Ngā Manukura O Āpōpō: Sustaining kaupapa Māori nurse and midwifery leadership

Kataraina Pipi Michelle Moss Louise Were About the authors: Kataraina Pipi (Ngāti Porou, Ngāti Hine), PGDip Social Sector Evaluation Research, Master in Applied Indigenous Knowledge, is an independent evaluator for FEM 2006 Ltd. Michelle Moss (Pākehā, Swedish immigrant), BA social anthropology, is an independent evaluator for MiMo Consulting. (Agreed correspondent.) Her correspondence address is [email protected] Louise Were (Ngāti Tūwharetoa, Ngāti Rongowhakaata), PGDip Social Sector Evaluation Research, BA Māori, is an independent evaluator for Hikitia Consulting. This article was accepted for publication in August 2021.	ABSTRACT Aim: The aim of this study was to explore the outcomes of Ngā Manukura o Āpōpō’s national Māori nursing and midwifery clinical leadership training programmes and to consider how the kaupapa Māori approach (Māori ways of doing things) has contributed to these outcomes. Background: In Aotearoa New Zealand, Māori – the indigenous peoples – experience the worst health inequality of any population group. Māori workforce development has long been recognised as key to improving Māori health and wellbeing. Ngā Manukura o Āpōpō is a significant programme designed to enhance the capacity of Māori leaders in the health and disability system. It covers clinical leadership, recruitment and profile raising, professional development and governance. Ngā Manukura o Āpōpō provides a marae-based kaupapa Māori leadership development programme for Māori nurses and midwives in Aotearoa. Methods: A content analysis and synthesis of findings from Ngā Manukura o Āpōpō evaluation reports to date was undertaken, using inductive strategies to categorise the data. Results/findings: Whakamana (a sense of empowerment) and ngā manukura (starting or progressing leadership journeys) were key themes identified through the synthesis. These centred on outcomes from the programme relating to personal and professional development, and cultural identity, as well as taking up leadership opportunities and contributing to change. The training also helped retain participants in the health workforce. The kaupapa Māori approach was a key contributor to these outcomes. Challenges that participants faced in their roles – including racism and bridging the Māori and western health paradigms – and their ability to contribute to better health outcomes for Māori, are consistent with experiences of other Māori nurses and midwives, and of indigenous nurses and midwives in other parts of the world. Conclusions: There is a significant need for Māori clinical leaders in the health and disability sector to help address current and future workforce and population health needs. Ngā Manukura o Āpōpō clinical leadership training can help meet this requirement.
KEYWORDS Māori, indigenous, leadership, workforce, inequity, policy

INTRODUCTION

IN AOTEAROA NEW ZEALAND, the legacy of colonisation contributes to poorer health statistics, poorer general wellbeing and to injustice for Māori, its indigenous peoples (Anaya, 2011). Māori health workforce development has long been signalled as a critical enabler of good health outcomes (CBG Health Research Ltd, 2009; Douglas, 1996; Ratima et al., 2008). Recent reviews of Aotearoa New Zealand’s health and disability system recognise Māori leadership in particular as key (HDSR, 2020; Waitangi Tribunal, 2019). Ngā Manukura o Āpōpō is Aotearoa New Zealand’s national Māori nursing and midwifery workforce development programme. It provides a unique and dedicated pathway for Māori leadership for Māori nurses and midwives.

This synthesis aimed to explore the outcomes of Ngā Manukura o Āpōpō’s clinical leadership training programmes and to consider how the kaupapa Māori approach (Māori ways of doing things) contributed to these outcomes.

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BACKGROUND

Māori comprise nearly 17 percent of the Aotearoa New Zealand population (Statistics NZ, 2020). Te Tiriti o Waitangi (the Māori text) of the Treaty of Waitangi (Te Tiriti) – an agreement between representatives of the British Crown and Māori, signed in 1840 – proposed to protect Māori rights to self-determination and obliged the Crown to ensure that public policy was as effective for Māori as it was for everybody else. However, Māori health status is significantly worse than non-Māori and inequities persist for the majority of health measures (MOH, 2015; MOH, 2019; Waitangi Tribunal, 2019). There is a strong link between health inequity for Māori and the unequal distribution of social determinants of health, inadequate access to services, poorer quality of care and worse health outcomes (MOH, 2015; MOH & University of Otago, 2006).

