umanga Whakaora reflects the current work and aspirations of Māori occupational therapists and tangata whaiora receiving services from occupational therapists. Ultimately, strengthening whānau capabilities comes about from an integrated approach to whānau wellbeing - that involves all of us. Uptake and utilisation by decision makers, managers, DHB funders and planners, the professional body, registration body and training institutions is important for this plan to be accomplished and to become a reality. I thank all of the Māori occupational therapists, the reference group, Te Rau Matatini, the New Zealand Association of Occupational Therapists and the Occupational Therapy Board of New Zealand, for their shared commitment to creating a culturally inclusive working environment. The value that the profession places on helping people to be independent and strong within the context of their whānau is an important step in helping healing happen. Te Umanga Whakaora is an excellent resource to help the occupational therapy workforce make the difference in the pathway towards whānau ora. Hon Tariana Turia Associate Minister of Health 1

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5 Ko koe te kaihanga o te katoa Ko koe taku rākau Ko koe taku tokotoko Ko koe taku oranga ngākau e Amine Tuia ki runga, Tuia ki raro, Tuia ki roto, Tuia ki waho, Tuia ki te Haki o Te Umanga Whakaora, Tui Tui Tuia, Tihei Mauri Ora. Thank you to all who have contributed to the development of Māori occupational therapists in multiple ways with your committed effort, energy, time, and dedication. Māori occupational therapists have shared their aspirations, challenges and dreams through hui, conversations and s to inform this plan. Thank you for your time and contribution. Thank you especially to the reference group who have informed and guided Te Umanga Whakaora: Kevin Brown Kristi Carpenter Georgina Davis Te Ara Whittington Jo-Anne Gilsenan Jake Tahitahi Ngāpuhi; Māori Occupational Therapist, Counties Manukau District Health Board (DHB) Kai Tahu; Māori Occupational Therapist; Lecturer and Fieldwork Associate; Otago Polytechnic Ngāpuhi, Ngāti Porou, Ngāi Tai; Māori Occupational Therapist; Te Huarahi Ora and Manaaki Ora; Adult Māori Mental Health; Counties Manukau DHB nee Isla Emery; Ngāti Kauwhata, Ngāti Maniapoto, Ngāti Kahungunu ki Wairarapa; Māori Occupational Therapist, He Kākano - Māori Child and Adolescence Mental Health Service, Counties Manukau DHB Ngāti Apa Ki Te Rā Tō, Ngāi Tahu; Māori Occupational Therapist; Manager Occupational Therapy Services Ngāti Manuhiri; Māori Occupational Therapist; Community Mental Health DHB; Whānau, Hapū and Iwi Development 3

6 Riwai Wilson Tania Marino Ngāti Porou; Māori Occupational Therapist; He Kākano - Māori Child and Adolescence Mental Health Service, Counties Manukau DHB Ngāti Ruanui; Tangata Whaiora Advisor We also wish to thank Brian Emery and Matua William Tangohau for your guidance as part of the reference group hui and during the development of the workforce plan. The whakataukī that best describes your guidance is Kimihia, Pātai, Rapua has been evident through the development process. We would like to also acknowledge Michael Iwama who inspires and encourages indigenous occupational therapists internationally and Kaja Jungersen for published articles that have contributed to the evidence for Māori occupational therapy practice. Without the support of the two significant occupational therapy organisations this strategy would not be a reality. The professional organisation for practitioners is the New Zealand Association of Occupational Therapists (NZAOT). They have been active in promoting opportunities for Māori within the profession and we acknowledge your contribution to this strategy. The registration body for the profession is the Occupational Therapy Board of New Zealand (OTBNZ). We appreciate their encouragement with developing this strategy and recognise the significant role they have in its success. Photograph of the first reference group hui: Matua Tunu Walker, Riwai Wilson, Te Ara Whittington, Jake Tahitahi, Georgina Davis, Isabella Folau, Kirsty Maxwell-Crawford, Jane Hopkirk, Tania Marino, Whāea Lucy Bush and present but photographer Quinton Bush. For the Te Rau Matatini Team involved see the back inside cover. 4

7 Contents Foreword... 1 Executive Summary... 7 Building a Māori Occupational Therapy Workforce Strategy Introduction Background Occupational Therapy Te Umanga Whakaora Challenges for the Profession Availability of Information Māori Health Disparities Māori Accessing Occupational Therapy Services Recruiting and Maintaining a Māori Occupational Therapy Workforce Opportunities for Training in Competencies for Māori Occupational Therapy 22 Māori Occupational Therapy Competency Building a Māori Occupational Therapy Workforce Framework Whānau ora Leadership Māori Development and Advancement Building Māori Responsiveness in Mainstream Relationships Research, Evaluation, Review and Measurement Building a Māori Occupational Therapy Workforce Action Plan Recruitment and Retention Cultural Competency

