COLLEGE MEMBERS POSITIONED AS TE RITO

Historically, midwifery has based its understanding of cultural safety on the foundational work of Irihapeti Ramsden, as a process which relates to individual practice and the way in which midwifery care is provided.

The Midwifery Council’s statement on Cultural Competence sets out that: “Cultural safety is the effective midwifery care of women by midwives who have undertaken a process of self-reflection on their own cultural identity and recognise the impact of their own culture on their practice”. It further states “A midwife who is culturally safe recognises that power imbalances are often invisible within professional relationships and healthcare services and works to address inequality and inequities and to transfer power to women as the users of midwifery services. However, it is the woman and her family/whānau who determines whether her relationship with her midwife and the midwifery care she receives is safe for her.”

The concept of cultural safety has since been expanded to consider what influence and accountability organisations have in bringing this concept to life. One of the desired outcomes of cultural safety is achieving health equity, which is a system-level responsibility. A critically conscious, empathetic and culturally safe health professional workforce is key to ensuring services are accessible and acceptable. However, this is only one of the necessary factors in reducing inequities; another is the health system environment in which practitioners work. Through the development of both a culturally safe health workforce and health care system, we move a step closer to eliminating inequities. A third major factor is one we have less direct influence over – the wider social policy settings which contribute to the social determinants of health – income, housing and education (among others).

With this in mind, at its November 2021 meeting, the College’s national board agreed to adopt the broad definition of cultural safety suggested by Curtis et al. – one which pertains not only to the practice of individual midwives but also to the College as an organisation.

The College has a role in leadership to champion the provision of high-quality health care that strives for equity of health outcomes, and to support midwives to provide care that meets the health care needs and aspirations of Māori. Although the College does not provide health care services directly, its role is central to the practice of midwives, just as the needs of women and their whānau are central to the midwife’s role.

from the chief executive, alison eddy

“Cultural safety requires healthcare professionals and their associated healthcare organisations to examine themselves and the potential impact of their own culture on clinical interactions and healthcare service delivery. This requires individual healthcare professionals and healthcare organisations to acknowledge and address their own biases, attitudes, assumptions, stereotypes, prejudices, structures and characteristics that may affect the quality of care provided. In doing so, cultural safety encompasses a critical consciousness where healthcare professionals and healthcare organisations engage in ongoing self-reflection and self-awareness and hold themselves accountable for providing culturally safe care, as defined by the patient and their communities, and as measured through progress towards achieving health equity. Cultural safety requires healthcare professionals and their associated healthcare organisations to influence healthcare to reduce bias and achieve equity within the workforce and working environment”. (Curtis et al. 2019)

It is against this background that the College took the decision to undertake a cultural review in 2022. The College acknowledges and thanks the many members who engaged with the external reviewers, Moe Milne, Linda Thompson and Koha Aperahama, in person through face-to-face interviews and focus groups, as well as those who completed the members’ survey. The reviewers completed their report in March 2023. The cultural review’s objectives, main findings and recommendations are summarised below. The six objectives of the review were:

• To identify improvements to the College structures and services which will help to build the development of a Māori cultural framework within the organisation and the establishment and appointment of a Māori midwifery advisor position

• Application of Te Tiriti o Waitangi and commitment to equitable outcomes for Māori through examining the College’s structures nationally and regionally to identify how they can be strengthened to drive equity

• To bring to life the expressions and application of Te Tiriti o Waitangi, as defined in Whakamaua, (Māori Health Action Plan) in College activity

- Mana tangata: Achieving equity in health and disability outcomes for Māori, enhancing the mana of people across their life course and contributing to the overall health and wellbeing of Māori

- Equity: Being committed to achieving equitable health outcomes for Māori

• To enable the College to be a culturally safe organisation that positively and effectively meets the professional support needs of Māori and non-Māori members

• To develop a Māori cultural framework that incorporates the following:

- Kawa Whakaruruhau - the continued development and promotion of cultural frameworks and infrastructures that ensure culturally safe practice

- Ngā Tāngata - upholding the integrity of Māori midwives and embracing the professional and cultural diversity that they bring to midwifery

- Mātauranga - Respecting the knowledge that has been given, celebrating successful Māori models of practice and integrating Kaupapa Māori into all aspects of midwifery

• To produce a high-quality report within the timeframes agreed that includes findings and recommendations for improvements

Review Outcomes

The reviewers utilised Te Pā Harakeke (the flax bush) as a framework to present their findings. Māori have long utilised Te Pā Harakeke as a metaphor for whānau wellbeing and structure, it is made up of many parts.

