Contemporary Nurse

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The nurse’s role in improving health disparities

experienced by the indigenous Māori of New
Zealand

Katherine Evelyn Theunissen

To cite this article: Katherine Evelyn Theunissen (2011) The nurse’s role in improving health
disparities experienced by the indigenous Māori of New Zealand, Contemporary Nurse, 39:2,
281-286, DOI: 10.5172/conu.2011.39.2.281

To link to this article: https://doi.org/10.5172/conu.2011.39.2.281

Published online: 17 Dec 2014.

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 Copyright © eContent Management Pty Ltd. Contemporary Nurse (2011) 39(2): 281–286.

The nurse’s role in improving health

disparities experienced by the
indigenous Mā- ori of New Zealand
KATHERINE EVELYN THEUNISSEN
Department of Nursing, Auckland University of Technology, Auckland, New Zealand

ABSTRACT
Many countries across the globe experience disparities in health between their indigenous and
non-indigenous people. The indigenous Māori of New Zealand are the most marginalized and
deprived ethnic group with the poorest health status overall. Factors including the historical British
colonization, institutional discrimination, healthcare workforce bias and the personal attitudes and
beliefs of Māori significantly contribute to disparities, differential access and receipt of quality health
services. Māori experience more barriers towards accessing health services and as a result achieve
poorer health outcomes. Contradicting translations of Te Tiriti o Waitangi have created much debate
regarding social rights as interpreted by Oritetanga (equal British citizenship rights) and whether
or not Māori are entitled to equal opportunities or equal outcomes. Inconsistent consideration of
Māori culture in the New Zealand health system and social policy greatly contributes to the current
health disparities. Nurses and healthcare professionals alike have the gifted opportunity to truly
change attitudes toward Māori health and move forward in adopting culturally appropriate care
practices. More specifically the nursing workforce provides 80% of direct patient care, thus are in a
unique position to be the forefront of change in reducing health disparities experienced by Māori.
Incorporating cultural safety, patient advocacy, and Māori-centred models of care will support nurses
in adopting a new approach toward improving Māori health outcomes overall.

Keywords: health disparities; indigenous health; Māori health social policy; cultural safety; nursing
advocacy; Māori cultural care

M any countries across the globe experience

disparities in health between their indig-
enous and non-indigenous people (Stephens,
Porter, Nettleton, & Willis, 2006). In Aotearoa
(New Zealand) Indigenous Māori are the most
marginalized and deprived ethnic group with the
poorest health status overall [Ministry of Health
(MOH), 2008]. Colonialism and numerous fac-
tors at the levels of individual patients, healthcare
processes and the health system contribute to poor
Māori health outcomes (Robson, 2004). There
are a number of factors to consider, however this
essay focuses on a select few in order to explore
the complexity involved in ethnic disparities. Te
Tiriti o Waitangi (The Treaty of Waitangi) is the
primary source through which Māori are able to
contest health disparities, however contradicting
interpretations give rise to dispute over enforce-
ment of Oritetanga (British Citizenship Rights;
Humpage & Fleras, 2001). Nurses have a large
role to play in reducing the barriers that Māori
experience toward health services and improving

