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He rei ngā niho, he paraoa ngā kauae

To have a whale's tooth, you must have also a whale's jaw

(One must have the right qualifications for great enterprises)

Contributed by Dr John Adams, Chair, Medical Council of New Zealand

“Cultural competence requires an awareness of cultural diversity and the ability to function effectively, and respectfully, when working with and treating people of different cultural backgrounds. Cultural competence means a doctor has the attitudes, skills and knowledge needed to achieve this.”
– Medical Council of New Zealand Statement on cultural competence

It is the New Zealand medical council’s view that knowledge and abilities in matters of culture are a pre-requisite to good care. As a statutory function under the Health Practitioners Competence Assurance Act 2003, we are required to “set standards of…cultural competence…” We take this obligation seriously, and over the last few years have put in place several initiatives, which are still evolving. A part of the development has been to contract Mauri Ora Associates to help develop some excellent council resources, including:

  • A statement on cultural competence
  • A statement on best practices when providing care to Māori patients and their whānau
  • A resource booklet “Best Health Outcomes for Māori: Practice implications”
  • A resource booklet “Best Health Outcomes for Pacific Peoples: Practice implications”

These are just the skeleton of what we hope to achieve. As a next step we plan to work with professional colleges to institute standards of cultural competence in their training programmes and continuing professional development requirements. A recent Memorandum of Understanding signed with the Australian Medical Council will ensure that programmes in New Zealand Medical Schools and Australasian Colleges will now be measured against the Councils standards of cultural competence.

The starting point

The Council became involved with the subject of cultural competence in 1998 when we reviewed our policies and statements in light of the Treaty of Waitangi. Out of this, concerns were raised about whether we were handling complaints to the Council in an appropriate manner. Cultural competence training for Council staff was arranged and undertaken in 2000.

Comments made by Professor Sir Mason Durie, sparked Council’s interest in the idea of developing cultural competence standards for all doctors. Professor Durie suggested that cultural competence should be examined in terms of the positive outcomes it can generate for patients and as a tool for improving public health and safety.

Cultural differences can, and do, get in the way of good doctor-patient relationships and good communication. Discrepancies in health indices and access between our main cultural groups suggest that improved cultural knowledge among all doctors could have significant impact on the health of all New Zealanders.

What the statements say

Cultural competence

This document outlines the benefits of appreciating and understanding cultural issues in the doctor-patient relationship which include:

  • Developing a trusting relationship
  • Gaining patient information
  • Improving communication
  • Increasing patient satisfaction

The key message we want to give to doctors is that because culture impacts on care, doctors have to be aware of cultural diversity and learn to function effectively and respectfully when working with, and treating people, of different cultural backgrounds.

A doctor’s culture and belief systems influence his or her interactions with patients and this may impact on the doctor-patient relationship:

“To enter into the patient’s world and see the illness through that person’s eyes is a difficult task requiring…the most crucial attribute of all – self knowledge. In this respect, the doctor is inevitably influenced by personal and cultural background and values, life experiences, beliefs and prejudices, educational and professional status, perception of the role of the physician and the individual, and the positive or negative feelings and emotional responses that the patient evokes.1”

This is not just about Māori patients; this statement recognises that in New Zealand there is a diverse range of ethnic and cultural differences between doctors and their patients. We have many ethnic groups within our population and also other groupings that patients may identify with.

The document outlines the attitudes, awareness, knowledge and skills doctors require for working successfully with patients of different cultural backgrounds. These include:

  • An awareness that cultural factors influence health and illness including disease prevalence and response to treatment
  • A preparedness not to impose your own values on patients
  • A willingness to appropriately challenge the cultural bias of individual colleagues or systemic bias within health care services where this will have a negative impact on patients
  • An awareness that general cultural information may not apply to specific patients and that individual patients should not be thought of as stereotypes
  • The ability to work with the patient’s cultural beliefs, values and practices in developing a relevant management plan.

Statement on best practices in providing care to Māori patients and their whānau

This document outlines the attitudes, awareness, knowledge and skills relevant to doctors in their dealings with Māori patients and their whānau. It provides practical guidance to doctors to enable them and their Māori patients to achieve the best possible outcomes.

Like the statement on cultural competence, this document also addresses the benefits of appreciating and understanding cultural issues in the doctor-patient relationship – and specifically from a Māori patient and whānau perspective.

The statement outlines areas where cultural differences may arise and cause confusion or misunderstanding with a Māori patient and their whānau:

  • Interpreting and sending non-verbal signals
  • Methods of expressing agreement and disagreement
  • Communicating medical information
  • Presence and inclusion of family members in medical settings
  • The use of karakia

It is noted that the ability to ask patients about their ethnic background demonstrates not only respect for the patient’s individual heritage, but provides an opportunity to discuss their cultural preferences.

The four key elements to cultural competence when treating a Māori patient and their whānau are:

Attitudes
A culturally competent doctor should be open to trying to engage and learn; be prepared to ask patients about their preferences and follow their lead; and will attempt to enter into, and understand, the patient’s world.

Awareness
A culturally competent doctor should also be aware of potential judgements and prejudices based on skin colour and appearance; be aware of Māori cultural expectations around consultations and personal interaction; and be aware of the importance of pronunciation (and when in doubt, ask the patient for help).

Knowledge
A culturally competent doctor will be aware of Māori history, have some knowledge and a respect of Māori culture.

Skills
The skills that a culturally competent doctor should have include; the ability to ask about the patient’s background and heritage; the ability to involve whānau; the ability to ensure that the patient understands what is being planned; and the ability to seek advice and the capacity to develop the connections through which this can happen.

Best health outcomes for Māori: Practice implications

Where the “Statement on best practices” sets the standards expected by the Council, the “Best health outcomes” resource expands on this with a focus on practice implications.

To quote from this resource:

“Just like people of other cultures, Māori place great emphasis on establishing a trusting relationship with their health care providers. Client satisfaction and acceptability of treatment reflect the ability of providers to show they understand their patients and are understood by their patients. Improving providers’ knowledge of Māori traditions will increase their cultural competence thus helping them to communicate more effectively with their Māori patients. This in turn will reduce patient delays in seeking care, improve the collection of clinical information, increase the understanding of Māori clients and enhance communications between Māori clients and providers. Together these can lead to improved patient/family/whānau satisfaction and greater compliance with individual care plans.”

Best Health Outcomes for Pacific Peoples: Practice implications

This booklet offers guidance on the cultural diversity of and cultural preferences for Pacific peoples in New Zealand. The description of Pacific culture in this booklet is necessarily generalised because there are at least 22 separate Pacific nations, each with its own culture and history.

New Zealand has a rich cultural heritage and an increasingly wonderful mixture of different cultures in its population. As a profession, we owe our Tangata Whenua and that diverse population the best care possible. There is an obligation on all doctors to understand their patients’ backgrounds and contexts, and have appropriate awareness, attitudes, knowledge and skills in relation to different cultures. Things that may seem quite simple such as learning Māori pronunciation can make big differences. We also urge our Māori doctors, and others of all cultures, to continue to be involved in helping all doctors understand the unique needs and ways of your populations. Better understanding breeds better communication which we know means better care.

Copies of all the resources referred to in this article are available on the Council’s website at: www.mcnz.org.nz

References

  1. Maoz B, Rabinowitz S, Hers M, Katz HE (Eds). Doctors and their feelings: a pharmacology of medical caring. Westport, Conn; Praeger: 1992.