8 Best Practice Pathways for Action Ākonga Students and Whānau Health Tertiary Students Occupational Therapy Trainees Occupational Therapy Graduates Māori Occupational Therapists Occupational Therapists Managers and Leaders Conclusion References Appendix A - Methodology Appendix B - Website Links to Pathway Appendix C - Glossary Te Rau Matatini Team

9 Executive Summary Te Umanga Whakaora provides a tool to help address critical workforce shortages and challenges in occupational therapy. The Minister of Health, Hon. Tony Ryall 2 states that: The Ministry of Health has confirmed the health system faces major challenges: increasing demand for health services with worsening finances and a workforce crisis. This strategy provides a framework and action plan for developing the Māori occupational therapy health workforce. It has been developed by Te Rau Matatini in consultation with Māori occupational therapy practitioners, tangata whaiora 3, occupational therapists, training providers, the New Zealand Association of Occupational Therapists and the Occupational Therapy Board of New Zealand. The framework aligns to He Korowai Oranga, the Māori Health Strategy 4. He Korowai Oranga acknowledges the disparities in Māori health, provides pathways for addressing these disparities and emphasises whānau ora as a fundamental health imperative. Where Māori families are supported to achieve the fullness of health and wellbeing within te ao Māori and Aotearoa society as a whole and provides the framework for health services to improve the health status of whānau. Occupational therapists have much to offer in supporting this participation. The development of the Māori health workforce correlates with improved Māori health gains and impacts positively on Māori development 5. Occupational therapy in Aotearoa has been working on understanding the implications of developing the Māori health workforce, Māori cultural competencies and Māori best practice models. This is a strategy which is not just for Māori practitioners but for the whole profession providing a seminal guide for these aims. A culturally and clinically competent profession will contribute to increasing Māori health gains 6. 2 Ryall (2008, p.1). 3 Tangata whai ora means a service user, person seeking health and is also frequently written as tangata whaiora, which refers to a person who has wellbeing (Ministry of Health and Te Rau Matatini, 2000). 4 Ministry of Health (2002). 5 Jansen, Bacal, and Crengle (2009). 6 Huriwai, Sellman, Sullivan, and Potiki (1998). 7

10 Māori workforce gains have already been made in health and mental health 7. Many of these developments are applicable and may be adaptable for occupational therapy and have been recognised in Te Umanga Whakaora to ensure this strategy builds on existing gains and does not duplicate relevant initiatives and developments. This is a strategy to enhance Māori responsiveness by the occupational therapy profession and advance Māori occupational therapy workforce development. Most Occupational Therapists work in District Health Boards (DHBs) with 52% 8 of the profession employed there. This offers DHBs the opportunity to take a leadership role in Te Umanga Whakaora. A recently released report to the New Zealand Association of Occupational Therapy confirms DHBs ongoing difficulties in recruiting staff with only 34.5% of vacancies being filled within 10 weeks of advertising 9. By increasing the number of Māori occupational therapists and the clinical and cultural competencies of practitioners, tangata whaiora and whānau will benefit from services that reflect their needs, realities and worldviews. These elements are fundamental to the satisfaction and engagement with health services 10. The strategy provides a practical guide for services, practitioners, communities, training and professional bodies and funders about workforce solutions that build: 1. Recruitment and Retention 2. Best Practice, and 3. Cultural Competency. Recruitment and Retention The number of Māori occupational therapists needs to be significantly increased to meet the needs of tangata whaiora. Accelerated pathways for Māori leading to occupational therapy are urgently needed as workforce numbers have remained stagnant over the last decade. Te Umanga Whakaora provides strategies that you can use to: target secondary and tertiary students and Māori currently in the health workforce who may be interested in occupational therapy as a rewarding profession 7 Baxter (2008) and Ministry of Health (2008). 8 New Zealand Health Information Service (2008). 9 Leach (2009). 10 Jansen, Bacal, and Crengle (2009) and Hurawai and Sellman (1998). 8

11 promote to other workforces as well as those enrolled with WINZ or Workbridge 11 who may be interested in occupational therapy with encouragement and accessible pathways alert wharekura and secondary teachers and tertiary lecturers that resources are available that align to existing curricula that promote whānau ora, Māori health determinants, and career opportunities for Māori in health including specific resources for occupational therapy. Once recruited and qualified, retaining the workforce is essential. Te Umanga Whakaora provides strategies that you can use to: create a culturally inclusive working environment 12 supported by cultural and clinical mentoring 13. Best Practice Opportunities to build and extend best practice in delivering occupational therapy services are included in this plan. Te Umanga Whakaora provides strategies that you can use to: access Māori responsiveness best practice models and evidence that is accessible to occupational therapy practitioners develop and use research priorities build a culture of continual improvement within the profession. Cultural Competency The development and implementation of cultural competencies within the occupational therapy profession will actively support effective services to tangata whaiora and whānau. The occupational therapy profession currently has no mechanism for measuring and recognising Māori cultural competencies. Te Umanga Whakaora provides strategies that you can use to: recognise and implement Māori cultural competencies as a core proficiency in occupational therapy 11 Workbridge is a professional employment service for people with all types of disability, including people who have lived with the long term effects of injury or illness. 12 Paki-Slater (2000). 13 McKinney (2006). 9