Māori workforce development and Māori leadership, as means to address these inequities, have been elevated as priorities in health policy and strategy documents since the 1990s (CBG Health Research Ltd, 2009; Douglas, 1996), including The New Zealand Public Health and Disability Act 2000, He Korowai Oranga: The Māori Health Strategy (MOH, 2002), Raranga Tupuake: the Māori Health Workforce Development Plan (MOH, 2006) and the Rauringa Raupa report (Ratima et al., 2008). Despite these strategic directions, Aotearoa New Zealand’s health system has not fulfilled its Te Tiriti obligations to provide equitably for Māori.

This failure has recently been affirmed through the Wai 2575 Health Services and Outcomes Kaupapa Inquiry (Wai 2575) (Waitangi Tribunal, 2019) and the Health and Disability Services Review (HDSR, 2019, 2020). They both identified systemic issues such as inequitable funding, under-representation and lack of decision-making functions by Māori at all levels of the system, and inadequate resources for Māori to design services and provide for their own wellbeing. Structural, policy and procedural reforms of the system were called for, including fully incorporating and ensuring the system recognises and supports te ao Māori (Māori world views), Māori authority, mātauranga Māori (Māori knowledge) and expression of Māori cultural identity (HDSR, 2019, 2020; Waitangi Tribunal, 2019). These intentions are being embodied in the establishment of a Māori Health Authority.1 Whakamaua: Māori Health Action Plan 2020-2025, the most recent roadmap for achieving He Korowai Oranga, also reflects these intentions (MOH, 2020).

Consistent with the findings of the HDSR and Waitangi Tribunal reports, is that Māori are under-represented in the nursing and midwifery sectors (Midwifery Council of New Zealand, 2020; Nursing Council of New Zealand, 2019). Both sectors grapple with systemic issues. There is a lack of Māori-specific workforce, health or leadership strategies; and Māori representation in decision-making, strategic leadership and care model design is either scant or lacking. Generally, in the nursing and midwifery workforce, there are few opportunities to develop governance roles and skills, and leadership programmes are ad hoc, limited in numbers and often have unfair and inequitable access. DHBs tend to favour professional development with significant clinical components, which limits nurses’ access to courses with other foci (NZCM, n.d; NZNO, 2018). Limited investment in professional development for nurses, and Māori nurses in particular, is reflected in national workforce development data (Brinkman, 2010; NZNO, 2018).

Ngā Manukura o Āpōpō – Tomorrow’s Clinical Leaders (Ngā Manukura o Āpōpō) was established in 2009 in recognition of the issues of Māori participation and retention in the health and disability workforce.2 As Aotearoa New Zealand’s national Māori nursing and midwifery clinical leaders network and workforce development programme, it aims to better position Māori nurses and midwives to improve the quality of health-service delivery. It does so by developing their capacity and capability, in culturally relevant ways, to deliver and re-design health services at all levels of the health and disability system.3 The programme affirms a need for bicultural praxis in the context of health but also in how leadership is defined, recognising that practising leadership and nursing and midwifery as Māori, are mutually reinforcing and transcend health contexts.

As highlighted by Mead (2006), the traditional Māori system of leadership is based on cultural criteria (eg kinship ties, appropriate whakapapa [genealogy], and spiritual assets such as tapu [sacredness] and mana [agency]) and expectations of and values held about leadership are very broad. Traditional information about expected pūmanawa (talents) of a Māori chief/leader specifies knowing the traditions and culture of one’s own people and wider community as a prerequisite for such a role. Reflecting this, Ngā Manukura o Āpōpō clinical leadership training programmes are kaupapa Māori. That is, Māori cultural processes, knowledge and theory are integral to their design, content and delivery. A kaupapa Māori approach is inherently multi-dimensional and collective, as reflected in the whakataukī (Māori proverb): “Ehara tāku toa i te toa takitahi, engari he toa takimano” (“My strength is not that of an individual but that of the collective”). Ngā Manukura o Āpōpō provides spaces for emerging and experienced leaders to travel together on their leadership journeys.

A key feature of Ngā Manukura o Āpōpō is clinical leadership training. The Foundation Leadership Training4 is well established in the sector and has been in place since 2010. It consists of four two-day noho marae (live-in) wānanga5 held over a four-month period, is situated within te ao Māori and underpinned by Māori pedagogy. The training is designed to integrate Māori and mainstream leadership theory and practice to enable participants to develop leadership knowledge and skills in the context of Māori health and disability services. It provides participants with practical tools and critical networks to undertake clinical leadership roles in their own workplaces. Ngā Manukura o Āpōpō is currently exploring follow-on options from the Foundation Leadership Training to create a more comprehensive leadership pathway. KuraWaka was the first such option to be trialled.6 It was delivered over a 10-month period through three two-day noho marae, one regional wānanga, two one-on-one coaching sessions9 and six online sessions by subject experts. KuraWaka aimed to guide Māori leadership to new levels of excellence, through a kaupapa Māori approach that had an explicit focus on learning journeys. The training immersed participants in te ao Māori, and sought to enable participants to customise their leadership experience and self-direct their learning and its impact. It also ran a concurrent, uniquely Māori hauora (health) component to foster the oranga (wellbeing) of participants.