• Te Rito - the new shoot or centre represents the baby or future potential within the plant.

• Awhi rito - outer leaves represent the mātua and tūpuna that provide the protection and support to ensure the rito is nurtured to grow strong and realise the potential held within.

The reviewers positioned the members of the College as te rito, or the centre of the plant, with the College entity represented by the awhi rito (mātua) or outer leaves, providing the support and structure that nurtures the developing rito (members). The College in turn is supported by tūpuna leaves, which represent ancestral knowledge, Te Tiriti o Waitangi and the importance of equity. These tūpuna leaves provide the foundational support and hold the practical, tangible actions to uphold the articles of Te Tiriti o Waitangi, which supports equity for Māori in the first instance and equity for all. Whakataukī were also used by the reviewers to illustrate and bring to life the concepts underpinning their findings and recommendations.

Me ngaki te whenua kia tupu ora ai ngā hua. Till the soil so the harvest is plentiful. Through careful preparation and planning, great outcomes can be achieved.

Finding 1: There was a call for change and restructuring of the organisation.

Recommendation 1: That the College takes deliberate steps, in a phased approach, to implement changes to its structures and services to include dedicated Māori positions.

Tungia te ururua kia tupu whakaritorito te tupu o te harakeke. Clearing away the undergrowth to allow new growth to emerge and flourish. Addressing the gaps and identifying the areas for potential development ensures quality improvement.

Finding 2: The importance of Te Tiriti o Waitangi to the membership.

Recommendation 2: That the College applies Te Tiriti o Waitangi in commitment to achieving equitable outcomes for Māori and formalising a Te Tiriti partnership relationship with Ngā Maia.

I hāere mai koe I te āhuru mōwai ki tea o mārama tau ana. Transferring the safety of te whare tapu o te tangata – the womb – a to the world of light. From one safe space to another.

Findings 3 & 4: Creating environments that are culturally safe and affirming, an environment that nurtures its membership, recognising the importance of addressing racism across the organisation.

Recommendations 3 & 4: That the College initiates a pathways programme and programme of training and education to address institutional and interpersonal racism in the organisation.

Hūtia te rito o te harakeke, kei hea te kōmako e kō? Uia mai ki a au, he aha te mea nui o te ao? Māku e kii atu, He tangata he tangata he tangata. If you cut out the centre of the flax bush, where will the Bellbird sing? Ask of me What is the most important thing in the world, I will reply it is people, it is people, it is people.

Finding 5: The importance to members of Te Tiriti and equity across the organisation.

Recommendation 5: That the College initiates a separate internal review of the cultural responsiveness of its Midwifery Standards Review process.

Te rito o te harakeke. The membership is the critical centre that ensures the success of the College and contributes greatly to the wider health and wellbeing of whānau.

The College has a key role in shaping and influencing midwifery practice and the profession as a whole.

Finding 6: The request is that the College applies a cultural framework to do this.

Recommendation 6: That the College adopt Turanga Kaupapa as the cultural framework for the organisation.

The full report has been presented to the College board and Ngā Maia board who are considering the recommendations and their response to them. The College’s board has been considering Te Tiriti and its role in supporting cultural safety in practice, its governance model and organisational capacity over recent times as the strategic plan was revised, so the cultural review recommendations presented no major surprises.

Some key decisions have already been made, which include changing the constitution to enable the election of tangata whenua and tangata tiriti co-presidents this year, as well as establishing two Māori midwifery advisor positions. The College is working to establish online Te Tiriti workshops (which we have been providing in person since 2018) to increase access and availability. Alongside this we are working to establish additional cultural education opportunities and embed elements of cultural safety throughout all of the College’s educational offerings. The board made a decision some time ago that it would develop a College cultural safety statement; however, it has been agreed that we await the outcome of the Midwifery Council’s Aotearoa Midwife Project and finalisation of the revised scope of practice before progressing the development of this statement. The way ahead for the College and its membership is exciting, as we work towards strengthening our organisation’s cultural responsiveness with a view to better-supporting midwifery practice and ensuring we meet the needs of wāhine, pēpi and their whānau. square

References available on request.

Te Rito College Members