12 access future training in Māori cultural competencies be part of the ongoing development of cultural competencies. Conclusion This strategy has brought together in one place, a wealth of resources, existing initiatives and strategies that you can utilise to progress Māori occupational therapy workforce development. Practical actions, initiatives and where to find more information is located in this plan, alongside the evidence and aspirations that underpin Te Umanga Whakaora. 10

13 Building a Māori Occupational Therapy Workforce Strategy Te Umanga Whakaora is a strategy designed to increase the cultural, clinical and technical capacity and competency of the occupational therapy workforce in Aotearoa. It aims to improve access to occupational therapy services that are reflective of the needs of Māori and to contribute effectively to whānau ora. Māori occupational therapists are committed to this strategy and to a partnership with the sector that focus on support and leadership that will ultimately enhance the cultural fluency of the profession. Nā tāu rourou, nā tāku rourou, ka ora ai te iwi 14. The overall aim is to ensure that Māori will have the choice of an effective occupational therapy service provided by Māori. This will not only require extension and expansion of the existing workforce but will require greater understanding of the need for and use of occupational therapists by whānau, hapū and iwi. The strategy intends to work towards those aims through partnerships and collaborative initiatives with employers of occupational therapists especially DHBs and Māori health service providers, Ministry of Education (Special Education), and social development sectors, Accident Compensation Corporation (ACC), and wider key stakeholders. Integral to this, is effective leadership and development of the current Māori occupational therapy workforce. Introduction This strategy has been developed for the occupational therapy profession, its leadership, practitioners and Māori users of services. Māori occupational therapy practitioners, tangata whaiora and kaumātua have assisted with developing the plan. The methodology (appendix A) has been developed with the knowledge and experiences of the profession and the sector. Ko koe, ko au, ko koutou, ko tātou 15. He Korowai Oranga, the Māori Health Strategy 16, establishes the path for Māori health development and wellbeing in both health and disability. This strategy embraces the 14 Your basket, my basket will feed the people. 15 The holding and sharing of knowledge. These two whakataukī (14 and 15) were provided by Brian Emery. 16 Ministry of Health (2002). 11

14 pinnacle of whānau ora - Māori families supported to achieve the fullness of health and wellbeing within te ao Māori and Aotearoa society. It also provides the framework for health services to improve the health status of whānau. There are two pathways in He Korowai Oranga, to affirm Māori approaches and to improve Māori outcomes 17. The New Zealand Public Health and Disability Act , identifies the need for the improvement of health and disability outcomes for all and to lower disparities by improving the health of Māori. Health services, health professions and practitioners need to continue to respond to the health needs of Māori. Occupational therapists in Aotearoa are registered health professionals and come under the Health Practitioners Competency Act This Act requires health practitioners to be competent and fit to practise. Having trained as occupational therapists they are engaged in the Continuing Competence Framework for Recertification 20 which requires that they access regular supervision and mentoring. The most common work settings of occupational therapists are in the DHBs, embedded in their services such as mental health, emergency departments, rehabilitation, out-patients and kaupapa Māori mental health services. Occupational therapy is also practised through ACC, Primary Health Organisations (PHOs), Non-Governmental Organisations (NGOs), schools (as part of the Ministry of Education), independent practitioners, health promotion and addiction services. Organisations that provide services to assist people into the workforce such as Work First 21 also use occupational therapy services. Occupational therapists are also employed in managerial and administration roles within the health sector. The shortage of health professionals in the health sector is well known and previously stated. Therefore the need for new workforce development solutions and a capable workforce is crucial to health service delivery and service development. In the provision of responsive services for Māori, a platform for development using national and local initiatives has been built. For example Te Rau Puawai 22, Vision 20:20 23, and Te Rau Matatini 24, including Manu 17 Ministry of Health (2002). 18 New Zealand Government (2000). 19 New Zealand Government (2003). 20 Occupational Therapy Board New Zealand (2004). 21 Work First is an initiative that actively supports mental health service users to fulfil their employment or study goals. 22 A programme established by the Ministry of Health, that in partnership with Massey University, provides bursaries and learning support to Māori undertaking study with a focus on Māori mental health. For more information visit 23 Vision 20:20 provides bursaries and learning support through the Faculty of Medical and Health Sciences, University of Auckland, aiming by the year 2020, to have up to 20% of the health workforce Māori and Pacific Islanders. 24 The national Māori health workforce development organisation, for more information visit 12