Between 2010 and 2021, 306 Māori nurses and 42 midwives graduated from the Foundation Leadership Training, across 40 cohorts. Of those graduates, 2510 completed KuraWaka. Participants of both programmes came from a range of settings such as district health boards, non-governmental organisations, Māori providers, mainstream providers, rural and urban, and also worked across a range of expertise levels – from entry to executive.

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METHODS

The aim of this synthesis was to analyse the findings of four evaluation reports to understand more about how Ngā Manukura o Āpōpō’s clinical leadership training contributes to leadership development of Māori nurses and midwives. The synthesis was undertaken using a qualitative descriptive design in the form of content analysis. Content analysis is an approach used to analyse text to identify patterns, trends and relationships (Pope et al., 2006; Vaismoradi & Snelgrove, 2019). A descriptive method was employed for the coding and interpretation of data. This interpretation was informed by a realist perspective, assuming data is an accurate representation of reality (Sandelowski, 2010). Content analysis is an approach that can be applied to analyse qualitative text as well as quantify numerical data (Gbrich, 2007). The aim of the data analysis was to describe phenomena in the textual and numerical data which were relevant to the research question, and group them into categories. (Vaismoradi et al., 2019). The research question was: “What are the outcomes of Ngā Manukura o Āpōpō’s clinical leadership training programmes, and how has the kaupapa Māori approach contributed to these outcomes?”

Data analysis

Data analysis involved using inductive strategies to develop coded categories from textual and numerical data selected from the four evaluation reports commissioned by Ngā Manukura o Āpōpō on the implementation and delivery of the Foundation Leadership Training and KuraWaka. The process for data analysis entailed creating codes from patterns in data, grouping data into categories or topic groups, and conceptualising the categories into descriptive categories.

The characteristics of the four evaluation reports included in the synthesis are set out in Table 1.

Table 1. Evaluation reports

Evaluation report	Method	Key findings	Limitations
King J, Pipi K, Moss M (2014). Ngā Manukura o Āpōpō Evaluation of Tomorrow’s Clinical Leaders training programme – final report. Julian King & Associates, a member of the Kinnect Group.	Leadership Foundation Training   Interviews with participants/graduates, employers, presenters, facilitators, advisory group members and other sector stakeholders.   Group interviews with graduates from cohorts 1-8.   Online survey for graduates of cohorts 1-8 (n=35, 22% response rate).   Review of the programme reporting and feedback forms.   Six success cases.   Causality was assessed qualitatively using Bradford Hill Criteria.7	The training contributed to:   Strengthened cultural identity and participants feeling comfortable viewing themselves as Māori clinical leaders.   New skills, knowledge and tools, which were being applied in participants’ personal and professional lives.   Progression into leadership roles and/or leadership activities.   Participants contributing to wider sector/social/whānau/hapū/iwi outcomes.   Evidence and acknowledgement of learnings being integrated into nationally and internationally disseminated work.	Relied principally on qualitative information and soft data (graduate survey and feedback forms).   Did not include longitudinal data on graduate outcomes, or a comparison group.
Wilson, D. (2017). Ngā Manukura o ĀpōpōProgramme Evaluation Report: 2015-2016.AUT: Taupua Waiora Centre for Māori Health Research.	Leadership Foundation Training   Group interviews with graduates from cohorts 10-13.   Review of 6-monthly provider reports.   Survey for graduates from cohorts 1-13 (n=53, 22% response rate).	The training contributed to:   Strengthened cultural identity and pride.   Participants extending themselves and their practice.   Participants feeling ready and well-positioned to undertake leadership opportunities professionally and beyond.   Reignited participants’ passion for nursing/midwifery.	None stated.
Pipi K, Were L, Moss, M. (2019). Ngā Manukura o Āpōpō Programme Evaluation 2019. Evaluation report FEM 2006.	Leadership Foundation Training   Online survey distributed to graduates (cohorts 1-17; n=49).   Group interviews with graduates (cohorts 15-17).   Online survey distributed to employers/colleagues/whānau of graduates (n=4).   Review of reporting and feedback forms.   The evaluation was underpinned by kaupapa Māori approaches, including pūrākaū8 and evaluation-specific methodology.	The training contributed to:   Strengthened leadership skills, including technical expertise and practical skills.   Increased confidence, competence and personal development.   Growing networks.   Development of Māori leaders.   More involvement in leadership activities professionally, personally and in the wider community.	Relied principally on qualitative information and soft data. Did not include a comparison group. Low survey response rate (16%; likely due to survey fatigue).
Pipi K, Were L, Moss, M. (2020). Ngā Manukura o Āpōpō Programme Evaluation 2020. Final Evaluation Report, FEM 2006.	Observation and engagement during four KuraWaka wānanga.   Interview with KuraWaka participants (n=22) and other stakeholders (n=11).   Online survey for KuraWaka participants (n=21).   Review of KuraWaka reporting. Follow-up online survey for Leadership Foundation Training graduates to explore leadership in action over time (n=15).   Online survey distributed to employers/colleagues/whānau of Leadership Foundation Training graduates (n=8).   The evaluation was underpinned by kaupapa Māori approaches, including pūrākaū methodology and evaluation-specific methodology.	The training contributed to:   Readiness for leadership.   Internal changes such as increased confidence, cultural identity and pride, feeling inspired, re-energised. Filling up kete (basket) with indigenous knowledge and skills.   Understanding importance of self-care.   Applying knowledge and tools.   Seeking out clinical leadership opportunities.   Increased leadership involvement in diverse contexts.	Relied principally on qualitative information and soft data. Did not include a comparison group.   Timing of KuraWaka evaluation coincided with design, delivery and completion of the programme, limiting exploration of post-programme outcomes.   No employer feedback on KuraWaka participant outcomes.

