Working with Maori in New Zealand Medicine

Information about working with Maori people in New Zealand Medicine

Sandrine Wyrich

If you make the move to New Zealand, there is no doubt you will meet and interact with Māori people and their culture on a daily basis. Their heritage is integral to Kiwi cultural identity and nowadays, there is a symbiotic dynamic between Māori and non-Māori people, known as Pākehā.

Generally, the Māori are recognised as calm, patient, hard-working and good-humoured people, so although some experiences will be new to you, they will usually be pleasant and enriching. Understanding and appreciating Māori culture is crucial to navigating life in New Zealand and if you’re not quite sure what to expect, don’t worry, we’ve got you covered.

 

WHO ARE THE MĀORI?

Māori are the indigenous people of New Zealand and came to the country more than 1000 years ago from their mythical Polynesian homeland of Hawaiki. They are frequently connected with a warrior-like identity, but the key characteristic of the Māori is a strong connection with their spirituality and with the natural world.

The Māori suffered societal oppression in the past, particularly during colonisation, an issue that should have been remedied by the 1840 Treaty of Waitangi signed by Māori chiefs and representatives of the British crown. Although the treaty had only limited effect, a renaissance since the 1980s has renewed the focus on biculturalism with government funding to preserve the Māori language and culture.

Today, one in seven Kiwis identifies as Māori, making them the country’s second-largest ethnic population group. About 90 per cent of the present-day Māori population lives in the North Island area, but the South Island too features some Māori presence.

Traditional Māori arts, including weaving, carving, moko (tattoo), whaikorero (oratory) and kapa haka (group performance), are practised in both their traditional forms and with exciting new techniques. Nowadays, Māori culture also includes art, film, television, theatre, poetry and even hip-hop dancing.

Top Tip: Te Ara, the Encyclopedia of New Zealand, [Te Ara Encyclopedia of New Zealand – Te Ara Encyclopedia of New Zealand] is the place to go. Besides offering excellent information on Māori arrival and settlement as well as an overview of Māori culture to the present day, it also discusses biculturalism and how the relationship between Māori and Pākehā has changed over time.

 

LANGUAGE

‘Te Reo Māori’ is an official language in New Zealand, along with English and New Zealand Sign Language, and is commonly heard in everyday settings. Many official place names are in Māori and New Zealand’s national anthem is usually sung in both English and te reo.

At first glance, te reo words may look impossible to pronounce, but here’s the good news: te reo has a logical structure and, unlike English, has very consistent rules of pronunciation. Making an effort to pronounce Māori names correctly will set you in good stead and you may also want to brush up on some basic Māori words and phrases like ‘kia ora’ which means hello. Such greetings are used frequently by both Māori and Pākehā and even just an attempt to use Māori phrases will elicit a delight response.

Top Tip: Radio New Zealand (RNZ) offers a selection of audio and video recordings of Māori greetings and phrases [Te Reo Māori on RNZ | RNZ] for you to practise. The use of a dictionary [Te Aka Māori Dictionary (maoridictionary.co.nz)] can also help you navigate daily life.

 

MĀORI CUSTOMS AND VALUES

Māori customs, known as tikanga, and their traditional values play a major role in daily and social life. Some of them are even part of New Zealand’s national identity in general. Understanding and appreciating the key concepts is important to avoid causing offence and to blend into Kiwi society. Below is a list of the most significant tikanga.

Some Māori concepts have also been modified and modernised. Prominently, where social structures were previously hierarchical with a patriarchal culture, gender equality is now acknowledged and respect of female opinion and authority has become the expectation.

Top Tip: Visiting a marae [The Beginner's Guide to Visiting the Marae | Television | NZ On Screen] is the best way to experience Māori heritage. Maraes are tribal meeting grounds where you can meet with local Māori people to discover more about their culture and history. Be aware that maraes are only accessible via organised tours or possibly by getting invited in your line of work, you can’t just locate one and show up.

Manaakitanga

Manaakitanga describes a natural sense of hospitality and welcoming guests with open arms. This kind and respectful social nature is a cultural trade the Kiwis pride themselves on.

Kaitiakitanga

Love for the environment and the duty of care that is installed in Kiwis from a young age and is known as Kaitiakitanga. This philosophy embodies the respect and guardianship Māori feel towards the natural world and anyone living in and visiting New Zealand is asked to preserve and do no harm to the environment.

Tapu

Something that’s tapu is so sacred it is untouchable – it should not be used, interfered with, or in some cases even spoken of. Many places and things in New Zealand are under this spiritual protection; lakes, for example, may be considered tapu so people must not fish them.