15 Tipuranga 25. There have also been responses to Māori workforce development within other health sectors. Health workforce development strategies build towards responsive services where policy, training, professional development and regulation of professionals are all considered integral to influencing provision of services. Te Umanga Whakaora and the placement of Māori occupational therapists sit in this context. Background Occupational Therapy Occupational therapy is based on the premise that part of being human requires us to be engaged in meaningful activity. Notions of practice are centred on activity or doing, independence, and self-reliance 26. Occupational therapists have defined their profession as supporting engagement in life by: enabling people to perform the occupations that foster health and wellbeing; and of enabling a just and inclusive society so that all people may participate to their potential in the daily occupations of life 27. Occupational therapy is defined here in Aotearoa as a profession that enables occupation to optimize human activity and participation in all life domains across the life span, and thus promote the health and wellbeing of individuals, groups, and communities 28. Occupational therapists work with people of all ages and with all manner of health needs. Occupational therapists have the time to appreciate the extraordinariness of every day living we appreciate how very special it is to be able to live your own life when you can t make your own cup of tea, when you can t drive a car, when you can t go to school and play because of illness, injury or disability. That is when occupational therapy comes in and shines and lets you do the ordinary things that are in fact very extraordinary Hutt Valley DHB Accelerated Māori Health Bursaries. 26 Iwama (2007). 27 Townsend and Polatajko (2007). 28 Occupational Therapy Board New Zealand (2004 p.1). 29 Personal Communication, Whittington (2008). 13

16 Occupations can be defined as a series of activities and everyday jobs which may be identified, prearranged, valued and hold meaning to people 30. The World Federation of Occupational Therapy 31 extends the definition of occupational therapy to the supportive or restricted place or environment such as physical, social, attitudinal and legislative environments and the effect they can have on participation. Occupational therapy is considered to have scopes of practice to change aspects of the environment to support participation. Tangata whaiora want to know what occupational therapy services are because there are many fish swimming in the sea, knowing which profession is going to be most useful and what each offers to me is really important 32. Clients are actively involved in the therapeutic process, and the outcomes of occupational therapy are diverse, client-driven and measured in terms of the participation or satisfaction derived from participation 33. Occupational therapists work across sectors in health, education, and social development. The philosophical environment outlined by the profession and its governing bodies provides a strong platform for the development of Māori focused practice within the profession. Te Umanga Whakaora Māori notions of health and wellbeing are centred on collective relationships and interdependence, the concept of being rather than doing, where doing is significant because of the contribution it has to the collective 34. Self-reliance or the position of deciding pathways in recovery is often enhanced with whānau support 35. Being Māori first is fundamental to the health and wellbeing of Māori. Some Māori occupational therapists have blended western cultural practice with clinical practice to provide a form of occupational therapy that is uniquely Māori. I am Māori first, an occupational therapist second 36 recognising the perspective of te ao Māori. 30 Townsend, and Polatajko (2007). 31 World Federation of Occupational Therapy (2008). 32 Personal Communication, Marino (2008). 33 World Federation of Occupational Therapy (2008). 34 Iwama (2006b). 35 Durie (1998). 36 Personal Communication, Tahitahi (2008). 14

17 At an international level, occupational therapy has originated out of Western paradigms with Iwama 37 stating: In Western occupational therapy, we often proceed with our assumptions that the entire world values and celebrates doing for its self-actualising effect. We see little wrong with the dualism of doing and becoming. Many other cultural groups view our reality as a collective-orientated ethic with belonging and our connecting to nature and ancestors as the shared social ethos. The vision of occupational therapy with its promise of individual enablement and empowerment is often both confusing and excluding 38. Indigenous occupational therapists, when defining occupational therapy practice find challenging international and most national definitions of culture, is often not acknowledged as significant to practice or health 39 and therefore excludes a significant part of being for an indigenous person. There are many benefits the unique role of occupational therapy can offer to tangata whaiora. Occupational therapists through art and science support tangata whaiora to participate in meaningful 40 everyday living despite disability, injury or illness. Through consultation with Māori occupational therapists at the initial hui for this workforce development plan and subsequent reference group meetings, examples of cultural capability emerged and are highlighted below: Fishing with tangata whaiora enabled connections to the moana and the acknowledgement of a connection to the area. The activity supported the use of karakia to provide protection and guidance as well as demonstrated respect for the environment, thus drawing strength from it. This linking with the environment supported restoration of wellness and recognises the role of kaitiakitanga (preservation). Being at the beach with tangata whaiora facilitated pūrākau (stories) being told of tipuna related to the setting. When these stories are used in this way, they then can be considered for their application to the present, and as an example of how great difficulties in the past were overcome by tipuna. In addition, gathering of kaimoana included karakia to Tangaroa and remembrances of atua, key to taking care of ngā tāngata. 37 Iwama (2006a). 38 Iwama (2006a, p.2). 39 Iwama (2006a). 40 to tangata whaiora and determined by them. 15