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FINDINGS

Two key themes emerged from analysing the outcomes of Ngā Manukura o Āpōpō leadership programmes: “whakamana” – a sense of empowerment, and “ngā manukura” – the process of starting or progressing leadership journeys. The following section presents the findings of the synthesis.

Whakamana: sense of empowerment

The theme “whakamana” indicated that the Ngā Manukura o Āpōpō clinical leadership training contributed to participants’ personal and professional development and cultural identity. Markers of personal development included participants feeling more confident (less shy, standing up for beliefs, speaking out more), more assertive and better prepared to respond to and manage challenging situations. Participants felt inspired and re-energised by peers and guest speakers, and felt better positioned to consider other roles (“listening to them makes me think, if they can – so can I”).

Further, the training motivated participants to remain in their profession. Some participants had considered leaving the health and disability workforce altogether prior to the training. They struggled with both implicit and explicit racism in their workplaces, including dual expectations because they are Māori (eg to lead cultural activities) while receiving no recognition for doing so. They also felt a constant need to justify Māori ways of doing things. Systemic racism also affected participants’ ability to access Ngā Manukura o Āpōpō programmes (being denied study leave to attend, employers not seeing the programmes as a critical part of professional development and non-Māori colleagues questioning the value of the programme and its costs). Ngā Manukura o Āpōpō often contributed pūtea (money) where cost was a barrier to participation in the programme.

The delivery of Ngā Manukura o Āpōpō training helped participants broaden and strengthen their networks. Each Foundation Leadership Training cohort has a network attached to it. These networks provided support, both during and beyond the training, and were particularly valuable when participants experienced racism at work, or faced other challenges that other Māori nurses and midwives could identify with. The advice, encouragement and support from these networks helped sustain participants in their roles, but also helped them progress their leadership journeys.

Markers of professional development included having learnt technical and practical skills and knowledge relating to public speaking, conflict management, change management, writing and submitting proposals, ethics, how to write and deliver project plans and higher strategic thinking. For KuraWaka participants, skills and knowledge gained centred more on te ao Māori, mātauranga Māori (maramataka [lunar calendar], mauri ora [wellbeing] goals, tikanga [customs/protocols] and whakapapa [genealogy]), tools for self-care and how to use coaching to support and sustain leadership. The new knowledge, skills and connections helped boost participants’ confidence to take on leadership activities or roles.

Strengthened cultural identity was another element of the whakamana theme, with participants noting a stronger sense of cultural connectedness and pride. They gained a deeper understanding of who they were and where they were from and felt encouraged to further develop their cultural identity to enhance their confidence and effectiveness as Māori clinical leaders. One participant pointed out that KuraWaka had taught her that, “knowing who you are is what strengthens and creates your ability to be a good leader”. The ways in which cultural identity was influenced varied. Some participants had little or no involvement with their “Māori side” before the training (for whom it was inspiring and supportive of exploration) and others had it integrated to different levels in their personal and professional lives (for whom it offered validation, affirmation, and/or ideas for how to take this further).