Volume 39, Issue 2, October 2011 CN 281

CN Katherine Evelyn Theunissen
Māori Ora (Māori holistic health and wellbeing)
overall (Wilson, 2006).
British colonization brought new disease
and weapons of war that drastically increased
the mortality rates of Māori. Furthermore, set-
tlers dominated the economic and political
stature through methods of land confiscation
and colonization, resulting in Māori inferiority
(Ellison-Loschmann & Pearce, 2006). The sign-
ing of Te Tiriti o Waitangi resulted in Māori
submitting Kawanatanga (Article one) to the
Crown in exchange for Oritetanga (Article three)
and Rangatiratanga (Article two). Essentially,
Kawanatanga allowed for the establishment
of a constitutional government that to this day
controls the development of the New Zealand
health system (Broom et al., 2007). It is widely
understood that the health system was originally
designed by non-Māori for non-Māori in accor-
dance with their own values, beliefs and objectives
(Ellison-Loschmann & Pearce, 2006).
The ongoing crisis of Māori inferiority is
reflected by the prevailing disparities in health
outcomes and inadequate cultural representation
within the healthcare system (Reid & Robson,
2006). The structural design of the system gives
rise to institutional discrimination in the form
of differential access to healthcare and receipt of
quality services (Hill et al., 2010). Māori experi-
ence a greater number of barriers to access, includ-
ing slower treatment processes, lengthy waiting
lists and socioeconomic deprivation impacting
on affordability and accessibility of services (i.e.,
transport costs or taking time off work; Jansen,
Bacal, & Crengle, 2008). Cormack, Purdie, and
Robson (2007) identify that Māori are only 9%
more likely to develop cancer but are 77% more
like to die from it in comparison to non-Māori.
This is a good example of the implications that
result from differential access experienced by
Māori.
Similarly institutional discrimination gives rise
to differential quality of receipt of services pro-
vided. Hill et al. (2010) explains that Māori colon
cancer patients were more likely to experience at
282 CN Volume 39, Issue 2, October 2011
least one month’s delay between diagnosis and
treatment, which suggests that their treatment
pathway is slower than that of non-Māori. Hill
et al. (2010) adds that patients were less likely
to be treated with additional chemotherapy.
Essentially this implies that these Māori patients
were receiving a lower quality of treatment time-
liness and thoroughness overall, contributing to
differential health outcomes in comparison to
non-Māori patients. Consequently differential
access and receipt leads to differential disease
incidence, with Māori experiencing the poor-
est health outcomes overall (Reid & Robson,
2006). It is evident that institutional discrimina-
tion derived from the health system design has
impacted on Māori health outcomes. Jansen et al.
(2008, p. 19) proposes that this may be a result
of having a ‘one service for all’ system that does
not appropriately accommodate for their cultural
needs and unique perspectives of health.
The discriminatory effect embedded in the
health system directly impacts on the health
processes level by promoting bias attitudes of
healthcare professionals and giving rise to inter-
personal discrimination. Healthcare profession-
als’ bias attitudes result in differential treatment
decision making (Jones, 2001). For example,
primary physicians are less likely to refer Māori
to specialist or surgical services in comparison to
non-Māori (Ellison-Loschmann & Pearce, 2006).
A 2002/2003 survey revealed that Māori had the
highest number of self-reported racial discrimi-
natory experiences with healthcare professionals
(Jansen et al., 2008). Racial discrimination is a
breach of human and Indigenous rights (Harris
et al., 2006) that impacts on Māori receipt of
quality health care and equitable health outcomes.
On an individual patient level, interpersonal
discrimination affects the attitudes that Māori
have towards accessing health services and fosters
mistrust in the workforce to cater for their cul-
tural needs (Jansen et al., 2008). Cram, Smith,
and Johnstone (2003) explain that Māori feel
their cultural perspective of health is undermined
by Pa- keha- dominance, and therefore exhibit
 The nurse’s role in improving health disparities
greater resistance toward trusting and engaging
in services. Consequentially Māori are generally
dissatisfied with a health sector that lacks cultural
consideration on every level; that is from health
system to healthcare workforce, through to the
patient level (Jansen et al., 2008). Furthermore,
Jansen et al. (2008) found that individual fears
of being diagnosed with disease, facing conse-
quences of illness, losing privacy or experiencing
whakama- also contribute to Māori avoidance of
health services.
Essentially the explored issues are a few of
the many factors causing Māori to experience
poorer health outcomes and a resultant life-
expectancy similar to that achieved by non-Māori
20–30 years ago (Tobias, Blakely, Matheson,
Rasanathan, & Atkinson, 2009). Te Tiriti o
Waitangi provides a framework through which
Māori are able to contest health disparities and
work towards achieving equitable health out-
comes. However, contradictory translations of the
Māori and English versions of Te Tiriti o Waitangi
have caused much debate regarding social rights