18 The platform is set for Māori-centred occupational therapy practice through existing Māori activities or practices and environments such as marae and pōwhiri. Utilising the pōwhiri model of practise with tamariki and whānau ensured the creation of a safe place for kōrero and relationships to occur. In using this model the time is taken to negotiate with whānau and tamariki the relationship, and practises that will keep tamariki and all safe. The space used for this, was not often the space provided at clinical services, but often a place tamariki felt on safe ground for example, the playground. This model is not time bound to the clock but rather is determined by the time required to achieve the negotiations, until all feel safe in the relationship, when further interventions can then progress. Some Māori occupational therapists are endeavouring to provide culturally appropriate and clinically specific Māori interventions with tangata whaiora and whānau. As discussed by Iwama41 occupational therapy [OT] recovery processes for service users based on doing is not the context of many Māori service users I have been providing services for. For most of the service users issues of belonging: who they are from, who they live with, who they relate to and who they identify with are what is significant for them 'activities of daily living' only have meaning or purpose for Māori when set in their world view. So in my own practice whakapapa, identifying with whānau, karakia [and] tikanga need to come first. The meaning of the day, it s contents and the significance of each part of it only then can be examined... the acknowledgement of the often doing aspect of OT possibly being incongruent with indigenous paradigms [clearly] has some challenge for my current practice... Any tools currently used with Māori service users require clinical skill and cultural adaptation to make them useful to Māori 42. There is support from, DHBs, NGOs, mainstream and Māori services to increase the Māori occupational therapy workforce. In the first instance, we must recognise the serious need in the sector to have enough health professionals and secondly, to actively support equitable Iwama 2006 cited in Hopkirk (2006). Hopkirk (2006 p.5-6). 16

19 outcomes for tangata whaiora 43. If Māori are to live longer, have healthier lives, and fulfil their potential to participate in Aotearoa society, then the factors that cause inequalities in health need to be addressed 44. Challenges for the Profession Availability of Information There is not enough information on occupational therapy in Aotearoa to draw a complete picture of the current situation regarding the interaction between occupational therapy and tangata whaiora. Most of the published work that has informed Te Umanga Whakaora is from generic sources. Information and evidence from Aotearoa pertaining specifically to Māori occupational therapy health is over 5 years old (Jungersen, 2002). A literature review done by Hayes, Bull, Hargreaves and Shakespare 45 had difficulty finding published works on retention in occupational therapy, with most research relying on the United Kingdom (UK). Most causes of poor retention were attributed to the generic role many occupational therapists filled, differing definitions of occupational therapy, role blurring with other professions, stress, burnout, and insufficient appropriate professional supervision. Across the health and disability sector there continues to be significant under-representation of Māori practitioners 46. The proportion of Māori across the professional health and disability workforce is approximately 5.7% of the regulated workforce 47. In 2008, only 2% (44) of the 2159 registered occupational therapists were Māori 48. Indications show a large number of Māori occupational therapists are not staying in the profession 49. While collated and analysed empirical evidence is not available and is not evident in these numbers alone, strong anecdotal evidence has influenced Te Umanga Whakaora. Pathways for Māori to enter occupational therapy training and continue in the profession are not clear, nor are the access and retention rates of Māori in occupational therapy training available. 43 Ratima et. al. (2007). 44 Ministry of Health (2002, p.2). 45 Hayes, Bull, Hargreaves and Shakespare (2008). 46 Health Workforce Advisory Committee, (2002) and Ratima et. al. (2007). 47 Ratima et. al. (2007). 48 Personal Communication, Occupational Therapy Board of New Zealand (2008). 49 Ratima et. al. (2007). 17

20 Māori occupational therapists are often isolated within their practice environment. Evidence from Rauringa Raupā 50 shows isolation and the associated difficulty in developing cultural practices, are a barrier to retention as informed by occupational therapists and other health professionals. Establishing effective and accessible communication tools for Māori practitioners which reduce isolation and increase flows of information to and from them, will go some way towards addressing this issue. Māori Health Disparities The Ministry of Health release A portrait 4of health: key results of the 2006/2007 New Zealand Health Survey 51 continues to show large disparities in health for Māori when compared to the general population. Though access to health services has improved for Māori, the disparities have yet to significantly reduce. This indicates that services still need to consider particular strengths that will enhance provision of effective services 52. Māori currently make up 14.6% of the Aotearoa population but continue to have poorer health than non-māori 53. Māori are presenting to disability services at higher rates at 24% of disability compared to non-māori at 17% 54. The proportion or rate of disability found within the Māori population is of such significance that Māori are more likely to require assistance than non-māori 55. This indicates a very real need for the role of occupational therapy in the health and wellbeing of whānau Māori. The call for Māori to have better health is mirrored by the need to have Māori health practitioners supporting this health gain. A competent capable Māori health workforce is crucial to providing appropriate care to Māori and their whānau 56. Research confirms 57 tangata whaiora are happier with health services when there is an ethnicity match between tangata whaiora and workers. However the disparities between Māori and non-māori standards of health are reflected by the disparities between Māori and non-māori in the workforce Ratima et.al. (2007). 51 Ministry of Health (2008). 52 Ministry of Health (2008). 53 Statistics New Zealand (2007). 54 With adjustment for the different age structures of the population. 55 Ministry of Health (2004). 56 Ministry of Health (2007). 57 Huriwai, Sellman, Sullivan, and Potiki, (1998) and Jansen, Bacal, and Crengle (2009). 58 Durie, 1999 in Ponga, Maxwell-Crawford, Ihimaera and Emery (2004, p.5). 18