KuraWaka provided an opportunity to further intensify immersion in te ao Māori, compared to the Foundation Leadership Training, and participants appreciated this stepped increase in the level of immersion. As a result, they felt further connected to whakapapa and tīpuna (ancestors), to te ao Māori and to the shared kaupapa (agenda) – to facilitate change to improve outcomes for whānau. Participants attributed the use of more te reo Māori (the Māori language), karakia (Māori prayer/chant) and their mihi (Māori ceremonial greeting) in a work environment than before the training. Some had also started te reo Māori classes during the training or post-graduation. The ability to sustain and continue to strengthen cultural identity was supported by the graduate networks. Feeling validated as Māori, having time to reflect, take stock and look to the future as well as having leadership capacity identified and/or re-discovered, helped participants to progress on their leadership journeys. This included having started or returned to post-graduate study. Overall, it was common for participants to describe their participation in the programmes as “life-changing”.

Ngā manukura: taking up leadership roles and achieving change

The “ngā manukura” theme centred on the application of new skills, knowledge and confidence gained from participation in Ngā Manukura o Āpōpō leadership training. Participants had completed professional portfolios, written, or contributed to publications, presented at national and international conferences, secured funding for project work, written practice guidelines, and promoted and applied indigenous concepts and tools (eg maramataka for planning, managing meetings and structuring reports). One director of nursing had applied a deepened understanding of te ao Māori, in terms of kotahitanga (collective unity/solidarity), integration, collaboration and reciprocity, when designing a new workforce strategy and attributed this to her participation in KuraWaka.

Participants also reported having progressed into leadership roles and/or taken on key leadership activities. This included securing more senior positions (nurse leader, Māori health manager, charge nurse manager, educator, director of nursing, clinical nurse manager); putting their names forward for national forums (Nursing Council of New Zealand); joining or being a key driver in setting up local boards and governance groups; taking on tuakana teina (a model for buddy systems) roles such as providing mentoring, supervision, support, and education; and getting involved in policy development.

Participation in the training also contributed to increased involvement in leadership activities outside work, including within whānau (extended family), hāpori (community), hapū (subtribe) and iwi (tribe). Graduates did so as chairpersons, trustees, committee members, project coordinators, event organisers, holders of Māori-specific leadership roles and through leading/supporting whānau in health-related kaupapa (matters).

Participants also undertook project work as part of the Foundation Leadership Training, including research/reviews/audits, education/awareness-raising activities and development of tools, education pathways, forums and support groups. Positive sector/social/whānau/hapū/iwi outcomes were demonstrably emerging as a result of these changes. These included free dental health care for 18 to 21-year-old rheumatic fever patients in the Far North, increased understanding and application of tikanga Māori and cultural safety in nursing practice, increased health literacy among whānau, and increased numbers of Māori women undertaking cervical screening.

There were factors that affected the extent to which participants were able to progress their leadership journeys. They were all at different stages in these journeys, had different levels of support (professionally and personally), worked in different types of environments (mainstream/kaupapa Māori; rural/urban), had various levels of cultural identity, as well as different notions of what leadership looked like. They also faced constraints such as institutional racism and implicit bias, lack of opportunities locally, lack of support from managers/colleagues, family/whānau life and health issues. Change was not always immediate, but continued to occur over time. Further, participants were all at different stages on the leadership continuum and differed in how far along the continuum they wanted to go.

Contribution of the kaupapa Māori approach

The kaupapa Māori approach was consistently identified in the evaluations as a key supportive factor of personal and professional development, strengthening cultural identity and progressing leadership journeys. Grounding content and delivery firmly in te ao Māori supported deep, rich cultural affirmation and learning, ensured safety for participants to be and express who they are – and helped them find their place in the leadership spectrum as Māori. It also ensured the training was culturally meaningful for participants and facilitated connections and networks that provided strong cultural foundations for leadership. Being connected to their Māori peers was considered invaluable in the wider context of working in a western-dominated health and disability system. Opportunities for whanaungatanga (establishing and sustaining relationships)contributed to a sense of belonging, and the ability to develop, maintain and use networks and connections.

The holistic aspect of the kaupapa Māori approach benefited participants spiritually, mentally and physically, and helped them feel stronger and more resilient as leaders. It also facilitated a collective approach that benefited participants and their whānau and wider communities. This was considered to have potential to support a ripple effect of change (eg intergenerational) with more sustainable solutions (rather than as a leader affecting change through a one-off event). Part of what enabled participants to grow in their leadership was that they were part of a collective, a growing network of Ngā Manukura o Āpōpō participants and graduates. This network could provide support, advice and encouragement, particularly when participants were facing challenges such as racism in their workplaces or feeling isolated as Māori in a mainstream setting.