as interpreted by Oritetanga in Article three
(Humpage & Fleras, 2001).
One argument contests that social rights were
not introduced to New Zealand law until long
after Te Tiriti o Waitangi was signed, therefore
should not be included in Oritetanga (Barrett &
Connolly-Stone, 1998). However, the Court of
Appeal declared Te Tiriti o Waitangi to be a liv-
ing document, able to adjust to new circumstances
rather than being confined to those that existed
at the time of its signing (Te Puni Kökiri, 2001).
Furthermore, the notion of ‘equal citizenship priv-
ileges’ implies that the Crown must ensure Māori
progress uniformly with non-Māori (Humpage &
Fleras, 2001). In effect citizenship rights include
social rights. The Royal Commission on Social
Policy has since established three Te Tiriti prin-
ciples (partnership, participation and protection)
with the purpose of supporting Māori representa-
tion in social policy (Oh, 2005).
Social policy aims to improve overall health out-
comes and life-expectancy and prevent avoidable
CN
deaths, injury and disease for all New Zealanders
(Ministry of Social Development, 2001). In para-
dox, health inequities are defined as being avoid-
able (Reid & Robson, 2006), thus social policy
does not deliver what it promises. Literature
argues that Te Tiriti, more specifically Oritetanga
(British citizenship rights), has not been accu-
rately represented in social policy leading to dif-
ferential distribution of health resources and poor
Māori health gains (Ellison-Loschmann & Pearce,
2006). This may be a result of the requirements
for Māori representation in social policy to con-
fine by the structure of a health system originally
developed for non-Māori.
Furthermore, the debate about Oritetanga
disputes whether ‘equal citizenship rights’ refer
to Māori having equal opportunities or outcomes
(Humpage & Fleras, 2001). One perspective
identifies Oritetanga as enjoyment of promised
benefits resulting in equal outcomes. An opposing
view identifies Oritetanga as equal opportunities
because equality under the law means there should
be no distinction between Māori and non-Māori
(Barrett & Connolly-Stone, 1998). Even if the lat-
ter interpretation is applied, Māori do not expe-
rience equal opportunities to quality and timely
health care. This is a result of Māori experiencing
differential access and receipt of services caused
by factors at the levels of institutional discrimi-
nation, health care professional prejudice and the
personal attitudes or beliefs of individual Māori
(Hill et al., 2010).
Essentially Aotearoa offers all residents equal
access to healthcare services, including free
specialist and hospital care (Hill et al., 2010).
However, while health care access may be equal
it is not equitable. Equity takes into account that
different population groups experience different
social advantages/disadvantages and therefore may
require different resourcing in order to achieve
similar health outcomes (Reid & Robson, 2006).
Evidently health disparities reveal that Māori
don’t enjoy the shared promises of Oritetanga as
guaranteed under Te Tiriti o Waitangi (Barrett &
Connolly-Stone, 1998).
Volume 39, Issue 2, October 2011 CN 283
CN Katherine Evelyn Theunissen
Talbot and Verrinder (2010) suggest that
equity is achieved through social justice and the
support of both policy and society to eliminate
factors harmful to health. New Zealand social
policy has a long journey ahead in the develop-
ment of accurate representation of Māori culture
in the healthcare system (Roorda & Peace, 2009).
On a societal level, individual healthcare profes-
sionals have the opportunity to change attitudes
towards Māori health and move forward in adopt-
ing culturally appropriate care practices.
Social justice exists when society acknowledges
the unique worth of every individual and recog-
nizes equality and solidarity in achieving human
rights (Humpage & Fleras, 2001). Where human
rights pertain to Oritetanga, Ma ¯ ori have the right
to be protected from discrimination and inequita-
ble health outcomes. Nurses have an ever expand-
ing role in reducing the misconduct that Ma ¯ ori
endure as a result of inappropriate representation
of cultural health perspectives in service (Ramsden,
2002). The nursing workforce provides 80% of
direct patient care (Holloway, Baker, & Lumby,
2009); consequently nurses are in a unique posi-
tion to personally be the forefront of change in the
levels of health processes and individual patients.
Cultural safety or Kawa Whakaruruhau was
initially developed by a group of Māori nurses
during the late 1980s in New Zealand. Their
aim was to raise awareness about the social
prejudices toward Māori people and change the
impact that this may have on the nursing care
that they receive. Essentially they hoped for the
Indigenous peoples’ voices to be heard and their
cultural rights and needs to be accepted and safely
cared for (Polaschek, 1998). It is widely under-
stood that the nurse’s personal cultural mindset
influences his/her ability to connect with patients
and form therapeutic relationships. For example,
interpersonal racism is often based on an unac-
ceptable societal prejudice that Māori are per-
sonally responsible for their disparities due to
an inferiority of genes and lack of intelligence or
effort in caring for self (Reid & Robson, 2006).
Therefore, if nurses are performing practice based
284 CN Volume 39, Issue 2, October 2011