 

MĀORI CULTURE AT THE WORKPLACE

Working in the public sector will involve many formal Māori ceremonies and will include plenty of Māori protocol. For starters, using te reo at workplaces is encouraged, important objects and buildings may be blessed, Māori iconography will be visible in displayed art pieces, Māori names for different rooms or te reo on business cards, and outdoor plantings may only comprise native species.

On a regular day, you may encounter karakia, prayer or incantation, at meal times and workplace waiata, traditional singing, sessions are enjoyed by both Māori and Pākehā. Welcome rituals like pōwhiri may be performed to greet important visitors and new staff members and generally, workplaces will seek a welcoming, warm, respectful and supportive environment.

Māori have a strong family connection and a wider set of obligations owed to their family. Whānau, family, involvement in the work-life balanced is therefore encouraged – whānau members are welcome at the workplace and will be invited to functions. Support and understanding towards whānau commitments is also a guarantee, especially in regard to children or unwell relatives. This also means that ‘cultural leave’ will usually be granted to attend rituals or whānau functions.

Top Tip: Many workplaces employ a kaihautū, a manager, who is responsible for a culturally-sensitive work environment and provides mentorship within an organisation to take it along a pathway towards biculturalism. If you have questions or are unsure about something, do have a chat with the kaihautū or a Māori colleague. Your interest will demonstrate respect and will be most appreciated.

 

INFLUENCE ON MEDICAL PRACTICES

A lot of medical service providers, from GP practices to hospitals, employ dedicated Māori staff – kaiatawhai – to support the spiritual and cultural needs of Māori patients. You should consult a kaiatawhai whenever you are unsure about something and value their input. At the same time, it is still vital for you to have an understanding of how to deal with Māori patients yourself and to acknowledge Māori beliefs and traditions in order to provide medical advice that is culturally sensitive.

For starters, make it a standard part of your practice to ask every patient what their ethnic background is. You should never make assumptions based upon skin colour or appearance. In fact, asking will reveal your respect for the individual’s heritage and provide an opening to discuss cultural preferences.

Be guided by the individual patient and/or their whānau when it comes to including customary Māori practices in medical procedures. Such can include pressing noses (hongi) to greet each other or reciting a blessing (karakia) at times of anxiety.

We have listed a number of typical issues that may be important to a Māori patient below. These should be honoured wherever possible and even if you simply cannot adhere to them, make sure to still acknowledge them.

Top Tip: The Medical Council of New Zealand has created a comprehensive guide on the best treatment of Māori patients. [Best_Health_Outcomes_for_Maori.pdf (indigenouspsych.org)] This resource booklet includes general and practice-specific advice as well as case studies illustrating scenarios you may encounter. We recommend putting this guide on your list of compulsory reading.

Names and Pronunciations

(Family) names are of outmost importance in Māori culture and making an effort to pronounce your patient’s name right is the single greatest way to show respect. If you are unsure about a pronunciation, do ask the patient (and do so before you make a halting attempt). You thereby demonstrate your understanding of the significance of names, your appreciation of the individual and their heritage, as well as your interest in learning more.

You should however note that it’s traditionally considered rude to ask someone’s name directly since that could imply that the person is not of enough importance to know their name beforehand. Many still adhere to this convention, so make sure to ask for advice on the pronunciation of a name rather than for the name itself.

You may also enquire about your patient’s background, in regard to locality and family – to show your respect and appreciation for names and family names. Something along the lines of ‘I see you are from Rotorua, do you know the Douglas family?’ will work wonders for your doctor-patient relationship.

Likewise, make sure to introduce yourself and the other members of staff and explain their roles within the practice. Māori culture relies on interpersonal connections and your patient will feel a lot more comfortable when knowing who the people around are.

Communication

Māori tend to seek a consensus and avoid disagreement. They may also defer to the authority of a practitioner who, after all, is an expert. These values of harmony and respect can in some cases be more important than expressing disagreement. This means that agreement in practice does not necessarily equal the patient approving your treatment plan and intending to continue as you suggest.

Make sure the answer you think you are getting is the one the patient really means and a “yes” or silence in practice means ‘we have agreed upon this plan and I will do my part as we have discussed’. You should therefore, as with any patient, fully explain details, solicit feedback from your patient and present yourself as open to questions. Another recommended approach is the use of open questions; ‘I want to be sure that I have given you all the information you need. Please tell me what you understand will happen to you, from what I have said’.

Māori will generally prefer face-to-face meetings over written communication, so wherever possible, try to see your patient in person. If you do choose to convey, for example, test result or medication instructions over written communication, remember that illiteracy rates are disproportionally higher among Māori.