“The connections and whakapapa that you make here, and you can only make here, enable us to stay connected, enable us to network. It’s probably the best asset ever as a Māori and as a Māori nurse. It’s the most important tool I’ve acquired on my nursing journey so far in terms of Māori and Māori leadership.”
– KuraWaka graduate

The marae setting and noho-marae delivery model are Māori preferences for teaching and learning, and they contributed to a sense of familiarity and safety that allowed participants to absorb new knowledge. The cultural significance of the setting contributed to experiences that reinforced the richness of Māori culture and identity. Delivery by Māori for Māori also contributed to a sense of safety and a deepened understanding of leadership as Māori. This included a better understanding of the expectations that accompany being a Māori nurse or midwife leader (to benefit Māori and whānau users of the health system), and how to effectively walk in and/or between the “two worlds” (Māori and Pākeha) that they operate in. These two worlds were challenging for participants to navigate as they represented two different worldviews and, as such, different views on models of care. The Māori concept of manaakitanga (the process of showing respect, generosity and care for others) was evident in feedback, and involved ongoing contact, mentoring and support by the trainers and Ngā Manukura o Āpōpō – often over and beyond what they were contracted to do. This helped sustain the momentum of participants’ leadership journeys, during and beyond the training. Participants noted that Ngā Manukura o Āpōpō’s clinical leadership training programmes were the most professional, relevant, useful and worthwhile Māori (and other) professional development programmes they had encountered.

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DISCUSSION

The themes identified in this synthesis are congruent with other research that indigenous approaches are necessary for the development of indigenous leadership (Spiller et al., 2015; Turner & Simpson, 2008; Young, 2006). They are also consistent with research that affirms the importance of cultural identity for a strong and effective indigenous health workforce (MOH, 2006; MOH 2020; Waitangi Tribunal, 2019). An increased presence of Māori in health roles may better meet health needs for Māori patients due to improved communication and trust between people of the same culture interacting. Strong and capable Māori leadership within the health workforce is necessary to inspire such change, and subsequently to lead institutions to more equitable and culturally effective health care (Burrel et al., 2005). Kaupapa Māori health and leadership programmes, and national health policy expectations, affirm that dedicated kaupapa Māori leadership development for Māori nurses and midwives is a valuable pro-equity response (HDSR 2020; NZNO, 2018; Ratima et al., 2008). However, there are still many challenges for Māori nurses and midwives that inhibit their ability to contribute to a more equitable system.

Dealing with racism

Institutional racism11 has been identified as a significant issue for Māori health, in terms of both access and delivery (Came, 2012; Longmore, 2018; Ministry of Health, 2018; Waitangi Tribunal, 2019). The literature on indigenous leadership in nursing and midwifery shares personal experiences of racism faced at work, coupled with the institutionalised racism that manifests in ways in which professions and services are structured, framed and practised (West et al., 2016; Power et al., 2014; Goold, 2011). Power et al. (2014) recognise that “Being Indigenous in a White profession means being exposed to relentless and frequent episodes of racism both personally as a health professional and vicariously through Indigenous patients” (p. 145). Power et al. (2014) also articulate the experience of being “progressively re-defined by western constructs of professionalism” (p.142) and highlight the dichotomy that indigenous women are naturally accepted as leaders in their communities, but as indigenous nursing leaders they are an oddity in the system. This “peculiarity” goes beyond the small but growing numbers of indigenous nurses and midwives, but more deeply recognises that it is during nursing education that whiteness becomes normalised in the nursing profession. It aligns itself with scientific hegemony that determines which knowledge systems are worthwhile, thus discounting indigenous knowledge. However, Power et al., and others (West et al., 2016; Chamberlain et al., 2015; West et al., 2013; Downing & Kowai, 2011) advocate for the reclamation and reassertion of indigenous history, culture and cultural practices within nursing and midwifery. West et al. (2016), while in reference to the success of Australian Aboriginal and Torres Strait Islander nursing students, put forward strategies to resist racism across nursing and midwifery including “valuing indigenousness and resisting racism” (p.351). In doing so, they provide a sense of clarity about the value of the unique experiences and ways of being indigenous peoples bring to the practice and professions of nursing and midwifery.