21 Māori Accessing Occupational Therapy Services Rates of access and the way Māori access occupational therapy services are not well documented. Ten years ago, a study by Hirini et. al. 59 indicated that kaumātua responded well to occupational therapy services. How that compares to Māori uptake of occupational therapy services today is not known. The research also revealed that kaumātua accessed other health professionals at the same rate or less than non-māori but for occupational therapy in particular Māori were more inclined (4.5%) to access occupational therapists than their counterparts MEDICAL SPECIALIST 20 DENTIST 10 OPTICIAN PHYSIOTHERAPIST 0 Māori Non-Māori OCCUPATIONAL THERAPIST Table 1 Māori and Non-Māori Visits to Other Health Professionals 60 The vast majority of Māori who use occupational therapy services are seeing non-māori clinicians and are less likely to have access to interventions and services delivered from a Māori world view 61. It is hard to assess how the occupational therapy profession has responded to The Primary Health Care Strategy and what outcomes have been achieved with regard to Māori health as a result. The Primary Health Care Strategy places a greater emphasis on the broader multidisciplinary primary health care team - GPs, nurses, pharmacists, allied health professionals (including physiotherapists, dieticians, psychologists, counsellors and 59 Hirini, Flett, Kazantzis, Long, Millar, and MacDonald (1999). 60 Hirini et. al. (1999, p.11). 61 Jeffery (2005). 62 Ministry of Health (2001). 19

22 occupational therapists) and disability professionals - so that people will have direct access to a range of primary health care providers 63. The demand for Māori responsive health services is not expected to reduce in the future, with a young Māori population. Current predictors indicate an increase in the need to access relevant health services in the future as the population ages 64 as indicated in He Korowai Oranga: The Māori Health Strategy: There is an added onus on providers of services to Māori, that not only shall clients be equipped to participate in mainstream Aotearoa society, but they should have the opportunity to participate in Māori society, to belong to Māori institutions, and importantly to remain Māori. The costs of disability are high; they should not include cultural alienation 65. Recruiting and Maintaining a Māori Occupational Therapy Workforce Recruitment, retention and transition from training to the workforce are big challenges in a health sector charged with increasing Māori health outcomes, and occupational therapy is no different in this regard. When this is done well, it can lead to well equipped Māori clinicians who are engaged in their work and enhance the opportunities to achieve whānau ora. Inflows of Māori to the health professions appear low and retaining Māori in the occupational therapy workforce as practitioners appears particularly difficult 66. These two factors combine to maintain a very low percentage of Māori occupational therapy practitioners. Furthermore of those known to Māori occupational therapists, three are currently working in a Māori environment and practise occupational therapy in a Māori context. Retention rates also add to concerns for workforce expansion with details in Table 2. In 2001, 84% of Māori occupational therapists were estimated to be in the workforce but by 2004, only 68% were retained; a drop of 16% raises retention concerns. 63 Ministry of Health (2001). 64 Statistics New Zealand (2007). 65 Ratima et. al cited in, Ministry of Health (2004, p.13). 66 Ratima et. al. (2007). 20

23 Year Number of Māori % Active workforce Retained from previous year Estimated retention % % 63% (12/19) 84% (16/19) % 54% (7/13) 71% (12/17) % 42% (11/26) 52% (14/27) % 65% (13/20) 68% (15/22) 2005 Not surveyed Table 2 Māori occupational therapists Indications revealed that there are a significant number of occupational therapists who are not seeking re-employment, with poor remuneration rates compared to other health professionals in the sector cited as a significant contributor to this fact 68. The workforce area most impacted by this is the DHBs as the biggest employers of occupational therapists. Whether some leave the profession because they are unable to work in a Māori way in their practise is not substantiated by research, but was found to be significant in a study of Māori staff by Paki-Slater 69. Māori staff in the study, have reported, that working in an environment that supports them to be Māori reduces stress and allows them to feel true to their cultural identity and safe. The challenge for health services is to create culturally sound environments where occupational therapists (and other Māori practitioners) are supported to provide Māoricentred services to Māori clients. Active strategies to encourage and assist Māori to enter the occupational therapy profession are not extensive. This suggests that the profession has not considered the opportunities available to it, by developing its Māori workforce, Māori services and access by Māori to those services. 67 Ratima et. al. (2007, p.3). 68 Department of Labour (2005). 69 Paki-Slater (2000). 21