Another factor to bear in mind is that terms used in a medical context, such as ‘complain’, ‘deny’ ‘report’ or ‘claim’, can be confusing and hurtful. ‘Complaining of a headache for the past two days’ may be misinterpreted as an accusation of whingeing; ‘Family denies drug use on the part of the patient’ could be seen as implying disbelief on the doctor’s part. A simple and open explanation will avoid or address hurt feelings here.

Body Language

Eye contact may be considered a sign of attention and respect in many cultures, but for Māori it is in fact a signal of conflict or opposition. Sustained eye contact could also possibly exclude someone else in the room from the conversation which would be considered rude. Your patient will instead likely look at a neutral spot and focus on the spoken word rather than your face. You too should not be seeking eye contact and only loosely look towards your patient (and the family member(s) accompanying them.

However, remember that, just as with any other patient, the avoidance of looking at the practitioner could indicate anxiety, anger, inattention or fear. Draw upon other signals and if you are unsure about this or other non-verbal communication, ask your patient how they are feeling.

Whānau/Family Support

It cannot be overemphasised how important whānau, family, is in Māori culture. You should not be surprised if a patient wishes for whānau members to be involved in all aspects of care and decision-making and wherever possible this wish should be granted.

Additionally, make it a standard practice to catch up with your patient about their whānau at every appointment. This will show your understanding of the importance of family and human connection and also support the trust and open communication between you and your patient.

Examining Patients

It is common courtesy in many practices to ask permission before touching or examining a person, but it is absolutely crucial when working with Māori. You should explain what you will do, why you are doing it, and request permission to proceed. The present whānau member(s) may or may not wish to remain – you should never assume anything and check with patient and whānau what their preference is.

The head is tapu in Māori culture, so it is of particular importance to be careful to ask consent and avoid touching a patient’s head casually. You should also make sure to have different coloured linens and pillowcases to differentiate between those used for head and those used for the rest of the body. The same applies to flannels used to wash the face and the rest of the body.

Your patient may wear taonga, valuables or heirlooms. These should only be removed if they present safety hazards and it is generally preferable to tape them in place. If a piece of taonga does need to be removed, ask for permission and allow the patient to do so themselves and retain it for safekeeping

Traditional Medicine/Rongoa

Some Māori adhere to the belief that illness is a result of wrongdoing or breaking of tapu, known as ‘mate Māori’. It is therefore advisable to ask patients about their feelings, views or ideas of causality about their illness. If a patient believes that mate Māori is involved, you may suggest that they visit a tohunga – this is commonly a relative who looks after the well-being of the whānau and will be very knowledgeable in human nature and psychology as well a Māori beliefs. A tohunga or a minister can address the mate Māori aspect of the condition while you provide the help afforded by Western medicine.

Treatment with rongoa, Māori medicine produced from native plants or herbs, may be favoured by some Māori. You should know of any alternative medicine your patient may be using – refer to the Medical Council of New Zealand’s ‘Statement on Complementary and Alternative Medicine’. [Doctors and CAM (complementary and alternative medicine) | Medical Council (mcnz.org.nz)]

Remember that your role is not to challenge Māori beliefs but to work with them and help your patient feel better. Of course, if the beliefs are dangerous or make a successful treatment impossible, it is appropriate to share your concerns and seek a compromise, but make sure to do so with respect.

Death and Dying

Death and dying are culturally significant for Māori and ignorance of traditional practices could unintentionally make what is a difficult time for the family anyway infinitely harder. The trust and understanding you have developed with the patient’s whānau is vitally as you can provide a much needed interface and ensure the experience is as painless as possible.

A patient’s whānau should be notified immediately when death is imminent. Be aware that they may prefer to take a terminally ill patient home rather than have them die in hospital and regardless of the location, they will want to be present during and after death, so a private room should be provided. The whānau may also wish to wash and dress the body themselves and wherever possible, these preferences should be honoured.

Delays in releasing the body to the family should be minimised as the whānau needs to see and speak to the deceased as part of a farewell ritual usually held at home or at a marae. Māori believe that the wairua, the spirit, of the deceased does not vacate immediately but wanders at will, leaving and returning to the body for three to five days before moving on. The ritual supports the wairua gain strength for its upcoming journey and is followed by further traditions, including meals, dances and the presentation of a tombstone, which can spread over several months.

As the deceased’s doctor, you may be invited to attend some of the ceremonies, but do not wait for an invitation – you will usually be most welcome and showing face will strengthen your relationship with the whānau.