Bridging two knowledge bases and value systems

Noted by Power et al. (2014) through the personal story of an indigenous nurse, “there is the expectation that we will be the bridge between our culture and the culture we work within” (p.143). A Māori leader is expected to be well-versed in mātauranga Māori as well as well-educated and schooled in the Pākehā knowledge of current times. Māori in leadership roles therefore have the challenge of negotiating the dynamic interplay between traditional Māori values and principles and contemporary ways of thinking (Mead et al., 2006, p. 14). The synthesis indicates that Māori nurses and midwives are not always recognised for what they bring as Māori. This has been identified in other Māori nursing and midwifery literature (Hunter, 2018; Longmore, 2018; Ramsden, 1993, 2002). Baker and Levy (2013) note that this concept of dual competency as it relates to the Māori health workforce is now commonly understood as acknowledging both clinical and cultural expertise. However, in the context of Māori and indigenous health, dual competency encompasses a much richer articulation. Sones et al. (2010) highlight that it explicitly recognises indigenous health as a specialised area of practice. A dual-competency framing visibly communicates that Māori have a body of knowledge and skills drawn from te ao Māori which is relevant for the delivery of effective health services for Māori. The synthesis shows that Ngā Manukura o Āpōpō’s clinical leadership training helped participants bridge the gap between Māori and Pākehā worlds. The opportunity for Māori nurses and midwives to develop and become effective leaders within the two worlds is considered important (West et al., 2013). Unique cultural experiences such as those provided by Ngā Manukura o Āpōpō enable Māori nurses and midwives to become better positioned to make a difference for Māori health and for equity in their professions (Wilson & Baker, 2012).

Retaining Māori in the workforce

Ratima et al. (2008) report that disillusionment is a reason many Māori leave the health workforce. Wilson (2017) noted in her evaluation report that Ngā Manukura o Āpōpō’s Foundation Leadership Training is an intervention and a retention strategy in its own right. The wānanga came at a time when many nurses and midwives were disillusioned with their profession and career prospects, and were considering leaving. Huria et al. (2014) report similar experiences, including racism on institutional and personal levels leading to Māori nurses being marginalised, overworked and undervalued. Tupara and Tahere (2020) also describe how Māori in the maternity sector struggle because of under-resourcing, inadequate remuneration, bullying culture, racism and feeling unheard as individuals and undervalued as a workforce. Research (Health Central, 2016; Ratima et al., 2007; Stewart, 2016) indicates that occupational stress experienced by Māori nurses is different from that experienced by their mainstream counterparts as there are higher expectations of Māori nurses (including cultural) which add to an already demanding profession. This is particularly so in the current climate where health strategies stress the need for more Māori nurses to help counter poor health statistics. There is an ongoing risk of burnout among Māori nurses which could have high consequences for a workforce that is expected to grow to meet government targets and community needs (Huria et al., 2014; Stewart, 2016).

Sustaining diverse Māori leadership

The synthesis demonstrated that leadership progress for Māori nurses and midwives is wide-ranging, not necessarily linear and affected by a range of factors. In particular, the diversity of participants and the contexts in which they operated affected their ability to grow and influence. Day et al. (2009) note that leadership development is integrally related to identity development and a belief that one can lead. Ngā Manukura o Āpōpō clinical leadership training has been successful in fostering that belief. However, where that takes participants varies; some progress up the hierarchical ladder, while others remain in their roles, but become more involved in leadership activities at work or in other settings such as whānau, hapū and the wider community.

This suggests that Ngā Manukura o Āpōpō contributes to an increasing number of Māori nurse and midwifery leaders who have influence at different levels of the health and disability system and different parts of society and, perhaps, at different times in their careers. Kenny (2012) notes it is not uncommon for indigenous leaders to prioritise serving their families and communities, rather than having a desire for a position or power. He Korowai Oranga, the Māori Health Strategy (MOH, 2002) positions whānau, hapū, iwi and community development as one of four pathways to achieve “pae ora” (healthy individuals, healthy families and healthy environments), the Government’s vision for Māori health. The strategy posits that effective Māori leadership is critical to achieving this vision, and that supporting this leadership involves empowering individuals, whānau members, local Māori and iwi leaders, as well as leaders at each level of the health and disability sector.

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LIMITATIONS OF THE SYNTHESIS

This synthesis focused on four programme evaluations from two training programmes, and as such is limited in its scope. What is presented would need to be contextualised to understand applicability for other practice contexts. However, this synthesis provides insight into the impact of kaupapa Māori leadership development approaches for Māori nurses and midwives. It also provides avenues for further research.