on an ideology such as this then they are more
likely to act inappropriately towards Māori and
deliver culturally disempowering care, which
causes distrust and avoidance of health services
(Ramsden, 2002).
In contrast, culturally safe nursing practice
empowers Tangata Whenua through actions that
acknowledge, nurture and value Māori cultural
needs and rights (Polaschek, 1998). By perform-
ing critical self-reflections on personal practice
nurses are able to identify and resolve attitudes
that put Māori at risk of cultural harm (Smye,
Josewski, & Kendall, 2010). This also promotes
open-mindedness, allowing nurses to empathise
with Māori beliefs of healing and health and
arrive at good nursing decisions. Consequently
nurses are better equipped to provide culturally
appropriate care that eradicates issues of differ-
ential treatment decision making and reinforces
Māori trust in health services overall (Ramsden,
2002). Daily application of culturally safe prac-
tice to nursing will improve individual Māori
experiences and responses to healthcare, whilst on
a greater scale contribute to the eventual elimi-
nation of discriminatory barriers to service and
improve Māori health outcomes.
The role of advocating for patients involves the
nurse becoming the ‘defender and promoter’ of
patient rights (Hyland, 2002, p. 473). In context,
this role provides nurses with the ability to defend
against ethnic and racial discrimination that result
in differential treatment delivery. For example;
nurses may advocate for Ma ¯ ori patients by ques-
tioning physicians who don’t make the necessary
referrals for specialist services. Constructive ques-
tioning may encourage physicians to recognize the
harmful effects of their conscious or unconscious
bias towards Ma ¯ ori (Ramsden, 2002). In turn
this may improve the quality and timeliness of
healthcare treatment for Ma ¯ ori. On a larger scale,
the massive nursing workforce has the strength
in numbers to advocate on a health systems level
(Jansen & Zwygart-Stauffacher, 2010), and there-
fore strive for consistency of Oritetanga in social
policy and cultural consideration in health systems.
 The nurse’s role in improving health disparities
Jansen et al. (2008) suggest that nurse-led inter-
ventions are the most suitable for providing health-
care that reduces inequalities, because they encompass
culturally tailored approaches within their practice.
In essence, a Ma ¯ ori-centred approach to caring may
support the nurse’s competency in providing cul-
turally appropriate care (Barton & Wilson, 2008).
Nurses are able to seek Ma ¯ ori-centred guidance in
Ma ¯ ori models of health such as; Te Whare Tapa Wha-
which outlines the four dimensions of Ma ¯ ori health
and encourages holistic recognition of cultural needs;
and He Korowai Oranga which is the Ma ¯ ori health
strategy that supports Ma ¯ ori self-determination and
partnership with the Crown to achieve wha ¯ nau ora
(King & Turia, 2002). By having an understanding
of health concepts developed by Ma ¯ ori for Ma ¯ ori
eradicates the possibility of Pa ¯ keha¯ incorrectly repre-
senting cultural principles (Cram et al., 2003). As a
result nurses will understand the Ma ¯ ori expectations
and needs for cultural care. For example, nurses
should understand that wha ¯ nau (family) participa-
tion in procedures is a preference for the majority of
Ma ¯ ori and positively impacts on their recover over
all. Therefore a Ma ¯ ori-centred nursing care-plan
should include wha ¯ nau participation in daily activi-
ties such as, showering the disabled Ma ¯ ori patient.
Barton and Wilson (2008) provide an interesting
notion whereby building onto the existing strengths
of Ma ¯ ori will enhance their attainment of improved
health outcomes. Essentially wha- nau is one of Ma ¯ ori
sources for strength, support and identity (King &
Turia, 2002).
Māori-Centred Models of Care
Te Whare Tapa Whā is the Māori model of
health that illustrates the four cornerstones
essential to their philosophy of holistic health
and wellbeing. These include: physical, spiri-
tual, family and mental health.
He Korowai Oranga is New Zealand’s Māori
health strategy that aims to achieve wha- nau
ora (healthy families) by supporting Māori
families to reach maximum standards of holis-
tic health and wellbeing. (King & Turia, 2002)
CN
It is evident that the complexity inherent in
health disparities between Māori and non-Māori
runs deep into the core of the health care sys-
tem, reaches as wide as the health processes level
and surfaces at the interactions with Māori indi-
vidual patients. Contradicting interpretations
of Te Tiriti o Waitangi impact on Māori ability
to contest health disparities and seek equitable
Oritetanga. Furthermore, failure to consider
Māori human, Indigenous and social rights in
health care contributes to ongoing health ineq-
uities in Aotearoa. The nursing workforce has a
major role to play in relinquishing Māori from
the health disparities that segregate them as a
population. Incorporating cultural safety, patient
advocacy and Māori-centred models of care will
support nurses as they work towards improving
Māori health outcomes. In truth Māori people
need to be able to live comfortably as both Māori
and citizens of Aotearoa in order to achieve
good health and a sense of meaningful wellbeing
(Durie, 2005).
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Received 27 June 2011 Accepted 18 August 2011