24 Opportunities for Training in Competencies for Māori Occupational Therapy Although access to professional development opportunities can support retention within a profession, it appears that Māori occupational therapists are not accessing generic Māori practitioner training (currently that training is not specific to occupational therapy practise). We know that occupational therapist employers are most likely to support staff to train by paying their fees. The number of Māori occupational therapists taking advantage of these opportunities is not known. We do know that there is no Māori specific occupational therapy training at a postgraduate level in Aotearoa and we have only partial information on the content of undergraduate programmes, e.g. training in Treaty of Waitangi and Te Whare Tapa Whā 70. Māori Occupational Therapy Competency A Māori practice framework for occupational therapy does not exist at present. Such a practice framework would provide an anchor for the development of best practice models and strengthens core cultural competencies, while relating them to necessary clinical competencies. From here, career pathways and succession strategies can be developed to retain and grow the Māori occupational therapy workforce and the occupational therapy profession. Occupational therapists were asked by Iwama to consider the cultural constructs of the profession itself and in particular, the theories that drive the profession. A concern for this profession lies in the maintenance of ideas and concepts that are out of sync with our clients real worlds of meaning. A profession that places the blinkers on alternative views and constructions of meaning in daily life stands to trivialize itself into extinction, and thus fall far short of occupational therapy s magnificent promise 71. Iwama 72 goes on to say: 70 Durie (1998). 71 Iwama (2006b, p.xviii). 72 Iwama (2006a). 22

25 Occupational therapists in New Zealand must have wondered at times how to relate the conceptual meaning and explanations of human occupation based on Euro- Western psychological and social norms, into the day to day realities and experiences of their clients especially those of Māori heritage 73. Durie 74 identifies differing perspectives of health found within clinical environments supporting Iwama s indigenous writings: Indigenous knowledge cannot be verified by scientific criteria nor can science be adequately assessed according to the tenets of indigenous knowledge. Each is built on distinctive philosophies, methodologies, and criteria 75. It is widely accepted that tangata whaiora need to have access to Māori interventions if they wish and this includes from occupational therapists. In order for Māori to practise as Māori occupational therapists, models of practice and methodologies need to be developed. This will take resources, time and appropriate spaces to build effective practice and provide services that improve outcomes for Māori. A growing concern has been expressed through occupational therapists at hui, national conferences, associated meetings and through mentoring, about the low numbers of Māori currently practising and the short length of time they remain in the profession. Embedding dual cultural and clinical practices, as an integral part of occupational therapy service provision, will be hindered without the necessary workforce to deliver these culturally specific services. Dual practice, in this context, is the interweaving of traditional and contemporary Māori practises and knowledge with clinical interventions of occupational therapy as appropriate for tangata whaiora. As the number of Māori, who explore working in the Māori mental health DHB services, Māori NGO and Māori primary health services and iwi and hapū organisations grows, so the cultural capability of the profession will grow. Current Māori occupational therapy practitioners are developing cultural interventions that are profession specific. More Māori within the profession will accelerate this development, as can the availability of applicable models from other health disciplines. Support for such endeavours from within the occupational therapy profession will also enable advancement of this. 73 Iwama (2006a, p.1). 74 Durie (2004). 75 Durie (2004, p.1138). 23

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28 Building a Māori Occupational Therapy Workforce Framework Concepts, values and ways of thinking in te ao Māori are different to Western paradigms 76. This strategy and framework is situated in te ao Māori, a Māori world view. The framework of Te Umanga Whakaora is based on He Kupenga. As a fishing net consists of multiple threads interwoven to link together to make a tool to feed the people, so the weaving together of workforce development priorities, forms a plan that will sustain Māori occupational therapists in their workforce development. There are a number of components required in order to use the He Kupenga framework and Te Umanga Whakaora effectively. Whānau ora Occupational therapists are relevant and effective in supporting Māori with illness, injury or disability, to participate in their communities as they choose. Occupational therapists can support the aspirations of Māori development and advancement because they enable Māori participation in Māori communities. In the restoration of tangata whaiora to participate in ways that are significant to them and their whānau, whānau ora is achieved. Māori occupational therapists can use traditional and present day tools such as fishing, weaving, kapa haka and pūrākau in their work with tangata whaiora. These taonga are seen as tools that assist with the restoration of tangata whaiora in their role in the whānau. A way to share this knowledge is through Māori practitioners writing and presenting at workshops and conferences. Iwama encouraged Māori practitioners to share their experience of practice development, to support other indigenous practitioners internationally. Leadership Improved responsiveness requires health services to recognise the significance of culture to health 77 and to adopt methods that actively engage patients through appropriate language, respect for custom, the use of culturally validated assessment 76 Durie (2004) and Iwama (2007). 77 Cited by Durie from Castillo (1997). 26