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CONCLUSION

Kaupapa Māori approaches to leadership development play a significant role in enabling Māori nurses and midwives to initiate and/or progress leadership journeys. In particular, they contribute to strengthening cultural identity, which provides the foundation for strong indigenous leadership. The Department of the Prime Minister and Cabinet (DPMC, 2021) has acknowledged the impact Māori leadership can have on achieving equity. Part of its vision for the future is a health and disability system that reinforces Te Tiriti o Waitangi principles and obligations with rangatiratanga (self determination) shaping care design for Māori. While awaiting the establishment of the Māori Health Authority, Whakamaua: Māori Health Action Plan 2020-2025 will help lead the way forward. It calls for a shift of cultural and social norms embedded across the health and disability system that will be critical to addressing and eliminating racism and discrimination and achieving equitable health outcomes. Key priority areas of the plan include Māori leadership and workforce development, in both capacity and capability (MOH, 2020). Ngā Manukura o Āpōpo is well-positioned to play a substantial role in fulfilling these directions, none the least through its clinical leadership development pathway which contributes to a growing pool of much-needed Māori clinical leaders.

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AUTHORS’ REFLECTIONS

As models of health-care delivery change to combat inequities in our health and disability system, programmes to support both clinical leadership and professional development for Māori nurses and midwives must be developed and sustained. The case for this is only stronger with the findings and recommendations from the HDSR and the Wai 2575 inquiry, culminating in the recent health reforms. The current COVID-19 pandemic also emphasises the need for a system more devised by and responsive to Māori, amid concerns that they are likely to experience a disproportionately negative impact of widespread illness (McLeod et al., 2020).

The authors maintain that Ngā Manukura o Āpōpō’s national Māori nursing and midwifery clinical leaders’ network and workforce development programme is well ahead of its time. It has worked to influence system-level determinants to Māori health and disability workforce participation and retention and increase Māori presence, capacity and capability in the health and disability sector for more than 10 years. However, they face persistent challenges that limit the sustainability and potential impact of their approach. These challenges include a need to keep validating the equity response provided by kaupapa Māori professional development pathways, slim budgets and short funding cycles.

Continued success relies heavily on the goodwill, commitment and dedication of those involved, with the leadership group providing countless voluntary hours to drive the Ngā Manukura o Āpōpō kaupapa (agenda). This reliance on Māori to drive change, often without remuneration or other recognition, is not uncommon (Haar & Martin, 2021). Nursing and midwifery leadership and education has been described as a tangible response to the imperatives of te Tiriti (Chalmers, 2020). Yet the ability for programmes such as Ngā Manukura o Āpōpo’s to contribute change rests heavily on the Government stepping up and commissioning Māori professional development programmes adequately and fairly, and committing to sustained, longer-term investment.

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RECOMMENDATIONS

• Funding structures for leadership development programmes for Māori nurses and midwives should be reviewed to better enable their contribution to increased leadership capacity and capability.

 

• Further research is needed on how leadership success might be measured for Māori clinicians, taking into consideration the diversity of Māori leadership and the realities in which they operate.

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DISCLOSURES

The authors, Michelle Moss, Louise Were and Kataraina Pipi, declare they have had contractual relationships with Ngā Manukura o Āpōpō Leadership Group via FEM (2006) Limited since 2014 to evaluate their leadership programmes. The authors have received financial payment for the preparation of this article.

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FOOTNOTES

1. On April 21, 2021, reforms to strengthen the health system were announced – these included the establishment of a Māori Health Authority (DPMC, 2021).
2. Ngā Manukura o Āpōpō was established in partnership with the District Health Board New Zealand Māori Workforce Champions, a cross-sector reference group of workforce leaders from within district health boards, non-government organisations, health professional organisations, tertiary institutions and the Ministry of Health.
3. Notably, the first Māori nurses in the history of Aotearoa New Zealand to become the Chief Nursing Officer in the Ministry of Health have a background in this programme.
   See: https://kaitiaki.org.nz/article/new-chief-nurse-seeks-leadership-shift/
4. The Foundation Leadership Training is delivered by Digital Indigenous.Com Ltd.
5. Culturally grounded space of deliberation and learning.
6. KuruWaka was co-designed with the provider, DWS Creative Ltd, Ngā Manukura o Āpōpō leadership group members and Foundation Leadership Group graduates. It was piloted in 2019. Another follow-up option to the Foundation Leadership Training is being trialled at the end of 2021.
7. The Bradford Hill criteria, otherwise known as Hill’s criteria for causation, are a group of nine principles that can be useful in establishing epidemiologic evidence of a causal relationship between a presumed cause and an observed effect and have been widely used in public health research.
8. Pūrākaū is used in research and evaluation as a narrative inquiry method, akin to a case study approach. Pūrākaū, in this context, provides a way of representing indigenous knowledge and stories that culturally connects with Māori.
9. Provided by Rise2025, a coaching leadership agency for indigenous women and girls.
10. This includes five Ngā Manukura o Āpōpō leadership group members, and the Ngā Manukura o Āpōpō KuraWaka project manager (n=5).

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