29 protocols and outcome measures, and the employment of indigenous health workers 78. A shift in focus in the definition and practice of occupational therapy requires leadership to create in Māori health, the approaches that Durie describes above. Strategic decision making and planning are required to address disparities in Māori health and occupational therapy has a role to play in improving Māori health outcomes. The infrastructure is already in place to develop a Māori practice dimension to the occupational therapy profession, with a professional board and a practice support network. Most occupational therapists are employed through DHBs and are often reliant on the leadership within, for the day to day delivery options in their service. DHBs as the largest provider of occupational therapy services are in a position to provide leadership in partnership with Māori occupational therapists, the Occupational Therapy Board of New Zealand, the New Zealand Association of Occupational Therapists and other significant employers of occupational therapists such as, the Ministry of Education and ACC. Increasing the quality of information the occupational therapy profession has about the services it provides, and the characteristics of tangata whaiora, will identify the opportunities available to grow the service as a whole, through the development of Māori specific occupational therapy practises. Recruiting and retaining Māori staff will remain at the heart of the challenge to the health sector, such as DHB s and the occupational therapy profession over the short to medium term. These two aspects of an evolving health practice are aided by the quality of the service environment and its ability to flex around the needs of tangata whaiora and those charged with meeting those needs to achieve whānau ora. Māori Development and Advancement Since the early 1970s, there has been a concerted effort by Māori to develop their resources and determine their advancement. Since then, the resurgence of independent Māori economies has continued at pace, with the repatriation of land through the Treaty of Waitangi Settlement process. Workforce development, better health outcomes and whānau ora are integral to supporting iwi development. A healthy community, or a community where whānau ora exists, 78 Durie (2003, p.408). 27

30 is a community that is developing and advancing. Building the Māori health workforce amplifies those outcomes, and through such developments, we can expect to see improved health outcomes for Māori, leading to whānau ora. Māori often stay in their employment, when they can see a correlation between what they are doing and the advancement of their whānau, hapū and iwi 79. Research compiled on retention in a tertiary institution indicated where individuals reported on the reason for staying in their current position. All four factors most commonly identified were: the contribution to Māori by the ability to make a difference working with tangata whaiora contributing to hapū and iwi providing a role model 80. Whakatātaka Tuarua Māori Health Action Plan has identified as priorities for attention: Whānau ora based models developed that effect outcomes Ensuring Māori participation in workforce and governance. Pathway two of the plan identifies the participation of Māori at: all decision making and planning levels of the health and disability sector, in all development and delivery of health and disability services 82. Building Māori Responsiveness in Mainstream With few Māori practitioners in occupational therapy, building Māori responsiveness must occur within the profession as well as the DHB services that most occupational therapists work within. There are many advantages in this approach, not least of which it brings the whole service, Māori and non-māori along. 79 Paki-Slater (2000). 80 Paki-Slater (2000). 81 Ministry of Health (2006). 82 Ministry of Health (2006). 28

31 The Māori responsive environment, established through this approach and the flow on effects of being able to recruit and retain Māori practitioners, will be a key indicator of success for this approach. The ultimate indicator is that whānau ora is achieved when tangata whaiora access occupational therapy services. The relationship between occupational therapists and tangata whaiora is unique in a Māori setting, due to the whānau relationship whether through whakapapa, or other connections brought about by common values and sharing similar te ao Māori perspectives of the world 83. In a study by Van der Haas and Hoorwood 84 tangata whaiora reported that occupational therapy was seen to generally provide a distinct and valuable tool to assist in recovery. The importance of participation in the recovery process is supported by many 85 as stated: Giving a man a fish will feed him for a day, teaching a man to fish will feed him for life 86. This proverb teaches us how to apply the net in this context and in the context of increasing whānau participation. Relationships Sitting alongside the foundation of the framework are the significant relationships critical to sector development. They consist of tangata whaiora, partnerships and Māori occupational therapists. Partnerships are placed at the centre of the framework, to indicate that there are many levels of partnership required to make this plan work; the relationship between occupational therapists and tangata whaiora and most importantly for this plan, the relationship between Māori occupational therapists, the rest of the profession and the sectors employing occupational therapists, such as DHBs. When all these foundations stand alongside each other, the rest of the framework will work towards whānau ora. Research, Evaluation, Review and Measurement Information and the quality of information is the environment within which He Kupenga is cast. This plan compels us to seek and increase the body of knowledge about the delivery of occupational therapy services to Māori, and their efficacy. Understanding what other health 83 Durie (2001b). 84 Van der Haas and Hoorwood (2006). 85 Aubin, Hachey and Mercier, Eklund, Erlandsson and Persson, Mee and Sumsion, cited in Van der Haas and Horwood (2006). 86 Tripp (1976) in Van der Haas and Horwood (2006, p.14). 29